Strategy to avoid vascular injuries in revision total hip arthroplasty with intrapelvic implants

Abstract

Aims: Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components.

Methods: Patients were defined as at risk to vascular injuries when components or cement migrated 5 mm or more beyond the ilioischial line in any of the pelvic incidences (anteroposterior and Judet view). In those patients, a serial investigation was initiated by a CT angiography, followed by a vascular surgeon evaluation. The investigation proceeded if necessary. The main goal was to assure a safe tissue plane between the hardware and the vessels.

Results: In ten at-risk patients undergoing revision hip arthroplasty and submitted to our algorithm, six were recognized as being high risk to vascular injury during surgery. In those six high-risk patients, a preventive preoperative stent was implanted before the orthopaedic procedure. Four patients needed a second reinforcing stent to protect and to maintain the vessel anatomy deformed by the intrapelvic implants.

Conclusion: The evaluation algorithm was useful to avoid blood vessels injury during revision total hip arthroplasty in high-risk patients.Cite this article: Bone Jt Open 2022;3(11):859-866.

Keywords: Hip; Hip arthroplasty; Intrapelvic implants; Vascular System Injuries.

Fig. 1

Pelvis anteroposterior radiograph demonstrating two screws (red arrow) overlapping the ilio ischiatic line (red line) > 5 mm. It is a red flag to vascular injury during revision total hip arthroplasty.

Fig. 2

Flux diagram of progressive investigation of patients at vascular injury risk.

Fig. 3

Intravascular ultrasound image. Vein wall (red circle) is extremely close (< 5 mm) to the screw (red arrows).

Fig. 4

a) CT pelvis showing intrapelvic screws (red arrows) on the right side.b) Venography demonstrating iliac external vein stenosis caused by screws. c) Venography showing balloon at the stenosis site.d) Venography after stent insertion. The image shows the full flow in iliac external vein. The patient was prescribed dual antiplatelet therapy with 100 mg of aspirin and 75 mg of clopidogrel daily for four weeks since the literature suggests that this a critical period o for early stent occlusion. Before surgery, antiplatelets were suspended one week before the planned surgery.