Transosseous Arterial Embolization during Percutaneous Sclerotherapy of a Sacral Aneurysmal Bone Cyst in a Pediatric Patient

Transosseous Arterial Embolization during Percutaneous Sclerotherapy of a Sacral Aneurysmal Bone Cyst in a Pediatric Patient | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Transosseous Arterial Embolization during Percutaneous Sclerotherapy of a Sacral Aneurysmal Bone Cyst in a Pediatric Patient Khaes Artyom, Omer Or, Adam Farkas This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8084384/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Aneurysmal bone cysts (ABCs) of the sacrum are uncommon, technically challenging lesions located near critical neurovascular structures. Both percutaneous sclerotherapy and transarterial embolization are established treatment options. However, inadvertent vascular access during transosseous needle placement is exceedingly rare. Case presentation: We report a case of a 15-year-old girl undergoing planned transosseous doxycycline sclerotherapy of a sacral ABC, during which arterial blood return occurred. Angiography confirmed accidental puncture of the distal left iliolumbar artery—the planned target for subsequent embolization. The transosseous route was successfully used for selective embolization using Squid-34 and a microcoil, avoiding the need for separate femoral arterial access. Sclerotherapy was then completed as planned. The patient recovered well and demonstrated clinical and radiologic stability at six-month follow-up. Conclusion This case highlights the importance of real-time procedural adaptability in interventional radiology and demonstrates that inadvertent transosseous vascular access can be safely utilized for therapeutic embolization when aligned with procedural goals. Aneurysmal bone cyst Sacrum Pediatric interventional radiology Percutaneous sclerotherapy Transarterial embolization Transosseous access Doxycycline Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Aneurysmal bone cysts (ABCs) are benign osteolytic lesions that primarily affect children and adolescents. Although commonly located in long bones and the spine, sacral involvement is uncommon and presents particular technical challenges due to deep location and proximity to sacral nerve roots. Minimally invasive therapies such as percutaneous sclerotherapy and transarterial embolization are increasingly used, with favorable outcomes. We present a rare case of an inadvertent transosseous puncture of the iliolumbar artery during intended sclerotherapy, which was successfully utilized as an access route for embolization. To our knowledge, this is the first reported case of technically successful transarterial embolization performed through an accidental transosseous arterial access. Patient Information A 15-year-old previously healthy girl presented with low back pain attributed to a sacral aneurysmal bone cyst. She had undergone the first stage of treatment three months earlier, which included transarterial embolization of feeding vessels and transosseous doxycycline sclerotherapy, with symptomatic improvement. Past medical history: unremarkable. Family history: noncontributory. Medications: none. No relevant social or environmental factors. Clinical Findings On presentation for the second stage of treatment, the patient had mild localized sacral pain without neurologic deficits. Physical examination revealed localized tenderness over the sacrum; motor and sensory function of the lower extremities were intact. Timeline Date Event April 2025 Stage 1: Transarterial embolization + sclerotherapy July 2025 Intended Stage 2 sclerotherapy; accidental arterial puncture and transosseous embolization July 2025 Completion of sclerotherapy session Discharge Same day, symptom improvement 6-month follow-up Asymptomatic, no interval lesion enlargement on MRI Diagnostic Assessment Cone-beam CT was used to guide placement of an 18G spinal needle into the dominant cystic component. Unexpected arterial blood return prompted contrast injection, which revealed opacification of the distal left iliolumbar artery (Figs. 1 – 3 ). No separate imaging was required, as the patient’s prior MRI and angiography were available. Differential diagnosis was not applicable because the lesion was already biopsy-proven aneurysmal bone cyst. Therapeutic Interventions 1. Transosseous arterial embolization (unexpected but therapeutic) Because the punctured artery matched the preplanned embolization target, the accidental access was used advantageously. A Headway-17 microcatheter was advanced coaxially through the transosseous needle into the proximal iliolumbar artery under roadmap guidance (Fig. 4 ). Embolization was performed with: Squid-34 liquid embolic agent , with minimal proximal reflux 4×3 mm coil deployed to seal the access tract (Fig. 5 ) Proximal rather than distal embolization was intentionally chosen to minimize the risk of ischemic injury to sacral nerve roots. 2. Completion of sclerotherapy A second needle was introduced into the cyst cavity. Cystography confirmed no venous outflow. Doxycycline foam (doxycycline + albumin + contrast, mixed 1:1 with air) was instilled in two aliquots (4 cc and 3 cc) with 10-minute dwell time and passive drainage. The patient was discharged the same day in good condition. Follow-up and Outcomes At six-month follow-up: The patient remained asymptomatic. MRI demonstrated no progression of the ABC. No neurologic deficits or complications were noted. The outcome was considered clinically and radiologically successful. Discussion This case illustrates an unusual scenario where inadvertent transosseous vascular puncture occurred during needle placement for sclerotherapy. Although vascular entry during spinal or pelvic bone interventions is uncommon, the deep location and vascularity of sacral ABCs create potential risk. The iliolumbar artery is a frequent feeder of sacral ABCs. Prior embolization of the lesion’s vasculature is known to reduce intraoperative bleeding and can be used as a primary therapeutic modality. Several studies report good outcomes with selective arterial embolization, particularly in axial lesions. The technical novelty in this case lies in the safe utilization of an accidental transosseous arterial access as the primary route for embolization. This avoided the need for femoral arterial puncture and did not compromise the sclerotherapy procedure. This case demonstrates the value of: procedural flexibility, careful angiographic assessment before withdrawing any inadvertently placed needle, and understanding of local vascular anatomy in complex sacral lesions. Declarations Informed Consent Written informed consent for participation and publication of this case report and accompanying images was obtained from the patient’s legal guardian. Ethics Approval and Consent to Participate The Institutional Review Board of Shaare Zedek Medical Center reviewed the case and waived the requirement for formal ethical approval, as single-patient case reports are exempt according to institutional policy. All procedures were performed in accordance with institutional and national ethical standards. Consent for Publication Written informed consent for publication—including clinical data and images—was obtained from the patient’s legal guardian. Data Availability All data generated or analyzed during this case report are included in this published article. No additional datasets were generated. Competing Interests The authors declare no competing interests. Funding No funding was received for this study. Authors’ Contributions A.K. – procedure, conceptualization, manuscript drafting O.O. – surgical consultation, manuscript review A.F. – procedure, supervision, manuscript editing All authors approved the final manuscript. References Rastogi S, Varshney MK, Trikha V, Khan SA, Choudhury B, Safaya R. Treatment of aneurysmal bone cysts with percutaneous sclerotherapy using polidocanol: a review of 72 cases with long-term follow-up. J Bone Joint Surg Br. 2006;88(9):1212–6. 10.1302/0301-620X.88B9.17438 . Lemos S, Soares T, Neves R, et al. Giant sacral aneurysmal bone cyst treated with endovascular embolization. Surg Neurol Int. 2023;14:373. 10.25259/SNI_561_2023 . Prasad HR, Singh V, Kumar N, et al. Percutaneous management of aneurysmal bone cyst of axis vertebra in a 12-year-old child. J Orthop Case Rep. 2023;13(9):47–51. 10.13107/jocr.2023.v13.i09.4073 . Cevolani L, Staals E, Campanacci L, et al. Aneurysmal bone cyst: Is selective arterial embolization effective as curettage and bone grafting? J Surg Oncol. 2023;128(8):1428–36. 10.1002/jso.27422 . Döring K, Puchner S, Vertesich K, et al. Results in the surgical treatment of aneurysmal bone cysts: a retrospective data analysis. Orthop Traumatol Surg Res. 2022;108(4):103095. 10.1016/j.otsr.2021.103095 . Deventer N, Schulze M, Gosheger G, et al. Primary aneurysmal bone cyst and its recent treatment options: a comparative review of 74 cases. Cancers (Basel). 2021;13(10):2362. 10.3390/cancers13102362 . Karaca MO, Bozkurt OE, Savran MD, et al. Aneurysmal bone cysts: retrospective analysis of 258 cases. Int Orthop. 2025. 10.1007/s00264-025-06603-3 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8084384","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":550159724,"identity":"c79e4940-baac-4a15-94c6-7dbe94f3b554","order_by":0,"name":"Khaes 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cyst.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8084384/v1/1f5a5ea540d95da419c08b99.jpg"},{"id":97122432,"identity":"7ff11725-906c-422f-94bd-261aad944ae7","added_by":"auto","created_at":"2025-12-01 07:58:40","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46199,"visible":true,"origin":"","legend":"\u003cp\u003eCompletion angiogram following transarterial embolization of lateral sacral artery with coils.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8084384/v1/cb601ed7f5aa4239eede4bac.jpg"},{"id":97142267,"identity":"61dc0a8f-6f36-4830-89d9-8385c3bd50b3","added_by":"auto","created_at":"2025-12-01 10:07:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":989898,"visible":true,"origin":"","legend":"\u003cp\u003eAccidental transosseous needle access (arrow) into distal iliolumbar artery and arteriography.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8084384/v1/056991a3e2cadcf72466bfbb.jpg"},{"id":97122439,"identity":"1696fedd-539a-4508-bebe-4714e427afc5","added_by":"auto","created_at":"2025-12-01 07:58:40","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":692751,"visible":true,"origin":"","legend":"\u003cp\u003eTransosseous needle placement (arrow) in distal iliolumbar artery and coaxial microcatheter tip in the proximal iliolumbar artery (arrowhead).\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8084384/v1/7368943331a3ce52fe58f5fc.jpg"},{"id":97122447,"identity":"f0d4354a-f8bb-4668-9e73-833b384dabc5","added_by":"auto","created_at":"2025-12-01 07:58:40","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":426894,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal and axial CT reconstruction showing embolic agent (Squid 34) within iliolumbar artery (arrow).\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8084384/v1/d7717f9826f0b680426d88bd.jpg"},{"id":103904340,"identity":"ecade255-040f-4b7f-9a93-c044cc8e338a","added_by":"auto","created_at":"2026-03-04 10:28:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3075071,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8084384/v1/65e7b1c3-230b-4e11-8aaa-9c628739d631.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transosseous Arterial Embolization during Percutaneous Sclerotherapy of a Sacral Aneurysmal Bone Cyst in a Pediatric Patient","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAneurysmal bone cysts (ABCs) are benign osteolytic lesions that primarily affect children and adolescents. Although commonly located in long bones and the spine, sacral involvement is uncommon and presents particular technical challenges due to deep location and proximity to sacral nerve roots. Minimally invasive therapies such as percutaneous sclerotherapy and transarterial embolization are increasingly used, with favorable outcomes.\u003c/p\u003e\u003cp\u003eWe present a rare case of an inadvertent transosseous puncture of the iliolumbar artery during intended sclerotherapy, which was successfully utilized as an access route for embolization. To our knowledge, this is the first reported case of technically successful transarterial embolization performed through an accidental transosseous arterial access.\u003c/p\u003e"},{"header":"Patient Information","content":"\u003cp\u003eA 15-year-old previously healthy girl presented with low back pain attributed to a sacral aneurysmal bone cyst. She had undergone the first stage of treatment three months earlier, which included transarterial embolization of feeding vessels and transosseous doxycycline sclerotherapy, with symptomatic improvement.\u003c/p\u003e\u003cp\u003ePast medical history: unremarkable. Family history: noncontributory. Medications: none. No relevant social or environmental factors.\u003c/p\u003e"},{"header":"Clinical Findings","content":"\u003cp\u003eOn presentation for the second stage of treatment, the patient had mild localized sacral pain without neurologic deficits. Physical examination revealed localized tenderness over the sacrum; motor and sensory function of the lower extremities were intact.\u003c/p\u003e\u003ch3\u003eTimeline\u003c/h3\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApril 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStage 1: Transarterial embolization + sclerotherapy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJuly 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntended Stage 2 sclerotherapy; accidental arterial puncture and transosseous embolization\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJuly 2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCompletion of sclerotherapy session\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDischarge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSame day, symptom improvement\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6-month follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAsymptomatic, no interval lesion enlargement on MRI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003ch3\u003eDiagnostic Assessment\u003c/h3\u003e\u003cp\u003eCone-beam CT was used to guide placement of an 18G spinal needle into the dominant cystic component. Unexpected arterial blood return prompted contrast injection, which revealed opacification of the distal left iliolumbar artery (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e–\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No separate imaging was required, as the patient’s prior MRI and angiography were available.\u003c/p\u003e\u003cp\u003eDifferential diagnosis was not applicable because the lesion was already biopsy-proven aneurysmal bone cyst.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTherapeutic Interventions\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e1. Transosseous arterial embolization (unexpected but therapeutic)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBecause the punctured artery matched the preplanned embolization target, the accidental access was used advantageously.\u003c/p\u003e\u003cp\u003eA Headway-17 microcatheter was advanced coaxially through the transosseous needle into the proximal iliolumbar artery under roadmap guidance (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEmbolization was performed with:\u003c/p\u003e\u003cp\u003e\u003cb\u003eSquid-34 liquid embolic agent\u003c/b\u003e, with minimal proximal reflux\u003c/p\u003e\u003cp\u003e\u003cb\u003e4×3 mm coil\u003c/b\u003e deployed to seal the access tract (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eProximal rather than distal embolization was intentionally chosen to minimize the risk of ischemic injury to sacral nerve roots.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Completion of sclerotherapy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA second needle was introduced into the cyst cavity. Cystography confirmed no venous outflow. Doxycycline foam (doxycycline + albumin + contrast, mixed 1:1 with air) was instilled in two aliquots (4 cc and 3 cc) with 10-minute dwell time and passive drainage.\u003c/p\u003e\u003cp\u003eThe patient was discharged the same day in good condition.\u003c/p\u003e\u003ch3\u003eFollow-up and Outcomes\u003c/h3\u003e\u003cp\u003eAt six-month follow-up:\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e The patient remained asymptomatic.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e MRI demonstrated no progression of the ABC.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNo neurologic deficits or complications were noted.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003eThe outcome was considered clinically and radiologically successful.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case illustrates an unusual scenario where inadvertent transosseous vascular puncture occurred during needle placement for sclerotherapy. Although vascular entry during spinal or pelvic bone interventions is uncommon, the deep location and vascularity of sacral ABCs create potential risk.\u003c/p\u003e\u003cp\u003eThe iliolumbar artery is a frequent feeder of sacral ABCs. Prior embolization of the lesion\u0026rsquo;s vasculature is known to reduce intraoperative bleeding and can be used as a primary therapeutic modality. Several studies report good outcomes with selective arterial embolization, particularly in axial lesions.\u003c/p\u003e\u003cp\u003eThe technical novelty in this case lies in the safe utilization of an accidental transosseous arterial access as the primary route for embolization. This avoided the need for femoral arterial puncture and did not compromise the sclerotherapy procedure.\u003c/p\u003e\u003cp\u003eThis case demonstrates the value of:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eprocedural flexibility,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ecareful angiographic assessment before withdrawing any inadvertently placed needle, and understanding of local vascular anatomy in complex sacral lesions.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for participation and publication of this case report and accompanying images was obtained from the patient\u0026rsquo;s legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Institutional Review Board of Shaare Zedek Medical Center reviewed the case and waived the requirement for formal ethical approval, as single-patient case reports are exempt according to institutional policy. All procedures were performed in accordance with institutional and national ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication\u0026mdash;including clinical data and images\u0026mdash;was obtained from the patient\u0026rsquo;s legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this case report are included in this published article. No additional datasets were generated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA.K.\u003c/strong\u003e \u0026ndash; procedure, conceptualization, manuscript drafting\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eO.O.\u003c/strong\u003e \u0026ndash; surgical consultation, manuscript review\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA.F.\u003c/strong\u003e \u0026ndash; procedure, supervision, manuscript editing\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRastogi S, Varshney MK, Trikha V, Khan SA, Choudhury B, Safaya R. Treatment of aneurysmal bone cysts with percutaneous sclerotherapy using polidocanol: a review of 72 cases with long-term follow-up. J Bone Joint Surg Br. 2006;88(9):1212\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.88B9.17438\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.88B9.17438\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLemos S, Soares T, Neves R, et al. Giant sacral aneurysmal bone cyst treated with endovascular embolization. Surg Neurol Int. 2023;14:373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25259/SNI_561_2023\u003c/span\u003e\u003cspan address=\"10.25259/SNI_561_2023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrasad HR, Singh V, Kumar N, et al. Percutaneous management of aneurysmal bone cyst of axis vertebra in a 12-year-old child. J Orthop Case Rep. 2023;13(9):47\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.13107/jocr.2023.v13.i09.4073\u003c/span\u003e\u003cspan address=\"10.13107/jocr.2023.v13.i09.4073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCevolani L, Staals E, Campanacci L, et al. Aneurysmal bone cyst: Is selective arterial embolization effective as curettage and bone grafting? J Surg Oncol. 2023;128(8):1428\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jso.27422\u003c/span\u003e\u003cspan address=\"10.1002/jso.27422\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eD\u0026ouml;ring K, Puchner S, Vertesich K, et al. Results in the surgical treatment of aneurysmal bone cysts: a retrospective data analysis. Orthop Traumatol Surg Res. 2022;108(4):103095. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.otsr.2021.103095\u003c/span\u003e\u003cspan address=\"10.1016/j.otsr.2021.103095\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeventer N, Schulze M, Gosheger G, et al. Primary aneurysmal bone cyst and its recent treatment options: a comparative review of 74 cases. Cancers (Basel). 2021;13(10):2362. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cancers13102362\u003c/span\u003e\u003cspan address=\"10.3390/cancers13102362\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaraca MO, Bozkurt OE, Savran MD, et al. Aneurysmal bone cysts: retrospective analysis of 258 cases. Int Orthop. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00264-025-06603-3\u003c/span\u003e\u003cspan address=\"10.1007/s00264-025-06603-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Aneurysmal bone cyst, Sacrum, Pediatric interventional radiology, Percutaneous sclerotherapy, Transarterial embolization, Transosseous access, Doxycycline","lastPublishedDoi":"10.21203/rs.3.rs-8084384/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8084384/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAneurysmal bone cysts (ABCs) of the sacrum are uncommon, technically challenging lesions located near critical neurovascular structures. Both percutaneous sclerotherapy and transarterial embolization are established treatment options. However, inadvertent vascular access during transosseous needle placement is exceedingly rare.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eWe report a case of a 15-year-old girl undergoing planned transosseous doxycycline sclerotherapy of a sacral ABC, during which arterial blood return occurred. Angiography confirmed accidental puncture of the distal left iliolumbar artery\u0026mdash;the planned target for subsequent embolization. The transosseous route was successfully used for selective embolization using Squid-34 and a microcoil, avoiding the need for separate femoral arterial access. Sclerotherapy was then completed as planned. The patient recovered well and demonstrated clinical and radiologic stability at six-month follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis case highlights the importance of real-time procedural adaptability in interventional radiology and demonstrates that inadvertent transosseous vascular access can be safely utilized for therapeutic embolization when aligned with procedural goals.\u003c/p\u003e","manuscriptTitle":"Transosseous Arterial Embolization during Percutaneous Sclerotherapy of a Sacral Aneurysmal Bone Cyst in a Pediatric Patient","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 07:58:35","doi":"10.21203/rs.3.rs-8084384/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"197fbeb5-1384-4ba7-9bf6-1dc6d75be7a0","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T10:27:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-01 07:58:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8084384","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8084384","identity":"rs-8084384","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}