Endovascular repair of external iliac vein injury caused by acetabular screw penetration during total hip arthroplasty: a case report

Abstract

Introduction:

Total hip arthroplasty (THA) is a common orthopedic procedure with low complication rates. However, vascular injuries, though rare (0.1%–0.3%), can lead to life-threatening hemorrhage and hemodynamic instability. External iliac vein (EIV) injuries during THA are exceptionally uncommon, and optimal management remains a clinical challenge.

Presentation of case:

We report a 62-year-old woman with diabetes and hypertension who underwent right THA for severe osteoarthritis. Intraoperatively, a significant hemorrhage occurred due to the acetabular screw penetration into the right EIV. Despite initial control with a balloon-expandable stent, persistent extravasation required urgent re-intervention. Multiple overlapping balloon-expandable stent grafts were deployed, achieving definitive hemostasis and restoring venous patency. The patient stabilized, recovered uneventfully, and was discharged on anticoagulation. At 1-week follow-up, she demonstrated satisfactory recovery without complications.

Discussion:

Vascular injuries during THA often result from acetabular screw overpenetration. While open repair has traditionally been the standard, it poses challenges due to limited exposure and increased morbidity. Endovascular stenting offers a minimally invasive, rapid, and effective alternative, particularly in unstable patients. Literature reports of iliac venous injuries treated with stent grafts are limited, making this case noteworthy. Our experience highlights the importance of careful preoperative planning, intraoperative vigilance, and multidisciplinary collaboration to reduce risk and improve outcomes.

Conclusion:

EIV injury during THA is a rare but potentially fatal complication. Endovascular repair with multiple overlapping stent grafts can provide a safe and effective treatment, serving as a valuable alternative to open repair in emergency settings.

Introduction

Total hip arthroplasty (THA) is widely accepted as a safe and effective procedure to relieve hip pain and restore function. However, complications – though uncommon – can lead to poor outcomes^[1]. Vascular injury is one such complication, with reported causes including improper placement of retractors, inadvertent screw insertion for fixation of acetabular components or bone grafts, and excessive acetabular reaming^[1]. The incidence of vascular injury during THA is low, ranging between 0.1% and 0.3%^[2].

With the increasing popularity of THA, the frequency of associated complications has also risen^[3]. Although rare, when vascular injury occurs, it can rapidly lead to catastrophic clinical outcomes such as massive hemorrhage and hemodynamic collapse. The vessels most commonly affected are the external iliac and femoral artery and vein^[2]. The earliest reports of vascular injury associated with hip surgery date back to 1964^[3].

HIGHLIGHTS

• Rare case of external iliac vein injury during primary total hip arthroplasty (THA).

• Endovascular repair was achieved using multiple overlapping covered stent grafts.

• Demonstrates a minimally invasive alternative to open venous repair in emergencies.

• Emphasizes the role of preoperative planning and intraoperative vigilance in THA.

In this report, we present a complex case of external iliac vein (EIV) injury during primary THA in a 62-year-old female, successfully managed with multiple overlapping venous stent grafts. This case report follows the SCARE 2025 guidelines for surgical case reporting^[4].

Case presentation

A 62-year-old female with a history of diabetes mellitus, hypertension, umbilical hernia repair, and cesarean section presented with progressive right hip pain for 1 year. Hip X-ray confirmed osteoarthritis (Fig. 1). The patient experienced hip pain and stiffness secondary to osteoarthritis, which significantly limited her mobility and activities of daily living. She required a cane or support for ambulation over long distances and had difficulty climbing stairs. Symptoms worsened despite analgesics, leading to referral for right THA.

Figure 1.

Preoperative anteroposterior (AP) radiograph of the right hip. The image demonstrates severe osteoarthritis, characterized by significant joint space narrowing, subchondral sclerosis, and osteophyte formation.

The patient underwent a thorough preoperative evaluation, including detailed history-taking and physical examination. Relevant laboratory investigations were as follows: Complete blood count showed a white blood cell count of 9.63 × 10³/μL (normal range: 5.0–10.0 × 10³/μL), red blood cell count of 4.23 × 10⁶/μL (4.2–5.4 × 10⁶/μL), hemoglobin (Hb) of 12.66 g/dL (12–16 g/dL), hematocrit (HCT) of 38.11% (36%–46%), mean corpuscular volume of 90.09 fL (82–92 fL), Platelet count was 342 × 10³/μL (150–450 × 10³/μL). Coagulation profile revealed a prothrombin time (PT) of 12.5 seconds (11–14 seconds), international normalized ratio of 0.96, and activated partial thromboplastin time of 20.8 seconds (25–36 seconds). Serum electrolytes showed sodium of 139.0 mEq/L (132–148 mEq/L), potassium of 4.1 mEq/L (3.9–5.7 mEq/L), and chloride of 104 mmol/L (96–109 mmol/L for adults). Serum creatinine was 0.8 mg/dL (0.6–1.2 mg/dL). Glycated hemoglobin (HbA1c) was 7.2%. Imaging studies, including pelvic X-rays, revealed hip joint osteoarthritis characterized by significant joint space narrowing, subchondral sclerosis, and osteophyte formation. The ECG was normal.

After the epidural catheter was placed by the anesthesia specialist for regional anesthesia, the patient was positioned in the lateral decubitus position, and the operation proceeded with standard layer-by-layer dissection. Upon exposure, the right hip capsule was opened, and a total hip replacement was performed by the orthopedic team. An acetabular cup was fixed using a single 25 mm screw. The screw trajectory and length were determined by patient-specific acetabular anatomy and the lateral positioning required during the procedure. The orientation appeared more oblique than usual due to these anatomic constraints but was placed carefully to achieve stable fixation while avoiding nearby neurovascular structures.

During surgery, significant bleeding occurred and was initially managed with pressure and cautery. Intraoperative imaging raised suspicion that the acetabular screw had penetrated near the course of the right EIV. This suspicion was supported by acute clinical signs, including tachycardia (heart rate: 145 bpm) and hypotension (BP: 73/50 mmHg). The surgical site was rapidly closed, the patient was turned to the supine position, and a bedside ultrasound revealed pelvic fluid collection. The patient was immediately intubated, and resuscitative measures were initiated. Two units of cross-matched blood were transfused, and fluid resuscitation with Ringer’s lactate was administered until blood products were ready. Intravenous phenylephrine (20 µg/mL) and ephedrine (10 mg/mL) boluses were given, followed by a norepinephrine infusion at 0.02–0.5 µg/kg/min, titrated to maintain perfusion pressure. In addition, 10 mL/kg of crystalloid solution and Tranexamic acid (15 mg/kg) were administered. The massive transfusion protocol was activated, and transfusion of nine units of packed red blood cells, nine units of fresh frozen plasma, and five units of platelets was initiated in the operating room and continued during transfer to the catheterization laboratory, with ongoing norepinephrine support. Hemodynamic stability gradually improved, with blood pressure reaching a borderline level. The diagnosis of vascular injury was ultimately confirmed intraoperatively based on direct visualization and ongoing hemorrhage.

Under the same epidural anesthesia and ultrasound guidance, bilateral common femoral arteries (CFAs) and femoral veins (CFVs) were cannulated with 6 Fr and 10 Fr sheaths. The left femoral arterial sheath was inserted to provide ready and secure vascular access, allowing the operator to perform multiple interventions if needed. Angiography showed a patent aorta, right common iliac artery (CIA), internal iliac artery (IIA), external iliac artery (EIA), and CFA with diffuse vasospasm but no arterial extravasation.

Venography revealed contrast extravasation from the right EIV (Fig. 2), and a balloon-expandable stent graft (12 × 39 mm) was deployed (Fig. 3). The repair was successful, with no further contrast extravasation seen on the final venography, and the patient regained hemodynamic stability. After removal of the 10 Fr sheath, hemostasis was achieved by manual compression, and no vascular closure device was used. Adequate hemostasis was confirmed before dressing the puncture site.

Figure 2.

Sequential images from the initial digital subtraction venography. (A) A catheter is positioned in the right common femoral vein. (B–D) A progressive and massive extravasation of contrast medium is seen originating from the external iliac vein at the level of the penetrating acetabular screw, confirming a high-flow iatrogenic venous injury.

Figure 3.

Deployment of the first stent graft. (A) A balloon-expandable stent graft (12 × 39 mm) is positioned across the site of venous injury. (B) The stent graft is expanded by balloon inflation.

About 20 hours later, the patient developed severe hypotension, cold lower extremities, prolonged capillary refill time, weak dorsalis pedis artery pulses, and rising vasopressor needs. Despite fluid resuscitation, there was no improvement. Vascular surgery was consulted, and urgent re-intervention was performed in the catheterization lab.

Bilateral lower limbs were re-prepared. Under local anesthesia, a 6 Fr sheath is placed at bilateral CFA under U/S guidance. Then, a 10 fr sheath is placed at left CFV, and a 6 Fr sheath at right CFV. Vascular access re-established, and repeat angiography confirmed patent right CIA, IIA, EIA, and CFA with persistent EIV extravasation (Fig. 4).

Figure 4.

Post-intervention venography after placement of the initial stent graft. The sequential images (A–E) demonstrate persistent, significant extravasation of contrast from the injury site, indicating failure of the single stent graft to achieve hemostasis.

Three additional balloon-expandable stents (12 × 39 mm, 16 × 38 mm, 8 × 37 mm, and 10 × 37 mm) were deployed to fully cover the injured segment. Post-procedure venography showed no residual extravasation or endoleak, with patency of the right CFV, EIV, and common iliac vein (CIV) (Fig. 5).

Figure 5.

Final completion venogram after the deployment of four overlapping stent grafts. (A) Unsubtracted view of the final stent construct. (B) Contrast injection demonstrates complete sealing of the external iliac vein injury with no extravasation and wide patency of the stented segment.

Postoperatively, the patient was admitted to the intensive care unit (ICU) for monitoring and remained intubated, being extubated after 48 hours as hemodynamics stabilized. She received intravenous ceftriaxone, metronidazole, magnesium sulfate, and furosemide as indicated, with close laboratory and urine output monitoring. No major complications occurred, and she maintained stable hemodynamics without vasopressors. After spending 7 days in the ICU and 3 days in the general ward, the patient was discharged in stable condition with a scheduled follow-up appointment in the vascular clinic. Upon discharge, the patient was prescribed Rivaroxaban 20 mg daily, Diclofenac Potassium 50 mg, Paracetamol 1 g, and Amoxicillin–Clavulanate 875 mg. At the 1-week follow-up, she reported marked improvement with no adverse effects. Examination showed no complications, and recovery was progressing well. The patient was adherent to her medications and satisfied with the outcome.

Discussion

Vascular injury during THA was first reported in 1964 and was initially considered rare, with early large series reporting no cases^[3]. More recent studies indicate that the EIA and CFA are the most commonly affected vessels, while venous injuries, particularly involving the EIV, remain exceptionally uncommon^[5,6].

Risk factors for vascular injury in THA include arteriosclerosis, prior vascular bypass, and severe acetabular deformities such as congenital dysplasia, rheumatoid arthritis, osteoporosis, and hyperplasia. Surgical factors include malpositioned retractors, aggressive reaming, and especially acetabular screw penetration, which is the most frequently implicated mechanism in revision THA^[3,7]. Anatomical distortion from advanced osteoarthritis may also increase the vulnerability of adjacent vessels, as likely occurred in our case.^[7]

The close anatomical proximity of the acetabulum to the iliac vessels makes screw overpenetration a significant risk. In our patient, intraoperative imaging confirmed EIV injury caused by acetabular screw placement, leading to hemorrhage and hemodynamic instability. This highlights the need for careful preoperative planning, including templating and intraoperative fluoroscopy, to minimize vascular complications^[3].

Traditionally, open surgical repair has been the standard for major venous injuries. However, in the context of THA, open repair is challenging due to limited exposure in the lateral decubitus position, potential delays in vascular control when converting to an abdominal approach, and the added complexity of hemodynamic instability^[8]. Moreover, open repair carries high morbidity, including infection, thrombosis, and prolonged recovery^[9].

Endovascular techniques have transformed vascular trauma management. The first use of a covered stent for traumatic vascular injury was reported in 1991, treating a subclavian arteriovenous fistula, following earlier success with endovascular aneurysm repair by Parodi et al in 1990^[10]. Since then, endovascular stenting has become a key minimally invasive strategy, although its application in iliac venous injuries remains rare^[6].

Stent selection in venous trauma must consider diameter, flexibility, and radial strength. The large-caliber, low-flow environment of the iliac vein predisposes to early stent thrombosis if poorly sized or inappropriate materials are used. Literature suggests using stents approximately 16 mm for the CIV, 14 mm for the EIV, and 12 mm for the CFV^[9]. In our case, initial hemostasis with a 12 × 39 mm covered stent was inadequate, necessitating additional stents (16 × 38 mm, 10 × 37 mm, and 8 × 37 mm) to fully seal the injured segment.

Our case illustrates the successful use of multiple balloon-expandable covered stents to manage EIV injury. This approach, commonly used in arterial trauma, may be required in venous injuries when a single stent fails due to extensive laceration, persistent leak, or risk of migration^[11]. While this method is well-documented in arterial settings, its use in iliac venous trauma remains exceptionally rare, adding significance to this case.

Additionally, the use of covered stent grafts in venous trauma is generally considered off-label; however, accumulating evidence supports their safety and effectiveness in selected cases. Smeets et al^[12] systematically reviewed all published reports of covered stent grafts used to treat traumatic injuries of the inferior vena cava and iliac veins, identifying 28 studies comprising 35 patients. The review demonstrated a technical success rate of 100% with a 30-day mortality rate of only 2.9%, substantially lower than reported mortality following open venous repair or ligation, which ranges from 16% to 25%. Perioperative complications were uncommon, limited to a few cases of early stent occlusion, partial thrombosis, and pulmonary embolism, while in-stent thrombosis occurred in three patients during follow-up.^[12]

Post-procedure management is vital to ensure long-term stent patency, typically involving systemic anticoagulation and regular imaging follow-up (venography or duplex ultrasound) to monitor for stent thrombosis, migration, or restenosis^[13].

To date, only a few cases have reported EIV injuries managed with endovascular stenting during orthopedic procedures. ^{[1,3,9,11,14–16]} Table 1 summarizes similar cases, outlining the type of vessel injured, mechanism, treatment, and outcomes for comparison with our report.

Table 1.

Comparison of the present case with previously reported cases of iatrogenic vascular injury during THA managed with endovascular techniques

Case	Artery or vein	Vessel name	Mechanism of injury	Management	Complications
Yiğit et al	Vein	External iliac vein	Screw-tip	Placing a stent graft across the damaged vein	DVT
Suzuki et al	Artery	External iliac artery	By electrocautery during dissection of soft tissue around acetabular fossa	Metal stent grafting	–
Braun et al	Vein	External iliac vein	Screw-tip	Rendezvous technique within the retroperitoneum and stent graft	–
An et al	Artery	Femoral artery	Compression or over-traction by the Hohmann retractor’s tip	Stenting	–
Aleto et al	Artery	Superficial femoral artery	Blockage by wire	Stenting	–
Makar et al	Artery	External iliac artery	Revision THA pseudoaneurysm	Endovascular covered stent after temporary control with Sengstaken tube	–
Arun et al	Vein	External iliac vein	Anterior spine exposure	Covered stent (multiple)	–
Our case	Vein	External iliac vein	Acetabular screw penetration	Covered stents (4 overlapping)	–

Conclusion

EIV injury during THA is an exceptionally rare but potentially life-threatening complication. This case demonstrates that endovascular repair using multiple overlapping stent grafts can be an effective alternative to open surgical repair, especially in unstable patients or when rapid hemostasis is required. Preoperative planning and intraoperative vigilance are critical in reducing the risk of such vascular injuries in high-risk orthopedic procedures.

Ethical approval

Ethical approval was not applicable for this study, as our institution’s IRB committee does not mandate approval for reporting individual cases or case series.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal if requested.

Sources of funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contributions

Conceptualization, case analysis, manuscript writing, and editing: A.M.N., D.I.H.; data collection, literature review, and manuscript drafting: D.I.H., T.Z.M., A.M.N.; clinical management of the patient, data interpretation, and manuscript revision: M.S.A., H.K.B., N.A.S.; all authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.

Conflicts of interest disclosure

The authors have no conflict of interest to declare.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Taha Z. Makhlouf.

Provenance and peer review

Not applicable.

Data availability statement

The data used to support the findings of this study are included in the article.

Acknowledgements

The authors express their profound gratitude to the Polytechnic Medical Students’ Research Association (PMRA) for their invaluable contributions and unwavering support that significantly enriched every stage of the research journey. Special thanks are also extended to Dr. Islam Frijat for his contribution to this work.