Figure 1
The patient is a 26 year old male who was admitted in shock after sustaining a single gunshot wound to the right flank.
Immediate laparotomy showed that the bullet had traversed in an inferior and leftward direction into the pelvis. A colonic resection and mutiple small bowel repairs were performed. An external iliac artery penetration was treated by arteriorrhaphy.
At the end of this portion of the procedure, bleeding began in earnest from deep in the pelvis which could not be isolated or ligated. Pelvic packing was performed. The patient received 28 units of blood in the OR. The patient was brought to the ICU with an anticipated return to the operating room after resuscitation.
Over the ensuing 12 hours, it was clear that the patient continued to bleed as he received an additional 20 units. Reexploration demonstrated no missed injuries but removal of the packs led to significant bleeding, the source of which could not be identified because of active bleeding. He was repacked but bleeding continued. A vascular clamp was placed across the origin of the left internal iliac artery and bleeding decreased considerably. He was repacked and brought to the angiography suite with the clamp extending out of the midline wound.
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Figure 1 |
Pelvic aortography showed that the internal iliac artery was occluded at its origin by the clamp.
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There was narrowing of the left external iliac artery repair but no bleeding was seen. The aortic catheter was exchanged for a selective catheter which was placed into the left internal iliac artery. Neither guidewire nor catheter could be advanced beyond the clamp.
The clamp was released but left surrounding the vessel. Selective arteriography showed active bleeding from the distal internal iliac artery
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which fistulized to the rectum. Blood pressure diminished during these maneuvers and the clamp was reapplied several times during the embolization procedure for resuscitation with success. The internal iliac transection was treated by coil occlusion of this conduit vessel.
The patient received more than 100 units of blood over the first twenty four hours. Eventually he stabilized. On the fourth postoperative week, the patient had a hypotensive episode resulting from blow out of the repaired external iliac artery. He ultimately died of multiple organ failure.
Commentary:
This case illustrates one of the extraordinary heroic techniques that can be used to facilitate interventional radiology in patients who cannot be transported to the interventional radiology suite because of uncontrolled hemorrhage. Two other methods include
The use of the angiography suite, however, is preferable and desirable. Intraoperative angiography is generally suboptimal because the field of view is quite small, maneuvering the catheters while moving the table is usually not smooth and fluoroscopic visualization of the catheter and guidewire are more difficult. Moreover the materials needed for these procedures are generally not available in the OR.
Some of the angiographic findings are quite subtle, especially the recurrent bleeding through collateral vessels. High quality fluoroscopy is necessary to detect both internal iliac bleeding as well as other sources of hemorrhage, such as liver, spleen and lumbar arteries.
Nonetheless, these maneurvers have been used with success.
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