Prearterial External Iliac Vein as a Rare Anomaly of the Iliac Vein Sosei Kuma,1 Masaru Ishida,1 Yoshitaka Nakamura,2 and Jin Okazaki,1 Kitakyushu, Japan
The coexistence of a retroperitoneal venous anomaly requires special consideration during open aortoiliac surgery. Anomalies of the external iliac vein are rare, and no anomalies of the right external iliac vein, which passes ventral to the external iliac artery, have been reported in the English literature to the best of our knowledge. We herein report the first case of Leriche syndrome combined with a prearterial external iliac vein treated with bypass surgery and a synthetic bifurcated graft.
Peripheral arterial disease and abdominal aortic aneurysm are common vascular diseases. Recently, endovascular surgery of the aortoiliac region has become widespread, although open aortoiliac surgery is still required in some cases. The coexistence of anomalies of adjacent organs, such as retroperitoneal venous anomaly1,2 or horseshoe kidney,3 requires special consideration during open aortoiliac surgery. Anomalies of the inferior vena cava (IVC) and/or its tributaries occur in approximately 2e3% of patients.4 However, anomalies of the external iliac vein are extremely rare. To the best of our knowledge, no anomalies of the right external iliac vein, which crosses the front of the external iliac artery, have been reported in the English literature. We herein report the first case of Leriche syndrome combined with a prearterial external iliac vein treated with bypass surgery and a synthetic bifurcated graft.
CASE REPORT A 58-year-old man with a history of smoking was admitted to our hospital because of severe calf intermittent claudication. He had no history of hypertension, hyperlipidemia, diabetes, trauma, or deep vein thrombosis of the legs or pelvis. A physical examination performed on presentation was notable for diminished femoral and peripheral pulses bilaterally. Multidetector computed tomography revealed occlusion of the terminal aorta to the right common iliac artery and left external iliac artery. In addition, the right external iliac vein passed ventral to the external iliac artery and
1 Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan. 2 Department of Radiological Technology, Kokura Memorial Hospital, Kitakyushu, Japan.
Correspondence to: Sosei Kuma, MD, PhD, Department of Vascular Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu 802-8555, Japan; E-mail: [email protected] Ann Vasc Surg 2015; 29: 836.e15–836.e17 http://dx.doi.org/10.1016/j.avsg.2014.09.036 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: July 31, 2014; manuscript accepted: September 30, 2014; published online: February 11, 2015.
Fig. 1. Computed tomography images obtained on admission. An axial image showing the right external iliac vein located at the front of the external iliac artery. The right external and internal iliac arteries were patent, whereas the left external iliac artery was occluded. The arrowhead indicates the right external iliac vein. 836.e15
836.e16 Case reports
Annals of Vascular Surgery
Fig. 2. Postperative computed tomographic angiography. (A) Anteroposterior view. The right external iliac vein passed ventral to the external iliac artery and connected with the right common iliac vein. (B) Posteroanterior view. The right external iliac artery passed dorsal to the
external iliac vein. The right internal iliac vein was duplicated and joined to the left common iliac vein. (C) Left anterior oblique view. The site of aorto-right external iliac and left femoral bypass using a synthetic bifurcated graft was patent.
connected with the right common iliac vein, but the left iliac venous system was normal and intact (Figs. 1 and 2A). Retrospectively, the right internal iliac vein was duplicated and joined to the left common iliac vein (Fig. 2B). Elective surgery was performed via the transperitoneal approach. Although the right external iliac vein was located at the front of the origin of the external iliac artery, the iliac arteries were safely exposed. After systemic heparinization, the patient underwent aorto-right external iliac and left femoral bypass using a synthetic bifurcated graft. The right limb of the graft was anastomosed from the iliac bifurcation to the origin of the external iliac artery (Fig. 2C), and thus, neither mobilization of the iliac vein nor tunneling of the graft was required. His perioperative course was uneventful.
vein7,8 and preaortic iliac confluence,9 have also been reported; however, anomalies of the external iliac vein are extremely rare. To the best of our knowledge, the venous anomaly observed in our case, in which the right external iliac vein passed ventral to the external iliac artery and connected with the right common iliac vein, has not been previously reported in the English literature. There have so far been few reports describing the embryogenesis of the external iliac veins than either the IVC or leg vein.10 The preaortic iliac confluence, named by Edwards9 as an anomaly of IVC formation anterior to the right common iliac artery or aortic bifurcation, has been suggested to possibly represent the persistence of the ventral limb of the circumaortic venous ring with the consequent disappearance of the normal dorsal limb of the ring; the formation of the prearterial external iliac vein may be a similar phenomenon. Recently, endovascular surgery of the aortoiliac region has become widespread, although open aortoiliac surgery is still required in some cases. Most abdominal venous anomalies are clinically silent and only detected incidentally on abdominal computed tomography or during surgical procedures. Such anomalies may predispose the patient to massive venous bleeding during aortoiliac surgery.
DISCUSSION Anomalies of the IVC and/or renal vein are rare, occurring in approximately 2e3% of patients.4 In contrast, iliac venous variations are common,5 observed in 19.9% of patients6; most such cases are caused by an abnormal opening of the internal iliac vein to a high level of the ipsilateral external iliac vein, contralateral common iliac vein, or contralateral internal iliac vein. Rare anomalies of the iliac veins, such as aplasia of the common or external iliac
Vol. 29, No. 4, May 2015
In our case, the right external iliac vein was located at the front of the origin of the external iliac artery; however, the iliac arteries were exposed safely, as we recognized the anomaly, and there was little adhesion between the artery and the vein. In addition to being aware of the anomaly, consideration is required during arterial exposure and graft tunneling, which tend to be a blind procedure, in patients undergoing aortofemoral bypass. If the abnormality is not recognized, unexpected venous injury may result in massive hemorrhaging, whereas graft compression may induce deep vein thrombosis. During retroperitoneal or pelvic surgery, it is important to pay attention to the possibility of anomalies of the IVC and/or its tributaries. In conclusion, we herein presented the first case of Leriche syndrome combined with a prearterial external iliac vein treated with bypass surgery and a synthetic bifurcated graft.
The authors thank Dr. Brian T. Quinn for providing critical comments on the article. The authors also thank Kazuhiro Umeda, Yoji Ono, and Joshin Matsuzaki in the Department of Radiological technology at Kokura Memorial Hospital for providing quality images of CT angiography.
Case reports 836.e17
REFERENCES 1. Baldridge ED Jr, Canos AJ. Venous anomalies encountered in aortoiliac surgery. Arch Surg 1987;122:1184e8. 2. Shindo S, Kubota K, Kojima A, et al. Anomalies of inferior vena cava and left renal vein: risks in aortic surgery. Ann Vasc Surg 2000;14:393e6. 3. O’Hara PJ, Hakaim AG, Hertzer NR, et al. Surgical management of aortic aneurysm and coexistent horseshoe kidney: review of a 31-year experience. J Vasc Surg 1993;17:940e7. 4. Aljabri B, MacDonald PS, Satin R, et al. Incidence of major venous and renal anomalies relevant to aortoiliac surgery as demonstrated by computed tomography. Ann Vasc Surg 2001;15:615e8. 5. Lotz PR, Seeger JF. Normal variations in iliac venous anatomy. AJR Am J Roentgenol 1982;138:735e8. 6. Shin M, Lee JB, Park SB, et al. Multidetector computed tomography of iliac vein variation: prevalence and classification. Surg Radiol Anat 2014 [Epub ahead of print]. 7. Yahyayev A, Bulakci M, Yilmaz E, et al. Absence of the right iliac vein and an unusual connection between both common femoral veins. Phlebology 2013;28:162e4. 8. Saxena AK, Aiyappan SK, Kaira N, et al. Anomaly of iliac veins: a rare cause of transient hepatic attenuation difference in a child. Pediatr Radiol 2009;39:1242e5. 9. Edwards EA. Clinical anatomy of lesser variations of the inferior vena cava and a proposal for classifying the anomalies of this vessel. Angiology 1951;2:85e99. 10. Lee BB. Venous embryology: the key to understanding anomalous venous conditions. Phlebolymphology 2012;19: 170e81.
The coexistence of a retroperitoneal venous anomaly requires special consideration during open aortoiliac surgery. Anomalies of the external iliac vein are rare, and no anomalies of the right external iliac vein, which passes ventral to the external iliac artery, have been reported in the English literature to the best of our knowledge. We herein report the first case of Leriche syndrome combined with a prearterial external iliac vein treated with bypass surgery and a synthetic bifurcated graft.
Peripheral arterial disease and abdominal aortic aneurysm are common vascular diseases. Recently, endovascular surgery of the aortoiliac region has become widespread, although open aortoiliac surgery is still required in some cases. The coexistence of anomalies of adjacent organs, such as retroperitoneal venous anomaly1,2 or horseshoe kidney,3 requires special consideration during open aortoiliac surgery. Anomalies of the inferior vena cava (IVC) and/or its tributaries occur in approximately 2e3% of patients.4 However, anomalies of the external iliac vein are extremely rare. To the best of our knowledge, no anomalies of the right external iliac vein, which crosses the front of the external iliac artery, have been reported in the English literature. We herein report the first case of Leriche syndrome combined with a prearterial external iliac vein treated with bypass surgery and a synthetic bifurcated graft.
CASE REPORT A 58-year-old man with a history of smoking was admitted to our hospital because of severe calf intermittent claudication. He had no history of hypertension, hyperlipidemia, diabetes, trauma, or deep vein thrombosis of the legs or pelvis. A physical examination performed on presentation was notable for diminished femoral and peripheral pulses bilaterally. Multidetector computed tomography revealed occlusion of the terminal aorta to the right common iliac artery and left external iliac artery. In addition, the right external iliac vein passed ventral to the external iliac artery and
1 Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan. 2 Department of Radiological Technology, Kokura Memorial Hospital, Kitakyushu, Japan.
Correspondence to: Sosei Kuma, MD, PhD, Department of Vascular Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu 802-8555, Japan; E-mail: [email protected] Ann Vasc Surg 2015; 29: 836.e15–836.e17 http://dx.doi.org/10.1016/j.avsg.2014.09.036 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: July 31, 2014; manuscript accepted: September 30, 2014; published online: February 11, 2015.
Fig. 1. Computed tomography images obtained on admission. An axial image showing the right external iliac vein located at the front of the external iliac artery. The right external and internal iliac arteries were patent, whereas the left external iliac artery was occluded. The arrowhead indicates the right external iliac vein. 836.e15
836.e16 Case reports
Annals of Vascular Surgery
Fig. 2. Postperative computed tomographic angiography. (A) Anteroposterior view. The right external iliac vein passed ventral to the external iliac artery and connected with the right common iliac vein. (B) Posteroanterior view. The right external iliac artery passed dorsal to the
external iliac vein. The right internal iliac vein was duplicated and joined to the left common iliac vein. (C) Left anterior oblique view. The site of aorto-right external iliac and left femoral bypass using a synthetic bifurcated graft was patent.
connected with the right common iliac vein, but the left iliac venous system was normal and intact (Figs. 1 and 2A). Retrospectively, the right internal iliac vein was duplicated and joined to the left common iliac vein (Fig. 2B). Elective surgery was performed via the transperitoneal approach. Although the right external iliac vein was located at the front of the origin of the external iliac artery, the iliac arteries were safely exposed. After systemic heparinization, the patient underwent aorto-right external iliac and left femoral bypass using a synthetic bifurcated graft. The right limb of the graft was anastomosed from the iliac bifurcation to the origin of the external iliac artery (Fig. 2C), and thus, neither mobilization of the iliac vein nor tunneling of the graft was required. His perioperative course was uneventful.
vein7,8 and preaortic iliac confluence,9 have also been reported; however, anomalies of the external iliac vein are extremely rare. To the best of our knowledge, the venous anomaly observed in our case, in which the right external iliac vein passed ventral to the external iliac artery and connected with the right common iliac vein, has not been previously reported in the English literature. There have so far been few reports describing the embryogenesis of the external iliac veins than either the IVC or leg vein.10 The preaortic iliac confluence, named by Edwards9 as an anomaly of IVC formation anterior to the right common iliac artery or aortic bifurcation, has been suggested to possibly represent the persistence of the ventral limb of the circumaortic venous ring with the consequent disappearance of the normal dorsal limb of the ring; the formation of the prearterial external iliac vein may be a similar phenomenon. Recently, endovascular surgery of the aortoiliac region has become widespread, although open aortoiliac surgery is still required in some cases. Most abdominal venous anomalies are clinically silent and only detected incidentally on abdominal computed tomography or during surgical procedures. Such anomalies may predispose the patient to massive venous bleeding during aortoiliac surgery.
DISCUSSION Anomalies of the IVC and/or renal vein are rare, occurring in approximately 2e3% of patients.4 In contrast, iliac venous variations are common,5 observed in 19.9% of patients6; most such cases are caused by an abnormal opening of the internal iliac vein to a high level of the ipsilateral external iliac vein, contralateral common iliac vein, or contralateral internal iliac vein. Rare anomalies of the iliac veins, such as aplasia of the common or external iliac
Vol. 29, No. 4, May 2015
In our case, the right external iliac vein was located at the front of the origin of the external iliac artery; however, the iliac arteries were exposed safely, as we recognized the anomaly, and there was little adhesion between the artery and the vein. In addition to being aware of the anomaly, consideration is required during arterial exposure and graft tunneling, which tend to be a blind procedure, in patients undergoing aortofemoral bypass. If the abnormality is not recognized, unexpected venous injury may result in massive hemorrhaging, whereas graft compression may induce deep vein thrombosis. During retroperitoneal or pelvic surgery, it is important to pay attention to the possibility of anomalies of the IVC and/or its tributaries. In conclusion, we herein presented the first case of Leriche syndrome combined with a prearterial external iliac vein treated with bypass surgery and a synthetic bifurcated graft.
The authors thank Dr. Brian T. Quinn for providing critical comments on the article. The authors also thank Kazuhiro Umeda, Yoji Ono, and Joshin Matsuzaki in the Department of Radiological technology at Kokura Memorial Hospital for providing quality images of CT angiography.
Case reports 836.e17
REFERENCES 1. Baldridge ED Jr, Canos AJ. Venous anomalies encountered in aortoiliac surgery. Arch Surg 1987;122:1184e8. 2. Shindo S, Kubota K, Kojima A, et al. Anomalies of inferior vena cava and left renal vein: risks in aortic surgery. Ann Vasc Surg 2000;14:393e6. 3. O’Hara PJ, Hakaim AG, Hertzer NR, et al. Surgical management of aortic aneurysm and coexistent horseshoe kidney: review of a 31-year experience. J Vasc Surg 1993;17:940e7. 4. Aljabri B, MacDonald PS, Satin R, et al. Incidence of major venous and renal anomalies relevant to aortoiliac surgery as demonstrated by computed tomography. Ann Vasc Surg 2001;15:615e8. 5. Lotz PR, Seeger JF. Normal variations in iliac venous anatomy. AJR Am J Roentgenol 1982;138:735e8. 6. Shin M, Lee JB, Park SB, et al. Multidetector computed tomography of iliac vein variation: prevalence and classification. Surg Radiol Anat 2014 [Epub ahead of print]. 7. Yahyayev A, Bulakci M, Yilmaz E, et al. Absence of the right iliac vein and an unusual connection between both common femoral veins. Phlebology 2013;28:162e4. 8. Saxena AK, Aiyappan SK, Kaira N, et al. Anomaly of iliac veins: a rare cause of transient hepatic attenuation difference in a child. Pediatr Radiol 2009;39:1242e5. 9. Edwards EA. Clinical anatomy of lesser variations of the inferior vena cava and a proposal for classifying the anomalies of this vessel. Angiology 1951;2:85e99. 10. Lee BB. Venous embryology: the key to understanding anomalous venous conditions. Phlebolymphology 2012;19: 170e81.
