PMC8105179_01
Left panel: digitally subtracted angiographic image with injection of the left common iliac artery aneurysm. Centre panel: digitally subtracted angiographic image with selective injection of the left internal iliac artery; its branches include the superior gluteal artery (blue arrow). Right panel: endovascular aneurysm repair with extension of the left iliac limb into the external iliac artery after embolising the internal iliac artery.
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Focused angiographic images showing the left iliac repair are shown in Fig. 1.
Mural calcifications (blue arrows) demarcate the inferior wall of the superior gluteal artery, allowing a needle to be directed into the vessel lumen under fluoroscopic guidance. The site of arterial entry is deep to the greater sciatic notch.
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The site of arterial entry was intrapelvic (deep to the greater sciatic notch; Fig. 2).
Digitally subtracted internal iliac artery injection demonstrating recanalisation of the previously embolised internal iliac artery, with contrast filling the caudal portion of the common iliac artery aneurysm sac (black arrows). The aneurysm sac and internal iliac artery (as demarcated by the coils) are superimposed in this projection. A blue arrow shows the superior gluteal artery where accessed.
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Contrast injection through the sheath revealed recanalisation of the previously coiled IIA with contrast flowing into the CIA aneurysm sac (Fig. 3), which was subsequently catheterised.
Post-treatment fluoroscopic image without injection showing additional coils deployed within the filling portion of the aneurysm, radio-opaque glue distributed diffusely throughout the aneurysm sac, and an Amplatzer plug within the internal iliac artery (white arrow).
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Jude Medical, Minnesota, MN, USA) was deployed in the IIA (Fig. 4).
Axial image from a six month follow up computed tomography angiogram showing the StarClose clip (white arrow) along the outside wall of the patent superior gluteal artery. Although the clip appears slightly oblique relative to the vessel, this does not appear to correlate with failure. Notably, mural calcifications are seen involving the intrapelvic segment of the superior gluteal artery. The internal iliac artery (blue arrow) remains patent peripheral to the site of embolisation.
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A six month follow up CTA demonstrated preserved patency of the superior gluteal artery and its branches, with the StarClose clip positioned just outside the vessel (Fig. 5).