Amit Bhakoo, MD
Mount Sinai Medical Center, Miami Beach, FL

CHIEF COMPLAINT & MEDICAL HISTORY
• CC: Generalized weakness and abdominal pain
• HPI: Patient is an 86 year old African American male who presented as an outpatient with generalized weakness and abdominal pain. He denies any nausea, vomiting, diarrhea or constipation. The onset of symptoms has been gradual with no alleviating or aggravating factors. He describes the pain as dull, nonradiating and moderate in severity. No particular time course for his time course throughout the day. No associated symptoms.
• ROS: Twelve-point review of systems otherwise negative
• PMHx: HTN, anemia, gout, GERD
• PSHx: None
• Meds: ASA, Coreg, Plavix, Colchicine, Sucralfate, Vitamin B12
• Allergies: Bactrim, ACEi
• FamHx: Non-contributory
• SocHx: Retiree, widowed, no history of alcohol, tobacco or illict drug use

PHYSICAL EXAM
• VS: Temp: 98, HR: 80, BP: 148/92, RR: 12, O2 Sat: 99%
• Gen: Well-appearing male, in no acute distress
• Skin: Intact, no ecchymoses, bruises or open wounds
• Psych: Normal mood and affect
• HEENT: NCAT, PERRLA, EOMI
• CV: RRR, Nl S1, S2, no M/R/G
• Pulm: CTAB
• Abd: Palpable, pulsatile mass above the umbilicus. Easily reducible R inguinal mass
• MSK: Decreased muscle tone otherwise normal
• Neuro: Normal
• Extr: Warm, well-perfused, no clubbing, cyanosis or edema
• Vasc: Palpable UE pulses, 1+ DP/PT

NON-INVASIVE IMAGING
Contrast-enhanced CT images through the abdomen and pelvis show eccentric mural thrombus throughout the aneurysmal infrarenal aorta and bilateral common iliac arteries
6.3 x 6.4 x
9.4 cm infrarenal aortic aneursym with extension into the right common iliac artery.
Aneursymal dilation of both common iliac arteries, 3.3 cm on the right, 2.4 cm on the left

NON-INVASIVE IMAGING
Extensive mural thrombus is seen throughout the aorta and bilateral iliac arteries.
The irregular contour of the contrast-opacified lumen is seen in these images.

DIAGNOSIS AND TREATMENT OPTIONS
• Diagnosis: Infrarenal AAA and bilateral common iliac aneursyms
• Treatment options:
• Endovascular stenting with embolization of the right internal iliac artery
• Technically less challenging but with the potential for claudication or ischemia to the pelvic organs, bowel or lower extremity musculature.
• Endovascular stenting with right external iliac to internal iliac grafting to maintain pelvic perfusion on the right
• Technically challenging and with potential complications from additional surgery/intervention to create external iliac - internal iliac graft
• Endovascular stenting with branching stent grafts to the aorta and iliac vasculature
• Maintains native blood flow but with significant technical challenges
• Open surgical repair
• Significant risk of morbidity and mortality in this 86 year-old male, higher risk of infection and other complications

INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
• Using sterile technique, the left common femoral artery was punctured. Using proper catheter and guidewire technique, a 6-French sheath was placed across the iliac bifurcation with its tip in the area of the right internal iliac artery.
• The right internal iliac artery lumen contained thrombus related to the 4-cm aneurysm.
• A microcatheter was then used to cannulate at least three divisions of the anterior division of the right internal iliac artery. The ultraselective cannulation was performed and embolization with coils was performed using the Penumbra coil system. Embolization of three ultra selective branches was performed with the coils extending back up into the ostium of the anterior division.
• Following this, microcatheter technique was used to ultraselectively cannulate three branches of the posterior division of the right internal iliac artery. Coils were then deposited within the three separate ultraselective branches of the right internal iliac artery posterior division. The embolization was then performed back up to the ostium of the internal iliac artery.
• Two coils were placed within the distal aspect of the right internal iliac artery distal to the large accumulation of thrombus. This was confirmed angiographically.

INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
• Using sterile technique, an 18-French sheath was inserted into the right common femoral artery and a 16-French sheath was inserted into the left common femoral artery.
• A 23 x 12 x 18 excluder modular bifurcated prosthesis was placed via the right groin and deployed. A small type 1 leak was seen but then corrected using a 16 x 12 x 7 distal extension.
• This extended the device into the mid aspect of the right external iliac artery and post-deployment and dilation, good seal was seen distally.
• The left-sided device was then deployed through the left groin which was previously cannulated using a Kumpe catheter and stiff Terumo guidewire. The left-sided prothesis measured 23 x 10 with a bell-bottom shape.
• Following placement of the contralateral limb and post dilatation, imaging was performed in multiple projections showing no evidence for type 1, type 2, type 3, or type 4 endoleak.

INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Catheter angiography of the aorta and iliac vessels show aneursymal dilation of the aorta and proximal portions of the bilateral common iliac arteries, arrow points to pigtail catheter in the aorta

INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Aneursymal dilation of the bilateral common iliac arteries

INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Embolization of the right internal iliac artery with the penumbra coil
Technically successful embolization of the anterior and posterior branches of the right internal iliac artery

INTERVENTION: ENDOVASCULAR STENTING
WITH EMBOLIZATION OF THE RIGHT INTERNAL
ILIAC ARTERY
Status-post placement of aortoiliac stent graft

SUMMARY
• 86 male presented with abdominal pain and weakness
• Found to have an infrarenal AAA with bilateral common iliac aneursyms
• Treatment options included endovascular repair with internal iliac embolization, endovascular repair with branching stent grafts, endovascular repair with ipsilateral external-internal iliac bypass or open surgery
• Patient was thought to be best suited for endovascular repair with internal iliac embolization which was completed successfully