Endovascular treatment of a ruptured iliac aneurysm: case report

Abstracts

A taxa de mortalidade cirúrgica do aneurisma de ilíaca roto é similar à do aneurisma de aorta abdominal roto, devido à sua localização profunda na pelve, dificuldade de exposição distal da ilíaca decorrente do hematoma, bridas devido a laparotomia prévia e proximidade com ureter e estruturas venosas. O objetivo do presente estudo é enfatizar o procedimento endovascular como mais uma opção na correção dessas lesões. Relata-se o caso de um paciente de 60 anos de idade, submetido a derivação com enxerto aorto-biilíaco prévio com prótese há 5 anos, por aneurisma de aorta abdominal infra-renal, apresentando rotura de aneurisma em segmento remanescente da ilíaca comum esquerda. Estava hemodinamicamente estável após ressuscitação com fluidos e foi submetido ao tratamento endovascular de urgência, com a exclusão do aneurisma e ausência de vazamentos.

Aneurisma de ilíaca roto; tratamento endovascular de aneurisma; endoprótese

CASE REPORT

Endovascular treatment of a ruptured iliac aneurysm: case report

Adinaldo Adhemar Menezes da Silva^I; Luis Fernando Reis^I; Daniel Gustavo Miquelin^II; Priscilla Yukiko Sano^II; Vlanna Sales Pereira^III; José Maria Pereirade Godoy^IV

^I

^IIPhysician, Vascular Surgery and Angiology Service, FAMERP, São José do Rio Preto, SP, Brazil

^IIIResidents, Vascular Surgery and Angiology Service, FAMERP, São José do Rio Preto, SP, Brazil

^IVProfessor, Vascular Surgery and Angiology Service, FAMERP, São José do Rio Preto, SP, Brazil

^{Correspondence}

ABSTRACT

The surgical mortality rate of ruptured iliac aneurysms is similar to ruptured abdominal aortic aneurysms in terms of their location deep in the pelvis, difficult access to the distal iliac artery due to hematoma, adherences due to prior laparotomy and proximity of the ureter and venous structures. This study aims at highlighting the endovascular procedure as an alternative in the correction of this lesion. We report the case of a patient submitted to aortobiiliac prosthetic graft due to infrarenal abdominal aortic aneurysm 5 years ago, who presented with a ruptured aneurysm in the remaining segment of the left common iliac artery. The patient was hemodynamically stable after fluid replacement therapy and was submitted to urgent endovascular treatment. The treatment resulted in the exclusion of the aneurysm without endoleaks.

Keywords: Ruptured iliac aneurysm, endovascular treatment of aneurysms, endograft.

Introduction

Iliac artery aneurysms (IAA) are rare and represent 2–7% of aneurysms in the aortoiliac segment.^1,2

The occurrence of IAA after abdominal aortic aneurysm (AAA) repair is variable (0,6–1,2%), underestimated due to the difficulty of clinical detection, and related with postoperative follow–up time. Most series report new formation or progressions of the aneurysmal disease in around 4–4,5 years, most cases being above 5 years.³

Patients with IAA are frequently asymptomatic (around 50%) and generally detected in imaging examinations to evaluate other clinical conditions, such as urologic, gynecologic and gastrointestinal disorders. Clinically, they may occur with symptoms related to compression of neighboring structures, generating unspecific symptoms common to other diseases. The most feared complication – and often the only form of disease presentation – is the rupture of the aneurysmal sac. The frequency of this complication varies, and the elective repair of these aneurysms is recommended when they reach 3 cm, in the absence of other severe diseases or high surgical risk.³

The mortality rate associated with the surgical treatment of ruptured IAA is around 33%, similar to the rate of ruptured AAA. IAA present technical particularities in their surgical approach, which make them more difficult to be repaired than AAA: deep location in the pelvis, proximity with ureter, intimate relation with veins and difficult exposure of distal branches, especially in the presence of rupture with bleeding and adherences due to previous laparotomy.^1–3

The emergency endovascular treatment of ruptured aortoiliac aneurysms is a therapeutic option being investigated and that has shown satisfactory results. These findings can be related to the less invasive condition of the method, since laparotomy is avoided, reducing the intraoperative bleeding and the use of local anesthesia.^4–6

Case report

A 60–year–old, Caucasian, male patient with no previous follow–up in our service. He presented sudden abdominal pain in the mesogastrium and lower left quadrant (4 hours of evolution) associated with signs of hypovolemic shock. An abdominal ultrasonography, performed at the first service and referred with the patient, showed fluid collection around the vascular graft used in a previous surgery and hypothesis of graft rupture. At the emergency sector, during his admission, 1,000 mLcrystalloid solution and a unit of concentrated red cells were infused. The patient improved in terms of hemodynamic instability, maintaining pain and pulsatile mass on palpation on the left hypogastric and mesogastric regions. He presented other antecedents, such as infrarenal AAA repair 5 years ago, with common aortobiiliac graft, and there was iliac dilatation below the anastomosis, chronic renal failure during hemodialysis and ischemic stroke 2 years ago. Emergency computed tomography (CT) showed patent aortobiiliac graft and aneurysm with signs of rupture in a remaining segment of the left common iliac artery (Figure 1). Due to the presence of comorbid conditions and fragile health status, the endovascular treatment was chosen. The patient was referred to the hemodynamic sector, where angiography showed presence of left common IAA with extravasation of the contrast agent filling the whole cavity of the recently formed pseudoaneurysm (Figure 2A).

The patient started presenting mental confusion and agitation, requiring general anesthesia. The left common femoral artery was surgically accessed using transverse arteriotomy and three stent–grafts were sequentially implanted (one 14/12 x 80 mm and two 12/12 x 60 mm – Braile Biomédica^®). The first stent–graft was anchored in the left branch of the previously existing Dacron graft, which migrated. A second stent–graft was placed between the left branch of the Dacron graft and the first stent–graft. The third module was installed until reaching a good segment of the external iliac artery, excluding the aneurysm due to complete absence of endoleaks (Figure 2B). The patient was sent to the intensive care unit and, during his evolution, presented difficulty for extubation, due to exacerbation of the swallowing disorder that already existed and was caused by the stroke, being successfully submitted to tracheostomy at the 15th postoperative day (POD) and weaning from respirator. On the 19th POD, the patient presented melena due to upper digestive hemorrhage (UDH) as a result of duodenal ulcer (Forrest IIB), and a clinical treatment was started. Tomographic control of stent–grafts at the 40th POD showed good placement and absence of endoleaks, with marked reduction in the hematoma (Figure 3). At the 49th POD, the patients died due to recurrent UDH.

Discussion

The present case reports the possibility of endovascular treatment of the ruptured IAA in a patient who remained hemodynamically stable and with favorable anatomy to the placement of a stent–graft. The presence of a previous laparotomy, associated with pelvic hematoma, reinforced this indication, since the present clinical conditions offered a high risk for conventional surgery. General anesthesia was used, because the patient was in an agitated state, which made local anesthesia impossible.

The standard treatment for ruptured aortoiliac aneurysms is laparotomy with aortic graft under general anesthesia.⁴ Some studies show the advantages of the endovascular treatment of ruptured aortoiliac aneurysms compared to conventional surgery, since it avoids laparotomy, can be performed under local or locoregional anesthesia, reduces blood loss, maintains the integrity of the abdominal wall and reduces morbidity and mortality resulting from iatrogenic lesions caused by the exploration of the retroperitoneal hematoma and distorted anatomy. The patients submitted to the endovascular treatment of ruptured aneurysm described in other series presented hemodynamic stability after fluid replacement therapy to perform CT, high surgical risk or hostile abdomen (obese, previous abdominal surgery, abdominal neoplasia).^1,4,5,7–9

Some factors limit the emergency endovascular treatment, such as the need of preoperative tomography, difficulty in obtaining stent–grafts with proper measures for each patient and more time for complete sealing of the aneurysm, when compared with the time for aortic clamping during the surgery. This latter limiting factor has been reduced with the use of balloon via percutaneous puncture of the femoral or axillary artery, promoting aortic occlusion until the stent–graft implantation.^4–6

The elective endovascular treatment of the iliac aneurysm has presented good outcome,¹⁰ and it has been increasingly more accepted as a choice of treatment. We believe this modality of treatment can be used in emergency situations, since a flowchart is created, providing fast tomographic examination, specialized medical team, adequate and available material resources in the sector and judicious evaluation of the patient's hemodynamic status.¹⁰ The follow–up of these patients is crucial, with the aim of identifying clinical events and interfering whenever necessary.¹⁰

References

Manuscript received May 13, 2006, accepted January 1, 2007.

• 1. Ricci MA, Najarian K, Healey CT. Successful endovascular treatment of a ruptured internal iliac aneurysm. J Vasc Surg. 2002;35:1274-6.
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• 3. Dosluoglu HH, Dryjski ML, Harris LM. Isolated iliac artery aneurysms in patients with or without previous abdominal aortic aneurysm repair. Am J Surg. 1999;178:129-32.
• 4. Hechelhammer L, Lachat ML, Wildermuth S, Bettex D, Mayer D, Pfammatter T. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 2005;41:752-7.
• 5. Ohki T, Veith FJ, Sanchez LA, et al. Endovascular graft repair of ruptured aortoiliac aneurysms. J Am Coll Surg. 1999;189:102-12; discussion 112-3.
• 6. Ohki T, Veith FJ. Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms. Ann Surg. 2000;232:466-79.
• 7. Bierdrager E, Lohle PN, Schoemaker CM, Lampmann LE, van Berge Henegouwen DP, Hamming JF. Successful emergency stenting of acute ruptured false iliac aneurysm. Cardiovasc Intervent Radiol. 2002;25:72-3.
• 8. Williamson AE, Annunziata G, Cone LA, Smith J. Endovascular repair of a ruptured abdominal aortic and iliac artery aneurysm with an acute iliocaval fistula secondary to lymphoma. Ann Vasc Surg. 2002;16:145-9.
• 9. Lee WA, Hirneise CM, Tayyarah M, Huber TS, Seeger JM. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg. 2004;40:211-5.
• 10. Sahgal A, Veith FJ, Lipsitz E, et al. Diameter changes in isolated iliac artery aneurysms 1 to 6 years after endovascular graft repair. J Vasc Surg. 2001;33:289-94; discussion 294-5.

Publication Dates

• Publication in this collection
  19 July 2007
• Date of issue
  Mar 2007

History

• Received
  13 May 2006
• Accepted
  01 Jan 2007