Successful endovascular therapy with "Direct tip injection in occlusive lesions (DIOL)" fashion for persistent sciatic artery aneurysmal occlusion: A case report

Persistent sciatic artery (PSA) is a rare congenital anomaly that may involve aneurysmal formations. During endovascular treatment for PSA aneurysm (PSAA) occlusion, guidewire crossing can be challenging due to complex anatomy. We report successful endovascular intervention for PSAA occlusion using the "direct tip injection in occlusive lesions (DIOL)" fashion, in which hydraulic pressure with contrast facilitates guidewire crossing by visualizing the vessel course and expanding the microchannel and vessel lumen. An 80-year-old woman presented with severe intermittent left calf claudication due to PSA occlusion with PSAA. Endovascular treatment was attempted for the occlusion; however, bidirectional wiring in the PSAA was unsuccessful. Therefore, bidirectional DIOL was applied; antegrade-DIOL visualized and enlarged the subintimal plane of the proximal PSAA, while retrograde-DIOL showed intramedial lumen enlargement in the middle and distal PSAA. Consequently, bidirectional guidewires were successfully advanced into the expanded lumen, achieving guidewire externalization. After balloon angioplasty, a self-expandable stent and three stent-grafts were implanted throughout the PSA occlusion, with stent-grafts overlapping around the hip joint to overcome chronic external compression. The final angiogram revealed sufficient blood flow, and the symptoms improved. A 2-year follow-up computed tomography angiography indicated no restenosis. Thus, the DIOL fashion facilitates guidewire crossing in complex occlusions.

Learning objective: This case report highlights the successful guidewire crossing for the treatment of a persistent sciatic artery aneurysm (PSAA) occlusion, which can be challenging. The "direct tip injection in occlusive lesions" fashion, using hydraulic pressure with a contrast medium to facilitate guidewire crossing with visualization of the vessel course and expansion of the lesion lumen, is a valuable and safe method for guidewire crossing in PSAA occlusion.