Excerpt

A 78-year-old male complained of resting pain in his left leg. He had a history of multiple atherosclerotic diseases, but there were no signs of connective tissue disease. The ankle brachial pressure index (ABI) was 0.33 on the left. Diagnostic angiography showed severe stenosis of the main part of the external iliac artery (EIA), and an enlarged vessel, considered to be branching from EIA just proximal to the stenosis, perfused the inferior epigastric artery (IEA) (Fig. 1A). Previous computed tomography around this lesion revealed that IEA normally bifurcated from EIA without anatomical anomalies (Fig. 1B, Arrow). Intravascular ultrasound (IVUS) demonstrated intimal continuity in the main part of EIA, and an intimal tear was observed at the point of bifurcation (Fig. 1C, D). On the other hand, the branching vessel connecting to IEA was suggested to lack an intimal structure (Fig. 1E). Confirming whether the intima was continuous on IVUS images, we found that re-entry occurred at the point where IEA bifurcated (Fig. 1F), and the intima was continuous in more distal vessels (Fig. 1G). We diagnosed this pathological entity as EIA dissection. Deploying a self-expandable stent in EIA covering the entry tear increased ABI to 0.84 and fully resolved the leg pain (Fig. 1H).

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