Vessels at risk
Extra-pelvic blood vessels
Femoral Artery
MCFA
LCFA
Profunda Femoris
Obturator artery
Intrapelvic vessels
External iliac artery and vein
Obturator artery
Superior and inferior gluteal
External Iliac Vessels
Anatomy
- anterior division of common iliacs / L5-S1
- runs down medial border of Psoas
- some psoas between EIA & intrapelvic surface of anterior column
- EIV accompanies EIA
Injury
Screws
Cement
Screws
Screws may penetrate VAN
- can be delayed diagnosis
- significant intrapelvic bleeding may occur before diagnosis
- AS quadrant: minimal protective ST interposition and often poor bone stock
- vein more at risk than artery
Cement
Aetiology
- heat
- kinking or occlusion from bolus
- erosion from spicule
- avulsion secondary to removal
Avoid cement intrusion into pelvis with wire mesh
Removal of intrapelvic cement
- required in revision for infection
- define NV relationships
- angiography / MRA preoperatively
- may require separate intrapelvic exposure
- alert general surgeons / vascular surgeons
Femoral blood vessels
Most commonly injured
Anatomy
- common femoral artery is continuation of EIA as passes under inguinal ligament
- passes anterior to hip capsule
- separated from it by psoas
Injury
Anterior retractors / dissection
Anterior quadrant screws and drills
Obturator AV
Anatomy
VAN traverse lateral wall together
- separated from quadrilateral plate by obturator internus
- lie at superolat aspect of obturator foramen
- exit pelvis via obturator canal
Injury
Screws in AI quad
Retractor under transverse acetabular ligament
Management
Bleeding at inferior transverse ligament
- can be very difficult to ligate
- pack with swab
- hold swab with inferior retractor
- finish acetabulum
- will usually be controlled
Other option is to embolise if still bleeding
Superor Gluteal BV
Anatomy
Branch Posterior Division IIA
- close to posterior column
- exits greater sciatic notch above piriformis
Injury
Screw near sciatic notch
Inferior Gluteal & Internal Pudendal AV
Anatomy
Branch anterior division IIA
- exit pelvis between piriformis & coccygeus
- close to posterior column near ischial spine
- internal pudendal artery re-enters pelvis through lesser notch
- IGA pass under piriformis
Injury
Very long screws through posterior column
Management on table torrential bleeding
Pack wound, tell anaesthetist & vascular surgeon & obtain proximal & distal control
Notify anaethetist
IV fluids
Coags, FBC, platelets, cross match
Transfuse blood
Organise cell saver
Control bleeding
Pack & wait
- uncontrollable, get proximal control
Call Vascular surgeon
Ilioinguinal approach
- clamp IIA, vessiloop IIV
Retro-peritoneal approach
- Rutherford-Morrison incision
- retroperitoneal approach
Post-operatively
- angiography
- transcatheter embolisation