Regarding “Endovascular management of iliac rupture during endovascular aneurysm repair”

Abstract

We were interested in the article by Fernandez et al on the endovascular management of iliac rupture during endovascular aneurysm repair (J Vasc Surg 2009;50:1293-9). We had noted a number of cases of acute occlusion in the first few weeks after endovascular abdominal aneurysm repair and retrospectively recognized that it was on the side that had been ballooned first with a Reliant or Coda balloon after graft deployment. We believed aortic bifurcation stenosis was causing compression of the limbs of the graft, and subsequently, whenever we thought that this might be a problem, used kissing angioplasty balloons to try and avoid these occlusions.We recently had a patient who developed hypotension in the recovery room. On return to the operating room, it was impossible to demonstrate any type I endoleaks angiographically, although a computed tomography scan had already shown a retroperitoneal hematoma. Ultimately, at surgical exploration, a vigorously bleeding middle sacral artery was ligated, although to expose this mobilization with one of the limbs disturbed it enough that we had to add an extension distally to maintain its seal.As such, it should be recognized that this direct rupture of an iliac artery is not the only potential hazard in diseased atherosclerotic vessels in endograft deployment.