Internal iliac artery transposition for vascular reconstruction in a patient with life-threatening iatrogenic common iliac artery injury

Abstract

Major vascular injury during surgery is life threatening and can be a nightmare for any surgeon.

We share our experience of a 42-year-old woman where right common iliac artery and both common iliac veins were accidentally injured during lumbar discectomy leading to haemorrhagic shock. Patient was resuscitated and explored. A 4 cm segment of right common iliac artery was found lacerated along with perforations of both iliac veins. Proximal segment of internal iliac artery was mobilised quickly and vascular continuity was restored by end-to-end anastomosis of this segment to the proximal segment of common iliac artery after excising the damaged segment. Iliac veins were repaired primarily. Patient made an uneventful recovery. We share this technique as it was found expeditious and effective and may benefit surgeons working in this field.

Background

Iatrogenic major vascular injury with life-threatening haemorrhage is a nightmare for any surgeon and may prove fatal to the patient.¹ Major abdominal vessels are vulnerable to injury during a variety of open, laparoscopic and robotic, orthopaedic, gynaecological, pelvic, general surgical and endovascular procedures.^1–6 These injuries require prompt recognition and appropriate surgical management by specialists involving appropriate multiple disciplines.

Common iliac artery (CIA) is at high risk for iatrogenic injuries during surgery for lumbar disc prolapse by posterior approach due to its close anatomic relation with intervertebral discs. A large number of authors have shared their experience with this injury during disc surgery. In all of the cases, the vessel was repaired either primarily or by a variety of prosthetic interposition grafts or endovascular stents.^{1 7–11} We report reconstruction of CIA injury using transposition of a segment of internal iliac artery (IIA). The technique is simple, reliable and fast that may prove invaluable in dealing with such injuries. We hope that the technique would be interesting and a good learning lesson for the surgeons operating in this area.

Case presentation

A 42-year-old woman was being operated by orthopaedic surgeons for symptomatic lumbar disc prolapse (L4–L5 level) via posterior approach. She was hypertensive, controlled on medication. Intraoperatively, she suddenly developed significant hypotension (blood pressure (BP) 60/40 mm Hg). The surgery was abandoned, patient was turned supine and resuscitation was commenced to which the patient temporarily responded (BP 110/70 mmHg).

Investigations

Intraoperative ultrasonography was performed which showed a large collection around lower part of inferior vena cava and aorta.

Differential diagnosis

Treatment

Resuscitation was continued with intravenous fluids and blood, and the patient was shifted immediately to CT room. Contrast enhanced CT showed a large haematoma around the iliac vessels along with contrast blush from right CIA suggesting iliac vessel injury. Patient was explored immediately via midline laparotomy but developed cardiac arrest. Anaesthetists restarted CPR immediately, but it was quickly realised that CPR was not effective due to open abdomen. Surgeons then performed a prompt left anterolateral thoracotomy and the patient was revived by performing open cardiac massage. The laparotomy was resumed, retroperitoneum was accessed quickly, the site of haematoma was explored and the major vessels were exposed. A 4 cm segment of right CIA was found lacerated at multiple places (figure 1) along with perforations of both common iliac veins. Due to the extent of injury, a primary repair of the artery was not possible but both iliac veins could be repaired primarily. The segment of injured CIA was excised leading to a defect of more than 5 cm; distal end of it was closed primarily.

Figure 1.

Injured common right iliac artery (Rt CIA) and planned mobilisation of right internal iliac artery (Rt IIA).

A 7 cm segment of right IIA was mobilised and transected; the distal end was ligated and the proximal end was anastomosed (end-to-end) to the proximal end of CIA. Thus, vascular continuity was restored between right common and external iliac artery using the mobilised segment of right IIA (figure 2).

Figure 2.

Final vascular reconstruction.

Outcome and follow-up

The patient made an uneventful recovery. An angiotomography with digital subtraction performed 7 days later showed normal flow across the repair with no contrast extravasation. The small distal residual stump of external iliac artery appeared like a pseudoaneurysm (figure 3).

Figure 3.

Angiotomography with digital subtraction 7 days post-reconstruction.

Discussion

Iatrogenic vascular injury during lumbar discectomy is uncommon with a reported incidence of less than 1% (0.01%–0.06%) but has a high mortality of 40%–100%.1 6 7 9 12 However, this may be an under-representation, as some of these injuries may go unnoticed and a large number of them remain unreported. The most common site of lumbar disc herniation is at L4–5 and L5–S1 levels. The common iliac arteries are anatomically juxtaposed to these vertebrae and therefore are at major risk during discectomy. In fact, in most of the reported series with iatrogenic vascular injuries during disc surgery, CIA was the most common injured vessel.^{6 11 13} Other vessels in the vicinity like external iliac artery, inferior vena cava and aorta may also be injured.

The presentation of patient following these injuries depends on the type and the extent of the vessel injured. Arterial injuries, being a high-pressure system, mostly present with haemorrhagic shock. However, a small arterial tear at times may go unnoticed and later present as pseudoaneurysm. Bleeding secondary to small tear in veins may arrest spontaneously as the flow is under low pressure and thus gets tamponaded. These are the injuries that may go unnoticed; however, large venous tear also lead to hypovolemic shock.

It is important that the operating surgeon as well as the anaesthetist be aware of this complication so that prompt surgical intervention in the form of haemorrhage control and repair of the injured vessel can be undertaken along with the help of an appropriate multidisciplinary team. A number of approaches have been described for vascular repair in this situation. Primary repair by end-to-end anastomosis is the most common technique described. This was not possible in our case as the injured segment was long and the subsequent defect after excising the injured segment became even longer which precluded the mobilisation and an end-to-end repair. Other options that have been tried in such circumstances are the use of autologous vein or prosthetic interposition grafts.

Though we were aware of these alternatives but the option of IIA appeared best to us, which fortunately proved easier and quicker. IIA transposition in the setting of common or external iliac artery injury has been described previously.¹⁴ Similar approach has also been used in the injury of internal carotid artery.¹⁵

IIA may safely be ligated without any adverse consequences as is routinely performed during renal transplant surgery and exsanguinating pelvic trauma. The technique described is simple and quick to perform that may be invaluable in complex injury to common or external iliac arteries.

Learning points.

• Iliac vessel injury is uncommon but a serious complication of lumbosacral spine surgery.

• The surgeon and the anaesthetist must be aware of this potentially lethal complication and be prepared to identify and address such injuries as quickly as possible.

• Internal iliac artery is an excellent choice for vascular reconstruction both as transposition or free graft. It is better than prosthetic graft, easy to dissect and saves time.