RUPTURE OF COMMON FEMORAL ARTERY ANEURYSM WITH CONCOMITANT ILIAC ARTERY ANEURYSMS IN POST RADIOTHERAPY PATIENT – CASE REPORT

Authors

  • Bogomila Chesmedzhieva UMHAT St.George, Plovdiv, Clinic of Vascular Surgery, Bulgaria
  • Georgi Hristov UMHAT St.George, Plovdiv, Clinic of Vascular Surgery, MU Plovdiv, Bulgaria
  • Anastas Cholakov UMHAT St.George, Plovdiv, Clinic of Vascular Surgery, Bulgaria
  • Stefan Stanev UMHAT St.George, Plovdiv, Clinic of Vascular Surgery, Bulgaria
  • Desislava Kostova-Lefterova Medical College, Medical University Pleven, Pleven, Bulgaria

Keywords:

Radiation induced peripheral artery disease, Common femoral artery aneurysm, Rupture of peripheral aneurysm, Aortob`ifemoral bypass, Deep venous thrombosis

Abstract

Femoral and popliteal aneurysms can be limb threatening because of their potential for distal embolization, acute thrombosis and rarely rupture. Aneurysms of the common femoral artery are especially rare (up to 10 times more seldom than aortic aneurysms. As spontaneous rupture of infrainguinal aneurysm is very rare, there is also a risk of such rupture after radiation therapy.
Case report: Seventy four year old female patient with history of pain and swelling of the right thigh and calf from 3 days. A hysterectomy due to cervical carcinoma with multiple chemo and radiotherapy courses was performed 3 years prior. Two computed tomography angiographies (CTAs) were performed to monitor for metastases. No relapse of the oncological disease was found, but the CTAs revealed multiple aneurysms of the iliac arteries, and one of the right common femoral artery. Clinical status: painful swelling of the right thigh with pulsatile mass in the groin, subfascial oedema of the calf. Palpable pulses on the tibial arteries. Doppler ultrasonography femoro popliteal phlebothrombosis, aneurysmal dilatation of the common femoral artery. Computer tomography angiography
aneurysm of the right common iliac artery 34mm diameter; aneurysm of the left common iliac artery 54mm diameter; aneurysm of the right common femoral artery 108mm diameter with contrast extravasation and oedema of the surrounding tissues. Compression of the right femoral vein. Operative treatment: A median laparotomy was undertaken under general anaesthesia. Aorta was clamped 2 cm proximal of its bifurcation, inferior mesenteric artery was preserved. The proximal anastomosis of the aortobifemoral bypass was constructed over the aortic bifurcation with silver knitted Dacron prosthesis 18/9mm. Tunnelling of the branches was extremely difficult due to severe adhesions of the retroperitoneum. Оperative access in the right inguinal area showed absence of arterial wall and capsule of false aneurysm. The ostial parts of superficial and deep femoral arteries were discovered in the cavity, approximately 10cm away from the most distal part of the external iliac artery. A neobifurcation was constructed and implanted to the right branch of the graft. In the left groin, a standard end to side anastomosis was constructed. The patient was discharged with therapy Edoxaban 30mg/daily and hypertension medications on the 15th postoperative day with primarily healing surgical wounds, actively mobilized with a bandage belt and elastocompression for the right leg. Bilateral foot pulses present.
Discussion: Radiation induced peripheral artery disease (RIPAD), after therapeutic irradiation of the abdomen, due to lymphoma, sarcoma or genitourinary malignancies has been reported by several studies. Clinical presentations of RIPAD in those cases vary from vase renal hypertonia, chronic claudication to acute limb ischemia. Rupture of major vessel after irradiation is uncommon, but acute complication of radiotherapy. Common femoral artery is rarely affected by spontaneous rupture after irradiation, but it has been reported several times, mostly in conditions of slowly or non healing wound, with death of haemorrhage as the most common outcome.
Conclusion: The presented clinical case demonstrates multiple vascular complications in irradiated patient, although we cannot fully associate those with the previous radiotherapy. Intraoperative challenges of tunnelling the right branch of the bypass were great, but the post radiotherapy adhesions prevented asymptomatic rupture of the common femoral artery aneurysm.

Author Biographies

Georgi Hristov, UMHAT St.George, Plovdiv, Clinic of Vascular Surgery, MU Plovdiv, Bulgaria

Department of Cardiovascular Surgery

Desislava Kostova-Lefterova, Medical College, Medical University Pleven, Pleven, Bulgaria

Radiology Department, National Cardiology Hospital, Sofia, Bulgaria

Radiology Department, University Hospital Aleksandrovska, Sofia, Bulgaria

References

Asaithamby, A. (2016). Ionizing radiation and heart risks. Semin. Cell Dev. Biol. , 58, 14 25

Azimzadeh O, Sievert W, Sarioglu H, et al. (2015). Integrative proteomics and targeted transcriptomics analyses in cardiac endothelial cells unravel mechanisms of long term radiation induced vascular dysfunction. J Proteome Res ;14:1203 19. doi:10.1021/pr501141b

Cade, S. (1940). Malignant Disease and Its Treatment by Radium. Baltimore, Williams & Wilkins, (1940); pp. 161

Diwan, Aparna & Sarkar, Rajabrata & Caridi, James & Zelenock, Gerald & Wakefield, Thomas. (2000). Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms. Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 31. 863 9. 10.1067/mva.2000.105955.

Dorresteijn LD, Kappelle AC, Boogerd W, Klokman WJ, Balm AJ, Keus RB, et al. (2002). Increased risk of ischemic stroke after radiotherapy on the neck in patients younger than 60 years. J Clin Oncol. 20:282 8. doi: 10.1200/JCO.2002.20.1.282

Fajardo, Luis & Lee, Alice. (1975). Rupture of Major Vessels After Radiation. Cancer. 36. 904 13. 10.1002/1097

(197509)36:3<904::AID CNCR2820360311>3.0.CO;2 U.

Kim JH, Jenrow KA, Brown SL. (2014). Mechanisms of radiation induced normal tissue toxicity and implications for future clinical trials. Radiat Oncol J. 32:103 15. doi: 10.3857/roj.2014.32.3.103

Lee MO, Song SH, Jung S, Hur S, Asahara T, Kim H, et al. (2012). Effect of ionizing radiation induced damage of endothelial progenitor cells in vascular regeneration. Arterioscler Thromb Vasc Biol. 32:343 52. doi: 10.1161/ATVBAHA.111.237651

Little M P, Azizova T V, Richardson D B, Tapio S, Bernier M, Kreuzer M et al. (2023). Ionising radiation and cardiovascular disease: systematic review and meta analysis BMJ 2023; 380:e072924 doi:10.1136/bmj 2022

Little MP, Gola A, Tzoulaki I. (2009). A model of cardiovascular disease giving a plausible mechanism for the effect of fractionated low dose ionizing radiation exposure[doi]. PLoS Comput Biol 2009;5:e1000539. doi:10.1371/journal.pcbi.1000539;

Liu E, Guan X, Wei R, Jiang Z, Liu Z, Wang G, Chen Y, Wang X. (2022). Association Between Radiotherapy and Death From Cardiovascular Disease Among Patients With Cancer: A Large Population Based Cohort Study. J Am Heart Assoc. 2022 Mar 15;11(6):e023802. doi: 10.1161/JAHA.121.023802. Epub 2022 Mar 5. PMID: 35253473; PMCID: PMC9075311

Lowe D, Raj K. (2014). Premature aging induced by radiation exhibits pro atherosclerotic effects mediated by epigenetic activation of CD44 expression. Aging Cell 2014;13:900 10. doi:10.1111/acel.12253;

Manenti, G.; Coppeta, L.; Kirev, I.V.; Verno, G.; Garaci, F.; Magrini, A.; Floris, R. (2024). Low Dose Occupational Exposure to Ionizing Radiation and Cardiovascular Effects: A Narrative Review. Healthcare 2024, 12, 238. https://doi.org/10.3390/healthcare12020238

Maruyama, K & Mishima, Kazuhiko & Saito, N & Fujimaki, Takamitsu & Sasaki, T & Kirino, T. (2000). Radiation

Induced Aneurysm and Moyamoya Vessels Presenting with Subarachnoid Haemorrhage. Acta neurochirurgica. 142. 139 43. 10.1007/s007010050016.

McCready RA, Hyde GL, Bivins BA, Mattingly SS, Griffen WO. Radiation induced arterial injuries. Surgery 1983; 93: 306 309

Mitchell JD, Cehic DA, Morgia M, Bergom C, Toohey J, Guerrero PA, Ferencik M, Kikuchi R, Carver JR, Zaha VG, Alvarez Cardona JA, Szmit S, Daniele AJ, Lopez Mattei J, Zhang L, Herrmann J, Nohria A, Lenihan DJ, Dent SF. (2021). Cardiovascular Manifestations From Therapeutic Radiation: A Multidisciplinary Expert Consensus Statement From the International Cardio Oncology Society. JACC CardioOncol. 2021 Sep 21;3(3):360 380. doi: 10.1016/j.jaccao.2021.06.003. PMID: 34604797; PMCID: PMC8463721.

Milutinovic J, Darcy M, Thompson KA. (1990). Radiation induced renovascular hypertension successfully treated with transluminal angioplasty: case report. Cardiovasc Interv Radiol. 13:29 31. doi: 10.1007/BF02576934

Moutardier V, Christophe M, Lelong B, Houvenaeghel G, Delpero JR. (2002). Iliac atherosclerotic occlusive disease complicating radiation therapy for cervix cancer: a case series. Gynecol Oncol. 84:456 9. doi: 10.1006/gyno.2001.6525

Nabiałek Trojanowska I, Lewicka E, Wrona A, Kaleta AM, Lewicka Potocka Z, Raczak G, Dziadziuszko R. (2020) .Cardiovascular complications after radiotherapy. Cardiol J;27(6):836 847. doi: 10.5603/CJ.a2018.0120. Epub 2018 Oct 19. PMID: 30338841; PMCID: PMC8079093;

Pararajasingam, Ravi & Todd, J & Oshodi, Taohid. (2002). Delayed Common Femoral Artery Rupture Following Irradiation Therapy for Carcinoma of the Vulva. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 22. 573 4. 10.1053/ejvs.2001.1510.

Qianjun Pan,Rui Zhao,Suzette Graham Hill (2024). From 60% to 5% in 12 Weeks: A Trastuzumab Induced Left Ventricular Ejection Fraction Drop, Cureus, . https://doi.org/10.7759/cureus.59172;

Rombouts C, Aerts A, Quintens R, et al. (2014). Transcriptomic profiling suggests a role for IGFBP5 in premature senescence of endothelial cells after chronic low dose rate irradiation. Int J Radiat Biol ;90:560 74. doi:10.3109/09553002.2014.905724;

Saka B, Bilge AK, Umman B, Yilmaz E, Nisanci Y, Erten N, et al. (2003). Bilateral renal artery stenosis after abdominal radiotherapy for Hodgkin’s disease. Int J Clin Pract. 57:247 8.

Saliou C, Julia P, Feito B, Renaudin JM, Fabiani JN. (1997). Radiation induced arterial disease of the lower limb. Ann Vasc Surg. 11:173 7. doi: 10.1007/s100169900030; Baerlocher MO, Rajan DK, Ing DJ, Rubin BB.(2004) Primary stenting of bilateral radiation induced external iliac stenoses. J Vasc Surg. 40:1028 31. doi: 10.1016/j.jvs.2004.08.031;

Savolainen, Hannu & Widmer, Matthias & Heller, Georg & Gerber, Martin & Carrel, Thierry & Schmidli, Juerg. (2003). Common Femoral Artery Uncommon Aneurysms. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 92. 203 5. 10.1177/145749690309200306.

Stewart FA, Heeneman S, Te Poele J, Kruse J, Russell NS, Gijbels M, et al. (2006). Ionizing radiation accelerates the development of atherosclerotic lesions in ApoE mice and redisposes to an inflammatory plaque phenotype prone to hemorrhage. Am J Pathol. 168:649 58. doi: 10.2353/ajpath.2006.050409

Virmani R, Farb A, Carter AJ, Jones RM. (1999). Pathology of radiation induced coronary artery disease in human and pig. Cardiovasc Radiat Med. 1:98 101. doi: 10.1016/S1522 865(98)00010 9

Yang EH, Marmagkiolis K, Balanescu DV, Hakeem A, Donisan T, Finch W, Virmani R, Herrman J, Cilingiroglu M, Grines CL, Toutouzas K and Iliescu C (2021). Radiation Induced Vascular Disease A State of the Art Review. Front. Cardiovasc. Med. 8:652761. doi: 10.3389/fcvm.2021.652761

Yentrapalli R, Azimzadeh O, Barjaktarovic Z, et al. (2013). Quantitative proteomic analysis reveals induction of premature senescence in human umbilical vein endothelial cells exposed to chronic low dose rate gamma radiation. Proteomics ;13:1096 107. doi:10.1002/pmic.201200463;

Yentrapalli R, Azimzadeh O, Sriharshan A, et al. (2013). The PI3K/Akt/mTOR pathway is implicated in the premature senescence of primary human endothelial cells exposed to chronic radiation. PLoS One ;8:e70024. doi:10.1371/journal.pone.0070024;

Zamorano JL, Lancellotti P, Rodriguez Muñoz D, et al. (2016). ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC) Eur Heart J. 2016;37(36):2768 2801. doi: 10.1093/eurheartj/ehw211;

Zinzani PL, Gherlinzoni F, Piovaccari G, Frezza G, Bendandi M, Ferretti RM, et al. (1996). Cardiac injury as late toxicity of mediastinal radiation therapy for Hodgkin’s disease patients. Haematologica. 81:132 7

Downloads

Published

2024-08-17

How to Cite

Chesmedzhieva, B., Hristov, G., Cholakov, A., Stanev, S., & Kostova-Lefterova, D. (2024). RUPTURE OF COMMON FEMORAL ARTERY ANEURYSM WITH CONCOMITANT ILIAC ARTERY ANEURYSMS IN POST RADIOTHERAPY PATIENT – CASE REPORT. KNOWLEDGE - International Journal , 65(4), 405–410. Retrieved from https://ikm.mk/ojs/index.php/kij/article/view/6941

Most read articles by the same author(s)