Emergent endovascular repair of a ruptured giant internal iliac artery aneurysm using an inverted iliac limb endograft

An 88-year-old man with hypertension, coronary artery disease, morbid obesity, and a remote history of a prior open abdominal aortic aneurysm repair with an infrarenal tube graft developed acute abdominal pain accompanied by dizziness after a bowel movement. He was taken to an outside hospital, where a computed tomography angiogramwas obtained. This demonstrated a right internal iliac artery aneurysmmeasuring 11.4 cmwith a large retroperitoneal rupture (A). He was transferredemergently toour tertiary referral center for repair.Onarrival, hewaspale andhypotensive. He initially refused interventionbut subsequently agreed to an attempt at endovascular repair. Retrograde right commonfemoral accesswasobtained, andangiographydemonstrated the large right internal iliac artery aneurysm. The right common iliac artery measured 22.8 mm, and the right external iliac artery measured 14.4mm. Repair with a bifurcated endovascular aneurysm repair device was considered, although this would have beenmore time-consuming in the setting of hemorrhagic shock. A 2716-mmGore Contralateral Leg Endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) provided excellent size match, but this device is designed for “large side down” deployment. Therefore, we proceeded to implant the device using the technique previously described by vander Steenhovenet al. Briefly, this involves removing thedevice from its delivery shaft, reversing it, placing itwithin a sheath, and using amodified sheath dilator as a pushing device to position and deploy the limbwith a “pin and pull”maneuver. This allowed rapid exclusion of the ruptured internal iliac artery aneurysm (B). Thepatient didwell postoperatively and was discharged after a short stay. This case illustrates that a knowledge of alternative techniques for endovascular device implantation can allow expeditious and effective emergency interventions. It also serves as a reminder that aneurysmal disease can be systemic and progressive and that repair of an infrarenal aneurysm does not protect against late rupture of other abnormal vessels. The patient’s wife, who functioned as his durable power of attorney, provided consent for publication of this case report and associated images.