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Concept: Internal iliac artery

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Late rupture of external iliac artery pseudo-aneurysm is an uncommon complication in patients who undergo extensive gynecologic radical surgeries. A 28-year-old woman with stage IB cervical cancer underwent pelvic lymphadenectomy and extrafascial trachelectomy. Two months after surgery, massive bleeding from ruptured pseudo-aneurysm of the external iliac artery occurred. Endovascular management with covered stent placement was feasible and safe to stop bleeding.

Concepts: Cervical cancer, Surgery, Radiation therapy, Stent, Pelvis, Hysterectomy, External iliac artery, Internal 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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We report a case of a 35-year-old woman who underwent uterine artery embolization (UAE) for symptomatic multiple uterine fibroids with collateral aberrant right ovarian artery that originated from the right external iliac artery. We believe that this is the first reported case in the literature of this collateral uterine flow by the right ovarian artery originated from the right external iliac artery. We briefly present the details of the case and review the literature on variations of ovarian artery origin that might be encountered during UAE.

Concepts: Uterus, Hysterectomy, External iliac artery, Internal iliac artery, Uterine fibroids, Uterine artery embolization, Uterine artery, Ovarian artery

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We report a case with a very rare complication of transcatheter aortic valve implantation. Rupture of the NovaFlex balloon (Edwards transfemoral balloon catheter) occurred during the inflation of the Edwards SAPIEN valve, resulting in dissection of the right common and external iliac arteries during withdrawal of the balloon catheter. The NovaFlex balloon is a part of the Edwards NovaFlex XT transfemoral delivery system.

Concepts: Right-wing politics, External iliac artery, Aortic valve, Internal iliac artery, Arteries, Iliac artery, Iliac vein, X-Force

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Purpose: To describe a bailout technique for in situ fenestration of an inadvertently covered internal iliac artery (IIA) associated with endovascular repair of an abdominal aortic aneurysm (AAA). Technique: The procedure is demonstrated in a 76-year-old patient who underwent elective repair of a 5-cm infrarenal AAA using an Excluder endovascular graft 2 years following thoracic aortic stent-graft repair of a chronic type B aortic dissection. A completion angiogram demonstrated unintentional coverage of the left IIA. The iliac limb of the stent-graft was not able to be displaced away from the ostium, so to preserve IIA perfusion in a patient with prior thoracic aortic stent-grafting, a bailout technique was performed using an Outback re-entry device to successfully fenestrate the polytetrafluoroethylene graft material. An iCast balloon-expandable stent was placed across the fenestration creating a patent side branch to maintain patency. Six-year follow-up demonstrates a stable repair. Conclusion: In situ fenestration of a stent-graft overlying the internal iliac artery can be a useful bailout technique when other options are unsuccessful.

Concepts: Aortic aneurysm, Aneurysm, Aortic dissection, Aorta, External iliac artery, Abdominal aortic aneurysm, Internal iliac artery, Vascular surgery

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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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This work aimed to study the prevalence and radiologic anatomy of the middle rectal artery (MRA) using computed tomographic angiography (CTA) and digital subtraction angiography (DSA). The retrospective study (October 2010-February 2012) focused in 167 male patients with prostate enlargement (mean age 64.7 years, range 47-81 years) who underwent selective pelvic arterial embolization for the relief of lower urinary tract symptoms. All patients underwent CTA previously to DSA to evaluate the vascular anatomy of the pelvis and to plan the treatment. MRAs were identified and classified according to their origin, trajectory, termination and relationship with surrounding arteries. We found MRAs in 60 (35.9 %) patients (23.9 % of pelvic sides, n = 80) and of those, 20 (12 %) had bilateral MRAs; 24 MRAs (30 %) were independent of neighbouring arteries and 56 MRAs (70 %) had common origins with prostatic arteries (prostato-rectal trunk). The most frequent MRA origin was the internal pudendal artery (60 %, n = 48), followed by the inferior gluteal artery (21.3 %, n = 17) and common gluteal-pudendal trunk (16.2 %, n = 13). In 2 patients the MRA originated from the obturator artery (2.5 %). Anastomoses to the superior rectal and inferior mesenteric arteries were found in 87.5 % of cases (n = 70). We concluded that MRAs are anatomical variants present in less than half of male patients; have variable origins and frequently share common origins with prostatic arteries. Their correct identification is likely to contribute to improve interventional radiology procedures and prostatic or rectal surgeries.

Concepts: Angiography, Radiology, Rectum, Interventional radiology, Internal iliac artery, Arteries of the abdomen, Middle rectal artery, Superior rectal artery

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We report a case of a life-threatening internal iliac artery aneurysm rupture managed successfully with an on-table reversed flared iliac limb stentgraft and embolization. This easily off-the-shelf reproducible technique avoids using a more complex and expensive bifurcated aorto-iliac graft and could be a good solution in emergency situation where a custom graft is not available.

Concepts: Aneurysm, External iliac artery, Internal iliac artery, Iliac artery, Off-label use

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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