Fig. 2.

Contrast-enhanced computed tomography (CT) and surgical findings 5 months post-onset. The left common iliac artery exhibited progressive expansion, with a maximum minor axis diameter of 46 mm (arrow; initially 43 mm) (A). Three-dimensional CT angiography demonstrated that the proximal 2 cm of the left common iliac artery (CIA) was normal (arrowhead), whereas the aneurysm sac was occluded by thrombus, and the distal segment of the external iliac artery (EIA) remained patent (B). An attempt to cross the occluded EIA retrogradely from the left common femoral artery (CFA) resulted in the guidewire entering the subintimal space (C). A sheath was inserted into the right CFA for an antegrade attempt, but crossing remained challenging. Consequently, a new sheath was inserted into the left CFA, and intravascular ultrasound (IVUS) guidance was employed to navigate the true lumen through the occluded EIA and aneurysmal sac in the CIA (D). IVUS-guided wire crossing was effective, allowing passage through the true lumen up to the origin of the left CIA (E), where docking with the antegrade sheath was achieved (arrowhead). Further aortography confirmed intraluminal positioning (F). Employing both antegrade and retrograde approaches, a wire was navigated through the occluded iliac artery, facilitating the placement of a stent graft (G). Completion angiography confirmed the absence of endoleak (H).