Preservation of Internal Iliac Artery after Endovascular Repair of Common Iliac Artery Dissection Using Modified Fenestrated Stent Graft

Hypogastric Artery Salvage Using an Unibody Bifurcated Aorto-Iliac Graft Associated to Double-Barrel Technique in Spontaneous Isolated Abdominal Aortic Dissection

A 54-year-old male patient was admitted with acute left lower limb ischemia (ALI). Computed tomography (CT) angiogram showed an isolated abdominal aortic dissection (IAAD) with a single entry tear just proximal to the aortic bifurcation and an intramural hematoma (IMH) extending to the descending thoracic aorta. The IAAD involved the left iliac bifurcation, with a flow limiting dissection flap into the internal iliac artery (IIA) and external iliac artery (EIA) thrombosis with femoro-popliteal embolization. A surgical thrombectomy of the femoral arteries was performed. An unibody bifurcated endograft was deployed into the true lumen to cover the entry tear, and a double-barrel technique was employed to restore the flow into the EIA and to preserve the IIA patency. The postoperative period was complicated by a compartment syndrome of the calf, requiring a fasciotomy. Follow-up imaging after 12 months showed complete resolution of the IAAD and patency of the stented vessels.

Management of endovascular treatment in spontaneous iliac artery dissections: Applications enabling classical surgery

Background

This study aims to investigate the effectiveness of endovascular applications for the treatment of spontaneous iliac artery dissections.

Methods

The medical records of 13 patients (12 males, 1 female; mean age 67.9±5.7 years; range, 58 to 75 years) with spontaneous iliac artery dissection between January 2017 and December 2019 were retrospectively reviewed. The diagnosis of spontaneous iliac artery dissection was made based on contrast-enhanced computed tomography. Demographic and clinical characteristics of the patients, physical examination and imaging findings, and hybrid treatments applied during endovascular treatment were analyzed.

Results

The mean follow-up was 12.5±1.1 (range, 6 to 16) months. Five patients received hybrid treatment during endovascular treatment. The re-entry site was closed by a patch plasty over the common femoral artery in one of these patients. Embolectomy was performed in the remaining four patients for the treatment of acute ischemia of the extremities. Since no patency could be achieved in two of the patients undergoing embolectomy, a femoropopliteal bypass was performed. The technical success and primary patency rates were 100%. No new false lumen formation, intra-stent occlusion or arterial occlusion was observed during the hospital stay and follow-up.

Conclusion

Endovascular methods can be safely used in the treatment of spontaneous iliac artery dissections; however, hybrid treatments may be also required in selected cases. We believe that it is effective and safe to apply endovascular and hybrid treatments without preventing possible surgical treatments which may be required in the future.

Iliac Arteries Dissection with a Rapid Dilatation as Debut of Fibromuscular Dysplasia

We report a case of a 38-year-old male diagnosed with fibromuscular dysplasia (FMD) and a dissection of both common iliac arteries without aortic involvement. It was revealed after an inguinal hematoma and a pelvic pain, which are not the typical FMD presentation. Surgical treatment was performed after a rapid iliac growth in the first month control computed tomography angiography. Although the clinical course of this entity is relatively benign, rupture of the common iliac artery has also been described.

Endografts with mini-cuff-augmented fenestrations for endovascular repair of thoracoabdominal aortic and common iliac artery aneurysms

OBJECTIVE

To report a technique of creating mini-cuff-augmented fenestrations in endografts for use in endovascular aneurysm repair.

METHODS

Circular fenestrations are made in Dacron thoracic (Valiant Captivia, Medtronic) or tapered iliac limb (Endurant, Medtronic) endografts using thermal cautery and the edges are strengthened with radio-opaque wire sutured on with 6-0 polypropylene. Straight thin-wall expanded polytetrafluoroethylene vascular graft of the same diameter as the fenestration is affixed to its edge with nonlocking 5-0 polypropylene suture, everted, trimmed, balloon-dilated to its nominal diameter and prevented from invaginating by relaxed external stay sutures. Mini-cuff-augmented fenestrations are often pre-cannulated with looped or externalized nitinol guidewires to facilitate catheter crossing. Successful use of mini-cuff-augmented fenestrations is illustrated in a symptomatic patient with Crawford extent-3 thoracoabdominal aortic and bilateral common iliac artery aneurysm undergoing endovascular repair. Seven mini-cuff-augmented fenestrations were created to preserve flow into five visceral arteries (celiac, superior mesenteric, left and dual right renal; all arising from the aneurysm) and both internal iliac arteries (arising at the aneurysm edge).

RESULTS

Effective sealing was achieved immediately at all mini-cuff-augmented fenestrations. At 6-month follow-up there were no endoleaks, all fenestration stents were patent and undistorted, and the aneurysm sac size had decreased.

CONCLUSION

Mini-cuff-augmented fenestrations accomplish effective fenestration sealing, despite being in aneurysmal zones, while preserving the advantages of fenestrations over cuffed branches.

Aortic Bifurcation Reconstruction after a Plane Crash

We report the case of a 26-year-old woman who presented to the emergency room after an airplane crash. The assessment of the lesions revealed a dissection of the left common iliac artery, which was treated by reimplantation of the left common iliac artery in the right common iliac artery.

Effectiveness of the conservative therapy for spontaneous isolated iliac artery dissection: Preliminary results

Purpose To investigate the effectiveness of conservative therapy for spontaneous isolated iliac artery dissection (SIIAD). Methods From February 2006 to May 2016, all patients with SIIAD were included and analyzed. The diagnosis of SIIAD was made based on contrast-enhanced computed tomography. The imaging morphologic characteristics, treatments, and outcomes for each patient were analyzed. Results A total of 11 patients (10 male and 1 female, age 71.1 ± 7.8 years) were included in this study. Of the 11 patients, 8 patients were asymptomatic and the SIIADs were discovered during the course of computed tomography for other diseases, and 3 patients were symptomatic. Initial computed tomography findings: iliac arterial calcification ( n = 7); compression of the true lumen ( n = 6), with stenosis of the true lumen from 25% to 50% ( n = 3) and ≥ 50% ( n = 3); thrombosed false lumen partially ( n = 4), and no thrombosis in false lumen ( n = 7); dissecting aneurysm ( n = 11); entry points ( n = 11); re-entry points ( n = 1); no dissection extended to the internal iliac or common femoral artery. Conservative treatment was performed in six patients, and the remaining five patients need no treatment. During 23.3 ± 14.2 months follow-up, none recurred symptoms and signs of symptomatic SIIAD; partial remodeling of SIIAD was achieved in four patients, and the remaining seven patients with no change of SIIAD. There was no presence of new false lumen enhancement on contrast-enhanced computed tomography during follow-up. Conclusions SIIAD without arterial rupture or lower limb necrosis can be safely treated with conservative therapy.

Isolated Spontaneous Dissection of the Iliac Arteries: False Lumen Embolization as an Adjunct to Percutaneous Stent Grafting

BACKGROUND

Spontaneous dissection of iliac arteries, without involvement of the aorta, is rare. Only few cases of endovascular treatment of this condition are reported in the current literature.

METHODS

We report false lumen embolization strategy as an adjunct to stent grafting of the true lumen.

RESULTS

A 68-year-old male patient was admitted to our institution with the incidental finding of an isolated iliac dissection with a false lumen aneurysm. He was electively treated with successful segmental iliac stent grafting to cover the primary entry tear in the common iliac artery. Coil embolization of the false lumen was chosen to provide distal seal of the false lumen aneurysm.

CONCLUSIONS

As in the treatment of aortic dissections, also in the iliac arteries, false lumen thrombosis should be targeted. To our knowledge, this is the first case of false lumen embolization of an isolated iliac dissection reported in literature. The technique we report was effective and could be easily reproduced.