Acetabular and Pelvic Fracture Repair Complicated by Phlegmasia Cerulea Dolens: A Report of Limb Salvage With Open Thrombectomy and a Modified Palma Procedure
Journal of Vascular Surgery
BackgroundVascular injury during repair of acetabular fractures is uncommon. Mechanisms include direct injury by fracture fragments or compression by fixation hardware. We present a case of iliac vein occlusion during acetabular and pelvic fracture repair resulting in phlegmasia cerulea dolens.
Case reportA 57-year-old man presented to the emergency department after a mechanical fall. Computed tomography scan revealed displaced, comminuted left pelvic and acetabular fractures. The patient was placed in traction and taken to the operating room for fixation. Several hours postoperatively, the patient reported worsening left leg (LLE) swelling and pain. Physical examination revealed decreased sensory-motor function with audible Doppler signals. Thigh and calf compartment pressures were elevated; the patient underwent emergent fasciotomies. Duplex ultrasound examination revealed extensive LLE and iliocaval deep vein thrombosis with symptoms consistent with phlegmasia cerulea dolens. To urgently restore venous outflow, the bilateral popliteal veins were accessed percutaneously. From the left, a wire was unable to be passed beyond the inguinal ligament. A vertical venotomy was made in the left common femoral vein and the LLE was wrapped with an Esmarch bandage to express thrombus. Intravascular ultrasound revealed a high grade right iliac vein stenosis and a stent was placed. A ringed 10-mm polytetrafluoroethylene graft was tunneled suprapubically and anastomosed to both common femoral veins. An arteriovenous fistula was created using a branch from the left saphenofemoral junction anastomosed to the superficial femoral artery. The patient’s postoperative course was unremarkable and he has regained full function of the LLE without stasis complications. The bypass graft and iliac stent remain patent 3 years postoperatively.
DiscussionIliac vein injury during acetabular fracture repair is an uncommon complication. Early recognition is critical to the initiation of appropriate treatment and prevention of limb loss.
Hetrick M, Long G. Acetabular and pelvic fracture repair complicated by phlegmasia cerulea dolens: a report of limb salvage with open thrombectomy and a modified Palma procedure. J Vasc Surg. 2023 Sep;78(3):E36. doi:https://www.jvascsurg.org/article/S0741-5214(23)01703-2/fulltext