Pseudo-aneurysms are consequences of arterial wall damage. The hematoma resulting becomes confined in the adjacent tissues by fascial planes . Common causes are trauma, tumor, infection, vasculitis and inflammation (even caused by radiation therapy), atherosclerosis, infarction and various iatrogenic complications, such as the ones from surgery and angiography . It is not clear whether arterial injury related to surgery might develop but it is well known that the complication of a pseudo-aneurysm can appear weeks or months after surgery . Our case is the first report to our knowledge of a late false aneurysm rupture after cervical cancer surgery, being apparently related to the sole procedure. There are few similar cases previously reported [1, 2, 4]. Most of them have been associated with radiation therapy delivered before the onset of the complication [2, 4]. In our case, the formation of the pseudo-aneurysm might be surgery-related as no other apparent causes were present.
Deep venous thrombosis of the femoral vein was likely to be caused by compression of the iliac vein as it appeared displaced by the mass.
Rupture of false aneurysms with massive blood loss is a serious life-threatening condition and requires immediate surgical correction of the arterial wall defect. An endovascular approach with covered stent placement appears to be successful and it should be the first choice in our opinion in these patients. The clearest advantage of this former approach, when compared to open surgery, is a much quicker control of the bleeding, which is paramount in these extremely urgent situations.
Our patient was young and without appearance of vascular disease so we do not have concerns about long-term patency. The consolidated experience with covered stents in older patients with vascular disease shows that both proximal and distal parts of the stent have to land in a healthy portion of the vessel as it was in our case. This is key to prevention of stent re-stenosis.
The choice of a stent like Viabahn® was made on our center experience in both urgent and elective settings. The primary patency rate for this stent at 12, 24, 36, and 48 months was 72 %, 63 %, 63 % and 59 %, respectively . Other stents are also available, such as Fluency® by BARD® medical, Covington, Georgia but in our case we believe there was no advantage in using this latter type.
One difference between stents is that Viabahn® is covered with one inner layer of expanded polytetrafluoroethylene (ePTFE) while Fluency® is covered with two layers (outer and inner) of ePTFE. Two layers of Gore-Tex® W. L. Gore & Associates, Inc. Medical Products Division Arizona USA (ePTFE) allow better resistance to external muscular compression and repetitive stress to the artery when stent is placed in peripheral vessels (for example; superficial femoral artery (SFA) in the Hunter’s canal).
Muscles or other physiological sources of potential stress or compression do not surround the external iliac artery. This makes us think that the stent choice was appropriate.