BACKGROUND: A persistent sciatic artery (PSA) is an exceedingly rare anatomic variant affecting about 0.03 to 0.06% of individuals, representing an anomalous connection between the internal iliac and popliteal arteries, often prone to atherosclerosis and aneurysmal degeneration. Here we describe a successful hybrid approach to managing a PSA aneurysm.
HISTORY: The patient is a 71 year-old male with a history of lumbosacral radiculopathy who presented with persistent right gluteal pain despite steroid injections, found to have an enlarging pulsatile gluteal mass. CT angiography demonstrated a 9cm aneurysmal right PSA.Preoperative angiography was performed to define the patient’s lower extremity vascular supply. He was found to have a patent CFA and profunda, a hypoplastic SFA, and a PSA which provided infrapopliteal perfusion.
CASE: The patient was placed in a semi lateral decubitus position. An incision was made overlying the PSA, which was then dissected. A femoral incision was then made, and CFA was dissected. A subsartorial tunnel was created extending from the femoral incision to the PSA incision with the assistance of a counter incision. Contralateral CFA access was obtained, the PSA was accessed and coil embolized. The aneurysm was transected and the proximal end was oversewn. A fusion graft was passed through the tunnel, an end-to-end anastomosis was performed at the distal PSA, and an end-to-side anastomosis was preformed at the CFA. Completion angiography revealed a patent graft and infrapopliteal runoff. The patient was discharged on postoperative day 2 without issues. Follow-up in clinic showed a significant improvement in his sciatica symptoms, and with a reduction in size of his ‘buttock mass’. Follow up CTA revealed a patent bypass graft and a fully excluded aneurysm sac.
CONCLUSION: Here is a case of a hybrid approach to managing an aneurysmal PSA with minimal peri-/postoperative complication. Preoperative angiography was imperative in delineating anatomy. Endovascular coil embolization successfully excluded the PSA aneurysm, and an extra-anatomic bypass re-established inline flow to the infrapopliteal vessels.
