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Post-Traumatic Aneurysm of the Iliac Artery with Rupture Directly into Bladder: A Case Report and Review of the Literature
Vol. 108, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
POST-TRAUMATIC ANEURYSM OF THE ILIAC ARTERY WITH RUPTURE DIRECTLY INTO BLADDER: A CASE REPORT AND REVIEW OF THE LITERATURE STEPHEN N. ROUS*
AND
JOSEPH T. ANDRONACO
From the Departments of Urology and Surgery, New York Medical College and Metropolitan Hospital Center, New York, New York
A recent case of almost fatal exsanguination from the rupture into the bladder of a post-traumatic pseudo-aneurysm of the external iliac artery is presented. In the literature we found 2 cases in which an iliac artery aneurysm produced intrinsic pressure on the bladder or bladder neck1 • 2 and 1 case in which an aneurysm secondary to tuberculous arteritis ruptured retroperitoneally with fatal results8 but it is believed that this is the first case in which an arterial aneurysm ruptured directly into the bladder. CASE REPORT
R. M., 47-70-14, a 33-year-old man, was seen on August 24, 1970 in profound shock with a blood pressure of 70/40. He had been hit in the left lower quadrant of the abdomen with a .45 caliber bullet and bright red blood had been passing from the rectum and from the urethra. A decreased femoral pulse was palpable on the left side. An immediate laparotomy revealed a 3 by 4-inch hole in the left lateral wall of the bladder, an extensive and ragged perforation of the sigmoid colon and an actively bleeding branch of the internal iliac artery. Inspection of the left common and external iliac vessels showed no abnormalities and the left femoral pulse was normal. Approximately 4 inches of sigmoid colon were resected and a proximal colostomy was created. The bladder, extensively filled with blood and blood clots, was repaired using a double row of interrupted 3-zero chromic sutures. The patient received 9 units of blood during the operation and did well for 1 week postoperatively. At that time he suddenly passed 1,500 cc bright red blood through the Foley catheter and went into shock. At emer-
Accepted for publication April 14, 1972. * Current address: Department of Surgery/Urology, Michigan State University, College of Human Medicine, East Lansing, Michigan 48823. 1 Harrow, B. R.: Traumatic perivesical hematoma: late sequela of false ileac aneurysm. J. Urol., 104: 271, 1970.
2 Anderson, E. E. and Silver, D.: Aneurysm of hypogastric artery presenting with bladder neck obstruction. J. Urol., 97: 90, 1967. 3 McCune, W. R., Galleher, E. P. and Oster, W.: Ureteral obstruction following rupture of an iliac artery secondary to tuberculous arteritis. J. Urol.,
94: 391, 1965.
gency operation the bladder was filled with blood and a strong thrill was palpable over the left side of the bladder. The iliac arteries and veins were dissected free before the bladder was opened. Consequent to the extensive fibrosis in the pelvis, the left ureter was inadvertently transected. This was subsequently repaired by primary anastomosis over a stent. The left internal iliac artery was ligated in the vain hope that this would diminish the bleeding which continued massively through the Foley catheter. A left external iliac arteriovenous fistula and pseudoaneurysm were found and when the bladder was opened it was seen that the pseudo-aneurysm had ruptured directly into the bladder through the suture lines of the recent bladder repair. The fistula was closed with 5-zero tycron sutures, the aneurysm was resected and the artery was closed with the same material. The bladder was closed in layers and the ureteral stent was brought out alongside a suprapubic tube. Femoral, popliteal and posterior tibial pulses were normal. The patient received 15 units of blood during the operation. The patient did well and was discharged from the hospital 6 weeks later. In March 1971 he was electively rehospitalized for colostomy closure and excretory urqgraphy at that time disclosed an entirely normal urinary tract. DISCUSSION
Although massive hemorrhage from major vessels into other hollow organs has been reported, 4 • 5 it is believed that this is the first time the bladder has been so involved. In retrospect, the diminished femoral pulse noted initially in the emergency room should have pointed to the possibility of external or common iliac artery trauma. However, it was thought to be due to reflex arterial spasm and this was seemingly corroborated by the normal pulses during operation. The tremendous blast effect of a high-caliber missile is well illustrated here and it is most likely that it devitalized enough 4 Byrne, J. J., Guardione, V. A. and Williams, L. F.: Massive gastrointestinal hemorrhage. Amer. J. Surg., 120: 312, 1970. 6 Foster, J. H. and Vetto, R. M.: Aortic intraaneurysmal abscess caused by sigmoid-aortic fistula. Amer. J. Surg., 104: 850, 1962.
722
POST-TRAUMATIC ANEURYSM OF ILIAC ARTERY
723
I arterial and venous tissue to permit delayed formation of the fistula and the pseudo-aneurysm and then aneurysmal rupture. 6 It was fortunate that the recently repaired bladder suture line was in close proximity to the pseudo-aneurysm and provided a convenient outflow tract for the hemorrhage. 6 Scott, R., Jr., Carlton, C. E., Jr. and Goldman, M.: Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969.
The patient undoubtedly would have exsanguinated fatally if the aneurysm had ruptured silently. SUMMARY
A case of almost fatal exsanguination from the rupture of an external iliac pseudo-aneurysm into a recently repaired bladder has been presented. It is believed that this is the first such case described in the literature.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
POST-TRAUMATIC ANEURYSM OF THE ILIAC ARTERY WITH RUPTURE DIRECTLY INTO BLADDER: A CASE REPORT AND REVIEW OF THE LITERATURE STEPHEN N. ROUS*
AND
JOSEPH T. ANDRONACO
From the Departments of Urology and Surgery, New York Medical College and Metropolitan Hospital Center, New York, New York
A recent case of almost fatal exsanguination from the rupture into the bladder of a post-traumatic pseudo-aneurysm of the external iliac artery is presented. In the literature we found 2 cases in which an iliac artery aneurysm produced intrinsic pressure on the bladder or bladder neck1 • 2 and 1 case in which an aneurysm secondary to tuberculous arteritis ruptured retroperitoneally with fatal results8 but it is believed that this is the first case in which an arterial aneurysm ruptured directly into the bladder. CASE REPORT
R. M., 47-70-14, a 33-year-old man, was seen on August 24, 1970 in profound shock with a blood pressure of 70/40. He had been hit in the left lower quadrant of the abdomen with a .45 caliber bullet and bright red blood had been passing from the rectum and from the urethra. A decreased femoral pulse was palpable on the left side. An immediate laparotomy revealed a 3 by 4-inch hole in the left lateral wall of the bladder, an extensive and ragged perforation of the sigmoid colon and an actively bleeding branch of the internal iliac artery. Inspection of the left common and external iliac vessels showed no abnormalities and the left femoral pulse was normal. Approximately 4 inches of sigmoid colon were resected and a proximal colostomy was created. The bladder, extensively filled with blood and blood clots, was repaired using a double row of interrupted 3-zero chromic sutures. The patient received 9 units of blood during the operation and did well for 1 week postoperatively. At that time he suddenly passed 1,500 cc bright red blood through the Foley catheter and went into shock. At emer-
Accepted for publication April 14, 1972. * Current address: Department of Surgery/Urology, Michigan State University, College of Human Medicine, East Lansing, Michigan 48823. 1 Harrow, B. R.: Traumatic perivesical hematoma: late sequela of false ileac aneurysm. J. Urol., 104: 271, 1970.
2 Anderson, E. E. and Silver, D.: Aneurysm of hypogastric artery presenting with bladder neck obstruction. J. Urol., 97: 90, 1967. 3 McCune, W. R., Galleher, E. P. and Oster, W.: Ureteral obstruction following rupture of an iliac artery secondary to tuberculous arteritis. J. Urol.,
94: 391, 1965.
gency operation the bladder was filled with blood and a strong thrill was palpable over the left side of the bladder. The iliac arteries and veins were dissected free before the bladder was opened. Consequent to the extensive fibrosis in the pelvis, the left ureter was inadvertently transected. This was subsequently repaired by primary anastomosis over a stent. The left internal iliac artery was ligated in the vain hope that this would diminish the bleeding which continued massively through the Foley catheter. A left external iliac arteriovenous fistula and pseudoaneurysm were found and when the bladder was opened it was seen that the pseudo-aneurysm had ruptured directly into the bladder through the suture lines of the recent bladder repair. The fistula was closed with 5-zero tycron sutures, the aneurysm was resected and the artery was closed with the same material. The bladder was closed in layers and the ureteral stent was brought out alongside a suprapubic tube. Femoral, popliteal and posterior tibial pulses were normal. The patient received 15 units of blood during the operation. The patient did well and was discharged from the hospital 6 weeks later. In March 1971 he was electively rehospitalized for colostomy closure and excretory urqgraphy at that time disclosed an entirely normal urinary tract. DISCUSSION
Although massive hemorrhage from major vessels into other hollow organs has been reported, 4 • 5 it is believed that this is the first time the bladder has been so involved. In retrospect, the diminished femoral pulse noted initially in the emergency room should have pointed to the possibility of external or common iliac artery trauma. However, it was thought to be due to reflex arterial spasm and this was seemingly corroborated by the normal pulses during operation. The tremendous blast effect of a high-caliber missile is well illustrated here and it is most likely that it devitalized enough 4 Byrne, J. J., Guardione, V. A. and Williams, L. F.: Massive gastrointestinal hemorrhage. Amer. J. Surg., 120: 312, 1970. 6 Foster, J. H. and Vetto, R. M.: Aortic intraaneurysmal abscess caused by sigmoid-aortic fistula. Amer. J. Surg., 104: 850, 1962.
722
POST-TRAUMATIC ANEURYSM OF ILIAC ARTERY
723
I arterial and venous tissue to permit delayed formation of the fistula and the pseudo-aneurysm and then aneurysmal rupture. 6 It was fortunate that the recently repaired bladder suture line was in close proximity to the pseudo-aneurysm and provided a convenient outflow tract for the hemorrhage. 6 Scott, R., Jr., Carlton, C. E., Jr. and Goldman, M.: Penetrating injuries of the kidney: an analysis of 181 patients. J. Urol., 101: 247, 1969.
The patient undoubtedly would have exsanguinated fatally if the aneurysm had ruptured silently. SUMMARY
A case of almost fatal exsanguination from the rupture of an external iliac pseudo-aneurysm into a recently repaired bladder has been presented. It is believed that this is the first such case described in the literature.