|Year : 2021 | Volume
| Issue : 2 | Page : 173-175
A peculiar case of iliac vein aneurysm
Rajeev Thilak Chellasamy, Hemachandren Munuswamy, BV Saichandran, Durga Prasad Rath
Department of Cardiothoracic and Vascular Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||04-Jun-2020|
|Date of Acceptance||09-Oct-2020|
|Date of Web Publication||13-Apr-2021|
Rajeev Thilak Chellasamy
Department of Cardiothoracic and Vascular Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Venous abdominal aneurysm is a rare entity, especially at the iliac vein. This condition is very rare and is usually grave when the aneurysm ruptures. It requires immediate treatment, surgically or by endovascular technique, to prevent such complications. Most of the iliac vein aneurysm cases are associated with arteriovenous fistula (AVF). We report the case of a 33-year-old male who presented with iliac vein aneurysm secondary to AVF. He was treated surgically after a failed endovascular procedure. The venous aneurysm had numerous feeder vessels which were difficult to manage intraoperatively. It prompted us to ligate the common iliac artery and do grafting between the common iliac artery and the common femoral artery. Iliac vein aneurysm diagnosis requires precise clinical suspicion, and the treatment is based on patients' clinical presentation and radiological features. Use of appropriate imaging modalities facilitates a correct preoperative diagnosis which consequently improves the surgical outcome.
Keywords: Aneurysm, arteriovenous fistula, iliac vein
|How to cite this article:|
Chellasamy RT, Munuswamy H, Saichandran B V, Rath DP. A peculiar case of iliac vein aneurysm. Indian J Vasc Endovasc Surg 2021;8:173-5
| Introduction|| |
Many sporadic cases of venous aneurysms have been reported all over the world, but a common iliac vein aneurysm is very rare. In 1989, Hurwitz and Gelabert reported the first case of thrombosed common and external iliac vein aneurysm. Because only few cases of iliac vein aneurysms have been reported in literature, very little is known about their natural history and treatment. The most common cause of iliac vein aneurysm is an arteriovenous fistula (AVF) secondary to trauma (43%). Primary aneurysm as such accounts for about 35%. Our case had iliac vein aneurysm with AVF between the internal iliac artery and the common iliac vein along with multiple feeders from the sacral plexus. This was unique and was the reason behind the failed stenting procedure. Iliac vessel injury following lumbar disc surgery is very rare. Patients present late as the symptoms due to AVF take time to develop.
| Case Report|| |
A 33-year-old male met with a road traffic accident following which he had low-back pain. Laminectomy was done 4 months following the accident. He started developing swelling in the right lower limb which gradually increased over a period of 6 months. There was a diffuse swelling of the right lower limb with dilated tortuous veins in the right thigh, leg, and right iliac region [Figure 1]. All distal pulses of the lower limb were palpable.
|Figure 1: Computed tomography showing the venous aneurysm with a stent in the right internal iliac artery|
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Arterial and venous Doppler showed focal dilatation of the right external iliac vein, and arterial flow was noted. Computed tomography (CT) angiogram showed an AVF between the right iliac artery and the right common iliac vein [Figure 2]. A covered stent was deployed in the right internal iliac artery. The patient had recurrence of symptoms. Repeat CT angiogram showed findings as presented earlier. Hence, the patient was taken up for surgery as the stent did not alleviate the problem. All feeders, including those from the lumbar branches and median sacral artery, were ligated. Right common iliac artery to right common femoral artery grafting was done. Inferior vena cava to common femoral vein bypass was done using Dacron graft. The leg swelling and varicosities reduced following the surgery.
|Figure 2: Clinical presentation showing multiple venous dilatations in the thigh|
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| Discussion|| |
Venous aneurysm is a very rare disease, and iliac veins are the least common system to be involved. It can be primary or secondary, with the latter being the most common cause. According to Sina Zarrintan et al., in 2019, left external iliac vein was found to be the most common site for venous aneurysm. Common iliac vein was the second most common. The incidence was found to be equal among men and women. Venous aneurysms may present with low-back pain, lower limb swelling, or venous insufficiency. Venous aneurysms can be asymptomatic and are detected incidentally on evaluation for low-back pain. These aneurysms may mimic adnexal masses. Venous thrombosis in the aneurysmal cavity can occur due to stasis of blood which may even lead to pulmonary thromboembolism. Venous aneurysms can rupture which may lead to profound shock. The rupture can be intraperitoneal or retroperitoneal, with the former being more morbid and associated with mortality. Our patient presented with lower-limb swelling.
The most common etiology of iliac vein aneurysm can be attributed to AVF following a trauma. These fistulae are associated with arterial flow in the iliac venous plexus, which later leads to aneurysmal degeneration of the veins. Major vessel AVF can occur after laminectomy procedure. Linton and White reported the first case of AVF following intervertebral disc surgery. The main cause for AVF is due to trauma caused by pituitary Rongeur passing through the anterior longitudinal ligament. Patients may present with wide pulse pressure and raised jugular venous pressure during the immediate postoperative period. Most of the patients develop signs and symptoms of AVF after few months. The patient in this study had a similar history and presented after 6 months of laminectomy.
Primary iliac vein aneurysms are more common in females. It should be considered after excluding all the secondary causes of venous aneurysm. IVC hypoplasia or duplication can also be associated with iliac vein aneurysm. May–Thurner syndrome is affiliated with compression of the left common iliac vein between the right common iliac artery and the underlying spine, which may subsequently lead to the development of deep-vein thrombosis and venous insufficiency. This venous obstruction can result in proximal aneurysmal degeneration in the external iliac vein. Patients can also present with testicular pain, which has been reported in literature. Venous aneurysms are also been reported in patients with tuberous sclerosis and Down syndrome.
Various imaging modalities can be used for the diagnosis, which include ultrasound, CT venography, magnetic resonance venography, and conventional venography. CT venography and conventional venography are more accurate in revealing the anatomy of the iliac vein aneurysm. CT angiogram can be useful in cases with iliac vein aneurysm secondary to arteriovenous fistula.
Iliac vein aneurysm can be treated by using either endovascular techniques or by surgical excision. Although conservative management of aneurysm has been reported in literature in selected cases, these patients may require frequent follow-up and anticoagulation therapy. Endovascular procedures are being performed in the management of iliac vein aneurysm. Stents are been used in venous aneurysm secondary to AVF. Aneurysm size should be monitored postoperatively. Primary internal iliac vein aneurysm can be managed by coil embolization. Simple aneurysm warrants surgical excision which is usually followed by venorrhaphy, patch venoplasty, or venous bypass to restore the venous drainage. Simple ligation of the proximal and distal parts of the venous system may be considered in chronic cases as collateral vessels would have been formed.
Venous aneurysms are rare and can be treated by both endovascular techniques and surgical repair. Preoperative imaging and planning is important. However, endovascular treatment can fail if the aneurysm has multiple feeder vessels, as in our case. It can complicate surgical repair as it can form dense adhesion following stenting. It is recommended to do a surgical excision of the aneurysm with restoration of axial venous flow concomitantly, as done in our patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
The authors would like to thank Dr. Ananth Kumar, Senior Resident, Department of Cardio-Thoracic and Vascular surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, for his contribution toward the collection of the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Metzger PB, Barbato HA, Angelieri FMR, Beteli CB, Petisco ACG, Barbosa JE, et al
. Giant external-iliac-vein aneurysm secondary to traumatic arteriovenous fistula: A case report. J Vasc Bras 2011;10:246-50.
Zarrintan S, Tadayon N, Kalantar-Motamedi SM. Iliac vein aneurysms: A comprehensive review. J Cardiovasc Thorac Res 2019;11:1-7.
Postma MP, McLellan GL, Northup HM, Smith R. Aneurysm of the internal iliac vein as a rare source of pulmonary thromboembolism. South Med J 1989;82:390-2.
Park JS, Kim JY, Kim M, Park SC, Lee KY, Won YS. Ruptured aneurysm of the external iliac vein. J Vasc Surg Venous Lymphat Disord 2016;4:92-4.
Davies JM. Ilio-iliac arteriovenous fistula following laminectomy. Clin Radiol 1969;20:103-4.
Gade A. Hypoplasia of the infrarenal inferior vena cava with compensatory left retroperitoneal venous aneurysm. Vasa 1991;20:283-7.
Landau YE, Schwarz M, Belenky A, Shapiro R, Amir J. Arteriovenous flstula and portal hypertension in a child with down syndrome. Isr Med Assoc J 2007;9:825-6.
Alatri A, Radicchia S. Bilateral aneurysm of the common iliac vein: A case report. Ann Ital Med Int 1997;12:92-3.
Audu CO, Boniakowski AE, Robinson S, Dasika NL, Wakefield T, Coleman DM. Internal iliac venous aneurysm associated with pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2017;5:257-60.
Calligaro KD, Ahmad S, Dandora R, Dougherty MJ, Savarese RP, Doerr KJ, et al
. Venous aneurysms: Surgical indications and review of the literature. Surgery 1995;117:1-6.
[Figure 1], [Figure 2]