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Surgical Management of Ruptured Iliac Artery Aneurysm by Inlay Grafting

Dept. of Cardiothoracic Surgery and Dept. of Anaesthesiology G. Kuppuswamy Naidu Memorial Hospital Pappanaickenpalayam Coimbatore 641037, India

We recently treated a case of ruptured isolated iliac artery aneurysm and would like to focus attention on the surgical repair of this uncommon and life-threatening lesion. The patient was an obese diabetic 64-year-old male who presented with hypertension and increasing pain in the right iliac fossa and dysuria. A 6.6-cm aneurysm of the right common iliac artery was demonstrated by abdominal ultrasound scan. No pulsatile mass could be detected. Shortly after admission he collapsed and was resuscitated with volume infusion. It was evident that the aneurysm was leaking and the patient underwent emergency exploration without further vascular studies.

With full monitoring, a laparotomy was carried out with a long midline incision. A parietal hernia had to be reduced. There was no blood in the peritoneal cavity. A region measuring 8 6 cm of the right iliac artery was discolored and pulsatile. The distal abdominal aorta and proximal common iliac artery on both sides were taped. The external iliac artery was not visible distally, hence distal control was secured from the right groin. The common iliac artery was clamped on the right and the common femoral artery was clamped distally. The opened aneurysmal sac was free of clots. The aneurysm had ruptured posteriorly. The proximal common iliac artery opening was 10 mm. This was anastomosed to an 8-mm Verisoft Cooley graft (Meadox Medical, Inc., Oakland, NJ, USA). The distal end could be identified only by passing a Fogarty catheter through the common femoral artery. The defect in the artery was bridged by the graft, restoring continuity. The internal iliac artery was not visualized at any stage. The common femoral artery opening was reconstructed and limb circulation restored.

The patient received 3 units of whole blood during the procedure and he was electively ventilated. Ventilatory support was needed for 4 days. There was serous drainage through the abdominal incision. Transient jaundice and deterioration of renal parameters was noted and on the 15th postoperative day he had wound dehiscence and was resutured. He subsequently made an uneventful recovery. His hypertension and diabetes were under control and he was prescribed aspirin in addition to his other medications. At the time of discharge the abdominal wound had healed well and distal pulses were palpable on both sides.

Isolated iliac artery aneurysms are relatively rare.¹ The most common cause is atherosclerosis although conditions such as pregnancy, infection, postoperative injury, dissection, trauma, Marfan syndrome, and other collagen disorders may be causative factors. The presentation reflects involvement of adjacent structures either by compression or erosion. Symptoms consequently arise from gastrointestinal, genitourinary, neurologic, or venous involvement. Rupture is inevitable and the perioperative mortality is in the range of 39% to 50%.² Recently, the use of self-expanding or balloon-expandable stents has been reported.^3,4 However, while these less invasive procedures are in the developmental phase, surgery with inlay grafting is the recommended treatment.⁵

REFERENCES

1. Brunkwall J, Hauksson H, Bengtsson H, et al. Solitary aneurysms of the iliac artery system: an estimate of their frequency of occurrence. J Vasc Surg 1989;10:381–4.[Medline]

2. Schuler JJ, Flanigan DP. Iliac artery aneurysms. In: Bergan JJ, Yao JST, editors. Aneurysms: diagnosis and treatment. New York: Grune & Stratton, 1982:469–85.

3. Vorwerk D, Gunther RW, Wendt G, Schurmann K. Ulcerated plaques and focal aneurysms of iliac arteries: treatment with noncovered, self-expanding stents. AJR Am J Roentgenol 1994;162:1421–4.[Abstract/Free Full Text]

4. Blais C, Bonneau D. Postangioplasty pseudoaneurysm treated with a vascular stent. AJR Am J Roentgenol 1994;162:238–9.[Medline]

5. McCready RA, Pairolero PC, Gilmore JC, et al. Isolated iliac artery aneurysms. Surgery l983;93:688–93.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Srinivasan Muralidharan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Muralidharan, S. Articles by Krishnan, E. Search for Related Content PubMed Articles by Muralidharan, S. Articles by Krishnan, E.