Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 114-117

Rare case of large saccular pseudoaneurysm from both iliac arteries and its management by endovascular repair using kissing balloon-stent technique


Department of Cardiology, A.J. Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India

Date of Submission03-Jul-2021
Date of Acceptance05-Jul-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Manjunath Venkataramaiah Bagur
Department of Cardiology, A.J. Institute of Medical Sciences and Research Centre, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_74_21

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  Abstract 


Isolated true and false iliac artery aneurysms are rare. Cases of iliac artery pseudoaneurysm are even less common and very rarely reported in the literature. Unless interventions are done immediately by either open surgical repair or endovascular repair, the mortality rate remains very high (>50%). We present a complicated case of large saccular pseudoaneurysm from both iliac arteries undergoing a unique procedure of “kissing balloon stent” technique.

Keywords: Endovascular repair, kissing balloon-stent technique, pseudoaneurysm


How to cite this article:
Bagur MV. Rare case of large saccular pseudoaneurysm from both iliac arteries and its management by endovascular repair using kissing balloon-stent technique. Indian J Vasc Endovasc Surg 2022;9:114-7

How to cite this URL:
Bagur MV. Rare case of large saccular pseudoaneurysm from both iliac arteries and its management by endovascular repair using kissing balloon-stent technique. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:114-7. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/114/340508




  Introduction Top


Pseudoaneurysms of the iliac arteries are extremely rare. They are usually secondary to trauma, but may be iatrogenic following intravascular catheterization. They have also been reported as a rare complication of pelvic surgery. Over the last few decades there has been an increase in the incidence of pseudoaneurysms in general, due to an increase in interventional vascular access, Infections, connective tissue disorders, vasculitis. Erosion secondary to malignancy may also be implicated in the formation of pseudoaneurysms. The rupture of a pseudoaneurysm represents a life threatening event. We are presenting one such case who underwent early EVR by unique technique.


  Case Report Top


A 71-year-old female patient was admitted to A.J. Hospital and Research Centre, Mangalore, with severe lower abdominal pain of 5 days duration in January 2017. She also gives a history of peripheral arterial disease, Type 2 diabetes mellitus, and systemic hypertension. She had a history of cerebrovascular accident, hypothyroidism, rheumatoid arthritis, chronic kidney disease, and coronary artery disease. She gives no history of any blunt or penetrating abdominal injury. Apart from a history of undergoing percutaneous transluminal coronary angioplasty in 2003, no other procedures were done through the femoral artery route. There was no history of connective tissue disorders or inflammatory diseases in the past which could attribute to the present condition.

Investigations

Clinical examination revealed tenderness over the right inner thigh area with bluish discoloration. The lower limb vessels were feeble to palpate. Other systemic examinations were not contributing to the present clinical finding. Electrocardiogram showed T inversions in anterior leads. Echocardiography showed normal systolic left ventricular function. Abdominal ultrasound revealed a large saccular pseudoaneurysm of the right iliac artery. computed tomography (CT) angiogram confirmed a large saccular aneurysm measuring 6.6 cm × 4.6 cm × 3.44 cm from proximal right common iliac artery with diffuse atherosclerotic changes in the abdominal aorta and bilateral lower limb arteries with complete occlusion of the left superficial femoral artery in its midsegment [Figure 1] and [Figure 2].
Figure 1: Coronal images showing the saccular aneurysm arising from the proximal left common iliac artery with a mural clot

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Figure 2: Saccular outpouching noted arising from proximal left common iliac artery with peripheral thrombus. Residual luminal diameter measures 3.4 cm (AP) ×4.6 cm (TR) ×6.2 cm (CC)

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Relevant laboratory investigations were done to assess the disease status before the procedure.

Procedure details

In view of the impending rupture of the saccular pseudoaneurysm, she was taken up for a diagnostic peripheral angiogram immediately. It showed a large saccular pseudoaneurysm, mainly from the proximal part of the right iliac artery, but also contributed by the left iliac artery proximally [Figure 3]. The proximal left iliac artery also had a 90% eccentric atherosclerotic lesion, in addition.
Figure 3: Peripheral angiogram showing leaking large saccular pseudoaneurysm from both iliac arteries

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It was decided to perform the endovascular repair (EVR) using covered stents for both iliac arteries to seal the entry of the leakage.

Under local anesthesia, both femoral artery access was obtained by Seldinger technique and 9F sheaths were inserted. Two 0.035-inch Amplatz Super Stiff guide wires were placed in both iliac arteries. The 90% eccentric proximal lesion of the left iliac artery was predilated with 6.0 mm × 4.0 cm Rival (Bard)® peripheral vascular balloon up to 6 atm. To cover the leakage of both iliac arteries, it was decided to do “kissing stent technique.” In this technique, we are simultaneously deploying two balloon-expandable stents to cover the bifurcation area and also preventing stent distortion. The size of the balloon and stents was determined according to the reference vessel diameter of the iliac arteries in the vicinity of the lesions.

An 8.0 mm × 4.0 cm LifeStream (Bard)® balloon-expandable vascular covered stent was placed in the proximal part of the right iliac artery toward bifurcation, covering the leaking portion. To cover the aortic bifurcation area, another 7.0 mm × 37 mm LifeStream (Bard)® balloon-expandable vascular covered stent was also placed in the proximal part of the left iliac artery toward bifurcation [Figure 4]. Now, we have both nondeployed stents in situ. First, the right iliac stent was deployed to nominal 6 atm pressure which covered the leaking segment of the right iliac artery. If we deploy the left iliac stent now, it is likely to crush the proximal part of already deployed right iliac stent; hence an 8.0 mm × 4.0 cm Rival (Bard)® peripheral balloon was placed above iliac bifurcation inside the existing expanded right iliac stent which will help to prevent distortion of the right iliac stent when left iliac stent inflated subsequently.
Figure 4: Balloon dilation of the proximal stenosis of the left iliac artery; right iliac artery covered stent and undeployed left iliac artery covered stent in situ

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Then, the left iliac stent and right iliac post dilatation balloon which is placed in the already deployed stent were simultaneously expanded (kissing balloon-stent technique) so that both stents are optimally dilated and placed at the bifurcation which avoided stent deformation. This unique technique ensured 100% sealing of both iliac arteries as well as covering the aortic bifurcation (carina) as evidenced by a check angiogram. This also ensured the regression of pseudoaneurysm [Figure 5]. Post procedure, recovery was uneventful.
Figure 5: Deployed right iliac stent; postdilation balloon in existing right iliac stent; dilatation of both stents simultaneously and final result showing significantly reduced pseudoaneurysm

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Repeat ultrasonography with Doppler study was done immediately after procedure which showed resolving pseudoaneurysm. The patient received antiplatelets and statins as lifelong therapy.

Follow-up

Follow-up Doppler study at the end of 1 month and 3 months showed complete resolution of the pseudoaneurysm. In view of existing chronic kidney disease, repeat CT angiography was not contemplated at the follow-up periods. The patient was followed up for 3 years (interquartile range-3 months). However, she succumbed in 2020 due to other existing comorbidities.


  Discussion Top


Pseudoaneurysm is a contained rupture of an artery due to disruption of the wall continuity. It forms a sac in direct communication with the donor artery. Unlike a true aneurysm which has all three wall layers, pseudoaneurysm is surrounded by only a thin layer of media or adventitia. Many pseudoaneurysms are caused by blunt or penetrating trauma. Recently, the number of iatrogenic pseudoaneurysms due to surgical and interventional procedures has increased.[1] Infection can be the cause of both pseudo and true aneurysms; however, pseudoaneurysms are more frequent due to easy disruption of the arterial wall.[2] Connective tissue disorders, vasculitis, inflammation, and erosion secondary to malignancy are the other reported causes of pseudoaneurysms.[3] Atherosclerotic aneurysms are usually true in nature, but pseudoaneurysms originating from penetrating atherosclerotic ulcers have been reported.[4]

Patients can present with a variety of symptoms based on the location of the aneurysm. Rupture is associated with high mortality (>50%). Presentation with pressure effects on surrounding structures is also reported.[5]

Endovascular approaches to repair these aneurysms are increasingly popular with largely positive results over the past two decades.[6]

The evolution and development of the various endovascular grafts for iliac artery aneurysms have substituted the conventional open surgical repair (OSR).[7] EVR is associated with fewer complications and shorter hospital stay when compared to open surgery.

Balloon-expandable covered stents are preferred to self-expanding stents in iliac interventions[8] and in this case, there was an eccentric significant proximal lesion in the left iliac artery in addition. The operative mortality rate for OSR after aneurysm rupture is as high as 40%–50% but very low for EVR.[9],[10]

In the present case, the arterial rupture was slow and gradually increased over 5 days which allowed us to investigate and intervene. A possible cause in the present case could be pseudoaneurysm secondary to penetrating atherosclerotic ulcerative lesions.


  Conclusion Top


Leaking pseudoaneurysm is a life-threatening clinical entity. Diagnosis at the earliest and prompt interventions such as EVR with stent grafts is a life-saving procedure. Kissing balloon-stent technique for the treatment of complex iliac bifurcating diseases can be considered in patients with poor prognoses due to serious comorbidities and those with high risk for open surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sueyoshi E, Sakamoto I, Nakashima K, Minami K, Hayashi K. Visceral and peripheral arterial pseudo aneurysms. AJR Am J Roentgenol 2005:185:741-9.  Back to cited text no. 1
    
2.
Ferreira J, Canedo A, Brandão D, Maia M, Braga S, Chaparro M, et al. Isolated iliac artery aneurysms: Six-year experience. Interact Cardiovasc Thorac Surg 2010;10:245-8.  Back to cited text no. 2
    
3.
Saad NE, Saad WE, Davires MG, Waldman DL, Fultz PJ, Rubens DJ, et al. Pseudo aneurysms and role of minimally invasive techniques in their management. Radio Graphics 2005;25:S173-89.  Back to cited text no. 3
    
4.
Taif S, Alrawi A, Al-kalbani J. Iliac artery pseudo aneurysm presentingas a para vertebral collection: a potentially fatal mimic. BMJ Case Rep 2014. doi. 10. 1136/bcr-2013-203428.  Back to cited text no. 4
    
5.
Arthur TI, Gillespie CJ, Butcher W, Lu CT. Pseudo aneurysm of the internal artery resulting in massive per rectal bleeding: J Surg Case Rep. vol.2013,issue10, oct 2013 /rjt069.01-02.  Back to cited text no. 5
    
6.
Fakhro A, Shah N, Barnes TL. Endovascular repair of a common iliac pseudoaneurysm and aortic ectasia in a patient with horseshoe kidney and pancreatitis: A case report. Ann Med Surg (Lond) 2013;2:65-7.  Back to cited text no. 6
    
7.
Carpenter JP, Garcia MJ, Harlin SA, Jordan WD, Jung MT, Krajcer Z, et al. Contemporary results of endovascular repair of abdominal aortic aneurysms: Effect of anatomical fixation on outcomes. J Endovasc Ther 2010;17:153-62.  Back to cited text no. 7
    
8.
Mwipatayi BP, Thomas S, Wong J, Temple SE, Vijayan V, Jackson M, et al. A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg 2011;54:1561-70.  Back to cited text no. 8
    
9.
McPhee J, Eslami MH, Arous EJ, Messina LM, Schanzer A. Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): A significant survival benefit over open repair is independently associated with increased institutional volume. J Vasc Surg 2009;49:817-26.  Back to cited text no. 9
    
10.
Mayer D, Aeschbacher S, Pfammatter T, Veith FJ, Norgren L, Magnuson A, et al. Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: A two-center 14-year experience. Ann Surg 2012;256:688-95.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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