Branches Of Iliac Artery Research Articles

Normal, accessory, and aberrant branches of the common iliac artery: angiographic prevalence and clinical implications.

Catheter angiography remains essential to detect, characterize, and treat many vascular, traumatic, and neoplastic conditions affecting the pelvis, but the angiographic literature rarely mentions the common iliac artery (CIA) and its branches. The "normal" branches of the CIA principally consist of subangiographic rami supplying neighboring structures. Larger branches participate in the vascularization of the psoas muscle and the ureter. Less often, the CIA provides anomalous branches that complement or replace critical neighboring vessels. This study investigates the prevalence, type, and clinical relevance of CIA branches detectable during pelvic angiography. This study analyzes the prevalence of CIA branches in 100 consecutive angiograms that included bilateral CIA injections as well as selective catheterizations of the median sacral artery, both L4 ISAs, and both internal iliac arteries. CIA branches were classified as normal (i.e., neither supplementing nor replacing a normal artery), accessory (i.e., supplementing a normal artery), or aberrant (i.e., replacing a normal artery). Forty-three branches arose from 38 CIAs (19% of CIAs) in 30 patients (30% of patients), including 20 normal branches (46.5%), 21 aberrant branches (48.8%), and 2 accessory branches (4.7%). Each of the 15 patients with aberrant branches had at least one anomalous vessel capable of providing a radicular or radiculomedullary artery. CIA branches were present in 30% of patients undergoing spinal angiography. While most normal branches were diminutive and clinically irrelevant, CIAs also provided vessels able to vascularize pelvic and vertebral structures, including the spinal cord or a spinal vascular malformation in 16% of cases. Our study therefore confirms that CIA injections represent an essential component of pelvic and spinal angiography.

Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement

Internal iliac artery (IIA) balloon occlusion catheters have been commonly inserted to decrease the risk of postpartum hemorrhage in placenta accreta spectrum disorders; however, there has been mixed success in clinical studies. Placement of an infrarenal aortic balloon has shown more consistent effectiveness in recent studies. A possible reason for this is collateral arterial supply to the placenta from external iliac artery branches. Retrospective chart review was conducted of angiography images during prophylactic IIA balloon occlusion catheter insertion over a 7-year period. Sixty-two individual cases were identified. Digital subtraction angiography (DSA) was performed in 32 (52%) cases, and 20 (62%) showed collateral blood supply from branches of the external iliac arteries, namely the round ligament artery. In conclusion, a high proportion of placenta accreta spectrum cases have arterial blood supply from branches of the external iliac artery, which may explain the discrepancy in effectiveness seen between IIA and infrarenal aortic sites of balloon occlusion catheter placement.

Surgical anatomy of superior gluteal artery in relation to lumbosacral plexus – A cadaveric study in the Indian population

Background: The superior gluteal artery (SGA) passes in between branches of the lumbosacral plexus after arising from the internal iliac artery. Variations in the course of SGA from the internal iliac artery till it passes out of the pelvis through the greater sciatic foramen are very important during pelvic surgeries. Pseudoaneurysm of SGA caused by iatrogenic injuries can compress branches of the lumbosacral plexus, causing foot drops and sciatica. Aims and Objectives: The aim is to study the course of the SGA in relation to branches of the lumbosacral plexus. Materials and Methods: A cross-sectional observational study was done on 25 formalin-fixed human adult cadavers. Dissections were performed in the pelvic region and branches of the internal iliac artery and lumbosacral plexus were identified. SGA was traced on both sides from origin till passing out of the greater sciatic foramen and its relation to branches of lumbosacral plexus was recorded. Results: Three types of pathways taken by SGA were identified in relation to the lumbosacral plexus. The most common path taken by the SGA was between the lumbosacral trunk (LST) and the first sacral nerve. Thirty-five out of 50 were of this type (70%). Ten out of 50 had the second most common type which was between L4 and L5 branches of LST (20%). Five cadavers had SGA lateral to LST (10%). Ten cadavers out of 25 (40%) had side differences in the type of course taken by SGA in relation to the lumbosacral plexus. Conclusion: A surgeon must keep in mind variations in the path taken by SGA in relation to the lumbosacral plexus to prevent pseudoaneurysms of SGA, which in turn can compress branches of lumbosacral plexus, causing foot drop and sciatica.

Incorporation of internal iliac arteries as target vessels during physician-modified fenestrated branched endovascular repair of pararenal abdominal aortic aneurysm with concomitant bilateral short common iliac artery aneurysms

This report describes an alternative endovascular approach to iliac branch devices for treatment of an abdominal aortic aneurysm with concomitant bilateral short common iliac aneurysms. The short distance between the renal arteries and internal iliac artery origins made the addition of distal iliac branch devices to the proximal fenestrated stent graft challenging. We elected to perform physician-modified fenestrated branched endovascular repair, using four fenestrations for the visceral and renal arteries and an additional two directional branches for the bilateral internal iliac arteries. The patient recovered uneventfully, and the 24-month follow-up imaging shows successful aneurysm exclusion with patent internal iliac artery branches.

Comparison of laparoscopic lateral lymph node dissection for rectal cancer with and without routine resection of the visceral branches of internal iliac artery.

This study aimed to explore the safety and feasibility of the modified lateral lymph node dissection (LLND) with routine resection of the visceral branches of internal iliac vessels (IIVs) for mid-low-lying rectal cancer. Consecutive patients undergoing LLND for rectal cancer were divided into the routine visceral branches of the IIVs resection group (RVR group) and the NRVR group (without routine resection). The main outcomes were postoperative complications and the number of lateral lymph nodes harvested. From 2012 to 2021, a total of 75 and 57 patients were included in the RVR and NRVR group, respectively. The operative time was reduced in the RVR group (p = 0.020). No significant difference was observed between the two groups for the incidence of total, major, or minor postoperative complications. Pathologically confirmed LLNM were 24 (32%) patients in the RVR group and 12 (21.1%) in the NRVR group (p = 0.162). The number of lateral lymph nodes harvested had no significant difference between two groups (11 vs. 12, p = 0.329). LLND with routine resection of visceral branches of IIVs is safe and feasible, which brings no major complication or long-term urinary disorder.

Usefulness of knowledge in anatomy of the internal iliac artery in its ligation during life-threatening pelvic haemorrhages

Introduction: Post-Partum haemorrhage is a significant cause of maternal mortality. Bilateral internal iliac artery ligation is a life-saving procedure to control massive obstetric and gynaecological haemorrhages. Bilateral internal iliac artery ligation results in toning down the pulsatility making the arterial flow a slow venous flow encouraging the clot formation of the damaged pelvic vessels. This study assesses the retroperitoneal anatomy and regional variations of the internal iliac artery.Methods: The study was based on examining 45 pelvic halves (23 right sides and 22 left sides), which were dissected during the gross anatomy laboratory at the faculty of medicine, Ragama, University of Kelaniya, from 2020 -2023. There were all adult pelvises. The internal iliac artery and its major branches were carefully dissected and examined. Adachi classification was used to classify the distribution pattern of the internal iliac artery. The study was done on the donated cadavers, and the nature of the study did not warrant any special ethical clearance. No conflict of interest.Results: No anatomical deviation has been noted with regard to the levels of division of aorta, common iliac artery, the division into internal and external iliac arteries and the division of anterior and posterior branches of the internal iliac artery from that of classical anatomical literature. It was also noted that there had been no significant deviation of anatomical relations with regard to the structures as described in the internal lilac artery in our study. In our study, Type Ia was found in 35/45 (78%) of the specimens, Type IIa in 3/45 (6%), Type III in 7 (16%), and no specimens were found with Type IV and. Type V.Conclusion: Our study showed no significant anomalies of the pelvic anatomical structural relations to the internal iliac artery. The type Ia branching pattern was found to be the commonest.

Systematic Review and Meta-Analysis of the Variants of the Obturatory Artery.

Knowledge of vascular anatomy and its possible variations is essential for performing embolization or revascularization procedures and complex surgery in the pelvis. The obturator artery (OA) is a branch of the anterior division of the internal iliac artery (IIA), and it has the highest frequency of variation among branches of the internal iliac artery. Possible anomalies of the origin of the obturator artery (OA) should be known when performing pelvic and groin surgery, where its control or ligation may be required. The purpose of this systematic review and meta-analysis, based on Sanudo's classification, is to analyze the origin of the obturator artery (OA) and its variants. Thirteen articles published between 1952 and 2020 were included. The obturator artery (OA) was present in almost all cases (99.8%): the pooled prevalence estimate for the origin from the IIA axis was 77.7% (95% CI 71.8-83.1%) vs. 22.3% (95% CI 16.9-28.2%) for the origin from EIA axis. In most cases, the obturator artery (OA) originated from the anterior division trunk of the internal iliac artery (IIA) (61.6%). Performing preoperative radiological examination to determine the pelvic vascular pattern and having the awareness to evaluate possible changes in the obturator artery can reduce the risk of iatrogenic injury and complications.

Internal iliac artery aneurysm masquerading as a sciatic nerve schwannoma: illustrative case.

Schwannomas are common peripheral nerve sheath tumors. Imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) can help to distinguish schwannomas from other types of lesions. However, there have been several reported cases describing the misdiagnosis of aneurysms as schwannomas. A 70-year-old male with ongoing pain despite spinal fusion surgery underwent MRI. A lesion was noted along the left sciatic nerve, which was believed to be a sciatic nerve schwannoma. During the surgery for planned neurolysis and tumor resection, the lesion was noted to be pulsatile. Electromyography mapping and intraoperative ultrasound confirmed vascular pulsations and turbulent flow within the aneurysm, so the surgery was aborted. A formal CT angiogram revealed the lesion to be an internal iliac artery (IIA) branch aneurysm. The patient underwent coil embolization with complete obliteration of the aneurysm. The authors report the first case of an IIA aneurysm misdiagnosed as a sciatic nerve schwannoma. Surgeons should be aware of this potential misdiagnosis and potentially use other imaging modalities to confirm the lesion before proceeding with surgery.

Accessory iliolumbar artery- A case report

The variant anatomy of pelvic vasculature is reported in fewer studies, especially the internal iliac artery branching pattern. Branches of the internal iliac artery are more critical when considering procedures such as iliac bone grafting, surgical approach to fix pelvic fractures or iatrogenic vascular haemorrhages in the pelvis. The present case shows the variation in the right ileal system, i.e. the accessory Iliolumbar artery (ILA), in addition to the principal ILA on the right side, which supplies the iliac and lumbar region.

Corona mortis in the setting of pelvic trauma: Case series and review of the literature

Corona mortis is a variant vessel located posteriorly against the superior pubic ramus, “crowning” the pelvis; actual prevalence is unknown due to broad definitions: A connection between the obturator artery and an external iliac artery branch or the external iliac artery anastomosis, or any variant vessel behind the superior pubic ramus. Rapid identification and immediate treatment of injury to an arterial corona mortis resulting from pelvic trauma or pelvic surgeries are essential as hemorrhage or death may result. Interventional radiology can selectively target corona mortis and obstruct hemorrhage through catheter-guided embolization. We present four cases of corona mortis and pelvic trauma with successful embolization and include a comprehensive literature review to further educate regarding the morbidity and potential mortality associated with this important anatomic variant.

Triple Threat: Spinal Dural Arteriovenous Fistula in Spinal Dysraphism and Tethered Cord Syndrome, a Case Report with Literature Review

Introduction: The incidence of spinal dural arteriovenous fistula (SDAVF) in patients with spinal dysraphism is exceedingly rare with fewer than 30 cases reported. We report such a case and discuss the etiology, diagnostic, and treatment challenges of such patients. Case Presentation: This is a 37-year-old gentleman with a history of myelomeningocele (MMC) repair at the age of 2 years who presented to us with worsening bilateral lower limb weakness and numbness. Clinical examination demonstrated affected motor and sensory functions from the level of L2. An MRI Lumbosacral revealed S3/S4 dysraphism with a tethered low-lying conus. A CT angiogram of the spine followed by a spinal angiogram confirmed the diagnosis of a SDAVF with feeders from the median sacral artery and other branches of the left internal iliac artery. He underwent angioembolization, following which we noted a residual SDAVF and hence underwent a difficult second-stage angioembolization to the right lateral sacral artery branch. The patient remained status quo on follow-up. Conclusion: SDAVFs occurring in spinal dysraphism requires a high index of suspicion to ensure the diagnosis is not missed or masked by co-existing tethered cord and dysraphism. These lesions should be managed in a multidisciplinary multimodal individualized fashion.

Prolonged, recurrent, spontaneous massive gluteal and femoral bleeding in a patient with five metachronous primary malignancies

Purpose: This study aimed to present the case of prolonged, recurrent, spontaneous massive bleeding in a patient with five metachronous primary malignancies.
 Case presentation: A 70-year-old male patient presented with massive hematomas in the gluteal and femoral regions and a 6-year history of prostatic, urethral (penile), right colonic, and right pulmonary carcinoma, with a myeloproliferative disease that recently ended with lymphatic leukemia. Fasciotomies with the evacuation of massive hematomas were performed due to the development of compartment syndrome, which were followed by persistent recurrent bleeding. Despite several surgical interventions with packing, local hemostatic agents and sutures, and selective embolization with immediate clinical discontinuation of bleeding, the digital subtraction angiography showed recurrent bleeding from the peripheral branches of the internal iliac and deep femoral arteries always a few days after the procedures. The coagulation and aggregation parameters and bleeding disorders tests were within normal ranges. The histology showed no malignancy in the affected regions, and no relapse was reported in any regions with previously operated malignant diseases on control computed tomography and positron emission tomography scans.
 Conclusion: We could stop the bleeding only with more aggressive, nontarget gradual embolization. Subsequently, hemostasis was achieved, with gradual healing of incisions.

COARCTATION OF AORTA IN A 33 YEARS-OLD UNCONTROLLED HYPERTENSIVE FEMALE PATIENT – A CASE REPORT

We report a 33-year-female patient of hypertension detected at the age of 19 year. Her blood pressure was not well controlled. The case was investigated for secondary hypertension. CT Thoracic and Abdominal aorta Angiogram of the present case showing the narrowing in the thoracic aorta extending at the level of T8 to T10 vertebral body level for the length of 7.5cm. Reconstructed CT of the case showed multiple tortuous collaterals between the branches of internal mammary artery and external iliac artery and between axillary and intercostal artery. Relevant history was reviewed and discussed.

Insight into Vietnamese women’s internal iliac artery anatomy

This study aims to assess the characteristics of the internal iliac artery and to examine correlations between the internal iliac artery and other anatomic structures in the pelvis. A cross-sectional study was conducted in the period between October 2019 and May 2020. Eighteen samples of the left and right internal iliac arteries were taken from formaldehyde-embalmed female cadavers at the Ho Chi Minh City University of Medicine and Pharmacy Department of Anatomy. The study showed that the origins of most internal iliac arteries were located by the lumbar vertebrae 4-5. The mean distance from the origin of the internal iliac artery origin to the sacral promontory was 33.95 ± 3.35 mm (on the left), and 31.70 ± 4.64 mm (on the right). The internal iliac artery always had two big branches – anterior and posterior. A third branch was an ilio-lumbar artery, often seen by 43.33%. The diameters of those internal iliac artery branches were comparable on both sides, and the branches of similar name had a little larger diameter on the left than on the right. The internal iliac artery always has two large anterior and posterior branches; in some cases, it has a third branch called ilio-lumbar artery. The internal iliac artery’s length from its origin to the initial branch division is comparable for both right and left sides. The distance from the internal iliac artery’s origin to the sacral promontory is suggestive for surgeons to find the internal iliac artery after determining the sacral promontory.

Variations in the origin of iliolumbar artery with its clinical significance

Introduction: The Iliolumbar artery mainly arises from the posterior division of the internal iliac artery. It extends oblique superiorly and laterally in front of the sacroiliac joint and lumbosacral trunk. It crosses the obturator nerve and external iliac vessels & reaches the medial edge of the psoas major. The aim of our study was to know the origin variability of the Iliolumbar artery. This helps to prevent any iatrogenic injury during various surgeries. Materials and Methods: 50 formalin-fixed adult human pelvic halves with known sex were procured from the Department of Anatomy, Medical College, Baroda. Site of origin of the Iliolumbar Artery was identified. Results: In the current study, we observed that the origin of the Iliolumbar Artery was from the posterior division of IIA in 52%, 38% from the trunk of the internal iliac artery, 4% from the single trunk with obturator artery from posterior division, and 6% absent. Conclusion: The variable origins of the ILA from different branches of the internal iliac artery should be taken into account during the surgical procedures involving the lower abdominal & pelvic region so as to modify the surgical tactics to prevent undesired hemorrhagic complications.

Outcomes of “Anterior Versus Posterior Divisional Branches of the Hypogastric Artery as Distal Landing Zone for Iliac Branch Devices”: The International Multicentric R3OYAL Registry

Objective: The aim of this multicentric registry was to assess the outcomes of “anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL).” Methods: The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability. Results: A total of 171 patients were included in the study, of which 50 received bilateral implantation of iliac branch devices (IBDs). This resulted in a total of 221 incorporated IIAs included in the final analysis, of which 40 were anterior divisional branches and 181 were posterior divisional branches. Technical success was high in both groups (anterior division: 98% vs posterior division: 100%, P = .18). Occurrence of any adverse event was noted in 14% of patients in both groups (P = 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test = .215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test = .009; secondary patency: 81% vs 97%, log-rank test < .001). Conclusions: The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA. Clinical Impact The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA.

The Pelvic and Sacral Splanchnic Nerves – Identification by Dissection, Trajectory

The modern principles in pelvic surgery imply the preservation of the nervous structures that are involved in the physiological functioning of the pelvic and genital organs. The main pelvic nervous element is represented by the inferior hypogastric plexus. This plexus receives sympathetic afferent fibres from the hypogastric nerve, parasympathetic afferent fibres from the pelvic splanchnic nerves and also sympathetic afferent fibres coming from the sympathetic sacral chain via the sacral splanchnic nerves. We aimed to demonstrate the anatomy of these structures through dissection and we exposed the origins, pathway and manner of distribution of the splanchnic nerves of the pelvis. We managed to clarify the main anatomical relations of these nerves, among which we highlighted the relation to the branches of the internal iliac artery. The parasympathetic fibres reach the pelvis by running through the anterior rami of the spinal nerves, which are the origin of the sacral plexus. We managed to exhibit the way in which the parasympathetic fibres emerge from the sacral nerves and form the pelvic splanchnic nerves. Pelvic surgery nowadays is focused on nerve-sparing, which essentially means the conservation of the integrity of splanchnic nerves, hypogastric nerves and inferior hypogastric plexuses in order to maintain the normal functioning of the anatomical sphincters and genital organs. In this respect, it is crucial for the surgeon who performs pelvic procedures to be more than well-acquainted to the anatomy of the pelvic splanchnic nerves, which are considered to be the erectile nerves, and to that of the sacral splanchnic nerves.

P1. Compression of the lumbosacral trunk and S1 nerve root by calcific posterior branches of the internal iliac artery: a potential source of sciatic pain

<h3>BACKGROUND CONTEXT</h3> Sciatic pain caused by nerve root compression can be painful and debilitating. Compression of the nerve roots comprising the sciatic nerve can occur at their immediate exit from the spinal cord or anywhere along their length. Identifying the precise location of nerve root compression is critical for effective treatment of clinical signs and symptoms. <h3>METHODS</h3> Pelvic dissections were performed on 20 human cadavers (7 males and 13 females) with a mean age of 79.9 years at the time of death (SD, 10.4; range, 63-101 years). The donors were not selected based on any particular medical history or by criteria other than their convenient availability. All of the donors were Caucasians from greater Minnesota. The bodies were embalmed in a solution containing isopropyl alcohol (70%), phenol (13%), formaldehyde (8%), sorbitol (8%) and Barquat MB-50 disinfectant (1%). Each cadaver was sectioned transversely with a handsaw at approximately the L3 vertebral level. The resulting abdominopelvic portion was then sectioned completely down the midline, producing two hemipelvis regions for dissection. The pelvic structures were dissected with conventional dissection instruments (forceps, scalpel, scissors and blunt probe). A Canon EOS Rebel T3i (with a Macro 0.25m/0.8 ft. lens) was used to take photographs during the various phases of each dissection. Both sides of the pelvis were dissected for each cadaver, except for two (due to poor tissue quality). The right side of one could not be dissected due to a large destructive hematoma in the pelvic wall. The left side of another could not be dissected due to tough fibrous adhesions in the pelvis from radiation therapy. <h3>RESULTS</h3> This study of cadaveric hemipelvis dissections provides evidence to support that calcific branches of the internal iliac artery may compress and deform underlying nerve roots. This deformation suggests nerve compression. Specifically, when the posterior division of the internal iliac artery or superior gluteal artery contains calcific plaque, they form a visible impression on the nerves they course over in approximately 85.7% of the time. In this study, the lumbosacral trunk is the most commonly compressed nerve root in the pelvis, but the S1 nerve root can be affected as well. When the blood vessels lacked calcific plaque, they did not produce visible deformation of the underlying nerves. <h3>CONCLUSIONS</h3> Understanding this potential mechanism of nerve compression in the pelvis has clinical significance for patients with sciatic pain. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes.

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

P203 CHALLENGES IN THE MANAGEMENT OF RECTUS MUSCLE HEMATOMA DURING TRIPLE ANTITHROMBOTIC THERAPY IN RECENT ANTERIOR STEMI COMPLICATED BY LEFT ENDOVENTRICULAR THROMBOSIS

Abstract A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.