Threatening External Iliac Vein Injury During Total Hip Arthroplasty

경희의학 : 제 27 권 제 1 호 □ 증 례 □ J Kyung Hee Univ Med Cent : Vol. 27, No. 1, 2011

Threatening External Iliac Vein Injury during Total Hip Arthroplasty

Kang Woo Lee, M.D., Jo Young Hyun, M.D., Jae Woo Yi, M.D., Ph.D.

Department of Anesthesiology and Pain Medicine, School of Medicine, Kyung Hee University, Seoul, Korea

INTRODUCTION nal iliac vein during total hip replacement, which resulted in hemorrhagic shock. Since its inception in the 1960’s, total hip arthroplasty (THA) has grown in volume and complexity. CASE REPORT Total hip arthroplasty has revolutionized the treatment of end-stage hip arthritis and is felt to be among the A 63-year-old female patient (150 cm, 59 kg) was most cost effective of all medical interventions diagnosed as secondary osteoarthritis of left hip joint. available.(1) The complications associated with THA She was scheduled to undergo total hip replacement. have been increased as a result of increasing life The patient’s previous medical history entailed ten expectancy and widened indications for THA. But the years of hypertension, which was well-controlled with complications related to total hip arthroplasty are not oral anti-hypertensive drugs. Routine monitors such as common. Especially vascular injuries are very rare but electrocardiogram, pulse oxymeter, non-invasive blood can cause limb loss or become life threatening. A pressure were used. Induction of anesthesia was achieved thorough understanding of the possible complications with propofol 120 mg, rocuronium 50 mg intravenously. following total hip arthroplasty aids in optimizing Anesthesia was maintained with sevoflurane. After loss patient outcomes The occurrence of the complication of all four twitches from the train-of-four obtained by related to THA has not been emphasized enough in ulnar nerve stimulation, endotracheal intubation was anesthesia literature and has been overlooked in the performed. The patient’s lungs were mechanically ven- anesthetic field. So we present a case of a massive tilated with a mixture of nitrous oxide (50%) in oxygen retroperitoneal bleed due to a perforation of the exter- (fresh gas flow rate=3 L/min-1, inspiratory : expiratory ratio=1 : 2). The arterial blood pressure was maintained to be 120～130/60～70 mmHg with the radial artery Correspondence Author: Jae Woo Yi, Department of Anes- thesiology and Pain Medicine, The East West Neo pressure monitoring. Intraoperative monitoring also in- Medical Center, Kyung Hee University, 149, Sangil-dong, cluded heart rate, central venous pressure (CVP), end- Gangdong-gu, Seoul 134-090, Republic of Korea tidal carbon dioxide (EtCO2), peak airway pressure, Tel: 02-440-6192, Fax: 02-440-7808 E-mail: [email protected] urine output, and temperature. Hemoglobin (Hb) con-

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Fig. 1. This figure shows the patient’s distended and tense lower abdomen.

centration was 14.6 g/dL before surgical incision, and Fig. 2. A CT scan of the abdomen shows large amount then 11.7 g/dL 1 hour after operation. Her blood pre- of hemoperitoneum and hemoretroperitoneum around liver, spleen and left abdominal wall ssure suddenly dropped from 100～130/60～80 mmHg and pelvic cavity. Active extravasation is noted to 50 mmHg of mean arterial pressure during closure in the pelvic cavity and abdominal wall hematoma. This figure reveals that active bleeding of the incision. Tachycardia and low EtCO2 (20～25 from the left inferior phrenic artery or the vein mmHg) were then followed by hypotension. Fluid between the left external iliac and the femoral vein is suggestive. resuscitation including blood transfusion and vaso- pressor support were done. However, blood loss was estimated to be about 300～400 mL by external obser- definite source of bleeding was observed. A blind vation of suction bottle, operation field, floor, surgeon’s embolization with gelfoam was done via left internal gown, blood-soaked gauzes and so on. Hb concent- iliac artery but was not so effective. She was trans- ration was 8.8 g/dL just before the end of operation. ferred for CT and then angiography room with digital After removing the surgical drapes and turning the fluoroscopy systems. An active extravasation was noted patient to the supine position, we could not find any between the left external iliac vein and the left other serious signs except that she was pale and common femoral vein (Fig. 2, 3, 4). She was transferred determined transferring her for computed tomography back to operation room. A laparotomy was undertaken (CT) to rule out pulmonary embolism. Her vital signs for venous ligation and bleeding control. Until the end became deteriorated just before exiting operating theater of surgery, she was transfused with 35 units of packed and she was back in the operation room again. We red blood cells, 35 units of fresh frozen plasma, and found that her lower abdomen was distended and tense 40 units of platelets. Three weeks later, she was (Fig. 1). An abdominal sonography revealed a huge discharged without any further complications. hematoma in the retroperitoneal and intraperitoneal cavity. Transthoracic echocardiography showed no signs DISCUSSION of cardiac dysfunction but hypovolemia. Angiogram with C-arm radiography was performed in the operation Major vessels may be injured during total hip arthro- room for immediate arterial embolization but no plasty (THA), although rare. The incidence of blood

- 61 - − 경희의학 제 27 권 제 1 호 2011 − vessel injury has been reported to be approximately 0.1 and give rise to symptoms appearing between a few ～0.2%.(2) The most prevalent injury areas are the days and several years after the operation external iliac artery, the common femoral artery, and The external iliac artery and vein travel along the the external iliac vein.(3). It occurs frequently in female medial surface of psoas muscle obliquely. Several patients and left hip arthroplasty, and it is associated muscles as well as blood vessels are located between with infection or resurgery in many cases.(4) The the anterior column of acetabulum. The external iliac mechanisms that are associated with blood vessel injury vein is located more deeply in the medial side, it is include cement incorporation of the iliac vessels, re- located along the pelvic brim, and interposed tissues tractor injury, reaming injury, excessive traction on that protect the artery are not sufficient.(6,7) Never- vessels, and improper intrapelvic cup migration, etc. theless, actually, cases that the artery rather than the (2,3) It is considered that in this patients, blood vessel external iliac vein is injured are more prevalent. injury is caused by the pelvic bone being pushed (3,4,6,8) In other words, it implies that the injury of inward excessively during osteotomy to resect aceta- the vein is not recognized in many cases. Hwang(9) bular labrum and osteophyte or transacetabular screw has reported a case who developed shock 26 hours fixation. The injury types are vessel lacerations, throm- after THA, and by laparotomy, laceration 0.5 cm in boembolism, pseudoaneurysm, and arteriovenous fistula. size in the external iliac vein could be found. This (2,3,5) In acute cases, severe hemorrhage occurs in implies that in cases with injury in the vein, regardless most cases. The injury that may develop delayed symp- of the size of laceration, the development of shock toms is broadly divided to three types, and in such may be delayed. In cases with intrapelvic arterial cases, symptoms may be developed from few days to damage, severe hemorrhage through the drill hole and few years after surgery. The symptoms are first of all, hypotension are shown characteristically.(3,4) However, pain in the hip caused by pressure of pseudoaneurysm, in cases with venous damage, hypotension may not be second ischemic symptoms in the affected limb due to detected clearly in the lateral position. In such cases, impaired blood flow or distal microembolization, and vein injury may be overlooked. Hence, anesthesiolo- third severe hemorrhage when extracting a hip pros- gists should pay attention on the hemodynamic state of thesis.(4) patients. Potential mechanism involved in vascular injury The most common mechanism being direct injury include cement incorporation of the iliac vessels, from a retractor placed too far medially over the retractor injury, reaming injury, excessive traction on anterior acetabular rim.(2) Injury is less likely with vessels and improper intrapelvic cup migration.(2,3) In more proximally placed retractors since there is this patient, vascular injury might be occurred due to increased soft-tissue coverage by the psoas muscle. pelvic bone being pushed inward excessively during Excessive medial acetabular reaming or cement extru- osteotomy to resect acetabular labrum and osteophyte sion through a medial acetabular defect(2,3,10) has or transacetabular screw fixation. Types of injuries been reported to result in direct injury to the external consisted of vessel lacerations, thromboembolism, pseu- iliac vein.(11) Avoidance of the anterior-superior qua- doaneurysm, and arteriovenous fistula.(2,3,5) The acute drant during insertion of acetabular screw fixation is injury most often give rise to severe hemorrhage. recommended to avoid injury to the external iliac Injury causing delayed symptoms are of three types vessels.

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Fig. 3. This CT scan shows that active extravasation is noted.

Fig. 4. This angiogram shows that active extravasation is When blood vessel damage occurs in the major noted between the left external iliac vein and the left common femoral vein. vessel, surgical intervention is required. It is important to diagnose early and perform surgical treatments immediately. Surgery may have to terminate imme- In conclusion, to understand the anatomical relation- diately, remove drapes, and turn the patient to the ship in the vicinity of hip joint and the mechanism of supine position. If internal bleeding that is associated vascular complications may be of help for anesthesio- with surgery is suspected first, the patient should be logists to properly manage the patients who are recei- managed properly. Moreover, to understand the uncer- ving THA. tain condition of patient, immediate sonographical examination performed in the operating room play a ABSTRACT very important role in this case. Transthoracic and transesophageal echocardiography may be of great help 고관절 전치환술 동안 발생한 to understand the hemodynamic state of patients. It is 치명적인 외부 장골정맥 손상 required for anesthesiologists to become familiar with 이강우․조영현․이재우 operating ultrasonographic equipment for the rapid diagnosis and management of patients in emergency 경희대학교 의학전문대학원 마취통증의학교실 condition. In addition, beside blood vessel injury, other side effects such as nerve injury, leg-length discre- 63세의 여자 환자가 고관절의 이차성 골관절염으 pancy, and instability may be developed. To manage 로 인하여 고관절 전치환술을 받기로 하였다. 수술 them properly, it is required to maintain a close 이 끝나갈 무렵 절개부위를 봉합하던 중 환자의 혈 collaboration with surgeons, and more attentions should 압과 혈색소치가 급격히 하락하기 시작하였으며 빈 be paid on the monitoring of patients. 맥과 호기 말 이산화탄수 수치의 하강이 나타났다.

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수술이 끝난 후 환자의 피부가 창백한 것을 제외하 4. Bergqvist D, Carlsson AS, Ericsson BF. Vascular 고는 별다른 이상을 발견할 수 없었으며 보다 자세 complications after total hip arthroplasty. Acta 한 검사를 위하여 전산화 단층촬영, 복부 초음파, 경 Orthop Scand 1983;54:157-63. 식도 심장 초음파, 혈관 조영촬영을 시행하였다. 그 5. Aust JC, Bredenberg CE, Murray DG. Mechanism 결과 좌측 외부 장골정맥과 좌측 총 장골정맥 사이 of arterial injuries associated with total hip re- 에서 현성 출혈이 관찰되었다. 환자는 즉시 응급 수 placement. Arch Surg 1981;116(3):345-9. 6. Wasielewski RC, Coopersterin LA, Kruger MP, 술을 받았으며 수술 도중 대량 수혈이 시행되었다. Rubash HE. Acetabular anatomy and the transaceta- 이에 본 저자는 수술 도중 출혈을 거의 동반하지 않 bular fixation of screws in total hip arthroplasty. J 은 고관절 전치환술 동안 발생한 외부 장골정맥의 Bone Joint Surg Am 1990;72:501-8. 손상에 의한 대량의 복막 뒤 출혈과 출혈성 쇼크를 7. Kirkpatrick JS, Callaghan JJ, Vandemark RM, 경험하였기에 보고하는 바이다. Goldner RD. The relationship of the intrapelvic vas- culature to the acetabulum. Implications in screw- 중심단어: 외부 장골정맥, 출혈성 쇼크, 고관절 전치 fixation acetabulum components. Clin Orthop Relat 환술 Res 1990;258:183-90. 8. Wasielewski RC, Crossett LS, Rubash HE. Neural REFERENCES and vascular injury in total hip arthroplasty. Orthop Clin North Am 1992;23:219-35. 1. Laupacis A, Bourne R, Rorabeck C, Feeny D, Wong 9. Hwang SK. Vascular injury during total hip arthro- C, Tugwell P, et al. The effect of elective total hip plasty: the anatomy of the acetabulum. Int Orthop replacement on health- related quality of life. J Bone 1994;18:29-31. Joint Surg Am 1993;75:1619-26. 10. Crispin HA, Boghemans JP. Thrombosis of the 2. Nachbur B, Meyer RP, Verkkala K, Zürcher R. The external iliac artery following total hip replacement. mechanisms of severe arterial injury in surgery of A case report. J Bone Joint Surg Am 1980;62:462-4. the hip joint. Clin Orthop Relat Res 1979;141: 11. Mallory TH. Rupture of the common iliac vein from 122-33. reaming the acetabulum during total hip replace- 3. Shoenfeld NA, Stuchin SA, Pearl R, Haveson S. ment. A case report. J Bone Joint Surg Am 1972; The management of vascular injuries associated with 54:276-7. total hip arthroplasty. J Vasc Surg 1990;11:549-55.

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