Iliac Artery Occlusion Research Articles

Resection of uterine arteriovenous fistula with temporary occlusion of the internal iliac arteries: Case series and literature review.

Uterine arteriovenous fistula (UAVF) is a rare vascular abnormality that can cause severe and potentially life-threatening hemorrhage. Uterine artery embolization is a common treatment that may affect ovarian and uterine perfusion and cause fertility problems. We herein report our experience treating 2 patients with UAVF who underwent resection after temporary occlusion of both internal iliac arteries. Both patients presented with a large UAVF after incomplete miscarriages in the second trimester. Magnetic resonance imaging revealed a UAVF measuring 3.6 × 2.6 × 2.1 cm over the myometrium of the posterior uterine in case 1, and a UAVF of 7.1 × 4.1 × 4.5 cm was identified in case 2. Uterine arteriovenous fistula, retained products of conception. The patients underwent resection of UAVF with temporary occlusion of the internal iliac arteries and hysteroscopic removal of the retained products of conception. Intraoperative bleeding were minimal. Neither patient exhibited abnormal uterine bleeding at the 6-month follow-up. Follow-up ultrasonography and magnetic resonance imaging showed normal uterine myometrium and endometrium and no residual disease. UAVF resection after temporary occlusion of the internal iliac arteries is a promising treatment approach for UAVF. This technique can reduce intraoperative bleeding and remove the potential hemorrhage-related lesion while preserving fertility.

A Man with Sudden Onset Leg Pain and Weakness

Case Presentation: An 89-year-old male who had been holding dabigatran in the setting of transcarotid artery revascularization presented to the emergency department with sudden onset leg pain and weakness. Computed tomography angiography revealed acute aortic occlusion and thrombosis of the bilateral common iliac arteries. He underwent aortoiliac and femoral embolectomies and stenting of the bilateral common iliac arteries and returned to his baseline functional status. Discussion: Acute aortic occlusion is a rare but often devastating vascular emergency characterized by obstruction of the aorta by an embolus or thrombosis. Diagnosis can be challenging as it may be mistaken for spinal pathology, which can lead to delays in diagnosis. Despite advances in diagnostic modalities and interventions, acute aortic occlusion often results in high rates of major morbidity and mortality.

Popliteal access for iliofemoral occlusive disease in the office-based catheter laboratory

ObjectivePopliteal access as an alternative to conventional femoral access has not been reported in the office-based catheter laboratory setting (OBL) and may be perceived to have higher risks. The purpose of this study was to evaluate the safety and efficacy of popliteal access for the endovascular treatment of iliofemoral arterial occlusive disease in an OBL setting. MethodsFrom October 2018 to October 2023, a total of 1408 interventions for peripheral artery disease were performed in our OBL. A cohort of 27 popliteal access consecutive procedures for femoral and iliac artery occlusions were studied. All interventions were done using a micropuncture needle under ultrasound guidance. All patients were discharged 1 hour after completion of the procedure. Indications for popliteal access were presence of aortoiliac stent grafts, aortobifemoral or aortoiliac bypasses, difficult contralateral or antegrade femoral access, and flush superficial femoral artery occlusions. Procedures were determined to be successful upon complete resolution of the target lesions and safety was measured perioperatively and at 90 days. Patency was determined clinically, by arterial duplex examination, and by need for reintervention for ≤2 years. ResultsWe performed 27 popliteal access procedures in 25 patients (21 complete femoral artery occlusions, 6 severe stenosis). Iliac disease was present in nine. Indications for popliteal access were existing aortoiliac stent graft in 11, aortobifemiliac bypass in 4, noncrossable iliac occlusions in 3, failed antegrade femoral access in 4, flush superficial femoral artery occlusion in 3, and bilateral common femoral artery disease precluding access in 2. Trans-Atlantic Inter-Society Consensus classification preoperatively was B, 4; C, 4; and D, 19. Treatments included atherectomy/balloon angioplasty and stent in 12, balloon angioplasty and stenting in 4, atherectomy/balloon angioplasty in 5, and balloon angioplasty alone in 6. Successful opening of occlusions occurred in 25 of 27 patients (92.5%). No complications or major adverse cardiac events occurred, except one asymptomatic small popliteal arteriovenous fistula. Of the 25 successful procedures, the duplex patency at 3, 6, and 12 months was 19/20 (95%), 11/15 (69.3%), and 11/13 (61%). Rutherford Classification improved from a preoperative value of >4 in 24 of 27 (89%) to a postoperative value of <2 at 1 month in 23 of 23 (100%), at 3 months in 19 of 20 (95%), at 6 months in 11 of 15 (69.3%), and at 12 months in 11 of 13 (61%). Freedom from reintervention at 3 months occurred in 19 of 20 (95%), at 6 months in 13 of 15 (86%), and at 12 months in 12 of 13 (79%). ConclusionsPopliteal artery access for complex iliofemoral disease is safe and effective and should be considered as a valid alternative option in the OBL setting.

Vascularsurgical Long-term Outcome - Comparison of Orthotopic and Extraanatomic Reconstructions in Unilateral Occlusions of Iliac Artery over 10 Years

In PAOD, several vascular regions are usually affected, the pelvic axis in 35% of cases. Interventional-radiological/endovascular or hybrid interventions have been established for recanalization, so that bypass procedures are increasingly taking a back seat, but are not losing their importance.To study unilateral iliac artery occlusions (inclusion criterion) that were repaired either by implantation of an orthotopic or extraanatomic bypass (oBP/eaBP).Over a defined period of time, the rate of open vessel, complications (frequency, type, severity) to characterize morbidity and mortality as well as the extent of clinical improvement after BP implantation were analyzed in a clinical-systematic, single-center observational study (for vascular surgical quality assurance and contribution to vascular medical-clinical health care research). The study method was not explicitly based on the STROBE criteria, but essentially corresponds to them.Over 10 years, 122 PAOD patients (50% in stage IIb-stage III and IV equally distributed; mean age: 63 [range, 44-87] years; majority ASA III) were included with the same number of reconstructions: 71 patients received an eaBP ("crossover"), 51 patients an iliacofemoral (orthotopic - oBP) bypass (neither significant difference regarding frequency nor number of risk factors per patient).The oBP is not superior to eaBP with regard to the analysis parameters of openness, complication rate and mortality. Furthermore, extraanatomic revascularization does not have to be reserved for polymorbid patients only.

The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower Limb Ischaemia (RAD-ALI Registry).

Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

PurposeThis retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. MethodsThis treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1–P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. ResultsForty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. ConclusionThe endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Acute Infrarenal Abdominal Aortic and Bilateral Common Iliac Artery Occlusions in an Elderly Female: A Case Report

Acute Infrarenal Abdominal Aortic and Bilateral Common Iliac Artery Occlusions in an Elderly Female: A Case Report

Abstract 1154: Length And Proximal Extent Of Occlusion Dictates Severity Of Disease In A Mini-swine Model Of PAD

Background: There is ongoing need for large animal models of peripheral artery disease (PAD) that replicate human disease. We present mild (MI), moderate (MD) and Severe (S) phenotypes of PAD in an Ossabaw mini-swine platform. Methods: Metabolic syndrome was induced in swine (N=16; age= 4 mo) with a high fat/fructose/sodium diet for 8 weeks. Ischemia induction (T0) consisted of: (1) open ligation and resection of R Superficial Femoral Artery (SFA) for MI(N=4); (2) endovascular coil occlusion of R External Iliac Artery (REIA), RSFA and popliteal artery for MD (N=9); and (3) coil occlusion of REIA, RSFA, and right internal iliac artery (RIIA) for S (N=4). At 4 weeks (T4) and 8 (T8), all swine underwent angiography via carotid access, and bilateral gastrocnemius biopsy. All swine had measurements of ankle brachial indices (ABIs), and calf muscle tissue oximetry (STO 2 ) measurements at T0, T4 and T8, along with weekly measurement of walking performance on a treadmill (WP). Results: At T4 and T8 R ABI were increasingly decreased from MI to MD to S (table 1). Mean STO 2 difference between R and L calf at T4 and T8 had no changes in MI, while the differences were larger in S compared to MD (table 1). WP was increasingly decreased from MI to MD to S (table 1). The artery that grew the most on angiography at T4 and T8 were R profunda artery (RPFA) in MI; RIIA in MD; and LIIA in S (table 1). In MI, R PFA had faster flow at T4 and T8 compared to L PFA. At T4, MD and S had similar delays of RPFA reconstitution, this improved at T8 in MD but did not in S (table 1). On histology, MI had no obvious myopathy, MD and S had moderate and severe myopathy respectively. All S subjects developed poorly-healing ischemic ulcers. Conclusion: Length and proximal extent of occlusion dictated the characteristics and severity of phenotypes in our Ossabaw swine model of PAD. This mirrors PAD in humans and can be used to develop therapies for different disease severities.

Mitochondrial and Microvascular Impairments in a Novel Swine Model of Peripheral Artery Disease

Introduction: Impaired skeletal muscle mitochondria and microvascular function have been reported in human peripheral artery disease (PAD). However, no large animal models of PAD have mimicked these impairments. Purpose: The purpose of this study was to examine the skeletal muscle microvasculature and mitochondria in a novel swine model of PAD. Hypothesis: We hypothesized that hindlimb ischemia leads to dysfunction of skeletal muscle microvessels and mitochondria. Methods: Ossabaw swine (n=5) with metabolic syndrome underwent endovascular coil occlusion of the right external iliac artery to generate hindlimb ischemia (ISC). The left leg served as a non-ischemic control (CON). After 4-weeks, biopsies were collected from both legs (lateral gastrocnemius). Skeletal muscle arterioles were assessed using video microscopy. Microvascular vasodilatory function was assessed in response to flow (Shear stress), acetylcholine (ACh), and sodium nitroprusside (SNP). Skeletal muscle mitochondrial function was assessed using high-resolution respirometry. Substrates were administered as follows: malate (M) &amp; glutamate (G), adenosine diphosphate (ADP), succinate (S), oligomycin, and ascorbate (Asc) &amp; N,N,N,N-tetramethyl-phenylenediamine (TMPD). Complex I state 2 (CI-S2) was assessed as M+G, complex I state 3 (CI-S3) was assessed as (M+G+ADP)-(M+G), complex II state 3 (CII-S3) was assessed as (M+G+ADP+S)-(M+G+ADP), complex I&amp;II state 3 (CI&amp;II S3) was assessed as (M+G+ADP+S)-(M+G), state 4 (S4) was assessed after oligomycin, and complex IV (CIV) respiration was assessed after Asc+TMPD. The respiratory control ratio (RCR) was calculated as CI&amp;II-S3/S4. Results: Vasodilation in response to flow was reduced in ISC vs. CON (Δ-13.1±13.7%, p=0.01). but not in response to ACh (Δ-6.2±17.7%, p=0.23) or SNP (Δ1.7±11.0%, p=0.53). Additionally, CI-S2 (Δ-0.3±3.7 pmolO2·s−1·mg−1, p=0.65), S4 (Δ-1.7±4.4 pmolO2·s−1·mg−1, p=0.14), and CIV (Δ-2.8±20.9 pmolO2·s−1·mg−1, p=0.65) were not different between ISC and CON. However, CI-S3 (Δ-4.7±5.0 pmolO2·s−1·mg−1, p&lt;0.01), CII-S3 (Δ-3.5±5.0 pmolO2·s−1·mg−1, p=0.02), CI&amp;II-S3 (Δ-8.5±8.7 pmolO2·s−1·mg−1, p&lt;0.01), and RCR (Δ-0.8±1.3 pmolO2·s−1·mg−1, p=0.04) were all reduced in ISC vs. CON. Conclusions: We found that skeletal muscle microvessels and mitochondria were impaired in our swine model. Based on the present findings, we conclude that our novel porcine model closely replicates the pathophysiology PAD, making it a promising large animal model for studying human PAD. This research was supported by the National Institutes of Health (R01HD106911, R01AG062198, R01AG0778031) and the Great Plains IdeA-CTR (U54 GM115458). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

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.

Outcomes of balloon angioplasty and stent placement for iliac artery lesions classified as TASC II A, B: a single-center study.

Iliac artery stenosis or occlusion is a critical condition that can severely impact a patient's quality of life. The effectiveness of balloon angioplasty and intraluminal stenting for the treatment of iliac artery lesions classified as TASC II A and B was evaluated in this single-center prospective study. Conducted between October 2016 and September 2020 at Cho Ray Hospital's Vascular Surgery Department, this prospective study involved PAD patients categorized by TASC II A and B classifications who underwent endovascular intervention. Intervention outcomes were assessed peri-procedure and during short-term and mid-term follow-ups. Of the total of 133 patients, 34.6% underwent balloon angioplasty, while 65.4% received stenting. The immediate technical success rate was 97.7%, while the clinical success rate was 62.4%. Complications were minimal, with major limb amputation reported in 1.5% of the cases. There was a significant improvement in Rutherford classification and ABI at short-term follow-up, with a patency rate of 90.2%. The mid-term post-intervention follow-up yielded similar results with an 86.1% patency rate. The mortality rates associated with arterial occlusion were 2.3% during short-term follow-up and 1.7% during mid-term follow-up. Balloon angioplasty and stent placement are effective and safe interventions for TASC II A and B iliac artery occlusions with favorable short and mid-term outcomes. Further, multi-center studies with larger sample sizes are recommended for more comprehensive conclusions, including long-term follow-up assessment.

MRI-Based Risk Factors for Adverse Maternal Outcomes in Prophylactic Aortic Balloon Occlusion for Placenta Accreta Spectrum and Placenta Previa

Purpose: We previously reported that T2 dark bands and placental bulges observed in magnetic resonance imaging (MRI) can predict adverse maternal outcomes in patients with placenta accreta spectrum (PAS) and placenta previa undergoing prophylactic balloon occlusion of the internal iliac artery. On the other hand, the risk factors associated with the use of prophylactic aortic balloon occlusion (PABO) have not been sufficiently investigated. This retrospective study aimed to identify MRI-based risk factors associated with adverse maternal outcomes in the context of PABO during a cesarean section (CS) for PAS and placenta previa. Materials and Methods: Ethical approval was obtained for a data analysis of 40 patients diagnosed with PAS and placenta previa undergoing PABO during a CS. Clinical records, MRI features, and procedural details were examined. The inclusion criteria for the massive bleeding group were as follows: an estimated blood loss (EBL) &gt; 2500 mL, packed red blood cell (pRBC) transfusion (&gt;4 units), and the need for a hysterectomy or transcatheter arterial embolization after delivery. The massive and nonmassive bleeding groups were compared. Results: Among the 22 patients, those in the massive bleeding group showed significantly longer operative durations, a higher EBL (p &lt; 0.001), an increased number of pRBC transfusions (p &lt; 0.001), and prolonged postoperative hospital stays (p &lt; 0.05). T2 dark bands on MRI were significant predictors of adverse outcomes (p &lt; 0.05). Conclusion: T2 dark bands on MRI were crucial predictors of adverse maternal outcomes in patients undergoing PABO for PAS or placenta previa during a CS. Recognizing these MRI features proactively indicates the need for effective management strategies during childbirth and emphasizes the importance of further prospective studies to validate and enhance these findings.

Internal iliac debranching in combination with abdominal aortic stent graft to treat bilateral common iliac aneurysms

Introduction&#x0D; Common iliac artery aneurysms are often diagnosed during routine screening for infrarenal abdominal aortic aneurysms. Preserving the internal iliac artery helps avoid colonic ischemia and buttocks claudication. Hybrid surgery combining internal iliac artery transposition and endovascular treatment is a method with good early and long-term results.&#x0D; Methods&#x0D; We report of a case of bilateral common iliac artery aneurysm treated by hybrid surgery and endovascular intervention at Dong Nai General Hospital&#x0D; Results&#x0D; A 69 year-old male, diagnosed with bilateral common iliac artery aneurysm and left internal iliac artery occlusion. Surgical transposition was performed to repimplant the right internal iliac artery into the right external iliac artery, folowed by endovascular treatment, the right branch of the graft was placed at the external iliac artery, the left branch of the graft was placed at the common iliac artery. Postoperative condition was stable, no early complications recorded&#x0D; Conclusion&#x0D; Hybrid surgery to treat iliac aortic aneurysms and common iliac artery aneurysms has quite good mid- and long-term results. The initial successful implementation of this technique at Dong Nai General Hospital contributes to team development, reduces the load on central hospitals and brings practical benefits to patients.

Endovascular abdominal aortic repair in a patient with common iliac artery occlusion

Endovascular abdominal aortic repair in a patient with common iliac artery occlusion

Abstract 14729: Association of Iliac Artery Non-Calcified Plaque Volume and Acute Limb Ischemia: Insights From the VOYAGER PAD Angiographic Core Lab

Introduction/Background: Acute limb ischemia (ALI) is a severe complication of peripheral artery disease. Lipid lowering and antithrombotic therapies reduce ALI but pathologic studies have described thrombus in distal arteries without plaque, suggesting that artery to artery embolism from proximal (aortic-iliac) athero-thrombosis may be a key driver. Research Questions/Hypothesis: We hypothesized that the burden and character of atherosclerosis in the iliac arteries of patients with PAD would be associated with long term risk of ALI. Methods: VOYAGER PAD enrolled 6,554 patients with PAD and collected 2,200 baseline angiograms in 1,664 patients including 400 CT angiograms enabling plaque characterization. A case-control of 9 who had ALI during follow up and 9 controls were matched on anatomic and patient characteristics, type of index revascularization and disease pattern. Images were read by a blinded, independent imaging core lab. Results/Data: Of the 9 ALI cases, 45% had iliac artery occlusion and 55% had distal artery occlusion. Plaque characteristics were different in cases relative to controls including significantly greater non-calcified plaque volume (OR 2.36, 95% CI 1.05 - 9.38, p=0.03) as well as similar trends for low attenuation plaque (OR 1.65, 95% CI 0.89 - 4.72, p=0.05), and plaque burden (OR 1.16, 95% CI 1.00 - 1.25, p=0.03, Figure). In patients who experienced ALI, there was a trend for greater non-calcified plaque in the limb that experienced the ALI relative to the contra-lateral limb (index 7.2 vs contra-lateral 5.4, p=0.08). Conclusions: In a case-control series, total non-calcified plaque volume and overall plaque burden in the iliac arteries were associated with future ALI over 3 years. Based on the observations in this case-control, we are now analyzing plaque and outcomes in the full cohort. These data are hypothesis generating and suggest that plaque characteristics may be associated with ALI and may serve a surrogate marker of risk.

Abstract 16128: The Winslow Pathway and Internal Mammary Artery Harvesting in Patients With Aortoiliac Occlusive Disease

Introduction We present a case where the left Internal Mammary Artery (IMA) was not a straightforward choice as the grafted vessel in a patient undergoing Coronary Artery Bypass Grafting (CABG). Case Presentation Patient was a 66 years old female with Hypertension, Hyperlipidemia, hypothyroidism, and tobacco use disorder. Evaluation for a motor vehicle accident secondary to a syncopal episode, and intermittent chest tightness over the past few months, showed ST depressions on ambulatory electrocardiographic monitoring, reversible ischemia in the anterior and apical walls on Exercise Stress Test and severe multivessel coronary artery disease involving the distal main left coronary artery and its branches on Coronary Angiography. CABG was advised. Preoperative peripheral angiogram showed bilateral common iliac artery occlusion, precluding IABP placement. Selective angiography of the left IMA showed the left IMA to be the major vessel supplying collateral circulation to the left iliac system. Patient subsequently underwent CABG with bilateral Saphenous Vein Harvest. Discussion IMA harvesting in patients with Aortoiliac Occlusive Disease (AOD) with prominent collaterals through the subclavian-IMA-inferior epigastric-external iliac pathway, AKA the Winslow Pathway (WP), can result in limb threatening ischemia, and elective IMA angiography and/or doppler flow evaluation before CABG can help identify this important collateral pathway. Alternative approaches in patients with AOD include simultaneous coronary and peripheral revascularization, completely avoiding IMA harvesting or in some cases, angioplasty, although there is no consensus thus far.

Hybrid-based approach for pervasive occlusive disease of iliofemoral arteries

Aim: Simultaneous multilevel hybrid-based reconstructions using both endovascular and open femoral endartectomy merit the interest with the widespread adoption of these techniques by vascular surgeons. Here we presented our experience on hybrid-based approach to treat total occlusive iliofemoral lesions and study the technical success and mid-term results of combined femoral endarterectomy and endovascular treatment of iliac occlusion. Material and Methods: This retrospective single center study included patients with only total occlusion in the unilateral iliac artery. The patients underwent hybrid procedure–open femoral endarterectomy and endovascular revascularization of the external or common iliac artery- between 2016 and 2022. Statistical analysis was performed by using SPSS software version 25. Results: Totally 103 patients who underwent hybrid procedures for pervasive unilateral iliac artery occlusions were included in this study. Of the study cohort, 76% were male patients with a mean age of 74±8.7 years. Technical success rate was 89.3%. Acute myocardial infarction was the most common complication. The 30-day mortality was 7.8% (n=8) and all of them were in-hospital deaths. The survival rates of this cohort at 30 days, 6 months and 12 months were 92.2%, 88.1% and 83.7%, respectively. The primary patency at 30 days, 6 months, and 12 months were 98.1%, 96.6%, and 93.7%, respectively. Conclusion: The clinical and technical outcomes in this study suggest that the hybrid approach to pervasive iliofemoral occlusions, combining femoral endarterectomy and endovascular iliac revascularization, is an effective and applicable treatment in terms of patency rates and perioperative complications.

Successful recanalization of an acute occlusion of the left internal carotid artery and the left cerebral middle artery via the transbrachial approach: A case report

Introduction: This case study presents an elderly patient with an acute ischemic stroke due to occlusion of the left internal carotid artery (ICA) and the left cerebral middle artery (MCA). The study aimed to evaluate the feasibility and effectiveness of a transbrachial approach for mechanical thrombectomy (MT) in patients with tandem occlusions. Patient concerns: The patient presented with stroke symptoms, including severe aphasia, right-sided facial palsy, left gaze deviation and right-sided weakness. The patient had a history of uncontrolled hypertension. Diagnosis: Diagnostic tests, including computed tomography and angiography, confirmed the presence of occlusions in both the left ICA and the left MCA. Interventions: The patient received MT bridging intravenous thrombolysis. When bilateral iliac arteries were found to be occluded, a puncture via the transbrachial approach was attempted. Angiography suggested an acute occlusion of both the left ICA and the left MCA. The C1 segment was inflated with a pre-dilated balloon and the thrombus in the M1 segment was removed successfully. Outcomes: Successful reperfusion was achieved, and the patient had a good outcome at discharge. No access-site complications were encountered. Conclusion: Transbrachial approach for MT, especially in those with tandem occlusions, is feasible and could provide an alternative to the transfemoral approach. This approach may be beneficial for patients with occlusions in multiple sites or with iliac artery occlusions. Further research is needed to evaluate the long-term effectiveness of this approach.

Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum

PurposeTo evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS). Materials and MethodsAn institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded. ResultsA total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475–1,000 mL) compared to 2,000 mL (IQR, 1,500–2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3–9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed. ConclusionsProphylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.

Incidence and Outcomes of Visceral Ischemia in Acute Aortic Occlusion

Acute aortic occlusion (AAO) is a morbid diagnosis in which mortality correlates with severity of ischemia on presentation. Visceral ischemia (VI) is challenging to diagnose and its presentation as a consequence of AAO is not well-studied. We aim to identify characteristics associated with VI in AAO to facilitate diagnosis. Patients diagnosed with AAO who underwent revascularization were identified retrospectively from institutional records (2006-2020). The primary outcome was the development of VI (intra-abdominal ischemia). Univariate analysis was used to compare demographic, exam, imaging, and intraoperative variables between patients with and without VI in the setting of AAO. Ninety-one patients were included. The prevalence of VI was 20.9%. Preoperative comorbidities, time to revascularization, and operative approach did not differ between patients with and without VI. Patients with VI more frequently were transferred from outside institutions (100% vs. 53%, P=0.02), presented with advanced acute limb ischemia (Rutherford III 36.9% vs. 7.5%, P<0.01), and had elevated preoperative serum lactate (4.31 vs. 2.41mmol/L, P<0.01). VI patients had an increased occurrence of bilateral internal iliac artery (IIA) occlusion (47.4% vs. 18.1%, P=0.01). Unilateral IIA occlusion, level of aortic occlusion, and patency of inferior mesenteric arteries were not associated with VI. Patients with VI had worse postoperative outcomes. In particular, VI conferred significant risk of mortality (odds ratio 5.45, P<0.01). Visceral ischemia is a common consequence of AAO. Elevated lactate, bilateral IIA occlusion, and advanced acute limb ischemia (ALI) should increase clinical suspicion for concomitant VI with AAO and may facilitate earlier diagnosis to improve outcomes.