Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Hypogastric artery aneurysm - a case report

Isolated hypogastric artery aneurysm (internal iliac artery aneurysm) is a rare disease, more often associated with the occurrence of aneurysms in other localities. It typically occurs in older men. Rupture as the most serious complication is associated with high mortality, which is many times higher than the mortality in case of elective repair. Nearly half of the patients are asymptomatic and eventual symptoms tend to be very diverse. Therefore, in the diagnostic process, it is necessary to consider this disease even in case of symptoms apparently unrelated to the arterial system. Treatment is surgical or endovascular. The report presents the case of a female patient with an isolated aneurysm of the hypogastric artery treated endovascularly. Key words: aneurysm hypogastric artery - stentgraft diagnosis.

Strategy for Isolated Iliac Artery Aneurysms

We retrospectively reviewed 41 patients with isolated iliac artery aneurysms presenting over a 21-year period. The mean age was 72 years. Mean aneurysmal diameter was 6.0 cm (range, 3.2–13 cm). The aneurysms were located in the common iliac artery in 31 patients, internal iliac artery in 7, and both arteries in 3. Rupture occurred in 20 patients (49%). The frequency of rupture of isolated iliac artery aneurysms was significantly higher than that of abdominal aortic aneurysms (8%) during the same period. The 30-day mortality was 9.8%; death in all 4 patients was due to rupture of the aneurysm. The surgical procedure was aneurysmectomy and replacement with a bifurcated prosthetic graft in 24 patients (59%), closure of the common iliac artery with a femorofemoral crossover in 7, minilaparotomy in 3, thromboexclusion in 6, and endoluminal stent-graft repair in one. In contrast to abdominal aortic aneurysms, isolated iliac artery aneurysms can be treated by various methods other than replacement with a bifurcated prosthetic graft. When selecting a strategy for such aneurysms, it is important to choose an approach appropriate to the location and risk, because of the frequency of rupture.

Role of Apoptosis and Proteolysis in the Pathogenesis of Iliac Artery Aneurysms

The objective of this study was to investigate the role of inflammation, programmed cell death, its molecular modulators, and proteolysis in the pathogenesis of iliac artery aneurysms (IAAs). Nineteen IAA specimens were obtained from patients undergoing elective surgical repair. All were males with ages ranging from 55 to 85 years (mean 73 years). Controls were iliac arteries ( n = 6) retrieved from surgical patients without aneurysmal disease. Standard histochemical techniques were used to assess elastic lamellae fragmentation and inflammatory infiltrate in aneurysmal and normal tissues. Identification of different types of cells in the aneurysm wall and detection of death-promoting molecules, Fas, p53, perforin, apoptosis-mediating bcl-2 family proteins, apoptotic death substrate, and poly(adenosine diphosphate–ribose) polymerase were performed immunohistochemically. Apoptosis was detected by terminal deoxynucleotidyl transferase–mediated digoxigenin–deoxyuridine triphosphate nick end-labeling (TUNEL) assay and caspase activity. Proteolytic activity was determined by 10% gelatin gel zymography. There is a conspicuous disruption and fragmentation of elastic lamellae in IAAs compared with normal arteries. Increased gelatinolytic activity was observed at 92, 72, and 67 kDa in the aneurysmal tissues. There was a significant loss of vascular smooth muscle cells (VSMCs) in the IAA walls compared with normal arteries ( p < .02). Large numbers of inflammatory cells were observed in the IAA specimens ( p = .01). Only aneurysmal arteries showed CD8+ T cells expressing death-promoting molecules. CD3+, CD8+, CD20+, CD30+, and CD68+ immunoreactive cells were significantly more prominent in the aneurysmal tissues than in the control arteries. There was a significant increase in the number of cells undergoing apoptosis in aneurysmal tissue than in the normal vessels ( p < .02), as well as in the expression of bax, p53, CPP-32, and Fas. Apoptotic cells and proapoptotic molecules predominantly localized to the inflammatory infiltrate. VSMC apoptosis was significant in IAAs. The data confirm the architectural disruption of the IAA wall and illustrate an apparent biologic response involving inflammatory infiltrate, apoptosis, and signaling molecules capable of initiating cell death. In addition to compromising the mechanical integrity of the vessel wall, VSMC loss may contribute to imbalance in the protein profile, accelerating extracellular matrix degradation that could favor IAA development.

Inflammatory aneurysm of the common iliac artery mimicking appendicitis

Isolated inflammatory aneurysm of the common iliac artery is a rare condition. Previously reported cases presented with urologic complications owing to entrapment of the ureter in the perianeurysmal fibrosis. We report a case of a healthy young man who presented with acute abdominal pain in the right lower quadrant without urologic complications mimicking acute appendicitis. The pain was caused by an isolated inflammatory aneurysm of the right common iliac artery measuring 4 cm in diameter. Three years after open aneurysmal resection and graft interposition, the patient is doing well, with excellent peripheral circulation. The available literature on presentation, diagnosis, and treatment is reviewed.

Peripheral vascular applications of the Amplatzer vascular plug

PURPOSE

To present our experience using the Amplatzer vascular plug in various arterial and venous systems, and follow-up results.

MATERIALS AND METHODS

Between May 2005 and October 2006, 20 Amplatzer vascular plugs were used to achieve occlusion in 20 vessels in 12 patients (10 male, 2 female) aged between 24 and 80 years (mean age, 55 years). Localization and indications for embolotherapy were as follows: pulmonary arteriovenous malformations (n = 3; 9 vessels), internal iliac artery embolization before stent-graft repair for aortoiliac aneurysms (n = 4; 4 vessels), preoperative (right hemipelvectomy) embolization of bilateral internal iliac arteries (n = 1), bilateral internal iliac aneurysms (n = 1), large thoracic side branch of the left internal mammary artery coronary by-pass graft causing coronary steal syndrome (n = 1), closure of a transjugular intrahepatic portosystemic shunt (n = 1), and testicular vein embolization for a varicocele (n = 1).

RESULTS

The technical success rate was 100%, with total occlusion of all the targeted vessels. Only one device was used to achieve total occlusion of the targeted vessel in all patients (device size range, 6-16 mm in diameter). No major complications occurred. Target vessel occlusion time after deployment of the Amplatzer vascular plug was 6-10 min in pulmonary arteries (mean, 7.5 min) and 10-35 min (mean, 24.4 min) in systemic arteries. Mean follow-up was 6.7 months (range, 1-18 months).

CONCLUSION

Embolization with the Amplatzer vascular plug is safe, feasible, and technically simple with appropriate patient selection in various vascular territories.

Giant iliac artery aneurysm--a rare cause of hydronephrosis

The presence of arterial aneurysm--an abnormal dilatation of an arterial segment due to various causes--might lead to compression effects and to various symptoms. Finding an etiology for unilateral hydronephrosis represents in some cases a real challenge for the clinician and targeted investigations must be ordered for the diagnostic approach. The abdominal ultrasound examination is one of the first imaging modalities but the abdominal computed tomography is helpful for definitive conclusions. We present a rare case of unilateral hydronephrosis due to a giant left iliac artery aneurysm in a 77-year-old male with history of peripheral artery disease.

Trends in prevalence of fatal surgical diseases at forensic autopsy

BACKGROUND

In 1992, there were major changes in Swedish law of the deceased, which had led to a dramatic decrease in autopsy rates. The aim of this study was to investigate the prevalence of fatal or potential fatal surgical diseases within a Swedish forensic autopsy cohort, before and after this change in legislation.

METHODS

Deaths referred for forensic autopsy at the Institution of Forensic Medicine, Lund University Hospital, Sweden, between 1970-1982 and 2000-2004, were studied regarding the prevalence of aorto-iliac diseases, acute abdomen and abdominal cancer.

RESULTS

The forensic autopsy rates in the population during the two time periods were 14.0% (29 399 patients) and 5.3% (4487 patients), respectively. The total prevalence of surgical diseases has increased significantly from 67.3 (95% confidence interval 64.3-70.2) to 83.4 (74.9-91.8) per 1000 autopsies, respectively. The cause-specific mortality ratios in patients with fatal acute abdomen increased significantly from 16.5 (15.1-18.0) to 39.0 (33.2-44.8) per 1000 autopsies, respectively, and there was almost a three-time increase in patients with fatal gastrointestinal haemorrhage and acute alcohol-related pancreatitis.

CONCLUSION

Forensic autopsy data continues to be invaluable, despite changes in legislation in Sweden, for epidemiological studies on fatal or potential fatal surgical diseases.

Internal iliac artery pseudoaneurysm following renal transplant biopsy successfully treated with endovascular stenting and thrombosis: a case report

A 49-year-old man underwent living donor renal transplantation in November 2005. The transplant renal artery was anastomosed to the right internal iliac artery with an end-to-end anastomosis. The patient achieved immediate graft function and the allograft was normally perfused. Seven weeks later, renal allograft function deteriorated with a serum creatinine level increased to 244 micromol/L. An ultrasound scan revealed adequate perfusion to the kidney and the absence of hydronephrosis. A transplant biopsy revealed Banff IB rejection, which was treated with high-dose prednisolone. Following biopsy, the patient's renal function rapidly deteriorated with a serum creatinine level increased to 627 micromol/L, requiring hemodialysis. A computed tomography (CT) angiogram demonstrated a 6-cm diameter pseudoaneurysm arising from the internal iliac artery with absence of kidney perfusion. The aneurysm was accessed percutaneously with a 4-F catheter and 1000 U of human thrombin injected, resulting in partial thrombosis of the pseudoaneurysm. A balloon expandable covered metal stent was then placed across the site of the transplant renal artery anastomosis, resulting in successful occlusion of the aneurysm. Intrarenal blood flow was established by dilating 2 intrarenal branches with 3-mm diameter balloons. The serum creatinine level started to decrease within 24 hours of the procedure and renal function improved rapidly to a level achieved immediately after transplantation. Three months later the patient had a well-functioning allograft with a serum creatinine level of 176 micromol/L, follow-up CT scan demonstrated good perfusion of the transplanted kidney with no further change in the pseudoaneurysm. At 12 months follow-up the patient remains with a well-functioning allograft.

Bilateral Dissection of External Iliac Artery

External iliac artery (EIA) dissection and especially bilateral involvement is very rare. We report the case of a 49-year-old male intense bicyclist who had presented a dissection of the left EIA responsible for claudication. He underwent an iliofemoral vein graft bypass. The histopathologic examination showed a dissection of the EIA with an otherwise normal arterial wall. Two years after he resumed his sporting activity, a dissection of the right EIA occurred with the onset of claudication. The patient underwent a right iliofemoral vein graft bypass. Histopathologic examination showed the same lesions as on the left side. Bilateral involvement of EIA dissection is possible especially when the mechanism leading to dissection is persistent. An attentive follow-up is thus to consider.

Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair

BACKGROUND

Multiple strategies have been devised to extend the applicability of endovascular aneurysm repair (EVAR) in patients with common iliac artery (CIA) aneurysms. This study was designed to examine outcome in patients undergoing EVAR with either hypogastric artery embolization or common iliac artery bifurcation advancement by hypogastric bypass.

METHODS

A retrospective review of all patients undergoing EVAR since the inception of our program (1997-2006) was performed. Data were prospectively collected in an EVAR registry. Patients with large common iliac artery aneurysms (> or = 20 mm) and patent hypogastric arteries not amenable to a cuff or "bell bottom" technique were treated with coil embolization (EMBO) and/or hypogastric revascularization (BYPASS). The perioperative and mid-term outcomes were compared with the larger group of patients undergoing EVAR that did not require either treatment (CTRL). Bilateral common iliac artery aneurysms were treated with unilateral coil embolization and contralateral bypass.

RESULTS

Common iliac artery aneurysms were present in 137 (31%) of the 444 patients undergoing EVAR, but only 57 (42%) of 137 required direct management. This included hypogastric artery embolization alone (EMBO) in 31 or hypogastric artery revascularization (BYPASS) in 26, with and without contralateral embolization (both revascularization/embolization in 46%). The procedure length (CTRL, 159 +/- 72 minutes; EMBO, 153 +/- 39 minutes; BYPASS, 283 +/- 75 minutes) and estimated blood loss (CTRL, 251 +/- 313 mL; EMBO, 233 +/- 158 mL; BYPASS, 400 +/- 287 mL) were significantly greater (P < .05) in the BYPASS group. The incidence of any postoperative complication (CTRL, 26%; EMBO, 68%; BYPASS, 54%), any ischemic complication (CTRL, 6%; EMBO, 55%; BYPASS, 27%), and new-onset buttock claudication (CTRL, 3%; EMBO, 39%; BYPASS, 27%) were all significantly greater in the BYPASS and EMBO group relative to the control (CTRL) group (n = 387). The incidence of new-onset buttock claudication ipsilateral to the hypogastric bypass was 4%; the balance of the new onset claudication in the BYPASS group was due to the contralateral embolization. The primary hypogastric artery bypass patency was 91 +/- 11% (SE) at 36 months by life-table analysis.

CONCLUSIONS

Despite its increased complexity, hypogastric artery bypass is an excellent alternative to embolization in terms of patency and freedom from ischemic symptoms for patients with large common iliac artery aneurysms undergoing EVAR.

[Acute limb ischemia as first symptom by contained ruptured pseudoaneurysm of an undifferentiated high grade pleomorphic sarcoma of the arteria iliaca externa]

Primary malignant vascular tumors represent a rare cause of acute extremity ischemia. Due to unspecific symptoms the correct diagnosis is often delayed and confirmed in many cases as late as post mortem. Differential diagnosis of malignant vascular tumors should be considered in patients with acute ischemia, atypical history and absence of typical risk factors for vascular diseases. The overall prognosis of such tumors is poor. If possible, complete curative resection in combination with arterial reconstruction should be performed. Multimodal therapy has to be considered and discussed in appropriate tumor boards. We report a case of a 70-year-old male patient with acute ischemia and contained rupture of a pseudoaneurysm of the external iliac artery due to an undifferentiated high grade pleomorphic sarcoma. At the time of the primary operation, diffuse skeletal metastases were present but even detected postoperatively during staging. Therefore, no adjuvant or palliative therapy was initiated. In the postoperative course, recurrent non reversible ischemia was present followed by amputation of the right leg. The patient died 5 months after first operation. In the autopsy further metastases of lung and liver were found.

Simultaneous surgical treatment of abdominal aortic aneurysm and bilateral aneurysms of the internal iliac artery

INTRODUCTION

The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AAA) and aneurysms in both the internal iliac arteries (IIA) at the same time.

METHODS

Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or -bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurysmorraphy.

RESULTS

No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from 'trash foot', which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia.

CONCLUSIONS

Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.

EndoFit Stent-Graft Repair of Isolated Common Iliac Artery Aneurysms With Short Necks

PURPOSE

To evaluate the feasibility and efficacy of repairing isolated iliac artery aneurysms with short proximal necks (<10 mm) by implanting the EndoFit stent-graft.

METHODS

Seven patients (6 men; median age 73 years, range 70-78) were diagnosed with an isolated common iliac artery (CIA) aneurysm that featured a short proximal landing zone, complicating endovascular treatment. The median aneurysm diameter was 4.4 cm (range 3.5-7.0), and the median proximal neck length was 7 mm (range 5-9).The aneurysms were treated using the EndoFit stent-graft, which can be deployed in a short proximal landing zone. The modified technique involves the deployment of the graft directly above the aneurysm sac without obstructing the contralateral iliac axis, thus affixing the bare proximal stent in the terminal aorta. Follow-up was performed by clinical evaluation and computed tomography at 1, 6, and 12 months postoperatively.

RESULTS

The EndoFit stent-graft was successfully deployed in all cases, with complete aneurysm exclusion. In 1 case, the deployment of a second cuff was necessary to secure complete aneurysm exclusion. The median follow-up was 18 months, during which no deaths occurred, and no endoleak or stent-graft migration was observed. Endograft thrombosis occurred in 1 case due to graft angulation caused by external iliac artery stenosis and kinking. None of the aneurysms has ruptured, and there have been no serious complications.

CONCLUSION

Direct endoluminal repair of isolated CIA aneurysms with short proximal necks is feasible using this technique. Efficacy and long-term results are to be confirmed by larger scale series over a long time period.

Absence of Buttock Claudication Following Stent-Graft Coverage of the Hypogastric Artery Without Coil Embolization in Endovascular Aneurysm Repair

PURPOSE

To evaluate the safety and efficacy of stent-graft coverage of the hypogastric artery origin without coil embolization during endovascular treatment of aortoiliac or iliac aneurysms.

METHODS

A retrospective study was conducted of patients who underwent endovascular aneurysm repair with endograft coverage of the hypogastric artery between September 2001 and September 2005. Among the 88 patients who underwent EVAR during the study period, 21 patients (19 men; mean age 77+/-6 years, range 67-86) had unilateral hypogastric artery coverage without coil embolization. Aneurysmal arteries included 11 aortoiliac, 8 isolated common iliac arteries (CIA), and 2 isolated hypogastric arteries. Preoperative AAA size was a mean 57 mm (range 46-73), and mean CIA aneurysm diameter was 36 mm (range 17-50). All covered hypogastric arteries were patent prior to the procedure. The stent-grafts implanted were 10 Excluder, 10 AneuRx, and 1 Zenith. Clinical outcome focused on mortality and morbidity, including the occurrence and duration of new-onset buttock claudication, which was further correlated with superior gluteal and profunda femoris artery patency.

RESULTS

Immediate seal was achieved in all patients. Mean follow-up was 16 months (range 1-54). No type I endoleaks developed from the aortic or external iliac artery, and no type II endoleaks were found from the origin of the hypogastric artery. New-onset buttock claudication occurred in 2 (9.5%) patients, but resolved in both within 4 months. No additional secondary procedures, aneurysm rupture, or aneurysm-related death occurred.

CONCLUSION

Stent-graft coverage of the orifice of the hypogastric artery without coil embolization is a safe and effective adjunct during the treatment of aortoiliac or iliac aneurysm, with a low incidence of buttock claudication.

Total videoscopic iliac artery aneurysm repair

We report a case of totally videoscopic iliofemoral bypass to treat an isolated iliac artery aneurysm. Both iliac and femoral approaches and anastomoses were performed under videoscopic control. This intervention allowed us to obtain the well-known long term results of conventional iliac artery aneurysm repair while reducing operative trauma.

Coexistence of cystic medial necrosis and segmental arterial mediolysis in a patient with aneurysms of the abdominal aorta and the iliac artery

Segmental arterial mediolysis is an unusual arterial lesion for which pathogenesis has remained controversial. We report on a 47-year-old Japanese woman who underwent surgery for an abdominal aortic aneurysm that was 10.5 cm in diameter and contiguous with a left common iliac aneurysm that was 2.3 cm in diameter; the aneurysms were considered to have progressed rapidly in size. Pathologic examinations of the respective aneurysms showed cystic medial necrosis in the aortic and segmental arterial mediolysis in the iliac aneurysm. Coexistence of these two pathologic findings indicates that there may be a strong relation between these two disease entities.

Inflammatory solitary iliac artery aneurysms: a report of two cases

Inflammatory abdominal aortic aneurysms are associated with atherosclerosis, which are characterized by specific clinical manifestation. We treated two patients with unilateral solitary iliac artery aneurysms with perianeurysmal fibrosis which compressed the ureter resulting in ipsilateral hydronephrosis. After the iliac artery aneurysm was repaired with a prosthetic graft, the hydronephrosis resolved. Microscopically, there was clear evidence of atherosclerosis in one case. There was a characteristic inflammatory reaction around the adventitia in both aneurysms. Localized iliac perianeurysmal fibrosis has not been particularly described. The clinicopathologic similarities between these cases and inflammatory abdominal aortic aneurysms suggest the same pathogenesis.

Common iliac artery aneurysm due to fibromuscular dysplasia in infants

A seven-month old female with a huge aneurysm of the right common iliac artery and multiple stenoses of her bilateral renal arteries is described. At surgery, a Gore-Tex graft was interposed between the proximal common iliac artery and the external iliac artery. A histological examination of the aneurysmal wall was compatible with medial fibromuscular dysplasia (FMD). After surgery, her blood pressure was controlled in the normal range on medical treatment. This case would be the first case of a huge common iliac artery aneurysm due to FMD in infants.

Diameter changes in isolated iliac artery aneurysms 1 to 6 years after endovascular graft repair

OBJECTIVE

Precise diameter changes in iliac artery aneurysms (IAAs) after endovascular graft (EVG) repair are yet to be determined. This report describes the midterm size changes in isolated IAAs 13 to 72 months after treatment with an EVG.

METHODS

From January 1993 to April 1999, 31 patients with 35 true isolated IAAs (32 common iliac and 3 hypogastric) had these lesions treated with EVGs and coil embolization of the hypogastric artery or its branches. The EVG used in this study consisted of a balloon-expandable stent attached to a polytetrafluoroethylene graft. Contrast-enhanced spiral computed tomographic scans were performed at 3- to 6-month intervals to follow the aneurysms for change in diameter and endoleaks.

RESULTS

Thirty patients had a decrease in the size of their iliac aneurysms with EVG repair. All EVGs remained patent. All patients, except for one, were followed up for 13 to 72 months (mean, 31 months). The pretreatment aneurysm size ranged from 2.5 to 11.0 cm in diameter (mean, 4.6 +/- 1.62 cm). After EVG treatment, the aneurysms ranged from 2.0 to 8.0 cm in diameter (mean, 3.8 +/- 1.36 cm). The change in aneurysm diameter ranged from 0.5 to 3.1 cm (mean, 1.1 +/- 0.62 cm) with an average change of -0.516 +/- 0.01 cm/y for the first year. Five patients died of their intercurrent medical conditions during the follow-up period. One of the patients had a new endoleak and an increase in common iliac aneurysm size 18 months after EVG treatment, despite an early contrast-enhanced computed tomographic scan that showed no endoleak. This patient's aneurysm ruptured, and a standard open surgical repair was successfully performed. Another patient had a decrease in hypogastric aneurysm size after EVG treatment and no radiographic evidence of an endoleak, but eventually the aneurysm ruptured. He was successfully treated with a standard open surgical repair.

CONCLUSIONS

EVGs can be an effective treatment for isolated IAAs. Properly treated with EVGs, IAAs decrease in size. The enlargement of an IAA, even if no endoleak can be detected, appears to be an ominous sign suggestive of an impending rupture. IAAs that enlarge should be closely evaluated for an endoleak. If an endoleak is detected, it should be eliminated if possible. If an endoleak cannot be found, open surgical repair should be considered.

Three-dimensional contrast-enhanced moving-bed infusion-tracking (MoBI-track) peripheral MR angiography with flexible choice of imaging parameters for each field of view

A technique to image peripheral arteries with flexible choice of scan parameters for separate stations was developed based on moving-bed single-bolus three-dimensional gradient-recalled echo magnetic resonance angiography. A volunteer study yielded higher signal- and contrast-to-noise ratios, less venous enhancement, and better subjective interpretability compared with imaging with fixed parameters for each station. Additionally, six patients were imaged to test the feasibility of the new method in a clinical setting. Imaging peripheral arteries with the new technique in volunteers yielded better image quality and is feasible for patients.

Covered stent implantation by the puncture method for the treatment of a small aneurysm of the common iliac artery

A method to repair endovascular aneurysms with covered stents has recently been developed. In the present paper, the implantation of a covered stent through a 12Fr sheath by the puncture method for the treatment of an isolated aneurysm of the right common iliac artery is reported. The aneurysm was less than 3 cm in diameter, and computed tomography showed no signs of aneurysm rupture, but the patient nonetheless complained of right lower abdominal pain and constipation. It was decided to implant a covered stent in lieu of surgical repair because it was difficult to prove a causal relationship between the aneurysm and the patient's complaints. Fortunately, after implantation, the symptoms were resolved. In conclusion, it is possible to choose this less invasive type of therapy for the treatment of an isolated iliac artery aneurysm if the patient complains only of general malaise and there are no certain signs of an impending rupture, although surgery should be indicated regardless of aneurysm size.

Persistent sciatic artery: report of an original aneurysm-associated case

Persistent sciatic artery (PSA) is a rare embryologic abnormality and can sometimes be bilateral. It may be discovered because of a gluteal aneurysm or ischemic or embolic complications in the lower limb. The case we report was a unilateral type III aneurysm-associated PSA. Since the abnormal artery may be the only source of blood supply to the lower limb, a thorough knowledge of the artery and its embryologic origins is essential.

Isolated iliac artery aneurysms with associated hydronephrosis

An isolated iliac artery aneurysm is where there is aneurysmal dilatation of one or more branches of the iliac system, with no associated dilatation of the aorta. Such aneurysms are rare and comprise 1% of all intra-abdominal aneurysms. The signs and symptoms of such an aneurysm are influenced by its concealed location within the bony pelvis. Awareness of these special characteristics improves the chances of early diagnosis and proper treatment before possible rupture. We present the clinical and radiological features of three such aneurysms. Ultrasound was the first imaging modality to be performed. Ipsilateral hydronephrosis was demonstrated in each case, this lead to imaging the pelvis and the correct diagnosis. We review the clinical and radiological literature and conclude that the pelvis should be imaged in all cases of unexplained hydronephrosis.

Grossly punched-out lesions in the aorto-iliac region can be histologically classified as false, pseudo-false, or disguised aneurysm

Aneurysms are morphologically classified as true or false based on the nature of their walls. True aneurysms are composed of all or parts of layers of the vessel. False aneurysms are the result of rupture and their walls have only fibrous tissues. The orifice of false aneurysms is narrow relative to the aneurysmal diameter and thus they are grossly or angiographically referred to as punched-out lesions. Hence false aneurysms present with punched-out lesions, but in reverse, are all of punched-out lesions false aneurysms? We experienced some cases of punched-out lesions which histologically contained traces of elastin, and the purpose of this report was to histologically investigate grossly punched-out lesions. We examined 671 elderly autopsy cases, and a total of 21 grossly punched-out lesions in the aorto-iliac region were selected. They were histologically classified as false, "pseudo-false", or "disguised" aneurysm. False aneurysms were found in 3 patients (0.45%), and were histologically mycotic. A total of 5 "pseudo-false" aneurysms were found in 3 patients (0.45%). They histologically contained traces of elastin, and thus they were categorised in true aneurysms. A total of 13 "disguised" aneurysms were found in 6 patients (0.89%). They were true fusiform aneurysms with an eccentric thrombus, on which a fibrin-cap formed a narrow orifice. Partial sections are insufficient for diagnosis; cross-sections are necessary. To the best of our knowledge, there have been no reports of "pseudo-false" or "disguised" aneurysms in the aorto-iliac region.

Morphologic assessment of abdominal aortic aneurysms by spiral computed tomographic scanning

PURPOSE

The aim of this study was to seek a relationship between the morphologic features of abdominal aortic aneurysms and the feasibility of endoaortic grafting.

METHODS

Between June 1995 and January 1996, 86 patients were prospectively studied with contrast-enhanced spiral computed tomographic scans, which provided 35 parameters concerning the aorta and iliac arteries. Four groups were established according to the diameter of abdominal aortic aneurysms: group A, 40 to 49 mm, 36 patients; group B, 50 to 59 mm, 26 patients; group C, 60 to 69 mm, 10 patients; and group D, greater than 70 mm, 14 patients.

RESULTS

There was a correlation between the diameter and length of the aneurysm (p < 0.0001) and between aneurysm diameter and length of the proximal neck (p < 0.001). Presence of a proximal neck or a distal neck was more frequent in groups A and B than in groups C and D (p < 0.01). The feasibility of endovascular grafting was estimated at between 50% and 61.6% and was higher in groups A and B than in groups C and D (p < 0.01).

CONCLUSIONS

This study has shown an inverse relationship between the diameter of the aneurysm and the length of the aortic neck (correlation coefficient, -0.3640, p < 0.001). The diameter of an aneurysm was the most useful of the 31 parameters measured in predicting the feasibility of endoaortic grafting, estimated at 71% for aneurysms less than 60 mm in diameter and 37.5% for aneurysms greater than 60 mm in diameter (p < 0.01).

Arteriomegaly and inflammatory abdominal aortic aneurysm. Case report

In this case report inflammatory abdominal aortic aneurysm (IAAA) was superimposed on an arteriomegaly condition complicated by bilateral aneurysm of the common iliac arteries. Obstruction of the right ureter, mild hydronephrosis of the left system and a slight impairment of renal function were also present. Preoperative cellular and humoral immunological parameters were within normal limits while the erythrocyte sedimentation rate (ESR) was elevated (74 mm). Histological analysis showed numerous scattered lymphoid cells or organized in follicles with germinal centers within the adventitial thickening of the IAAA wall. Immunohistochemical analysis on frozen sections demonstrated that dispersed and perivascular lymphoid cells were mainly composed of similar amounts of CD3+/CD4+ and CD3+/CD8+ T lymphocytes. Histological analysis of the common iliac artery aneurysm showed a mild intimal thickening will small aggregates of macrophages. After aneurysm repair all peripheral blood analysis normalized within one month after surgery. The IAAA observed in our patient with arteriomegaly as underlying arterial disease cannot be interpreted as an inflammatory variation of an atherosclerotic aneurysm. The histological pattern of the inflammatory reaction and its resolution after surgery give, in our opinion, more credit to the etiopathogenetic hypothesis of a reaction elicited by an antigen within the arterial wall of the infrarenal aorta which might be enhanced by the lymphatic stasis subsequent to aneurysm compression.

Arterial dissections associated with pregnancy

Two cases of spontaneous arterial dissection occurring in young, multiparous women shortly after delivery of uncomplicated pregnancies are described. Histologic analysis of arterial tissue samples obtained in both cases at points near and remote from the dissection sites shows evidence of significant arterial degeneration and loss of integrity, with changes similar to those observed in pregnant women, women using oral contraceptives, and animals given female sex hormones. The types of arterial lesions associated with pregnancy and their sites of predilection and the etiologic roles of the hemodynamic stresses of pregnancy and hormones are discussed.

[Rupture of an external iliac artery aneurysm into the bladder: a case report and review of the literature]

A case of fatal hemorrhage caused by rupture of the external iliac artery aneurysm into the urinary bladder is presented. The patient, a 58-year-old Japanese female, had undergone total hysterectomy, and post-operative therapeutic radiation, for uterine cancer in 1974. A vesicocecal fistula was observed, and surgical intervention for closure was performed in May, 1992. On July, 13, 1992, she presented with pulsating hemorrhage from the urinary bladder. Angiography was consistent with rupture into the bladder of an iliac artery aneurysm. Surgical intervention for closure of the aneurysm was performed but the aneurysm could not be resected. She had relapse of the fistula which became infected with methicillin-resistant Staphylococcus aureus (MR-SA), and died 3 months postoperatively. To the best of our knowledge, there have been only 3 cases in which an iliac artery aneurysm ruptured directly into the urinary bladder. This case indicates that resection of the aneurysm for therapy is a vital requirement.

Endoluminal aortic aneurysm repair using a balloon-expandable stent-graft device: a progress report

We describe our experience with endoluminal repair of abdominal aortic aneurysms using the stent-graft device. Twenty-four patients underwent 25 procedures in the 27-month period ending December 31, 1992. Twenty-one of the patients were considered high-risk candidates for conventional surgical repair. The endoluminal stented grafts were aortoaortic in 16 procedures and unilateral aortoiliac in eight. One patient underwent a second procedure consisting of an ilioiliac graft to repair a separate common iliac artery aneurysm. Technical problems were primarily related to retrograde transluminal access across the iliac arteries, tortuous aneurysms, and misjudgments as to measurement of length. One patient died and another required secondary deployment of a distal stent at 4 months; subsequent aneurysm expansion mandated surgical replacement at 18 months. It is clear that this device and methodology will have to undergo further refinement before the technique is acceptable for wider clinical application. Current experience, however, is encouraging. Aneurysm exclusion with an endoluminal prosthesis is likely to become an important therapeutic alternative over the next several years.