Limb Ischemia After Coil Migration Used for Hypogastric Aneurysm Embolization

Introduction

Hypogastric artery aneurysms are a rare condition with a low incidence in the general population. While often asymptomatic, larger aneurysms pose significant health risks, including rupture and ischemic complications. A recent case report explores the challenges of treating such aneurysms with endovascular embolization and highlights the potential for coil migration leading to limb ischemia.

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Case Overview

A 73-year-old male presented with an acute right lower limb ischemia three weeks post-endovascular coil embolization for a right hypogastric artery aneurysm. The aneurysm, measuring 30mm in diameter, was treated using multiple embolization coils without a covered stent placement. The patient developed worsening claudication and rest pain, prompting an urgent hospital visit.

Key Findings:

• A contrast-enhanced CT scan revealed coil migration from the hypogastric artery to the external iliac artery (EIA), leading to arterial occlusion.
• Emergency surgery was performed via a transfemoral approach, successfully extracting the migrated coil and performing thrombectomy.
• The patient was discharged without complications and remained asymptomatic at follow-up.

Clinical Implications & Management Considerations

Endovascular Approach in Hypogastric Aneurysm Treatment

Endovascular embolization is considered the first-line treatment for internal iliac artery aneurysms (IIAA). However, proper device fixation is crucial to avoid complications such as coil migration.

• Preferred Techniques:
  • Aneurysm exclusion with a covered stent: Effective when there is a proximal and distal sealing zone of at least 14mm.
  • Iliac branch device placement: Useful when distal hypogastric sealing is feasible but proximal fixation is inadequate.
• Risk Factors for Coil Migration:
  • Lack of covered stent placement at the hypogastric artery ostium.
  • Inadequate embolization leading to persistent intra-aneurysmal pressure.
  • Use of small or improperly positioned coils.

Recommendations for Improved Patient Outcomes

• Covered stent placement at the common iliac artery and external iliac artery should be considered to minimize the risk of distal embolization.
• A self-expanding stent may be preferable to accommodate the tortuous iliac anatomy and maintain radial force.
• Future guidelines should establish standardized protocols for embolization techniques to reduce migration risks.

External Insights on Endovascular Best Practices

The Society for Vascular Surgery (SVS) highlights that embolization procedures require meticulous planning to balance aneurysm exclusion while preserving pelvic circulation. Ensuring adequate coil deployment and assessing collateral blood flow can help prevent complications such as buttock claudication, erectile dysfunction, and ischemic injuries.

Further Reading & References

For an in-depth analysis of this case, read the full study at https://doi.org/10.29328/journal.acr.1001045.

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