Superior gluteal artery as a reliable back door to embolize mycotic pseudoaneurysm of an isolated Internal Iliac artery

BACKGROUND: Antegrade access through the origin of the internal iliac and direct percutaneous access under cross-sectional imaging guidance are commonly used for embolization of internal iliac artery aneurysms, pseudoaneurysms, or endoleaks. Here, we report superior gluteal artery retrograde access to treat internal iliac artery mycotic pseudoaneurysm in a patient with failed direct percutaneous access. CASE PRESENTATION: We present a 65-year-old female with a history of diverticulitis and sigmoidectomy. Post-sigmoidectomy course was complicated by left common iliac artery (CIA) iatrogenic injury which required surgical ligation of the left CIA and graft placement. However, the graft was subsequently resection due to infection. Follow up CT imaging showed a 6 cm mycotic pseudoaneurysm (PSA) of the left internal iliac artery. Initially, the PSA sac was directly accessed and embolized under direct CT-guidance using Onyx. However, enlargement of the PSA sac was noted on one week follow-up CT images. Then, superior gluteal artery was accessed under ultrasound guidance, and the PSA sac and feeding vessels were re-embolized with coil and Onyx under fluoroscopy. CONCLUSION: Retrograde access through superior gluteal artery is a feasible and safe approach to embolize internal iliac aneurysms, pseudoaneurysms, or endoleaks, when the antegrade or direct percutaneous access is limited.