Common iliac artery thrombosis as a possible complication of the pluck technique in nephroureterectomy

Abstract

Common iliac artery (CIA) thrombosis is a rare surgical complication which may cause serious leg damage and may occasionally be fatal. We experienced two cases of CIA thrombosis in nephroureterectomy with the pluck technique for upper tract urothelial carcinoma. Patients were treated using emergent femoro–femoral bypass, and one patient was treated with fasciotomy of the lower extremity for compartment syndrome. CIA thrombosis is considered a possible complication of nephroureterectomy, particularly with the pluck technique in open surgery. Arterial thrombosis in intrapelvic surgery including nephroureterectomy should be carefully considered for patients at risk.

Background

Acute arterial thrombosis is a serious and emergent condition that may result in permanent organ damage. Common iliac artery (CIA) thrombosis is rarely reported as a surgical complication.^{1 2} Herein, we present two cases of CIA thrombosis in nephroureterectomy with the pluck technique for upper tract urothelial carcinoma.

Case presentation

Case 1

A 70-year-old man was diagnosed with left renal pelvic tumour on follow-up CT for bladder cancer previously treated at our hospital. His history included smoking. Coagulopathy was not detected via coagulation studies, and prophylaxis for deep venous thrombosis (DVT) was performed with compression stockings and foot pumps. Open left nephroureterectomy was performed in the decubitus lateral position. Antecedently, the left ureteral orifice was incised circumferentially using the transurethral approach. After completion of nephrectomy, the distal ureter was mobilised without adhesion, digitally detached at the ureterovesical junction and extracted en bloc through a single loin incision. Lymph node dissection was not performed. Operation time and blood loss were 112 min and 50 mL, respectively. After extubation, paresis of the left foot and toe joint was observed, which persisted after cessation of epidural anaesthesia. Additionally, cyanosis and pain of the left lower leg without femoral pulsation was observed. CT revealed left CIA thrombosis, which could be attributed to dissection (figure 1B). Femoro–femoral bypass was immediately performed, and cilostazol administration was initiated. Atherosclerotic change with calcification at the left CIA was retrospectively observed on preoperative CT (figure 1A).

Figure 1.

Abdominal CT imaging of the left common iliac artery (CIA) (arrows). (A, C) Calcification of the left CIA before surgery was observed in each case. (B, D) After surgery, thrombosis with dissection of the left CIA was suspected in each case.

Case 2

A 72-year-old man was referred to our hospital for suspicion of gastric cancer, which was revealed to be gastritis on biopsy. CT revealed tumour of the left renal pelvis, upper ureter and bladder. His history included hypertension, hyperuricaemia, smoking and ureteral stone. The bladder tumour was treated with transurethral resection and proved to be low-grade urothelial carcinoma. No coagulopathy was detected via coagulation studies, and prophylaxis for DVT was performed with compression stockings and foot pumps. Open left nephroureterectomy was performed with the same procedure as the first case, followed by lymph node dissection at the para-aorta. There was no definite adhesion around the left ureter. Operation time and blood loss were 260 min and 550 mL, respectively. Immediately following surgery, the patient complained of left foot pain and foot drop in the recovery room, which persisted after removal of epidural anaesthesia. CT revealed left CIA thrombosis with dissection (figure 1D) and thrombosis of the left popliteal artery. He was immediately treated with femoro–femoral bypass and distal thrombectomy. Compartment syndrome of the left lower leg was also suspected, and emergent fasciotomy was performed. Next, aspirin administration was initiated. Atherosclerosis of the left CIA was also confirmed on preoperative CT (figure 1C).

Outcome and follow-up

Case 1

The symptoms of the left leg were completely recovered. Pathological examination revealed low-grade urothelial carcinoma with stage of pTaNxM0. No recurrence was reported on 8 years of follow-up.

Case 2

The symptoms were improved except for paraesthesia on the left sole. Pathological examination revealed low-grade urothelial carcinoma with stage of pTaN0M0. No recurrence was reported on 1 year of follow-up.

Discussion

CIA thrombosis is a rare and serious complication following surgery. In general, thrombotic obstruction of an artery is associated with atherosclerosis or traumatic injury.^{1 2} In the present cases, atherosclerotic changes were confirmed on preoperative CT, and both patients had some risk factors for atherosclerosis, such as hypertension and/or smoking. As CIA thromboses in the present cases occurred at the ipsilateral side of nephroureterectomy, some common surgical procedures may have been responsible. In both cases, there was no definite adhesion or direct injury to the CIA during dissection of the ureter. Lymph node dissection in the second case was limited to the para-aortic region. In the present cases, the ‘pluck technique’, which is a transurethral procedure, was employed for the removal of the distal ureter. The pluck technique is frequently used as a minimally invasive method, which reduces the wound length by transurethral incision of the ureteral orifice in nephroureterectomy. However, there have been concerns of tumour cell spillage with urine to the extraperitoneum. Therefore, patients with concomitant bladder tumour or lower ureteral tumour are excluded as candidates in general, and the ureter should be ligated earlier during nephrectomy. Despite oncological concerns of cancer seeding, previous reports demonstrated outcomes of disease-specific survival comparable with published data of classic or laparoscopic nephroureterectomy without transurethral procedures.³

In a review of distal ureter management, Gkougkousis et al reported that 8 of 508 patients (2%) developed complications related to cystoscopic detachment of the distal ureter, including haematuria, retroperitoneal extravasation requiring prolonged drainage, urinary retention and urinary tract infection.⁴ We could find only two reports of CIA dissection or thrombosis in nephroureterectomy but not in nephrectomy, which is a similar surgery without lower ureteral dissection.^{5 6} Therefore, the contribution of ureteral procedure in the pelvis to this complication is considerable. One of the two reports was described as a case with transvesical procedure.⁶ All four CIA lesions including the present cases were ipsilateral to the nephroureterectomy, and there was no laterality. In the conventional pluck technique, digital manipulation with the operator’s hand over the CIA is imperative for removal of the distal ureter. In this process, compression of the CIA may trigger arterial dissection or thrombosis, particularly in a patient with atherosclerosis. Furthermore, CIA thrombosis was reported in other intrapelvic surgeries. Van Buren et al reported a case of coagulopathy after inguinal hernia repair with mesh.⁷ Therefore, intrapelvic surgery itself may have a potential risk for CIA thrombosis in patients at risk.

The symptoms of acute limb ischaemia are characterised by pain, pallor, paralysis, paraesthesia and pulselessness.¹ Treatment of acute limb ischaemia involving the CIA comprises conservative therapy with anticoagulant, endovascular thrombectomy and vascular reconstruction according to grade and symptoms.¹ In the present cases, surgical revascularisation was selected because both patients demonstrated severe symptoms including foot drop with suspicion of arterial dissection on CT. Recirculation of acute arterial obstruction is frequently accompanied by compartment syndrome, which is local oedema, and compartment hypertension caused by increased capillary permeability, and can cause permanent neuromuscular or organ damage.¹ In the second case, emergent fasciotomy was performed as the standard treatment for compartment syndrome of the left lower leg.

In conclusion, CIA thrombosis should be recognised as a rare but possible complication of nephroureterectomy, particularly with the pluck technique in open surgery. Therefore, careful selection of surgical procedures and delicate manipulation around the vessels in nephroureterectomy is necessary. Arterial thrombosis in general intrapelvic surgery should be considered for patients at risk of atherosclerosis or coagulopathy.

Learning points.

• Common iliac artery thrombosis should be recognised as a possible complication of nephroureterectomy particularly with the pluck technique in open surgery.

• Appropriate selection of surgical procedures and delicate manipulation around vessels in nephroureterectomy are necessary.

• Symptoms of acute limb ischaemia should be carefully considered in general intrapelvic surgery for patients at risk of atherosclerosis or coagulopathy.