Emergency Endovascular Repair of a Large Ruptured Isolated Internal Iliac Artery Aneurysm in a 98-Year-Old Patient: A Case Report

Background/Objectives: Isolated internal iliac artery aneurysm (IIAA) is rare and carries a high mortality when ruptured. Management is particularly challenging in very elderly, anticoagulated patients in whom open repair may carry substantial perioperative risk. Herein, we report a case that illustrates device selection when a marked common iliac–external iliac size discrepancy precludes bridging with the available iliac limbs. Case Presentation: A 98-year-old man receiving apixaban presented with lower abdominal pain, nausea, and diarrhea. Computed tomography demonstrated a ruptured right IIAA measuring 79 × 72 mm in the axial plane, with retroperitoneal hematoma. A marked size discrepancy between the common iliac artery (20 mm) and external iliac artery (approximately 10 mm), together with vessel tortuosity, made common iliac–external iliac bridging with an iliac limb unsuitable with the devices available. Emergency endovascular aneurysm repair with a full aortic bifurcated endograft was combined with coil embolization of the inferior gluteal artery and gelatin sponge embolization of the sac. The contralateral internal iliac artery, which harbored a 31 mm aneurysm, was preserved. A suspected type IV endoleak had resolved on CT at day 4, and the patient was discharged on postoperative day 8 without complications. At 6-month follow-up, the aneurysm sac had decreased from 79 × 72 mm to 72 × 62 mm in the axial plane with no evidence of endoleak, and he remained ambulatory without pelvic ischemic symptoms. Conclusions: A full aortic bifurcated endograft combined with coil and sac embolization may be a feasible bail-out option when a marked common iliac–external iliac size discrepancy precludes bridging with the available iliac limbs, even in a nonagenarian receiving apixaban.