The unmarried female patient was 28 years old with normal menstruation. At the age of 13 years, she experienced menarche. The last menstruation started on April 27, 2020 and lasted approximately ten days. The patient had undergone abdominal myomectomy for hysteromyoma in the local hospital 22 days prior. She denied a history of congenital or acquired bleeding disorders, liver disease, or use of antiplatelet drugs, anticoagulants, or nonsteroidal anti-inflammatory drugs. Because of this abnormal menstruation, she went to a local hospital, and color Doppler ultrasound showed 8 × 9 × 7 cm3 uterine fibroids. On May 6, 2020, the patient underwent abdominal myomectomy. During the operation, a myomatous protrusion (7 × 6 × 5 cm3) was found in the posterior wall of the uterus. The muscle layer of the surface was cut, revealing a brown mass with an uneven surface and no obvious capsule. The mass was a fusion of several small masses that had penetrated the endometrial layer. The pathological results after the operation showed low-grade endometrial stromal sarcoma with hemorrhagic necrotic cystic changes and a tumor thrombus in the tumor vessels (Fig. 1A, B). The patient returned to our hospital 10 days after the operation. Until this point, she had no complaints of obvious discomfort, a normal gait, no obstacles to lower limb movement and no history of left leg pain associated with walking and relieving by rest. There was no significant difference in muscle tension or skin temperature between the two legs and no claudication in her left leg. The results of serum tumor markers showed a CA125 level of 68.8 U/ml (< 35.0 U/ml), and normal levels of alpha-feroprotein (AFP), carcinoembryonic antigen (CEA), CA15-3, CA19-9, human epididymis protein 4 (HE4) and squamous cell carcinoma antigen (SCCA). After admission, coagulation function showed that the D-dimer level was 1.86 µg/ml, the activated partial thromboplastin time was 43.9 seconds (29.0–42.0 seconds), and other indexes were normal. Three-dimensional ultrasound showed that the volume of the uterus was 5.5 × 4.5 × 6 cm3, the echo of the posterior wall of the uterus was disordered, a short linear strong echo could be seen, and the thickness of the endometrium was 0.3 cm. Pelvic magnetic resonance imaging (MRI) evaluation showed that the endometrium was slightly thickened and that the signal of the myometrium was uneven. Diffusion-weighted imaging (DWI) showed no obvious, abnormally high signal or abnormally enhanced focus in either the pelvic floor muscle or pelvic bone.
The laparoscopic operation showed that the sigmoid colon, a portion of the rectum and the left side of the pelvic wall were densely adhered, and the uterus and double appendages were difficult to expose. After lymphadenectomy of the paraaortic and right pelvic lymph nodes, the left peritoneum was opened to expose the left iliac vessels during resection of the left pelvic lymph 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.
A surgical multidisciplinary team (MDT) consultation was launched and evaluated the severity of the emergency. Arterial pulsation in the left dorsalis pedis artery was weaker than that in the right artery. The skin temperature and color of the left foot were normal, and there was no significant difference in the body temperatures of the two lower extremities. She had palpable left dorsalis pedis and posterior tibialis pulses. 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, the experts suggested that the status of the disconnection of the left EIA was nonacute and indicated that an organic thrombus may have been present in the lumen of the artery. In addition, collateral circulation of the left lower limb was established and could meet the blood supply of the lower limbs, which was also confirmed by computed tomography angiography (CTA). 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 there was no need to use artery bypass to establish a new collateral circulation. Because the two blind ends of the left external iliac artery were far away from each other, it was impossible to perform end-to-end anastomosis; therefore, the blind ends were ligated with 10 silk threads.
After the second operation, another two CTA results after the operation showed that no new branch was involved in the collateral circulation network at the proximal broken end (Fig. 3B, C and Fig. 4). Ultrasound was used to evaluate the blood flow of the main arteries of the lower limbs four times. Compared with that of the arterial blood flow of the opposite lower extremity, the spectrum value of the peak velocity of the femoral artery, superficial femoral artery, popliteal artery and dorsalis pedis artery in the left lower limb was not greatly affected by the presence of the abnormal left external iliac artery (Fig. 5A-D). Furthermore, 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 extremity. No obvious abnormality was 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 the maximum voluntary contraction (MVC) of the bilateral rectus femoris and anterior tibialis muscles (Fig. 7).
Since no evidence of external iliac artery injury was found in the previous operation record, we could only inquire about the history in detail again. During postoperative chemotherapy, the patient finally indicated that she started smoking when she was 16 years old. In recent years, she smoked more than 20 cigarettes a day. Furthermore, she had been working in a nightclub and drank every day. In addition, the patient had a bad fall and landed on the ground in the bath.
After surgery, pelvic MRI revealed that the uterus showed postoperative changes, and no abnormal signal was found in the uterus six months after the operation. The patient received liposomal doxorubicin intravenous chemotherapy (30 mg/m2) and oral aromatase inhibitors (letrozole, 2.5 mg once daily) for six months. We managed this particular case as threatening but not dangerous. Eleven months after the second operation, there was no obvious abnormality in her left lower limb, no claudication had developed, and the patient remained asymptomatic.