External Iliac Artery Aneurysm Associated with Multiple Lower Extremity Arteriovenous Malformations
Sally Schonefeld, Lili Sadri, Donald Baril, Cassra Arbabi, Ali Azizzadeh, NavYash Gupta
Cedars Sinai Medical Center, Los Angeles, CA
BACKGROUND: A 32-year-old man with a history of venous insufficiency status post 3 left great saphenous vein ablation procedures presented to orthopedic surgery for work up of left hip osteoarthritis secondary to avascular necrosis and dysplasia. Additional work up with Duplex ultrasonography and computed tomography angiogram (CTA) revealed a 6cm left external iliac aneurysm and extensive left lower extremity arteriovenous malformations (AVMs).(Figure 1). 
METHODS: Given the patient’s age and anatomy, open repair of the left iliac aneurysm was contemplated. In an attempt to reduce venous hypertension related to the left lower extremity AVMs, the patient underwent angiogram and embolization by interventional radiology. However the extensive nature of the AVMs precluded meaningful reduction of venous hypertension. Hence, an endovascular approach for repair of the left external iliac artery aneurysm was planned. To achieve and adequate proximal landing zone, the internal iliac artery was embolized with a 12mm Amplatzer plug from a right femoral artery approach. Because of the enlarged native left common and distal external iliac arteries, thoracic aortic endografts were used for the repair. Two Gore C-TAG 28mm x15cm devices were selected for placement via left femoral approach with the first device starting in the proximal common iliac artery and second device overlapped 5cm and extended to the distal external iliac artery. Post-deployment balloon angioplasty was performed and completion angiogram revealed an excellent result with no evidence of endoleak (Figure 2). 
RESULTS: The patient was observed overnight and recovered well from the procedure. He was discharged on the first post-operative day. On his one month follow up, he denied any pain. Follow up CTA showed well placed endograft with no evidence of endoleak. The patient will be referred to interventional radiology for further embolization of the lower extremity AVMs prior to attempted left hip surgery.
CONCLUSIONS: Isolated external iliac artery aneurysms are exceeding rare and can present unique management challenges, especially when associated with multiple lower extremity AVMs and venous hypertension. Iliac artery aneurysms carry significant risk of rupture when they attain a large size and should be fixed at 3.5cm or larger. An open repair is often the standard approach for isolated iliac aneurysms, but endovascular techniques have been employed successfully with good results and low mortality. In this case, endovascular approach was selected due to enlarged and high pressured venous system that would have made open repair fraught with potential massive bleeding.
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