Delayed Rupture of an Internal Iliac Artery Aneurysm Following Proximal Ligation for Abdominal Aortic Aneurysm Repair Baskhar Deb, MD, Marshall Benjamin, MD, Anthony J. Comerota, MD, Philadelphia, Pennsylvania
This is a report of a patient presenting with a contained rupture of an internal lilac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the Internal lilac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal lilac artery aneurysms is emphasized by this case. (Ann VascSurg 1992;6:537-540). KEY WORDS:
Aneurysm; lilac artery aneurysm; abdominal aortic aneurysm.
Although the incidence of iliac artery aneurysm is low, ranging from 0.3% to 2.2% [I,2], rupture of these aneurysms is associated with mortality rates ranging from 29 to 80% [3,4]. The operative management of iliac artery aneurysms has varied from ligation and resection, to endoaneurysmorraphy with graft interposition [2]. In 1913, MacLaren became the first surgeon to successfully treat a symptomatic internal iliac artery aneurysm by ligation [5]. However, simple proximal ligation of the internal iliac artery aneurysm has been associated with recurrence and persistence of the aneurysm [6]. The practice of simple proximal ligation of an internal iliac aneurysm is occasionally performed during resection of an associated abdominal aortic aneurysm and/or common iliac artery aneurysm. Simple proximal ligation fails to control the distal
From the Section of Vascular Surgery, Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania. Reprint requests: Anthony J. Comerota, MD, FACS, Section of Vascular Surgery, Temple University Hospital, Broad and Ontario Streets, Philadelphia, Pennsylvania 19140.
branches of the aneurysm and may do little to reduce the luminal pressure, and therefore elevated wall tension persists. We present a recent case of a ruptured internal iliac artery aneurysm three years following simple proximal ligation at the time of abdominal aortic aneurysm repair.
CASE REPORT A 76-year-old man was referred to the Vascular Surgery Service with abdominal pain, syncope, anemia and a large pelvic mass. An iliac artery aneurysm, thought to be either a right internal iliac artery aneurysm or right iliac pseudoaneurysm was suspected. Three years prior to admission the patient had a resection of an abdominal aortic aneurysm and proximal ligation of the right internal iliac artery aneurysm (Fig. 1). An aortic bifurcation graft was inserted with a fight external iliac end-to-end anastomosis and a left common iliac end-to-end anastomosis (Fig. 2). Approximately one month prior to admission the patient developed symptoms of urgency, frequency, dysuria, tenesmus and fever. The patient also developed intermittent lightheadedness, weakness and general malaise. There was constant pelvic pain with occasional pain
537
538
DELAYED R U P T U R E OF I N T E R N A L ILIAC ARTER Y A N E U R YSM
ANNALS o r VASCULAR SURGERY
) Fig. 1. Initial arteriogram for evaluation of abdominal aortic aneurysm, demonstrating incidental 3.5 cm aneurysm of right internal lilac artery (arrow). in the distribution of the right sciatic nerve. A computed tomographic (CT) scan of the abdomen and pelvis revealed a large pelvic mass, thought to be a right internal iliac artery aneurysm, measuring 11 cm in diameter with a lamellar appearance and displacement of the urinary bladder (Fig. 3). Blood cultures were negative. An intravenous urogram demonstrated displacement and dilation of the right ureter. The patient had no symptoms of vomiting, melena, or rectal bleeding. The patient's current medical problems included coronary artery disease and hypertension. On admission the patient's temperature was 37°C, blood pressure was 150/90, pulse rate was 96 per minute and respirations, 18 per minute. Pertinent physical findings included an irregular heart rhythm with a grade III/VI systolic ejection murmur and a soft right cervical bruit. There were normal bowel sounds without abdominal bruits. The patient had mild suprapubic tenderness with a fullness in the lower abdomen. Rectal examination revealed a large anterior mass without pulsation, and the stool failed to show evidence of occult blood. The femoral pulses were normal with slightly diminished popliteal and distal pulses. Laboratory values included a hemoglobin of 8.6 grams, hematocrit of 26.5 and a WBC of 7,900. The BUN was 22 and the creatinine 1.8. Urinalysis was within normal limits as were coagulation parameters. An aortogram was performed, which demonstrated a patent aortobiiliac bifurcation graft without any evidence of pseudoaneurysm or contrast extravasation (Fig. 2). The left iliac arteries were ectatic and there was no
Fig. 2. Preoperative aortogram demonstrating patent aortic bifurcation graft, right limb anastomosed to external lilac artery, and left limb anastomosed to ectatic common lilac artery. No pseudoaneurysm is appreciated on delayed views.
opacification of the large pelvic mass. Arterial duplex examination had weak signals within the mass but failed to show communication with either iliac artery or the aortic graft. The patient was admitted to the surgical intensive care unit for hemodynamic optimization prior to his operative procedure. Exploratory laparotomy revealed an intact infrarenal aortic graft. A large pelvic mass arose adjacent to the right limb of the graft but did not communicate with it. There was no evidence of a pseudoaneurysm. Following complete mobilization and control of the aortic graft proximally and distally, the pelvic mass was punctured with an 18 gauge needle and dark blood was aspirated. The wall of the mass was then incised, and the contents were found to be thrombus and old blood. Following evacuation of the clot, brisk arterial bleeding from the pelvic branches of the right internal iliac artery was observed from the remnants of the arterial wall. Therefore the mass was deemed to be a large, contained rupture of the right internal iliac aneurysm. Bleeding was controlled with direct suture ligation. Since a large pelvic defect was present and since the graft was completely exposed, the greater omentum was mobilized from the greater curvature of the stomach to cover the graft and fill the large pelvic cavity. The patient's postoperative course was unremarkable, and he was discharged on the seventh postoperative day tree from his presenting symptoms. He has remained well during the three years of follow-up since his operation.
VOLUME 6 N o 6 - 1992
D E L A Y E D R U P T U R E OF I N T E R N A L ILIAC A R T E R Y A N E U R Y S M
Fig. 3. Preoperative CT scan demonstrating large pelvic mass without evidence of communication to other vascular structures, consistent with diagnosis of contained rupture of right internal iUac aneurysm.
DISCUSSION Aneurysms of the internal iliac arteries are most commonly associated with aortoiliac aneurysms. The frequency of iliac artery aneurysms which are not associated with abdominal aortic aneurysms in one series was reported to be 0.9% [7], and the frequency of isolated internal iliac artery aneurysms was I in 12,000 postmortem examinations. The diagnosis and treatment of iliac artery aneurysm is complicated by their location. Since they are located deep in the pelvis, they escape detection on physical examination. Most will remain asymptomatic until they are large and exert pressure on adjacent structures or until rupture occurs [7]. The natural history of aortic aneurysms is to expand and eventually rupture, with the size of the aneurysm correlating directly with the risk of rupture. It has been difficult to correlate the size of iliac artery aneurysms with the risk of rupture, most likely due to the small numbers reported. It is intuitively accepted that the risk of rupture of internal iliac artery aneurysms is related to their size relative to the normal diameter of the internal iliac artery. Case reports of rupture of aneurysms 2 cm in diameter exist [8-11], and several authors recommend repair of an internal iliac aneurysm if it is greater than 3 cm in diameter [2,6]. The principles of repair include proximal and distal ligation of the aneurysm, removal of the laminated clot from the aneurysm sac, and oversewing of the ostia of the feeding branches from within [5]. Failure to achieve both proximal and distal ligation of an aneurysm may be associated with significant morbidity and mortality. This principle is well demonstrated by subsequent rupture of abdominal aortic aneurysms in several cases treated only by proximal ligation. In 1965 Blaisdell and associates
539
[12] described a method to reduce operative mortality in high-risk patients with abdominal aortic aneurysms, using an axillofemoral bypass followed by ligation of the neck of the aneurysm and ligation of the iliac arteries. Since then, Berguer [13], Leather [14], and Savarese [15] have described variations of this technique. The latter two employ iliac artery ligation and axillobifemoral bypass. Several cases of rupture of the aneurysm following similar techniques have been reported [16--19]. These have drawn attention to the importance of collaterals which provide continued potential flow but most importantly sustained pressure to the ligated aneurysm, thereby maintaining high wall tension. Exclusion of aneurysms by proximal and distal ligation and obliterating all sources of collateral inflow insures the most complete control [18] and is the prevailing principle in the treatment of aneurysmal disease. Unfortunately, these principles are occasionally breached, especially in the treatment of internal iliac artery aneurysms associated with aneurysms of the abdominal aorta or common iliac arteries, as demonstrated by this case. Distal ligation of internal iliac artery aneurysms may be difficult if not hazardous, due to their location and the surrounding pelvic venous structures. In such cases, proximal ligation with obliterative aneurysmorraphy is a reasonable technical alternative. Partial circumferential exposure followed by ptedgeted suture obliteration will achieve luminal control. This case illustrates the consequences of not obtaining complete control and obliteration of internal iliac artery aneurysms and highlights the potential complications when distal control and/or luminal obliteration are not obtained during the first operation. REFERENCES 1. LOWRY SF, KRAFT RO. Isolated aneurysms of the iliac system. Arch Surg 1978;113:128%1293. 2. RICHARDSON JW, G R E E N F I E L D LJ. Natural history and management of iliac aneurysms. J Vasc Surg 1988;8: 165-171. 3. K U S U L K E RJ, CLIFFORD A, NICHOLS WK, et al. Isolated atherosclerotic aneurysms of the internal iliac artery. Arch Surg 1982;117:73-77. 4. WIRTHLIN LS, WARSHAW AL. Ruptured aneurysm of the hypogastric artery. Surge~ 1973;73:629--633. 5. MACLAREN A. Aneurysm of the internal iliac, probably immediately following a severe instrumental delivery. Ann Surg 1913;58:269-270. 6. BRIN BJ, BUSUTTIL RW. Isolated hypogastric artery aneurysms. Arch Surg 1982;117:1329-1333. 7. McCREADY RA, PAIROLERO PC, GILMORE JC, et al. Isolated iliac artery aneurysms. Surgery 1983;93:688-693. 8. LUCKE B, REA MH. Studies on aneurysm. I. General statistical data on aneurysms. JAMA 1921 ;77:935-940. 9. PURDUE GD, MITTENHAL MJ, SMITH RB, et al. Aneurysms of the internal iliac artery. Surgery 1983;93:243-246. 10. Case records of MGH 15-1967. NEngIJ Med 1967;276:800-807.
540
DELAYED RUPTURE OF INTERNAL ILIA C ARTERY ANEUR YSM
11. Case records of MGH 3-1978. N Engl J Med 1978;298:208-213. 12. BLAISDELL FW, H A L L AD, THOMAS AN. Ligation treatment of an abdominal aortic aneurysm. Am J Surg 1965;109:560-565. 13. BERGUER R, SCHNEIDER J, W l L N E R HI. Induced thrombosis of inoperable abdominal aortic aneurysm. Surgery 1978;84:425-429. 14. LEATHER RP, SHAH D, GOLDMAN M, et al. Nonresecrive treatment of abdominal aortic aneurysms. Arch Surg 1979;114:1402-1408. 15. SAVARESE RP, ROSENFELD JC, DELAURENTIS DA. Alternatives in the treatment of abdominal aortic aneurysms. Am J Surg 1981;142:226-230. 16. CHO SI, JOHNSON WC, BUSH HS, et al. Lethal compli-
mum
17. 18. 19. 20.
ANNALS OF VASCULAR SURGERY
cations associated with nonresective treatment of abdominal aortic aneurysms. Arch Surg 1982;117:t214-1217. KARMODY AM, LEATHER RP, GOLDMAN M, et al. The current position of nonresective treatment for abdominal aortic aneurysm. Surgery 1983;94:591-597. KWAAN JHM, DAHL RK. Fatal rupture after successful surgical thrombosis of an abdominal aortic aneurysm. Surgery 1984;95:235-237. SCHANZER H, PAPA MC, MILLER CM. Rupture of surgically thrombosed abdominal aortic aneurysm. J Vasc Surg 1985;2:278-280. KWAAN JHM, KHAN RJ, CONNOLLY JE. Total exclusion technique for the management of abdominal aortic aneurysms. Am J Surg 1983;146:93-97.
This is a report of a patient presenting with a contained rupture of an internal lilac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the Internal lilac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal lilac artery aneurysms is emphasized by this case. (Ann VascSurg 1992;6:537-540). KEY WORDS:
Aneurysm; lilac artery aneurysm; abdominal aortic aneurysm.
Although the incidence of iliac artery aneurysm is low, ranging from 0.3% to 2.2% [I,2], rupture of these aneurysms is associated with mortality rates ranging from 29 to 80% [3,4]. The operative management of iliac artery aneurysms has varied from ligation and resection, to endoaneurysmorraphy with graft interposition [2]. In 1913, MacLaren became the first surgeon to successfully treat a symptomatic internal iliac artery aneurysm by ligation [5]. However, simple proximal ligation of the internal iliac artery aneurysm has been associated with recurrence and persistence of the aneurysm [6]. The practice of simple proximal ligation of an internal iliac aneurysm is occasionally performed during resection of an associated abdominal aortic aneurysm and/or common iliac artery aneurysm. Simple proximal ligation fails to control the distal
From the Section of Vascular Surgery, Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania. Reprint requests: Anthony J. Comerota, MD, FACS, Section of Vascular Surgery, Temple University Hospital, Broad and Ontario Streets, Philadelphia, Pennsylvania 19140.
branches of the aneurysm and may do little to reduce the luminal pressure, and therefore elevated wall tension persists. We present a recent case of a ruptured internal iliac artery aneurysm three years following simple proximal ligation at the time of abdominal aortic aneurysm repair.
CASE REPORT A 76-year-old man was referred to the Vascular Surgery Service with abdominal pain, syncope, anemia and a large pelvic mass. An iliac artery aneurysm, thought to be either a right internal iliac artery aneurysm or right iliac pseudoaneurysm was suspected. Three years prior to admission the patient had a resection of an abdominal aortic aneurysm and proximal ligation of the right internal iliac artery aneurysm (Fig. 1). An aortic bifurcation graft was inserted with a fight external iliac end-to-end anastomosis and a left common iliac end-to-end anastomosis (Fig. 2). Approximately one month prior to admission the patient developed symptoms of urgency, frequency, dysuria, tenesmus and fever. The patient also developed intermittent lightheadedness, weakness and general malaise. There was constant pelvic pain with occasional pain
537
538
DELAYED R U P T U R E OF I N T E R N A L ILIAC ARTER Y A N E U R YSM
ANNALS o r VASCULAR SURGERY
) Fig. 1. Initial arteriogram for evaluation of abdominal aortic aneurysm, demonstrating incidental 3.5 cm aneurysm of right internal lilac artery (arrow). in the distribution of the right sciatic nerve. A computed tomographic (CT) scan of the abdomen and pelvis revealed a large pelvic mass, thought to be a right internal iliac artery aneurysm, measuring 11 cm in diameter with a lamellar appearance and displacement of the urinary bladder (Fig. 3). Blood cultures were negative. An intravenous urogram demonstrated displacement and dilation of the right ureter. The patient had no symptoms of vomiting, melena, or rectal bleeding. The patient's current medical problems included coronary artery disease and hypertension. On admission the patient's temperature was 37°C, blood pressure was 150/90, pulse rate was 96 per minute and respirations, 18 per minute. Pertinent physical findings included an irregular heart rhythm with a grade III/VI systolic ejection murmur and a soft right cervical bruit. There were normal bowel sounds without abdominal bruits. The patient had mild suprapubic tenderness with a fullness in the lower abdomen. Rectal examination revealed a large anterior mass without pulsation, and the stool failed to show evidence of occult blood. The femoral pulses were normal with slightly diminished popliteal and distal pulses. Laboratory values included a hemoglobin of 8.6 grams, hematocrit of 26.5 and a WBC of 7,900. The BUN was 22 and the creatinine 1.8. Urinalysis was within normal limits as were coagulation parameters. An aortogram was performed, which demonstrated a patent aortobiiliac bifurcation graft without any evidence of pseudoaneurysm or contrast extravasation (Fig. 2). The left iliac arteries were ectatic and there was no
Fig. 2. Preoperative aortogram demonstrating patent aortic bifurcation graft, right limb anastomosed to external lilac artery, and left limb anastomosed to ectatic common lilac artery. No pseudoaneurysm is appreciated on delayed views.
opacification of the large pelvic mass. Arterial duplex examination had weak signals within the mass but failed to show communication with either iliac artery or the aortic graft. The patient was admitted to the surgical intensive care unit for hemodynamic optimization prior to his operative procedure. Exploratory laparotomy revealed an intact infrarenal aortic graft. A large pelvic mass arose adjacent to the right limb of the graft but did not communicate with it. There was no evidence of a pseudoaneurysm. Following complete mobilization and control of the aortic graft proximally and distally, the pelvic mass was punctured with an 18 gauge needle and dark blood was aspirated. The wall of the mass was then incised, and the contents were found to be thrombus and old blood. Following evacuation of the clot, brisk arterial bleeding from the pelvic branches of the right internal iliac artery was observed from the remnants of the arterial wall. Therefore the mass was deemed to be a large, contained rupture of the right internal iliac aneurysm. Bleeding was controlled with direct suture ligation. Since a large pelvic defect was present and since the graft was completely exposed, the greater omentum was mobilized from the greater curvature of the stomach to cover the graft and fill the large pelvic cavity. The patient's postoperative course was unremarkable, and he was discharged on the seventh postoperative day tree from his presenting symptoms. He has remained well during the three years of follow-up since his operation.
VOLUME 6 N o 6 - 1992
D E L A Y E D R U P T U R E OF I N T E R N A L ILIAC A R T E R Y A N E U R Y S M
Fig. 3. Preoperative CT scan demonstrating large pelvic mass without evidence of communication to other vascular structures, consistent with diagnosis of contained rupture of right internal iUac aneurysm.
DISCUSSION Aneurysms of the internal iliac arteries are most commonly associated with aortoiliac aneurysms. The frequency of iliac artery aneurysms which are not associated with abdominal aortic aneurysms in one series was reported to be 0.9% [7], and the frequency of isolated internal iliac artery aneurysms was I in 12,000 postmortem examinations. The diagnosis and treatment of iliac artery aneurysm is complicated by their location. Since they are located deep in the pelvis, they escape detection on physical examination. Most will remain asymptomatic until they are large and exert pressure on adjacent structures or until rupture occurs [7]. The natural history of aortic aneurysms is to expand and eventually rupture, with the size of the aneurysm correlating directly with the risk of rupture. It has been difficult to correlate the size of iliac artery aneurysms with the risk of rupture, most likely due to the small numbers reported. It is intuitively accepted that the risk of rupture of internal iliac artery aneurysms is related to their size relative to the normal diameter of the internal iliac artery. Case reports of rupture of aneurysms 2 cm in diameter exist [8-11], and several authors recommend repair of an internal iliac aneurysm if it is greater than 3 cm in diameter [2,6]. The principles of repair include proximal and distal ligation of the aneurysm, removal of the laminated clot from the aneurysm sac, and oversewing of the ostia of the feeding branches from within [5]. Failure to achieve both proximal and distal ligation of an aneurysm may be associated with significant morbidity and mortality. This principle is well demonstrated by subsequent rupture of abdominal aortic aneurysms in several cases treated only by proximal ligation. In 1965 Blaisdell and associates
539
[12] described a method to reduce operative mortality in high-risk patients with abdominal aortic aneurysms, using an axillofemoral bypass followed by ligation of the neck of the aneurysm and ligation of the iliac arteries. Since then, Berguer [13], Leather [14], and Savarese [15] have described variations of this technique. The latter two employ iliac artery ligation and axillobifemoral bypass. Several cases of rupture of the aneurysm following similar techniques have been reported [16--19]. These have drawn attention to the importance of collaterals which provide continued potential flow but most importantly sustained pressure to the ligated aneurysm, thereby maintaining high wall tension. Exclusion of aneurysms by proximal and distal ligation and obliterating all sources of collateral inflow insures the most complete control [18] and is the prevailing principle in the treatment of aneurysmal disease. Unfortunately, these principles are occasionally breached, especially in the treatment of internal iliac artery aneurysms associated with aneurysms of the abdominal aorta or common iliac arteries, as demonstrated by this case. Distal ligation of internal iliac artery aneurysms may be difficult if not hazardous, due to their location and the surrounding pelvic venous structures. In such cases, proximal ligation with obliterative aneurysmorraphy is a reasonable technical alternative. Partial circumferential exposure followed by ptedgeted suture obliteration will achieve luminal control. This case illustrates the consequences of not obtaining complete control and obliteration of internal iliac artery aneurysms and highlights the potential complications when distal control and/or luminal obliteration are not obtained during the first operation. REFERENCES 1. LOWRY SF, KRAFT RO. Isolated aneurysms of the iliac system. Arch Surg 1978;113:128%1293. 2. RICHARDSON JW, G R E E N F I E L D LJ. Natural history and management of iliac aneurysms. J Vasc Surg 1988;8: 165-171. 3. K U S U L K E RJ, CLIFFORD A, NICHOLS WK, et al. Isolated atherosclerotic aneurysms of the internal iliac artery. Arch Surg 1982;117:73-77. 4. WIRTHLIN LS, WARSHAW AL. Ruptured aneurysm of the hypogastric artery. Surge~ 1973;73:629--633. 5. MACLAREN A. Aneurysm of the internal iliac, probably immediately following a severe instrumental delivery. Ann Surg 1913;58:269-270. 6. BRIN BJ, BUSUTTIL RW. Isolated hypogastric artery aneurysms. Arch Surg 1982;117:1329-1333. 7. McCREADY RA, PAIROLERO PC, GILMORE JC, et al. Isolated iliac artery aneurysms. Surgery 1983;93:688-693. 8. LUCKE B, REA MH. Studies on aneurysm. I. General statistical data on aneurysms. JAMA 1921 ;77:935-940. 9. PURDUE GD, MITTENHAL MJ, SMITH RB, et al. Aneurysms of the internal iliac artery. Surgery 1983;93:243-246. 10. Case records of MGH 15-1967. NEngIJ Med 1967;276:800-807.
540
DELAYED RUPTURE OF INTERNAL ILIA C ARTERY ANEUR YSM
11. Case records of MGH 3-1978. N Engl J Med 1978;298:208-213. 12. BLAISDELL FW, H A L L AD, THOMAS AN. Ligation treatment of an abdominal aortic aneurysm. Am J Surg 1965;109:560-565. 13. BERGUER R, SCHNEIDER J, W l L N E R HI. Induced thrombosis of inoperable abdominal aortic aneurysm. Surgery 1978;84:425-429. 14. LEATHER RP, SHAH D, GOLDMAN M, et al. Nonresecrive treatment of abdominal aortic aneurysms. Arch Surg 1979;114:1402-1408. 15. SAVARESE RP, ROSENFELD JC, DELAURENTIS DA. Alternatives in the treatment of abdominal aortic aneurysms. Am J Surg 1981;142:226-230. 16. CHO SI, JOHNSON WC, BUSH HS, et al. Lethal compli-
mum
17. 18. 19. 20.
ANNALS OF VASCULAR SURGERY
cations associated with nonresective treatment of abdominal aortic aneurysms. Arch Surg 1982;117:t214-1217. KARMODY AM, LEATHER RP, GOLDMAN M, et al. The current position of nonresective treatment for abdominal aortic aneurysm. Surgery 1983;94:591-597. KWAAN JHM, DAHL RK. Fatal rupture after successful surgical thrombosis of an abdominal aortic aneurysm. Surgery 1984;95:235-237. SCHANZER H, PAPA MC, MILLER CM. Rupture of surgically thrombosed abdominal aortic aneurysm. J Vasc Surg 1985;2:278-280. KWAAN JHM, KHAN RJ, CONNOLLY JE. Total exclusion technique for the management of abdominal aortic aneurysms. Am J Surg 1983;146:93-97.
