A hybrid approach to appendicitis with right external iliac artery pseudo aneurysm: A case report

Abstract

Introduction: While acute appendicitis is a common surgical problem, the simultaneous occurrence of appendicitis and an infected iliac artery pseudoaneurysm is exceedingly rare. We report the successful treatment of an infected right external iliac artery pseudo aneurysm in the 1setting of acute appendicitis.

Presentation of case: The patient is an 83-year-old male who presents with severe sepsis, right lower quadrant and right leg pain. Additional past medical history is significant for rectal cancer status post resection and radiation therapy in 1997. Computed tomography (CT) on admission revealed a right iliopsoas muscle abscess, an inflamed Appendix and a pseudo aneurysm arising from the right external iliac artery. After consultations by multiple specialties, the plan was to proceed with percutaneous drainage of the abscess, antibiotic therapy and subsequent repair of the pseudoaneurysm. CT guided drainage of the iliopsoas abscess was performed with return of hemorrhagic fluid. Due to the concern of contained pseudoaneurysm rupture, the patient was taken for expedited repair. Due to the patient's frailty and hostile abdomen, we performed embolization of the right external iliac artery pseudoaneurysm with Amplatzer I plugs (St. Jude Medical, St. Paul MN) and left common femoral to right superficial femoral bypass with cryopreserved cadaveric femoral vein. Following pseudoaneurysm exclusion, continued percutaneous drainage and antibiotic therapy, the patient has done well with no further evidence of infection.

Conclusion: Repair of infected pseudo aneurysms can prove challenging. Ongoing infection, a hostile surgical abdomen and patient frailty further complicates the treatment of these patients. This case displays a minimally invasive approach to this rare but morbid condition.

Keywords: Appendicitis; Iliac artery reconstruction; Iliopsoas muscle abscess; Mycotic aneurysm; Pseudoaneurysm.

Fig. 1

Pre-operative axial images from computed tomography demonstrating (A) a right iliopsoas abscess measuring 7 × 5 × 4 cm, (B) a distended and hyperemic Appendix along with a pseudo aneurysm arising from the lateral wall of the right external iliac artery measuring 9 × 7 mm. Additionally, (C) infection is seen tracking into the right groin precluding the right common femoral artery as a site for distal revascularization.

Fig. 2

Successful computed tomography guided drainage (A) and placement of 12 French Dawson Mueller tube (B) in right iliopsoas abscess with immediate return of hemorrhagic fluid concerning for contained rupture of right external iliac pseudo aneurysm.

Fig. 3

Digital subtraction angiography (DSA) demonstrating a right external iliac artery pseudo aneurysm pre- and post-embolization, respectively (A & B).

Fig. 4

Digital subtraction angiography (A) and three-dimensional volume-rendered images (B) demonstrating successful embolization of the right external iliac artery pseudoaneurysm with Amplatzer I plugs (St. Jude Medical, St. Paul MN) and left common femoral to right superficial femoral bypass with cryopreserved cadaveric femoral vein.

Fig. 5

Post-operative axial images from computed tomography demonstrating a nearly resolved right iliopsoas abscess and successful exclusion of infected right external iliac artery pseudoaneurysm (A–C).