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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 54-56

Endovascular treatment of bilateral spontaneous dissection of common iliac artery involvement of the aorta and 3-year follow-up results


Department of Vascular Surgery, People's Hospital of Fuyang, Anhui, China

Date of Submission11-Jan-2021
Date of Decision12-Feb-2021
Date of Acceptance13-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Jun-Ding Hu
Department of Vascular Surgery, People's Hospital of Fuyang, 501 San Qing Road, Fuyang, 236000 Anhui
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT-D-21-00004

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  Abstract 


Spontaneous dissection of the iliac artery is very rare. We report the case of a 49-year-old man who presented with spontaneous dissection of common iliac artery involvement of the aorta. We treated him by unibody bifurcated stent grafting and deployed the second stent-graft to prevent the collapse of the true lumen of the right iliac artery. For the sake of preserving pelvic blood flow, proximal type I endoleak was not treated. After 3 years, the endoleak still existed, without any aneurysmal formation. Further, the dissection of the distal external iliac artery still existence after 3 months, but the virtual disappearance after 3 years.

Keywords: Common iliac artery, dissection, management


How to cite this article:
Li XX, Hu JD, Wu C, Geng JW, Wang M, Wang HR, Gao WB, Wang J. Endovascular treatment of bilateral spontaneous dissection of common iliac artery involvement of the aorta and 3-year follow-up results. Vasc Invest Ther 2021;4:54-6

How to cite this URL:
Li XX, Hu JD, Wu C, Geng JW, Wang M, Wang HR, Gao WB, Wang J. Endovascular treatment of bilateral spontaneous dissection of common iliac artery involvement of the aorta and 3-year follow-up results. Vasc Invest Ther [serial online] 2021 [cited 2021 Jul 27];4:54-6. Available from: https://www.vitonline.org/text.asp?2021/4/2/54/319598




  Introduction Top


Spontaneous dissection of the iliac artery is rare and it is even more unusual for such dissection occurs on both sides. Moreover, there are few reports in the domestic literature. We report a case of a bilateral spontaneous dissection of common iliac artery (CIA) involvement of the aorta that we have successfully managed and 3 years of follow-up. Informed consent was obtained from the patient included in this study.


  Case Report Top


A 49-year-old male presented with abdominal pain that persisted for 4 days. The pain was worse on the middle and lower, with radiation to the waist. After symptomatic treatment in the local hospital, on-going abdominal pain prompted his referral to our hospital 4 days later. His history of tobacco use has lasted for 20 years, with 30 cigarettes per day. There was no history of diabetes, hypertension, or heart disease. The medical history was uneventful and there was no recent surgery or trauma. He denied a family history of the disease. He presented with a temperature of 36.8°C, blood pressure of 126/90 mm Hg, heart rate of 114 beats/min. On examination, femoral and distal pulses were intact and equal with no signs of ischemia. The examination result was normal except for the mild middle and lower quadrant abdominal tenderness without evidence of peritoneal signs. An emergent routine blood test showed WBC 11.4 × 109/L, N71.3%. Color-flow duplex imaging showed a dissection in the branches of the abdominal aorta. Angio computed tomography (CT) detected a dissection flaps extending from the branches of the abdominal aorta to both iliac arteries and there are multiple distal crevasses in the right external iliac artery dissection [Figure 1]a. The bilateral internal iliac artery is supplied by the true lumen [Figure 1]b. Mild aneurysmal dilatation of the right internal iliac artery (1.09 cm diameter) is also noted compared with the left external iliac artery (0.78 cm diameter).
Figure 1: (a) The dissection of iliac artery involvement of the aorta and multiple distal crevasses in the right external iliac artery. (b) The bilateral internal iliac artery is supplied by the true lumen

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The abdominal pain was not relieved after conservative treatment and the decision to treat the dissection via an endovascular approach was made, at a state of general anesthesia. After placement of 10-F (right side) and 8-F (left side) introducer sheaths, a 0.035-inch guidewire (Radiofocus M; Terumo, Tokyo, Japan) was inserted and advanced to the distal aorta from the right femoral artery. A dose of intravenous heparin (5000 IU) was administered after the placement of both femoral introducer sheaths. Next, a marked pigtail catheter angiogram was used to check angio-CT scan measurements [Figure 2]. For the management of the dissection, a partially membrane-covered 2030144 unibody bifurcated stent-graft (Microport, China) was inserted into the left CIA to obstruct the entry site. To further cover dissections of the right external iliac artery, the second stent-graft 16 mm × 14 mm (Microport, China) was deployed to prevent the collapse of the distal true lumen [Figure 2]. The right internal iliac artery was kept after stent coverage, considering proximal type I endoleak [Figure 3]. However, the balloon catheter was not used for the sake of preserving pelvic blood flow. The patient was discharged home on the postoperative day 5 and was in good physical condition without pain or claudication. Outpatient management continued to be conservative with low-dose aspirin.
Figure 2: Intraoperative angiogram reveals bilateral iliac artery dissection; the collapse of external iliac artery true lumencollapse of external iliac artery true lumen

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Figure 3: Intraoperative angiogram following stent placement and the right internal iliac artery was keptiliac artery was kept

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Follow-up control CT angiography at 3 months showed pelvic flow was still preserved [Figure 4]a and dissection of the distal external iliac artery still existed [Figure 4]b. Further angiography scheduled at 3 years thereafter showed the preserved pelvic flow [Figure 4]c, the dissection nearly disappeared [Figure 4]d and properly located stents with excellent patency.
Figure 4: Computed tomography angiogram 3 months following the procedure: (a) The right pelvic flow was still preserved. (b) The dissection of the distal external iliac artery still existed. 3 years following the procedure: (c) The right pelvic flow was still preserved. (d) The dissection of the distal external iliac artery almost disappeared

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  Discussion Top


Spontaneous CIA dissections have been described but rare. In a literature review, 27 cases were reported before 2018, most of which are case reports. Spontaneous CIA dissections have been described in connection with atherosclerosis, Marfan's syndrome,[1] Ehlers-danlos syndrome,[2] a1-antitrypsin deficiency,[3] fibromuscular dysplasia,[4] vigorous exercise,[5] pregnancy.[4] The first five kinds of etiology are mainly related to degeneration, calcification, or necrosis of tunica intima and tunica media, while high turbulence and low shear stress contribute to the others.[5] The most common contributing cause was atherosclerosis,[5] a few cases were related to vigorous exercise, i.e., a cyclist and a swimmer.[6]

Typical early symptoms are acute onset of lower limb short-distance claudication, accompanied by decreased skin temperature of the affected limb.[4],[5],[7],[8],[9] However, other cases presented with lower abdominal pain with radiation to the affected side of the waist, groin area, or hip,[6] with[10] or without[6] symptoms of lower limb ischemia.

With regret, a standardized treatment algorithm does not exist. According to the literature, nonflow-limiting dissections can generally be managed conservatively and usually resolve spontaneously, including low-dose aspirin, anticoagulation, and beta-blockers. In these cases, such as abdominal pain, lower extremity ischemia as well as the prevention of future aneurismal degeneration, can be managed surgical intervention,[11] including open surgery and endovascular approaches. Where significant obstruction to flow resulting in acutely ischemic limb, open surgical repair is the treatment of choice,[5] including patch grafts and bypass grafts. In our case, the patients have persistent abdominal pain, and the pain was not relieved with after conservative treatment. Finally, endovascular treatment is gaining in popularity because of its minimal invasiveness. Considering the true lumen of the proximal external iliac artery is very small and sealing the reentry site, the second stent was used to enlarge the true lumen, produced enough radial force to promote true lumen expansion and false lumen thrombosis. There was no presence of aneurysmal dilation of the external iliac artery or lower limb necrosis during a 3-year follow-up.

The reasons we chose unibody bifurcated stent grafting mainly based on the following considerations: First, the entry site lies in common iliac bifurcation. Second, there is mild aneurysmal dilatation of the right internal iliac artery. Given the uncertainty of long-term data on the use of endovascular stenting for iliac dissections, further, follow-up are required to provide more information about this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barker SG, Burnand KG. Retrograde iliac artery dissection in Marfan's syndrome. A case report. J Cardiovasc Surg 1989;30:953-4.  Back to cited text no. 1
    
2.
Mehta S, Dhar SU, Birnbaum Y. Common iliac artery aneurysm and spontaneous dissection with contralateral iatrogenic common iliac artery dissection in classic ehlers-danlos syndrome. Int J Angiol 2012;21:167-70.  Back to cited text no. 2
    
3.
Savolainen H. Spontaneous dissection of common iliac artery a case report. Vasc Endovascular Surg 2004;38:263-5.  Back to cited text no. 3
    
4.
Lück I, Hanschke D, Geissler C, Gruss JD. Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia. Vasa 2002;31:115-21.  Back to cited text no. 4
    
5.
Teh LG, Sieunarine K, Van SG, Vasudevan T. Spontaneous common iliac artery dissection after exercise. J Endovasc Ther 2003;10:163-6.  Back to cited text no. 5
    
6.
Goodman KD. Bilateral spontaneous dissecting common iliac artery aneurysms: A rare presentation. J Emerg Med 2013;44:757-9.  Back to cited text no. 6
    
7.
Declemy S, Kreitmann P, Popoff G, Diaz F. Spontaneous dissecting aneurysm of the common iliac artery. Ann Vasc Surg 1991;5:549-51.  Back to cited text no. 7
    
8.
Fernández AL, Herreros JM. Spontaneous and isolated dissection of the common iliac artery. J Cardiovasc Surg (Torino) 1997;38:377-9.  Back to cited text no. 8
    
9.
Cook PS, Erdoes LS, Selzer PM, Rivera FJ, Palmaz JC. Dissection of the external iliac artery in highly trained athletes. J Vasc Surg 1995,22:173-7.  Back to cited text no. 9
    
10.
Yoshida Rde A, Kolvenbach R, Vieira PR, Moura R, Jaldin RG, Yoshida WB. Endovascular treatment of spontaneous isolated common and external iliac artery dissections with preservation of pelvic blood flow. Ann Vasc Surg 2015;29:126.e9-14.  Back to cited text no. 10
    
11.
Kwon SH, Jh. O. Successful interventional treatment of a spontaneous right common iliac artery dissection extending retrogradely into the left external iliac artery. J Vasc Interv Radiol, 2006;17:717-21.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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