Displaced urinary bladder: a sign of iliac rupture

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Cardiovascular Intervention and Therapeutics (2022) 37:234–235 https://doi.org/10.1007/s12928-020-00736-5

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IMAGES IN CARDIOVASCULAR INTERVENTION

Suko Adiarto¹

Received: 9 November 2020 / Accepted: 17 November 2020 / Published online: 27 November 2020

A 57-year-old diabetic male whose distal left common and external iliac artery are occluded underwent Percutaneous Transluminal Angioplasty (PTA) and stenting in our cath- lab. The totally occluded segment could not be crossed intra- luminally, so we proceeded with sub-intimal approach which was successfully used to cross the lesion.

Balloon angioplasty and stenting was then performed without difficulty. Final angiogram showed patent left iliac artery with adequately expanded stent. However, while removing the catheter out under fluoroscopic guidance, we noticed that the contrast-filled bladder was displaced laterally (Fig. 1a). The fluoroscopic seen just before this one showed the normal position of the bladder (Fig. 1b). We immediately performed angiogram to confirm iliac rupture and identified contrast extravasation from external iliac artery (Fig. 1c) Long balloon inflation and implantation of 8.0–60 mm covered stent successfully sealed the rupture (Fig. 1d). The tip of urinary dower catheter that was inserted just before the completion of the procedure was

in the middle of contrast circle, confirming the position of the displaced urinary bladder (Fig. 1e) Hospitalization was uneventful, and the patient was discharged on third post- operative day. The iliac artery remained patent at 6-month follow-up.

External iliac artery is the most common site of iatrogenic rupture during aorto-iliac intervention (PTA). Rupture in this site may lead to fatality caused by retro-peritoneal bleeding and hemorrhagic shock if not recognized and treated promptly [1, 2]. The rupture may not be immediate that the operator would not find it during angiogram after post-dilatation [3]. The displaced contrast-full urinary bladder is an indirect sign of iliac rupture. Retroperitoneal bleeding caused by the rupture pushes the bladder laterally. The presence of this condition during fluoroscopy may alert the operator to immediately confirm and treat the rupture.

* Suko Adiarto

[email protected]

1 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia

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235 Displaced urinary bladder: a sign of iliac rupture

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References

1. Formichi M, Raybaud G, Benichou H, Ciosi G. Rupture of the external iliac artery during balloon angioplasty: endovascular treatment using a covered stent. J Endovasc Surg. 1998;5:37–41.

2. Awan MU, Omar B, Qureshi G, Awan GM. Successful treatment of iatrogenic external iliac artery perforation with covered stent: case report and review of the literature. Cardiol Res.

2017;8(5):246–53.

3. Park JK, Oh SJ, Shin JY. Delayed rupture of the iliac artery after percutaneous angioplasty. Ann Vasc Surg. 2014;28:491.e1-491.

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Fig. 1 a Angiographic view of displaced contrast-filled urinary bladder. b Angiographic view of the iliac artery and the bladder just before a, showing the bladder in the normal position.

c Extravasation of contrast from left external iliac artery confirming rupture of the ves- sel. d Angiographic view after implantation of covered stent. e Dower catheter implanted con- firmed the position of urinary bladder