Diagnosis and Ultrasound-Guided Repair of an Iliac Artery Dissection

Abstract

Introduction

Although contrast arteriography (CA) has historically been considered the gold standard for imaging of the lower extremity arteries, it has known limitations and complications. Duplex ultrasound (DU) imaging has emerged as a viable, and in some instances superior, alternative to CA. The following case study describes the use of DU to diagnose and treat an iliac artery dissection not appreciated by conventional multi-planar contrast arteriography.

Case Report

The patient is a 46-year-old man with a significant smoking history and symptomatic peripheral vascular disease who has undergone percutaneous transluminal coronary angioplasty and stent placement after a myocardial infarction. He presented with complaints of progressively worsening right leg claudication. The workup included a duplex arterial mapping performed prior to diagnostic CA. DU revealed a short segment right superficial femoral artery (SFA) occlusion and normal Doppler flow characteristics in the common femoral artery. Arteriography confirmed the presence of the SFA occlusion. A follow-up duplex to rule out a groin pseudoaneurysm was then performed. This study revealed no pseudoaneurysm but identified a dissection extending from the mid external iliac artery (EIA) to the distal common femoral artery that was not appreciated by CA. Because of the DU findings, intraoperative CA to evaluate the EIA was performed at the time of SFA endarterectomy and patch angioplasty. Again, the dissection was not evident, and as a result of the inconclusive arteriogram, ultrasound was used intraoperatively to image and facilitate its repair. A 9 × 40-mm SMART stent (Cordis®, Warren, NJ) was deployed in the EIA under ultrasound guidance to seal the leading edge of the dissection. Completion DU showed sealing of the origin of the dissection and near-complete elimination of flow in the false lumen.

Conclusions

DU diagnosed an EIA dissection that was not detected on CA and was subsequently used as the sole imaging modality to guide deployment of a stent for its repair. This case illustrates that duplex evaluation can be superior to arteriography for both the diagnosis and treatment of patients with peripheral arterial disease.