Endovascular balloon assistance during hip disarticulation

Abstract

articulation usually is reserved for patients with neoplasms or gangrene from severe artherosclerosis. During hip disarticulation, hemodynamic stability can be altered by hemorrhagic events in the femoral artery. The authors propose an endovascular technique for proximal control of the femoral artery to reduce blood loss during hip disarticulation. The procedure was done in a 78-year-old man who had a history of prostate resection for cancer and was under oncological treatment at our institution for 10 years. He developed bone and muscle metastases in the left femur with femoral neck involvement. Because of the slow progression of the disease and the absence of other metastatic lesions, life expectancy was considered to be good, and it was decided to proceed with left hip disarticulation. Because of the proximal location of the tumor, near the femoral neck, the use of a compressive tourniquet was considered impossible, and the vascular surgeon recommended controlling an eventual hemorrhagic event by placing an angioplasty balloon catheter intotheleft external iliacartery. Color-duplex scanning was performed preoperatively, which showed patency of the iliac and femoral vessels with severe calcifications. Plain abdominal radiographs confirmed diffuse calcification in the arterial axis. TECHNIQUE Surgery was performed using spinal anesthesia. The vascular access was percutaneous at the right common femoral artery. A 6 French (Fr) introducer sheath (Avanti Introducer Sheath, Cordis Johnson & Johnson, Miami, USA) was placed using the Seldiger technique. Under fluoroscopic control, with a portable vascular C-arm capable of digitally subtracted angiogram and roadmap angiography, a 0.035-in hydrophilic guide wire (Terumo, Leuven, Belgium) was crossed over into the left iliac artery through a 5F contra angiographic catheter (Boston Scientific, Natick, USA) placed at the aortic bifurcation. After a diagnostic angiography (Figure 1) the guide wire was replaced with an Amplatz 0.035-in, 260-cm long, super stiff guide wire (Boston Scientific, Natick, USA). Then, a 7-mm x 20-mm Ultra-thin TM SDS balloon catheter (Boston Scientific, Natick, USA) was placed in the left external iliac artery (Figure 2), and systemic heparinization with 5000 UI was performed. The balloon catheter was inflated (Figure 3) and femoral pulsation ceased immediately. After proximal, endovascular occlusion, left hip disarticulation was accomplished without any hemorrhagic complication. At the end of the procedure, the balloon was deflated and removed. Hemostasis of the surgical field completed the procedure. The femoral access in the right common femoral artery was controlled with a 6 Fr Angio-seal percutaneous hemostatic system (St Jude Medical, Zaventen, Belgium).