Percutaneous Balloon Catheter Occlusion to Treat Extravasation from an Inferior Vena Cava Laceration Associated With a Pelvic Fracture Following Blunt Abdominal Trauma: A Case Report

Abstract

Blunt abdominal injury with pelvic fracture is common in polytrauma cases and is a major challenge for emergency physicians. Fluid resuscitation and massive transfusion protocol should be activated when pelvic fracture patients are found in hypovolemic shock. At the emergency department, resuscitative endovascular balloon occlusion of the aorta may be performed to temporarily control bleeding. Finally, a damage control operation or trans-arterial embolization may be performed in the hybrid operating room.

Introduction

Blunt abdominal injury with pelvic fracture and inferior vena cava (IVC) injury is highly uncommon. The incidence of and mortality due to blunt IVC injury are 1.0%–3.2% and 49%–70%, respectively,[1,2] but both are lower than penetrating mechanism because of the lower pressure of the venous system.[3] Correct diagnosis may be delayed because the clinical symptoms of IVC injuries are not initially obvious. We report a case of blunt abdominal injury with pelvic fracture and IVC laceration and discuss its diagnosis and treatment.

Case Report

A 37-year-old male who accidentally fell from the fifth to the second floor was immediately sent to the emergency department (ED). The blood pressure was 99/70 mmHg, and the pulse rate was 134 beats/minute. Extended-focused abdominal sonography for trauma (eFAST) showed a hematoma in the retroperitoneum. Fluid resuscitation and blood transfusion protocol were performed at the ED. Contrast-enhanced computed tomography (CT) of the abdomen showed a pelvis with an acetabular complicated fracture left side and an 18-cm retroperitoneal hematoma around the IVC extending to the ilio-caval bifurcation and involving the right kidney (Figure 1). Extravasation of contrast medium from the IVC laceration was noted, the antegrade venography and percutaneous transluminal angioplasty with 8-French sheath and 14-mm size balloon long-inflation 15 minutes for occlusion of the IVC injured site were performed by the cardiologist in the hybrid operating room. The extravasation bleeding of the infrarenal IVC injured site stopped and was confirmed by venography and intravascular ultrasound (IVUS) (Figures 2‒5). After the procedure, the patient’s vital signs were stable, and he was taken to the intensive care unit for further treatment. After a few days, he underwent open reduction internal fixation of the pelvic and left acetabulum fractures. Three weeks after admission, he was discharged in stable condition. There were no endovascular procedure-related complications or sequelae.

Figure 1. Contrast-enhanced computed tomography images of the abdomen showing a large retroperitoneal hematoma with extravasation of contrast medium from the left common iliac vein at the ilio-caval bifurcation (white arrow). The pelvic fracture and acetabular complicated fracture left side (white arrow head) were showing.

Figure 2. Venography confirmed extravasation of contrast medium from the left common iliac vein at the ilio-caval bifurcation (white arrow).

Figure 3. Complete occlusion of injured site achieved with a percutaneous balloon catheter. There was no extravasation of contrast medium from the inferior vena cava (IVC) injured site (white arrow).

Figure 4. Intravascular ultrasound confirmed extravasation of contrast medium from the left common iliac vein at the ilio-caval bifurcation (white arrow) and the surrounding hematoma.

Figure 5. Intravascular ultrasound confirmed complete occlusion of the injured site (white arrow) using a percutaneous balloon catheter and the surrounding hematoma.

Discussion

A pelvic fracture is often associated with abdominal visceral organs or vascular injury. The bleeding causing hemodynamic instability in the pelvic fracture is the most common due to hemorrhage from the pelvic venous plexus or iliac arteries. The incidence of pelvic fracture with IVC laceration after blunt abdominal injury is very rare. Initially, the hemodynamics of these patients may be stable compared to that of patients with penetrating injury because of the retroperitoneum containment and surrounding the IVC. Many investigators have observed that a retroperitoneal hematoma associated with IVC injury may not be large and that there may be little intraperitoneal blood if the hematoma is spread across the injury site. Although most IVC injuries may cease to bleed owing to self-tamponade, 40% of patients with IVC laceration may die of exsanguination after the tamponade is surgically decompressed.[3] Because the clinical symptoms of these patients are not initially obvious, diagnosis may be delayed at the ED. Contrast-enhanced CT is the golden standard for detecting, quantifying, and localizing retroperitoneal hemorrhage due to extravasation from the IVC laceration in polytrauma cases.[4,5] CT can also help the emergency physician or surgeon to determine which cases should receive conservative management rather than open surgical repair. Although eFAST is widely used in EDs, in contrast to IVUS, it cannot confirm and localize the injured site of the IVC.

Because of the 50%–100% mortality and morbidity rate of traditional surgical procedures,[6,7] Bui et al.[8] used percutaneous balloon catheter occlusion for vascular control prior to operating on an infrarenal IVC injury. Castelli et al.[9] also reported the treatment of an IVC injury with hemorrhage using emergency placement of an endovascular stent graft. The advantages of percutaneous balloon catheter occlusion include its relative ease of use, short operation time, greater safety, and lower bleeding. Recent reports have shown positive outcomes and a significantly improved survival rate for endovascular management. Balachandran et al.[10] proposed an algorithm for the management of penetrating IVC injuries. The authors also emphasize the collaborative role of endovascular management even in hemodynamically unstable patients undergoing surgery.

In conclusion, although the blunt abdominal injury with pelvic fracture and IVC injury are rare, they must be early identified and treated aggressively. Contrast-enhanced CT is the golden standard for diagnosing IVC injury at ED. In addition to surgical procedures, early endovascular treatment should be considered for hemodynamically unstable patients with IVC injury. This may lead to lower mortality, better outcomes, and avoidance of exsanguination in major surgery.

Conflicts of Interest Statement

Nothing to declare.