A 64-year-old woman with recurrent metastatic endocervical cancer and history of pelvic surgery and radiation, with recent history of contained sigmoid colon perforation (managed conservatively after patient refused surgery) presented to the emergency department with recurrent attacks of bright red blood per rectum over the past day (10 attacks) with dizziness, tachycardia and a Hb of 6.6 mg/dL. Patient has indwelling ureteric stents that were exchanged 6 weeks prior, with no complications. Computed Tomography Angiography of the abdomen and pelvis showed a 9 mm pseudoaneurysm arising from the proximal left external iliac artery related to impingement on the vessel by two surgical clips, and in close proximity to the contained sigmoid perforation, which was expected to be the source of the hematochezia (Fig. 1a & b). Patient was taken to the interventional radiology angiography suite for endovascular management of the pseudoaneurysm.
In the angio suite, the patient had another attack of bright red blood per rectum immediately before starting the procedure. Right common femoral artery access was achieved and a Sos Omni 2 catheter (Soft-Vu; Angiodynamics Inc., New York, USA) was used to cross into the left Common Iliac artery. Left Common Iliac artery angiography showed the pseudoaneurysm arising just distal to the origin of the left external iliac artery, with stenosis and tortuosity just proximal to its origin, likely related to the surgical clips (Fig. 2a), with contrast extravasation seen reaching the contained colonic perforation, and delayed images showing contrast reaching the sigmoid colon (Fig. 2b). Attempts to cross the pseudoaneurysm using a 2.8 Fr microcatheter (Progreat; Terumo Medical, Tokyo, Japan) were unsuccessful, likely due to severe stenosis by the surgical clips, with passage of the microcatheter into the colonic perforation. Left common femoral artery access was achieved and attempts to cross the pseudoaneurysm retrograde using a 2.8 Fr microcatheter were also unsuccessful, with the microcatheter again leaving the intra-vascular space and passing into the colonic perforation cavity. The right access microcatheter was then navigated into the colonic perforation cavity over a 0.018″ inch microwire (Glidewire GT guidewire; Terumo Medical, Tokyo, Japan) and a snare device (ENsnare 9–15 mm; Merit Medical, Philadelphia, USA) was then navigated into the same cavity from the left access (Fig. 3a). The microwire was snared successfully within the colonic perforation cavity and pulled out of the left groin access, achieving access across the pseudoaneurysm (Fig. 3b). The microcatheter was then advanced across the pseudoaneurysm and out of the left groin access. With the distal tip of the microcatheter secured outside, the 0.018″ inch Glidewire was exchanged for an exchange-length stiff microwire (300 cm V-18 Controlwire; Boston Scientific, Marlborough, Massachusetts) which was secured outside the patient’s body, providing secure access across the pseudoaneurysm. The microcatheter was removed, and two overlapping 7 mm × 5 cm covered stents (Viabahn; Gore medical, Delaware, USA) were deployed over the wire across the pseudoaneurysm. The stent diameter was chosen based on measurements of the proximal external iliac artery, and initially one stent was placed covering the pseudoaneurysm, but the stent was extended distally when angiographic evidence of dissection was seen distal to the stent. The final angiogram showed no contrast extravasation with good flow into the left External Iliac Artery (Fig. 3c).
The patient was placed on broad-spectrum antibiotics immediately following the procedure and admitted to the intensive care unit. Five days later, the patient was discharged from the intensive care unit after stabilization of her acute clinical course, with negative blood cultures. Following extensive family discussions and given progression of her disease, the patient requested to assume Do Not Resuscitate/Do Not Intubate status and the patient succumbed to her disease 20 days later.