|Year : 2018 | Volume
| Issue : 2 | Page : 120-122
Collateral arterial circulation of the leg in postcatheterization iliofemoral occlusion
Vitaliy F Petrov
Pediatric Cardiac Surgery Department, Lviv Regional Clinical Hospital, Lviv, Ukraine
|Date of Web Publication||3-May-2018|
Dr. Vitaliy F Petrov
Pediatric Cardiac Surgery Department, Lviv Regional Clinical Hospital, Lviv
Source of Support: None, Conflict of Interest: None
Seldinger's femoral puncture is a routine approach for endovascular interventions in children. It is a safe method, albeit the procedure may be complicated by iliofemoral occlusion sometimes. We report a case of a chronic postcatheterization iliofemoral occlusion and discuss patterns of arterial collateral circulation of the leg in an asymptomatic teenager.
Keywords: Arterial collateralization, iliofemoral occlusion, Seldinger's puncture
|How to cite this article:|
Petrov VF. Collateral arterial circulation of the leg in postcatheterization iliofemoral occlusion. Indian J Vasc Endovasc Surg 2018;5:120-2
| Introduction|| |
Femoral puncture with Seldinger's technique, performed during endovascular interventions in children, induces complications of the iliofemoral arterial tract sometimes. Although early years kids are prone to experience transient losses of pedal pulses shoertly after such procedures, the majority will regain normal arterial blood flow without negative consequences. Less frequently, acute or chronic ischemia, hemorrhage, pseudoaneurysm, or arteriovenous fistula may develop. We report a case of an asymptomatic teenager with chronic postcatheterization occlusion of the iliofemoral tract and discuss collateral arterial circulation of her leg.
| Case Report|| |
A 16-year-old asymptomatic girl with a single ventricle and Fontan condition underwent cardiac catheterization. She was born with tricuspid atresia, large atrial septal defect, mild ventricular septal defect, and pulmonary stenosis. At the age of 2 years, a cardiac catheterization, which included aortography, was performed. The catheterization took place at another hospital, and no data were available regarding the technique and perioperative heparin administration. Two years later, a bidirectional cavopulmonary shunt was created. At 10 years of age, a repeat catheterization was done; during the procedure, the right femoral artery puncture was not successful and the left femoral access was reported. After the diagnostic intervention, the child had an extracardiac cavopulmonary conduit implanted to complete her Fontan palliation. The patient had been doing well, and during routine echocardiography, a left pulmonary artery stenosis was suspected, which was an indication for the subsequent catheterization.
During the intervention, the right femoral artery failed to pass the guidewire; therefore, the left groin was chosen to proceed with an arteriography. As soon as the cardiac protocol was finished, attention switched to the limb vessels and occlusion of the right iliofemoral tract was visualized. The circulation of the right leg was completely dependent on the rich collateral network.
During the inspection of the contrast medium flow from the descending aorta, certain findings were observed. The blood flow met higher resistance on the right than on the left side since it entered the left common iliac artery more easily [Figure 1].
|Figure 1: Aortography scan showing contrast medium flow presumably to the undamaged side in the early phase (1st second)|
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The right external iliac and common femoral arteries could not be visualized with antegrade contrast medium filling, opposed to the left side where this axis was patent [Figure 2].
|Figure 2: The left external iliac artery is patent; the contrast medium does not fill the right iliofemoral tract. (1) Left external iliac artery (3rd second)|
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The right internal iliac artery gave off branches that provided the leg with collateral circulation, namely the inferior gluteal, obturator, internal pudendal, and the superior gluteal arteries [Figure 3].
|Figure 3: (a) Right internal iliac artery branches: (2) inferior gluteal, (3) obturator, (4) superior gluteal, (5) internal pudendal. The left sacral arteries feed the right side (arrow) (5th second). (b) Antegrade filling of the normal arterial tree on the left side (4th second)|
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The inferior gluteal artery was enlarged and long; it descended downward and laterally to feed the first perforating arteries. The first perforating arteries ended with tiny branches to nourish the medial and lateral circumflex femoral arteries.
The obturator artery traveled downward and medially to reach the obturator foramen and find itself dividing into the anterior and posterior branches. Numerous collaterals from both meet the circumflex medial femoral artery. Some branches from the obturator also supported the inferior gluteal artery.
The internal pudendal artery granted tiny vessels to the medical circumflex artery. In the result, the inferior gluteal, obturator, and pudendal arteries end into an arcade to feed the medial circumflex femoral artery.
The superior gluteal artery was enlarged, especially its deep branch. The upper ramus of the deep superior gluteal artery on approaching the iliac spine curved downward to anastomose with the lower branch. The latter was found to travel further downward to nourish the lateral circumflex femoral artery. The flow in the lateral circumflex femoral artery was retrograde and filled the superficial femoral artery [Figure 4]. The medial collateral group filled up the deep femoral artery a bit earlier than the lateral.
|Figure 4: (a) The medial and lateral collaterals feed the deep femoral artery, the latter fills the superficial femoral artery: (6) Medial deep femoral, (7) lateral deep femoral artery (8th second). (b) Antegrade filling of the arterial tree on the left (6th second)|
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| Discussion|| |
Larger catheters as compared to the artery diameter, earlier age at intervention, repeat interventions, and lack of periprocedural heparin have been shown to place children at risk for the groin events during endovascular arterial interventions. Both acute (acute leg ischemia and bleeding) and chronic (claudication or unequal limb length) complications may follow.,
In chronic consequences, should the pediatric patients have symptom indications for surgical restoration of the blood flow via angioplasty or bypass grafting emerge. However, complete compensation of artery occlusion occurs in favorable scenarios. The collateralization can be so advantageous that the diagnosis of arterial occlusion is occasionally missed.,, In such cases, the collaterals dilate, their network increases, and resistance falls favoring new blood flow patterns. As shown in [Figure 3]a and [Figure 3]b, the intact internal iliac artery branches on the left side are at least twice smaller than that on the right side, indicating the difference of their functional load – the hemipelvis blood supply on the left and entire leg circulation of the right side. According to [Figure 4]a and [Figure 4]b, femoral arteries on both sides are effectively contoured, suggesting high natural potency of the described bypasses, although with a time delay of approximately 2 s.
Effective collateral engagement after main artery occlusion requires sufficient blood pressure to open the initially tiny bypass vessels. The newly loaded arteries experience high resistance and slow flow, placing the area for a higher risk of thrombosis. Therefore, stable hemodynamics and heparinization favor collateralization through the engagement of reentry vessels.,,
Finally, the collateral network must have a free distal basin; the runoff will simply not progress if the outflow is absent or blocked. Endovascular access is typically performed in the common femoral artery, above the deep femoral artery branch insertion. The particular site of arterial trauma is an important contributor to adequate collateral circulation.
In the described case, we observed complete filling of the distal femoral artery through the collateral network, albeit with a slower time pattern as compared to the unaffected limb. The preexisting arterial communications dilated and acted as a natural bypass to provide the distal organs with circulation. The medial group of collaterals experienced lower resistance and tended to feed the femoral artery faster; the phenomenon could be explained by their shorter length and a more numerous outflow points. With time, the collaterals expanded and precluded the patient from limb symptoms.,
| Conclusion|| |
The internal iliac artery branches are capable of successful collateralization of the leg after postcatheterization injury of the iliofemoral tract due to anastomoses to the deep femoral circumflex branches, which are below to the puncture site.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]