Case Report Midterm Failure after Endovascular Treatment of a Persistent Sciatic Artery Aneurysm Elie Girsowicz,1 Yannick Georg,1 Anne Lejay,1 Mickael Ohana,2 Charline Delay,1 Nour Bouamaied,3 Fabien Thaveau,1 and Nabil Chakfe,1 Strasbourg and Altkirch, France
Persistent sciatic artery (PSA) is a rare arterial embryologic malformation that tends to present early atherosclerotic degeneration such as aneurysmal formation. Open surgical treatment of PSA aneurysms has been considered as the gold standard but endovascular techniques have been recently proposed in the literature. We report the case of a 65-year-old man, diagnosed with a PSA aneurysm on peripheral thromboembolic complications. We achieved an endovascular repair with a covered stent. Despite an uneventful postoperative course, the covered stent demonstrated fracture and thrombosis 6 months after implantation without any symptoms.
The sciatic artery is an embryonic artery that regresses to form the proximal part of the gluteal artery after the third month of embryonic life, when the femoral artery starts to develop. If the development of the femoral system fails, the sciatic artery remains as the dominant blood supply to the lower extremity. According to an angiographic study, the persistent sciatic artery (PSA) is present in 0.025e0.06% of the population,1,2 both sexes equally. PSA tends to atherosclerotic degeneration: about 47%1 of the cases present aneurysm formation that can cause symptoms such as painful pulsatile buttock mass and/or sciatic neuropathy due to sciatic nerve compression. Thromboembolic 1 Department of Vascular Surgery and Kidney Transplantation, University Hospital, Strasbourg, France. 2
Department of Radiology, University Hospital, Strasbourg, France.
3
Department of Medicine, Altkirch General Hospital, Altkirch, France. Correspondence to: Nabil Chakfe, MD, PhD, Department of Vascular Surgery and Kidney Transplantation, Nouvel H^opital Civil, H^opitaux Universitaires de Strasbourg, 1 place de l’H^opital, BP 426, 67091 Strasbourg Cedex, France; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–6 http://dx.doi.org/10.1016/j.avsg.2014.01.022 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: August 13, 2013; manuscript accepted: January 8, 2014; published online: ---.
complications have been reported in 41e47% of patients, and some cases of rupture have also been described.3 More than 160 cases of PSA have been reported since the first case described by Green in 18324 on anatomic dissection, and the first case of a PSA aneurysm has been reported by Fagge in 1864.5 We report a case of PSA aneurysm with thromboembolic complications treated with an endovascular approach by a covered stent using a surgical retrograde popliteal approach.
CASE REPORT A 65-year-old man was admitted at the outpatient clinic of another institution where clinical examination revealed a cold and cyanotic right foot. Cardiovascular risk factors were diabetes and dyslipidemia. He suffered from right lower limb claudication for 2 weeks, with recent worsening over the last 24 hours. Vascular examination demonstrated that both femoral and popliteal pulses were present but the right distal pulses were absent. The ankle-brachial Index (ABI) was 0.8; the patient was Rutherford category 3. On the left leg, all pulses were found without any signs of ischemia. Subacute ischemia related to distal embolization was diagnosed, and a curative intravenous heparinotherapy was instituted. Computed tomography angiogram demonstrated a right PSA in its complete form with a 24-mm sacciform 1
2 Case Report
Fig. 1. Computed tomography angiogram with a tridimensional reconstruction (posterior view) showing a persistent right sciatic artery in its complete (A) form
Annals of Vascular Surgery
with hypoplasia of the superficial femoral artery and presence of a 24-mm sacciform partially thrombosed aneurysm (B).
Fig. 2. Peroperative angiogram: partially thrombosed aneurysm (A) successfully treated using a 11 110 mm endoprothesis (B). Remodeling of the endoprothesis (C) and final result after deployment (D).
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Case Report 3
Fig. 3. CT scan evolution of the endograft at 4 days (A), 3 months (B), and 6 months (C), showing an early myointimal hyperplasia, fracture of the endoprothesis, and finally occlusion. aneurysm. The right superficial femoral artery was underdeveloped without any continuity with the popliteal artery (Fig. 1). Subsequent physical examination of the posterolateral aspect of the right buttock revealed a pulsatile and expandable mass of which the patient was never complaining.
The patient was referred to our institution, and we proposed to perform an endovascular exclusion of the aneurysm. The procedure was performed electively, under general anesthesia, in supine position, with systemic injection of heparin (150 IU/kg). The right popliteal artery was surgically exposed in the popliteal fossa, and then we
4 Case Report
Annals of Vascular Surgery
Fig. 4. Right lower limb CT scan: distal perfusion is maintained because of collateral arteries developed from the hypoplastic right superficial femoral artery. introduced a 15-cm 12-Fr sheath to allow the insertion of an 11 mm diameter and 110 mm long VIABAHN endograft (WL GoreÒ, Flagstaff, AZ) on a Rosen guidewire (Cook Medical, Bloomington, IN). The endograft was satisfactorily deployed, with a complementary gentle remodeling with a 10 mm diameter noncompliant angioplasty balloon. Heparin was entirely reversed with protamine sulfate at the end of the procedure. Postprocedure angiogram did not show any endoleak (Fig. 2). Early postoperative period was uneventful. The patient was discharged from the hospital at day 4 with antiplatelet (aspirin) and statin (rosuvastatin) therapy. Clinical examination did not show any pulsatile mass of the right
buttock. Computed tomography (CT) scan performed on day 4 confirmed the patency of the endoprothesis without endoleak or stenosis (Fig. 3A). At 1 month, clinical and ultrasonography evaluations were normal. At 3 months, the CT scan revealed a myointimal hyperplasia with a distal stenosis of the endograft we decided not to treat (Fig. 3B). At 6 months, the CT scan demonstrated a total thrombosis of the endograft with stent fracture (Fig. 3C), distal perfusion was maintained through collateral arteries developed from the hypoplastic femoral artery (Fig. 4). The patient was asymptomatic with a distal pressure
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Table I. Review of published cases of endovascular repair of persistent sciatic artery aneurysm Author, year of Age Discovery publication (years) mode
Gabelmann 63 et al. 200113
Jain et al. 200416 Fearing et al. 200517 Wijeyaratne et al. 200915 Verikokos et al. 201018
83 88 55 57
Aneurysm size (mm) Prothesis
Approach technique
Acute lower Unknown HEMOBAHN limb ischemia 10 60 mm flexible covered stent Lower limb 35 WALLGRAFT ischemia Unknown 100 mm Painful buttock 50 ANEURX 120 11.5 mass and 120 8.5 mm Lower limb 35 VIABAHN 6 150 mm ischemia Assessment of 26 VIABAHN 80 5 mm an AAA
70 Oliveira et al. 201114
Lower limb ischemia
44 39
Shibutani 74 et al. 201319
Lower limb ischemia
21 36
Present 65 article 2014
Lower limb ischemia
24
Initial Extended follow-up follow-up (months) (months)
Controlateral 22 femoral approach
Open above knee Distal PSA in the thigh Retrograde popliteal Controlateral femoral approach VIABAHN 8 150 mm Controlateral femoral approach FLUENCY 10 80 mm Controlateral femoral approach VIABAHN 11 110 mm Retrograde popliteal
Stent permeability
Unknown Yes
3
Unknown Yes
39
Unknown Yes
48
62
Yes
6
Unknown Yes
6
18
6
Unknown Yes
6
12
Yes
No
AAA, abdominal aortic aneurysm.
perfusion at 120 mm Hg and an ABI of 0.8. We decided to set up a conservative treatment. Six months later the patient was still asymptomatic. We performed a literature review and sent a form to authors, who previously published cases, to get the most recent information concerning their patients and to improve the follow-up duration. Only 2 authors answered our correspondence (Table I).
DISCUSSION While management of asymptomatic PSA is observation,6,7 management of symptomatic PSA depends on the anatomy of the sciatic artery and iliofemoral system, on the presence or absence of an aneurysm and on the clinical presentation. There are 2 types of PSA. Most cases are of the complete type where the PSA has direct communication from the internal iliac artery to the popliteal artery through the sciatic foramen, with a hypoplastic or aplastic superficial femoral artery. In the incomplete type, the superficial femoral artery still provides the major blood supply to the lower extremity with a hypoplastic PSA. Surgical treatment of PSA aneurysm can be open, with resection or aneurysmorrhaphy, or endovascular, with exclusion or embolization. Open surgery with iliofemoropopliteal bypass and exclusion of the PSA aneurysm has been
described as the first intention treatment.8 In situ graft replacement9,10 has also been used but carries risks because of the vessel control, the proximity of the sciatic nerve, and bony structures in the buttock. Moreover, this technique presents a risk of prosthesis occlusion from compression in the seated position.10 Nevertheless, both open techniques offer good results, with a recent publication showing an 18-year patency after an in situ graft replacement.11 Endovascular techniques have also been considered since 2001, with embolization of incomplete PSA aneurysm12 or endovascular exclusion in its complete form. Endovascular exclusion was first described by Gabelmann et al.13 using a femoral controlateral approach. Theoretically, this mini-invasive technique allows excluding the aneurysm with low rates of complications and endoleaks. But, as it has been suggested that chronic trauma from the surrounding structures and stretching of the artery during hip flexion could cause the aneurysm formation,2,8 putting the endograft at the same site would expose to the identical mechanical stress and a high risk of fracture and occlusion. Our case seems to confirm this hypothesis. For those reasons, long-term durability of endovascular repair remains questionable. In the literature, 7 cases of endovascular treatment of PSA aneurysms with endograft have been reported.
6 Case Report
Only 3 publications reported midterm patency results, with follow-up longer than 6 months, after 22 months and 4 years.14,15 In this case, we chose this technique to reduce the morbimortality of the open technique and because of biomechanical improvements of the latest generation of endoprothesis. However, the radial resistive force of this endograft seems to be insufficient. Our case suggests less enthusiasm over endovascular repair of PSA aneurysm compared with other published articles. Indeed, the mechanical stress sustained by the endograft in its posterior location and the poor long-term follow-up of the other published articles are casting doubt on the indication of endovascular repair in this indication. In conclusion, the PSA is a rare arterial malformation associated with high rates of complications including aneurysm formation and ischemia that may lead to amputation. In the era of miniinvasive surgery, endovascular treatment can logically be considered but failures can occur and are probably unreported in the literature. Strategies for follow-up could not be strongly deduced from current available literature. REFERENCES 1. Jung AY, Lee W, Chung JW, et al. Role of computed tomographic angiography in the detection and comprehensive evaluation of persistent sciatic artery. J Vasc Surg 2005;42: 678e83. 2. 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;20:96e103. 3. Ishida K, Imamaki M, Ishida A, Shimura H, Miyaki M. A ruptured aneurysm in persistent sciatic artery: a case report. J Vasc Surg 2005;42:556e8. 4. Green PH. On a new variety of the femoral artery: with observations. Lancet 1831;1:730e1. 5. Fagge CH. Case of aneurysm, seated on an abnormal main artery of the lower limb. Guy’s Hosp Reports 1864;10:151e7.
Annals of Vascular Surgery
6. Mandell VS, Jacques PF, Delany DJ, Oberheu V. Persistent sciatic artery: clinical, embryologic, and angiographic features. AJR Am J Roentgenol 1985;144:245e9. 7. Brantley SK, Rigdon EE, Raju S. Persistent sciatic artery: embryology, pathology, and treatment. J Vasc Surg 1993;18:242e8. 8. van Hooft M, Zeebregts CJ, van Sterkenburg SMM, de Vries WR, Reijnen MMPJ. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585e91. 9. Hutchinson JE, Cordice JW Jr, McAllister FF. The surgical management of an aneurysm of a primitive persistent sciatic artery. Ann Surg 1968;167:277e81. 10. Bito Y, Sakaki M, Iida O, Inoue K, Yoshioka Y, Mizoguchi H. Clinical management of lower limb ischemia secondary to a persistent sciatic artery aneurysm: report of a case. Surg Today 2011;41:402e5. 11. Dro_zd_z W, Urbanik A, Budzy nski P. A case of bilateral persistent sciatic artery with unilateral aneurysm: an 18year period of graft patency after excision of aneurysm. Med Sci Monit 2012;18:CS12e5. 12. Sultan SAH, Pacainowski JP, Madhavan P, et al. Endovascular management of rare sciatic artery aneurysm. J Endovasc Ther 2000;7:415e22. 13. Gabelmann A, Kramer SC, Wisianowski C, Tomczak R, Palmer R, Gorich J. Endovascular interventions on persistent sciatic arteries. J Endovasc Ther 2001;8:622e8. 14. Oliveira FM, Mour~ao GS. Endovascular repair of symptomatic sciatic artery aneurysm. Vasc Endovascular Surg 2011;45:165e9. 15. 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;38:91e2. 16. Jain S, Munn JS, Simoni EJ, Jain KM. Endograft repair of a persistent sciatic artery aneurysm. Eur J Vasc Endovasc Surg Extra 2004;8:5e6. 17. Fearing NM, Ammar DA, Hutchinson SA, Lucas ED. Endovascular stent graft repair of a persistent sciatic artery aneurysm. Ann Vasc Surg 2005;19:438e41. 18. Verikokos C, Avgerinos ED, Chatziioannou A, Katsargyris A, Klonaris C. Endovascular repair of a persistent sciatic artery aneurysm. Vascular 2010;18:162e5. 19. Shibutani S, Hayashi E, Obara H, et al. Rapid development of aneurysmal formation after successful endovascular treatment of chronic total occlusion of a persistent sciatic artery. Ann Vasc Surg 2013;27:499.e5e8.
Persistent sciatic artery (PSA) is a rare arterial embryologic malformation that tends to present early atherosclerotic degeneration such as aneurysmal formation. Open surgical treatment of PSA aneurysms has been considered as the gold standard but endovascular techniques have been recently proposed in the literature. We report the case of a 65-year-old man, diagnosed with a PSA aneurysm on peripheral thromboembolic complications. We achieved an endovascular repair with a covered stent. Despite an uneventful postoperative course, the covered stent demonstrated fracture and thrombosis 6 months after implantation without any symptoms.
The sciatic artery is an embryonic artery that regresses to form the proximal part of the gluteal artery after the third month of embryonic life, when the femoral artery starts to develop. If the development of the femoral system fails, the sciatic artery remains as the dominant blood supply to the lower extremity. According to an angiographic study, the persistent sciatic artery (PSA) is present in 0.025e0.06% of the population,1,2 both sexes equally. PSA tends to atherosclerotic degeneration: about 47%1 of the cases present aneurysm formation that can cause symptoms such as painful pulsatile buttock mass and/or sciatic neuropathy due to sciatic nerve compression. Thromboembolic 1 Department of Vascular Surgery and Kidney Transplantation, University Hospital, Strasbourg, France. 2
Department of Radiology, University Hospital, Strasbourg, France.
3
Department of Medicine, Altkirch General Hospital, Altkirch, France. Correspondence to: Nabil Chakfe, MD, PhD, Department of Vascular Surgery and Kidney Transplantation, Nouvel H^opital Civil, H^opitaux Universitaires de Strasbourg, 1 place de l’H^opital, BP 426, 67091 Strasbourg Cedex, France; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–6 http://dx.doi.org/10.1016/j.avsg.2014.01.022 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: August 13, 2013; manuscript accepted: January 8, 2014; published online: ---.
complications have been reported in 41e47% of patients, and some cases of rupture have also been described.3 More than 160 cases of PSA have been reported since the first case described by Green in 18324 on anatomic dissection, and the first case of a PSA aneurysm has been reported by Fagge in 1864.5 We report a case of PSA aneurysm with thromboembolic complications treated with an endovascular approach by a covered stent using a surgical retrograde popliteal approach.
CASE REPORT A 65-year-old man was admitted at the outpatient clinic of another institution where clinical examination revealed a cold and cyanotic right foot. Cardiovascular risk factors were diabetes and dyslipidemia. He suffered from right lower limb claudication for 2 weeks, with recent worsening over the last 24 hours. Vascular examination demonstrated that both femoral and popliteal pulses were present but the right distal pulses were absent. The ankle-brachial Index (ABI) was 0.8; the patient was Rutherford category 3. On the left leg, all pulses were found without any signs of ischemia. Subacute ischemia related to distal embolization was diagnosed, and a curative intravenous heparinotherapy was instituted. Computed tomography angiogram demonstrated a right PSA in its complete form with a 24-mm sacciform 1
2 Case Report
Fig. 1. Computed tomography angiogram with a tridimensional reconstruction (posterior view) showing a persistent right sciatic artery in its complete (A) form
Annals of Vascular Surgery
with hypoplasia of the superficial femoral artery and presence of a 24-mm sacciform partially thrombosed aneurysm (B).
Fig. 2. Peroperative angiogram: partially thrombosed aneurysm (A) successfully treated using a 11 110 mm endoprothesis (B). Remodeling of the endoprothesis (C) and final result after deployment (D).
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No.
-, -
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Case Report 3
Fig. 3. CT scan evolution of the endograft at 4 days (A), 3 months (B), and 6 months (C), showing an early myointimal hyperplasia, fracture of the endoprothesis, and finally occlusion. aneurysm. The right superficial femoral artery was underdeveloped without any continuity with the popliteal artery (Fig. 1). Subsequent physical examination of the posterolateral aspect of the right buttock revealed a pulsatile and expandable mass of which the patient was never complaining.
The patient was referred to our institution, and we proposed to perform an endovascular exclusion of the aneurysm. The procedure was performed electively, under general anesthesia, in supine position, with systemic injection of heparin (150 IU/kg). The right popliteal artery was surgically exposed in the popliteal fossa, and then we
4 Case Report
Annals of Vascular Surgery
Fig. 4. Right lower limb CT scan: distal perfusion is maintained because of collateral arteries developed from the hypoplastic right superficial femoral artery. introduced a 15-cm 12-Fr sheath to allow the insertion of an 11 mm diameter and 110 mm long VIABAHN endograft (WL GoreÒ, Flagstaff, AZ) on a Rosen guidewire (Cook Medical, Bloomington, IN). The endograft was satisfactorily deployed, with a complementary gentle remodeling with a 10 mm diameter noncompliant angioplasty balloon. Heparin was entirely reversed with protamine sulfate at the end of the procedure. Postprocedure angiogram did not show any endoleak (Fig. 2). Early postoperative period was uneventful. The patient was discharged from the hospital at day 4 with antiplatelet (aspirin) and statin (rosuvastatin) therapy. Clinical examination did not show any pulsatile mass of the right
buttock. Computed tomography (CT) scan performed on day 4 confirmed the patency of the endoprothesis without endoleak or stenosis (Fig. 3A). At 1 month, clinical and ultrasonography evaluations were normal. At 3 months, the CT scan revealed a myointimal hyperplasia with a distal stenosis of the endograft we decided not to treat (Fig. 3B). At 6 months, the CT scan demonstrated a total thrombosis of the endograft with stent fracture (Fig. 3C), distal perfusion was maintained through collateral arteries developed from the hypoplastic femoral artery (Fig. 4). The patient was asymptomatic with a distal pressure
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Case Report 5
Table I. Review of published cases of endovascular repair of persistent sciatic artery aneurysm Author, year of Age Discovery publication (years) mode
Gabelmann 63 et al. 200113
Jain et al. 200416 Fearing et al. 200517 Wijeyaratne et al. 200915 Verikokos et al. 201018
83 88 55 57
Aneurysm size (mm) Prothesis
Approach technique
Acute lower Unknown HEMOBAHN limb ischemia 10 60 mm flexible covered stent Lower limb 35 WALLGRAFT ischemia Unknown 100 mm Painful buttock 50 ANEURX 120 11.5 mass and 120 8.5 mm Lower limb 35 VIABAHN 6 150 mm ischemia Assessment of 26 VIABAHN 80 5 mm an AAA
70 Oliveira et al. 201114
Lower limb ischemia
44 39
Shibutani 74 et al. 201319
Lower limb ischemia
21 36
Present 65 article 2014
Lower limb ischemia
24
Initial Extended follow-up follow-up (months) (months)
Controlateral 22 femoral approach
Open above knee Distal PSA in the thigh Retrograde popliteal Controlateral femoral approach VIABAHN 8 150 mm Controlateral femoral approach FLUENCY 10 80 mm Controlateral femoral approach VIABAHN 11 110 mm Retrograde popliteal
Stent permeability
Unknown Yes
3
Unknown Yes
39
Unknown Yes
48
62
Yes
6
Unknown Yes
6
18
6
Unknown Yes
6
12
Yes
No
AAA, abdominal aortic aneurysm.
perfusion at 120 mm Hg and an ABI of 0.8. We decided to set up a conservative treatment. Six months later the patient was still asymptomatic. We performed a literature review and sent a form to authors, who previously published cases, to get the most recent information concerning their patients and to improve the follow-up duration. Only 2 authors answered our correspondence (Table I).
DISCUSSION While management of asymptomatic PSA is observation,6,7 management of symptomatic PSA depends on the anatomy of the sciatic artery and iliofemoral system, on the presence or absence of an aneurysm and on the clinical presentation. There are 2 types of PSA. Most cases are of the complete type where the PSA has direct communication from the internal iliac artery to the popliteal artery through the sciatic foramen, with a hypoplastic or aplastic superficial femoral artery. In the incomplete type, the superficial femoral artery still provides the major blood supply to the lower extremity with a hypoplastic PSA. Surgical treatment of PSA aneurysm can be open, with resection or aneurysmorrhaphy, or endovascular, with exclusion or embolization. Open surgery with iliofemoropopliteal bypass and exclusion of the PSA aneurysm has been
described as the first intention treatment.8 In situ graft replacement9,10 has also been used but carries risks because of the vessel control, the proximity of the sciatic nerve, and bony structures in the buttock. Moreover, this technique presents a risk of prosthesis occlusion from compression in the seated position.10 Nevertheless, both open techniques offer good results, with a recent publication showing an 18-year patency after an in situ graft replacement.11 Endovascular techniques have also been considered since 2001, with embolization of incomplete PSA aneurysm12 or endovascular exclusion in its complete form. Endovascular exclusion was first described by Gabelmann et al.13 using a femoral controlateral approach. Theoretically, this mini-invasive technique allows excluding the aneurysm with low rates of complications and endoleaks. But, as it has been suggested that chronic trauma from the surrounding structures and stretching of the artery during hip flexion could cause the aneurysm formation,2,8 putting the endograft at the same site would expose to the identical mechanical stress and a high risk of fracture and occlusion. Our case seems to confirm this hypothesis. For those reasons, long-term durability of endovascular repair remains questionable. In the literature, 7 cases of endovascular treatment of PSA aneurysms with endograft have been reported.
6 Case Report
Only 3 publications reported midterm patency results, with follow-up longer than 6 months, after 22 months and 4 years.14,15 In this case, we chose this technique to reduce the morbimortality of the open technique and because of biomechanical improvements of the latest generation of endoprothesis. However, the radial resistive force of this endograft seems to be insufficient. Our case suggests less enthusiasm over endovascular repair of PSA aneurysm compared with other published articles. Indeed, the mechanical stress sustained by the endograft in its posterior location and the poor long-term follow-up of the other published articles are casting doubt on the indication of endovascular repair in this indication. In conclusion, the PSA is a rare arterial malformation associated with high rates of complications including aneurysm formation and ischemia that may lead to amputation. In the era of miniinvasive surgery, endovascular treatment can logically be considered but failures can occur and are probably unreported in the literature. Strategies for follow-up could not be strongly deduced from current available literature. REFERENCES 1. Jung AY, Lee W, Chung JW, et al. Role of computed tomographic angiography in the detection and comprehensive evaluation of persistent sciatic artery. J Vasc Surg 2005;42: 678e83. 2. 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;20:96e103. 3. Ishida K, Imamaki M, Ishida A, Shimura H, Miyaki M. A ruptured aneurysm in persistent sciatic artery: a case report. J Vasc Surg 2005;42:556e8. 4. Green PH. On a new variety of the femoral artery: with observations. Lancet 1831;1:730e1. 5. Fagge CH. Case of aneurysm, seated on an abnormal main artery of the lower limb. Guy’s Hosp Reports 1864;10:151e7.
Annals of Vascular Surgery
6. Mandell VS, Jacques PF, Delany DJ, Oberheu V. Persistent sciatic artery: clinical, embryologic, and angiographic features. AJR Am J Roentgenol 1985;144:245e9. 7. Brantley SK, Rigdon EE, Raju S. Persistent sciatic artery: embryology, pathology, and treatment. J Vasc Surg 1993;18:242e8. 8. van Hooft M, Zeebregts CJ, van Sterkenburg SMM, de Vries WR, Reijnen MMPJ. The persistent sciatic artery. Eur J Vasc Endovasc Surg 2009;37:585e91. 9. Hutchinson JE, Cordice JW Jr, McAllister FF. The surgical management of an aneurysm of a primitive persistent sciatic artery. Ann Surg 1968;167:277e81. 10. Bito Y, Sakaki M, Iida O, Inoue K, Yoshioka Y, Mizoguchi H. Clinical management of lower limb ischemia secondary to a persistent sciatic artery aneurysm: report of a case. Surg Today 2011;41:402e5. 11. Dro_zd_z W, Urbanik A, Budzy nski P. A case of bilateral persistent sciatic artery with unilateral aneurysm: an 18year period of graft patency after excision of aneurysm. Med Sci Monit 2012;18:CS12e5. 12. Sultan SAH, Pacainowski JP, Madhavan P, et al. Endovascular management of rare sciatic artery aneurysm. J Endovasc Ther 2000;7:415e22. 13. Gabelmann A, Kramer SC, Wisianowski C, Tomczak R, Palmer R, Gorich J. Endovascular interventions on persistent sciatic arteries. J Endovasc Ther 2001;8:622e8. 14. Oliveira FM, Mour~ao GS. Endovascular repair of symptomatic sciatic artery aneurysm. Vasc Endovascular Surg 2011;45:165e9. 15. 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;38:91e2. 16. Jain S, Munn JS, Simoni EJ, Jain KM. Endograft repair of a persistent sciatic artery aneurysm. Eur J Vasc Endovasc Surg Extra 2004;8:5e6. 17. Fearing NM, Ammar DA, Hutchinson SA, Lucas ED. Endovascular stent graft repair of a persistent sciatic artery aneurysm. Ann Vasc Surg 2005;19:438e41. 18. Verikokos C, Avgerinos ED, Chatziioannou A, Katsargyris A, Klonaris C. Endovascular repair of a persistent sciatic artery aneurysm. Vascular 2010;18:162e5. 19. Shibutani S, Hayashi E, Obara H, et al. Rapid development of aneurysmal formation after successful endovascular treatment of chronic total occlusion of a persistent sciatic artery. Ann Vasc Surg 2013;27:499.e5e8.
