Emergency Vascular Surgery Maneuvers to achieve hemostasis!

[Paulista]

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A friend of mine who is a PGY-4 general surgery resident was first assisting an orthopod in an elective reconstruction of acetabular area one evening.
He tells me all of sudden, blood was shooting out from the site of reconstruction. He was suspecting the orthopedic surgeon must have injured either the femoral artery or one of iliacs. He said patient died on Table since the orthopod could not control the bleeding.

I was thinking about this particular case since this is definitely an M&M case in the perspective of a vascular surgeon on emergency consult.

My friend was pretty much not so interested but if you are working in a small hospital and if the vascular guy is away then the general surgery should be able to manage this complication.

I was thinking different approaches to control this massive bleeding:
1- apply direct pressure to this area.
2- if the bleeding is massive I don't think the use of fogarty cath would make much sense. or maybe you can go through the other femoral artery into the lower portion of aorta for tamponade via fogarty cath.
3- the other option seemed to be more dramatic and maybe larger operation; do an emergency laparotomy and directly clamp the aorta at the lower segment before iliac bifurcation while patient is being being bolused with ringer lactate or 2 units of Prbc if it was a massive loss.
Once aorta is clamped, then you can approach the vessel repair better. maybe do an emergent angio on table to see the vessel damage.

What do you guys think about this serious complication and possible management possibilities??? I would be very curious to know your thoughts!

 

[Tenesma]

aortic clamp is definitely of assistance... but if it is a venous tear, then you are in deep ****.... sometimes the only choice you have in that kind of tear is an emergent hemipelvectomy w/ aortic cross-clamping.... otherwise the mortality is very high

 

[Celiac Plexus]

Um... if "blood was shooting out" of the operative field then you can pretty much rule out a venous bleed.

Also, you can probably say with a high degree of certainty that an artery has been damaged by the surgeon.

In this specific case, an emergent page to the vascular surgeon would be a great idea. In the mean time, local exploration of the surgical wound is a great first step. If blood is "shooting out" then chances are the bleeder is already exposed and may be pretty obvious. Put pressure on the bleeder and wait for captain vascular to get to the or.

If there's no vascular surgeon available, I would consider calling interventional radiology down to the or for evaluation. If the patient is initally stable, an on-table angiogram is an option. If the bleeder is identified this way, then the IR guy might be able to stent, or embolize a repair.

If there's no vascular surgeon, no IR person, and the patient is unstable then you really have no choice but to explore the wound until you can visualize the bleeder. That might be a big-ass surgery in which case you're gonna need a general surgeon. I don't think an orthopaedic surgeon is the right person to take that kind of case on. I'd rather see the pgy-4 gsurg resident take over at that point than the ortho guy (the ortho guy would probably prefer that too). Either way, someone is going to be sacrificed on the m&m altar of doom for this case.

 

[Paulista]

Since it was a high pressure outflow of blood, i am most certainly sure this is arterial injury.

Being an older patient, I think time is critical and most of hospital unless you are in a tertiary center would not have vascular surgeon in the OR in 15 min.

This PGY-4 was really clueless and maybe not so interested, however I did find this case extremely interesting. Something like this a vascular guy or even a general or trauma fellows should be able to do some problem solving.

I would not have wasted anymore time and risk the hemodynamic instability!
I would have gone for emergency celiotomy and cross clamping of aorta at the level of right iliac before its bifurcation. This would allow continued perfusion of the other limb. then, suction all the gunk in this area then make an attempt to identify the vessel. Emergency on table angio may help if the injured portion is not readily visible. Then attempt arterioarterial anastomosis or if it is short do a synthetic graft for reanastomosis.

I am going to suggest my friend to study this case in the resident conference for real learning purposes and maybe this can be a paper on management of complications.

The other entirely different issue is who gets to repair thoracic aorta aneurysms CT guy or Vascular specialist?

 

[ortho2003]

there is a good chance that the patient was prone and the surgeon caught the the superior gluteal, which then retracted into the pelvis. When that happens, you have to close (quickly) and turn the patient to get into the abdomen. Most the time, you are going to lose the race and the patient is going to have the same outcome.

If it was an anterior approach, a likely culprit was the corona mortise, and arterial-arterial anastamosis betweent he obturator and the pudendal (I think). When you hit that, it bleeds like stink also, but you fortunately have the patient supine and can get proximal control.

It is highly unlikely for the surgeon to hit a major vessel like the femoral or iliac. It is the little arteries that will get you in trouble.

 

[Tenesma]

my apologies - i over looked the initial statement about "shooting out" blood... so yes, more than likely arterial bleeding (however if pt has high right sided pressures due to pulmonary hypertension or other etiology, venous blood may appear very pulsatile and under a lot of pressure as well)...

since this patient died on the table (and i am assuming that this happened at a normal hospital outside of the third world) i would think that the bleed was more likely to be venous.... It is very difficult to bleed out from an arterial bleed (especially if it occurs during dissection as opposed to blunt trauma 🙂 ). Unless of course this patient had a huge cardiac hx that couldn't tolerate the hypotension/anemia...