Surgical Treatment for Acute Rupture of Iliac Artery Aneurysm Caused by Invasion of Retroperitoneal Leiomyosarcoma

A 66-year-old female presented with a > 10-year history of hypertension. She began to experienced dull pain in the lower abdomen and abdominal distension two days prior to admission. When she defecated six hours before admission, the pain suddenly aggravated and gradually spread to the whole abdomen, accompanied by dizziness, nausea, and vomiting, as well as symptoms of shock, including prefuse whole-body sweating and chills in all four limbs. Blood pressure was only 74/59 mmHg, she was semilucid with a pained expression, and limbs were wet and cold. Her stomach was distended and felt soft. The whole abdomen was sensitive to applied pressure, particularly the lower abdomen. Abdominal puncture was performed to draw a sample of non-condensable blood. Immediate emergency care included rapid fluid infusion and a blood transfusion. A CT scan revealed an abdominal enhancement consistent with expansion of the right iliac artery and there were masses in the soft tissues adjacent to the common iliac artery. There also appeared to be retroperitoneal hematomas, hence rupture of the aneurysm was suspected (Figure 1). Emergent exploratory laparotomy was performed under general anesthesia, and ≈3000 ml of clotted blood was removed. There was still active bleeding at the site where the pelvic retroperitoneal rupture occurred. Pressure was applied to the site, hematocele was drawn completely. The abdominal aortic branch to the renal lower segment was quickly dissociated and controlled, after which active bleeding decreased significantly. The right iliac artery was expanded significantly to around 3.0 cm in diameter and dilation extended to the initial parts of the common and internal iliac artery. Inside the artery was a solid tumor about 5.0 cm × 5.0 cm × 4.0 cm. The surface of the tumor was ulcerated and bled, its center was necrotized and liquefied and it appeared fish–flesh. The lower border was unclear, and the other extreme was close to the bifurcation of the right common iliac artery (Figure 2). The distal and proximal arteries to the right iliac aneurysm were re-clamped and finely dissociated from around the solid tumor. The distant end of the aneurysm was found to be eroded by ulceration of the solid tumor, forming a laceration about 0.6 cm in diameter. The laceration was connected to the necrotized center of the solid tumor. The bottom of the solid tumor adhered to the pelvic wall. The solid tumor and the right iliac aneurysm were completely resected, and a prosthetic graft (D=8mm, Intervascular) were used to form an end-to-end anastomosis of the common external iliac arteries (Figure 3). Postoperative pathology showed fusocellular sarcoma cells in a fascicular arrangement with high mitotic counts and cytoplasmic acidophilia, consistent with retroperitoneal leiomyosarcoma. Sections of the iliac artery expanded with the tumor and cholesterol crystals were observed in the vessel wall under a microscope. Nearby giant cells reacted with calcification. Postoperative vital signs were fairly stable and the patient recovered without complications. Adjuvant chemotherapy was given after surgery. Follow-up continued for 16 months, at which time CT detected local recurrence, but the patient refused another operation or chemotherapy and died 20 months later from tumor metastasis. Volume 7 Issue 2 2017