Simultaneous laceration of external iliac artery and vein complicating anterior vaginal wall sling operation for stress urinary incontinence

CASE REPORT

We report a case of simultaneous injury of right external iliac artery and vein by a needle carrier that was inserted from the suprapubic area down to the vaginal lumen during anterior vaginal wall sling procedure.

DISCUSSION

The risk factors and measures to be taken to avoid this life threatening complication are discussed.

Use of an endovascular occlusion balloon for control of unremitting venous hemorrhage

This report describes a new approach for management of iliac vein injury. These injuries are often difficult to expose, and the associated hemorrhage further hinders visualization and subsequent repair. In this case, the use of an endovascular balloon from groin access controlled venous hemorrhage and permitted a primary repair of a torn left iliac vein. We believe that this approach is unique in that it uses a compliant, low-pressure balloon, thus preventing further iatrogenic injury in otherwise fragile venous structures and allowing direct access to the tear when exposure in the operative field is limited.

Iatrogenic major venous injuries incurred during cancer surgery

PURPOSE

Iatrogenic operative injury to the major veins is associated with significant morbidity and mortality. This study was conducted to review the pattern, management, and outcome of iatrogenic major venous injuries incurred during cancer surgery.

METHODS

We reviewed 24 patients with collective 30 venous injuries, evaluating clinical characteristics; operative and postoperative data, including location and type of venous injury, operative repair, blood loss, and transfusion requirements; and outcome.

RESULTS

Thirty venous and 12 associated arterial injuries were identified. The two most common sites of venous trauma were the iliac and femoral veins with 10 (33.3%) and 9 (30.0%) injuries, respectively. Twenty-three (76.7%) of the venous injuries were repaired primarily or with end-to-end anastomosis, while the remaining injuries required interposition grafts, patch venoplasty, or venous ligation. Postoperative revision procedures were performed in 3 (12.5%) patients. Perioperative mortality was 16.7% and major complications developed in 11 (45.8%) patients.

CONCLUSIONS

Serious complications can be minimized by immediate recognition and prompt repair of iatrogenic vascular injuries. Close collaboration with a vascular surgeon during resection of tumors in proximity to the vascular structures may be helpful in preventing iatrogenic vascular injuries. In hospitals where tumor resection procedures are frequently performed, a vascular surgeon must be readily available.

Iatrogenic vascular injury during to lumbar disc surgery

We report two patients who sustained vascular injury while undergoing intervertebral disc surgery at the lumbar four and five level. Each patient suffered from massive bleeding and shock, urgent laparatomy was performed, and the vascular injuries were successfully primarily repaired. The experience prompted us to review reports in the literature since 1965 of vascular complications associated with surgical excision of hernia disc via a posterior approach. From our analysis, we highlight the clinical features and management, emphasising that rapid diagnosis and immediate intervention can result in a favourable outcome, as in our patients.

Neurovascular injuries in acetabular reconstruction cage surgery: an anatomical study

Acetabular reconstruction cages are indicated for severe combined segmental and cavitary acetabular bone defects. The purpose of this study was to evaluate the implications of screw placement and drill plunge and the potential insult to anatomical structures when implanting acetabular reconstruction cages. A segmental cavitary defect was reamed into the acetabulum and a cage was implanted in each of the 10 hemipelvises. The relative course of the superior gluteal neurovascular bundle was mapped to assess dissection intervals. When cage screws were placed at least 15 mm longer than needed, 13% and 20% of screws of the superior flange and anterior rim hit the femoral nerve, respectively, and approximately 60% of the screws placed in the posterior rim endangered the obturator nerve. A "safe zone" for screw size may be a 15- and 25-mm screw for the superior flange and posterior rim, respectively.

Avulsion of ascending lumbar and iliolumbar veins in anterior spinal surgery: An anatomical study

To expose the disc between the 4th and 5th lumbar vertebrae in anterior spinal surgery, left to right retraction of inferior vena cava and aorta is required. This manoeuvre can be complicated by venous haemorrhage that, in most cases, is due to avulsion of the left ascending lumbar vein (ALV) or the left iliolumbar vein (ILV). We dissected 23 embalmed cadavers to assess the factors that contribute to the risk of tearing these two veins during retraction. We describe a triangular region that should help surgeons in identifying the ALV and ILV. This triangle is defined by the lateral border of the common iliac vein, the medial border of the psoas major muscle, and the superior end-plate of the L5 vertebral body. We observed that 3 cm between the termination of the left ALV, or a common stem with the ILV, and the termination of the common iliac vein is the critical distance, less than which the risk of venous avulsion is highest. Although the sample considered is small, our study seems to suggest that male patients tend to have a higher risk of venous avulsion than female patients.

Left internal iliac artery and vein tear during microendoscopic lumbar discectomy - a case report

As minimally invasive techniques have gained popularity across surgical specialties, microendoscopic discectomy has been hailed as one of the newest and best methods for disc removal. Although problems are unusual and infrequent, the complications that can be associated with this procedure should be realized. Iatrogenic major vascular injury is a rare but serious complication during microendoscopic discectomy, and early detection is difficult due to the surgical positions, the specific anatomy of the spine, and the subtle changes of signs and symptoms the patient manifests. Here, we present a female patient who suffered from left internal iliac artery and vein tear during microendoscopic lumbar discectomy. We conclude that both surgeons and anesthesiologists should be aware of the possibility of this complication during surgery. When this complication occurs, it is vitally important that the correct crisis resolution protocols, such as proper massive transfusion algorithm and successful surgical interventions, be applied immediately during the critical period.

Successful endovascular management of an acute iliac venous injury during lumbar discectomy and anterior spinal fusion

A 61-year-old woman experienced laceration of the left common iliac vein with significant hemorrhage during lumbar discectomy. An endovascular approach using stent grafts provided a minimally invasive and successful solution to the problem.

Venous injury in lumbar anterior spine surgery

To assess the clinical and angiological outcome of venous injury in lumbar anterior spine surgery.

DESIGN

Follow-up study.

METHODS

During a seven-year time span 77 consecutive patients underwent lumbar anterior spine surgery. Of these patients three patients suffered two minor and two major vein injuries. In two cases this was a common iliac vein injury. The other two injuries were at the level of the junction of the iliac veins with the inferior vena cava. The injuries were repaired by direct suture and the patients were followed-up by an independent angiologist.

RESULTS

The follow-up, done clinically and with duplex sonography, plethysmography and ankle pressures showed no sequelae from the venous injuries.

CONCLUSIONS

Venous injuries following anterior spine surgery are rare and may have a good recovery. Preoperative informed consent is recommended.

[Penetrating injuries to the pelvis]

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Vascular complications of prosthetic inter-vertebral discs

Five consecutive cases of prosthetic inter-vertebral disc displacement with severe vascular complications on revisional surgery are described. The objective of this case report is to warn spinal surgeons that major vascular complications are likely with anterior displacement of inter-vertebral discs. We have not been able to find a previous report on vascular complications associated with anterior displacement of prosthetic inter-vertebral discs. In all five patients the prosthetic disc had eroded into the bifurcation of the inferior vena cava and the left common iliac vein. In three cases the aortic bifurcation was also involved. The fibrosis was so severe that dissecting out the arteries and veins to provide access to the relevant disc proved impossible. Formal division of the left common iliac vein and artery with subsequent repair was our solution. Anterior inter-vertebral disc displacement was associated with severe vascular injury. Preventing anterior disc displacement is essential in disc design. In the event of anterior displacement, disc removal should be planned with a Vascular Surgeon.

Positional Anatomy of Vessels That May Be Damaged at Laparoscopy: New Access Criteria Based on CT and Ultrasonography to Avoid Vascular Injury

BACKGROUND AND PURPOSE

To study the relations of major blood vessels (aortoiliac bifurcation and iliocaval confluence) and the inferior epigastric arteries to the umbilicus and the anterior superior iliac spine (ASIS) planes and to apply this information to define ideal, anatomically based locations for primary and secondary laparoscopic port insertions to minimize vascular injuries.

MATERIALS AND METHODS

Two hundred randomly selected postcontrast CT images of the abdomen and pelvis were assessed by two radiologists. The position of the umbilicus (mobile point), ASIS (fixed point), and relations with the great vessels were measured. The angle of the umbilicus with the aortic bifurcation, theta (theta), was calculated using trigonometric principles. The position and course of the inferior epigastric arteries (IEA) was analyzed in 103 patients with color Doppler ultrasonography.

RESULTS

The median distance of the aortoiliac bifurcation was 8 mm (interquartile range [IQR] 28.8 mm] and that of the iliocaval venous confluence 25 mm (IQR 32 mm) below the umbilicus. The aorta divided 48 mm (IQR 16 mm) and the iliac veins joined 33 mm (IQR 9 mm) above the ASIS plane. The angle of the umbilicus to the aortoiliac bifurcation in the sagittal plane had a range of 14 degrees to 34 degrees with a median of 21.6 degrees . The median distance from the right IEA to the midline at the umbilicus was 4.75 cm (IQR 0.7 cm), and the same distance in the ASIS plane was 4.8 cm (IQR 0.7 cm). The distance of the IEA to the midline did not exceed 6 cm in any patient on either side or in either plane.

CONCLUSION

The position of the umbilicus should not be relied on for access planning. The relation between the level of the ASIS and the aortic bifurcation is more consistent. The ideal primary port entry (or Veress needle site) is at the ASIS plane in the midline, and the ideal lateral port entry is in the same plane >6 cm from the midline. If the umbilicus is to be used, a Hasson insertion is desirable, but if a Veress needle is used at the umbilicus, an angle of 45 degrees in the sagittal plane should be used.

Delayed Presentation of Ilio-Iliac Arteriovenous Fistula Following Laparoscopic Cholecystectomy Treated with Percutaneous Graft-Covered Stent Placement

Major vascular injuries during laparoscopic cholecystectomy are rare, usually readily apparent, and immediately treated. We report a case of delayed presentation of a retroperitoneal vascular injury. The patient presented with abdominal pain and increasing edema of the lower extremities 1 year after laparoscopic cholecystectomy and was found to have an ilio-iliac arteriovenous fistula. Endovascular treatment was accomplished using a graft-covered polytetrafluoroethylene stent. The patient remained free of symptoms at 1-year follow-up.

Vascular anatomy of the presacral space: a fresh tissue cadaver dissection

OBJECTIVE

To assess variability in the vascular structures of the presacral space and to estimate the risk of injury because of blind suture placement during sacral colpopexy.

STUDY DESIGN

Ten fresh frozen female cadavers were evaluated. Three 0-polyester sutures were placed blindly through the peritoneum and around the midline of the anterior longitudinal ligament. The presacral space was dissected and the sutures examined for injury to vessels. The midline of the anterior longitudinal ligament was marked from the promontory to its inferior edge, and measurements were taken to the leading edge of vessels proximal to the presacral space. On a template, all vessels larger than 2 mm were drawn to scale and overlaid on the template.

RESULTS

Unequivocal vascular injury was found in 5 cadavers because of blind sutures. Four injuries occurred to the middle sacral artery and 1 to the left common iliac vein. There was significant variability in location of vessels, particularly on the left side of the ligament.

CONCLUSIONS

The vascular pattern of the presacral space is variable, and major vessels may deviate significantly from their expected positions. Surgeons should carefully expose this space prior to placing sutures during sacral colpopexy.

Iliac Vein Injuries in Hemodynamically Unstable Patients with Pelvic Fracture Caused by Blunt Trauma

BACKGROUND

Major pelvic venous injuries secondary to blunt trauma can be a difficult problem in diagnosis and management. This study aimed to elucidate the clinical significance of iliac vein injuries demonstrated by venography in patients with blunt pelvic injuries who remained unstable even after transcatheter arterial embolization (TAE).

METHODS

We reviewed the records of 72 patients with unstable pelvic fracture who presented with shock at our center after blunt trauma from 1999 through 2003. The average Injury Severity Score was 34.3 in this study population.

RESULTS

TAE was the first method of choice to control bleeding from pelvic fracture in 61 patients. Thirty-six patients recovered from shock after TAE. Eighteen of 25 who did not recover from shock died. In 11 of these 25, transfemoral venography with a balloon catheter was performed, revealing significant venous extravasation in 9: common iliac vein in 5, internal iliac vein in 3, and external iliac vein in 1. The average Injury Severity Score of patients with iliac vein injury was 45.8. Treatments for venous injuries were laparotomy for hemostasis (n = 1, survivors = 0), retroperitoneal gauze packing (n = 3, survivors = 1), and endovascular stent placement (n = 3, survivors = 3). Two patients suffered from cardiac arrest before treatment for venous injury. External fixations were performed after TAE according to fracture type.

CONCLUSION

The iliac vein injury is the principal cause of hemorrhagic shock in some patients with unstable pelvic fractures after blunt trauma. Venography is useful for identifying iliac vein injuries.

[Roentgenendovascular stenting (stent-graft) of the external iliac artery for elimination of post-traumatic arteriovenous anastomosis]

Presented herein is a case report concerning successful treatment of the post-traumatic pathological anastomosis between the left external iliac artery and iliac vein using the stent-graft Jostent-graft. The anastomosis emerged after gunshot injury to the abdominal cavity.

Endovascular Repair of Spontaneous or Traumatic Iliac Vein Rupture

Spontaneous rupture of the iliac vein and rupture resulting from blunt trauma are both very unusual. Herein one case of each are reported and were managed by emergent endovascular repair with use of covered stents. Favorable outcomes were achieved in both cases.

Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy

BACKGROUND

Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy.

METHODS

We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002.

RESULTS

The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality.

CONCLUSIONS

The surgeon's experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.

Vascular injury during anterior lumbar surgery

BACKGROUND CONTEXT

With the number of anterior lumbar procedures expected to increase significantly over the next few years, it is important for spine surgeons to have a good understanding about the incidence of vascular complications during these operations.

PURPOSE

To determine the incidence of vascular injury in 1,315 consecutive cases undergoing anterior lumbar surgery at various levels from L2 to S1.

STUDY DESIGN/SETTING

Patients undergoing anterior lumbar surgery were studied.

PATIENT SAMPLE

A total of 1,310 consecutive patients undergoing 1,315 anterior lumbar procedures between August 1997 and December 2002 were included in the study.

OUTCOME MEASURES

All patients were evaluated for incidence of vascular injury during and immediately after surgery.

METHOD

A concurrent database was maintained on all these cases. All the patients had distal pulse evaluation preoperatively. Patients with venous injuries were further analyzed to determine location and extent of injury, amount of blood loss, completion of the procedure and postoperative sequelae. Patients with pulse deficits or evidence of ischemia during or immediately after surgery were further analyzed in particular in relation to demographic, preoperative variables and management.

RESULTS

Six patients were identified as having left iliac artery thrombosis (0.45%), and 19 had major vein lacerations (1.4%).

CONCLUSION

This study shows that the incidence of vascular injury is relatively low (25 in 1,315 or 1.9%). Because only five of these patients experienced significant sequelae from the approach, it appears that anterior lumbar surgery is quite safe, although it must be carried out with utmost respect for the vessels to avoid possible catastrophic outcomes.

Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication

PURPOSE

Epidemiologic studies of vascular injuries are usually limited to those caused by trauma. The purpose of this study was to review the management and clinical outcome in patients with operative injuries to abdominal and pelvic veins.

METHODS

Clinical data and outcome in all patients with iatrogenic venous injuries during abdominal and pelvic operations between 1985 and 2002 were reviewed.

RESULTS

Forty patients (21 men, 19 women; mean age, 51 years [range, 27-87 years]) sustained 44 venous injuries. Injuries occurred during general (30%), colorectal (23%), orthopedic (20%), gynecologic (15%), and other (12%) operations. Factors leading to injury included oncologic resection (65%), difficult anatomic exposure (63%), previous operation (48%), recurrent tumor (28%), and radiation therapy (20%). All patients had substantial bleeding (mean, 3985 mL; range, 500-20,000 mL). Injuries were located in the inferior vena cava (n = 6), portal vein (n = 7), renal vein (n = 1), and iliac vein (n = 30). Repair was performed with venorrhaphy (64%), end-to-end anastomosis (14%), interposition graft (20%), and vessel ligation (2%). Seven patients (18%) died of injury-related causes, including multisystem organ failure (n = 4), uncontrollable bleeding (n = 2), and pulmonary embolism (n = 1). Thirteen patients (32.5%) had major injury-related complications, including repeat exploration because of bleeding (n = 6), multisystem organ failure (n = 6), and venous thrombosis (n = 4). In two patients (5%) unilateral lower extremity edema developed, with no evidence of thrombosis. There was no late graft or venous thrombosis. Variables associated with increased risk for death were massive bleeding, acidosis, hypotension, and hypothermia (P <.05).

CONCLUSION

Operative injuries of abdominal and pelvic veins occur in patients undergoing oncologic resection and those with difficult anatomic exposure, owing to previous operation, recurrent tumor, or radiation therapy. Massive blood loss, acidosis, hypotension, and hypothermia are associated with increased risk for death. Repair of venous injuries offers durable results with low incidence of graft or venous thrombosis.