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Persistent Sciatic Artery Aneurysm
Persistent Sciatic Artery Aneurysm Cesar Nu~ no-Escobar,1 Mario Alberto Perez-Duran,1 Ruben Ramos-Lopez,1 Guillermo Hern andez Ch avez,2 Francisco Llamas-Macı´as,2 Marı´a Baltazar-Flores,2 Alejandro Gonz alez-Ojeda,3 Michel Dassaejv Macı´as-Amezcua,3 and Clotilde Fuentes-Orozco,3 Guadalajara, Jalisco, Mexico
A persistent sciatic artery (PSA) is an exceptionally rare embryologic vascular anomaly with a reported incidence of 0.01e0.05% based on angiography. Most PSAs do not require treatment and 50% of affected individuals are asymptomatic. However, all PSA-related aneurysms should be treated because they involve a high risk of complications.We report the case of 53year-old man with a 7-cm aneurysm arising from a left dominant PSA together with a hypoplastic left femoral artery, who presented with acute left limb ischemia. The patient had realized the presence of a pulsating mass in his left buttock 12 months before the ischemic event. He was treated initially with below-knee popliteal embolectomy and exclusion of the aneurysm with 2 overlapping, self-expanding, 10 50-mm stent grafts. On diagnosis, PSA aneurysms require neither potentially harmful ligation nor a technically challenging open procedure. Endovascular aneurysm exclusion using an antegrade or a retrograde approach is safe and efficient; however, long-term follow-up is required to establish the efficacy of this endovascular procedure.
INTRODUCTION The sciatic artery is an embryonic blood vessel that normally regresses to form the proximal part of the inferior gluteal artery after the third month of embryonic life.1 A persistent sciatic artery (PSA) is a rare developmental anomaly in which the internal iliac artery and the embryonic axial artery continue to provide the major blood supply to the lower limb after birth.2 This pathology affects approximately 1 Department of Vascular and Endovascular Surgery, Specialties Hospital Western Medical Center Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico. 2 Department of Radio-Guided Neurosurgery, Specialties Hospital Western Medical Center Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico. 3
Research Unit in Clinical Epidemiology, Specialties Hospital Western Medical Center Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico. Correspondence to: Clotilde Fuentes-Orozco, PhD, Surgical Division of Medical Research Unit, Western Medical Center Mexican Institute of Social Security, Belisario Dominguez 1000, Col. Independencia, Guadalajara, Jalisco 44340, Mexico; E-mail: [email protected] Ann Vasc Surg 2013; 27: 1182.e13–1182.e16 http://dx.doi.org/10.1016/j.avsg.2013.04.003 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: October 3, 2011; manuscript accepted: April 1, 2013; published online: July 26, 2013.
0.05% of individuals of both genders equally and up to 46% of cases present with an aneurysm. The aneurysm’s etiology is multifactorial with both acquired and congenital components.3,4 This abnormality was first described by Green in 1832 in a postmortem study.5 It was then demonstrated in an arteriogram by Cowie et al. in 1960.6 Up to 2007, 159 individuals with a PSA had been described in 122 cases.7 Here in we describe a patient with a PSA who presented with an acute ischemic event of the lower leg with an aneurysmatic degeneration of the artery as the source of a distal embolization.
CASE REPORT A 53-year-old man was admitted to our emergency room with an immediate clinical history of 24 hours of sudden, severe pain in his left leg along with pallor and hypothermia. The pain in the left leg was accompanied by intense pallor. Physical examination revealed diminished femoral and popliteal pulses; the pedal and posterior tibial pulses were not palpable but the right leg pulses were normal. Twelve months before admission the patient had noticed a fixed, tender, pulsating mass in his left buttock measuring 10e12 cm in diameter. A clinical diagnosis of acute arterial ischemia to the lower limb was established. At the time of this patient’s 1182.e13
1182.e14 Case reports
Annals of Vascular Surgery
Fig. 3. Second release of Hemobahn prothesis. Fig. 1. Left common iliac arteriography. Hypertrophy of the femoral arteries can be seen along with persistent dilation of the sciatic artery.
the pulsatile mass could be performed. A contralateral transfemoral study of the left common iliac, left internal, and external arteries demonstrated a complete PSA with incompletely developed femoral arteries and an aneurysm at the level of the head of the femur of w7 cm in diameter (Fig. 1). With these findings, endovascular exclusion of the aneurysm was performed successfully with 2 overlapping, self-expanding stent grafts (10 50-mm Gore Hemobahn stents; W.L. Gore & Associates, Flagstaff, AZ, USA), as shown in Figures 2 and 3. A larger stent was not available at our institution when this patient was treated. A control arteriogram demonstrated complete aneurysm exclusion without endoleaks (Fig. 4). The pulsating mass disappeared and the distal limb pulses returned to normal. The patient’s postoperative recovery was uneventful and he left the hospital 72 hours after the endovascular procedure. He has remained asymptomatic during a 6month medical follow-up.
DISCUSSION Fig. 2. Progress of the second Hemobahn endoprothesis (11 mm 50 mm).
admission, the angiography suite of our hospital was not available. He was treated surgically with below-knee popliteal embolectomy. During the procedure, abundant, well-formed thrombi located in the anterior tibial artery and the tibioperoneal trunk were removed completely, with satisfactory blood reflux and the reappearance of distal pulses. The patient was managed with anticoagulation therapy postoperatively with an unfractionated heparin infusion of 18 U/kg/hr. He recovered completely and anticoagulation was maintained until a vascular evaluation of
The sciatic artery is a continuation of the internal iliac artery, which represents the major vascular supply to the lower limb bud during early embryonic life. As the femoral artery develops, the sciatic artery involutes and its remnant forms the inferior gluteal artery. Rarely, it persists as a vascular anomalydthe PSA.8 The most frequent complication of a PSA appears to be aneurysm formation and the associated risk of thrombosis and distal embolization.9e11 Most incidental cases of a PSA do not require treatment and 50% are partially asymptomatic.12 However, all PSA-related aneurysms should be treated because they involve a high risk of
Vol. 27, No. 8, November 2013
Fig. 4. Control arteriography after the procedure.
complications. Similar to other arterial aneurysms, these are susceptible to thromboembolic events and distal ischemia and they commonly present in this way.7 As with other aneurysms, they may rupture, although this is rare. Because of their location in the buttock region, they can present with signs secondary to local compression and irritation of the sciatic nerve.13 PSA aneurysms also present as a pulsatile mass in the buttock in 31% of cases.7 However, these can be easily missed and patients often do not detect their presence, or the patient may be obese with only a small aneurysm. The differential diagnoses include a gluteal artery aneurysm, an arteriovenous malformation, soft-tissue neoplasms, and infections.13-16 A literature search reveals various published therapies for PSA aneurysms, mainly oriented to whether the PSA is considered a complete or incomplete blood provider of the lower limb. Surgical options include exclusion of the aneurysm with simple ligation or embolization for an incomplete PSA and a complex bypassdincluding a degree of exposure and the risk of sciatic nerve injurydfor a complete PSA.17 These alternatives are currently being challenged by the advent of minimally invasive endovascular technology. The first repair of a PSA aneurysm using a contralateral puncture to place a stent graft was reported by Gabelmann et al.14 However, experience with the endovascular approach, which could reduce the risks of open surgery or an undesirable ligation, is limited to only a few reported cases. Jain et al. reported a PSA aneurysm stent graft exclusion through an open, above-knee popliteal exposure to facilitate
Case reports 1182.e15
a concomitant distal embolectomy in a patient with limb-threatening ischemia.15 They noted the importance of a complete angiographic evaluation, because 3 surgical goals were achieved through a single approach: exclusion of the aneurysm; reestablishment of vascular continuity; and distal embolectomy. Wijeyaratne and Wijewardene proposed ipsilateral popliteal puncture and a retrograde approach as a preventive measure for anticipated difficulties in deploying a long stent via a tortuous antegrade approach.16 Mousa and Santaolalla recently reported 2 cases of a left aneurysmal PSA treated with open bypass procedures and posterior embolization of the aneurysms.17,18 Mascarenhas de Oliveira and de Souza Mour~ ao successfully treated a high-risk surgical patient with a complete persistent sciatic artery aneurysm with endovascular exclusion without a surgical bypass procedure. Graft patency was observed after a 6-month follow-up.19 Verikokos et al. described the case of a 57-year-old patient with a bilateral PSA, with a type 1 aneurysm on the right side associated with postaneurysmal stenosis and a concomitant 4.2-cm abdominal aortic aneurysm. The lesion was treated with exclusion and dilation with 2 overlapping, self-expanding stents.20 Intermediate- and long-term outcomes after treatment of a symptomatic PSA using different techniques were reported by Yamamoto et al.,21 who identified 24 articles published between 1995 and 2009. Twenty-eight patients with 29 PSAs were followed up for between 2 months and 10 years. Regardless of the method of arterial reconstruction (arterial bypass or aneurysm repair and direct revascularization) or endovascular management, the outcomes were considered satisfactory. Our case was treated initially with an open procedure to remove the embolus and after clear identification of the complicated aneurysm located in a left PSA. A contralateral endovascular approach allowed us to treat it successfully with 2 overlapping, self-expanding stent grafts. We recognize that, under ideal conditions, such patients should be evaluated angiographically to establish an accurate diagnosis and to resolve the acute complication and its origin through a single surgical approach. In Mexico, many hospitals do not have angiography suites available 24 hours per day throughout the year. However, treatment of this patient was successful with complications noted at 6-month follow-up. In conclusion, PSA aneurysmsdwhen diagnoseddrequire neither a potentially harmful ligation nor technically challenging open procedures. Endovascular aneurysm exclusion using an antegrade or
1182.e16 Case reports
Annals of Vascular Surgery
retrograde approach is safe and efficient; however, long-term follow-up is required to establish the efficacy of this endovascular procedure. 11.
REFERENCES 1. Mandell VS, Jaques PF, Delany DJ, Oberheu V. Persistent sciatic artery: clinical, embryologic and angiographic features. AJR Am J Roentgenol 1985;144:245e9. 2. Brantley SK, Rigdon EE, Raju S. Persistent sciatic artery: embryology, pathology and treatment. J Vasc Surg 1993;18: 242e8. 3. Ikezawa T, Naiki K, Moriura S, Ikeda S, Hirai M. Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature. J Vasc Surg 1994;20:96e103. 4. Sultan SA, Pacainowski JP, Madhavan P, et al. Endovascular management of rare sciatic artery aneurysm. J Endovasc Ther 2000;7:415e22. 5. Green PH. On a new variety of the femoral artery: with observations. Lancet 1832;1:730e1. 6. Cowie TN, McKellar NJ, McLean N, Smith G. Unilateral congenital absence of the external iliac femoral arteries. Br J Radiol 1960;33:320e2. 7. van Hooft IM, Zeebregts CJ, van Sterkenburg SM, de Vries WR, Reijnen MM. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585e91. 8. Baumgartner FJ, Kalinowski A, Grant S. Endovascular repair of injury to a persistent sciatic artery. Tex Heart Inst J 2009;36:61e4. 9. Ito H, Okadome K, Odashiro T, et al. Persistent sciatic artery: two case reports and a review of the literature. Cardiovasc Surg 1994;2:275e80. 10. Maldini G, Teruya TH, Kamida C, Eklof B. Combined percutaneous endovascular and open surgical approach in the
12.
13. 14.
15.
16.
17.
18. 19.
20.
21.
treatment of a persistent sciatic artery aneurysm presenting with acute limb threatening ischemiada case report and review of the literature. Vasc Endovasc Surg 2002;36: 403e8. Hassan A. Symptomatic persistent sciatic artery. J Am Coll Surg 2004;199:171e3. Abularrage CJ, Crawford RS, Patel VI, Conrad MF. Diagnostic strategies for the persistent sciatic artery. Vasc Endovasc Surg 2009;43:485e9. Knight BC, Tait WF. Massive aneurysm in a persistent sciatic artery. Ann Vasc Surg 2010;24:1135.e13e8. Gabelmann A, Kr€amer SC, Wisianowski C, Tomczak R, Pamler R, G€ orich J. Endovascular interventions on persistent sciatic arteries. J Endovasc Ther 2001;8:622e8. Jain S, Munn JS, Simoni EJ, Jain KM. Endograft repair of a persistent sciatic artery aneurysm. Eur J Vasc Endovasc Surg 2004;8:5e6. Wijeyaratne SM, Wijewardene N. Endovascular stenting of a persistent sciatic artery aneurysm via retrograde popliteal approach: a durable option. Eur J Vasc Endovasc Surg 2009;38:91e2. Mousa A, Rapp Parker A, Emmett MK, AbuRahma A. Endovascular treatment of symptomatic persistent sciatic artery aneurysm: a case report and review of literature. Vasc Endovasc Surg 2010;44:312e4. Santaolalla V, Bernabe MH, Hipola Ulecia JM, et al. Persistent sciatic artery. Ann Vasc Surg 2010;24:691.e7e10. Mascarenhas de Oliveira F, de Souza Mour~ao G. Endovascular repair of symptomatic sciatic artery aneurysm. Vasc Endovasc Surg 2011;45:165e9. Verikokos C, Avgerinos ED, Chatziioannou A, Katsargyris A, Klonaris C. Endovascular repair of a persistent sciatic artery aneurysm. Vascular 2010;18:162e5. Yamamoto H, Yamamoto F, Ishibashi K, et al. Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques. Ann Vasc Surg 2011;25:837.e9e15.
A persistent sciatic artery (PSA) is an exceptionally rare embryologic vascular anomaly with a reported incidence of 0.01e0.05% based on angiography. Most PSAs do not require treatment and 50% of affected individuals are asymptomatic. However, all PSA-related aneurysms should be treated because they involve a high risk of complications.We report the case of 53year-old man with a 7-cm aneurysm arising from a left dominant PSA together with a hypoplastic left femoral artery, who presented with acute left limb ischemia. The patient had realized the presence of a pulsating mass in his left buttock 12 months before the ischemic event. He was treated initially with below-knee popliteal embolectomy and exclusion of the aneurysm with 2 overlapping, self-expanding, 10 50-mm stent grafts. On diagnosis, PSA aneurysms require neither potentially harmful ligation nor a technically challenging open procedure. Endovascular aneurysm exclusion using an antegrade or a retrograde approach is safe and efficient; however, long-term follow-up is required to establish the efficacy of this endovascular procedure.
INTRODUCTION The sciatic artery is an embryonic blood vessel that normally regresses to form the proximal part of the inferior gluteal artery after the third month of embryonic life.1 A persistent sciatic artery (PSA) is a rare developmental anomaly in which the internal iliac artery and the embryonic axial artery continue to provide the major blood supply to the lower limb after birth.2 This pathology affects approximately 1 Department of Vascular and Endovascular Surgery, Specialties Hospital Western Medical Center Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico. 2 Department of Radio-Guided Neurosurgery, Specialties Hospital Western Medical Center Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico. 3
Research Unit in Clinical Epidemiology, Specialties Hospital Western Medical Center Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico. Correspondence to: Clotilde Fuentes-Orozco, PhD, Surgical Division of Medical Research Unit, Western Medical Center Mexican Institute of Social Security, Belisario Dominguez 1000, Col. Independencia, Guadalajara, Jalisco 44340, Mexico; E-mail: [email protected] Ann Vasc Surg 2013; 27: 1182.e13–1182.e16 http://dx.doi.org/10.1016/j.avsg.2013.04.003 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: October 3, 2011; manuscript accepted: April 1, 2013; published online: July 26, 2013.
0.05% of individuals of both genders equally and up to 46% of cases present with an aneurysm. The aneurysm’s etiology is multifactorial with both acquired and congenital components.3,4 This abnormality was first described by Green in 1832 in a postmortem study.5 It was then demonstrated in an arteriogram by Cowie et al. in 1960.6 Up to 2007, 159 individuals with a PSA had been described in 122 cases.7 Here in we describe a patient with a PSA who presented with an acute ischemic event of the lower leg with an aneurysmatic degeneration of the artery as the source of a distal embolization.
CASE REPORT A 53-year-old man was admitted to our emergency room with an immediate clinical history of 24 hours of sudden, severe pain in his left leg along with pallor and hypothermia. The pain in the left leg was accompanied by intense pallor. Physical examination revealed diminished femoral and popliteal pulses; the pedal and posterior tibial pulses were not palpable but the right leg pulses were normal. Twelve months before admission the patient had noticed a fixed, tender, pulsating mass in his left buttock measuring 10e12 cm in diameter. A clinical diagnosis of acute arterial ischemia to the lower limb was established. At the time of this patient’s 1182.e13
1182.e14 Case reports
Annals of Vascular Surgery
Fig. 3. Second release of Hemobahn prothesis. Fig. 1. Left common iliac arteriography. Hypertrophy of the femoral arteries can be seen along with persistent dilation of the sciatic artery.
the pulsatile mass could be performed. A contralateral transfemoral study of the left common iliac, left internal, and external arteries demonstrated a complete PSA with incompletely developed femoral arteries and an aneurysm at the level of the head of the femur of w7 cm in diameter (Fig. 1). With these findings, endovascular exclusion of the aneurysm was performed successfully with 2 overlapping, self-expanding stent grafts (10 50-mm Gore Hemobahn stents; W.L. Gore & Associates, Flagstaff, AZ, USA), as shown in Figures 2 and 3. A larger stent was not available at our institution when this patient was treated. A control arteriogram demonstrated complete aneurysm exclusion without endoleaks (Fig. 4). The pulsating mass disappeared and the distal limb pulses returned to normal. The patient’s postoperative recovery was uneventful and he left the hospital 72 hours after the endovascular procedure. He has remained asymptomatic during a 6month medical follow-up.
DISCUSSION Fig. 2. Progress of the second Hemobahn endoprothesis (11 mm 50 mm).
admission, the angiography suite of our hospital was not available. He was treated surgically with below-knee popliteal embolectomy. During the procedure, abundant, well-formed thrombi located in the anterior tibial artery and the tibioperoneal trunk were removed completely, with satisfactory blood reflux and the reappearance of distal pulses. The patient was managed with anticoagulation therapy postoperatively with an unfractionated heparin infusion of 18 U/kg/hr. He recovered completely and anticoagulation was maintained until a vascular evaluation of
The sciatic artery is a continuation of the internal iliac artery, which represents the major vascular supply to the lower limb bud during early embryonic life. As the femoral artery develops, the sciatic artery involutes and its remnant forms the inferior gluteal artery. Rarely, it persists as a vascular anomalydthe PSA.8 The most frequent complication of a PSA appears to be aneurysm formation and the associated risk of thrombosis and distal embolization.9e11 Most incidental cases of a PSA do not require treatment and 50% are partially asymptomatic.12 However, all PSA-related aneurysms should be treated because they involve a high risk of
Vol. 27, No. 8, November 2013
Fig. 4. Control arteriography after the procedure.
complications. Similar to other arterial aneurysms, these are susceptible to thromboembolic events and distal ischemia and they commonly present in this way.7 As with other aneurysms, they may rupture, although this is rare. Because of their location in the buttock region, they can present with signs secondary to local compression and irritation of the sciatic nerve.13 PSA aneurysms also present as a pulsatile mass in the buttock in 31% of cases.7 However, these can be easily missed and patients often do not detect their presence, or the patient may be obese with only a small aneurysm. The differential diagnoses include a gluteal artery aneurysm, an arteriovenous malformation, soft-tissue neoplasms, and infections.13-16 A literature search reveals various published therapies for PSA aneurysms, mainly oriented to whether the PSA is considered a complete or incomplete blood provider of the lower limb. Surgical options include exclusion of the aneurysm with simple ligation or embolization for an incomplete PSA and a complex bypassdincluding a degree of exposure and the risk of sciatic nerve injurydfor a complete PSA.17 These alternatives are currently being challenged by the advent of minimally invasive endovascular technology. The first repair of a PSA aneurysm using a contralateral puncture to place a stent graft was reported by Gabelmann et al.14 However, experience with the endovascular approach, which could reduce the risks of open surgery or an undesirable ligation, is limited to only a few reported cases. Jain et al. reported a PSA aneurysm stent graft exclusion through an open, above-knee popliteal exposure to facilitate
Case reports 1182.e15
a concomitant distal embolectomy in a patient with limb-threatening ischemia.15 They noted the importance of a complete angiographic evaluation, because 3 surgical goals were achieved through a single approach: exclusion of the aneurysm; reestablishment of vascular continuity; and distal embolectomy. Wijeyaratne and Wijewardene proposed ipsilateral popliteal puncture and a retrograde approach as a preventive measure for anticipated difficulties in deploying a long stent via a tortuous antegrade approach.16 Mousa and Santaolalla recently reported 2 cases of a left aneurysmal PSA treated with open bypass procedures and posterior embolization of the aneurysms.17,18 Mascarenhas de Oliveira and de Souza Mour~ ao successfully treated a high-risk surgical patient with a complete persistent sciatic artery aneurysm with endovascular exclusion without a surgical bypass procedure. Graft patency was observed after a 6-month follow-up.19 Verikokos et al. described the case of a 57-year-old patient with a bilateral PSA, with a type 1 aneurysm on the right side associated with postaneurysmal stenosis and a concomitant 4.2-cm abdominal aortic aneurysm. The lesion was treated with exclusion and dilation with 2 overlapping, self-expanding stents.20 Intermediate- and long-term outcomes after treatment of a symptomatic PSA using different techniques were reported by Yamamoto et al.,21 who identified 24 articles published between 1995 and 2009. Twenty-eight patients with 29 PSAs were followed up for between 2 months and 10 years. Regardless of the method of arterial reconstruction (arterial bypass or aneurysm repair and direct revascularization) or endovascular management, the outcomes were considered satisfactory. Our case was treated initially with an open procedure to remove the embolus and after clear identification of the complicated aneurysm located in a left PSA. A contralateral endovascular approach allowed us to treat it successfully with 2 overlapping, self-expanding stent grafts. We recognize that, under ideal conditions, such patients should be evaluated angiographically to establish an accurate diagnosis and to resolve the acute complication and its origin through a single surgical approach. In Mexico, many hospitals do not have angiography suites available 24 hours per day throughout the year. However, treatment of this patient was successful with complications noted at 6-month follow-up. In conclusion, PSA aneurysmsdwhen diagnoseddrequire neither a potentially harmful ligation nor technically challenging open procedures. Endovascular aneurysm exclusion using an antegrade or
1182.e16 Case reports
Annals of Vascular Surgery
retrograde approach is safe and efficient; however, long-term follow-up is required to establish the efficacy of this endovascular procedure. 11.
REFERENCES 1. Mandell VS, Jaques PF, Delany DJ, Oberheu V. Persistent sciatic artery: clinical, embryologic and angiographic features. AJR Am J Roentgenol 1985;144:245e9. 2. Brantley SK, Rigdon EE, Raju S. Persistent sciatic artery: embryology, pathology and treatment. J Vasc Surg 1993;18: 242e8. 3. Ikezawa T, Naiki K, Moriura S, Ikeda S, Hirai M. Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature. J Vasc Surg 1994;20:96e103. 4. Sultan SA, Pacainowski JP, Madhavan P, et al. Endovascular management of rare sciatic artery aneurysm. J Endovasc Ther 2000;7:415e22. 5. Green PH. On a new variety of the femoral artery: with observations. Lancet 1832;1:730e1. 6. Cowie TN, McKellar NJ, McLean N, Smith G. Unilateral congenital absence of the external iliac femoral arteries. Br J Radiol 1960;33:320e2. 7. van Hooft IM, Zeebregts CJ, van Sterkenburg SM, de Vries WR, Reijnen MM. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585e91. 8. Baumgartner FJ, Kalinowski A, Grant S. Endovascular repair of injury to a persistent sciatic artery. Tex Heart Inst J 2009;36:61e4. 9. Ito H, Okadome K, Odashiro T, et al. Persistent sciatic artery: two case reports and a review of the literature. Cardiovasc Surg 1994;2:275e80. 10. Maldini G, Teruya TH, Kamida C, Eklof B. Combined percutaneous endovascular and open surgical approach in the
12.
13. 14.
15.
16.
17.
18. 19.
20.
21.
treatment of a persistent sciatic artery aneurysm presenting with acute limb threatening ischemiada case report and review of the literature. Vasc Endovasc Surg 2002;36: 403e8. Hassan A. Symptomatic persistent sciatic artery. J Am Coll Surg 2004;199:171e3. Abularrage CJ, Crawford RS, Patel VI, Conrad MF. Diagnostic strategies for the persistent sciatic artery. Vasc Endovasc Surg 2009;43:485e9. Knight BC, Tait WF. Massive aneurysm in a persistent sciatic artery. Ann Vasc Surg 2010;24:1135.e13e8. Gabelmann A, Kr€amer SC, Wisianowski C, Tomczak R, Pamler R, G€ orich J. Endovascular interventions on persistent sciatic arteries. J Endovasc Ther 2001;8:622e8. Jain S, Munn JS, Simoni EJ, Jain KM. Endograft repair of a persistent sciatic artery aneurysm. Eur J Vasc Endovasc Surg 2004;8:5e6. Wijeyaratne SM, Wijewardene N. Endovascular stenting of a persistent sciatic artery aneurysm via retrograde popliteal approach: a durable option. Eur J Vasc Endovasc Surg 2009;38:91e2. Mousa A, Rapp Parker A, Emmett MK, AbuRahma A. Endovascular treatment of symptomatic persistent sciatic artery aneurysm: a case report and review of literature. Vasc Endovasc Surg 2010;44:312e4. Santaolalla V, Bernabe MH, Hipola Ulecia JM, et al. Persistent sciatic artery. Ann Vasc Surg 2010;24:691.e7e10. Mascarenhas de Oliveira F, de Souza Mour~ao G. Endovascular repair of symptomatic sciatic artery aneurysm. Vasc Endovasc Surg 2011;45:165e9. Verikokos C, Avgerinos ED, Chatziioannou A, Katsargyris A, Klonaris C. Endovascular repair of a persistent sciatic artery aneurysm. Vascular 2010;18:162e5. Yamamoto H, Yamamoto F, Ishibashi K, et al. Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques. Ann Vasc Surg 2011;25:837.e9e15.