Iliac Artery Compression Research Articles

Acute Limb Arterial Ischemia Following Iliac Vein Stenting in the Setting of a Frozen Pelvis.

The authors report on a young patient with previous radiation to her pelvis who presented with acute limb ischemia following iliac vein stenting believed to be secondary to extrinsic iliac artery compression in the setting of a frozen pelvis. She underwent revascularization and a trans-femoral amputation, ultimately needing a femoral to femoral artery crossover bypass in order to achieve amputation stump healing. This case describes a potential arterial complication of venous stenting in a previously irradiated field.

Bilateral ascending uterine arteries ligation for conservative management of complete placenta previa: three case reports

Placenta previa (PP) is considered one of the major causes of both antepartum and intrapartum bleeding, which necessitates preterm delivery typically by cesarean section. The optimal management is controversial. Surgical techniques to control severe bleeding after placental removal include uterine/internal iliac artery ligation, compression sutures, and embolization of pelvic vessels; however, cesarean hysterectomy remains the ultimate rescue procedure for uncontrolled maternal hemorrhage. The authors present a modified surgical technique of the uterine arteries ligation for successful management of complete PP. The method was effective and hysterectomy was avoided in all cases. Serious complications such as hypovolemic shock, disseminated intravascular coagulopathy, urinary tract injuries, febrile infections, and uterine necrosis were not recorded. Double bilateral ligation of the ascending uterine arteries before placental removal constitutes a prophylactic method that prevents postpartum hemorrhage and emergency obstetric hysterectomy. This method has an additional advantage as if it proves ineffective for hemorrhage control, the basic steps for cesarean hysterectomy would have been done.

Extravasal methods of preventing bleeding in patients with morbidly adherent placenta undergoing fertility-sparing surgery

Introduction: To evaluate the efficacy of different methods of surgical hemostasis, including the ligation of internal iliac arteries (IIA), temporary occlusion of the common iliac artery (CIA) and combined compression hemostasis, during cesarean section in patients with morbidly adherent placenta (MAP).

Alternative approaches to surgical hemostasis in patients with morbidly adherent placenta undergoing fertility-sparing surgery

Aim: To evaluate the efficacy of different methods of surgical hemostasis, including the ligation of internal iliac arteries (IIA), temporary occlusion of the common iliac artery (CIA) and combined compression hemostasis, during cesarean section in patients with morbidly adherent placenta (MAP).Materials and methods: The study included 54 patients with MAP. All patients underwent cesarean section with application of surgical hemostasis techniques. In Group 1 (n = 15), ligation of IIA was performed, in Group 2 (n = 18) extravasal temporary occlusion of CIA, and in Group 3 (n = 21) combined compression hemostasis was applied. The latter technique included placement of bilateral tourniquets on the upper uterine pedicles and on the cervicoisthmic segment, and controlled Zhukovsky balloon tamponade of the uterus, with subsequent resection of the uterine wall with abnormal placental invasion, evacuation of placenta from the uterine cavity and closure of the uterine wall defect with a double suture. The studied outcomes were total blood loss, duration of surgery, the hemoglobin level alteration, hysterectomy rate, and length of postoperative hospital stay.Results: Total blood loss in Group 1 was 2440 ± 1215 ml, in Group 2 – 2186 ± 1353 ml, and in Group 3 – 1295 ± 520.3 ml (p = .0045). In Group 3, the lowest number of cases with blood loss >2000 ml was observed [8 (53.3%) versus 9 (50.0%) and 2 (9.5%), respectively; p = .0411]. The duration of surgery, the hemoglobin level alteration, hysterectomy rate, and length of hospital stay after delivery did not differ significantly between the groups.Conclusions: All surgical techniques used in the study were effective to decrease the blood loss during cesarean section in patients with MAP; however, the combined compression hemostasis showed the highest efficacy.

Abdominal aortic and iliac artery compression following penetrating trauma: a study of feasibility.

Penetrating junctional trauma is a leading cause of preventable death on the battlefield. Similarly challenging in civilian settings, exsanguination from the vessels of the abdomen, pelvis, and groin can occur in moments. Therefore, iliac artery or abdominal aortic compression has been recommended. Based on prior research, 120 lbs (54 kg) or 140 lbs (63 kg) of compression may be required to occlude these vessels, respectively. Whether most rescuers can generate this amount of compression is unknown. To determine how many people in a convenience sample of 44 health care professionals can compress 120 lbs and 140 lbs. This study simulated aortic and iliac artery compression. Consent was obtained from 44 clinicians (27 female; 17 male) from two large urban hospitals in Edmonton, Alberta, Canada. Participants compressed the abdominal model, which consisted of a medical scale and a 250 ml bag of saline, covered by a folded hospital blanket and placed on the ground. In random order, participants compressed a force they believed maintainable for 20 minutes ("maintainable effort") and then a maximum force they could maintain for two minutes ("maximum effort"). Compression was also performed with a knee. Descriptive statistics were used to evaluate the data. Compression was directly proportional to the clinician's body weight. Participants compressed a mean of 55% of their body weight with two hands at a maintainable effort, and 69% at a maximum effort. At maintainable manual effort, participants compressed a mean of 86 lbs (39 kg). Sixteen percent could compress over 120 lbs, but none over 140 lbs. At maximum effort, participants compressed a mean of 108 lbs (48 kg). Thirty-four percent could compress greater than 120 lbs and 11% could compress greater than 140 lbs. Using a single knee, participants compressed a mean weight of 80% of their body weight with no difference between maintainable and maximum effort. This work suggests that bimanual compression following penetrating junctional trauma is feasible. However, it is difficult, and is not likely achievable or sustainable by a majority of rescuers. Manual compression (used to temporize until device application and operative rescue) requires a large body mass. To maintain 140 lbs of compression (for example during a lengthy transport), participants needed to weigh 255 lbs (115 kg). Alternatively, they needed to weigh 203 lbs (92 kg) to be successful during brief periods. Knee compression may be preferable, especially for lower-weight rescuers.

Tissue Loss Secondary to Extrinsic Compression of Common Iliac Artery From Uterine Leiomyoma

Uterine leiomyomas are commonly reported to cause deep venous thrombosis and rarely arterial compression. A 48-year-old woman was transferred to our institution with acute right lower limb ischemia and tissue loss. She underwent urgent iliac thrombectomy and was subsequently found to have right common iliac artery compression by a large uterine leiomyoma. She underwent successful resection of the tumor followed by endovascular iliac stent placement. This case emphasizes the importance of preoperative imaging when possible in the setting of acute arterial ischemia to evaluate for sources of extrinsic compression. Management requires correction of the etiology of extrinsic compression.

Occlusion of the Profunda Femoris Artery in Competitive Cyclists

Symptomatic lower limb ischaemia in endurance athletes and competitive cyclists is usually due to iliac artery compression syndrome. We report the cases of two competitive cyclists who presented with thigh claudication, with no previous cardiovascular or thrombo-embolic risk factors. They both had normal conventional and sports exercise tests. Further investigations revealed flush occlusion of the profunda femoris artery, believed to be due to dissection. Both patients improved with graduated exercise. We recommend contrast-enhanced MRA as the investigation of choice for this previously unreported condition.

Lower Extremity Claudication Resulting From Uterine Leiomyoma–Associated Common Iliac Artery Compression

Rarely, uterine leiomyomas have been associated with deep venous thrombosis secondary to compression. Affected vessels include the inferior vena cava and the common iliac, iliac, and distal veins. Arterial compression has not been reported previously. Bilateral uterine artery embolization for symptomatic leiomyomata provides relief of bulk-related symptoms and reduction in menstrual flow. A 42-year-old woman presented with menorrhagia secondary to a myomatous uterus. Claudication of the right lower extremity was attributed to imaging-confirmed leiomyoma pressure-associated compression of the right common iliac artery. Examination disclosed an absent right common femoral artery pulse. Bilateral uterine artery embolization resulted in long-term resolution of the claudication. Claudication of the lower extremity may result from pressure-associated compression of the common iliac artery caused by uterine leiomyomas, and may be amenable to bilateral uterine artery embolization.

Iliac Artery Compression in Cyclists: Mechanisms, Diagnosis and Treatment

Objectives: To review the mechanisms, diagnosis and treatment options for symptomatic iliac artery compression in cyclists. Methods: Pubmed, Medline, Embase and Google were searched using combinations of the terms ‘iliac artery disease', ‘iliac artery compression', ‘iliac artery stenosis', ‘cyclists' and ‘athletes'. Results: Tethering of the iliac artery by the psoas arterial branch and fibrous tissue, and muscular hypertrophy predispose the vessel to kinking and compression during cycling. Symptoms may only be present on maximal exercise in the cycling position. Provocative exercise tests using a cycling ergometer with ankle brachial pressure index measuring has a sensitivity of 85% to detect arterial insufficiency. Magnetic resonance imaging is increasingly being used as the investigation of choice to confirm the diagnosis, although digital subtraction angiography and colour duplex ultrasonography may also help. Conservative measures including adjustments to the cycling posture and bicycle setup should be recommended to all patients. The evidence for surgical and endovascular treatments is limited and the use of prosthetic graft should be avoided. Conclusions: Iliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although the optimal treatment strategy remains unclear, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management.

Long-term results of pediculo-body fixation and posterolateral fusion for lumbar spondylolisthesis

Grob et al. (Eur Spine J 5:281-285, 1996) illustrated a new fixation technique in inveterate cases of grade 2-3 spondylolisthesis (degenerative or spondylolytic): a fusion without reduction of the spondylolisthesis. Fixation of the segment was achieved by two cancellous bone screws inserted bilaterally through the pedicles of the lower vertebra into the body of the upper slipped vertebra. Since 1998 we have been using this technique according to the authors' indications: symptomatic spondylolisthesis with at least 25% anterior slippage and advanced disc degeneration. Afterwards this technique was used also in spondylolisthesis with low reduction of the disc height and slippage less than 25%. In every case we performed postero-lateral fusion and fixation with two AO 6.5 Ø thread 16 mm cancellous screws. From 1998 to 2002 we performed 62 fusions for spondylolisthesis with this technique: 28 males (45.16%) and 34 females (54.84%), mean age 45 years (14-72 years). The slipped vertebra was L5 in 57 cases (92%), L4 in 2 cases (3.2%), L3 in 1 case (1.6%), combined L4 and L5 in 2 cases (3.2%). In all cases there was an ontogenetic spondylolisthesis with lysis. Lumbar pain was present in 22 patients and lumbar-radicular pain was present in 40 patients. The mean preoperative VAS was 6.2 (range 5-8) for lumbar pain, and 5.5 (range 4-7) for leg pain. The fusion area was L5-S1 in 53 cases (85.5%), L3-L4 in 1 case (1.6%), L4-S1 in 8 cases (12.9%). A decompression of the spinal canal by laminectomy was performed in 33 procedures (53%). When possible a bone graft was done from the removed neural arc, and from the posterior iliac crest in the other cases. The mean blood loss was about 254 ml (100-1,000). The mean operative time was 75 min (range 60-90). The results obtained by computerized analysis at follow-up at least 5 years after surgery showed a significant improvement in preoperative symptoms. The patients were asymptomatic in 52 cases (83.9%); strained-back pain was present in 8 cases (12.9%), and there was persistent lumbar-radicular pain in 2 cases (3.2%). The mean ODI score was 2.6%, the mean VAS back pain was 1.3, the mean VAS leg pain 0.7. Some complications were observed: a nerve root compression by a screw invasion of intervertebral foramen, resolved by screw removal; an iliac artery compression by a lateral exit screw from pediculo, resolved by screw removal; a deep iliac vein phlebitis with thrombosis caused by external compression due to a wrong intraoperative position, treated by medicine. Two cases of synthesis mobilization and two cases of broken screws was detected. No cases of pseudoarthrosis and immediate or late superficial or deep infection were observed. The analysis of the long-term results of the spondylolisthesis surgical treatment with direct pediculo-body screw fixation and postero-lateral fusion gave a very satisfactory response. The technique is reliable in allowing an optimal primary stability, creating the best biomechanical conditions to obtain a solid fusion.

Iliac Artery Compression in Cyclists: Mechanisms, Diagnosis and Treatment

To review the mechanisms, diagnosis and treatment options for symptomatic iliac artery compression in cyclists. Pubmed, Medline, Embase and Google were searched using combinations of the terms 'iliac artery disease', 'iliac artery compression', 'iliac artery stenosis', 'cyclists' and 'athletes'. Tethering of the iliac artery by the psoas arterial branch and fibrous tissue, and muscular hypertrophy predispose the vessel to kinking and compression during cycling. Symptoms may only be present on maximal exercise in the cycling position. Provocative exercise tests using a cycling ergometer with ankle brachial pressure index measuring has a sensitivity of 85% to detect arterial insufficiency. Magnetic resonance imaging is increasingly being used as the investigation of choice to confirm the diagnosis, although digital subtraction angiography and colour duplex ultrasonography may also help. Conservative measures including adjustments to the cycling posture and bicycle setup should be recommended to all patients. The evidence for surgical and endovascular treatments is limited and the use of prosthetic graft should be avoided. Iliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although the optimal treatment strategy remains unclear, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management.

Unusual Case of Right-Sided May-Thurner Syndrome and Review of Its Management

May-Thurner syndrome is a phenomenon commonly described as an acquired stenosis of the left common iliac vein as a result of right common iliac artery compression. We report an unusual case of right-sided May-Thurner syndrome in a patient found to have a left-sided inferior vena cava. We also review the management of this patient using angioplasty, intraoperative thrombolysis, and endoluminal stent placement.

Iliac vein compression in an asymptomatic patient population

Objective May-Thurner syndrome is a well-recognized anatomic variant that is associated with the development of symptomatic acute venous thrombosis of the left iliac vein. However, the natural frequency of compression of the left iliac vein and its clinical significance in asymptomatic disease has not been established. Therefore the purpose of this descriptive anatomic study was to determine the incidence of left common iliac vein compression in an asymptomatic population. Methods A retrospective analysis of medical records and helical abdominal computed tomography scans was conducted in 50 consecutive patients evaluated in the emergency department because of abdominal pain. Medical records were reviewed for symptoms and risk factors for deep venous thrombosis, and data were collected and reported according to the Joint Society Reporting Standards for acute lower extremity venous thrombosis. All computed tomography was performed with intravenous contrast medium, and 2-mm to 5-mm axial images were obtained. The minor diameter of the common iliac arteries and veins was measured. The technique of transverse image measurement was validated with multiplanar reconstructions and orthogonal diameter measurements in a subset of subjects. Statistical analysis was performed with the Student t test or Spearman rank correlation. Results Mean age of subjects without symptoms was 40 years (range, 19-85 years), and 60% (n = 30) were female patients. The mean acute lower extremity venous thrombosis risk factor score was 1.16 ± 0.23 (range, 0-6; maximum possible score, 28). It was surprising that 24% (n = 12) of patients had greater than 50% compression and 66% (n = 33) had greater than 25% compression. Mean compression of the left common iliac vein was 35.5% (range, −5.6%-74.8%). The structure most often compressing the left common iliac vein against the vertebral body was the right common iliac artery (84%). There was no strong correlation between patient age or common iliac artery size and compression of the left common iliac vein. However, women had greater mean compression of the left common iliac vein (women, 41.2% ± 3.1%; men, 27.0% ± 3.0%; P = .003). Conclusion Hemodynamically significant left common iliac vein compression is a frequent anatomic variant in asymptomatic individuals. Therefore compression of the left iliac vein may represent a normal anatomic pattern that has thus far been thought of as a pathologic condition.

Nerve monitoring changes related to iliac artery compression during anterior lumbar spine surgery

BACKGROUND CONTEXT: There are no studies in the literature that correlate compression of the iliac vessels resulting in obstruction of blood flow with changes in nerve monitoring parameters during anterior lumbar surgery. PURPOSE: To determine whether there is significant compression of the iliac vessels that can cause temporary nerve root ischemia or limb ischemia that could be responsible for loss of somatosensory evoked potentials (SSEP) while retractors are in place for exposure during anterior lumbar interbody fusion (ALIF). SETTING: Patients coming to the operating room for ALIF from levels L2–L3 to L5–S1 would be studied for nerve monitoring changes during the procedure with particular attention to the intervals just before placement of a retractor, while the retractor was in place and immediately after removal of the retractor. PATIENT SAMPLE: Forty-five consecutive patients were studied for changes in SSEP and oxygen saturation (SaO 2) while undergoing ALIF. OUTCOME MEASURES: Patients were considered to have lost saturation if the SaO 2 decreased to below 90%. Patients were considered to have abnormal SSEP with any increase in latency and decrease in amplitude. METHODS: SSEP and SaO 2 were monitored continuously and simultaneously before exposure of the disc spaces, during exposure with retractors in place and after removal of the retractors. RESULTS: Thirteen of 23 patients with exposure at L4–L5 had both loss of SSEP signals and loss of SaO 2 with exposure. All 13 patients had return to normal saturation and recovery of the SSEP signals within 15 minutes of removal of the retractors. Both of these are significant correlations (p<.001). CONCLUSION: This study showed that the majority (57%) of patients undergoing ALIF at the L4–L5 level are subject to compression of the left iliac vessels enough to cause desaturation distally as measured by pulse oxymetry. This vascular compromise, as well as the return to normal saturation, correlates with changes noted in SSEP soon after both deployment and removal of the retractors used for exposure. The mechanism appears to be a transient ischemic response. Failure of the SSEP signals to recover may be diagnostic of left iliac artery thrombosis.

Reply

The comments made in the letter by Dr Russell Samson and Dr David Showalter are much appreciated. All patients in our series presented with severe claudication that limited their sporting and, occasionally, their daily activities. As part of the initial diagnostic workup, each patient was evaluated using noninvasive studies that included tests intended to exclude hemodynamically significant aortoiliac inflow stenosis. Both limbs of all patients were evaluated by contrast arteriography, and in all cases the aortoiliac segment was carefully studied to exclude inflow disease before treating the patient for popliteal artery entrapment. In only one patient was a lesion of the aortoiliac segment detected, and in this female the pathology was stenosis due to fibromuscular dysplasia, which was subjected to successful balloon angioplasty. She has remained asymptomatic and with normal inflow on noninvasive tests after 5 years' follow-up. We are very aware of the existence of the iliac artery compression syndrome that has been described in competitive cyclists. We have actively pursued such a diagnosis in our series, as we believe that the pathological changes in the arterial wall of such cases are similar to those degenerative changes that we have described in the popliteal artery with entrapment and in the subclavian artery with thoracic outlet syndrome.1Levien LJ. Popliteal artery thrombosis caused by popliteal entrapment syndrome.in: Inflammatory and thrombotic problems in vascular surgery. WB Saunders, London1997: 159-168Google Scholar, 2Levien LJ. Historical changes in external arterial compression syndromes.Cardiovasc Surg. 1999; 7: 57-58Google Scholar The majority of our patients in whom a diagnosis of functional popliteal artery entrapment was made were referred after full evaluation at sports medicine clinics where compartmental syndromes and other more common causes of leg pain in the athlete had been excluded. In addition, virtually all patients diagnosed with symptomatic functional popliteal artery entrapment and treated with myotomy of the medial head of the gastrocnemius muscle have returned to full sporting activities after the surgery. In conclusion, we have carefully excluded the iliac artery compression syndrome in our series of symptomatic popliteal artery entrapments reported in the Journal. We continue to believe that this condition, both anatomic and functional, is a frequently underdiagnosed cause of symptoms in the young, athletic claudicant.