Transgluteal approach to hypogastric artery aneurysm type II endoleak

Abstract

An enlarging internal iliac artery aneurysm secondary to a type II endoleak after endovascular aortic repair is an uncommon entity. It carries a significant rupture risk and mortality if not addressed. The present patient had had a 6.8-cm, rapidly growing, excluded hypogastric aneurysm. The results included both a failed transarterial approach and successful percutaneous transgluteal internal iliac artery aneurysm embolization using XperCT software (Philips Healthcare, Andover, MA) for guidance. The salient points included that treatment of the "nidus" alone will not be sufficient for complete endoleak embolization, the use of direct endoleak sac angiography might better delineate the inflow and outflow dynamics than conventional transarterial angiography, and XperCT guidance (Philips Healthcare) can facilitate complex endoleak access.

Keywords: Endovascular aortic repair; Hypogastric aneursym; Iliac artery aneurysm; Transarterial angiography; Type II endoleak.

Fig 1

Axial computed tomography angiography (CTA) of the pelvis showing a large endoleak in the posterior left hypogastric aneurysm sac with superior gluteal artery outflow (arrow).

Fig 2

Angiogram of the left common femoral artery obtained via contralateral right groin access showing a large collateral pathway supplying the hypogastric aneurysm endoleak with deep circumflex to iliolumbar artery inflow (dashed arrow). The obturator artery served as outflow (straight arrow).

Fig 3

Angiogram of the left deep circumflex artery after glue embolization showing that glue had occluded several deep circumflex to iliolumbar collateral arteries (arrow), with a small amount of glue in the aneurysm sac. However, the endoleak pathway remained intact.

Fig 4

Percutaneous transgluteal access approach. A, Axial non–contrast-enhanced computed tomography showing percutaneous transgluteal approach adjacent to the ischium and avoiding the sciatic neurovascular bundle. B, Initial angiogram showing large endoleak cavity with outflow via the superior gluteal and obturator arteries.

Fig 5

Angiogram showing large Onyx cast filling most of the endoleak cavity, with continued outflow through the superior gluteal artery. Subsequently, the inflow iliolumbar artery and outflow superior gluteal arteries were embolized with glue.