CASE 10117 Published on 20.12.2012
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External iliac artery aneurysm treatment by rendez-vous technique and stent-graft deployment: the movie

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Fabio Pozzi Mucelli, Vincenzo Savoca, Sandro Pulvirenti, Roberta Pozzi Mucelli, Maria Assunta Cova

Struttura Complessa di Radiologia,
Az. Ospedaliero-Universitaria Ospedali Riuniti di Trieste,
Italy
Email:pozzi-mucelli@libero.it

*Struttura Complessa di Chirurgia Vascolare,
Az. Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Italy
Connected authors
Patient

78 years, male

Categories
Area of Interest Arteries / Aorta ; Imaging Technique Catheter arteriography, CT-Angiography
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Clinical History
62-year-old male patient, multiple comorbidities (diabetes, hypertension). Two months before critic limb ischaemia of left lower limb. He is referred again after a CT-angiography reevaluation of peripheral arteries. An unexpected finding is detected: a right external iliac artery (EIA) pseudoaneurysm; the patient suffers from right pelvic pain without other symptoms (Fig.1).
Imaging Findings
Considering the faint right femoral pulse, we started with a left femoral access. Preliminary angiogram confirmed a large pseudoaneurysm of the EIA (Fig. 2a). Multiple attempts to advance the guidewire "from the top" were done but this one always entered into the pseudoaneurysm, without finding the right way out. So we tried to advance correctly the guidewire in the EIA using a right femoral access, but the result was the same (Fig. 2b,c). Thus we decided to try a "rendez-vous" manoeuvre inside the sac: we inserted a "snare" device in the sac (Fig. 3-movie) and retrieved it capturing the guidewire (Fig. 4-7-movies). Finally the wire was taken out, allowing us to advance a stiff-guidewire (Fig. 8a) and deploy a stent-graft (Fluency-Bard 10x80 mm). The stent was fully expanded using a balloon catheter 9x40 mm. Final check showed complete exclusion of the previously identified aneurysm (Fig. 8b,c).
Discussion
We believe that this case is particular both for the diagnostic aspect and for the treatment modality. Concerning the diagnosis we believe this lesion is a pseudoaneurysm for the morphology and the absence of peripheral calcifications (Fig. 1a, b). Furthermore an angiography done two months before was completely negative (Fig. 9). Pseudoaneurysms of iliac arteries are unfrequent and reported as a complication of surgery at this level (f.e.:renal transplantation) [1]. Frequently these are mycotic pseudoaneurysms, however, in our case no significant clinical or laboratory signs of infections were found. We can't exclude a iatrogenic nature during the previous angiography which was done with a right femoral access however no symptoms were reported during that procedure and the days following (Fig.9). Concerning the modality of treatment we believe that the solution used here is original and we were able to find only one case report recently pubblished by Fanelli et al [2] who reported a successful treatment done in a similar way but at the level of the superficial femoral artery. However, the "Rendezvous technique" is already known and it is mainly used and reported by gastroenterologist and urologists [3, 4, 5, 6] for the recanalization of complex obstruction in the biliary tree or in the ureters. In the arterial bed a similar technique is used in complex below the knee recanalizations and is named "Safari technique" [7]. Sometimes during EVAR procedure, a similar technique using "snare devices" is adopted for the cannulation of the "gate". However, we believe that in the case shown here the idea to do the "rendezvous" inside the pseudoaneurysm was particularly challenging and effective.
Differential Diagnosis List
External iliac aneurysm treatment by rendez-vous technique and stent-graft deployment
Iliac aneurysm
Iliac pseudoaneurysm
Final Diagnosis
External iliac aneurysm treatment by rendez-vous technique and stent-graft deployment
Case information
URL: https://www.eurorad.org/case/10117
DOI: 10.1594/EURORAD/CASE.10117
ISSN: 1563-4086
Figure 1

MDCT-angiography

MDCT-angiography
Axial scan (MIP elaboration): large pseudoaneurysm of the right external iliac artery.
MDCT-angiography
The multiplanar reformatted image shows the saccular pseudoaneurysm with a small neck.
MDCT-angiography
Volume rendering elaboration: same findings.
Figure 2

Endovascular treatment

Endovascular treatment
The preliminary angiography confirms the large pseudoaneurysm in the proximal tract of the external iliac artery.
Endovascular treatment
Multiple attempts to correctly advance the guidewire were done from either a left and a right femoral access.
Endovascular treatment
The guidewires always entered in the pseudoaneurysm without finding the right way out.
Figure 3

The Rendezvous

The Rendezvous
Play Video
Both guidewires are advanced into the pseudoaneurysm.
Figure 4

The Rendezvous (Part II)

The Rendezvous (Part II)
Play Video
The catheter with radiopaque distal marker of the snare device (Multisnare set-PFM Medical) is introduced through the right femoral access and advanced into the pseudoaneurysm.
Figure 5

The Rendezvous (Part III)

The Rendezvous (Part III)
Play Video
The snare device is opened in the sac.
Figure 6

The Rendezvous (Part IV)

The Rendezvous (Part IV)
Play Video
The guidewire introduced from the left femoral access is captured from the snare.
Figure 7

The Rendezvous (Final Act)

The Rendezvous (Final Act)
Play Video
The guidewire is pulled out from the introducer sheath. The job is done!
Figure 8

Endovascular treatment: stent deployment

Endovascular treatment: stent deployment
Angiogram before stent-graft deployment confirms the right position of the guidewire.
Endovascular treatment: stent deployment
Final angiogram after stent-graft deployment (Fluency-Bard 10x80 mm). Complete exclusion of the pseudoaneurysm.
Endovascular treatment: stent deployment
Later phase which shows regular filling of the internal iliac artery.
Figure 9

Angiography (two months before)

Angiography (two months before)
This angiogram was done 2 months before during a failed attempt to recanalize a distal left SFA occlusion. No significant abnormalities to the right iliac arteries are identifiable.