A Rare Case of External Iliac Vein Injury without Significant Pelvic Fracture
Shelley Maithel, MD, Michael E. Lekawa, MD, Viktor Gabriel, MD, Nii-Kabu Kabutey, MD, Sahil Gambhir, MD, Brian Sheehan, MD, Roy M. Fujitani, MD.
University of California, Irvine, Orange, CA, USA.
DEMOGRAPHICS: We report a case of a 59-year-old Hispanic female, who was a pedestrian struck by a motor vehicle traveling at approximately 30 miles per hour resulting in significant blunt force torso injury.
HISTORY: The patient was emergently transferred with initial normal vital signs. Focused assessment with sonography in trauma (FAST) scan was reported as negative. Patient had a precipitous drop in systolic blood pressure to 80 mmHg soon after arrival. This transient episode of hypotension responded to 2 units of packed red blood cells and 2 units of fresh frozen plasma transfusion after initial 2000-milliliter crystalloid infusion. No pelvic fracture was present on x-ray. CT scan with contrast revealed only slight cortical irregularity near sacral ala but no fracture. However, there was active extravasation with surrounding hemoperitoneum around the distal right external iliac vein.
PLAN: She was taken emergently to the hybrid-operating suite, where diagnostic transfemoral venography demonstrated a significant anterior wall disruption of the external iliac vein with active extravasation. Intravascular ultrasonography (IVUS) was also performed verifying the location and extent of the injury. This injury was treated with percutaneous external iliac stenting (Bard Fluency self-expanding covered stent 10x80mm), which effectively excluded the venous injury and controlled bleeding. No other associated arterial or venous injuries were present. Patient did well and was discharged on post-operative day 3 in stable condition on dual anti-platelet therapy.
DISCUSSION: This is a rare case of isolated blunt force traumatic external iliac vein injury without associated pelvic fracture. Heightened awareness of pelvic vascular injury in blunt trauma is usually reserved only for hemodynamically unstable patients with concurrent pelvic fractures. However, a higher index of suspicion should be considered for possible traumatic vascular injury even in the setting of no significant pelvic fracture in patients presenting with blunt force torso trauma. 
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