EXTERNAL ILIAC ARTERY PSEUDOANEURYSM AND VESICAL FISTULA

Alper Kunt, *Canser Yılmaz Demir

SSK Malatya Hastanesi, Kalp Damar Cerrahisi Kliniği, Malatya
*SSK Malatya Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, Malatya

Abstract

Diagnosis of an isolated external iliac artery aneurysm is rendered extremely diffucult. A 69 years old female who had external iliac artery pseudoaneurysm and vesical fistula and who had had progressively symptomatic urinary bleeding was admitted to our clinic. Arteriography revealed an aneurysm of the right external iliac artery with compression of the vesica. Ultrasound and computerised tomography showed right external iliac aneurysm. Cystoscopy revealed active bleeding. Arteriography revealed an aneurysm of the right external iliac artery with compression of the vesica. Patient did well postoperatively and was discharged. We suggest that definitive treatment is open surgery like this life-threatening external iliac artery pseudoaneurysm and vesical fistula.

Abstract

An isolated iliac aneurysm is a rare vascular entity. The true incidence of isolated iliac aneurysm is quite small and has been considered 1.5% of that of an abdominal aortic aneurysm [1]. Diagnosis of an isolated external iliac artery aneurysm is rendered extremely difficult because of its indisious onset and its often deep pelvic location. As these aneurysms enlarge they produce symptoms of compression on the intra-pelvic structures, notably the lumbosacral plexus, urinary bladder, or bowel. Arteriovesical fistulas are rare, but have been reported more commonly over the last decades. Classic treatment is based on open surgery. We report one patient in whom acute life-threatening external iliac artery pseudoaneurysm and vesical fistula was successfully treated with open surgery.

Case Presentation

A 69 years old female patient developed anaemia with macroscopic haematuria. She had a history of coronary bypass surgery five years ago. Ultrasound showed a right external iliac aneurysm (Figure 1). Computerised tomography (CT) of the abdomen confirmed a right external iliac aneurysm of 7.1 cm in length and 4.2 cm in diameter and an encased right side of vesica (Figure 2). Cystoscopy revealed active bleeding. Arteriography revealed an aneursym of the right external iliac artery with compression of the vesica (Figure 3). At exploration an isolated aneurysm of the right external iliac artery, 7.1 cm in length, and entrapment the right side of vesica and perianeurysmal fibrosis was observed. Aneurysm was not invaded into the right ureter. We resected the aneurysm and aortofemoral bypass graft was placed and the bladder defect was suturated. The right renal function has been stable after the surgery.

Figure 1. Ultrasound showed right external iliac aneurysm.

Figure 2. Right iliac artery aneurysm and encased right side of vesica on computerized tomography.

Figure 3. Arteriography revealed an aneurysm of the right external iliac artery with compression of the vesica.

Case Presentation

Discussion

The incidence of isolated iliac artery aneurysm is 1.5%. Patients with iliac artery aneurysms are most likely to present with urological manifestations [2,3]. Isolated iliac aneurysm often gives rise to urinary tract obstruction. Iliovesical fistula are very rare but have become more common in the last few decades because of a greater prevelance of the factors involved in their etiology (prior pelvic or vascular surgery, pelvic radiotherapy, prolonged uretheric stending, and associated vascular pathology) [4,5].

Most investigations, apart from arteriography, rarely provide specific findings (because of the intermittent nature of the fistula), and the diagnosis depends upon the clinical evidence (ureteric haemorrhage and the presence of predisposing factors). In some cases the definitive diagnosis is made only at the time of surgical exploration. Aneurysms may be more extensive in the retroperitoneum, resembling idiopatic retroperitoneal fibrosis [2,3].

Surgical management of iliac aneurysms is based on general principles of adequate exposure, isolation of the artery, excision, and interposition of a graft. We resected the aneurysm and aortofemoral bypass graft was placed.

We have reported one patient who underwent successfully repair of external iliac pseudoaneurysm and vesical fistula. We concluded that definitive treatment is based on open surgery.

Discussion

References

1) Haimovici H. Isolated iliac aneurysms. In: Haimovici H, ed. Haimovici’s Vascular Surgery. Massachuatess: Blackwell Science, 1996:853-62.

2) Minato N, Itoh T, Natsuaki M, et al. Surgical treatment of isolated iliac artery aneurysm with ureteral obstruction and/or renal failure. J Cardiovasc Surg 1990;31:189-93.

3) Marıno R, Mooppan UM, Zein TA, Flores L, Kim H. Urological manifestations of isolated iliac artery aneurysms. J Urol 1987;137:232-4.

4) Batter SJ, McGovern FJ, Cambria RP. Ureteroarteriel fistula: Case report and review of the literature. Urology 1996;48:481-9.

5) Cass AS, Odland M. Ureteroarterial fistula: Case report and review of literature. J Urol 1990;143:582-3.

References

Keywords : Iliac artery, vesical fistula, pseudoaneurysm

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