Direct Puncture Embolization of a Recurrent Internal Iliac Artery Aneurysm with N-Butyl-2-Cyanoacrylate Under Flow-Control with Balloon

Background If only proximal embolization or ligation is performed for an internal iliac artery aneurysm (IIAA), transcatheter arterial embolization is sometimes difficult due to complex collateral circulation. A new method of direct percutaneous n-butyl-2-cyanoacrylate (NBCA) sac embolization (b-DNSE) under balloon arterial occlusion for re-intervention of an IIAA after proximal ligation is presented. Methods The patient was placed in the supine position under local anesthesia. A 20-cm-long, 20G-PTCD needle was advanced to the aneurysmal sac using fluoroscopy. A 5F, 11-cm sheath was inserted via the left common femoral artery, and a Selecon MP catheter was advanced to the left limb. Sacography showed the sac with only the iliolumbar artery as the involved branch. Then, the left limb was balloon-occluded, and the sac was more widely visualized with the appearance of the superior gluteal artery and the obturator artery on sacography. Sac embolization using 10 ml of 50% NBCA diluted with lipiodol was performed under balloon arterial occlusion, and the needle was removed. Completion arteriography showed good Lipiodol distribution without a residual sac or involved branches. No obvious complications were seen, and the procedure was completed. Results The patient was discharged 2 days after the procedure. At 6-month follow-up, contrast-enhanced computed tomography showed no sac enhancement without Lipiodol washout and no expansion of the excluded aneurysm. Conclusion b-DNSE for re-intervention of an IIA aneurysm is feasible when embolization of all involved branches proves difficult. We intend to further investigate this technique.