Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 256-259

Iatrogenic superior gluteal artery pseudoaneurysm due to iliac bone marrow biopsy treated with endovascular coil embolization


1 Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission27-Nov-2021
Date of Decision12-Jan-2022
Date of Acceptance17-Jan-2022
Date of Web Publication21-Aug-2022

Correspondence Address:
K Nagarajan
Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_126_21

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  Abstract 


Superior gluteal artery pseudoaneurysms are uncommon with the main causes being trauma and iatrogenic. They have been treated by coil embolization, open surgery, or thrombin injection. A 36-year-old female with leucocytosis underwent bone marrow biopsy following which she developed pain and left lower limb weakness. Magnetic resonance imaging showed hematoma in the left pyriformis muscles probably compressing the sciatic nerve. A computed tomography angiogram confirmed a left superior gluteal artery partially thrombosed pseudoaneurysm which was subsequently treated by coil embolization. A high degree of suspicion of this complication early imaging and management can prevent significant blood loss and mortality.

Keywords: Coil embolization, iliac bone marrow biopsy, superior gluteal artery pseudoaneurysm


How to cite this article:
Ariharan K, Nagarajan K, Vivekanandan Pillai M, Amuthabharathi M. Iatrogenic superior gluteal artery pseudoaneurysm due to iliac bone marrow biopsy treated with endovascular coil embolization. Indian J Vasc Endovasc Surg 2022;9:256-9

How to cite this URL:
Ariharan K, Nagarajan K, Vivekanandan Pillai M, Amuthabharathi M. Iatrogenic superior gluteal artery pseudoaneurysm due to iliac bone marrow biopsy treated with endovascular coil embolization. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Oct 1];9:256-9. Available from: https://www.indjvascsurg.org/text.asp?2022/9/3/256/354067




  Introduction Top


Pseudoaneurysms form secondary to damage to arterial walls and subsequent localized collection of blood surrounded by hematoma which communicates with the parent artery through a neck. Pseudoaneurysms can be iatrogenic following percutaneous puncture injuries. Gluteal artery aneurysms are known since first reported by William Dublin in 1803[1] and Fried and Wright[2] in their review of 175 cases in 2015 collated 122 cases reported till 1995 and further 53 since then. Most were traumatic pseudoaneurysms, and superior gluteal are three times more common that of inferior gluteal aneurysms. They are more common in men and on the left side than the right side. The two main causes of superior gluteal artery injuries are trauma and iatrogenic, and can result in hematomas, pseudoaneurysms and compartment syndrome. The main treatment options available for superior gluteal artery pseudoaneurysms include coil embolization and open surgery.


  Case Report Top


A 36-year-old female patient presented with complaints of progressive loss of weight and malaise for 6 months. Her clinical examination showed splenomegaly, hemogram showed leucocytosis with left shift, basophilia and occasional megakaryocyte fragments suggestive of chronic myeloid leukemia (CML) in chronic phase. Bone marrow biopsy was done as part of evaluation of the patient from left iliac bone to confirm the diagnosis of CML. After the biopsy, the patient developed local pain and progressive left lower limb weakness. On inspection, she had externally rotated left hip, foot drop and high stepping gait. Motor examination revealed power of 4/5 in left hip flexors and extensors, left knee flexors with 0/5 in ankle dorsi-flexors. Deep tendon reflexes were absent in the calf muscles and normal in quadriceps and hamstrings. Sensory examination revealed decreased sensation in L5, S1 and S2 distribution. Based on these findings, a clinical diagnosis of left lumbo-sacral radiculopathy was made. There was no drop in her blood hemoglobin. Her coagulation profile was also within normal range. Magnetic resonance imaging (MRI) of pelvis was done which showed T1/T2–weighted heterogenous mixed signal intensity hematoma in the left pyrifomis muscle measuring about 3.0 cm × 4.8 cm (maximum orthogonal transverse dimensions) with central flow void suggestive of pseudoaneurysm and causing compression of the left lumbar plexus [Figure 1]. MRI showed no evidence of nerve compression at the vertebral or disc level. Computed tomography (CT) angiography revealed a pseudoaneurysm arising from left superior gluteal artery (14 mm × 15 mm) surrounded by the hematoma/thrombus in the left pyriformis muscle [Figure 2]. The patient was taken up for digital subtraction angiography (DSA) and embolization.
Figure 1: MRI T2-weighted axial sections (a & b), STIR coronal (c), T1-weighted axial (d) and sagittal (e) sections showing heterogeneous mixed signal intensity hematoma in left greater sciatic foramen region along the pyriformis muscle with central flow-void (arrows)

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Figure 2: CT angiography axial section (a), coronal reformation (b) and volume rendered (VRT) image (c) showing arterial-enhancing pseudoaneurysm within the same hematoma (arrows in a & b) in continuity with first branch of posterior division of left internal iliac artery - the superior gluteal artery (arrow in c). Digital subtraction angiography (DSA) of left internal iliac artery (d) showing the partially thrombosed pseudoaneurysm (arrow) with non-visualization of distal vessel or branches

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Under local anesthesia, through right common femoral artery access using regular 6F check-flow sheath and 5F diagnostic catheter (visceral C1, Cook), the left internal iliac artery was catheterized and selective angiography was done. DSA showed a pseudoaneurysm of the proximal left superior gluteal artery with no visualization of distal branches or flow. The 5F catheter was taken to the neck of the pseudoaneurysm, and pushable coil (MReye, 38-4-3) was deployed. Postembolization check angiogram showed total occlusion of the pseudoaneurysm and the superior gluteal artery [Figure 3]. There was reduction in pain over the next few days and contrast CT showed complete obliteration of the pseudoaneurysm sac and resolving hematoma. On discharge after 1 week, patient had no pain but mild muscle weakness and advised physiotherapy. The patient was referred back for further management of CML.
Figure 3: DSA (a) immediate post-coiling shows the cut-off of proximal superior gluteal artery (arrow). The fluoroscopy image (b) showing the detached coil distal to the catheter. Post-procedure CTA (c) and VRT (d) showing the coil and occluded stump of superior gluteal branch (arrows)

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  Discussion Top


The superior gluteal artery arises from the posterior division of internal iliac artery in the pelvis and course backward between the lumbosacral trunk and first sacral nerve and traverses above the pyriformis muscle. The close proximity to the iliac bone makes it vulnerable to injuries. In cases of contained hematoma, symptoms such as swelling, palpable mass, persistent local pain, sciatica and muscle weakness can occur. Differential diagnosis for this subacute presentation includes hematoma, abscess and neoplastic diseases.[2],[3] Pseudoaneurysms with active bleeding can present with hypotension, bradycardia or persistent bleeding. In our case, the patient presented with lower limb weakness and examination revealed reduced sensations and motor weakness. The time of presentation and the symptoms can be misleading, so this complication should be suspected in patients following any procedure which can potentially injure the superior gluteal artery. Angiography is done if there is strong suspicion or evidence of vascular injury. The commonly used treatment options include thrombin injection, open surgery and endovascular embolization.

Though posttraumatic cases of superior gluteal artery pseudoaneurysms have been known before, the first iatrogenic case was reported by Smyth et al.[1] in 1965 after an intramuscular injection and was treated surgically. The other iatrogenic causes reported include bone marrow biopsy, bone graft harvesting, pelvic C-clamp application, percutaneous ilio-sacral screw-fixation, intramedullary nailing of femoral fracture and even in vitro fertilization technique like transvaginal ultrasound-guided follicle aspiration.[4],[5],[6],[7],[8] The treatment has evolved recently, from mainly surgical to almost exclusive minimally invasive endovascular techniques. Schorn et al.[9] in their review of gluteal aneurysms, both true degenerative and pseudoaneurysms, mentioned that transarterial treatment was tried in 7 of 19 cases documented from 1977 to 1995, but was the definitive treatment in 44 of 53 cases over next two decades (1995–2015). The earliest description of transarterial treatment was by Rankin et al.[10] using balloon occlusion technique. Singh et al.[11] reviewed nine cases of gluteal artery pseudoaneurysms after bone marrow biopsy and treated either by coil embolization (six) or thrombin injection (three cases including one of their case). They suggested faulty needle localization, using power drill and experience of the haematologists to be predisposing factors for gluteal artery injury. In this regard, the concept of 'safe zone' in posterior superior iliac crest by Kahn[12] may be important during iliac marrow biopsy or bone harvesting to avoid such gluteal vessel injury.

Roblin et al.[13] reported the use of stent-graft in the treatment of superior gluteal artery pseudoaneurysm following pelvic surgery as patient underwent pelvic bony reconstruction and coil embolization was not preferred. Chu et al.[14] reported an unusual case in which injury to the anterior division of the internal iliac artery injury was suspected during iliac bone marrow aspiration. After suspicion of arterial injury, the Jamshidi aspiration needle was not removed and the stylet was quickly replaced followed by injection of absorbable gelatin sponge through the same needle to embolize the distal branches, and further n-butyl cyanoacrylate glue (50% glue: Lipiodol) injection to occlude the arterial segment and needle tract.[14]

Though bone marrow biopsy or aspiration is one of the commonest medical procedures done, an awareness of this uncommon complication will help in early management in those presenting with symptoms of postprocedure unexplained blood loss or neural compression. Once identified, endovascular occlusion is the safe and effective treatment of these pseudoaneurysms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Smyth NP, Rizzoli HV, Ordman CW, Khoury JN, Chiocca JC. Gluteal aneurysm. Arch Surg 1965;91:1014-20.  Back to cited text no. 1
    
2.
Fried JA, Wright LM. True superior gluteal artery aneurysm. J Vasc Surg Cases 2015;1:221-3.  Back to cited text no. 2
    
3.
Ge PS, Ng G, Ishaque BM, Gelabert H, de Virgilio C. Iatrogenic pseudoaneurysm of the superior gluteal artery presenting as pelvic mass with foot drop and sciatica: Case report and review of literature. Vasc Endovascular Surg 2010;44:64-8.  Back to cited text no. 3
    
4.
Yurtseven T, Zileli M, Göker EN, Tavmergen E, Hoşcoşkun C, Parildar M. Gluteal artery pseudoaneurysm, a rare cause of sciatic pain: Case report and literature review. J Spinal Disord Tech 2002;15:330-3.  Back to cited text no. 4
    
5.
Kang S, Chung PH, Kim JP, Kim YS, Lee HM, Eum GS. Superior gluteal artery injury during percutaneous iliosacral screw fixation: A case report. Hip Pelvis 2015;27:57-62.  Back to cited text no. 5
    
6.
Marmor M, Lynch T, Matityahu A. Superior gluteal artery injury during iliosacral screw placement due to aberrant anatomy. Orthopedics 2010;33:117-20.  Back to cited text no. 6
    
7.
Ailaney N, O'Connell R, Giambra L, Golladay G. Superior gluteal artery pseudoaneurysm following intramedullary nailing of an atypical femoral fracture. BMJ Case Rep 2019;12:e231490.  Back to cited text no. 7
    
8.
Kim WY, Lee SW, Kim KS, Lee JY. Superior gluteal artery pseudoaneurysm caused by pelvic C-clamp blind application: A case report. Hip Pelvis 2017;29:145-9.  Back to cited text no. 8
    
9.
Schorn B, Reitmeier F, Falk V, Oestmann JW, Dalichau H, Mohr FW. True aneurysm of the superior gluteal artery: Case report and review of the literature. J Vasc Surg 1995;21:851-4.  Back to cited text no. 9
    
10.
Rankin RN, Youngson GG, McKenzie FN. Management of superior gluteal artery aneurysm by percutaneous balloon catheter occlusion: A case report. Surgery 1979;85:235-7.  Back to cited text no. 10
    
11.
Singh AP, Pendurti G, Singh S, Shestopalov A, Pacello T, Reed LJ. Gluteal artery injuries including pseudoaneurysm associated with powered bone marrow biopsies. Hematol Rep 2017;9:7131.  Back to cited text no. 11
    
12.
Kahn B. Superior gluteal artery laceration, a complication of iliac bone graft surgery. Clin Orthop Relat Res 1979;140:204-7.  Back to cited text no. 12
    
13.
Roblin P, Alexiou T, Sabharwal T, Reidy J, Ross DA. Successful stent-graft placement for the treatment of a superior gluteal artery pseudoaneurysm in a patient following complex pelvic surgery. Br J Radiol 2007;80:e7-10.  Back to cited text no. 13
    
14.
Chu F, Tse D, Chan T, Kwong YL. Arterial injury during bone marrow aspiration: Embolization through the biopsy needle. J Vasc Interv Radiol 2018;29:584.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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