J Korean Soc Traumatol Search

CLOSE


J Trauma Inj > Epub ahead of print
Park, Kim, Hwang, and Cho: Endovascular treatment of traumatic iliac venous injury combined with phlegmasia cerulea dolens: a case report

Abstract

Traumatic iliac venous injury is rare but can be fatal. Although surgical management is considered a primary treatment method, urgent treatment is required when deep venous thrombosis and subsequent phlegmasia cerulea dolens is combined. It is difficult to treat by surgical management, and pharmaceutic thrombolysis cannot be applied due to the trauma history. Here, we describe a case of unilateral traumatic iliac venous injury and subsequent diffuse venous thrombosis in the affected iliofemoral and infrapopliteal veins, combined with phlegmasia cerulea dolens, treated with endovascular management, including bare metal stent insertion and aspiration thrombectomy.

INTRODUCTION

Traumatic iliac venous injury (TIVI) is rare and often underestimated but can be fatal [1]. TIVI without pelvic bone fracture is reported to be even more rare [2,3]. Surgical repair or ligation is considered a first-line treatment modality [4]; however, it has not yet been established and remains controversial. In particular, urgent treatment is required when deep venous thrombosis (DVT) and subsequent phlegmasia cerulea dolens (PCD) are complicated by TIVI. It is difficult to treat those patients with surgery alone, and pharmaceutic thrombolysis cannot be applied due to trauma history. There is no consensus on a treatment strategy for TIVI combined with DVT and PCD.
We describe a case with unilateral TIVI and subsequent diffuse DVT in the affected lower limb, combined with PCD, treated by endovascular management.

CASE REPORT

A 46-year-old male patient who had a pedestrian traffic accident was admitted to a regional trauma center. The patient was in a semicomatose state with unstable initial vital signs (blood pressure, 63/32 mmHg; heart rate, 110 beats/min). Complete blood count (serum hemoglobin, 13.5 g/dL; hematocrit, 39.6%) and coagulation profile (platelet count, 276×103/mm3; international normalized ratio, 1.1) was normal. Contrast-enhanced abdominopelvic computed tomography (CT) showed a retroperitoneal hematoma, without evidence of pelvic bone fracture, and DVT in the adjacent right common and external iliac veins. Iliac venous rupture and subsequent adjacent hematoma formation were suspected, but it was thought that active venous bleeding had stopped due to the formation of venous thrombus; therefore, conservative treatment with blood transfusion (4 units of packed red blood cells and 4 units of fresh frozen plasma) was initiated for the lesion. The patient’s vital signs were stabilized. However, PCD developed in the right lower extremity 1 day later. Follow-up lower extremity CT venography showed not only an increased volume of pelvic hematoma and diffuse DVT involving the right iliofemoral and right infrapopliteal veins (Fig. 1A) but also decreased enhancement of the muscles of the right deep thigh and calf (Fig. 1B, C).
Urgent fasciotomy was performed at the bedside, and subsequent endovascular treatment for DVT and TIVI was requested. A retrievable filter (Denali; Bard Peripheral Vascular Inc., Tempe, AZ, USA) was inserted into the infrarenal inferior vena cava via the right internal jugular vein to prevent pulmonary artery embolism that might occur during the procedure. The patient was placed in a prone position, and the right popliteal vein was punctured under ultrasonographic guidance. An 8F sheath (Glidesheath; Terumo Interventional Systems, Somerset, NJ, USA) was inserted. Venography showed diffuse DVT involving the right iliofemoral vein and extravasation of contrast media from the right external iliac vein (Fig. 2A). One 14×100-mm self-expandable bare metal stent (E-luminexx, Bard Peripheral Vascular Inc.) was inserted across the rupture site, and poststent balloon dilation was performed inside the stent using a 12×100-mm balloon catheter (Mustang; Boston Scientific Corp., Natick, MA, USA). Aspiration thrombectomy was performed in the right iliofemoral vein using an 8F guiding catheter (Mach 1, Boston Scientific Corp.). A large amount of the red thrombus was aspirated, but small DVT was still remaining in the external iliac vein and venous flow was not improved. Additional stent insertion was performed using a stent of the same size overlapping the existing stent, and additional poststent balloon dilation was performed using the same balloon catheter. Completion venography showed improved venous drainage and the absence of contrast media extravasation (Fig. 2B). The access sheath was removed, and access site hemostasis was achieved by manual compression. A 6-week follow-up CT venography showed a patent stent, a significantly decreased volume of the right pelvic hematoma without evidence of hemorrhage (Fig. 3A), and improved perfusion of the thigh muscles (Fig. 3B), although that of calf muscles were not (Fig. 3C).
Informed consent for publication of the research details and clinical images was obtained from the patient.

DISCUSSION

TIVI may be fatal, with a mortality of 50% to 70%, if left untreated [1,5]. Surgical treatments, including packing, surgical repair, or ligation, are considered the treatment of choice if conservative treatment fails [4,6]; however, surgery is challenging because the overlying hematoma interferes with the surgical field and the tamponade effect decreases during surgery [7]. Therefore, endovascular management has been reported as an alternative treatment modality, most of which involves covered stent insertion [6,810], and there are a few case reports of bare metal stent insertion [1,5,7].
Massive exposure to thrombogenic agents in the bloodstream due to traumatic vascular shearing injury can cause thrombosis [11]. In particular, massive amounts of iliofemoral and infrapopliteal DVT can occur in a short period of time due to acute blockage of the draining iliac vein, which can lead to complications such as PCD and phlegmasia alba dolens. Surgical or interventional procedures in most of the previously reported TIVI cases have been performed to treat hemorrhage due to iliac venous rupture rather than DVT and subsequent PCD. Hu et al. [12] reported a case in which PCD, which occurred after surgical ligation was performed for TIVI, was treated with surgical venous reconstruction.
In contrast, in our case, diffuse iliofemoral and infrapopliteal DVT and subsequent PCD were present and urgent intervention was requested. It is noteworthy that the contrast media leakage disappeared even though bare metal, not covered, stents were inserted. Stent placement likely pushed the remaining thrombus towards the injured venous wall, and hemostasis was achieved by covering the ruptured site.
Compared to covered stents, bare metal stents are suitable for emergency use because they usually have higher availability in hospitals and have lower migration risk, even with stents with relatively smaller diameters [5]. And it is also a method worth considering because venous pressure is much lower than arterial pressure. For this reason, the use of bare metal stents as treatment for venous injury is increasing [13]. Although not indicated in our case, prolonged balloon tamponade or additional coil embolization might be considered if bleeding is not resolved with bare metal stent insertion [14,15].
In conclusion, we successfully treated a patient with PCD complicated by TIVI-related DVT using aspiration thrombectomy, bare metal stent insertion and subsequent balloon tamponade.

Notes

Ethical statements

Informed consent for publication of the research details and clinical images was obtained from the patient.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

None.

Author contributions

Conceptualization: JHK; Data curation: SP, JHH, JC; Visualization: JHH, JC; Writing–original draft: SP; Writing–review & editing: JHK.

All authors read and approved the final manuscript.

Fig. 1.
Contrast-enhanced computed tomography and the photo of right lower extremity. (A-C) Contrast-enhanced computed tomography taken 1 day after the onset of trauma. (A) Hyperdense fluid collection in the pelvic cavity (asterisk), suggestive of hematoma, contrast filling defect in a right iliac vein (arrow), and (B, C) right femoral vein (arrowhead), suggestive of thrombosis, and decreased enhancement of right deep thigh and calf muscles (arrows), suspicious of ischemic changes. (D) The photo of right lower extremity taken during fasciotomy before the endovascular procedure shows the color change with edematous muscles.
jti-2022-0039f1.jpg
Fig. 2.
Images taken during the interventional procedure. (A) Venography during procedure shows contrast media extravasation from the right external iliac vein (arrows). Bare metal stent insertion, balloon tamponade, and aspiration thrombectomy were performed. (B) Completion of venography shows improvement of venous drainage and absence of contrast media leakage. The native image is marked on the left to determine the location.
jti-2022-0039f2.jpg
Fig. 3.
Follow-up contrast-enhanced computed tomography. (A) Patent stent (arrow) is shown with decreased volume of right pelvic hematoma with chronic changes (asterisk). (B) Perfusion of the thigh muscles are improved, (C) but that of calf muscles are not (arrows).
jti-2022-0039f3.jpg

REFERENCES

1. Kataoka Y, Maekawa K, Nishimaki H, Yamamoto S, Soma K. Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma. J Trauma 2005;58:704–8.
crossref pmid
2. Boulanger B, Green J, Rodriguez A. Blunt traumatic iliac vein laceration without pelvic fracture: a rare entity. J Vasc Surg 1992;16:87–9.
crossref pmid pmc
3. Sheets NW, Roderick O, Plurad DS. Common iliac vein injury in blunt abdominal trauma without pelvic fractures. Cureus 2021;13:e14401
crossref pmid
4. Smith WR, Moore EE, Osborn P, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma 2005;59:1510–4.
crossref pmid pdf
5. Cha JG, Lee SY, Hong J, Park JM, Lim KH, Kim D. Traumatic iliac vein rupture managed using a bare metal stent. Trauma Case Rep 2021;37:100589.
crossref pmid
6. Demir D, Smeets R, Schurink GW, Mees BM. Use of thoracic stent grafts to control major iliac vein bleeding. J Vasc Surg Venous Lymphat Disord 2021;9:1058–61.
crossref pmid
7. Sofue K, Sugimoto K, Mori T, Nakayama S, Yamaguchi M, Sugimura K. Endovascular uncovered Wallstent placement for life-threatening isolated iliac vein injury caused by blunt pelvic trauma. Jpn J Radiol 2012;30:680–3.
crossref pmid
8. Uppot RN, Garcia M, Nguyen H, Wills JS. Traumatic common iliac vein disruption treated with an endovascular stent. AJR Am J Roentgenol 2001;177:606.
crossref
9. Zieber SR, Mustert BR, Knox MF, Fedeson BC. Endovascular repair of spontaneous or traumatic iliac vein rupture. J Vasc Interv Radiol 2004;15:853–6.
crossref pmid
10. Smeets RR, Demir D, van Laanen J, Schurink GW, Mees BM. Use of covered stent grafts as treatment of traumatic venous injury to the inferior vena cava and iliac veins: a systematic review. J Vasc Surg Venous Lymphat Disord 2021;9:1577–87.
crossref pmid
11. Kaufman JA, Lee MJ. Vascular and interventional radiology: the requisites. 2nd ed. Philadelphia: Elsevier; 2013.

12. Hu H, Cai Y, Wang C, et al. Successful treatment of posttraumatic phlegmasia cerulea dolens by reconstructing the external iliac vein: a case report. J Med Case Rep 2014;8:149.
crossref pmid pmc pdf
13. Lauerman MH, Rybin D, Doros G, et al. Characterization and outcomes of iliac vessel injury in the 21st century: a review of the National Trauma Data Bank. Vasc Endovascular Surg 2013;47:325–30.
crossref pmid pdf
14. Hathi R, Patel S, Wilson P. An unusual case of pseudoaneurysm of the left brachiocephalic vein secondary to rupture during central venous catheterization treated with self-expanding, uncovered stent and coils. Clin Radiol 2011;66:89–92.
crossref pmid
15. Choi SJ, Do YW, Oh TH, et al. Central venous catheterization-induced right brachiocephalic vein pseudoaneurysm: successfully treated with stent-assisted coiling. J Vasc Access 2018;19:319–23.
crossref pmid pdf


ABOUT
BROWSE ARTICLES

Browse all articles >

EDITORIAL POLICY
FOR CONTRIBUTORS
FOR READERS
Editorial Office
2619 Twincity-namsan, 366, Hangang-daero, Yongsan-gu, Seoul. 04323, Korea
Tel: +82-10-4391-0788    E-mail: office@jtraumainj.org                

Copyright © 2022 by The Korean Society of Traumatology.

Developed in M2PI

Close layer
prev next