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Concept: Common iliac artery

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BACKGROUND: Iliac artery atherosclerotic disease may cause intermittent claudication and critical limb ischemia. It can lead to serious complications such as infection, amputation and even death. Revascularization relieves symptoms and prevents these complications. Historically, open surgical repair, in the form of endarterectomy or bypass, was used. Over the last decade, endovascular repair has become the first choice of treatment for iliac arterial occlusive disease. No definitive consensus has emerged about the best endovascular strategy and which type of stent, if any, to use. However, in more advanced disease, that is, long or multiple stenoses or occlusions, literature is most supportive of primary stenting with a balloon-expandable stent in the common iliac artery [1]. Recently, a PTFE-covered balloon-expandable stent (Advanta V12, Atrium Medical Inc., Hudson, NH, USA) has been introduced for the iliac artery. Covering stents with PTFE has been shown to lead to less neo-intimal hyperplasia and this might lower restenosis rates [2-4]. However, only one RCT, of mediocre quality has been published on this stent in the common iliac artery [5,6]. Our hypothesis is that covered balloon-expandable stents lead to better results when compared to uncovered balloon-expandable stents. METHODS: This is a prospective, randomized, controlled, double-blind, multi-center trial. The study population consists of human volunteers aged over 18 years, with symptomatic advanced atherosclerotic disease of the common iliac artery, defined as stenoses longer than 3 cm and occlusions. A total of 174 patients will be included.The control group will undergo endovascular dilatation or revascularization of the common iliac artery, followed by placement of one or more uncovered balloon-expandable stents. The study group will undergo the same treatment, however one or more PTFE-covered balloon-expandable stents will be placed. When necessary, the aorta, external iliac artery, common femoral artery, superficial femoral artery and deep femoral artery will be treated, using the standard treatment.The primary endpoint is absence of binary restenosis rate. Secondary endpoints are reocclusion rate, target-lesion revascularization rate, clinical success, procedural success, hemodynamic success, major amputation rate, complication rate and mortality rate. Main study parameters are age, gender, relevant co-morbidity, and several patient, disease and procedure-related parameters.Trial registrationDutch Trial Register, NTR3381.

Concepts: Atherosclerosis, Stent, Femoral artery, Arteries of the lower limb, External iliac artery, Internal iliac artery, Arteries of the abdomen, Common iliac artery

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A 60 year-old woman presented with large extensive aneurysms in the thoracic aorta and infra-renal abdominal aorta with a normal segment of visceral aorta in between; the entire right common iliac artery was also aneurysmal. Concurrent endovascular repair of all aneurysmal regions was successfully performed using a left common iliac artery conduit to access the aorta, and multiple stent-grafts; a chimney graft preserved blood flow into the left subclavian artery. There were no features of spinal cord ischaemia despite coil embolisation of the right hypogastric artery. CT angiogram at six months showed patent stent-grafts with no endoleaks. The patient continued to do well at one-year clinical follow-up. Concurrent endovascular repair of thoracic and abdominal aortic aneurysms can be safely and successfully performed when anatomically feasible, and is an attractive alternative to staged or hybrid repair.

Concepts: Abdominal aorta, Aortic aneurysm, Brachiocephalic artery, Aorta, Descending aorta, Arteries of the thorax, Arteries of the abdomen, Common iliac artery

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OBJECTIVE: To further characterize the vascular and ureteral anatomy relative to the mid sacral promontory, a landmark often used during sacrocolpopexy, and suggest strategies to avoid complications. STUDY DESIGN: Distances between the right ureter, aortic bifurcation, and iliac vessels to the mid sacral promontory were examined in 25 unembalmed female cadavers and 100 computed tomography (CT) studies. Data were analyzed using Pearson chi-square, unpaired Student'st test and analysis of covariance. RESULTS: The average distance between the mid sacral promontory and right ureter was 2.7 cm (range 1.6-3.8 cm) in cadavers and 2.9 cm (1.7-5.0) on CT ( P =.209). The closest cephalad vessel to the promontory was the left common iliac vein; average distance of 2.7 cm (0.95-4.75) in cadavers and 3.0 cm (1.0-6.1) on CT ( P =.289). The closest vessel to the right of the promontory was the internal iliac artery, average distance 2.5 cm (1.4-3.9) in cadavers and 2.2 cm (1.2-3.9) on CT ( P =.015). The average distance from the promontory to the aortic bifurcation was 5.3 cm (2.8-9.7) in cadavers and 6.6 (3.1-10.1) on CT ( P <.001). The average distance from the aortic bifurcation to the inferior margin of the left common iliac vein was 2.3 cm (1.2-3.9) in cadavers and 3.5 cm (1.7-5.6) on CT ( P <.001). CONCLUSIONS: The right ureter, right common iliac artery, and left common iliac vein are found within 3 cm from the mid sacral promontory. A thorough understanding of the extensive variability in vascular and ureteral anatomy relative to the mid sacral promontory should help avoid serious intraoperative complications during sacrocolpopexy.

Concepts: Ureter, Abdominal aorta, External iliac artery, Internal iliac artery, Iliac vein, Superior vesical artery, Common iliac artery, Common iliac vein

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To evaluate the efficacy of different methods of surgical hemostasis, including the ligation of internal iliac arteries (IIA), temporary occlusion of the common iliac artery (CIA) and combined compression hemostasis, during cesarean section in patients with morbidly adherent placenta (MAP).

Concepts: Anesthesia, External iliac artery, Internal iliac artery, Arteries, Iliac artery, Common iliac artery, Placenta accreta, Placenta praevia

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Acute and chronic venous disorders of the lower extremities affect millions of people and cause substantial disability. Long ago, surgeons and pathologists identified the presence of ‘spur-like’ abnormalities of the left common iliac vein; these abnormalities were hypothesized to result from compression and/or irritation from the adjacent crossing right common iliac artery. In the 1990s, physicians, starting to perform catheter-directed thrombolysis to treat extensive deep vein thrombosis (DVT), observed that about 50% of patients had an iliac vein stenosis. Vascular physicians have become aware of the occasional patient with otherwise-unexplained extremity swelling and/or pain but without a DVT history who is subsequently found to have an iliac vein abnormality. These ‘lesions’ have been hypothesized to elevate ambulatory venous pressures and thereby produce lower-extremity symptoms, increase the risk of initial and recurrent DVT episodes, and increase the risk of treatment failure with medical and endovascular therapies for thrombotic and non-thrombotic venous conditions. As a result, many practitioners now actively seek iliac venous obstructive ‘lesions’ when evaluating patients with known or suspected venous disease. However, for many patients, it continues to be unclear what degree of obstruction to venous blood flow is being caused by such lesions, how clinically significant they are, how much emphasis should be placed on identifying them, and when they should be treated. This article seeks to improve the knowledge base of vascular practitioners who make clinical decisions about the diagnosis and treatment of obstructive iliac vein lesions.

Concepts: Blood, Thrombosis, Hematology, Vein, Deep vein thrombosis, Deep vein, Common iliac artery, Common iliac vein

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Uterus transplantation may become the surgical therapeutic modality of choice for uterine factor infertility. However, this procedure still faces technical, therapeutic, and immunologic challenges that limit its success and clinical application. Experimental studies are therefore still needed to address various challenges in the field of uterus transplantation. Among various laboratory animals, small animals are ideal models for the purpose of experimental uterus transplant. However, clinical success in small animal models is not generalizable to clinical application and treatment for uterine factor infertility in humans. Large animal models are necessary because their uterine anatomy and reproductive physiology closely resemble those of humans. In the literature, in general with small or large animal models, the same striking characteristic has been previous regular menstruation. Anesthesia was usually induced through inhalation and/or intraperitoneal injection in small models and intravenous injection in large models. Systemic heparinization was usually performed after preparation of uterus and vessels and before crossclamping of the vessels. Flushing of the graft was performed through the interior iliac artery or aorta. A grafted segment was frequently selected only from one horn of the uterus. The uterine artery, internal iliac artery, and aorta have been frequently used for arterial revascularization into the recipient’s external iliac artery or abdominal aorta. The uterine vein, internal iliac vein, and inferior vena cava have been used for venous drainage into the recipient’s inferior vena cava, external iliac vein, or uteroovarian vein. In most models, the native uterus was resected to reconstruct the grafted uterus continuity. Other models have left the native uterus in the recipient’s abdomen, and stomas have been used for end of the grafted uterus.

Concepts: Vein, Pelvis, External iliac artery, Inferior vena cava, Internal iliac artery, Arteries of the abdomen, Common iliac artery, Uterine artery

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In almost every type of artificial valve, structural failure has been described. We are reporting on a case of a sudden leaflet escape of an Edwards TEKNA mitral valve prosthesis 12 years after implantation. The patient had a sudden onset of dyspnea and severe pulmonary edema with subsequent cardiogenic shock. An emergency mitral replacement was successfully performed. A multi-detector computed tomography scanning and three-dimensional imaging showed two fragments that had embolized in the terminal aorta and the left common iliac artery. The patient presented visual field abnormality, and postoperative head computed tomography showed watershed cerebral infarction. The escaped leaflet that fractured transversely was removed, following the patient’s recovery, during cardiac surgery.

Concepts: Myocardial infarction, Heart, Mitral valve, Left ventricle, Pulmonary edema, Artificial heart valve, Common iliac artery

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The EXCLUDER iliac branch endoprosthesis (IBE) is designed to exclude a common iliac artery aneurysm (CIAA), preserving the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR). We assessed the anatomical suitability of the IBE in patients whose aortoiliac aneurysms (AIAs) had already been treated with a standard EXCLUDER endograft, compromising their IIAs.

Concepts: Atherosclerosis, External iliac artery, Abdominal aortic aneurysm, Internal iliac artery, Arteries of the abdomen, Common iliac artery, Common iliac vein

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We present a case of 20-year-old woman who presented with a large pedunculated skin covered mass lesion arising from the left thigh, measuring 40 × 25 cm, with no history of pain or skin ulceration and a feeling of a lump with dragging pain in the left side of the abdomen for about 7 years. Subsequently, ultrasound, contrast-enhanced computed tomography, and magnetic resonance imaging of abdomen and left thigh region were carried out. The lesion was broad-based toward the left upper thigh with a central core of interspersed fat supplied by branches of the superficial and deep femoral arteries. Another lesion was seen in the left retroperitoneum anterior to the psoas muscle in a left paravertebral location encasing the left common iliac vessels extending into the left pelvic cavity and inguinal region inferiorly. The lesion showed dense post-acoustic shadowing on ultrasound, mild enhancement on contrast-enhanced computed tomography, and appeared hypointense on T1- and T2-weighted images. A left thigh lesion was excised, whereas incisional biopsy was done for the left retroperitoneal lesion. The diagnosis of a giant fibroepithelial polyp arising from the left thigh and left retroperitoneal fibromatosis was made. This is the first report of such a giant fibroepithelial polyp arising from the thigh with associated retroperitoneal fibromatosis.

Concepts: Medical imaging, Nuclear magnetic resonance, Magnetic resonance imaging, Pelvis, Ultrasound, External iliac artery, Abdominal cavity, Common iliac artery

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To report the endovascular treatment of a spontaneous iliac artery dissection (IAD) involving iliac bifurcation, complicated by a type B intramural aortic hematoma (IMH).

Concepts: Common iliac artery