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Rupture of internal iliac artery aneurysm presenting as rectus sheath hematoma: case report
Rupture of internal iliac artery aneurysm presenting as rectus sheath hematoma: Case report Gianmarco de Donato, MD, Eugenio Neri, MD, Irene Baldi, MD, and Carlo Setacci, MD, Siena, Italy This report describes a ruptured internal iliac artery aneurysm that presented as a rectus sheath hematoma (RSH). The patient developed abdominal pain and a large, tense lower abdominal wall mass without peritoneal signs. Computed tomography scan demonstrated a massive RSH contiguous with a ruptured left internal iliac artery aneurysm. Hypovolemic shock prompted immediate laparotomy, aneurysmorrhaphy of the ruptured aneurysm, and evacuation of the rectus hematoma. This uncommon presentation of internal iliac aneurysm rupture should caution against a simple diagnosis of “spontaneous” RSH in a patient with a potentially ruptured iliac aneurysm. (J Vasc Surg 2004;39:250-3.)
CASE REPORT A 77-year-old man presented to the emergency room with acute left lower quadrant abdominal pain. The patient’s history included an infrarenal abdominal aortic aneurysm (AAA) that had been repaired 7 years previously with a bifurcated graft anastomosed at the level of the distal common iliac arteries bilaterally. No follow-up information was available beyond the first year after operation. Physical examination at presentation revealed a palpable, tender lower abdominal mass that expanded over the next 3 hours to become visible in the left lower quadrant. Immediate ultrasound examination demonstrated a large rectus sheath hematoma (RSH). A subsequent abdominal computed tomography (CT) scan confirmed the finding of a RSH, which extended from the pubis to 10 cm above the umbilical line, and demonstrated the presence of a ruptured 5.5-cm-diameter left internal iliac artery (IIA) aneurysm (Fig 1). The patient subsequently developed rapid onset of hemorrhagic shock (blood pressure 70/40 mm Hg; Hb 8,2 g/dL, Ht 26%), which prompted emergent laparotomy through a midline incision. After some initial difficulties caused by vigorous bleeding from rectus muscles and by intestinal adhesions, the previous aortic prosthesis was exposed and cross-clamped. Following this maneuver we observed a marked reduction of bleeding from the sheath of the rectus abdominis muscle. The left external iliac artery was then controlled. We then identified the thrombosed sac of the left common iliac artery aneurysm treated in the course of the initial AAA repair. Careful dissection of the IIA aneurysm showed rupture in its lower segment adjacent to the pelvis. The resulting massive hematoma had created a passage through the pelvic floor to the lower insertion of rectus muscles, expanding into the rectus sheath. The transversalis fascia appeared lacerated below the linea semicircularis. The surgical treatment was completed by IIA aneurysmorrhaphy, with ligature, from inside the aneurysm of both proximal and distal necks and of the feeding collaterals. Drainage of the RSH was From the University of Siena. Competition of interest: none. Reprint requests: Gianmarco de Donato, MD, Chirugia Vascolare, Universita di Siena, Policlinico Le Scotte, Viale Bracci, 53100 Siena, Italy (e-mail: [email protected]). 0741-5214/2004/$30.00 ⫹ 0 Copyright © 2004 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2003.07.023
250
performed with two 10-mm Jackson-Pratt drains. The patient recovered well from the operation and was discharged on postoperative day 15, after a period of respiratory rehabilitation imposed by a long-standing severe chronic obstructive lung disease.
DISCUSSION To our knowledge, RSH as a presentation of a ruptured IIA aneurysm has never been described previously in the literature. RSH results from the accumulation of extravasated blood into the sheath of the rectus abdominis muscles. It is, in general, secondary to rupture of an epigastric vessel or muscle tear, although it may also result as a consequence of direct trauma or occur spontaneously, as a result of either violent twisting or abrupt change in position. Other precipitating factors include anticoagulation therapy, coagulation disorders, recent surgery, medication injection, or increased intra-abdominal pressure from coughing or pregnancy. A RSH typically presents as a palpable lower abdominal mass that becomes fixed and often tender with abdominal wall contraction.1 The diagnosis is usually confirmed with ultrasonography or CT. RSH not invading the prevesicular space or peritoneum in a stable patient will often resolve nonoperatively with rectus rest and correction of any predisposing factors. RSH occurring in surgical patients in the postoperative period or in those subjects upon anticoagulation therapy should be strictly followed, as in such cases surgical interventions may be required to control hemorrhage.2-3 The rectus sheath consists of two vertically aligned parallel muscles, a posterior blood supply originating from the internal thoracic and external iliac arteries, and an enveloping fascial sheath. Above the arcuate line, the rectus muscles are enveloped by fascia from the aponeurosis of the external oblique, internal oblique, and transversus muscles. Below the arcuate line, there is represented only by the anterior rectus sheath. Three to four tendinous inscriptions anchor the rectus muscles to the enveloping fascia above the arcuate line (Fig 2). A RSH generally occurs after the rupture of a rectus muscle and the corresponding perforating epigastric vessels as a result of the significant mobility of the rectus muscles in the region below the arcuate line, which make the firmly attached epigastric vessels liable to injury. Below the linea
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de Donato et al 251
Fig 1. Preoperative pelvic computed tomography scan sequence (a-f) showing the passage of “dissecting” blood along the pelvic floor, in the extraperitoneal space. 3a, the left hypogastric aneurysm (black arrow; and the rectus sheath hematoma (double black arrows). To note both the lateral shift of the rectum (222), caused by the aneurysmatic mass, and the compression of the bladder (double open arrows), resulting from the spreading bleeding of internal iliac artery.
Fig 2. The rectus sheath anatomy.
semicircularis, the absence of a posterior rectus sheath creates a locus minoris resistentiae. In our case the bleeding from the ruptured IIA aneurysm created a hematoma that expanded toward the small pelvis. The adhesions caused by the previous operation contained the intra-abdominal expansion of the aneurysm and forced it to expand toward the pelvis; after its rupture and bleeding, the resulting hematoma spread in the extra-
peritoneal space at the level of the pelvic floor and proceeded through the lower insertion of the rectus muscles, which was the locus minori resistentiae, thus forming the RSH (Fig 3). This pathway of hematoma expansion is similar to the course of the umbilical artery during in fetal life: It spreads from anterior face of IIA, in contact medially with the lateral and anterior bladder wall and laterally with the psoas
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252 de Donato et al
Fig 3. The way of hematoma expansion from the rupted internal iliac artery aneurysm: sliding on the pelvic floor, always in the extraperitoneal space, the hematoma spreads in contact medially with the lateral and anterior bladder wall and laterally with the psoas muscle, the innominate line of iliac bone, and the internal obturator muscle, up to the base of pubis and the posterior face of inferior rectus muscles, forming the HRS.
muscle, the innominate line of iliac bone, and the internal obturator muscle, up to the base of pubis and the posterior face of inferior rectus muscles (Fig 3). There is a paucity of epidemiologic data on IIA aneurysm, accounting for approximately 0.4% of intra-abdominal aneurysms.4 However the widespread use of abdominal ultrasound and of computed tomography scans and the growth of the aging population may increase the incidence of diagnosed IIA aneurysm. The vast majority of IIA aneurysms are atherosclerotic aneurysms occurring predominantly in elderly males. More rarely found are pseudoaneurysm as a complication of previous vascular anastomosis, hysterectomy, drainage of ischiorectal abcesses, lumbar disk surgery, hip replacement, and pelvic fractures.4-5 In many patients IIA aneurysm is discovered in association with an aortic aneurysm. Early recognition is uncommon because patients often have limited symptoms.6 The more frequent symptoms result from the direct compression of an ureter. Another presentation can be sciatic neuralgia as a result of direct nerve compression or the desmoplastic reaction that surrounds the aneurysm.7 Usually the first symptom of an IIA aneurysm is its rupture. This is generally contained in the retroperitoneal space; less frequently it enters the peritoneal space. The
literature describes ruptures into the bladder and into the common iliac vein and the rectum.8-11 A variety of techniques have been described for treatment of this aneurysm,12 including open surgery (including exclusion, aneurysmorrhaphy, resection, and bypass) and, more recently, the endovascular repair. Open surgery often has technical difficulties in relation to the depth of the operative field. Proximal ligation and suture exclusion are the oldest and technically simplest modalities. However, both carry the risk of long-term complications because the aneurysm is still supplied by collaterals and can thus continue to expand and even rupture. Better long-term results can be obtained by distal ligation of the anterior and posterior branches of the IIA in association with aneurysmorrhaphy. Unilateral aneurysm ligation is well tolerated if the contralateral IIA is free of occlusive or aneurysmal disease, whereas a bilateral aneurysm ligation may cause colonic ischemia and vasculogenic impotence.13-16 CONCLUSION This case demonstrates an uncommon presentation of a ruptured IIA aneurysm and should warn against a simple diagnosis of “spontaneous” RSH in a patient with an IIA aneurysm. It should also show the necessity of thorough investigation of the causes underlying this condition. Fur-
JOURNAL OF VASCULAR SURGERY Volume 39, Number 1
thermore, a search for iliac aneurysms would appear to be warranted in patients presenting with RSH if they are in the demographic group likely to harbor such aneurysms.
de Donato et al 253
9. 10. 11.
REFERENCES 1. Edlow JA, Juang P, Margulies S, Burstein J. Rectus sheath hematoma. Ann Emerg Med 1999;34:671-5. 2. Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg 1988;54:630-3. 3. Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21: 62-4. 4. Brin BJ, Busuttil RW. Isolated hypogastric artery aneurysms. Arch Surg 1982;117:1329-33. 5. Desiron Q, Detry O, Sakalihasan N. Isolated atheroscelrotic aneurysms of internal iliac arteries. Ann Vasc Surg 1995;9:62-6. 6. Giordanengo F, Vandone PL, Trimarchi S. Ruptured aneurysm of the internal iliac artery. Panminerva Med 1995;37:150-4. 7. Bacourt F, Mercier F, Benoist M. Rupture of hypogastric artery aneurysm presenting as sciatic paralysis. J Mal Vasc 1994;19:147-50. 8. Metairie S, Denimal F, Floch I, Pillet JC, Pittaluga P, Patra P, et al.
12. 13.
14.
15.
16.
Rupture of internal iliac artery aneurysm into the bladder following aortic aneurysm repair. Ann Vasc Surg 2001;15:693-5. Lepront D, Crozat T, Martin F. Rupture of aneurysm of the internal iliac artery into the primary iliac vein. J Chir (Paris) 1995;132:191-5. Feldtman RW, Archie JP Jr. Hypogastric artery aneurysm: survival after rupture into the rectum. South Med J Mar 1982;75:350-2. Katoh J, Shindo S, Kina S. Rupture of an isolated internal iliac artery aneurysm into the rectum: report of a case. Surg Today 1995;25:554-6. Soury P, Brisset D, Gigou F. Aneurysms of the internal iliac artery: management strategy. Ann Vasc Surg 2001;15:321-5. Brings HA, Murray JD, Light JT, Hemp JR, Ranbarger KR. Internal iliac artery aneurysm following aortic reconstruction. Ann Vasc Surg 1996;10:59-62. Plate G, Hollier LA, O’Brien P, Pairolero PC, Cherry KJ, Kazmier FJ. Recurrent aneurysm and late vascular complications following repair of abdominal aortic aneurysms. Arch Surg 1985;120:590-4. Deb B, Benjamin M, Comerota A. Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair. Ann Vasc Surg 1992;6:537-40. Aboulafia ED, Dardano AN, Engle J, Brown OW. Isolated internal iliac artery aneurysm eleven years after tube graft repair of an abdominal aortic aneurysm: case report and literature review. Angiology 1998;7: 157-9.
Submitted Mar 25, 2003; accepted Jul 31, 2003.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Journal of Vascular Surgery for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. Please write to Elsevier Inc., Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000 for information on availability of particular issues and prices.
CASE REPORT A 77-year-old man presented to the emergency room with acute left lower quadrant abdominal pain. The patient’s history included an infrarenal abdominal aortic aneurysm (AAA) that had been repaired 7 years previously with a bifurcated graft anastomosed at the level of the distal common iliac arteries bilaterally. No follow-up information was available beyond the first year after operation. Physical examination at presentation revealed a palpable, tender lower abdominal mass that expanded over the next 3 hours to become visible in the left lower quadrant. Immediate ultrasound examination demonstrated a large rectus sheath hematoma (RSH). A subsequent abdominal computed tomography (CT) scan confirmed the finding of a RSH, which extended from the pubis to 10 cm above the umbilical line, and demonstrated the presence of a ruptured 5.5-cm-diameter left internal iliac artery (IIA) aneurysm (Fig 1). The patient subsequently developed rapid onset of hemorrhagic shock (blood pressure 70/40 mm Hg; Hb 8,2 g/dL, Ht 26%), which prompted emergent laparotomy through a midline incision. After some initial difficulties caused by vigorous bleeding from rectus muscles and by intestinal adhesions, the previous aortic prosthesis was exposed and cross-clamped. Following this maneuver we observed a marked reduction of bleeding from the sheath of the rectus abdominis muscle. The left external iliac artery was then controlled. We then identified the thrombosed sac of the left common iliac artery aneurysm treated in the course of the initial AAA repair. Careful dissection of the IIA aneurysm showed rupture in its lower segment adjacent to the pelvis. The resulting massive hematoma had created a passage through the pelvic floor to the lower insertion of rectus muscles, expanding into the rectus sheath. The transversalis fascia appeared lacerated below the linea semicircularis. The surgical treatment was completed by IIA aneurysmorrhaphy, with ligature, from inside the aneurysm of both proximal and distal necks and of the feeding collaterals. Drainage of the RSH was From the University of Siena. Competition of interest: none. Reprint requests: Gianmarco de Donato, MD, Chirugia Vascolare, Universita di Siena, Policlinico Le Scotte, Viale Bracci, 53100 Siena, Italy (e-mail: [email protected]). 0741-5214/2004/$30.00 ⫹ 0 Copyright © 2004 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2003.07.023
250
performed with two 10-mm Jackson-Pratt drains. The patient recovered well from the operation and was discharged on postoperative day 15, after a period of respiratory rehabilitation imposed by a long-standing severe chronic obstructive lung disease.
DISCUSSION To our knowledge, RSH as a presentation of a ruptured IIA aneurysm has never been described previously in the literature. RSH results from the accumulation of extravasated blood into the sheath of the rectus abdominis muscles. It is, in general, secondary to rupture of an epigastric vessel or muscle tear, although it may also result as a consequence of direct trauma or occur spontaneously, as a result of either violent twisting or abrupt change in position. Other precipitating factors include anticoagulation therapy, coagulation disorders, recent surgery, medication injection, or increased intra-abdominal pressure from coughing or pregnancy. A RSH typically presents as a palpable lower abdominal mass that becomes fixed and often tender with abdominal wall contraction.1 The diagnosis is usually confirmed with ultrasonography or CT. RSH not invading the prevesicular space or peritoneum in a stable patient will often resolve nonoperatively with rectus rest and correction of any predisposing factors. RSH occurring in surgical patients in the postoperative period or in those subjects upon anticoagulation therapy should be strictly followed, as in such cases surgical interventions may be required to control hemorrhage.2-3 The rectus sheath consists of two vertically aligned parallel muscles, a posterior blood supply originating from the internal thoracic and external iliac arteries, and an enveloping fascial sheath. Above the arcuate line, the rectus muscles are enveloped by fascia from the aponeurosis of the external oblique, internal oblique, and transversus muscles. Below the arcuate line, there is represented only by the anterior rectus sheath. Three to four tendinous inscriptions anchor the rectus muscles to the enveloping fascia above the arcuate line (Fig 2). A RSH generally occurs after the rupture of a rectus muscle and the corresponding perforating epigastric vessels as a result of the significant mobility of the rectus muscles in the region below the arcuate line, which make the firmly attached epigastric vessels liable to injury. Below the linea
JOURNAL OF VASCULAR SURGERY Volume 39, Number 1
de Donato et al 251
Fig 1. Preoperative pelvic computed tomography scan sequence (a-f) showing the passage of “dissecting” blood along the pelvic floor, in the extraperitoneal space. 3a, the left hypogastric aneurysm (black arrow; and the rectus sheath hematoma (double black arrows). To note both the lateral shift of the rectum (222), caused by the aneurysmatic mass, and the compression of the bladder (double open arrows), resulting from the spreading bleeding of internal iliac artery.
Fig 2. The rectus sheath anatomy.
semicircularis, the absence of a posterior rectus sheath creates a locus minoris resistentiae. In our case the bleeding from the ruptured IIA aneurysm created a hematoma that expanded toward the small pelvis. The adhesions caused by the previous operation contained the intra-abdominal expansion of the aneurysm and forced it to expand toward the pelvis; after its rupture and bleeding, the resulting hematoma spread in the extra-
peritoneal space at the level of the pelvic floor and proceeded through the lower insertion of the rectus muscles, which was the locus minori resistentiae, thus forming the RSH (Fig 3). This pathway of hematoma expansion is similar to the course of the umbilical artery during in fetal life: It spreads from anterior face of IIA, in contact medially with the lateral and anterior bladder wall and laterally with the psoas
JOURNAL OF VASCULAR SURGERY January 2004
252 de Donato et al
Fig 3. The way of hematoma expansion from the rupted internal iliac artery aneurysm: sliding on the pelvic floor, always in the extraperitoneal space, the hematoma spreads in contact medially with the lateral and anterior bladder wall and laterally with the psoas muscle, the innominate line of iliac bone, and the internal obturator muscle, up to the base of pubis and the posterior face of inferior rectus muscles, forming the HRS.
muscle, the innominate line of iliac bone, and the internal obturator muscle, up to the base of pubis and the posterior face of inferior rectus muscles (Fig 3). There is a paucity of epidemiologic data on IIA aneurysm, accounting for approximately 0.4% of intra-abdominal aneurysms.4 However the widespread use of abdominal ultrasound and of computed tomography scans and the growth of the aging population may increase the incidence of diagnosed IIA aneurysm. The vast majority of IIA aneurysms are atherosclerotic aneurysms occurring predominantly in elderly males. More rarely found are pseudoaneurysm as a complication of previous vascular anastomosis, hysterectomy, drainage of ischiorectal abcesses, lumbar disk surgery, hip replacement, and pelvic fractures.4-5 In many patients IIA aneurysm is discovered in association with an aortic aneurysm. Early recognition is uncommon because patients often have limited symptoms.6 The more frequent symptoms result from the direct compression of an ureter. Another presentation can be sciatic neuralgia as a result of direct nerve compression or the desmoplastic reaction that surrounds the aneurysm.7 Usually the first symptom of an IIA aneurysm is its rupture. This is generally contained in the retroperitoneal space; less frequently it enters the peritoneal space. The
literature describes ruptures into the bladder and into the common iliac vein and the rectum.8-11 A variety of techniques have been described for treatment of this aneurysm,12 including open surgery (including exclusion, aneurysmorrhaphy, resection, and bypass) and, more recently, the endovascular repair. Open surgery often has technical difficulties in relation to the depth of the operative field. Proximal ligation and suture exclusion are the oldest and technically simplest modalities. However, both carry the risk of long-term complications because the aneurysm is still supplied by collaterals and can thus continue to expand and even rupture. Better long-term results can be obtained by distal ligation of the anterior and posterior branches of the IIA in association with aneurysmorrhaphy. Unilateral aneurysm ligation is well tolerated if the contralateral IIA is free of occlusive or aneurysmal disease, whereas a bilateral aneurysm ligation may cause colonic ischemia and vasculogenic impotence.13-16 CONCLUSION This case demonstrates an uncommon presentation of a ruptured IIA aneurysm and should warn against a simple diagnosis of “spontaneous” RSH in a patient with an IIA aneurysm. It should also show the necessity of thorough investigation of the causes underlying this condition. Fur-
JOURNAL OF VASCULAR SURGERY Volume 39, Number 1
thermore, a search for iliac aneurysms would appear to be warranted in patients presenting with RSH if they are in the demographic group likely to harbor such aneurysms.
de Donato et al 253
9. 10. 11.
REFERENCES 1. Edlow JA, Juang P, Margulies S, Burstein J. Rectus sheath hematoma. Ann Emerg Med 1999;34:671-5. 2. Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg 1988;54:630-3. 3. Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21: 62-4. 4. Brin BJ, Busuttil RW. Isolated hypogastric artery aneurysms. Arch Surg 1982;117:1329-33. 5. Desiron Q, Detry O, Sakalihasan N. Isolated atheroscelrotic aneurysms of internal iliac arteries. Ann Vasc Surg 1995;9:62-6. 6. Giordanengo F, Vandone PL, Trimarchi S. Ruptured aneurysm of the internal iliac artery. Panminerva Med 1995;37:150-4. 7. Bacourt F, Mercier F, Benoist M. Rupture of hypogastric artery aneurysm presenting as sciatic paralysis. J Mal Vasc 1994;19:147-50. 8. Metairie S, Denimal F, Floch I, Pillet JC, Pittaluga P, Patra P, et al.
12. 13.
14.
15.
16.
Rupture of internal iliac artery aneurysm into the bladder following aortic aneurysm repair. Ann Vasc Surg 2001;15:693-5. Lepront D, Crozat T, Martin F. Rupture of aneurysm of the internal iliac artery into the primary iliac vein. J Chir (Paris) 1995;132:191-5. Feldtman RW, Archie JP Jr. Hypogastric artery aneurysm: survival after rupture into the rectum. South Med J Mar 1982;75:350-2. Katoh J, Shindo S, Kina S. Rupture of an isolated internal iliac artery aneurysm into the rectum: report of a case. Surg Today 1995;25:554-6. Soury P, Brisset D, Gigou F. Aneurysms of the internal iliac artery: management strategy. Ann Vasc Surg 2001;15:321-5. Brings HA, Murray JD, Light JT, Hemp JR, Ranbarger KR. Internal iliac artery aneurysm following aortic reconstruction. Ann Vasc Surg 1996;10:59-62. Plate G, Hollier LA, O’Brien P, Pairolero PC, Cherry KJ, Kazmier FJ. Recurrent aneurysm and late vascular complications following repair of abdominal aortic aneurysms. Arch Surg 1985;120:590-4. Deb B, Benjamin M, Comerota A. Delayed rupture of an internal iliac artery aneurysm following proximal ligation for abdominal aortic aneurysm repair. Ann Vasc Surg 1992;6:537-40. Aboulafia ED, Dardano AN, Engle J, Brown OW. Isolated internal iliac artery aneurysm eleven years after tube graft repair of an abdominal aortic aneurysm: case report and literature review. Angiology 1998;7: 157-9.
Submitted Mar 25, 2003; accepted Jul 31, 2003.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Journal of Vascular Surgery for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. Please write to Elsevier Inc., Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000 for information on availability of particular issues and prices.