Case Report
Loss of Limb by Inadvertent Embolization of the Persistent Sciatic Artery
Vascular and Endovascular Surgery 2016, Vol. 50(1) 60-62 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574416629563 ves.sagepub.com
Xianchen Huang, MD1, Yao Tang, MD1, Guoxiong Xu, MD1, Zhixuan Zhang, MD1, Liming Shen, MD1, and Yiqi Jin, MD1
Abstract Persistent sciatic artery (PSA) is a rare anatomic variant and is normally clinically silent. It can be found occasionally during uterine arteries embolization (UAE) and can lead to technical failure or complications. The authors present a patient with bilateral PSAs who was referred for emergency UAE because of uncontrollable postabortion hemorrhage. Inadvertent embolization of the right PSA led to unsalvageable ischemia and amputation of the right lower limb 12 days later. Keywords persistent sciatic artery, uterine artery embolization, postabortion hemorrhage
Introduction Emergency uterine artery embolization (UAE) is an effective method to treat postabortion hemorrhage with low complications.1,2 However, technical failure and complication of lower limb artery embolization caused by persistent sciatic artery (PSA) have been reported.3,4 Persistent sciatic artery is a rare anatomic variant, resulting from incomplete degeneration of the sciatic artery after the third month of gestation.5 We report a case of postabortion hemorrhage with amputation after inadvertent embolization of the PSA. To our knowledge, this is the only case of complication of irreversible ischemic damage of a lower limb caused by embolization of the PSA. This case report was approved by the committee on human research of the Institutional Review Board at the authors’ institution. Written informed consent was obtained from the patient.
Case Description The patient, a 32-year-old female, was referred to our institution for emergency UAE because of uncontrollable uterine hemorrhage after induced abortion. Her estimated blood loss was about 1500 mL during 3 hours before arriving at the hospital. She presented with a blood pressure of 80/50 mm Hg on the fluoroscopy table. Written consent was obtained before the procedure. The pulse of the right femoral artery was normal. Puncture was made of the right femoral artery, and a 5F sheath was inserted. Angiography of the bilateral internal iliac artery was performed using a 4F Cobra catheter (Terumo, Tokyo, Japan) and showed multiple contrast extravasations. However, bilateral aberrant branches which came from the internal iliac arteries and went to the lower legs were ignored, and a further angiogram of these branches was not performed (Figure 1A and B). Left side
embolization was performed with gelfoam slurries with a catheter inserted in the uterine artery. Selective catheterization of the right uterine artery could not be achieved due to vasospasm, despite attempt with a 3F microcatheter (Terumo). Considering persisting bleeding and our previous experience, embolization of the anterior division of the internal iliac artery was performed on the right side using gelfoam slurries. The postembolization angiogram showed contrast stasis in the left uterine artery and the right anterior division of the internal iliac artery. The right aberrant branch which was embolized was not appreciated at the time (Figure 1C). Hemostasis was obtained by manual compression after catheter and sheath were removed. After completing the procedure, uterine hemorrhage ceased and patient’s blood pressure went up to 110/70 mm Hg. The patient was transferred to gynecology ward without any complaint. Nevertheless, the patient claimed numbness and pain of her right lower limbs 12 hours later. Physical examination showed that the lower limb was cold, and the pulsation of the dorsalis pedis artery was not palpable. Subsequently, emergency computer tomography angiography (CT) suggested that the bilateral aberrant branches (which were recognized as PSAs) exited the pelvis via the sciatic foramen, descended down the posterior thigh, and were continuous with popliteal artery. The right calf arteries were occluded distally (Figure 1D-F).
1 Department of Vascular Surgery, Nanjing Medical University affiliated Suzhou Hospital, Suzhou, China
Corresponding Author: Yiqi Jin, Department of Vascular Surgery, Nanjing Medical University affiliated Suzhou Hospital, 26, Daoqian Street, Suzhou City, Jiangsu Province, 215000, China. Email: [email protected]
Downloaded from ves.sagepub.com at Bobst Library, New York University on March 2, 2016
Huang et al
61
Figure 1. A 32-year-old female with bilateral persistent sciatic arteries (PSAs). A, Left common iliac artery angiogram showed PSA (white arrow) came from the internal iliac arteries which were ignored. B, Right common iliac artery angiogram showed PSA (white arrow) came from the internal iliac arteries which were ignored. C, Angiogram after embolization showed that the left PSA (white arrow) was patent and the right PSA was not visualized. D, Computed tomography angiography (CTA) showed that bilateral PSAs (white arrow) and hypoplastic superficial femoral arteries (white arrowhead). The PSAs arose from the internal iliac arteries. E, The right calf arteries were occluded distally.
Considering the serious ischemia and anatomical variant, a right popliteal artery embolectomy was performed. Digital subtraction angiography (DSA) during the procedure showed that the right PSA, the right popliteal artery, and distal arteries were occluded. Thrombus and gelfoam were withdrawn from the right limb with a Fogarty catheter. Popliteal artery pulsation was obvious after embolectomy. However, the angiogram showed contrast stasis in the distal arteries. Anticoagulation was performed with heparin 5 mg/hour after the procedure. The right dorsalis pedis pulsation did not recover 24 hours after embolectomy. Then catheter-directed thrombolysis was attempted using a 4F catheter (Terumo) inserted into the right PSA from the left femoral artery. Urokinase was injected
through the catheter, 10 000 IU/hr. Ultimately, necrosis appeared in the calf at the end of 24 hours of thrombolysis. The right lower limb was amputated below the knee 12 days after embolization and the wound healed 2 months later.
Discussion Persistent sciatic artery is a very rare congenital malformation. The incidence of PSA is estimated to be 0.025% to 0.04%.6 The sciatic artery is a branch of the internal iliac artery and feeds the lower limb in the early embryonic stage. Normally, the sciatic artery involutes, while the superficial femoral artery which develops from the external iliac artery becomes the major
Downloaded from ves.sagepub.com at Bobst Library, New York University on March 2, 2016
62
Vascular and Endovascular Surgery 50(1)
blood supply of the lower extremity. However, the sciatic artery remains as the dominant blood supply to the limb during the absence of femoral artery development. It may continue in a complete or incomplete form and occur bilaterally or unilaterally. In the complete form, PSA forms an anastomosis with the popliteal artery, while the superficial femoral artery degenerates and ends in the thigh. In the incomplete form, PSA persists but vanishes above the popliteal artery level, and the superficial femoral artery continues into the popliteal artery as the main supply of the extremity. Normally, PSA is clinical silent; it can be found incidentally or presents with syndromes of ischemia or compression. In most previous literature, PSAs were reported in connect with aneurysm formation. The morbidity was about 40% to 60% in reported cases.7 Also, some authors described symptomatic atherosclerotic narrowing as another complication of PSA, and it appeared in about 7% to 9% of reported cases.8 Uterine artery embolization to treat uncontrollable postabortion hemorrhage was reported only in 3 studies.2,9,10 However, it was widely used in postpartum hemorrhage and uterine fibroid with minimal morbidity and high technical success.1,11 There were 3 papers about PSA found occasionally during UAE in literature. Technical failure and complication of UAE caused by PSA were described in 2 reports. Soyer et al3 detected bilateral PSAs while attempting UAE for a patient of postpartum hemorrhage and gave up embolization because of selective catheterization failure. Hsu et al4 described a case of pelvic trauma. A few embolization particles were injected into the internal iliac artery before recognizing the PSA. Nonetheless, no ischemic sequela of the lower limb was noted. However, there was 1 author who reported of a successful UAE. Malhotra et al12 found 3 cases of PSA in 360 patients who underwent UAE for symptomatic uterine leiomyomatomas. Uterine artery catheterization was achieved, and embolization was performed without complications in all 3 cases. In the present case, embolization of the right internal iliac artery was performed at the level of anterior division. It was done safely in previous patients in life-threatening conditions or when superselective catheterization was not feasible. It was as effective as a more selective one and was not correlated with a higher degree of morbidity.13 Conversely, embolization of the anterior division may result in complications in rare condition of PSA. Especially, when PSA presents in complete form, the risk of irreversible ischemic damage of the lower limb is very high. In our case of complete form of PSA, the operator did not study the angiogram carefully or identify the existence of PSAs. Inadvertent embolization of the PSA led to unsalvageable limb ischemia and amputation.
Conclusion Persistent sciatic artery is a rare anatomic variant which is normally clinical silent. We reported a case of bilateral PSA. Internal iliac artery embolization which was performed at the level of the anterior division resulted in calf necrosis. This case demonstrates that meticulous angiogram and a detailed understanding
of vascular anatomic variants are very important for interventional radiologists to reduce complications. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception. 2013;87(3):331-342. 2. Steinauer JE, Diedrich JT, Wilson MW, Darney PD, Vargas JE, Drey EA. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol. 2008;111(4):881-889. 3. Soyer P, Boudiaf M, Jacob D, et al. Bilateral persistent sciatic artery: a potential risk in pelvic arterial embolization for primary postpartum hemorrhage. Acta Obstet Gynecol Scand. 2005;84(6): 604-605. 4. Hsu WC, Lim KE, Hsu YY. Inadvertent embolization of a persistent sciatic artery in pelvis trauma. Cardiovasc Intervent Radiol. 2005;28(4):518-520. 5. Aziz ME, Yusof NR, Abdullah MS, Yusof AH, Yusof MI. Bilateral persistent sciatic arteries with unilateral complicating aneurysm. Singapore Med J. 2005;46(8):426-428. 6. Ikezawa T, Naiki K, Moriura S, Ikeda S, Hirai M. Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature. J Vasc Surg. 1994; 20(1):96-103. 7. Yang S, Ranum K, Malone M, Nazzal M. Bilateral persistent sciatic artery with aneurysm formation and review of the literature. Ann Vasc Surg. 2014;28(1):264. e1-e7. 8. van Hooft IM, Zeebregts CJ, van Sterkenburg SM, de Vries WR, Reijnen MM. The persistent sciatic artery. Eur J Vasc Endovasc Surg. 2009;37(5):585-591. 9. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol. 2001;185(3):530-536. 10. Haddad L, Delli-Bovi L. Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation. Contraception. 2009;79(6):452-455. 11. Toor SS, Jaberi A, Macdonald DB, McInnes MD, Schweitzer ME, Rasuli P. Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis. AJR Am J Roentgenol. 2012; 199(5):1153-1163. 12. Malhotra AD, Kim HS. Persistent sciatic artery and successful uterine artery embolization: report of three cases. J Vasc Interv Radiol. 2009;20(6):813-818. 13. Pelage JP, Soyer P, Le Dref O, et al. Uterine arteries: bilateral catheterization with a single femoral approach and a single 5-F catheter–technical note. Radiology. 1999;210(2):573-575.
Downloaded from ves.sagepub.com at Bobst Library, New York University on March 2, 2016
Loss of Limb by Inadvertent Embolization of the Persistent Sciatic Artery
Vascular and Endovascular Surgery 2016, Vol. 50(1) 60-62 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574416629563 ves.sagepub.com
Xianchen Huang, MD1, Yao Tang, MD1, Guoxiong Xu, MD1, Zhixuan Zhang, MD1, Liming Shen, MD1, and Yiqi Jin, MD1
Abstract Persistent sciatic artery (PSA) is a rare anatomic variant and is normally clinically silent. It can be found occasionally during uterine arteries embolization (UAE) and can lead to technical failure or complications. The authors present a patient with bilateral PSAs who was referred for emergency UAE because of uncontrollable postabortion hemorrhage. Inadvertent embolization of the right PSA led to unsalvageable ischemia and amputation of the right lower limb 12 days later. Keywords persistent sciatic artery, uterine artery embolization, postabortion hemorrhage
Introduction Emergency uterine artery embolization (UAE) is an effective method to treat postabortion hemorrhage with low complications.1,2 However, technical failure and complication of lower limb artery embolization caused by persistent sciatic artery (PSA) have been reported.3,4 Persistent sciatic artery is a rare anatomic variant, resulting from incomplete degeneration of the sciatic artery after the third month of gestation.5 We report a case of postabortion hemorrhage with amputation after inadvertent embolization of the PSA. To our knowledge, this is the only case of complication of irreversible ischemic damage of a lower limb caused by embolization of the PSA. This case report was approved by the committee on human research of the Institutional Review Board at the authors’ institution. Written informed consent was obtained from the patient.
Case Description The patient, a 32-year-old female, was referred to our institution for emergency UAE because of uncontrollable uterine hemorrhage after induced abortion. Her estimated blood loss was about 1500 mL during 3 hours before arriving at the hospital. She presented with a blood pressure of 80/50 mm Hg on the fluoroscopy table. Written consent was obtained before the procedure. The pulse of the right femoral artery was normal. Puncture was made of the right femoral artery, and a 5F sheath was inserted. Angiography of the bilateral internal iliac artery was performed using a 4F Cobra catheter (Terumo, Tokyo, Japan) and showed multiple contrast extravasations. However, bilateral aberrant branches which came from the internal iliac arteries and went to the lower legs were ignored, and a further angiogram of these branches was not performed (Figure 1A and B). Left side
embolization was performed with gelfoam slurries with a catheter inserted in the uterine artery. Selective catheterization of the right uterine artery could not be achieved due to vasospasm, despite attempt with a 3F microcatheter (Terumo). Considering persisting bleeding and our previous experience, embolization of the anterior division of the internal iliac artery was performed on the right side using gelfoam slurries. The postembolization angiogram showed contrast stasis in the left uterine artery and the right anterior division of the internal iliac artery. The right aberrant branch which was embolized was not appreciated at the time (Figure 1C). Hemostasis was obtained by manual compression after catheter and sheath were removed. After completing the procedure, uterine hemorrhage ceased and patient’s blood pressure went up to 110/70 mm Hg. The patient was transferred to gynecology ward without any complaint. Nevertheless, the patient claimed numbness and pain of her right lower limbs 12 hours later. Physical examination showed that the lower limb was cold, and the pulsation of the dorsalis pedis artery was not palpable. Subsequently, emergency computer tomography angiography (CT) suggested that the bilateral aberrant branches (which were recognized as PSAs) exited the pelvis via the sciatic foramen, descended down the posterior thigh, and were continuous with popliteal artery. The right calf arteries were occluded distally (Figure 1D-F).
1 Department of Vascular Surgery, Nanjing Medical University affiliated Suzhou Hospital, Suzhou, China
Corresponding Author: Yiqi Jin, Department of Vascular Surgery, Nanjing Medical University affiliated Suzhou Hospital, 26, Daoqian Street, Suzhou City, Jiangsu Province, 215000, China. Email: [email protected]
Downloaded from ves.sagepub.com at Bobst Library, New York University on March 2, 2016
Huang et al
61
Figure 1. A 32-year-old female with bilateral persistent sciatic arteries (PSAs). A, Left common iliac artery angiogram showed PSA (white arrow) came from the internal iliac arteries which were ignored. B, Right common iliac artery angiogram showed PSA (white arrow) came from the internal iliac arteries which were ignored. C, Angiogram after embolization showed that the left PSA (white arrow) was patent and the right PSA was not visualized. D, Computed tomography angiography (CTA) showed that bilateral PSAs (white arrow) and hypoplastic superficial femoral arteries (white arrowhead). The PSAs arose from the internal iliac arteries. E, The right calf arteries were occluded distally.
Considering the serious ischemia and anatomical variant, a right popliteal artery embolectomy was performed. Digital subtraction angiography (DSA) during the procedure showed that the right PSA, the right popliteal artery, and distal arteries were occluded. Thrombus and gelfoam were withdrawn from the right limb with a Fogarty catheter. Popliteal artery pulsation was obvious after embolectomy. However, the angiogram showed contrast stasis in the distal arteries. Anticoagulation was performed with heparin 5 mg/hour after the procedure. The right dorsalis pedis pulsation did not recover 24 hours after embolectomy. Then catheter-directed thrombolysis was attempted using a 4F catheter (Terumo) inserted into the right PSA from the left femoral artery. Urokinase was injected
through the catheter, 10 000 IU/hr. Ultimately, necrosis appeared in the calf at the end of 24 hours of thrombolysis. The right lower limb was amputated below the knee 12 days after embolization and the wound healed 2 months later.
Discussion Persistent sciatic artery is a very rare congenital malformation. The incidence of PSA is estimated to be 0.025% to 0.04%.6 The sciatic artery is a branch of the internal iliac artery and feeds the lower limb in the early embryonic stage. Normally, the sciatic artery involutes, while the superficial femoral artery which develops from the external iliac artery becomes the major
Downloaded from ves.sagepub.com at Bobst Library, New York University on March 2, 2016
62
Vascular and Endovascular Surgery 50(1)
blood supply of the lower extremity. However, the sciatic artery remains as the dominant blood supply to the limb during the absence of femoral artery development. It may continue in a complete or incomplete form and occur bilaterally or unilaterally. In the complete form, PSA forms an anastomosis with the popliteal artery, while the superficial femoral artery degenerates and ends in the thigh. In the incomplete form, PSA persists but vanishes above the popliteal artery level, and the superficial femoral artery continues into the popliteal artery as the main supply of the extremity. Normally, PSA is clinical silent; it can be found incidentally or presents with syndromes of ischemia or compression. In most previous literature, PSAs were reported in connect with aneurysm formation. The morbidity was about 40% to 60% in reported cases.7 Also, some authors described symptomatic atherosclerotic narrowing as another complication of PSA, and it appeared in about 7% to 9% of reported cases.8 Uterine artery embolization to treat uncontrollable postabortion hemorrhage was reported only in 3 studies.2,9,10 However, it was widely used in postpartum hemorrhage and uterine fibroid with minimal morbidity and high technical success.1,11 There were 3 papers about PSA found occasionally during UAE in literature. Technical failure and complication of UAE caused by PSA were described in 2 reports. Soyer et al3 detected bilateral PSAs while attempting UAE for a patient of postpartum hemorrhage and gave up embolization because of selective catheterization failure. Hsu et al4 described a case of pelvic trauma. A few embolization particles were injected into the internal iliac artery before recognizing the PSA. Nonetheless, no ischemic sequela of the lower limb was noted. However, there was 1 author who reported of a successful UAE. Malhotra et al12 found 3 cases of PSA in 360 patients who underwent UAE for symptomatic uterine leiomyomatomas. Uterine artery catheterization was achieved, and embolization was performed without complications in all 3 cases. In the present case, embolization of the right internal iliac artery was performed at the level of anterior division. It was done safely in previous patients in life-threatening conditions or when superselective catheterization was not feasible. It was as effective as a more selective one and was not correlated with a higher degree of morbidity.13 Conversely, embolization of the anterior division may result in complications in rare condition of PSA. Especially, when PSA presents in complete form, the risk of irreversible ischemic damage of the lower limb is very high. In our case of complete form of PSA, the operator did not study the angiogram carefully or identify the existence of PSAs. Inadvertent embolization of the PSA led to unsalvageable limb ischemia and amputation.
Conclusion Persistent sciatic artery is a rare anatomic variant which is normally clinical silent. We reported a case of bilateral PSA. Internal iliac artery embolization which was performed at the level of the anterior division resulted in calf necrosis. This case demonstrates that meticulous angiogram and a detailed understanding
of vascular anatomic variants are very important for interventional radiologists to reduce complications. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception. 2013;87(3):331-342. 2. Steinauer JE, Diedrich JT, Wilson MW, Darney PD, Vargas JE, Drey EA. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol. 2008;111(4):881-889. 3. Soyer P, Boudiaf M, Jacob D, et al. Bilateral persistent sciatic artery: a potential risk in pelvic arterial embolization for primary postpartum hemorrhage. Acta Obstet Gynecol Scand. 2005;84(6): 604-605. 4. Hsu WC, Lim KE, Hsu YY. Inadvertent embolization of a persistent sciatic artery in pelvis trauma. Cardiovasc Intervent Radiol. 2005;28(4):518-520. 5. Aziz ME, Yusof NR, Abdullah MS, Yusof AH, Yusof MI. Bilateral persistent sciatic arteries with unilateral complicating aneurysm. Singapore Med J. 2005;46(8):426-428. 6. Ikezawa T, Naiki K, Moriura S, Ikeda S, Hirai M. Aneurysm of bilateral persistent sciatic arteries with ischemic complications: case report and review of the world literature. J Vasc Surg. 1994; 20(1):96-103. 7. Yang S, Ranum K, Malone M, Nazzal M. Bilateral persistent sciatic artery with aneurysm formation and review of the literature. Ann Vasc Surg. 2014;28(1):264. e1-e7. 8. van Hooft IM, Zeebregts CJ, van Sterkenburg SM, de Vries WR, Reijnen MM. The persistent sciatic artery. Eur J Vasc Endovasc Surg. 2009;37(5):585-591. 9. Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol. 2001;185(3):530-536. 10. Haddad L, Delli-Bovi L. Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation. Contraception. 2009;79(6):452-455. 11. Toor SS, Jaberi A, Macdonald DB, McInnes MD, Schweitzer ME, Rasuli P. Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis. AJR Am J Roentgenol. 2012; 199(5):1153-1163. 12. Malhotra AD, Kim HS. Persistent sciatic artery and successful uterine artery embolization: report of three cases. J Vasc Interv Radiol. 2009;20(6):813-818. 13. Pelage JP, Soyer P, Le Dref O, et al. Uterine arteries: bilateral catheterization with a single femoral approach and a single 5-F catheter–technical note. Radiology. 1999;210(2):573-575.
Downloaded from ves.sagepub.com at Bobst Library, New York University on March 2, 2016
