A 58 years-old woman with a history of recurrent abdominal pain, especially post prandial, and occasional episodes of diarrhoea, underwent a magnetic resonance enterography (MRE) that demonstrated a saccular vascularized formation near the aorta. Therefore, the patient underwent Computed Tomography (CT) angiogram that showed an aneurysm of the iPDA measuring 2,6 cm × 2,1 cm in maximum diameter, with a relatively wide aneurysm neck of 12 mm; maximum intensity projected reconstruction of the CT images revealed celiac trunk occlusion with dilated iPDA (Fig. 1).
In view of the aneurysm size, a decision was made in consensus with the patient for endovascular treatment following discussion at a multidisciplinary meeting.
Under local anaesthesia, a bilateral common femoral artery access was granted under ultrasound guidance. On the right a 7F guiding sheath (Mach1 Boston Scientific, Cork, Ireland) was advanced into the abdominal aorta while on the left side a 5F sheath (St. Jude Medical™USA) was positioned. We choose two groin punctures to have greater control of the devices and grant further access in case of complications.
We tried unsuccessfully to catheterize the celiac trunk occlusion to treat the aneurysm. Then we decided to treat the aneurysmal sac through superior mesenteric artery (SMA). This latter was catheterized with 5F Cobra 2 catheter (Terumo, Tokyo, Japan) and a 0,0035″ angled guidewire (Terumo, Tokyo, Japan); subsequent DSA (digital subtraction angiography) obtained from the origin of SMA angiogram confirmed the saccular aneurysm, dilated iPDA with evidence of revascularization through this branch of the celiac trunk (Fig. 2a).
In order to avoid iPDA embolization and preserve celiac branches, a 6 × 40 mm balloon (Mustang™, Boston Scientific, Cork, Ireland), sized on the basis of CT images, was advanced through the right access and positioned across aneurysm neck; then across the left side access, we catheterized the aneurysmal sac with a microcatheter (2.7 F tip Progreat®; Terumo, Tokyo, Japan) (Fig. 2b). Following administration of 3000 units of heparin, the balloon was carefully inflated to low pressure under fluoroscopic control; after balloon inflation, 5 detachable non-fibered coils, 20 mm × 50 cm, (Concerto™ Detachable Coil System, Medtronic) were delivered to pack the aneurysmal sac until its complete filling (Fig. 2c).
Then, balloon was deflated and a diagnostic angiography was performed that showed completely exclusion of the sac from blood filling with preserved flow through PDA to the celiac axis (Fig. 2d).
Haemostasis was obtained with closure device 8F (AngioSeal® Vip Vascular Vip closure devise) on the right and manual compression on the left side.
There were no immediate peri-procedural complications and patient was discharged after 24H.
The patient came back, as a standard of our Institute, for a follow-up abdominal CT at 3 and 12 months later to monitor the onset of complications, the maintenance of visceral flow and the persistence of our success. Both CT images confirmed complete exclusion of the aneurysmal sac from blood flow with patency of iPDA and preserved vascularization of celiac branches (Fig. 3).