DOI: 10.1148/rg.25si055517
Endovascular Treatment of Iliac Artery Aneurysms1
Ichiro Sakamoto, MD,
Eijun Sueyoshi, MD,
Shiro Hazama, MD,
Kenji Makino, MD,
Akifumi Nishida, MD,
Tetsuji Yamaguchi, MD,
Kiyoyuki Eishi, MD and
Masataka Uetani, MD
1 From the Departments of Radiology (I.S., E.S., K.M., A.N., T.Y., M.U.) and Cardiovascular Surgery (S.H., K.E.), Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received April 1, 2005; revision requested May 6 and received July 5; accepted July 12. All authors have no financial relationships to disclose.
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Figure 1a. Aneurysm of the right common iliac artery in a 66-year-old man with an initial symptom of intermittent claudication. (a) Angiogram shows severe to moderate stenoses in the right common iliac artery that mimic arteriosclerosis obliterans. (b) Coronal computed tomographic (CT) scan shows an aneurysm of the right common iliac artery with severe narrowing of the vessel lumen due to a large volume of mural thrombus. (c) Angiogram obtained immediately after stent-graft placement in the right common and external iliac arteries shows complete exclusion of the aneurysm and restoration of the luminal diameter.
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Figure 1b. Aneurysm of the right common iliac artery in a 66-year-old man with an initial symptom of intermittent claudication. (a) Angiogram shows severe to moderate stenoses in the right common iliac artery that mimic arteriosclerosis obliterans. (b) Coronal computed tomographic (CT) scan shows an aneurysm of the right common iliac artery with severe narrowing of the vessel lumen due to a large volume of mural thrombus. (c) Angiogram obtained immediately after stent-graft placement in the right common and external iliac arteries shows complete exclusion of the aneurysm and restoration of the luminal diameter.
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Figure 1c. Aneurysm of the right common iliac artery in a 66-year-old man with an initial symptom of intermittent claudication. (a) Angiogram shows severe to moderate stenoses in the right common iliac artery that mimic arteriosclerosis obliterans. (b) Coronal computed tomographic (CT) scan shows an aneurysm of the right common iliac artery with severe narrowing of the vessel lumen due to a large volume of mural thrombus. (c) Angiogram obtained immediately after stent-graft placement in the right common and external iliac arteries shows complete exclusion of the aneurysm and restoration of the luminal diameter.
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Figure 2a. Gradual shrinkage of an IAA treated with coil embolization. (a) Preembolization CT scan shows an aneurysm of the right internal iliac artery. (b) CT scan obtained 22 months after coil embolization shows gradual interval shrinkage of the thrombosed aneurysm.
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Figure 2b. Gradual shrinkage of an IAA treated with coil embolization. (a) Preembolization CT scan shows an aneurysm of the right internal iliac artery. (b) CT scan obtained 22 months after coil embolization shows gradual interval shrinkage of the thrombosed aneurysm.
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Figure 3a. Stent-graft placement for an infected aneurysm of the right common iliac artery in a 78-year-old man with a serious case of pneumonia. (a) Pelvic angiogram shows a saccular aneurysm of the right common iliac artery. (b) Angiogram obtained immediately after stent-graft placement shows complete exclusion of the aneurysm. (c) Coronal CT scan obtained 2 months later shows revascularization and interval enlargement of the treated aneurysm. In addition, a newly developed infected aneurysm is seen in the lower abdominal aorta (arrow). Treatment of an infected aneurysm with stent-graft placement is controversial because of the risk of stent-graft infection and the fragility of the affected artery. Therefore, the use of stent-grafts should be restricted to patients for whom open surgery poses a high risk.
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Figure 3b. Stent-graft placement for an infected aneurysm of the right common iliac artery in a 78-year-old man with a serious case of pneumonia. (a) Pelvic angiogram shows a saccular aneurysm of the right common iliac artery. (b) Angiogram obtained immediately after stent-graft placement shows complete exclusion of the aneurysm. (c) Coronal CT scan obtained 2 months later shows revascularization and interval enlargement of the treated aneurysm. In addition, a newly developed infected aneurysm is seen in the lower abdominal aorta (arrow). Treatment of an infected aneurysm with stent-graft placement is controversial because of the risk of stent-graft infection and the fragility of the affected artery. Therefore, the use of stent-grafts should be restricted to patients for whom open surgery poses a high risk.
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Figure 3c. Stent-graft placement for an infected aneurysm of the right common iliac artery in a 78-year-old man with a serious case of pneumonia. (a) Pelvic angiogram shows a saccular aneurysm of the right common iliac artery. (b) Angiogram obtained immediately after stent-graft placement shows complete exclusion of the aneurysm. (c) Coronal CT scan obtained 2 months later shows revascularization and interval enlargement of the treated aneurysm. In addition, a newly developed infected aneurysm is seen in the lower abdominal aorta (arrow). Treatment of an infected aneurysm with stent-graft placement is controversial because of the risk of stent-graft infection and the fragility of the affected artery. Therefore, the use of stent-grafts should be restricted to patients for whom open surgery poses a high risk.
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Figure 4a. Limitations of catheter angiography in aneurysm evaluation. (a) Catheter angiogram shows an aneurysm of the left internal iliac artery, the proximal neck of which (arrow) appears to be long enough to allow safe embolization. (b) Coronal CT scan demonstrates a short distance between the aneurysm and the iliac artery bifurcation, indicating that proximal coil embolization would be technically unfeasible. In aneurysms with a large volume of mural thrombus, the exact length of the proximal and distal necks is difficult to evaluate with catheter angiography alone.
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Figure 4b. Limitations of catheter angiography in aneurysm evaluation. (a) Catheter angiogram shows an aneurysm of the left internal iliac artery, the proximal neck of which (arrow) appears to be long enough to allow safe embolization. (b) Coronal CT scan demonstrates a short distance between the aneurysm and the iliac artery bifurcation, indicating that proximal coil embolization would be technically unfeasible. In aneurysms with a large volume of mural thrombus, the exact length of the proximal and distal necks is difficult to evaluate with catheter angiography alone.
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Figure 5a. MR angiographic evaluation of the iliac arteries. (a) Maximum-intensity-projection image allows accurate measurement of the luminal diameters of the bilateral iliac arteries. (b, c) On left (b) and right (c) anterior maximum-intensity-projection images, the tortuosity of the iliac arteries is clearly displayed.
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Figure 5b. MR angiographic evaluation of the iliac arteries. (a) Maximum-intensity-projection image allows accurate measurement of the luminal diameters of the bilateral iliac arteries. (b, c) On left (b) and right (c) anterior maximum-intensity-projection images, the tortuosity of the iliac arteries is clearly displayed.
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Figure 5c. MR angiographic evaluation of the iliac arteries. (a) Maximum-intensity-projection image allows accurate measurement of the luminal diameters of the bilateral iliac arteries. (b, c) On left (b) and right (c) anterior maximum-intensity-projection images, the tortuosity of the iliac arteries is clearly displayed.
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Figure 6. Drawings illustrate the two treatment options that are available for a type I IAA: proximal and distal embolization (left) and coil packing and proximal embolization (right). The aneurysm is far enough from the origin of the internal iliac artery to allow proximal embolization.
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Figure 7a. Proximal and distal embolization of an aneurysm of the left internal iliac artery in an 80-year-old man. (a) Preembolization angiogram shows an aneurysm of the left internal iliac artery and dilatation of the left common iliac artery. (b) Postembolization angiogram shows that the aneurysm has been completely excluded. An aneurysm of the left common iliac artery was treated with stent-graft placement 12 months later.
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Figure 7b. Proximal and distal embolization of an aneurysm of the left internal iliac artery in an 80-year-old man. (a) Preembolization angiogram shows an aneurysm of the left internal iliac artery and dilatation of the left common iliac artery. (b) Postembolization angiogram shows that the aneurysm has been completely excluded. An aneurysm of the left common iliac artery was treated with stent-graft placement 12 months later.
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Figure 8a. Coil packing and proximal embolization of a ruptured aneurysm of the left internal iliac artery in an 86-year-old man. (a) Pretherapeutic angiogram shows an aneurysm of the left internal iliac artery and extravasated contrast material (arrow). (b) Posttherapeutic angiogram of the left internal iliac artery shows complete exclusion of the ruptured aneurysm.
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Figure 8b. Coil packing and proximal embolization of a ruptured aneurysm of the left internal iliac artery in an 86-year-old man. (a) Pretherapeutic angiogram shows an aneurysm of the left internal iliac artery and extravasated contrast material (arrow). (b) Posttherapeutic angiogram of the left internal iliac artery shows complete exclusion of the ruptured aneurysm.
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Figure 9. Drawings illustrate treatment of a type II IAA with a stent-graft (left) and a bare stent (right). Such an aneurysm is not far enough from the origin of the internal iliac artery to allow proximal embolization.
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Figure 10a. Embolization and stent-graft placement in an ipsilateral internal iliac artery for an aneurysm of the left internal iliac artery in a 73-year-old woman. (a) Sagittal multiplanar reformatted CT image shows an aneurysm of the left internal iliac artery located a short distance from the iliac artery bifurcation. The aneurysm was treated with embolization of distal branches of the left internal iliac artery followed by stent-graft placement in the left common and external iliac arteries. (b) Angiogram obtained immediately after the procedure shows complete exclusion of the aneurysm. (c) Coronal multiplanar reformatted CT image obtained 2 months later shows complete thrombosis of the aneurysm.
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Figure 10b. Embolization and stent-graft placement in an ipsilateral internal iliac artery for an aneurysm of the left internal iliac artery in a 73-year-old woman. (a) Sagittal multiplanar reformatted CT image shows an aneurysm of the left internal iliac artery located a short distance from the iliac artery bifurcation. The aneurysm was treated with embolization of distal branches of the left internal iliac artery followed by stent-graft placement in the left common and external iliac arteries. (b) Angiogram obtained immediately after the procedure shows complete exclusion of the aneurysm. (c) Coronal multiplanar reformatted CT image obtained 2 months later shows complete thrombosis of the aneurysm.
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Figure 10c. Embolization and stent-graft placement in an ipsilateral internal iliac artery for an aneurysm of the left internal iliac artery in a 73-year-old woman. (a) Sagittal multiplanar reformatted CT image shows an aneurysm of the left internal iliac artery located a short distance from the iliac artery bifurcation. The aneurysm was treated with embolization of distal branches of the left internal iliac artery followed by stent-graft placement in the left common and external iliac arteries. (b) Angiogram obtained immediately after the procedure shows complete exclusion of the aneurysm. (c) Coronal multiplanar reformatted CT image obtained 2 months later shows complete thrombosis of the aneurysm.
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Figure 11a. Placement of a bare stent and proximal embolization through its wire mesh for an aneurysm of the right internal iliac artery in a 72-year-old man. (a) Pelvic angiogram shows an aneurysm of the right internal iliac artery with a wide mouth and a short neck. An aneurysm of the left common iliac artery is also seen. Insertion of a stent-graft was considered to be unfeasible because of the extreme tortuosity of the right external iliac artery (arrow). Therefore, treatment consisted of placement of a bare stent (Wallstent; Boston Scientific, Natick, Mass) in the right common and external iliac arteries, followed by embolization with a catheter inserted through the wire mesh of the stent into a proximal part of the internal IAA. (b) Fluoroscopic image obtained immediately after stent placement shows the catheter (black arrows). Coil embolization was subsequently performed via the catheter. White arrows indicate distal embolization coils. (c) Posttreatment angiogram shows complete exclusion of the right internal IAA. The left common IAA was treated with stent-graft placement 1 month later.
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Figure 11b. Placement of a bare stent and proximal embolization through its wire mesh for an aneurysm of the right internal iliac artery in a 72-year-old man. (a) Pelvic angiogram shows an aneurysm of the right internal iliac artery with a wide mouth and a short neck. An aneurysm of the left common iliac artery is also seen. Insertion of a stent-graft was considered to be unfeasible because of the extreme tortuosity of the right external iliac artery (arrow). Therefore, treatment consisted of placement of a bare stent (Wallstent; Boston Scientific, Natick, Mass) in the right common and external iliac arteries, followed by embolization with a catheter inserted through the wire mesh of the stent into a proximal part of the internal IAA. (b) Fluoroscopic image obtained immediately after stent placement shows the catheter (black arrows). Coil embolization was subsequently performed via the catheter. White arrows indicate distal embolization coils. (c) Posttreatment angiogram shows complete exclusion of the right internal IAA. The left common IAA was treated with stent-graft placement 1 month later.
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Figure 11c. Placement of a bare stent and proximal embolization through its wire mesh for an aneurysm of the right internal iliac artery in a 72-year-old man. (a) Pelvic angiogram shows an aneurysm of the right internal iliac artery with a wide mouth and a short neck. An aneurysm of the left common iliac artery is also seen. Insertion of a stent-graft was considered to be unfeasible because of the extreme tortuosity of the right external iliac artery (arrow). Therefore, treatment consisted of placement of a bare stent (Wallstent; Boston Scientific, Natick, Mass) in the right common and external iliac arteries, followed by embolization with a catheter inserted through the wire mesh of the stent into a proximal part of the internal IAA. (b) Fluoroscopic image obtained immediately after stent placement shows the catheter (black arrows). Coil embolization was subsequently performed via the catheter. White arrows indicate distal embolization coils. (c) Posttreatment angiogram shows complete exclusion of the right internal IAA. The left common IAA was treated with stent-graft placement 1 month later.
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Figure 12. Drawing illustrates treatment of a type III aneurysm of the common iliac artery. The aneurysm is far enough from the aortoiliac bifurcation to allow placement of a straight stent-graft.
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Figure 13a. Embolization and stent-graft placement in an ipsilateral internal iliac artery for an aneurysm of the left common iliac artery in a 78-year-old man. (a) CT angiogram shows a large aneurysm extending from the left common iliac artery to the internal iliac arteries. The aneurysm was treated with embolization of distal branches of the left internal iliac artery followed by stent-graft placement in the left common and external iliac arteries. (b) Angiogram obtained immediately after the procedure shows complete exclusion of the aneurysm. (c) Coronal multiplanar reformatted CT image obtained 2 months later shows complete thrombosis of the aneurysm and patency of the stent-graft.
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Figure 13b. Embolization and stent-graft placement in an ipsilateral internal iliac artery for an aneurysm of the left common iliac artery in a 78-year-old man. (a) CT angiogram shows a large aneurysm extending from the left common iliac artery to the internal iliac arteries. The aneurysm was treated with embolization of distal branches of the left internal iliac artery followed by stent-graft placement in the left common and external iliac arteries. (b) Angiogram obtained immediately after the procedure shows complete exclusion of the aneurysm. (c) Coronal multiplanar reformatted CT image obtained 2 months later shows complete thrombosis of the aneurysm and patency of the stent-graft.
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Figure 13c. Embolization and stent-graft placement in an ipsilateral internal iliac artery for an aneurysm of the left common iliac artery in a 78-year-old man. (a) CT angiogram shows a large aneurysm extending from the left common iliac artery to the internal iliac arteries. The aneurysm was treated with embolization of distal branches of the left internal iliac artery followed by stent-graft placement in the left common and external iliac arteries. (b) Angiogram obtained immediately after the procedure shows complete exclusion of the aneurysm. (c) Coronal multiplanar reformatted CT image obtained 2 months later shows complete thrombosis of the aneurysm and patency of the stent-graft.
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Figure 14. Drawings illustrate treatment of a type IV aneurysm of the common iliac artery. The aneurysm is not far enough from the aortoiliac bifurcation to allow proximal embolization.
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Figure 15a. Stent-graft placement in the aorta and a single iliac artery and femorofemoral crossover bypass grafting for an aneurysm of the right common iliac artery in a 78-year-old man. (a, b) Angiogram (a) and coronal multiplanar reformatted CT image (b) show an aneurysm of the right common iliac artery located a short distance from the aortoiliac bifurcation. Mural thrombus is also seen in the aneurysm (arrows in b). The patient underwent stent-graft placement in the lower abdominal aorta and the left common iliac artery and embolization of the right common and internal iliac arteries. Femorofemoral bypass grafting was subsequently performed to preserve blood flow to the right leg. (c) Angiogram obtained immediately after the procedure shows complete exclusion of the common IAA and patency of the femorofemoral bypass graft.
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Figure 15b. Stent-graft placement in the aorta and a single iliac artery and femorofemoral crossover bypass grafting for an aneurysm of the right common iliac artery in a 78-year-old man. (a, b) Angiogram (a) and coronal multiplanar reformatted CT image (b) show an aneurysm of the right common iliac artery located a short distance from the aortoiliac bifurcation. Mural thrombus is also seen in the aneurysm (arrows in b). The patient underwent stent-graft placement in the lower abdominal aorta and the left common iliac artery and embolization of the right common and internal iliac arteries. Femorofemoral bypass grafting was subsequently performed to preserve blood flow to the right leg. (c) Angiogram obtained immediately after the procedure shows complete exclusion of the common IAA and patency of the femorofemoral bypass graft.
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Figure 15c. Stent-graft placement in the aorta and a single iliac artery and femorofemoral crossover bypass grafting for an aneurysm of the right common iliac artery in a 78-year-old man. (a, b) Angiogram (a) and coronal multiplanar reformatted CT image (b) show an aneurysm of the right common iliac artery located a short distance from the aortoiliac bifurcation. Mural thrombus is also seen in the aneurysm (arrows in b). The patient underwent stent-graft placement in the lower abdominal aorta and the left common iliac artery and embolization of the right common and internal iliac arteries. Femorofemoral bypass grafting was subsequently performed to preserve blood flow to the right leg. (c) Angiogram obtained immediately after the procedure shows complete exclusion of the common IAA and patency of the femorofemoral bypass graft.
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Figure 16. Drawings illustrate treatment options for a type V aneurysm (common or internal IAA that develops after AAA repair with a bifurcated graft).
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Figure 17. Drawings illustrate AAA repair in which a bifurcated graft is implanted with the graft limbs anastomosed end-to-side with the external iliac arteries. In cases treated with this method, pelvic circulation is retrograde via the bilateral external iliac arteries, and continued perfusion of cul-de-sac–shaped common iliac arteries may induce progressive dilatation.
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Figure 18a. Proximal and distal embolization for an aneurysm of the right common iliac artery in a 78-year-old man. The patient had a history of AAA repair in which a bifurcated graft was implanted with the graft limbs anastomosed end-to-side with the external iliac arteries. (a) MR angiogram obtained 10 years after AAA repair shows an aneurysm of the right common iliac artery. (b) Angiogram obtained after the injection of contrast material into the right external iliac artery shows the fusiform aneurysm and retrograde enhancement of the right graft limb. (c) Immediate postembolization angiogram shows complete exclusion of the aneurysm.
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Figure 18b. Proximal and distal embolization for an aneurysm of the right common iliac artery in a 78-year-old man. The patient had a history of AAA repair in which a bifurcated graft was implanted with the graft limbs anastomosed end-to-side with the external iliac arteries. (a) MR angiogram obtained 10 years after AAA repair shows an aneurysm of the right common iliac artery. (b) Angiogram obtained after the injection of contrast material into the right external iliac artery shows the fusiform aneurysm and retrograde enhancement of the right graft limb. (c) Immediate postembolization angiogram shows complete exclusion of the aneurysm.
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Figure 18c. Proximal and distal embolization for an aneurysm of the right common iliac artery in a 78-year-old man. The patient had a history of AAA repair in which a bifurcated graft was implanted with the graft limbs anastomosed end-to-side with the external iliac arteries. (a) MR angiogram obtained 10 years after AAA repair shows an aneurysm of the right common iliac artery. (b) Angiogram obtained after the injection of contrast material into the right external iliac artery shows the fusiform aneurysm and retrograde enhancement of the right graft limb. (c) Immediate postembolization angiogram shows complete exclusion of the aneurysm.
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Figure 19a. Iliac artery injury with subsequent stent-graft thrombosis. (a) Angiogram obtained immediately after stent-graft placement for an aneurysm of the right common iliac artery shows acute thrombosis of the stent-graft. The patient subsequently underwent thrombectomy. (b) Angiogram obtained immediately after thrombectomy shows recanalization of the stent-graft and severe stenosis of the right external iliac artery (arrow) caused by insertion of the delivery system. (c) Angiogram obtained after stent placement in the stenosed lesion shows restoration of the luminal diameter.
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Figure 19b. Iliac artery injury with subsequent stent-graft thrombosis. (a) Angiogram obtained immediately after stent-graft placement for an aneurysm of the right common iliac artery shows acute thrombosis of the stent-graft. The patient subsequently underwent thrombectomy. (b) Angiogram obtained immediately after thrombectomy shows recanalization of the stent-graft and severe stenosis of the right external iliac artery (arrow) caused by insertion of the delivery system. (c) Angiogram obtained after stent placement in the stenosed lesion shows restoration of the luminal diameter.
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Figure 19c. Iliac artery injury with subsequent stent-graft thrombosis. (a) Angiogram obtained immediately after stent-graft placement for an aneurysm of the right common iliac artery shows acute thrombosis of the stent-graft. The patient subsequently underwent thrombectomy. (b) Angiogram obtained immediately after thrombectomy shows recanalization of the stent-graft and severe stenosis of the right external iliac artery (arrow) caused by insertion of the delivery system. (c) Angiogram obtained after stent placement in the stenosed lesion shows restoration of the luminal diameter.
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Figure 20a. Stent-graft thrombosis. (a) CT scan obtained 1 week after stent-graft placement for an aneurysm of the left common iliac artery shows patency of the stent-graft. (b) CT scan obtained 2 months after treatment shows occlusion of the stent-graft. The patient subsequently underwent a femorofemoral crossover bypass procedure. (c) Coronal multiplanar reformatted CT image shows patency of the bypass graft.
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Figure 20b. Stent-graft thrombosis. (a) CT scan obtained 1 week after stent-graft placement for an aneurysm of the left common iliac artery shows patency of the stent-graft. (b) CT scan obtained 2 months after treatment shows occlusion of the stent-graft. The patient subsequently underwent a femorofemoral crossover bypass procedure. (c) Coronal multiplanar reformatted CT image shows patency of the bypass graft.
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Figure 20c. Stent-graft thrombosis. (a) CT scan obtained 1 week after stent-graft placement for an aneurysm of the left common iliac artery shows patency of the stent-graft. (b) CT scan obtained 2 months after treatment shows occlusion of the stent-graft. The patient subsequently underwent a femorofemoral crossover bypass procedure. (c) Coronal multiplanar reformatted CT image shows patency of the bypass graft.
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Figure 21a. Collateralization to distal branches of the IMA via mesenteric collateral vessels. The patient had previously undergone proximal ligation of the IMA during AAA repair. Angiograms of the SMA demonstrate sufficient collateral flow to distal branches of the IMA, including the superior rectal artery (arrows in b). In this case, bilateral exclusion of the internal iliac arteries was tolerated without major complications.
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Figure 21b. Collateralization to distal branches of the IMA via mesenteric collateral vessels. The patient had previously undergone proximal ligation of the IMA during AAA repair. Angiograms of the SMA demonstrate sufficient collateral flow to distal branches of the IMA, including the superior rectal artery (arrows in b). In this case, bilateral exclusion of the internal iliac arteries was tolerated without major complications.
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Copyright © 2005 by the Radiological Society of North America.
