What is the best management approach for a 70-year-old patient with a history of renal mass, right hydronephrosis (R hydro), ligated right iliac aneurysm, and recent significant bleeding requiring massive transfusion, now presenting with a right pelvic mass, possibly a thrombosed aneurysm, large periprostatic venous varices, and minimal right hydronephrosis with a stent in place?

Management of Complex Pelvic Vascular Pathology with Renal Mass History

This 70-year-old patient with a right pelvic mass (possibly thrombosed iliac aneurysm), periprostatic venous varices, and history of massive hemorrhage requiring ligation of the right iliac artery requires urgent multidisciplinary vascular surgery consultation with immediate cross-sectional imaging (CT angiography) to define the vascular anatomy, assess for active bleeding or impending rupture, and determine if endovascular or open surgical intervention is needed to prevent life-threatening hemorrhage recurrence. 1, 2

Immediate Diagnostic Priorities

Obtain emergent CT angiography of the abdomen and pelvis to:

• Characterize the 8.5 cm right pelvic mass and determine if it represents a thrombosed aneurysm, organized hematoma, or other pathology 2, 3
• Assess for active contrast extravasation indicating ongoing bleeding 1
• Evaluate the status of the previously ligated right iliac artery and identify collateral circulation 4
• Define the relationship between the pelvic mass, periprostatic venous varices, and urinary tract (given the ureteral stent) 1, 5
• Rule out arteriovenous fistula or malformation that could explain the venous varices 3, 6

Laboratory assessment must include:

• Complete blood count with hemoglobin/hematocrit to assess for ongoing blood loss 1, 2
• Comprehensive metabolic panel including renal function (creatinine, GFR) given the history of hydronephrosis and current stent 1, 2
• Coagulation studies (PT/INR, PTT) to optimize hemostatic status before any intervention 1
• Type and screen given the recent massive transfusion requirement 1

Vascular Surgery Consultation Framework

The vascular surgery team should evaluate for:

• Risk of rupture: An 8.5 cm pelvic mass concerning for aneurysm carries significant rupture risk, particularly if it represents a residual or recurrent iliac aneurysm 5, 7
• Hemodynamic stability: Using ATLS criteria (blood pressure >90 mmHg, heart rate <120 bpm, adequate perfusion), determine if the patient is stable, unstable, or at risk for decompensation 1
• Limb viability: Assess distal pulses, capillary refill, and ankle-brachial index to evaluate adequacy of collateral circulation after previous iliac artery ligation 1, 4

Treatment Algorithm Based on Clinical Scenario

If Hemodynamically Unstable or Active Bleeding on Imaging:

Activate massive transfusion protocol immediately and proceed with:

• Endovascular intervention as first-line: Non-selective bilateral internal iliac artery embolization if multiple bleeding sources or unstable patient 1
• Selective embolization: If single bleeding target identified and patient stable enough for selective catheterization 1
• Surgical packing and external fixation: Only if patient cannot be safely transferred to angiography suite or embolization fails 1
• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta): Consider as temporizing measure during transfer or preparation for definitive intervention 1

If Hemodynamically Stable:

Elective endovascular or open surgical repair should be planned based on:

• Anatomy of the pelvic mass: If confirmed aneurysm, endovascular stent-graft placement is preferred (rated 8/9 for appropriateness) over open surgery (rated 6-7/9) 1
• Relationship to previous ligation site: May require extra-anatomic bypass if standard reconstruction not feasible 5
• Presence of infection: If any concern for mycotic aneurysm or infected graft material, open resection with extra-anatomic bypass is mandatory 4, 5

Management of Periprostatic Venous Varices

These varices likely represent:

• Collateral venous drainage following iliac artery ligation and altered hemodynamics 6
• Possible arteriovenous shunting if underlying renal pathology involves vascular malformation 3, 6
• Venous hypertension from pelvic mass compression 6

Intervention for varices is indicated only if:

• Active bleeding source identified on imaging 1
• Symptomatic (hematuria, pain, urinary obstruction beyond what stent addresses) 5, 7
• Associated with arteriovenous fistula requiring embolization 3

Renal Mass Considerations

The original renal mass requires re-evaluation:

• Obtain high-quality multiphase CT or MRI to characterize current status of the renal mass, as previous imaging predates the vascular complications 1, 2
• Renal mass biopsy should be performed if the mass remains indeterminate and histologic diagnosis would alter management, particularly given the complex vascular anatomy 1, 2
• Assess renal function and CKD stage based on current GFR and proteinuria, as the patient has had hydronephrosis and now has a stent 1, 2
• Nephrology referral is indicated if GFR <45 mL/min/1.73m² or confirmed proteinuria, given the increased risk of CKD progression 1, 2

Defer definitive renal mass treatment until vascular issues are stabilized, as the immediate mortality risk from vascular complications far exceeds oncologic risk from delayed renal mass management 1, 2

Critical Pitfalls to Avoid

• Do not assume the pelvic mass is benign or stable without vascular imaging—iliac aneurysms can rupture into the rectum, bladder, or retroperitoneum with catastrophic bleeding 5, 7
• Do not delay vascular surgery consultation in a patient with this history—the combination of previous massive hemorrhage, iliac artery ligation, and new 8.5 cm pelvic mass represents extremely high rupture risk 1, 5
• Do not remove the ureteral stent until the pelvic mass is fully characterized and treated, as it may be providing critical drainage in the setting of mass effect 1
• Do not perform open surgical exploration without preoperative angiography and embolization capability immediately available, given the high risk of uncontrollable hemorrhage 1
• Do not assume adequate collateral circulation after iliac artery ligation without formal vascular assessment—while limb loss is rare, ischemic complications can occur 4

Surveillance After Stabilization

If endovascular repair performed:

• CT angiography at 1 month, 6 months, then annually to assess for endoleak, stent migration, or aneurysm expansion 1
• Maintain arterial access port with anti-reflux valve for 24 hours post-embolization to allow repeat intervention if bleeding recurs 1

Renal mass surveillance:

• Resume appropriate imaging protocol (CT or MRI every 3-6 months) once vascular issues stabilized 1, 2
• Definitive treatment planning only after patient recovers from vascular intervention and hemodynamic stability confirmed 1, 2