Retrograde transarterial embolization of a persistent internal iliac artery aneurysm after prior plug embolization and EVAR in a 90-year-old patient

Authors

DOI:

https://doi.org/10.59667/sjoranm.v6i1.12

Keywords:

internal iliac artery aneurysm, embolization, EVAR, microvascular plug, Onyx, obturator artery, deep external pudendal artery

Abstract

Persistent perfusion of an internal iliac artery aneurysm after endovascular aortic repair can be difficult to treat when the usual antegrade route is no longer available. We report a 90-year-old patient with a 5.2 cm partially thrombosed right internal iliac artery aneurysm and substantial comorbidity. Previous embolization with three microvascular plugs followed by endovascular aortic repair had markedly reduced but not eliminated aneurysm perfusion. Follow-up CT angiography demonstrated retrograde filling through a hypertrophied obturator artery connected to the deep external pudendal artery. Under local anesthesia, the deep external pudendal artery was accessed antegradely from the right common femoral artery using a micropuncture set. A microcatheter was advanced retrogradely to the aneurysm; two branches were coiled and the aneurysm lumen and feeding vessels were embolized with Onyx 34. The patient was monitored for six hours and discharged on the same day. CT angiography four months later demonstrated complete aneurysm occlusion with preserved peripheral pelvic perfusion. This case illustrates a collateral-based retrograde access strategy for persistent aneurysm perfusion in a patient considered unsuitable for major open surgery.

Author Biographies

  • Frank Mosler, Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital of Bern, University of Bern

    Board-certified Radiologist & Neuroradiologist; Senior Consultant, Inselspital, Bern University Hospital

    Dr. med. Frank Mosler is a board-certified radiologist and neuroradiologist with more than 30 years of clinical and academic experience across major European university centers. He completed his medical education and early specialty training in radiology and neurosurgery at Charité University Hospital in Berlin. He later specialized in interventional neuroradiology at Alfried Krupp Hospital in Essen, where he also held senior leadership responsibilities.

    His professional career has included academic medicine, diagnostic and interventional radiology, neuroradiology, healthcare management, quality assurance, and scientific publishing in Germany and Switzerland. Since 2017, he has been affiliated with the Department of Diagnostic, Interventional and Pediatric Radiology (DIPR) at Inselspital, Bern University Hospital.

    As Editor-in-Chief of the Swiss Journal of Radiology and Nuclear Medicine, Dr. Mosler leads the journal's editorial and scientific strategy and holds overall responsibility for editorial policy, publication standards, scientific integrity, and final editorial decision-making.

    Institutional affiliation: University Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital
    Location: Bern, Switzerland
    ROR: 01q9sj412

  • Gerd Nöldge, Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Founding Editor & Honorary Editor
    Switzerland & Germany
    Senior Consultant Radiology, University Hospitals Heidelberg & Bern

    Prof. Dr. med. Gerd Nöldge is a renowned German radiologist and pioneer in interventional radiology. As former Senior Consultant at Heidelberg University Hospital, he made groundbreaking contributions to gastrointestinal artery embolization, for which he received the inaugural Wilhelm Conrad Röntgen Prize in 1985. He played a key role in advancing kyphoplasty techniques for osteoporotic vertebral fractures, providing long-term evidence for the efficacy and stability of calcium phosphate cement in vertebral body augmentation.

    Prof. Nöldge has also significantly contributed to the clinical development and refinement of transjugular intrahepatic portosystemic shunt (TIPS) procedures, improving outcomes in patients with portal hypertension. His dedication to education and international collaboration has fostered enduring partnerships, including medical exchange programs with leading institutions in China.

    As Founding Editor of the Swiss Journal of Radiology and Nuclear Medicine, Prof. Nöldge played a decisive role in the establishment and early development of SJORANM. His appointment as Honorary Editor recognizes his founding contribution, his longstanding scientific commitment, and his lasting importance to the journal. 

    Former institutional affiliation: University Hospital Heidelberg – Diagnostic and Interventional Radiology
    Location: Heidelberg, Germany & Bern, Switzerland
    ROR: 013czdx64

References

1. Scheurig-Münkler C, Zerwes S. Isolated iliac artery aneurysm: clinical background and interventional treatment strategies. Radiologie (Heidelb). 2022;62(7):607-613. https://doi.org/10.1007/s00117-022-01002-w DOI: https://doi.org/10.1007/s00117-022-01002-w

2. Perini P, Mariani E, Fanelli M, et al. Surgical and endovascular management of isolated internal iliac artery aneurysms: a systematic review and meta-analysis. Vasc Endovascular Surg. 2021;55(3):254-264. https://doi.org/10.1177/1538574420981812 DOI: https://doi.org/10.1177/1538574420981812

3. Kang J, Chung BH, Hyun DH, Park YJ, Kim DI. Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneurysm repair. Int Angiol. 2020;39(4):323-329. https://doi.org/10.23736/S0392-9590.20.04328-X DOI: https://doi.org/10.23736/S0392-9590.20.04328-X

4. Dix FP, Titi M, Al-Khaffaf H. The isolated internal iliac artery aneurysm: a review. Eur J Vasc Endovasc Surg. 2005;30(2):119-129. https://doi.org/10.1016/j.ejvs.2005.04.035 DOI: https://doi.org/10.1016/j.ejvs.2005.04.035

5. Parry DJ, Kessel D, Scott DJA. Simplifying the internal iliac artery aneurysm. Ann R Coll Surg Engl. 2001;83(5):302-308. https://pubmed.ncbi.nlm.nih.gov/11806552/

SJORANM article cover, Vol. 6 No. 1 (2024). Holographic symbolic illustration for article 20.

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Published

2024-03-30

Data Availability Statement

All data relevant to this case report are included in the article.

Issue

Vol. 6 No. 1 (2024)

Section

Case reports

License

Copyright (c) 2024 Nando Mertineit, Carlos Buitrago Tellez, Pascal Kissling, Frank Mosler, Johannes Heverhagen, Gerd Nöldge

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

This license requires that reusers give credit to the creator. It allows reusers to distribute, remix, adapt, and build upon the material in any medium or format, even for commercial purposes.

How to Cite

Mertineit, N., Buitrago Tellez, C., Kissling, P., Mosler, F., Heverhagen, J., & Nöldge, G. (2024). Retrograde transarterial embolization of a persistent internal iliac artery aneurysm after prior plug embolization and EVAR in a 90-year-old patient. Swiss Journal of Radiology and Nuclear Medicine, 6(1), 1-8. https://doi.org/10.59667/sjoranm.v6i1.12

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