PMC6319503_01
Static image from angiogram post stent graft deployment. Arrowheads demonstrate type II endoleak within the aneurysm sac. Arrow demonstrates patent left IIA
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Fig1
However, a tortuous right CIA made coiling of the left IIA extremely difficult and following a prolonged attempt, the decision was made to proceed with EVAR without coiling the IIA (Fig. 1).
Reformatted CT angiogram image showing contrast filling of left internal iliac artery (arrowhead) and type II endoleak in the aneurysm sac (short arrow). The anterior division of the left IIA is demonstrated with the long arrow
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Fig2
On a follow up CT 1 month post repair, the left IIA remained patent with a large type 2 endoleak demonstrated but the sac size remained static (Fig. 2).
Angiogram via a 4 Fr catheter inserted in the anterior branch of the left IIA (arrow) demonstrating type II endoleak within the aneurysm sac (arrowhead)
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Fig3
The intention was to puncture the posterior division of the IIA but visualisation with ultrasound was limited and a vessel was punctured, which on subsequent angiography was shown to be the anterior division of the left IIA (Fig. 3).
Photograph showing 4F dilator inserted into the angioseal sheath (arrow) to illustrate the method of injecting contrast through the sheath to visualise the tip on fluoroscopy (arrowhead)
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Fig4
The angioseal was not visualised on ultrasound and therefore a 4 French dilator was inserted within the Angio-Seal (Terumo) sheath through which contrast was injected to directly visualise the tip to the sheath within the artery (Fig. 4).
Angiogram via 4Fr dilator inserted through AngioSeal sheath (arrow) to visualise angioseal sheath tip (arrowhead)
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Fig5
The sheath was then withdrawn until just inside the vessel lumen and the plug deployed with immediate haemostasis (Fig. 5).