Common Iliac Vein Injury Due to a Rectal Impalement Wound Treated Conservatively

Introduction

Iliac vascular injury after abdominal trauma is a severe and often life-threatening condition [1]. These injuries occur in approximately 2.3% of abdominal trauma cases [2]. The mortality rates for these injuries are high: 16.5% for iliac vein injuries, 19.3% for iliac artery injuries, and 48.7% combined iliac arteriovenous injuries [2]. Consequently, common iliac vein injuries are recognized as traumatic conditions with high mortality rates.

Previous reports have suggested that conservative management, including nonsurgical treatment, may be effective for spontaneous and blunt traumatic common iliac vein pseudoaneurysms [3,4]. However, are no reports on conservative treatment of penetrating injuries to the iliac vein, and the potential complications associated with such an approach remain unknown.

This report presents a case of common iliac vein injury resulting from an impalement wound, a type of penetrating trauma. The injury was initially managed conservatively; however, the patient subsequently developed deep vein thrombosis (DVT) and a pulmonary embolism (PE).

Case Report

A 51-year-old man with a history of hepatitis C, successfully treated with direct-acting antivirals without developing cirrhosis or ascites, sustained an injury involving a foldable chair at home (Table 1). When the chair collapsed, a pipe penetrated his anus. Approximately 1 h later, a family member discovered him in the bathroom, immobile, and covered in blood, prompting an emergency call. Upon arrival at the emergency medical service, his initial assessment showed a Glasgow Coma Scale (GCS) score of E2V3M4, blood pressure (BP) of 70 mmHg, heart rate (HR) of 80 bpm, respiratory rate (RR) of 20/min, body temperature (BT) of 35.3°C, and oxygen saturation (SpO2) of 100% using a 10-L reservoir mask. Paramedics faced challenges maintaining an intravenous line. The patient was transported to the emergency center.

In the emergency department, his GCS was E4V4M5, and his vital signs included a BP of 70 mmHg, HR of 80 bpm, RR of 20/min, BT of 37.6°C, and SpO2 of 98% with a 10 L reservoir mask. The focused assessment for trauma using sonography was negative. Rapid fluid administration ameliorated the BP, leading to recovery from shock. Physical examination revealed no active bleeding from the anus; however, a lateral fissure was observed. Rectal examination revealed a fissure 5 cm from the anal verge in the 11 o’clock position. The prostate was palpable, and a tunnel-like passage suggested the trajectory of the pipe. A urinary catheter was inserted, without gross hematuria. Contrast-enhanced abdominal computed tomography (CT) revealed no free gas in the abdominal cavity, but free gas extended from the rectum to the periprostatic retroperitoneal area. Additionally, contrast-enhanced CT ruled out arterial injury due to the absence of contrast extravasation and excluded ureteral injury because no ureteral discontinuity was observed in the excretory phase. However, a narrowed right common iliac vein surrounded by a hematoma without any evidence of contrast leakage was observed (Figure 1). We administered 2 units (total 280 mL) of packed red blood cells and 6 units (total 720 mL) of fresh frozen plasma, beginning just before the surgery and continuing throughout the intra-operative period. Laboratory results at the time of admission and postoperatively are shown in Table 2.

Following initial resuscitation, the patient’s hemodynamics stabilized. However, a growing hematoma necessitated emergency laparotomy. The procedure, involving a midline incision, revealed no ascites or blood in the abdominal cavity. The retroperitoneal hematoma did not enlarge, indicating successful hemostasis. Given the evidence of rectal damage, a colostomy was performed, and a double-barrel stoma was placed in the transverse colon. Since the hematoma remained stable, the decision was made to avoid incising the retroperitoneum to maintain the tamponade effect, and the abdomen was subsequently closed.

Postoperative management in the intensive care unit included extubation on the first day. Oral hydration and mobilization were initiated shortly thereafter. A second postoperative CT scan confirmed the absence of hematoma expansion or thrombosis in the right common femoral vein. The patient resumed eating on postoperative day (POD) 3 and was ambulatory in a stable condition, thus obviating the need for prophylaxis for DVT. The patient was discharged on POD 11 after a consistent decrease in D-dimer levels was noted.

Four days after discharge, right lower-extremity edema prompted an emergency room visit 7 days later. A CT scan revealed edema and thrombosis in the right common iliac vein (Figure 2), accompanied by PE. Following emergency readmission, treatment for DVT and PE was initiated with intravenous heparin at a rate of 416 units/h, adjusted according to body weight. The following day, the patient expressed a strong and persistent desire to be discharged, citing an inability to tolerate the hospital environment. After careful consideration, the patient was discharged with a prescription for the direct oral anticoagulant (DOAC) edoxaban, 60 mg/day. Regular outpatient follow-up was scheduled.

Since then, the patient has regularly attended outpatient follow-up appointments without any recurrence of lower-extremity swelling, and he has resumed driving without issues. Regular monitoring of D-dimer levels and inflammatory markers and follow-up CT scans showed no evidence of DVT or PE recurrence.

Discussion

This report presents a case of hemorrhagic shock resulting from a common iliac vein injury caused by an impalement wound, which was managed conservatively. The patient experienced postoperative DVT and PE, which were managed with DOAC to resolve the thrombus, without rebleeding.

Upon arrival at the hospital, the patient was in shock but was successfully resuscitated with infusion therapy. Immediate hemostasis is crucial for managing hemodynamically unstable common iliac vein injuries that result in persistent shock. Hemostatic measures include ligation, temporary repair, bypass, and stent insertion [5]. While previous reports suggested that iliac vein injuries should be managed with hemoperfusion, our patient’s stable hemodynamic status justified a conservative approach in this case. The choice of conservative treatment was reinforced by contrast-enhanced CT findings, which ruled out both arterial injuries due to the absence of contrast extravasation and ureteral injury based on the lack of ureteral discontinuity in the excretory phase. The intraoperative findings further supported this decision, confirming the absence of arterial or ureteral injury. Recent case reports indicated that common iliac vein injuries from blunt trauma can be managed conservatively if the patient is hemodynamically stable [6,7]. However, reports on conservatively managed sharp injuries, particularly from impalement wounds to the common iliac vein, which generally require repair, are lacking. In this case, the confinement of bleeding to the retroperitoneum due to the transanal impalement wound, which did not extend to the abdominal cavity, likely facilitated early hemostasis. A case report by Hamada et al described a common iliac vein injury caused by a transabdominal wooden puncture that required surgical repair because of bleeding in the free space of the abdominal cavity, which was not confined within the retroperitoneum and led to hemorrhagic shock [8].

Conservative management may be appropriate for iliac vein rupture injuries with spontaneous rupture or stable hemodynamics, similar to our case, where the rupture was contained within the retroperitoneum, justifying conservative management as a reasonable approach [9]. Historically, packing of a common iliac vein injury, even in cases of blunt trauma, has proven effective in achieving hemostasis, underscoring the importance of controlling bleeding [7].

After conservative management of the common iliac vein injury, our patient developed DVT and PE, necessitating rehospitalization. The thrombus was effectively treated with anticoagulation therapy, and no subsequent occurrence of DVT or PE. Although Magee et al reported use of conservative management of DVT in 14% of patients following repair or ligation of the common iliac vein [2], anticoagulation should be preferred when there is a risk, such as narrowing of the common iliac vein. In our case, DOAC therapy was initiated at the time of patient discharge, and follow-up was conducted in an outpatient setting, monitoring trends in blood test results, including D-dimer levels. Thrombus resolution was confirmed based on clinical symptoms and contrast-enhanced CT findings. When administering DOACs or warfarin to trauma patients, careful monitoring of laboratory data and other relevant indicators throughout the course of treatment is essential.

This case represents a specific type of damage due to trans-anal impalement. As most penetrating trauma to the iliac vein occurs through intra-abdominal injuries, our experience with this case may not be generalizable. Additionally, the treatment strategy was determined in a surgical environment accessible to trauma surgeons who also conducted follow-up examinations, an environment necessary for effective conservative treatment.

Conclusions

We present a case of conservative management for a common iliac vein injury resulting from an impalement wound. Prophylactic anticoagulation therapy should be considered to prevent DVT in cases where there is narrowing of the common iliac vein.