Fig. 1 CT image of the pelvis demonstrates increased soft-tissue attenuation adjacent to the right common iliac artery (arrows).   Case Reference No. CC-0398-08 The patient is a 41-year-old man who was crushed by a big stone towards the abdomen, while his back was fixed against another hard object. On admission to the hospital, he was hemodynamically stable. CT scanning revealed a fracture to the left inferior pubic ramus. Hematuria was present, but no severe injury was seen to the bladder or urethra on an ascending urethrogram. His right lower extremity was acutely ischemic. No right femoral or distal pulses were palpable. The CT scan obtained to evaluate the pelvic fracture showed increased soft-tissue attenuation around the right common iliac artery and calcification in the right common iliac artery (Figs. 1,2). The right common iliac artery had a blunt injury. An angiogram was obtained via a pigtail catheter introduced from the left leg. It showed complete occlusion at the right common iliac artery (Fig. 3). Retrograde injection through a sheath in the right femoral artery showed this was a short segment of occlusion. After discussion with the surgical team, it was decided to treat the artery with stent placement. A covered stent (Cragg stent, 10 mm in diameter, 6 cm long) rather than a simple noncovered stent was placed through the occlusion, as it was difficult to exclude a complete tear through the arterial wall. Heparin was not given in view of the risk of bleeding from the injured artery. After deployment of the first stent no flow could be seen through the stent (Fig. 4). We supposed this was due to less than ideal stent positioning, so another stent was deployed. Angiography showed thrombosis inside the stent (Fig. 5). We attempted clot aspiration through the sheath and introduction system; although some clot was removed, there was no improvement. Doppler ultrasound of the popliteal artery showed a clot. At this juncture, surgery was performed. Clots were removed form the lower limb using a Fogarty catheter. The patient was also given a heparin infusion. The patient improved gradually. Questions: 1) Should heparin be used in acute injury of the artery? Is low-molecular-weight heparin a substitute? 2) Which is the preferred procedure in a case such as this, endovascular intervention or surgery? According to the surgeon, our second stent was near the junction of the aorta and the common iliac artery, which made it very difficult to apply a clamp during surgery. 3) Is a covered stent a wise choice in this situation?		Fig. 2. Increased soft-tissue attenuation is visible near the right common iliac artery.   Fig. 3. Angiography reveals right exernal iliac artery occlusion with some reconstitution of the common femoral artery. Fig. 4. After stent-graft deployment. Contrast injection in the right common iliac artery demonstrates flow into the right internal iliac, however there is no flow through the graft. Fig. 5. After additional stent-graft placement, thrombus is visible lining the graft lumen.
Related Cases: Case 897_03 -- Iliac rupture after recanalization, treated with covered stent Case 997_03 -- Iliac artery covered stent for enlarging pseudonaneurysm Case 1097_10 --External iliac artery pseudoaneurysm and vesical fistula