{"title":"Challenges and management of iliac-to-femoral artery injuries in endovascular aneurysm repair.","authors":"Antonio Marzano, Enrico Sbarigia, Carola D'Amico, Vincenzo Brizzi, Ombretta Martinelli, Simone Cuozzo","doi":"10.1016/j.tcr.2026.101405","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Iatrogenic injuries to iliac-to-femoral arteries during complex endovascular procedures remain serious and potentially life-threatening. These events are influenced by adverse anatomy, procedural difficulties, and prolonged device manipulation. This report assesses the occurrence and risk factors associated with arterial disruption during endovascular thoracoabdominal aortic aneurysm (TAAA) repair and highlights adjunctive techniques that may optimize outcomes in challenging iliac anatomies.</p><p><strong>Case report: </strong>A 70-year-old woman underwent TEVAR and iB-EVAR with an <i>E</i>-nside stent-graft for a type I TAAA. Preoperative imaging confirmed anatomy suitable for an off-the-shelf device despite a narrow (6.8 mm) and tortuous (X = 1.48) external iliac artery (EIA). Because of comorbidities, a surgical conduit was reserved as a bailout if advancing the 24 F devices proved difficult. Adjunctive maneuvers, including retroperitoneal mobilization of the EIA to straighten the vessel and multiple serial dilations, were preferred. The EIA accommodated both the thoracic stent-graft and the <i>E</i>-nside system. Difficult catheterization of target vessels prolonged operative time and increased the duration of device presence within the artery. During sheath withdrawal, unexpected resistance caused hemodynamic instability due to EIA rupture, requiring emergent iliac-to-femoral bypass. Postoperative imaging showed loss of patency of the celiac trunk and left renal artery, prompting secondary occlusion of the corresponding side branches. Three-year follow-up confirmed aneurysm sac shrinkage without endoleaks.</p><p><strong>Conclusion: </strong>Well-documented risk factors increase the likelihood of EIA injury, highlighting the need to balance patient comorbidities, anatomical challenges, and therapeutic strategies. Standardized protocols are essential for managing large-bore access, and refinements in delivery system design may further enhance procedural safety and effectiveness.</p>","PeriodicalId":23291,"journal":{"name":"Trauma Case Reports","volume":"64 ","pages":"101405"},"PeriodicalIF":0.0000,"publicationDate":"2026-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13234208/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Trauma Case Reports","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1016/j.tcr.2026.101405","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2026/8/1 0:00:00","PubModel":"eCollection","JCR":"Q4","JCRName":"Medicine","Score":null,"Total":0}
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Abstract
Background: Iatrogenic injuries to iliac-to-femoral arteries during complex endovascular procedures remain serious and potentially life-threatening. These events are influenced by adverse anatomy, procedural difficulties, and prolonged device manipulation. This report assesses the occurrence and risk factors associated with arterial disruption during endovascular thoracoabdominal aortic aneurysm (TAAA) repair and highlights adjunctive techniques that may optimize outcomes in challenging iliac anatomies.
Case report: A 70-year-old woman underwent TEVAR and iB-EVAR with an E-nside stent-graft for a type I TAAA. Preoperative imaging confirmed anatomy suitable for an off-the-shelf device despite a narrow (6.8 mm) and tortuous (X = 1.48) external iliac artery (EIA). Because of comorbidities, a surgical conduit was reserved as a bailout if advancing the 24 F devices proved difficult. Adjunctive maneuvers, including retroperitoneal mobilization of the EIA to straighten the vessel and multiple serial dilations, were preferred. The EIA accommodated both the thoracic stent-graft and the E-nside system. Difficult catheterization of target vessels prolonged operative time and increased the duration of device presence within the artery. During sheath withdrawal, unexpected resistance caused hemodynamic instability due to EIA rupture, requiring emergent iliac-to-femoral bypass. Postoperative imaging showed loss of patency of the celiac trunk and left renal artery, prompting secondary occlusion of the corresponding side branches. Three-year follow-up confirmed aneurysm sac shrinkage without endoleaks.
Conclusion: Well-documented risk factors increase the likelihood of EIA injury, highlighting the need to balance patient comorbidities, anatomical challenges, and therapeutic strategies. Standardized protocols are essential for managing large-bore access, and refinements in delivery system design may further enhance procedural safety and effectiveness.
期刊介绍：
Trauma Case Reports is the only open access, online journal dedicated to the publication of case reports in all aspects of trauma care and accident surgery. Case reports on all aspects of trauma management, surgical procedures for all tissues, resuscitation, anaesthesia and trauma and tissue healing will be considered for publication by the international editorial team and will be subject to peer review. Bringing together these cases from an international authorship will shed light on surgical problems and help in their effective resolution.
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