Surgical Access of the Gluteal Artery to Embolize a Previously Excluded, Expanding Internal Iliac Artery Aneurysm

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Surgical access of the gluteal artery to embolize a previously excluded, expanding internal iliac artery aneurysm

Katsuaki Magishi, MD, PhD, Yuichi Izumi, MD, PhD, Kazuyuki Tanaka, MD, Noriyuki Shimizu, MD, PhD, and Daiki Uchida, MD, Nayoro, Japan

We describe open exposure of the inferior gluteal artery to allow coil embolization on an enlarging internal iliac artery aneurysm after previous abdominal aortic aneurysm (AAA) repair. An 84-year-old man with a stoma had undergone open AAA repair surgery 8 years previously, during which the proximal aortic neck and both proximal external iliac arteries were ligated, followed by an aorta to right external iliac and left common femoral bypass. Eight years later, he complained of abdominal pain, and a computed tomographic (CT) scan revealed persistent flow in the right internal iliac artery with enlargement to 8 cm in diameter. Because prograde access to the internal iliac artery was not possible as a result of the previous exclusion, the inferior gluteal artery was exposed surgically. Coil embolization of the arteries supplying the internal iliac artery aneurysm was successfully performed. The AAA and internal iliac artery aneurysm were treated by the exclusion technique. Eight years after the operation, CT revealed that the iliac artery had expanded to approximately 8 cm in diameter. The patient was placed face down, and a catheter was directly inserted into the internal iliac artery from the inferior gluteal artery. Four embolization coils were placed in the internal iliac artery and its branches. Absence of blood flow and shrinkage of the aneurysm were subsequently confirmed in the aneurysm, as shown by echogram color duplex scanning and CT scanning at 1 year. This technique could also be applicable for persistent blood flow in an internal iliac aneurysm after endovascular AAA repair, and the size of the aneurysm was reduced to approximately 1 cm 1 year after the operation. (J Vasc Surg 2007;45:387–90.)

Aneurysms of the internal iliac artery are sometimes in a retrograde manner via surgical access to the inferior difficult to treat because of difficulties in obtaining surgical gluteal artery. exposure. This is especially true when the aneurysm in- volves the distal internal iliac artery or when the aneu- CASE REPORT rysm is inflammatory. In such instances, if the aneurysm is small, it is sometimes simply excluded by ligating the An 84-year-old man complained of abdominal pain and loss of proximal internal iliac artery and leaving the distal runoff appetite and was subsequently found to have an 8-cm-diameter branches intact. However, excluded aneurysms can expand right internal iliac artery aneurysm. His surgical history was signif- and even rupture. To avoid such late complications, the icant for resection of rectal cancer and creation of a stoma; these outflow vessels of the aneurysm sac should be interrupted procedures were performed when the patient was aged 55 years. At whenever possible, either surgically or endovascularly, with age 76, he had undergone open surgical repair of an abdominal embolization coils. The internal iliac artery divides into aortic aneurysm (AAA) and a right common and internal iliac superior and inferior gluteal arteries, which traverse artery aneurysm. Because of the left-sided colostomy, surgery was through the pelvic cavity to the buttock. Catheter-based performed via a right pararectal incision with a retroperitoneal access to the internal iliac artery can therefore be gained via approach. The AAA and the right common and internal iliac artery the superior and inferior gluteal arteries in a retrograde aneurysms (25 mm in diameter) were treated with the exclusion manner. This technique has been used to administer che- technique. The proximal neck of the AAA was oversewn, and the motherapy for the treatment of gynecologic or urologic external iliac arteries were ligated bilaterally. An aortic/right ex- cancers, as well as to obtain hemostasis in patients with ternal iliac/left common femoral artery bypass was then con- pelvic injury.1-4 There are several reports on the antegrade structed. Antiplatelet drugs and anticoagulant therapy were not approach for coil embolization of the internal iliac artery administered after surgery. aneurysm; however, prograde access is not always possible. Eight years after this aneurysm operation, an abdominal com- We report a new technique to access the internal iliac artery puted tomographic (CT) scan showed that the excluded right internal iliac aneurysm had expanded to 8 cm in maximum diameter. A contrast CT scan showed the presence of blood flow in the From the Department of Thoracic and Cardiovascular Surgery, Nayoro City General Hospital. right internal iliac aneurysm (Fig 1). Because of the advanced age Competition of interest: none. of the patient and the presence of the stoma, we decided to avoid Reprint requests: Katsuaki Magishi, MD, PhD, Nayoro City General Hos- a third laparotomy. pital, Nishi 7 Minami 8-1, Nayoro Hokkaido, 096-8511 Japan (e-mail: The patient was placed in a prone position under general [email protected]). anesthesia. As described by Noguchi et al,1 an approximately 0741-5214/$32.00 Copyright © 2007 by The Society for Vascular Surgery. 10-cm diagonal incision was made in the right buttock. The doi:10.1016/j.jvs.2006.10.040 gluteus maximus muscle was split, and the inferior gluteal artery 387 JOURNAL OF VASCULAR SURGERY 388 Magishi et al February 2007

Fig 1. Preoperative contrast-enhanced computed tomographic scan of the internal iliac artery aneurysm. Persistent blood ﬂow is seen in the previously excluded internal iliac aneurysm. The proximal side of the aneurysm is not enhanced. An axial view (a) and Maximum Intensity Projection MIP-constructed view (b) are shown. Arrowheads point to the excluded internal aneurysm and to the inferior gluteal artery.

Fig 2. (a) Schematic skin incision and operative view. After the gluteus maximus muscle is split, the inferior gluteal artery is identified below the piriformis muscle. (b) Angiography of the internal iliac aneurysm before coil embolization. The aneurysm, obturator (O), and supragluteal (S) and infragluteal (I) arteries were identified. Contrast material was injected from the sheath inserted in the inferior gluteal artery. (c)A completion angiogram after coil embolization shows an absence of flow inside the internal iliac aneurysm. was identified below the piriformis muscle (Fig 2, a). A 5F intro- by using a directional catheter, embolization coils (20 ϫ 200 mm ducer sheath was inserted into the inferior gluteal artery by using and three coils of 15 ϫ 150 mm; Tornado Embolization Micro- the Seldinger technique, and then the distal inferior gluteal artery coils; Cook, Bloomington, Ind) were inserted into the aneurysm was ligated. An angiogram showed a right common and internal and the feeding arteries, including the obturator artery and the iliac artery aneurysm and its branches (Fig 2, b). After angiography, inferior gluteal artery. Completion angiogram confirmed the ab- JOURNAL OF VASCULAR SURGERY Volume 45, Number 2 Magishi et al 389

care, with attempts to occlude the arteries as proximally as possible.6 As far as the risk of ongoing perfusion of a previously excluded aneurysm is concerned, Darling et al7 reported that 4% of excluded AAAs had persistent blood flow in the aneurysm sac and that, of these, 0.6% went on to rupture. Thus, we believed that it was reasonable to treat this large iliac aneurysm. The presence of blood flow in the aneurysm was seen with a higher frequency in patients who were receiving anticoagulation therapy.7 However, our patient was not taking chronic anticoagulation therapy. The reason why flow persisted in our patient may be related to the fact that the inferior and superior gluteal arteries and the obturator artery served as inflow and outflow. Our case is analogous to a type II endoleak after endovascular aneurysm repair. Although the clinical significance and the risk of a type II endoleak are controversial, several Fig 3. Enhanced computed tomographic scan (delay phase) ob- reports have suggested that rupture can occur from type II 8 tained 1 year after the procedure. The aneurysm is not enhanced by endoleaks. For example, Bade et al reported on a rupture contrast medium. The high-density area in the aneurysm corre- of an excluded hypogastric aneurysm after endovascular sponds to the coils. aneurysm repair. Although we were able to obtain complete thrombosis of the aneurysm with coils, long-term follow-up imaging sence of blood flow in the aneurysm (Fig 2, c). Contrast CT scan studies are needed. This is because, as pointed out by Marty 9 obtained 2 weeks after the embolization procedure revealed com- et al, the absence of endoleak on angiographic and CT plete thrombosis of the aneurysm. This was also confirmed with a scans does not always mean that the aneurysm has been transabdominal duplex scan. The postoperative course was un- depressurized effectively. eventful. The patient did not experience buttock claudication or In summary, we report a novel access to the internal any ischemic complications. A follow-up CT scan obtained 1 year iliac artery via the inferior gluteal artery. This approach may after the procedure showed shrinkage of the aneurysm by 1 cm and be especially valuable in cases in which prograde access to also an absence of blood flow (Fig 3). the internal iliac artery is difficult or impossible, including persistent flow in an internal iliac artery after exclusion during endovascular aneurysm repair. DISCUSSION We thank Dr Takao Ohki, Jikei University, for his Surgical exposure and control of the distal internal iliac editorial assistance. artery are sometimes difficult. In our case, an 8-cm aneurysm had developed in the internal iliac aneurysm that was excluded from the circulation with proximal ligation 8 years REFERENCES before presentation. Surgical access was believed to be 1. 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