Clinical History
This patient with a known infrarenal abdominal aortic aneurysm came to our observation for the follow-up of the aneurysm. In the meantime the patient started suffering from bilateral intermittent claudication of both legs.
Imaging Findings
A follow-up CT-angiography was performed for the aneurysmal sac growth monitoring (Fig. 1). This investigation revealed the development of a collateral circulation pathway from enlarged lumbar arteries (Fig. 2 to 4) and a bilateral severe stenosis with a linear pattern of the common iliac arteries origin (Fig. 5 and 6) due to an ab-extrinseco compression of the aortic carrefour by the downwards enlargening aneurysmal sac.
The patient bore a high anaesthesiological risk, due to recent myocardial infarction, but his aneurysm had an adequate proximal neck, starting at a good distance from the renal arteries ostia and for these reasons, an EndoVascular Aneurysm Repair (EVAR) procedure was scheduled. A Talent bifurcated endoprosthesis (Medtronic) was implanted. The procedure was performed through a bilateral common femoral groin surgical arteriotomy.
The device placement was not particulary challenging, as the femuro-iliac axes were regular and with an adequate diameter on both sides.
The purpose was both to exclude the aneurysm and to treat the stenosis at the origin of both iliac axes by means of the branches of the stent-graft.
The intraoperative angiogram after endoprosthesis placement and deployment showed the absence of both type I end type II endoleak; the prosthetic bifurcation and the common iliac arteries diameter showed a good diameter.
A follow-up CT-angiography at 30 days shows aneurysmal sac exclusion and absence of endoleak (Fig. 7a to 7c) and iliac patency and good diameter were confirmed (Fig 8), with a reduction of the size of lumbar collaterals (Fig. 9).
Discussion
Abdominal aortic aneurysms often are asymptomatic and frequently they are discovered during screening examinations done for other reasons. The "intermittent claudication" symptom due to ab extrinseco compression by a kinking effect from the same abdominal aorta aneurysm is very unusual. To our knowledge, we found only one case report of a large uterine leyo-myoma causing claudication due to ab extrinseco compression. Another atypical cause reported is iliac occlusion due to pelvic radiotherapy but we were unable to find case reports similar to the one shown here. CT appeared very effective in demonstrating the hypertrophic lumbar arteries (Fig. 2) reperfusing the hypogastric arteries (Fig. 3,4) and the stenosis at the origin of common iliac arteries (Fig. 5,6).
At the present time, open surgical repair of abdominal aortic aneurysm still represents the gold standard treatment option; however endovascular procedure is significantly growing.
In our case the endovascular approach proved to be a winning choice, obtaining both the successful exclusion of this enlargening aneurysm and the restoration of an adequate flow through the iliac arteries (demonstrated by the reduction in size of the lumbar arteries).
The follow-up investigation proved the absence of endoleak complications and the claudicatio symptoms were completely solved.
Differential Diagnosis List
Ab extrinseco compression of the aortic carrefour from aortic aneurysm
Final Diagnosis
Ab extrinseco compression of the aortic carrefour from aortic aneurysm
