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CASE REPORT Open Access
An iliac arterial pseudoaneurysm diagnosed
40 years after suffering blunt trauma
Atsushi Guntani* , Eisuke Kawakubo and Shinsuke Mii
Abstract
Background: A chronic iliac arterial pseudoaneurysm caused by blunt trauma is very rare.
Case presentation: The patient had gunshot wound in the right thigh and blunt trauma 40 years earlier. An abdominal
computed tomography revealed the presence of a right iliac arterial pseudoaneurysm, and we successfully treated the
pseudoaneurysm by resection and in situ reconstruction with a bifurcated vascular prosthesis.
Conclusions: We herein present a rare case of a pseudoaneurysm of the right iliac artery diagnosed decades
after blunt trauma.
Keywords: Iliac arterial pseudoaneurysm, Blunt trauma, Chronic course
Background
Pseudoaneurysms of the iliac artery are rare and are
typically caused by infection, blunt trauma, or surgical
procedures. The clinical signs and symptoms may
appear within a few days of the event [1–4]. We herein
report a rare case of a pseudoaneurysm of the right iliac
artery that was diagnosed decades after blunt trauma.
Case presentation
A 69-year-old male patient was admitted for right hip
pain. The patient had been healthy until he developed a
cardiogenic cerebral infarction in 5 years prior to this
presentation. Although the details were unclear, the
patient had suffered a gunshot wound to the right thigh
and the superficial femoral artery had been ligated to
achieve hemostasis 40 years previously. He had also been
thrown from a bridge of approximately 40 m in height.
At that time, he injured his waist and back, however, he
successfully recovered while being conservatively treated.
The relationship between these traumatic events and the
current event was unknown; however, he had been
aware of a pulsatile mass in his right groin for at least
20 years. Subsequent contrast-enhanced abdominal com-
puted tomography revealed the presence of an irregular
aneurysm from the right common iliac artery to the
right common femoral artery, the maximum diameter of
which was 50 mm (Fig. 1a, b). Since the patient had no
history of connective tissue disorders or vasculitis, and a
blood analysis revealed no inflammatory findings, we
clinically diagnosed the patient with a right iliac arterial
pseudoaneurysm, which was thought to have been
caused by an old infection or past trauma. We per-
formed surgery to resect the aneurysm and performed in
situ reconstruction with a bifurcated vascular prosthesis
(Hemashield 16 × 8 mm; MAQUET Holding B.V. & Co.
KG, Rastatt, Germany). Since the right common femoral
artery was enlarged and showed severe adhesion to the
surrounding tissues due to previous surgery for the gun-
shot wound, we decided to use the right deep femoral
artery for peripheral anastomosis. On entering the
abdominal cavity, the right iliac arterial aneurysm was
irregular, with a whitish surface, and it adhered to the
small intestines. These findings were suggestive of
chronic inflammation. According to the usual procedure,
the prosthetic bifurcated graft was anastomosed to the
transected aorta, distal of the inferior mesenteric artery,
and the left limb of the graft was anastomosed to the left
common iliac artery. When the right limb of the graft
was introduced to the right inguinal region through the
incised common iliac arterial pseudoaneurysm, we found
that the right external iliac arterial aneurysm had pene-
trated the right common iliac arterial aneurysm. Part of the
aneurysmal wall was excised and submitted for culturing
and microscopic examination. The reconstructed pros-
thetic bifurcated graft was wrapped with the remaining
* Correspondence: aguntani@yahoo.co.jp
Department of Vascular Surgery, Saiseikai Yahata General Hospital, 5-9-27
Haruno-machi, Yahatahigashi-ku, Kitakyushu 805-8527, Japan
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Guntani et al. Surgical Case Reports  (2017) 3:40 
DOI 10.1186/s40792-017-0315-1
aneurysmal wall and omentum. No bacteria were
detected in the resected aneurysmal wall tissue, and a
pathological examination showed that the arterial wall
structure had disappeared and been replaced by fibrous
tissue with hyalin, hemosiderin, and macrophage infil-
tration (Fig. 2a, b). No recurrence of any other infection
or inflammation was observed during the 1-year follow-
up period (Fig. 3).
Discussion
Pseudoaneurysms are often caused by infection or
trauma. The number of iatrogenic cases has increased in
recent years; however, the patient in our case had never
undergone laparotomy or interventional procedures in
the past. Furthermore, symptoms due to aneurysms are
likely to appear early after trauma, and the rupture of a
pseudoaneurysm represents a life threatening event [1, 2].
Few cases describe symptoms that appeared several years
later [3, 4]. Our case had experienced traumatic events
40 years previously and had been aware of a pulsatile mass
in his right groin for at least 20 years. Based on this evi-
dence, it is assumed that the pseudoaneurysm of the iliac
artery increased chronically. Although stent grafts have
been reported to be effective for the treatment of pseudoa-
neurysms [5, 6], we decided to perform open surgery
because the aneurysm extended to the common femoral
artery, which meant that there was not enough landing
zone for stent graft.
No pus or ascites was observed during surgery, and
there were no findings of infection from cultures or
resected specimens. Additionally, the iliac arterial aneu-
rysms had penetrated each other and a pathological
examination showed that the arterial wall structure had
disappeared. We considered that the iliac arterial
aneurysm had been caused by past trauma and that it
might have been sealed by surrounding tissue in the
retroperitoneal cavity and gradually increased in size.
Thereafter, the pseudoaneurysm gradually expanded and
became associated with local infection and inflammation
from the common iliac artery to the common femoral
artery. The possibility of infectious aneurysms was ruled
out based on the lack of inflammatory findings and the
negativity of the blood culture. Indeed, no apparent
infections were observed intraoperatively or in an
Fig. 1 Preoperative contrast-enhanced abdominal computed tomography revealed the presence of an irregular aneurysm from the right common
iliac artery to the right common femoral artery, the maximum diameter of which was 50 mm (a left anterior oblique view in three-dimensional
computed tomography; b sagittal view)
Fig. 2 A pathological examination showed that the arterial wall structure had disappeared and been replaced by fibrous tissue with hyalin, hemosiderin,
and macrophage infiltration (a elastica van Gieson staining, low-magnification; b hematoxylin and eosin staining, high-magnification)
Guntani et al. Surgical Case Reports  (2017) 3:40 Page 2 of 3
examination of the excised specimens. As a result, the
postoperative course was uneventful, and no recurrence
of any other infection or inflammation was observed
during the 1-year follow-up period.
Conclusions
We herein presented a rare case of the successful treat-
ment of a pseudoaneurysm of the right iliac artery that
was diagnosed decades after blunt trauma. Since pseu-
doaneurysms may occur even a long period after a trau-
matic event, computed tomography should be used to
make a precise diagnosis. Treatment should be adminis-
tered soon after the diagnosis because of the high rate of
mortality associated with the rupture of these lesions.
Authors’ contributions
AG contributed to writing the manuscript. SM supervised the study. All authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Written consent was obtained from the patient for publication of this article.
Ethics approval and consent to participate
Not applicable.
Received: 18 January 2017 Accepted: 22 February 2017
References
1. Osgood MJ, Heck JM, Rellinger EJ, Doran SL, Garrard III CL, Guzman RJ, et al.
Natural history of grade I-II blunt traumatic aortic injury presenting over
10 years at a single institution. J Vasc Surg. 2014;59(2):334–41.
2. Laohapensang K, Aworn S, Orrapin S, Rutherford RB. Management of the
infected aortoiliac aneurysms. Ann Vasc Dis. 2012;5(3):334–41.
3. Queiroz AB, Silva ES, Aun R, Benitti DA, Bertoldi V, Puech-Leão P. Abdominal
aortic pseudoaneurysm diagnosed 42 years after abdominal gunshot wound.
Clinics. 2011;66(6):1113–4.
4. Taif S, Alrawi A, Al-Kalbani. Iliac artery pseudoaneurysm presenting as a
paravertebral collection: a potentially fatal mimic. BMJ Case Rep 2014.
doi:10.1136/bcr-2013-203428.
5. Carollo A, Gagliardo G, DeVito PM, Cicchillo M. Stent graft repair of anastomotic
pseudoaneurysm of femoral–popliteal bypass graft following patch angioplasty.
J Surg Case Rep. 2016;12:1–3.
6. Tielliu IFJ, Verhoeven ELG, Zeebregts CJ, Prins TR, Oranen BI, van den Dungen
JJAM. Endovascular treatment of iliac artery aneurysms with a tubular
stent-graft: mid-term results. J Vasc Surg. 2006;43:440–5.
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Fig. 3 Follow-up contrast-enhanced computed tomography, which
was performed 6 months after the surgery, revealed that no recurrence
of any other infection or inflammation
Guntani et al. Surgical Case Reports  (2017) 3:40 Page 3 of 3


An iliac arterial pseudoaneurysm diagnosed 40 years after suffering blunt trauma

A ranging code based on the improved Logistic map for future GNSS signals: code design and performance evaluation

Nothing magical: pantomimed grasping is controlled by the ventral system

Hiroyuki Kaneko

Ari Shinojima

Mori Ryusaburo

Akiyuki Kawamura

Mitsuko Yuzawa

Kaneko et al. BMC Res Notes  (2017) 10:16 
DOI 10.1186/s13104-016-2359-x
CASE REPORT
Choroidal thickness findings in two 
siblings with nanophthalmos by swept 
source-OCT: a case report
Hiroyuki Kaneko, Ari Shinojima*, Mori Ryusaburo, Akiyuki Kawamura and Mitsuko Yuzawa
Abstract 
Background: We investigated choroidal thicknesses at five sites in two siblings (four eyes) with nanophthalmos 
using swept-source optical coherence tomography.
Case presentation: Case 1, a 51-year-old Japanese female with high hyperopia (Right: +20.5 Dioptors, Left: +19.5 
Dioptors), had axial lengths of 15.6 mm in both eyes. Case 2, a 55-year-old Japanese male with high hyperopia (Right: 
+22.5 Dioptors, Left: +22.8 Dioptors), had axial lengths of 14.8 and 14.7 mm in the right and left eyes, respectively. 
Choroidal thickness was measured at five sites in each eye using swept-source optical coherence tomography; 
subfoveal, nasal, temporal, superior and inferior (the 4 non-subfoveal sites were measured 3000 µm from the fovea).
Conclusion: The mean choroidal thickness was 355.8 ± 63.6 μm at the subfoveal, 466.3 ± 85.1 μm at the 
nasal, 274.8 ± 77.2 μm at the temporal, 396.8 ± 54.6 μm at the superior, and 480.8 ± 66.8 μm at the inferior 
(mean ± standard deviation) site. Choroidal thickness was maximal at the inferior site. The choroid was thinnest, in 
diminishing order, at the nasal, superior, subfoveal and temporal sites.
Keywords: Axial length, Choroidal thickness, Hyperopia, Nanophthalmos, Optical coherence tomography
© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License 
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, 
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, 
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Background
Nanophthalmos is a rare condition without other ocular 
or systemic anomalies, in which axial length (AL) is less 
than 20 mm and the eye volume is about two-thirds less 
than normal [1]. Nanophthalmos is associated with high 
hyperopia, narrow palpebral fissures, enophthalmos, 
shallow anterior chamber and scleral wall thickening. 
It can cause complications such as angle-closure glau-
coma and uveal effusion [1]. Posterior segment findings 
in nanophthalmic cases reportedly include papillomacu-
lar folds, dilated vessels, cysts, pseudopapilledema, and 
thickened choroid [2, 3]. Genetic mutations are associ-
ated with nanophthalmos according to some reports, 
which described associations with the serine protease 
gene (PRSS56) and membrane frizzled-related protein 
gene (MFRP) [4, 5].
The choroid is the vascular layer containing pigmented 
tissues, and is located between the sclera and the retinal 
pigment epithelium (RPE). The choroid, which is essen-
tial for retinal function, provides oxygen and nourish-
ment to the outer layer of the retina.
Recently, swept source-optical coherence tomography 
imaging (SS-OCT) has been used to evaluate choroidal 
changes. SS-OCT is known to have greater scanning 
speed and a longer wavelength (1050  nm), enabling 
deeper penetration through the RPE into the choroid, 
than other modalities. Hirata et  al. reported choroidal 
thickness (CT) and volume at different sites in normal 
subjects using SS-OCT [6]. Demircan et al. detected sub-
foveal choroid thickening using enhanced depth imaging 
optical coherence tomography in patients with nanoph-
thalmos [3]. There are many reports describing CT at 
the fovea itself, as well as at sites inferior, nasal, superior, 
and temporal to the fovea [6–8]. However, no studies 
have used SS-OCT to measure CT at different sites in 
nanophthalmos cases. The purposes of this study were to 
Open Access
BMC Research Notes
*Correspondence:  ariearly7@gmail.com 
Division of Ophthalmology, Department of Visual Science, Nihon 
University School of Medicine, Nihon University Hospital, 1-6 Surugadai, 
Kanda, Chiyoda-ku, Tokyo 101-8309, Japan
Page 2 of 4Kaneko et al. BMC Res Notes  (2017) 10:16 
measure CT at different sites in two siblings with nano-
phthalmos and to compare the findings of our cases and 
those of normal eyes.
Case presentation
Case 1: A 51-year-old Japanese female with nano-
phthalmic eyes. An objective refraction test (ORT) 
revealed high hyperopia in both eyes (Right: +20.5 
Diopters (D), Left: +19.5 D). AL was 15.6 mm in both 
eyes.
Case 2: A 55-year-old Japanese male, the brother of 
Case 1, with nanophthalmic eyes. ORT revealed high 
hyperopia in both eyes (Right: +22.5 D, Left: +22.8 D). 
AL was 14.8 mm in the right and 14.7 mm in the left eye.
The AL was measured using an intraocular lens master 
(Carl Zeiss, Germany). Retinal folds at the macula 
and dilated veins were detected in all 4 eyes. SS-OCT 
revealed retinal folds at the fovea and a thickened choroid 
in all 4 eyes (Fig. 1).
CT was measured manually at the fovea and 4 other 
sites (nasal, temporal, superior and inferior to the 
subfoveal measurement point) 3000 µm from the foveal 
site in each eye using SS-OCT (DRI OCT-1 “Atlantis”; 
Topcon Medical Inc., Tokyo, Japan) (Fig.  2). CT was 
measured manually with a built-in caliper (H.K.), 
according to Rhaman et al. [8]. CT was measured from 
the bottom of the hyper-reflective line of the RPE to 
the chorioscleral border at each measurement point. 
The mean CT values at each site in the four eyes were 
analyzed.
Conclusions
The mean CT measurements are shown in Table  1. CT 
was maximal at the inferior site. The second largest CT 
value was measured at the nasal site, followed in order by 
the superior, subfoveal and temporal sites, with the latter 
being the thinnest portion of the choroid.
There are reports describing CT at the nasal site as 
being less than that at the other 4 sites (subfoveal, tem-
poral, inferior and superior) in healthy subjects [6, 7]. In 
healthy Japanese subjects, the mean CT at the fovea was 
reported to be 202.6 ± 83.5 µm, the mean CT at the nasal 
measurement point 152.5  ±  71.1  µm [7]. In our cases, 
however, the mean CT at the inferior and nasal sites were 
greater than those at the same sites in healthy subjects. 
The CT values at the subfoveal and nasal sites were also 
greater than those at the same sites in healthy Japanese 
subjects, serving as controls.
The ALs in the four eyes of our two subjects were 
equivalent to those seen in nanophthalmos cases exam-
ined between the postnatal period and 2 years of age [9]. 
Furthermore, in our cases, ultrasonic B-mode imaging 
revealed thickened sclera and short AL. Therefore, it was 
suspected that development of the sclera in these four 
eyes had stopped during this early period of life. It has 
been hypothesized that retinal folds are molded by nor-
mal retinal development with arrested scleral develop-
ment [10]. This hypothesis may apply to our cases.
Primordial tissues of the choroid and sclera are com-
prised of mesenchymal cells around an optic cup. From 
the 6-week embryonic stage, differentiation into choroid 
Fig. 1 The color fundus photographs and swept-source optical coherence tomography images of both cases. The color fundus photographs of 
Case 1 and Case 2 show macular folds and dilated vessels (top). The swept source-optical coherence tomography images reveal macular folds and 
thickened choroid at the subfoveal point in all four eyes. The horizontal arrows indicate horizontal images through the fovea (middle). The vertical 
arrows indicate vertical images through the fovea (bottom)
Page 3 of 4Kaneko et al. BMC Res Notes  (2017) 10:16 
and sclera starts via induction of the RPE. Therefore, we 
theorized that development of the choroid had stopped 
in these siblings with nanophthalmos, since the primor-
dial tissues of the choroid and sclera were the same. If the 
eyeball develops normally, the choroid may extend from 
the disc in the temporal direction, and the nasal site is 
thinner in normal eyes. In these four eyes, however, the 
nasal site near the disc was thickened due to poor exten-
sion of the eyeball.
It is easy to obtain non-invasive OCT images, even in 
relatively young patients. Salchow et  al. reported only 4 
(3.3%) of 121 subjects younger than 18 years to be unco-
operative [11]. Based on only one horizontal OCT image, 
we can surmise that strong hyperopia is present with a 
short AL, if the OCT image has findings indicating that 
the nasal choroid is thicker than the temporal choroid, 
there are papillomacular folds and non-inflammatory 
cells are present in the vitreous cavity.
The major limitation of this study is the small num-
ber of patients. Also, we were not able to perform a 
genetic analysis in these cases. Further study is needed 
to clarify the features of and genetic contributions to 
nanophthalmos.
In conclusion, CT was maximal at the inferior site. The 
choroid was thinnest, in diminishing order of CT measure-
ment values, at the nasal, superior, subfoveal and temporal 
sites. Unlike normal eyes, the nasal site of the choroid in 
these four nanophthalmic eyes was thickened, presumably 
due to arrest of choroidal and scleral development.
Abbreviations
AL: axial length; CT: choroidal thickness; D: diopters; ORT: objective refraction 
test; SS-OCT: swept source-optical coherence tomography; RPE: retinal pig-
ment epithelium.
Authors’ contributions
HK and AS conceived this study, and participated in its conception and design, 
as well as data acquisition. HK and AS wrote the manuscript. RM, AK, and MY 
critically revised the manuscript for important intellectual content. HK, AS, RM, 
AK, and MY gave final approval of the version to be published. All authors read 
and approved the final manuscript.
Acknowledgements
The authors have no competing interests to declare. Nihon University School 
of Medicine provided financial support for this study. Neither the sponsor nor 
any other funding organization had a role in the design of the study and col-
lection, analysis, and interpretation of data and in writing the manuscript.
Competing interests
The authors declare that they have no competing interests.
Availability of data and materials
Data for this study is available as additional documents and can be down-
loaded through the link provided in the end of this manuscript (Figs. 1, 2).”
Ethics approval and consent to participate
All procedures adhered to the tenets of the Declaration of Helsinki.
Consent for publication
Written informed consent was obtained from both patients for publication of 
this Case Report and any accompanying images.
Received: 21 February 2016   Accepted: 20 December 2016
Fig. 2 The infrared image (left) and the swept source-optical coherence tomography image (right) from Case 2 (left). The horizontal line is through 
the fovea on the infrared image. White circles indicate the fovea and the other four sites (nasal, temporal, superior and inferior, each measured 
3000 µm from the fovea). (Right) Choroidal thickness was measured from the bottom of the hyper-reflective line of the retinal pigment epithelium to 
the chorioscleral border at each measurement point
Table 1 Average choroidal thickness at five sites
Site Choroidal thickness 
(mean ± standard deviation) µm
Inferior 480.8 ± 66.8
Nasal 466.3 ± 85.1
Superior 396.8 ± 54.6
Subfoveal 355.8 ± 63.6
Temporal 274.8 ± 77.2
Page 4 of 4Kaneko et al. BMC Res Notes  (2017) 10:16 
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Choroidal thickness findings in two siblings with nanophthalmos by swept source-OCT: a case report

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