British Journal of Radiology (2007) 80, e7-e10
© 2007 British Institute of Radiology
doi: 10.1259/bjr/21729994
Successful stent-graft placement for the treatment of a superior gluteal artery pseudoaneurysm in a patient following complex pelvic surgery
P Roblin, FRCS(Plast), MSc
1
T Alexiou, MD
2
T Sabharwal, FRSCI, FRCR
2
J Reidy, FRCP, FRCR
2 and
D A Ross, FRCS(Plast)
1
Departments of 1Plastic Surgery 2Interventional Radiology, St Thomas' Hospital, Lambeth Road, London SE1 7EH, UK
Correspondence: Mr Paul Roblin, Department of Plastic Surgery, St Thomas' Hospital, Lambeth Road, London SE1 7EH, UK. E-mail: paulroblin{at}doctors.org.uk
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Abstract
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Aneurysms of the gluteal arteries are rare and were previously managed with open surgical procedures. Recently percutaneous embolisation techniques have helped reduce morbidity and mortality. A case is presented of a 63-year-old man who presented with haemorrhage and had developed a superior gluteal artery aneurysm following treatment for an invasive squamous cell carcinoma in the sacral area. There was concern that embolisation of the aneurysm might compromise the survival of the myocutaneous buttock rotation flaps that had been used for reconstruction. To overcome this, an endovascular stent was deployed to successfully close off the aneurysm whilst at the same time maintaining blood flow through the superior gluteal artery. Aneurysms in larger peripheral vessels have been managed with stents. However, this is the first reported case of this method of treatment being used in the management of gluteal artery aneurysms.
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Introduction
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This report reviews the management of an aneurysm of the superior gluteal artery (SGA), which developed following resection of a large squamous cell carcinoma over the sacroiliac (SI) joint. The joint was unstable as a result of sepsis and prior irradiation, which is thought to have resulted in trauma to the vessel. The patient had presented with repeated episodes of haemorrhage that were thought to be from this vessel site. The aneurysm was managed percutaneously via a transcatheter approach. The choice of procedure was complicated by previous reconstructive surgery to close a wound in the sacral area that would have interfered with the normally abundant collateral blood supply in this region.
In recent years, bleeding and aneurysms from this site have increasingly been managed by percutaneous embolisation rather than open surgical procedures. In this case it was thought inappropriate to embolise the SGA as this may have compromised the survival of myocutaneous buttock rotation flaps. Instead, an endovascular stent was inserted into the SGA across the neck of the aneurysm to successfully arrest the bleeding whilst maintaining distal flow through the artery.
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Case report
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A 63-year-old man with a 30 year history of a chronic pilonidal sinus was referred to our department with a large, 11 cm diameter, biopsy proven invasive squamous cell carcinoma in the sacral region. This was initially treated with chemotherapy and radiotherapy. Due to a left ventricular function of only 30% (the patient had a history of two myocardial infarctions), immediate surgical resection of the tumour was delayed by 3 months, during which time he underwent two-vessel coronary artery bypass grafting.
When the patient recovered, the tumour was completely resected, including the dorsal process of the sacrum. The defect was closed with a free latissimus dorsi muscle flap (anastomosed to the 11th intercostal artery and the 12th intercostal vein) and split skin grafts (SSG).
1 month post-operatively, the wound dehisced along the inferior margin and, at debridement of the wound, sepsis was discovered in the left SI joint. This was opened and "burred" and the wound closed with bilateral inferomedially based myocutaneous buttock rotation flaps and further SSGs. The wound dehisced once more, but was managed conservatively with dressings and the patient discharged home.
At a review 2 months later, the patient was found to be actively bleeding into the wound (haemoglobin 7.3 g dl–1). Exploration failed to reveal any specific bleeding points. Following transfusion he was monitored for 1 week, during which time the bleeding was intermittent although substantial, and seemingly related to mobility of the left SI joint. Exploration once again failed to reveal the source, although it appeared to be originating from within the pelvis. The buttock rotation flaps were re-advanced and the wound closed over suction drainage. Post-operatively there was intermittent bleeding into the drainage tubes and further blood transfusions were required to maintain the haemoglobin level.
A CT scan failed to reveal an intrapelvic collection of blood (Figure 1
). However, angiography indicated a pseudoaneurysm of the left SGA (Figure 2). At the time, there was no active extravasation from this. After clinical discussion and consent from the patient, it was decided to manage the aneurysm percutaneously.
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Figure 1. A CT scan of the pelvis(oral and intravenous contrast) showing the dissociation of the left sacroiliac joint. No significant haematoma is seen.
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Figure 2. Selective left internal iliac artery angiogram showing pseudoaneurysm(arrow) of the superior gluteal artery (SGA).
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The right common femoral artery was punctured and a standard J guide wire advanced in the abdominal aorta. A rim catheter was used to cross the aortic bifurcation and the guide wire advanced into the left common iliac artery. An Amplatz ultra stiff guide wire was positioned in the left internal iliac artery and over that wire a 6 Fr Balkin sheath (William Cook, Europe), positioned into the left internal iliac artery. Over the Balkin sheath, a 4 Fr cobra 2 catheter (William Cook, Europe) was manipulated with a Terumo guide wire into the SGA and an angiogram performed.
The angiogram revealed the extent of the aneurysm and a stiff 0.014 inch guide wire (Monorail system) was advanced through the Cobra catheter, into the SGA beyond the aneurysm. Parallel to the guide wire, a pre-mounted stent-graft (JOSTENT, Supreme System, Jomed AB, Helsingborg, Sweden) (4 mm diameter by 16 mm length) was positioned so that it covered the neck of the aneurysm (Figure 3). The balloon was filled with a positive pressure of 14 bar, and the covered stent-graft fully expanded to shield the neck of the aneurysm. The post-stenting angiogram showed a normal SGA and no compromise of the distal branches (Figure 4). No prophylactic antibiotics were given prior to the stent insertion.
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Figure 4. Post-stent grafting angiogram showing successful exclusion of the superior gluteal artery (SGA) pseudoaneurysm and with preservation of distal branches.
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After insertion of the stent there were no immediate complications or further episodes of bleeding. The patient was able to mobilize and was discharged 1 week later. It was then reported to us that the patient died a short while later, but unrelated to his bleeding episode.
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Discussion
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Aneurysms of the gluteal arteries are infrequent and account for less than 1% of all aneurysms. By 1995 only 123 cases had been reported, with the majority arising from the SGA rather than the inferior gluteal artery (IGA) [1].
The majority are due to either penetrating [2, 3] or blunt (with and without a pelvic fracture) trauma [4–6]. Iatrogenic injury can occur during orthopaedic procedures [7, 8] and from buttock injections [9, 10]. Rare causes are infective (mycotic aneurysms) [11, 12], polyarteritis nodosa [13] and artherosclerosis [1, 14]. In the case reviewed here, the SGA was thought to have been injured either during the resection of the SI joint or from movement and subluxation of this joint when mobilizing post-operatively.
Usually these aneurysms present as a swelling in the buttock and, if progressive, can cause pressure effects on the sciatic nerve. They may have a palpable thrill and a bruit on auscultation [3]. Diagnosis is confirmed with angiography. Any swelling in this region needs definitive diagnosis before any surgical intervention is attempted.
The management of these aneurysms has traditionally been surgical, by direct ligation of the aneurysm that was fraught with danger and usually inadequate because of the collateral blood supply, or by ligation of the internal iliac artery. Successful treatment was first described by Battle in 1898 when he combined both of these techniques [2]. A retroperitoneal or transperitoneal approach to the internal iliac artery allows control of any haemorrhage, permitting a safe direct exposure of the aneurysm for endoaneurysmorraphy [2, 3].
As this surgery is demanding and is accompanied by risks of haemorrhage and injury to the sciatic nerve, percutaneous techniques have been pursued. At first a combined approach with perioperative control of bleeding with a transcatheter balloon allowed the direct surgical procedure to proceed safely [1]. The percutaneous approach was advanced further by performing embolisation of the artery via this route. Materials used for this include coils [10, 14], coils and tissue adhesives [11], and coils and gelfoam [4, 8]. The materials are placed close to, or on either side of the neck of the aneurysm so that there is as little retrograde filling from the collateral blood supply as possible [10].
Due to the general condition of our patient, it was thought that a percutaneous technique would offer the safest method of arresting bleeding and occluding the pseudoaneurysm. However, a straightforward embolisation of the SGA proximal and distal to the neck of the aneurysm was not the ideal solution in this case because of the previous reconstructive procedures. The blood supply to the buttock rotation flaps is from the SGA and the IGA. During the raising of these flaps, the collateral blood supply that would normally supply the arteries distal to the embolisation point would have been interrupted and could not be relied upon.
Our aim was to block off the pseudoaneurysm to prevent further haemorrhage, but maintain the distal flow of blood through the SGA. True and false aneurysms have been packed which would ensure continued distal arterial flow, but this is difficult and dangerous due to the aneurysm's thin walls, particularly in false aneurysms where there is not a true wall [15]. To overcome this problem an endovascular stent was used, with the wall of the mid-portion of the stent placed over the neck of the pseudoaneurysm.
Balloon expanded and self-expanding covered stents have been used with a high immediate success rate for the management of aneurysms at other sites (subclavian, iliac, femoral, popliteal, axillary, splenic, renal, and head and neck arteries) [15–21], whilst maintaining flow through the vessels. Self-expanding covered stents have increased flexibility, allowing easier placement in more tortuous vessels [19]. In our case, the use of a self-expanding covered stent could have been considered. However, the ideal size was not available at that moment. Endovascular stents have not been previously used in the gluteal vessels. In this case they proved to be successful in achieving our dual aims of arresting bleeding and maintaining distal blood flow in addition to avoiding further operative risk.
Received for publication May 31, 2005.
Revision received November 16, 2005.
Accepted for publication January 10, 2006.
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Abstract
Introduction
