Endovascular revascularization of isolated internal iliac artery for symptomatic occlusive atherosclerotic disease is a viable and underused option for patients with gluteal muscle claudication

Abstract

Often confused with pseudoclaudication, gluteal muscle claudication is a difficult condition to diagnose and treat. We present the case of a 67-year-old man with a history of back and buttock claudication. He had undergone lumbosacral decompression with no relief of buttock claudication. Computed tomography angiography of the abdomen and pelvis showed occlusion of the bilateral internal iliac arteries. Exercise transcutaneous oxygen pressure measurements obtained on referral to our institution revealed a significant decrease. He underwent successful recanalization and stenting of the bilateral hypogastric arteries with complete resolution of his symptoms. We also reviewed the reported data to highlight the trend in the management of patients with this condition.

Keywords: Endovascular repair; Exercise TcPo2; Gluteal muscle claudication; Hypogastric artery stenosis or occlusion; Internal iliac stenosis or occlusion; Ischemic buttock claudication.

Fig 1

Flow chart showing inclusion and exclusion criteria and studies found from advanced PubMed search of the following terms: (internal iliac OR hypogastric) AND (unilateral OR bilateral) AND (occlusion∗ OR Thrombosis∗ OR obstruction OR stenosis∗ OR narrowing∗).

Fig 2

Three-dimensional reconstruction of preoperative computed tomography angiography (CTA) of abdomen and pelvis. Note the presence of an occluded bilateral internal iliac artery with, otherwise, no flow-limiting stenosis of the infrarenal aorta or common iliac or external iliac arteries (A). Preoperative exercise transcutaneous oxygen pressure (TcPO₂) study of the gluteal muscles. When corrected for the absolute change in the TcPO₂ at the chest electrode, a decrease of ≥15 mm Hg (15 mm Hg on the right and 18 mm Hg on the left) was seen during exercise on both sides (B,C).

Fig 3

Intraoperative imaging showing occlusion of bilateral internal iliac arteries (A) with a large middle sacral artery supplying the distal right hypogastric (B). Steps used to recanalize and stent the right (B-D) and left (E-H) hypogastric arteries from contralateral common femoral artery access. Note the unusually large middle sacral artery appeared normal once both hypogastric arteries had been successfully recanalized and stented (I).

Fig 4

Exercise transcutaneous oxygen pressure (TcPO₂) study obtained after intervention showing significant improvement with a gradient. Although slightly lower, compared with the preoperative values and after adjustment for the absolute change in TcPO₂ at the chest electrode, hemodynamically significant improvement (≥15 mm Hg) had occurred in the TcPO₂ after intervention. We considered the 5-minute mark the most important threshold because it is the equivalent of an exercise ankle brachial index test immediately after exercise, for which one would likely see the absolute decrease that occurs with exercise.