Following informed consent and verification of the correct patient and planned procedure, the bilateral groins were prepped and draped in the usual sterile fashion. Puncture of the left common femoral artery was performed and a 5Fr sheath was placed. A 5Fr RC1 catheter was introduced into the left external iliac artery. Contrast was injected and DSA imaging of the pelvis was performed in the RAO projection. Over a glidewire, the RC1 was advanced into the left internal iliac artery. Contrast was injected and DSA imaging was performed as a left internal iliac arteriogram. Over the wire, the catheter was further advanced into the iliolumbar artery. Contrast was injected and DSA imaging was performed as a selective arteriogram. Through the catheter, a Renegade microcatheter was advanced over a Synchro 2 wire, an 018 Terumo wire, and an 018 GT wire distally into two separate collateral beds of the distal iliolumbar artery. On each occasion, contrast was injected and DSA imaging was performed. Aggressive attempts were made at crossing the collateral bed without success and resulting in perforation of a small collateral branch. This was treated by coil embolization. The microcatheter was removed. The RC1 was exchanged for a 5Fr Simmons 1 catheter. The catheter was advacned up through the endograft, formed in the descending thoracic aorta, and used to select and inject the SMA origin. The catheter was injected and DSA imaging was performed. After review of the images, the catheter and sheath were removed and pressure was applied to the puncture site until hemostasis was achieved.
The left limb of the endograft, left internal and left external iliac arteries are patent and without stenosis. The left iliolumbar artery supplies a rich retroperitoneal collateral bed the reconstitutes the left L4 lumbar artery. There is left to right cross filling of the right L4 lumbar artery. The aneurysm sac was not opacified. As described, failed attempts were made at negotiating the collateral to gain access to the L4 lumbar arteries in order to perform embolization. Perforation of a small collateral was treated by coil emboliation to occlusion. Injection of the SMA showed classic anatomy and an enlarged middle colic artery that supplies the IMA branches. The main IMA trunk does not fill nor does the aneurysm sac.
1. Probable type 2 endoleak from the L4 lumbar arteries. Attempt at embolization from the left was unsuccessful. Attempt at embolization from the right can be performed at another date.