Iliac artery rupture during balloon dilatation: what treatment?

Hybrid management of iliac injury during thoracic endovascular aortic repair: A case report

Thoracic endovascular aortic repair is nowadays the preferred option to manage descending thoracic aorta diseases. However, despite feasibility and safety of the procedures, several complications may occur. We report the case of an 83-year-old female patient with inadvertent iliac rupture occurred during thoracic endovascular aortic repair. To limit massive bleeding, considering the patient's comorbidities contraindicating open surgical repair and the morphology of the arterial injury (circumferential rupture of the artery from its origin), we chose to perform a homolateral hypogastric and common iliac artery embolization and an aorto-uniliac balloon expandable stent graft deployment from the distal aorta to the contralateral common iliac artery. A femoro-femoral crossover bypass graft was performed to restore both lower limbs perfusion. Final angiography documented correct positioning and regular patency of the implanted grafts and bypass with no blood loss from the right iliac vessels. Despite careful preoperative assessment, iliac artery injury can represent a challenging complication of thoracic endovascular aortic repair, particularly in the setting of inadequate iliac diameter, calcification and vessel tortuosity, or when large-caliber introducers are required. The hybrid approach we describe is a valid and effective solution to minimize blood loss and avoid major consequences in the management of iatrogenic iliac artery rupture during endovascular procedures.

Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm

Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.

Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting

Purpose

Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to severe claudication or chronic limb-threatening ischemia. Stent placement for AIOD demonstrated excellent outcomes in terms of long-term patency. However, iliac artery rupture is the most fearful complication during the aortoiliac stenting (AIS). This study aimed to evaluate the incidence and risk factors of iliac artery rupture during AIS.

Materials and Methods

A retrospective review of consecutive patients with AIOD treated with AIS from 2009 to 2021 was completed. We excluded patients with instent restenosis. All types of stents, including self-expanding stent (SES), balloon-expandable stent (BES), or balloon-expandable covered stent (CS), were used. Angiographic characteristics and procedural outcomes were analyzed. Procedural success was defined as the residual stenosis <30%.

Results

A total of 242 patients (86.8% male; mean age 68.8±10.0 years) with de novo AIOD were treated with AIS. The procedural success rate was 100%. Rupture occurred in six patients (2.5%) and all ruptures were occurred in the external iliac artery (EIA). Stenting of the EIA and less calcified lesion were risk factors for iliac rupture (P=0.028). All cases of iliac artery rupture were successfully treated with the CSs. Overall primary patency rates were 98.0% and 93.4% at 12 and 36 months, respectively. Primary patency rates of SES, BES, and CS were 87.7%, 88.4%, and 100% at 36 months, respectively.

Conclusion

The incidence of iliac artery rupture during AIS was 2.5%. Stent placement in the less calcified lesion and EIA was a risk factor for rupture during AIS. Placement of the CS can be the straightforward solution in case of iliac artery rupture during AIS.

Delayed rupture of the iliac artery after endovascular therapy

Iliac artery rupture during endovascular therapy (EVT) is a life-threatening complication requiring prompt diagnosis and treatment. However, delayed rupture of the iliac artery after EVT is rare, and its predictive value remains unknown. Herein, we present the case of a 75-year-old woman who developed delayed iliac artery rupture 12 h after balloon angioplasty and placement of a self-expandable stent in the left iliac artery. Hemostasis was achieved with a covered stent graft. However, the patient died of hemorrhagic shock. From the review of previous case reports and the pathological findings of the current case, increased radial force due to overlapping stent and kinking of the iliac artery may be associated with delayed iliac artery rupture.

Learning objective

Delayed iliac artery rupture after endovascular therapy is rare but with a poor prognosis. Hemostasis can be achieved using a covered stent; however, the outcome could be fatal. Based on pathological findings and previous case reports, increased radial force at the stent site and kinking of the iliac artery may be associated with delayed iliac artery rupture. Self-expandable stent probably should not be overlapped at the site where kinking is likely to occur, even if long stenting is needed.

Management of Acute Complications during Endovascular Procedures in Peripheral Arterial Disease: A Review

Endovascular therapy, as opposed to surgical bypass, has become the mainstay for peripheral arterial disease even in long segment occlusions. Complications can occur during the arterial access, catheter manipulation, balloon dilation, and/or stent placement. Given the high prevalence of comorbidities such as diabetes, hypertension, renal dysfunction, and coronary artery disease in these patients, early identification of procedural complications and initiation of treatment are of paramount importance. This review aims to provide comprehensive data on the identification and management of commonly encountered endovascular complications during endovascular interventions in peripheral arterial disease.

How to perform a percutaneous coronary intervention, when no conventional arterial access site is available: A case report

Coronary artery disease is one of the leading causes of mortality in the world. The presence of concomitant peripheral artery disease increases the risks of cardiovascular events along with limiting the arterial access for coronary intervention. Invasive management of such cases includes either alternate site access or combined peripheral and coronary revascularization. We hereby report a patient of the infrarenal abdominal aorta and bilateral subclavian arterial occlusion, who presented with acute coronary syndrome. To perform the percutaneous coronary intervention, we first performed the endovascular stenting of occluded aortoiliac disease, followed by stenting of the right coronary artery. We had discussed the limitation of arterial access to perform PCI in such a situation.

Percutaneous Intervention of Iatrogenic Iliac Artery Vascular Complication

The mortality of patients from a retroperitoneal hematoma remains high if treatment is delayed or inappropriate. Percutaneous endovascular repair of iatrogenic vascular complications is quickly becoming the treatment of choice. Here, we report a case of a 76-year-old female with a non-ST-elevation myocardial infarction, whose cardiac catheterization revealed a 70% distal left main coronary artery (LMCA) stenosis. She underwent successful rotational atherectomy and deployment of drug-eluting stents of the distal LMCA. Following percutaneous coronary intervention, she suffered acute profound hypotension and was found to have a retroperitoneal hematoma. Given the high cardiac risk for vascular surgery due to recent intervention and overall comorbidities, she was immediately taken to the cardiac catheterization laboratory and had a diagnostic angiogram, which revealed a right external iliac artery perforation that was treated with a covered stent. She tolerated the procedure well. This case highlights the importance of early diagnosis of retroperitoneal bleed, the prompt decision to take the patient to the cardiac catheterization laboratory, and potential use of intravascular interventions to ensure a successful outcome.

A systematic review of covered balloon-expandable stents for treating aortoiliac occlusive disease

OBJECTIVE

To evaluate and compare studies reporting the outcomes of the use of covered balloon-expandable (CBE) stents for the treatment of aortoiliac occlusive disease.

METHODS

A systematic literature search was conducted to identify studies that investigated the use of CBE stents for the treatment of aortoiliac occlusive disease and were published between 2000 and 2019. Baseline demographic data, procedural variables, and long-term outcomes were extracted from publications for analysis.

RESULTS

A total of 15 published articles about 14 studies were included in the review. Of these, eight studies were prospective clinical trials and six studies were retrospective real-world studies. The articles included data regarding five different CBE stents, namely, the iCast/Advanta V12, Viabahn VBX, BeGraft, LifeStream, and JOSTENT. Lesion severity was higher in real-world studies, with more TransAtlantic Inter-Society Consensus Classification class D lesions and a higher percentage of occlusions. All studies showed high rates of technical success and patency over the course of 12 months. Long-term data were only available for the iCast/Advanta V12 device, which had a primary patency rate of 74.7% at 5 years.

CONCLUSIONS

CBE stents are a viable treatment option for patients with complex aortoiliac lesions because of their high rates of technical success and favorable patency across all devices at 12 months. However, long-term data are only available for a single device, the iCast/Advanta V12. The results of using this device were favorable over the course of 5 years.

Using bifurcated endoprosthesis after iliac artery recanalization for concomitant abdominal aortic aneurysm and chronic total occlusions of access routes

OBJECTIVE

Concurrent abdominal aortic aneurysm (AAA) and unilateral iliac occlusion is a challenge in the implantation of bifurcated stent grafts (BFGs). The endovascular approach is less invasive than open surgery; the aortouni-iliac (AUI) graft with crossover femorofemoral bypass (CFFB) has many problems associated with extra-anatomic reconstruction. We attempted endovascular aneurysm repair (EVAR) using BFGs in such cases and evaluated the outcomes.

METHODS

This was a retrospective study. Between October 2012 and December 2017, there were 649 patients who underwent surgery for AAA, of whom 32 patients underwent open reconstruction and 617 patients underwent endovascular aneurysm repair; 15 patients with unilateral occluded iliac arteries and AAA were included. The analysis included patients with unilateral iliac chronic total occlusion (CTO). The intraoperative, postoperative, and follow-up variables were reviewed.

RESULTS

The occluded lesions were the common iliac artery in 5 patients, the common iliac artery-external iliac artery (EIA) in 2 patients, the EIA in 7 patients, and the EIA-common femoral artery in 1 patient. The mean occlusive length was 89.7 ± 43.6 mm, and the mean AAA size was 54.6 ± 5.6 mm. Technical success was achieved in 13 patients (87%). All patients underwent recanalization through the true lumen and stent placement. The only procedure-related complication was distal embolism, which was treated with intraoperative thrombectomy. Recanalization of CTO lesions was not possible in two patients (13%), who underwent AUI graft placement with CFFB. The 30-day mortality and morbidity rates were 0%. The mean follow-up periods were 12 and 32 months for patients who underwent BFG placement and AUI graft placement with CFFB, respectively. During follow-up, the primary patency rate of successfully recanalized arteries was 100%. Aneurysm size decreased in four patients who underwent BFG placement; no change was seen in the other 11 patients. Freedom from aneurysm-related events was 100%; no patient needed secondary interventions. All patients with claudication pain preoperatively reported improvement in their symptoms during follow-up. In addition, the ankle-brachial index improved significantly from 0.51 ± 0.25 preoperatively to 0.88 ± 0.20 postoperatively (P < .001) in patients who underwent BFG placement.

CONCLUSIONS

Recanalization of unilateral iliac CTO lesions and placement of BFG in cases with concomitant aneurysmal disease and unilateral iliac occlusive disease demonstrated a significant primary patency rate with improvements in claudication and ankle-brachial index.

Endovascular and Hybrid Management of Patients Affected by Abdominal Aortic Aneurysm and Occlusion of the Iliac Arteries

The presence of a concomitant aortoiliac occlusive disease and abdominal aortic aneurysm (AAA) is rare and limits the implant of a bifurcated endograft.

BACKGROUND

The objective of the study was to evaluate early and midterm results of an endovascular or a hybrid approach in patients undergoing iliac revascularization and AAA exclusion.

METHODS

We reviewed our clinical series of patients from January 2016 to February 2018. Inclusion criterion was an iliac occlusion with concomitant aortic aneurysm.

RESULTS

We treated 8 male patients: 8 common iliac arteries (CIAs) and 5 external iliac arteries (EIAs). We implanted 8 bifurcated devices and 13 covered stents, 8 in CIA and 5 in EIA. In 5 cases, when the EIA was involved, we also performed a common femoral artery endarterectomy with a patch. During a mean follow-up of 10 months, the primary patency of the recanalized iliac arteries was 100%, no endoleaks, sac growth, or rupture were also recorded.

CONCLUSIONS

Endovascular or hybrid treatment of the iliac occlusion combined with infrarenal aortic aneurysm is feasible with favorable early and midterm results.

External Iliac Occlusion Does Not Preclude Endovascular Management of Aortoiliac Disease-Technique and Evolution of Therapy

BACKGROUND

Controversy remains over how to best manage chronic total occlusions of the aortoiliac (AI) system. Uncovered stents are the traditional choice but offer less durability in theory with the risk of stent ingrowth. External iliac artery (EIA) occlusions are challenging due to access difficulty.

METHODS

We performed a retrospective study of patients who had undergone endovascular AI intervention between December, 2014 and March, 2017 for Trans-Atlantic Inter-Society Consensus D lesions. The primary study end point was overall survival. Secondary end points included primary assisted or secondary patency and procedural complications.

RESULTS

Twenty-one patients were identified in the 22-month period that underwent recanalization of at least 1 iliac segment, using Atrium iCAST in the aorta and common iliac segments and/or Viabahn stents in the external iliac arteries. Overall AI patency was 100% (mean 6.8 months). Six AI bifurcation advancements were performed (primary patency 100%, mean 8 months). Eight patients with EIA occlusion underwent total percutaneous revascularization (primary patency 88%, secondary patency 100% mean 6 months). Five outflow procedures were performed concurrent to the AI recanalization. Two patients (15.4%) died of cardiovascular events. No access site complications were observed in the cohort.

CONCLUSIONS

AI occlusive disease remains a surgical challenge. Although uncovered stents are a common therapy for revascularization of this vascular bed, our experience with balloon-expanding and self-expanding covered stents suggests they may be used to good effect with minimal complications in the intermediate term.

Successful Treatment of Iatrogenic External Iliac Artery Perforation With Covered Stent: Case Report and Review of the Literature

Retroperitoneal hemorrhage from iliac artery injury is a potentially serious complication of vascular interventional procedures leading to hemorrhagic shock and death if not diagnosed early and treated promptly. We report a 70-year-old male admitted to our facility with non-ST-elevation myocardial infarction, whose heart catheterization revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease. The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to perform high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device support. Left femoral artery angiogram revealed severely tortuous and calcified aorta, left external iliac and left common iliac arteries, and was accessed with 14-inch Impella sheath. He developed groin pain with mild hypotension thought to be due to sedation, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of drug-eluting stents. Following PCI, he suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle and right ventricle systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right indicative of retroperitoneal hematoma. A digital subtraction angiogram revealed extravasation of blood at the vascular injury site. An 8.0 × 59 mm iCAST covered stent was deployed to the left external iliac artery with successful sealing of the perforation. The Impella device site was closed with two Perclose devices. The patient required 4 units of packed red blood cell transfusion. His hospital course was complicated by transient acute kidney injury, with return of his renal function to baseline at discharge 10 days later. This case underscores the importance of prompt recognition and treatment of vascular complications associated with interventional procedures, and highlights some of the risk predictors of such complications, which should be anticipated and planned for prior to intervention.

Peripheral Artery Stent Dehiscence: Percutaneous Management

An elderly male presented with left abdominal swelling of 1-week duration and inability to move the left lower limb. He had undergone bilateral common iliac and left external iliac artery stenting with self-expandable stents for aortoiliac occlusive disease 1 month back. Clinical examination revealed tender abdominal nonpulsatile mass with systolic bruit. Ultrasonography suggested retroperitoneal hematoma. His hemoglobin was 7 g%. Echocardiogram showed ejection fraction of 40%. Computed tomography angiogram revealed large 10 × 10 retroperitoneal hematoma with possibility of continued bleeding from the left external iliac artery. He was taken up for urgent catheterization after consultation with the vascular surgeons who deemed him high risk for surgery in view of left ventricular dysfunction. Abdominal aortogram showed diffuse extravasation of contrast from the junction of left common iliac artery and external iliac artery into the retroperitoneal space. Sustained balloon occlusion of the vessel across the extravasated portion was done, still the leak persisted. Two covered stents were deployed in the external iliac artery overlapping each other, percutaneously resulting in complete closure of leak with good distal runoff. His symptoms improved considerably the next day with a decrease in abdominal swelling and he was able to move his left lower limb. Ultrasound of the abdomen showed regression of the retroperitoneal hematoma and no suspicion of leak. Computed tomography angiogram done 10 days and 2 months later showed regression of retroperitoneal hematoma and no extravasation with good peripheral runoff.

Massive Bleeding from Guidewire Perforation of an External Iliac Artery: Treatment with Hand-made Stent-Graft Placement

We report life-threatening bleeding from an external iliac artery perforation following guidewire manipulation in a patient with atherosclerotic iliac artery disease. This complication was successfully managed by indigenous hand-made stent-graft made from two peripheral stents in the catheterization laboratory.

Covered stents for endovascular repair of iatrogenic injuries of iliac and femoral arteries

BACKGROUND

The growing number of complex endovascular procedures is expected to increase the risk of iatrogenic injuries of peripheral arteries. A strategy of percutaneous transluminal angioplasty (PTA) with covered stent (CS) may represent a valuable alternative to open surgery. However, systematic evaluations of CS in this setting represent a scientific gap. In the present study, we investigate the procedural and clinical outcomes associated with PTA and CS implantation to repair iatrogenic injuries of peripheral arteries.

METHODS

All patients undergoing PTA with CS for endovascular repair of iatrogenic injuries of peripheral arteries between August 2010 and July 2013 at our Institution were retrospectively analyzed. The primary endpoint was the technical success. Secondary endpoints were in-hospital mortality and cumulative death, target lesion revascularization (TLR), amputation and major stroke at 12-month follow-up.

RESULTS

During the period of observation, a total of 30 patients underwent PTA with either self-expandable (43.3%) or balloon-expandable CS (56.7%) for iatrogenic injuries of peripheral arteries. Injuries consisted of perforation/rupture (76.7%), arteriovenous fistula (16.7%) and pseudoaneurysm (6.7%) of iliac-femoral arteries. Technical success was achieved in all cases. Median follow-up was 409days [210-907]. The incidence of in-hospital mortality was 10.0%. At 12-month follow-up, the incidence of death, TLR, amputation and major stroke was 20.0%, 17.0%, 3.3% and 6.7%, respectively.

CONCLUSION

The use of covered stents for endovascular repair of iatrogenic injuries of peripheral arteries shows a high technical success and may be alternative to surgery. Further studies with larger populations are needed to confirm these preliminary findings.

Midterm outcomes of stent placement for long-segment iliac artery chronic total occlusions: a retrospective evaluation in a single institution

PURPOSE

To assess the clinical and patency results of stent placement for long-segment iliac artery chronic total occlusions (CTOs).

MATERIALS AND METHODS

A retrospective analysis of 217 patients (141 men and 76 women; mean age, 76.6 y; 256 limbs) with long-segment (>5 cm) iliac artery CTOs treated with stent placement was conducted in a single institution from January 2005 to July 2011. Demographics, clinical presentation, classification, comorbidity, ankle-brachial index (ABI) before and after treatment, technical success, patency, and complications were recorded at follow-up. The approach was initial access from the left brachial artery or the contralateral femoral artery.

RESULTS

According to the TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) classification, 27 patients were type B, 143 were type C, and 47 were type D. Clinical presentation was recorded according to the Rutherford-Becker classification: 35 patients presented with stage 3; 108, with stage 4; 53, with stage 5; and 21, with stage 6. Technical success was 96.5% (247 of 256). Periprocedural in-stent thrombosis occurred in nine patients and was treated successfully with catheter-directed thrombolysis. ABI increased from 0.36±0.16 (range, 0-0.57) before the procedure to 0.79±0.24 (range, 0.56-1.12) after the procedure. The mean duration of follow-up was 25.4 months (range, 1-72 months). The primary, primary assisted, and secondary patency of the iliac artery was 95.1%, 98.4%, and 99.2% at 1 year and 91.9%, 95.6%, and 97.5% at 2 years, respectively. Major complications were encountered in 17 (6.6%) patients, and minor complications occurred in 12 (4.7%) patients.

CONCLUSIONS

These data suggest that stent placement is an effective, safe, and feasible method for treating long-segment iliac artery CTOs.

Delayed rupture of the iliac artery after percutaneous angioplasty

Rupture of the iliac artery during percutaneous angioplasty is a life-threatening condition that requires prompt diagnosis and treatment to rescue the patient. Recently, percutaneous angioplasty has become an outpatient procedure, but there is no reliable guideline for observation time in the hospital after percutaneous angioplasty. We describe a 67-year-old man with bilateral lesions in the iliac artery who experienced a delayed rupture of the iliac artery 2 days after percutaneous balloon angioplasty and placement of a self-expandable stent. The patient was successfully treated by endovascular intervention with a stent graft. In our department, percutaneous angioplasty is not performed in an outpatient clinic, and all patients are admitted to the hospital and observed for at least 3 days after percutaneous angioplasty. Because our patient was in the hospital when the iliac artery ruptured, prompt diagnosis and treatment were possible. Moreover, because appropriately sized stent grafts were prepared in the hospital, timely endovascular treatment could be performed, and the patient recovered successfully. From this case, we conclude that observing patients for a sufficient time in the hospital and preparing appropriately sized stent grafts are 2 important factors for the safety of patients who undergo percutaneous angioplasty.

Rupture of the Left External Iliac Artery and Right Groin Pseudoaneurysm Formation following Angioplasty in a Patient with Neurofibromatosis Type 1 and Undiagnosed Bilateral Phaeochromocytoma

Neurofibromatosis type 1 (NF1) is a genetic condition, which affects 1 in every 3000 births. Patients with NF1 are at increased risk of a variety of vascular abnormalities. This report presents the case of a 60-year-old male with NF1 who suffered a left external iliac rupture and a right pseudoaneurysm following angioplasty. In addition, these were further complicated by previously undiagnosed, bilateral phaeochromocytomas. The inherent weakness in vessel wall architecture found in NF1 coupled with the hypertension evident during and after the procedure contributed to haemorrhage and pseudoaneurysm formation. Caution must be taken in such patients when considering vascular intervention.

Abdominal vascular emergencies: US and CT assessment

Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn't firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.

Heavily calcified occlusive lesions of the iliac artery: long-term patency and CT findings after stent placement

PURPOSE

To evaluate the influence of heavy calcification on iliac arterial stent expansion and patency and to define the spatial relationship between the stent and heavy calcifications on computed tomography (CT).

MATERIALS AND METHODS

Thirteen patients (11 men, two women; mean age, 66.5 y) with 14 heavily calcified iliac arteries received primary stent treatment between 1998 and 2008. Anatomic success was defined by less than 30% residual stenosis on final follow-up CT angiography. Hemodynamic success was defined as an increase in the ankle-brachial index (ABI) of at least 0.15 versus baseline. Clinical success was defined by achievement of clinical improvement of at least one clinical category. Stent patency; anatomic, hemodynamic, and clinical success rate; morphology of heavy calcifications; calcium score; and stent geometry were evaluated.

RESULTS

Stents were successfully inserted in all cases. During a mean follow-up of 33.6 months (range, 8-55 mo), the stent-implanted iliac arteries remained anatomically patent in all patients on final follow-up. The anatomic, hemodynamic, and clinical success rates were 28.6%, 60%, and 78.6%, respectively. Mean ABIs were 0.68 ± 0.22 before the procedure and 0.91 ± 0.23 after the procedure (P = .021). Mean luminal stenosis measurements were 77.9% before the procedure and 47.9% after the procedure (P = .008).

CONCLUSIONS

Iliac stents in heavily calcified lesions showed hemodynamically significant residual stenosis in a considerable number of cases. However, stent patency was not affected even with incomplete expansion of the stent.

Endovascular management of iliac rupture during endovascular aneurysm repair

BACKGROUND

Inadequate iliac artery diameter, calcification, and tortuosity are associated with increased incidence of iliac injury during abdominal (EVAR) and thoracic endovascular aneurysm repair (TEVAR). Despite careful preoperative assessment and use of iliac conduits, inadvertent iliac rupture is a source of morbidity and mortality. This report details our single-center, 10-year experience with intraoperative iliac artery rupture and describes a successful endovascular salvage technique.

METHODS

All patients undergoing EVAR and TEVAR between August 1997 and June 2008 were reviewed. Computed tomography (CT) measurements of access vessels were obtained for all patients. The smallest diameter of the external or common iliac artery was used to determine suitability for access based on the instructions for use for each device. Patients who underwent repair of a procedure-related iliac artery rupture were identified. Outcomes among patients who did not have an access vessel rupture (nonruptured group) and those who did (ruptured group) were compared. Patency of the endovascular iliac repair is reported.

RESULTS

During the study period, 369 EVARs and 67 TEVARs were performed. Eleven iliac conduits were used, all during TEVAR (16%). There were 18 ruptured iliac arteries in 17 patients; 11 EVAR patients (2.98%) sustained iliac rupture vs six TEVAR patients (8.9%). One EVAR patient was converted to open repair. Seventeen ruptures in 16 patients were successfully treated with endovascular stent graft placement. Iliac rupture was more likely to occur during TEVAR (8.9%) than EVAR (2.98%; P = .0239, Fisher exact test). Significantly more women were in the ruptured group (76% vs 19%; P < .0001, Fisher exact test). Patients in the ruptured group had longer lengths of stay (7.6 vs 5.1 days; P = .0895, t test), no 30-day mortality, but a procedure-related mortality of 11.8%. In the nonrupture group, 30-day mortality was 6.6% (4 of 61) and 2.8% (10 of 358) for TEVAR and EVAR, respectively, and procedure-related mortality was 9.8% (6 of 61) and 3.1% (11 of 358). For endovascular repair of iliac rupture, primary and primary-assisted patency was 88.2% and 94.1%, respectively, with median follow-up of 40 months (range 10-115 months).

CONCLUSION

Iliac rupture during EVAR or TEVAR can be successfully managed with endovascular stent grafting. Higher mortality and length of stay associated with iliac artery rupture confirm that there is no substitute for prevention. Access vessels of all patients undergoing EVAR should be examined closely for suitability. The threshold for using an iliac conduit, especially in women undergoing TEVAR, should be low.

Use of stent grafts and coils in vessel rupture and perforation

Vessel rupture and perforation are important complications of percutaneous treatment of coronary and peripheral arterial disease. These complications can result in abrupt vessel closure, distal organ injury, bleeding into the surrounding tissue, and death. Prompt management of such complications is therefore critically important. This paper reviews the management of vessel rupture and perforation, including the use of different types of covered stents (balloon-expandable and self-expanding), as well as the various types of embolization coils. Particular focus will be placed on percutaneous coronary artery and peripheral arterial interventions.

Percutaneous recanalization of the occluded iliac artery: examples, techniques, and complications

Recanalization of an occluded iliac artery represents a technically challenging endovascular technique. Prior to attempting recanalization, the operator must have an approach in mind and understand the risks and complications associated with this endeavor. In this article, the authors provide 2 cases and review the techniques and complications associated with iliac artery recanalization.

Emergency percutaneous treatment of arterial iliac axis ruptures

The objective of this paper is to assess the feasibility and effectiveness of emergency percutaneous treatment of ruptures of the iliac axis. In 5 years, we observed 13 patients (mean age, 62.1 years), 11 with rupture of the external iliac artery and two with rupture of the common iliac artery (six traumatic and seven iatrogenic). All patients were treated with stent grafts. A follow-up was performed with a color Doppler ultrasound at 1, 3, 6, and 12 months during the first year and then yearly. Immediate technical success was obtained in all cases. During a mean follow-up of 22.3 months, one stent-graft occlusion and one infection of a retroperitoneal hematoma occurred. The primary patency rate is 92.3%. Percutaneous treatment is a feasible and safe tool for iliac axis ruptures because it can provide a fast and definitive exclusion of bleeding with a patency rate comparable to surgery and less major morbidity and mortality.

Acute Iliac Artery Rupture: Endovascular Treatment

The authors present 7 patients who suffered iliac artery rupture over a 2 year period. In 5 patients, the rupture was iatrogenic: 4 cases were secondary to balloon angioplasty for iliac artery stenosis and 1 occurred during coronary angioplasty. In the last 2 patients, the rupture was secondary to iliac artery mycotic aneurysm. Direct placement of a stent-graft was performed in all cases, which was dilated until extravasation was controlled. Placement of the stent-graft was successful in all the cases, without any complications. The techniques used, results, and mid-term follow-up are presented. In conclusion, endovascular placement of a stent-graft is a quick, minimally invasive, efficient, and safe method for emergency treatment of acute iliac artery rupture, with satisfactory short- and mid-term results.