CASE 10117 Published on 20.12.2012

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
Patient

78 years, male

Categories
Area of Interest Arteries / Aorta ; Imaging Technique Catheter arteriography, CT-Angiography
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