Hematochezia due to rectal invasion by an internal iliac artery aneurysm: A case report

BACKGROUND This case report presents the rare occurrence of hematochezia due to an internal iliac artery aneurysm leading to an arterioenteric fistula,expanding the differential diagnosis for gastrointestinal bleeding.It emphasizes the importance of considering vascular origins in cases of atypical hematochezia,particularly in the absence of common gastrointestinal causes,and highlights the role of imaging and multidisciplinary management in diagnosing and treating such unusual presentations.CASE SUMMARY A 75-year-old man with a history of hypertension presented with 12 d of hematochezia,experiencing bloody stools 7-8 times per day.Initial computed tomography(CT)scans revealed an aneurysmal rupture near the right internal iliac artery with suspected hematoma development.Hemoglobin levels progressively decreased to 7 g/dL.Emergency arterial angiography and iliac arterycovered stent placement were performed,followed by balloon angioplasty.Despite initial stabilization,minor rectal bleeding and abdominal pain persisted,leading to further diagnostic colonoscopy.This identified a neoplasm and potential perforation at the proximal rectum.An exploratory laparotomy confirmed the presence of a hematoma and an aneurysm invading the rectal wall,necessitating partial rectal resection,intestinal anastomosis,and ileostomy.Postoperative recovery was successful,with no further bleeding incidents and normal follow-up CT and colonoscopy results after six months.CONCLUSION In cases of unusual gastrointestinal bleeding,it is necessary to consider vascular causes for effective diagnosis and intervention.

Emergency internal iliac artery temporary occlusion after massive hemorrhage during surgery of cesarean scar pregnancy:A case report

BACKGROUND Cesarean scar pregnancy(CSP)is rare but may result in uterine rupture during pregnancy or massive hemorrhage during abortion procedures.Awareness of this condition is increasing,and most patients with CSP are now diagnosed early and can be managed safely.However,some atypical patients are misdiagnosed,and their surgical risks are underestimated,increasing the risk of fatal hemorrhage.CASE SUMMARY A 27-year-old Asian woman visited our institution because of abnormal pregnancy,and she was diagnosed with a hydatidiform mole through transvaginal ultrasound(TVS).Under hysteroscopy,a large amount of placental tissue was found in the scar of the lower uterine segment,and a sudden massive hemorrhage occurred during the removal process.The bilateral internal iliac arteries were temporarily blocked under laparoscopy,and scar resection and repair were rapidly performed.She was discharged in good condition 5 d after the operation.CONCLUSION Although TVS is widely used in the diagnosis of CSP,delays in the diagnosis of atypical CSP remain.Surgical treatment following internal iliac artery temporary occlusion may be an appropriate management method for unanticipated massive hemorrhage during CSP surgery.

Does kidney transplantation onto the external iliac artery affect the haemodynamic parameters of the cavernosal arteries？

Reduced cavernosal arterial inflow has been hypothesized to be the likely cause of erectile dysfunction after kidney transplants in recipients revascularized through end-to-end anastomosis to the internal lilac artery, suggesting that end-to-side anastomosis at the external iliac artery is preferable. The aim of this study was to prospectively evaluate the effect of the use of the external iliac artery on erectile function, hormone profiles and penile blood flow by evaluating changes in penile colour Doppler ultrasound parameters in a consecutive series of 22 recipients before and after end-to-side external lilac artery transplantation. The mean International Index of Erectile Function-Erectile Function （IIEF-EF） domain score decreased significantly 3 months after transplant （18.09±6.33 vs. 22.50±7.09, P=O.01）. The reduction in peak systolic velocity （PSV） was significant for the cavernous artery homolateral to the side of transplant （42.60±18.77 vs. 52.01±19.91, P=0.01）. The mean postoperative end diastolic velocity （EDV） did not differ significantly from the preoperative value （P=0.74）. No statistical differences were found in the serum levels of testosterone or prolactin. Kidney grafts anastomosed at the external lilac artery produced significant （P=0.01） reductions in arterial inflow at the homolateral cavernosal artery that remained above the normal threshold. Whether these haemodynamic changes can explain the worsening of postoperative erectile function remains to be proven.

Management of retroperitoneal sarcoma involving the iliac artery:Single-center surgical experience

BACKGROUND Management of retroperitoneal sarcoma(RPS)involving the iliac artery is challenging and requires the concerted efforts of multidisciplinary team(MDT)members during surgical treatment.AIM To summarize the clinicopathologic features of RPS involving the iliac artery and our retroperitoneal soft tissue tumor MDT surgical experience.METHODS In this retrospective study,15 patients with RPS involving the iliac artery who underwent surgery at our retroperitoneal soft tissue tumor center from July 2004 to June 2020 were analyzed.Statistical analyses were performed by Student’s ttest with SPSS 16.0.RESULTS Complete tumor resection(R0/R1)and iliac artery reconstruction were achieved in all 15 patients.All the operations were successful,with no serious complications or perioperative death.Resection with bilateral iliac artery reconstruction required a higher intraoperative blood transfusion volume than resection with unilateral iliac artery reconstruction.Recurrent cases were more likely to bleed and required a higher blood transfusion volume than primary cases.As of January 2021,11 patients were alive,and 4 had died.Local recurrence occurred in two patients,one of whom developed liver metastasis.CONCLUSION Resection of RPS involving iliac vessels is feasible and effective when performed by MDT members.Iliac artery oncovascular resection and reconstruction are key to a successful operation.Adequate blood preparation is important for successful completion of surgery.

Ureteral-artificial iliac artery fistula:A case report

BACKGROUND Ureteral-iliac artery fistula is a rare disease resulting from the pathological connection between the ureter and iliac artery,with artificial iliac artery-ureteral fistula being rarer.Iliac artery ureteral fistula is challenging to diagnose,and the misdiagnosis and mortality rates are high.CASE SUMMARY A case of artificial iliac artery ureteral fistula was reported in this paper.The patient was a 69-year-old male with paroxysmal painless hematuria.The artificial iliac artery ureteral fistula was diagnosed by angiography.The hematuria was stopped after intravascular embolization,and no bleeding occurred after 6 months of follow-up.CONCLUSION Ureteral arterial fistula should be considered when inconspicuous hematuria with previous iliac vessels is encountered in addition to local ureteral surgery history.A rapid endovascular approach is recommended for fistula identification.

Spontaneous Coronary Artery Dissection with Iliac Artery Dissection: A Case Report and Literature Review

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome or sudden cardiac death.It often occurs in females with no conventional cardiovascular risk factors.Bilateral iliac artery dissection is also a rare disease.This case report describes a patient with spontaneous coronary artery dissection and iliac artery dissection.The authors believe that a conservative approach could be used as an effective therapy for a clinically stable patient.

A Polymer Coated Cicaprost-Eluting Stent Increases Neointima Formation and Impairs Vessel Function in the Rabbit Iliac Artery

Drug-eluting stents have been successful in reducing in-stent restenosis but are not suitable for all lesion types and have been implicated in causing late stent thrombosis due to incomplete regeneration of the endothelial cell layer. In this study we implanted stents coated with cicaprost, a prostacyclin analogue with a long plasma half-life and antiproliferative effects on vascular smooth muscle cells, into the iliac arteries of rabbits. At 28-day follow-up we compared neointima formation within the stented vessels and vascular function in adjacent vessels, to assess if cicaprost could reduce restenosis without impairing vessel function. Arteries implanted with cicaprost eluting stents had significantly more neointima compared to bare metal stents. In adjacent segments of artery, endothelium-dependent relaxation was impaired by the cicaprost-eluting stent but vasodilation to an endothelium-independent vasodilator was maintained. We conclude that the presence of the polymer and sub-optimal release of cicaprost from the stent may be responsible for the increased neointma and impaired functional recovery of the endothelium observed. Further experiments should be aimed at optimising release of cicaprost and exploring different stent polymer coatings.

Role of Anterior Division of Internal Iliac Artery Ligation in Refractory Postpartum Haemorrhage—A Tertiary Care Hospital Based Study

Objective: Postpartum haemorrhage (PPH) is one of the important obstetrical emergencies and a leading cause of maternal morbidity and mortality. According to the World Health Organization, postpartum haemorrhage constitutes 25% of all maternal deaths worldwide. In situations where medical line of management fails to control postpartum haemorrhage, anterior division of internal iliac artery ligation can play an important role as a lifesaving and fertility preserving surgical procedure. Keeping this in mind, our study aimed to analyze indications and efficacy of anterior division of Internal Iliac artery ligation in the form of uterine salvage and saving maternal life. Study design: This was a retrospective study carried out in the Department of Obstetrics and Gynaecology, Government Medical College, Aurangabad during the period of July 2014-January 2016. A total of 57 cases that had undergone ligation of anterior division of internal iliac artery were included in the study and different indications and efficacy were studied. Results: Atonic PPH (52.63%) leads the list of indications for ligation anterior division of internal iliac artery ligation followed by traumatic (19.29%), adherent placenta (12.2%), mixed variety (10.52%) and coagulopathy (5.26). Maximum efficacy in terms of preserving fertility and saving maternal life was 73.33% and 93.3% respectively in atonic PPH. Overall efficacy of this procedure in terms of uterine salvage was 54.38% and in terms of saving maternal life was 87.71%. Conclusion: Anterior division of IIAL was effective method in controlling refractory PPH, reducing morbidity and preserving uterus and future fertility. It is safe life saving procedure at experienced hands.

Subsequent pregnancy outcomes and fertility rates in the case series that underwent bilateral hypogastric artery ligation(BHGAL)due to severe postpartum hemorrhage

Objective:To evaluate the effect of bilateral hypogastric artery ligation(BHGAL)on women's pregnancy outcomes and fertility rates in cases with severe postpartum hemorrhage.Methods:Patients hospitalized in a tertiary care center between 2007 and 2018 were included in the study.The records of cases were obtained from the hospital database,retrospectively.Maternal demographic data,morbidities or complications associated with BHGAL surgery,any additional haemostatic interventional or surgical procedures,preoperative admission and lowest postoperative haematocrit-hemoglobin values,blood products given,type of anaesthesia,intensive care unit(ICU)and length of hospital stay were recorded.In cases without surgical sterilization,future fertility and subsequent pregnancy outcomes were assessed for at least two years after operation.Information was obtained through face-to-face or telephone interviews with patients whose long-term fertility and subsequent pregnancy outcomes were assessed.Results:Sixty-eight patients with BHGAL surgery history were included in the study.26 Of 37 cases(70%)that did not undergo surgical sterilization had a desire for pregnancy after the surgery.Six of these cases(23%)were diagnosed with secondary infertility.The fertility rate of these cases was 77%,and subsequent pregnancy was detected in 20 women.A total of 25 pregnancies,including first and second pregnancies,developed,and 15 of these pregnancies resulted in term delivery,six preterm births,one stillbirth,and three abortions.Conclusions:The postoperative pregnancy rate was found to be higher than the rate of women with infertility problems,and this surgery does not seem to adversely affect pregnancy outcomes.This is a tertiary center experience and cohort studies with large patient series are needed.

Isolated blunt iliac artery injury successfully treated with endovascular stent

Common or external iliac artery injury due to blunt trauma is unusual without an associated pelvic fracture.Here we report on a 62 years old man that sustained left external iliac artery thrombosis due to blunt trauma following fall from motorbike.There was no immediate circulatory compromise.Contrasted CT of abdomen revealed an associated left lower abdominal wall traumatic hernia.The iliac artery was intervened with an endovascular stent to restore luminal flow and the hernia was repaired electively.The entire clinical course and management dilemma are described in this article.

Fatal spontaneous rupture of common iliac artery associated with fibromuscular dysplasia

A previously healthy 25-year-old man with no known risk factors was presented at the emergency room with a 3 h history of abdominal and loin pain.Physical examination and lab data showed no specific findings except tenderness,slight white cell count elevation and decreased haemoglobin level.The patient’s condition deteriorated over the following hours and he died despite resuscitation attempts.Autopsy revealed a 2.5-cm longitudinal tear in the intima of the right common iliac artery,which formed a thrombosed false lumen extending to the abdominal aorta proximally and to the left common iliac artery.Histopathologic examination revealed the characteristic changes of fibromuscular dysplasia(FMD).FMD involving the common iliac arteries is extremely rare;only six cases have been reported previously,and only two of those included forensic findings.The presented case is the first case of FMD with intimal tearing in the right common iliac artery,with propagation to the left common iliac artery and abdominal aorta.When a previously healthy young adult without hypertension or other risk factors presents with acute abdominal and loin pain,systemic vascular disease should be on the list of differential diagnoses.Careful and complete evaluation of multiple arteries can be critical.

Long Term Clinical and Angiographic Outcome Following Percutaneous Transluminal Angioplasty and Stent Placement for Iliac and Femoral Artery Stenosis

Objective This study reportsthe initial and late results of percutaneous transluminal angioplasty (PTA) and intravascular stenting for atherosclerotic stenosis of the iliac and femoral arteries. Methods and Results From December 1994 to March 1997, we performed iliac and femoral artery angioplasty and primary intravascular stent placement in 37 vessel of 33 patients (19 men and 14 women; mean age, 70. 5 years). A total of 43 self - expanding Wallstents (Boston, Inc. ) were deployed. All patients underwent angioplasty and stent placement successfully. Clinical follow - up was available for all patients at a mean of 26±14months. All patient clinical is-chemic category (claudication or rest pain) was improved. Angiographic follow - up was completed for 17 of 23 patients at a mean follow-up of 10±5 months, The iliac artery restenosis rate was 0(0/8). The femoral artery restenosis rate was 33 % (3/9), All 3 patients underwent repeat balloon angioplasty successfully. Conclusion The iliac and femoral arteries can be performed and reasonable early and late patency rates.

Outflow reconstruction with arterial patch in domino liver transplantation: a new technical option

Domino liver transplantation（LT）, using livers from familial amyloidotic polyneuropathy（FAP） patients, is a well described technique useful to expand donor pool. One of the main difficulties of this type of LT arises from the necessity to share the vascular pedicles between the graft and the donor. The most important challenge resides in restoring a proper hepatic venous outflow in the FAP-liver recipient.This is specially challenging when using the piggy-back technique, because the hepatic stumps may be too short. To overcome this issue, surgeons explored several techniques using different types of venous grafts. We describe a new technical option by using an arterial graft from the deceased donor. By using both iliac arteries a long graft is created and sutured as needed to the hepatic vein stump. We describe herein this new technique employed in a domino liver recipient who underwent retransplantation for ischemic cholangitis. The procedure was performed using the piggy-back technique; the venous stump of the FAP liver was reconstructed with the arterial graft. The patient had uneventful postoperative and mid-term hepatic function, and anastomosis was patent 24 months after LT.

Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft:A case report

BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity.The advent of endovascular aortic repair(EVAR)has reduced perioperative complications,although the utilization of such techniques is limited by lesion characteristics,such as involvement of the visceral or renal arteries(RA)and/or presence of a sealing zone.CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm(CAAA)starting directly distal to the diaphragm extending to both common iliac arteries(CIAs).The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.Due to the poor performance of the patient and the expansive disease,we planned a stepwise-combined surgery and EVAR to minimize invasiveness.A branched graft was implanted after surgical debranching of the visceral and RA.Since the patient had renal and liver injury after surgery,the second stage EVAR was performed 10 mo later.The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.

Endovascular repair of aortoiliac aneurysm with a hybrid ：echnique to preserve pelvic perfusion

Endovascular aneurysm repair （EVAR） has been proven to be an effective and safe technique for abdominal or iliac artery aneurysm. However, for aneurysms extending to both iliac bifurcations, routine EVAR will occlude both internal iliac arteries （llAs）, which may increase the risk for pelvic ischemia. New endovascular techniques have been developed to preserve the pelvic perfusion in EVAR for such situation. This article reports an endovascular repair of an aortoiliac aneurysm with an external iliac artery （EIA） to the IIA endograft to preserve the pelvic perfusion. First, an endograft was advanced into the left IIA under the help of an inflated aortic balloon. Coils were deployed to embolize the distal type-1 endoleak from the tunnel around the endograft, and an aortouniiliac endograft and an iliac extension were deployed below the renal arteries extending to the right EIA. Finally, a right-to-left femoro-femoral artery bypass was constructed. Angiography at completion and computed tomography after 6 months demonstrated patency of all grafts and complete exclusion of the aneurysm without any endoleak. Endovascular repair with an EIA-to-IIA endograft to preserve the pelvic inflow is a feasible and effective technique for aortoiliac aneurysms. Coil embolization might be an option to repair the distal type of endoleak. The balloon assisted U-turn technique may help advance the endovascular device over a sharp-angled vessel bifurcation.

Use of arterial conduit for arterial revascularization during liver and multivisceral transplantation

Background At present, revascularization is still one of the most critical technologies in orthotopic liver transplantation （OLT）. Hepatic artery （HA） variations occur frequently in both donors and recipients. Moreover, there are always some pathological changes in the recipient hepatic artery. If handled improperly, it may cause complications after anastomosis.Therefore, arterial conduit could be used in primary OLT, re-OLT and multiple-OLT. This study aimed to investigate the indications, methods and techniques with usage of arterial conduit for HA revascularization during adult OLT.Methods We reviewed 1200 patients of consecutive OLTs performed during 2000-2009 in the First Affiliated Hospital of Sun Yat-sen University. Of these patients, 48 recipients with artery variations received HA revascularization with usage of arterial conduit and special postoperative managements. The indications, methods, techniques, and the managements of postoperative complications in adult OLT with usage of arterial conduit for HA revascularization were analyzed.Results In 48 cases with artery bypass, the arterial conduit were anastomosed between donor hepatic artery and recipient infrarenal aorta （n=32）, between donor hepatic artery and recipient suprarenal aorta （n=10）, and between donor upper abdominal organ cluster artery and recipient suprarenal aorta （n=6）. The technique was applied in 4% （48/1200 cases） of the whole OLTs performed in the same period, and the patency rate of the conduits was 100%. Forty patients （83.3%） survived, and the average survival time was 3.9 years. Eight patients （16.7%） died （all due to tumor recurrence）,while the average survival time was 1.2 years. All these patients have not experienced artery-related complications in their survival time.Conclusions When recipient HA has variations or pathological changes in OLT, the donor artery should be anastomosed to recipient abdominal aorta with an arterial conduit to achieve satisfactory outcomes. For arterial anastomosis can not be routinely performed, donor iliac artery as a conduit to be anastomosed with the recipient abdominal aorta is safe and effective.

Evidence of apoptotic smooth muscle cells in proliferative intima of injured arteries

OBJECTIVE: To investigate the occurrence and extent of apoptosis in the course of restenosis. METHODS: The experimental models of vessel narrowness and intima thickness were established in minipigs' iliac arteries by balloon injury and specimens were retrieved on the 1st, 3rd, 6th, 12th and 30th days for dynamic observation. Apoptotic smooth muscle cells (SMCs) were detected by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL). RESULTS: Apoptotic SMCs occurred only in the thickened intima 12 days after injury accompanied with the proliferative SMCs, the percentage of apoptosis was 1.94% +/- 0.42% on the 12th day and 1.36% +/- 0.31% on the 30th day respectively. The low frequency of apoptosis compared with the proliferative SMCs was a feature in the restenotic pathology. CONCLUSIONS: Apoptosis participates in the pathogenetic process of intimal thickening and its level was low compared with proliferation. The findings suggest that attempts to modulate apoptosis after vessel injury constitute a theoretical approach to the prevention of restenosis.