|Year : 2015 | Volume
| Issue : 1 | Page : 30-32
Endovascular Management of Iliac Arterial Injury in Blunt Pelvic Trauma
Ahmed Reyad Tawfik
Department of Vascular Surgery, Kasr Ani Hospital, Cairo University, Giza, Egypt
|Date of Web Publication||5-Mar-2015|
Dr. Ahmed Reyad Tawfik
Department of Vascular Surgery, Kasr Ani Hospital, Cairo University, Giza
Source of Support: None, Conflict of Interest: None
Iliac arterial injury in blunt pelvic trauma is rare, associated with fracture pelvis, massive retroperitoneal bleeding from the presacral, prevesical and venous plexuses, which is self-limiting but carries high mortality rate if it is allowed to re-expand after it was sealed. Most of the vascular injuries range from intimal injury with intimal flap formation to complete transection and total or partial occlusion by thrombus formation. Advances in endovascular therapy significantly change management of such vascular injuries and serves as a damage control helping the recovery from acute systemic injury and delay open surgical intervention. External fixation and endovascular management have increased in frequency and become the preferred method of intervention as it is safe with low complication rate. These are two case reports of two young males suffered blunt pelvic trauma, with huge retroperitoneal bleeding; left external iliac artery thrombosis managed with balloon mounted covered stent.
Keywords: Angioplasty, blunt pelvic trauma, iliac arterial injury
|How to cite this article:|
Tawfik AR. Endovascular Management of Iliac Arterial Injury in Blunt Pelvic Trauma. Indian J Vasc Endovasc Surg 2015;2:30-2
| Introduction|| |
Iliac vascular injury following trauma accounts for (11%) vascular injury, 3.5% results from blunt trauma and associated fracture pelvis presents in 4-9.3%. Ten percent of fracture pelvis characterized by mechanical and/or hemodynamic instability  in which pelvic retroperitoneal hematoma is up to four liters with 90% is of venous origin. The associated mortality rate is 7-33%. Motor car accidents responsible for 70% of them. ,
Opening the retroperitoneal space to explore associated vascular injury may end in exanguation of this hematoma, visceral injury and in-stability of the patient general condition,  so management of such injuries remains challenge to surgical trauma team.
| Case Reports|| |
A 27-year-old Male patient came after fall from height then run over accident, shocked, tachycardia, and hematuria.
He responded to fluid resuscitation. Secondary trauma survey revealed left upper thigh hematoma and absent left lower limb pulsations.
Routine X-ray work up revealed the fracture of both pubic rami, right sacro-iliac joint with vertical shear, and left intertrochanteric fracture of the left femur. Computed tomography abdomen and pelvis with intravenous contrast were requested to evaluate associated vascular and visceral injuries revealing huge retroperitoneal hematoma in zone II and III with no intra-peritoneal collection, no associated visceral injury.
Patient put under observation over-night, and he was hemodynamically stable. Hemoglobin level was stable, normal creatinine level (0.9 mg %). and urine got clear gradually.
Patient was taken to angio-suite for management of left lower limb vascular injury preparing the patient to be transferred for external fixation of this unstable fracture pelvis.
A 7F sheath (AVANTI, Cordis, a Johnson and Johnson company) was inserted in the right femoral artery. Aortography revealed partial thrombosis of 3 cm of the left external iliac artery (EIA) below the bifurcation of the left common iliac artery by 1 cm.
Primary balloon premounted covered stent 8 mm × 59 mm (ATRIUM, V12, Atrium Medical Corporation) was deployed under10 ATM [Figure 1].
|Figure 1: (a) Three-dimensional reconstruction fracture pelvis illustrate fracture both pubic rami, right sacro-iliac joint with vertical shear, and intertrochanteric fracture of the left femur. (b) Angiography picture illustrates partial thrombosis of the left external iliac artery (EIA). (c) The left EIA after stent insertion|
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A 32-year-old Male patient came with same clinical scenario as the previous case but his left foot crushed. Radiological investigation revealed fracture of both pubic rami, fracture metatarsal bone of left foot, and retroperitoneal hematoma in zone III with no intra-peritoneal collection.
The patient was taken to the angio-suite; aortography that revealed total occlusion of 3 cm in the distal left EIA. As the wire (angled Terumo Corporation 0.035) crossed the lesion, the intima dissected and the origin of the profunda-femoris was in danger. Using an ipsilateral retro-grade access, the wire crossed the lesion, intra-luminal position confirmed proximal to the lesion, the wire get out the contra-lateral access to complete the procedure from ante-grade direction.
While the balloon mounted covered stent on its way to the lesion, stent slipped over the balloon, retrieved by applying slight tension over the wire in-between femoro-femoral access aiming to straighten the tortuous iliac vessels. Slight push of the balloon aided in the partial engagement of the balloon into the stent, partial inflation of the balloon (1.5 ATM.) tucking it into the stent guarding against stent re-slip. Primary balloon premounted covered stent 8 mm × 59 mm (ATRIUM, V12, Atrium Medical Corporation) deployed [Figure 2].
|Figure 2: (a and b) Computed tomography (CT) angiography illustrates the total thrombosis of the distal 1/3 of left external iliac artery (EIA). (b): Aortography confirming lesion (c) angiography from the contra-lateral access to confirm intra-luminal position after the wire crossed the lesion showed intimal dissection and the dye filled superficial femoral artery only not the profunda. (d) X-ray illustrates an ipsilateral left femoral access and wire crossing the lesion. (e) Angiography to confirm intra-luminal position of the wire crossed the lesion from ipsilateral access. (f) Aortography through ipsilateral femoral access confirming intra-luminal position of the wire. (g) Photo illustrates the wire entered from the ipsilateral access while trail to get it out the contra-lateral sheath, and it was folded up on itself in its shaft. (h) Photo illustrates the after it gets out the valve of the contra-lateral sheath. (i) Angiograghy after the balloon premounted stent was inserted in the distal left EIA lesion, the there was also a small dissection at left common iliac artery (CIA) bifurcation as a result of manipulating slipped stent in these tortuous iliac arteries. (j) CT angiography after insertion of the balloon mounted stent to treat the distal left EIA injury and self-expandable stent for management of dissection at left CIA|
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Both patients continued on clexane for 5 days and clopidogrel 75 mg/day for 1-year.
| Discussion|| |
Management of arterial injuries in blunt pelvic trauma remains a challenge to surgical trauma team owing to its difficulty especially in narrow male pelvis, carrying the propensity for massive bleeding and potential risk of iatrogenic injury to ureters or underlying iliac veins. ,
Endovascular intervention and external fixation considered as a damage control procedure  in cases, which associated with fracture pelvis as in these two cases that were males, subjected to a high energy trauma; disrupting the pelvic ring, classified as complex fracture pelvis, characterized by huge retroperitoneal bleeding, initial hemodynamic instability and mechanical instability of the fracture. 
Primary balloon mounted covered stent deployed with no predilatation for precise stent positioning and reducing the incidence of distal thrombo-embolization.
The mechanism of arterial injury in blunt pelvic trauma described as it ranged from intimal injury with intimal flap formation to complete transection  so, in the second case where the wire seems to be increasing the intimal flap dissection endanger the origin of the profunda-femoris artery [Figure 2]: Which is the main supply for thigh muscles in such young active patient, ipsilateral retro-grade short sheath used as an access through the common femoral artery to cross the lesion was mandatory, the intra-luminal position of the wire confirmed by injecting the dye just proximal to the lesion. Completing the procedure from the contra-lateral access was to ensure patency of the profunda-femoris artery origin and distal arterial tree. In spite of narrow working area would be expected in inserting this ipsilateral access, but I considered it should be attempted before converting the procedure to open intervention taking the risk of exsanguination of retroperitoneal bleeding and patient decompensating.
Tortuosity of iliac arterial tree considered to aid in the slipping of the covered stent off its balloon. Trying to straightened arterial tree to retrieve the stent and avoid the stent to be distally embolized and main patent artery to be occluded.
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[Figure 1], [Figure 2]