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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00741-6
10.1016/j.radcr.2024.07.156
Case Report
Giant external iliac-vein aneurysm presenting urinary urgency as first symptom: A rare case report
Jama Shuayb Moallim Ali MD khayreqaataa1@gmail.com
a⁎
Osman Faisal Abdi Osoble MD b
Elmi Abdinasir Mohamed MD c
Ali Abdijalil Abdullahi MD d
Dirie Abdikadir Mohamed MD e
a Radiology Department, Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital, Zona-k, Hodan district, Mogadishu, Somalia
b Radiology Department, Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital, Bulohubey, Wadajir district, Mogadishu, Somalia
c Radiology Department, Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital, 30 Street, NBC, Hodan district, Mogadishu, Somalia
d Cardiovascular Surgery Department at Mogadishu Somali Turkish Training and Research Hospital, Digfer, Road, Mogadishu, Somalia
e Radiology Department, Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital, afgeye Street, Hodan district, Mogadishu, Somalia
⁎ Corresponding author. khayreqaataa1@gmail.com
24 8 2024
11 2024
24 8 2024
19 11 52215225
4 5 2024
25 7 2024
26 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A venous aneurysm is the dilation of a single communicating venous system, with or without an associated arteriovenous fistula. The literature documents a few cases of such aneurysms. A seventy-year-old man came to our hospital complaining of increased urinary frequency for the last few months, a left leg ulcer, and swelling of the left lower quadrant of the abdomen for 2 years. Doppler ultrasonography and CT angiography demonstrated a large external femoral vein aneurysm with arteriovenous fistula formation. Surgeons managed the case surgically, using a PTFE interposition grating to ligate the artery-vein connection. Early diagnosis and appropriate management are necessary to avoid fatal complications such as pulmonary embolism and aneurysmal rupture.

Keywords

Venous aneurysms
Arteriovenous fistulas
Poly-tetra-flour-ethylene
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pmcIntroduction

Abdominal venous aneurysms (VA) are rare. There have been a few reports of aneurysms in superficial and deep venous systems in the literature over the past 90 years [[1], [2], [3], [4]]. The external iliac vein is a relatively uncommon location for iliac vein aneurysms, which are an exceptionally rare entity. Hurwitz and Gelabert (1989) described the first case as a thrombosed common and external iliac vein aneurysm [[1], [2], [3], [4]].

Iliac vein aneurysms are rare and can be primary or secondary to an underlying cause. Arteriovenous fistulas (AVFs) are the most prevalent secondary causes of iliac aneurysms [2,4]. Aneurysm symptoms include pelvic tissue compression, local vasculature thrombosis, thromboembolism, and aneurysmal rupture [1,5].

We present a rare case report of a large external iliac vein aneurysm secondary to a traumatic superficial femoral arteriovenous fistula, with urinary urgency as the initial symptom.

Case report

A 70-year-old man came to our hospital complaining of increased urinary frequency for the last few months, a left leg ulcer, and swelling of the left lower quadrant of the abdomen for 2 years. The leg ulcers were chronic and had not healed in the past few years. He had increased urinary frequency and urgency in the past 2 years, which was increasing and progressively disabling the patient's daily activity. The patient has a history of a gunshot wound to the abdomen and left lower extremity, which occurred 20 years ago. On examination, there was swelling of the left lower quadrant of the abdomen and pulsation with a thrilling sound on the anteromedial side of the left thigh.

Doppler sonography of his abdomen and left lower extremity showed aneurysmal dilation with a yin-yang color in the lumen of the external iliac vein, as well as dilation of the external iliac artery with significant superficial venous enlargement (Fig. 1). The CT angiography revealed an arteriovenous fistula in the proximal superficial femoral artery and vein, which led to a large aneurysmal dilatation measuring approximately 13 × 8 cm in size. This dilatation connected to the external iliac vein and was associated with tortuous dilatation of the lower extremity venous system (Fig. 2).Fig. 1 Grey-scale (A and C) and Doppler (B) ultrasound demonstrated large turbid flow swirls of pseudoaneurysm in the left external iliac vein (A) with a yin-yang appearance in color Doppler (B) and communication of the superficial femoral artery with the femoral vein (C).

Fig 1:

Fig. 2 Axial and Coronal CT angiography (A and C) showing huge left external iliac aneurysm with 15 cm in diameter (Yellow arrow) causing right side displacement and marked compression of the bladder (Blue arrow); (B) an arteriovenous fistula in the proximal superficial femoral artery and vein(Red arrow); (D) with contrast opacification in both arterial and venous systems resulting in multiple tortuous superficial venous dilations in the left lower limb. The back flow pressure of the AV fistula resulting in gaint external iliac vein.

Fig 2

To repair arterio-venous fistulas and aneurysms, we used a multidisciplinary approach, treating pathological conditions secondary to these circumstances, such as mass effect-related debilitating urinary frequency, venous ulcers, and swelling. The patient underwent an operation where the arteriovenous fistula was ligated. A PTFE interposition for end-to-end anastomosis was done. An initial follow-up is performed at 6 months postoperatively, followed by evaluations every 6 to twelve months for the subsequent 2 years. The CT angiography showed a favorable outcome after surgery, with the aneurysm shrinking significantly compared to the earlier images. There is also no similarity in contrast opacification between the artery and vein (Fig. 3). The patient's preoperative lower urinary tract symptoms have improved.Fig. 3 Axial CT angiography has shown a good postoperative result (A) showing intense regression of the aneurysm compared to the previous images, and there is no similarity of contrast opacification between the artery and vein (Yellow arrow),in addition the bladder compression is relieved and The patient's lower urinary tract symptoms have improved (Blue arrow), (B) AV fistula between the proximal femoral artery and vein is completely resolved (Red arrow), (C) the tortuous superficial venous dilations in the left lower limb are regressed compared to the previous images.

Fig 3

Discussion

Venus aneurysms are single dilated veins that connect to a main vein structure, with or without arteriovenous fistulae present at the same time. Even among vein aneurysms, iliac vein aneurysms are extremely uncommon [6]. Vein aneurysms are rare and challenging to diagnose, and they are typically discovered inadvertently during physical examination or through imaging modalities [1]. Primary or secondary iliac vein aneurysms can occur in combination with prior trauma or vascular malformation syndromes, such as Parkes-Weber [6,5]. They have been reported in a variety of locations, although they are rarely found in the external iliac vein [1].

The most common causes of iliac VA are arteriovenous fistulas which are mainly attributable to trauma (43%), venous outflow blockage (17%), and primary aneurysms(35%) [2]. The diagnosis of primary iliac vein aneurysm is made when the secondary causes, such as previous trauma are ruled out [2]. The pathogenesis of iliac vein aneurysms is unknown [1,2,4,5]. It has been postulated that increased blood flow and subsequent arterial dilatation proximal to the fistula induce considerable venous outflow blockage, resulting in local venous hypertension. Aneurysmal enlargement occurs as a result of high blood pressure and increased venous wall pressure [1].

In our case, the iliac vein aneurysm was likely secondary, developing over the past 20 years as a result of vascular trauma (gunshot at the proximal superficial femoral artery, causing an AV fistula). A pulmonary embolism, deep vein thrombosis, or unilateral leg swelling could be the patients' initial symptoms [1,5,4]. Iliac vein aneurysms can be difficult to differentiate from lymphadenopathy and groin hernia, making diagnosis a challenge. Among the other things that can be mistaken for venous aneurysms are intravascular and extravascular retroperitoneal tumours, like ovarian cysts, lymphoceles, and “urinomas.”

In our knowledge, this represents the second documented case of an iliac vein aneurysm manifesting symptoms related to the lower urinary tract, along with additional symptoms such as swelling in the left groin area accompanied by thrill pulsation and persistent edoema on the left lower limb.

Doppler ultrasonography, venography, computed tomography (CT), and magnetic resonance imaging (MRI) are used to differentiate between them. These imaging techniques play an important role in planning surgical interventions for venous aneurysms [1,3,4].

In cases of symptomatic venous aneurysm, surgical intervention is necessary to prevent potentially fatal consequences such as rupture-related severe hemorrhage, distant embolism, or compression of nearby structures [1,4]. The risk of thromboembolism and the necessity for veno cava filters to mitigate the risk of pulmonary embolism in these patients must be determined by preoperative Doppler ultrasonography or CT angiography [1]. Venous aneurysms do not have a single course of treatment; both conservative and surgical measures are suggested [2]. The literature contains reports of aneurysmal compression treated with endovascular, surgical, and sclerosing techniques. Venous reanastomosis can be performed using PTFE grafts for lower limb venous and arterial repairs, endovascular stent grafts for small veins, and cephalic vein grafts [3,5]. In our case, a PTFE interposition graft was employed along with ligating the artery-vein connection.

Conclusion

External iliac vein aneurysms are extremely rare and present in a variety of ways clinically. To avoid symptoms like pain, mass effect, limb edema, and major life-threatening complications like pulmonary embolism, aneurysmal rupture, and death, early diagnosis and appropriate treatment are essential.

Ethics approval

Ethical approval for this study was waived by ethical committee of Mogadishu Somali Turkey, Recep Tayyip Erdogan Training and Research Hospital.

Consent to participate

The patient was invited to participate and written informed consent was obtained.

Patient consent

The Patient was invited and written informed consent was obtained for his anonymized information to be published in this study.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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