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internal iliac artery Case report and embryologic review

internal iliac artery Case report and embryologic review

A 25-year-old woman with anomalous circulation to the right leg was seen with a symptomatic aneurysm of the abnormal vessel. The artery, which did share some features of the classic persistent sciatic artery, also had important differences that were not previously described in the literature. The patient manifested several associated vascular and nonvascular congenital anomalies. She underwent resection of the aneurysm and primary operative repair of the artery without difficulty. An embryologic interpretation is offered, and the clinical implications and management strategy are discussed. (J VascSurg 1998;28:1112-4.)
Persistent sciatic artery (PSA) is a well-recognized disorder that was first reported in the literature by Green in 1832. The sciatic artery, the earliest fetal blood supply to the lower extremity, may persist in the adult and is associated with a high incidence rate of complications, which include aneurysm formation, 2-5 embolism, and nerve compression. The classic syndrome of pulsatile buttock mass and absent femoral 2-5 pulse may be absent if the anomaly is partial.Other anomalies of the vasculature that supply the leg are extremely rare, and few reports that describesuch disorders exist in the literature. This report describes a patient in whom the fetal circulation to the leg persisted in a form different from the classic PSA, although the embryology shared some characteristics with the usual anomaly. This variation has not been reported elsewhere in association with aneurysm formation, and a literature review disclosed only 1 other example of similar anatomy.
CASE REPORT
A 25-year-old woman was seen 5 years before the operation with severe right-sided pelvic pain. The extensive evaluation at that time included an arteriogram that revealed an aneurysm of an anomalous artery that supplied
the right leg. The treating physicians did not appreciate its significance at that time, however, and the aneurysm was managed conservatively. The patient was known to have a number of congenital anomalies, including a right-sided From the Section of Vascular Surgery, University of Rochester School of Medicine and Dentistry. Reprint requests: Dr Cynthia Shortell, 1415 Portland Ave, Suite 125, Rochester, NY 14621-3000. Copyright  1998 by the Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/98/$5.00 + 0 24/4/94035 1112 aortic arch and an obstruction of the duodenum by a fibrous band at the root of the mesentery, which had been corrected surgically 5 years earlier. Her pain persisted despite several gynecologic procedures, which included right oophorectomy and lysis of adhesions. Before she underwent a third exploratory gynecologic procedure, the patient was referred for vascular reevaluation of the aneurysm. A pulsatile mass was found on pelvic examination, and there were normal pulses at the femoral, popliteal, and pedal levels. A second arteriogram was obtained (Fig 1). The right leg was supplied by an unbranched vessel that originated from the aorta and terminated in the common femoral artery. An oblique view showed no posterior displacement of the vessel. There was a tortuous, aneurysmal segment of the artery in the pelvis that gave rise to numerous branches. Distal views showed a normal run-off via the profunda and the superficial femoral, popliteal, and the tibial arteries. Other significant findings included an accessory right renal artery that originated from the anomalous vessel, a transposition of the inferior mesenteric artery to the right side of the aorta, and an abundant left hypogastric system, which probably supplied the sigmoid colon. The left-sided iliac system was otherwise normal.A resection of the aneurysm was undertaken because of the patient°Os severe, intractable pain. The findings at th time of the operation are shown in Fig 2: the vessel originated from the aorta and descended without branches into the pelvis. In the pelvis, the vessel became extremely tortuous and aneurysmal with multiple branches. The usual anatomic relationships were also distorted°(TM)the iliac vei was located anterior to the vessel, and the ureter passed posteriorly. An additional anomaly, a noncommunicating right uterine horn, was resected by surgeons in the gynecologic service. Because of the patient°Os young age and the lack oprecedent for the management of this anomaly, we elected to reconstruct the artery primarily after the aneurysm
resection rather than replace an extensive length of gross-ly normal artery with a prosthesis. Mobilization of the
normal portions with primary reanastomosis was performed without difficulty because of the relatively short
distance that is involved with aneurysmal change. The patient recovered uneventfully with the reestablishment of
normal flow to the right leg and the complete resolution of her pain. details>>
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