External iliac vein injury during total hip arthroplasty resulting in delayed shock

* E-mail: cba05803{at}nifty.com

Editor—Vascular injuries related to total hip arthroplasty (THA) are very rare, but can cause limb loss or become life threatening.1 2 The occurrence of this has not been emphasized enough in anaesthesia literature. We present a case of external iliac vein injury during THA, which resulted in shock despite minimal bleeding during surgery. A 157 cm, 51 kg, 68-yr-old female with a 20 yr history of osteoarthritis underwent total hip arthroplasty under general anaesthesia. Her blood pressure suddenly dropped from 100–120/60–70 mm Hg to 60 mm Hg of systolic pressure during closure of the incision. The artificial joint had been placed 20 min earlier. Tachycardia, ST depression (–1.5 mV) on ECG were then followed by hypotension. Haemoglobin (Hb) concentration fell from 9.6 g dl–1 before surgery to 6.5 g dl–1 at THA completion in 30 min. Iatrogenic bleeding was doubtful as there had been little bleeding during the operation. Haemodynamic instability required fluid resuscitation including blood transfusion and vasopressor support. Vascular injury from drilling was suspected and the operation incision was closed immediately. Hb concentration fell to 3.7 g dl–1 40 min after initial hypotension. A large retroperitoneal haematoma was found on abdominal echography. A laparotomy was undertaken 50 min after initial hypotension and revealed a 2.0 cm long laceration of the left external iliac vein. This laceration was repaired by vascular surgeons, and subsequent Hb concentration was 8.5 g dl–1. She was discharged 21 days after surgery without any further complications.

The external iliac vein appears to be more vulnerable than the artery because of its more medial position and the paucity of interposed tissue along the pelvic brim, which protects the artery.3 4 However, injury to the external iliac artery has been reported more frequently than the vein.1 2 This fact may indicate that venous injuries have been failed to be properly noticed. Hwang5 reported a case of a patient which resulted in shock 26 h after THA and the patient was found to have a 0.5 cm long laceration of the external iliac vein at laparotomy. This supports the conclusion that venous injury can lead to slow onset of shock, regardless of whether the laceration is large or small. Marked bleeding from the drill hole and profound hypotension are characteristic of intrapelvic arterial damage.1 2 However, venous damage that is of lower pressure may not present with the patient in a lateral position. As such, venous injury can be concealed and anaesthetists should pay close attention to the patient's haemodynamics.

Vascular injuries occurring in major vessels require urgent surgical intervention. Early diagnosis and immediate control of any haemorrhage should prevent morbidity and mortality. This may involve interrupting THA, covering the incision with drapes, and returning the patient to a supine position.

S. Doi*, Y. Motoyama and H. Itoh

Tokyo, Japan

References

1 Shoenfeld NA, Stuchin SA, Pearl R, Haveson S. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg 1990; 11: 549–55[CrossRef][ISI][Medline]

2 Bergqvist D, Carlsson AS, Ericsson BF. Vascular complications after total hip arthroplasty. Acta Orthop Scand 1983; 54: 157–63[ISI][Medline]

3 Wasielewski RC, Coopersterin LA, Kruger MP, Rubash HE. Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg 1990; 72: 501–8[Abstract]

4 Kirkpatrick JS, Callaghan JJ, Vandemark RM, Goldner RD. The relationship of the intrapelvic vasculature to the acetabulum. Implications in screw-fixation acetabulum components. Clin Orthop 1990; 258: 183–90[Medline]

5 Hwang K. Vascular injury during total hip arthroplasty: the anatomy of the acetabulum. Int Orthop 1994; 18: 29–31[ISI][Medline]





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