Complex Iliac Artery And Venous Reconstruction In Case Of Polytrauma

Complex Iliac Artery and venous reconstruction in a case of Polytrauma

Arunagiri Viruthagiri

Consultant Vascular & Endovascular Surgeon, Kauvery Hospital, Tennur, Trichy

Case Presentation

A 42-year-old (nulliparous) female presented with an alleged history of a road traffic accident (two-wheeler versus bus). She had sustained injury to her right lower abdomen and was not able to move her right lower limb. There was a brief episode of loss of consciousness without ENT bleeding. She was able to move her both upperlimb and left lowerlimb.

On Examination

On arrival to the emergency services, her GCS was 15/15, and her vitals were BP – 90/60 mmHg, PR – 118/min, SpO2 – 97% on ambient air. Her chest compression test was negative. She had multiple abrasions on her face and a longitudinal degloving injury in her right lower abdominal wall in the suprapubic area extending along the entire breadth of her abdomen ,exposing the caecum and the right Iliac blade (Fig.1). Pulses in her right lower limb were absent. The right leg showed signs of compartment syndrome, with reduced foot temperature and absent sensory and motor functions.

Management

She was started on aggressive fluid resuscitation. Tetanus toxoid and immunoglobulin were administered. Meropenam, Amikacin, Metronidazole were initiated considering the gross contamination of her wounds. Supportive medications (analgesics, proton pump inhibitors) were initiated. Her CT brain showed no demonstrable intracranial injury. CT chest revealed a fracture of the left 10^th rib, with no hemothorax or pneumothorax. CT angiogram (CTA) showed non-opacification of the right lower limb arteries from the external iliac artery (EIA) near the bifurcation (Fig.3), along with multiple pelvic bone fractures and fractures of the L3-L5 vertebrae. Emergency consultations with an orthopedic surgeon, surgical gastroenterologist, and plastic surgeon were obtained.

She was immediately shifted to the emergency operating theater (OT) and underwent a four-compartment fasciotomy in her right leg. All the muscles appeared viable and contracting, except for the proximal anterior compartment group of muscle (Fig.4). Exploratory laparotomy revealed no injury to the solid organs. A small serosal tear in the rectum was repaired with 3-0 PDS. Her right ovary with endometriosis was found to be ruptured with Gross peritoneal contamination. Contusion thrombosis of the right external iliac artery (EIA) extending from 2 cm distal to its origin to the right common femoral artery (CFA) above its bifurcation, approximately 15 cm in length was noted along with transection of the Right external iliac vein (EIV). The Right femoral nerve was found to be transected. The right iliac bone was found to be splayed open with rupture of its muscle (Iliacus) (Fig.2).The ureter was found to be noninjured.

Right ovarian cystectomy was performed. The contused, thrombosed segment of the right EIA and CFA were resected and the continuity was restuited using interposition GSV graft in an end-to-end manner (Fig.6).Distal thrombectomy was performed using 4Fr Fogarty catheter and distal arterial tree was filled with heparin saline. After arterial anastomosis, a large amount of clots were evacuated from the common femoral vein (CFV).Open reduction and internal fixation of the torn iliac blade was performed by the orthopedic collegue. Following the completion of the arterial continuity ,it was decided to replace the vein.

Left internal jugular vein (IJV) harvesting was done. The transected edges of the right external iliac vein (EIV) were trimmed and repaired using an interposition IJV graft in an end-to-end manner (Fig.6).The vein which would match the diameter of the EIV was IJV(Fig.5). Abdominal wall reconstruction was performed using a pedicled rectus flap by the plastic surgery team (Fig.7). At the end of the surgery, a palpable popliteal pulse was achieved. The patient was then shifted to the ICU for further care.