[Pseudoaneurysm of the gluteal artery: 2 case reports]

Gluteal artery pseudoaneurysms are very rare [1]. They mostly occur after gunshot and stub wounds [2]. However, gluteal artery pseudoaneurysms can be caused by pelvic fracture [1]. Also, they can be isolated or associated with trauma of the pelvic and abdominal viscera [3]. The authors present two cases of gluteal artery pseudoaneurysms. Case 1. A 30-year-old man was treated for large swelling of the left buttock. One month previously he manifested a gunshot wound in the gluteal region. He also had symptoms of lumboischialgia with peroneal nerve paresis. The physical examination revealed a large pulsatile mass over the left buttock with an associated overlying bruit. Selective angiography of the internal iliac artery (Figure 1) revealed a large inferior gluteal artery pseudoaneurysm that caused dislocation of both external and internal iliac arteries. The patient was operated under epidural anaesthesia by the combined abdominal (extraperitoneal) and gluteal approach. By extraperitoneal approach the internal iliac artery was identified and ligated. After the closure of the wound, the patient was placed on the abdomen, and pseudoaneurysm was opened by an incision made between gluteus maximus and medius muscles. After evacuation of the parietal thrombus and pseudocapsule resection, nutrient vessels were ligated. The postoperative recovery was good, and the patient was free of neurologic symptoms two days after the operation. The late result (after 4 years) is also good. Case 2. A-53-year-old man was treated for small haematoma pulsans (Figure 2) in the right buttock. Fifteen days previously he was treated in the regional hospital by intramuscular "antirheumatic cocktails". The physical examination revealed a small pulsatile mass over the right buttock associated with overlying bruit. The selective angiography of the internal iliac artery demonstrated a small inferior gluteal artery pseudoaneurysm. The patient was operated by the procedure described. The postoperative recovery and the late result (after 6 months) were good.

According to our knowledge, only 8 cases of gluteal artery pseudoaneurysms are reported in literature in the last 11 years (including the first three months of this year) [4-8]. The lesions of the gluteal arteries, especially pseudoaneurysms, have no specific symptoms and signs. usually, they appear as haematoma pulsans and neurologic deficiency due to compression. (One of our patients). The gluteal abscess can be a differential diagnostic problem. Duplex ultrasonography, CT and selective angiography can be used in the diagnosis [5]. The standard surgical treatment of gluteal artery pseudoaneurysms consists of the ligature of the internal iliac artery (using transperitoneal or extraperitoneal approach) and pseudoaneurysmal resection and ligation of nutrient vessels by gluteal approach [9]. The second procedure is the temporary clamping of the internal iliac artery and transgluteal ligation of the nutrient vessels [7]. The microcatheter embolization of the nutrient vessels using standard invasive radiologic approaches via femoral artery is the method of choice in the treatment of gluteal artery pseudoaneurysms [10]. A buttock pulsatile mass and neurological deficiency in a patient with history of penetrating gluteal trauma, suggest the existence of gluteal artery pseudoaneurysm and require diagnostic evaluation.