Ruptured internal iliac artery aneurysm: case report

Afonso, Cristina Toledo; Procópio, Ricardo Jayme; Navarro, Túlio Pinho; Kleinsorge, Gustavo Henrique Dumont; Rodrigues, Beatriz Deoti e Silva; Rodrigues, Marco Antônio Gonçalves

doi:10.1590/S1677-54492009005000006

Abstracts

Isolated internal iliac artery aneurysms are rare. They affect 0.1% of the population, and account for 1% of aortoiliac aneurysms. Patients are mostly asymptomatic, yet they can have abdominal pain, pulsatile mass in the hypogastrium or iliac fossa, or urinary, gastrointestinal or neurological compressive symptoms. Such aneurysms are likely to course with an acute abdomen, especially when ruptured. Early diagnosis of isolated internal iliac artery aneurysms is difficult, as they are more easily detected when larger or ruptured, which significantly raises their morbidity and mortality rate and determines a poor prognosis. Therefore, they are a therapeutic challenge. Surgical ligation has been the most common treatment; however, the endovascular approach has presented good outcomes, even in the event of ruptured aneurysms. A case of ruptured isolated iliac artery aneurysm diagnosed during a laparotomy (acute abdomen approach) is reported.

Ruptured aneurysm; iliac artery; acute abdomen

Aneurismas isolados da artéria ilíaca interna são raros, acometem 0,1% da população e correspondem a 1% dos aneurismas aorto-ilíacos. Na maioria das vezes, os pacientes são assintomáticos, mas podem apresentar dor abdominal, massa pulsátil no hipogástrio ou na fossa ilíaca, sintomas compressivos urinários, gastrointestinais ou neurológicos. Podem ocasionar quadro de abdome agudo, principalmente quando há ruptura. O diagnóstico precoce dos aneurismas isolados de artéria ilíaca interna é incomum, sendo identificados quando mais volumosos ou rotos, o que aumenta significativamente sua morbimortalidade e torna seu prognóstico mais reservado. Dessa forma, representam um desafio terapêutico. A ligadura cirúrgica tem sido o tratamento mais comum, entretanto a cirurgia endovascular tem mostrado bons resultados, inclusive nos aneurismas rotos. É relatado caso de aneurisma de artéria ilíaca interna isolado roto diagnosticado durante laparotomia para abordagem de abdome agudo.

Aneurisma roto; artéria ilíaca; abdome agudo

CASE REPORT

^I

^IICoordinator, Department of Endovascular Surgery, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil

^IIICoordinator, Department of Vascular Surgery, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil

^IVResident, Vascular Surgery, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil

^VMSc., Surgery, UFMG, Belo Horizonte, MG, Brazil. Member, Emergency and Proctology Group, Instituto Alfa de Gastroenterologia, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil

^VIProfessor, Department of Surgery, Faculdade de Medicina, UFMG, Belo Horizonte, MG, Brazil

Correspondence

ABSTRACT

Isolated internal iliac artery aneurysms are rare. They affect 0.1% of the population, and account for 1% of aortoiliac aneurysms. Patients are mostly asymptomatic, yet they can present with abdominal pain, pulsatile mass in the hypogastrium or iliac fossa, or urinary, gastrointestinal or neurological compressive symptoms. Such aneurysms can present as an acute abdomen, especially when ruptured. Early diagnosis of isolated internal iliac artery aneurysms is difficult, as they are more easily detected when larger or ruptured, which significantly increases their morbidity and mortality rates and determines a poor prognosis. Therefore, they are a therapeutic challenge. Surgical ligation has been the most common treatment; however, the endovascular approach has presented good outcomes, even in ruptured aneurysms. A case of ruptured isolated iliac artery aneurysm diagnosed during a laparotomy for acute abdomen is reported.

Keywords: Ruptured aneurysm, iliac artery, acute abdomen.

Introduction

Isolated internal iliac artery aneurysms are rare, severe and hard to be diagnosed. They affect about 0.1% of the general population and account for approximately 1% of aortoiliac aneurysms.^1-3 The common iliac artery is the most frequently affected (85%), followed by the internal iliac artery (10%) and the external iliac artery (1%).⁴ This type of aneurysm is more frequent in men and elderly individuals (mean 69 years).^2-4 Approximately 50% are bilateral aneurysms.⁵

They are mostly asymptomatic and are frequently ruptured in manifested cases.⁶ When symptomatic, signs and symptoms depend on size, location and relation with adjacent structures.

Case report

A 67-year old male patients was admitted with sudden abdominal pain, reported in the lumbar region and right iliac fossa, associated with dysuria and constipation for 24 hours. He had preserved general status, hemodynamic stability, oliguria, reduced peristalsis and palpable suprapubic hard mass. The patient is a smoker, hypertensive and was submitted to coronary stent angioplasty 2 years ago.

Laboratory tests showed hemoglobin of 11.3 g/dL and leukocytes of 14,500/mm.³ Abdominal x-ray showed intestinal dilatation with no air-fluid levels and sigmoidoscopy showed signs of mucosal ischemia. Relief urinary catheterization was performed without advancing the catheter. The patient progressed with worsening of pain, increased mass, hypotension and shock. He was sent to the surgical room with suspicion of sigmoid volvulus.

Laparotomy showed extensive hematoma infiltrating through the bladder, retroperitoneum and anterior musculature of the abdominal wall. Proximal aortic control and exploration of the aortoiliac axis were performed. A ruptured right internal iliac artery aneurysm was identified, measuring 5 cm in diameter, with anterior ureter detachment and compression of bladder and rectum, without other aneurysmal formations. The aneurysmal sac was then opened and ligated to its proximal and distal origins (Figures 1 and 2). Red cell concentrate (900 mL) and plasma (600 mL) were transfused. The patient was sent to the intensive care unit, where he progressed with clinical stability. He was discharged to the ward on the sixth postoperative day, and hospital discharge occurred on the ninth postoperative day. He has been under outpatient control for 4 months, is asymptomatic and in good clinical conditions.

Discussion

Isolated iliac artery aneurysms have diagnostic and therapeutic challenges. The most common etiologic factor is a degenerative process of the vascular wall mainly associated with atherosclerosis.⁴ Other causes include infection, trauma, iatrogenesis, vasculitis, collagen diseases, and pregnancy. They can be clinically manifested by pulsatile mass, abdominal and/or lumbar-sacral pain, urinary, gastrointestinal or neurological symptoms, in addition to thromboembolic phenomena.⁶ Pulsatile palpable mass in the iliac fossa or at vaginal and rectal exam is found in 55% of cases.² Pain can be either acute, due to expansion or rupture, or chronic, due to compression of nerves and viscera.^7,8 Compression of ureters and bladder may trigger urinary symptoms (54% of cases).^9-11 Intestinal loops can suffer compression, leading to constipation, tenesmus, pain at rectal exam and rectal bleeding.^12,13 Deep venous thrombosis and pulmonary embolism may result from compression of the iliac-femoral system.^14,15

However, in most cases, such patients are asymptomatic until rupture. Clinically, the classical triad of abdominal aneurysm rupture, comprised of acute and progressive pain, hypotension and pulsatile mass, is present in 38-51% of patients. Rupture can be retroperitoneal or intraperitoneal, but also for rectum, ureter or bladder.^16,17 When there is rupture, the mortality rate in emergency surgeries ranges between 50 and 100%, which is significantly higher when compared with the rate of elective surgeries, usually lower than 10%.¹⁸ The patient in this case report had intensive pain associated with compressive symptoms of pelvic structures, signaling to ruptured internal iliac artery aneurysm. Pelvic hematoma explains dysuria, oliguria, constipation, distension and signs of intestinal loop impairment.

Diagnosis of isolated aneurysms of the internal iliac artery, due to their deep location in the pelvis, is hardly performed in an early period. They are usually found incidentally during surgeries, periodic examinations, investigations of other conditions or autopsy.

Abdominal and pelvic ultrasound is useful in the diagnosis, screening and follow-up of patients.⁶ Angiographic tomography has been the gold standard for the diagnosis of such aneurysm.^19,20 It is able to determine location, size, tortuosity, aneurysm pathway, relation with adjacent organs, signs of rupture and retroperitoneal hemorrhage.²¹ Angiographic resonance is an exception method used in patients that cannot receive iodinated contrast medium. Nowadays, angiography is only performed when the other methods are not available.

Iliac aneurysm diameter influences indication of intervention: those with diameters lower than 3 cm can be treated conservatively; intervention is indicated for symptomatic patients and/or for those that had aneurysm in expansion or with diameter higher than 3 cm.^22,23

Treatment of isolated internal iliac artery aneurysms is a challenge due to their topography in the pelvis, large size at diagnosis and risks offered by proximity with important adjacent structures. Surgical ligation has been the most widely used method. The endovascular treatment has also been used for iliac aneurysms, including isolated internal iliac aneurysms.

Aneurysm ligation can only be proximal or combined with distal ligation, as in the reported case. Proximal ligation has lower risk of bleeding for being fast. However, risk of rupture may persist due to maintenance of retrograde intra-aneurysmal flow through the artery or collateral distal bleeding, and not solve compressive symptoms.²⁴ For that reason, combined ligation is the treatment of choice for most patients.

Resection is a little used technique due to fibrosis around the aneurysm, with increased risk of hemorrhage or damage to neighboring structures, especially ureter and iliac veins, which are frequently adhered to its wall.⁶ Therefore, circumferential dissection of iliac arteries should be avoided with the aim of minimizing such complications.²⁵

Use of endovascular surgery has increased because it has advantages, such as enabling access to the femoral artery by percutaneous puncture, in addition to result in lower traumas, hemorrhages, need of blood derivates and hospital stay.²⁶ Moreover, such surgery is not influenced by resection difficulties, such as in obese patients and in hostile abdomen. Some studies compared endovascular and conventional treatment and showed similar results, with good outcomes in ruptured aneurysms.^27-30

There is no consensus in the literature about how to proceed in cases of bilateral aneurysms of the internal iliac artery.^31,32 However, preservation of at least one artery is recommended by most authors, since sexual impotence, colonic, vesical and pelvic muscle ischemia are common complications associated with bilateral ligation of such arteries. Surgical repair using graft interposition is the most adequate therapeutic modality in such circumstances.^25,33

Conclusion

Internal iliac artery aneurysms are rare and, when ruptured, may be associated with acute abdomen. They have high morbidity and mortality rates and prognosis is quite reserved, particularly in cases of rupture. Surgical vessel ligation, in these situations, is the most widely used technique to stop hemorrhage and treat the aneurysm, avoiding extensive dissections and reducing surgical time.

References

1. Olsen PS, Schroeder T, Agerskov K, et al. Surgery for abdominal aortic aneurysms. A survey of 656 patients. J Cardiovasc Surg. 1991;32:636-42.
2. Richardson JW, Greenfield LJ. Natural history and management of iliac aneurysms. J Vasc Surg. 1988;8:165-71.
3. Schuler JJ, Flanigan DP. Iliac artery aneurysms. In: Bergan JJ, Yao JST, editors. Aneurysms, diagnosis and treatment. New York: Grune & Stratton; 1982. p. 469-85.
4. McCready RA, Pairolero PC, Gilmore JC, Kazmier FJ, Cherry KJ, Hollier LH. Isolated iliac artery aneurysms. Surgery. 1983;93:688-93.
5. Krupski WC, Selzman CH, Floridia R, Strecker PK, Nehler MR, Whitehill TA. Contemporary management of isolated iliac aneurysms. J Vasc Surg. 1998;28:1-11.
6. Dix FP, Titi M, Al-Khaffaf H. The isolated internal iliac artery aneurysm: a review. Eur J Vasc Endovasc Surg. 2005;30:119-29.
7. Chapman EM, Shaw RS, Kubik CS. Sciatic pain from arteriosclerotic aneurysm of pelvic arteries. N Engl J Med. 1964;271:1410-1.
8. Wider C, Kuntzer T, Von Segesser LK, Qanadli SD, Bogousslavsky J, Vingerhoets F. Bilateral compressive lumbosacral plexopathy due to internal iliac artery aneurysms. J Neurol. 2006;253:809-10.
9. Honma I, Takagi Y, Shigyo M, Sunaoshi K, Inaoka M, Miyao N. Massive hematuria after cystoscopy in a patient with an internal iliac artery aneurysm. Int J Urol. 2002;9:407-9.
10. Mineta K, Nomura M, Fujimoto N, Takahashi K, Matsumoto T. Ureteral obstruction due to retroperitoneal fibrosis secondary to a solitary internal iliac aneurysm. Int J Urol. 2004;11:1024-27.
11. O'Driscoll D, Fitzgerald E. Isolated iliac artery aneurysms with associated hydronephrosis. J R Coll Surg Edinb. 1999;44:197-9.
12. Wu C, Nguyen BD, Regan F. An internal iliac artery aneurysm masquerading as a rectal mass. Clin Radiol. 2000;55:319-20.
13. Ozergin U, Vatansev C, Durgut K, Ozulku M, Gormus N. An internal iliac artery aneurysm causing a colonic obstruction: report of a case. Surg Today. 2001;31:839-41.
14. Rosenthal D, Matsuura JH, Jerius H, Clark MD. Iliofemoral venous thrombosis caused by compression of an internal iliac artery aneurysm: a minimally invasive treatment. J Endovasc Surg. 1998;5:142-5.
15. Su WT, Goldman KA, Riles TS, Rosen R. Deep venous thrombosis with pulmonary embolus after selective embolization of an internal iliac artery aneurysm. J Vasc Surg. 1996;23:152-5.
16. Jackman RJ, McGuarrie HB, Edwards JE. Fatal hemorrhage caused by aneurysm of the internal iliac artery: report of a case. Proc Mayo Clinic. 1948;23:305.
17. De Donato G, Neri E, Baldi I, Setacci C. Rupture of internal iliac artery aneurysm presenting as rectus sheath hematoma: case report. J Vasc Surg. 2004;39:250-3.
18. Boyarsky AH, Burks WP, Davidson JT, Chandler JJ. Ruptured aneurysm of the internal iliac artery. South Med J. 1985;78:1356-7.
19. Raptopoulos V, Rosen MP, Kent KC, Kuestner LM, Sheiman RG, Pearlman JD. Sequential helical CT angiography of aortoiliac disease. AJR Am J Roentgenol. 1996;166:1347-54.
20. Rieker O, Duber C, Neufang A, Pitton M, Schweden F, Thelen M. CT angiography versus intraarterial digital subtraction angiography for assessment of aortoiliac occlusive disease. AJR Am J Roentgenol. 1997;169:1133-8.
21. Todd GJ, Nowygrod R, Benvenisty A, Buda J, Reemtsma K. The accuracy of CT scanning in the diagnosis of abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg. 1991;13:302-10.
22. Santilli SM, Wernsing SE, Lee ES. Expansion rates and outcomes for iliac artery aneurysms. J Vasc Surg. 2000;31:114-21.
23. Owen RJ, Jackson R, Loose HW, Lees TA, Dunlop P, Rose JD. Percutaneous ablation of an internal iliac aneurysm using tissue adhesive. Cardiovasc Intervent Radiol. 2000;23:389-91.
24. Ruurda JP, Rijbroek A, Vermeulen EG, Wisselink W, Rauwerda JA. Continuing expansion of internal iliac artery aneurysms after surgical exclusion of the inflow. A report of two cases. J Cardiovasc Surg. 2001;42:389-92.
25. Carvalho ATY, Prado V, Neto HJG, Caffaro RA. Aspectos cirúrgicos dos aneurismas isolados das artérias ilíacas. J Vasc Bras. 2006;5:203-8.
26. Chaer RA, Barbato JE, Lin SC, Zenati M, Kent KC, McKinsey JF. Isolated iliac artery aneurysms: a contemporary comparison of endovascular and open repair. J Vasc Surg. 2008;47:708-13.
27. Van Kelckhoven BJ, Bruijninckx BM, Knippenberg B, Van Overhagen H. Ruptured internal iliac artery aneurysm: staged emergency endovascular treatment in the interventional radiology suite. Cardiovasc Intervent Radiol. 2007;30:774-7.
28. Ricci MA, Najarian K, Healey CT. Successful endovascular treatment of a ruptured internal iliac aneurysm. J Vasc Surg. 2002;35:1274-6.
29. Silva AAM, Reis LF, Miquelin DG, Sano PY, Pereira VS, Godoy JMP. Tratamento endovascular de aneurisma de ilíaca roto: relato de caso. J Vasc Bras. 2007;6:78-81.
30. Lobato AC, Almeida FHM. Aneurismas periféricos: tratamento endovascular. In: Brito CJ, Duque AC, Merlo I, Silva RM, Filho VLF, organizadores. Cirurgia vascular, cirurgia endovascular e angiologia. 2Ş ed. Rio de Janeiro: Revinter; 2008. p. 1339-50.
31. Karch LA, Hodgson KJ, Mattos MA, Bohannon WT, Ramsey DE, McLafferty RB. Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2000;32:676-83.
32. Bratby MJ, Munneke GM, Belli AM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR? Cardiovasc Intervent Radiol. 2008;31:246-53.
33. Faries PL, Morrissey N, Burks JA, et al. Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms. J Vasc Surg. 2001;34:892-9.