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• W2056545673 abstract "Arterial rupture after transluminal balloon angioplasty is a life-threatening event, reported to occur in 0.8%–0.9% of cases (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar). Acute, sharp, or unremitting pain may be indicative of arterial rupture. Contrast medium extravasation is diagnostic of arterial rupture (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar). Urinary bladder displacement is an indirect sign of rupture of the iliac arteries (2Lois J.F. Takiff H. Schechter M.S. Gomes A.S. Machleder H.I. Vessel rupture by balloon catheters complicating chronic steroid therapy.AJR Am J Roentgenol. 1985; 144: 1073-1074Crossref PubMed Scopus (27) Google Scholar). Late presentations include the development of pseudoaneurysm (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar) or delayed rupture with shock (3Puijlaert C.B. Mali W.P. Rosenbusch G. van Straalen A.M. Klinge J. Feldberg M.A. Delayed rupture of the renal artery after renal percutaneous transluminal angioplasty.Radiology. 1986; 159: 635-637PubMed Google Scholar). Arterial rupture after percutaneous transluminal angioplasty (PTA) has been linked to guide wire perforation (3Puijlaert C.B. Mali W.P. Rosenbusch G. van Straalen A.M. Klinge J. Feldberg M.A. Delayed rupture of the renal artery after renal percutaneous transluminal angioplasty.Radiology. 1986; 159: 635-637PubMed Google Scholar), the use of an oversize balloon (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar), the use of a cutting balloon (4Maruo T. Yasuda S. Miyazaki S. Delayed appearance of coronary artery perforation following cutting balloon angioplasty.Catheter Cardiovasc Interv. 2002; 57: 529-531Crossref PubMed Scopus (30) Google Scholar), recanalization of occlusions and high-grade stenoses associated with heavily calcified arteries (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar), recent endarterectomy (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar), and steroid therapy (2Lois J.F. Takiff H. Schechter M.S. Gomes A.S. Machleder H.I. Vessel rupture by balloon catheters complicating chronic steroid therapy.AJR Am J Roentgenol. 1985; 144: 1073-1074Crossref PubMed Scopus (27) Google Scholar). Treatment consists of gently reinflating the balloon across or proximal to the injury to temporarily stop the leakage (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar). Definitive control of persistent hemorrhage is accomplished with either placement of a stent-graft or surgical repair (1Allaire E. Melliere D. Poussier B. Kobeiter H. Desgranges P. Becquemin J.P. Iliac artery rupture during balloon dilatation: what treatment?.Ann Vasc Surg. 2003; 17: 306-314Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar). Delayed ruptures have been reported after angioplasty of the renal (3Puijlaert C.B. Mali W.P. Rosenbusch G. van Straalen A.M. Klinge J. Feldberg M.A. Delayed rupture of the renal artery after renal percutaneous transluminal angioplasty.Radiology. 1986; 159: 635-637PubMed Google Scholar) and coronary (4Maruo T. Yasuda S. Miyazaki S. Delayed appearance of coronary artery perforation following cutting balloon angioplasty.Catheter Cardiovasc Interv. 2002; 57: 529-531Crossref PubMed Scopus (30) Google Scholar) arteries. The purpose of this letter is to report a rupture of the external iliac artery 12 hours after PTA and stent placement despite an unremarkable control arteriogram and an apparently uneventful immediate postinterventional period. A 68-year-old man with a history of heavy smoking and apparently controlled high blood pressure presented with a nonhealing ischemic right leg ulcer. The arteriogram showed occlusion of the right superficial femoral artery. A polytetrafluoroethylene bypass graft was put in place from the right common femoral artery to the popliteal artery below the knee. At 10-month follow-up, the leg ulcer had recurred and the femoral pulse was absent. The femoropopliteal bypass was occluded. Computed tomographic (CT) arteriography showed narrow and calcified stenotic iliac arteries and occlusion of the right external iliac artery (Fig 1). It was decided to recanalize the right external iliac artery in the operating room with a portable digital imaging system (BV Endura; Philips, Eindhoven, the Netherlands). General anesthesia was chosen because this procedure could be lengthy and, should it fail, a femorofemoral bypass graft would be put in place straightaway. Urinary bladder catheterization was not successful. Left retrograde common femoral puncture was done and a 6-F introducer inserted. Unfractioned heparin (5,000 units) was administered intravenously. Digital subtraction arteriography showed total occlusion of the right external iliac artery. Unlike on the CT arteriogram, the right common femoral artery was not visualized and reconstitution occurred at the profunda femoris artery. The lesion was crossed with use of the crossover approach, with a straight 0.035-inch stiff Glidewire (Terumo, Tokyo, Japan) and a J-curve III catheter (Cordis, Miami, Fla). A subintimal passage was chosen, as the Glidewire was advanced with resistance and in a large loop configuration. Reentry into the true lumen was achieved at the origin of the profunda femoris artery. The Glidewire was exchanged for an Amplatz Super Stiff guidewire (Boston Scientific, Natick, MA) and the introducer for a 45-cm-long guiding sheath (Destination; Terumo), which was advanced across the aortic bifurcation to the origin of the right common iliac artery. The lesion was predilated with a 6 × 100-mm balloon (Powerflex P3; Cordis). Three overlapping self-expanding stents—two measuring 8 × 80 mm and one measuring 9 × 80 mm (SMART stent; Cordis)—were deployed from the proximal profunda femoris artery to the distal common iliac artery. Then, dilation was carried out with balloons (Powerflex P3; Cordis), which were inflated to 5 × 40 mm at the profunda femoris and 7 × 40 mm at the common femoral and iliac arteries. The balloon size was chosen by juxtaposing the image of the inflated 6-mm balloon to the image of the artery. Completion arteriography in an anteroposterior view showed good flow without residual stenosis or contrast medium extravasation (Fig 2). The urinary bladder was filled with contrast medium and was not displaced to the side. Finally, débridement of the leg ulcer was performed. The patient was stable throughout this 2-hour-long procedure. When the patient was waking from the anesthesia, there was a brief drop in blood pressure to 70–50 mm Hg, which responded promptly to saline infusion. Heart rate was unchanged. At the end, a bladder catheter was put in place and drained approximately 2 L of clear urine. The leg ulcer dressing was changed twice due to blood oozing. Ulcer pain was controlled with intravenous acetaminophen. The abdomen and thigh were painless. A drop in hemoglobin level, from 11.7 g/dL (117 g/L) before the procedure to 9.3 g/dL (93 g/L) after the procedure, necessitated transfusion of 1 unit of packed red cells, which was effective in increasing the hemoglobin level to 10.2 g/dL (102 g/L). Blood pressure and heart rate were stable overnight. Unexpectedly, 12 hours after PTA, the blood pressure dropped to 70–50 mm Hg, the heart rate increased to 130 beats per minute, and the patient lost consciousness (Fig 3). A large bulging mass, hitherto unnoticed, was observed in the right lower abdominal quadrant. The repeat hemoglobin level was 6.2 g/dL (62 g/L). Rupture of the right iliac artery with the stent was strongly suspected. Interventional radiology facilities were not readily available, and the patient underwent emergency open surgery. Laparotomy revealed a massive right lower quadrant retroperitoneal hematoma. The aorta was cross clamped below the renal arteries. There was a 1-cm-wide tear in the middle of the anterior wall of the right external iliac artery, at the 8 × 80- and 9 × 90-mm stent overlap. These stents were trimmed to enable ligation of the artery. After unclamping the aorta, the left iliac artery was found to be thrombosed. It was decided to put an aortobifemoral bypass graft in place. Despite achieving hemorrhage control, the patient died 2 days later from multiple organ failure.Figure 2Control arteriogram obtained after stent placement in the external iliac, common femoral, and profunda femoris arteries. A good result was obtained: There is no residual stenosis, contrast medium extravasation, or displacement of the urinary bladder.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Graph shows the time course of the blood pressure and heart rate during and after PTA. Notice the brief drop in blood pressure immediately after PTA. The patient was stable in the postinterventional period until the abrupt onset of shock 12 hours later.View Large Image Figure ViewerDownload Hi-res image Download (PPT) On reflection, there had been two possible early warning signs of bleeding: the brief postinterventional hypotension and the drop in hemoglobin level. We did not believe that there was reason for concern because (a) the control arteriogram was unremarkable; (b) the hypotension was short-lived, without tachycardia, and recovered promptly with saline infusion; (c) there were causes for the decrease in hemoglobin level (blood loss during catheter handling and ulcer oozing after revascularization and débridement); (d) the patient did not have pain at the angioplasty location; (e) the vital signs were stable; and (f) the blood transfusion was effective in increasing the hemoglobin level. The late onset of the rupture could have been due to the continuous expansion and radial force exercised by the stents, which further stretched the weakened arterial wall, eventually causing it to burst. This could have gone unrecognized on the control arteriogram because the distended urinary bladder might have contained the arterial tear. Even after drainage of the bladder, however, the patient was stable for 12 hours. An enlarged urinary bladder can cause a pressure effect on adjacent structures in the pelvis and induce iliac vein extrinsic compression (5Evans J.M. Owens Jr, T.P. Zerbe D.M. Rohren C.H. Venous obstruction due to a distended urinary bladder.Mayo Clin Proc. 1995; 70: 1077-1079Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar). Last, patient movement might have disturbed a contained rupture because the onset of shock took place in the morning, after a quiet night. A few lessons can be learned from this case: (a) local anesthesia may be preferable to avoid abolishing patient pain, which is a warning sign of arterial rupture; (b) in patients with chronic distended urinary bladder and in lengthy procedures involving the iliac vessels, it is important to catheterize the urinary bladder; (c) in subintimal recanalization of occluded arteries, it may be advantageous to undersize balloon and stent diameters (in this case to 6 and 7 mm, respectively); (d) even a satisfactory control arteriogram, absence of pain, and stable vital signs do not rule out the possibility of a delayed arterial rupture; and (e) if there is a decrease in hemoglobin level, consider performing CT even if there are other potential causes of bleeding." @default.
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• W2056545673 title "Delayed Rupture of the External Iliac Artery after Balloon Angioplasty and Stent Placement" @default.
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