Rupture of left common iliac artery aneurysm

Abstract

A hypertensive 73-year-old man was found unconscious after cardiopulmonary arrest at his home and was brought to the emergency department by ambulance with cardiopulmonary resuscitation in progress. His Glasgow coma scale was 3, and there was no blood pressure. At the time, the hemoglobin value was 9.7 g/dL and the serum creatinine level was 2.0 mg/dL. Arterial blood gas analysis showed severe metabolic acidosis. The patient was resuscitated and underwent a rapid computed tomography (CT) scan. This detected a rupture of a left common iliac artery aneurysm (56 mm diameter), with a massive hematoma in the left retroperitoneal space (A, B). He was taken to the operating room, but on arrival had again lost his blood pressure despite fluid and blood resuscitation. In an attempt to obtain hemodynamic control, the descending thoracic aorta was rapidly clamped through a 5th right intercostal space thoracotomy. After the blood pressure returned, a laparotomy was performed. Bloody fluid was encountered in the peritoneal cavity, and the retroperitoneal space was filled with hematoma, consistent with rupture of the left common iliac artery. The patient died in the operating room before repair could be accomplished. Stent-graft treatment was not possible because it is not available in our institution. Subsequent three-dimensional CT (3D-CT) reconstruction demonstrated a bleeding mass from the left common iliac artery aneurysm that appeared as a “fireball” (C, Cover). The mortality rate of patients with ruptured abdominal aortic aneurysm arriving at hospital ranges from 32% to 70%, and in one study, the mortality rate increased to 90% if patients who died in transit or at home were included. Ruptured iliac aneurysms, although much less common, have a similar prognosis. The factors associated with a mortality rate are unconsciousness, low systolic blood pressure, cardiac arrest, low urine output, high serum creatinine levels, and signs of blood loss. In the present case, all these factors were present. The unusual appearance of the reconstructed 3-D CT scan was most likely associated with very rapid blood extravasation from the ruptured aneurysm.