
==== Front
Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

AMSU-D-24-00921
10.1097/MS9.0000000000002382
00092
3
Case Reports
Incidental diagnosis of bilateral common iliac artery aneurysms: a case report and comprehensive literature review
katwal Shailendra MD a*shailendrakatwal@gmail.com

Katwal Srijana MBBS bdrsrikknepal@gmail.com

Bhandari Sushmita MBBS gdrsush.9988@gmail.com

Paudel Pratiksha MBBS cpratiksha.paudel96@gmail.com

Bhandari Devendra MBBS dppbh.dev@gmail.com

Bhandari Shristi MBBS shristibhandari8848@gmail.com
e
Maharjan Santosh MD fsantosh512240@gmail.com

a Department of Radiology, Dadeldhura Subregional Hospital, Dadeldhura
b Department of Cardiology, National Academy of Medical Science
c Department of Radiology, All Nepal Hospital
d Department of Medicine, Manmohan Memorial Medical College and Teaching Hospital
e Department of Medicine, Sukraraj Tropical and Infectious Disease Hospital
f Department of Radiology, Tribhuvan University Teaching Hospital, Kathmandu
g Shankar Nagar Health Post, Butwol, Nepal
* Corresponding author. Address: Department of Radiology, Dadeldhura subregional Hospital, Dadeldhura, Tufandada, 10300. Tel.: +977 984 914 9630. E-mail: shailendrakatwal@gmail.com (S. Katwal)
9 2024
17 7 2024
86 9 55455550
7 5 2024
5 7 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nd/4.0/ This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. http://creativecommons.org/licenses/by-nd/4.0/

Introduction and importance:

Aneurysms are dilatations of arteries, with abdominal aortic ectasias (AAE) considered precursors to abdominal aortic aneurysms (AAA). Iliac artery aneurysms (IAAs), often accompanying AAA, present a serious risk, particularly due to rupture. Here, the authors present a case highlighting the importance of recognizing and managing isolated bilateral common iliac artery aneurysms (CIAAs).

Case presentation:

A 66-year-old male presented following a road traffic accident (RTA) with ankle and leg pain. Examination revealed tenderness in the leg, mild right flank tenderness, and a history of mild pelvic pain. Biochemical studies showed deranged glucose and lipid levels. Imaging revealed large CIAAs, prompting surgical intervention. The patient’s fracture was also managed accordingly.

Clinical discussion:

CIAAs are rare but serious, typically occurring in elderly males with risk factors including advanced age, male sex, smoking, and hypertension, while diabetes and hyperlipidemia may exert protective effects. While often asymptomatic, they can lead to complications such as thrombosis or rupture. Diagnosis relies on imaging, and intervention is recommended for larger or symptomatic aneurysms.

Conclusion:

It’s crucial to consider CIAAs in high-risk individuals and recognize the significance of early detection and intervention to prevent potentially life-threatening complications. Prompt management, either through open surgical repair or endovascular options, is crucial for improving patient outcomes.

Keywords:

common iliac artery
early diagnosis
hyperlipidemia
iliac aneurysm
risk factors
OPEN-ACCESSTRUE
==== Body
pmcIntroduction

Highlights

This study highlights the importance of early detection and management of isolated bilateral common iliac artery aneurysms (IAAs), particularly in high-risk individuals.

Understanding the protective role of comorbidities like diabetes and hyperlipidemia can inform treatment decisions.

Timely intervention is essential to prevent potentially life-threatening complications associated with IAAs.

Aneurysms are characterized by dilatations that are at least 150% larger than the unaffected proximal part of the artery. Abdominal aorta diameters between 25 and 29 mm are classified as abdominal aortic ectasias (AAE), which are considered precursor lesions to abdominal aortic aneurysm (AAA)1. Iliac artery aneurysms (IAAs), although relatively uncommon, frequently co-occur with AAA. Risk factors for aneurysm development include advanced age, smoking, hypertension, hyperlipidemia, hyperglycemia, male gender, and trauma. Patients with aortoiliac aneurysms are often asymptomatic and may present with systemic cardiovascular disease and other comorbidities2. Rupture is a common initial manifestation of IAA, often resulting in acute abdominal pain and hypovolemic shock2. Early diagnosis and prompt intervention are crucial in managing this serious condition to prevent catastrophic complications. Abdominal ultrasound and duplex ultrasonography are first-line imaging tools for detection. Due to the asymptomatic nature and high mortality rates associated with ruptured aneurysms, a high index of suspicion and screening is recommended for high-risk individuals2.

This case has been reported in line with Surgical Case Reports (SCARE) 2023 guidelines3.

Case details

A 66-year-old male presented to the emergency department following a road traffic accident (RTA) with complaints of pain in his ankle and leg. Upon arrival, his vital signs were recorded as follows: blood pressure 130/90 mmHg, pulse rate 102 beats per min, respiratory rate 18 breaths per min, temperature 98°F, and SpO2 98% on room air. Physical examination revealed tenderness in the leg and ankle region with limited range of motion. While the remainder of the systemic examination was unremarkable, mild tenderness was noted on the right flank upon palpation of the abdomen. Further inquiry revealed a history of mild right-sided pelvic pain over the past two years, which the patient had not sought medical attention for as the pain was not bothersome. There was no family history of similar complaints, and the patient had no history of any type of abdominal surgery. However, he has a positive history of hypertension, hyperlipidemia, and type 2 diabetes mellitus for which he is taking medications but is non-compliant.

The pain was not accompanied by dysuria, back pain, or dyspnea. The patient is a non-smoker and does not consume alcohol. His biochemical study showed increased glucose levels and a deranged lipid profile (Table 1).

Table 1 Biochemical parameters of the patient.

Test	Result	Unit	Reference	
WBC	12 900	/cumm	4000–10 000	
Differential count	
 Neutrophil	79	%	40–70	
 Lymphocyte	20	%	20–45	
 Eosinophil	01	%	1–6	
 Monocyte	00	%	2–10	
 Basophil	00	%	0–1	
 Hemoglobin	15.7	g/dl	13–18	
 P.C. V	44	%	40–54	
 Platelets	244 000	/cumm	150 000-400 000	
 Blood glucose	428	mg/dl	70–140	
 Blood urea	37	mg/dl	10–45	
 Creatinine	0.7	mg/dl	0.4–1.4	
 Sodium	143	meq/l	135–150	
 Potassium	4.2	meq/l	3.0–5.0	
Thyroid function tests	
 FT3	4.6	pmol/l	3.1–6.8	
 FT4	21.3	pmol/l	12–22	
 TSH	1.9	uIU/ml	0.27–4.2	
Lipid profile	
 Total cholesterol	312	Mg/dl	<200	
 Triglyceride	154	Mg/dl	<150	
 HDL cholesterol	26	Mg/dl	>40	
 LDL cholesterol	115	Mg/dl	<100	
 D Dimer	1.7	mg/dl	<0.5	
HDL, high-density lipoprotein; LDL, low-density lipoprotein; TSH, thyroid stimulating hormone; WBC, white blood cell.

The patient’s leg and calf pain were managed, followed by an e-FAST scan of the abdomen as part of the trauma protocol. The e-FAST scan revealed a cystic structure in the right pelvic cavity, prompting further investigation. Color Doppler imaging showed an outpouching from the common iliac artery with a swirling flow and reduced velocity (Fig. 1). Subsequently, a computed tomography (CT) angiography of the abdomen and pelvis was performed, revealing a large-sized (9.72 ×7.9 cm) atherosclerotic fusiform aneurysm in the right common iliac artery just distal to the bifurcation, with eccentric wall thrombus and a small aneurysm in the middle aspect of the left common iliac artery. An aneurysm of the left common iliac artery (3 ×2.9 cm) with ectasia of the infra-renal part of the abdominal aorta (2.9 cm wide) was also noted (Fig. 2A, B, and C). There were no extensions of the aneurysm to the external or internal iliac artery. Additionally, atherosclerotic changes with wall calcifications were observed in the abdominal aorta and its branches.

Figure 1 Gray scale and color doppler ultrasound image showing the cystic outpouching arising from common iliac artery showing Ying and Yang pattern in color doppler study.

Figure 2 (A) Contrast enhanced computed tomography axial image showing contrast filled dilatation of right common iliac artery with peripherally displaced wall calcification. (B) Coronal reformatted contrast enhanced computed tomography image showing the bilateral common iliac artery aneurysm (right shown by green arrow, left shown by green line). (C) Three-dimensional volume rendered image showing the bilateral common iliac artery aneurysm.

Due to the large size of the aneurysm with eccentric thrombus and the patient’s multiple risk factors, including hypertension, diabetes, and hyperlipidemia, there was concern for impending rupture of the aneurysm. Therefore, the vascular surgery and interventional radiology teams were consulted, and the patient underwent open surgery (Fig. 3). There were no intraoperative or postoperative complications, and the patient was advised on lifestyle modifications and measures to mitigate risk factors, with follow-up recommended. The case was also consulted for a comminuted fracture in the right tibial and fibular shaft (Fig. 4) and managed accordingly. Follow-up ultrasound evaluation for the abdominal aortic ectasia and left common iliac artery aneurysm showed no significant increase in size.

Figure 3 Intraoperative image showing the surgical repair of the common iliac artery aneurysm.

Figure 4 Xray Anteroposterior and lateral view showing the comminuted fracture of distal shaft of tibia and proximal shaft of fibula.

Discussion

This is a case of a 66-year-old man who was incidentally diagnosed as having a bilateral common iliac artery aneurysm. Isolated iliac artery aneurysm is a rare condition, with a prevalence of 0.03% in the general population, comprising 2–7% of all abdominal aneurysms4. The most frequently encountered types of isolated iliac artery aneurysms involve the common iliac artery (found in 70–90% of cases), followed by the internal and external iliac arteries5–7. Common iliac artery aneurysm (CIAA) typically occurs in elderly males, with a mean age ranging from 62 to 72 years, which aligns with our case8,9. Similarly, Bolin et al. 10 observed a median age of 69 years in a patient with an isolated iliac artery aneurysm. Charisis et al. 11‘s systematic review identified a predominance of the disease among males, with an average age of 72 years.

Similar to abdominal aortic aneurysms, CIAA is associated with risk factors such as advanced age, male sex, white race, smoking, and hypertension7. Less common risk factors include pregnancy, infection, connective tissue disorders, arteritis, trauma, and iatrogenic injuries10,12,13. One of the main risk factors for atherosclerotic lesions is diabetes mellitus (DM). Conversely, individuals with diabetes exhibit a reduced rate of aneurysm development, a decreased rupture rate, delayed age of rupture (beyond 65 years), a lower mortality rate, and a shorter hospital stay for patients with abdominal aortic aneurysms14. This protective effect is attributed to vascular remodeling induced by hyperglycemia and increased glycation end-products15.

Similarly, in patients aged 60 years and older, as well as in females, hyperlipidemia has been associated with a reduced risk of death in abdominal aortic aneurysm cases16. This phenomenon may be attributed to the direct impact of hyperlipidemia on the vascular system, potentially slowing the progression of an aneurysm8. Additionally, some research suggests that the protective effect of hyperlipidemia may be linked to statin therapy17. Nevertheless, the precise mechanism behind this protective effect remains unclear and warrants further investigation. Our patient had a history of hypertension but did not smoke. He also had a background of diabetes and hyperlipidemia. Despite the significant size of the CIAA, the patient remained asymptomatic, possibly due to the described protective role of diabetes in disease progression. A review of CIAA case reports is outlined in Table 2 5,12,13,18–24.

Table 2 Literature review of the case reports

Authors	Year	Age/sex	Presenting features	Risk factor	Comorbidities	Diagnostic modality	Size of aneurysm	Management	
Hariri et al. 11	2022	36 years/male	Unspecific left lower limb pain,
numbness,
paresthesia
coldness of the affected lower limb	Ex-smoker (3 pack year)
Ehlers Danlos syndrome	NA	Doppler US
CTA	4 ×5 cm left common iliac artery	Open surgery with aorto-bi-femoral bypass (ABFB)	
Asad et al. 18	2020	82 years/ female	Abdominal pain
Weight loss
Appetite loss
Incidental finding of a non-pulsatile, right iliac fossa mass on physical examination	Ex-smoker (< 1 per day)
Consumed little alcohol	Hypertension (HTN)
Cerebrovascular Accident (CVA)
osteopenia	CTA	8 cm isolated right common iliac artery	Hybrid approach: Right aorto-uni-iliac stent graft and right to left femoro-femoral crossover graft and right internal iliac artery embolization	
Hu et al. 19	2017	68 years/ male	Chest pain
Back pain	Smoker	HTN
Penetrating aortic ulcer	3D CTA	3.6 cm right common iliac artery	Single stage endovascular repair	
Willems et al. 20	2021	79 years/ male	Acute and progressive abdominal pain	NA	Brucellosis melitensis	CTA	3.1 cm right CIA
2.7 cm left CIA	Endovascular repair	
Hwang et al. 21	2023	58 years/ male	Referral case following incidental detection of left CIAA	NA	Hepatitis B carrier
Right inguinal hernia	CTA	7×4 cm left CIA	Endovascular repair with use of Iliac branch device	
Centofanti et al. 22	2021	75 years/ male	Asymptomatic	NA	NA	CTA	3.2 cm left CIA	Endovascular repair with use of Iliac branch device	
Ida and Taniguchi23	2016	49 years/ male	Sudden left lower quadrant abdominal pain after defecation	HTN	HTN	CECT abdomen and pelvis	Left CIA aneurysm and dissection	Conservative treatment with antihypertensive medications	
Zahdi and Lekehal24	2021	67 years/ male	Abdominal pain

	Smoking
Hypertension	NA	CTA	4 cm right CIA	Open surgery	
Selim et al. 13	2020	80 years/ male	Lower urinary tract symptoms
Low back pain with numbness	NA	Asthma
Diabetes
Hypertension
Chronic kidney disease
Ischemic heart disease with PCI done	CT Abdomen and pelvis with contrast	4.2 ×3.6 ×5.9 cm left CIA	Endovascular approach under ultrasound with fluoroscopy guidance with elective stent angioplasty	
Jiber et al. 5	2019	75 years/ male	Urinary retention
large tender pulsatile mass in lower left abdominal quadrant	NA	NA	CTA	9 ×6 × 4 cm in left CIA	Open surgery	
Our Study	2024	66 years/male	Mild tenderness in right lower abdominal region.	NA	Type II DM, Dyslipidemia	Ultrasound abdomen
CTA	9.7×7.9×8 cm in left CIA	Open surgery	
CECT, contrast enhanced computed tomography; CIA, common iliac artery; CTA, computed tomography angiography; NA, not available; US, ultrasound.

Due to their deep location within the pelvic cavity, IAAs typically remain asymptomatic and are often incidentally discovered due to the increased utilization of ultrasound (US) and CT scans5,13. However, if symptoms do manifest, they may include lower abdominal and flank pain, the presence of an abdominal mass, or other nonspecific symptoms like nausea, constipation, urinary symptoms, paresthesia, chronic vague lower leg discomfort, sciatica, or syncope13,18. In addition to these compressive symptoms, some individuals may present with thrombosis or rupture, leading to significant mortality rates6,7,12,18. Diagnosis is often delayed since these symptoms are not directly related to the vascular system. However, Krupski et al. 25 found that a significant proportion (57%) of patients with isolated IAAs experienced symptoms such as abdominal pain (19%), neurological symptoms (9.5%), calf claudication (9.5%), urinary tract infection (9.5%), or hemodynamic instability (9.5%). Additionally, a pulsatile abdominal mass may sometimes be palpable, particularly during vaginal or rectal examinations, which provide better access to the pelvis. Despite this, physical examinations often yield inconclusive results10. In our study, the aneurysm was detected incidentally while performing workup for trauma.

A CIAA is characterized by a permanent localized dilation measuring 2.0 cm or larger, as determined by various imaging modalities such as US, CT scans, magnetic resonance imaging (MRI), angiography, or surgical records8. Doppler ultrasound is suitable for both screening and diagnosing aneurysms, while CT angiography (CTA) and MRI offer higher accuracy in diagnosis and provide detailed anatomical images of the affected arteries12. Additionally, CTA plays a crucial role in planning pretreatment interventions5. Although aneurysm was detected incidentally in ultrasound imaging of abdomen, detailed evaluation was done with CTA in our patient.

Patients with symptomatic IAAs and asymptomatic IAAs larger than 3.5 cm in diameter are recommended for intervention, whereas those with asymptomatic IAAs smaller than 3 cm should undergo regular imaging surveillance12. In our case, we opted for surgical intervention due to the aneurysm’s substantial size. While open surgical repair (OR) using prosthetic grafts has historically been the preferred treatment for CIAAs, endovascular repair has become increasingly common and is considered safe and effective, particularly for high-risk patients such as the elderly and those with multiple comorbidities2,5,8,18.

Conclusion

This study emphasizes the significance of early detection and management of isolated bilateral common IAAs, especially in high-risk individuals. Understanding the protective role of comorbidities like diabetes and hyperlipidemia can aid in decision-making. Timely intervention is crucial to prevent potentially life-threatening complications associated with IAAs.

Ethical approval

None.

Consent

Written informed consent was obtained from the patient’s legal guardian for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal on request.

Source of funding

None.

Author contribution

S.K.: conceptualization, as mentor and reviewer for this case report and for data interpretation. S.K.: contributed in conceptualization and reviewer. S.B.: contributed in performing literature review and editing. P.P.: contributed in performing literature review and editing. D.B.: contributed in writing the paper and reviewer for this case. S.B.: contributed in writing the paper. S.M.: contributed in writing the paper. All authors have read and approved the manuscript.

Conflicts of interest disclosure

All the authors declare that they have no competing interest.

Research registration unique identifying number (UIN)

None.

Guarantor

Shailendra Katwal.

Data availability statement

Data sharing is available upon reasonable request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
==== Refs
References

1 Shirasu T Takagi H Kuno T . Editor’s Choice – Risk of rupture and all cause mortality of abdominal aortic ectasia: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2022;64 :15–22.35537643
2 Kotsis T Louizos LA Pappas E . Complex common and internal iliac or aortoiliac aneurysms and current approach: individualised open-endovascular or combined procedures. Int J Vasc Med 2014;2014 :178610.25328706
3 Sohrabi C Mathew G Maria N . Collaborators. The SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg 2023;109 :1136–1140.37013953
4 Kimura F Ookubo R Kobayashi D . Successful endovascular repair of a ruptured isolated iliac artery aneurysm: a case report. Clin Case Rep 2019;7 :1880–1884.31624601
5 Jiber H Naouli H Bouarhroum A . Urinary retention revealing a large common iliac artery aneurysm. J Med Vasc 2019;44 :86–89.30770087
6 Melas N Saratzis A Dixon H . Isolated common iliac artery aneurysms: a revised classification to assist endovascular repair. J Endovasc Ther Off J Int Soc Endovasc Spec 2011;18 :697–715.
7 Kolster L Biggs D Patwa A . Bilateral common iliac artery aneurysm, a case report. J Educ Teach Emerg Med 2020;5 :V8–V11.37465595
8 Huang Y Gloviczki P Duncan AA . Common iliac artery aneurysm: expansion rate and results of open surgical and endovascular repair. J Vasc Surg 2008;47 :1203–1211.e2.18514838
9 Hiromatsu S Hosokawa Y Egawa N . Strategy for isolated iliac artery aneurysms. Asian Cardiovasc Thorac Ann 2007;15 :280–284.17664198
10 Bolin T Lund K Skau T . Isolated aneurysms of the iliac artery: what are the chances of rupture? Eur J Vasc Surg 1988;2 :213–215.3063554
11 Charisis N Bouris V Rakic A . A systematic review on endovascular repair of isolated common iliac artery aneurysms and suggestions regarding diameter thresholds for intervention. J Vasc Surg 2021;74 :1752–1762.e1.33617979
12 Hariri O Al Laham O Mohammad A . A distinguished case of a spontaneously dissecting Left Common Iliac Artery Aneurysm, associated with an Elastinopathy, in a healthy 36-year-old male, successfully treated with open surgical repair—a case report. Int J Surg Case Rep 2022;95 :107253.35661499
13 Selim M Nasr MA Alkhouzaie MT . Incidental unruptured isolated left common iliac artery aneurysm: a rare entity. Cureus 2020;12 :e11588.33224687
14 Patel K Zafar MA Ziganshin BA . Diabetes mellitus: is it protective against aneurysm? A narrative review. Cardiology 2018;141 :107–122.30453299
15 Climent E Benaiges D Chillarón JJ . Diabetes mellitus as a protective factor of abdominal aortic aneurysm: possible mechanisms. Clin Investig Arterioscler 2018;30 :181–187.
16 Ding D Yang Y Jiang G . Relationship between hyperlipidemia and the risk of death in aneurysm: a cohort study on patients of different ages, genders, and aneurysm locations. Front Physiol 2023;14 :1081395.37408590
17 Salata K Syed M Hussain MA . Statins reduce abdominal aortic aneurysm growth, rupture, and perioperative mortality: a systematic review and meta-analysis. J Am Heart Assoc 2018;7 :e008657.30371297
18 Asad M Venigalla K Rahi MA . An uncommon presentation and hybrid approach for the management of an unruptured 8 cm common iliac artery aneurysm. Int J Surg Case Rep 2020;66 :126–129.31838431
19 Hu H Guo J Bai H . Single-stage endovascular treatment of a penetrating aortic ulcer with a concomitant “Isolated” iliac aneurysm. Aorta Stamford Conn 2017;5 :177–180.29766010
20 Willems SA Buntinx M Gelinck LBS . Ruptured aneurysm of the common iliac artery caused by brucella melitensis: a case report. EJVES Vasc Forum 2021;52 :26–29.34382029
21 Hwang D Yun WS Kim HK . Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: a case report. Medicine (Baltimore) 2023;102 :e32640.36637963
22 Centofanti G Nishinari K De Fina B . Isolated iliac artery aneurysm in association with congenital pelvic kidney treated with iliac branch device: case report. J Cardiothorac Surg 2021;16 :26.33731177
23 Ida H Taniguchi N . Isolated common iliac artery dissection and aneurysm. BMJ Case Rep 2016;2016 :bcr2016214989.
24 Zahdi O Lekehal B . Isolated common iliac artery aneurysm. Pan Afr Med J 2021;38 :151.33995759
25 Krupski WC Selzman CH Floridia R . Contemporary management of isolated iliac aneurysms. J Vasc Surg 1998;28 :1–13.9685125
