External iliac artery injury following total hip arthroplast
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Here presents case of an 82-year old man with symptoms of osteoarthritis of the right hip. Radiographic examination confirmed this diagnosis.

The patient’s medical history included: atrial fibrillation, for which a coumarin derivate was started in 2009, idiopathic thrombocytopenia, with platelet counts of circa 60 × 109 (normal 150–400 × 109), and prostate carcinoma. After transurethral prostate resection in 2016, at the request of the patient, anticoagulant treatment was replaced by ASA (Ascal). Moreover, despite suffering from atrial fibrillation and a low ventricular rate, the patient had chosen not to receive a pacemaker. Ascal was discontinued 7 days before the planned total hip arthroplasty (THA). Therapy to increase platelet function was not administered preoperatively because of the low risk of bleeding associated with platelet counts > 30 × 109.

Surgical management
After a period of nonoperative treatment the patient was scheduled for uncemented THA via direct anterior approach (DAA) using spinal anesthesia. After incision, the fascia of the tensor fascia lata was incised. The tensor fascia lata and gluteus medius muscles were retracted laterally with a Hohmann retractor (Figure 1), and the sartorius and rectus muscles were retracted medially with a blunt Hohmann retractor in order to expose the anterior hip capsule. The third, pointed, Hohmann retractor was placed under the rectus tendon just at the bony border of the acetabular rim (Figure 2). The retractor aimed in the direction of the contralateral kidney and was fixed using a device that statically holds both the second and third retractor. After opening the anterior capsule, the osteotomy of the femoral neck was performed. There was minimal blood loss, by suction, 50 mL. The labrum was excised and the acetabulum reamed. In the meantime, the patient had become hemodynamically unstable with hypotension, tachycardia and no response to vasopressors and intravenous fluids. In view of the poor circulatory situation, the patient was intubated and cardiopulmonary resuscitation was started.

The surgery was interrupted immediately. The wound was quickly closed with only an implanted acetabular cup and without the use of drainage systems. Transthoracic cardiac duplex ultrasound was performed in the operating theater. There was a poor contraction of the anterior wall of the heart. With a high likelihood of acute coronary syndrome, the patient was immediately taken to the cardiac catheterization room. Percutaneous coronary intervention via the right femoral artery showed diffuse coronary artery disease but no significant occlusions. Simultaneously the hematology and biochemistry markers were assessed; the hemoglobin was 3.2 mmol/L (normal 8.5–11.0) and the hematocrit was 0.15 (normal 0.40–0.50). Troponin-T was only mildly elevated at 23 ng/L (normal < 14).

Under the suspicion of persisting hemorrhagic shock a multiphase, multislice abdominal aorta-iliac and femoral contrast-enhanced CT scan (ceCTa) was performed. The ceCTa revealed a large retroperitoneal hematoma on the right, with extravasation of contrast in the arterial phase, likely from the distal external iliac artery. Beneath, an asymptomatic left common iliac artery aneurysm with a diameter of 3.5 cm was demonstrated (Figure 3).

The patient was brought back to the operating theater for emergency vascular repair. Due to the uncertainty of the location of the bleeding and the severe hemodynamic instability of the patient an endovascular approach was considered to be less appropriate. The distal aorta and the right common, external, and internal iliac arteries were dissected by a right-sided retroperitoneal approach and a small laparotomy. The distal aorta was controlled, and thereafter the patient was stabilized. Downstream exploration was performed and a nearby circular defect of at least half of the circumference of the external iliac artery was found. The external iliac artery was re-anastomosed end-to-end with Prolene 5-0. The patient was hemodynamically stable and transferred to the intensive care unit. A pacemaker was implanted due to a high-grade atrioventricular block. After 5 days it was considered to be sufficiently safe to finish the THA by implanting the stem of the prothesis. The patient was transferred to the nursing ward within 10 days and discharged to the rehabilitation center on the 16th postoperative day without further complications.

In conclusion, vascular injury during THA is a rare complication. This complication during DAA has not been described in literature before. Surgeons should be mindful of the fact that injury to the external iliac artery can occur during THA via the DAA, by either direct or indirect means. Last of all it is important to remember that hemorrhagic shock in peracute hemodynamically unstable patients cannot be excluded if there are no signs of significant blood loss in the surgical field.
Source: https://www.tandfonline.com/doi/full/10.1080/17453674.2020.1748287?af=R
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