Endovascular Treatment of Bleeding External Iliac Artery Pseudo-Aneurysm Following Control of Haemorrhage with Sengstaken Tube During Revision Total Hip Arthroplasty

Abstract

We report a case of false aneurysm of the external iliac artery and compression of the external iliac vein, which subsequently caused deep venous thrombosis in a 63-year-old female patient with a revised total hip arthroplasty. This is the first case of control of life-threatening intraoperative haemorrhage of an external iliac pseudo-aneurysm by Sengstaken tube which allowed time for successful management of the external iliac artery pseudo-aneurysm with endovascular covered stent. Recognition of delayed vascular injury following revision of total hip arthroplasty and the need of pre-operative imaging should be considered in revision hip arthroplasty.

Injury to a major vessel is an uncommon, but well recognised, complication of total hip arthroplasty. An increased risk of such injuries had been reported in revision surgery.¹ Delayed vascular injury after revision total hip arthroplasty is a serious complication. We report a case of false aneurysm of the external iliac artery and compression of the external iliac vein which subsequently caused deep venous thrombosis which was successfully managed with endovascular covered stent.

We present the first case of control of life-threatening intra-operative haemorrhage of an external iliac pseudo-aneurysm by Sengstaken tube.

Case report

A 63-year-old woman was admitted for removal of infected total right hip replacement (THR) Originally performed in 1983, it was revised in 2000. A chronic hip sinus developed following the revision surgery with continuous oozing which, on occasions, was bloody; however, the culture swabs from the exudates were negative. Gradually, symptoms of pain and decreased hip motion developed. During admission to another hospital, she was found to be anaemic and received blood transfusion. No immediate investigation was made to identify the cause of anaemia. She noticed right leg swelling prior to her admission to our hospital. She had no other systemic medical diseases. On examination, she had normal temperature and non-pitting oedema in the right leg. Distal pulses were present and no palpable swellings or bruit in the groin.

Blood tests showed haemoglobin 9.5 g/dl, white blood cell count 7.7/mm³ and a normal coagulation screen. A radiograph of the right hip showed erosion of the Makar, Salem, McGee, Campbell, Bateson Endovascular treatment of bleeding external iliac artery pseudo-aneurysm acetabulum and adjacent pelvic bone with protrusion of the prosthesis and cup into the medial pelvis. Isotope bone scan revealed diffuse increased uptake in and around the femoral prosthesis in keeping with infection. Doppler ultrasound scan of the right leg showed expanded, non-compressible femoral vein suggestive of deep venous thrombosis (DVT): the venogram confirmed iliofemoral DVT. A retrievable inferior vena cava filter was inserted, the patient had warfarin stopped and she was started on low molecular heparin prior to the THR revision. Repeated swabs showed methicillin-resistant organisms and intravenous antibiotics were started. Through a standard lateral approach and after opening the joint capsule, uncontrollable bleeding was encountered around the loose cup; the cup was removed. Immediate control of haemorrhage was achieved by packing. In the meantime, the vascular surgeon was contacted and transfusion of 2U of blood was started.

Within the acetabular cavity, a gastric balloon of a Sengstaken tube was inflated up to 100 ml, tamponade was achieved and the wound closed. The distal end of the tube was cut prior to its installation to allow proper lodgement of the balloon. A CT scan of the pelvis (Fig. 1) showed no intraperitoneal fluid, a haematoma in the right thigh and the gastric balloon in situ. Angiogram showed extravasations from the right external iliac artery adjacent to right acetabulum (Fig. 2). A PTFE-covered, 6–12 mm/60 mm length of Jostent (JOMED, Germany) was deployed and repeated angiogram showed no further extravasations. One day later, the gastric balloon was deflated and 2 days later the Sengstaken tube removed. The right leg continued to be warm with palpable full set of pulses and the swelling started to decrease.

Figure 1.

CT scan of pelvis showing the displaced external iliac artery (arrow 1), the inflated balloon of Sengstaken tube (arrow 2) and iliacus muscle (arrow 3).

Figure 2.

Right iliac angiogram showing extravasations from the displaced external iliac artery (arrow).

Discussion

Pseudo-aneurysm of the external iliac artery is a rare vascular complication of total hip arthroplasty. The anatomical relation of the external iliac vessels makes the occurrence of vascular injuries in association with total hip arthroplasty a possibility that is rare, but serious. These injuries were reported to have 7% mortality and 15% incidence of limb loss.²

Central acetabular protrusion into the pelvis may produce extrinsic compression of the external iliac vein.³ In our case, the development of unilateral DVT may have been secondary to the compression by the displaced acetabulum or the external iliac pseudo-aneurysm. The development of the pseudo-aneurysm might have been due to the underlying infection as considered by some authors⁴ or mechanical arterial wall injury by the protruding acetabular cup.

The control of the massive haemorrhage by the use of balloon tamponade using a Sengstaken tube proved to be life-saving. In this case, it allowed time for patient stabilisation, transfer to radiology department and endovascular treatment. The size of the pseudo-aneurysm and the difficult access for direct compression prompted the use of a Sengstaken tube. The Sengstaken tube was originally designed for balloon tamponade of oesophageal varices bleeding; however, the gastric balloon has been successfully used for management of massive postpartum haemorrhage and bleeding rectal angiodysplasia.⁵

The use of emergency stenting of iliac false aneurysm has been an effective treatment of ruptured iliac artery pseudo-aneurysm in our case. Ting et al⁶. reported a successful endovascular stent repair of infected thoracic aortic pseudo-aneurysms under intravenous antibiotic cover followed by life-long oral antibiotics with a long-term follow-up (> 30 months) in three of their eight patients. Others have also reported a successful cover stent exclusion of external artery MRSA-infected pseudo-aneurysm followed by 3 months of oral antibiotics.^7,8 However, there is not enough evidence to support the duration and the effectiveness of follow-up antibiotic treatment to avoid further infection at the stent site in the long term.

Conclusions

Retrospectively, clinical suspicion of vascular complications should have been aroused when the patient had recurrent attacks of bloody discharge from the hip sinus, anaemia and the development of the unilateral DVT. Pre-operative imaging should be considered in the presence of marked acetabular medial protrusion to check the anatomical relationship between the acetabular component and the pelvic vessels.