AbstractVascular injuries in a multi-trauma patient are associated with significant cardiovascular instability and organ injury. Injuries with active bleeding are best treated with a quick, safe and the least less invasive procedure available to the trauma surgeon. We report two cases of blunt trauma induced common and external iliac vessel injury, managed by endovascular treatment. In the second case, endovascular treatment prevented histological examination of the artery, which would have revealed an alternative diagnosis

Akhtar, Y.

Courtney, D.

Hynes, N.

Jawad, A.

Mahendran, B.

Sultan, S.

Tawfik, S.

Elsevier - Publisher Connector 

SHORT REPORT*Correspond
Endovascular
Surgery, West
Galway, Irela
E-mail address
1533–3167/00Endovascular Management of Traumatic Iliac Vessel
Disruption—Report of Two Cases
B. Mahendran, N. Hynes, Y. Akhtar, A. Jawad, S. Tawfik, D. Courtney and S. Sultan*Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital,
Galway, IrelandVascular injuries in a multi-trauma patient are associated with significant cardiovascular instability and organ injury.
Injuries with active bleeding are best treated with a quick, safe and the least less invasive procedure available to the trauma
surgeon. We report two cases of blunt trauma induced common and external iliac vessel injury, managed by endovascular
treatment. In the second case, endovascular treatment prevented histological examination of the artery, which would have
revealed an alternative diagnosis.Keywords: Blunt trauma; Iliac artery injury; Iliac vein injury; Pelvic fracture; Stent-graft; Cystic median necrosis;
Endovascular.Introduction
Endovascular methods are evolving to treat arterial
trauma.1 Endovascular intervention can be success-
fully extended to vascular trauma by the use of
covered stent-grafts.2 Parodi3 was the first to success-
fully treat of an arterio-venous fistula after a traumatic
vascular injury. Vascular injuries in a multi-trauma
patient are associated with significant cardiovascular
instability and organ injury. Contamination of wounds
in the acute setting, either due to visceral injury or
open wound, makes non-autogenous repair of such
injuries less appealing. However, vascular injury with
active bleeding in a trauma patient is best treated with
a quick, safe and less onerous procedure available to
the trauma surgeon. We report two cases of blunt
trauma induced common and external iliac vessel
injury, managed by endovascular treatment.ing author. Mr Sherif Sultan, Consultant Vascular and
Surgeon, Department of Vascular and Endovascular
ern Vascular Institute, University College Hospital, 123
nd.
: sherifsultan@esatclear.ie
0131+ 04 q 2005 Published by Elsevier Ltd.Open access undCase 1
A 66-year-old female pedestrian was admitted follow-
ing a road traffic accident. She had sustained a head
injury, severe lower abdominal injury with marked
bruising of the upper legs and an ischemic right leg.
She was unstable on arrival with hypotension.
Following resuscitation, a computed tomography
(CT) scan was performed that showed a large pelvic
haematoma and a complex pelvic fracture (Fig. 1). In
the operating room, arteriogram showed right external
iliac artery rupture that was crossed by a 9 mm
Jomedw covered stent with good angiographic result
and complete resolution of extravasation. On the left,
avulsion of common iliac vein to IVC was demon-
strated by venography and a12 mm Jomedw covered
stent was used with good immediate result (Fig. 2).
The ruptured left sapheno-femoral junction was
surgically repaired. The right leg required fasciotomy.
Pelvic fracture was stabilised with an external fixator
(Fig. 3). At 6 months the patient is fully ambulatory
with patent right iliac arterial stent and left distal DVT.
She is on long-term anticoagulants and elastic
stocking.EJVES Extra 9, 131–134 (2005)
doi:10.1016/j.ejvsextra.2005.04.003, available online at http://www.sciencedirect.com oner CC BY-NC-ND license. 
Fig. 1. Case 1. Preoperative CT scan showing contrast
extravasation from right common iliac artery injury (A),
and from left common iliac vein injury (B).
B. Mahendran et al.132Case 2
A 42-year-old male presented a few weeks after
sustaining a kick from a farm animal. He was found to
have a saccular aneurysmof the left common iliac artery.
This aneurysm was excluded with a Wallw 9 mm stent-
graft. He presented 8 months later to our department,
complaining of pain in his left leg with weakness,
numbness and pallor. He had two episodes of these
symptoms lasting about 2–3 h each. He underwent anFig. 2. Case 1. Completion picture following right common
iliac artery stent-graft (A) and left common iliac vein stent-
graft (B).
EJVES Extra Vol 9, June 2005angiogram, which showed intimal hyperplasia within
the Wallw stent and encroachment into the lumen. A
Cordis SMARTw stent 9 mm by 6 cm was inserted with
goodpost procedural angiographic results and palpable
femoral pulse. He was discharged with good symptom
relief and reviewed in OPD. Six months later he was
admitted to another hospital following chest pain and
collapsewhileworking inhisfield. Postmortemshowed
complete aortic dissection and myocardial infarction
(Figs. 4 and 5). Histological sections of the aorta
demonstrated cystic medial necrosis.Discussion
Arterial and venous injuries involving large calibre
vessels are common in unstable pelvic fractures with
hypotension and significant blood loss occurs from
arterial and venous haemorrhage and fractured bone
edges. The first case, had suffered injury to both iliac
vessels, venous injury on the left and arterial injury on
the right. The aorta and the iliac vessels are protected
by their location in the abdomen and the bony pelvis.
Iliac vein injuries caused by blunt trauma are
uncommon.4 However, hyperextension injuries cause
intimal tears with resultant thrombosis.5 Bleeding in
pelvic fractures is from injury to internal iliac and its
branches and is common in posterior pelvic fractures.
Lateral compression fractures often causes bleeding
from pudendal and obturator vessels.6 This lady had
suffered a complex pelvic fracture. Injuries to Iliac
veins with low-pressure and high-flow are compli-
cated by higher morbidity and mortality due to
difficult anatomic exposure and substantial blood
loss. Although the venous system is a low-flow state,
iliac vein injuries carry up to a 51% mortality rate.7
Evaluation is made by CT.8 Survival of the patient
depends upon the time interval between the occur-
rence of the injury and operative repair. The active
arterial bleed is isodense with intra-arterial contrast
and can be seen as a focal hyperdense region in the
early arterial phase and the venous extravasation is
seen in the later equilibrium phase, adjacent to venous
structures. Immediate surgical intervention is indi-
cated in the presence of contrast extravasation in an
unstable patient.
Surgical options, both endovascular and open will
depend upon the associated injuries and the endovas-
cular expertise of the trauma surgeon. Direct suture
repair of iliac vessels with autogenous patching,
would result in massive haemorrhage from the retro-
peritoneum. Extra-anatomic bypass with a prosthetic
conduit presents risk of infection and late haemor-
rhage. Ligation of either veins or arteries in an
Fig. 3. Case 1. Post-operative CT scan showing stent in right
common iliac artery (A) and external fixator (B).
Fig. 5. Case 2. SMART stent within Wall stent-graft and
intimal hyperplasia.
Endovascular Management of Traumatic Iliac Vessel Disruption—Report of Two Cases 133unstable patient has been shown to be an acceptable
option.9 Delayed vascular reconstruction can be
performed with adequate planning on a stable patient.
This option was precluded in our patient due to
acutely ischaemic leg. Endovascular approach in
pelvic fractures with injuries involving branches of
the internal iliac or deep femoral arteries can be
effectively treated by catheter-directed arterial embo-
lisation.10,11 The use of stent-grafts is associated with
decreased blood loss, a less invasive procedure,
reduced requirements for anaesthesia, and a limited
need for an extensive dissection in the traumatised
field. These advantages are particularly important to
those patients who are critically ill from other
coexisting injuries or medical co-morbidities.12 This
was the ideal option in the first case and was
successfully executed. Her iliac arterial stent wasFig. 4. Case 2. Post-mortem appearance of stent-graft in
diseased common iliac artery.functioning normally at 6 months. On the other
hand, in spite of the left iliac venous stent was patent,
she developed left limb DVT in the early post-
operative period due to her prolonged immobility.
Reports regarding patency of stent in venous occlusive
disease are about 50% at 1 and 4 years.13 However, the
objective in this patient was immediate control of
bleeding and survival, which was achieved with
minimal morbidity.
In the case of the young male patient, a history of
trauma had played amajor part in the clinical decision.
This patient presented with a stable isolated saccular
iliac aneurysm. Given the literature on the nature of
trauma required to cause iliac arterial injury, there was
a suspicion of other causes. Though rare, isolated iliac
artery aneurysms occurring on the background of
cystic medial necrosis have been reported.14,15 There
are no reports of in-stent restenoses in connective
tissue disorder. Had the patient undergone standard
surgical procedure, the pathological diagnosis would
have been established and appropriate further inves-
tigations, long-term medical management and follow-
up would have been initiated.Conclusion
The endovascular management of haemodynamically
unstable patient is an exciting and promising appli-
cation of covered stent-grafts. As operative identifi-
cation and exposure of injured vessels can be
technically difficult, endovascular approach permits
minimally invasive alternative treatment procedures
to be performed from remote, easily accessible site.
However, in stable patients one should rely on clinical
insight to deduce pathology before treatment.EJVES Extra Vol 9, June 2005
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Accepted 6 April 2005


Endovascular Management of Traumatic Iliac Vessel Disruption—Report of Two Cases 

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Endovascular Management of Traumatic Iliac Vessel Disruption—Report of Two Cases

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