Transradial emergency covered stent placement for iatrogenic iliac artery rupture during mechanical circulatory support

Iatrogenic iliac artery rupture is a rare but life-threatening complication of large-bore access. We report a successful bailout strategy using transradial covered stent implantation when femoral access was unavailable. A man in his 70s with non–ST-segment elevation myocardial infarction underwent percutaneous coronary intervention via the right radial artery with intra-aortic balloon pump support through the right femoral artery. Because of worsening hemodynamics, extracorporeal membrane oxygenation was initiated through the left femoral artery. During exchange of the intra-aortic balloon pump for an Impella sheath, active extravasation occurred from the right iliac artery. Attempts to recross the rupture site with a guidewire from the femoral side failed, and surgery was considered unfeasible because of ongoing bleeding and instability. Via the existing radial access, a 6 Fr, 110 cm guiding sheath and a 135 cm delivery system were used to deploy a 7.0 × 59 mm balloon-expandable covered stent from the distal external iliac artery to the proximal common femoral artery. Hemostasis was achieved, and the patient recovered without further vascular complications. Learning objectives This case highlights transradial covered stent implantation using long-shaft devices as a bailout strategy for iatrogenic iliac artery rupture when femoral access is unavailable. It emphasizes the importance of alternative access planning, device compatibility, and endovascular troubleshooting in life-threatening large-bore access complications.