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OBJECTIVES - Common traumatic arterial injuries include transections, dissections, arteriovenous fistulas, and pseudoaneurysms. Blunt bilateral common iliac artery (CIA) intimal shearing injuries are rare. Traditionally, aortobifemoral bypasses have been used to treat these lesions. However, endovascular stenting may be an alternative to open surgery.
METHODS - We present a 22-year-old male with two hours of severe bilateral lower extremity ischemia after a high-speed motor vehicle collision. On presentation, he had no motor function or sensation below his knees. CTA of the chest, abdomen, and pelvis revealed bilateral proximal CIA occlusive injuries. Open bilateral common femoral artery exposure and right iliofemoral thrombectomy were performed. No significant thrombus was removed, and inflow was still very weak. A sheath was placed, and angiography demonstrated bilateral CIA intimal shearing; no transections or dissections were evident. Endovascular stent grafts were deployed in bilateral CIAs. A grade 1 splenic injury and intraperitoneal free air suggestive of perforated viscus were seen on CT scan. During abdominal exploration, it was noted that the retroperitoneal space was compromised and included a segment of bluntly denuded sigmoid colon. There was also a small perforation of the ileum. These circumstances would have made an open revascularization challenging.
RESULTS - A combined open and endovascular technique was successfully used to treat bilateral CIA intimal injuries. On completion angiogram, there was brisk flow into both iliac vessels. At the end of the procedure, only the left PT pulse had Doppler signals due to vasoconstriction. By postoperative day two, bilateral PT and DP pulses became palpable. The patient regained full sensorimotor function in his right lower extremity with limited recovery of sensory and gross motor function in his left lower extremity.
CONCLUSIONS - Blunt traumatic bilateral CIA intimal injury in the absence of thrombus, transection, or dissection is a rare finding. In this situation, endovascular stent grafts are a viable option.