PROFUSE ARROSIVE BLEEDING AFTER SUTURING THE PERFORATING WOUNDS OF THE ILIAC ARTERY IN A PATIENT WITH ASSOCIATED INJURY

PROFUSE ARROSIVE BLEEDING AFTER SUTURING THE PERFORATING WOUNDS OF THE ILIAC ARTERY IN A PATIENT WITH ASSOCIATED INJURY 

Panasyuk A.I., Kopylova A.S., Muravyev P.I., Sadakh M.V., Panasyuk M.A. 

Irkutsk Regional Clinical Hospital of Honour Badge,  Irkutsk State Medical University, Irkutsk, Russia 

During 2013-2018, 21 patients received medical care for the associated injury with abdominal magistral venous damages in the surgery unit of Irkutsk Regional Clinical Hospital (the table 1).

Table 1. Injured abdominal vessels in associated injury for the period of 2013-2018

Vessels

Number of observations

Inferior vena cava

8

Superior mesenteric vein

2

Common iliac artery

2

Splenic vein

2

Renal artery

3

Renal vein

3

Aorta

2

Portal vein

1

Inferior mesenteric artery

1

Common iliac vein

2

Hepatic vein

2

Total

21

Various types of hemostasis were realized owing to different reasons, mainly due to severity of the patient’s condition, but not due to skills of the operating surgeon (the certified cardiovascular surgeon is on duty in the team during 24 hours) (the table 2). Magistral blood flow was restored in most cases.

Table 2. Variants of hemostasis in associated injury with abdominal vascular injury for the period 2013-2018

Surgery

Suturing

Dressing

Organ removal

Number

14

4

3

One patient died. He was admitted with decompensated irreversible hemorrhagic shock. The mortality was 4.8 %.
There were not any complications relating to vascular manipulations in early postsurgical period in most cases, except for profuse arterial bleeding into abdominal cavity after suturing the penetrating wound of the right common iliac artery. 

CLINICAL CASE

The presented clinical follow-up includes the features of medical care for the patient with polytrauma with the iliac artery injury.
The study was conducted in compliance with the ethical principles of Helsinki Declare and the Rules for Clinical Practice in the Russian Federation confirmed by the Order of Health Ministry of RF on 19 June 2003, No.266. The study was approved by the local ethical committee of Irkutsk Regional Clinical Hospital (Irkutsk, Russia). The patient gave his informed consent for publishing the clinical case.
The patient, age of 24, was admitted one hour after trauma. He was in condition of alcohol intoxication and hemorrhagic shock. The diagnosis was: “Associated injury. Multiple stab and slash wounds of the chest with penetration into right and left pleural cavities. Hemopneumothorax to the left. Hemothorax to the right. A stab and slash wound of the abdomen with penetration into abdominal cavity. Compensated hemorrhagic shock”.
The patient was immediately admitted to the surgery room. Pleural cavities were drained on both sides. Ongoing bleeding was to the left. Anteriolateral thoracotomy was performed in the 5th intercostals space. Pleural cavity contained about 500 ml of blood with clots. A penetrating wound of the 8th segment of the lung with ongoing bleeding was sutured. Hemostasis and aerostasis were appropriate. The surgery was completed with pleural cavity draining.
Complete middle-line laparotomy. Abdominal cavity contained about 500 ml of fluid blood. There was a tense massive retroperitoneal hematoma to the right. The revision showed a defect in parietal peritoneum in the plane of iliac vascular bundle to the right. The cardiovascular surgeon on duty performed an approach to iliac vessels: a penetrating wound of the common iliac artery about 0.5 cm. Two continuous vascular sutures were made with prolene 4/0. Hemostasis. Distal blood flow was evident.
Considering the condition severity, anemia and diffuse bleeding in retroperitoneal cellular tissue, the surgery was completed with programmed packing of abdominal cavity. Five swabs without compression of iliac vessels were placed. A drain into small pelvis.
After 24 hours, after condition stabilizing, the programmed relaparatomy was conducted. The swabs were removed. The abdominal cavity revision showed a penetrating wound of the ileum. It was sutured. A hematoma was removed in the region of the right iliopsoas muscle. Non-intensive bleeding from the transected muscle and retroperitoneal cellular tissue was arrested with suturing and electric coagulation. Abdominal cavity was sanitated. A swab was placed near the wound of the muscle and was drawn out in the right region of the abdominal wall.
The postsurgical course was normal. The pleural cavity drains were removed on the third day, abdominal drains – on the second day, the swab – on the seventh day. The patient was transferred to the surgery unit.
The patient’s condition sharply worsened on the tenth day. There were some clinical signs of intraabdominal bleeding and hemorrhagic shock.
Relaparotomy was urgently carried out. The abdominal cavity contained about 2 L of blood with clots. The bleeding source was in the region of the vascular suture. There were no pus and fibrin. The vessel was resected 3.5 cm from the vessel (1 cm from the suture line). Lineal prosthetics was realized with the synthetic prosthesis endovascular No.10, with continuous vascular suture with prolene 5/0 (Fig. 1).

Figure 1. Prosthetics of common right iliac artery. The final stage

Histological conclusion: the arterial fragment 3.5 × 1.0 cm, histological wall of muscular and elastic type, adventitia and surrounding tissues with regions of necrosis with polymorphocellular inflammatory infiltration, bleeding and suturing material.
The postsurgical course was normal. Anemia was arrested. The patient was discharged on the seventh day after arterial prosthetics. His condition was satisfactory.
MSCT-angiography: arterial phase. Abdominal aorta and its visceral branches are evenly contrasted, with usual path and diameter. The right iliac artery includes the prosthesis (length – about 55 mm, width – about 11 mm), with good contrasting more proximal and more distal than the prosthesis. The left iliac artery is about 7.5 mm in diameter (Fig. 2).

Figure 2. MSCT-angiogram. Prosthesis of external iliac artery (arrow)

Duplex scanning of iliac arteries: normal patency, magistral blood flow on both sides, with usual spectral and speed features. The lineal speed of blood flow is 104 cm\sec. to the right and 103 cm/sec. to the left.
Ultrasonic dopplerography of lower extremity arteries. On the right side: the common femoral artery – with smooth contours; blood flow of magistral type; lineal velocity of blood flow – 94 cm/sec. The deep artery – diameter without changes, with normal patency. The superficial femoral artery is patent up to the distal segment, with smooth contours. Blood flow is spotted (magistral type). The popliteal artery – normal diameter, patent trifurcation, blood flow without changes (magistral type). Lineal velocity of blood flow – 87 cm/sec. 

DICUSSION

The clinical follow-up shows the stages in realization of medical care for the patient with the associated injury with hemorrhagic shock. The first stage is correction of dominating, life-threatening injuries – arresting of intrapleural and intraabdominal bleeding. Magistral blood flow restored. The second stage – detailed abdominal revision was not conducted due to condition severity. Damage control (second look) was used. 24 hours later, after condition stabilization, programmed laparotomy was conducted, as well as final hemostasis and suturing for a small bowel defect. The third one – timely identified postsurgical intraabdominal bleeding allowed saving the patient’s life with extremity preservation, and restoration of magistral blood flow with iliac artery prosthetics.
Provision of efficient treatment for patients with associated vascular injury is the task for special clinics [1, 2, 3] (level 1 trauma centers) since mortality and disability remain high in magistral vascular injuries [4, 5, 6].
The presented complication is determined by infection in vascular suture region, and, as result, by arrosive bleeding. Despite the absence of pus and fibrin during abdominal examination, the histological examination of the resected arterial segment shows the contamination of its wall along the line of sutures.

CONCLUSION

Patients with restored blood flow after magistral injuries require for postsurgical clinical monitoring and realization of dopplerography. After the patient’s condition stabilization, the recurrent abdominal examination allowed realization of final hemostasis after removal of programmed swabs. At the background of stable condition, full abdominal revision identified a small intestinal wound, which was sutured. 

Information on financing and conflicts of interests

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.

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