Vessel rupture by balloon catheters complicating chronic steroid therapy.

Abstract

A 69-year-old white woman with a 6-year history of steroid use for collagen vascular disease was admitted for disabling bilateral hip, thigh, and calf claudication. Femoral pulses were diminished bilaterally, and no palpable pulses were present distally. Outpatient intravenous digital subtraction angiogram showed bilateral iliac artery stenoses. Medical history was remarkable for an 8-year history of a poorly defined collagen vascular disorder labeled as systemic lupus erythematosus, hypersensitivity angiitis, and polyarteritis nodosa. She had been treated with high-dose steroids for 6 years. On admission, she was on prednisone, 40 mg alternating with 60 mg daily. Arteriography revealed diffuse atherosclerotic disease with a 70%80% irregular distal right common iliac artery stenosis and an 80% concentric distal left external iliac artery stenosis (fig. 1A). The right external iliac artery measured 8 mm in diameter in its most normalappearing part. The left external iliac artery at the pelvic rim level measured 8 mm in diameter. Both lesions were dilated with a 7.0-French woven Dacron balloon angioplasty catheter with a balloon 8 mm in diameter and 3 cm long. The right common iliac artery lesion was dilated easily with two balloon inflations for about 45 sec each. A postdilatation arteriogram revealed significant improvement in the lumen with a nonobstructive subintimal dissection. The left external iliac artery lesion was then dilated twice to about 6 atm without elimination of a significant waist in the balloon. On the third inflation, there was sudden disappearance of the balloon waist. Postdilatation test angiograms revealed extravasation from the angioplasty site. The final arteriogram showed occlusion of the left external iliac artery with severe displacement of the bladder to the right by an enlarging pelvic mass (fig. 1 B). The angioplasty catheter was advanced into the left common iliac artery for possible tamponade. At emergency surgery, the subcutaneous fat and supporting tissues were very fragile and edematous with atrophic muscle and attenuated fascia. Macroscopically, there was a 4-cm-long arterial disruption that was partially obscured by the hemorrhagic process and local tissue discoloration. Any chronic arterial changes that might have been present were thus obscured at the time of surgery. Part of the iliac artery, however, was sent for histologic evaluation, and the sections showed a relatively typical elastic artery in which the media was thinned and disrupted. The elastic membranes were noted to be distorted and focally destroyed. In addition to these unusual changes, rather typical atherosclerotic findings were also present, with the intima showing signs of proliferation associated with ulceration and complex atherosclerotic plaque formation. Endarterectomy of the external iliac and common femoral arteries was carried out, followed by a Dacron patch angioplasty. Hypotension and cardiac arrest occurred intraoperatively, but the patient was successfully resuscitated, and a Swan-Ganz catheter was placed in the right pulmonary artery for monitoring. Postoperatively, difficulty was encountered in wedging the SwanGanz catheter. The introducing sheath was accidentally removed, and the Swan-Ganz catheter subsequently pulled out. One hour later, bleeding was observed in the endotracheal tube and the patient became hypotensive, but responded to intravenous fluid replacement and vasopressor, and the bleeding decreased spontaneously. A new Swan-Ganz catheter was placed, but the catheter was not wedged. A bedside chest radiograph revealed a new right-lower-lobe infiltrate in the area related to the Swan-Ganz catheter. Bronchoscopy revealed a small hemorrhage from the right lower lobe. While under observation 24 hr later, the patient suddenly became hypotensive and arrested. She failed to respond to the usual resuscitative measures. Right chest thoracentesis revealed a hemothorax. A right thoracotomy showed a ruptured right pulmonary artery. The hilum was clamped, but the patient died.