TRAUMATIC INFERIOR GLUTEAL ARTERY PSEUDOANEURYSM PRESENTING AS RECURRENT BLEEDING AND ANEMIA A CASE REPORT AND REVIEW OF THE LITERATURE

Objectives: Pseudoaneurysms are localized dilations of an artery contained only by a single fibrous layer of tissue. Among them, gluteal pseudoaneurysms are rare, thought to account for less than 1% of all pseudoaneurysms. Of these, pseudoaneurysms of the inferior gluteal artery (IGA) are especially rare. They are commonly caused by blunt and penetrating traumas. Among these, gunshots, stab wounds, and iatrogenic injuries are common. Since IGA pseudoaneurysms were first described in 1803, relatively little has been written on them. Their rarity makes dedicated studies difficult. They have a variable presentation, can easily be misdiagnosed, and mistreatment can be deadly. Clinically they can be silent, cause mass effects, or have systemic manifestations—e.g., distal ischemia, embolization, and even sepsis. Most often, they present as a painful buttock mass. The dilations can cause compressive neuropathy of the sciatic nerve, superior and inferior gluteal, pudendal and posterior cutaneous nerves.

Methods: An 18-year-old male patient was brought in as an activated trauma with stab wounds to the left upper quadrant and left flank. The patient underwent an exploratory laparotomy which was significant for two mesenteric vessel bleeds, retroperitoneal oozing, and a small colonic mesentery laceration which was ligated with clips. The patient’s midline incision and stab wounds were then closed with staples. He was discharged on post-op day 4 after an uneventful recovery. After four days the patient returned to the ED with intermittent bleeding from the wound over his left iliac crest. The wound was packed with iodoform dressing and the patient was sent home. He returned 3 days later with active oozing from the same wound and complaining of generalized fatigue, dizziness, and difficulty in ambulation. His hematocrit and hemoglobin had declined since after his laparotomy from 28.6 to 20.7 and 9.7 to 7.2 respectively.

Results: A CTA demonstrated a left inferior gluteal artery pseudoaneurysm with active extravasation. Digital subtraction angiography was performed with left femoral artery access. Selective inferior gluteal artery catheterization confirmed the diagnosis after which two coils were deployed and reinforced with thrombin injection. The patient had an unremarkable post-procedure course and was discharged days later.

Conclusion: IGA pseudoaneurysms are extremely rare and prone to misdiagnosis. This case illustrates the necessity of including in the differential for a mass in the buttock area and the role endovascular embolization plays in the stabilization and definitive treatment of these potentially life-threatening lesions.