case_images: PMC11814309_01
case_images: Preoperative findings. (a) Contrast-enhanced CT showing a 69 mm left CIAA containing a mural thrombus.. (b) The aneurysm was compressed by a sharp bone spur in the lumber vertebrae.. (c) The abdominal aortic aneurysm measured 33 mm in diameter, and the right CIAA measured 29 mm.. (d) Extensive calcification was observed from the abdominal aorta to both EIA.. (e) Chest radiograph showing decreased transparency in the lung fields.. CIAAs, common iliac artery aneurysms; EIA external iliac arteries; CT, computed tomography
case_images: cureus-0017-00000077349-i01.jpg
case_images: PMC11814309_01_cureus-0017-00000077349-i01.jpg
case_images: FIG1
case_images: Contrast-enhanced CT showed a 69 mm left CIAA containing a mural thrombus (Figure 1a). The aneurysm was compressed by a sharp bone spur in the lumbar vertebrae (Figure 1b). The abdominal artery aneurysm measured 33 mm, and the right CIAA measured 29 mm (Figure 1c). Extensive calcification was observed from the abdominal aorta to both EIAs (Figure 1d). Chest radiography revealed decreased lung field transparency (Figure 1e).
case_images: Intraoperative findings. (a) Angiography of a giant CIAA showing a looped left EIA (blue arrow) and occlusion of the IIA.. (b) The left tortuous iliac artery prevented the DrySeal  from advancing to the terminal aorta.. (c) In order to avoid CIAA rupture, we began to withdraw the DrySeal  sheath, but the loop got more enlarged.. (d) We assumed CIAA rupture and removed the stiff wire to the distal EIA in order to unleash the enlarged EIA loop. In reality, the tip of the Lunderquist  (orange arrow) was located in the retroperitoneal cavity.. (e) Angiography of the left DrySeal  sheath showing extravasation into the retroperitoneal cavity.. (f) A pigtail catheter with a guidewire was advanced via the right femoral artery to the left CIAA and tried to catch the guidewire via left femoral access with an Indy OTW  vascular retriever.. CIAAs, common iliac artery aneurysms; EIA external iliac arteries; IIA, internal iliac artery
case_images: cureus-0017-00000077349-i02.jpg
case_images: PMC11814309_01_cureus-0017-00000077349-i02.jpg
case_images: FIG2
case_images: Angiography from the CIAA revealed looped and tortuous EIA (Figure 2a). However, the left tortuous iliac artery prevented the DrySeal  from advancing to the terminal aorta (Figure 2b). In order to avoid CIAA rupture, we began to withdraw the DrySeal  sheath, but the loop got more enlarged (Figure 2c) and then systolic blood pressure dropped to 45 mmHg. We assumed CIAA rupture and removed the stiff wire to the distal EIA in order to unleash the enlarged EIA loop (Figure 2d). Angiography from the left DrySeal  sheath showed extravasation from the left EIA to the retroperitoneal cavity (Figure 2e); thus, we suspected EIA rupture. A pigtail catheter with a guidewire was advanced via the right femoral artery to the left CIAA and tried to catch the guidewire via left femoral access with an Indy OTW  vascular retriever (Cook Medical, Indiana, USA) (Figure 2f); however, it was impossible to catch the guidewire in the CIAA.
case_images: Intraoperative and postoperative findings. (a) We advanced a pigtail catheter with a guidewire via the left brachial access to the left CIAA and attempted to catch the guidewire again in the CIAA via the left femoral access and to make a through-through, only to fail.. (b) We delivered the upside-down stent graft via the right access using upside-down DrySeal  dilator whose distal edge was cut and deployed it in the trunk of the bifurcated Excluder  to occlude the contralateral opening.. (c) The CIAA was embolized using n-butyl-2-cyanoacrylate via the left brachial access to control retroperitoneal bleeding.. (d) Contrast-enhanced CT on POD 8 revealed a patency crossover bypass and no endoleak.. CIAAs, common iliac artery aneurysms; CT, computed tomography; POD, postoperative day
case_images: cureus-0017-00000077349-i03.jpg
case_images: PMC11814309_01_cureus-0017-00000077349-i03.jpg
case_images: FIG3
case_images: We advanced a pigtail catheter with a guidewire via the left brachial access to the left CIAA and attempted to catch the guidewire again in the CIAA via the left femoral access and to make a through-through (Figure 3a), only to fail. We delivered the upside-down stent graft via the right access using upside-down DrySeal  dilator whose distal edge was cut and deployed it in the trunk of the bifurcated Excluder  to occlude the contralateral opening (Figure 3b). Additionally, the CIAA was embolized using n-butyl-2-cyanoacrylate via the left brachial access to control retroperitoneal bleeding (Figure 3c). Contrast-enhanced CT on POD 8 revealed a patency crossover bypass and no endoleak (Figure 3d).