Tratamiento endovascular de la enfermedad obstructiva aortoilíaca / Endovascular management of aortoiliac occlusive disease

Resumen Introducción: La angioplastia transluminal percutánea (ATP), se ha convertido en una técnica aceptada, en el tratamiento de la enfermedad obstrutiva aortoilíaca, con tasas de éxito del 90-92% y permeabilidad primaria del 55-72% a 5 años. Objetivo: Evaluar los resultados del tratamiento endovascular del sector aortoilíaco. Material y Método: Estudio descriptivo, retrospectivo (revisión de serie de casos unicéntrica), de pacientes, sometidos consecutivamente al tratamiento endovascular (ATP simple y ATP con stent) de la patología obstructiva del sector aortoilíaco, durante un período de 7 años (2002-2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizaron 103 procedimientos en 94 pacientes, sexo masculino: 63,83%, femenino: 36,17%, edad promedio: 67,4 años (rango 47-96), distribución de las lesiones según la clasificación TASC II: A (46,24%), B (39,78%), C (8,60%), D (5,38%), remodelando la biburfaccción aórtica (kissing stent) en un 6,80%, procedimientos híbridos (12,62%), seguimiento promedio (47,13 meses), éxito clínico (90,29%), exito técnico (94,17%), permeabilidad primaria, primaria asistida y secundaria a 5 años del 68,09%, 75,53% y 81,91% respectivamente, tasa de salvación de la extremidad a 5 años del 84,04%, mortalidad < 30 días del 1,94%, supervivencia a 5 años del 90,42%. Discusión: Las técnicas endovasculares del sector aortoilíaco son fiables, sus resultados ténicos y permeabilidad, están influenciados por el estadio clínico del paciente y severidad de las lesiones tratadas. Conclusión: En pacientes adecuadamente seleccionados, el tratamiento endovascular del sector aortoilíaco presenta excelentes resultados, permitiendo aumentar la indicación de tratamiento en pacientes considerados de alto riesgo.

Introduction: Percutaneous transluminal angioplasty (PTA) has become an accepted technique in the treatment of aortoiliac occlusive disease, with success rates of 90-92%, and primary patency of 55-72% at 5 years. Aim: To evaluate the results of endovascular treatment (PTA or PTA with stents) of the aortoiliac sector. Material and Method: Descriptive, retrospective study (single-center case series) of patients, consecutively subjected to endovascular treatment (PTA or PTA with stents) of aortoiliac occlusive disease, during a period of 7 years (2002 - 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: 103 procedures were performed in 94 patients, male: 63.83%, female: 36.17%, mean age: 67.4 years (range 47-96), distribution of the lesions according to the TASC II classification: A (46.24%), B (39.78%), C (8.60%), D (5.38%), remodeling the aortic bifaction (kissing stent) in 6.80%, hybrid procedures (12.62%), average follow-up (47.13 months), clinical success (90.29%), technical success (94.17%), primary patency, assisted primary and secondary at 5 years of 68.09%, 75, 53% and 81.91% respectively, 5-year limb salvage rate of 84.04%, mortality < 30 days of 1.94%, 5-year survival of 90.42%. Discussion: Endovascular techniques in the aortoiliac sector are reliable, their technical results and patency are influenced by the clinical stage of the patient and the severity of the lesions treated. Conclusion: In appropriately selected patients, endovascular treatment of the aortoiliac sector, presents excellent results, allowing an increase in the indication for treatment in patients considered to be at high risk.

Identificação pela ultrassonografia vascular da compressão da veia ilíaca comum esquerda em mulheres assintomáticas: ortostatismo pode influenciar o diagnóstico? / Left common iliac vein compression identified by vascular ultrasonography in asymptomatic women: does standing position influence diagnosis?

Resumo Contexto A ultrassonografia vascular é o exame de imagem de escolha para rastreamento inicial da compressão na veia ilíaca comum esquerda, cujo achado assintomático pode ser encontrado em até 25% em algumas casuísticas. Objetivo Identificar, pela ultrassonografia vascular, se há diferença na avaliação da compressão na veia ilíaca comum esquerda em mulheres assintomáticas em decúbito dorsal e ao ortostatismo. Métodos Trata-se de um estudo observacional transversal em 50 mulheres voluntárias, sem sintomas de compressão venosa pélvica. Os parâmetros avaliados pela ultrassonografia vascular em decúbito dorsal e ao ortostatismo foram os diâmetros e as velocidades máximas na veia ilíaca comum esquerda no local do cruzamento com a artéria ilíaca comum direita e antes desse cruzamento, além dos índices de velocidade na veia ilíaca comum esquerda no local do cruzamento. Resultados Foram identificados oito casos de compressão significativa na veia ilíaca comum esquerda na avaliação em decúbito dorsal (16%) e somente dois casos (4%) ao ortostatismo. Os diâmetros na veia ilíaca comum esquerda foram estatisticamente maiores (p = 0,002) no local de cruzamento com a artéria ilíaca comum direita ao ortostatismo, e as velocidades e índices de velocidades foram estatisticamente maiores (p < 0,001) em decúbito dorsal. Não houve identificação de compressão significativa na veia ilíaca comum esquerda em ortostatismo quando os índices de velocidades estavam normais em decúbito dorsal. Conclusão Não houve diferença na detecção de compressão significativa da veia ilíaca comum esquerda ao ortostatismo em relação ao decúbito dorsal; no entanto, o estudo mostrou que pode haver menor compressão anatômica da veia ilíaca comum esquerda em posição ortostática.

Abstract Background Vascular ultrasonography is the imaging exam of choice for initial screening for left common iliac vein compression, which is an asymptomatic finding that can be detected in up to 25% of some patient samples. Objective To determine, using vascular ultrasonography, whether findings of left common iliac vein compression in asymptomatic women are different when assessed in the prone and standing positions. Methods This is a cross-sectional observational study of 50 adult female volunteers with no symptoms of pelvic venous compression. The parameters assessed with vascular ultrasonography in the prone and standing positions were diameters and maximum velocities of the left common iliac vein at the point at which it crosses behind the right common iliac artery and before this point, in addition to left common iliac vein velocity indices at the crossing. Results Eight cases of significant compression of the left common iliac vein were identified when assessed in prone position (16%) and just two cases (4%) were identified in the standing position. Left common iliac vein diameters were statistically larger (p = 0.002) at the point where it crosses behind the right common iliac artery in the standing position and velocities and velocity indices were statistically higher (p < 0.001) in the prone position. No significant compression of the left common iliac vein was identified in the standing position when velocity indices were normal in the prone position. Conclusions There was no difference in detection of significant compression of the left common iliac vein when assessed in the standing position in comparison with assessment in the prone position. However, the study showed that anatomic compression of the left common iliac vein may be reduced in the standing position.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES: This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients. METHODS: This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping. RESULTS: From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter. CONCLUSIONS: The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Protocolo de embolizacion arterial como parte del control de la hemorragia por fractura pélvica: serie de casos en un centro de referencia de trauma / Arterial embolization protocol as control of pelvic fracture hemorrhage: case series in a trauma reference center

Introducción Las fracturas pélvicas se asocian a sangrado arterial y/o venoso, ocasionando mortalidad elevada. El objetivo del estudio es diseñar, implementar y evaluar un protocolo para el tratamiento de fracturas pélvicas Materiales y métodos estudio prospectivo observacional, de pacientes con fractura pélvica que ingresaron a la clínica Medical. Variables: edad, sexo, arteria comprometida, lesión unilateral o bilateral, tipo de fractura pélvica (clasificación de Tile), indicación de la arteriografía, acceso uni o bilateral, éxito angiográfico, complicaciones del procedimiento, lesiones asociadas, mortalidad a 30 días, mecanismo de trauma, días de estancia en cuidado intensivo. Resultados 56 pacientes con fractura pélvica, 17 pacientes se llevaron a arteriografía pélvica por sospecha de sangrado, 14 pacientes tenían sangrado arterial, promedio de 36 años, las arterias más comúnmente lesionadas fueron la arteria hipogástrica, arteria sacra lateral y la arteria obturatriz. la mayoría de sangrados se asociaron a fracturas tipo C, las lesiones asociadas se encontraron en un 34% de casos, la indicación de la arteriografía fue inestabilidad hemodinámica al momento del ingreso, el control del sangrado se logró en el 86% de casos, la punción fue única en el 100% de casos, se requirió empaquetamiento pélvico 12% de casos. Discusión El trauma pélvico asociado a accidentes de motocicleta es común, el manejo multidisciplinario y la oportuna intervención del cirujano vascular es decisiva para el diagnóstico y tratamiento temprano de las lesiones vasculares pélvicas; la realización de un protocolo de manejo con un algoritmo de embolización mostró ser efectivo y seguro para el control del sangrado pélvico. Nivel de Evidencia: III

Background Pelvic fractures are frequently associated with arterial and / or venous bleeding, leading to high mortality (10 and 50%). Aim of study is to show our experience, based on an institutional protocol developed for the management of the patient with major pelvic trauma. Methods We conducted a prospective observational study for a 3 years period of time. The variables analyzed were: age, sex, artery involved, unilateral or bilateral lesion, type of pelvic fracture (Tile classification), indication of arteriography, unilateral or bilateral access, angiographic success, complications of the procedure, associated injuries, mortality at 30 days, trauma mechanism, days of stay in ICU and floor. Results We found 56 patients with pelvic fracture, 17 patients were taken to pelvic arteriography due to suspected bleeding, 14 patients had arterial bleeding, with an average age of 36 years, the arteries most commonly injured were the hypogastric artery, lateral sacral artery and the obturator artery, 50% of cases the bleeding was bilateral, the majority of bleeds were associated with type C fractures, associated lesions were found in 34% of cases, the indication of arteriography was hemodynamic instability at the time of admission, control of bleeding was achieved in 86% of cases (n: 15), the puncture was unique in 100% of cases (n: N: 14), pelvic packing was required in 2 patients (12%) Discussion Pelvic embolization for pelvic fracture is a safe and feasible procedure. A multidisciplinary approach and a high suspicion of pelvic arterial injury must be always in mind. Mortality in our trial was very low comparative with previous reports. Evidence Level: III

Rare origin of the obturator artery from the external iliac artery with two obturator veins / Origem rara de artéria obturatória a partir da artéria ilíaca externa acompanhada por duas veias obturatórias

Abstract The obturator artery is a branch of the internal iliac artery, although there are reports documenting variations, with origin from neighboring vessels such as the common iliac and external iliac arteries or from any branch of the internal iliac artery. It normally runs anteroinferiorly along the lateral wall of the pelvis to the upper part of the obturator foramen where it exits the pelvis by passing through said foramen. Along its course, the artery is accompanied by the obturator nerve and one obturator vein. It supplies the muscles of the medial compartment of the thigh and anastomoses with branches of the femoral artery on the hip joint. We report a rare arterial variation in a Brazilian cadaver in which the obturator artery arose from the external iliac artery, passing beyond the external iliac vein toward the obturator foramen, and was accompanied by two obturator veins with distinct paths. We also discuss its clinical significance.

Resumo A artéria obturatória é um ramo da artéria ilíaca interna, embora haja grande variabilidade a respeito de sua origem, pois tal vaso pode surgir de diversas artérias vizinhas, como a artéria ilíaca comum e a artéria ilíaca externa, assim de como qualquer ramo da artéria ilíaca interna. Normalmente, a artéria obturatória corre anteroinferiormente pela parede lateral da pelve até a porção superior do forame obturatório, ponto em que sai da pelve. No seu trajeto, a artéria é acompanhada pelo nervo e veia obturatórios. Ela supre os músculos do compartimento medial da coxa e possui anastomoses com ramos da artéria femoral na articulação do quadril e coxa. Este trabalho visa relatar e discutir os aspectos clínicos de uma variação incomum na artéria obturatória, na qual ela se origina da artéria ilíaca externa acompanhada de duas veias obturatórias com trajetos distintos.

Development of Advanced Atherosclerotic Plaque by Injection of Inflammatory Proteins in a Rabbit Iliac Artery Model

PURPOSE: Appropriate animal models of atherosclerotic plaque are crucial to investigating the pathophysiology of atherosclerosis, as well as for the evaluation of the efficacy and safety of vascular devices. We aimed to develop a novel animal model that would be suitable for the study of advanced atherosclerotic lesions in vivo. MATERIALS AND METHODS: Atherosclerotic plaque was induced in 24 iliac arteries from 12 rabbits by combining a high cholesterol diet, endothelial denudation, and injection into the vessel wall with either saline (n=5), olive oil (n=6), or inflammatory proteins [n=13, high-mobility group protein B1 (HMGB1) n=8 and tumor necrosis factor (TNF)-α n=5] using a Cricket™ Micro-infusion catheter. Optical coherence tomography (OCT) was performed to detect plaque characteristics after 4 weeks, and all tissues were harvested for histological evaluation. RESULTS: Advanced plaque was more frequently observed in the group injected with inflammatory proteins. Macrophage infiltration was present to a higher degree in the HMGB1 and TNF-α groups, compared to the oil or saline group (82.1±5.1% and 94.6±2.2% compared to 49.6±14.0% and 46.5±9.6%, p-value<0.001), using RAM11 antibody staining. On OCT, lipid rich plaques were more frequently detected in the inflammatory protein group [saline group: 2/5 (40%), oil group: 3/5 (50%), HMGB1 group: 6/8 (75%), and TNF-α group: 5/5 (100%)]. CONCLUSION: These data indicate that this rabbit model of atherosclerotic lesion formation via direct injection of pro-inflammatory proteins into the vessel wall is useful for in vivo studies investigating atherosclerosis.

Imaging Spectrum after Pancreas Transplantation with Enteric Drainage

Since the introduction of pancreas transplantation more than 40 years ago, surgical techniques and immunosuppressive regiments have improved and both have contributed to increase the number and success rate of this procedure. However, graft survival corresponds to early diagnosis of organ-related complications. Thus, knowledge of the transplantation procedure and postoperative image anatomy are basic requirements for radiologists. In this article, we demonstrate the imaging spectrum of pancreas transplantation with enteric exocrine drainage.

Aberrant Ovarian Artery Arising from the Common Iliac Artery: Case Report

A 46-year-old Vietnamese woman received embolization therapy in order to control postpartum hemorrhage. Angiography revealed an aberrant ovarian artery arising from the right common iliac artery. Superselective catheterization and subsequent embolization of the aberrant ovarian artery and bilateral uterine arteries were performed. Precise knowledge of the anatomic variations of the ovarian artery is important for successful embolization.

A Case of Lower Gastrointestinal Bleeding Caused by Primary Iliac Arterio-colic Fistula / 대한소화기학회지

Arterio-enteric fistula is a very rare cause of massive lower gastrointestinal hemorrhage. We report here on a case of massive hematochezia caused by iliac arterio-colic fistula in a 60-year-old woman who had a recent history of spinal surgery for herniated nucleus pulposus. Abdomen computed tomography showed the extravasation of radiocontrast media from right iliac artery encased by an intraabdominal abscess into the adjacent dilatated colon. Also, diagnostic angiography revealed the active extravasation of radiocontrast media via a fistula between right iliac artery and colon. Although successful endovascular exclusion of the fistula with stent graft and coils was performed, disseminated intravascular coagulation and multi-organ failure were developed.

Acute Embolic Occlusion of the Left Common Iliac Artery Treated With Intra-Arterial Thrombolysis and Percutaneous Thrombectomy

Acute embolic occlusion of the common iliac artery is a rare medical emergency that is not only limbthreatening, but also potentially life-threatening. Several treatment options exist for acute limb ischemia, although no treatment is clearly best. We report a case of acute embolic occlusion of the left common iliac artery in a patient with atrial fibrillation who was treated successfully using mechanical thrombectomy following intra-arterial thrombolysis.

Concurrent coronary, bilateral iliac and left renal artery direct stenting.

We describe a patient who underwent percutaneous coronary intervention combined with bilateral iliac and left renal artery angioplasty during the same sitting. Stenting of the coronary and peripheral arteries was performed employing the "direct stenting" technique. No complications occurred. The patient was discharged 2 days after the intervention and remains asymptomatic, leading a fully active life during 1 year of follow-up. To our knowledge, unstaged coronary stenting combined with direct stenting of the renal and both common iliac arteries has not been reported previously in India.

Aortic-common iliac bifurcation, a haemodynamic factor in the genesis of atherosclerosis: a radiographic study

Radiographic study of geometric anatomy of the aortic-common iliac bifurcation in 27 Nigerian male cadavers revealed a mean length of 5.1 cm for right common iliac artery and 5.4 cm for left common iliac artery. The take off angle of the left common iliac [mean 27.2 degrees] is more than that of the fight common iliac artery, [mean 25.2 degrees]. The mean of radius of curvature is greater on the left [3.6 cm] than the right [2.9 cm]. There is a positive correlation [r.= + 0.53] between the length of the left common iliac artery and the radius of curvature of the right common iliac artery whereas negative correlation [r = 0.95] between its length and take off angle and negative correlation [r = -0.64] between length of the right common iliac artery and take off angle of the left common iliac artery. Studies of the geometric radiographic anatomy of the aortic-common iliac bifurcation can be utilized to see whether a person is prone to occlusive vascular disease of the lower extremity even if no lesion is present at the time of investigation