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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3663_Библиотеки_им_академика_М_И_Перельмана
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7 “Mind theGap”: Bridging theBranched Graft Disconnect
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ab
23
Fig. 7.2 (a) Diagnostic catheter was advanced through the branch
identied by three proximal (white arrow) and two distal (black arrow)
markers. (b) Wire loop created in the aneurysm sac facilitated catheter-
ization though the proximal ostium of the Fluency stent (white arrows)
into the SMA
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Fig. 7.3 A 12-mm balloon was inated in the Fluency stent graft (a) allowing for straightening of the loop (b, c)
24
A. Hadziomerovic
Fig. 7.4 Completion angiogram following deployment of Advanta
V12 stent graft conrming patency of the SMA and no further endo
leak
Fig. 7.5 Reconstructed CTA at 33months shows in line ow into the
SMA
Percutaneous Iliac Artery Type II
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Endoleak Embolization Complicated
byActive Extravasation
HowardM.Richard III
A 79-year-old male underwent endograft treatment of a
6.2 cm × 6.9 cm diameter right iliac artery aneurysm.
Thereafter, an endoleak was treated with an Amplatzer plug.
Following a decrease in size, the aneurysm grew to 8 ×
7.1cm diameter.
Using a combined CT and uoroscopy suite, a 4 French
11 cm sheath and a 4 French angled catheter were placed
directly into the aneurysm sac through a transabdominal
approach (Fig. 8.1) [1]. Angiography was performed to
dene any outow. During catheter manipulation, the 4
French sheath inadvertently backed out of the aneurysm
leaving the 4 French Kumpe catheter alone within the aneurysm sac. Angiography demonstrated an increasing amount
of contrast overlying the pelvis (Fig.8.2) and active extravasation was conrmed by immediate repeat pelvic CT. This
conrmed a large amount intra-pelvic extravasation
(Fig. 8.3). The patient became hemodynamically unstable
and was resuscitated with normal saline boluses and emergency blood transfusion.
In parallel to the resuscitation, the 4 French sheath was
exchanged for a 5 French 25cm sheath, advanced into the
aneurysm sac. The aneurysm sac was rapidly embolized with
130 Nester coils (Cook Medical, Inc) and 5000 units of
thrombin. The thrombin-soaked Nester coils were injected
into the aneurysm with a 1 mL syringe at a rate greater than
four coils per minute. The patient’s hemodynamic status
improved. Distal aortic and pelvic angiography conrmed
that the extravasation had ceased; both the catheter and
sheath were removed. He was admitted for observation. He
received a total of two units of blood. Daily pelvic ultrasound
demonstrated aneurysm stability and he was discharged on
the third post-embolization day. One-month follow-up ultra-
8
Fig. 8.1 CT guided transabdominal aneurysm sac puncture
sound demonstrated a 9cm aneurysm without Doppler ow.
At 1-year follow-up, the endoleak recurred. A CT scan scout
image demonstrated the right iliac artery aneurysm sac and
coils (Fig.8.4). A third embolization procedure, of the anterior and posterior internal iliac artery outow, was successful. Eight-year follow-up conrmed durable control of the
4.1cm aneurysm.
When performing direct sac embolization, it is imperative
to maintain constant control to prevent inadvertent retraction
of the “base” entry catheter. This phenomenon may be a
greater risk when working under pure CT guidance or in a
non-orthogonal, i.e., down the gun-barrel uoroscopic view.
H. M. Richard III (*)
Division of Interventional Radiology, Department of Diagnostic
Imaging, University of Maryland School, Baltimore, MD, USA
e-mail: HRICHARD@umm.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_8
26
8 Percutaneous Iliac Artery Type II Endoleak Embolization Complicated byActive Extravasation
Fig. 8.2 Digital subtracted angiography demonstrates contrast medial
and lateral to the aneurysm (arrowheads). Coils and Amplatzer plug
were placed at the time of prior interventions
Fig. 8.4 Follow up CT scout image demonstrates coils within the
aneurysm sac
27
Fig. 8.3 CT scan demonstrates active contrast extravasation and hematoma in the pelvis
Bibliography
1. Zener R, Oreopoulos G, Beecroft R, Rajan DK, Jaskolka J, Tan
KT.Transabdominal direct sac puncture embolization of type II
endoleaks after endovascular abdominal aortic aneurysm repair. J
Vasc Interv Radiol. 2018;29(8):1167–73.
“One Way In”: Percutaneous
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Transarterial Embolization
ofaPersistent Iliac Aneurysm
BrianFunaki
9
A 67-year-old man who had undergone endovascular aortic
stent graft repair for bilateral common iliac and left internal
iliac aneurysms had continued perfusion of the left internal
iliac aneurysm; it enlarged further by 1.2cm over the course
of 9months (Fig. 9.1). The left internal iliac aneurysm had
been partly embolized with coils, then covered with the left
limb of the stent graft at the time of initial repair, precluding
subsequent arterial access (Fig.9.2).
Using CT guidance, the aneurysm sac was punctured with
a 21-gauge needle directed into the perfused cavity (Fig.9.3a).
Upon obtaining blood return, 20 microcoils (Nestors, Cook,
Bloomington, IN) were deployed through the puncture needle
into the aneurysm (Fig.9.3b). Despite this, continued backbleeding through the needle occurred (Fig.9.4). The patient
was moved to the IR suite and the needle exchanged for a 5 F
dilator. An angiogram showed multiple feeding arteries and a
larger than expected residual cavity (Fig.9.5). Multiple feeding branches were then catheterized using a microcatheter
advanced co-axially through 5 F dilator and embolized with
microcoils (Nestors, Cook) until hemostasis was achieved
(Fig.9.6). At 2years follow- up, CT showed no further perfusion and no further growth of the aneurysm (Fig.9.7).
Fig. 9.1 CT images showing enlargement of left internal iliac artery aneurysm
B. Funaki (*)
Department of Radiology, University of Chicago,
Chicago, IL, USA
e-mail: bfunaki@bsd.uchicago.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_9
28
9 “One Way In”: Percutaneous Transarterial Embolization ofaPersistent Iliac Aneurysm
29
Fig. 9.2 CT reconstruction and illustration of left internal iliac artery aneurysm
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Fig. 9.3 (a) Axial CT image shows needle puncture of left hypogastric artery aneurysm. (b) Axial CT image demonstrates multiple deployed coils
in perfused portion of aneurysm
30
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B. Funaki
Fig. 9.4 Photograph shows continued backbleeding through needle
Fig. 9.6 Final uoroscopic image showing coil embolization of per-
fused cavity and multiple feeding arteries
Fig. 9.5 Angiogram obtained via the puncture needle shows multiple
feeding arteries (red dotted line shows overall size of aneurysm sac)
Fig. 9.7 Coronal reformatted CT showing embolized nidus with no
residual perfusion of aneurysm
Percutaneous Ilio-Femoral Arterial
Bypass
BulentArslan
10
A 42-year-old male presented with toe pain, and purulent toe
wound and claudication. He had undergone multiple surgeries after a pelvic gunshot wound 15years earlier.
Computed tomography (CT) and catheter angiography
showed a failed fem-fem bypass graft, occlusion of left common and external iliac arteries, and reconstitution of the left
common femoral artery (Fig.10.1a, b).
Using a right proximal SFA approach, an 8.5 Fr Aptus
steerable sheath (Medtronic) was advanced into occluded
left common iliac artery (Fig.10.1c); the left common femoral artery was inaccessible due to extensive surgical scarring.
The back-end of an HydroST 0.014 wire (Cook) and a
Quickcross catheter (Merit Medical) were used to reach the
external iliac artery (EIA) level (Fig.10.1d). The back-end of
a −0.035″ Glidewire (Boston Scientic) was advanced from
the contralateral approach to reach the same level (Fig.10.2a).
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Cone beam CT showed the ureter to lie between the two
wires, thus the contralateral sheath was advanced further to the
mid left EIA.At that level, a 30mm Ensnare (Merit) deployed.
A second steerable sheath was advanced from left SFA
approach and through this sheath, a transseptal needle (Cook)
was advanced into the snare after conrming its position by
orthogonal uoroscopy (Fig. 10.2b, c) and cone beam
CT.Through the transseptal needle a 0.014″ HydroST guidewire was grasped and externalized (Fig.10.2e). Two 8 ×15
and 8×10 Viabahn stent grafts (W.L Gore) were deployed and
dilated (Fig.10.3a–c). Suture mediated closure of the SFA was
performed. Patient was placed on Clopidogrel 75 mg and
Aspirin 81mg for 1month, followed by Aspirin indenitely.
At 1month, CTA demonstrated a patent iliofemoral system (Fig.10.3d, e). The patient maintained his newly palpable distal pulses and wound showed interim healing.
Fig. 10.1 (a) Aortogram demonstrates the occluded left common iliac
artery with a short stump. (b) Reconstitution at the proximal left common femoral artery through collaterals. (c) Advancement of the contra-
B. Arslan (*)
Vascular and Interventional Service Line, Rush University Medical
Center, Chicago, IL, USA
e-mail: BULENT_ARSLAN@rush.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_10
lateral balloon-assisted steerable sheath with sharp recanalization using
back-end of a 0.035″ hydrophilic wire. (d) Sharp recanalization using
back-end of a 0.014″ guidewire through the triaxial system
32
10 Percutaneous Ilio-Femoral Arterial Bypass
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33
Fig. 10.2 (a) The contralateral steerable sheath and triaxial retrograde
access are at the same level but actually distant from each other. (b, c)
The retrograde steerable sheath faces towards the up-and-over Ensnare,
seen in different obliquities (d) Failed attempt to use the back-end of a
0.014″ wire to connect into snare (e) Successful attempt to advance
through the snare with a transseptal needle
34
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B. Arslan
Fig. 10.3 Digital subtraction angiography after placement of the 8mm Viabahn stent grafts spanning the left common iliac artery stump to proximal left common femoral artery (a–c); Follow-up CTA in 1month demonstrates patency (d, e)
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