Successful staged management of a spontaneous iliac vein rup
Spontaneous iliac vein ruptures have only been reported in approximately 50 cases. An accurate preoperative diagnosis is difficult even with contrast-enhanced computed tomography (CT), and the operative mortality and morbidity rates are quite high. The cause of spontaneous iliac vein ruptures and their optimal diagnosis and management remain unclear.

A 69-year-old woman without a history of prior trauma presented with low back pain, left lower limb swelling, and hypovolemic shock. An initial contrast-enhanced CT revealed a large retroperitoneal hematoma without arterial extravasation. Her blood pressure dropped again under a noradrenaline administration. A second venous phase contrast-enhanced CT revealed venous extravasation in the external iliac vein with a suspected compression of the common iliac vein (May-Thurner syndrome) and deep vein thrombosis (DVT).

Her haemodynamics were stabilised whilst a laparotomy was arranged. An inferior vena cava (IVC) filter was placed due to concerns about rebleeding with initiating anticoagulation therapy. Given the failed conservative management, elective endovascular treatment (EVT) was performed including percutaneous Fogarty venous thrombectomy and placement of self-expanding and covered stents. After the intervention, the lower limb swelling significantly improved under oral anticoagulation therapy, and the IVC filter was retrieved. At the 3-month follow-up, the lower limb swelling completely disappeared, and the contrast-enhanced CT demonstrated the complete disappearance of the retroperitoneal hematoma and DVT.

This case provided not only the potential value of the venous phase contrast-enhanced CT in diagnosing a spontaneous iliac vein rupture, but also the potential benefit of conservative management followed by elective EVT.