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Case 01

A 45-year-old gentleman presented with severe pain in the right buttock and right thigh on walking. This pain had progressively increased over the last 6 months, and on presentation to us, he was unable to walk more than 100 meters. Clinical examination revealed an absent right femoral artery pulse. The right leg was slightly colder than the left. Arterial Doppler ultrasound examination revealed that the right common iliac artery was totally occluded, with very minimal flow into the distal right leg.

The patient was posted for peripheral angioplasty. The left superficial femoral artery was cannulated under local anesthesia, and a catheter was placed in the aorta to perform angiography. This confirmed the total occlusion of the right iliac artery (Figure 1). The distal femoral artery was visualized filling via collaterals. Using this roadmap, the right femoral artery was cannulated, and a Terumo guidewire was used to cross the total occlusion of the iliac artery. Following balloon dilatation ( Figure 2), a stent was placed across the blockage, with a final result showing the excellent opening of the vessel, with the good distal flow. The entire procedure was performed in about 30 minutes.

Points To Note:
Total occlusion of the Iliac artery can nowadays be easily tackled with angioplasty and stenting procedure. With the use of Nitinol stents, the chances of restenosis are extremely low. Vascular surgery for Iliac artery stenosis or occlusion is rarely indicated.

Angioplasty is the initial treatment of choice for Iliac Disease:
Technical Success Rate : 90%
Angiographic Patency : 73% at 2 years ( Only Balloon)
94% at 2 years ( Stent)
(Cleveland Clinic J of Med, 1997; 64:429-436)

Case 02

A 53-year-old male, chronic smoker, diabetic and hypertensive, presented with severe claudication pain in both lower limbs, right more than the left. The right femoral pulse was absent, and the left femoral artery was weakly palpable. Digital subtraction angiography revealed a total occlusion of the right iliac artery, with critical stenosis of the left iliac artery. Under local anesthesia, both the femoral arteries were cannulated, inspite of the absence of pulses, and balloon dilatation and stenting of the iliac arteries performed, with an excellent post angioplasty result. The patient had immediate relief of symptoms.

Case 03

A 50-year-old gentleman, with a history of pain in the right thigh on walking more than 50 meters since one month. The right femoral artery pulse was weakly felt, and the arterial Doppler ultrasound study confirmed the presence of significant calcific stenosis of the right common iliac artery. This case was performed as a day care case with angioplasty and stenting of the right iliac artery.

Case 04

Total Occlusion of The Left Iliac Artery Saving Amputation of The Leg Without Surgery. A 60 years old man, hypertensive, diabetic, and known case of ischemic heart disease presented with a history of severe pain in the left leg since 15 days.

Clinically, no pulses were felt in the left leg which was extremely cold. Colour doppler ultrasound confirmed total occlusion of the left iliac artery. Angiography was performed which confirmed the total occlusion of the left external iliac artery.

Heparin was infused into the iliac artery, and a 0.035 inch guide wire was negotiated through the total occlusion, followed by a 5 French multipurpose catheter. Partial recanalisation was seen with some antegrade flow into the femoral artery, which also demonstrated a complex stenosis. The multipurpose catheter was placed in the mid SFA, and angio done showed a total occlusion of the distal SFA with no distal flow. Urokinase bolus was given 500,000 units, and the iliac artery and the SFA were stented with two serial stents. The multipurpose catheter was advanced upto the distal SFA and Urokinase infusion continued for 24 hours.

Check angio 48 hours later confirmed fully patent arteries right upto the toes of the left foot. Patient improved dramatically, and was discharged from hospital after 3 days.