Successful Treatment of Iatrogenic External Iliac Artery Perforation With Covered Stent: Case Report and Review of the Literature

Abstract

Retroperitoneal hemorrhage from iliac artery injury is a potentially serious complication of vascular interventional procedures leading to hemorrhagic shock and death if not diagnosed early and treated promptly. We report a 70-year-old male admitted to our facility with non-ST-elevation myocardial infarction, whose heart catheterization revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease. The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to perform high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device support. Left femoral artery angiogram revealed severely tortuous and calcified aorta, left external iliac and left common iliac arteries, and was accessed with 14-inch Impella sheath. He developed groin pain with mild hypotension thought to be due to sedation, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of drug-eluting stents. Following PCI, he suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle and right ventricle systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right indicative of retroperitoneal hematoma. A digital subtraction angiogram revealed extravasation of blood at the vascular injury site. An 8.0 × 59 mm iCAST covered stent was deployed to the left external iliac artery with successful sealing of the perforation. The Impella device site was closed with two Perclose devices. The patient required 4 units of packed red blood cell transfusion. His hospital course was complicated by transient acute kidney injury, with return of his renal function to baseline at discharge 10 days later. This case underscores the importance of prompt recognition and treatment of vascular complications associated with interventional procedures, and highlights some of the risk predictors of such complications, which should be anticipated and planned for prior to intervention.

Iatrogenic Arterial Perforation During Endovascular Interventions

“…External iliac artery complications are potentially serious events that can present elusively due to its retroperitoneal location and may lead to hemorrhagic shock or death if they are not identified and managed rapidly. The reported incidence of retroperitoneal hematoma formation after interventional endovascular management is 0.49%-0.74% with a mortality risk of 4%-12% [ 7 ].…”

“…Advancing a catheter without wire can cause trauma to the vessel when making contact with the open tip, resulting in dissection or perforation [ 6 ]. Moreover, the use of large sheaths has been associated with an increase in iatrogenic vascular access complications [ 7 ]. Table 1 summarizes the modifiable and nonmodifiable risk factors for iatrogenic vascular complications [ 7 ].…”

Vascular Trauma

“…A perforation or tear of the arterial wall not in the access site is the second very frequent complication of the endovascular procedure. The typical location of the perforation is iliac arteries, when during the approach to the target lesion (coronary arteries, carotid arteries, abdominal aorta) a hydrophilic guidewire perforates the vessel typically in the location of arteriosclerotic plaque [5,39]. If the guidewire perforation is noticed quickly, usually it has no consequences besides small extravasation which may require a low-pressure balloon inflation to seal the leak.…”

Morphometric Analysis of Significant Vascular Structures in Posterior Disc Surgery in Computed Tomography Angiography

“…Ulus Travma Acil Cerrahi Derg 2019;25:105-110. and 4.7% abdominal aorta. [3] When we review the literature, it is seen that external iliac artery is injured in endovascular interventions, [4] whereas LCIA/V injury and at the level of L4-5 is more frequent in lumbar disc surgery. [5,6] In this study, morphometric analysis of vascular structures likely to be injured in CT angiography was performed by considering lumbar disc surgery associated vascular injuries.…”