Emergency Balloon Sealing of a Ruptured Giant Anastomotic Aneurysm of the Groin

Abstract

An 85-year-old patient presented with a giant pseudo-aneurysm in the groin fifteen years after placement of an aortobifemoral graft (ABG). The pseudo-aneurysm was expanding rapidly. To prevent massive haemorrhage an inflatable balloon was inserted into the native distal aorta. The balloon was inserted via the contralateral groin. After inflation, the pseudo-aneurysm was safely excluded by the interposition of a new prosthetic segment between the left prosthetic branch of the ABG and the common femoral artery. This technique, which has been used for more than 50 years in several other indications, is an elegant method to minimise blood loss in the treatment of large pseudoaneurysms of the groin.

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Introduction
Anastomotic aneurysms are a late complication after
ABG placement. In contrast to true aneurysms, which
are composed of all the layers of the vascular wall, an
anastomotic or pseudo-aneurysm is an extra-arterial
haematoma surrounded by reactive fibrotic tissue. It is
due to partial or complete disruption of the suture line
between the native vessel and the prosthesis.
Complications include rupture, embolism, thrombosis
and compression of nearby structures. Interposition
grafting is the preferred surgical approach since simple
repair has a higher recurrence rate (1, 2). Currently,
endovascular exclusion is reserved for high-risk patients
when feasible (3-5).
We present a complex case of a giant rupturing anas-
tomotic aneurysm of the left groin where the pulsatile
mass started from just below the umbilicus.
Case report
An 85-year-old man was seen at the outpatient clinic
with a giant painless anastomotic aneurysm in the left
groin, fifteen years after placement of an ABG for
abdominal aortic aneurysm (AAA) repair. In the right
groin a smaller anastomotic aneurysm was seen. Angio-
CT scan confirmed an anastomotic aneurysm with a
maximal diameter of 10.3 cm in the left groin and a
smaller one in the right groin. We repeatedly pointed out
the poor prognosis and proposed surgical treatment as
soon as possible. The patient and his family refused
operation. Three months later he came to the emergency
department with a giant painful pulsatile mass in the left
groin and a painless, smaller pulsatile mass in the right
groin. Pain in the left groin had started a few months pre-
viously, but had worsened during the last three days.
Popliteal pulse was absent on the left side. Angio-CT
scan confirmed two anastomotic aneurysms. The pseu-
do-aneurysm in the left groin had grown from 10.3 to
12.8 cm (Fig. 1) and was actively leaking. Initially, the
patient was haemodynamically stable with a haemoglo-
Acta Chir Belg, 2008, 108, 741-743
Emergency Balloon Sealing of a Ruptured Giant Anastomotic Aneurysm of the
Groin
M. D’Hondt, L. Van Lysebeth, G. De Smul, P. Wallaert, H. Ceuppens
Department of Vascular and Thoracic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium.
Key words. Pseudoaneurysm ; balloon occlusion.
Abstract. An 85-year-old patient presented with a giant pseudo-aneurysm in the groin fifteen years after placement of
an aortobifemoral graft (ABG). The pseudo-aneurysm was expanding rapidly. To prevent massive haemorrhage an
inflatable balloon was inserted into the native distal aorta. The balloon was inserted via the contralateral groin. After
inflation, the pseudo-aneurysm was safely excluded by the interposition of a new prosthetic segment between the left
prosthetic branch of the ABG and the common femoral artery. This technique, which has been used for more than
50 years in several other indications, is an elegant method to minimise blood loss in the treatment of large pseudo-
aneurysms of the groin.
Fig. 1
Angio CT showing the anastomotic aneurysm. Maximal dia -
meter of 12,8 cm.

Under roadmap a 0.035’’ guide wire was advanced
into the aorta. After parking the wire in the aorta an
inflatable balloon of 20 mm was inflated in the distal
aorta at the level of the anastomosis with the ABG
(Fig. 3). The false aneurysm in the left groin was incised.
The prosthesis was retrieved and clamped. The balloon
was deflated to re-establish renal blood flow (total bal-
loon occlusion time was 5 minutes).
Further dissection of the groin showed a suture line
disruption of the medial side of the anastomosis (Fig. 4).
The common, superficial and the deep femoral arteries
were isolated and clamped and a new prosthetic segment
(8mm Silver) was interposed. Total blood loss was
150 cc. The postoperative course was uneventful.
Discussion
Despite improved surgical techniques and the availabili-
ty of better graft and suture materials, enhanced patient
survival rates and the use of postoperative imaging of
patients with aorto-iliac graft have resulted in an increase
in the observed incidence of anastomotic aneurysms,
varying from 0.2% to 15% (6, 7). MULDER et al. reported
that 44% of patients with untreated anastomotic pseudo-
aneurysms die of rupture after a mean follow-up of
6 years and postoperative mortality rates of 7.6% have
been reported (8). The operative management of rup-
Fig. 2
Picture of the giant pseudoaneurysm. Note the cyano tic skin
and necrotic spots.
Fig. 4
Picture after incision of the anastomotic aneurysm : disruption
of the anastomosis.
bin level of 10.8 g/dl. In the following hour blood pres-
sure dropped and haemoglobin had fallen to 4.5 g/dl by
the time of the operation. Proximal control of the graft
was considered a high risk because of the proximal
extent of the pulsatile mass (Fig. 2). Initially, an unsuc-
cessful attempt was made to place a percutaneous bal-
loon catheter in the left branch of the ABG by cross-over
technique. Thereafter, we opted for placement of an
inflatable (20 mm) balloon in the native aorta at the level
of the renal arteries to control the inflow of the pseudo-
aneurysm. Access was established by seldinger catheter-
isation of the right superficial femoral artery and the
introduction of a 9 Fr sheath.
742 M. D’Hondt et al.
Fig. 3
Peroperative image while inflating the 20 mm occlusion
balloon.

a simple technique introduced more than 50 years ago, it
is still useful in modern vascular surgery.
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M. D’Hondt
Department of Vascular and Thoracic Surgery
AZ Groeninge Hospital
Loofstraat 33
8500 Kortrijk, Belgium
E-mail : mathieudhondt2000@yahoo.com
Emergency Balloon Sealing 743
tured anastomotic aneurysms is challenging. The need
for direct inflow control and reconstruction in areas
scarred from previous operative dissection, which fre-
quently extends deep into the pelvis, increases the tech-
nical difficulty, and substantially increases morbidity and
mortality rates.
Distal aortic balloon occlusion is a fast way of gaining
control over giant ruptured anastomotic aneurysms and
gives surgeons the possibility of interposing a new pros-
thetic segment without massive haemorrhage in haemo-
dynamically unstable patients. To our knowledge this is
the first cast report of a ruptured anastomosic aneurysm
treated by this hybrid technique.
Emergency balloon sealing is a well-known technique
with a long history. In 1954 Lieutenant Colonel CW
Hughes introduced the technique of intra-aortic balloon
catheter tamponade in two moribund war casualties with
uncontrolled intra-abdominal haemorrhage. Although
both patients expired, the technique enabled the surgeon
to temporarily restore blood pressure in one case (9). In
1961 a similar method was described for controlling
blood loss from ruptured AAA by means of intraluminal
aortic tamponade using an ordinary Foley catheter (10).
In the endovascular era Veith et al. described a modern
version of this technique. Their patients, who are pre-
sumed to have ruptured aorto-iliac aneurysms, receive a
brachial or femoral guidewire and undergo an arteriogra-
phy. If the anatomy is suitable an endovascular graft
repair is performed. If the anatomy is unfavourable and
if circulatory collapse occurs, a supraceliac balloon is
placed and inflated using the previously placed
guidewire prior to open repair (11). Currently, temporary
balloon occlusion as therapy of uncontrollable arterial
haemorrhage from the internal iliac artery, is a technique
that is also used in obstetrics and in trauma surgery (12,
13).
Nowadays, a precutaneous transluminal angioplasty
(PTA) balloon catheter is also used to control haemor-
rhage after arterial rupture during PTA followed by sur-
gical repair and, since the introduction of balloon
expandable intraluminal stentgrafts, selected cases can
be treated without subsequent surgery (14, 15).
In conclusion, repair of giant anastomotic aneurysms
in the groin can be associated with life-threatening blood
loss. Occluding the distal abdominal aorta minimises
blood loss during anastomotic aneurysm repair.
Although balloon sealing of an anastomotic aneurysm is