Successful Endovascular Treatment of a Symptomatic Common Iliac Aneurysm using a Vascular Plug
Article Outline
Abstract
Direct pressure on the lumbosacral plexus can result in varying patterns of pain, weakness and sensory disturbance in the lower limbs. We report a case of lumbosacral plexopathy due to direct compression from a 7
cm common iliac artery aneurysm in an 87-year-old gentleman. This was treated with an Amplatzer Vascular Plug (AVP), leading to resolution of the symptoms and successful exclusion of the aneurysm at one year.
Keywords: Iliac aneurysm, Lumbosacral plexus, Blood vessel prosthesis
Introduction
Lumbosacral plexopathy is caused by compression or damage to branches of the lumbosacral plexus (formed from the anterior rami of T12-S5), resulting in varying patterns of lower limb weakness, muscle wasting and altered sensation. A common iliac artery aneurysm is an infrequent cause, not previously been described in a patient with an aortobifemoral graft. The Amplatzer Vascular Plug (AVP) is a relatively new expandable occlusive device with a potentially widespread application for embolisation of vessels unsuitable for conventional endovascular coiling.1 Here we report a case of successful treatment of lumbar plexopathy caused by common iliac artery aneurysm using the AVP Fig. 1, Fig. 2.
Fig. 1
(a) Digital subtraction angiograms (DSA) prior to endovascular deployment of AVPs; (b) deployment of AVP in EIA with AVP in situ in IIA.
Fig. 2
(a) Contrast CT. 7
cm CIA aneurysm pre-embolisation; (b) IIA and EIA occluded by single AVPs; (c) thrombosed, excluded aneurysm 1 year post-procedure.
Case Report
An 87-year-old gentleman, who was previously independently mobile, presented with a two month history of worsening right iliac fossa pain, right leg weakness and increasing difficulty walking. Fifteen years previously he underwent open repair of an abdominal aortic aneurysm with an aortobifemoral graft. His only regular medication was Aspirin.
Examination revealed a tender pulsatile right iliac fossa mass, intense pain on right straight leg raise, and weakness of right hip flexion and knee extension (Medical Research CouncilPower grade 3). Sensation was decreased to light touch and pin-prick in the right leg in an L3/L4 dermatomal distribution. Deep tendon reflexes were reduced bilaterally. C-reactive protein was 61, but otherwise blood results were normal.
A CT scan revealed a 7cm fusiform aneurysm of the right native common iliac artery (CIA) overlying the lumbosacral plexus, which backfilled the right internal iliac artery (IIA). The right IIA and external iliac artery (EIA) were each occluded by a 14mm AVP introduced with an 8Fr sheath via a single ipsilateral retrograde femoral artery approach. A follow-up contrast run confirmed exclusion of the aneurysm with absence of perfusion, and CT scans at seven days and one year post-procedure confirmed the accurate position of the two AVPs with complete exclusion and thrombosis of the aneurysm, with no evidence of recanalisation.
His pain improved rapidly and hip flexion and knee extension was improved with physiotherapy. He regained his premorbid function, and returned home with no additional support.
Discussion
Lumbosacral plexopathy has been described in several cases with internal iliac artery aneurysms, but in only two patients with common iliac artery aneurysms.2 There are no previous reports involving a common iliac artery aneurysm with an aortobifemoral graft. Other causes include diabetic neuropathy, local invasion or compression by neoplasm, radiation therapy, psoas abscess, retroperitoneal haematoma, abdominal aortic aneurysm, renal transplantation, and endometriosis.3
The Amplatzer vascular plug (AVP) is an expandable occlusive device made of nitinol mesh with a simple deployment mechanism, which allows the device to be repositioned prior to deployment after a check angiogram. It is not widely used, although a number of applications have been described in the literature.4 In the largest series to date of 23 varied cases, complete occlusion was achieved after 10–15min using an AVP alone in 61%.5 The use of additional coils was found to be unnecessary in most circumstances if adequate time was allowed for thrombosis to occur.
The AVP deployment sheath does requires a larger catheter than for simple coil placement and spontaneous recanalisation of an AVP has been described.6 The plug is currently expensive compared to standard steel coils, although fewer devices are required. It can therefore be cost-effective and time-saving, with appropriate case selection. It is also useful for situations where titanium or steel coils would be unsuitable, such as in large, short, or high-flow vessels, where multiple coils would be required, or risk of coil migration is high.
In this case, we describe a novel application of the Amplatzer AVP, in the successful treatment of lumbar plexopathy secondary to a CIA aneurysm in a patient with an aortobifemoral graft.
References
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- . Recurrent rupture of a hypogastric aneurysm caused by spontaneous recanalization of an Amplatzer vascular plug. J Vasc Interv Radiol. 2006;17(6):1037–1041
PII: S1533-3167(08)00013-7
doi:10.1016/j.ejvsextra.2008.08.003
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
