Impotence due to External Iliac Steal Syndrome: Treatment with Percutaneous Transluminal Angioplasty and Stent Placement
A 53-year-old man was referred to our interventional radiology unit for claudication on the right leg, after walking 300 m. His symptoms had started three months before admission. He did not experience thigh or buttock pain while walking. Physical examination revealed a weak pulse in the right groin and ankle and a normal pulse in the left leg. The patient underwent a coronary artery bypass graft operation two years prior to treatment. Hypercholesterolemia was a risk factor, and his other laboratory tests were within normal limits. He did not have DM, hypertension (HT), or chronic renal disease. Color Doppler ultrasonography revealed occlusion of the right external iliac artery and patency of the right common iliac and common femoral arteries. The left iliac artery was patent throughout its course. The distal abdominal aorta was aneurismal, with an outer diameter of 36 mm. Endovascular treatment of the occlusion was planned as the aneurysmal dilatation of the distal infrarenal aorta was mild (). The patient did not mention ED, and it was not part of our procedure to question each patient with claudication about ED. Thus, further evaluation for ED, such as urology consultation or penile Doppler ultrasonography examination, was not performed. The procedure was explained to the patient, and written informed consent was obtained.\nThe procedure was performed under conscious sedation and analgesia with fentanyl citrate and midazolam, as required. Knowing about the occlusion on the right side, we decided to gain access to the artery from the right femoral artery; crossing the occlusion and placing the stent would be simpler on the ipsilateral side. The right common femoral artery was punctured under ultrasonography, and a 6 Fr vascular sheath was placed in common femoral artery. The occlusion was crossed with a 0.035-inch straight hydrophilic guide wire (Radiofocus, Terumo Europa, Leuven, Belgium) with the help of a diagnostic catheter (Vertebral catheter, Cook, Bloomington, IN, USA). Next, a pigtail catheter was placed in the distal aorta, over the wire. Angiograms of the aorta, pelvic arteries (anteroposterior and oblique views) and both lower extremity arteries were obtained. Angiograms confirmed fusiform aneurysmatic dilatation of the distal infrarenal abdominal aorta as well as occlusion of the entire length of the right external iliac artery (). The right internal iliac artery was patent and was considerably dilated, with a high volume flow on the angiogram (). The right internal iliac artery was the main feeder or blood supplier for the right common femoral artery and the leg arteries distal to the occlusion. The dilatation of, and very high flow through, the right internal iliac artery was likely a result of the redirection of blood flow to the right leg (). The left common and external iliac arteries were normal (). The left internal iliac artery was patent, without stenotic lesions, throughout its course. Based upon angiographic observations, we did not know that this patient may have erectile dysfunction. The lower extremity arteries were normal on both sides.\nPrimary stent placement with a self-expanding nitinol stent was used, as the lesion was an occlusion. 5000 IU of heparin was administered intra-arterially prior to the placement of the stent. After placement of the vascular sheath, a stiff, 0.035-inch, 180-cm guide wire (Amplatz, Boston Scientific, Miami, FL, USA) was placed through the pigtail catheter, and a 7 × 80 mm self-expanding nitinol stent (ev3, Plymouth, MN, USA) was deployed and dilated with a 6 mm balloon catheter (Ultrathin, Boston Scientific, Galway, Ireland). Angiogram after stent placement showed excellent patency of the occluded external iliac artery (). There was abrupt decrease of flow velocity in the right internal iliac artery, as if the contrast had been suspended in the artery (). This occured due to the large diameter of the artery, as a response to the long-standing occlusive lesion. The late phase of post-stent iliac arteriography shows better internal iliac artery branches (). The procedure was completed without complications. The patient was discharged the same day, 6 hours after removal of the vascular sheath, and was instructed to take 300 mg of acetyl salicylic acid per day for an indefinite period of time.\nThe patient was seen in the interventional radiology outpatient clinic a month after the procedure, and intermittent claudication had resolved completely. The patient also stated that he had had ED developing alongside claudication, but he had not mentioned this prior to angiography. He expressed that erectile dysfunction recovered promptly and completely directly following the interventional procedure as did his claudication. The angiograms performed prior to intervention were reevaluated. The diagnosis of external iliac artery steal syndrome, not considered at the beginning of treatment, was established with angiography findings and an understanding of the patient's symptoms. The hypertrophied right internal iliac artery was likely feeding the right lower extremity by diverting blood away from the pelvic arteries, including the right pudendal artery feeding the penis. Although the left internal iliac artery was patent, its contribution to the penile tissues was probably insufficient, and blood flow to the penis could not be compensated for by the left side. We did not take a selective angiogram of the left internal iliac before prior to placement and, thus, further discussion would be mere speculation. However, it is possible that the left internal iliac artery also fed the right leg through connections between the right and left internal iliac arteries and the right common femoral artery.