Case 497_05 -- Pediatric pelvic trauma

Fig. 1. Mid stream, nonselective pelvic arteriogram shows transections of branches of both internal iliac arteries (arrowheads) and intimal injury of right external iliac artery (arrow).

Fig. 2. Distal runoff of the right lower extremity shows occlusion of the tibioperoneal trunk (arrow).

Case Reference No. CC-497-05

The patient is a 12-year-old male who was roller blading down a hill, struck the side of a moving bus, slid under it, and was run over by the rear tires. At the scene, he was alert and awake, hemodynamically stable, with good oxygen saturation, and a Glasgow coma scale of 15.

In the emergency department, he was alert, oriented, calm, and cooperative. He complained of abdominal and pelvic pain. His blood pressure was 106/77 mm Hg, heart rate of 122, respiratory rate of 16, temperature of 33.7 degrees Celsius and an oxygen saturation of 96%. Physical examination disclosed a diffusely tender abdomen with a right flank hematoma, blood at the urethral meatus, a pelvis unstable to compression and distraction, a large perineal laceration extending to his rectum and a cold, pale right lower extremity. A diagnostic peritoneal lavage was performed and was grossly bloody.

The patient was taken to the operating theatre for an exploratory laporatomy. He had a liver laceration, a grade IV splenic laceration necessitating a splenectomy, perforated rectosigmoid colon necessitating a diverting loop sigmoid colostomy, and peritoneal irrigation.

An expanding pelvic hematoma was noted. Therefore, upon completion of the surgery, the patient was transported to the angiography suite. His right lower extremity was pink but had very slow capillary refill. Using a micropuncture set, a left common femoral artery access was achieved. A 4-F pigtail catheter was introduced, positioned in the infrarenal aorta, and contrast material was injected. Digital subtraction images were obtained of the pelvis in the anteroposterior projection. There was acute extravasation from branches of both internal iliac arteries; transection of the left superior gluteal artery, anterior and posterior trunks of the right internal iliac artery; and intimal injury of the left external iliac artery which was flow limiting.

After embolization of both internal iliac arteries with Gelfoam slurry and Gianturco stainless steel coils to stasis, a selective right lower extremity angiogram was performed. There was occlusion of the tibioperoneal trunk, presumably from a thromboembolus. The anterior tibial and dorsalis pedis arteries were patent, with no reconstitution of the distal peroneal or posterior tibial arteries. The right external iliac artery injury was crossed with a 0.035-inch Compass wire with roadmap assistance. A 6-mm diameter by 20-mm long Wallstent endoprosthesis was deployed across the injured right external iliac artery after the intraarterial administration of 60 mg of papaverine.

Postdeployment angiogram showed a widely patent right external iliac artery with mild spasm of the remainder of the right iliofemoral vessels. On physical exam, there was now a palpable right femoral artery pulse and mark improvement in the capillary return of the toes. However, the ankle-brachial index was 0.43. In light of the patient's hypothermia and coagulopathic status, the decision was made to transport the patient to the intensive care unit for rewarming and correction of his coagulopathy.

Fig. 3. Selective right iliac arteriogram following stent deployment shows a patent external iliac artery with spasm of the iliofemoral vessels both proximal and distal to the stent.

Fig. 4. 48-hour follow-up pelvic arteriogram shows widely patent iliofemoral vessels with relief of the vasospasm and occluded bilateral internal iliac arteries with reconstitution of their distal branches via collaterals.

Fig. 5. 48-hour follow-up right lower extremity runoff shows patent trifurcation vessels with a focal short segment occlusion of the posterior tibial artery at the ankle.

Fig. 6. 48-hour follow-up right lower extremity runoff shows patent trifurcation vessels with a focal short segment occlusion of the posterior tibial artery at the ankle (arrow).

By early morning his right lower extremity was warmer and there was a palpable dorsalis pedis pulse. Repeat ankle-brachial index was 1.0 and a follow-up 48-hour angiogram showed relief of the spasm with widely patent iliofemoral vessels, patent right tibioperoneal trunk with a small embolus in the posterior tibial artery at the ankle. However, his plantar arch was filling by the dorsalis pedis artery.

Questions

1) Would you have embolized both internal iliac arteries with gelfoam slurry and coils?

2) Would you have stented the injured right external iliac artery?

3) Would you have treated the right tibioperoneal trunk thromboembolus? If so, how?