Hybrid Management of Iliac Injury During Thoracic Endovascular Aortic Repair: A Case Report

Thoracic endovascular aortic repair is nowadays the preferred option to manage descending thoracic aorta diseases. However, despite feasibility and safety of the procedures, several complications may occur. We report the case of an 83-year-old female patient with inadvertent iliac rupture occurred during thoracic endovascular aortic repair. To limit massive bleeding, considering the patient's comorbidities contraindicating open surgical repair and the morphology of the arterial injury (circumferential rupture of the artery from its origin), we chose to perform a homolateral hypogastric and common iliac artery embolization and an aorto-uniliac balloon expandable stent graft deployment from the distal aorta to the contralateral common iliac artery. A femoro-femoral crossover bypass graft was performed to restore both lower limbs perfusion. Final angiography documented correct positioning and regular patency of the implanted grafts and bypass with no blood loss from the right iliac vessels. Despite careful preoperative assessment, iliac artery injury can represent a challenging complication of thoracic endovascular aortic repair, particularly in the setting of inadequate iliac diameter, calcification and vessel tortuosity, or when large-caliber introducers are required. The hybrid approach we describe is a valid and effective solution to minimize blood loss and avoid major consequences in the management of iatrogenic iliac artery rupture during endovascular procedures.