Extremely rare external iliac artery disconnection and new collateral remodeling in a woman with endometrial stromal sarcoma | BMC Women’s Health

The unmarried patient was 26 years old and had normal menstruation. At the age of 13, she had her first period. The last menstruation started on April 27, 2020 and lasted about ten days. She denied having a history of congenital or acquired bleeding disorders, liver disease, or use of antiplatelet drugs, blood thinners, or nonsteroidal anti-inflammatory drugs. The patient indicated that she started smoking when she was 16 years old. In recent years, she has smoked more than 20 cigarettes a day. In addition, she worked in a nightclub and drank every day. In addition, the patient had a bad fall and landed on the floor in the bath. Due to this abnormal menstruation, she went to a local hospital and the color Doppler ultrasound showed 8×9×7 cm3 uterine fibroids. On May 6, 2020, the patient underwent an abdominal myomectomy at this hospital. During the operation, a myomatous protrusion (7 × 6 × 5 cm3) was found in the posterior wall of the uterus. The surface muscle layer was cut away, revealing a brown mass with an uneven surface and no obvious capsules. The mass was a fusion of several small masses that had penetrated the endometrial layer. Pathological findings after operation showed low-grade endometrial stromal sarcoma with hemorrhagic necrotic cystic changes and tumor thrombus in tumor vessels (Fig. 1A,B).

Fig. 1

Pathological results of the two operations. Low-grade endometrial stromal sarcoma and tumor thrombus in the vessels are shown in A and B at the first operation. No tumor metastasis was found in any lymph nodes (VS, D)

The patient came back to our hospital 10 days after the operation. So far, she has not complained of any obvious discomfort, normal gait, impediments to lower extremity movement, and a history of pain in her left leg associated with walking and relaxation through rest. . There was no significant difference in muscle tension or skin temperature between the two legs and no claudication in his left leg. Serum tumor marker results showed a CA125 level of 68.8 U/ml (3, and the echo from the posterior wall of the uterus was disordered. Pelvic magnetic resonance imaging (MRI) evaluation showed that the endometrium was slightly thickened and myometrial signal was irregular on May 18. floor muscle or pelvic bone. Pelvic MRI/DWI imaging before laparoscopic surgery could not reflect external iliac artery abnormalities.

The laparoscopic operation showed that the sigmoid colon, part of the rectum and the left side of the pelvic wall were densely bonded, and the uterus and double appendages were difficult to expose. After lymphadenectomy of the right paraaortic and pelvic nodes, the left peritoneum was opened to expose the left iliac vessels during resection of the left pelvic node. Approximately 2.5 cm from the bifurcation of the left common iliac artery, the left external iliac artery was found to be discontinuous (Fig. 2). The diameter of the left external iliac artery was significantly smaller than that of the right side. There were no electrocautery changes, acute inflammation, or perivascular hemorrhage preferentially surrounding the left external iliac artery.

Figure 2
Figure 2

Abnormal left external iliac artery discovered during laparoscopic surgery. The severed left external iliac artery is shown in Aand the distal end of the left external iliac artery is shown in B. The red arrowheads indicate the two ends of the artery. The dotted column indicates the distance between the two ends

A multidisciplinary surgical team (EMD) consultation was initiated and the severity of the emergency was assessed. The arterial pulsation of the left dorsal pedal artery was weaker than that of the right artery. The temperature and skin color of the left foot were normal, and there was no significant difference in the body temperatures of the two lower limbs. She had palpable pulses in the left dorsal foot and posterior tibialis. The blood flow spectrum of the femoral artery could be seen by color Doppler ultrasound during the operation. After a comprehensive assessment of skin temperature, arterial pulsation, and arterial blood flow, experts suggested that the status of the left IAE disconnection was non-acute and indicated that an organic thrombus may have been present. in the lumen of the artery. Additionally, the left lower extremity collateral circulation was established and could respond to blood supply from the lower extremities, which was also confirmed by computed tomography angiography (CTA) on June 1, 2020. The collateral circulation was visible in the left external iliac artery. (Fig. 3A). Daily activities such as walking were not affected before the second operation. The experts agreed that it was not necessary to use an arterial bypass to establish new collateral circulation. The two blind ends of the left external iliac artery being far from each other, it was impossible to perform an end-to-end anastomosis; therefore, the blind ends were tied off with 10 silk threads.

Figure 3
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Imaging of the left external iliac artery and other bilateral lower extremity vessels with computed tomography angiography (A the sixth day after the second operation; B three months after the operation) and correlative illustration of B (VS). Collateral circulation was visible in the left external iliac artery (yellow arrows), indicating that the left lower extremity blood supply was unaffected

After the second operation, two more CTA results (August 12, 2020 and February 5, 2021) after the operation showed that no new branches were involved in the collateral circulation network at the broken proximal end (Figs. 3B, C and 4). Ultrasound was used to assess the blood flow of the main arteries of the lower extremities four times after the second operation. Compared with that of the arterial blood flow of the opposite lower limb, the spectral value of the maximum velocity of the femoral artery, the superficial femoral artery, the popliteal artery and the dorsal pedal artery of the left lower limb n was not greatly affected by the presence of the abnormal left external iliac artery (Fig. 5A–D). Moreover, the resistance index of the four main arteries of the left lower limb was lower than that of the arteries of the contralateral lower limb (Fig. 5E,F). At the same time, electromyography was used to analyze the effect of the abnormal external iliac artery of the left lower limb. No obvious abnormalities were found in the compound muscle action potential (CMAP) of the tibial nerve or peroneal nerve or in the sensory nerve action potential (SNAP) of the superficial peroneal nerve or sural nerve of the left lower limb (Fig. 6). There was no significant difference between the bilateral lower limbs in maximal voluntary contraction (MVC) of bilateral rectus femoris and tibialis anterior muscles (Fig. 7).

Figure 4
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Computed tomography angiography imaging of the bilateral lower limbs on February 5, 2021 (ACTA image of lower limb vessels; Babnormal left external iliac artery and collateral circulation in the left external iliac artery)

Figure 5
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Arterial blood flow of the lower limbs after the second operation. Maximum systolic and end-diastolic velocities of blood flow and resistance indices of bilateral lower extremity arteries are shown in AF at different times after the second surgery

Figure 6
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Nervous examination of the left lower limb. The compound muscle action potential (CMAP) of the tibial nerve and peroneal nerve of the left lower limb is shown in A, Band the sensory nerve action potential (SNAP) of the superficial peroneal nerve and the sural nerve of the left lower limb are shown in panels VS, D

Picture 7
number 7

Muscle examination of the lower limb. Maximum voluntary contraction (MVC) of the bilateral rectus femoris and tibialis anterior muscles is shown in A, B

The patient was diagnosed with stage IB endometrial stromal sarcoma. While the patient was undergoing fertility preservation surgery, a tumor thrombus was observed in the tumor vessels. Therefore, after fully communicating with the patient and signing the informed consent form, she received intravenous chemotherapy with liposomal doxorubicin (30 mg/m2) and oral aromatase inhibitors (letrozole, 2.5 mg once daily) for six months. We handled this particular case as threatening but not dangerous. After surgery, pelvic MRI revealed that the uterus showed postoperative changes and no abnormal signals were found in the uterus sixteen months after the operation. There were no obvious abnormalities in her left lower extremity, no claudication had developed, and the patient remained asymptomatic. The surgical/imaging and follow-up timeline for this case is shown in Fig. 8.

Picture 8
figure 8

The chronology of surgery/imaging and the follow-up of this case

Irene B. Bowles