Spontaneous Rupture of the Internal Iliac Artery in an Elderly Patient: A Case Report Exploring the Possible Role of Klebsiella Pneumoniae Infection

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors

  Good case

Please comment on the stent graft surveillance, since you  comment on bacteremia, do plan to perform a PET  scan to make sure that the stent is not infected?

 Was coiling considered, if not why?   What was the cause of the endoleak,   Was the initial graft sizing inaccurate?

Author Response

Response to Reviewer 1:
Thank you for your valuable comments.

Comment 1: Please comment on the stent graft surveillance, since you  comment on bacteremia, do plan to perform a PET  scan to make sure that the stent is not infected?

Response 1: We have added details on the planned surveillance consideration of PET-CT scanning, added in the case description as follows: "Given the history of bacteremia, consideration for a PET-CT scan was discussed within the multidisciplinary team. However, due to the patient's clinical stability and normalization of inflammatory markers, PET-CT was deferred unless clinical or biochemical signs of infection emerged."

 Comment 2: Was coiling considered, if not why?   What was the cause of the endoleak,   Was the initial graft sizing inaccurate?

Response 2:

• Coiling consideration: Coiling was considered but was not pursued due to the anatomical challenges and active rupture, as detailed in the discussion section of the revised manuscript as follows: "Coiling was considered; however, the anatomical configuration and the presence of an active rupture site made complete exclusion challenging with coiling alone. The endovascular approach with stent grafting ensured rapid hemostasis and vessel preservation."
• Cause of endoleak: The endoleak was attributed to graft sizing challenges during an emergency procedure of fragility of the vessel. This has been clarified in the manuscript as follows: 

  "The cause of the endoleak or secondary rupture may be attributed to incomplete apposition of the stent graft to the vessel wall, likely due to undersizing of the initial graft in relation to the dynamically changing vessel diameter post-rupture or arterial wall degeneration and fragility due to the infection. The sizing during the emergency procedure was based on available preoperative imaging, which may not have accurately reflected the post-rupture anatomy. The subsequent intervention aimed to address this by extending the landing zone and utilizing additional graft material for better sealing."

 

Reviewer 2 Report

Comments and Suggestions for Authors

This case report deals with a potentially infection - related rupture of the internal iliac artery. At the first bleeding occasion,  an endovascular procedure was performed, seemingly successful. However, 30 days later a rebleeding occurred, that was also managed by stent graft procedure and plug insertion. The patient had formerly sufferred antibiotic resistant Klebsiella Pneumoniae pneumonia.

1.Based on the information on previous infection, this should have been taken in consideration regarding selection of treatment. (Klebsiella infection is rare, but is described (e.g. Wang TH et al. World J Clin Cases 2020; 8:6529; Chen CL et al. Surg Infect 2021; 22:680). The first attempt to treatment by endovascular technique might be reasonable, but the second endovascular procedure may be discussed. Open surgery with ligation at the basis of the internal iliac artery should have been a reasonable alternative as a less dangerous procedure regarding the risk of further bleeding. Now more synthetic material is inserted.

Do the authors claim a connection between a plaque rupture and the vessel rupture ?  

   

Comments on the Quality of English Language

Only minor modifications required

Author Response

Response to Reviewer 2:
Thank you for your insightful feedback. We appreciate the reviewers' suggestions, which have significantly improved our manuscript.

Comment 1. Based on the information on previous infection, this should have been taken in consideration regarding selection of treatment. (Klebsiella infection is rare, but is described (e.g. Wang TH et al. World J Clin Cases 2020; 8:6529; Chen CL et al. Surg Infect 2021; 22:680). The first attempt to treatment by endovascular technique might be reasonable, but the second endovascular procedure may be discussed. Open surgery with ligation at the basis of the internal iliac artery should have been a reasonable alternative as a less dangerous procedure regarding the risk of further bleeding. Now more synthetic material is inserted.

Response 1: We have acknowledged the impact of the patient's Klebsiella infection and cited relevant literature. The decision for a second endovascular intervention, despite infection concerns, was based on the patient's clinical status and risk assessment. Added in the discussion section as follows: 

"The presence of carbapenem-resistant Klebsiella pneumoniae bacteremia posed an additional challenge in the management of this patient. Literature suggests that Klebsiella infections, while rare in vascular graft infections, have been reported.5,6 Although the initial endovascular procedure was justified by the patient's hemodynamic instability and comorbidities, an open surgical approach with proximal ligation was considered after the endoleak. However, given the patient's frailty, the risk of extensive open surgery was deemed higher than a secondary endovascular repair, despite the addition of more synthetic material."

Added references 5 and 6 as suggested.

Comment 2: Do the authors claim a connection between a plaque rupture and the vessel rupture ?  

Response 2. We have clarified that the plaque rupture was considered the primary mechanical cause of the vessel rupture, likely secondary to vessel wall porosity caused by CRKP infection. We have also added reference n.9 to support this evidence. added in the discussion section as follows: 

"Cai et al. described a case of donor-derived carbapenem-resistant Klebsiella pneumoniae infection in one patient following liver transplantation and two patients following renal transplantation (involving one liver and two kidneys from the same donor). All three patients presented with sudden abdominal pain and hemorrhage shortly after transplantation. Graft artery rupture, attributed to corrosion caused by carbapenem-resistant Klebsiella pneumoniae  infection, was confirmed through computed tomography, blood culture, laparotomy, and pulsed-field gel electrophoresis.9"

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have responded in an acceptable manner. My criticism remains concerning the second operation, If possible the authors should find out the present status of this patient to add to the discussion.  

Author Response

Comment1: The authors have responded in an acceptable manner. My criticism remains concerning the second operation, If possible the authors should find out the present status of this patient to add to the discussion.  

 

Response1: We appreciate the reviewer’s suggestion to provide an update on the patient’s status following the second intervention. In accordance with this recommendation, we have added relevant details to the Discussion section. The patient initially showed clinical stability and was discharged to a rehabilitation clinic. However, during our attempt to obtain long-term follow-up data, we were informed by the family that the patient had unfortunately passed away due to causes unrelated to the vascular intervention. While further clinical details are unavailable, we believe this underscores the frailty of such patients and the importance of individualized treatment strategies.

 

We hope this addition sufficiently addresses the reviewer’s concerns and provides valuable context while maintaining patient confidentiality.