Endovascular management of life threatening bleeding from a radiation induced internal iliac artery branch pseudoaneurysm

BACKGROUND: Among radiation induced arterial complications, stenoses and occlusions are commonly reported. Radiation induced pseudoaneurysms (PSA) and their management outcomes are rarely reported. CASE PRESENTATION: A 48 year old male underwent low anterior resection surgery for a clinically staged T2N0M0 rectal adenocarcinoma and adjuvant chemoradiation for the findings of lymphovascular invasion and focally positive distal margin 2 years prior to current admission. The patient now presented with syncope and anemia. The patient was hypotensive after an episode of hematochezia during the hospital stay. An urgent sigmoidoscopy revealed bleeding from friable necrotic rectal mucosa with focal pulsations along the left posterolateral aspect of the rectal wall. An emergent pelvic angiogram revealed active extravasation from a 3 mm PSA from the anterior division of left internal iliac artery. After coil embolization of the affected vascular branch on either side of the neck of PSA, there was no opacification of PSA or extravasation. The patient remained asymptomatic for 3 years. CONCLUSIONS: Radiation induced PSA must be considered in the absence of trauma. Endovascular coil-embolization of radiation induced PSAs from small caliber vessels can be an effective treatment.