Effectiveness of exclusion of a persistent sciatic artery aneurysm with an Amplatzer™ plug Allen Lee, MD, Stephen E. Hohmann, MD, and William P. Shutze, MD
Persistent sciatic artery is a rare developmental anomaly. In its complete form, it provides the major arterial supply to the lower leg since the femoral system is hypoplastic. These unique arteries are prone to aneurysm formation and most commonly present with complications related to aneurysm formation, which can lead to limb loss. We encountered a 68-year-old man presenting with bilateral lower-extremity ischemia who was found to have bilateral persistent sciatic artery aneurysms. One aneurysm had already thrombosed, but the other was still patent. We treated this patient with a hybrid open and endovascular repair on the patent side. The aneurysm was excluded with an Amplatzer™ plug (St. Jude Medical, Inc., St. Paul, MN) followed by a femoropopliteal bypass with saphenous vein in situ to revascularize the lower leg. To our knowledge, this is only the second report of a persistent sciatic artery aneurysm successfully treated with Amplatzer plug occlusion.
dis and posterior tibial pulses were present by Doppler only. A computed tomographic arteriogram (CTA) demonstrated bilateral PSA aneurysms (Figure 1). The left sciatic artery aneurysm measured 4.5 × 4.0 cm and contained thrombus, but the lumen was patent. The right sciatic aneurysm measured 5.4 × 2.5 cm and was completely occluded by thrombus. The superficial
T
he sciatic artery is an embryonic continuation of the internal iliac artery that provides the axial blood supply to the lower extremity. In approximately 0.025% to 0.04% of the population, the sciatic artery does not regress in utero and persists to be the major arterial supply to the lower extremity (1). A persistent sciatic artery (PSA) was first described in 1832 (2), and the first death caused by a ruptured sciatic artery aneurysm was reported in 1864 (3). These aberrant arteries are associated with a predisposition for aneurysm formation. Aside from the risk of rupture, sciatic artery aneurysms pose a risk of distal embolization and subsequent limb loss (4). We report a case of acute limb ischemia due to thromboembolism from a sciatic artery aneurysm treated with a combination of open and endovascular techniques. This is the second known reported case of the use of an Amplatzer™ vascular plug (St. Jude Medical, Inc., St. Paul, MN) to exclude a PSA aneurysm. CASE REPORT A 68-year-old man presented to the emergency department after experiencing acute onset of bilateral lower-extremity pain while playing golf, with more severe pain in the left leg. He was otherwise healthy and had no prior history of claudication. On examination, he had palpable bilateral femoral and left popliteal pulses. The right popliteal pulse and the bilateral dorsalis pe210
Figure 1. Coronal reconstructed contrast-enhanced CT angiogram demonstrating bilateral persistent sciatic arteries. Note the left persistent sciatic artery (PSA), which begins as a continuation of the internal iliac artery and proceeds caudally exiting the pelvis to course inferiorly into the thigh. The patent PSA aneurysm on the left is marked by the arrow. The sciatic artery aneurysm on the right is thrombosed, and while it is not demonstrated on this reconstructed image, it is easily identified on the original axial CT slices (not shown). Both superficial femoral arteries are hypoplastic, and the PSA supplies both popliteal arteries. From the Division of Vascular Surgery, Baylor University Medical Center at Dallas. Corresponding author: William P. Shutze, MD, Texas Vascular Associates, 621 N. Hall Street, Suite 100, Dallas, TX 75226 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2015;28(2):210–212
a
b
Figure 2. (a) The popliteal artery was accessed in a retrograde fashion (arrow) to perform the sciatic artery aneurysm embolization. (b) The superficial femoral artery (arrow) was noted to be hypoplastic.
femoral artery (SFA) was present but incomplete bilaterally, and the popliteal arteries were supplied by the PSAs. The patient was started on a heparin infusion for the presumed thromboembolic event that caused the left leg pain. The leg pain resolved overnight. Ankle brachial indices were 0.84 on the right and 0.89 on the left. Retrograde embolization of his left PSA aneurysm was performed through exposure of the above-knee popliteal artery, which was then accessed with a 45-cm 7 French sheath. The PSA aneurysm was then easily accessed and an angiogram was performed to determine the extent of the aneurysm. A 14-mm Amplatzer plug was placed proximal to the aneurysm, and a 12mm Amplatzer plug was placed distal to the aneurysm. Platinum and stainless steel coils (Cook Medical, Bloomington, IN) were also placed within the aneurysmal sac (Figures 2a, 2b, 3a). Distal perfusion was then reestablished by femoropopliteal bypass using reversed great saphenous vein. The right-sided aneurysm was not
treated, as it was already thrombosed and the patient was no longer symptomatic. The patient did well and was discharged home with palpable pedal pulses on the left. At 6-month follow-up, he continued to be asymptomatic, and thrombosis of the PSA aneurysm was documented on repeat CTA (Figure 3b).
DISCUSSION In the human embryo, the sciatic artery provides in-line flow to the lower limb buds via the internal iliac artery. The sciatic artery normally involutes by the third month as the femoral artery develops. Remnants of the sciatic artery persist as parts of the internal iliac artery and portions of the popliteal and peroneal arteries (5). Rarely, the sciatic artery persists as the dominant inflow vessel to the lower extremity. PSAs can be classified as “complete” or “incomplete.” In the complete type (75% of PSAs), the SFA is hypoplastic and the sciatic artery maintains its caliber to provide the major inflow to the thigh and the popliteal artery (5). In the incomplete type a b (25% of PSAs), the SFA is still the major inflow vessel, and the sciatic artery becomes hypoplastic in the thigh (6). PSAs are usually detected after a vascular complication or incidentally after imaging for another indication. Aneurysm formation occurs in up to 46% of cases (6). Repetitive minor trauma with sitting is thought to contribute to aneurysm formation due to immature elastic properties, but the exact mechanism is unclear (4). Limb ischemia is the most likely complication of PSA and is usually secondary to distal embolization. Buttock pain or a painful pulsatile mass in the buttocks may suggest a sciatic artery aneurysm, and a rapidly expanding mass may be indicative of aneurysm rupture (7). Duplex ultrasound can be useful in confirming a suspected case of a PSA aneurysm if used to investigate a pulsatile gluteal mass. Magnetic resonance angiography, CTA, or arteriography is more helpful in diagnosing the PSA Figure 3. (a) Coils were left within the aneurysm sac (dashed arrow) and a second Amplatzer plug (solid arrow) was placed just distal to the aneurysm sac. (b) Amplatzer plugs with endovascular coils (circle) are noted within as well as in identifying whether the PSA is complete or incomplete (8). the persistent sciatic artery aneurysm with no flow. The femoropopliteal artery bypass (arrow) is patent. April 2015
Effectiveness of exclusion of a persistent sciatic artery aneurysm with an Amplatzer™ plug
211
Treatment generally requires exclusion of the aneurysm and revascularization if the PSA is the dominant inflow vessel to the lower leg (9). Historically, this was done surgically, but currently an endovascular or hybrid approach is used. In addition to being less invasive than open ligation, endovascular embolization is recommended to decrease the risk of sciatic nerve injury. In the incomplete type of PSA, aneurysm exclusion is sufficient (9). Numerous endovascular exclusion approaches have been described in the literature, including femoral, transgluteal, and open retrograde popliteal access (10–13). In the complete type of PSA, limb revascularization is mandatory, as the blood supply to the lower limb will be entirely dependent on the sciatic artery. Revascularization requires a femoral distal bypass (13). Endovascular approaches to excluding the aneurysm sac with covered stent grafts have been described in the literature; however, the durability of such repairs is yet to be determined and may be a problem in the long term because the stent graft will be in an area that undergoes repetitive trauma with walking and sitting (11, 12). Endovascular treatment of the aneurysm should probably be reserved for patients with prohibitively high operative risk or limited survival. Multiple cases of therapeutic embolization of PSA aneurysms have been reported, with most using intravascular coils. Amplatzer plugs are self-expanding nitinol mesh devices that are easily delivered with great precision and are capable of occluding large-diameter vessels. They come in a variety of sizes, ranging from 4 mm to 22 mm, and are delivered through sheaths ranging from 4 to 7 French. There are several advantages to using vascular plugs for vessel occlusion. Amplatzer plugs can be deployed more precisely than endovascular coils, which can be difficult to place accurately and can embolize distally. This makes coil embolization challenging in larger-caliber vessels such as PSAs (14). In our previous experience with a similar case of PSA aneurysm, this problematic event occurred (Figure 4). Additionally, in that case, we found that many coils were required, and we eventually exhausted our coil supplies and had to resort to using long wire fragments to finally achieve aneurysm sac thrombosis.
Amplatzer plugs have been compared with coil embolization for internal iliac embolization and have shown equivalent efficacy in achieving vascular occlusion with shorter procedure times (15). At our institution, the larger coils each cost approximately $200, whereas the Amplatzer plugs cost about $800 individually. The break-even point between these two options is exceeded after eight coils have been placed. This estimate does not include the additional 15 to 30 minutes of operating time required for coil embolization. In our case, we did use adjunctive coils. However, in retrospect, this was unnecessary, and in the previously reported case, only two plugs were necessary (16). Another potential benefit of Amplatzer plugs is less scatter on follow-up CT scans, which better renders the follow-up imaging. Acknowledgment The authors wish to thank Kelli R. Trungale, MLS, ELS, for editorial assistance. 1.
2. 3. 4.
5. 6. 7.
8.
9.
10.
11.
12.
13.
14.
15.
Figure 4. Conventional radiograph of the pelvic region showing endovascular coils within the persistent sciatic artery aneurysm (circle) and distally migrated coils (arrow). 212
16.
Cowan MM, Hamweyah KM, Sabbagh MD, Swaid BA, Alkattan AK, Ganguly P. Persistent bilateral sciatic artery: report of a rare case. Int J Angiol 2010;19(1):e43–e44. Green PH. On a new variety of the femoral artery. Lancet 1832;1:730–731. Fagge CH. Case of aneurysm, seated on an abnormal main artery of the lower limb. Guy’s Hosp Rep 1864;10:151–159. Mandell VS, Jaques PF, Delany DJ, Oberheu V. Persistent sciatic artery: clinical, embryologic, and angiographic features. AJR Am J Roentgenol 1985;144(2):245–249. Shutze WP, Garrett WV, Smith BL. Persistent sciatic artery: collective review and management. Ann Vasc Surg 1993;7(3):303–310. Mascarenhas de Oliveira F, de Souza Mourão G. Endovascular repair of symptomatic sciatic artery aneurysm. Vasc Endovascular Surg 2011;45(2):165–169. Fung HS, Lau S, Chan MK, Tang KW, Cheung YL, Chan SC. Persistent sciatic artery complicated by aneurysm formation and thrombosis. Hong Kong Med J 2008;14(6):492–494. Jung AY, Lee W, Chung JW, Song SY, Kim SJ, Ha J, Jae HJ, Park JH. Role of computed tomographic angiography in the detection and comprehensive evaluation of persistent sciatic artery. J Vasc Surg 2005; 42(4):678–683. Ikezawa T, Naiki K, Moriura S, Ikeda S, Hirai M. Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature. J Vasc Surg 1994;20(1):96–103. Verikokos C, Avgerinos ED, Chatziioannou A, Katsargyris A, Klonaris C. Endovascular repair of a persistent sciatic artery aneurysm. Vascular 2010;18(3):162–165. Mousa A, Rapp Parker A, Emmett MK, AbuRahma A. Endovascular treatment of symptomatic persistent sciatic artery aneurysm: a case report and review of literature. Vasc Endovascular Surg 2010;44(4):312–314. Wijeyaratne SM, Wijewardene N. Endovascular stenting of a persistent sciatic artery aneurysm via retrograde popliteal approach: a durable option. Eur J Vasc Endovasc Surg 2009;38(1):91–92. Gargiulo NJ 3rd, O’Connor DJ, Phangureh V, Lipsitz EC, Benros RM, Veith FJ. Management of persistent sciatic artery embolization to the lower extremity using covered stent through a transgluteal approach. Am Surg 2011;77(3):366–368. Maldini G, Teruya TH, Kamida C, Eklof B. Combined percutaneous endovascular and open surgical approach in the treatment of a persistent sciatic artery aneurysm presenting with acute limb-threatening ischemia—a case report and review of the literature. Vasc Endovascular Surg 2002;36(5):403–408. Ryer EJ, Garvin RP, Webb TP, Franklin DP, Elmore JR. Comparison of outcomes with coils versus vascular plug embolization of the internal iliac artery for endovascular aortoiliac aneurysm repair. J Vasc Surg 2012;56(5):1239–1245. McEnaney RM, Baril DT, Gupta N, Marone LK, Makaroun MS, Chaer RA. Persistent sciatic artery aneurysm treated with concomitant tibial bypass and vascular plug embolization. J Vasc Surg 2009;50(4):915–918.
Baylor University Medical Center Proceedings
Volume 28, Number 2
Persistent sciatic artery is a rare developmental anomaly. In its complete form, it provides the major arterial supply to the lower leg since the femoral system is hypoplastic. These unique arteries are prone to aneurysm formation and most commonly present with complications related to aneurysm formation, which can lead to limb loss. We encountered a 68-year-old man presenting with bilateral lower-extremity ischemia who was found to have bilateral persistent sciatic artery aneurysms. One aneurysm had already thrombosed, but the other was still patent. We treated this patient with a hybrid open and endovascular repair on the patent side. The aneurysm was excluded with an Amplatzer™ plug (St. Jude Medical, Inc., St. Paul, MN) followed by a femoropopliteal bypass with saphenous vein in situ to revascularize the lower leg. To our knowledge, this is only the second report of a persistent sciatic artery aneurysm successfully treated with Amplatzer plug occlusion.
dis and posterior tibial pulses were present by Doppler only. A computed tomographic arteriogram (CTA) demonstrated bilateral PSA aneurysms (Figure 1). The left sciatic artery aneurysm measured 4.5 × 4.0 cm and contained thrombus, but the lumen was patent. The right sciatic aneurysm measured 5.4 × 2.5 cm and was completely occluded by thrombus. The superficial
T
he sciatic artery is an embryonic continuation of the internal iliac artery that provides the axial blood supply to the lower extremity. In approximately 0.025% to 0.04% of the population, the sciatic artery does not regress in utero and persists to be the major arterial supply to the lower extremity (1). A persistent sciatic artery (PSA) was first described in 1832 (2), and the first death caused by a ruptured sciatic artery aneurysm was reported in 1864 (3). These aberrant arteries are associated with a predisposition for aneurysm formation. Aside from the risk of rupture, sciatic artery aneurysms pose a risk of distal embolization and subsequent limb loss (4). We report a case of acute limb ischemia due to thromboembolism from a sciatic artery aneurysm treated with a combination of open and endovascular techniques. This is the second known reported case of the use of an Amplatzer™ vascular plug (St. Jude Medical, Inc., St. Paul, MN) to exclude a PSA aneurysm. CASE REPORT A 68-year-old man presented to the emergency department after experiencing acute onset of bilateral lower-extremity pain while playing golf, with more severe pain in the left leg. He was otherwise healthy and had no prior history of claudication. On examination, he had palpable bilateral femoral and left popliteal pulses. The right popliteal pulse and the bilateral dorsalis pe210
Figure 1. Coronal reconstructed contrast-enhanced CT angiogram demonstrating bilateral persistent sciatic arteries. Note the left persistent sciatic artery (PSA), which begins as a continuation of the internal iliac artery and proceeds caudally exiting the pelvis to course inferiorly into the thigh. The patent PSA aneurysm on the left is marked by the arrow. The sciatic artery aneurysm on the right is thrombosed, and while it is not demonstrated on this reconstructed image, it is easily identified on the original axial CT slices (not shown). Both superficial femoral arteries are hypoplastic, and the PSA supplies both popliteal arteries. From the Division of Vascular Surgery, Baylor University Medical Center at Dallas. Corresponding author: William P. Shutze, MD, Texas Vascular Associates, 621 N. Hall Street, Suite 100, Dallas, TX 75226 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2015;28(2):210–212
a
b
Figure 2. (a) The popliteal artery was accessed in a retrograde fashion (arrow) to perform the sciatic artery aneurysm embolization. (b) The superficial femoral artery (arrow) was noted to be hypoplastic.
femoral artery (SFA) was present but incomplete bilaterally, and the popliteal arteries were supplied by the PSAs. The patient was started on a heparin infusion for the presumed thromboembolic event that caused the left leg pain. The leg pain resolved overnight. Ankle brachial indices were 0.84 on the right and 0.89 on the left. Retrograde embolization of his left PSA aneurysm was performed through exposure of the above-knee popliteal artery, which was then accessed with a 45-cm 7 French sheath. The PSA aneurysm was then easily accessed and an angiogram was performed to determine the extent of the aneurysm. A 14-mm Amplatzer plug was placed proximal to the aneurysm, and a 12mm Amplatzer plug was placed distal to the aneurysm. Platinum and stainless steel coils (Cook Medical, Bloomington, IN) were also placed within the aneurysmal sac (Figures 2a, 2b, 3a). Distal perfusion was then reestablished by femoropopliteal bypass using reversed great saphenous vein. The right-sided aneurysm was not
treated, as it was already thrombosed and the patient was no longer symptomatic. The patient did well and was discharged home with palpable pedal pulses on the left. At 6-month follow-up, he continued to be asymptomatic, and thrombosis of the PSA aneurysm was documented on repeat CTA (Figure 3b).
DISCUSSION In the human embryo, the sciatic artery provides in-line flow to the lower limb buds via the internal iliac artery. The sciatic artery normally involutes by the third month as the femoral artery develops. Remnants of the sciatic artery persist as parts of the internal iliac artery and portions of the popliteal and peroneal arteries (5). Rarely, the sciatic artery persists as the dominant inflow vessel to the lower extremity. PSAs can be classified as “complete” or “incomplete.” In the complete type (75% of PSAs), the SFA is hypoplastic and the sciatic artery maintains its caliber to provide the major inflow to the thigh and the popliteal artery (5). In the incomplete type a b (25% of PSAs), the SFA is still the major inflow vessel, and the sciatic artery becomes hypoplastic in the thigh (6). PSAs are usually detected after a vascular complication or incidentally after imaging for another indication. Aneurysm formation occurs in up to 46% of cases (6). Repetitive minor trauma with sitting is thought to contribute to aneurysm formation due to immature elastic properties, but the exact mechanism is unclear (4). Limb ischemia is the most likely complication of PSA and is usually secondary to distal embolization. Buttock pain or a painful pulsatile mass in the buttocks may suggest a sciatic artery aneurysm, and a rapidly expanding mass may be indicative of aneurysm rupture (7). Duplex ultrasound can be useful in confirming a suspected case of a PSA aneurysm if used to investigate a pulsatile gluteal mass. Magnetic resonance angiography, CTA, or arteriography is more helpful in diagnosing the PSA Figure 3. (a) Coils were left within the aneurysm sac (dashed arrow) and a second Amplatzer plug (solid arrow) was placed just distal to the aneurysm sac. (b) Amplatzer plugs with endovascular coils (circle) are noted within as well as in identifying whether the PSA is complete or incomplete (8). the persistent sciatic artery aneurysm with no flow. The femoropopliteal artery bypass (arrow) is patent. April 2015
Effectiveness of exclusion of a persistent sciatic artery aneurysm with an Amplatzer™ plug
211
Treatment generally requires exclusion of the aneurysm and revascularization if the PSA is the dominant inflow vessel to the lower leg (9). Historically, this was done surgically, but currently an endovascular or hybrid approach is used. In addition to being less invasive than open ligation, endovascular embolization is recommended to decrease the risk of sciatic nerve injury. In the incomplete type of PSA, aneurysm exclusion is sufficient (9). Numerous endovascular exclusion approaches have been described in the literature, including femoral, transgluteal, and open retrograde popliteal access (10–13). In the complete type of PSA, limb revascularization is mandatory, as the blood supply to the lower limb will be entirely dependent on the sciatic artery. Revascularization requires a femoral distal bypass (13). Endovascular approaches to excluding the aneurysm sac with covered stent grafts have been described in the literature; however, the durability of such repairs is yet to be determined and may be a problem in the long term because the stent graft will be in an area that undergoes repetitive trauma with walking and sitting (11, 12). Endovascular treatment of the aneurysm should probably be reserved for patients with prohibitively high operative risk or limited survival. Multiple cases of therapeutic embolization of PSA aneurysms have been reported, with most using intravascular coils. Amplatzer plugs are self-expanding nitinol mesh devices that are easily delivered with great precision and are capable of occluding large-diameter vessels. They come in a variety of sizes, ranging from 4 mm to 22 mm, and are delivered through sheaths ranging from 4 to 7 French. There are several advantages to using vascular plugs for vessel occlusion. Amplatzer plugs can be deployed more precisely than endovascular coils, which can be difficult to place accurately and can embolize distally. This makes coil embolization challenging in larger-caliber vessels such as PSAs (14). In our previous experience with a similar case of PSA aneurysm, this problematic event occurred (Figure 4). Additionally, in that case, we found that many coils were required, and we eventually exhausted our coil supplies and had to resort to using long wire fragments to finally achieve aneurysm sac thrombosis.
Amplatzer plugs have been compared with coil embolization for internal iliac embolization and have shown equivalent efficacy in achieving vascular occlusion with shorter procedure times (15). At our institution, the larger coils each cost approximately $200, whereas the Amplatzer plugs cost about $800 individually. The break-even point between these two options is exceeded after eight coils have been placed. This estimate does not include the additional 15 to 30 minutes of operating time required for coil embolization. In our case, we did use adjunctive coils. However, in retrospect, this was unnecessary, and in the previously reported case, only two plugs were necessary (16). Another potential benefit of Amplatzer plugs is less scatter on follow-up CT scans, which better renders the follow-up imaging. Acknowledgment The authors wish to thank Kelli R. Trungale, MLS, ELS, for editorial assistance. 1.
2. 3. 4.
5. 6. 7.
8.
9.
10.
11.
12.
13.
14.
15.
Figure 4. Conventional radiograph of the pelvic region showing endovascular coils within the persistent sciatic artery aneurysm (circle) and distally migrated coils (arrow). 212
16.
Cowan MM, Hamweyah KM, Sabbagh MD, Swaid BA, Alkattan AK, Ganguly P. Persistent bilateral sciatic artery: report of a rare case. Int J Angiol 2010;19(1):e43–e44. Green PH. On a new variety of the femoral artery. Lancet 1832;1:730–731. Fagge CH. Case of aneurysm, seated on an abnormal main artery of the lower limb. Guy’s Hosp Rep 1864;10:151–159. Mandell VS, Jaques PF, Delany DJ, Oberheu V. Persistent sciatic artery: clinical, embryologic, and angiographic features. AJR Am J Roentgenol 1985;144(2):245–249. Shutze WP, Garrett WV, Smith BL. Persistent sciatic artery: collective review and management. Ann Vasc Surg 1993;7(3):303–310. Mascarenhas de Oliveira F, de Souza Mourão G. Endovascular repair of symptomatic sciatic artery aneurysm. Vasc Endovascular Surg 2011;45(2):165–169. Fung HS, Lau S, Chan MK, Tang KW, Cheung YL, Chan SC. Persistent sciatic artery complicated by aneurysm formation and thrombosis. Hong Kong Med J 2008;14(6):492–494. Jung AY, Lee W, Chung JW, Song SY, Kim SJ, Ha J, Jae HJ, Park JH. Role of computed tomographic angiography in the detection and comprehensive evaluation of persistent sciatic artery. J Vasc Surg 2005; 42(4):678–683. Ikezawa T, Naiki K, Moriura S, Ikeda S, Hirai M. Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature. J Vasc Surg 1994;20(1):96–103. Verikokos C, Avgerinos ED, Chatziioannou A, Katsargyris A, Klonaris C. Endovascular repair of a persistent sciatic artery aneurysm. Vascular 2010;18(3):162–165. Mousa A, Rapp Parker A, Emmett MK, AbuRahma A. Endovascular treatment of symptomatic persistent sciatic artery aneurysm: a case report and review of literature. Vasc Endovascular Surg 2010;44(4):312–314. Wijeyaratne SM, Wijewardene N. Endovascular stenting of a persistent sciatic artery aneurysm via retrograde popliteal approach: a durable option. Eur J Vasc Endovasc Surg 2009;38(1):91–92. Gargiulo NJ 3rd, O’Connor DJ, Phangureh V, Lipsitz EC, Benros RM, Veith FJ. Management of persistent sciatic artery embolization to the lower extremity using covered stent through a transgluteal approach. Am Surg 2011;77(3):366–368. Maldini G, Teruya TH, Kamida C, Eklof B. Combined percutaneous endovascular and open surgical approach in the treatment of a persistent sciatic artery aneurysm presenting with acute limb-threatening ischemia—a case report and review of the literature. Vasc Endovascular Surg 2002;36(5):403–408. Ryer EJ, Garvin RP, Webb TP, Franklin DP, Elmore JR. Comparison of outcomes with coils versus vascular plug embolization of the internal iliac artery for endovascular aortoiliac aneurysm repair. J Vasc Surg 2012;56(5):1239–1245. McEnaney RM, Baril DT, Gupta N, Marone LK, Makaroun MS, Chaer RA. Persistent sciatic artery aneurysm treated with concomitant tibial bypass and vascular plug embolization. J Vasc Surg 2009;50(4):915–918.
Baylor University Medical Center Proceedings
Volume 28, Number 2
