Extreme obesity is a risk factor for hemorrhagic complications of femoral access (FA) (Hibbert et al. 2012). Femoral lines, hematomas, pelvic binders and coagulopathy in the trauma scenario may also add difficulty and/or risk to FA. In recent years, radial access (RA) for routine peripheral endovascular procedures has been popularized owing to decreased hemorrhagic complications (Posham et al. 2016) as well as improved patient satisfaction and decreased operator radiation dose (Yamada et al. 2018). However, not all investigators have found RA superior to traditional FA (Hung et al. 2019), and though uncommon, cerebrovascular complications from RA approach are a known risk. Stroke has been reported from peripheral angiography via RA (Al-Hakim et al. 2017), and compared to FA, patients undergoing cardiac angiography procedures from RA have been shown to have 2.1 times increased risk of silent stroke (Göksülük et al. 2018). Relatively recently, tibial access (TA) has been used for lower extremity peripheral vascular disease interventions (Montero-Baker et al. 2008; Walker et al. 2016; Sanghvi et al. 2018; Kwan et al. 2015). We report the feasibility of TA for supra-inguinal embolization in two extremely obese patients {body mass index (BMI) > 40 kg/m2}.
Tibial access for embolization of Suprainguinal hemorrhage
Two patients with pelvic or abdominal wall hemorrhage following motor vehicle accidents were treated at our institution with trans-catheter embolization via TA. Patencies of tibio-pedal arteries {anterior tibial (ATA), posterior tibial (PTA), dorsalis pedis (DPA)} were documented pre-procedurally with palpation and/or ultrasound. With ultrasound guidance and micropuncture technique, a 5 French Glidesheath Slender (Terumo, USA) was placed, hand injection of contrast via the sheath was performed, and 2000–3000 IU of heparin and 200 μg of nitroglycerin were instilled through the sheath as previously reported for RA (Yamada et al. 2018). An additional 1500 IU of heparin was administered 2 h later to our first described patient immediately before procedure’s termination. Access site hemostasis was achieved with a large TR band radial artery compression device (Terumo, USA) reinforced with cloth tape. This study was performed in compliance with our Institutional Review Board, and patient consent for publication of their cases was obtained.
Case 1
A 51-year-old male with a BMI of 42.3 kg/m2 suffered a motorcycle accident. On admission, his blood pressure was 92/51 mmHg, his heart rate was 134 beats/min, and his hemoglobin (Hgb) declined from 14.2 to 11.1 g/dL despite 8 units of blood products. Radiography demonstrated open book pelvic fractures (Fig. 1a), and focused assessment with sonography for trauma (FAST) examination demonstrated free intraperitoneal fluid consistent with hemorrhage. He was transported emergently to the operating room for exploratory laparotomy where bladder rupture was identified and pelvic packing was performed, but due to continued uncontained pelvic hemorrhage he was placed in a pelvic binder and brought to Interventional Radiology (IR). Via left RA, pelvic angiography was performed, and an actively extravasating left pudendal artery (Fig. 1b) was coil embolized; no other bleeding source was identified (Fig. 1c, d). Following sheath removal, patent hemostasis was achieved with a TR band. CT of the head, neck and torso was performed following the angioembolization. CT demonstrated intra- and extra-peritoneal contrast extravasation thought related to bladder injury, but did not show definitive active vascular extravasation.
However, overnight he had continued hemodynamic instability and blood drainage through his negative pressure wound therapy device on his anterior abdominal wound, necessitating blood product replacement. Therefore, he was returned to IR for empiric embolization of the bilateral internal iliac arteries due to high level of suspicion for active pelvic bleeding prior to planned orthopedic pelvic stabilization surgery later that day. Physical examination revealed an occluded left radial artery with patent ulnar artery and good hand perfusion.
Via the 2.5 mm diameter distal right ATA (Fig. 2a, b), a steam-shaped 5 French 130 cm Mariner catheter (Angiodynamics, USA) was advanced into the contralateral left internal iliac artery where a negative angiogram was obtained (Fig. 2c). A Renegade STC microcatheter (Boston Scientific, USA) was advanced coaxially into its anterior division, and embolization was performed with Gelfoam slurry (Pfizer Pharmacia & Upjohn, USA) capped by platinum coils. A Waltman loop was formed with the base catheter and its tip repositioned into the right internal iliac artery, where a negative angiogram was obtained (Fig. 2d). The microcatheter was advanced into its anterior division, and Gelfoam slurry embolization was performed to stasis. Following sheath removal, patent hemostasis was achieved with a TR band (Fig. 2e). Post-procedurally, he stabilized. One year follow-up physical examination revealed mildly decreased sensation over the dorsal radial aspect of his left hand and a strong right ATA pulse.
Case 2
A 48-year-old male driver with a BMI of 50.6 kg/m2 suffered an automobile accident while wearing a seatbelt. On admission, his blood pressure was 58/51 mmHg leading to vasopressor support, and his Hgb dropped from 14.3 to 11.4 g/dL. CT revealed active hemorrhage in the lower left anterolateral abdominal wall (Fig. 3a), for which a pelvic binder was placed.
Via the 3.4 mm diameter left PTA (Fig. 3b, c), a 5 French 100 cm KMP (Cook Medical, USA) was advanced into the ipsilateral external iliac artery and hand injection angiography performed (Fig. 4 a). The KMP catheter was then advanced into the deep circumflex iliac artery (DCIA) and negative angiogram was obtained (Fig. 4b). Superselective access was achieved more distally within this vessel with a Renegade STC microcatheter, and Gelfoam slurry embolization was performed. Next, the inferior epigastric artery (IEA) was catheterized with a 5 French 100 cm Judkins right 4 (Cordis, USA) catheter. Superselective access was achieved more distally within this vessel with the micro-catheter, through which a negative angiogram was obtained (Fig. 4c); the IEA was then embolized with 355–500 um polyvinyl alcohol particles (Boston Scientific, USA). Following sheath removal, patent hemostasis was achieved with a TR band (Fig. 4d).
Post-procedurally, he stabilized. Ultrasound the following day revealed a patent left PTA, and he was subsequently transferred to a rehabilitation hospital. Patient stated on phone follow-up 11 months later that he was ambulating without difficulty.