Iliac injury during abdominal and thoracic aortic endovascular intervention

Iliac injury is a devastating and potentially avoidable complication of endovascular aortic intervention. To our knowledge, this study is the first investigation of demographic, anatomic, and device factors related to injury in vascular surgery patients.

We retrospectively examined 1859 endovascular aortic interventions and found 42 iliac injuries, including 21 ruptures. Demographic, anatomic, and device data were extracted from these patients and a cohort of 200 case-matched control patients derived from the group of uninjured patients. Anatomic data include centerline and straight distance measurement of the iliac system from the aortic bifurcation to the inguinal ligament. The ratio of the two ("tortuosity index") was calculated. Additional data include midpoint and narrowest diameters in the iliac system along with the most acute angle. Each measurement was taken on both limbs of each patient.

Nonwhite race was the only demographic factor associated with injury (P = .028). None of the examined comorbidities were associated with iliac injury. Increasing sheath size was associated with injury (P < .001), whereas abdominal aortic segment intervention was inversely correlated with injury (P = .017). Anatomic factors that correlated with injury were decreasing iliac midpoint (P < .01), narrowest diameters (P < .001), and a higher ratio of sheath size to midpoint diameter (P < .001). Injury was associated with a longer hospital length of stay (P = .042) and inpatient death (P < .001), with iliac rupture conferring an odds ratio of 15.3 (95% confidence interval, 3.74-62.7; P < .001).

Iliac injury is associated with an increased hospital length of stay and death on the index admission. Nonwhite race, nonabdominal aortic segment intervention, larger relative and absolute sheath sizes, and smaller iliac artery diameters are associated with iliac injury. These findings should be prospectively evaluated along with interventions to reduce injury.