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Acute Limb Ischemia After Iliac Vein Stenting
George Titomihelakis, MD, MS, Brian Leoce, MD, Cassandra M. Soto, MD, Ajit Rao, MD, Christopher Smolock, MD, Rami Tadros, MD, Justin George, MD.
The Mount Sinai Hospital (NY), New York, NY, USA.
DEMOGRAPHICS
A 52-year-old female with cervical cancer post-chemoradiation, multiple abdominal surgeries, and history of DVT (off anticoagulation due to bleeding) presented with ultrasound-confirmed extensive left external iliac to popliteal vein thrombosis. She underwent venogram with left lower extremity thrombectomy and placement of bilateral kissing iliac venous stents extending into the IVC. The procedure was complicated by right iliac vein rupture requiring balloon-expandable stent placement.
HISTORYOn post-operative day 1, she developed a painful, cool right lower extremity with absent pedal pulses and sensorimotor deficits consistent with Rutherford IIb acute limb ischemia, prompting emergent surgical intervention.
PLANAn IVC filter was first placed. Diagnostic angiography via left CFA access revealed right common/external iliac artery occlusion with reconstitution into the CFA via hypogastric collaterals. A right femoral cutdown was performed with proximal/distal control, followed by open Fogarty thrombectomy of the right CIA and EIA. Wire and sheath were passed through the arteriotomy beyond the area of compression from the venous stent. A 7x10 mm self-expanding stent was deployed in the right CIA/EIA, post-dilated with a 6 mm balloon. A 7x39 mm Gore VBX stent was then expanded to its nominal diameter of 7 mm. Completion angiography showed brisk flow through the CIA/EIA into the CFA. Given the prolonged ischemia, a four-compartment fasciotomy was performed.
DISCUSSION
Iliac venous stents can cause external compression of adjacent iliac arteries due to their outward radial force, particularly in patients with scarred, fibrotic, or surgically altered pelvic anatomy
1,2. This risk is amplified in smaller individuals or those with pre-existing iliac arterial narrowing. Oversizing of venous stents further increases this risk.
Although rare, arterial compression by iliac venous stents can cause acute limb ischemia. Pre-procedural planning should consider anatomic constraints, particularly in patients with prior pelvic surgery, radiation, or small body habitus. Careful stent sizing and awareness of this potential complication are essential during iliac venous interventions.
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