CASE REPORT
Ruptured Pseudoaneurysm of the External Iliac Artery in an Advanced Cervical Cancer Patient Treated by Endovascular Covered Stent Placement Wan-Yi Huang, Chia-Yen Huang, Chi-An Chen, Chang-Yao Hsieh, Wen-Fang Cheng* The formation of pseudoaneurysms in patients with gynecologic malignancies is rare. We describe a patient with locally advanced cervical cancer who had life-threatening rectal bleeding due to a ruptured pseudoaneurysm of the right external iliac artery, which was successfully treated by emergent endovascular covered stent placement. This 56-year-old woman had received concurrent chemoradiation, salvage hysterectomy and systemic chemotherapy for advanced cervical cancer. About 25 months after her diagnosis of cervical cancer, she suffered from acute life-threatening rectal bleeding. Angiography revealed active extravasation from a pseudoaneurysm of the right external iliac artery. A covered stent was placed across the pseudoaneurysm via an endovascular approach to stop the bleeding. The patient recovered well without any sequelae. We believe that this technique might also be useful in other irradiated gynecologic cancer patients, especially when direct surgical repair is difficult to perform due to pelvic irradiation or tumor recurrence. [J Formos Med Assoc 2008;107(4):348–351] Key Words: cervical cancer, covered stent, external iliac artery, pseudoaneurysm
Case Report
Iliac artery pseudoaneurysms are rare and often result from trauma, tumor, infection, vasculitis and inflammation, atherosclerosis, infarction, and various iatrogenic complications such as those from surgery or angiography.1 Although pseudoaneurysms may undergo spontaneous thrombosis, symptomatic pseudoaneurysms with infection, local compression or rupture should be treated properly.2 We present a patient with locally irradiated advanced cervical cancer who had sudden life-threatening rectal bleeding due to a ruptured pseudoaneurysm of the right external iliac artery. The emergent placement of an endovascular covered stent was performed and successfully stopped the bleeding.
A 56-year-old, gravida 6, para 4, woman was diagnosed with cervical squamous cell carcinoma stage IIb. She had received concurrent chemoradiation with weekly cisplatin treatment and external beam radiation therapy of 59.4 Gy in 33 fractions to her whole pelvis plus brachytherapy. Salvage total abdominal hysterectomy with bilateral salpingooophorectomy was performed due to persistent disease. However, magnetic resonance imaging 7 months later detected local recurrence at the right parametrium and right pelvic sidewall. Bilateral obstructive uropathy with vesicovaginal fistula and rectovaginal fistula were also noted. Loop
©2008 Elsevier & Formosan Medical Association .
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Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan. Received: February 26, 2007 Revised: June 12, 2007 Accepted: August 7, 2007
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*Correspondence to: Dr Wen-Fang Cheng, Department of Obstetrics and Gynecology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail:
[email protected]
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colostomy of the transverse colon and bilateral nephrostomy were performed. Palliative chemotherapy with 5-fluorouracil and leucovorin was given every 3 weeks. Sudden onset of massive rectal bleeding was noted the day after her fifth chemotherapy session in the hospital, about 25 months after the diagnosis of cervical cancer. No definite history of trauma or preceding abdominal pain could be identified. Loss of consciousness and cardiovascular collapse occurred immediately. Physical examination showed that the bleeding was from the rectum. Although cardiopulmonary resuscitation and massive blood transfusion with 10 units of whole blood were given, the patient remained unconscious and in a state of shock. Lower gastrointestinal bleeding with unstable hemodynamics was highly suspected. Emergent aortogram and selective pelvic angiogram showed a pseudoaneurysm arising from the right external iliac artery with active contrast extravasation into the rectum (Figure 1). Mild irregularity of the adjacent vascular wall was also noted. Due to the patient’s poor clinical condition and extensive tumor recurrence in the pelvis, vascular surgery was not recommended. Endovascular management of the ruptured pseudoaneurysm was attempted to stop the bleeding. A 10-Fr vascular sheath was inserted into the right femoral artery under local anesthesia. A self-expandable covered stent (Wallgraft®; Boston Scientific/Medi-tech, Natick, MA, USA), measuring 6 mm in diameter and 30 mm long, was then placed across the pseudoaneurysm of the right external iliac artery. The post-stenting angiogram showed successful obliteration of the pseudoaneurysm with a patent right external iliac artery (Figure 2). The whole procedure, including the diagnostic angiography and stenting, took 1 hour and 25 minutes. The rectal bleeding stopped dramatically after stenting, and the patient’s hemodynamics became stable. She regained consciousness within several hours and was extubated the next day. She was discharged from our hospital 3 weeks later. No specific complication related to endovascular covered stent placement could be identified. J Formos Med Assoc | 2008 • Vol 107 • No 4
Figure 1. Angiography shows that the pseudoaneurysm (arrow) arising from the right external iliac artery has ruptured into the rectum.
Figure 2. Post-stenting angiography shows obliteration of the pseudoaneurysm by the covered stent (between arrows) with a patent right external iliac artery.
Discussion Pseudoaneurysms represent a pulsating hematoma arising from a disruption in arterial wall continuity.1,2 The common causes of pseudoaneurysms include trauma, tumor, infection, vasculitis and inflammation, atherosclerosis, infarction, and 349
W.Y. Huang, et al
various iatrogenic complications such as those from surgery and angiography.1 Pseudoaneurysms are usually asymptomatic and detected incidentally during surgery or radiographic study unless infection, local compression on neurovascular structures, or rupture occurs.2,3 Isolated iliac artery pseudoaneurysms related to malignancies are rare, and rupture at this site usually manifests as acute low abdominal pain with unstable hemodynamics.4,5 In some cases, iliac artery pseudoaneurysms have communication or fistulas with adjacent visceral organs, so bleeding from the gastrointestinal tract or genitourinary tract may occur.6,7 Rupture of iliac artery pseudoaneurysms usually demands immediate surgical repair, but surgery involves high mortality and morbidity risks, especially for debilitated patients in the emergency setting.8 Recently, there have been reports of successful management of ruptured pseudoaneurysms by endovascular approaches. In the internal iliac arteries, embolization of the bleeding arteries by coil occlusion can be achieved without further bypass surgery.6,9 However, in the common iliac arteries or external iliac arteries, after temporary vascular control with balloon occlusion or coil occlusion, bypass surgery is required to prevent ischemia in the ipsilateral lower extremity.5,6 A covered stent is an attractive alternative choice that could eliminate the need for further difficult open bypass surgery, especially for patients who have previously received radiation therapy or surgery.4,7,8 It is also a safe and convenient method that can be performed immediately after diagnostic angiography via the same vascular sheath.10 There are only a few case reports of iliac artery pseudoaneurysms related to gynecologic malignancies.6,7 In our case, the formation of the external iliac artery pseudoaneurysm might be radiationinduced or the result of vasculitis and inflammation secondary to extensive tumor recurrence. The poor clinical condition of this patient, previous surgery and radiation therapy, and locally advanced cancer status all excluded the possibility of direct surgical repair. Conventional angiography enabled prompt diagnosis and management in this patient, 350
and endovascular treatment with covered stent was safe and effective even in such a critical condition. Endovascular treatment is considered to be a lowrisk procedure for repairing various types of peripheral vascular lesions, including pseudoaneurysms.10 Not only can it be performed under local anesthesia in an emergent setting, but it also has a more rapid recovery period after the procedure, thus leading to shorter hospitalization times.10 Endovascular covered stent placement is indicated in excluding a pseudoaneurysm arising from an inexpendable donor artery with a wide neck relative to the diameter of its donor artery.2 The immediate risk of covered stent placement is intraprocedural rupture of the pseudoaneurysm.2 However, physicians should also be aware of possible late complications such as stent occlusion, infection, stent deformation and kinking, loss of vessel branches after placement, and intimal hyperplasia.2,10 In conclusion, we demonstrated that the utilization of endovascular covered stent placement was successful in this patient. This technique might also be used in similar situations in other irradiated gynecologic cancer patients. Awareness of this rare complication, prompt diagnosis, and immediate treatment are key factors in saving the lives of such patients.
References 1. Sueyoshi E, Sakamoto I, Nakashima K, et al. Visceral and peripheral arterial pseudoaneurysms. AJR Am J Roentgenol 2005;185:741–9. 2. Saad NE, Saad WE, Davies MG, et al. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005;25(Suppl 1):S173–89. 3. Morgan R, Belli A. Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Intervent Radiol 2003;14:697–710. 4. Bierdrager E, Lohle PN, Schoemaker CM, et al. Successful emergency stenting of acute ruptured false iliac aneurysm. Cardiovasc Intervent Radiol 2002;25:72–3. 5. Teodorescu VJ, Reiter BP. Common iliac artery pseudoaneurysm following inguinal hernia repair—a case report and literature review. Vasc Surg 2001;35:239–44. 6. de Baere T, Qusehal A, Kuoch V, et al. Endovascular management of bleeding iliac artery pseudoaneurysms complicating radiation therapy for pelvic malignancies. AJR Am J Roentgenol 1998;170:349–53.
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Aytekin C, Boyvat F, Yildrim E, et al. Endovascular stent-graft placement as emergency treatment for ruptured iliac pseudoaneurysm. Cardiovasc Intervent Radiol 2002;25:320–2. 8. Sanada J, Matsui O, Arakawa F, et al. Endovascular stentgrafting for infected iliac artery pseudoaneurysm. Cardiovasc Intervent Radiol 2005;28:83–6.
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9. de Godoy JM, Reis LF, Casagrande M, et al. Treatment of internal iliac artery pseudoaneurysm by an endovascular approach. J Chin Med Assoc 2005;68:435–6. 10. Onal B, Ilgit ET, Kosar S, et al. Endovascular treatment of peripheral vascular lesions with stent-grafts. Diagn Intervent Radiol 2005;11:170–4.
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