A 77-year-old male was transferred to our hospital for chills, a high fever for 2 days and left-sided lumbosacral pain for 5 h. The patient had a history of varicose vein surgery on his bilateral great saphenous veins and cholecystectomy for pyogenic cholecystitis. On admission the patient has fever (Temperature 38.2 °C), heart rate 112 beat/min, blood pressure 92/60 mmHg and respiratory rate of 27 breaths/min. Physical examination shows clear consciousness, a feeling of pain, a palpable mass in the left lower abdomen that was pulseless and had marked tenderness, and good bilateral femoral arterial pulses. Routine blood tests showed a White Blood Cell (WBC) count of 19.4 × 10
9/L, neutrophil percentage of 96.6%, Procalcitonin (PCT) 6.16 ng/mL, Blood Lactate 2.7 mmol/L and C-reactive Protein (CRP) level of 108 mg/L. On enhanced Computed Tomography (CT), manifestations were the occurrence of haematoma around the left iliac artery and contrast medium extravasation (Fig.
1). Rupture of the left iliac artery pseudoaneurysm was diagnosed. The patient was in critical medical condition and was assigned to receive emergency surgery. The patient gave consent for treatment and publication of his clinical notes. The procedure was performed under general anesthesia in an operating theatre equipped with a portable fluoroscopy unit in order to perform and endovascular balloon occlusion for hemorrhage control. After systemic heparinization, percutaneous access was achieved via percutaneous access of left common femoral artery. Abdominal aortography showed localized outward bulging of the left lower common iliac artery and signs of contrast medium extravasation (Fig.
1). Considering the existing typical symptoms of infection and high levels of inflammatory indices in laboratory tests, the patient was suspected to have infectious pseudoaneurysm rupture and was not suitable to receive covered stent implantation. The left common iliac artery block was obtained by balloon introduction, and laparotomy was performed to present visible rupture of the medial wall anterior to the left common iliac artery surrounded by a large haematoma. We excised an 10 × 4 cm segment of posterior rectus fascia-peritoneal layer which lateral to the linea alba and posterior to the left rectus abdominus muscle. Then we used running suture to sew the material into a 7 mm diameter tube with 5−0 Polypropylene non-absorbable suture (PROLENE™, ETHICON, USA) (Fig.
2). Artery reconstruction was then performed on the left common iliac artery and the external iliac artery with a section of the peritoneum and the posterior rectus sheath based on the arterial calibre. Both arteries exhibited good morphology on the aortogram (Fig.
2). Suture of the left internal iliac artery was performed starting from the initial segment. Following haematoma removal, full drainage of hematic and gas was obtained by two indwelling drainage tubes placed in the residual cavity. Local tissues from the arterial wall were harvested for bacterial culture to grow
Enterococcus faecium. After the operation, he was given meropenem 1.0 g intravenous q12h infusion for 5 days, and then replaced with cefoperazone and sulbactam 2.0 g intravenous infusion q12h infusion for 10 days. Amoxicillin and clavulanate potassium were taken orally for 3 months after discharge. On the CT scan performed 4 weeks after surgery, the left iliac artery and the autologous interposition displayed good morphology, no signs of abscess or hemathoma were present and the indwelling drainage tubes were removed (Fig.
3). The indwelling drainage tubes were pulled out. At 6 months follow-up the patient was in good general condition with no evidence of abdominal wall hernia, fever, abdominal pain, limb pain or intermittent lower limb claudication. Arterial color Doppler ultrasound showed normal blood flow in the left iliac artery.