Common Iliac Artery Dissection Research Articles

Aortic remodeling after endovascular aortic repair and tailored distal entry tears exclusion in Crawford type III or IV dissection aneurysm

Thoracic endovascular aortic repair (TEVAR) can only promote 55-80% false lumen (FL) thrombosis when only the proximal primary tear is covered during the repair of type B aortic dissection (TBAD). This study evaluated the effectiveness and clinical outcome of tailored exclusion of the primary entry tear with TEVAR and distal fenestrations with ancillary devices in patients with subacute or chronic Crawford type III and IV aortic dissection aneurysm. All patients underwent either TEVAR for primary entry tear; subsequently, various ancillary devices were applied on each distal fenestration. These techniques included covered stent occlusion of detached visceral artery entry tears, TL stenting and FL occlusion with vascular plugs in the common iliac artery dissection, or TEVAR coverage for multiple fenestrations from segmental arteries. This case series included nine patients (seven men and two women; mean age: 63.4 years) during January 2013 to May 2019. Outcome analysis included the rates of technical success and procedure-related complications, completeness of FL occlusion, aortic remodeling, and midterm mortality at 2 years. The mean follow-up duration was 37.7 months without in-hospital mortality. One patient was lost to follow-up at the second month, the rest of patients were all alive during the follow-up period. All patients achieved complete FL thrombosis, and six patients exhibited aneurysm diameter shrinkage. Tailored exclusion of visceral and iliac distal fenestrations with proximal primary tear coverage can promote FL thrombosis and aortic remodeling in the visceral aortic segment in patients with Crawford type III or IV aortic dissection aneurysm.

Management of Spontaneous Dissection and Rupture of Common Iliac Artery in Ehlers-Danlos Type IV

Ehlers-Danlos syndromes (EDSs) are rare disorders of the connective tissue. The subtype important to vascular surgeons is vascular subtype IV. The reported operative mortality ranges from 7% to 41%. EDS-IV only affects 5% of all cases of EDS, leading to limited experience and society guidelines regarding the management of vascular complications. We report the case of a common iliac artery dissection with associated rupture resulting in acute limb ischemia in a 28-year-old man with EDS-IV. An endovascular stent was used to successfully restore flow and repair the iliac arterial rupture, minimizing access site complications with specific open exposure techniques.

Acute lower extremity ischaemia after surgical interventricular communication closure in a newborn.

We report a 5-month-old infant who developed an unexpected acute ischaemia of the right lower limb following a surgical perimembranous interventricular communication closure. This rare case of ischaemia was due to an occlusive right common iliac artery dissection. It was early managed by angioplasty with two ABSORB® bioresorbable stents, resulted in complete revascularisation of the right leg.

A Systematic Review of the Use of Endoanchors in Endovascular Aortic Aneurysm Repair

Objectives Endoanchor fixation might be a potential adjunct for the prevention and treatment of type Ia endoleak (TIaE) and graft migration in thoracic or abdominal endovascular aortic aneurysm repairs (TEVAR or EVAR). This review aimed to explore the safety and effectiveness of endoanchor fixation in TEVAR and EVAR. Methods A systematic review and random effects meta-analysis was conducted. Data sources were PubMed/MEDLINE, Embase, and the Cochrane Library. Results Seven EVAR and three TEVAR studies using the Heli-FX™ EndoAnchor™ system were included in the meta-analysis. A total of 455 EVAR patients underwent primary endoanchor fixation. Technical success was 98.4% (95% CI 95.7–99.8%). The rate of TIaE and graft migration was 3.5% (95% CI 1.7–5.9%) and 2.0% (95% CI 0.12–6.0%), respectively, after 15.4 months (95% CI 1.76–29.0) follow up. A total of 107 EVAR patients underwent secondary fixation with a technical success of 91.8% (95% CI 86.1–96.2%). Rates of TIaE and graft migration were 22.6% (95% CI 9.1–40.0%) and 0% after a mean 10.7 month (95% CI 7.8–13.6) follow up. Adverse events included three endoanchor fractures, three dislocated endoanchors, one entrapped endoanchor, and one common iliac artery dissection. All cause 30 day EVAR mortality was 0.82% (95% CI 0.20–1.85%). Sixty-six TEVAR patients underwent endoanchor fixation with a mean 9.8 month (95% CI 8.1–11.5) follow up. Technical success was 90.3% (95% CI 72.1–99.4%). The rates of TIaE and migration were 8.7% (95% CI 1.0–18.9%) and 0%, respectively. Adverse events included two misdeployed endoanchors with one fatal aortic dissection. All cause 30 day TEVAR mortality was 11.9% (95% CI 5.4–20.6%). Conclusion Endoanchor fixation in EVAR is technically feasible and safe, with at least comparable early outcomes to the latest generation of stent grafts. Endostapling in TEVAR is associated with lower technical success, higher peri-operative mortality, and potential serious adverse events. Current evidence lacks long term follow up and case controlled trials to recommend endoanchor use in routine practice.

45. Large vessel vasculitis associated with common iliac artery aneurysm and limb ischaemia

IntroductionAn 81-year-old gentleman with no prior medical history presented with a 5-month history of gradual onset malaise and reduced appetite. Weight loss of 2 stone was noted. Mild intermittent headache was present. After 3 months, he developed intermittent claudication of the right leg. A diagnosis of giant cell arteritis (GCA) was made. Disease was corticosteroid resistant, on the basis of clinical findings, biochemistry and imaging. Tocilizumab was commenced. Imaging also revealed dissection of the proximal right common iliac artery. The intermittent claudication progressed to acute limb ischaemia, which responded well to conservative treatment with heparin.Case descriptionHeadache was unilateral, intermittent and lasted a few minutes only, although it was described as severe. There were no visual symptoms, no scalp tenderness and no jaw or tongue claudication. His mobility was severely impacted by intermittent claudication. He was previously playing 3 rounds of golf per week but exercise tolerance reduced to fifty metres. There were no specific risk factors for atherosclerotic disease. He was a retired head teacher and had never smoked. Alcohol intake was 3 units per week. He was not taking any medication.The predominant features in the history were systemic upset and weight loss and the initial focus was on ruling out malignancy. Extensive investigations were performed by the general practitioner (GP). Erythrocyte sedimentation rate (ESR) was 80 and C-reactive protein (CRP) 74. A full blood count and serum biochemistry were otherwise unremarkable. Immunoglobulins were normal with no paraprotein detected. Thyroid stimulating hormone (TSH) was within the normal range. Prostate specific antigen (PSA) was raised at 17.8 but urology investigations revealed no evidence of malignancy.Computed tomography (CT) of the thorax, abdomen and pelvis showed non-specific inflammation of jejunum & mesenteric fat. Subsequent magnetic resonance imaging (MRI) of the small bowel showed resolution of these changes but noted a chronic focal area of dissection at the proximal right common iliac artery.The GP commenced prednisolone 40mg daily, increased after twelve days to 60mg daily due to partial response. Review in rheumatology clinic two weeks later noted ongoing intermittent claudication. Headache had resolved and weight stabilised. The right temporal artery was difficult to palpate and the right ulnar pulse was absent. Temporal artery ultrasound scan (TA USS) in clinic demonstrated bilateral ongoing active inflammation. Three pulses of 500mg intravenous methylprednisolone were arranged.DiscussionWhilst ESR had initially improved to 10 and CRP to < 3, they subsequently increased to 53 and 45 respectively. Subsequent positron emission tomography with computed tomography (PET-CT) showed diffuse metabolic activity in thoracic aorta, bilateral subclavian, axillary and femoral arteries.On the basis of bloods, ongoing claudicant symptoms and strongly positive TA-USS and PET-CT, the disease was felt to meet criteria for steroid non-responsiveness. As per NICE guidelines, permission was sought and granted from the local tertiary centre to commence tocilizumab. The patient was noted to have diverticulosis on the basis of imaging but had never been symptomatic. After appropriate patient counselling on the risks of gastrointestinal perforation, a decision was made to proceed with treatment.The finding of dissection at the proximal right common iliac artery prompted urgent referral to the vascular surgery team. However, whilst awaiting review, the patient developed acute limb ischaemia with pallor, weakness and pain of the right leg. He was admitted and managed conservatively with intravenous heparin, followed by subcutaneous heparin and clopidogrel. He responded well to medical therapy and remains under vascular follow up. Notably, the aneurysm was retrospectively noted on CT scan imaging, confirming that it predated corticosteroid treatment.Key learning pointsWhilst aneurysm formation is a recognised complication of giant cell arteritis, they are typically aortic and involvement of lower limb arteries is rareThere is no consensus opinion on optimal surveillance of extra-aortic aneurysms in GCA; decisions should be made on a case by case basisTocilizumab is an effective treatment for refractory GCA. The current NICE guideline on its usage is based on the GiACTA study findingsConflicts of interestThe authors have declared no conflicts of interest.

An attempt to retrieve an embolized ductal closure device leading to iliac artery dissection in an 11-month-old child: A case report

An 11-month-old patient was referred with the diagnosis of Amplatzer duct occluder II embolization to the right common iliac artery during transcatheter patent ductus arteriosus closure procedure, and unsuccessful retrieval. Following extraction of the device through median laparotomy, a graft interposition was compulsorily performed due to right common iliac artery dissection. Transcatheter device occlusion of patent ductus arteriosus with low complication rates has become the preferred treatment modality in children. However, insisting on transcatheter retrieval of an occluder device should be avoided, as the outcomes can be devastating including limb loss, death or need for multiple surgical and/or endovascular procedures in the future.

Abstract 492: Intra Mural Aortic Hematoma: An Unusual Case Presenting With Acute Limb Ischemia

A 50 YO F with PMH of HTN, HLD, DM2, presented with claudication of right lower extremity with cyanotic changes of her toes for past few months, with increasing pain and discoloration. CT Angio showed ulcerated plaque of abdominal aorta and 1.5 cm dissection and stenosis of right common iliac artery. Intervention done with urgent stent placement. Patient returned 5 days later with worsening of pain and cyanosis of right toes with increasing symptoms of heaviness and claudication with about 1-2 blocks. Physical examination suggestive of discoloration of right foot toes, audible pedal pulses on right. Repeat Ct angio showed focal intramural hematoma and dissection within the right common iliac artery just above the stent, with 75% stenosis. Possibly from rupture of ulcer from surgical manipulation. Vascular surgeon and Interventional radiologist, both agreed on stent graft placement based on current guidelines. Patient underwent procedure without complications, pain and cyanosis improved within in next few days. Discussion: Intramural hematoma is currently defined as a hematoma in the medial layer without evidence of an intimal tear, which would otherwise indicate aortic dissection. The exact mechanism of intramural hematoma is unknown, 2 proposed mechanisms are penetrating atheroslerotic lesion or rupture of vasovasorum. Management is based on location; Type A is a surgical emergency, whereas type B is managed medically or by endovascular intervention. It should be noted that penetrating aortic ulcers and intramural hematomas can occur in the distal abdominal aorta and proximal bifurcation, and that these lesions can be managed successfully with endovascular intervention.

Surgical Repair of Spontaneous Ruptured Dissection of the Left Common Iliac Artery in a Patient with Vascular Ehlers-Danlos Syndrome

Surgical Repair of Spontaneous Ruptured Dissection of the Left Common Iliac Artery in a Patient with Vascular Ehlers-Danlos Syndrome

Abstract P439: Fibromuscular Dysplasia Of The Iliac And Renal Arteries: A Rare Case Report And Literature Review

Background: Iliac arterial fibromuscular dysplasia (FMD) is an orphan type of FMD, a non-atherosclerotic non-inflammatory arteriopathy predominantly among women aging from 20 to 60. The demographic, clinical features and therapeutic algorithm of iliac arterial FMD have not been precisely described. Patient Concerns: A 31-year-old Chinese male was referred for 3-month-ago onset hypertension, low serum potassium, and small-sized right kidney with normal renal artery under ultrasound examination. Spirolactone was poorly effective in this patient. Diagnosis: Contrast-enhanced computed tomographic angiography (CTA) and three-dimensional reconstruction of the whole aorta discovered an aneurysm from right common iliac artery (CIA) to the internal iliac artery, consistent with left CIA dissection and a remarkable right renal artery aneurysm before a stenosis, which was then confirmed through digital subtraction angiography. Intervention: Percutaneous transluminal angioplasty (PTA) of right renal artery was operated and a stent was deployed in left CIA. Outcome: This patient was normotensive, asymptomatic and free from recurrence without any antihypertensive agents at an 8-month follow-up. Conclusions: A total of 111 iliac arterial FMD cases (female, 84.7%; median age, 52±12.8 years) have been reported. Asymptomatic condition (49.5%) and claudication (40.5%) consist the majority of clinical presentations. Bruit (64.9%) and pulse deficits (39.4%) are the most popular signs. External iliac artery involved is approximate threefold of common and internal iliac arteries, usually accompanied with renal artery (71.2%, presenting hypertension) or carotid artery involvement (50.5%). A system screening among iliac or renal arterial FMD patients is therefore suggested with CTA from neck to pelvis and MRA in head. Dissection accounts for 15.3% cases, usually presenting ischemia symptoms with an inclination to young males. Conservative medication is efficient among 61.3% patients and PTA was operated in 15 patients with satisfactory outcomes in 86.7%. Stenting is an optimal recommendation of iliac artery FMD with progressive dissection. PTA is the first choice of short-duration renovascular hypertension due to FMD especially in young patient.

Acute onset of lower limb claudication as a manifestation of a spontaneous common iliac artery dissection

Isolated abdominal aortic dissection constitutes a relatively small percentage of all aortic dissections. In this paper we present a case of a 59-year-old man who reported to the hospital because of the sudden appearance of intermittent claudication of his left lower limb. After establishing the diagnosis the patient was qualified for endovascular treatment due to dissection involving the final 1 cm of his abdominal aorta and extending to his left common iliac artery with significant true lumen compression. Stent was implanted into the left common iliac artery with almost complete occlusion of the false lumen and expansion of the true lumen of his iliac artery. During the 70-month follow-up we achieved a good result with evidence of stent patency and no signs of expansion of the false lumen. The paper discusses the epidemiology, aetiology, diagnosis and treatment of isolated abdominal dissections.

Preservation of Internal Iliac Artery after Endovascular Repair of Common Iliac Artery Dissection Using Modified Fenestrated Stent Graft.

Standard endovascular repair of iliac/aortoiliac pathologies can lead to complications, such as buttock claudication, colon ischemia and erectile dysfunction. Branch grafts have been developed but require at least 6 weeks for customization and are not currently available in China; they are also quite expensive. To our knowledge, modified fenestrated stent grafts (MFSGs) are a safe and effective alternative for treating patients with juxtarenal aneurysms. Most MFSGs are used for the preservation of renal and left subclavian arteries. Few cases of MFSGs have been reported in the treatment of iliac pathologies. The use of an MFSG is decided on a case-by-case basis. This report presents our first clinical use of an MFSG for preservation of the internal iliac artery.

Isolated aneurysm and dissection of iliac arteries incidentally detected on spinal Magnetic Resonance Imaging

Spinal magnetic resonance imaging is a routine examination carried out to explain symptoms of discopathy. Radiologists usually focus on spinal pathologies and extraspinal findings might be ignored. In this case, we present a 54 year-old male patient with low back pain who was referred to the radiology department for lumbar magnetic resonance imaging. Isolated aneurysm of both common iliac arteries and dissection of the left common iliac artery were incidentally detected. We conclude that some of the extraspinal findings may be more crucial than the spinal pathologies and may give the patient a chance of early diagnosis and treatment. Hence it is of great importance for the radiologists not to concentrate only on the spinal canal but to analyse from a broader perspective.

Common Iliac Artery Aneurysm and Spontaneous Dissection with Contralateral Iatrogenic Common Iliac Artery Dissection in Classic Ehlers-Danlos Syndrome

We describe a 43-year-old man who developed a spontaneous dissection of a right iliac artery aneurysm after performing vigorous physical exercise. Additionally, during peripheral intervention, the patient developed iatrogenic dissection of the left iliac artery. The patient had the characteristic physical findings of Ehlers-Danlos syndrome (EDS), classic type. Genetic testing revealed a mutation in the COL5A1 gene associated with EDS, classic type. Vascular aneurysms and dissections are characteristics of EDS vascular type, but not the classic type. Only one previous case with EDS, classic type with spontaneous iliac artery dissection has been described.

Endovascular repair of extent I thoracoabdominal aneurysms with landing zone extension into the aortic arch and mesenteric portion of the abdominal aorta

Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative for patients at prohibitive risk for open thoracic or thoracoabdominal surgery, decreasing perioperative morbidity and mortality. Aneurysms that involve both the left subclavian artery (LSA) proximally and the celiac artery (CA) distally present a unique challenge to the use of TEVAR. We report a series of six high-risk patients presenting with extent I thoracoabdominal aortic aneurysms who were successfully treated with TEVAR including coverage of the LSA and the CA.

Warfarin-induced Primary Dissection of Lower Peripheral Arteries: A Case Report

Primary dissection of a peripheral artery without involvement of the aorta is a rare entity. Warfarin is currently used as the standard oral anticoagulant in a variety of clinical settings. We report here on a case of focal dissection of the common iliac artery and the superficial femoral artery following prophylactic treatment with warfarin for a prosthetic heart valve. The patient’s laboratory results showed a high international normalized ratio and prolongation of the activated partial thromboplastin time. Angiography showed a dissection of the left common iliac artery and the right superficial femoral artery. His symptoms immediately disappeared after deploying stents to the arterial dissections.

Spontaneous Renal Artery Thrombosis and Common Iliac Artery Dissection in a Previously Healthy Young Adult

A previously healthy 20-year-old male with a history of easy bruising presented to the emergency department complaining of intermittent left lower quadrant abdominal pain for one week. He was diagnosed with vascular (type IV) Ehlers-Danlos syndrome (EDS) and attendant defects in type III collagen leading to spontaneous left renal artery thrombosis and common iliac artery dissection. Treatment was conservative. The types of EDS and their general management are discussed.

Successful Interventional Treatment of a Spontaneous Right Common Iliac Artery Dissection Extending Retrogradely into the Left External Iliac Artery

Spontaneous dissection of the iliac artery is very rare. In the present report, a patient presented with progressive right lower extremity pain and claudication and received a diagnosis of the even rarer condition of a spontaneous right common iliac artery dissection extending retrogradely into the contralateral left external iliac artery through the lower abdominal aorta. Treatment with primary stent-graft and stent placement followed by balloon angioplasty was successful.

Spontaneous dissection and rupture of common iliac artery in a patient with fibromuscular dysplasia: A case report and review of the literature on iliac artery dissections secondary to fibromuscular dysplasia

Spontaneous dissection and rupture of the iliac artery is an unusual finding in patients with fibromuscular dysplasia (FMD). We report the case of a patient with FMD who required emergent surgery because of rupture of an iliac artery dissection, and review 9 previously reported cases of iliac artery dissection associated with FMD. A 30-year-old man had abdominal pain, and went into shock. Angiograms revealed dissection of the left common iliac artery with extravasation. At emergent surgery the rupture site was in the proximal left common iliac artery and extended to the left external iliac artery. Interposition of the diseased artery with a Dacron graft was attempted, but cardiac arrest occurred, and resuscitation was unsuccessful. Pathologic examination showed typical characteristics of diffuse medial FMD. Ten cases (5 male and 5 female patients), including the present case, with dissection of iliac arteries associated with FMD have been reported. Median patient age was 45 years (range, 29-56 years). Three of the 10 patients had acute onset of symptoms, and the remainder had gradual development of intermittent claudication or groin pain. Only the present case had evidence of rupture. The site of dissection was in the external iliac artery in 8 patients and the common iliac artery in 2 patients. Anatomic bypass or interposition of the diseased artery was performed in 8 patients; the others received conservative treatment. There was no mortality in the 9 previously reported cases. Fatal acute dissection and rupture of the common iliac artery occurred in a patient with FMD, even though the clinical course of this disease is relatively benign. FMD should be considered the cause of dissection and rupture of the iliac artery in a patient with symptoms but of non-atherosclerotic age.

Spontaneous Common Iliac Artery Dissection After Exercise

<b>Spontaneous Common Iliac Artery Dissection After Exercise</b>

Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia

Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia. A case of spontaneous dissection of the external iliac artery due to fibromuscular dysplasia is presented. In a 45-year-old man with a history of sudden onset of intermittent claudication a dissection of the right external iliac artery was found by duplex ultrasound. The patient, who was first treated with conservative therapy, subsequently required operative treatment because of further progression of the dissection. Considering the age of the patient a retrograde thrombendarterectomy manoeuver over guide wire was performed. Angiographic control at the end of operation demonstrated a good reconstructive result without any changes in the right common iliac artery and the aorta. Histopathological examination of the removed material showed fibromuscular dysplasia of the media. In the postoperative course the patient was clinically asymptomatic with ankle/brachial pressure indices of 1.0 on both legs. But shortly after discharge the intermittent claudication in the right leg recurred. Angiography and duplex ultrasound revealed focal stenosis of the right common iliac artery as well as retrograde dissection of the right common iliac artery extending into the distal aorta. Conservative therapy was recommended to the patient by the local hospital and no further progression of clinical and duplex findings within the last six months was found.