Recanalization of external iliac artery occlusion in a patient with spinal stenosis using medications: a case report

Abstract

Background

Iliac artery occlusion accompanied by spinal canal stenosis is rare. All reported cases were treated with endovascular stenting for iliac artery occlusion. We report the first case of external iliac artery occlusion accompanied by spinal stenosis, which was successfully treated with conservative treatment.

Case presentation

A 66-year-old man with lower extremity pain and claudication visited the outpatient spine clinic. He complained of a tingling sensation in the L5 dermatome of the right leg and L4 dermatome of the left leg. Magnetic resonance imaging showed central stenosis in at the L4–5 and L5–S1 levels, and lateral recess stenosis at the L5–S1 level. The patient's symptoms were ambiguous with mixed neurological claudication and vascular claudication. Computed tomography of the lower extremity artery showed complete occlusion in the right external iliac artery. Conservative treatment with clopidogrel and beraprost sodium was performed. After treatment, his symptoms gradually improved. Clopidogrel and beraprost sodium were continued for 4 years. Follow-up computed tomography at 4 years showed recanalization of the right external iliac artery occlusion.

Conclusions

We describe a rare case of external iliac artery occlusion and spinal stenosis. External iliac artery occlusion may be successfully treated only with conservative treatment using medication.

Introduction

Iliac artery occlusion accompanied by spinal canal stenosis makes distinguishing the cause of claudication and leg pain difficult owing to mixed and ambiguous symptoms, and eventually treating iliac artery occlusion is difficult. Iliac artery occlusion accompanied by spinal canal stenosis is rare, and several cases have been reported. All reported cases were treated with endovascular stenting for iliac artery occlusion (Table 1).^1,2 We report the first case of external iliac artery occlusion accompanied by spinal stenosis, which was successfully treated with conservative treatment.

Table 1.

Problems associated with the Iliac artery accompanying spinal stenosis reported in the literature.

Author and year	Age (y)	Sex	Symptoms	Vessel problem	Spinal problem	Treatment
Huml et al. (2018) 1	65	M	Back, right hip, and leg pain	Right common iliac artery occlusion	Lumbar foraminal stenosis	Stenting
Shields et al. (2021) 2	68	F	Low back, right hip, and groin painRight thigh anterior numbness	Right common iliac artery stenosisLeft common iliac artery stenosis	L4–5 stenosis with spondylolisthesis	Endovascular stenting

M, male; F, female.

Case report

A 66-year-old man with hypertension and coronary artery disease as underlying diseases had pain in both lower extremities. His symptoms occurred after walking for approximately 100 m. He received acupuncture at an oriental clinic. However, his symptoms did not improve. According to the patient's description, his symptoms rose from the feet to the top. On a physical examination, the straight leg raise test was negative and the motor grade for both lower extremities was grade V. He also complained of a tingling sensation in the L5 dermatome of the right leg and L4 dermatome of the left leg. Conservative treatment was performed using non-steroidal anti-inflammatory drugs.

One month later, his pain in the left leg was improved, but the pain in the right leg had worsened. Therefore, lumbar spine magnetic resonance imaging (MRI) was performed, which showed central stenosis at the L4–5 and L5–S1 levels, and lateral recess stenosis at the L5–S1 level was observed (Figure 1). The patient’s symptoms were ambiguous with mixed neurological claudication and vascular claudication. We performed a Doppler test for both lower extremities. No pulsations in the right dorsalis pedis or posterior tibialis artery were detected. Under the suspicion of a problem in a vessel, computed tomography (CT) scans for the lower extremity arteries were taken. CT scans showed complete occlusion in the right external iliac artery (Figure 2a). The patient was referred to the General Surgery Department. The ankle–brachial pressure index (ABI) was 0.1 to 0.2 (normal range: 1.0–1.4). Conservative treatment with 75 mg of clopidogrel/day and 20 mcg of beraprost sodium every 8 hours was initially performed for external iliac artery occlusion in the right leg. We obtained consent for this treatment from the patient. After the treatment, his symptoms were improved by 30% to 35% at 1 month after the diagnosis, 60% to 70% after 3 months, and 80% to 85% after 6 months. The patient refused further surgery for the spinal stenosis because he was satisfied with the clinical results.

Figure 1.

Magnetic resonance imaging (MRI) of the lumbar spine. (a) Axial T2-weighted MRI showing L4–5 central stenosis and (b) Axial T2-weighted MRI showing L5–S1 central and lateral recess stenosis.

Figure 2.

(a) Computed tomography scan of lower extremity arteries showing occlusion in the right external iliac artery (arrow) and (b) Computed tomography scan of lower extremity arteries showing recanalization of the right external iliac artery (arrow).

Clopidogrel and beraprost sodium were continued for 4 years. The ABI was continuously measured during the follow-up period, and it continued to rise to 0.56 after 1 year, 0.69 after 2 years, and 0.73 after 4 years. A follow-up CT scan performed 4 years later showed recanalization of the right external iliac artery occlusion (Figure 2b).

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. All consent procedures and details of this study were approved by the Institutional Review Board of the Catholic University of Korea (approval number: SC16ZISE0080). The reporting of this study conforms to the CARE guidelines. ³

Discussion and conclusions

Although claudication and leg pain are common symptoms of lumbar spinal stenosis, these symptoms can also occur in patients with peripheral arterial disease such as iliac artery occlusion. ⁴ Claudication associated with vascular or spinal pathology has several distinguishing characteristics. ⁵ Vascular claudication is typically felt in the upper calf. Vascular claudication is relieved after a short rest, and it worsens after walking uphill or riding a stationary bicycle. ⁶ Neurogenic claudication improves with trunk flexion, stooping, and lying. These patients often report better endurance walking uphill or up steps, and they can tolerate riding a bicycle. ⁶ However, if spinal stenosis and arterial occlusion in the lower extremities are present at the same time, the patient’s symptoms may be mixed and ambiguous. In our case, spinal stenosis was observed on MRI. Therefore, we thought that there would be neurogenic claudication, but the symptoms were ambiguous with the complaint of pain from the foot to the top. Consequently, we performed a Doppler test and CT scans for both lower extremities to determine if there was peripheral arterial disease, and we observed occlusion in the right external iliac artery. Therefore, even if there is a clear spinal stenosis lesion on lumbar MRI, vascular problems may be present if the patient has ambiguous symptoms.

Concomitant peripheral artery disease in patients with lumbar spinal stenosis is associated with old age, diabetes, the presence of aortic calcification, and an ABI < 0.9. ⁵ In our case, spinal stenosis was observed on MRI. Additionally, aortic calcification and a low ABI of 0.1 to 0.2 were observed, consistent with a previous report that it was likely to be accompanied by peripheral artery disease. ⁵

For the treatment of iliac artery occlusion, conservative treatment using medications (e.g., aspirin, clopidogrel, cilostazol, and pentoxifylline), surgical treatment (e.g., thromboendarterectomy and aortobifemoral bypass), and endovascular therapy can be used.^7,8 Depending on the location and degree of iliac artery occlusion, the treatment method can be adjusted. According to the Trans-Atlantic Inter-Society Consensus (TASC) document on the management of peripheral arterial disease, TASC A lesions are considered appropriate for endovascular intervention, TASC B/C lesions are potentially amenable to endovascular approaches, and TASC D lesions are treated preferentially with open surgery. ⁹ Our case had a TASC D lesion due to complete occlusion of the right external iliac artery and superficial femoral artery. Therefore, we considered endovascular stenting or bypass surgery, but first attempted conservative treatment using clopidogrel and beraprost sodium before an invasive procedure. After taking this medication for 1 month after the diagnosis, we attempted to decide whether to perform surgery according to the patient’s progress. At this time, the patient’s symptoms were improved by 30% to 35%. Therefore, we decided to continue conservative treatment. After conservative treatment, the patient's symptoms were improved by 60% to 70% 3 months after the diagnosis and by 80% to 85% 6 months after the diagnosis. Generally, conservative treatment using medications aims to reduce adverse cardiovascular events and control for risk factors for atherosclerosis. ⁹ However, in our case, the ABI continuously improved during the follow-up period with only medication. CT scans performed 4 years later showed recanalization of the right external iliac artery occlusion. To the best of our knowledge, this is the first report demonstrating that external iliac artery occlusion accompanied by spinal stenosis can be recanalized with clopidogrel and beraprost sodium.

In conclusion, we describe a rare case of external iliac artery occlusion and spinal stenosis. Our findings suggest that external iliac artery occlusion can be successfully treated only using conservative treatment using medication.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605231170550 - Supplemental material for Recanalization of external iliac artery occlusion in a patient with spinal stenosis using medications: a case report

Supplemental material, sj-pdf-1-imr-10.1177_03000605231170550 for Recanalization of external iliac artery occlusion in a patient with spinal stenosis using medications: a case report by Wan-Jae Cho, Hee-Man Chi, Ji-Hyun Ryu and Jun-Seok Lee in Journal of International Medical Research