Persistent sciatic artery aneurysm with limb-threatening ischemia

A 50 year old lady with bilateral persistent sciatic artery aneurysm presented with severe limb ischemia due to distal embolization from a thrombus filled persistent sciatic artery aneurysm on one side. Persistent sciatic artery is a rare embryological anomaly which results due to the failure of development of the femoral system. Its complete variant can be clinically recognised by the presence of a weak femoral pulse with a normal popliteal pulse. The diagnostic and treatment considerations of this rare anomaly are described.     

Persistent sciatic artery: Case report,anatomy, and review of the literature

We report the case of a 64-year-old woman with an aneurysm of a left persistent sciatic artery presenting with arterial insufficiency from distal embolization. Treatment was exclusion of the aneurysm and femoropopliteal bypass after distal embolectomy with a Fogarty balloon catheter. We reviewed 71 cases in the literature to define characteristics of this anomaly which has many synonyms: including persistent sciatic artery, persistent axial artery, ischiopopliteal trunk. The persistence of the sciatic portion of the embryonic dorsal axial artery and failure of development of anastomoses with the ventral femoral network results in the anomaly. The persistent sciatic artery was "complete" in 75% of cases. In this configuration, it arises from the internal iliac artery, leaves the pelvic cavity through the lower part of the greater sciatic foramen caudad to the pyriformis muscle, reaches the posterior compartment of the thigh and continues as the popliteal artery. In 35% of cases, the artery is aneurysmal with a pulsatile mass in the buttock or a complication of the aneurysm. Arteriography required for diagnosis of the mass leads to discovery of the anomaly in many cases. The treatment of choice is exclusion followed by femoropopliteal vein bypass.     

Coil embolization of symptomatic persistent sciatic artery aneurysm: a case report

Persistent sciatic artery is a rare congenital vascular anomaly of the lower extremity. This artery is predisposed to atherosclerosis or aneurysm formation. Persistent sciatic artery aneurysm often causes limb-threatening ischemia owing to its thrombosis or its mural thrombus. We report a case of successful transcatheter coil embolization for persistent sciatic artery aneurysm. An 89-year-old woman presented to our hospital, suffering from severe ischemia of the right leg and a pulsatile mass in the right buttock. Angiography and enhanced computed tomography revealed right persistent sciatic artery aneurysm with mural thrombus and complete occlusion of the distal end. After she underwent major amputation because of the advanced ischemia following unsuccessful thrombectomy, we performed coil embolization for the aneurysm successfully. Endovascular treatment including transcatheter embolization for persistent sciatic artery aneurysm is safe, effective, and less invasive than surgery. Its application gives various therapeutic options for the treatment of persistent sciatic artery aneurysm.     

Angioplasty via retrograde popliteal approach in a stenosed persistent sciatic artery.

Persistent sciatic arteries are a rare developmental anomaly prone to aneurysm formation and atherosclerotic disease. We present a case of a patient with bilateral persistent sciatic arteries presenting with unilateral claudication due to a symptomatic stenosis. The stenosis (just above knee) was treated with angioplasty via popliteal puncture. The puncture was complicated by pseudoaneurysm formation. Persistent sciatic arteries can cause diagnostic difficulties as Duplex ultrasound can give the impression of an occluded superficial femoral artery. Angiographic techniques are the mainstay of diagnosis and we demonstrate both conventional and CT angiographic appearances.     

Combined percutaneous endovascular and open surgical approach in the treatment of a persistent sciatic artery aneurysm presenting with acute limb-threatening ischemia--a case report and review of the literature

Persistent sciatic artery (PSA) is a continuation of the internal iliac artery into the popliteal-tibial vessels and provides the major supply to the lower limb bud in early embryologic development, and its remnants participate in the formation of the inferior gluteal, deep femoral, popliteal, peroneal, and pedal vessels. When the femoral artery develops, the PSA involutes. In rare circumstances it persists and has a bilateral location in 22% of cases of PSA. This rare vascular anomaly is associated with aneurysmal formation in 15% to 46% of cases. Persistent sciatic artery aneurysm (PSAA) was first described in 1864. At present 87 cases, including this case, have been reported in the international literature. The authors describe a patient affected with PSAA and treated with a combination of thrombolysis, arterial reconstruction, and aneurysm embolization in a staged fashion. Embryology, anatomy, pathology, clinical presentation, diagnosis, and treatment of this rare disease are briefly discussed.     

Intermittent claudication associated with persistent sciatic artery: Report of two cases

Two elderly women complaining of intermittent claudication complicated with persistent sciatic artery are herein reported. A direct femoral arteriogram showed hypoplasty of the superficial femoral artery and an unnatural anatomical relationship between the distal superficial femoral artery and the proximal popliteal artery, thus suggesting the presence of persistent sciatic artery. The diagnosis of persistent sciatic artery was finally made based on the aortography findings including the iliac arterial system and computed tomography (CT) scan. Magnetic resonance imaging (MRI) was helpful to demonstrate the entire image of this anomaly in cases with non-thrombolized sciatic artery. These diagnostic methods were useful in designing the optimal surgical strategy. The first case with a gluteal pulsating mass underwent exclusion of the persistent sciatic artery including the aneurysm through a retroperitoneal approach with a combination of femorotibial bypass, while the second case with thrombosed persistent sciatic artery only underwent femoropopliteal bypass. To recognize such a rare lesion, awareness of the differential diagnosis is important, and to provide appropriate treatment, an accurate whole image including adequate angiography, a CT scan, and magnetic resonance imaging is necessary.     

Surveillance and conservative management of a persistent sciatic artery aneurysm

A persistent sciatic artery aneurysm is a rare congenital vascular anomaly. Surgical intervention is reserved for symptomatic cases. The authors report the case of a 72-year-old woman who presented with thromboembolic occlusion of an aneurysmal persistent sciatic artery. Although initially symptomatic, she was managed expectantly with the aid of serial duplex sonographic imaging. The persistent sciatic artery subsequently thrombosed as a result of hypotension secondary to a myocardial infarction. No surgical intervention was required. The current literature on this condition is reviewed.     

Role of computed tomographic angiography in the detection and comprehensive evaluation of persistent sciatic artery

PURPOSE: To define the role of computed tomographic (CT) angiography in the evaluation of persistent sciatic artery and to identify its potential advantages as a diagnostic modality. METHODS: Between July 2002 and August 2004, 307 consecutive patients underwent CT angiography for suspected lower-extremity arterial insufficiency. All CT angiograms were retrospectively reviewed to determine the presence and laterality of persistent sciatic artery and its associated vascular abnormalities, such as aneurysm, thrombus, distal thromboembolism, and atherosclerotic change. The relationship of persistent sciatic artery with adjacent structures, such as sciatic nerve, muscle, accompanying vein, and femoral artery, as well as the presence of other anomalies, was analyzed. Clinical data regarding the presenting symptoms and hospital course were obtained from patient charts. RESULTS: Six persistent sciatic arteries, with or without occlusion, were identified in five female patients (age range, 54 to 80 years). CT angiography revealed unilateral persistent sciatic artery in four patients (left, 3; right, 1) and bilateral persistent sciatic artery in one patient. Aneurysm was present in two (mean size, 26 mm x 20 mm), thrombosis in three, and distal thromboembolism in all six persistent sciatic arteries. All persistent sciatic arteries coursed along the sciatic nerve and continued as popliteal artery. Characteristically, in all these instances, the superficial femoral arteries were hypoplastic and tapered smoothly. Anomalous popliteal venous drainage was noted in all ipsilateral limbs with persistent sciatic artery and even in contralateral limbs with normal superficial femoral artery in all but one. CONCLUSION: CT angiography enables the detection of persistent sciatic artery even in the presence of complete occlusion and is useful in the comprehensive evaluation of various complications and associated venous anomalies. It can potentially be used as the sole imaging modality for persistent sciatic artery.     

Treatment of the persistent sciatic artery.

The persistent sciatic artery is a rare vascular anomaly, with only 37 reported cases in the world literature. Estimates of incidence, based on angiographic series, range from 0.04 to 0.06%. It may pose a threat to the viability of the lower extremity, for the pathologic character of the persistent sciatic artery is such that it is especially prone to atheromatous degeneration, thrombosis, distal thromboembolization, aneurysmal formation, and rupture. Although rare, the possibility of such an anomaly must be borne in mind with certain clinical presentations, during orthopedic procedures on the hip, and during angiographic studies of the leg. Successful surgical correction of the problem necessitates excluding the anomalous artery from the circulation while revascularizing the lower extremity.     

A surgical case of aneurysm of the persistent sciatic artery

Seventy two-year-old woman was admitted in September, 1985 to our hospital with complaints of painful mass in the right buttock and ischias. Aorto-peripheral arteriogram showed that enlarged right internal iliac and inferior gluteal arteries passed posteriorly to cross the right hip and down the posterior aspect of the femur to supply the popliteal artery. A saccular aneurysm was seen immediately posterior to the right femoral head. The femoral artery was small in size, but connecting to the popliteal artery. Delayed flow to the popliteal artery through the sciatic artery was noted in contrast to the femoral system. With Osborne's right buttock approach, the gluteus maximus muscle was divided in the direction of its fibers, exposing a 3.5 by 5 cm aneurysm which was located above, the sciatic nerve and adherent to it. The proximal sciatic artery and the trunk of the sciatic nerve passed beneath the piriformis muscle. The pressure of the dorsalis pedis artery decreased from 156/77 to 117/72 mmHg after ligation of the proximal sciatic artery. The aneurysm was dissected free from the sciatic nerve. Postoperatively she had no more gluteal discomfort, nor did she have any ischemic symptoms by walking.     

Limb ischemia associated with persistent sciatic artery aneurysms-a report of 2 cases

Persistent sciatic artery (PSA) is a rare developmental anomaly, usually associated with iliofemoral hypoplasia and dependence on the sciatic artery as the dominant inflow to the lower extremity. Although rare, this anomaly is associated with a very high rate of aneurysm formation and frequent thromboembolic complications presenting as lower extremity ischemia, and requires familiarity on the part of the vascular surgeon to properly diagnose the disorder and plan therapy. The authors present 2 cases of PSA presenting with lower extremity ischemia and review the pathophysiology, diagnosis, and treatment of this rare but important anomaly.     

Concurrent thrombosed aneurysmal sciatic artery and anomalous aortic arch

A persistent sciatic artery is a rare developmental anomaly which may predispose to a range of vascular complications. We report a 60-year-old woman presenting with right lower limb ischemia. Computed tomography angiography revealed an aneurysmal right-sided sciatic artery occluded by thrombus. An aberrant right subclavian artery and anomalous common carotid origins were also incidentally discovered. It is unknown whether an association exists between a persistent sciatic artery and other congenital arterial abnormalities. This is the first case report, so far as we are aware, describing both such arterial anomalies coexisting in a patient.     

Persistent sciatic artery. Case report

In a man with ischemia of the right leg due to embolism of popliteal artery, arteriography following failure of embolectomy via the common femoral artery revealed the internal iliac artery continuing as an aneurysmally dilated sciatic artery distally to the popliteal artery. The aneurysm was ligated and bypass established from the common femoral to the popliteal artery.     

Endovascular repair of symptomatic sciatic artery aneurysm

Persistent sciatic artery (PSA) is a rare embrionary anomaly in which the internal iliac artery and the embryonic axial artery continue to provide the major blood supply to the lower limb after birth. Aneurysm formation occurs in as many as 46% of cases. We describe a percutaneous treatment of a complete PSA aneurysm in a high operative risk patient.     

The Persistent Sciatic Artery

BackgroundA persistent sciatic artery (PSA) is a rare vascular anomaly with an estimated incidence of 0.03–0.06%. During early embryonic development, the sciatic artery usually disappears when the superficial femoral artery has developed properly. This study aimed to assess the clinical presentation and outcome of a PSA.MethodA systematic review of all cases of PSA published between 1964 and 2007 was performed.ResultsIn this review, 159 PSAs were described in 122 patients. The mean age at which the PSA was discovered was 57 years, and the incidence was equally distributed with regards to gender. The majority of PSAs was unilateral (70%) and of the complete type (79%). Ninety-one patients (80%) presented with symptoms including intermittent claudication, ischaemia, a pulsating mass or neurological symptoms. An aneurysm was found in 48%, a stenosis in 7%, an occlusion of the PSA in 9% and an occlusion of an artery distal to the PSA in 6% of the subjects. The treatment depended on the symptoms and classification of the PSA. In nine cases (8%), an amputation was required eventually.ConclusionThe PSA is a rare anomaly with a high incidence of complications including aneurysm formation and ischaemia that may lead to amputation. Strategies for follow-up could not be deduced from the available literature.     

Damned if you do and damned if you don't: medical ethics and a second career

Persistent sciatic artery (PSA) is a rare congenital anomaly, but in many cases it is a clinically important condition. PSA is susceptible to atherosclerotic degeneration, resulting in aneurysmal dilatation, occlusive thrombosis, or thromboembolization. PSA aneurysm is associated with distal embolization, sciatic neuropathy, or rupture. We describe a case of a patient with a ruptured PSA aneurysm treated by exclusion of the aneurysm and bypass between the common iliac artery and the PSA distal to the aneurysm, and discuss treatment of PSA aneurysm.     

Popliteal artery entrapment syndrome with distal embolization. A report of two cases

The popliteal vascular entrapment syndrome has been recognized as a cause of arterial occlusion in young males for several decades. The ischemia is usually caused by thrombosis of the popliteal artery due to intimal trauma or aneurysm formation. Distal embolization to the tibial arteries and to the foot arch and digital vessels is common but is not emphasized in the literature. This distal embolization may precipitate severe ischemia which may preclude reconstruction or compromise the results of repair of the popliteal lesion. Early repair of the muscle anomaly is advocated even in the asymptomatic limb. Two patients with bilateral popliteal artery entrapment causing unilateral popliteal occlusion with distal embolization are reported.     

A case of a developmental anomaly of the femoral artery: Persistent sciatic artery

A case of a persistent sciatic artery in a 68-year-old farmer, showing symptoms of acute arterial occlusive lesion of the right lower limb is presented. The persistent sciatic artery was joined to the internal iliac artery proximally and to, the popliteal artery distally. The anomalous artery was occluded by atheromatous thrombi. The superficial femoral artery was hypoplastic and terminated in the descending genicular artery at the midthigh level. A successful bypass was performed between the common femoral artery and proximal popliteal artery utilizing a woven teflon graft.     

Aneurysm of anterior communicating artery associated with aortitis syndrome--a treated case by aneurysmal neck clipping (author's transl)

A rare case of the cerebral aneurysm associated with aortitis syndrome was reported. It seems to be the first case in which neck clipping was successfully performed for aneurysm of the anterior communicating artery. The patient was a 48-year-old female afflicted with pulseless disease. She was admitted to Iwate Central Hospital with severe headache, vomiting and unconsciousness on November 16, 1980. Her radial pulse was faint on the right side. The left carotid angiography revealed an aneurysm in the anterior communicating artery, and neck clipping of the aneurysm was performed 17 days after the onset. The right serial brachiocephalic arteriography revealed occlusion of the right brachiocephalic artery and the right common carotid artery. The serial aortography revealed stenosis of the left common carotid artery and the left vertebral artery. In the literature, 4 cases of those 7 cases associated with aortitis syndrome had aneurysms at the basilar bifurcation or basilar top. It seems to be the reason that the vertebral artery outlasts longer in aortitis syndrome. In our case, we can relate the aneurysmal formation of the anterior communicating artery to the hemodynamic overload of the left A1. General anesthesia in such cases was discussed.