case_images: PMC10627186_01
case_images: Initial computed tomography scan shows (A) dissecting aneurysms (yellow arrow) from right common iliac artery to (B) external iliac artery and aneurysmal dilatation of left external iliac artery (yellow arrowhead). (B, C) Hemoperitoneum was detected in the pelvic cavity and the area surrounding right superficial femoral artery; however, no active bleeding was detected. (D) Intraoperative fluoroscopic angiography shows pathological aneurysms on both sides.
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case_images: PMC10627186_01_fsurg-10-1268671-g001.jpg
case_images: F1
case_images: The patient had a history of bruising easily since childhood and his skin was so lucent that the superficial vein was markedly visible (Supplementary Figure S1). Hemoperitoneum was observed in the right groin and pelvic cavity, but there was no evidence of active bleeding (Figures 1A-C). Due to concerns associated with ruptured iliac artery aneurysm, urgent operation was performed and intraoperative fluoroscopic angiography confirmed the CT findings (Figure 1D).
case_images: Field of the 1st operation. (A) After the 8-mm Dacron graft and the right common femoral artery were anastomosed using felt pledgets, the Dacron interposition graft was punctured near the distal anastomosis and a 7 Fr sheath and 0.035-inch guidewire were inserted. The Dacron graft was inserted to overlap the iliac stent-graft by approximately 5 cm in length while controlling inflow with an inflated balloon catheter along the guidewire that entered the iliac stent-graft. A 10 mm x 58 mm LifeStream  balloon-expandable covered stent (Bard Peripheral Vascular, Tempe, AZ, USA) was then placed in the nested area for fixation. (B) After removal of sheath and before wound closure, reinforcement with 6-0 Prolene sutures was performed sparsely between the stent-graft of external iliac artery (EIA) and Dacron graft, which was inserted within the EIA stent-graft. (C) The final angiogram shows successful placement of the overlapping stent-grafts with no folds.
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case_images: PMC10627186_01_fsurg-10-1268671-g002.jpg
case_images: F2
case_images: The final angiogram revealed no extravasation or stenotic occlusions (Figure 2). Fourteen months after the second operation, the patient is currently on a beta-blocker to control blood pressure and has been monitored in an outpatient clinic (Supplementary Figures S2, S3).
case_images: The initial computed tomography angiography before the 2nd operation reveals (A, B) an arteriovenous fistula (yellow arrow) between left internal iliac artery and left common iliac vein. Simultaneous contrast enhancement of arteries and veins is confirmed. (C, D) Large amount of hematoma near infrarenal inferior vena cava probably due to the intravenous high pressure generated by the iliac arteriovenous fistula and disease-specific vascular fragility.
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case_images: PMC10627186_01_fsurg-10-1268671-g003.jpg
case_images: F3
case_images: A CT scan showed an arteriovenous fistula (AVF) between left internal iliac artery (IIA) and left common iliac vein (CIV), and a large amount of hematoma near infrarenal inferior vena cava (Figure 3). Fourteen months after the second operation, the patient is currently on a beta-blocker to control blood pressure and has been monitored in an outpatient clinic (Supplementary Figures S2, S3).
case_images: (A) A schematic diagram showing preoperative planning [red, left iliac artery; blue, left common iliac vein (CIV); yellow, self-expanding stent; light green, stent-graft; gray, microcoils]. (B) Initial intraoperative angiography shows simultaneous contrast filling in the left iliac artery and left CIV. (C) Even after coil embolization on both ends of the self-expanding stent, angiography shows contrast-filled left CIV. Proximal internal iliac artery before fistula was too short and the fistula was larger than expected. The yellow arrowhead indicates fluttering coils into the iliac vein through the fistula. (D) The 13 mm stent-grafts were placed across the left iliac arteries to block the flow through the fistula. (E) A final angiogram shows that patent stent-grafts in the iliac arteries without any flow through the fistula into the iliac veins. (F) On postoperative day 10, a CT scan revealed a decreased extent of intraabdominal hematoma with no signs of bleeding. Additionally, the scan showed calcinosis surrounding the right common femoral artery and external iliac artery, as well as well-patent iliac stent-grafts and successful embolization of the left internal iliac artery.
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case_images: PMC10627186_01_fsurg-10-1268671-g004.jpg
case_images: F4
case_images: The final angiogram revealed no leakage (Figures 4A-E). On postoperative day 18, the patient was discharged with an anticoagulant prescription after confirmation of no further bleeding (Figure 4F).