Persistent Buttock Claudication After Endovascular Abdominal Aortic

Case Report

AORTA, December 2017, Volume 5, Issue 6:173-176 Received: March 20, 2017 DOI: https://doi.org/10.12945/j.aorta.2017.17.036 Accepted: April 15, 2017 Published online: December 2017

Persistent Buttock Claudication after Endovascular Abdominal Aortic Aneurysm Repair A Surgical Solution Alessandro Robaldo, MD*, Stefano Pagliari, MD, Filippo Piaggio, MD, Patrizio Colotto, MD Vascular and Endovascular Surgery Unit, Imperia Hospital, Imperia, Italy

Abstract The English literature contains conflicting reports of We describe the successful surgical treatment of a the incidence and severity of symptoms. While many 71-year-old man affected by right buttock claudication authors find internal iliac artery (IIA) coil embolization after a right internal iliac artery (IIA) coil embolization as a relatively trouble-free procedure, there are reports an adjunct to endovascular iliac artery aneurysm repair. of devastating sequelae and mortality associated with Computed tomography angiography revealed extensive the technique [1, 2]. A variety of new endovascular aortoiliac calcifications and thrombus in the vessel walls. devices and surgical procedures have been proposed Despite patency of the contralateral IIA and preservation for situations in which the hypogastric artery must be of right distal collateral flow through ipsilateral hypogas- covered by the iliac limb endograft [3, 4]. The aim of tric branches, the symptom was persistent and disabling. The high-risk patient underwent an “open” repair of the this report is to present a successful surgical technique infrarenal abdominal aneurysm with removal of the en- of hypogastric artery bypass to treat persistent buttock tire stent-graft and concomitant revascularization of the claudication occurring after endovascular common IIA right IIA. Post-operative recovery was uneventful, and repair with unilateral IIA interruption. the patient remained asymptomatic during a 30-month follow-up. This case underscores the importance of con- Case Presentation sidering all potential solutions, including open surgery, to preserve pelvic inflow after aortoiliac stent grafting, A-71-year-old man with a history of heart failure, particularly for high-risk patients with vulnerable plaque hypertension, peripheral arterial disease, and hyper- and higher risk of thrombus embolization. cholesterolemia presented to our department for Copyright © 2017 Science International Corp. persistent and disabling right buttock claudication. The symptom occurred subsequent to ipsilateral IIA Key Words: coil embolization performed 24 h prior to endograft Buttock claudication • Coil embolization • Internal iliac limb extension to the external iliac artery (EIA) as an artery • Endovascular abdominal aortic aneurysm repair adjunct to endovascular repair of a common iliac artery aneurysm. No antecedent back trauma or history Introduction of prolapsed lumbar discs was reported. Abdominal duplex scan showed complete Buttock claudication is the most frequent ischemic occlusion of the right IIA with stent-graft exclu- complication after hypogastric artery occlusion prior sion of the right common iliac artery aneurysm. to endovascular abdominal aortic aneurysm repair. Patency of the contralateral IIA was detected. No

© 2017 AORTA * Corresponding Author: Published by Science International Corp. Alessandro Robaldo, MD ISSN 2325-4637 Vascular and Endovascular Surgery Unit Fax +1 203 785 3552 Imperia Hospital E-Mail: [email protected] Accessible online at: Via Sant’Agata, 57 18100, Imperia, Italy http://aorta.scienceinternational.org http://aorta.scienceinternational.org Tel.: +39 0183 537214; Fax: +39 0183 537317; E-Mail: [email protected] Case Report 174

Figure 1. Preoperative computed tomography angiography. Axial and sagittal images demonstrating proximal coil placement into the iliac bifurcation and patency of the distal portion of the right internal iliac artery (arrows). other aneurysm sites or aortoiliac stenotic lesions iliac artery and the distal part of the right IIA, respec- were recognized. Continuous wave Doppler re- tively. Second, a separate graft, proximally anasto- vealed a signal at the right buttock level with a mosed end-to-side with the corresponding anterior lower intensity than that of the contralateral side. aspect of the main body of the aorto iliac graft, was Contrast-enhanced multidetector computed to- jumped to the right EIA (Figure 2). mography angiography confirmed the diagnosis Post-operative recovery was uneventful. The and showed patency of the distal portion of the patient was discharged in good general condition right IIA and its branches, with preserved distal with complete pain relief on life-long mono-anti- collateral flow ( Figure 1). Additional findings in- platelet treatment (acetylsalicylic acid 300 mg). At cluded severe aortic and iliac calcifications and 30-month follow-up, there was no buttock claudica- mural thrombus. Preoperative cardiac testing did tion, pelvic ischemia, or complaint of paresthesias, not detect atrial fibrillation and the patient was pain, discomfort, or walking limitation. Computed considered to have grade III preoperative risk ac- tomography angiography showed patency of both cording to American Society of Anesthesiologists grafts with no anastomotic stenosis/pseudoaneu- classification. rysms. The right IIA at the level of its first branch was Under general anesthesia, through median trans- well perfused (Figure 3). peritoneal access and infrarenal clamping, the stent- graft and IIA coil were removed. After retrograde right Discussion hypogastric blood flow was assessed, revascularization was performed in two steps. First, a bifurcated Pooled data from different studies reveal that the Dacron graft was anastomosed in an end-to-end incidence of buttock claudication after coil emboliza- fashion from the infrarenal aorta to the left common tion of one or both IIAs ranges from 11% to 50%, with

AORTA, December 2017 Volume 5, Issue 6:173-176 175 Case Report

Figure 2. The left image shows the removed stent-graft and embolization coil placed on a schematic design of the previous implant. The right images show intraoperative surgical direct aortoiliac revascularization of the right internal iliac artery and both common iliac arteries via a transperitoneal approach. differences in type and severity [1]. Persistent buttock claudication represents approximately 13% of all of Figure 3. Follow-up computed tomography angiography at 6 IIA coil embolization procedures, with no statistically months showed a good result of the procedures with patency of significant difference between unilateral and bilateral all branches of the graft without further complications. IIA interruption [2]. Although some studies report that IIA embolization is a well-tolerated procedure with a small chance of severe morbidity, recent literature Different surgical solutions have been designed to appears to support the notion that every effort must restore hypogastric perfusion. Many surgeons prefer a be made to preserve one or both hypogastric arteries retrograde IIA revascularization with relocation of the during endovascular aneurysm repair [3, 4]. IIA to the external iliac or femoral arteries via a retro- This report demonstrates the potentially problematic peritoneal approach to avoid extensive pelvic dissec- nature of the management of the disabling sequelae of tion, reduce trauma to the abdominal wall muscula- this complication. Despite the fact that the IIA emboli- ture, and achieve less postoperative patient discomfort zation was performed in a staged fashion and the coil [6]. However, in our case, we believe the best choice to placement was proximal to the internal iliac bifurcation restore buttock circulation was to perform direct re- with evidence of distal patent collateral vessels and con- vascularization. In fact, retrograde perfusion may be sequent time to develop a collateral pelvic circulation inadequate for many reasons. First, the short available with blood flow from the contralateral IIA and ipsilateral segment of the EIA due to extension of the endograft EIA, the patient experienced constant and painful but- limb and the deep location of the patent IIA vessel tock claudication. Likely, periprocedural distal emboliza- branches can make the surgical area uncomfortable tion or a hypotension episode may have contributed to and the entire procedure technically complicated, with the onset of the early buttock claudication [5]. a risk of injury to large veins. Second, perfusion may Case Report 176 be not achieved in case of severe atherosclerotic exter- risk of steal syndromes. Moreover, in case of occlusion nal deterioration of the iliac-femoral junction. Finally, of the IIA branch, there is reduced risk of thrombotic prolonged clamping of the EIA associated with difficult involvement of the anastomosed branch to the EIA. control of intraoperative activated clotting time during Finally, the anastomosis achieved on the anterior as- performance of the anastomosis can cause potential pect of the main body is technically easier and pro- peri-postoperative limb thrombosis. vides better perioperative control of bleeding when Based on these considerations, whenever possi- compared with an end-to-side proximal anastomosis ble and reasonable according to American Society of of a separate IIA graft to the corresponding posteri- Anesthesiologists score, our choice has been to per- or side of an aorto-iliac prosthesis branch. Although form direct bypass from the aorta to the IIA with an treatment should be individualized, we recommend end-to-end anastomosis between a branch of a bifur- this surgical approach in cases of persistent buttock cated Dacron graft and the residual distal part of the claudication to restore hypogastric artery circulation hypogastric artery via a transperitoneal approach. We after IIA coil embolization. believe that this offers better exposure of distal IIA branches. From a technical point of view, to perform Conflict of Interest an “octopus” trifurcated graft, as described above, with a separate jump to the EIA from the main body The authors have no conflict of interest relevant to graft shows some advantages. First, unless a poor run- this publication. off or quality of the artery wall were intraoperatively detected, this configuration can result in an optimal Comment on this Article or Ask a Question perfusion pressure of each target vessel without any

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AORTA, December 2017 Volume 5, Issue 6:173-176