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9781841846439-Ch68 2/26/08 68 1:53 PM Page 606 Iliac occlusive diseases DT Cragen and RR Heuser Introduction Approximately one-third of lower extremity occlusive disease occurs in the iliac arteries, with the remaining two-thirds of disease in the femoral, popliteal, and infrapopliteal systems Surgical revascularization has been the mainstay of invasive treatment of aortoiliac disease for decades More recently, percutaneous techniques have been developed and shown to have similar efficacy with less associated morbidity and mortality As supporting technology improves and new percutaneous techniques are developed, a greater number of patients and their physicians are choosing percutaneous repair over surgical bypass Furthermore, symptoms can be treated sooner with percutaneous repair due to its lower morbidity and mortality, thus helping patients maintain active lifestyles that will further slow the progression of atherosclerotic obstruction Traditional surgical revascularization of iliac occlusive disease involved aortoiliac, aortofemoral, or femoral–femoral bypass grafting and has been highly effective, its success only being limited by its significant morbidity and mortality The Veterans Administration Cooperative Study demonstrated in a randomized trial nearly two decades ago that percutaneous transluminal angioplasty (PTA) produced similar results to surgery with similar symptomatic relief, durability, and freedom from amputation.1 PTA was somewhat less successful acutely (15% failure rate) but had fewer complications and no deaths while three deaths (2.4%) occurred in the surgical arm At 4-year follow-up, these results were sustained and there was a trend in survival favoring the PTA arm.2 Similar results were obtained in a randomized, single-center Swedish study with similar success and complication rates for both arms.3 Advances in technology during the last two decades have allowed more complicated lesions to be treated endovascularly with ever-increasing procedural success While most patients with iliac disease are asymptomatic, patients may present for evaluation with a range of symptoms from mild exertional claudication to acute critical limb ischemia Claudication from iliac occlusive disease usually involves both the thigh and the calf of the ipsilateral leg, but buttock claudication and vasculogenic impotence occur and suggest iliac stenosis The severity of symptoms varies according to the degree of stenosis, the recruitment of collateral circulation, and the presence of other proximal and/or distal stenoses Percutaneous intervention has become the mainstay of therapy for patients with iliac occlusive disease who have acute limb ischemia, critical limb ischemia, and stable claudication refractory to exercise and medical programs 606 In addition, percutaneous revascularization of the iliac artery can be critical in order to maintain a patent conduit for coronary and carotid catheters in these patients with diffuse atherosclerosis Diagnosis While most significant occlusive iliac disease is discovered in response to patient symptoms, more patients are being seen with asymptomatic disease—in part because of the rapid proliferation of other angiography procedures, especially coronary, which require passage of guidewires and catheters through the femoral and iliac systems to access the aorta and its branches Iliac disease may impede guidewire and catheter advancement, require additional manipulation of guidewires and catheters, or even prohibit passage altogether Finally, routine angiography of the iliofemoral system on the access side is routinely done at the conclusion of these procedures to assess puncture location and adequacy for closure devices and this may frequently uncover occult disease Known or suspected iliac occlusive disease should prompt a thorough history and physical exam Special attention should be given to history of co-morbidities, functional status, and cardiopulmonary symptoms including angina and dyspnea A detailed exploration of exertional limb discomfort should be undertaken as ipsilateral limb claudication is the most common presenting symptom in patients with significant plaque burden Care should be taken to distinguish the symptoms from those of other disease processes that may overlap significantly such as pseudoclaudication from spinal stenosis, peripheral neuropathies, and venous insufficiency Any history of non-healing ulcers should be elicited and prompt further evaluation Correctable and treatable risk factors such as nicotine usage, physical inactivity, diabetes mellitus, hyperlipidemia, and hypertension should be identified and management options discussed with the patient Physical examination should focus on the cardiac and pulmonary systems to assess for co-morbid conditions of significance such as obstructive pulmonary disease, valvular heart disease, cardiomyopathy, and arrhythmias A detailed examination of the peripheral pulses in the upper and lower extremities should be undertaken and documented Finally, non-invasive studies such as ankle–brachial indices with or without segmental pressures, Doppler imaging of the extremities, and pulse volume recordings can assist in 9781841846439-Ch68 2/26/08 1:53 PM Page 607 Iliac occlusive diseases localizing obstructive disease as well as determining the severity Advances in both computed tomography and magnetic resonance imaging allow these powerful modalities to more exactly define the nature and extent of disease burden Vascular access An important part of planning any interventional procedure is determining the access point that will permit the greatest likelihood of procedural success and least risk of complication Generally, the ipsilateral retrograde femoral artery (FA) can be chosen for high iliac lesions if the FA is relatively free of disease and there is an adequate “landing zone” for the sheath This ipsilateral approach is favored when intervention is planned near the aortic bifurcation as positioning a PTA balloon or a stent accurately using the crossover technique from the contralateral FA can be very difficult due to the angulation of the guidewire and/or sheath Contralateral retrograde femoral artery access with a crossover sheath is very effective for most common iliac, internal iliac, and external iliac lesions This technique provides excellent support and is especially useful if the patient’s ipsilateral disease hinders access or advancement of the vascular sheath Certain lesions may require both ipsilateral and contralateral femoral access, particularly with aortoiliac bifurcation disease (Figure 68.1), chronic occlusions, and during interventions when a dissection may have occurred and it is critical to preserve the vessel via the true lumen In uncommon scenarios, popliteal access may also be required (Figure 68.2) Finally, brachial or radial artery access may be indicated in patients with severe aortoiliac bifurcation disease or when bilateral iliofemoral disease limits access from the femoral arteries This approach can provide optimal guidewire angulation for precise delivery of balloons and stents to the aortoiliac bifurcation Of critical importance is that once vascular access is obtained via any route, care must be taken to avoid losing that access It can often be quite difficult to obtain initial access when there is a heavy disease burden and loss of access can lead to multiple complications including hematomas, vascular dissections, excess radiation exposure to the patient and operators, and sometimes cancellation or postponement of the procedure Angiography Angiography of the abdominal aorta and bifurcation is generally performed with a pigtail or similar side-hole catheter placed in the mid-abdominal aorta As needed, each iliac can be selectively entered with a catheter and/or sheath and selective views can be obtained to further demarcate lesion sites and severity Both inflow and outflow of each lesion should be clearly demarcated by the films and run-off views of bilateral lower extremities should be obtained Once all views are obtained, a working view should be selected A radio-opaque ruler placed in the field adjacent to the diseased artery is useful to establish landmarks to guide precise sizing and deployment of balloons and stents 607 Selecting revascularization: endovascular vs surgical Multiple studies have shown that the site of stenosis is highly predictive of both immediate procedural success and durability of results The TransAtlantic Inter-Society Consensus statement proposed a widely adopted classification system for iliac stenoses that categorizes them in increasing risk for poor endovascular procedural outcomes (Table 68.1).4 The consensus statement proposed that type A iliac lesions should be treated by percutaneous revascularization and type D lesions were best managed surgically Type B and C lesions are intermediate risk and there was less consensus over the preferred treatment The consensus statement said that percutaneous management for type B and surgical management for type C lesions are the preferred approach, but there is no clear evidence to support this recommendation Over the past several years, endovascular methods have been refined, interventionists are becoming more adept at advanced techniques, and stent technology in particular has improved and greatly expanded the scope of endovascular management It has become common practice for interventionists to treat TASC type B, C, and even complex D lesions successfully with endovascular procedures A recent study published by the Cleveland Clinic presented their findings in 89 patients who underwent 92 endovascular procedures for symptomatic iliac occlusions (TASC B, C, and D lesions).5 Their reported procedural success was 91% overall but 95 and 94% in TASC B and C lesions respectively The most common intraoperative complication was flow-limiting dissection (5/92) but all of these were successfully treated with prolonged balloon inflation and stent placement Primary and secondary (i.e after repeat revascularization) patency of the treated artery was 76% and 90% respectively at 36 months Limb salvage rate was an impressive 97% Peri-procedural mortality was 3.3%: one patient died of complications from distal embolization and two patients died of cardiorespiratory events This compares favorably to open aortobifemoral grafting which also carries a peri-operative mortality of approximately 3.3% in recent studies.5 Endovascular treatment has become the mainstay of revascularization of iliac artery occlusive disease for the aforementioned reasons This has been paralleled by a significant and sustained decrease in aortobifemoral graft surgery as patients and providers opt for the efficacy, safety, and durability of endovascular repair.6,7 As further refinements occur, we can only expect that endovascular repair will be more and more widely adopted Peri-procedural medical considerations Patients with known or suspected peripheral vascular disease should be managed with aggressive medical therapy (aspirin, statins, cilostazol, etc.) before considering endovascular therapy for refractory symptoms If the patient is not on aspirin at initial presentation, they should be started on a daily dose (preferably 325 mg daily) several days prior to planned intervention After completing diagnostic angiography, if intervention is indicated then the appropriate interventional sheath is placed in the access site Once the sheath exchange has been performed and before significant guidewire and 9781841846439-Ch68 608 2/26/08 1:53 PM Page 608 Textbook of peripheral vascular interventions (a) (b) (c) (d) Figure 68.1 ‘Kissing’ stents at aortoiliac bifurcation A 61-year-old female with a 75-pack-year history of smoking, uncontrolled hypertension, and hyperlipidemia had 12 months of bilateral hip and buttock claudication and developed blue toe syndrome weeks previously on the right Her ABIs were 0.53 and 0.58 on the right and left, respectively (a) Initial angiography with access obtained from the right common femoral artery revealed high-grade bilateral proximal common iliac artery stenoses A second arterial access was obtained in the left common femoral artery to permit simultaneous balloon deployment on both sides; (b) After predilatation with × 40 mm kissing balloons, two × 37 mm stents were deployed in ‘kissing’ fashion with approximately cm overlap in the distal aorta; (c) Angiography performed after the stents were deployed revealed resolution of the disease proximally, but residual complex disease at the distal edge of the right common iliac stent; (d) A third stent, × 27 mm, was deployed in an overlapping fashion and the final angiogram shows an excellent result On the day after this procedure, her ABIs were 1.0 and 0.91 on the right and left, respectively, and the patient was discharged home in good condition 9781841846439-Ch68 2/26/08 1:53 PM Page 609 Iliac occlusive diseases (a) (b) (c) (d) 609 Figure 68.2 A complicated external iliac artery case A 52-year-old man with a history of coronary disease, tobacco abuse, and hyperlipidemia presented for symptomatic claudication of the right leg reproducible at < block of walking and refractory to medical therapy and exercise (a) Initial angiography showed occlusion of the external iliac artery just distal to the take-off of the internal iliac artery; and (b) reconstitution of the distal external iliac artery via collaterals; (c) After angioplasty and stenting of the external iliac artery, initial angiography showed a perforation with a free-flowing jet of contrast An angioplasty balloon was reinflated at the perforation site until a covered stent could be deployed; (d) Angiography after covered-stent deployment confirmed resolution of the perforation but poor distal run-off Further evaluation confirmed that the stents had been deployed in a dissection plane and there was no significant antegrade flow to the common femoral artery The patient returned month later and access was obtained from both the contralateral femoral artery and the ipsilateral popliteal artery Once the true lumen was crossed, angioplasty and stenting was performed and the previously placed stents were crushed to the side 9781841846439-Ch68 610 2/26/08 1:53 PM Page 610 Textbook of peripheral vascular interventions (e) Figure 68.2, cont’d (e) Final angiography confirmed excellent antegrade flow and the patient experienced resolution of his symptoms catheter manipulation, intravenous heparin (3000–6000 units) is routinely given in our laboratory During prolonged (>1 hour) procedures or if thrombus is observed in catheters or on guidewires, strong consideration should be given to administering further heparin either empirically or to target a modestly elevated activated clotting time (ACT) of at least 200 seconds In the absence of serious perforation or bleeding complications, we not routinely reverse heparin after the intervention Postprocedurally, sheaths should be left in place until the ACT is 10 cm) 10 Unilateral occlusion involving both the CIA and EIA 11 Bilateral EIA occlusions 12 Diffuse disease involving the aorta and both iliac arteries 13 Iliac stenoses in a patient with an abdominal aortic aneurysm or other lesion requiring aortic or iliac surgery CIA, common iliac artery; EIA, external iliac artery; CFA, common femoral artery 9781841846439-Ch68 2/26/08 1:53 PM Page 611 Iliac occlusive diseases planned intervention would suffice as an estimate of vessel size It may also be appropriate in some instances to use intravascular ultrasound guidance to facilitate vessel measurements and assess lesion morphology and composition The balloon diameter should be chosen 0–1 mm larger than the reference vessel diameter such that when inflated it causes 15–20% overdilation of the lesion.16 The length of the balloon should allow it to extend just beyond the lesion margins proximally and distally to minimize barotrauma to the surrounding segments Inflation of the balloon should be carried out at the minimal pressure that eliminates the waist, or pinching, of the balloon at the site of stenosis Repeat angiography should be performed to determine success of the procedure; generally a residual stenosis of < 30% is considered acceptable and appropriate with balloon angioplasty A translesional gradient should be measured with the sheath or guide catheter and should be < mmHg to document resolution of the hemodynamically significant stenosis If results are not optimal (> 30% residual stenosis or translesional gradient of >5 mmHg) or if a significant dissection occurs, consideration should be given to further angioplasty and/or stent placement Stents As described above, PTA alone of the iliac artery is highly successful but limited by elastic recoil of the vessel which decreases acute gain, acute closure, and restenosis of the occluded segment; and by intimal dissections which can sometimes be flow limiting In addition, PTA has been less successful with certain lesion characteristics: irregular, ulcerated stenoses, occlusions, eccentric, or long lesions The deployment of stent endoprostheses primarily or immediately after PTA has significantly reduced the impact of each of these limitations and contributed to the success of endovascular revascularization A 4-year multicenter trial done by Palmaz et al documented the results of placing the Palmaz stent in the iliac artery of 486 patients and 567 limbs and showed angiographic patency was 92% at 8.7 months.17 A smaller study examined the results of deployment of Palmaz stents in the iliac arteries of 83 patients and 103 limbs.18 This study showed a primary patency rate of 87.5% at a mean follow-up of 10.4 months and sustained clinical benefit in 86.4% of patients at years A retrospective study of 288 patients showed high initial success rates, low complication rates, and similar patency data as had previously been reported with PTA use alone.19 More recent reports have sought to examine long-term results of stent deployment Vorwerk et al reported a 4-year primary patency of 78% and secondary patency of 82% in a small study of 100 patients.20,21 Schurmann and colleagues reported a similar patency rate of 83% at 5-year follow-up using nitinol self-expanding stents in 110 patients.22 Park et al recently reported 10-year follow-up data on 249 limbs in 203 patients in which technical success was very high (98%) and the primary patency of the stents was 87%, 83%, 61%, and 49% at 3, 5, 7, and 10 year follow-up, respectively.23 Factors that predicted loss of stent patency included stent diameter and lesions in the external iliac artery alone and tandem lesions in the common and external iliac artery These results are comparable to results obtained with surgery but 611 with significantly less complications, morbidity, and mortality associated with the index procedure.24 Given the favorable data supporting the use of stents, they are utilized in the vast majority of percutaneous interventions in the iliac arteries Deployment of the stents is similar to PTA as described above in terms of sizing of the stent As stent technology improves, stents are increasingly lower profile, more flexible, and hence more deliverable Balloon-expandable stents are preferred when precise placement is desired Occasionally, the stent may be difficult to deliver to the region due to calcification or vessel irregularity In these cases, it may be useful to advance the delivery sheath or catheter across the lesion, advance the stent to the treatment site, and then unsheathe the stent by withdrawing the sheath while fixing the stent in place Balloon-expandable stents are generally sized 1:1 to the reference vessel diameter As with PTA, during deployment of balloon-mounted stents, the operator should seek to achieve full expansion of the balloon and stent with no evidence of a “waist” within the stent length Post-dilatation may be required for persistent narrowing within the stented region or if there is a concern of malapposition of the stent to the vessel wall There is concern that post-dilatation may be a significant source of intraprocedural embolic material as material is extruded through the stent struts, so it should be employed judiciously Self-expanding stents are generally sized approximately mm larger than the reference vessel diameter such that they will continue to exert radial pressure along the length of the lesion They are also sized approximately cm longer than the lesion due to the difficulty in precise deployment of the stent and because the stent will shorten beyond its nominal length as it is post-dilated Once positioned and deployed, postdilatation is routine with self-expanding stents to assure wall apposition circumferentially and to prevent migration of the stent Perforation of the iliac artery, or its major branches, was previously often catastrophic due to the large vessel size and high flow rates through the artery Initially, a balloon was reinflated at the site of perforation to tamponade the artery until definitive therapy could be performed or hemostasis was achieved Recently, placement of a polytetrafluoroethylenecovered stent has become routine and has been safe and effective (Figure 68.3) These stents are either available in balloon-mounted versions for precise delivery or the more common self-expanding variety Conclusion The care of iliac occlusive disease has been revolutionized over the last two decades with the advent and development of percutaneous endovascular techniques Angioplasty and stenting of the iliac artery is the procedure of choice for the vast majority of patients and clinicians when local expertise in these endovascular procedures is available Studies have consistently shown that percutaneous intervention in the iliac artery is effective, safe, and produces durable results that rival those of surgical bypass techniques As interventionists become more facile with advanced endovascular techniques and incorporate the latest technological advances, the scope and severity of disease that can be treated percutaneously will continue to grow 9781841846439-Ch68 612 2/26/08 1:53 PM Page 612 Textbook of peripheral vascular interventions (a) (b) (c) Figure 68.3 Exclusion of an internal iliac aneurysm A 64-year-old man with hypertension, hyperlipidemia, and recent onset impotence was found to have an infrarenal abdominal aortic aneurysm (AAA) on computed tomography of the abdomen performed for unrelated reasons It was recommended that he proceed with angiography and then endoluminal grafting (ELG) of the AAA (a) On angiography, he was found to also have aneurysmal dilatation of the left common iliac artery and a focal aneurysm of the proximal left internal iliac artery with occlusion of the right internal iliac artery Given the difficulty of contralateral access after placement of ELG, we opted to proceed with exclusion of the left internal iliac artery aneurysm prior to placement of the ELG; (b) Once access was obtained with a 0.035-inch guidewire, a balloon-mounted × 59 mm iCast PTFE-covered stent (Atrium Medical Corp, Hudson, NH) was deployed across the aneurysm with successful; (c) exclusion of the aneurysm The patient underwent successful ELG placement a few weeks later 9781841846439-Ch68 2/26/08 1:53 PM Page 613 Iliac occlusive diseases 613 REFERENCES 10 11 12 Wilson S, Wolf G, Cross A Percutaneous transluminal angioplasty versus operation for peripheral arteriosclerosis Report of a prospective randomized trial in a selected group of patients J Vasc Surg 1989; 9: 1–9 Wolfe G, Wilson S, Cross A et al Surgery or balloon angioplasty for peripheral vascular disease: a randomized clinical trial Principal investigators and their Associates of Veterans Administration Cooperative Study Number 199 J Vasc Interv Radiol 1993; 4: 639–48 Holm J, Arfvidsson B, Jivegard L et al Chronic lower limb ischaemia A prospective randomised controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty Eur J Vasc Surg 1991; 5: 517–22 Management of peripheral arterial disease (PAD) TransAtlantic Inter Society Consensus (TASC) J Vasc Surg 2000; 31(suppl.): 1–296 de Vries S, Hunink M Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis J Vasc Surg 1997; 26: 558–69 Leville C, Kashyap V, Clair D et al Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients J Vasc Surg 2006; 43: 32–9 Whitely M, Ray-Chaudhuri S, Galland R Changing patterns in aortoiliac reconstruction: a 7-year audit Br J Surg 1996; 83: 1367–9 Freiman D, Spence R, Gatenby R et al Transluminal angioplasty of the iliac and femoral arteries: follow-up results without anticoagulation Radiology 1981; 141: 347 Johnston K Iliac arteries: reanalysis of results of balloon angioplasty Radiology 1993; 186: 207–12 Van Andel G, Van Erp W, Krepel V et al Percutaneous transluminal dilatation of the iliac artery: long-term results Radiology 1985; 156: 321 Gallino A, Mahler F, Probst P et al Percutaneous transluminal angioplasty of the arteries of the lower limbs: a year follow up Circulation 1984; 70: 619–23 Becker GJ, Katzen BT, Dake MD Non coronary angioplasty Radiology 1989; 170: 403–12 13 14 15 16 18 19 20 21 22 23 24 Van Andel GJ, Van Erp W, Krepel M Percutaneous transluminal dilatation of the iliac artery Long term results Radiology 1985; 156: 321–3 Tegtmeyer CJ, Hartwell GD, Selby JB et al Results and complications of angioplasty in aortoiliac disease Circulation 1991; 83(suppl I): 153–60 Wilson SE, Wolf GL Cross AP Percutaneous transluminal angioplasty versus operation for peripheral atherosclerosis J Vasc Surg 1989; 9: 1–9 Kalman P, Johnston K, Sniderman K Indications and results of balloon angioplasty for arterial occlusive lesions World J Surg 1996; 20: 630–417 Palmaz JC, Laborde JC, Rivera FJ et al Stenting of the iliac arteries with the Palmaz stent: experience from a multicenter trial Cardiovasc Intervent Radiol 1992; 15: 291–7 Murphy KD, Encarnacion CE, Le VA, Palmaz JC Iliac artery stent placement with the Palmaz stent: follow-up study J Vasc Interv Radiol 1995; 6: 321–9 Richter GM, Roeren T, Noeldge G et al Initial long-term results of a randomized 5-year study: iliac stent implantation versus PTA Vasa – Supplementum 1992; 35: 192–3 Vorwerk D, Gunther R, Schurmann K et al Primary stent placement for chronic iliac artery occlusions: follow-up results in 103 patients Radiology 1995; 194: 745–9 Vorwerk D, Gunther R, Schurmann K et al Aortic and iliac stenoses: follow-up results of stent placement after insufficient balloon angioplasty in 118 cases Schurmann K, Mahnken A, Meyer J et al Long-term results 10 years after iliac arterial stent placement Radiology 2002; 224: 731–8 Park K, Do Y, Kim J et al Stent placement for chronic iliac arterial occlusive disease: the results of 10 years experience in a single institution Kor J Radiol 2005; 6: 256–66 Devries SO, Hunink MG Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta analysis J Vasc Surg 1997; 26: 558–69 9781841846439-Ch69 2/26/08 69 3:29 PM Page 614 Procedures for the hypogastric artery J Cynamon and P Prabhaker Introduction For a long time the hypogastric artery was a neglected vessel, with few procedures being performed by interventional radiologists except for a limited number of angioplasties done for significant claudication or erectile dysfunction Recently, this vessel has become of prime importance to various procedures Fibroids are currently treated by embolizing the uterine artery as it stems from the anterior division of the hypogastric artery Pudendal arteriography and iliac angioplasty are being performed for evaluation and management of impotency Rarely, buttock claudication, which can be due to significant hypogastric artery stenosis, can be treated by angioplasty The most frequent intervention of the hypogastric artery performed at our institution is preoperative hypogastric artery coil embolization for stent-graft or operative repair of abdominal aortic and iliac artery aneurysms to prevent collateral endoleaks This chapter will review these indications and techniques that have now become commonplace in the angiography suite Claudication Since angioplasty for claudication has been around for many years, we will begin with this topic, Isolated hypogastric artery stenosis causing significant claudication occurs rarely (Figure 69.1).1 Occasionally, an external iliac artery occlusion occurs with a proximal hypogastric artery stenosis In this situation, where the common femoral artery and the distal vessels are supplied by the hypogastric artery, a focal stenosis of the hypogastric artery may lead to severe thigh or calf claudication and thus may warrant treatment via angioplasty An alternative to angioplasty would be recanalization of the external iliac artery, which is significantly more invasive than a focal hypogastric artery angioplasty Unfortunately, there are no large series reporting the initial and long-term results of hypogastric artery angioplasties for the treatment of claudication Erectile dysfunction The evaluation and possible treatment of impotency is another procedure that involves the hypogastric artery Although there are many methods of evaluation of the cause of impotency, such as duplex ultrasonography, magnetic resonance imaging, and radionuclide imaging, pudendal arteriography remains the gold standard for penile arterial assessment Pudendal arteriography allows for an anatomic study of the causes of 614 impotence, which is necessary when considering penile arterial reconstructive surgery The distal aorta, common iliac artery, proximal hypogastric artery, and pudendal arteries must be evaluated Pudendal arteriography is best performed by bilaterally catheterizing the hypogastric arteries and using the image intensifier to visualize in the ipsilateral anterior oblique projection, with the penis positioned across the contralateral thigh so that the dorsal and cavernosal arteries become visible (Figure 69.2) The angiogram is performed after injecting 60 mg of papaverine directly into the cavernosum using a 25 or 27 gauge needle.2 This causes a partial or complete erection in most patients, which improves flow and helps visualize the dorsal penile artery The classic penile anatomy is the dorsal penile, cavernosal, and bulbar arteries stemming from each pudendal artery.3,4 A great deal of variation exists, with only 18% of cases in one study having the classic pudendal anatomy.5 To avoid misinterpretation of normal variants, such as the dorsal penile artery branching from the iliac or common femoral artery, these variants should be searched for if a dorsal penile artery is not seen with hypogastric artery injection (Figure 69.3) If a stenosis is identified in one of the inflow vessels such as the common iliac or proximal hypogastric arteries, the patient may benefit from transluminal angioplasty In addition, a focal lesion in the pudendal artery can be dilated with a small vessel balloon.6 However, many patients with arterial erectile dysfunction not have a focal lesion amenable to angioplasty These patients can benefit from a surgical bypass to the dorsal penile artery Uterine artery embolization Transcatheter uterine artery embolization was once an uncommon procedure performed for emergency control of hemorrhage related to pelvic trauma, post-partum and postcesarean bleeding, placental abnormalities, ectopic pregnancy, hemorrhage from gestational trophoblastic disease, intraoperative bleeding, and pelvic arteriovenous malformations.7 Recent use of uterine artery embolization for the treatment and management of symptomatic uterine leiomyomas has further stretched the application of this procedure Uterine leiomyomas produce significant morbidity by causing uterine enlargement, abnormal bleeding, anemia, pelvic pain, and infertility Prior therapeutic techniques, such as treatment with gonadotrophin-releasing hormone (GnRH) analogs, myomectomy, or hysterectomy, have proved to be either inadequate or associated with significant morbidity, mortality, and potential infertility Thus, the utilization of uterine artery embolization to shrink 9781841846439-Ch69 2/26/08 3:29 PM Page 615 Procedures for the hypogastric artery (a) (b) 615 (c) Figure 69.1 (a) A 62-year-old man with three block buttock claudication with a focal stenosis of the proximal hypogastric artery (b) Percutaneous transluminal angioplasty (PTA) with a × balloon performed via an ipsilateral common femoral artery puncture (c) Post-PTA angiogram demonstrating a good result The patient no longer suffered from buttock claudication leiomyomas by obstructing their blood supply appears to be a better and less-invasive approach to the treatment of symptomatic fibroids.8,9 Uterine artery embolization is performed via selective catheterization of the hypogastric and uterine arteries Bilateral embolization is required for treatment of symptomatic leiomyomas since bilateral arterial anastomoses provide the blood supply to fibroids The most common agents used include Gelfoam sponges and polyvinyl alcohol particles (Figure 69.4).10 Other agents such as Biospheres and Onyx are being evaluated Complications have been infrequent, with the most common complication being groin hematomas and arterial perforations Post-embolization pain resulting from (a) leiomyoma ischemia is also fairly common and is controlled with appropriate narcotics Other observed but very rare complications include endometritis and ischemia to pelvic organs seen with emergency embolization done for hemostasis Studies have shown a high rate of success, with decreased symptomatology and reduction in leiomyoma volume of between 20 and 80% Limited follow-up of patients undergoing uterine artery embolization has prevented knowledge of the exact frequency of embolization failure and of the consequences on post-embolization fertility However, successful pregnancies have been reported after the procedure, which offers hope that uterine artery embolization may one day be the main modality of treatment for symptomatic uterine fibroids (b) Figure 69.2 Right anterior oblique view of a selective right hypogastric artery (a) before and; (b) after injection of 60 mg papaverine The pudendal artery is visualized and is seen as it enters the dorsum of the penis and becomes she dorsal penile artery The cavernosal and bulbar arteries are also seen Note this elongated view of the dorsal penile artery can only be obtained in the anterior oblique projection with the penis draped across the contralateral thigh ... true lumen In uncommon scenarios, popliteal access may also be required (Figure 68.2) Finally, brachial or radial artery access may be indicated in patients with severe aortoiliac bifurcation disease... Inflation of the balloon should be carried out at the minimal pressure that eliminates the waist, or pinching, of the balloon at the site of stenosis Repeat angiography should be performed to determine... diameter As with PTA, during deployment of balloon-mounted stents, the operator should seek to achieve full expansion of the balloon and stent with no evidence of a “waist” within the stent length