Spontaneous rupture of the iliac vein: report of a case

Clinical characteristics and treatment outcomes of 68 patients with spontaneous iliac vein rupture: A case report and systematic review

Objective

Spontaneous iliac vein rupture (SIVR) is a rare but life-threatening condition with limited understanding regarding its clinical presentation, pathogenesis, diagnosis, management, and risk factors for mortality. This study aims to address this gap by providing comprehensive insights into SIVR through personal case reports and a systematic review of previous cases.

Methods

We detail a case of right SIVR caused by inappropriate positioning of the stent in the inferior vena cava and systematically reviewed previous cases. Logistic regression analysis was used to identify risk factors for mortality.

Results

Our SIVR case was successfully managed with percutaneous mechanical thrombectomy and covered stent placement. In the systematic review, 68 patients were included in the analysis with an average age of 62.01 ± 13.25 years; 86.76% were female, 91.17% had left iliac vein rupture, 55.88% presented hemodynamic instability, 76.47% had lower abdomen or iliac fossa pain, 67.64% had deep venous thrombosis (DVT), and 32.35% had May‒Thurner syndrome (MTS). The mortality rates of conservative treatment and open surgery were 2.94% and 17.65%, respectively. All 12 patients receiving endovascular treatment survived. The factors associated with a worse outcome were younger age (52.86 ± 12.96 years, OR: 1.085, 95% CI: 1.002-1.174) and SIVR patients without DVT (OR:10.111, 95% CI: 1.637-62.443).

Conclusion

This first systematic review on SIVR shows that SIVR should be highly suspected in elderly females who develop lower extremity DVT and concurrent lower abdominal pain, particularly those with a retroperitoneal mass and unstable hemodynamics. Thrombosis secondary to MTS may be the main cause of SIVR. Angiography and endovascular therapy should be prioritized for DVT patients with unexplained retroperitoneal hematoma. This study classifies SIVR into two types: iliac vein rupture alone and iliac vein rupture with DVT. These findings provide critical insights for clinicians to accurately diagnose and manage SIVR, thereby improving patient outcomes.

Successful Management of Spontaneous Iliac Vein Rupture with Double Bare Stent Technique: A Case Report and Review of Literature

Spontaneous rupture of the iliac vein is a rare cause of retroperitoneal hematoma. A misdiagnosis may delay the treatment and consequently put the patient in a life-threatening emergency. We report the case of a 73-year-old woman who presented with hemorrhagic shock from bleeding caused by a large left retroperitoneal hematoma. She was successfully treated with an endovascular approach by using a double bare stent technique. An extensive review of the literature was conducted and a total 44 articles with 50 patients were identified. Among these patients, 88.2% were women, 94.1% presented with a left-sided rupture, and the mortality rate was 13.7%. Spontaneous iliac vein rupture was more likely to occur in the left side in female patients. Conservative treatment was an option in hemodynamically stable patients. Exploratory laparotomy and surgical iliac vein repair was necessitated in most patients. Endovascular treatment including placement of covered stent and coil embolization had been widely used to treat spontaneous vein rupture since 2003. Double bare stent technique was also an effective alternative if a suitable covered stent was unavailable.

Spontaneous Iliac Vein Ruptures: A Systematic Review

INTRODUCTION

Spontaneous iliac vein rupture is a rare, but frequently lethal condition. It is important to timely recognize its clinical features and immediately start adequate treatment. We aimed to increase awareness to clinical features, specific diagnostics, and treatment strategies of spontaneous iliac vein rupture by evaluating the current literature.

METHODS

A systematic search was conducted in EMBASE, Ovid MEDLINE, Cochrane, Web of Science, and Google Scholar from inception until January 23, 2023, without any restrictions. Two reviewers independently screened for eligibility and selected studies describing a spontaneous iliac vein rupture. Patient characteristics, clinical features, diagnostics, treatment strategies, and survival outcomes were collected from included studies.

RESULTS

We included 76 cases (64 studies) from the literature, mostly presenting with left-sided spontaneous iliac vein rupture (96.1%). Patients were predominantly female (84.2%), had a mean age of 61 years, and frequently presented with a concomitant deep vein thrombosis (DVT) (84.2%). After various follow-up times, 77.6% of the patients survived, either after conservative, endovascular, or open treatment. Endovenous or hybrid procedures were frequently performed if the diagnose was made before treatment, and almost all survived. Open treatment was common if the venous rupture was missed, for some cases leading to death.

CONCLUSION

Spontaneous iliac vein rupture is rare and easily missed. The diagnose should at least be considered for middle-aged and elderly females presenting with hemorrhagic shock and concomitant left-sided DVT. There are various treatment strategies for spontaneous iliac vein rupture. An early diagnose brings options for endovenous treatment, which seems to have good survival outcomes based on previously described cases.

Spontaneous left external iliac vein rupture

We report a 72-year-old female patient with spontaneous rupture of the left external iliac vein. She visited our hospital for abdominal and back pain. She had the abnormal finding of hemoperitoneum. We performed an emergency operation with diagnosis of left ovarian cyst rupture though she suffered from spontaneous rupture of the left external iliac vein. This case provides insight to the experience of spontaneous rupture of the left external iliac vein.

Spontaneous Iliac Vein Rupture: Case Report and Comprehensive Review of the Literature

Iliac vein rupture is a rare cause of retroperitoneal hemorrhage. It is occasionally lethal, with no clear precipitating factors. We report a case of spontaneous left common iliac vein rupture in a 56-year-old man with a history of deep vein thrombophlebitis (DVT). To date, 32 cases have been reported in the literature. The 32 existing cases and the case presented here were analyzed. A comparative review was performed for chief complaints, basic demographics, potential predisposing factors, treatment modalities, and outcomes. Possible etiological factors to explain this phenomenon were formulated. The patient presented with abdominal pain of 4 hr duration and a near-syncope episode. In the emergency room, he was found to be in hypovolemic shock that was responsive to crystalloids. An urgent exploratory laparotomy was performed for a suspected iliac artery rupture. An uncontrollable hemorrhage from a spontaneous posteromedial tear of the left common iliac vein resulted in intraoperative death. Interestingly, 85% of reported cases occurred in women with an overall average age of 60.6 +/- 13.4 years; 94% of cases were left-sided; 79% reported clinical or histological evidence of DVT or thrombophlebitis; 94% were treated operatively, with a survival rate of 71%. Only one reported case was treated conservatively, with success, and one reported case of endovascular repair resulted in significant morbidity. Iliac vein rupture is an uncommon diagnosis associated with trauma and even rarer when it is spontaneous. We report the thirty-third documented case in the literature since 1961. There is a clear predominance in females and on the left side and a probable association with thrombophlebitis. Our calculated operative success may be overestimated due to a biased literature reporting of favorable outcomes.

A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: Case report and review of the literature

We reported a case in a previously healthy 45-year-old woman of spontaneous rupture of the left external iliac vein, which was revealed as a phlegmasia cerulea dolens with acute lower limb ischemia. A tear on the anterior surface of the vein was discovered during an emergency laparotomy, and the rent was repaired successfully. Twenty-four hours later, the leg swelling increased, and at the reexploration, the common iliac vein was found to be occluded by an organized thrombus as the result of a well-endothelialized membranous band (Cockett or May-Turner syndrome). A Palma-Dale operation (crossover saphenous bypass grafting) was performed secondarily. The swelling in the leg diminished slowly, and the patient was discharged 10 days later with an oral anticoagulant therapy and elastic stockings.

Spontaneous rupture of the left common iliac vein

We report a case of spontaneous rupture of the left common iliac vein in a 58-year-old woman. Because of hemorrhagic shock, the intervention had to be performed under emergency circumstances, precluding repair of the external iliac vein, which was ligated. The postoperative course was uneventful. We also review the 17 prior cases found in the literature.