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.

The vasculogenic pain due to gluteal muscle claudication bears striking similarities to the pain caused by pseudoclaudication, which results from processes such as pelvic venous congestion, sciatica, lumbar spine stenosis, hip osteoarthritis, and bone metastasis.1, 2, 3 As such, buttock claudication is often a diagnosis of exclusion because most patients with this condition will be seen first by orthopedic or other nonvascular specialists. Complicating the diagnosis is that both claudication and pseudoclaudication can occur concomitantly in the same patient.

We present the case of a 67-year-old man with back pain, bilateral buttock claudication, and impotence. He had undergone lumbosacral (L4–S1) decompression with some relief of back pain but persistent disabling buttock claudication. Subsequent computed tomography angiography (CTA) of the abdomen and pelvis demonstrated bilateral internal iliac artery (IIA) occlusion that were successfully recanalized and stented with complete resolution of his buttock claudication and improvement of erectile dysfunction. Because this intervention has rarely been offered for this indication, we performed an advanced PubMed search with the following search terms designed to be inclusive of symptomatic chronic IIA occlusion or stenosis: (internal iliac OR hypogastric) AND (unilateral OR bilateral) AND (occlusion∗ OR Thrombosis∗ OR obstruction OR stenosis∗ OR narrowing∗). The search generated 438 publications, 17 of which contained the full text and included only patients treated for atherosclerotic occlusive disease. Ten of these were excluded because they had included patients treated for concomitant aortic disease, patients not offered any treatment, patients treated for impotence only, and/or patients who had undergone open revascularization (Fig 1; Table). The patient provided written informed consent for the report of his case details and imaging studies.

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∗).

Table.

Literature review^a

Investigator	Patients, No.	Laterality, No.	Treatment modality, No.	Technical success, %	Follow-up, months	Outcome, No.
Morse et al,4 1986	2	Unilateral, 2	PTA	100	NR	Resolved, 1; improved, 1
Chaer et al,5 2005	1	Bilateral, 1	PTA + stenting	100	12	Resolved
Batt et al,6 2006	6	Unilateral, 5; bilateral, 1	PTA	100	13	Resolved, 6; restenosis, 1 (repeat PTA)
Donas et al,7 2009	21	Unilateral, 20; bilateral, 1	PTA, 14; PTA + stenting, 8	100	14.7 ± 5.7	Resolved, 21; restenosis, 1 (asymptomatic)
Thompson et al,8	9	Bilateral, 6; unilateral, 3	PTA, 7; PTA + stenting, 2	100	1	Resolved, 7; unchanged, 2
Adlakha et al,9 2009	2	Unilateral, 2	PTA, 2	100	NR	Resolved, 2
Ozkan et al,10 2018	12	Bilateral, 4; unilateral, 8	PTA, 12	100	16.5 ± 3.7	Resolved, 12; restenosis, 1 (repeat PTA)

NR, Not reported; PTA, percutaneous transluminal angioplasty.

Data presented as mean ± standard deviation, unless noted otherwise.

^aStudies of patients with symptomatic hypogastric artery stenosis or occlusion treated using endovascular therapy (percutaneous transluminal angioplasty and/or stenting).

Case report

A 67-year-old man with cardiovascular risk factors significant for hypertension, hyperlipidemia, erectile dysfunction, osteoarthritis of both knees, and ongoing tobacco abuse was referred to the spine surgery team for complaints of back and disabling bilateral buttock claudication occurring at 15 yards of walking on a flat terrain and 5 yards of incline walking. The patient had previously undergone partial sigmoid colectomy. He was diagnosed with degenerative disk disease and had undergone two-level (L4–S1) posterior spine fusion with some relief of his back pain but not of his buttock claudication. Subsequent CTA of the abdomen and pelvis revealed occluded bilateral IIAs (Fig 2, A) with diseased, but otherwise patent, infrarenal aorta and bilateral common and external iliac arteries. An attempt at endovascular revascularization at an outside institution was unsuccessful, and he was referred to our center for evaluation.

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).

The patient had palpable femoral and pedal pulses, and arterial ultrasound showed patent vessels with multiphasic waveforms down to both feet. An exercise study did not show any decrease in the ankle brachial indexes, but the patient had developed buttock pain 30 seconds into the study, which was stopped at 4 minutes because of his severe buttock claudication. An exercise transcutaneous oxygen pressure (TcPO₂) study of the bilateral buttocks revealed a decrease from 80 mm Hg at rest to 65 mm Hg on the right and 62 mm Hg on the left buttock while walking at 1.7 miles/h at a 10% incline (Fig 2, B). The patient was offered and agreed to undergo endovascular revascularization of the bilateral IIAs.

The procedure was performed in a hybrid operating room with the patient under sedation. After ultrasound-guided percutaneous access of the bilateral common femoral arteries, the patient was systemically heparinized to achieve an activated clotting time of >250 seconds, which was maintained throughout the case. Angiography confirmed the presence of occluded bilateral IIAs with an unusually large middle sacral artery (Fig 3, A and B). The occluded left IIA was recanalized using a combination of a Berenstein catheter (Boston Scientific, Marlborough, MA) and a glide wire (Terumo, Somerset, NJ). Serial dilation with 3-mm and, subsequently, 5-mm balloons was followed by the placement of a 6-mm × 100-mm Eluvia stent and 6-mm × 40-mm Eluvia stent (Boston Scientific). The stents were postdilated with a 6-mm × 80-mm balloon with a good angiographic result. The right IIA was similarly recanalized from the left side. A 6-mm × 80-mm Eluvia stent and a 6-mm × 40-mm Zilver PTX stent (Cook Medical, Bloomington, IN) were deployed and postdilated with a 6-mm × 80-mm balloon with good angiographic results (Fig 3, C-I). The common femoral arteries were closed using Perclose ProGlide (Abbott Vascular, Abbott Park, IL), and the patient was discharged to home the same day. The fluoroscopy time was 36 minutes, with a total dose of 1168 mGy. His buttock claudication had immediately resolved, and a repeat buttock TcPO₂ study revealed significant improvement (Fig 4).

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.

Discussion

Although acute occlusion or ligation of the IIA can result in manifestations as drastic as colonic or buttock necrosis, patients with chronic IIA stenosis or occlusion often complain of progressive buttock and thigh claudication. The true incidence of isolated symptomatic IIA stenosis or occlusion is unknown, and the diagnosis is most likely overlooked. Furthermore, even in the era of minimally invasive vascular interventions, no consensus has been reached regarding the best endovascular therapy, with some vascular specialists recommending balloon angioplasty (percutaneous transluminal angioplasty [PTA]) as the primary treatment modality and others favoring stenting. Even in this latter group, no consensus has been reached regarding the type of stent—bare metal vs covered, self-expanding vs balloon expandable—to use. A careful review of the existing literature suggested that PTA of the IIA as a standalone therapy has a very high technical success rate and is clinically effective at relieving vasculogenic pain of gluteal muscle claudication.4, 5, 6, 7, 8, 9, 10

As was the case with our patient, the diagnosis of this condition can be challenging, and patients might undergo orthopedic procedures with underwhelming clinical results or have their symptoms dismissed altogether, especially in the setting of a normal distal pulse examination. Thus, a high index of suspicion is required. Once suspected, the diagnosis can be secured using noninvasive methods such as gluteal duplex ultrasound scanning which has 100% sensitivity, 96% specificity, and a negative predictive value of 100%.¹¹ However, the diagnostic modality of choice in our practice has been an exercise TcPO₂ study because it is readily available and has been shown to have >80% sensitivity and specificity. With this test, a decrease of −15 mm Hg is considered diagnostic of hemodynamically significant IIA stenosis or occlusion.12, 13, 14, 15 Exercise near-infrared spectroscopy has been used for the diagnosis; however, it has low sensitivity and accuracy.16, 17, 18 The use of preoperative CTA is extremely important and should be obtained for all patients with normal renal function to guide therapy.

Our decision to offer our patient PTA and stenting was because (1) stenting, in the common iliac artery territory, has been shown to be superior to PTA alone; (2) the follow-up period from reported studies was relatively short; and (3) the restenosis rate was 6% (3 of 53 patients) with all 3 of these patients having undergone PTA alone (Table). Our choice of drug-eluting stents was based on their superior patency compared with non–drug-eluting bare metal stents. The use of covered stents was contemplated; however, we decided to reserve their use in the case of vessel perforation only.

Conclusions

The diagnosis of buttock claudication requires a high index of suspicion, and the findings from an exercise TcPO₂ study and CTA can help with the diagnosis and guide the therapeutic intervention. When indicated, PTA, with or without stenting, represents the best option owing to its high success rate and low morbidity compared with open revascularization. Further studies are needed to determine the long-term performance of these treatment modalities.