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The critical hypogastric circulation
J I Iliopoulos1, P E Howanitz, G E Pierce
1Department of Surgery, University of Kansas Medical Center, Kansas City 66103.
Insights
Maintaining hypogastric artery patency is crucial after aortoiliac reconstruction to prevent severe ischemic complications. Ligation or thrombosis can lead to paralysis, necrosis, and increased mortality.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Ischemic Complications
Background:
- Aortoiliac reconstruction is a common procedure for vascular disease.
- Hypogastric arteries (internal iliac arteries) supply pelvic organs and lower extremities.
- Ischemic complications can arise from alterations in blood flow to these critical vessels.
Purpose of the Study:
- To investigate the incidence and severity of ischemic complications following aortoiliac reconstruction.
- To determine the impact of hypogastric artery compromise on patient outcomes.
- To emphasize the importance of preserving hypogastric artery patency.
Main Methods:
- Retrospective review of eleven patients who experienced ischemic complications.
- Analysis of complications related to hypogastric artery ligation, hypoperfusion, exclusion, or thrombosis.
- Correlation of specific ischemic events with patient morbidity and mortality.
Main Results:
- Ligation of one hypogastric artery caused buttock claudication in 3 patients.
- Bilateral hypogastric artery ischemia occurred in 8 patients, leading to paralysis (8/8), buttock necrosis (4/8), sphincteric dysfunction (2/8), and colorectal ischemia (3/8).
- Overall mortality was 63% (5/8), and 100% if buttock necrosis developed.
Conclusions:
- Hypogastric artery patency is essential in aortoiliac reconstructions.
- Compromise of these vessels can lead to devastating ischemic sequelae and high mortality.
- Surgical strategies should prioritize maintaining blood flow through the hypogastric arteries.
Abstract:
Eleven patients had ischemic complications secondary to ligation, hypoperfusion, exclusion, or thrombosis of the hypogastric arteries after aortoiliac reconstruction or spontaneous aortoiliac thrombosis. Ligation of one hypogastric artery resulted in persistent ipsilateral buttock claudication in three patients. Bilateral acute hypogastric artery ischemia occurred in eight patients and resulted in paralysis in all eight patients, buttock necrosis in four patients, anal and bladder sphincteric dysfunction in two patients, and colorectal ischemia in three patients. Five of these patients (63 percent) died. The mortality rate was 100 percent when buttock necrosis developed. In most of these patients, the neurologic deficit suggested ischemic injury of the lumbosacral plexus rather than spinal cord ischemia. These complications occurred despite patent bypass grafts to the iliac or femoral vessels. These observations suggest that it is essential to maintain patency of the hypogastric vessels in all aortoiliac reconstructions.