A Case Report of Femoral Hematoma following Obturator Nerve Block

Background. When an obturator nerve block (ONB) is performed, the conventional landmark method or ultrasound-guided method is used. The major complications of this block are hematoma, but there are very few reports of its complications. We encountered massive bleeding and a huge hematoma after ONB. Case Presentation. A 95-year-old female underwent transurethral resection of the bladder tumor. Induction of anesthesia was accomplished via spinal anesthesia and right ONB using the landmark method. Postoperatively, subcutaneous bleeding was detected in the lower right interior thigh. Concentrated red cell transfusion was conducted to address the anemia. There was no subsequent expansion of the hematoma. It resolved on postoperative day (POD) 53. The hematoma was deemed to be inadvertently introduced due to an obturator artery puncture during the obturator nerve block. Conclusions. Close attention is necessary to avoid advancing the needle too deep into the obturator during obturator nerve block.

EP.FRI.680 “Avulsion of the Corona Mortis following low energy pubic rami fracture: a rare but life-threatening injury.”

We describe the case of an 81 year old gentleman who presented after a trivial fall with haemodynamic instability and worsening abdominal pain and swelling. An initial trauma CT identified superior and inferior pubic rami fractures associated with a large intra-pelvic collection. A subsequent CT angiogram confirmed a large pelvic haematoma with an active arterial bleeding from a ruptured vessel adjacent to the superior pubic rami fracture. This was managed by resuscitating him with fluids and blood transfusions followed by fluoroscopic guided Internal Iliac artery embolisation. The “Corona Mortis” is an aberrant arterial connection between the inferior epigastric artery and obturator artery and is prevalent in the hemipelvis of more than 49.3% of the population. Very rarely it can be damaged during low energy pubic rami fractures leading to haemodynamic compromise and potential death. For this reason and the fact there is a high chance that it could be missed, we wish to highlight this case, and management and emphasise the need to consider this life-threatening complication even in cases when the mechanism of injury may seem trivial.

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study

Background Ipsilateral branches of the deep femoral artery (DFA) are qualitatively identified as collateral arteries based on angiography after internal iliac artery (IIA) interruption. The purpose of this study was to quantitatively identify the major collateral pathway after unilateral IIA interruption during endovascular aortoiliac aneurysm repair to preserve the pelvic circulation and reduce the risk of ischemic complications. Methods The study population included 28 patients (mean age 76.3 years) with aortoiliac aneurysm who underwent endovascular aneurysm repair with unilateral IIA interruption from August 2012 to January 2020. The diameters of the bilateral preoperative and postoperative DFA, lateral femoral circumflex artery (LFCA), medial femoral circumflex artery (MFCA) and obturator artery (ObA) were measured on contrast-enhanced computed tomography using a 3-dimensional image analysis system. The measured values were evaluated and analyzed with a repeated measures two-way analysis of variance and Dunnett’s test. Results The postoperative diameters of the MFCA (P = 0.051) and ObA (P = 0.016) were observed to be larger than the preoperative diameters. Such increases in the MFCA (P < 0.001) and ObA (P < 0.001) diameters were only found to be significant on the unilateral side of the IIA interruption, and the diameter of the ipsilateral LFCA (P < 0.001) was also found to have significantly increased in size. However, no significant arterial extension was found on the contralateral side. Conclusions The ipsilateral MFCA-ObA pathway might therefore be a major collateral pathway arising from the DFA to preserve pelvic circulation after unilateral IIA interruption.

Embolization in Patient with Hypovolemic Shock after Transobturator Sling Procedure

The placement of a suburethral sling is standard treatment for stress urinary incontinence. The transobturator technique (TOT) emerged as an alternative to minimize the risks of the blind insertion of needles, leading to a lower rate of perforation complications compared with the retropubic approach. We present a case of injury to a branch of the left obturator artery following the placement of a urethral sling using TOT, followed by intense bleeding and hemodynamic instability, which was treated with embolization.

Prevalence and Utilization of Obturator Artery Anatomic Variant in Autologous Breast Reconstruction

Background The objective of this study is to quantify the prevalence and describe the utilization of an anatomic vascular variant in which the obturator artery (OA) arises from the trunk of the deep inferior epigastric artery (DIEA) in stacked/dual-pedicled autologous breast reconstruction. When this variant is identified preoperatively on computed tomography angiography (CTA), it may be utilized in a “flow-through” fashion to direct antegrade internal mammary artery (IMA) flow into a second free flap to facilitate anastomotic arrangement and optimize perfusion. Methods Preoperatively obtained abdomen/pelvis CTA imaging of 121 autologous breast reconstruction patients were retrospectively reviewed for the unilateral or bilateral presence of the OA branch arising from the DIEA (OA variant). The results were analyzed using descriptive statistics. Results Our analysis revealed the presence of the OA variant in 60 of the 121 (49.6%) breast reconstruction candidates, either unilaterally or bilaterally. Out of these patients, the variant was present unilaterally in 33 (55%) and bilaterally in 27 (45%) patients. Of the unilateral variants, 12 (36.4%) patients demonstrated right-sided laterality, while 21 (63.6%) patients demonstrated left-sided laterality. Clinically, this anatomic variant has been utilized in several cases of autologous breast reconstruction with flap survival in all cases. Conclusion Utilization of this anatomic variant in stacked or dual-pedicled autologous breast reconstruction results in antegrade IMA perfusion of both primary and secondary flaps, as well as improved size match compared with other anastomotic options. Knowledge of the vascular anatomy and variations in the inferior epigastric system is crucial to both preventing complications and optimizing flap planning and outcome.

A Phylogenetic and Ontogenetic Perspective of the Unique Accumulation of Arterial Variations in One Human Anatomic Specimen

Background and objectives: Anatomical dissection is an indispensable means of acquiring knowledge about the variability of the human body. We detected the co-existence of several arterial variations within one female anatomic specimen during routine anatomical dissection. The aim of this study was to evaluate if this status is a regular pattern in any of other vertebrates. Materials and Methods: Besides of a meticulous anatomic dissection, we performed a literature review concerning the frequency, the phylogenesis, and ontogenesis of all of these variations. Results: Exceptionally, the middle colic artery arose from an extraordinarily divided celiac trunk. The kidneys received three polar arteries. On the left side, a corona mortis replaced the obturator artery. The aortic arch gave rise to a bicarotid trunk, and the right subclavian artery originated and coursed as a typical lusorial artery leading to a non-recurrent laryngeal nerve on the right side. Furthermore, variations of the branches of the thyrocervical trunk were found to be present. Extraordinarily, in their cervical portion both internal carotid arteries gave rise to two arteries each. All of these variations developed within two to three weeks, around the sixth week of gestation. It was not possible to ascribe all or even one of the variations to a singular species of vertebrates. Conclusion: Apparently, arterial variations are frequently a result of random development. Medical professionals must always be aware of anatomical variations; the absence of such awareness would create major difficulties during surgery. The present case confirms the relevance of anatomical dissection, particularly for medical students.

Frequency and Clinical Review of the Aberrant Obturator Artery: A Cadaveric Study

The occurrence of an aberrant obturator artery is common in human anatomy. Detailed knowledge of this anatomical variation is important for the outcome of pelvic and groin surgeries requiring appropriate ligation. Familiarity with the occurrence of an aberrant obturator artery is equally important for instructors teaching pelvic anatomy to students. Case studies highlighting this vascular variation provide anatomical instructors and surgeons with accurate information on how to identify such variants and their prevalence. Seven out of eighteen individuals studied (38.9%) exhibited an aberrant obturator artery, with two of those individuals presenting with bilateral aberrant obturator arteries (11.1%). Six of these individuals had an aberrant obturator artery that originated from the deep inferior epigastric artery (33.3%). One individual had an aberrant obturator artery that originated directly from the external iliac artery (5.6%).