69 - Endovascular and Percutaneous Management of a Distal Abdominal Aortic Pseudoaneurysm
K. Wattamwar, P. Goyal, J. Cynamon
Purpose: Endovascular embolization of an aneurysm or pseudoaneurysm (PSA) may be challenging due to sac geometry and/or difficult super selective catheterization. Percutaneous techniques may offer a direct approach to embolization.
Material and Methods: A 74 year old male with a right iliopsoas abscess underwent a series of abdominal computed tomography angiograms (CTAs) revealing phlegmonous changes surrounding the right common iliac artery (CIA), an occluded right CIA stent, and a patent left CIA stent with a 1 to 2 cm expanding and possibly mycotic PSA arising from the distal abdominal aorta or a lumbar vessel just above the aortic bifurcation.
Results: An aortogram demonstrated a bilobed PSA either arising directly off the distal aorta or a lumbar artery. During attempted lumbar artery catheterization the selective catheter entered the PSA, demonstrating its origin off the distal aorta. A lumbar artery was noted arising off the PSA. A stent graft was considered but due to the lumbar artery and the possibility of underlying infection, it was decided to attempt exclusion with embolization. A 2.7-French Progreat (Terumo, Tokyo, Japan) microcatheter was advanced into the left lobe of the PSA and a 6 mm x 10 cm Azur (Terumo, Tokyo, Japan) coil was detached after confirming stability of the coil. Attention was then directed towards embolizing the right lobe of the PSA, which demonstrated persistent filling. Due to concern that further manipulation may dislodge the existing coil, a percutaneous approach to the right lobe was chosen. A 21G needle was advanced percutaneously to access the right lobe under fluoroscopic guidance. A 6 mm x 20 cm Azur coil was deployed within the right lobe of the PSA. A small portion of the right sided coil was noted to prolapse into the left CIA, which was of concern. Using the coil mass as scaffolding, 0.3 mL of Onyx 34 (Medtronic, Dublin, Ireland) was carefully injected into the PSA to avoid nontarget embolization. To secure the coil and prevent migration, a 10 mm x 4 cm SMART stent (Cordis, Hialeah, FL) was deployed in the left CIA. Cone beam CT showed exclusion of the PSA. Left lower extremity arteriograms were performed to rule out distal non target embolization.
Conclusions: Percutaneous embolization of an aneurysm or PSA may be suitable instead of, or in conjunction with, an endovascular approach, when there is complex sac geometry or risk of disturbing a partially completed embolization.