Stent-Graft Placement for the Management of Iliac Artery Hemorrhage in Patients With Pelvic Malignancy: Clinical Outcomes and Patency

Abstract

Purpose:

To evaluate clinical outcomes and patency of endovascular stent-graft placement for iliac artery hemorrhage in patients with pelvic malignancy.

Methods:

We retrospectively reviewed 15 patients (21 cases) with pelvic malignancy undergoing emergency stent-graft placement for iliac artery hemorrhage from December 2011 to April 2025. Technical and clinical success, complications, primary patency, rebleeding rates, and survival were analyzed. Risk factors for rebleeding, specifically the degree of tumor invasion (encasement vs abutment), were assessed.

Results:

Technical and clinical success were 100%. Significant hemodynamic improvements were achieved: systolic blood pressure (85.5±32.8 vs 114.8±15.7 mmHg; p=0.014), and heart rate (110.7±24.0 vs 93.7±15.9 bpm; p=0.037). During a mean follow-up of 11.5 months, rebleeding occurred in 6 cases (28.6%). Tumor encasement was associated with a numerically higher rebleeding rate compared with abutment (40.0% vs 0%; p=0.123). Cumulative 1-year primary patency and survival rates were 82.9% and 52.5%, respectively.

Conclusion:

Stent-graft placement appears to be a feasible and potentially effective approach for immediate hemostasis in iliac artery hemorrhage associated with pelvic malignancy. However, careful surveillance is warranted due to a clinically notable risk of rebleeding, particularly in cases with tumor encasement.

Clinical Impact

Stent-graft placement offers a reliable, vessel-preserving endovascular option for achieving immediate hemostasis in catastrophic iliac artery hemorrhage associated with pelvic malignancy. This study demonstrates excellent technical and clinical success while identifying progressive tumor encasement as a potential marker for delayed hemorrhagic recurrence. These findings may help clinicians stratify rebleeding risk and tailor post-procedural surveillance according to the degree of tumor-vessel involvement. In cases of recurrent hemorrhage despite repeated stent-graft placement, collateral circulation should be carefully assessed, as therapeutic arterial sacrifice with coil embolization may represent an effective salvage strategy. This study provides practical guidance for managing a rare but life-threatening clinical condition.

Keywords

iliac artery hemorrhage stent-graft pelvic neoplasms endovascular procedures

Introduction

Massive hemorrhage from the iliac artery in patients with advanced pelvic malignancy is a rare but catastrophic complication associated with high mortality rates.^1-3 This life-threatening condition can arise from direct tumor invasion, radiation-induced arteritis, or the formation of arterio-enteric or arterio-ureteral fistulas following extensive pelvic surgery and radiotherapy.^4,5

Managing these patients poses a significant clinical challenge. Traditional open surgical repair is often precluded by the poor general condition of the patient and hostile surgical fields resulting from prior radical surgeries, radiation therapy, and extensive tumor infiltration.^2,3 While transcatheter arterial embolization has been the mainstay for controlling pelvic hemorrhage, permanent occlusion of the common iliac artery (CIA) or external iliac artery (EIA) carries a high risk of severe ischemic complications, such as gluteal necrosis and lower-limb ischemia, which can devastatingly impact the quality of life in palliative care settings.^6,7

Endovascular stent-graft placement has emerged as a viable alternative, offering the distinct advantage of excluding the bleeding focus while preserving distal arterial flow.⁵ The efficacy of this vessel-preserving technique is already well recognized in other vital anatomic territories such as visceral, carotid, and subclavian arteries where maintaining perfusion to end-organs is critical.^8-11 Although stent-graft utility is established in traumatic iliac injuries,^12,13 literature regarding its specific use in malignant iliac artery erosion remains limited to small case series.^1,2 Furthermore, concerns remain regarding the long-term durability of stent-grafts in infected or tumor-encased fields and the potential risk of delayed rupture or rebleeding complications.¹⁴

Therefore, the purpose of this study was to evaluate the technical feasibility, clinical efficacy, and long-term patency of emergency stent-graft placement for the management of massive iliac artery hemorrhage in patients with pelvic malignancy. In addition, we sought to identify specific risk factors associated with rebleeding in this high-risk cohort.

Materials and Methods

Study Population

This retrospective study was approved by the institutional review board of our institution, and the requirement for informed consent was waived (approval no. SMC-2026-01-028-001). From December 2011 to April 2025, a total of 15 patients (21 procedural cases) with pelvic malignancy who underwent emergency stent-graft placement for iliac artery hemorrhage were included. The inclusion criteria were: (1) massive hemorrhage from the CIA or EIA confirmed by contrast-enhanced computed tomography (CT) or angiography; (2) underlying pelvic malignancy; and (3) unsuitability for surgical repair due to advanced disease or poor performance status. Patients were excluded if the hemorrhage originated from vessels other than the iliac arteries or if the bleeding was managed without the use of a stent-graft.

Interventional Procedures

All procedures were performed by experienced interventional radiologists under local anesthesia. Common femoral artery access was obtained, typically from the contralateral side (crossover approach) or the ipsilateral side depending on the lesion location and vascular tortuosity. Depending on the lesion location identified on CT, diagnostic aortography using a 5F pigtail catheter or ipsilateral iliac angiography was performed to identify the bleeding site. Once the lesion was localized, a stiff guidewire was advanced across the bleeding site. The stent-graft diameter was selected to be equal to or 1 to 2 mm larger than the reference diameter of the healthy proximal and distal vessel segments, as measured on pre-procedural CT scans. The length was chosen to ensure comprehensive segmental coverage of the lesion, providing at least 1 cm of overlap with the normal vessel wall at both the proximal and distal ends. The stent-grafts used in this study included self-expandable stent-grafts (Covera plus™; Becton Dickinson, Tempe, AZ, USA and Viabahn®; W.L. Gore & Associates, Flagstaff, AZ, USA) and balloon-expandable stent-grafts (Lifestream™; Becton Dickinson). The choice of stent-graft was determined by the availability of devices under national reimbursement guidelines or, otherwise, by the operator’s preference. Post-dilation was performed if necessary to ensure adequate wall apposition. Completion angiography was performed to confirm the exclusion of the bleeding focus and the preservation of distal flow.

Definitions and Follow-up

Technical success was defined as immediate exclusion of the bleeding sign such as extravasation or pseudoaneurysm and preservation of distal arterial flow. Clinical success was defined as the cessation of clinical signs of bleeding, stabilization of hemodynamic parameters, and no requirement for additional surgical or interventional procedures for hemostasis. Tumor invasion was classified as abutment (≤180^o) or encasement (>180^o) based on pre-procedural CT findings.^15,16 Tumor necrosis was defined as a non-enhancing low-attenuation area within the tumor, with air-containing necrosis specifically identified by the presence of extraluminal gas bubbles.^17,18 Prophylactic intravenous antibiotics (eg, piperacillin/tazobactam) were administered to patients with extensive tumor necrosis to prevent secondary infection. No graft-specific infectious complications were documented during the follow-up period. Follow-up contrast-enhanced CT was routinely performed at 1, 3, 6, and 12 months after the procedure, and additional imaging was performed as needed based on the patient’s clinical condition. Stent-graft patency was defined as the preservation of intraluminal flow through the stent-graft confirmed by follow-up CT or ultrasonography, without the need for any re-intervention. Rebleeding was defined as the reappearance of bleeding-related symptoms (eg, wound site bleeding, hematochezia, or hematemesis) following the initial treatment, with subsequent confirmation of a bleeding focus via CT or angiography that necessitated additional intervention or surgery.

Statistical Analysis

Continuous variables are presented as mean±standard deviation (SD) or median (range), and categorical variables are expressed as numbers and percentages. Paired t tests were used to compare pre- and post-procedural hemodynamic parameters (systolic blood pressure and heart rate). Univariate analysis using Fisher’s exact test or Pearson’s chi-square test was performed to identify risk factors associated with rebleeding. The cumulative rates of primary patency and patient survival were estimated using the Kaplan-Meier method. All statistical analyses were performed using SPSS software (version 27.0; IBM Corp., Armonk, NY, USA). A p value <0.05 was considered statistically significant.

Results

The baseline characteristics of the 15 patients (21 cases) are summarized in Table 1. The mean age was 62.7±15.9 years (range 34–93 years), and 60.0% were female. Gynecologic malignancies, including cervical, endometrial, and ovarian cancers, were the most common underlying pathologies (53.3%), followed by rectal cancer (13.3%) and liposarcoma (13.3%). The EIA was the most frequent site of bleeding (81.0%). Pre-procedural CT findings revealed tumor encasement of the affected vessel in 16 cases (76.2%) and tumor necrosis in 12 cases (57.1%) (Figure 1).

Table 1.

Baseline Demographics and Clinical Characteristics of Patients with Iliac Artery Hemorrhage (15 patients, 21 cases).

Characteristics	Value
Age (years)	62.7±15.9 (range 34–93)
Sex
Male	6 (40.0%)
Female	9 (60.0%)
Underlying malignancy
Cervical cancer	3 (20.0%)
Endometrial/uterine cancer	3 (20.0%)
Rectal cancer	2 (13.3%)
Ovarian cancer	2 (13.3%)
Liposarcoma	2 (13.3%)
Others*	3 (20.0%)
Direction
Right	12 (57.1)
Left	9 (42.9)
Bleeding site
External iliac artery	17 (81.0%)
Common iliac artery	3 (14.3%)
Internal iliac artery	1 (4.8%)
Presenting symptoms*
Overt bleeding (hematochezia/hematuria)	10 (66.7%)
Pain (abdominal/inguinal)	8 (53.3%)
Hemodynamic instability (shock)	3 (20.0%)
Pre-procedural vital signs and labs
Systolic blood pressure (mmHg)	85.5±32.8
Heart rate (beats/min)	110.7±24.0
Hemoglobin (g/dL)	5.9±1.7
Transfusion (units)	8.8±6.2 (range 2–21)
CT findings
Tumor invasion
Encasement	16 (76.2%)
Abutment	5 (23.8%)
Tumor necrosis
Present	12 (57.1%)
Absent	9 (42.9%)

Etc includes sigmoid colon cancer (n = 1), vulvar cancer (n = 1), and bladder cancer (n = 1).

Figure 1.

Comparison of tumor-vessel relationships and endovascular management. (A–C) Case of tumor abutment in a 69-year-old female with cervical cancer. (A) Computed tomography (CT) reveals a tumor containing air bubbles (arrow) abutting the external iliac artery (EIA) (arrowhead) with adjacent contrast extravasation. (B) Roadmap angiography confirms active contrast extravasation from the EIA. (C) Completion angiography demonstrates successful hemostasis after stent-graft placement. (D–F) Case of tumor encasement in a 43-year-old female with cervical cancer. (D) CT demonstrates the EIA (arrow) being encased by the tumor, which also contains air bubbles (arrowhead), accompanied by extravasation. (E) Initial aortography reveals contrast media extravasation from the encased arterial segment. (F) Final aortography confirms complete exclusion of the bleeding focus following stent-graft deployment.

Procedural details and immediate outcomes are presented in Table 2. On initial angiography, contrast extravasation was observed in 13 cases (61.9%) and pseudoaneurysm in 8 cases (38.1%). Technical success was achieved in all 21 cases (100%). Notably, in one case involving the internal iliac artery, a stent-graft was selected over embolization to preserve pelvic circulation and prevent ischemia, as the patient had previously undergone contralateral internal iliac artery ligation. Clinical success was also 100%, with immediate hemodynamic stabilization in all patients. Following the procedure, systolic blood pressure significantly increased from 85.5±32.8 to 114.8±15.7 mmHg (p=0.014), and heart rate significantly decreased from 110.7±24.0 to 93.7 ± 15.9 bpm (p=0.037).

Table 2.

Procedural Details and Clinical Outcomes of Endovascular Stent-Graft Placement.

Variable	Value
Angiographic finding
Extravasation	13 (61.9%)
Pseudoaneurysm	8 (38.1%)
Stent-graft details
Self-expandable
Covera™	13 (61.9%)
Viabahn®	5 (23.8%)
Balloon-expandable
Lifestream™	3 (14.3%)
Diameter (mm)	8–13 (median: 10)
Length (mm)	40 – 100 (median: 60)
Technical success	21 (100%)
Clinical success	21 (100%)
Rebleeding	6 (28.6%)
Follow-up (months)	11.5±10.8 (range 1–37)
Stent-graft occlusion*	2 (10.0%)
Patency duration (months)	10.2±10.4 (range 1–37)
Patient survival
Dead	9 (60.0%)
Alive	5 (33.3%)
Unknown (lost to follow-up)	1 (6.7%)

Includes 20 patients due to 1 patient lost to follow-up.

The mean follow-up period was 11.5±10.8 months (range 1–37 months), with one patient lost to follow-up. During the follow-up, stent-graft occlusion occurred in 2 cases (10.0%). The cumulative 1-year primary patency rate was 82.9%. Nine patients (60.0%) died during the follow-up period due to disease progression. The estimated median survival time was 26 months, and the cumulative 1-year survival rate was 52.5% (Figure 2).

Figure 2.

Kaplan-Meier analyses of clinical outcomes. (A) The cumulative 1-year primary patency rate of the stent-grafts. (B) The overall survival curve of the patients.

Rebleeding occurred in 6 cases (28.6%) during the follow-up period. The results of the univariate analysis for factors associated with rebleeding are shown in Table 3. Although formal statistical significance was not reached, tumor encasement on pre-procedural CT was associated with a higher rebleeding rate compared with tumor abutment (40.0% vs 0%; none of the 6 abutment cases experienced rebleeding; p=0.123). Other factors, including sex (p=1.000), bleeding site (p=0.803), stent-graft type (p=0.526), and history of prior pelvic radiation therapy (p=0.598), were not significantly associated with rebleeding. There were no procedure-related major complications. One patient experienced a minor complication, specifically a pseudoaneurysm at the puncture site, which was successfully resolved with ultrasound-guided compression.

Table 3.

Univariate Analysis of Risk Factors Associated with Rebleeding (n=21).

Variable	No rebleeding (n=15)	Rebleeding (n=6)	p value
Sex
Male	6 (40.0%)	3 (50.0%)	1.000
Female	9 (60.0%)	3 (50.0%)
Bleeding site
CIA	2 (13.3%)	1 (16.7%)	0.803*
EIA	12 (80.0%)	5 (83.3%)
IIA	1 (6.7%)	0 (0.0%)
Direction
Right	7 (46.7%)	5 (83.3%)	0.178
Left	8 (53.3%)	1 (16.7%)
Radiologic findings (CT)
Tumor invasion			0.123
Encasement	9 (60.0%)	6 (100.0%)
Abutment	6 (40.0%)	0 (0.0%)
Tumor necrosis			1.000
Present	9 (60.0%)	3 (50.0%)
Absent	6 (40.0%)	3 (50.0%)
Procedural details
Angiographic finding			0.336
Extravasation	8 (53.3%)	5 (83.3%)
Pseudoaneurysm	7 (46.7%)	1 (16.7%)
Stent-graft type			0.526
Self-expandable	12 (80.0%)	6 (100.0%)
Balloon-expandable	3 (20.0%)	0 (0.0%)
Radiation therapy			0.598
Yes	3 (20.0%)	2 (33.3%)
No	12 (80.0%)	4 (66.7%)

Abbreviations: CIA, common iliac artery; CT, computed tomography; EIA, external iliac artery; IIA, internal iliac artery.

p values were calculated using Fisher’s exact test, except for bleeding site (*Pearson’s chi-square test, 3 categories).

A p value <0.05 was considered statistically significant.

The detailed characteristics and mechanisms of the 6 rebleeding events are summarized in Table 4. Notably, 5 of the 6 events (83.3%) occurred at the distal edge of the stent-graft, despite angiographic and radiologic confirmation that the devices had been placed with sufficient longitudinal margins. Among these distal edge complications, the recurrences were primarily driven by progressive tumor encasement at the transition site (events 1, 4, 5, and 6). The remaining distal edge case (event 2) was attributed to mechanical failure, specifically proximal migration of the stent-graft leading to distal dissection. In contrast, one rebleeding event (event 3) occurred at the right CIA and was caused by arterial wall erosion secondary to progressive tumor invasion.

Table 4.

Detailed Characteristics and Mechanisms of Rebleeding Events (6 Events in 5 Patients).

Patient no.	Event no.	Sex	Age (years)	Underlying malignancy	Time to rebleeding	Site of rebleeding	CT findings (invasion/necrosis)	Angiographic finding	Mechanism of rebleeding	Management
1	1	M	52	Retroperitonealliposarcoma	1123 daysfrom initial procedure	Right EIA	Encasement /no necrosis	Extravasation	Arterial wall perforation at the distal stent-graft edge due to progressive tumor invasion	Additional stent-graft placement (Viabahn 8 mm×100 mmand 11 mm×50 mm) with 2.5-cm overlap to seal thedistal leakage site
1	2	M	52	Retroperitonealliposarcoma	446 daysfrom event 1	Right EIA	Encasement /no necrosis	Pseudoaneurysm	Proximal migration of the stent-graft leading to distal dissection and pre-perforating aneurysmal change	Stent migration correction and distal dissection repairvia additional Viabahn stent-grafts(10 mm×100 mm and 13 mm × 100 mm)
2	3	M	91	Liposarcoma	88 daysfrom initial procedure	Right CIA	Encasement /necrosis	Extravasation	Arterial wall erosion secondary to progressive tumor invasion	Additional Viabahn stent-graft (8 mm×60 mm)to reinforce the previous stent-graft
3	4	F	57	Endometrialcarcinoma	785 daysfrom initial procedure	Right EIA	Encasement /necrosis	Extravasation	Recurrent arterial rupture at the distal stent-graft edge due to progressive tumor invasion	Additional Covera Plus stent-graft (10 mm×60 mm)via through-and-through technique
4	5	F	63	Ovariancarcinoma	724 daysfrom initial procedure	Right EIA	Encasement /no necrosis	Extravasation	Recurrent arterial rupture at the distal stent-graft edge due to progressive tumor invasion	Additional Covera Plus stent-graft (8 mm×60 mm)Placement
5	6	F	34	Ovariancarcinoma	26 daysfrom initial procedure	Left EIA	Encasement /necrosis	Extravasation	Recurrent arterial rupture at the distal stent-graft edge due to progressive tumor invasion in the setting of circumferential encasement	Additional Covera Plus stent-graft (8 mm×40 mm)with overlap to exclude the bleeding point

Abbreviations: CIA, common iliac artery; CT, computed tomography; EIA, external iliac artery.

Patient 1 (retroperitoneal liposarcoma, M/52) experienced 2 rebleeding events (events 1 and 2) during follow-up.

Time to rebleeding is calculated from the immediately preceding procedure (initial or repeat stent-graft placement).

Among the patients with rebleeding, 2 required complex repeated interventions. One patient underwent a total of 3 stent-graft procedures due to stent migration and subsequent dissection which was successfully managed with an additional stent-graft placement. Another patient experienced recurrent hemorrhage despite 2 successful stent-graft placements. Upon the third bleeding episode, angiography demonstrated robust collateral circulation from the internal iliac artery to the ipsilateral superficial femoral artery. Given the recurrent nature of the bleeding and the presence of adequate collaterals, the decision was made to sacrifice the EIA. The vessel was permanently occluded using coil embolization, which effectively controlled the hemorrhage without causing limb ischemia (Figure 3).

Figure 3.

Sequential management of refractory hemorrhage in a 57-year-old female with endometrial cancer. (A) Follow-up Computed tomography (CT) shows extravasation at the stent-graft’s distal end with severe tumor encasement. (B) Aortography confirms recurrent extravasation. (C) Due to vessel disruption, a guidewire traversed the tumor cavity and was captured by a gooseneck snare (through-and-through technique) to re-establish access. (D) Angiography shows hemostasis after additional stent-graft placement. (E) Three-month follow-up CT reveals an additional rebleeding episode. (F) Angiography shows active bleeding with a faintly visualized superficial femoral artery (SFA). (G) Internal iliac arteriography demonstrates robust collaterals (arrow) reconstituting the SFA (arrowhead). (H) Final aortography after external iliac artery embolization confirms hemostasis with preserved limb perfusion via collaterals.

Discussion

In this study, endovascular stent-graft placement demonstrated 100% technical and clinical success in controlling massive iliac artery hemorrhage in patients with pelvic malignancy. These findings underscore the effectiveness of stent-grafts as a rapid and reliable method for achieving hemostasis and hemodynamic stabilization in emergency settings. The cumulative 1-year primary patency rate was 82.9%. While this result is clinically acceptable given the patients’ critical condition, it is slightly lower than the outcomes reported in benign settings. In patients treated with stent-grafts for atherosclerotic iliac artery occlusive disease, the 1-year primary patency rates are reported to be as high as 91% to 96%.¹⁹ Similarly, stent-grafts used for iatrogenic iliac artery rupture typically show excellent long-term patency with minimal complications.^12,13,20 The comparatively lower patency in our study may be attributed to the patients’ poor general condition and hemodynamic instability, which frequently result in a low-flow state, predisposing to graft thrombosis. Furthermore, unlike benign lesions that merely compress the vessel, malignant tumors actively invade and destroy the arterial wall structure. This transmural erosion compromises the vessel’s integrity, creating a fragile hostile environment where the stent-graft lacks a healthy landing zone, thereby increasing the susceptibility to rebleeding or delayed rupture.^14,21

In managing hemodynamically-unstable cases, we prioritized immediate and definitive stent-graft deployment. This approach is consistent with previous literature demonstrating that emergent endografting can successfully stabilize patients in hypovolemic shock by providing rapid and reliable exclusion of the bleeding focus.²² Given that appropriate devices are typically accessible in emergency settings, direct stent-graft placement allows for streamlined hemostasis and effective clinical stabilization without the need for additional preparatory endovascular steps.

A notable finding in our study was the rebleeding rate of 28.6% during the follow-up period. This stands in sharp contrast to iatrogenic or traumatic iliac artery injuries, where rebleeding is extremely rare once the vessel is successfully excluded with a stent-graft.^12,20 The degree of tumor invasion emerged as the most clinically relevant factor associated with rebleeding. Although univariate analysis did not demonstrate a statistically significant association between tumor encasement and rebleeding (p=0.123), likely attributable to the limited statistical power of this small cohort, the absolute difference in rebleeding rates between the two groups was clinically noteworthy. Rebleeding occurred in 6 of 15 encasement cases (40.0%), whereas none of the 6 abutment cases (0%) experienced any rebleeding event. In this small cohort, the absence of rebleeding among abutment cases may suggest that the degree of circumferential tumor involvement could serve as a potential prognostic indicator for hemorrhagic recurrence; however, given the small number of abutment cases (n=6 at the case level; n=5 at the patient level), these findings should be considered exploratory and hypothesis-generating, requiring validation in larger future studies. Radiologically, tumor encasement often implies transmural invasion of the vessel wall by the malignancy.¹⁶ In such cases, the chronic radial force exerted by the stent-graft against a friable, tumor-infiltrated arterial wall may accelerate vessel erosion, potentially leading to delayed rupture.¹⁴ In contrast, vessels with only partial tumor abutment likely retain some residual structural integrity of the arterial wall, allowing them to withstand the mechanical stress imposed by the stent-graft. If confirmed in larger studies, these exploratory findings could have potential clinical implications for risk stratification and post-procedural surveillance planning in this patient population.

Given the high rebleeding rate associated with tumor encasement, the extent of stent-graft coverage remains a critical procedural consideration. In our series, we primarily adopted a comprehensive segmental coverage strategy, ensuring the stent-graft encompassed the active bleeding site and the arterial segment significantly narrowed or encased by the tumor. However, we intentionally avoided extending the stent-graft into adjacent segments that appeared structurally intact on pre-procedural imaging. This decision was made to minimize potential mechanical complications, such as stent kinking or thrombotic occlusion. Therefore, we prioritized a balanced approach: providing definitive coverage for the vulnerable, tumor-involved segment while preserving the flexibility and patency of the surrounding vessel.

A characteristic finding in our rebleeding cases was that the majority of recurrent hemorrhages occurred specifically at the distal edge of the stent-graft, despite ensuring adequate coverage of the initially tumor-involved arterial segments. This observation suggests that rebleeding was not merely a result of insufficient initial coverage, but rather a consequence of progressive tumor invasion into the distal landing zone, where it synergistically interacted with existing biomechanical stresses. This mechanism parallels the biomechanical principles underlying a well-recognized complication of aortic endovascular repair, in which a mechanical mismatch between a rigid stent-graft and a fragile arterial wall at the distal landing zone generates excessive strain at the transition zone, leading to arterial wall injury.²³ The stiffness of a stented segment is significantly higher than that of the adjacent non-stented vessel, concentrating mechanical stress at the stent edge.

In the context of the iliac artery, its inherent mobility during hip movement may further exacerbate this stress.²⁴ The tendency of self-expanding stents to recoil toward their original straight configuration exerts continuous radial pressure and shear stress specifically at the distal landing zone.²³ As the malignancy progresses beyond the initially protected segment, this newly invaded distal wall, already weakened by tumor infiltration, becomes highly susceptible to erosion or new tear formation under such chronic mechanical irritation. Therefore, our findings underscore that even with sufficient initial coverage, the distal landing zone remains a vulnerable site for ongoing tumor-mediated destruction and mechanical failure, necessitating vigilant long-term surveillance.

Although prior radiation therapy and tumor necrosis were not statistically significant risk factors for rebleeding in our small cohort (p>0.05), their detrimental effects on vascular integrity are well-documented in other anatomical territories. A parallel can be drawn with carotid blowout syndrome (CBS) in head and neck cancer patients, which shares a similar pathophysiology of radiation-induced arteritis and tissue necrosis. Chang et al¹⁰ and Wan et al²¹ reported that while stent-grafts achieve high immediate hemostasis in CBS, they are associated with high rates of rebleeding and infection due to the hostile irradiated neck environment. Similarly, in cases of post-pancreaticoduodenectomy hepatic artery hemorrhage, which often involves skeletonized arteries exposed to pancreatic juice, stent-grafts are lifesaving but prone to long-term occlusion or infection.²⁵ Our study’s outcomes may align with these findings, suggesting that in a hostile pelvis characterized by radiation, malignancy, and potential infection, the stent-graft is vulnerable to similar complications, necessitating vigilant surveillance.

The management of rebleeding or mechanical failure following stent-graft placement presents a significant clinical challenge in patients with pelvic malignancy. As observed in our study, the hostile pelvic environment can lead to progressive vessel erosion or stent migration. In such complex situations, while vessel preservation remains the primary goal, permanent embolization can serve as a crucial bailout option when stent-grafts fail repeatedly. In our study, one patient experienced recurrent hemorrhage despite multiple stent-graft placements. Angiography revealed robust collateral circulation from the internal iliac artery to the ipsilateral femoral artery. Consequently, therapeutic occlusion of the EIA was performed, which successfully secured hemostasis without compromising limb viability. This approach is supported by previous studies suggesting that ligation or occlusion of the EIA can be well tolerated if the internal iliac artery and deep femoral artery are patent, allowing for adequate collateral perfusion.²⁶ This underscores the importance of individualized salvage strategies that adapt to the changing vascular anatomy and collateral status of the patient.

This study has several limitations. First, it is a retrospective study from a single center with a relatively small sample size, which limits the statistical power of our analyses. In particular, the limited number of abutment cases (n=6) precluded adequate statistical power to detect a formally significant difference in rebleeding rates (40.0% vs 0%), despite the clinically notable absolute risk difference. Second, the study population was heterogeneous, including patients with various primary malignancies, such as cervical, bladder, and rectal cancers, making it difficult to assess disease-specific outcomes. Third, due to the advanced stage of the underlying malignancies, the overall survival of the patients was short, preventing the assessment of long-term stent-graft durability and very late complications. Future multicenter studies with larger cohorts are needed to validate these findings.

Conclusion

Endovascular stent-graft placement appears to be a feasible and potentially effective palliative option for iliac artery hemorrhage in patients with pelvic malignancy. However, close surveillance is warranted, particularly in patients with tumor encasement, given the clinically notable risk of rebleeding. The exploratory observation that no rebleeding occurred among abutment cases warrants further investigation in larger prospective studies.

Footnotes

ORCID iD

Chang Hoon Oh

Ethical Considerations

This study was performed in line with the principles of the Declaration of Helsinki. The approval was granted by the Institutional Review Board of Samsung Medical Center (approval no. SMC 2026-01-028-001).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Informed Consent

The requirement for informed consent was waived by the institutional review board due to the retrospective nature of the study.

Trial Registration

Not applicable (Retrospective study).

References

Huang

Chen

Hsieh

Cheng

WF.

Ruptured pseudoaneurysm of the external iliac artery in an advanced cervical cancer patient treated by endovascular covered stent placement. J Formos Med Assoc. 2008;107(4):348-351.

Ricciardi

Di Martino

Maniglio

, et al. Life-threatening bleeding after pelvic lymphadenectomy for cervical cancer: endovascular management of ruptured false aneurysm of the external iliac artery. World J Surg Oncol. 2012;10:149.

Chen

Shen

Ding

Life-threatening bleeding after pelvic exenteration for recurrent cervical cancer: endovascular management of ruptured external iliac artery pseudoaneurysm: a case report and literature review. Clin Exp Obstet Gynecol. 2022;49(11):252.

Hata

Satoh

Shin

, et al. Life-threatening rupture of an external iliac artery pseudoaneurysm caused by necrotizing fasciitis following laparoscopic radical cystectomy: a case report. BMC Res Notes. 2014;7:290.

de Baere

Ousehal

Kuoch

Sapoval

Lagrange

Roche

. Endovascular management of bleeding iliac artery pseudoaneurysms complicating radiation therapy for pelvic malignancies. AJR Am J Roentgenol. 1998;170(2):349-353.

Pisco

Martins

Correia

MG.

Internal iliac artery: embolization to control hemorrhage from pelvic neoplasms. Radiology. 1989;172(2):337-339.

Hare

Holland

CJ.

Paresis following internal iliac artery embolization. Radiology. 1983;146(1):47-51.

Venturini

Marra

Colombo

, et al. Endovascular repair of 40 visceral artery aneurysms and pseudoaneurysms with the Viabahn stent-graft: technical aspects, clinical outcome and mid-term patency. Cardiovasc Intervent Radiol. 2018;41(3):385-395.

Tulsyan

Kashyap

Greenberg

, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 2007;45(2):276-283; discussion283.

10.

Chang

Lirng

Luo

, et al. Carotid blowout syndrome in patients with head-and-neck cancers: reconstructive endovascular treatment with self-expandable stent-grafts. AJNR Am J Neuroradiol. 2008;29(6):1181-1185.

11.

Du Toit

Strauss

Blaszczyk

de Villiers

Warren

BL.

Endovascular treatment of penetrating thoracic outlet arterial injuries. Eur J Vasc Endovasc Surg. 2000;19(5):489-495.

12.

Bierdrager

Lohle

Schoemaker

Lampmann

van Berge Henegouwen

Hamming

JF.

Successful emergency stenting of acute ruptured false iliac aneurysm. Cardiovasc Intervent Radiol. 2002;25(1):72-73.

13.

Aytekin

Boyvat

Yildirim

Coşkun

Endovascular stent-graft placement as emergency treatment for ruptured iliac pseudoaneurysm. Cardiovasc Intervent Radiol. 2002;25(4):320-322.

14.

Nakase

Yahagi

Komiyama

, et al. Delayed rupture of the iliac artery after endovascular therapy. J Cardiol Cases. 2023;27(5):237-240.

15.

Al-Hawary

Francis

Chari

, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology. 2014;270(1):248-260.

16.

Loyer

David

Dubrow

Evans

Charnsangavej

Vascular involvement in pancreatic adenocarcinoma: surgical resectability versus CT diagnosis. AJR Am J Roentgenol. 1997;169(1):179-184.

17.

Miyake

Hori

Makiyama

Maruyama

Miyazaki

Fujisawa

Impact of extensive tumor necrosis on prognosis of patients with metastatic renal cell carcinoma treated with sorafenib. Hum Pathol. 2015;46(5):740-745.

18.

Gayer

Zissin

Apter

Papa

Hertz

Urachal anomalies: CT diagnosis of complications. Clin Radiol. 2002;57(9):822-830.

19.

Mwipatayi

Thomas

Wong

, et al. A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg. 2011;54(6):1561-1570.

20.

Grimme

Reijnen

MM.

The Covera stent graft for the treatment of an iatrogenic external iliac artery rupture. J Vasc Surg Cases Innov Tech. 2021;7(3):479-482.

21.

Wan

Lai

Lau

Wong

Poon

Tan

CB.

Endovascular treatment challenges of carotid blowout syndrome. Interv Neuroradiol. 2011;17(2):237-246.

22.

Dalainas

Nano

Stegher

Bianchi

Malacrida

Tealdi

DG.

Endovascular treatment of ruptured iliac aneurysm previously treated by endovascular means. Cardiovasc Intervent Radiol. 2008;31(2):394-397.

23.

Berkenheide

Janosi

Osswald

, et al. Mechanism of distal stent graft-induced new entry and its prevention. JVS-Vascular Insights. 2025;3:100265.

24.

Peach

Schep

Palfreeman

Beard

Thompson

Hinchliffe

RJ.

Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg. 2012;43(2):208-217.

25.

Lim

Kim

Yoon

, et al. Long-term clinical and radiologic outcomes after stent-graft placement for the treatment of late-onset post-pancreaticoduodenectomy arterial hemorrhage. J Korean Soc Radiol. 2022;83(6):1346-1355.

26.

Zhu

Zhao

Huang

Yuan

Yang

Ligation of the external iliac artery for the treatment of infected pseudoaneurysms in drug addicts: is it safe?

Ann Vasc Surg. 2013;27(8):1136-1140.