EJVES Extra
Volume 19, Issue 2 , Pages e13-e15, February 2010

Intraoperative Buttock Ischemia with Postoperative Necrosis following Infrainguinal Bypass Surgery

Sheffield Vascular Institute, Northern General Hospital, Sheffield, South Yorkshire, England, UK

Received 17 August 2009; accepted 31 October 2009. published online 07 December 2009.

Article Outline

Abstract 

Buttock necrosis is a rare presentation of severe pelvic ischaemia. It has been reported following open abdominal aortic repair and after internal iliac embolisation prior to endovascular treatment of aortic aneurysm. The internal iliac arteries are the major blood supply to the pelvis and buttocks. Collateral connections between the rectal and gluteal branches of the internal iliac artery and the deep femoral artery are well recognised. Iatrogenic interruption of this collateral circulation following rectal surgery resulting in limb ischaemia has been described. We present an exceptional case of buttock necrosis following infrainguinal bypass in a patient with bilateral internal iliac and left external iliac artery occlusions. The case is the first such reported to our knowledge.

Keywords: Buttock necrosis, Gluteal necrosis, Internal iliac artery occlusion, Femoro-popliteal bypass

 

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Introduction 

The internal iliac artery (IAA) is the major blood supply to the buttocks through its posterior division and to the rectosigmoid and genital areas through its anterior division.1

There is a rich collateral blood supply to the pelvic organs from other arteries, including the gonadal, superior hemorrhoidal, circumflex, and perforating branches of deep femoral artery. This explains the rare presentation of severe pelvic ischaemia and the safety of embolisation of the internal iliac arteries in certain medical indications, such as control of severe bleeding or prior to endovascular aortic aneurysm repair.1 However, iatrogenic occlusion of the internal iliac artery can result in severe complications, including buttock ischaemia, rectosigmoid ischameia or sexual dysfunction.2 In unusual cases, severe gluteal necrosis may occur.2 We report a case of pelvic ischaemia in a patient with existing bilateral internal iliac and left external iliac artery occlusions who underwent femoro-politeal artery bypass surgery.

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Case Report 

A 61 year old smoker with rest pain and a non healing ulcer in his right foot was admitted to hospital for an elective angiogram of right lower limb. He previously had a left above knee amputation following a failed femoro-popliteal bypass in 2008. He also had right common iliac artery (CIA) and right external iliac artery (EIA) stents. His angiogram demonstrated patent right CIA and EIA stents. However, there were occlusions of the left CIA and both IIAs (Fig. 1).

On the right side, diffuse multiple stenoses of the superficial femoral artery (SFA) and popliteal artery (PA) were demonstrated with the anterior tibial artery (ATA) as the single run off crural vessel. Percutanous transluminal angioplasty (PTA) of the SFA, PA and ATA was performed. Following the procedure, the patient continued to have rest pain and duplex scan confirmed occlusion of the SFA. Therefore, a decision was made to perform a right femoro-popliteal below knee bypass. A polytetrafluoroethylene (PTFE) graft with a Miller cuff was used.

However, there were occlusions of the left EIA and both IIAs (Fig. 1). Both CFAs and deep femoral arteries were also patent. On the right side, diffuse multiple stenoses of the superficial femoral artery (SFA) and popliteal artery (PA) were demonstrated with the anterior tibial artery (ATA) as the single run off crural vessel. Percutanous transluminal angioplasty (PTA) of the SFA, PA and ATA was performed. Following the procedure, the patient continued to have rest pain and duplex scan confirmed occlusion of the SFA. Therefore, a decision was made to perform a right femoro-popliteal below knee bypass. A polytetrafluoroethylene (PTFE) graft with a Miller cuff was used.

Postoperatively, the right dorsalis pedis pulse was palpable and his rest pain improved. Two days following the procedure, the patient complained of pain in both buttocks. Physical examination revealed a large (approximately 20×20cm) area of tender bruising across both buttocks, not involving the anal verge. He had palpable right femoral artery pulse, while the left femoral pulse was absent. His right foot was well perfused with good doppler signals. A diagnosis of postoperative superficial buttock necrosis was made based on the angiographic evidence of bilateral IIA occlusion. In view of his palpable right femoral pulse, the patient was managed conservatively with IV heparin. The superficial necrosis improved over the next few weeks and the patient made a full recovery (Fig. 2).

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Discussion 

Buttock ischaemia is infrequent because the extensive pelvic collateral circulation ensures adequate compensation. However, bilateral IIA interruption during standard open aortic aneurysm repair has been associated with considerable morbidity, including buttock necrosis, severe lower extremity neurologic deficits, ischaemic colitis, impotence, and buttock claudication.3, 4

In patients with bilateral IIA disease, the extensive collateral circulation between branches of the IIA, and the deep femoral artery prevents pelvic ischamia. The superior gluteal artery communicates with the lateral sacral, the deep iliac circumflex, and the lateral femoral circumflex artries.5 In our patient, clamping of the deep femoral artery interrupted these communications. In addition, there was lack of collaterals from left deep femoral artery due to left EIA occlusion. This probably resulted in perioperative buttock ischaemia compounded by the pressure of lying on the operating table. In conclusion, preservation of pelvic blood flow during vascular procedures involving aortic and lower limbs is paramount to prevent pelvic and buttock ischaemia, particularly in patients who have evidence of bilateral IIA occlusion. Attention to buttock pressure relief with the use of bean bags or pillows should also be considered.

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Conflict of Interest 

None.

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Funding 

None.

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Ethical Approval 

None.

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References 

  1. Ha CD, Calcagno D. Amplatzer vascular plug to occlude the internal iliac arteries in patients undergoing aortoiliac aneurysm repair. J Vasc Surg. 2005;42:1058–1062
  2. Lee CW, Kaufman JA, Fan CM, Geller SC, Brewster DC, Cambria RP, et al. Clinical outcome of internal iliac artery occlusion during endovascular treatment of aortoiliac aneurismal disease. J Vas Interv Radiol. 2000;11:567–571
  3. Gloviczki P, Cross SA, Stanson AW, Carmichael SW, Bower TC, Pairolero PC, et al. Ischameic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction. Am J Surg. 1991;162:131–136
  4. Su WT, Stone DH, Lamparello PJ, Rockman CB. Gluteal compartment syndrome following elective unilateral internal iliac artery embolization before endovascular aortic aneurysm repair. J Vasc Surg. 2004;39:672–675
  5. Batt M, Desjardin t, Rogopoulos A, Hassen-Khodja R, Le Bas P. Buttock claudication from isolated stenosis of the gluteal artery. J Vasc Surg. 1997;25:584–586

PII: S1533-3167(09)00037-5

doi:10.1016/j.ejvsextra.2009.10.002

Refers to article:

  • Intraoperative Buttock Ischemia with Postoperative Necrosis following Infrainguinal Bypass Surgery , 21 December 2009

    W. Al-Jundi, A. Durham-Hall, E. Oakley, J. Beard
    European Journal of Vascular & Endovascular Surgery March 2010 (Vol. 39, Issue 3, Page 378)

EJVES Extra
Volume 19, Issue 2 , Pages e13-e15, February 2010

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