PMC5424651_01
Ultrasound (US) image (oblique para-sagittal plane) showing an anechoic, eccentric, large sac clearly communicating with the lumen of the grafted left external iliac artery. The finding is consistent with a para-anastomotic pseudoaneurysm.
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The leakage involved both the internal and the external left iliac artery and it was detected during a routine ultrasound (US) examination (Figure 1) performed after a long time with no follow-up during which no claudication, limb ischemia nor any other symptoms were referred.
CT-Angiography image (shaded surface rendering) showing a large false aneurysm involving both the left iliac branches which are less opacified due to contrast media leakage into the sac. The CT-A also demonstrates kinking of the vessels upstream of the pseudoaneurysm.
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The scan confirmed the ultrasound findings (Figure 2), showing a 55-mm-sized pseudoaneurysm encasing both the internal and external left iliac artery on their prosthetic anastomoses.
Pre-procedural Digital Subtraction Angiography (DSA), confirming CT-A findings and demonstrating a pseudoaneurysm on the left side with clear communication with both the iliac arteries. The complex anatomy of the upstream vessels on the left and a proximal occlusion of the right hypogastric artery are also shown.
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After the retrograde approach, (6F Destination peripheral guiding sheath, Terumo) we performed a diagnostic aortography that confirmed a communication of the pseudoaneurysm at the distal anastomoses with the lumen of both the left iliac arteries, as suspected after angio-CT (Figure 3).
A DSA image during the procedure showing a vascular plug inside the proximal segment of the left internal iliac artery. Note the retrograde navigation of the device through the external artery and the pseudoaneurysmal sac, confirming the communication of both the branches with the leakage.
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Initially, systemic heparinization was induced and a 9x12 mm vascular plug (Amplatzer Vascular Plug II) was deployed via the retrograde left femoral access, navigating from the external iliac artery through the pseudoaneurysm (Figure 4).
Post-procedure DSA image demonstrating a complete exclusion of the pseudoaneurysm after the placement of a covered stent into the external iliac artery and following the occlusion of the hypogastric artery with a vascular plug.
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A complete exclusion of the pseudoaneurysm was also confirmed on post-procedural angiography (Figure 5).
Follow-up CT-A (shaded surface rendering) confirms a complete exclusion of the pseudoaneurysm and the consequent restoration of a normal opacification in the external iliac artery. Distal recanalization of both the hypogastric arteries can also be observed.
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CT-A performed one month after the procedure showed a regular opacification of the left external iliac artery, while the hypogastric artery demonstrated distal recanalization (Figure 6).