Distal Embolization and Proximal Stent-Graft ...

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that the superior gluteal artery (SGA) is involved more often than the inferior. De- spite the .... ways between the gluteal, lumbar, sacral, and rectal ar- teries.
Case Reports

Distal Embolization and Proximal Stent-Graft Deployment A Dual Approach to Endovascular Treatment of Ruptured Superior Gluteal Artery Aneurysm

Germano Melissano, MD Massimo Venturini, MD Domenico Baccellieri, MD Fabio Calliari, MD Alessandro Del Maschio, MD Roberto Chiesa, MD

Key words: Aneurysm/ etiology/therapy; aneurysm, false/complications/ultrasonography/therapy; blood vessel prosthesis implantation; buttocks/blood supply; combined modality therapy; embolization, therapeutic/ methods; stents From: Departments of Vascular Surgery (Drs. Baccellieri, Calliari, Chiesa, and Melissano) and Radiology (Drs. Del Maschio and Venturini), Scientific Institute H. San Raffaele, “Vita-Salute” University School of Medicine, 20132 Milan, Italy Address for reprints: Germano Melissano, MD, Scientific Institute H. San Raffaele, Via Olgettina 60, 20132 Milan, Italy E-mail: [email protected] © 2008 by the Texas Heart ® Institute, Houston

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Aneurysmal disease of the hypogastric branches is rare; it may be life-threatening, and the treatment is often challenging. Herein, we report the case of an 81-year-old man with arterial hypertension, obesity, renal insufficiency, and psychiatric disorders who was emergently admitted for a symptomatic ruptured aneurysm of a hypogastric arterial branch, as seen on magnetic resonance angiography. Endovascular treatment was performed by means of a dual approach: distal embolization with microspheres and Gianturco coils, followed by proximal complete exclusion via deployment of a stent-graft in the common iliac artery. The outcome was favorable, with complete exclusion of the aneurysm and normalization of renal function. Endovascular treatment with distal embolization and proximal stent-graft release can be safe and effective, and the technique can be used in emergency circumstances with good morphologic and clinical results. (Tex Heart Inst J 2008;35(1):50-3)

solated aneurysms of the gluteal artery constitute fewer than 1% of all aneurysms. Most are pseudoaneurysms. Causes include penetrating or blunt trauma to the buttocks, atherosclerosis, polyarteritis nodosa, infection, and persistent sciatic artery.1 The true incidence is unknown; a 1995 survey of the medical literature reported just over 140 gluteal artery aneurysms.1 In 1965, Smyth and colleagues2 observed that the superior gluteal artery (SGA) is involved more often than the inferior. Despite the lesion’s location in the iliac fossa and the small size of a normal gluteal artery, these aneurysms can become large enough to cause symptoms through compression and displacement of adjacent structures. The treatment most commonly reported in the English-language medical literature is surgical repair; however, several reports have shown the effectiveness of transcatheter embolization3,4 or transcatheter direct puncture and embolization, this last by ultrasonographic guidance.5 Of 5 reported cases of ruptured SGA aneurysms, 3 were treated through an endovascular approach.6-8 Herein, we report the case of an 81-year-old man who was emergently admitted for anuria and hypogastric pain. His diagnosis and treatment are described; a discussion of other treatments is included.

Case Report In May 2006, an 81-year-old man with a history of arterial hypertension, obesity, renal insufficiency, contracted left kidney, and psychiatric disorders was admitted to the emergency room in stable cardiovascular condition for investigation of anuria and hypogastric pain. The clinical examination showed abdominal globosity that was associated with tenderness in the right hypogastrium. On the patient’s admission to the hospital, blood tests showed an increased serum creatinine level of 6.2 mg/dL, a urea level of 167 mg/dL, and a potassium level of 5.51 mEq/L. The patient’s hemoglobin level was 14 g/dL on admission and 10 g/dL 3 hours later. Duplex ultrasonographic scanning showed a large arterial dilation but did not effectively clarify its size or shape. Magnetic resonance imaging (Figs. 1 and 2) revealed a very large pseudoaneurysm of the right SGA (8.5 × 9 cm), with an anterolateral area of contained rupture and a prevesical hematoma (7 cm). Pyelic dilation and urethral compression were also

Endovascular Treatment of Superior Gluteal Aneurysm

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observed. The aorta and iliac arteries were normal. In consideration of the patient’s poor general condition, old age, obesity, and psychiatric disorders, endovascular treatment was planned to exclude the ruptured aneurysm with minimal invasiveness. The patient was immediately transferred to the operating room, and the procedure was carried out with a

Fig. 1 Magnetic resonance imaging shows an aneurysm of the right superior gluteal artery (arrow) and an anterolateral area of contained rupture and prevesical hematoma (arrowheads).

Fig. 2 Magnetic resonance angiography shows an aneurysm of the right superior gluteal artery (asterisk) that is directly perfused by the right hypogastric artery (arrow).

Texas Heart Institute Journal

portable C-arm (Moonray VE-R, Simad Medical Technology; Mirandola, Italy). Via a percutaneous right femoral approach, an 8F introducer sheath was positioned in the right iliac axis, and a Simmons catheter was used to selectively catheterize the ipsilateral hypogastric artery. After the positioning of a 6F, 55-cm guiding catheter (Mach 1, Boston Scientific Corporation; Natick, Mass) in the internal iliac artery, the efferent branches of the aneurysm were embolized by use of 350- to 710-µm Contour SE microspheres (Boston Scien­tific), which were released through a 5F Bernstein catheter. Then, three 5- to 8-mm Gianturco coils (Boston Scientific) were released in the efferent branches; 1 coil was accidentally released in the aneurysmal sac; and a larger, 5th coil was delivered in the afferent branch. Fluoroscopy showed the intrasac coil “dancing” inside the aneurysm. Of interest, after the release of the coil in the afferent branch, the movements of the intrasac coil stopped, and selective angiography confirmed substantial flow reduction in the aneurysm. The 2nd step was complete exclusion of the hypogastric artery by use of an Excluder contralateral-limb stent-graft (16 × 16 × 70 mm, W.L. Gore & Associates, Inc.; Flagstaff, Ariz), which was percutaneously positioned in the iliac axis through a 12F sheath and released with success. Final angiographic evaluation confirmed the complete exclusion of the right hypogastric circle and successful treatment of the aneurysm (Fig. 3). During the perioperative period, blood tests showed a substantial increase of creatine kinase to 11,373 U/I and lactate dehydrogenase to 834 U/L, and the patient experienced pain in the buttocks. On postoperative day 6, decreased levels of serum creatinine (1.18 mg/dL) and

Fig. 3 Final angiography shows successful treatment of the right hypogastric artery and exclusion of the aneurysm. Gian­ turco coils were released during the procedure into the afferent and efferent branches (arrowheads) and inside the aneurysm (arrow).

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Fig. 4 Magnetic resonance angiography at 6-month follow-up shows the hypogastric artery exclusion by stent-graft (bracket) with successful treatment of the aneurysm.

urea (70 mg/dL) were recorded, along with normalization of the blood potassium levels. The patient was discharged on postoperative day 7, asymptomatic and with complete normalization of creatine kinase and lactate dehydrogenase levels. Six months later, he was well, and ultrasonography showed persistent exclusion of the aneurysm with normal patency of the iliofemoral arteries. Magnetic resonance angiography confirmed satisfactory placement of the stent-graft with internal iliac artery and aneurysmal exclusion (Fig. 4). A companion drawing (Fig. 5) illustrates the dual endovascular techniques.

Discussion Superior gluteal artery aneurysm was first described in 1898; it was treated surgically with a proximal arterial ligation.9 Since then, more than 140 SGA aneurysms have been reported; treatment has been by means of different methods and approaches.1 Elective treatment is recommended for aneurysms with diameters larger than 25 mm; such aneurysms are often asymptomatic. When an aneurysm reaches a diameter of 50 to 60 mm, symptoms become common due to compression of pelvic structures: there can be venous obstruction, neuro52

Endovascular Treatment of Superior Gluteal Aneurysm

Fig. 5 Technique used for the double endovascular approach. The endograft was deployed in the right iliac branch to exclude hypogastric circulation; Gianturco coils were delivered into the aneurysm’s branches (arrowheads) and inside the aneurysm (black arrow); and microspheres (gray arrows) were released into the efferent branches to occlude peripheral collateral circulation.

logic compression with radicular pain or numbness, and urologic symptoms with the possibility of renal failure and intestinal compression. A posterior surgical approach is technically demanding. The dissection between the gluteus maximus and the gluteus medius is difficult, with the risk of sciatic nerve injury, muscular necrosis, and problems in controlling massive hemorrage.3 Whereas some authors have proposed surgical ligation of the hypogastric artery via an extraperitoneal approach, Burchell10 showed that ligation of the hypogastric artery resulted in only a 50% decrease in efferent flow because of collateral pathways between the gluteal, lumbar, sacral, and rectal arteries. A direct surgical approach that involves proximal ligation of the aneurysm’s neck and endoaneurysmorraphy with internal interruption of collateral branches is accepted as an effective method of repair.11 Although this technique prevents the refilling of the sac by collateral vessels and completely resolves compressive symptoms, several reports of surgical treatment of iliac aneurysm showed an increased mortality risk, with various rates Volume 35, Number 1, 2008

from 0 to 10%.12-14 Other authors, however, have reported the disappearance of compressive symptoms after the embolization of a large hypogastric aneurysm15-17; de Medici and colleagues15 recommended endovascular treatment of aneurysms that are less than 50 mm in diameter or asymptomatic, especially in high-risk patients. The approach, via a contralateral femoral artery to enable selective embolization of hypogastric aneurysms, is derived from a technique that was developed to prevent type-2 endoleak of the hypogastric artery during aortic endografting.15 Endovascular therapy of the SGA has been reported in 7 patients1 (5 cases of transcatheter embolization,4,6-8,18 1 of selective embolization followed by surgery,19 and 1 of intraluminal thrombosis achieved by 48 hours of balloon occlusion).20 Isolated embolization is indeed often insufficient. All collateral vessels and branches need to be treated selectively in order to achieve complete thrombosis. Coils of various diameters and inflatable balloons have been used with differing outcomes. Vasseur and associates3 have confirmed high rates of failure when aneurysms were large. In our patient, the embolization with microspheres and coils was performed in order to achieve superselective microembolization and thrombosis of collateral arteries, in order to prevent refilling of the sac. The ipsilateral percutaneous approach enabled subsequent deployment of the endograft in order to produce complete proximal hypogastric exclusion, effective pressurereduction in the pelvic arteries, and optimal treatment of the aneurysm. Intraoperatively, we decided not to perform contralateral hypogastric selective angiography. We wanted to avoid excessive administration of contrast media in a patient who had acute renal insufficiency and to avoid prolonging the procedure in an acute setting. The patient’s buttocks pain and muscle-enzyme increase, secondary to embolization of the microcirculation, was not followed by serious ischemic complication. The restoration of pelvic circulation reduced compression on the ureter and enabled improvement of renal function. A possible alternative treatment can be the selective cannulation of each branch of the right internal iliac artery followed by coil embolization. This treatment potentially averts ischemia and prevents massive embolization of the terminal branches of the internal iliac artery. In conclusion, the possibility of gluteal artery aneurysms should be considered during the diagnosis of a pelvic mass. Endo­vascular treatment with transcatheter or percutaneous embolization has been recognized as an alternative to surgery in treating these lesions. The case of our patient has shown that endovascular treatment with distal embolization and proximal stent-graft deployment can be safe, effective, and useful in emerTexas Heart Institute Journal

gency circumstances with good morphologic and clinical results.

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