AJR 2001; 177:606
© American Roentgen Ray Society
Trauma Case from the Christiana Care
Health System |
Traumatic Common Iliac Vein Disruption Treated with an Endovascular Stent
Raul N. Uppot1,
Mark Garcia1,
Hien Nguyen2 and
John S. Wills1
1
Department of Radiology, Christiana Care Health System, 4755 Ogletown-Stanton
Rd., Newark, DE 19718.
2
Department of Surgery, Christiana Care Health System, Newark, DE 19718.
Received January 17, 2001;
accepted after revision March 12, 2001.
Address correspondence to R. N. Uppot.
Introduction
An 18-year-old unrestrained backseat passenger was involved in a motor
vehicle collision with intrusion into the passenger side. The patient was
found pinned against the passenger door complaining of right hip pain.
IV-enhanced CT of the abdomen and pelvis showed a fractured spleen and active
contrast extravasation in the right lower pelvic extraperitoneal compartment.
An associated extraperitoneal hematoma was displacing the bladder
(Fig. 1A). An arteriogram
showed no extravasation from the pelvic arteries. A venogram showed contrast
extravasation from the right common iliac vein
(Fig. 1B). To control the
active hemorrhage, a 10 x 40 mm Cordis Endovascular S.M.A.R.T (shape
memory alloy recoverable technology) nitinol stent (Johnson & Johnson,
Miami, FL) was deployed across the area of extravasation
(Fig. 1C). After balloon
tamponade, no more extravasation was seen
(Fig. 1D). A splenectomy for an
avulsed spleen was subsequently performed. No further treatment of the common
iliac vein laceration was required.
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —18-year-old male trauma patient who was involved in motor
vehicle collision. IV-enhanced axial CT scan shows large pelvic
extraperitoneal hemorrhage with mass effect displacing bladder to left.
High-density material (arrow) represents extravasation of vascular
contrast material from disrupted iliac vein.
|
|
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —18-year-old male trauma patient who was involved in motor
vehicle collision. Venogram shows stent deployed across area of vascular
disruption. Mild extravasation (arrow) is still seen.
|
|
Discussion
Active contrast extravasation from a vascular disruption is a
life-threatening emergency. Although the venous system is a low-flow state,
iliac vein injuries carry up to a 51% mortality rate
[1]. The time interval between
the occurrence of the injury and operative repair is crucial to the survival
of the patient.
Rapid evaluation of an injured patient can be made with CT. Extravasated
contrast material, representing active hemorrhage, has a mean Hounsfield unit
(H) of 132 and a range of 85-370 H. This is in distinction to clotted blood,
which has a mean attenuation of 51 H and a range of 40-70 H
[2]. Active arterial contrast
extravasation may be seen as a focal hyperdense region that is isodense with
adjacent arterial structures in the early arterial phase. Venous extravasation
should be seen only in the later equilibrium phase adjacent to venous
structures. Contrast extravasation on CT is a critical finding. Its presence,
taken in context with the clinical status of the patient, should prompt
immediate consideration of percutaneous or surgical intervention to control
active hemorrhage [3].
Traditionally, management of common iliac vein injury has involved
operative repair in stable patients; ligation is reserved for unstable
patients and for those with severe vessel injury. Recently, covered stent
grafts have been used in the management of traumatic injuries to the iliac
arteries [4]. Because
identification and operative exposure of injured vessels can be technically
difficult, covered stent grafts provide a viable alternative for the treatment
of these arterial injuries. In the venous system, covered stent grafts have
been limited to use in veno-occlusive disease.
In our patient, when the venous injury was identified, a stent was placed
across the area of injury. Because initial stent placement failed to
completely seal the leak, a 10-mm balloon catheter was placed across the stent
and inflated twice for 3 min, which sealed the laceration.
This case shows that when time to diagnose and treat is crucial to the
survival of a patient with active hemorrhage and when the patient is judged
sufficiently stable to undergo percutaneous intervention in lieu of surgery,
rapid diagnosis with CT and angiography, immediate treatment with a stent,
and, if necessary, balloon occlusion can result in a successful outcome.
References
-
Wilson RF, Wiencek RG, Balog M. Factors affecting mortality rate
with iliac vein injuries. J Trauma
1990;30:320
-323[Medline]
-
Shanmuganathan K, Mirvis SE, Sover ER. Value of contrast-enhanced
CT in detecting active hemorrhage in patients with blunt abdominal or pelvic
trauma. AJR
1993;161:65
-69[Abstract/Free Full Text]
-
Federle MP, Courcoulas AP, Powell M, Ferris JV, Peitzman AB. Blunt
splenic injury in adults: clinical and CT criteria for management with
emphasis on active extravasation. Radiology
1998;206:137
-142[Abstract/Free Full Text]
-
Nyman U, Uher P, Lindh M, Lindblad B, Brunkwall J, Ivancev K.
Stent-graft treatment of iatrogenic iliac artery perforations: report of three
cases. Eur J Vasc Endovasc Surg
1999;17:259
-263[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Discussion
