Abstract
Case
A 30‐year‐old woman had her left thigh run over by a train. We tried to compress the left femoral area to control the arterial bleeding, but bleeding continued from the stump and injured soft tissue. The application of a tourniquet bandage also failed because of the limited remaining thigh. She developed impending cardiac arrest. As the left femoral arterial pulsation was still palpable, we inserted an intra‐aortic balloon occlusion catheter percutaneously. The hemorrhage from the stump region decreased rapidly. She was transferred to an operating room to carry out surgical hemostasis, and it was confirmed with deflation of the balloon in the common iliac artery.
Outcome
There was no complication of the skin or soft tissue at the surgical site caused by impaired circulation, and her consciousness fully recovered.
Conclusion
We report the successful control of bleeding by the emergently modified application of intra‐aortic balloon occlusion in the left common iliac artery.
Keywords: Hemostasis, intra‐aortic balloon occlusion (IABO), mobile digital subtraction angiography (mobile DSA), shock, thigh amputation
Introduction
We encountered a patient with left thigh amputation, due to being run over by a train, and severe hemorrhage shock. In general, in order to stop bleeding, it is necessary to identify and control the damaged blood vessels located in the proximal part at the site of bleeding.1 In this case, however, a tourniquet bandage could not be applied because of the limited remaining thigh. We report the successful control of bleeding by the emergently modified application of intra‐aortic balloon occlusion (IABO) in the left common iliac artery.
Case Report
A 30‐year‐old woman fell from the platform at a train station, and had her left thigh run over by a train. She was transported to our tertiary trauma center approximately 1 h after the accident with blunt proximal thigh amputation and hemorrhagic shock. On arrival, her consciousness level was comatose, with slight spontaneous breathing and a respiratory rate of 4 breaths/min. Her heart rate was 103 b.p.m., and her blood pressure could not be measured due to shock. Her left thigh had been amputated proximally, soft tissue was severely damaged, and bleeding was continuous (Fig. 1).
Figure 1.
Injury site. The left thigh was amputated proximally, soft tissue was severely damaged, and bleeding was continuous.
Initial trauma care was started according to the following primary A‐B‐C approach. At first, we tried to compress her left femoral area to control the arterial bleeding. However, we could not control the bleeding completely from the stump and injured soft tissue. The application of a tourniquet bandage also failed because of the limited remaining thigh. Although massive fluid replacement was initiated, the pulse began to decrease. Chest and pelvic X‐rays and Focused Assessment of Sonography for Trauma showed no abnormality except for a small cardiac shadow. We recognized that severe hemorrhage shock with impending cardiac arrest was due to bleeding from the site of amputation.
We decided to carry out interventional radiology with mobile digital subtraction angiography2 rather than exposure of the femoral artery in this impending cardiac arrest case. As the left femoral arterial pulsation was still palpable, we inserted an intra‐aortic balloon occlusion (IABO) catheter (Senko Medical Instrument Manufacturing Co., Ltd., Tokyo, Japan) percutaneously (Fig. 1). Major contrast extravasations from the left external iliac artery were identified. We applied the balloon occlusion of the IABO catheter in the abdominal aorta first, and the tip of IABO catheter was placed distally to the bifurcation of the aorta. (Fig. 2A).
Figure 2.
A, An intra‐aortic balloon occlusion catheter was placed percutaneously through the left femoral artery in a 30‐year‐old female patient with left thigh amputation due to being run over by a train. B, The intra‐aortic occlusion catheter balloon was inflated in the left common iliac artery.
We emergently modified the application of IABO. Subsequently (Fig. 2B), the hemorrhage from the stump region decreased rapidly and the blood pressure recovered to 90 mmHg. We confirmed the position of the IABO catheter and the absence of extravasations of contrast medium in the pelvis and buttocks.
The patient was transferred to an operating room to carry out surgical hemostasis, and it was confirmed with deflation of the balloon in the common iliac artery. The left thigh stump was then closed with drainage. We left the deflated IABO catheter in situ, and removed it on the first postoperative day. There was no complication of the skin or soft tissue at the surgical site caused by impaired circulation. The patient's vital signs were stable postoperatively, and her consciousness fully recovered. She was transferred to another hospital for rehabilitation on the 15th postoperative day.
Discussion
An IABO is primarily designed to inflate in the descending aorta in order to stop blood flow below the site of inflation, particularly to control hemorrhagic shock in cases of ruptured abdominal aortic aneurysms,3 abdominal trauma, pelvic fracture, gastrointestinal bleeding, and postpartum hemorrhage.4, 5 The emergently modified application of this device for inflation in the common iliac artery was successful to control bleeding in a patient with impending cardiac arrest caused by massive bleeding from the stump following proximal thigh amputation.
In general, in order to stop bleeding, it is necessary to identify and control the damaged blood vessels located in the proximal part at the site of bleeding.1 However, in crush wounds such as in the present case, it is very difficult to identify the injured vessels. Other options for impending cardiac arrest are ER thoracotomy (ERT) and aortic clamping. However, these procedures are more invasive.
The indication of IABO is basically a patient who is in shock due to a hemoperitoneum or retroperitoneal hemorrhage, and the device is inflated in the descending aorta. The complications of IABO are aortic injury, aortic dissection, ischemia below the site of inflation, thrombosis, and damage of the balloon. Furthermore, it is controversial how long we can inflate the IABO until causing ischemia below the interception part. According to the study of Ishihara et al.,6 a safe inflation time that avoids ischemia is less than 40 min. We carried out occlusion intermittently, and the present case required occlusion of the left common iliac artery for over 10 h. However, there was no serious complication after deflation. We consider that the IABO position to maintain circulation to the abdominal organs is key. In addition, anastomotic branches of the common iliac artery on the non‐damaged side also supply blood to the pelvic viscera.
When we encounter severe femoral vessel injury, we should try to identify the injured vessels to initially occlude the proximal artery. If the identification is difficult, then we should consider the indication of IABO at the same time as ERT. A long inflation time may be possible if the IABO is inserted just above the injured site and balloon placement in the common iliac artery is limited. Of course, we should not hesitate to carry out ERT and aortic clamping when the patient's hemodynamic status is life‐threatening.
In such cases of severe blunt trauma amputation, modified application may be useful to save patients' lives. A general device not only for the aorta but also for major arteries may be required, and techniques to handle such a device for primary endovascular treatment would consequently be required by those responsible for acute trauma care.
Conflict of Interest
None.
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