1Rytis Kijauskas, 1Milda Staniulytė
1Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Aim: To present a clinical case in which abdominal aortic aneurysm (AAA), common iliac artery (CIA) and internal iliac artery (IIA) aneurysms were cured for an unusually young patient, to discuss the methods of treatment and to present their results.
Case report: A 57-year-old man was presented at LUHS Kaunas Clinics Department of Vascular Surgery in 2014 with bilateral CIA stenosis. In 2016, he was presented again because of acute thrombosis of his left superficial femoral artery. Femoropopliteal bypass was formed and popliteal artery aneurysm (PAA) was resected. In 2017, an identical procedure was made on his right leg. In 2019, a Computer Tomography (CT) scan showed a widened infrarenal aneurysm (from 56 mm to 88 mm of length), changes in both CIA (23 mm and 23 mm respectively) and bilateral IIA (19 mm on the right side and 23 mm on the left side) so a spiral embolization of bilateral IAA was performed. In 2020 02 14 an endovascular artery repair (EVAR) was performed placing an aorto-bi-iliac stent graft.
Conclusion: According to the prevalence of AAA and IAA, the patient (57 years old) was unusually young to experience the occurrence of these pathologies (> 65 years). He had some typical risk factors: male gender, arterial hypertension, dyslipidaemia. PAA was treated by forming a femoropopliteal bypass, bilateral IIA were embolised using spirals, and CIA and aorta were treated by using EVAR aorto-bi-iliac endograft.
Keywords: aortic aneurysm, iliac artery aneurysm, young age, endovascular treatment.
Journal of Medical Sciences. May 18, 2020 - Volu me 8 | I ss ue 1 6. Electronic-ISSN: 2345-0592
48
Medical Sciences 2020 Vol. 8 (16), p. 48-52
Young a g e p a t i e n t w i t h aortic and bilateral il i a c a r t e r y a n e u r y s m : r i sk
factors and strategy of endovascular treatment - case study
1
Rytis Kijauskas,
1
Milda Staniulytė
1
Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Aim: To present a clinical case in which abdominal aortic aneurysm (AAA), common iliac artery (CIA) and internal iliac
artery (IIA) aneurysms were cured for an unusually young patient, to discuss the methods of treatment and to present their
results.
Case report: A 57-year-old man was presented at LUHS Kaunas Clinics Department of Vascular Surgery in 2014 with
bilateral CIA stenosis. In 2016, he was presented again because of an acute thrombosis of his left superficial femoral artery.
Femoropopliteal bypass was formed and popliteal artery aneurysm (PAA) was resected. In 2017, an identical procedure was
made on his right leg. In 2019, a Computer Tomography (CT) scan showed a widened infrarenal aneurysm (from 56 mm to
88 mm of length), changes in both CIA (23 mm and 23 mm respectively) and bilateral IIA (19 mm on the right side and 23
mm on the left side) so a spiral embolization of bilateral IAA was performed. In 2020 02 14 an endovascular artery repair
(EVAR) was performed placing an aorto-bi-iliac stent graft.
Conclusion: According to the prevalence of AAA and IAA, the patient (57 years old) was unusually young to experience
the occurrence of these pathologies (> 65 years). He had some typical risk factors: male gender, arterial hypertension,
dyslipidaemia. PAA was treated by forming a femoropopliteal bypass, bilateral IIA were embolised using spirals, and CIA
and aorta were treated by using EVAR aorto-bi-iliac endograft.
Keywords: aortic aneurysm, iliac artery aneurysm, young age, endovascular treatment.
Journal of Medical Sciences. May 18, 2020 - Volu me 8 | I ss ue 1 6. Electronic-ISSN: 2345-0592
49
1. Introduction
Abdominal aortic aneurysm (AAA) is a potentially lethal
condition responsible for a significant mortality. Up to 40
percent of patients who present with AAA have at least
one iliac artery aneurysm (IAA) with common iliac
artery (CIA) affected in 70 percent of patients who have
IAA (1, 2). Although typically asymptomatic, CIAs
expand over time with a potential for life-threatening
rupture similar to that of AAAs (3 - 5).
Infrarenal aorta is the most common site of aortic
aneurysm formation which is defined as a dilatation of an
artery to at least 1.5 times of its usual size. As an average
diameter of the adult human infrarenal aorta is
approximately 2 cm, infrarenal aorta with a diameter of ≥
3.0 cm is considered to be aneurysmal (6, 7). Common
iliac artery normally averages 1.2 ± 0.2 cm in men and
the internal iliac artery in both genders averages 0.54 ±
0.15 cm. According to these values, an aneurysm in
males can be diagnosed if a common iliac artery
measures > 1.85 cm and the diameter of internal iliac
artery measures > 0.8 cm (8).
Generally accepted risk factors for AAA include
hypertension, chronic obstructive pulmonary disease
(COPD), history of cigarette smoking, male gender, and
family history of an aortic aneurysm (9, 10). The
prevalence of AAA increases with age in both men and
women, although the age-related increase is more
prominent in men and rises sharply in individuals over 65
years (9 - 12). Most of the risk factors for degenerative
IAA matches the ones for AAA and include male gender,
white race, advancing age, history of smoking, and
hypertension. (13, 15).
Elective AAA repair prior to the development of
symptoms is the most effective measure to prevent
rupture and aneurysm-related sudden death.
Endovascular abdominal aortic aneurysm repair (EVAR)
is widely accepted as a less invasive alternative to open
repair. (14) General recommendations suggest that even
asymptomatic iliac artery aneurysms should be repaired
when their diameter reaches 3.0 cm or more; a smaller
than 3.0 cm aneurysm may be considered for a treatment
if a coexisting AAA is present and meets the criteria for
repair. (15,16)
2. Aim
To present a clinical case in which AAA, CIA and
internal iliac artery (IIA) aneurysms were cured for an
unusually young patient. To discuss methods of diagnosis
and treatment which were used and present their results.
3. Case report
A 57 year old man was treated at LUHS Kaunas Clinics
Department of Vascular Surgery in 2020 due to multiple
aneurysms. He was a continuous patient of this clinic
since 2014, had normal BMI (25,83 kg/m2) and one
previous laparoscopic surgery because of a pancreatic
pathology. Patient did not smoke and had no known
allergies. He was diagnosed with II degree arterial
hypertension thirty years ago, had ischaemic heart
disease (classis functionalis 2, NYHA II) and
dyslipidemia. He was firstly presented with bilateral CIA
stenosis in 2014 02 14. Later, in 2016 05 04, he was
presented again because of an acute thrombosis of his left
superficial femoral artery occurring at the first third of
distal popliteal artery. Femoropopliteal bypass was
formed and popliteal artery aneurysm (PAA) was
resected. Then, in 2017 11 29, an identical procedure was
made on his right leg. During the examination of
abdominal aorta in 2017 12 04 a dilation of 35 mm was
found in its infrarenal part. Later, in 2019 05 23, during a
Computer Tomography (CT) scan the same infrarenal
Journal of Medical Sciences. May 18, 2020 - Volu me 8 | I ss ue 1 6. Electronic-ISSN: 2345-0592
50
aneurysm was found to be widened to 56 mm and
reached a total length of 88 mm. Changes were also seen
in both CIA (23 mm and 23 mm respectively) and
bilateral IIA (19 mm on the right side and 23 mm on the
left side) while external iliac arteries (EIA) were normal.
It was decided to perform a first stage of bilateral IIAs
spiral embolization in 2019 06 12 and embolize the right
IIA. However, a complete effect was not reached and a
sufficient amount of spirals could not be used due to the
risk of possible dislocation. Later that year, an ultrasound
check of abdominal aorta (performed in 2019 11 07)
showed its dilation to 49 x 53 mm with a length of 80
mm and bilateral CIA dilations (25 mm on the right, 23
mm on the left). In 2019 11 29, a second stage of bilateral
IIA embolization was executed with a fully successful
embolization of the left IIA. In 2020 01 02 a CT scan was
performed again in order to evaluate any possible
changes. Dilated suprarenal artery was found (up to 23 x
23 mm). Infrarenal aortic aneurysm reached bifurcation
and was enlarged (61 x 58 mm, length 94 mm). Also, a
parietal thrombus was found (~ 17 mm in width). CIA
were evaluated: right CIA has enlarged by an extra 3 mm,
left by an extra 5 mm. Parietal thrombi were found in
CIA (~ 9 mm in thickness). EIA remained without any
pathological changes. Due to these findings, an
endovascular artery repair (EVAR) was performed in
2020 02 14 through the small incisions in both groins
placing aorto-bi-iliac stent graft. After successful surgery
the patient was observed for 6 days and, in absence of
any early complications, was sent to rehabilitation.
4. Discussion
Multiple aneurysms, especially bilateral PAA leading to a
development of AAA, mostly occur in older than 65
years old patients (17). One of the main factors leading to
aneurysm formation is atherosclerotic changes of the
artery walls. Multiple aneurysms in a young population
are often associated with Behçet's disease or syndromes
such as Ehlers-Danlos syndrome or Marfan syndrome.
However, none of these conditions were diagnosed for
the patient discussed in our case (18, 19). On the other
hand, our patient had other cardiovascular risk factors
leading to artery wall damage: history of smoking,
dyslipidemia, and arterial hypertension which lasted for
thrity years. According to Ravn H et al bilateral PAA are
usually linked with generalized aneurysm disease more
than the conjunction of two - PAA and an AAA, which is
also reflected in our study (20). In their research Björck
M et al raised a hypothesis about the relation between the
occurrence of multiple aneurysms and the length of blood
cell telomeres, but no direct connection was found.
Instead, a strong linkage between cardiovascular risk
factors and the length of telomeres was discovered (21).
Patients with bilateral common iliac artery aneurysms or
patients with coexistent AAA are usually managed with
aorto-bi-iliac or aorto-bifemoral graft placement (8). The
origin of the graft in patients with bilateral iliac artery
aneurysms should be just below the renal arteries due to
the increased risk of future aneurysmal aortic wall
degeneration (22). In the case we discussed, aorto-bi-iliac
stent graft was successfully used and placed in the
favourable location without any early post - operative
complications.
Internal iliac artery aneurysms are usually treated with a
combination of embolization and stent-grafting.
However, embolization alone can also be used and in our
case it was chosen as a method of treatment for IIA on
both sides. Adequate coil embolization of internal iliac
artery aneurysms is considered to be reached when there
is an effective arrest of the blood flow within the
aneurysm sac due to which it should thrombose
afterwards (23). Even though this was successfully
achieved while embolising left IIA, the same effect could
Journal of Medical Sciences. May 18, 2020 - Volu me 8 | I ss ue 1 6. Electronic-ISSN: 2345-0592
51
not be reached on the right IIA and no measures were
taken to fix it due to the high risk of dislocation.
When bilateral IIA embolization is chosen, a staged
approach with one to two weeks between procedures may
allow the development of pelvic collaterals (24). In the
case we discussed, a staged approach was also performed
with the gap between the both stages being more than 5
months. It must be mentioned that there are a few
nonrandomized studies which compared simultaneous
and sequential IIA embolization and found lower rates of
ischemic complications with simultaneous embolization
(25, 26). However, due to the lack of more convincing
evidence as these studies were quite small, many
clinicians prefer staged repair when bilateral IIA
aneurysms complicate endovascular aortic aneurysm
repair.
5. Conclusions
Compared to the usual prevalence of AAA and IAA the
patient (57 years old) was 8 years younger for the typical
manifestation of these pathologies (> 65 years). He had
some distinctive risk factors: male gender, arterial
hypertension, dyslipidemia. PAA was treated by forming
a femoropopliteal bypass, bilateral IIA were embolised
using spirals, and CIA and aorta were treated by using
EVAR aorto-bi-iliac endograft.
6. References
1. Kirkwood ML. Iliac artery aneurysm. Pubmed
[Internet]. 2019.
https://www.uptodate.com/contents/iliac-artery-aneurysm
2. Takagi H, Mori Y, Manabe H, Hirose H.
Multiple arterial aneurysms. Journal of vascular surgery.
2003;38(6):1440.
3. Huang Y, Gloviczki P, Duncan AA, Kalra M,
Hoskin TL, Oderich GS, McKusick MA, Bower TC.
Common iliac artery aneurysm: expansion rate and
results of open surgical and endovascular repair. J Vasc
Surg 2008;47:1203-10; discussion 1210-1.
10.1016/j.jvs.2008.01.050.
4. Melas N, Saratzis A, Dixon H, Saratzis N,
Lazaridis J, Perdikides T, Kiskinis D. Isolated common
iliac artery aneurysms: a revised classification to assist
endovascular repair. J Endovasc Ther 2011;18:697-715.
10.1583/11-3519.1.
5. Santilli SM, Wernsing SE, Lee ES. Expansion
rates and outcomes for iliac artery aneurysms. J Vasc
Surg 2000;31:114-21. 10.1016/S0741-5214(00)70073-5.
6. Chaikof EL, Brewster DC, Dalman RL,
Makaroun MS, Illig KA, Sicard GA, Timaran CH,
Upchurch GR Jr, Veith FJ. The care of patients with an
abdominal aortic aneurysm: the Society for Vascular
Surgery practice guidelines. J Vasc Surg. 2009;50(4
Suppl):S2.
7. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW,
Creager MA, Halperin JL, Hiratzka LF, Murphy WR,
Olin JW, Puschett JB, Rosenfield KA et al. ACC/AHA
2005 Practice Guidelines for the management of patients
with peripheral arterial disease (lower extremity, renal,
mesenteric, and abdominal aortic): a collaborative report.
Circulation. 2006;113(11):e463.
8. Bacharach JM, Slovut DP. State of the art:
management of iliac artery aneurysmal disease. Catheter
Cardiovasc Interv. 2008;71(5):708.
9. Wanhainen, A., et al., Risk factors associated
with abdominal aortic aneurysm: a population-based
study with historical and current data. J Vasc Surg, 2005.
41(3): p. 390-6.
10. Calero, A., & Illig, K. A. Overview of aortic
aneurysm management in the endovascular era. Seminars
in Vascular Surgery, 2016. 29(1-2), 3–17.
11. Singh K, Bønaa KH, Jacobsen BK, Bjørk L,
Solberg S. Prevalence of and risk factors for abdominal
aortic aneurysms in a population-based study : The
Journal of Medical Sciences. May 18, 2020 - Volu me 8 | I ss ue 1 6. Electronic-ISSN: 2345-0592
52
TromsøStudy. Am J Epidemiol. 2001;154(3):236.
12. Powell JT, Greenhalgh RM. Clinical practice.
Small abdominal aortic aneurysms. N Engl J Med.
2003;348(19):1895.
13. Patel NV, Long GW, Cheema ZF, Rimar K,
Brown OW, Shanley CJ. Open vs. endovascular repair of
isolated iliac artery aneurysms: A 12-year experience. J
Va sc S ur g. 20 0 9;49 (5 ) :114 7. Epub 2009 Feb 23.
14. Gimzewska M, Jackson AI, Yeoh SE, Clarke M.
Totally percutaneous versus surgical cut-down femoral
artery access for elective bifurcated abdominal
endovascular aneurysm repair. Cochrane Database Syst
Rev, 2017. 2:CD010185.
15. Wang Y, Zhu C, Leach J, Gasper W, Saloner D,
Hope M. Growth of common iliac artery aneurysms
coexisting with abdominal aortic aneurysms: associated
factors and potential role of intraluminal thrombus.
Quant Imaging Med Surg. 2020;10(3):703‐712.
doi:10.21037/qims.2020.02.12.
16. Huang Y1, Gloviczki P, Duncan AA, Kalra M,
Hoskin TL, Oderich GS, McKusick MA, Bower TC.
Common iliac artery aneurysm: expansion rate and
results of open surgical and endovascular repair. J Vasc
Surg. 2008 Jun;47(6):1203-1210.
17. Shiwani H, Baxter P, Taylor E, Bailey MA, Scott
DJA. Modelling the growth of popliteal artery
aneurysms. The British journal of surgery. U.S. National
Library of Medicine 2018; 105(13):1749-1752.
18. Bartlett ST, McCarthy WJ, Palmer AS, Flinn
WR, Bergan JJ, Yao JS. Multiple aneurysms in Behçet's
disease. Archives of surgery (Chicago, Ill. : 1960). U.S.
National Library of Medicine, 1988 Aug; 123(8):1004-8.
19. Gui X, Li F, Wu L, Zheng Y. Systemic Multiple
Aneurysms Caused by Vascular Ehlers-Danlos
Syndrome. Vascular and endovascular surgery. U.S.
National Library of Medicine; 2016 Jul; 50(5):354-8.
20. Ravn H, Wanhainen A, Björck M. Risk of new
aneurysms after surgery for popliteal artery aneurysm.
The British journal of surgery. U.S. National Library of
Medicine; 2008 May; 95(5):571-5.
21. Björck M, Ravn H, Nilsson TK, Wanhainen A,
Nilsson PM. Blood cell telomere length among patients
with an isolated popliteal artery aneurysm and those with
multiple aneurysm disease. Atherosclerosis. U.S.
National Library of Medicine; 2011 Dec; 219(2):946-50.
22. Kirkwood ML, Saunders A, Jackson BM, Wang
GJ, Fairman RM, Woo EY. Aneurysmal iliac arteries do
not portend future iliac aneurysmal enlargement after
endovascular aneurysm repair for abdominal aortic
aneurysm. J Vasc Surg. 2011; 53(2):269.
23. Rana MA, Kalra M, Oderich GS, de Grandis E,
Gloviczki P, Duncan AA, Cha SS, Bower TC Outcomes
of open and endovascular repair for ruptured and
nonruptured internal iliac artery aneurysms. J Vasc Surg.
2014 Mar; 59(3):634-44.
24. Uberoi R, Tsetis D, Shrivastava V, et al.
Standard of practice for the interventional management
of isolated iliac artery aneurysms. Cardiovasc Intervent
Radiol. 2011; 34: 3–13.
25. Bratby MJ, Munneke GM, Belli AM,
Loosemore TM, Loftus I, Thompson MM, Morgan RA.
How safe is bilateral internal iliac artery embolization
prior to EVAR? Cardiovasc Intervent Radiol. 2008;
31(2):246.
26. Engelke C, Elford J, Morgan RA, Belli AM.
Internal iliac artery embolization with bilateral occlusion
before endovascular aortoiliac aneurysm repair-clinical
outcome of simultaneous and sequential intervention.J
Va sc I nt e rv R ad i ol. 2002 ; 13 (7 ) :667 .