Revascularization
of the internal iliac artery for critical lower limb ischemia treatment
(Portuguese
PDF version)
Hugsmaer
Pelicioni Filho1, Marcus Ageu Ribeiro Batista1,
George Carchedi Luccas2
1.
Resident physician, Universidade Estadual de Campinas (UNICAMP), Campinas,
SP, Brazil.
2. Professor, School of Medicine, Universidade Estadual de
Campinas (UNICAMP), Campinas, SP, Brazil.
Correspondence:
Hugsmaer Pelicioni Filho
Rua Pedro Vieira da Silva, 415/31 Bl. F
CEP 13080-570 - Campinas, SP
Brazil
E-mail: hugsmaer@uol.com.br
ABSTRACT
Patients
with aortoiliac occlusive disease and critical lower limb ischemia
depend on large collateral circulation to maintain limb viability,
in which the internal iliac artery plays a fundamental role. We
present a case report of critical left lower limb ischemia treatment
in a patient with ostial occlusion of the ipsilateral common iliac
artery and refilling of internal iliac artery, deep femoral artery
branches and supragenicular popliteal. Revascularization of internal
iliac was successfully performed after previous attempt of early-occluded
femoral-popliteal bypass graft. This procedure was able to reverse
limb critical ischemia by offering increased blood flow to the limb
through the collateral circuit that links the pelvis to the root
of the thigh. This is discussed in the literature review.
Key-words:
iliac artery, ischemia, artery occlusion.
Palavras-chave: artéria ilíaca, isquemia,
obstrução arterial.
J
Vasc Br 2004;3(2):161-4
Chronic
aortoiliac occlusive disease is known for causing lower limb (LL) ischemia
and erectile dysfunction. In these cases, the viability of lower limbs
is afforded by an appropriate collateral circulation network formed
by several arteries (internal mammary, intercostal, lumbar, and internal
iliac). Internal iliac artery, located near the deep femoral artery,
constitutes a collateral circuit that connects the pelvis to the root
of the thigh. A case of critical lower limb ischemia treated by revascularization
of the internal iliac artery is presented.
CASE
REPORT
A 52-year-old
male, smoker and alcoholic patient had been enduring lower limb claudication
for 13 years, and pain at rest in the left foot and leg for the last
4 months, with trophic lesion in the lateral and medial malleolus and
dorsum of foot. Physical examination (Table 1) showed absence of a femoral
and distal pulse in the left lower limb (LL), and femoral and popliteal
pulse in the right LL, with ankle-brachial index (ABI) of zero on the
left side and 0.7 on the right side. Mobility and sensitivity were preserved
in both limbs, which presented with lack of hair on the distal portion.
The arteriographic examination showed ostial occlusion of the left common
iliac artery, with refilling of the internal iliac, supragenicular popliteal,
and anterior tibial arteries, whereas the common iliac and femoral arteries
were contrasted on the right (Figure 1).
 Table
1 - Physical examination
|
|
| Pulse
|
Femoral
|
Popliteal
|
Posterior
Tibial |
Foot
|
ABI* |
 |
| Right
|
Present
|
Present
|
Absent
|
Absent
|
0.7 |
| Left
|
Absent
|
Absent |
Absent |
Absent
|
0.0 |
|
*ABI
= ankle-brachial index.
Figure
1 - Preoperative arteriographic examination.
Graft
from the right common femoral to the left infragenicular popliteal artery,
with inversion and anastomosis of the bilateral greater saphenous veins
was performed. Pain relief, palpable popliteal pulse, and ABI of 0.3
in the left LL were observed during the postoperative period. After
31 days, the patient sought medical care at the emergency room because
of the same symptoms presented in the preoperative period, i.e. intense
pain in the left leg and foot. Sensitivity and mobility were preserved
and low perfusion was present. The arteriographic examination showed
graft occlusion.
Due to the vein graft occlusion, a 6-mm extraanatomic dacron graft was
inserted from the right external iliac to the left internal iliac artery
(Figure 2). On the 1st postoperative day, the patient presented pain
relief with ABI of 0.58. After 5 months, there was total lesion recovery,
and non-limiting claudication.
Figure
2 - Graft from the right external iliac to the left internal iliac artery.
DISCUSSION
Considering
the chronic aortoiliac occlusive disease, the viability of the lower
limb is maintained if collateral circulation network can provide blood
flow to the affected region. This collateral circulation is composed
of two major components, a visceral and a parietal component. The visceral
component includes inferior and superior mesenteric arteries (branches
of the aorta), and inferior and middle hemorrhoidal arteries (branches
of the internal iliac artery). The parietal component is formed by internal
mammary (branch of the subclavian artery), intercostal, lumbar and middle
sacral (branches of the aorta), iliolumbar, superior and inferior gluteal,
obturator, internal pudendal (branches of the internal iliac artery),
deep circumflex iliac (branch of the external iliac artery) and, finally,
the circumflex arteries (branches of the deep femoral artery). The parietal
collateral arteries usually provide blood flow to the same side of the
body, and the visceral circulation provides blood flow to both sides.1
In this context, the internal iliac artery plays the essential role
of linking the abundant pelvic circulation to the root of the thigh,
supplying blood flow even to the popliteal region through the deep femoral
artery and its branches. The internal iliac artery receives blood flow
from the branches of the aorta and the contralateral iliac artery, and
sends this blood supply to the lower limbs mainly through its superior
gluteal, obturator and internal pudendal branches.2
In the case reported here, the popliteal and distal regions of the lower
limb benefited from the collateral circulation of the internal iliac
artery and the branches of the deep femoral artery.
The importance of internal iliac artery revascularization for the prophylaxis
of pelvic ischemia in patients who underwent vascular reconstructions
of the aortofemoral segment is widely spread in the literature. Occlusion
or nonrevascularization of the internal iliac artery may lead to visceral
and pelvic ischemia in few, but significant cases, resulting in vasculogenic
dysfunction and gluteal claudication, or even more severe and rare cases
of genital necrosis and intestinal ischemia. There are also studies
about internal iliac artery revascularization for the treatment of vasculogenic
dysfunction. Regarding the internal iliac artery revascularization for
the treatment of lower limb ischemia, there are few descriptions in
the literature. In these studies, the procedure includes aortoiliac
endarterectomy, aortopopliteal graft with reimplantation of the internal
iliac artery. However, there are not descriptions of the use of extraanatomical
graft. The use of an extraanatomical graft can spare the patient a procedure
with greater risk of sequelae and mortality by approaching the aorta
if aortoiliac endarterectomy or graft from the aorta is the procedure
of choice. Extraanatomical grafts are usually recommended in cases of
high-risk surgeries.3
In the case reported by the authors, an autologous vein graft was initially
attempted, since it offers greater patency and lower risk of infection
on a long-term basis if compared to synthetic prostheses. Additional
reasons for the use of an autologous vein graft were the length of the
graft and the fact that it would be placed across some articulations.
The advantages of the autologous vein graft mentioned above and the
reduced diameter (3 mm) of the veins explain the choice for this kind
of graft. The intense calcification of the supragenicular popliteal
artery observed in the intraoperative period made the performance of
the anastomosis extremely difficult. Therefore, distal anastomosis in
the infragenicular popliteal artery was carried out. Although the procedure
was performed in accordance with the technical requirements, the patient
presented early occlusion of the venous graft. This outcome is attributed
to the following factors: length of the graft; presence of two articulations
in the route of the graft (coxofemoral and knee); and reduced diameter
of the vein. A new attempt of popliteal artery revascularization below
the knee was rejected because it should be performed with the use of
prosthesis. The patency of distal graft placed across the knee articulation
is not satisfactory. The only option was internal iliac artery revascularization,
since it was the only trunk and proximal artery available. Toshiro et
al.4 have described a case of internal aortoiliac
endarterectomy in a patient with aortoiliac occlusive disease without
presence of contrast in the femoral arteries, which resulted in a primary
patency of 3 years up to the publication of the article. Batt et al.5
have reported 200 cases of internal iliac artery revascularization with
the use of synthetic bypass grafts or endarterectomy, which resulted
in successful treatment of critical lower limb ischemia. Menezes et
al.6 have described the internal iliac artery
revascularization for salvage of the amputation stump, and for treating
gluteal and genital ischemia.
The extraanatomical interposition graft from the right external iliac
artery to the left internal iliac was performed because of its lower
surgical risk. In this case, the hypothesis of performing a primary
suprapatelar amputation was also considered due to the morbidity of
this kind of surgical procedure, such as complications in the surgical
wound and 8 to 10% of mortality.7 However,
the internal iliac artery revascularization was considered a viable
and feasible choice. The postoperative outcome was satisfactory with
immediate pain relief and total lesion recovery in 5 months.
CONCLUSION
Taking
into consideration the results, we conclude that the internal iliac
artery revascularization is an alternative procedure that can provide
satisfactory results in cases of critical lower limb ischemia.
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