PMC3096297_01
Contrast-enhanced pelvic CT (a) reveals 12 x 7 cm air- and fluid-filled abscess (arrowheads) in abdominal right lower quadrant. Encasement of right external iliac artery (arrow) by abscess noted. (b) Presence of bowel contrast (arrow) within collection confirms fistula to colon.
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Computed tomography (CT) scan obtained in the ED demonstrated a large heterogeneous air and fluid filled collection with thick irregular enhancing walls in the region of the patient's original primary tumor, suggestive of fistula formation to adjacent bowel with resultant abscess formation within a large residual necrotic pelvic tumor (Figure 1).
Noncontrast CT image following percutaneous drainage shows 12 French catheter (arrowheads) in anterior aspect of pelvic abscess.
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Subsequent percutaneous CT-guided catheter drainage of the right pelvic abscess aspirated foul-smelling debris (Figure 2).
Digital subtraction (a) and unsubtracted (b) images from right iliac arteriogram reveal contrast extravasation (arrowheads) from right external iliac artery pseudoaneurysm (arrow).
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Arteriography demonstrated active hemorrhage from a pseudoaneurysm arising from the right external iliac artery segment traversing the known pelvic abscess (Figure 3).
Fluoroscopic spot image demonstrates covered stents deployed across right common and external iliac arteries.
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Three overlapping 9 mm x 60 mm, 8 mm x 80 mm, and 8 mm x 60 mm Fluency-Plus (Bard, Murray Hill NJ) covered stents were then deployed across the right external iliac artery (Figure 4) to the level of the right femoral artery, successfully excluding the bleeding pseudoaneurysm.
Right common femoral arteriogram (a) reveals acute thrombosis (arrow) of distal segment of stented artery. Of note, unsaved manual injections of contrast better documented thrombus burden throughout entire course of stented iliac artery segment. Fluoroscopic spot image (b) shows 5 French catheter (arrow) and infusion wire (arrowheads) system used for catheter-directed thrombolysis.
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Immediate postdeployment arteriography revealed thrombosis of the newly stented right external iliac artery with thrombus extending to the right common femoral artery bifurcation (Figure 5), likely related in part to prolonged balloon tamponade. Alteplase (Activase; Genentech, South San Francisco CA) was delivered via the catheter and coaxial wire with a total infusion dose of 0.48 mg per hour (Figure 5), with systemic heparin titrated to maintain a partial thromboplastin time (PTT) of approximately 60-80 seconds.
Digital subtraction angiogram, obtained 28 hours after initiation of catheter-directed thrombolysis, shows patency of stented right common and external iliac arteries.
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After an additional 12 hours of therapy, angiographic reassessment demonstrated complete lysis of thrombus (Figure 6).
Contrast-enhanced CT scan, obtained four months after-stent insertion, demonstrates interval local tumor progression (arrowheads) but maintained patency of stented iliac artery (arrow).
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Follow-up CT scan performed four months after covered stent insertion revealed local progression of right lower quadrant tumor, buttressing the patent stented right external iliac artery (Figure 7).