|Year : 2020 | Volume
| Issue : 1 | Page : 56-58
External iliac artery pseudoaneurysm following radical cystectomy: A report of two cases
Abhishek Laddha, Ginil Kumar Pooleri, Appu Thomas
Department of Urology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
|Date of Submission||13-Aug-2019|
|Date of Acceptance||02-Nov-2019|
|Date of Web Publication||2-Jan-2020|
Department of Urology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
External iliac artery pseudoaneurysm is a rare complication following radical cystectomy and pelvic lymph node dissection. We report two cases that developed external iliac artery pseudoaneurysm following radical cystectomy and pelvic lymph node dissection with an ileal conduit. Survival in these patients is dependent on early diagnosis and prompt intervention. Mortality in such cases remains high even with aggressive management.
|How to cite this article:|
Laddha A, Pooleri GK, Thomas A. External iliac artery pseudoaneurysm following radical cystectomy: A report of two cases. Indian J Urol 2020;36:56-8
| Introduction|| |
Radical cystectomy is the current gold standard of care for muscle-invasive bladder cancer. The procedure is associated with considerable morbidity (complications rates around 25%–57%) and mortality (around 3% or less). Vascular/peripheral vascular complications are reported in <1% of patients in radical cystectomy. Commonly reported complications include intraoperative injury to blood vessels, thromboembolism, phlebitis, or thrombophlebitis after procedure or transfusion. We report two cases of vascular aneurysm of the external iliac artery after radical cystectomy.
| Case Reports|| |
A 72-year-old diabetic and hypertensive male presented to us with a history of radical radiotherapy (66 Gy/33 cycles) for muscle-invasive bladder cancer in May 2005. He underwent radical cystectomy and pelvic lymph node dissection with ileal conduit in April 2018 for recurrent bladder tumor and intractable hematuria. He developed urine leak and was managed conservatively with urinary diversion by placement of the percutaneous nephrostomy on the 12th postoperative day (POD). On the 20th POD, he presented with pain and swelling in the right lower limb and was diagnosed to have right lower limb deep venous thrombosis on color Doppler with thrombus extending from the infrapopliteal area up to the external iliac vein. He was started on low-molecular-weight heparin (LMWH) followed by warfarin. He presented to us again at 2-month follow-up with complaints of right groin pain, and on magnetic resonance imaging (MRI), the abdomen was found to have an aneurysm in the right external iliac artery [Figure 1]. He underwent coiling of the aneurysm with femorofemoral bypass [Figure 2]. He developed features of sepsis after 1 month (92 POD) and was admitted in intensive care unit, required inotropic support and mechanical ventilation. On 94 POD, he developed cardiac arrest resulting from multiorgan dysfunction and sepsis and could not be revived.
|Figure 1: (a and b) Magnetic resonance imaging abdomen suggestive of the right external iliac artery pseudoaneurysm measuring 10 cm × 4.2 cm × 6.3 cm|
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|Figure 2: (a) Angiogram done before coiling showing the right external iliac artery pseudoaneurysm. (b) Angiogram done after procedure showing coil in place|
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A 71-year-old diabetic and hypertensive male underwent open radical cystectomy and pelvic lymph node dissection with ileal conduit following neoadjuvant chemotherapy for muscle-invasive bladder cancer in March 2019. He was discharged in stable condition on the 9th POD. He presented again with complaints of mild breathing difficulty on and off on the 17th POD. Doppler of bilateral lower limb veins was suggestive of deep vein thrombosis involving the right calf veins with a normal pulmonary angiogram. He was started on LMWH and shifted to warfarin with target INR of 2 on discharge. On the 31st POD, he presented to us in emergency with continuous bleeding from the stoma with features of shock. He was rushed to the operative room and urgent exploration with right common iliac artery ligation + femorofemoral bypass was done. Intraoperatively, massive blood transfusion with 8 units of packed red blood cells and 9 units of cryoprecipitate was given. Postoperatively, the patient continued to have hypotension and was on inotropic and ventilatory support. 42 h postexploration (33 days after primary surgery), he developed cardiac arrest and could not be revived.
| Discussion|| |
Iliac artery pseudoaneurysms are rarely reported after pelvic surgery.,, Pseudoaneurysms can be caused by trauma, infiltration by the tumor, infections, vasculitis, atherosclerosis, and iatrogenic injury to vessels during surgery. Vascular pseudoaneurysm can present with massive bleeding through stoma or sometimes with pain in the iliac fossa.
When the presentation is in less acute condition with stable vitals, options of management include endovascular interventions such as stent grafts or endovascular coiling and femorofemoral bypass if stenting is not possible. Successful endovascular intervention using a covered stent was reported in case of external iliac artery pseudoaneurysm rupture following pelvic lymphadenectomy for cervical cancer. In the case of infective pathology, stent placement is not advisable. In our first case, the patient presented with pain in the right iliac fossa; MRI was suggestive of the right external iliac pseudoaneurysm. The patient underwent endovascular coiling followed by femorofemoral bypass. Unfortunately, the patient went into sepsis after 1 month of surgery and could not be revived back to life.
In case of bleeding, urgent exploration is required as patients usually present with shock due to heavy intra-abdominal bleeding. After control of bleeding, continuity of vessels can be achieved by surgical revascularization (vascular grafts and autologous vessels) or ligation of the vessel and femorofemoral bypass. The second patient presented in emergency with continuous bleeding from the stoma with features of shock. He was taken for emergency exploration and ligation of the common iliac artery to control bleeding followed by femorofemoral bypass. In the immediate postoperative period, the patient developed cardiac arrest and could not be revived back.
Both patients were elderly diabetic with a history of deep vein thrombosis after surgery. Infection (local or resulting from embolism) and weakening of the vascular wall associated with the lymphadenectomy may have probably resulted in pseudoaneurysm in the early postoperative period with rupture. Microscopic injury to a vessel not detected during surgery is another probable cause. Infection in diabetic patients may result in brittle vessels resulting in rupture. Old diabetic patients may have atherosclerosis plaque which may rupture, resulting in weakness of vessel wall during lymphadenectomy possibly resulting in aneurysm at later date.
| Conclusion|| |
External iliac artery pseudoaneurysm is a rare life-threatening complication after radical cystectomy with pelvic lymphadenectomy. Elderly diabetic patients who present with a triad of diabetes, deep vein thrombosis, and infection are may be at higher risk of pseudoaneurysm and rupture. Key to management is early recognition and prompt intervention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest:
There are no conflicts of interest.
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[Figure 1], [Figure 2]