he was taking warfarin for deep vein thrombosis and had a hemoglobin level of 4.5 g / dl .
he had undergone low anterior resection and partial bladder resection with adjuvant chemotherapy to treat sigmoid colon cancer 3 years earlier .
the anemia and the prolongation of the prothrombin time were easily corrected ; thus , continuous bleeding was not suspected .
nevertheless , in order to rule out gastrointestinal bleeding as a cause of the severe anemia , abdominal computed tomography ( ct ) was performed .
however , there was no evidence of intra - abdominal bleeding . instead , a 55-mm abdominal aortic aneurysm with eccentric bulging combined with a right common iliac artery aneurysm ( fig .
the aneurysm size increased by 10 mm compared with the size 2 years previously . because severe intra - abdominal adhesion and wound problems after laparotomy were expected , endovascular aortic aneurysm repair ( evar ) was recommended instead of open surgery .
evar was started with the deployment of a bifurcated main body using an aortic stent graft of 303040 mm and an inner bare stent 323250 mm in size ( s&g biotech inc . ,
subsequent extension of the right graft limb was performed uneventfully using two covered stents ( 121280 mm and 121260 mm ) to exclude the right common iliac artery aneurysm .
dreadful complications occurred during the last procedure of the left graft limb extension . after the selection of the left graft limb and the guide wire exchange to a lunderquist stiff wire ( cook inc . , bloomington ,
in , usa ) , a 16f introducer sheath was inserted for the delivery of a limb extension graft , but the tip of the sheath perforated the left proximal external iliac artery during the advancement of the sheath ( fig .
sheath - pushing against the tortuous iliac artery caused the guide wire to slip back into the sheath , and the dilator tip punctured the arterial wall . although the extension of the left graft limb was scheduled to end at the distal common iliac artery , the extension was promptly determined to be lengthened to the external iliac artery to cover the perforated site .
the left graft limb of the main body was reselected , and a stent graft of 1212100 mm was deployed .
however , subsequent aortography showed an occlusion of the left graft limb , and acute thrombosis was suspected ( fig .
a prompt balloon thrombectomy was attempted after the left superficial and deep femoral arteries were clamped to prevent distal embolization .
a 6f balloon catheter was advanced through the occlusion and withdrawn carefully not to cause disjunction of the overlapped stent grafts .
fresh thrombus was successfully removed , and the graft flows became excellent without any endoleak upon the completion of angiography ( fig .
3 ) . at the 3-month follow - up , the patient was doing well without any symptoms like buttock claudication .
although the surgery reduces the risk of rupture of the aortic aneurysm , the mortality of surgery has been reported to be approximately 2% to 8% .
in fact , in the high - risk group for surgery , the morbidity is as high as 30% .
since the first successful endovascular treatment of an abdominal aortic aneurysm in 1991 , this procedure has been performed with increasing frequency for high - risk patients . recently , with the development of smaller and more precise devices , evar has been accepted as a useful treatment method for patients at high risk for postoperative complications and patients refusing surgery .
however , evar also has many complications related to the procedures , such as ruptures , thrombi within stent grafts , endoleaks , dislocation of the stent grafts , and infections .
we experienced combined iliac artery rupture and graft limb thrombosis , which would cause a fatal outcome unless addressed immediately . although the main cause of the iliac artery perforation in this case was the fact that the push of the introducer sheath was careless and jerky , one of the keys for successful endovascular repair of aortic aneurysm is adequate vascular access through the femoral and iliac arteries .
calcification , diminished diameter , and severe tortuosity of the iliac arteries have been associated with an increased incidence of iliac injury during evar . however , even after careful preoperative assessment , inadvertent iliac rupture can occur and be a source of morbidity and mortality .
this case calls attention to the importance of a careful manipulation of wires and catheters during the endovascular procedure . with respect to the management of acute iliac artery rupture , endovascular repair with a stent graft
intraoperative invasive arterial blood pressure monitoring , maintenance of stiff wire access , readily available intra - aortic occlusion balloons , and an inventory of iliac stent grafts are the prerequisites for the prompt endovascular management of a ruptured iliac artery during evar .
almost all the previous literature reported delayed or late stent graft thrombosis rather than acute or intraoperative thrombosis as in this case .
the incidence rates have been reported to be 2.7% to 23.8% , and underlying stenosis or kinks have been pointed out as the main causes .
however , the main cause of the acute graft limb thrombosis in this case was thought to be inadequate anticoagulation during the management of the ruptured iliac artery .
the goal of the management of the stent graft thrombosis is the restoration of appropriate blood flow to the lower extremities .
therefore , the available treatment methods are thrombectomy , catheter thrombolysis , and extra - anatomical bypass , such as axillo - femoral or cross - femoral bypass . according to the eurostar ( european collaborators on stent / graft techniques for aortic aneurysm repair ) registry , as a secondary procedure after evar , 11% of the patients required femoro - femoral bypass grafting . in this case , thrombectomy was performed rather than thrombolysis or extra - anatomical bypass because thrombolysis right after the event of iliac artery perforation was inappropriate , and extra - anatomical bypass should be a second - line treatment option considering that the thrombus was fresh
. the limitations of thrombectomy are mainly associated with technical difficulty in the introduction of a catheter into the lumen of the stent graft , particularly in the case of late thrombosis and with the possibility of stent migration or disconnection of graft elements , which can lead to type i or type iii endoleaks . to prevent thrombosis in the stent graft , adequate anticoagulation during and after the procedure is necessary . in summary , we report a rare case of combined iliac artery rupture and graft limb occlusion complicating evar , which were successfully managed without additional open surgery
. careful manipulation of catheters and guide wires , as well as maintenance of optimal anticoagulation throughout the procedure , is fundamental but the most important requirement for an endovascular procedure . to decide on the best treatment option among the various surgical and endovascular modalities
 for high - risk patients , endovascular aortic aneurysm repair ( evar ) is a good option but may lead to serious complications , which should be addressed immediately . a 75-year - old man with a history of abdominal surgery underwent evar for an aneurysm of the abdominal aorta and iliac arteries . 
 during evar , iliac artery rupture and graft limb occlusion occurred , and they were successfully managed by the additional deployment of an iliac stent graft and balloon thrombectomy , respectively . 
 we , herein , report a rare case of the simultaneous development of the two fatal complications treated by the endovascular technique . 
CASE REPORT
DISCUSSION