Download Rectum stenosis secondary to arterial embolization for pelvic

CASE REPORT
Rectum stenosis secondary to arterial embolization for pelvic
fracture: case report
Estenose retal secundária à embolização arterial em trauma pélvico: relato de caso
Guilherme de Palma Abrão1, Alexandre Tarso Machado2, Cláudia Mendes Tagliari3, Patrick Baquet4, Jacques Sedat5,
José Guilherme Mendes Pereira Caldas6
Abstract
Transcatheter arterial embolization of the internal iliac artery branches is a technique used for control of hemorrhage caused by pelvic fracture.
Despite the widespread use of the technique, complications have been rarely described. We report a case of ischemic stenosis of the rectum following
embolization of the lateral sacral artery to control a hard-to-treat hemorrhage from a pelvic fracture.
Keywords: pelvis; embolization; rectum.
Resumo
A embolização de ramos da artéria ilíaca interna é uma técnica empregada no controle da hemorragia secundária à fratura pélvica. Apesar de
largamente utilizada, são poucas as complicações relatadas relacionadas ao uso dessa técnica. Apresentamos um caso de estenose isquêmica de reto
secundária à embolização da artéria sacral lateral para controle de hemorragia em uma paciente com fratura pélvica.
Palavras-chave: pelve; embolização; reto.
Introduction
Hemorrhage is a severe complication often found in
cases of pelvic trauma, and the endovascular treatment
may be a reliable option in the presence of associate arterial
lesions. Ischemic complications secondary to arterial
embolization (AE) are rare, and there are no reports on
rectal ischemia after embolization of pelvic arteries in the
literature.
Case description
Female patient, 70 years old, who fell from a height of
2 meters and was admitted with hemodynamic instability.
Pelvic radiographies and abdominal ultrasonography
showed double-rupture fracture of the pelvic ring
and hemoperitoneum, respectively,with not signs of
intra-abdominal lesions. We opted to perform pelvic
arteriography, which identified contrast extravasation from
the right lateral sacral artery (Figures 1A and 1B). Selective
catheterization was carried out with a 2,3F microcatheter
(Prowler 10, Codman, Miami, USA) and 0.014”guidewire
(Agility, Codman, Miami, USA), and the artery was
occluded using a liquid tissue adhesive (Histoacryl, B.
Braun Medical, Pennsylvania, USA) (Figures 2A and 2B).
During injection of the embolic agent, we observed
backflow into the contralateral lateral sacral artery and into
the median sacral artery. Follow-up angiography showed
absence of active bleeding.
From the Service of Vascular and Interventionist Radiology at Hospital St. Roch, Centre Hospitalier Universitaire de Nice, France, and at the Service of Vascular and Interventionist
Radiology of Instituto de Radiologia (Inrad) of Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo (SP), Brazil.
1
Post-graduate student at the Service of Vascular and Interventionist Radiology of Inrad, Hospital das Clínicas, Faculdade de Medicina da USP – São Paulo (SP), Brazil.
2
Post-graduate student at the Service of Vascular and Interventionist Radiology of Inrad, Hospital das Clínicas, Faculdade de Medicina da USP – São Paulo (SP), Brazil.
3
Trainee at the Service of Vascular and Interventionist Radiology of Hospital St. Roch – Nice, France.
4
Head of the Service of Surgery at Hospital St. Roch – Nice, France.
5
Head of the Service of Vascular and Interventionist Radiology at Hospital St. Roch – Nice, France.
6
Head of the Service of Vascular and Interventionist Radiology at Inrad, Hospital das Clínicas, Faculdade de Medicina da USP – São Paulo (SP), Brazil.
Financial support: none
Conflict of interest: nothing to declare
Submitted on: 09.12.11. Accepted on: 10.04.12.
J Vasc Bras. 2012;11(3):250-253.
J Vasc Bras 2012, Vol. 11, Nº 3
Rectum stenosis secondary to arterial embolization - Abrão GP et al.
A
B
251
A
B
Figure 1. (A) Angiogram of the right internal iliac artery (arterial phase)
showing contrast leakage in lateral sacral arteries (arrow). (B) Angiogram of the right internal iliac artery (late phase) confirming contrast
leakage from the lateral sacral arteries.
Figure 2. (A) Selective catheterization of the lateral sacral branch, préembolization, with contrast leakage. (B) Follow-up radiography postembolization showing tissue adhesive (Histoacryl®) in the topography of
the right lateral (arrow) and median (arrowhead) sacral arteries.
The patient was stable after the procedure and had an
uneventful recovery until the 28th day, when she presented
with fecal leakage associated with tissue necrosis. CT
scan showed significant rectal stenosis with adjacent fat
infiltration (Figure 3). Colonoscopy identified extensive
and impassable filiform stenosis with ulcers in the rectal
mucosa. Biopsy confirmed the findings of ischemic necrosis
of the rectal mucosa.
Colostomy was performed aiming at the recovery
of the bowel transit, and she had a good response. The
patient is currently on preparation for surgical intestinal
reconstruction with colostomy closure.
Discussion
In pelvic trauma, hemorrhage represents a challenge
due to the variety of vessels affected and secondary
hemodynamic instability. The mechanisms of pelvic trauma
are car accidents in 60% of the cases. In 10% of cases, the
bleeding originates in troncular arteries or distal branches1.
Endovascular treatment is indicated in the presence
of associated vascular lesions. The effectiveness of arterial
embolization to control pelvic hemorrhage ranges from
85-94%2-4, and ischemic complications are rare due to the
numerous existing pelvic anastomoses and to the presence
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J Vasc Bras 2012, Vol. 11, Nº 3
Figure 3. Pelvic CT scan showing significant rectal stenosis with
thickening of mucosa and perilesional fat infiltration (arrow).
of pre-capillary collateral network5,6. The literature describes
some cases of bladder necrosis7, parestesia by injury of a
spinal nerve8, avascular femoral necrosis9, impotence10,
ischemia of the uterus, skin, and gluteal muscles11.
The cranial segment of the rectum is specially fed
by the superior rectal artery, a branch of the inferior
mesenteric artery, but also by the lateral and medium sacral
arteries, terminal branches of the abdominal aorta and of
the posterior division of the right and left internal iliac
arteries, which form an extended anastomotic network in
the coccygeal region.
The choice of the material for the treatment of
bleeding is related to the affected vessel caliber, flow,
extension and complexity, besides the characteristics of
embolic agents — liquid (Histoacryl®, Gluebran2®, Onyx®),
particulate polyvinyl alcohol (PVA), occluders (gelfoam,
coils, detachable balloon, covered stent), — and whether
their effect is definitive or temporary. In some situations,
different agents may be used in association aiming at a
better result, and sometimes different materials may have
the very same effect. That is why the best material is often
the one that is available in an emergency, as long as it is
compatible with the angioarchitecture of the vessel affected,
and the physician has experience with its use.
In the case reported, we used Histoacryl®, a liquid
embolic agent that acts permanently and is commonly used
to treating hemorrhagic lesions resulting from the trauma
or small-caliber vessels.
The adhesive effect of this agent occurs after getting in
contact with ionic solutions such as the plasma, causing it
to polymerize, or solidify. When it is diluted in Lipidiol®,
a radiopaque oil, the polymerization is delayed for a few
seconds, which enables a better adhesion.
Rectal ischemia is a complication that may occur
after embolization of sacral arteries for the control of
hemorrhage in pelvic trauma. In our case, the ischemic
lesion was attributed to backflow during the injection of the
liquid embolic agent (Histoacryl®) through the anastomoses
between the sacral artery and the superior rectal artery.
Due to the risks of complications, liquid agents
should only be indicated after an accurate identification
of the vascular anatomy in the target region by means of
superselective catheterization of the artery responsible
for the hemorrhage, avoiding inadvertent backflow into
adjacent branches. Hence, the manipulation and control of
injection should be performed by experienced professionals.
References
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Hare WS, Holland CJ. Paresis following internal iliac artery
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Rectum stenosis secondary to arterial embolization - Abrão GP et al.
Correspondence:
Guilherme de Palma Abrão
Alameda das Acácias 416 – Itaipu
CEP: 24355-150 – Niterói (RJ), Brazil
E-mail: [email protected]
Authors’ contributions
Study conception and design: GPA, ATM, JS.
Data analysis and interpretation: GPA, ATM, PB.
Data collection: GPA, JS.
Writing: GPA, ATM, CMT.
Critical analysis: GPA.
Final approval*: GPA, JGPC.
Overall responsibility: GPA, JGPC.
Financing information: GPA.
*All authors have read and approved the final paper submitted to J Vasc Bras.
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