Letter to the editor: severe groin pain associated with loss of flow in internal iliac artery in a female patient.

Dear Editor, We have read the interesting article by Babaev and Jhaveri about endovascular revascularization of pudendal artery atherosclerotic disease in patients with medically refractory erectile dysfunction. During percutaneous interventions to common iliac (CIA) or external iliac artery lesions (EIA), the internal iliac artery (IIA) usually gets less attention, especially in female patients. In fact, during concomitant endovascular repair of abdominal aortic aneurysms and CIA aneurysms, endograft limb extension into the external iliac artery is often necessary and usually the internal IIA is coil embolized or covered by the stent in such a case to prevent endoleak. We did have a 47-year-old black female patient with hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease who presented with severe claudication of her right thigh and calf on walking 10 to 15 feet and abnormal ankle-brachial index of 0.59 on the right lower extremity. Selective angiography of the right lower extremity showed a patent CIA and chronic total occlusion (CTO) of proximal and mid EIA and 90% lesion of IIA ostial-proximally (Figures 1 and 2). Due to limiting symptoms, it was decided to intervene on the right EIA occlusion. After left to right crossover with a 6 x 45 cm sheath, a Confianza wire (Abbott Vascular) was used to cross the CTO of EIA and a Fox SV 5.0 x 40 mm balloon (Abbott Vascular) was used for balloon angioplasty (BA) of the lesion. During and after BA, the patient experienced severe pain in the hip, right groin, and genital area. Repeat images showed compromised flow in the right IIA (Figure 3). There was no evidence for a perforation at the side of the pain, abdomen was soft and there was no tenderness or change in pain with deep palpation of the right groin. Then, a Prowater wire (Abbott Vascular) was advanced in the right internal iliac artery and a Fox SV 5.0 x 40 mm balloon (Abbott Vascular) was inflated at 4 atm with establishment of normal flow in the vessel with less than 20% residual and immediate resolution of the pain (Figure 4). The EIA lesion was stented with Absolute pro 7.0 x 80 mm and 7.0 x 40 mm self-expanding stents (Abbott Vascular). Due to residual significant gradient in proximal edge of the first stent, a Protégé Everflex 8.0 x 20 mm self-expanding stent (ev3) was deployed across the IIA for full coverage of the ostial EIA and postdilated with a Fox SV 7.0 x 20 Severe Groin Pain Associated With Loss of Flow in Internal Iliac Artery in a Female Patient