Clinical Radiology (1995) 50, 876-877

Case Report: Iliac Artery Rupture - Percutaneous Treatment By

Stent Insertion

A. J. K E L L Y

Department of Diagnostic Imaging, Royal Preston Hospital, Preston, UK

Arterial rupture is a well recognized bu t rare complica- t ion of Percutaneous Trans lumina l Angioplas ty (PTA). In the iliac artery such a rupture can lead to massive life threa tening haemorrhage which requires urgent surgical in te rvent ion to repair the damaged vessel. A case is described where such a compl ica t ion occurred and the leakage was s temmed by the inser t ion of a metall ic stent.

C A S E R E P O R T

A 62-year-old male complained of intermittent claudication in the fight leg after walking less than 100 yards. He had noticed the symptoms some four months previously and he was slowly getting worse. He had had a similar problem in the left leg some three years previously. This was dealt with by PTA and stent insertion and he continued to have no complaints on this side. He is a pipe smoker and does not drink but suffers from angina which is controlled with atenolol and verapimil.

Examination revealed reduced femoral and popliteal pulses on the right side (normal on the left). Dorsalis-pedis pulses were not palpable.

Peripheral angiogram revealed a nodular stenosis in the fight external iliac artery and normal flow on the left. The superficial femoral circulation was intact but run-off was slow through the calf vessels.

After corrected measurement of cross sections of normal diameter of the vessel the right external iliac artery was dilated to 10 mm with a 4 cm long, 10ram diameter standard coaxial balloon catheter. Whilst he experienced some discomfort there was no unusual or severe pain and there was no evidence of a vasovagal reaction. An immediate check angiogram revealed contrast extravasation from a tear in the vessel well (Fig. 1). An 11 mm diameter 4 cm long Strecker stent was inserted and fully expanded under low balloon pressure. A further check angiogram showed that leakage had ceased, the artery being smoothly outlined and restored to normal calibre (Fig. 2). Intra-arterial heparin, routinely given as a 5000 unit bolus, was not administered in this instance. He was, however, started on aspirin, 150mg daily, and asked to continue this permanently.

He remained well with stable vital signs and was discharged two days later. Follow-up one month later revealed that all femoral and popliteal pulses were palpable and of good volume. This patency of the artery and stent were confirmed by Doppler ultrasound. There was no evidence of any pelvis haematoma or pseudoaneurysm. He is now able to walk a mile or more without problems.

by redilat ing the angioplas ty ba l loon to seal the leak prior to emergency surgery [1]. In a pat ient who may not be a suitable candidate for laparotomy, a percutaneous method of dealing with complicat ions would be ideal. To this end an effective 'cure ' by percutaneous means would be advantagous . Previously, coil embol iza t ion [2] and simple ba l loon reinflat ion [4] have been described as effective. More recently stents have been used to limit dissection [5] and bleeding due to coronary artery rup- ture in P T A [6]. A search of the Med-l ine computer index does no t reveal any previous report of a metallic stent being used to effect t a m p o n d a d e of an acute iliac artery tear. In this case inser t ion of a metallic stent 1 m m larger than the original ba l loon had the desired effect of sealing the leak. Hepar in , 5000 uni ts 6-hourly, has been rout inely given for 48 h following stent inser t ion but was omit ted in this case to reduce the possibility of further bleeding. As this m a n remains well it is specu- lative as to how the effect has been b rought about , bu t it could be surmised that layers of to rn arterial wall were compressed to form a seal. This is in cont ra-dis t inc t ion to the mechanism proposed in the fo rmat ion of pseudo- aneurysm following stent insert ion. Here, it has been suggested that, by prevent ing elastic recoil of to rn medial and /o r adventi t ial layers following di latat ion, a stent can cont r ibute towards the development of a subacute pseu- doaneurysm [7]. The mechanism is not unders tood and is

D I S C U S S I O N

Arter ial rupture dur ing angioplasty has long been recognized as a rare compl ica t ion of P T A which, never- theless, can have devastat ing consequences [1,2]. Part i- cularly in the iliac arteries, potent ia l ly life threa tening haemorrhage necessitat ing immediate surgical repair, can develop rapidly. As there is no way of predict ing the degree or extent of haemorrhage, when it is detected, immediate a t ten t ion is warranted. The value of an immedia te check angiogram is emphasized as this pat ient did no t suffer any severe pain or vasovagal reaction, considered a lmost a sine qua non of severe complicat ions [3]. Convent ional ly , t emporary t amponade is established

Correspondence to: Dr A.J. Kelly, Department of Diagnostic Imaging, Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 4HT, UK.

�9 1995 The Royal College of Radiologists.

Fig. 1 - Angiogram showing contrast extravasation from the right external iliac artery after balloon angioplasty.

CASE REPORTS 877

not constant. Indeed, treatment of pseudoaneurysm fol- lowing stent insertion has been described [8]. Such variation between cause and effect would be resolved by the intro- duction and general availability of sheathed stents to aid the percutaneous treatment of occlusive arterial disease and its complications.

Fig. 2 - Angiogram showing appearances following stent insertion, no leakage is now visible.

References

1 Chong WK, Cross FW, Raphael MS. Iliac artery rupture during percutaneous angioplasty. Clinical Radiology 1990;41:358-359.

2 Jensen SR, Voegeli DR, Crummy AB et al. Iliac artery rupture during Transluminal Angioplasty, treatment by embolisation and surgical by- pass. American Journal of Roentgenology 1985;145:381-382.

3 Korogi Y, Takahashi M, Bussaka H et al. Percutaneous transluminal angioplasty: pain during balloon inflation. British Journal of Radi- ology 1992:65:141-142.

4 Smith TP, Cragg AH. Non-surgical treatment of iliac artery rupture following angioplasty. Journal of lnterventional Radiology 1989;4:16 18.

5 Haude M, Erbel R, Staub U et al. Results ofintracoronary stents for management of coronary artery dissection after balloon angioplasty. American Journal of Cardiology 1991 ;67:691-696.

6 Thomas MR, Wainwright RJ. Use of intracoronary stent to control intra-pericardial bleeding complicating coronary angioplasty. Cathe- terisation and Cardiovascular Diagnosis 1993;30:169-172.

7 Chalmers N, Eadington DW, Grandanhamo D et al. Infected false aneurysm at the site of an iliac stent, British Journal of Radiology 1993;66:996-998.

8 Blais C, Bonneau D. Post-angioplasty pseudo-aneurysm treated with a vascular stent. American Journal of Radiology 1994;162: 238-239.

�9 1995 The Royal College of Radiologists, Clinical Radiology, 50, 876 877.