A 76-year-old male patient presented with severe resting pain and right foot discoloration. His past medical history included hypertension, end-stage renal disease with hemodialysis, and stroke. He underwent left iliac arterial stenting and right femoral artery balloon angioplasty due to a disabling claudication 7 months ago. After the procedure, the symptom persisted. In the last 1 month, his right leg pain became more aggravated and his right foot showed discoloration. He was then referred to Kyung Hee University Hospital at Gangdong.

Computed tomography angiography (CTA) revealed a 28×30-mm-sized pseudoaneurysm at the right distal external iliac artery suspected with guidewire (GW) injury during the previous intervention, severe calcified occlusion at the right common femoral artery (CFA), and a 10-cm-long segmental occlusion at the right superficial femoral artery (Fig. 1).

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After exposing the right femoral artery, long-segment endarterectomy and conventional patch angioplasty of the ipsilateral greater saphenous vein were performed. Before the completion of patch angioplasty, an approximately 2 cm segment was retained and a vascular clamp was applied to the remaining portion. An 8-F hydrophilic-coated Ansel guiding sheath (Cook Inc., Bloomington, IN, USA) was inserted into the left CFA and pushed into the right CFA via an up-and-over technique (Fig. 2). A surgeon-modified 8-mm expanded polytetrafluoroethylene (ePTFE) graft (W.L. Gore & Associates, Flagstaff, AZ, USA) was made; the graft was beveled and measured 3 cm in length. A 0.014-inch, 2-cm-long Command ES GW (Abbott Vascular, Santa Clara, CA, USA) was attached onto the ePTFE graft using a 6-0 Prolene suture (Ethicon, Somerville, NJ, USA) as a radio-opaque marker (Fig. 3A). To properly position the ePTFE graft at the pseudoaneurysm, two 3-0 Prolene sutures were attached to the beveled side of the graft. These sutures were inserted through the Ansel sheath using a Gooseneck snare wire (Medtronic, Santa Rosa, CA, USA). Another 3-0 Prolene suture was suspended on the opposite side to maintain the ePTFE graft. A 0.035-inch GW was inserted through the graft for the safe delivery of the stent (Fig. 3B). The graft was positioned at the orifice of the pseudoaneurysm by pulling the Ansel sheath and proximally attaching two Prolene sutures. After successfully positioning the ePTFE graft, an Absolute Pro self-expanding stent (Abbott Vascular) measuring 8×60 mm was positioned within the ePTFE graft. After ballooning, completion angiography showed the complete sealing of the pseudoaneurysm (Fig. 3C, D). Patch angioplasty was then completed (Fig. 3E). Postoperative CTA showed a completely resolved right external iliac artery pseudoaneurysm and removed calcified plaque in the right CFA and superficial femoral artery (Fig. 4).

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