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Endovascular Treatment of Persistent Sciatic Artery Aneurysm With the Multilayer Stent: Is It a Miraculous Solution for All Complex Conditions?

Persistent sciatic artery (PSA) is a congenital anomaly during the embryologic evolution of the lower limb arterial system. In this issue of the JEVT, Modugno et al. present the use of the Multilayer Aneurysm Repair System (MARS; Cardiatis SA, Brussels, Belgium) for the treatment of a PSA aneurysm. Five types of PSA have been previously described. According to this classification, the case presented seems to be a type IIa (PSA with incomplete or hypoplastic superficial femoral artery without a popliteal junction). The peculiarities of this case are that the MARS has been used in an arterial segment as yet unexplored with this technology and, moreover, on an aberrant artery. Generally, the position of a PSA aneurysm cannot be anticipated, and the treatment strategy requires adequate planning and meticulous evaluation of the disease anatomy. The choice of the optimal technique for treatment is dictated case by case. Today, the management of PSA aneurysm can be either endovascular or surgical treatment, with good results in either scenario. Excluding the surgical option, the flow-modulating MARS is an alternative treatment for aneurysmal arteries in cases where the conventional endovascular techniques are not suitable or when it is necessary to maintain patency of collateral branches of the target artery. The literature contains many cases in which the MARS was used in selected cases for arterial aneurysm with initial enthusiastic results. However, there are also some failures reported after MARS treatment, especially when used outside the indications for use (IFU) or in compassionate cases without alternative treatment. Even for complex aortic disease, this new technology should not be overused, thinking it to be a simple and practical treatment rather than an experimental device. Generally, these negative results have been reported anecdotally based on individual cases or small series, but they warn us against improper use of this multilayer technology. In the current article, Modugno et al. present successful management of a symptomatic PSA aneurysm using two MARS devices, but some questions arise. Despite having achieved an immediate good result, there is still concern about short and midterm efficacy. Could not the release of two stents in an area subjected to different mechanical stresses (bending, compression, torsion, and flexing) promote the disconnection or fracture of the stents? Would it be better to place a single multilayer stent, maybe longer, to avoid the potential disconnection of the two devices? Would it not be better to have a .2 cm overlap to avoid the potential disconnection risk? Was it really necessary to use the multilayer stents to preserve collateral vessels