Embolization of External Iliac Artery Pseudoaneurysm: Importance of the Corona Mortis скачать в хорошем качестве

Embolization of External Iliac Artery Pseudoaneurysm: Importance of the Corona Mortis

The Corona Mortis, while potentially dangerous if injured during surgery, can actually be beneficial in certain situations. In this case, the collateral blood flow provided by the Corona Mortis anastomosis between the inferior epigastric and obturator arteries allowed for immediate opacification of the internal iliac artery after stent placement, without needing support from the contralateral side. So in this instance, the Corona Mortis acted as a lifesaver rather than a liability! A 57-year-old man with a history of substance abuse admitted to the infectious disease department with right lower limb edema due to staphylococcal sepsis. His complete blood count shows a decline in hemoglobin levels from 13.7 to 10.5 to 9.5. The abdomen is tender on the right flank with guarding. An abdominal CT scan is requested to rule out bleeding. Significant retroperitoneal fluid collection. Retroperitoneal fluid collection (yellow arrows) with a coarse formation showing a hemorrhagic blush consistent with a pseudoaneurysm. The coarse formation with a hemorrhagic blush consistent with a pseudoaneurysm is seen in the coronal reconstructions. It is unclear whether the pseudoaneurysm originates from the external or internal iliac artery. Right common femoral puncture and angiography via the introducer reveal occlusion of the right external iliac artery at the center of the pseudoaneurysm. Angiography via the introducer highlights occlusion of the right external iliac artery at the center of the pseudoaneurysm (red arrow tips) with patency of the internal iliac artery. Advancement of a 4F vertebral catheter in an attempt to cross the occlusion: visualization of the pseudoaneurysm, but contrast extravasation into the retroperitoneum. Advancement of a 4F vertebral catheter in an attempt to cross the occlusion: visualization of the pseudoaneurysm and the internal iliac artery (green arrows), but contrast extravasation into the retroperitoneum. Contralateral access and selective catheterization of the right common iliac artery with a 4F Simmons catheter: occlusion of the right external iliac artery just beyond the origin and patency of the internal iliac artery. In a later phase after selective catheterization of the right common iliac artery: the right external iliac artery maintains patency through a filiform channel; the pseudoaneurysm and the internal iliac artery are also visualized. From the right common iliac artery, a smart mask and Progreat microcatheter allow access to the filiform channel of the external iliac artery. The Progreat microcatheter navigates through the filiform channel and reaches the right common femoral artery using the microguide. The microguide enters the introducer, bringing the Progreat microcatheter along with it. Leftward advancement of the Simmons catheter and extraction of the introducer on the right while pulling the microguide and microcatheter; push and pull technique. After removing the Simmons catheter, a 0.35 guidewire is inserted from the right to cross the stenosis, repositioning the introducer. The 0.35 guidewire from the right is advanced significantly into the aorta. Search for the best projection to position the stents with vascular anatomy study: note the presence of the Corona Mortis anastomosis between the inferior epigastric and obturator arteries. Search for the best projection with simultaneous double injection from the right and left: note the length of the filiform segment of the external iliac artery. Vascular anatomy study with partial image subtraction: note the retropubic position of the Corona Mortis anastomosis between the inferior epigastric and obturator arteries. Placement of an 8x59mm GORE VIABAHN VBX covered stent near the origin of the internal iliac artery. Release of the 8x59mm GORE VIABAHN VBX covered stent (purple arrows) just after the origin of the internal iliac artery (yellow arrow tip) with preservation of the internal iliac artery. In agreement with the vascular surgeon, it is decided to close the internal iliac artery to ensure greater long-term stability of the covered stent. Complete exclusion of the pseudoaneurysm and the internal iliac artery, which is well compensated by the contralateral internal iliac artery: note the immediate opacification of the internal iliac artery even without collateral support from the contralateral side, thanks to the Corona Mortis anastomosis connecting the inferior epigastric artery with the obturator artery. Slightly later phase where the right common femoral artery and the internal iliac artery are still visible, thanks to the Corona Mortis anastomosis connecting the inferior epigastric artery with the obturator artery. Interventional Radiology Cremona - Case a123 www.radiologiacremona.it