Iliac Vein Injury during Total Hip Replacement: A Rare Iatrogenic Complication and its Successful Surgical Treatment

Vascular injury during total hip replacement is a rare condition with the incidence varying between 0.1% and 0.3%. However when develops, it has a potential of serious complications such as extremity loss and even death. Prompt identifi cation and appropriate surgical management of this condition are crucial and may decrease the rate of morbidity and mortality. In this report, we presented a case of iatrogenic iliac vein injury during total hip replacement and its successful surgical management. Case Report Iliac Vein Injury during Total Hip Replacement: A Rare Iatrogenic Complication and its Successful Surgical Treatment Ayhan Müdüroğlu1, Taha Oğuz Kayhan2 and Ahmet Yüksel3* 1Department of Cardiovascular Surgery, Bursa Anatolia Hospital, Bursa, Turkey 2Department of Emergency, Beylikduzu State Hospital, Istanbul, Turkey 3Department of Cardiovascular Surgery, Bursa State Hospital, Bursa, Turkey Dates: Received: 16 March, 2017; Accepted: 0 3 April, 2017; Published: 04 April, 2017 *Corresponding author: Ahmet Yüksel, Department of Cardiovascular Surgery, Bursa State Hospital, Tophane Street, 16041, Bursa, Turkey, Tel: + 90 505 8460753; Fax: + 90 224 2132993; E-mail:


Introduction
Vascular injury during total hip replacement (THR) is an uncommon phenomenon, but when occurs it may threaten both the extremity and the life of the patient. The most common affected vessels from a vascular injury during THR are external iliac artery and vein, and common femoral artery and vein [1,2]. The early complications of a major vascular injury are mainly bleeding and ischemia, while the late complications are arteriovenous fi stula and pseudoaneurysm formation [1,3]. If a bleeding occurs as an early complication, the main indicator of mortality depends on whether the patient is in shock or not [4]. Here, it was reported a case of iatrogenic iliac vein injury during THP, which was successfully treated with appropriate surgical approach. We decided to present this subject as it is seen very rarely.

Case Presentation
An 18 year-old female patient has undergone THR and shortening procedures in Orthopedic Department due to congenital hip dislocation (CHD). She was consulted to our Cardiovascular Surgery Department because of the existence of hemodynamic instability in the early postoperative period.
When the patient examined immediately, it was decided to perform an urgent operation, since there was a strong suspicion of the existence of a massive retroperitoneal hemorrhage.

Discussion
Vascular injury as a complication of THR surgery is very rare with an incidence range varying between 0.1% and 0.3% in the literature [1,[5][6][7]. However, when develops it may cause a catastrophic clinical status including extremity loss and even mortality [1,6]. These hazards can be higher particularly in patients required revision surgery. Early identifi cation and appropriate management of this condition can reduce the rate of morbidity and mortality [1,6,[8][9][10]. Since these risks will increase during revision surgery it has been postulated that in such cases retroperitoneal exposure or to decrease the rate of vascular injuries perioperative angiography should be employed on a routine basis [11]. Lately the frequent use of three-dimensional computed tomography has enabled localizing the vessels surrounding the acetabulum thus aiding the planning of the surgical procedure and avoiding any possible vascular injury [12,13]. The most common affected vessels are the external iliac vein and artery and the femoral artery and vein [1,2,14]. In the literature, Pan et al. reported three vascular injuries in 721 THR operations. Two of them were iliac vein injury, while the third one was femoral artery injury [14]. According to the study performed by Schoenfeld et al., in 68 patients with vascular injury during THR, the reported rate of mortality and extremity loss were 7% and 15%, respectively [1]. In another study performed by Beguin et al., similarly, it was stated that the rate of mortality and possible functional squeal following vascular injury were 7% and 19%, respectively [6]. The drilling of the anteriosuperior quadrant of the acetabulum in the cement less THR massive retroperitoneal bleeding can occur due to the injury of the external iliac vein. In a study with cadavers posterior inferior and posterior superior quadrants were found to be more suitable drilling [15]. Siegel et al. advocated that their case which dynamic hip drilling was used was one of the few people cases in the literature and was not the fi rst fatal case. Their case was stable in the postoperative period before suddenly displaying circulatory collapse and eventually did not respond to resuscitation.
Postmortem evaluation had disclosed massive hemorrhage due to external iliac vein injury [16].
As a result, it should be keep in mind that the vascular injuries can be still unavoidable in THR surgery despite planning with preoperative further tests and employing appropriate surgical techniques. Although the risk of development of vascular injury after THR surgery may be very low, its results could be    catastrophic if it occurs. It should be emphasized that the most important factor is to suspect for prompt identifi cation of this condition. Early diagnosis and quick surgical intervention can reduce both mortality and morbidity.