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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 31-33

Ruptured mycotic lumbar artery pseudoaneurysm: Successful treatment by transarterial embolization


Department of Diagnostic and Intervention Radiology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Web Publication29-Feb-2016

Correspondence Address:
Dr. Shaileshkumar S Garge
Room No. 1502, MRC, 15th Floor, Doctors Quarters, Bombay Hospital, Marine Lines, Mumbai - 400 020, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

Rupture of a lumbar artery pseudoaneurysm (LAPA) is a rare cause of significant retroperitoneal hemorrhage. Early diagnosis followed by endovascular transcatheter embolization is a very effective treatment to control bleeding in patients who do not respond to conservative management or where surgery is contraindicated. We report a patient with mycotic pseudoaneurysm of the lumbar artery who was treated successfully with transcatheter arterial embolization. This case highlights that timely intervention can be successful in emergency situations such as active bleeding even if surgery is contraindicated.

Keywords: Lumbar artery, mycotic pseudoaneurysm, transcatheter arterial embolization


How to cite this article:
Garge SS, Rathod KR, Thaker NR, Kashikar RK, Lala SK. Ruptured mycotic lumbar artery pseudoaneurysm: Successful treatment by transarterial embolization. Sifa Med J 2016;3:31-3

How to cite this URL:
Garge SS, Rathod KR, Thaker NR, Kashikar RK, Lala SK. Ruptured mycotic lumbar artery pseudoaneurysm: Successful treatment by transarterial embolization. Sifa Med J [serial online] 2016 [cited 2021 Jun 19];3:31-3. Available from: https://www.imjsu.org/text.asp?2016/3/1/31/177695


  Introduction Top


Lumbar artery aneurysms are relatively rare when compared to other peripheral aneurysms. [1] The lumbar artery pseudoaneurysms (LAPAs) are commonly secondary to trauma or are iatrogenic. [2],[3] Till date, there have only been a few case reports in the literature of mycotic (or infected) pseudoaneurysms of the lumbar artery secondary to an adjoining infective spondylitis and no obvious reported case of a pseudoaneurysm caused by infective endocarditis. [4] We report a patient who had a mycotic LAPA in a clinical setting of infected endocarditis who was then treated successfully with transcatheter arterial embolization.


  Case Report Top


A 58-year-old male on a foreign trip developed fever and breathlessness and was hence, rushed to the emergency department. He was a known case of renal transplant on immunosuppressants with a past history of prosthetic mitral valve replacement and was on anticoagulants. A transesophageal echocardiography revealed mitral paravalvular leakage (prosthetic) and vegetation on the aortic valve. Blood culture was positive for  Escherichia More Details coli (E. Coli). Serum creatinine was 1.6 mg%, prothrombin time-international normalized ratio (PT-INR) was 1.37, and hemoglobin (Hb) was 12 g%. The patient was managed with antibiotics after which he improved symptomatically and was discharged as per his narration. But while flying back to India, he again developed fever and pain in the left thigh and was admitted to our institute where clinical examination showed reduced sensation over left the L1, L2, and L3 regions with a systolic murmur. Over the next 24 h, the patient developed severe backache and difficulty in micturition. While shifting for an ultrasound of the abdomen, the patient became unresponsive and hypotensive (blood pressure 80/50 mmHg) with Hb dropping to 8.8 g%. He was urgently shifted to the intensive care unit and urgent bedside portable ultrasound showed a large retroperitoneal hematoma running along the left psoas muscle extending up to the left iliac fossa measuring 18 cm Χ 8 cm [Figure 1]. The patient meanwhile also received resuscitation with intravenous (IV) fluids, two packed cells, and four units of fresh frozen plasma. On examination, the abdomen was persistently tense with an increase in abdominal girth and intraabdominal pressure measuring 15 mmHg. Hb continued to fall (4.5 g%). As the patient was hemodynamically unstable and was not responding to conservative management with deranged coagulation profile (high PT-INR), digital subtraction angiograpy (DSA) was planned for an unexplained drop in Hb. DSA showed active bleeding from the ruptured pseudoaneurysm from one of the tiny branches of the left lumbar artery (L1) [Figure 2] that was successfully embolized with glue [Figure 3] and [Figure 4] bypassing the  Artery of Adamkiewicz More Details. After the procedure, the patient became hemodynamically stable with Hb rising from 4.5 g% to 9.5 g%. Surgical evaculation of the large retroperitoneal hematoma was carried out successfully. Abdominal girth reduced and urine output improved. The patient was continued on antibiotics for 10 days and was immunosuppressant for renal transplant. On follow-up after 1 month, the patient was asymptomatic with Hb of 12.3 g%.
Figure 1: Ultrasound of the abdomen showing large hypoechoic lesion in the retroperitoneal region adjacent to the left psoas muscle extending till the left iliac fossa

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Figure 2: DSA of the left first lumbar artery showing active bleeding from a ruptured pseudoaneurysm from one of the tiny branches of L1 lumbar artery (thick arrow). Artery of Adamkiewicz was seen arising from the left L1 lumbar artery proximal to the origin of active bleeder artery (small arrow)

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Figure 3: DSA of the left first lumbar artery showing microcatheter and glue embolization of the active bleeder

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Figure 4: DSA of the left first lumbar artery showing glue cast in situ with complete exclusion of the pseudoaneurysm from the circulation with preservation of the rest of the left L1 lumbar artery

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  Discussion Top


Pseudoaneurysms are a well-recognized complication of traumatic or surgical damage to the blood vessels. The major causes of LAPA are trauma and iatrogenic complications. [2] The causes of mycotic aneurysms include endocarditis, penetrating trauma, reconstructive surgery, vascular catheterization, and direct extension from the cellulitis, lymphadenitis, or osteomyelitis. [5] In the literature, we found only a few case reports of mycotic LAPA. [4] The pathogenesis of LAPA in our patient was secondary to infective endocarditis in the background of immunosuppression, as evident by aortic valve vegetation and positive blood culture.

When LAPA ruptures, pain is the most common symptom and is presumably caused by stretching of the retroperitoneal tissue as a result of the expansion of the pseudoaneurysm or its rupture. [2] A ruptured LAPA can be a potential source of life-threatening retroperitoneal hemorrhage that requires some intervention. [2]

Treatment of LAPA has traditionally been surgical but transcatheter arterial embolization of the pseudoaneurysm could have some role in selected cases where surgery is contraindicated or risky. Angiography with selective embolization using coils or gelfoam has been successful in arresting the bleeding from these pseudoaneurysms. [6] In view of the rich collateral circulation by the lumbar, intercostal, and pelvic arteries, proximal occlusion would not be sufficient to stop continued hemorrhage. Even if the main feeding artery is occluded proximally by coil embolization, occlusion of all the feeding branches is necessary. After embolization, aortography is essential to ensure that the LAPA is not filled via the collateral branches. In our patient, DSA lumbar angiography revealed active leaking from a ruptured pseudoaneurysm from one of the tiny branches of the lumbar artery that was successfully embolized using glue. After embolization, DSA showed the complete exclusion of LAPA from circulation.

Although angioembolization appears to be a relatively safe and successful method to obtain hemostasis, it could be accompanied by complications such as infarction of the spinal cord, peripheral nerve, and muscle. [7] The lumbar artery should be scrutinized carefully for major spinal branches, such as the artery of Adamkiewicz, prior to the procedure; in our case, the artery of Adamkiewicz arose from the same lumbar artery as the LAPA and so we bypassed the artery of Adamkiewicz and went beyond it to embolize the LAPA. Transcatheter embolization of the LAPA under fluoroscopic guidance might be preferred because it is a safe and effective procedure for controlling hemorrhage without the need for general anesthesia.


  Conclusion Top


In conclusion, mycotic LAPA is but a treatable cause of life-threatening retroperitoneal hemorrhage. Transarterial catheter embolization is a technically feasible and effective method for treating mycotic LAPA in situations where surgery is contraindicated or risky.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rich NM, Hobson RW 2 nd , Collins GJ Jr. Traumatic arteriovenous fistulas and false aneurysms: A review of 558 lesions. Surgery 1975;78:817-27.  Back to cited text no. 1
    
2.
Kalangos A, Walder B, Faidutti B. Ruptured lumbar artery pseudoaneurysm: A diagnostic dilemma in retroperitoneal hemorrhage after abdominal trauma. J Trauma 1998;45:829-32.  Back to cited text no. 2
    
3.
Maleux G, Vermylen J, Wilms G. Lumbar artery pseudoaneurysm and arteriovenous fistula as a complication of laparoscopic splenectomy: Treatment by transcatheter embolization. Eur Radiol 2002;12:1401-4.  Back to cited text no. 3
    
4.
Shigematsu Y, Kudoh K, Nakasone Y, Fujisaki T, Uemura S, Yamashita Y. Nontraumatic rupture of lumbar artery causing an intravertebral body pseudoaneurysm: Treatment by transcatheter embolization. Cardiovasc Intervent Radiol 2006;29:870-4.  Back to cited text no. 4
    
5.
Patel S, Johnston KW. Classification and management of mycotic aneurysm. Surg Gynecol Obstet 2002;144:691-4.  Back to cited text no. 5
    
6.
Sclafani SJ, Florence LO, Phillips TF, Scalea TM, Glanz S, Goldstein AS, et al. Lumbar arterial injury: Radiologic diagnosis and management. Radiology 1987;165:709-14.  Back to cited text no. 6
    
7.
Doppman JL, Di Chiro G. Paraspinal muscle infarction. A painful complication of lumbar artery embolization associated with pathognomonic radiographic and laboratory findings. Radiology 1976;119:609-13.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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