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pain and calcification with renal transplantation. Archives of Internal Medicine, 137, 375-377. MASSRY, S. G., COBURN, J. W. & POPOUTZER, M. M.,

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Secondary hyperparathyroidism in chronic renal failure. Archives of Internal Medicine, 124, 431-441. MEEMA, H. E., OREOPOULOS, D. G. & DE VEBER, G. A.,

1976.

their relationship to dialysis treatment, renal transplant and parathyroidectomy. Radiology, 121, 315-321. PARFITT, A. M., 1969. Soft tissue calcification in uraemia. Archives of Internal Medicine, 124, 544-553. SANG, Y. H. & WITTEN, D. M., 1977. Diffuse calcification of

the breast in chronic renal failure. American Journal of Roentgenology, 129, 341-342.

Arterial calcifications in severe chronic renal disease and

The development of an infected false aneurysm following iliac angioplasty By J . C. Cooper, C h M , FRCS, D. A. Woods, M B , ChB, *P. Spencer, FRCR and *A. E. Procter, FRCR Departments of Surgery and 'Radiology, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK

(Received September 1990 and in revised form January 1991) Keywords: Aneurysm, Angioplasty

Percutaneous transluminal angioplasty is now an established effective treatment for some patients with peripheral vascular disease. The effect of angioplasty is to stretch all layers of the vessel wall which results in splitting of the atheromatous plaque and intima and to some extent the media (Sandborn et al, 1983). Surprisingly, acute arterial rupture and false aneurysm formation at the site of angioplasty are rare complications and few cases have previously been reported (Simmonetti et al, 1983; Samson et al, 1984; Creasy & McMillan, 1987; Moran & Ruttley, 1987). We describe the development of an infected false aneurysm in a patient following iliac angioplasty. As far as we are aware this complication has not previously been recorded.

haematuria on two occasions and increasingly severe right iliac fossa pain. On examination he was unwell with a pyrexia of 39.5°C and marked tenderness and guarding in the right iliac fossa with an overlying bruit. The right femoral pulse was absent and the leg was cool with poor capillary return. His white cell count was 2 2 x l 0 9 l - l and urine and blood cultures proved sterile. An emergency intravenous pyelogram was normal, but an ultrasound scan revealed a 3.5 cm mass in the right iliac fossa with

Case report A 39-year-old man presented with a 4 year history of claudication affecting both legs, left worse than right. His general health was otherwise good and he was on no medication. A right transfemoral arteriogram revealed two localized stenoses of the right external iliac artery (Fig. 1), and a 6 cm occlusion of the left superficial femoral artery. Immediately after arteriography the patient underwent angioplasty to both iliac stenoses using a 4 cm long 6 mm inflated diameter polyethylene balloon, and inflation pressures of between 5 and 8 atmospheres. Three thousand units of heparin were given intraarterially prior to dilatation. A 40 mmHg systolic pressure gradient across the lesions was successfully abolished by angioplasty. The patient was commenced on 75 mg daily of Aspirin and discharged home the following day after an uncomplicated recovery with plans to undertake angioplasty of the left leg at a later date. He was readmitted to hospital 2 weeks later with a 10 day history of general malaise, frequent night sweats, macroscopic Address correspondence to: Mr J. C. Cooper, Senior Registrar General Surgery, Chesterfield and North Derbyshire Royal Hospital, Calow, Chesterfield S44 5BL, UK.

Vol. 64, No. 764

Figure 1. Arteriogram showing two localized stenoses of the (right) external iliac artery.

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Case reports

Figure 2. Arteriogram showing a false aneurysm of the (right) external iliac artery.

an arterial signal and visual expansion suggestive of an iliac artery aneurysm. An arteriogram confirmed an aneurysm of the right external iliac artery at the site of previous angioplasty (Fig. 2). At laparotomy a 2 cm longitudinal split in the external iliac artery was found with an associated infected false aneurysm. Thrombus from the aneurysm and part of the disrupted arterial wall were sent for bacteriology. The disrupted segment of the arterial wall was repaired and the external iliac artery tied off proximally and distally. The abdomen was then closed and a left to right femoro-femoral cross-over graft was carried out using an 8 mm externally supported polytetraflouroethylene (PTFE) (Impra Inc., USA). The patient was placed on intravenous antibiotics for 7 days post-operatively and made an uncomplicated recovery, being discharged from hospital after 10 days, with oral antibiotics for a further 2 weeks. Culture of both the thrombus and the arterial wall revealed a significant growth of Staphylococcus pyogenes. Discussion

Our own experience (Belli et al, 1990) would support the generally held view that percutaneous transluminal angioplasty is a relatively safe treatment for peripheral vascular disease. Nevertheless, this should not allow the clinician to develop a false sense of security, and he should be aware of the possible complications that may arise, however rare. We are not aware of any previous reports of an infected false aneurysm developing at the

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site of angioplasty. Only four instances of a non-infected false aneurysm have previously been reported (Samson et al, 1984; Creasy & McMillan, 1987; Moran & Ruttley, 1987), although its true incidence may be higher as follow-up angiography following angioplasty is not routine (Creasy & McMillan, 1987; Moran & Ruttley, 1987). It is unclear exactly why false aneurysms form following angioplasty but factors such as previous endarterectomy, anti-coagulation, or incorrect balloon size or inflation pressure have been suggested (Creasy & McMillan, 1987; Moran & Ruttley, 1987). None of these factors could be implicated in our case, however, where there was no departure from our usual technique (Belli et al, 1990). One explanation could be that a bacteraemia occurred at the time of the procedure or some days after it, allowing an infection to settle at the site of intimal disruption and thus weakening the vessel wall further and leading to false aneurysm formation. Our case illustrates the importance of recognizing the infective nature of the false aneurysm. We believe that surgeons should be aware of the possibility when treating this condition, so that ligation of the aneurysm and extra-anatomical by-pass grafting is carried out rather than simple repair of the artery, which we feel would be inappropriate treatment. Acknowledgments We thank Mr C. L. Welsh for allowing us to report this case, and Mrs O. M. Woods for typing the manuscript. References BELLI, A. M., CUMBERLAND, D. C , KNOX, A. M., PROCTER,

A. E. & WELCH, C. L., 1990. The complication rate of percutaneous peripheral balloon angioplasty. Clinical Radiology, 41, 380-383. CREASY, T. S. & MCMILLAN, P. M., 1987. False aneurysm after percutaneous transluminal angioplasty. British Journal of Surgery, 74, 1069. MORAN, C. G. & RUTTLEY, M. S. T., 1987. Development of a

false aneurysm following percutaneous transluminal angioplasty. British Journal of Surgery, 74, 652. SAMSON, R. H., SPRAYREGAN, S., VEITH, F. J., SCHER, A. L., GUPTA, S. K. & ASCER, E., 1984. Management of

angioplasty complications, unsuccessful procedures and early and late failures. Annals of Surgery, 199, 234-240. SANDBORN, T. A., FAXON, D. P., HAUDENSCHILD, C , GOTTSMAN, S. B. & RYAN, T. J., 1983. The mechanism of

transluminal angioplasty: evidence for formation of false aneurysms in experimental atherosclerosis. Circulation, 68, 1136-1140. SIMONETTI, G., Rossi, P., PASSRIELLO, R., FARAGLIA, V., SPARATERA, C , PISTOLESE, R. & FIORANI, P., 1983. Iliac

artery rupture: a complication of transluminal angioplasty. American Journal of Roentgenology, 140, 989-990.

The British Journal of Radiology, August 1991

The development of an infected false aneurysm following iliac angioplasty.

1991, The British Journal of Radiology, 64, 759-760 Case reports MCDOUGAL, B. A. & LUKER, B. P., 1977. Resolution of breast pain and calcification wi...
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