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Introduction

Bladder cancer is one of the 10 predominant malignancies globally, with an estimated 573,278 new cases and 212,536 deaths recorded in 2020(1). It can be divided into muscle-invasive bladder cancer (MIBC) and non-MIBC. MIBC accounts for ~25% of bladder cancer cases at the time of initial diagnosis (2). Radical cystectomy with extended pelvic lymphadenectomy remains the guideline-recommended treatment for MIBC and may provide optimal cancer control (3). Vascular complications, such as intraoperative injury to blood vessels, which results in massive bleeding, are commonly reported complications of radical cystectomy, which is a catastrophic event and may potentially have an unfavorable effect on surgical mortality rates (4,5). Iliac artery pseudoaneurysm and arterioureteral fistula are rare complications following radical cystectomy (6,7). The present study described another rare case of delayed right external iliac artery disruption that occurred one month after laparoscopic radical cystectomy, without any obvious evidence of iliac artery pseudoaneurysm or arterioureteral fistula.

Case report

A 60-year-old male patient was admitted to the emergency department of the Second Affiliated Hospital of Zhejiang University (Hangzhou, China) in May 2019 with a 2-day history of acute anaemia and fever. The patient had a medical history of poorly controlled diabetes mellitus. Furthermore, the patient had been subjected to a successful laparoscopic radical cystectomy with bilateral pelvic lymph node dissection and urinary diversion and was discharged one month prior. The patient presented with septic and haemorrhagic shock on admission. Enhanced abdominal CT showed diffuse extravasation of the contrast medium from the right external iliac artery, without any evidence of iliac artery pseudoaneurysm or arterioureteral fistula (Fig. 1A). Based on these findings, a diagnosis of right external iliac artery disruption was made.

Figure 1 (A) Abdominal enhanced CT scan showed diffuse extravasation of the contrast medium from the right external iliac artery before surgery, as indicated by the red arrow. (B) Postoperative CT scan showed no medium effusion after surgery, with placement of a vascular stent and abdominal drainage tube.

Broad-spectrum antibiotics (imipenem) were started empirically and then, an open, exploratory operation was undertaken immediately, during which extensive adhesion formation and inflammation around the ileal bladder and external iliac artery were found. More importantly, a vessel split of the right external iliac artery was found after removing the visible blood clots and hematoma around it. Therefore, the diagnosis of disruption and bleeding of the right external iliac artery was confirmed. A vascular stent was inserted to cover the artery split by a vascular surgeon. The patient was then transferred to the intensive care unit for further resuscitation.

Klebsiella pneumoniae subsp. Pneumoniae (KPSP) was isolated in blood culture which was performed according to standard protocols three days later. The standard drug susceptibility test determined that KPSP was more sensitive to tigecycline and imipenem. Appropriate antibiotics (tigecycline plus imipenem) were then administered based on the above results of bacterial culture and drug sensitivities. The vital signs and corresponding blood tests of the patient became normal within three weeks. Furthermore, repeat enhanced CT indicated no effusion of the contrast medium one month later (Fig. 1B). The patient was discharged one week after the repeat CT scan. Follow-up was carried out every 3 months in the first year and every 6 months thereafter. To date, the patient has been followed up for nearly 4 years with no relapse.

Discussion

KP is a common pathogen that causes infections involving the urinary tract, lungs, surgical sites, abdominal cavity, intravascular devices, soft tissues and subsequent bacteremia, particularly in alcoholics and diabetic patients (8,9). For the patient of the present study, diabetes mellitus and immunosuppression due to a major operation were possible risk factors for KP infection in the blood.

Previous studies indicated that KP entry through an overt or occult break in the skin resulted in initial bacteremia (10). The subsequent spread of bacteremia may lead to various complications, such as endophthalmitis, meningitis and aneurysm (11-13). As a gram-negative encapsulated rod, KP has a higher tendency to expand and rupture the vessel wall where it colonizes (14). It was thus speculated that KPSP, which belongs to the KP family, was seeded from the initial bacteremia and then colonized into the right external iliac artery, causing uncontrollable sepsis and arteritis. KPSP infection eventually leads to such catastrophic vessel rupture. The corresponding antibiotics for KPSP were subsequently changed based on the drug sensitivity test to control the bacterial infection and the vessel wall exhibited no evidence of split recurrence at the time of writing the present report.

As interventions, endovascular treatments such as vascular stent grafts are now suggested to be a better choice than conventional surgical vessel repair because severe vessel injuries destabilize the haemodynamic status of the patient and preclude open repair of the lesion (8). In the present case, vascular stent insertion but not vessel suturing was carried out. Both antibiotics and endovascular operation had an important role in the quick recovery of the patient.

In conclusion, timely detection, adequate antibiotic treatment and emergency vascular stent insertion are important strategies for physicians to manage this rare but life-threatening condition. However, large-scale, prospective, controlled trials are in high demand to comprehensively evaluate the effectiveness and feasibility of these antibiotic and surgical treatments.

Acknowledgements

Not applicable.

Funding

Funding: This study was supported by the Natural Science Foundation of Zhejiang Province (grant no. LQ20H1 60032) and the Natural Science Foundation of Fujian Province (grant no. 2018J05124).

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Authors' contributions

LD contributed to the conception and design of the study, obtained the raw data of the patient, such as laboratory data and imaging examinations, and wrote the manuscript. LD and ZW participated in the diagnosis and treatment of the patient. LD and ZW checked and confirmed the authenticity of all the raw data. Both authors have read and approved the final manuscript.

Ethics approval and consent to participate

The present study was approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University (Hangzhou, China).

Patient consent for publication

The patient provided written consent for the publication of the case details and any associated images.

Competing interests

The authors declare that they have no competing interests.

References