circumflex artery with alcohol after a failed prior internal iliac artery ligation to control benign pelvic haemorrhage in a 41-year-old woman. No case of late ...
1995, The British Journal of Radiology, 68, 920-922
Case report: Avascular necrosis of the femoral head as a complication of complex embolization for severe pelvic haemorrhage R 0 OBARO, DMRD, FMCR, FRCR and K W SNIDERMAN, MD, FRCP(C)
Vascular Radiology Unit, Department of Radiology, The Toronto Hospital, Toronto, Canada Abstract
We present a case of avascular necrosis of the femoral head following embolization of the right medial femoral circumflex artery with alcohol after a failed prior internal iliac artery ligation to control benign pelvic haemorrhage in a 41-year-old woman. No case of late necrosis of the head of the femur as a complication of iliac artery vessel embolization to control haemorrhage has been documented previously. The problems associated with therapeutic pelvic embolization following ligation of the internal iliac artery and the disruption of the femoral head arterial supply are discussed. Case report
A 41-year-old woman presented with severe pelvic haemorrhage following an abdominal hysterectomy for uterine fibroids. An estimated 2 1 of blood was lost per vaginum. Conservative methods failed to stop the bleeding. The patient was examined under general anaesthesia and the bleeding was thought to be arising from the right side of the pelvis. She went on to have a laparotomy and ligation of the right internal iliac artery. The haemorrhage continued in spite of this surgical intervention. The patient was referred for pelvic angiography with a view to subsequent embolization. The anterior division of the left internal iliac artery was first studied and, although no bleeding point or abnormality was demonstrated, embolization of the artery with gelfoam and coil was carried out. This did not stop the bleeding per
first case of control of pelvic haemorrhage through embolization of the medial femoral circumflex artery [1]. Both hip joints were normal. The patient developed tachypnoea following embolization. Ventilation and perfusion lung scans were indeterminate in excluding a pulmonary erobolus but pulmonary arteriography was normal. The patient presented with right hip pain 2 years later. Radiography of the hip joint showed loss of cortex, collapse of the femoral head and joint incongruity
vaginum.
The collateral pathways formed on the right side following surgical ligation of the right internal iliac artery were demonstrated by injection of the right profunda femoris artery. This showed retrograde flow in the inferior gluteal artery and extravasation of contrast medium from a branch of the internal iliac artery (Figure 1). The right medial femoral circumflex artery was embolized using 3 ml of dehydrated alcohol, gelfoam pledgets and a 3 mm coil. After embolization, the internal iliac artery no longer opacified on injection of contrast medium and no further bleeding was seen. The medial and lateral femoral circumflex arteries also did not opacify (Figure 2). This has been previously reported as the Received 30 June 1994 and in final form 9 March 1995, accepted 27 March 1995.
Address correspondence to R O Obaro, FRCR, 205 Woodcote Road, Wallington, Surrey SM6 OQQ, UK. 920
Figure 1. Right profunda femoris arteriogram demonstrating retrograde filling of the inferior gluteal artery (large arrowhead) via the circumflex femoral artery (small arrowhead) with extravasation from a branch of the internal iliac artery. Note normal right femoral head.
The British Journal of Radiology, August 1995
Case report: Avascular necrosis of the femoral head after embolization for pelvic haemorrhage
Figure 2. Right common femoral arteriogram after embolization, showing a coil in the medial femoral circumflex artery (arrowhead), no flow in the femoral circumflex and internal iliac arteries, and no further bleeding.
(Figure 3). Dynamic and static bone scan of the hip joint also showed changes compatible with femoral head necrosis. There was no documented history of any systemic illness or infection of the right hip joint at presentation or during the period succeeding the embolization. Discussion
Severe pelvic haemorrhage is often managed by surgical ligation of the internal iliac artery after failure of conservative methods. Surgical ligation for the control of pelvic haemorrhage has a success rate of only 42-57% [2, 3]. In females, these failures may require hysterectomy to control the haemorrhage, although hysterectomy can itself be complicated by haemorrhage which does not respond to conservative management. The immediate formation of collaterals in the pelvis following ligation of the internal iliac artery contributes to the low success of internal iliac artery ligation. These collateral pathways have been well documented [4-6]. Embolization of bleeding pelvic vessels has a success Vol. 68, No. 812
Figure 3. Anteroposterior film of the right hip showing an area of destruction and sclerosis in the superolateral aspect of the femoral head with preservation of the joint space.
rate in the order of 90% [2]. However, this management option becomes more difficult, sometimes impossible, and riskier following ligation of the internal iliac artery [4, 7]. The risks associated with pelvic embolization include buttock ischaemia, sciatic and femoral nerve ischaemia leading to lower limb paresis, the BrownSequard syndrome and bladder necrosis. There has been no recorded case of late femoral head necrosis following embolization for benign pelvic haemorrhage. The embolization is carried out with materials such as coils, gelfoam, autologous blood clot, cyanoacrylate and alcohol. The smaller particulate agents and alcohol, which is a tissue necrosant, increase the embolization risks due to the occlusion of critical vessels, leading to tissue ischaemia. The case presented here illustrates some of the problems that may be encountered in pelvic embolization after ligation of the internal iliac artery. The haemorrhage was only controlled with embolization of the right medial femoral circumflex artery, which was acting as a collateral artery to the bleeding branch of the right internal iliac artery. The size of the artery made catheterization technically more difficult. The embolization and the volume of alcohol used carried the risk of 921
R 0 Obaro and K WSniderman
occlusion of its distal branches. In view of this, it is our opinion that the use of alcohol should be avoided in favour of small gelfoam particles. The arterial supply to the femoral head arises from an arterial ring formed at the base of the femoral neck by branches of the lateral femoral and medial femoral circumflex arteries. The vertically running retinacular arteries carry blood to the femoral head. An additional supply to the femoral head comes from the artery of the ligamentum teres, which is a branch of either the medial femoral circumflex or the obturator artery [8, 9]. The collateral pathway that opened up in this patient following the ligation of the right internal iliac artery is the medial femoral circumflex-obturator pathway. We postulate that the coil embolization of the medial femoral circumflex artery in association with alcohol occlusion of the retinacular and ligamentum teres arteries resulted in ischaemia of the femur head. This ischaemia is the genesis of the femur head necrosis. The time interval between the vascular insult and the occurrence of the hip pain and known femoral head changes suggest that this patient had avascular necrosis of the femoral head, although some authors describe an entity known as late femoral head collapse distinct from the classical avascular necrosis of the femoral head [10]. These authors define late femoral head collapse as the entity that occurs much later, after the vascular insult and its incidence is less than that of classical avascular necrosis of the femoral head. Acknowledgment
References 1. ODURNY, A and COLAPINTO, R F, Control of postoperative vaginal hemorrhage by embolization of the medial circumflex femoral artery, AJR, 149, 319-320 (1987). 2. GILBERT, W, MOORE, T R, RESNIK, R ET AL, Angiographic embolisation in the management of hemorrhagic complication of pregnancy, Am. J. Obstet. GynecoL, 166,493-497 (1992). 3. EVANS, S and McSHANE, P, The efficacy of internal iliac artery ligation in obstetric hemorrhage, Surg. Gynecol. Obstet., 160, 250-253 (1985). 4. GREENWOOD, L H, GLICKMAN, M G, SCHWARTZ, P E ET AL, Obstetrical and non-malignant gynecologic bleeding: treatment with angiographic embolisation, Radiology, 164, 154-159(1987). 5. BURCHELL, R C, Physiology of internal iliac artery ligation, J. Obstet. Gynecol. Br. Commonwealth, 75, 642-651 (1968). 6. CHAIT, A, MOLTZ, A and NELSON, J, The collateral arterial circulation in the pelvis: an angiographic study, AJR, 702,392-400(1968). 7. HARE, W S C and HOLLAND, C T, Paresis following internal iliac artery embolisation, Radiology, 146, 47-51 (1983). 8. CROCK, H V, A revision of the anatomy of the arteries supplying the upper end of the human femur, J. Anatomy (Lond),l, 77-88 (1965). 9. HOWE, W W, LACEY, T and SCHWARTZ, R P, A study of the gross anatomy of the arteries supplying the proximal portion of the femur and acetabulum, J. Bone Joint Surg., 32A, 856-866(1950). 10. CATTO, M, The histological appearance of late segmental collapse of the femoral head after transcervical fracture, J. Bone Joint Surg., 47B, 777-791 (1965).
We would wish to express our sincere appreciation to Mr James Woods, Radiology Department, The Toronto Hospital, General Division for his secretarial support.
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