Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting

KwangJin Lee; Sungsin Cho; Hyangkyoung Kim; Jin Hyun Joh

doi:10.5758/vsi.230114

Original Article

Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting

KwangJin Lee¹, Sungsin Cho¹, Hyangkyoung Kim²

, and Jin Hyun Joh¹

Author Info ⁺

¹Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul,
²Department of Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, Korea

Correspondence to:

Jin Hyun Joh
Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
Tel: 82-2-440-6261
Fax: 82-504-082-3410
E-mail: jhjoh@khu.ac.kr
https://orcid.org/0000-0002-8533-6755

Received: November 17, 2023; Revised: January 23, 2024; Accepted: February 5, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Vasc Specialist Int (2024) 40:5

Published online February 23, 2024 https://doi.org/10.5758/vsi.230114

Article Tools

Share this article on :

Article Tools

Article Tools Split Viewer

Abstract

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

Purpose: Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to severe claudication or chronic limb-threatening ischemia. Stent placement for AIOD demonstrated excellent outcomes in terms of long-term patency. However, iliac artery rupture is the most fearful complication during the aortoiliac stenting (AIS). This study aimed to evaluate the incidence and risk factors of iliac artery rupture during AIS.
Materials and Methods: A retrospective review of consecutive patients with AIOD treated with AIS from 2009 to 2021 was completed. We excluded patients with instent restenosis. All types of stents, including self-expanding stent (SES), balloon-expandable stent (BES), or balloon-expandable covered stent (CS), were used. Angiographic characteristics and procedural outcomes were analyzed. Procedural success was defined as the residual stenosis <30%.
Results: A total of 242 patients (86.8% male; mean age 68.8±10.0 years) with de novo AIOD were treated with AIS. The procedural success rate was 100%. Rupture occurred in six patients (2.5%) and all ruptures were occurred in the external iliac artery (EIA). Stenting of the EIA and less calcified lesion were risk factors for iliac rupture (P=0.028). All cases of iliac artery rupture were successfully treated with the CSs. Overall primary patency rates were 98.0% and 93.4% at 12 and 36 months, respectively. Primary patency rates of SES, BES, and CS were 87.7%, 88.4%, and 100% at 36 months, respectively.
Conclusion: The incidence of iliac artery rupture during AIS was 2.5%. Stent placement in the less calcified lesion and EIA was a risk factor for rupture during AIS. Placement of the CS can be the straightforward solution in case of iliac artery rupture during AIS.

Keywords

Iliac artery, Stents, Angioplasty, Rupture, Risk factors

INTRODUCTION

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

Aortoiliac occlusive disease (AIOD) is widely prevalent and leads to severe claudication or chronic limb-threatening ischemia. Due to its comparable patency rate and lower morbidity than open surgery, endovascular treatment is widely used for steno-occlusive abdominal aorta and iliac artery disease [1-3]. However, there are still disadvantages because iliac artery rupture is one of the most fatal complications [4,5]. Retroperitoneal hemorrhage from an iliac artery is a potentially serious complication leading to hemorrhagic shock and death if not diagnosed early and treated promptly [6]. Therefore, it is important to anticipate the possibility of rupture and treat it appropriately when such a situation occurs.

Few studies have focused on the risk factors of iliac artery rupture following aortoiliac stenting (AIS) despite the wide use of stent placement in the iliac arteries. This study aimed to evaluate the incidence and risk factors for iliac artery rupture following AIS and to report the mid-term follow-up outcomes.

MATERIALS AND METHODS

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

1) Study design

From 2009 to 2021, consecutive patients who underwent AIS due to abdominal aortic and iliac arterial steno-occlusive disease were included in this study. Two vascular surgeons performed all procedures in a single center. Patients who underwent unilateral or bilateral AIS procedures and patients who underwent at least one follow-up were included. We excluded the patients with in-stent restenosis. Four patients who had missing medical records were excluded from this study. Additionally, two patients were transferred to another hospital after operation due to personal issues. Thus, we excluded a total of six patients in this study. Clinical data and images were retrospectively reviewed for all patients. The primary outcome was the incidence of iliac artery rupture and its associated risk factors. The secondary outcome was the primary patency and survival rate.

This study was approved by the Institutional Review Board of Kyung Hee University Hospital at Gangdong (IRB no. KHUH-2022-06-043). The Institutional Review Board waived the need for informed consent because of a lack of information on the participant’s identity. This study complied with the principles of the Declaration of Helsinki.

2) Procedure details

After femoral access was obtained under ultrasound guidance, heparin was given in doses up to 3,000 IU, and digital subtraction angiography was performed. In patients who underwent self-expanding stent (SES) placement, vessel preparation was performed using a balloon with a diameter equivalent to 50%-60% diameter of the original artery as reference diameter. Balloon inflation was maintained for a minimum of 1 minute. Following balloon dilatation, the stent was placed with the size of reference diameter. Post-ballooning was performed with a balloon 1 mm smaller than the reference diameter. In the case of balloon-expandable stent (BES), the sequence mentioned above was the same, but the post-ballooning process was omitted. Stent placement with a covered stent (CS) procedure was the same as the BES placement because balloon-expandable CS was used. Procedural success was defined as the residual stenosis <30% and no in-hospital major adverse events.

3) Management of rupture

When arterial rupture was found during the procedure, prompt balloon tamponade was done. The inevitable removal of the occluding balloon was needed due to the change of proper sheath for introducing CS or endograft limb. After the CS or endograft preparation, a suitable introducer sheath for the CS or endograft was inserted. A CS or limb endograft, 1 mm larger than the target artery diameter, was placed at the rupture site; post-ballooning was then done. Finally, we confirmed the rupture resolution with a completed angiogram.

4) Follow-up protocol

After the AIS procedure, all patients were evaluated clinically with physical examination and assessment of patients’ symptoms according to the Rutherford classification. The objective tests measuring ankle-brachial index (ABI) at rest were performed. If the patient had ischemic symptoms and ABI decreased more than 0.15, lower extremity computed tomography (CT)-angiography was done. Follow-up was performed at 1 month, 3 months, and then every 6 months for 2 years, and every 1 year thereafter. Physical examination was checked at follow-up, and ABI was performed before discharge and every year after that. A CT angiography was performed if the patient’s symptoms recurred and ABI decreased by more than 0.15 compared with the previous test.

5) Variables investigated

The incidence of iliac artery rupture was calculated on a per-patient basis. The following factors were analyzed to find out factors related to rupture: TASC (TransAtlantic Inter-Societal Consensus) classification [7], Calcium grade (grade 0, no calcification; grade 1, calcification circumference, 1˚-89˚; 2, 90˚-179˚; 3, 180˚-269˚; 4, 270˚-360˚) [8], stent type (BES versus SES), implementation of pre- and post-stent balloon inflation, and post-ballooning diameter (more than or less than 7 mm).

6) Statistical analysis

Continuous data are shown as mean after the normality test (Kolmogorof-Smirnov and Levene tests). Discrete data are shown as counts and percentages. The Chi-square test (or Fisher exact test) and independent-sample t-test were used to compare the ruptured and non-ruptured groups. Continuity correction with the Bonferroni test was done before the Chi-square test. The cumulative primary patency rate after AIS was estimated using Kaplan-Meier methods with the log-rank test. Findings were considered significant if the P-value was less than 0.05. Medcalc version 20.110 software was used for Kaplan-Meier methods, and all other statistical tests were performed using SPSS for Windows version 23.0 software (IBM Corp.).

RESULTS

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

1) Baseline patient characteristics

During the study, a total of 248 patients underwent stenting of abdominal aorta and iliac arteries with steno-occlusive diseases. Among them, six patients were excluded due to follow-up loss or missing medical records. Therefore, 242 patients (male, 86.8%; mean age, 68.8±10.0 years) were analyzed for this study (Fig. 1). Bilateral iliac artery stenting was performed in 22 patients. Associated comorbidities included hypertension in 181 patients (74.8%), diabetes in 117 patients (48.3%), cerebrovascular disease in 56 patients (23.1%), coronary artery disease in 37 patients (15.3%), dyslipidemia in 32 patients (13.2%), renal disease in 25 patients (10.3%), and chronic obstructive pulmonary disease in 10 patients (4.1%). A history of smoking was noted in 44 patients (18.2%), whereas 62 patients (25.6%) were current smokers. Among 242 patients, 162 patients were treated with the SES and 80 patients with BES. Five patients used CS, and one patient used the limb endograft for the bailout procedure after rupture. Patient characteristics are summarized in Table 1.

Table 1 . Baseline patient characteristics.

Factors	Total	Patient groups		P-value^a

		Unruptured	Ruptured
Number of patients	242 (100)	236 (97.5)	6 (2.5)
Age (y)	68.8±10.0	68.8±10.0	66.7±8.5	0.617
Sex				0.801
Male	210 (86.8)	205 (86.9)	5 (83.3)
Female	32 (13.2)	31 (13.1)	1 (16.7)
Number of iliac arteries^b	264 (100)	258 (97.7)	6 (2.3)
Diabetes	117 (48.3)	115 (48.7)	2 (33.3)	0.456
Hypertension	181 (74.8)	176 (74.6)	5 (83.3)	0.626
Coronary artery disease	37 (15.3)	36 (15.3)	1 (16.7)	0.924
Cerebrovascular disease	56 (23.1)	55 (23.3)	1 (16.7)	0.703
COPD	10 (4.1)	10 (4.2)	0 (0.0)	0.607
Dyslipidemia	32 (13.2)	31 (13.1)	1 (16.7)	0.801
Renal diseasec	25 (10.3)	25 (10.6)	0 (0.0)	0.400
Smoking				0.603
None	136 (56.2)	133 (56.4)	3 (50.0)
Ex-smoker	44 (18.2)	42 (17.8)	2 (33.3)
Current smoker	62 (25.6)	61 (25.8)	1 (16.7)
Laboratory results
Hemoglobin (g/dL)	13.2±2.1	13.2±2.1	13.7±2.2	0.573
Platelet (×10³/μL)	245.3±79.3	246.8±78.3	179.2±101.1	0.038
Albumin (g/dL)	4.0±0.5	4.0±0.5	4.3±0.5	0.115
PT (INR)	1.0±0.1	1.0±0.1	0.98±0.04	0.318
aPTT (seconds)	35.6±15.7	35.7±15.9	31.1±3.4	0.486
Preoperative antiplatelet	41 (16.9)	41 (17.4)	0 (0.0)	0.324
Preoperative anticoagulation	5 (2.1)	5 (2.1)	0 (0.0)	0.881

Values are presented as number (%) or mean±standard deviation..

COPD, chronic obstructive pulmonary disease; PT, prothrombin time; INR, international normalized ratio; aPTT, activated partial thromboplastin time..

aChi-square test or Fisher exact test was used (except laboratory results which were analyzed with independent samples t-tests). bBilateral iliac artery stenting was performed in 22 patients. cRenal disease was defined as the estimated glomerular filtration rate <15 mL/min/1.73 m2 or dialysis-dependent state..

Figure 1.Flow diagram.

2) Incidence of rupture

Iliac artery rupture occurred in six patients (2.5%). Fig. 2 demonstrates typical cases of iliac artery rupture and its management. All ruptures were detected by intraoperative angiography (Fig. 2A). All ruptures were managed with a CS or limb endograft, and completion angiography showed successful control of bleeding (Fig. 2B). The CS was used in five patients with iliac artery rupture. A limb endograft was used in one patient (Table 2). After the bail-out procedure for iliac artery rupture, the access site was successfully closed with the percutaneous closure device in all cases.

Table 2 . Details of patients with iliac artery rupture.

Number	Age/sex	Rupture site	Calcification grade^a	Rupture-related device	Stent or balloon diameter (mm)	Post-balloon diameter (mm)	Management of rupture
1	73/female	EIA	0	SES	9	8	Covered stent
2	64/male	EIA	1	SES	9	8	Covered stent
3	81/male	EIA	1	SES	8	7	Endograft
4	60/male	EIA	2	SES	9	8	Covered stent
5	62/male	EIA	0	SCB	7	7	Covered stent
6	60/male	EIA	1	SES	8	7	Covered stent

EIA, external iliac artery; SES, self-expandable stent; SCB, semi-compliant balloon..

aCalcification grade was classified with the presence of circumferential calcium in one or more of the four 90 sectors: grade 0 (no calcification), grade 1 (0-90), grade 2 (0-180), grade 3 (0-270), and grade 4 (0-360)..

Figure 2.Iliac artery rupture and management. Images were taken of iliac artery rupture (A) (arrows) and its management (B) in four patients. Patient 1: right external iliac artery rupture at post-ballooning with 8 mm balloon catheter after placement of 9 mm self-expandable stent (Absolute Pro; Abbott) and managed with 9 mm covered stent (Viabahn; Gore). Patient 2: right external iliac artery rupture at post-ballooning with 9 mm balloon catheter (Armada; Abbott) after placement of 9 mm self-expandable stent and managed with 9 mm covered stent (Lifestream; BD). Patient 3: right external iliac artery rupture at ballooning with a 7 mm balloon catheter and managed with a 7 mm covered stent (Covera; BD). Patient 4: left external iliac artery rupture at post-ballooning with 7 mm balloon catheter (Mustang; Boston Scientific) after placement of 7 mm self-expandable stent (Absolute Pro; Abbott) and managed with 7 mm covered stent (Lifestream; BD).

3) Risk factor for rupture

There were no significant differences between the ruptured and non-ruptured groups in terms of sex (P=0.801), age (P=0.617), diabetes (P=0.456), hypertension (P=0.626), coronary artery disease (P=0.924), cerebrovascular disease (P=0.703), chronic obstructive pulmonary disease (P=0.703), dyslipidemia (P=0.801), renal disease (P=0.400), and smoking status (P=0.603). Preoperative platelet count significantly differed when comparing the rupture and non-rupture groups (P=0.038). In contrast, others, including hemoglobin, albumin, prothrombin time (PT), and activated partial thromboplastin time (aPTT), showed no significant difference between the groups (P>0.05; Table 1).

In the analysis based on stent type, among 162 patients treated with the SES, six experienced ruptures whereas no rupture occurred in the 80 patients treated with BES. In all six patients with ruptures, the rupture site was the external iliac artery (EIA) (Table 2). Four patients soly experienced rupture during the treatment in the EIA, while the remaining two patients ruptured during stent placement from the common iliac to the EIA.

The TASC classification of the ruptured patient group was one (16.7%) type A, one (16.7%) type B, 0 (0.0%) type C, and four (66.7%) type D lesions. Regarding the TASC classification, there was no statistical significance (P=0.720). The calcification grade, which was classified with a degree of luminal calcification, showed statistical significance that the risk of rupture would increase if there was little or no calcification (P=0.028; Table 3). Table 4 demonstrated the pre-balloon, stents, and post-balloon diameters between unruptured and ruptured patients. The mean diameter of pre-balloon, stents, and post-balloon were 5.9±1.3 mm, 9.1±1.3 mm, and 7.8±1.1 mm, respectively. There was no statistical significance of iliac artery rupture depending on the diameter of the balloon and stents.

Table 3 . TASC classification and calcium grade of rupture and non-rupture patients.

Factors	Total	Patient groups		P-value^a

		Unruptured	Ruptured
TASC classification	(n=242)	(n=236)	(n=6)	0.720
A	45 (18.6)	44 (18.6)	1 (16.7)
B	76 (31.4)	75 (31.8)	1 (16.7)
C	24 (9.9)	24 (10.2)	0 (0.0)
D	97 (40.1)	93 (39.4)	4 (66.7)
Calcification grade^b	(n=264)	(n=258)	(n=6)	0.028
0	16 (6.1)	14 (5.4)	2 (33.3)
1	77 (29.2)	74 (28.7)	3 (50.0)
2	56 (21.2)	55 (21.3)	1 (16.7)
3	67 (25.4)	67 (26.0)	0 (0.0)
4	48 (18.2)	48 (18.6)	0 (0.0)

Values are presented as number (%)..

TASC, TransAtlantic Inter-Societal Consensus..

^aFisher exact test was used to analyze the risk factors. ^bCalcification grade was classified with the presence of circumferential calcium in one or more of the four 90 sectors: grade 0 (no calcification), grade 1 (0-90), grade 2 (0-180), grade 3 (0-270), and grade 4 (0-360)..

Table 4 . Diameter of pre-balloon, stents, and post-balloon.

Factors	Total	Patient groups		P-value^a

		Unruptured	Ruptured
Pre-balloon (mm) (n=187)	5.9±1.3	5.9±1.3	5.3±1.1	0.285
≤4	21 (11.2)	20 (95.2)	1 (4.8)	0.453
≥5	166 (88.8)	161 (97.0)	5 (3.0)	0.930
≥6	71 (38.0)	71 (100)	0 (0.0)	0.066
Stents (mm) (n=250)	9.1±1.3	9.1±1.3	8.3±0.8	0.146
≤7	16 (6.4)	15 (93.7)	1 (6.3)	0.330
≥8	234 (93.6)	229 (97.9)	5 (2.1)	0.330
≥9	168 (67.2)	165 (98.2)	3 (1.8)	0.214
Post-balloon (mm) (n=163)	7.8±1.1	7.8±1.1	7.8±0.8	0.923
≤7	65 (39.9)	63 (96.9)	2 (3.1)	0.664
≥8	97 (59.5)	94 (96.9)	3 (3.1)	0.683
≥9	30 (18.4)	29 (96.7)	1 (3.3)	0.643

Values are presented as number (%) or mean±standard deviation..

^aChi-square test was used (except continuous variables of diameter of balloon and stents which were analyzed with independent samples t-tests)..

4) Outcomes

There was no in-hospital or early mortality associated with rupture. Preoperative ABI was 0.73±0.23. Postoperative ABI increased with 1.01±0.18 (P<0.01). Follow-up ABIs were measured as 1.01±0.17, 1.01±0.19, and 1.03±0.21 at 1, 2, and 3 years, respectively (P<0.01). The overall primary patency rates were 98.0% and 93.4% at 12 and 36 months, respectively. The primary patency rates at 3 years according to stent type were 87.7%, 88.4%, and 100% for BES, SES, and CS, respectively. The primary patency rates at 1 and 3 years were 98.9% and 93.3% in the non-rupture group and 100% and 100% in the rupture group, respectively. The survival rates at 1 and 3 years were 97.0% and 91.8% in the non-rupture group and 100% and 100% in the rupture group, respectively. There were no significant differences in primary patency and overall survival rates between the rupture and non-rupture groups (P=0.88 for primary patency and P=0.57 for overall survival; Fig. 3).

Figure 3.Primary patency rate and overall survival rate.

DISCUSSION

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

For patients with AIOD, a range of surgical and endovascular treatment options are available. Primary stenting of the AIOD showed excellent long-term patency with decreased morbidity compared with open surgical procedures [9]. However, fatal complications of iliac artery rupture might be encountered during the endovascular procedures, although it uncommonly occurs. Reported rupture prevalence during iliac intervention ranged from 0.8% to 0.9% [10,11]. Awareness of the risk factors for rupture is important for preparing for rupture and thereby avoiding catastrophic consequences. Previous literature suggested luminal calcification, oversized balloon use, manual overinflation without manometric control, recent endarterectomy, diabetes mellitus, and corticosteroid use as risk factors [10,12-14].

Only a few reports dealt with the anatomic location prone to rupture during AIS. In our series, all of the ruptures occurred in the EIA. In addition, several reports showed ruptures in the EIA [15,16]. Firstly, the high risk of rupture in the EIA can be explained by its anatomical characteristics. The EIA is more curved and tortuous than the common iliac artery. The stent strut can likely penetrate through the arterial wall when the stent is inserted. Second, access sheaths can cause injury to the EIA when the retrograde approach is used for AIS [17]. Third, if the occluded lesion is an EIA, partial entry could be obtained through the subintimal space by the guidewire for recanalization. In this case, a stent is inserted into the subintimal space and compressed eccentrically by the plaque and thrombus in the true lumen, increasing the fragility of the artery [18]. Iliac artery ruptures have been reported in some studies by Fernandez et al. [19] in a single-center, single-surgeon experience with endovascular aneurysm repair and thoracic endovascular aortic repair.

An interesting result was obtained through this study, which was that the lower the calcification, the higher the risk of rupture. Generally, it is known that the more calcification, the higher the risk of iliac artery rupture [19-21]. The first reason for our result may be that the reported number of ruptures is too small, so the sample can lack sufficient power to generalize the results to the population. Second, if the calcification is severe, there can be a tendency not to attempt ballooning aggressively during the procedure. Therefore, calcification may act as a kind of confounding bias. Third, a small diameter of the target iliac artery can influence the rupture. Diameters of iliac artery ruptures were 7 mm in one patient, 8 mm in two patients, and 9 mm in three patients.

The endovascular management of iliac artery rupture was very successful in this study. Even with rupture, endovascular treatment has advantages over open surgery because it does not require the clamping of blood vessels and sutures of calcified vessels [22]. Several endovascular techniques can be utilized for iliac artery rupture, such as balloon tamponade, a coagulated thrombus injection, and stent graft placement [17,19,23-25]. If the rupture was confirmed during the procedure, temporary hemostasis should be performed through a balloon tamponade while preparing the CS or endograft, which has been mentioned in previous studies as well [26,27]. All ruptures were successfully managed without any rebleeding or complications throughout the follow-up. The successful results could be attributed to the fact that all ruptures were detected intraoperatively. There was no statistical difference in the primary patency rate and overall survival rate between ruptured and non-ruptured groups.

There are several limitations in our study. First, this study was a retrospective design. Factors that could be risk factors for rupture such as the duration of pre-ballooning and applied pressure were not used in this study due to many missing medical records. Second, there were only six patients with ruptures. A large-scale study is needed in the future. Nevertheless, we believed that our research had strength in that this study focused on the rupture during AIS, that has rarely been dealt with previously.

CONCLUSIONS

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

In this study, the prevalence of iliac artery rupture during AIS was 2.5%. Stent placement in the EIA and lower calcified lesion can be a risk factor for rupture. The preparation of CS or endograft is needed before AIS when the patient has a high-risk factor for iliac artery rupture.

FUNDING

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

None.

CONFLICTS OF INTEREST

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

The authors have nothing to disclose.

AUTHOR CONTRIBUTIONS

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

Concept and design: all authors. Analysis and interpretation: all authors. Data collection: KJL, SC, JHJ. Writing the article: all authors. Critical revision of the article: all authors. Final approval of the article: all authors. Statistical analysis: all authors. Obtained funding: none. Overall responsibility: all authors.

References

Go to

Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
FUNDING
CONFLICTS OF INTEREST
AUTHOR CONTRIBUTIONS
References

Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45(Suppl S):S5-S67. https://doi.org/10.1016/j.jvs.2006.12.037.
Leville CD, Kashyap VS, Clair DG, Bena JF, Lyden SP, Greenberg RK, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg 2006;43:32-39. https://doi.org/10.1016/j.jvs.2005.09.034.
Ahmad FA, Hennessy MM, Nath AF. Fate of asymptomatic limb after kissing stents in aortoiliac occlusive disease. Vasc Specialist Int 2022;38:7. https://doi.org/10.5758/vsi.210074.
Belli AM, Cumberland DC, Knox AM, Procter AE, Welsh CL. The complication rate of percutaneous peripheral balloon angioplasty. Clin Radiol 1990;41:380-383. https://doi.org/10.1016/s0009-9260(05)80595-1.
Moniaci D, Maiorano F, Corrado F. Bilateral iliac endobypass solution in iliac artery rupture during TEVAR procedure: a case report and review of the literature. Vasc Specialist Int 2022;38:35. https://doi.org/10.5758/vsi.220042.
Asensio JA, Petrone P, Roldán G, Kuncir E, Rowe VL, Chan L, et al. Analysis of 185 iliac vessel injuries: risk factors and predictors of outcome. Arch Surg 2003;138:1187-1193; discussion 1193-1194. https://doi.org/10.1001/archsurg.138.11.1187.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 2007;33 Suppl 1:S1-S75. https://doi.org/10.1016/j.ejvs.2006.09.024.
Fanelli F, Cannavale A, Gazzetti M, Lucatelli P, Wlderk A, Cirelli C, et al. Calcium burden assessment and impact on drug-eluting balloons in peripheral arterial disease. Cardiovasc Intervent Radiol 2014;37:898-907. https://doi.org/10.1007/s00270-014-0904-3.
Sachwani GR, Hans SS, Khoury MD, King TF, Mitsuya M, Rizk YS, et al. Results of iliac stenting and aortofemoral grafting for iliac artery occlusions. J Vasc Surg 2013;57:1030-1037. https://doi.org/10.1016/j.jvs.2012.09.038.
Allaire E, Melliere D, Poussier B, Kobeiter H, Desgranges P, Becquemin JP. Iliac artery rupture during balloon dilatation: what treatment? Ann Vasc Surg 2003;17:306-314. https://doi.org/10.1007/s10016-001-0404-1.
Palmaz JC, Laborde JC, Rivera FJ, Encarnacion CE, Lutz JD, Moss JG. Stenting of the iliac arteries with the Palmaz stent: experience from a multicenter trial. Cardiovasc Intervent Radiol 1992;15:291-297. https://doi.org/10.1007/BF02733953.
Lois JF, Takiff H, Schechter MS, Gomes AS, Machleder HI. Vessel rupture by balloon catheters complicating chronic steroid therapy. AJR Am J Roentgenol 1985;144:1073-1074. https://doi.org/10.2214/ajr.144.5.1073.
Creasy TS, McMilan PM. False aneurysm after percutaneous transluminal angioplasty. Br J Surg 1987;74:1069. https://doi.org/10.1002/bjs.1800741149.
Rizk T, Patel D, Young E, Ramakrishnan V, Mansour K. Multidisciplinary management of subclavian artery perforation and complications. Cureus 2020;12:e8009. https://doi.org/10.7759/cureus.8009.
Shah SK, Parodi FE, Eagleton MJ, Bena JF, Clair DG. Iliac injury during abdominal and thoracic aortic endovascular intervention. J Vasc Surg 2016;64:726-730. https://doi.org/10.1016/j.jvs.2016.04.037.
Chatziioannou A, Mourikis D, Katsimilis J, Skiadas V, Koutoulidis V, Katsenis K, et al. Acute iliac artery rupture: endovascular treatment. Cardiovasc Intervent Radiol 2007;30:281-285. https://doi.org/10.1007/s00270-005-0357-9.
Rizk T, Patel D, Dimitri NG, Mansour K, Ramakrishnan V. Iatrogenic arterial perforation during endovascular interventions. Cureus 2020;12:e10018. https://doi.org/10.7759/cureus.10018.
Higashiura W, Kubota Y, Sakaguchi S, Kurumatani N, Nakamae M, Nishimine K, et al. Prevalence, factors, and clinical impact of self-expanding stent fractures following iliac artery stenting. J Vasc Surg 2009;49:645-652. https://doi.org/10.1016/j.jvs.2008.10.019.
Fernandez JD, Craig JM, Garrett HE Jr, Burgar SR, Bush AJ. Endovascular management of iliac rupture during endovascular aneurysm repair. J Vasc Surg 2009;50:1293-1299; discussion 1299-1300. https://doi.org/10.1016/j.jvs.2009.06.020.
Motarjeme A, Keifer JW, Zuska AJ. Percutaneous transluminal angioplasty of the iliac arteries: 66 experiences. AJR Am J Roentgenol 1980;135:937-944. https://doi.org/10.2214/ajr.135.5.937.
Connolly JE, Kwaan JH, McCart PM. Complications after percutaneous transluminal angioplasty. Am J Surg 1981;142:60-66. https://doi.org/10.1016/S0002-9610(81)80013-X.
Duran C, Naoum JJ, Smolock CJ, Bavare CS, Patel MS, Anaya-Ayala JE, et al. A longitudinal view of improved management strategies and outcomes after iatrogenic iliac artery rupture during endovascular aneurysm repair. Ann Vasc Surg 2013;27:1-7. https://doi.org/10.1016/j.avsg.2012.04.017.
Kufner S, Cassese S, Groha P, Byrne RA, Schunkert H, Kastrati A, et al. Covered stents for endovascular repair of iatrogenic injuries of iliac and femoral arteries. Cardiovasc Revasc Med 2015;16:156-162. https://doi.org/10.1016/j.carrev.2015.02.007.
Awan MU, Omar B, Qureshi G, Awan GM. Successful treatment of iatrogenic external iliac artery perforation with covered stent: case report and review of the literature. Cardiol Res 2017;8:246-253. https://doi.org/10.14740/cr596w.
Hamilos MI, Kochiadakis GE, Hatzidakis AA, Vardas PE. Treatment of a large rupture of the external iliac artery by implantation of a coated metal stent. Hellenic J Cardiol 2005;46:354-355.
Nyman U, Uher P, Lindh M, Lindblad B, Brunkwall J, Ivancev K. Stent-graft treatment of iatrogenic iliac artery perforations: report of three cases. Eur J Vasc Endovasc Surg 1999;17:259-263. https://doi.org/10.1053/ejvs.1998.0589.
Scheinert D, Ludwig J, Steinkamp HJ, Schröder M, Balzer JO, Biamino G. Treatment of catheter-induced iliac artery injuries with self-expanding endografts. J Endovasc Ther 2000;7:213-220. https://doi.org/10.1177/152660280000700308.

Article

Original Article

Vasc Specialist Int (2024) 40:5

Published online February 23, 2024 https://doi.org/10.5758/vsi.230114

Incidence and Risk Factors of Iliac Artery Rupture during Aortoiliac Stenting

KwangJin Lee¹, Sungsin Cho¹, Hyangkyoung Kim² , and Jin Hyun Joh¹

¹Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul,
²Department of Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, Korea

Correspondence to:Jin Hyun Joh
Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
Tel: 82-2-440-6261
Fax: 82-504-082-3410
E-mail: jhjoh@khu.ac.kr
https://orcid.org/0000-0002-8533-6755

Received: November 17, 2023; Revised: January 23, 2024; Accepted: February 5, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.