Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair

This is a report of a patient presenting with a contained rupture of an internal iliac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the internal iliac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal iliac artery aneurysms is emphasized by this case.     

Exclusion of a sciatic artery aneurysm and an obturator bypass

This case report describes surgical treatment in a sciatic artery aneurysm with hypoplastic external iliac and femoral arteries. An obturator bypass grafting procedure from the internal iliac artery to the distal sciatic artery was performed after aneurysmal exclusion was achieved by proximal and distal ligation. This method offers an acceptable option for surgery in some types of sciatic artery aneurysms. (J Vasc Surg 1997;26:697-9.)     

Continuing expansion of internal iliac artery aneurysms after surgical exclusion of the inflow. A report of two cases

Two patients with continuing expansion of an internal iliac artery aneurysm following earlier repair of an aortoiliac aneurysm are described. At the primary operation, inflow to small internal iliac aneurysms had been interrupted by simple proximal ligation only. During follow-up, however, increasing diameter of the by CT-angiography completely thrombosed internal iliac aneurysms required re-operation. The observation of continuing growth of thrombosed internal iliac artery aneurysms following proximal ligation emphasises the danger of persistent collateral circulation and supports the concept of endotension in the absence of endoleak following endovascular AAA repair.     

Exclusion of internal iliac arterial aneurysm concomitant with abdominal aortic aneurysm repair.

BACKGROUND: To study the long-term outcomes after exclusion of internal iliac arterial aneurysm performed concomitantly with abdominal aortic aneurysm repair in patients with ruptured aortic aneurysm or other high-risk conditions. METHODS: The 31 patients who participated in this study underwent emergency (N = 9) or elective surgery (N = 22). The abdominal aortic aneurysm and the common iliac artery were excluded together with the internal iliac aneurysm in 7 patients. Forty-three (12 bilateral and 19 unilateral) internal iliac aneurysms were excluded: 35 by proximal ligation only, 5 by proximal and distal ligation, and 3 by partial resection of the proximal part of the aneurysm. The platelet count and fibrinogen level were evaluated pre- and postoperatively. Pelvic organ ischemia, classed as ischemic colitis, buttock claudication and sexual dysfunction, was examined. RESULTS: The inferior mesenteric artery was reimplanted in 21 patients. The platelet count dropped significantly postoperatively, but the fibrinogen level increased and no bleeding tendency was noted. Ischemic colitis occurred in 7 patients, resulting in colonic infarction in 2 patients. The operative mortality was 16%, and the postoperative observation periods ranged from 4 days to 217 months (mean, 60 months). The incidence of buttock claudication and sexual dysfunction was 12% and 39%, respectively. The excluded aneurysms were all thrombosed at discharge, and no late rupture was noted. The 5- and 10-year survival rate after surgery was 56% and 51%, respectively. CONCLUSIONS: Exclusion of the internal iliac aneurysm concomitant with abdominal aortic aneurysm repair shows acceptable outcome when performed in patients with high-risk conditions.     

Endovascular Treatment of Isolated Iliac Artery Aneurysms

We report our experience of endovascular repair of isolated iliac artery aneurysms using commercially available stent grafts (SGs). Twenty-five patients (mean age 71 ± 7 years) presented with 33 isolated iliac artery aneurysms (common iliac artery n = 29, external iliac artery n = 4). Five patients were symptomatic. Depending on the proximal iliac neck and the presence of unilateral or bilateral iliac artery aneurysms, the patient was treated by tube or bifurcated SG that was delivered percutaneously (n = 14) or through surgical exposure of one femoral artery (n = 12). In our follow-up control protocol, the patients are routinely scheduled after 1, 4, and 12 months and then annually after the intervention. Primary technical success with an instant exclusion of the aneurysm was achieved in all patients. The perioperative (<30 days) mortality rate was 0. Major complications did not occur. Mean hospitalization was 6 ± 6 days (range 2-28, median 4). Four patients (16%) died during follow-up. At a mean follow-up of 32 months (range 3-72, median 36), we detected three type 1 endoleaks (14.3%) that were managed with additional SG; two stenoses at the distal extremity of the SGs, treated with mechanical thrombectomy; and additional stent. In the remaining patients (n = 17), computed tomography angiography confirmed the patency of the SG and the absence of device complication (e.g., endoleak, migration, breakage); shrinkage of the aneurysm was observed in 11 cases (52.4%). Overall, survival rates at 1, 4, and 5 years were 91.6%, 73.3%, and 58.6%, respectively; event-free rates at 1 and 3 years were 79.4% and 67.4%, respectively. In our experience, SG treatment for isolated iliac artery aneurysm proved to be a feasible and low-risk procedure with acceptable mid-term results. At our institute, it is the primary alternative to conventional surgical repair and is offered as first-line treatment.     

腔内修复术治疗孤立性髂动脉瘤14例

目的探讨腔内治疗孤立性髂动脉瘤的疗效。方法回顾性分析2004年10月至2006年5月腔内修复孤立性髂动脉瘤14例的临床资料。其中,右髂总动脉瘤8例,左髂总动脉瘤5例,左髂内动脉瘤破裂1例。髂动脉瘤腔内修复的标准是瘤体直径〉3．0cm。结果14例均取得技术成功。8例右髂总动脉瘤,钢圈栓塞右髂内动脉后选用分叉支架型人工血管行腔内修复术。其中1例右髂总动脉瘤累及腹主动脉下端,选用AUl支架型人工血管腔内修复加股．股动脉旁路术。5例左髂总动脉瘤栓塞同侧髂内动脉后选用直型支架型人工血管。1例左髂内动脉瘤破裂急诊行钢圈栓塞后选用直型支架覆盖左髂内动脉开口。术后即刻数字减影血管造影显示动脉瘤消失,远近端支架型人工血管与宿主动脉结合处均未见明显渗漏。1例术后出现急性左心功能不全和肺水肿,经抢救痊愈,其余13例无手术并发症。术后CTA随访10．2个月（3～19个月）,瘤体无增大,支架无移位,无内漏,旁路人工血管通畅。结论腔内修复术治疗孤立性髂动脉瘤具有可行、安全、微创等特点,近期疗效较好,远期效果需进一步随访。     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Midterm results of endovascular stented grafts for the treatment of isolated iliac artery aneurysms.

PURPOSE: Isolated aneurysms of the iliac arteries are uncommon lesions that require surgical repair to prevent rupture. METHODS: During a 4-year period, we used endovascular stented grafts (EGs) to treat 28 iliac artery aneurysms that were not associated with aortic aneurysms. Twenty-five patients, with a total of 24 common iliac (15 right, nine left) and four internal iliac (two right, two left) artery aneurysms, underwent endovascular grafting. There were 24 men and 1 woman, with a mean age of 74 years (range, 51 to 88 years). Combined common and internal iliac artery aneurysms were present in three patients. Nineteen patients who underwent treatment with EGs were administered epidural anesthesia (22 epidural, two local, one general). Before surgery, one patient had lower extremity embolization and ischemia from the aneurysm, three had abdominal or back pain, and the remaining were asymptomatic. The EGs were constructed of polytetrafluoroethylene grafts and balloon expandable stents. RESULTS: Four procedure-related complications (12%) occurred (distal extremity embolization, n = 1; wound complications, n = 2; colonic mucosal ischemia, n = 1). Only a minimal reduction in the aneurysmal diameter was seen in 90% of the iliac artery aneurysms treated. The remaining lesions showed no change in size, and no aneurysm had an increase in cross-sectional diameter on computed tomographic images enduring a follow-up period up to 4 years (mean, 24 months). One aneurysm ruptured after successful endovascular exclusion, and the patient underwent treatment with open repair. The 3-year primary patency rate of iliac EGs was 86%. CONCLUSION: EGs appear to show satisfactory safety and efficacy for the repair of isolated aneurysms of the iliac arteries.     

Treatment of intracranial aneurysms by combined proximal ligation and extracranial-intracranial bypass with vein graft

Seven patients with internal carotid artery aneurysms, and one patient with a middle cerebral artery aneurysm, were managed by combining proximal ligation with an extracranial-intracranial bypass procedure. Five bypasses were done with an interposed vein graft between the external carotid artery and the distal middle cerebral artery (vein graft), and three were superficial temporal-middle cerebral artery bypasses (superficial temporal artery grafts). As demonstrated in postoperative angiograms, all eight patients had patent bypasses with nonfilling of the aneurysm. One patient developed transient dysphasia, but there were no permanent neurological deficits associated with carotid occlusion. Four patients had resolution of their neurological problems, and another three patients improved. The distribution of flow from vein grafts is more extensive than from superficial temporal artery grafts. This offers increased protection against ischemia, and increases the likelihood of internal carotid artery aneurysm thrombosis by reducing the turbulence in the distal internal carotid artery.     

Branched grafting for aortoiliac aneurysms.

PURPOSE: To evaluate a novel approach to preserve pelvic perfusion during endovascular AAA repair in patients with common iliac aneurysms extending to the iliac bifurcation. MATERIALS AND METHODS: A multicenter prospective analysis of patients undergoing implantation of a branched endograft designed to perfuse the internal iliac artery was conducted. All patients enrolled were considered high risk for open surgical repair and presented with common iliac artery aneurysms greater than 20mm and anatomy amenable to implant the branched device. Preoperative high resolution spiral CT, and follow-up CT studies in addition to abdominal radiographs were obtained at discharge, 1, 6, 12, and 24 months. RESULTS: Between 2003 and 2006, 52 patients (53 internal iliacs) were implanted with an investigational device. Mean common iliac aneurysm maximal diameter was 38 mm. The branch graft was combined with a proximal standard bifurcated component (61%), a fenestrated or a visceral branch component (33%), an aortouni-iliac component (2%), and alone in 2 patients (4%, following prior aortobi-iliac repair). Technical success was achieved in 94% of patients. Within the first month, 6 (11%) internal iliac branches occluded. No occlusions were noted after 1 month. The mean follow-up was 14.2 months. Common iliac aneurysm shrinkage was noted in 42% and 81% of patients at 6 and 12 months. There were no rupture, aneurysm related deaths or conversions, but there were 7 deaths during follow-up. CONCLUSIONS: The placement of endovascular prostheses that maintain antegrade perfusion of one or both internal iliac arteries is feasible, and early results provide evidence for optimism with regard to safety and efficacy.     

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目的 评价腔内人造血管内支撑术在治疗血管外科疾病中的早期临床疗效。方法 ９例病人接受腔内人造血管内支撑术治疗。其中腹主动脉瘤６例，左锁骨下动脉瘤１例，左髂总动静脉瘘１例，左髂股动脉重度硬化性狭窄１例。术前均行Ｄｒｐｌｅｘ彩超、四肢节段性测压（ＰＶＬ）和ＤＳＡ造影，６例动脉瘤病人术前行三维重建螺ＣＴ。结果 术后即刻ＤＳＡ造影显示，７例动脉瘤消失，近远端人造血管与宿主动脉结合外均未见渗漏；１例左髂动静     

Modified "stent-graft sandwich" technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified "stent-graft sandwich" technique, with preservation of the internal iliac artery perfusion. The modified "stent-graft sandwich" technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).     

Neurosurgical management of intracranial aneurysms previously treated with endovascular therapy

OBJECTIVE: With the increased use of endovascular therapy, an increasing number of patients with incompletely treated intracranial aneurysms are presenting for further surgical management. This study reviews our experiences with such patients. METHODS: During a 7-year period, 38 patients with 40 intracranial aneurysms who were initially treated with endovascular therapy underwent surgical obliteration of refractory or recurrent lesions. All patients were recorded in a prospective registry, and their clinical data and imaging studies were analyzed retrospectively. RESULTS: Twenty-six anterior and 14 posterior circulation aneurysms were treated. Four aneurysms were on the cavernous internal carotid artery, 13 were on the distal internal carotid artery, 6 were on the anterior communicating artery complex, 2 were on the middle cerebral artery, 3 were on the posteroinferior cerebellar artery, 1 was at the vertebrobasilar junction, 3 were on the superior cerebellar artery, 4 were at the basilar apex, 2 were on the posterior cerebral artery, and 1 was on the distal vertebral artery. Two pseudoaneurysms-one on the petrocavernous segment of the internal carotid artery and one on the distal VA-also were treated. The median time until recurrence was 6 months. Thirty-one aneurysms were clip-ligated, and six were treated with trapping. Three extracranial-intracranial bypasses were performed. One aneurysm was treated with muslin wrapping. Two aneurysms required the use of surgical approaches that involved hypothermic circulatory arrest. Nine aneurysms required coil mass extraction and/or complex vascular reconstruction to complete lesion obliteration. All aneurysms except the single wrapped aneurysm were successfully excluded from the intracranial circulation. Two deaths occurred as a result of the operative procedures, and another patient died as a result of subarachnoid hemorrhage-induced massive myocardial infarction. Ultimately, 86.8% of patients achieved an excellent or good recovery. CONCLUSION: With endovascular therapy assuming an increasing role in the treatment of patients with intracranial aneurysms, more lesions that are refractory to initial treatment will require surgical management. Our experience indicates that good results are attainable, although technical challenges are frequently encountered.     

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.     

腹主动脉瘤腔内修复术中髂动脉瘤的处理策略

目的:探讨腹主动脉瘤合并髂动脉瘤的腔内修复术(EVAR)方法。方法:回顾性分析2007年8月—2014年3月35例腹主动脉瘤合并髂动脉瘤行EVAR术患者资料,其中9例合并单侧髂内动脉瘤,1例合并双侧髂内动脉瘤,14例合并单侧髂总动脉瘤(直径18 mm),11例合并双侧髂总动脉瘤,所用腔内技术包括栓塞髂内动脉瘤后覆盖,髂内动脉瘤单纯覆盖,"喇叭口"支架,以及"三明治"技术重建一侧髂内动脉等。结果:所有腔内技术均获得成功,手术时间(125±40)min,出血量(173±65)m L。术中发现内漏8例(22.9%),其中I型内漏4例(近端2例,远端2例)均经球囊扩张后内漏消失,III型内漏1例,经扩张及部分加弹簧圈栓塞后内漏消失,II型内漏2例及IV型内漏1例,均未予处理。35例术后随访6~60个月,无动脉瘤破裂,2例术后6个月发现腹主动脉瘤体增大,造影确诊远端I型内漏,经弹簧圈栓塞后内漏消失,其余33例瘤体直径无增大。结论:对于合并髂动脉瘤的腹主动脉瘤患者,有效处理髂内动脉,然后根据髂总动脉直径选择合适的治疗方法可以达到理想的近期效果。     

Characteristics and surgery of aneurysms of the proximal (A1) segment of the anterior cerebral artery

AIM: Proximal anterior cerebral artery (A1) aneurysms are considered to be rare or even unique. Proper surgical planning around A1 segment is particularly essential in order to avoid injury of tiny perforating arteries. METHODS: In 17 patients with angiographically or intraoperatively diagnosed A1 aneurysms, representing 0.8% of 2 124 aneurysm patients treated surgically at our institution between 1991 and 2003, clinical presentation, neuroradiological findings, surgical treatment methods and outcome were retrospectively analyzed. RESULTS: Sixteen patients presented with subarachnoid hemorrhage; A1 aneurysms were ruptured in 13 cases. Five patients (29%) had multiple aneurysms. In all cases A1 aneurysms were saccular and their maximum diameter ranged from 4 to 25 mm, average, 7.2 mm; in 4 cases they projected from the origin of the perforating artery, in 6 at the bifurcation of the internal carotid artery, in 5 at the anterior communicating artery and in 2 from the convexity of the parent artery. In 15 patients aneurysms were clipped via ipsilateral pterional approach and in the remaining 2, including a case with a second middle cerebral artery aneurysm, through contralateral approach. Eleven patients had excellent outcome, three good, and three died. CONCLUSIONS: Angiograms must be thoroughly analyzed to correctly assess origin of the aneurysmal neck, and to plan the operative procedure as radiological presentations of distal or proximal A1 lesions resemble those of anterior communicating artery and internal carotid artery bifurcation aneurysms, respectively. Contralateral approach may facilitate surgical elimination of selected A1 aneurysms or enable one-stage clipping in patients with multiple bilateral aneurysms.     

Isolated Hypogastric Artery Aneurysms

Iliac artery aneurysms are rare in the absence of concomitant abdominal aortic aneurysm (AAA), and isolated internal iliac (hypogastric) aneurysms in particular are extremely rare. From 1986 to 1997 we repaired 572 aortic and/or iliac artery aneurysms in 440 patients. Among these there were only seven hypogastric aneurysms and three of these occurred in the absence of, or remote to, AAA. Hypogastric aneurysms are difficult to diagnose, and large aneurysms are associated with significant morbidity and mortality due to compression of adjacent structures and a high rate of rupture. They pose technical challenges in repair because of their location deep in the pelvis and because it is difficult to gain distal control of the hypogastric artery and its branches. However, the technique of obliterative endoaneurysmorrhaphy has made repair of these aneurysms safe and straightforward. Moreover, this method, unlike percutaneous endovascular techniques, eliminates the compressive mass that is often associated with significant symptomatology. We report three isolated hypogastric aneurysms repaired over an 11-year period, illustrating the technique of proximal ligation and obliterative endoaneurysmorrhaphy, and review the literature on the topic.     

Management of inoperable cerebral aneurysms by the navigational balloon technique

Intravascular navigation with nondetachable balloons is a safe, effective method of treatment for inaccessible aneurysms of the internal carotid artery. The rate of ischemic complications is lower than that associated with carotid ligation, and the rate of subsequent hemorrhage is lower than that associated with either carotid ligation or direct clipping. Therefore, for many internal carotid artery aneurysms that originate at or proximal to the ophthalmic artery, the nondetachable balloon technique is an alternative treatment choice. During a 7-year period, 21 aneurysms of the internal carotid artery were treated by the nondetachable balloon technique. All 21 aneurysms were successfully excluded from the circulatory system by either proximal occlusion or trapping of the aneurysm neck. This series consisted of 8 carotid-ophthalmic artery aneurysms, 11 carotid-cavernous aneurysms (6 spontaneous, 5 traumatic), 1 petrous segment aneurysm, and 1 cervical segment aneurysm. At 3 years of follow-up, the following incidences were noted: transient ischemia, 4.7%; infarction, 9.6%; and hemorrhage, 0%. The complications were 1 case of transient hemiparesis and 2 late ischemic events. Fifty per cent of the patients underwent follow-up computed tomography, and thrombosis of the aneurysm was confirmed in all except one case, which was partially thrombosed.     

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

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.     

Vein compression by arterial aneurysms

This study was done to emphasize the importance of early, accurate diagnosis of arterial aneurysms that show the symptoms of venous obstruction. Fourteen patients were identified as having atherosclerotic aneurysms producing venous compression. Nine patients had popliteal aneurysms, causing popliteal vein thrombosis in three patients and vein compression without thrombosis in six patients. Five patients had iliac artery aneurysms, producing left iliac vein thrombosis in one patient and venous compression without thrombosis in four patients. In 10 patients the cause of the venous compression symptoms was correctly identified and appropriate revascularization was performed with successful results. In four patients, two with iliac artery aneurysms and two with popliteal artery aneurysms, the associated aneurysm was not identified. One patient died of a ruptured aneurysm and three patients had below-knee amputations because of untreatable distal ischemia. Inappropriate treatment of patients with venous obstruction from unrecognized arterial aneurysms is associated with unacceptable morbidity and mortality. Accurate diagnosis with timely aneurysm repair eliminates the risk of aneurysm rupture or thrombosis and simultaneously alleviates venous compression symptoms.