Aortic Occlusion after Iliac Branch Device: A Word of Caution
Richard Schutzer, MD.
Columbia University Medical Center, New York, NY, USA.
OBJECTIVES: The FDA approval of iliac branch stent grafts has led rapid acceptance as the standard of care in patients with anatomically appropriate iliac aneurysms .This adoption is due to the ability of maintaining aneurysm exclusion while decreasing the approximately 30% incidence of pelvic ischemia with staged internal iliac artery coil embolization. Despite the significant promise of the devices, however, data on outcomes remain limited. Outside of the pELVIS registry, trials include a relatively small number of patients. This case represents the first known aortic occlusion after iliac branch stent-graft.
METHODS: A 49-year old male with past medical history only for osteoarthritis was diagnosed with an isolated common iliac artery aneurysm. He underwent placement of an aortic stent-graft along with iliac branch device at an outside institution and was discharged uneventfully. Three weeks later, he collapsed at home. A CT demonstrated collapse of the aortic stent as well as a second collapse of the iliac stent. He was transferred to Columbia for further treatment.
RESULTS: The patient was emergently brought to the operating room, where he underwent thrombectomy of the stent-grafts along with placement of a Palmaz stent proximally and relining the iliac limb. Due to the complexity of his presentation, he underwent a CT post-operatively. This demonstrated a widely patent stent-graft, with a small thrombus in the contralateral hypogastric. He subsequently underwent a percutaneous thrombectomy of this thrombus. He regained motor strength and sensation in his lower extremities and was discharged to home. He has now been followed for 6 months without any recurrent difficulties.
CONCLUSIONS: Although iliac branch stent-grafts represent a significant advance in the armamentarium for treating aneurysmal disease, the experience is still limited. Based on this, the specific complexities and complications related to its use are still unknown. The pELVIS registry demonstrated a 1.5% external iliac artery occlusion rate, but to date, this is the first description of an aortic occlusion. It therefore serves as a demonstration of the unique mechanical properties associated with these devices.
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