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An Unusual Giant Pseudoaneurysm with Proximal and Distal Necks Bypassing an Occluded Midsuperficial Femoral Artery
Volume 22 䡲 Number 1 䡲 January 䡲 2011
attenuation Histoacryl/Lipiodol cast. In case 1, a small endoleak was readily shown on initial follow-up CT angiography (Figure, b), but after the second n-BCA embolization, artifact from the larger Histoacryl/Lipiodol cast obscured some detail making it difficult to see a small endoleak. In this case, the reduction in sac size provided sufficient evidence that the n-BCA embolization was successful. In case 2 with a smaller Histoacryl/Lipiodol cast, detail was readily seen, with no endoleak and a stable sac size. From this limited experience, it is suggested that as long as the Histoacryl/Lipiodol cast is relatively small, the artifact produced at CT angiography does not obscure a small endoleak, but it may if the cast is relatively large. Both patients are on a routine surveillance program that will provide information regarding long-term durability.
REFERENCES 1. Peynircioglu B, Turkbey B, Ozkan M, Cil BE. Use of glue and microcoils for transarterial catheter embolization of a type 1 endoleak. Diagn Interv Radiol 2008; 14:111–115. 2. Maldonado TS, Rosen RJ, Rockman CB, et al. Initial successful management of type I endoleak after endovascular aortic aneurysm repair with n-butyl cyanoacrylate adhesive. J Vasc Surg 2003; 38:664 – 670. 3. Yamaguchi T, Maeda M, Abe H, et al. Embolization of perigraft leaks after endovascular stent-graft treatment of distal arch anastomotic pseudoaneurysm with coil and n-butyl 2-cyanoacrylate. J Vasc Interv Radiol 1998; 9:61– 64. 4. Pollak JS, White RI Jr. The use of cyanoacrylate adhesives in peripheral embolization. J Vasc Interv Radiol 2001; 12:907–913. fault
An Unusual Giant Pseudoaneurysm with Proximal and Distal Necks Bypassing an Occluded Midsuperficial Femoral Artery Nicolas W. Shammas, MD Midwest Cardiovascular Research Foundation Cardiovascular Medicine, PC 1236 E. Rusholme, Suite 300 Davenport, IA 52803
This work was supported by the Nicolas and Gail Shammas Research Fund at the Midwest Cardiovascular Research Foundation, Davenport, Iowa. The author has not identified a conflict of interest. DOI: 10.1016/j.jvir.2010.09.025
107
Editor: The present communication reports an unusual case of a giant superficial femoral artery (SFA) pseudoaneurysm (Figure) in a 76-year-old male who presented with an enlarging pulsatile mass over the medial aspect of the left thigh. The pulsatile mass developed 35 months after treatment of a chronically totally occluded left SFA with nitinol self-expanding stents (ev3, Plymouth, Minnesota). Digital subtraction angiography confirmed the presence of the giant pseudoaneurysm emerging from the proximal and distal left SFA and tracking along the SFA length bypassing the occluded midsegment of this vessel. There was a very focal nodisplaced fracture noted in the midportion of the stentimplanted segment of the SFA, but this did not seem to be related to the origin of the pseudoaneurysm necks. The patient elected against surgical intervention. After percutaneous recanalization of the native midportion of the left SFA, the SFA was implanted with 7-mm Viabahn covered stents (W.L. Gore and Associates, Flagstaff, Arizona) in tandem fashion. The pseudoaneurysm was excluded completely, with immediate abolishment of the pulsation in the left medial thigh after the procedure. At the time of writing of this report, a 6-week follow-up duplex ultrasound has been performed and continued patency of the stent-implanted SFA was noted, with a thrombosed pseudoaneurysm. The hematoma around the stent was smaller and measured at 4.7 ⫻ 6.2 ⫻ 10.2 cm compared with an immediate posttreatment size of 6.1 ⫻ 4.9 ⫻ 17 cm. SFA pseudoaneurysm can occur several years after placement of nitinol self-expanding stents, but is a rare complication reported in the literature (1,2). Pseudoaneurysm or vessel rupture in the SFA after stent placement is thought to be related to stent erosion into the treated vessel (1). Stent fracture or displacement at the site of the pseudoaneurysm has been reported (2) but is not always present. The risk factors for pseudoaneurysm formation are unknown given the rarity of this condition. The SFA in the present case was heavily calcified and the vessel was tortuous, conditions that presumably might have contributed to the pseudoaneurysm formation. Covered stents have been used successfully in the treatment of pseudoaneurysm of the SFA (3). In the present case, proximal and distal necks of the pseudoaneurysm needed to be covered because persistence of retrograde flow into the pseudoaneurysm was seen with only the proximal neck covered.
108 䡲 Letters to the Editor
Shammas 䡲 JVIR
Figure. (a) Large left medial thigh pulsatile mass. (b) Digital subtraction image shows the proximal neck of the pseudoaneurysm (PSA) emerging proximally in the left SFA and reconstituting distally a chronically occluded mid-SFA stent. (c) Digital subtraction angiography of the left SFA after recanalization of the occluded old stent and treatment of the entire SFA with covered stents in tandem fashion to exclude the pseudoaneurysm. (Available in color online at www.jvir.org.)
REFERENCES 1. León LR Jr, Goshima KR. Delayed superficial femoral artery stent erosion and pseudoaneurysm following endovascular therapy for occlusive disease. Vasc Endovascular Surg 2009; 43:502–508.
2. Rivolta N, Fontana F, Piffaretti G, Tozzi M, Carrafiello G. A case of late femoral pseudoaneurysm caused by stent disconnection. Cardiovasc Intervent Radiol 2010; 33:1036 –1069. 3. Farraj N, Srivastava A, Pershad A. One-year outcomes for recanalization of long superficial femoral artery chronic total occlusions with the Viabahn stent graft. J Invas Cardiol 2009; 21:278 –281.
attenuation Histoacryl/Lipiodol cast. In case 1, a small endoleak was readily shown on initial follow-up CT angiography (Figure, b), but after the second n-BCA embolization, artifact from the larger Histoacryl/Lipiodol cast obscured some detail making it difficult to see a small endoleak. In this case, the reduction in sac size provided sufficient evidence that the n-BCA embolization was successful. In case 2 with a smaller Histoacryl/Lipiodol cast, detail was readily seen, with no endoleak and a stable sac size. From this limited experience, it is suggested that as long as the Histoacryl/Lipiodol cast is relatively small, the artifact produced at CT angiography does not obscure a small endoleak, but it may if the cast is relatively large. Both patients are on a routine surveillance program that will provide information regarding long-term durability.
REFERENCES 1. Peynircioglu B, Turkbey B, Ozkan M, Cil BE. Use of glue and microcoils for transarterial catheter embolization of a type 1 endoleak. Diagn Interv Radiol 2008; 14:111–115. 2. Maldonado TS, Rosen RJ, Rockman CB, et al. Initial successful management of type I endoleak after endovascular aortic aneurysm repair with n-butyl cyanoacrylate adhesive. J Vasc Surg 2003; 38:664 – 670. 3. Yamaguchi T, Maeda M, Abe H, et al. Embolization of perigraft leaks after endovascular stent-graft treatment of distal arch anastomotic pseudoaneurysm with coil and n-butyl 2-cyanoacrylate. J Vasc Interv Radiol 1998; 9:61– 64. 4. Pollak JS, White RI Jr. The use of cyanoacrylate adhesives in peripheral embolization. J Vasc Interv Radiol 2001; 12:907–913. fault
An Unusual Giant Pseudoaneurysm with Proximal and Distal Necks Bypassing an Occluded Midsuperficial Femoral Artery Nicolas W. Shammas, MD Midwest Cardiovascular Research Foundation Cardiovascular Medicine, PC 1236 E. Rusholme, Suite 300 Davenport, IA 52803
This work was supported by the Nicolas and Gail Shammas Research Fund at the Midwest Cardiovascular Research Foundation, Davenport, Iowa. The author has not identified a conflict of interest. DOI: 10.1016/j.jvir.2010.09.025
107
Editor: The present communication reports an unusual case of a giant superficial femoral artery (SFA) pseudoaneurysm (Figure) in a 76-year-old male who presented with an enlarging pulsatile mass over the medial aspect of the left thigh. The pulsatile mass developed 35 months after treatment of a chronically totally occluded left SFA with nitinol self-expanding stents (ev3, Plymouth, Minnesota). Digital subtraction angiography confirmed the presence of the giant pseudoaneurysm emerging from the proximal and distal left SFA and tracking along the SFA length bypassing the occluded midsegment of this vessel. There was a very focal nodisplaced fracture noted in the midportion of the stentimplanted segment of the SFA, but this did not seem to be related to the origin of the pseudoaneurysm necks. The patient elected against surgical intervention. After percutaneous recanalization of the native midportion of the left SFA, the SFA was implanted with 7-mm Viabahn covered stents (W.L. Gore and Associates, Flagstaff, Arizona) in tandem fashion. The pseudoaneurysm was excluded completely, with immediate abolishment of the pulsation in the left medial thigh after the procedure. At the time of writing of this report, a 6-week follow-up duplex ultrasound has been performed and continued patency of the stent-implanted SFA was noted, with a thrombosed pseudoaneurysm. The hematoma around the stent was smaller and measured at 4.7 ⫻ 6.2 ⫻ 10.2 cm compared with an immediate posttreatment size of 6.1 ⫻ 4.9 ⫻ 17 cm. SFA pseudoaneurysm can occur several years after placement of nitinol self-expanding stents, but is a rare complication reported in the literature (1,2). Pseudoaneurysm or vessel rupture in the SFA after stent placement is thought to be related to stent erosion into the treated vessel (1). Stent fracture or displacement at the site of the pseudoaneurysm has been reported (2) but is not always present. The risk factors for pseudoaneurysm formation are unknown given the rarity of this condition. The SFA in the present case was heavily calcified and the vessel was tortuous, conditions that presumably might have contributed to the pseudoaneurysm formation. Covered stents have been used successfully in the treatment of pseudoaneurysm of the SFA (3). In the present case, proximal and distal necks of the pseudoaneurysm needed to be covered because persistence of retrograde flow into the pseudoaneurysm was seen with only the proximal neck covered.
108 䡲 Letters to the Editor
Shammas 䡲 JVIR
Figure. (a) Large left medial thigh pulsatile mass. (b) Digital subtraction image shows the proximal neck of the pseudoaneurysm (PSA) emerging proximally in the left SFA and reconstituting distally a chronically occluded mid-SFA stent. (c) Digital subtraction angiography of the left SFA after recanalization of the occluded old stent and treatment of the entire SFA with covered stents in tandem fashion to exclude the pseudoaneurysm. (Available in color online at www.jvir.org.)
REFERENCES 1. León LR Jr, Goshima KR. Delayed superficial femoral artery stent erosion and pseudoaneurysm following endovascular therapy for occlusive disease. Vasc Endovascular Surg 2009; 43:502–508.
2. Rivolta N, Fontana F, Piffaretti G, Tozzi M, Carrafiello G. A case of late femoral pseudoaneurysm caused by stent disconnection. Cardiovasc Intervent Radiol 2010; 33:1036 –1069. 3. Farraj N, Srivastava A, Pershad A. One-year outcomes for recanalization of long superficial femoral artery chronic total occlusions with the Viabahn stent graft. J Invas Cardiol 2009; 21:278 –281.