Acute Surgical Management of Vascular Injuries in Hip and Knee Arthroplasties

Christopher M. Melnic, MD; Marilyn Heng, MD, MPH, FRCSC; Santiago A. Lozano-Calderon, MD, PhD

Disclosures

J Am Acad Orthop Surg. 2020;28(21):874-883. 

In This Article

Surgical Techniques for the Treatment of Vascular Injury in Total Hip Arthroplasty

Independent of the approach, the ideal point for proximal control for bleeding in THA vascular injury is the external iliac artery as the most common location for vascular injuries during THA is in the distal external iliac artery, the common femoral artery, or less likely, the superficial and/or the deep femoral arteries, and their respective branches. Nevertheless, during the surgical dissection through the posterior approach, an injury to the superior gluteal vessels may occur, especially during revision surgery. Most of the time, the damage is to a branch of the main vessel, but on occasion, the injury occurs to the superior gluteal artery proper with subsequent retraction of the vessel into the pelvis. Inability to visualize and reach the proximal end of the vessel makes proximal control almost unattainable. Because of the retraction, pressure might be insufficient to control bleeding and stabilize the patient hemodynamically. In either the supine or the lateral position, both the lateral and anterolateral portions of the pelvis can be exposed and accessible through an additional surgical approach (Figure 10). The straight lateral (in the lateral decubitus) or the anterior lateral (in the supine position) portions of the iliofemoral approach are a quick and direct access to both the internal and external iliac vessels. Direct pressure over the vessels without dissecting them is sufficient in most cases to control bleeding while awaiting the arrival of vascular surgery expertise, especially if the patient is not stable for transport and the initial measures of local pressure have failed to achieve hemodynamic stability.

Figure 10.

Figure demonstrating both the lateral and anterolateral portions of the pelvis that can be exposed and accessible through an additional surgical approach, as demonstrated by the "*," which allows for direct access to both the internal and external iliac vessels.

With the patient in the lateral position, the incision is started at the posterior iliac crest and extended along the palpable surface of the iliac crest anteriorly. The incision is extended 2 cm medially and inferiorly to the anterior superior iliac spine (Figure 11A). Rapid dissection with electrocautery is done down to the periosteum. Rapid dissection with electrocautery with the assistance of retractors and a Cobb is done to access the inner retroperitoneal pelvis while keeping the iliacus muscle attached to the pelvis (Figure 11B). Through this approach, direct pressure in either or both, the internal and external iliac arteries, can be applied controlling in a more efficient manner the bleeding rate, especially if it is of arterial origin. If the bleeding seems to be originating from the internal iliac system, identification of the sciatic notch is helpful to localize the intrapelvic internal iliac artery and apply pressure (Figure 12). If the bleeding seems to be originating from the external iliac artery, identification of the external iliac pulse can be done manually. Once identified, compression can be applied with simultaneous external pressure to successfully collapse the vessels. With the support of vascular surgery, additional exposure can be done with further dissection and identification of the vessels with application of vessel loops for proximal control. With control achieved, additional vascular reconstructive procedure can be done if necessary.

Figure 11.

A and B, Image demonstrating the location of the second incision and the approach to locating the internal and external iliac vessels.

Figure 12.

Figure demonstrating the relationship between the greater sciatic notch of the ilium and the internal iliac vessels.

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