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Transcatheter Embolization of a Giant Posttraumatic Pseudoaneurysm of Superior Gluteal Artery
EJVES Extra 7, 66–68 (2004) doi: 10.1016/j.ejvsextra.2004.03.004, available online at http://www.sciencedirect.com on
SHORT REPORT
Transcatheter Embolization of a Giant Posttraumatic Pseudoaneurysm of Superior Gluteal Artery B. Radanovic1, I. Cikara1, S. Radanovic-Coric1, M. Pervan1*, I. Tonkovic2 and M. Petrunic2 Departments of 1Radiology, and 2Vascular Surgery, University Hospital Zagreb, Croatia
Introduction Pseudoaneurysm of the gluteal artery commonly develops secondary to pelvic trauma which is occasionally iatrogenic.1,2 Permanent transcatheter embolization with coils and detachable balloons are an alternative to surgical intervention.3 In this case report, we describe successful embolization of a giant posttraumatic pseudoaneurysm of the superior gluteal artery.
Case Report A 44-year-old man presented in the Accident and Emergency Department following a motor vehicle accident. He was found to be unresponsive, in haemorrhagic shock, with a systolic blood pressure of 60 mmHg. There were signs and symptoms of intraabdominal bleeding and the patient underwent an emergency surgical procedure. Exploration of his abdomen revealed large amount of blood, a ruptured spleen, a small bowel perforation with mesenteric laceration, and a huge left retroperitoneal haematoma. A splenectomy with repair of the small bowel and mesentery were carried out. The patient underwent five days intensive care during which his condition stabilised. He then reported intensive pain in his left leg. It was extremely oedematous, hard, shortened and in external rotation. Peripheral pulses were normal. Xray of the pelvis showed a comminuted fracture of the left hemipelvis. *Corresponding author. Marijana Pervan MD, Department of Radiology, University Hospital Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia.
Duplex ultrasound revealed a deep venous thrombosis of the left external iliac vein. An abdominal ultrasound revealed a huge retroperitoneal haematoma in the area of the left hemipelvis. Computed tomography and magnetic resonance imaging revealed a giant pseudoaneurysm (14 £ 10 cm) adjacent to the left iliac artery and vein. Digital subtraction angiography was carried out with selective catheterization of the left internal iliac artery and superior gluteal artery via a contralateral transfemoral arterial approach. This revealed a pseudoaneurysm of the superior gluteal artery with an arteriovenous fistula to the right iliac vein. The left iliac vein was thrombosed. We proceeded with coil embolization of the superior gluteal artery and the internal iliac artery (Cook-Tornado coils, diameter 10 mm). Successful embolization with six coils was confirmed by follow-up DSA with absence of pseudoaneurysm and AV fistula. The whole intervention took 45 min. See Figs. 1 and 2. Serial postoperative duplex ultrasound procedures confirmed complete obstruction of blood flow in both the pseudoaneurysm and the AV fistula. There were no complications during and after the procedure. Follow-up ultrasound and duplex of the pelvis at 3 and 6 months demonstrated regression of the thrombosed haematoma to 8 £ 4 cm at 6 months.
Discussion Pseudoaneurysm of the superior gluteal artery can sometimes be encountered in trauma patients with comminuted pelvic fractures.2 It can also occur after
1533–3167/050066 + 03 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.
Transcatheter Embolization
67
Fig. 1. Contrast enhanced pelvic computed tomography scan showing giant pseudoaneurysm (10 £ 14 cm) with wide parietal thrombus, in left hemipelvis. Comminuted fracture of left hemipelvis with fragmental dislocation.
ortopædic surgery in the region. Signs and symptoms such as a painful pulsating mass with compression of nerve structures in severe trauma patients may be subtle and may go unrecognised. Diagnosis is by invasive or non-invasive means. Non-invasive diagnosis involves standard and duplex ultrasonography followed by CT and/or MRI when indicated. DSA is a more invasive diagnostic approach and is capable of accurate visualisation of anatomic and haemodynamic structures such as pseudoaneurysm and AV fistula. We believe that the angiographic approach is
essential for successful surgical intervention and also as a pathway towards transluminal treatment in these severely injured patients where an operation is fraught with hazard. Transcatheter embolization is the method of choice. The advantages of this approach are: percutaneous puncture under local anaesthesia, short duration of procedure, complete treatment with fast recovery and minimal side effects.224 Following embolization significant regression of the patient’s symptoms and the size of the haematoma can be expected. The simplicity of transluminal intervention carried out by experienced interventional radiology staff
Fig. 2. (A) Digital subtraction angiogram—selective catheterization of left internal iliac artery: oval pseudoaneurysm of left superior gluteal artery with arteriovenous fistula draining to right iliac vein. Left iliac vein is thrombosed. (B) Digital subtraction angiogram—selective catheterization of left internal iliac artery after coil embolization: occlusion of superior gluteal artery. EJVES Extra, 2004
B. Radanovic et al.
68
represents a major advantage over a surgical procedure. Surgery is only required if transluminal procedures fail.
References 1 Schorn B, Reitmeier F, Falk V, Oestmann JW, Dalichau H, Mohr FW. True aneurysm of the superior gluteal artery: case report and review of the literature. J Vasc Surg 1995; 21(5):851–854. 2 Holland AJ, Ibach EG. False aneurysm of the inferior gluteal
EJVES Extra, 2004
artery following penetrating buttock traulma: case report and review of the literature. Cardiovasc Surg 1996; 4(6):841–843. 3 McMillan WD, Smith ND, Nemcek Jr A, Pearce WH. Transcatheter embolization of a ruptured superior gluteal artery aneurysm: case report and review of the literature. J Endovasc Surg 1997; 4(4):376–379. 4 Grand C, Delcour C, Bank WO, Braude P, Dereume JP, Struyven J. Emergency embolization of a mycotic aneurysm of the superior gluteal artery: case report. Cardiovasc Intervent Radiol 1992; 15(2):117–119. Accepted 16 March 2004
SHORT REPORT
Transcatheter Embolization of a Giant Posttraumatic Pseudoaneurysm of Superior Gluteal Artery B. Radanovic1, I. Cikara1, S. Radanovic-Coric1, M. Pervan1*, I. Tonkovic2 and M. Petrunic2 Departments of 1Radiology, and 2Vascular Surgery, University Hospital Zagreb, Croatia
Introduction Pseudoaneurysm of the gluteal artery commonly develops secondary to pelvic trauma which is occasionally iatrogenic.1,2 Permanent transcatheter embolization with coils and detachable balloons are an alternative to surgical intervention.3 In this case report, we describe successful embolization of a giant posttraumatic pseudoaneurysm of the superior gluteal artery.
Case Report A 44-year-old man presented in the Accident and Emergency Department following a motor vehicle accident. He was found to be unresponsive, in haemorrhagic shock, with a systolic blood pressure of 60 mmHg. There were signs and symptoms of intraabdominal bleeding and the patient underwent an emergency surgical procedure. Exploration of his abdomen revealed large amount of blood, a ruptured spleen, a small bowel perforation with mesenteric laceration, and a huge left retroperitoneal haematoma. A splenectomy with repair of the small bowel and mesentery were carried out. The patient underwent five days intensive care during which his condition stabilised. He then reported intensive pain in his left leg. It was extremely oedematous, hard, shortened and in external rotation. Peripheral pulses were normal. Xray of the pelvis showed a comminuted fracture of the left hemipelvis. *Corresponding author. Marijana Pervan MD, Department of Radiology, University Hospital Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia.
Duplex ultrasound revealed a deep venous thrombosis of the left external iliac vein. An abdominal ultrasound revealed a huge retroperitoneal haematoma in the area of the left hemipelvis. Computed tomography and magnetic resonance imaging revealed a giant pseudoaneurysm (14 £ 10 cm) adjacent to the left iliac artery and vein. Digital subtraction angiography was carried out with selective catheterization of the left internal iliac artery and superior gluteal artery via a contralateral transfemoral arterial approach. This revealed a pseudoaneurysm of the superior gluteal artery with an arteriovenous fistula to the right iliac vein. The left iliac vein was thrombosed. We proceeded with coil embolization of the superior gluteal artery and the internal iliac artery (Cook-Tornado coils, diameter 10 mm). Successful embolization with six coils was confirmed by follow-up DSA with absence of pseudoaneurysm and AV fistula. The whole intervention took 45 min. See Figs. 1 and 2. Serial postoperative duplex ultrasound procedures confirmed complete obstruction of blood flow in both the pseudoaneurysm and the AV fistula. There were no complications during and after the procedure. Follow-up ultrasound and duplex of the pelvis at 3 and 6 months demonstrated regression of the thrombosed haematoma to 8 £ 4 cm at 6 months.
Discussion Pseudoaneurysm of the superior gluteal artery can sometimes be encountered in trauma patients with comminuted pelvic fractures.2 It can also occur after
1533–3167/050066 + 03 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.
Transcatheter Embolization
67
Fig. 1. Contrast enhanced pelvic computed tomography scan showing giant pseudoaneurysm (10 £ 14 cm) with wide parietal thrombus, in left hemipelvis. Comminuted fracture of left hemipelvis with fragmental dislocation.
ortopædic surgery in the region. Signs and symptoms such as a painful pulsating mass with compression of nerve structures in severe trauma patients may be subtle and may go unrecognised. Diagnosis is by invasive or non-invasive means. Non-invasive diagnosis involves standard and duplex ultrasonography followed by CT and/or MRI when indicated. DSA is a more invasive diagnostic approach and is capable of accurate visualisation of anatomic and haemodynamic structures such as pseudoaneurysm and AV fistula. We believe that the angiographic approach is
essential for successful surgical intervention and also as a pathway towards transluminal treatment in these severely injured patients where an operation is fraught with hazard. Transcatheter embolization is the method of choice. The advantages of this approach are: percutaneous puncture under local anaesthesia, short duration of procedure, complete treatment with fast recovery and minimal side effects.224 Following embolization significant regression of the patient’s symptoms and the size of the haematoma can be expected. The simplicity of transluminal intervention carried out by experienced interventional radiology staff
Fig. 2. (A) Digital subtraction angiogram—selective catheterization of left internal iliac artery: oval pseudoaneurysm of left superior gluteal artery with arteriovenous fistula draining to right iliac vein. Left iliac vein is thrombosed. (B) Digital subtraction angiogram—selective catheterization of left internal iliac artery after coil embolization: occlusion of superior gluteal artery. EJVES Extra, 2004
B. Radanovic et al.
68
represents a major advantage over a surgical procedure. Surgery is only required if transluminal procedures fail.
References 1 Schorn B, Reitmeier F, Falk V, Oestmann JW, Dalichau H, Mohr FW. True aneurysm of the superior gluteal artery: case report and review of the literature. J Vasc Surg 1995; 21(5):851–854. 2 Holland AJ, Ibach EG. False aneurysm of the inferior gluteal
EJVES Extra, 2004
artery following penetrating buttock traulma: case report and review of the literature. Cardiovasc Surg 1996; 4(6):841–843. 3 McMillan WD, Smith ND, Nemcek Jr A, Pearce WH. Transcatheter embolization of a ruptured superior gluteal artery aneurysm: case report and review of the literature. J Endovasc Surg 1997; 4(4):376–379. 4 Grand C, Delcour C, Bank WO, Braude P, Dereume JP, Struyven J. Emergency embolization of a mycotic aneurysm of the superior gluteal artery: case report. Cardiovasc Intervent Radiol 1992; 15(2):117–119. Accepted 16 March 2004