Departmencine, Inje Univ

CorrespondHaeundae PaiJwa-Dong, HE-mail: jkpark

Ann Vasc Surghttp://dx.doi.or� 2014 Elsevi

Manuscript re

2013; publishe

Delayed Rupture of the Iliac Artery AfterPercutaneous Angioplasty

Jong Kwon Park, Sung Jin Oh, and Jin Yong Shin, Busan, Republic of Korea

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

Percutaneous angioplasty has become an outpatient

procedure, and the hospital stay after vascular inter-

vention is usually not longer than 1 day.1,2 Gener-

ally, the main pursuit of a short hospital stay after

percutaneous angioplasty is cost savings without

sacrificing patient safety. However, our patient

experienced a delayed rupture of the iliac artery 2

days after percutaneous balloon angioplasty and

placement of a self-expandable stent. If the patient

had been discharged earlier than 2 days after percu-

taneous angioplasty, the patient might have been at

risk of death at home.

We describe the successful treatment of a de-

layed rupture of the iliac artery by endovascular

t of Surgery, Haeundae Paik Hospital, College of Medi-ersity, Busan, Republic of Korea.

ence to: Jong Kwon Park, MD, Department of Surgery,k Hospital, College of Medicine, Inje University, 1435aeundae-Gu, Busan, Republic of Korea 612-080;@paik.ac.kr

2014; 28: 491.e1–491.e4g/10.1016/j.avsg.2013.05.008er Inc. All rights reserved.

ceived: January 19, 2013; manuscript accepted: May 8,

d online: October 23, 2013.

intervention with a stent graft 2 days after percuta-

neous angioplasty.

CASE REPORT

A 67-year-old man had resting pain in both legs for 6

months. A computed tomography angiography (CTA)

scan revealed critical stenosis of the right common iliac

artery and total occlusion of the left common and prox-

imal external iliac arteries (Fig. 1A). The patient’s right

and left ankleebrachial indices (ABIs) were 0.74 and

0.55, respectively.

Percutaneous angioplasty was performed in the oper-

ating room using a C-arm radiograph system (ARCADIS

Avantic; Siemens, Munich, Germany). At both sides of

the groin, 8-French sheaths were inserted percutaneously

into the right and left common femoral arteries in a retro-

grade direction under local lidocaine anesthesia. The total

occlusion along the left common and proximal external

iliac arteries was crossed with a conventional 5-French

multipurpose angiographic catheter (Cordis, Bridgewater,

NJ) and a 0.035-inch guidewire (Terumo, Tokyo, Japan)

(Fig. 1B). Then, over the wire, a pigtail catheter (Terumo)

was inserted into the distal aorta. By confirming free rota-

tion of the pigtail catheter and the aortoiliac angiographic

findings, we certified that the pigtail catheter was in the

491.e1

Fig. 1. Preoperative and postoperative computed

tomography angiography (CTA) and percutaneous

angioplasty. (A) Preoperative CTA revealed critical

stenosis of the right common iliac artery and a total

occlusion in the left common and proximal external iliac

arteries. (B) The total occlusion along the left common

and proximal external iliac arteries was crossed with

a guidewire. (C) The aortoiliac angiography revealed

the proper location of the pigtail catheter in the

true lumen of the aorta without any subintimal

recanalization at the distal aorta. (D) By performing

the kissing balloon technique, the self-expandable stents

were dilated simultaneously in the right and left iliac

arteries. (E and F) A CTA scan revealed active bleeding

(arrow) from the proximal portion of the left external

iliac artery. (G) Completion angiography confirmed no

bleeding from the left external iliac artery. (H and I)

A follow-up CTA scan revealed no bleeding from the

left external iliac artery.

491.e2 Case reports Annals of Vascular Surgery

Vol. 28, No. 2, February 2014 Case reports 491.e3

true lumen of the aorta without any subintimal recanali-

zation at the distal aorta (Fig. 1C).

After predilatation of the occlusive lesion at the left

iliac artery with a 10-mm � 80-mm balloon (Admiral

Xtreme; INVATEC Inc., Invatec Inc., Bethlehem, PA),

a 10-mm � 80-mm self-expandable stent (Maris Deep;

Invatec Inc., Bethlehem, PA) was placed along the left

common and proximal external iliac arteries. The stenotic

portion of the right common iliac artery was crossed with

a 0.035-inch guidewire, and then a 10-mm� 60-mm self-

expandable stent was placed. By performing the kissing

balloon technique, the self-expandable stents in the right

and left iliac arteries were dilated simultaneously using

9-mm � 60-mm and 9-mm � 80-mm balloons, respec-

tively (Fig. 1D). The percutaneous endovascular treat-

ment was successful, and there was no unexpected event.

One day after the procedure, the patient’s right and left

ABIs increased from 0.74 and 0.55, respectively, to 1.14

and 1.11, respectively. However, 2 days after the proce-

dure, the patient suddenly complained of severe pain in

the left buttock and flank, and his systolic blood pressure

was 60 mm Hg. His serum hemoglobin level was 6.7

mg/dL. An emergency CTA scan was performed, and

active bleeding from the proximal portion of the left

external iliac artery was identified (Fig. 1E, F). Thirty

minutes elapsed from the detection of the low blood pres-

sure to the diagnosis of the iliac rupture. The patient was

immediately sent to the operating room.

Under general anesthesia, the left common femoral

artery was exposed surgically, and a 12-French sheath

was inserted in the left common femoral artery in a retro-

grade direction. By endovascular intervention, the

bleeding portion of the left iliac artery was treated with

a 10-mm � 100-mm stent graft (Viabahn Endoprosthesis;

W. L. Gore & Associates, Inc., Flagstaff, AZ) and dilated

with a 9-mm � 40-mm balloon (Admiral Xtreme; Invatec

Inc., Bethlehem, PA).

Completion angiography confirmed no bleeding from

the left external iliac artery (Fig. 1G). The sheath was

removed, and the puncture site was closed surgically

with a 6-0 polypropylene suture. Two and a half hours

elapsed between symptom onset and completion of the

surgical repair.

The next day, a follow-up CTA scan confirmed that

there was no bleeding from the left iliac artery (Fig. 1H,

I). The patient was discharged 1 week after the procedure

without any complications. During 5 months of follow-

up, the patient did not have any complications.

DISCUSSION

Inendovascular intervention, the iliac artery servesas

either an access or a target vessel. Rupture of the iliac

artery has been reported to occur in various endovas-

cular procedures, such as coronary angioplasty,3,4

endovascular aortic aneurysmrepair,5,6 andendovas-

cular treatment of iliac artery lesions.3,7e10 Endovas-

cular treatment of a stenosis or occlusion of the iliac

artery by balloon or stent carries the risk of rupture

of the iliac artery, and previous studies have shown

that rupture of the iliac artery after angioplasty occurs

in 0.8e3% of cases.8e10

Rupture of the iliac artery may result in acute

bleeding or pseudoaneurysm formation.8 In the

case of pseudoaneurysm formation, there is no

active bleeding outside of the pseudoaneurysmal

cavity; therefore, the hemodynamic status of the

patient is usually stable, and the patient can be

treated on an elective basis.8 On the contrary, acute

bleeding from the ruptured iliac artery can lead to

a fatal outcome because the iliac artery is located

in the pelvic cavity and is covered only by a thin

retroperitoneal membrane.7,10 Rupture of the iliac

artery after percutaneous angioplasty is usually

diagnosed early because the symptoms of acute

bleeding appear rapidly during or immediately after

the procedure.3,7e10 However, in the current case,

the patient experienced a delayed rupture of the

left external iliac artery 2 days after balloon angio-

plasty and stent placement.

Although inadequate diameter, heavy calcifica-

tion, and severe tortuosity are well known risk

factors for the rupture of the iliac artery,6,8 there is

no convincing parameter to predict the time of

rupture. Moreover, there is no clear guideline on

the timing of discharge after a percutaneous endo-

vascular procedure. In previous reports, pseudoa-

neurysms have been found between 5 days and 1

year after balloon angioplasty or stent placement.8

However, acute bleeding from a ruptured iliac artery

has been shown to occur during angioplasty3,8e10 or

12 hrs after angioplasty.7

In our department, we routinely observe patients

in the hospital for at least 3 days after percutaneous

angioplasty to deal with any unexpected complica-

tions. If our patient had been discharged earlier than

2 days, the rupture would have occurred at home,

and the patient might have been at risk of death.

In the case of a ruptured iliac artery, the treat-

ment option is open surgery or endovascular inter-

vention with a stent graft. Endovascular treatment

has shown less morbidity and mortality than open

surgical repair.5,11,12 Therefore, endovascular treat-

ment is usually the first option. We treated the

patient with an endovascular method and success-

fully controlled the acute bleeding.

In our department, we always prepare appropri-

ately sized stent grafts before endovascular angio-

plasty. If we had not prepared the stent grafts

before the percutaneous angioplasty in this case,

there would have been only 1 option (open

surgery), and the patient might have been exposed

to an increased risk of morbidity and mortality.

491.e4 Case reports Annals of Vascular Surgery

In conclusion, observing patients for a sufficient

amount of time in the hospital and preparing appro-

priately sized stent grafts are 2 important factors for

the safety of patients who undergo percutaneous

angioplasty. Moreover, the development of a safety

guideline on the timing of discharge after endovas-

cular angioplasty of the iliac artery is warranted to

avoid exposing the patient to the risk of a delayed

rupture of the iliac artery.

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