Case Report Hybrid Approach in a Case of Persistent Sciatic Artery Aneurysm Carolina Vaz, Rui Machado, Duarte Rego, Arlindo Matos, and Rui Almeida, Porto, Portugal
Persistent sciatic artery is a rare congenital vascular malformation with a reported incidence between 0.03% and 0.06%. An 82-yr-old woman presented to our institution with right acute lower limb ischemia compatible with a cardioembolic etiology. A popliteal embolectomy was performed to the patient, and at the end of the procedure, she had bilateral lower limb distal pulses. Six months after the procedure, the patient complained with right lower limb rest pain, an angiography and a computed tomography angiography were performed showing a sciatic artery aneurysm with 4.6 cm of diameter and patency of the sciatic artery to the popliteal artery. A femoropopliteal bypass and retrograde coil embolization of the sciatic aneurysm through the popliteal artery and distal sciatic artery ligation were performed. The patient was discharged 7 days after the procedure, and she remains asymptomatic. Our patient had a complete type of persistent sciatic artery with aneurysmatic degeneration. Correction of the distal ischemia with aneurysm exclusion was achieved with a simple noncomplicated hybrid procedure.
CASE REPORT The case reports on an 82-yr-old woman presented with right acute lower limb ischemia. She had a previous history of hypertension, dyslipidemia, and paroxistic atrial fibrillation. On vascular examination, she had similar bilateral femoral pulses, popliteal and distal pulses absent on the right limb and palpable on the left limb. The duplex ultrasound examination showed popliteal and tibial arteries thrombosis, with no thrombus on common femoral artery. A cardioembolic etiology was assumed as the most probable cause. A popliteal embolectomy was performed to the patient, at the end of the procedure, angiography was not performed because she had palpable bilateral distal pulses associated with good Doppler signals.
Department of Angiology and Vascular Surgery, Hospital de Santo Antonio - Centro Hospitalar do Porto, Porto. Correspondence to: Carolina Vaz, MD, Centro Hospitalar do Porto, Servic¸ o de Angiologia e Cirurgia Vascular, Largo Professor Abel Salazar, 4200 - Porto, Portugal; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2013.08.028 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: May 11, 2013; manuscript accepted: August 26, 2013; published online: ---.
On the follow-up, 6 months after the procedure, the patient complained with right lower limb rest pain. She had palpable femoral pulse and popliteal and distal pulses were absent on the right limb examination. The vascular left limb examination was normal. The angiogram and computed tomography showed a 4.6 cm right sciatic artery aneurysm with patency of the sciatic artery to the popliteal artery (Figs. 1 and 2) and a right hypoplastic superficial femoral artery. Posterior tibial and peroneal arteries were absent, but patent popliteal and anterior tibial arteries were visualized. The left lower extremity vessels appeared to have normal anatomy and to be free of significant disease. These findings established the diagnosis of a complete type of persistent sciatic artery (PSA) with aneurysmatic degeneration. An above-knee popliteal surgical approach was performed. This approach was used to access the sciatic aneurysm using selective retrograde catheterization of the sciatic artery. Transcatheter embolization of the aneurysm with 8 mm diameter coils (Cook MReye) and ligation of the distal sciatic artery segment by the popliteal approach were performed. Then an above-Knee femoropopliteal bypass with 6 mm polytetrafluorethylene was made. The computed tomography angiography, performed after the procedure, showed thrombosis of the aneurysm sac (Fig. 3) and a patent femoropopliteal bypass. The patient was discharged on the seventh postoperative day with antiplatelet medication. At 1 year follow-up, she remains asymptomatic.
1
2 Case Report
Fig. 1. Computed tomography angiography showing 46-mm right sciatic artery aneurysm.
Annals of Vascular Surgery
scan
Fig. 2. Computed tomography angiography scan showing a complete sciatic artery with aneurysm degeneration and hypoplastic femoral artery.
DISCUSSION PSA is an unusual anatomic anomaly, first reported with angiographic evidence in 1960.1 It is an anomalous and persistent axial artery that results from a failure to regress between the 10th- and 12thweek gestation. This sciatic or axial artery is the major blood supply to the primitive foot and is later replaced by the iliofemoral artery as the limb develops.2,3 Its failure to regress is sometimes associated with femoral arterial hypoplasia becoming the anomalous sciatic artery, the dominant inflow to the lower extermity.1 PSA can be diagnosed by a painful, pulsatile gluteal mass, but most cases reported in the literature are secondary to vascular complications.4 Intermittent
Fig. 3. Computed tomography angiography scan showing thrombosis of the sciatic artery aneurysm with coils.
claudication, critical limb ischemia, aneurysmatic degeneration, and neurologic symptoms (sciatic nerve compression) are frequently associated with this pathology.2 Aneurysm formation is described in 46% of the cases; this high incidence is because of the constant external trauma under a vulnerable anatomic position.4 Our patient presented with acute lower limb ischemia secondary to sciatic artery aneurysm embolization. Moreover, she also presented femoral pulse and popliteal pulse was absent on right lower limb vascular examination; the opposite (absence of femoral pulse and presence of popliteal and distal pulses, Cowie’s sign) is often seen. Computed tomography angiography is a better image modality because it provides details such as a total occluded sciatic artery that cannot be visualized with conventional angiography.5 According to the degree of involution of the sciatic artery and the hypoplastic changes of the femoral arterial system, PSA can be divided into complete and incomplete forms.4 Our patient had the complete form in which the popliteal artery was supplied completely by the PSA, with an associated hypoplastic femoral artery. Indications for surgical treatment depend on the patient symptoms, the vascular anatomy of the sciatic artery and the iliofemoral system, the presence of associated vascular occlusive disease, and aneurysmatic degeneration.1,2 An asymptomatic PSA does not require operative management and should be closely monitored, but in presence of an aneurysm, indication for treatment is absolute.1 The traditional open repair carries risks
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due to difficult exposure and the anatomic proximity to the sciatic nerve.3 Endovascular techniques include aneurysm exclusion with coils and endovascular stent grafts. Endovascular techniques are the preferable treatment option in the recent literature because they are associated with fewer complications.5,6 Endovascular aneurysm exclusion using an anterograde or a retrograde approach is safe and efficient; however, neurologic symptoms may still persist with this treatment modality.5,6 Our treatment, femoropopliteal bypass with retrograde coil embolization, was a good treatment modality. Correction of the distal ischemia with aneurysm exclusion and restored vascular continuity were achieved with a simple, noncomplicated revascularization hybrid procedure through a well-tolerated surgical approach. PSA is a rare vascular anomaly with a high rate of aneurysm formation. A hybrid treatment modality
Case Report 3
(aneurysm embolization with coils and femoropopliteal bypass) seems to be a good treatment option in this pathology. REFERENCES 1. van Hooft IM, Zeebregts CJ, van Sterkenburg SM, et al. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585e91. 2. Noblet D, Gasmi T, Mikati A, et al. Persistent sciatic artery: case report, anatomy, and review of the literature. Ann Vasc Surg 1988;4:390e6. 3. Wijeyaratne SM, Wijewardene N, et al. Endovascular stenting of a persistent sciatic artery aneurysm via retrogade popliteal approach: a durable option. Eur J Vasc Endovasc Surg 2009;38:91e2. 4. Jain S, Munn JS, Simoni EJ, et al. Endograft repair of a persistent sciatic artery aneurysm. EJVES Extra 2004;8:5e6. 5. Richter O, Schneider R, Moche M, et al. A pulsating buttock mass as a rare presentation of a persistent sciatic artery. EJVES Extra 2010;20:e4e7. 6. Rezayat C, Sambol E, Goldstein L. Ruptured persistent sciatic artery aneurysm managed by endovascular embolization. Ann Vasc Surg 2010;24:115.e5e9.
Persistent sciatic artery is a rare congenital vascular malformation with a reported incidence between 0.03% and 0.06%. An 82-yr-old woman presented to our institution with right acute lower limb ischemia compatible with a cardioembolic etiology. A popliteal embolectomy was performed to the patient, and at the end of the procedure, she had bilateral lower limb distal pulses. Six months after the procedure, the patient complained with right lower limb rest pain, an angiography and a computed tomography angiography were performed showing a sciatic artery aneurysm with 4.6 cm of diameter and patency of the sciatic artery to the popliteal artery. A femoropopliteal bypass and retrograde coil embolization of the sciatic aneurysm through the popliteal artery and distal sciatic artery ligation were performed. The patient was discharged 7 days after the procedure, and she remains asymptomatic. Our patient had a complete type of persistent sciatic artery with aneurysmatic degeneration. Correction of the distal ischemia with aneurysm exclusion was achieved with a simple noncomplicated hybrid procedure.
CASE REPORT The case reports on an 82-yr-old woman presented with right acute lower limb ischemia. She had a previous history of hypertension, dyslipidemia, and paroxistic atrial fibrillation. On vascular examination, she had similar bilateral femoral pulses, popliteal and distal pulses absent on the right limb and palpable on the left limb. The duplex ultrasound examination showed popliteal and tibial arteries thrombosis, with no thrombus on common femoral artery. A cardioembolic etiology was assumed as the most probable cause. A popliteal embolectomy was performed to the patient, at the end of the procedure, angiography was not performed because she had palpable bilateral distal pulses associated with good Doppler signals.
Department of Angiology and Vascular Surgery, Hospital de Santo Antonio - Centro Hospitalar do Porto, Porto. Correspondence to: Carolina Vaz, MD, Centro Hospitalar do Porto, Servic¸ o de Angiologia e Cirurgia Vascular, Largo Professor Abel Salazar, 4200 - Porto, Portugal; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2013.08.028 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: May 11, 2013; manuscript accepted: August 26, 2013; published online: ---.
On the follow-up, 6 months after the procedure, the patient complained with right lower limb rest pain. She had palpable femoral pulse and popliteal and distal pulses were absent on the right limb examination. The vascular left limb examination was normal. The angiogram and computed tomography showed a 4.6 cm right sciatic artery aneurysm with patency of the sciatic artery to the popliteal artery (Figs. 1 and 2) and a right hypoplastic superficial femoral artery. Posterior tibial and peroneal arteries were absent, but patent popliteal and anterior tibial arteries were visualized. The left lower extremity vessels appeared to have normal anatomy and to be free of significant disease. These findings established the diagnosis of a complete type of persistent sciatic artery (PSA) with aneurysmatic degeneration. An above-knee popliteal surgical approach was performed. This approach was used to access the sciatic aneurysm using selective retrograde catheterization of the sciatic artery. Transcatheter embolization of the aneurysm with 8 mm diameter coils (Cook MReye) and ligation of the distal sciatic artery segment by the popliteal approach were performed. Then an above-Knee femoropopliteal bypass with 6 mm polytetrafluorethylene was made. The computed tomography angiography, performed after the procedure, showed thrombosis of the aneurysm sac (Fig. 3) and a patent femoropopliteal bypass. The patient was discharged on the seventh postoperative day with antiplatelet medication. At 1 year follow-up, she remains asymptomatic.
1
2 Case Report
Fig. 1. Computed tomography angiography showing 46-mm right sciatic artery aneurysm.
Annals of Vascular Surgery
scan
Fig. 2. Computed tomography angiography scan showing a complete sciatic artery with aneurysm degeneration and hypoplastic femoral artery.
DISCUSSION PSA is an unusual anatomic anomaly, first reported with angiographic evidence in 1960.1 It is an anomalous and persistent axial artery that results from a failure to regress between the 10th- and 12thweek gestation. This sciatic or axial artery is the major blood supply to the primitive foot and is later replaced by the iliofemoral artery as the limb develops.2,3 Its failure to regress is sometimes associated with femoral arterial hypoplasia becoming the anomalous sciatic artery, the dominant inflow to the lower extermity.1 PSA can be diagnosed by a painful, pulsatile gluteal mass, but most cases reported in the literature are secondary to vascular complications.4 Intermittent
Fig. 3. Computed tomography angiography scan showing thrombosis of the sciatic artery aneurysm with coils.
claudication, critical limb ischemia, aneurysmatic degeneration, and neurologic symptoms (sciatic nerve compression) are frequently associated with this pathology.2 Aneurysm formation is described in 46% of the cases; this high incidence is because of the constant external trauma under a vulnerable anatomic position.4 Our patient presented with acute lower limb ischemia secondary to sciatic artery aneurysm embolization. Moreover, she also presented femoral pulse and popliteal pulse was absent on right lower limb vascular examination; the opposite (absence of femoral pulse and presence of popliteal and distal pulses, Cowie’s sign) is often seen. Computed tomography angiography is a better image modality because it provides details such as a total occluded sciatic artery that cannot be visualized with conventional angiography.5 According to the degree of involution of the sciatic artery and the hypoplastic changes of the femoral arterial system, PSA can be divided into complete and incomplete forms.4 Our patient had the complete form in which the popliteal artery was supplied completely by the PSA, with an associated hypoplastic femoral artery. Indications for surgical treatment depend on the patient symptoms, the vascular anatomy of the sciatic artery and the iliofemoral system, the presence of associated vascular occlusive disease, and aneurysmatic degeneration.1,2 An asymptomatic PSA does not require operative management and should be closely monitored, but in presence of an aneurysm, indication for treatment is absolute.1 The traditional open repair carries risks
Vol.
-,
No.
-, -
2014
due to difficult exposure and the anatomic proximity to the sciatic nerve.3 Endovascular techniques include aneurysm exclusion with coils and endovascular stent grafts. Endovascular techniques are the preferable treatment option in the recent literature because they are associated with fewer complications.5,6 Endovascular aneurysm exclusion using an anterograde or a retrograde approach is safe and efficient; however, neurologic symptoms may still persist with this treatment modality.5,6 Our treatment, femoropopliteal bypass with retrograde coil embolization, was a good treatment modality. Correction of the distal ischemia with aneurysm exclusion and restored vascular continuity were achieved with a simple, noncomplicated revascularization hybrid procedure through a well-tolerated surgical approach. PSA is a rare vascular anomaly with a high rate of aneurysm formation. A hybrid treatment modality
Case Report 3
(aneurysm embolization with coils and femoropopliteal bypass) seems to be a good treatment option in this pathology. REFERENCES 1. van Hooft IM, Zeebregts CJ, van Sterkenburg SM, et al. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585e91. 2. Noblet D, Gasmi T, Mikati A, et al. Persistent sciatic artery: case report, anatomy, and review of the literature. Ann Vasc Surg 1988;4:390e6. 3. Wijeyaratne SM, Wijewardene N, et al. Endovascular stenting of a persistent sciatic artery aneurysm via retrogade popliteal approach: a durable option. Eur J Vasc Endovasc Surg 2009;38:91e2. 4. Jain S, Munn JS, Simoni EJ, et al. Endograft repair of a persistent sciatic artery aneurysm. EJVES Extra 2004;8:5e6. 5. Richter O, Schneider R, Moche M, et al. A pulsating buttock mass as a rare presentation of a persistent sciatic artery. EJVES Extra 2010;20:e4e7. 6. Rezayat C, Sambol E, Goldstein L. Ruptured persistent sciatic artery aneurysm managed by endovascular embolization. Ann Vasc Surg 2010;24:115.e5e9.
