Rupture of multiple pseudoaneurysms as a rare complication of common iliac artery balloon occlusion in a patient with placenta accreta: A case report and review of literature

Abstract

Rationale: Placenta accreta is the main cause of severe obstetric postpartum hemorrhage (PPH) and hysterectomy. Several hemostatic techniques have been performed in patients with placenta accreta to prevent PPH and reserve fertility. Abdominal aorta and pelvic arteries balloon occlusion are the only techniques which could be performed before cesarean section (CS) in patients who want to keep the fetus and reserve fertility. However, abdominal aorta and pelvic arteries balloon occlusion might lead to severe complications such as formation and rupture of pseudoaneurysm, angiorrhexis, etc.

Patient concerns: We report a case diagnosed with pernicious placenta previa (PPP) combined with Rh(D) negative blood type, who was performed with bilateral common iliac arteries (CIA) balloon occlusion during CS. However, on the first day after CS, the patient caught sudden left-side lumbago and backache accompanied with palpitation and shortness of breath.

Diagnoses: Formation and rupture of multiple pseudoaneurysms in left CIA.

Interventions: Covered stent was inserted into the proximal part of the left CIA and the ipsilateral internal iliac artery was embolized by coil to prevent endoleak.

Outcomes: The patient recovered and discharged from hospital in stable condition without other complications 9 days after CS.

Lessons: It is of paramount importance that obstetricians and radiologists correctly estimate the appropriate occlusion volume and pressure of pelvic arteries before CS to avoid formation and rupture of a pseudoaneurysm. And if the rupture of a pseudoaneurysm occurred, it should be quickly identified and treated with endovascular intervention.

Figure 1

USG and MRI images before cesarean section. (A) USG showed placenta accreta, fluid dark areas in placenta, and rich blood flow between placenta and the anterior wall of lower segment of uterine. (B) MRI revealed placenta completely covered the lower segment of anterior and posterior wall of the uterine, and implanted into the uterus cesarean scar of the lower segment.

Figure 2

CTA and DSA images before covered stent placement. (A) CTA showed multiple pseudoaneurysms of the left common iliac artery. (B) DSA revealed extravasation of a little contrast agent 0.6 cm from the bifurcation of common iliac artery.

Figure 3

CTA images after covered stent placement. (A) CTA revealed the area of the multiple pseudoaneurysms was completely covered by the covered stent. (B) CTA showed normal position and morphology of the covered stent 1 year after.