A 67 year-old male patient was referred for coronary angiography because of intermittent episodes of chest pain accompanied by severe sweating during which ECG showed transient LBBB. Physical examination was unremarkable and lab tests were within normal limits except borderline diabetes mellitus for which no specific treatment had been given. ECG at stable patient condition was normal and echocardiography showed no abnormality at rest. After prep and drape, 7F sheath was inserted in right femoral artery. Left coronary angiography showed significant stenosis of LAD midportion. Selection of RCA was impossible due to severe tortousity of right external iliac artery and kinking of right Judkin's catheter. So a 135 cm, 0.035 inch guidewire was inserted, deformed catheter was removed and replaced by another right Judkin's catheter. But advancement of guidewire and the second Judkin's catheter was difficult and the patient had extreme discomfort, so sheath angiogram was performed ().
Tiny dissection and perforation of external iliac artery.
Right iliac artery dissection and perforation was diagnosed, procedure was prematurely terminated, sheath was removed and firm compression was applied to puncture site for about 30 minutes. Several minutes after release of compression, the patient developed severe right leg pain which was accompanied by coldness and absence of pulse in distal portion. Duplex sonography confirmed weak arterial impulse in right leg and patient was transferred emergently to operating room with the impression of acute arterial occlusion. Arteriotomy was done and several pieces of arterial clots were extracted by Fogarty catheter. A small hole which was attributed to arterial puncture and sheath insertion was primarily repaired in common femoral artery. No other site of perforation was found in external iliac artery exploration. The patient had an uneventful post-operative course except wound infection which was managed successfully by IV antibiotics and debridement. Two weeks later, PCI was done on LAD via left femoral artery. RCA angiography showed no significant stenosis. Abdominal aortography was done and external iliac artery revealed to be patent and free of disease ().
Final appearance of external iliac artery