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Iliac vein laceration caused by blunt trauma to the pelvis
CASE
REPORTS
Iliac Vein Laceration Caused by Blunt Trauma to the Pelvis MAJ Phillip Yosowitz, MC, USA, Washington,
DC
LTC Robert W. Hobson, II, MC, USA, Washington, LTC Norman M. Rich, MC, USA, Washington,
DC
DC
A major pelvic venous injury secondary to blunt trauma can be a difficult and urgent problem in diagnosis and management. Injuries of this type are uncommon. Those recorded are associated with a high mortality because of persistent retroperitoneal hemorrhage and severe coexisting injuries. Pelvic fractures are invariably present which alone can produce hemorrhage and hypovolemic shock not readily reversed by transfusions. Unless the possibility of a major pelvic vascular injury is considered early, or evidence of intraperitoneal injury makes immediate laparotomy imperative, valuable time may be lost pondering the advisability of surgical intervention to control retroperitoneal bleeding. The following case report emphasizes the problems in diagnosing a major pelvic venous injury and discusses recommendations for management of the patient with massive retroperitoneal hemorrhage resulting from blunt pelvic trauma. Case Report A twenty-seven year old woman was admitted to Walter Reed General Hospital on October 28, 1970, twenty minutes after being struck from the left side and thrown several yards by a hit and run automobile. Physical examination on admission revealed an unresponsive Caucasian woman, breathing spontaneously, with a palpable systolic blood pressure of 45 mm Hg and a weak pulse of 140 per minute. The patient had right forehead and left parietal scalp lacerations without palpable skull fractures. Her pupils were equal and reacted to light. On auscultation her chest was clear and there was no external evidence of trauma. The abdomen was soft and nondistended, with hypoactive bowel sounds, and From the Departments of General and Peripheral Vascular Surgery, Walter Reed General Hospital, Washington, DC 20012. Reprint requests should be addressed to Dr Rich, Chief, Department of Peripheral Vascular Surgery, Walter Reed General Hospital, Washington, DC 20012.
Volume 124, July 1972
there were no palpable masses. There were obvious bilateral femoral and left tibia1 fractures. These were associated with large soft tissues hematomas and moderate venous bleeding from a 2 cm laceration of the left midthigh. Her peripheral pulses were weak and equal as resuscitative efforts proceeded. Moderate venous bleeding was present from a 4 cm left vaginal wall laceration. X-ray studies confirmed the fractures of the legs and revealed bilateral fractures of the superior and inferior pubic rami. (Figure 1.) Four quadrant abdominal paracentesis gave negative findings. There was no gross hematuria in a catheter-drawn urine specimen. Resuscitative efforts included initial intravenous administration of Ringer’s lactate solution (4,500 cc) and dextran 70 (1,500 cc) which were followed by cross matched whole blood (3,000 cc) transfusions during the first two hours after admission. Her blood pressure rose to 90 mm Hg systolic; however, she remained unresponsive and required intubation and respiratory support. Approximately three hours after admission, the patient’s blood pressure fell to 40 mm Hg systolic. The lower part of the abdomen had become distended and bowel sounds were absent. Repeat paracentesis gave negative results. Further swelling and ecchymosis developed over the pubis, labia, and groin areas. Because of the liklihood of persistent extensive retroperitoneal hemorrhage and the possibility of intraperitoneal injury, abdominal exploration was elected. As the peritoneal cavity was entered, cardiac arrest occurred. The patient responded to initial resuscitation and a palpable aortic pulse was obtained but without audible blood pressure. On exploration, no intraperitoneal injuries were noted. Massive pelvic and left retroperitoneal hematomas were seen bulging beneath an intact peritoneum. Exploration of the left pelvic retroperitoneal area revealed a 5 cm laceration of the left common iliac vein. (Figure 1.) Left common iliac venorraphy was performed but pelvic hemorrhage continued. A second cardiac arrest occurred from which the patient could not be resuscitated. Additional postmortem findings were urinary bladder contusion, bilateral subarachnoid hemorrhages, contusion
91
Yosowitz,
Hobson, and Rich
of both frontal lobes and the right temporal lobe, an 8 mm area of hemorrhagic necrosis in the right lenticular nucleus and a 3 cm linear fracture in the left middle cranial fossa. Comments
A major . pelvic
cause of early mortality in patients with fractures is massive hemorrhage. An autopsy
analysis by Braunstein et al [1] of 200 consecutive fatally injured pedestrians revealed pelvic fractures in ninety of the victims. In twenty-one, pelvic fractures were the only injuries and massive pelvic hemorrhage was considered the direct cause of death. McCarroll et al [2] found ‘that ninety-three of 200 fatally injured pedestrians had pelvic fractures, and retroperitoneal hemorrhage was considered sufficient to cause death in twenty-eight. Management of retroperitoneal hemorrhage- related to pelvic fractures remains a controversial subject. Ravitch [3] has recommended continuing whole blood transfusion and nonoperative management unless signs of continuing severe hemorrhage persist despite transfusion of as many as 20 units of blood. It is generally agreed that attempting to locate and control bleeding from bone ends, lacerated soft tissue, and small caliber veins in the retroperitoneum is unrewarding. Packing technics are usually ineffective [4] and could increase the risk of infection. The use of hypogastric artery ligation in acute pelvic fractures may have limited value because of the rich collateral pelvic circulation. Nevertheless, favorable experience with this procedure has been reported in cases in which brisk hemorrhage from a ruptured branch of the hypogastric artery, frequently the superior gluteal, rendered nonoperative management inadequate [5,6]. Although laceration or rupture of a major pelvic vein due to blunt pelvic trauma is an uncommon injury, it has been highly lethal. In five previously /
Common Iliac 5 cm. laceration
Figure 1. Bilateral fractures of superior pubic rami and left iliac vein laceration.
92
and inferior
reported cases, mortality has been 100 per cent [7,8]. Severe brain damage probably precluded successful resuscitation in two of these patients and was also a factor in the patient described herein. In our patient, an extensive retroperitoneal hematoma had dissected to the splenic flexure on the left side, into the mesentery, and to the kidney on the right side. The lacerated left common iliac vein in its superficial position beneath the peritoneum did not tamponade sufficiently to bring about cessation of bleeding. It is possible that the expanding retroperitoneal hematoma would have ruptured into the peritoneal cavity in due time. Baylis, Lansing, and Glass [9] documented this complication in thirteen of twenty-five patients who underwent laparotomy for injuries resulting from blunt trauma and they attributed rupture of the peritoneum over the retroperitoneal hematoma to mechanical and ischemic causes. External signs of a major pelvic vein injury may be absent. Retroperitoneal hemorrhage can cause vague generalized abdominal pain and tenderness in the conscious patient. A boggy mass felt anterior to the rectum on rectal exam, loss of bowel sounds, ecchymosis of subcutaneous tissue over the groin [2], and microscopic hematuria frequently occur with retroperitoneal bleeding, but these are not specific findings. Patients with major pelvic vein injury may be unconscious, having sustained severe trauma and multiple injuries including fractures of the leg which contribute to hypovolemia. Abdominal findings can be difficult to interpret in such a patient. Peritoneal lavage or paracentesis may be of value in ruling out significant intraperitoneal hemorrhage. If there is gross hematuria, the urinary tract should be evaluated with cystogram and intravenous pyelogram. A urethrogram is indicated if a catheter cannot be passed or the prostate is displaced on rectal examination. Early diagnosis of a major pelvic vein injury requires constant observation and a high index of suspicion when a patient with severe pelvic fractures fails to respond adequately to resuscitative measures. If there is a double break in the pelvic ring or sacroiliac joint disruption, the need for extensive blood replacement should be anticipated [10,11] and suspicion of a major pelvic venous injury heightened [ 7) Recently, Reynolds and Balsano [12] employed pelvic venography utilizing bilateral simultaneous femoral vein injections to demonstrate the integrity of the external and common iliac veins in twenty-five patients with pelvic fractures. In one instance, an iliac vein laceration was identified. They recommended use of this technic in patients with severe
The American Journal of Surgery
Iliac
pelvic fractures, particularly with sacroiliac joint disruption. In treating a patient with major pelvic vein laceration [a], an attempt should be made to restore normal flow through injured vessel [13]. Lateral suture of lacerations and end to end anastomosis of transections are recommended. Venous patch grafts or autogenous vein grafts may be used but are probably not necessary. Prosthetic materials should be avoided in most venous reconstruction because of the high failure rate due to thrombosis and infection. If iliac vein ligation is deemed necessary, continued severe pelvic hemorrhage may result from increased flow through injured collaterals. Also, there is greater risk of edema in the legs and postoperative pulmonary embolization after venous ligation than after repair [13]. If hemostasis is still not adequate after iliac vein hemorrhage has been controlled, a trial with bilateral hypogastric artery occlusion may be warranted. Summary
A fatal case of iliac vein laceration caused by blunt trauma is presented. Problems in diagnosis and management of this uncommon injury are discussed.
Volume124, July 1972
Vein Laceration
References 1. Braunstein PW, Skudder PA, f&Carroll JR, Musolino A. Wade PA: Concealed hemorrhage due to pelvic fracture. J Trauma 4: 632, 1964. 2. McCarroll JR, Braunstein PW, Cooper W, Helpern M, Seremetis M, Wade PA, Weinberg SB: Fatal pedestrian automotive accidents. JAMA 180: 127, 1962. 3. Ravitch MM: Hypogastric artery ligation in acute pelvic trauma. Surgery 56: 601, 1964. 4. Hawkins L, Pomerantz M, Eisman B: Laparotomy at the time of pelvic fracture. J Trauma 10: 619, 1970. 5. Hauser CW, Perry JF: Control of massive hemorrhage from pelvic fractures by hypogastric artery ligation. Surg Gynec Obsfef 121: 313, 1965. 6. Seavers R, Lynch J, Ballard R, Jernigan S, Johnson J: Hypogastric artery ligation for uncontrollable hemorrhage in acute pelvic trauma. Surgery 55: 516, 1964. 7. Motsay GJ, Manlove C, Perry JF: Major venous injury with pelvic fracture. J Trauma 9: 343, 1969. 8. Perry JF, McClellan RJ: Autopsy findings in 127 patients following fatal traffic accidents. Surg Gynec Obstet 119: 586,1964. 9. Baylis SM, Lansing EH, Glass WW: Traumatic retroperitoneal hematoma. Amer J Surg 103: 477, 1962. 10. Hauser CW: Initial treatment of pelvic fractures. Lancet 86: 285,1966. 11. Peltier LF: Complications associated with fractures of the pelvis. J Bone Joint Surg 47: 1060, 1965. 12. Reynolds BM, Balsano NA: Venography in pelvic fractures: a clinical evaluation. Ann Surg 173: 104, 1971. 13. Rich NM, Hughes CW, Baugh JH: Management of venous injuries. Ann Surg 171: 724, 1970.
93
REPORTS
Iliac Vein Laceration Caused by Blunt Trauma to the Pelvis MAJ Phillip Yosowitz, MC, USA, Washington,
DC
LTC Robert W. Hobson, II, MC, USA, Washington, LTC Norman M. Rich, MC, USA, Washington,
DC
DC
A major pelvic venous injury secondary to blunt trauma can be a difficult and urgent problem in diagnosis and management. Injuries of this type are uncommon. Those recorded are associated with a high mortality because of persistent retroperitoneal hemorrhage and severe coexisting injuries. Pelvic fractures are invariably present which alone can produce hemorrhage and hypovolemic shock not readily reversed by transfusions. Unless the possibility of a major pelvic vascular injury is considered early, or evidence of intraperitoneal injury makes immediate laparotomy imperative, valuable time may be lost pondering the advisability of surgical intervention to control retroperitoneal bleeding. The following case report emphasizes the problems in diagnosing a major pelvic venous injury and discusses recommendations for management of the patient with massive retroperitoneal hemorrhage resulting from blunt pelvic trauma. Case Report A twenty-seven year old woman was admitted to Walter Reed General Hospital on October 28, 1970, twenty minutes after being struck from the left side and thrown several yards by a hit and run automobile. Physical examination on admission revealed an unresponsive Caucasian woman, breathing spontaneously, with a palpable systolic blood pressure of 45 mm Hg and a weak pulse of 140 per minute. The patient had right forehead and left parietal scalp lacerations without palpable skull fractures. Her pupils were equal and reacted to light. On auscultation her chest was clear and there was no external evidence of trauma. The abdomen was soft and nondistended, with hypoactive bowel sounds, and From the Departments of General and Peripheral Vascular Surgery, Walter Reed General Hospital, Washington, DC 20012. Reprint requests should be addressed to Dr Rich, Chief, Department of Peripheral Vascular Surgery, Walter Reed General Hospital, Washington, DC 20012.
Volume 124, July 1972
there were no palpable masses. There were obvious bilateral femoral and left tibia1 fractures. These were associated with large soft tissues hematomas and moderate venous bleeding from a 2 cm laceration of the left midthigh. Her peripheral pulses were weak and equal as resuscitative efforts proceeded. Moderate venous bleeding was present from a 4 cm left vaginal wall laceration. X-ray studies confirmed the fractures of the legs and revealed bilateral fractures of the superior and inferior pubic rami. (Figure 1.) Four quadrant abdominal paracentesis gave negative findings. There was no gross hematuria in a catheter-drawn urine specimen. Resuscitative efforts included initial intravenous administration of Ringer’s lactate solution (4,500 cc) and dextran 70 (1,500 cc) which were followed by cross matched whole blood (3,000 cc) transfusions during the first two hours after admission. Her blood pressure rose to 90 mm Hg systolic; however, she remained unresponsive and required intubation and respiratory support. Approximately three hours after admission, the patient’s blood pressure fell to 40 mm Hg systolic. The lower part of the abdomen had become distended and bowel sounds were absent. Repeat paracentesis gave negative results. Further swelling and ecchymosis developed over the pubis, labia, and groin areas. Because of the liklihood of persistent extensive retroperitoneal hemorrhage and the possibility of intraperitoneal injury, abdominal exploration was elected. As the peritoneal cavity was entered, cardiac arrest occurred. The patient responded to initial resuscitation and a palpable aortic pulse was obtained but without audible blood pressure. On exploration, no intraperitoneal injuries were noted. Massive pelvic and left retroperitoneal hematomas were seen bulging beneath an intact peritoneum. Exploration of the left pelvic retroperitoneal area revealed a 5 cm laceration of the left common iliac vein. (Figure 1.) Left common iliac venorraphy was performed but pelvic hemorrhage continued. A second cardiac arrest occurred from which the patient could not be resuscitated. Additional postmortem findings were urinary bladder contusion, bilateral subarachnoid hemorrhages, contusion
91
Yosowitz,
Hobson, and Rich
of both frontal lobes and the right temporal lobe, an 8 mm area of hemorrhagic necrosis in the right lenticular nucleus and a 3 cm linear fracture in the left middle cranial fossa. Comments
A major . pelvic
cause of early mortality in patients with fractures is massive hemorrhage. An autopsy
analysis by Braunstein et al [1] of 200 consecutive fatally injured pedestrians revealed pelvic fractures in ninety of the victims. In twenty-one, pelvic fractures were the only injuries and massive pelvic hemorrhage was considered the direct cause of death. McCarroll et al [2] found ‘that ninety-three of 200 fatally injured pedestrians had pelvic fractures, and retroperitoneal hemorrhage was considered sufficient to cause death in twenty-eight. Management of retroperitoneal hemorrhage- related to pelvic fractures remains a controversial subject. Ravitch [3] has recommended continuing whole blood transfusion and nonoperative management unless signs of continuing severe hemorrhage persist despite transfusion of as many as 20 units of blood. It is generally agreed that attempting to locate and control bleeding from bone ends, lacerated soft tissue, and small caliber veins in the retroperitoneum is unrewarding. Packing technics are usually ineffective [4] and could increase the risk of infection. The use of hypogastric artery ligation in acute pelvic fractures may have limited value because of the rich collateral pelvic circulation. Nevertheless, favorable experience with this procedure has been reported in cases in which brisk hemorrhage from a ruptured branch of the hypogastric artery, frequently the superior gluteal, rendered nonoperative management inadequate [5,6]. Although laceration or rupture of a major pelvic vein due to blunt pelvic trauma is an uncommon injury, it has been highly lethal. In five previously /
Common Iliac 5 cm. laceration
Figure 1. Bilateral fractures of superior pubic rami and left iliac vein laceration.
92
and inferior
reported cases, mortality has been 100 per cent [7,8]. Severe brain damage probably precluded successful resuscitation in two of these patients and was also a factor in the patient described herein. In our patient, an extensive retroperitoneal hematoma had dissected to the splenic flexure on the left side, into the mesentery, and to the kidney on the right side. The lacerated left common iliac vein in its superficial position beneath the peritoneum did not tamponade sufficiently to bring about cessation of bleeding. It is possible that the expanding retroperitoneal hematoma would have ruptured into the peritoneal cavity in due time. Baylis, Lansing, and Glass [9] documented this complication in thirteen of twenty-five patients who underwent laparotomy for injuries resulting from blunt trauma and they attributed rupture of the peritoneum over the retroperitoneal hematoma to mechanical and ischemic causes. External signs of a major pelvic vein injury may be absent. Retroperitoneal hemorrhage can cause vague generalized abdominal pain and tenderness in the conscious patient. A boggy mass felt anterior to the rectum on rectal exam, loss of bowel sounds, ecchymosis of subcutaneous tissue over the groin [2], and microscopic hematuria frequently occur with retroperitoneal bleeding, but these are not specific findings. Patients with major pelvic vein injury may be unconscious, having sustained severe trauma and multiple injuries including fractures of the leg which contribute to hypovolemia. Abdominal findings can be difficult to interpret in such a patient. Peritoneal lavage or paracentesis may be of value in ruling out significant intraperitoneal hemorrhage. If there is gross hematuria, the urinary tract should be evaluated with cystogram and intravenous pyelogram. A urethrogram is indicated if a catheter cannot be passed or the prostate is displaced on rectal examination. Early diagnosis of a major pelvic vein injury requires constant observation and a high index of suspicion when a patient with severe pelvic fractures fails to respond adequately to resuscitative measures. If there is a double break in the pelvic ring or sacroiliac joint disruption, the need for extensive blood replacement should be anticipated [10,11] and suspicion of a major pelvic venous injury heightened [ 7) Recently, Reynolds and Balsano [12] employed pelvic venography utilizing bilateral simultaneous femoral vein injections to demonstrate the integrity of the external and common iliac veins in twenty-five patients with pelvic fractures. In one instance, an iliac vein laceration was identified. They recommended use of this technic in patients with severe
The American Journal of Surgery
Iliac
pelvic fractures, particularly with sacroiliac joint disruption. In treating a patient with major pelvic vein laceration [a], an attempt should be made to restore normal flow through injured vessel [13]. Lateral suture of lacerations and end to end anastomosis of transections are recommended. Venous patch grafts or autogenous vein grafts may be used but are probably not necessary. Prosthetic materials should be avoided in most venous reconstruction because of the high failure rate due to thrombosis and infection. If iliac vein ligation is deemed necessary, continued severe pelvic hemorrhage may result from increased flow through injured collaterals. Also, there is greater risk of edema in the legs and postoperative pulmonary embolization after venous ligation than after repair [13]. If hemostasis is still not adequate after iliac vein hemorrhage has been controlled, a trial with bilateral hypogastric artery occlusion may be warranted. Summary
A fatal case of iliac vein laceration caused by blunt trauma is presented. Problems in diagnosis and management of this uncommon injury are discussed.
Volume124, July 1972
Vein Laceration
References 1. Braunstein PW, Skudder PA, f&Carroll JR, Musolino A. Wade PA: Concealed hemorrhage due to pelvic fracture. J Trauma 4: 632, 1964. 2. McCarroll JR, Braunstein PW, Cooper W, Helpern M, Seremetis M, Wade PA, Weinberg SB: Fatal pedestrian automotive accidents. JAMA 180: 127, 1962. 3. Ravitch MM: Hypogastric artery ligation in acute pelvic trauma. Surgery 56: 601, 1964. 4. Hawkins L, Pomerantz M, Eisman B: Laparotomy at the time of pelvic fracture. J Trauma 10: 619, 1970. 5. Hauser CW, Perry JF: Control of massive hemorrhage from pelvic fractures by hypogastric artery ligation. Surg Gynec Obsfef 121: 313, 1965. 6. Seavers R, Lynch J, Ballard R, Jernigan S, Johnson J: Hypogastric artery ligation for uncontrollable hemorrhage in acute pelvic trauma. Surgery 55: 516, 1964. 7. Motsay GJ, Manlove C, Perry JF: Major venous injury with pelvic fracture. J Trauma 9: 343, 1969. 8. Perry JF, McClellan RJ: Autopsy findings in 127 patients following fatal traffic accidents. Surg Gynec Obstet 119: 586,1964. 9. Baylis SM, Lansing EH, Glass WW: Traumatic retroperitoneal hematoma. Amer J Surg 103: 477, 1962. 10. Hauser CW: Initial treatment of pelvic fractures. Lancet 86: 285,1966. 11. Peltier LF: Complications associated with fractures of the pelvis. J Bone Joint Surg 47: 1060, 1965. 12. Reynolds BM, Balsano NA: Venography in pelvic fractures: a clinical evaluation. Ann Surg 173: 104, 1971. 13. Rich NM, Hughes CW, Baugh JH: Management of venous injuries. Ann Surg 171: 724, 1970.
93