Salvage of the carotid artery with covered stent after perforation with dialysis sheath. A case report.

We present a rare case of carotid tear caused by iatrogenic erroneous insertion of a dialysis sheath into the common carotid artery (CCA). This was treated by placement of a covered stent-graft in the CCA over the puncture site. This treatment achieved hemostasis while preserving the carotid artery with good outcome. The technical details are presented and the relevant literature regarding treatment of carotid blowout syndrome is discussed. This case suggests that placement of a covered stent-graft is a good option not only for the "usual" blowout syndrome due to head and neck tumors, but also for treatment of iatrogenic injury to the carotid artery.

Clinical utility of ultrasound versus magnetic resonance imaging for deciding to proceed with uterine artery embolization for presumed symptomatic fibroids.

AIM: To compare the diagnostic utility of pelvic ultrasound (US) and magnetic resonance imaging (MRI) on the clinical decision to proceed with uterine artery embolization (UAE). MATERIALS AND METHODS: Over 2 years, 180 consecutive women (mean age 43) sought consultation for UAE, 116 underwent pelvic US and MRI before possible UAE. US was performed prior to MRI. Imaging was analysed for leiomyoma quantity, size and location, uterine volume, and the presence of potential contraindications to UAE. Discrepancies between imaging methods and cases where discrepancies could have altered management, were recorded. RESULTS: For the 116 patients who completed imaging, the average uterine volume was 701 cm(3) using MRI versus 658 cm(3) using US (p=0.48). The average dominant leiomyoma volume was 292 cm(3) using MRI versus 253 cm(3) using US (p=0.16). In 14 (12.1%) patients US did not correctly quantify or localize leiomyomas compared with MRI (p=0.0005). Thirteen patients did not undergo UAE (patient preference n=9, pre-procedural imaging findings n=4). In the four cases where UAE was not performed due to imaging findings, relevant findings were all diagnosed by MRI compared with two by US (p=0.5). The two cases not detected by ultrasound were adenomyosis and a pedunculate subserosal leiomyoma. Of the 103 patients who underwent UAE, 14 were treated (without complication) despite the presence of a relative contraindication; all 14 relative contraindications were identified by MRI compared with 13 by US (p=1.0). CONCLUSION: MRI is more accurate than US for characterizing uterine leiomyomas. In a small but statistically insignificant number of cases, MRI identified findings that were missed by US, which changed management. For patients that are unsuitable to be assessed with MRI, ultrasound alone is sufficient for pre-UAE assessment.

Portopulmonary hypertension in decompensated cirrhosis with refractory ascites.

BACKGROUND: The prevalence of portopulmonary hypertension (PPHTN) in patients with cirrhosis and refractory ascites is unknown. Its presence may preclude patients from receiving a transjugular intrahepatic portosystemic shunt or liver transplantation as a definitive treatment for their end stage cirrhosis. PURPOSE: To determine the prevalence, possible aetiological factors, and predictive factors for the development of PPHTN in these patients. METHODS: Sixty two patients (53 males, nine females; mean age 54.5 (1.4) years) with biopsy proven cirrhosis and refractory ascites underwent angiographic measurements of pulmonary and splanchnic haemodynamics. Endothelin 1 levels were measured from the pulmonary artery. Forty nine patients underwent radionuclide angiography for measurements of central blood volume, pulmonary vascular, and cardiac chamber volumes. Forty seven patients also underwent two dimensional echocardiography for measurements of cardiac structural and functional parameters. Cardiac output, and systemic and pulmonary vascular resistance were calculated. RESULTS: Ten patients (16.1%) fulfilled the criteria for PPHTN (mean pulmonary artery pressure >/= 25 mm Hg and pulmonary vascular resistance >/= 120 dynxs/cm(5)), with significantly higher mean right atrial (15.4 (1.2) v 7.9 (0.5) mm Hg; p<0.001), and right ventricular pressures (24.7 (1.5) v 14.7 (0.6) mm Hg; p<0.001), and endothelin 1 levels (3.04 (0.40) v 1.98 (0.12) pg/ml; p=0.02). No significant differences in any of the other parameters measured were detected between the two groups. A right atrial pressure of >/= 14 mm Hg had a 83% positive predictive value for the presence of PPHTN. CONCLUSIONS: Portopulmonary hypertension is common in cirrhosis with refractory ascites, possibly due to excess endothelin 1 in the pulmonary circulation. An elevated right atrial pressure >/= 14 mm Hg predicts the presence of PPHTN, which may be helpful in deciding management options in these patients.

Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial.

OBJECTIVE: To compare the effectiveness and safety of low-dose unfractionated heparin and a low-molecular-weight heparin as prophylaxis against venous thromboembolism after colorectal surgery. METHODS: In a multicenter, double-blind trial, patients undergoing resection of part or all of the colon or rectum were randomized to receive, by subcutaneous injection, either calcium heparin 5,000 units every 8 hours or enoxaparin 40 mg once daily (plus two additional saline injections). Deep vein thrombosis was assessed by routine bilateral contrast venography performed between postoperative day 5 and 9, or earlier if clinically suspected. RESULTS: Nine hundred thirty-six randomized patients completed the protocol and had an adequate outcome assessment. The venous thromboembolism rates were the same in both groups. There were no deaths from pulmonary embolism or bleeding complications. Although the proportion of all bleeding events in the enoxaparin group was significantly greater than in the low-dose heparin group, the rates of major bleeding and reoperation for bleeding were not significantly different. CONCLUSIONS: Both heparin 5,000 units subcutaneously every 8 hours and enoxaparin 40 mg subcutaneously once daily provide highly effective and safe prophylaxis for patients undergoing colorectal surgery. However, given the current differences in cost, prophylaxis with low-dose heparin remains the preferred method at present.

Treatment of nonresectable hepatocellular carcinoma with intrahepatic 90Y-microspheres.

UNLABELLED: Treatment for nonresectable hepatocellular carcinoma (HCC) is palliative. The relatively greater arteriolar density of hepatic tumors compared with normal liver suggests that intrahepatic arterial administration of 90Y-microspheres can be selectively deposited in tumor nodules and results in significantly greater radiation exposure to the tumor than external irradiation. The purpose of this study was to determine the proportion (frequency) and duration of response, survival, and toxicity after intrahepatic arterial injection of 90Y-microspheres in patients with HCC. METHODS: Patients with documented HCC, Eastern Cooperative Oncology Group performance status 0-3, adequate bone marrow, and hepatic and pulmonary function were eligible for study. Patients who had significant shunting of blood to the lungs or gastrointestinal (GI) tract or who could not undergo cannulation of the hepatic artery were excluded. Patients received a planned dose of 100 Gy through a catheter placed into the hepatic artery. RESULTS: Twenty-two patients were treated with 90Y-microspheres; 20 of the treated patients (median age, 62.5 y) were evaluated for treatment efficacy. Nine patients were Okuda stage I, and 11 were Okuda stage II. The median dose delivered was 104 Gy (range, 46-145 Gy). All 22 treated patients experienced at least 1 adverse event. Of the 31 (15%) serious adverse events, the most common were elevations in liver enzymes and bilirubin and upper GI ulceration. The response rate was 20%. The median duration of response was 127 wk; the median survival was 54 wk. Multivariable analysis suggested that a dose >104 Gy (P = 0.06), tumor-to-liver activity uptake ratio >2 (P = 0.06), and Okuda stage I (P = 0.07) were associated with longer survival. CONCLUSION: Significantly higher doses of radiation can be delivered to a HCC tumor by intrahepatic arterial administration of 90Y-microspheres than by external beam radiation. This treatment appears to be beneficial in nonresectable HCC with acceptable toxicity.

Long-term follow-up of management of failing in situ saphenous vein bypass grafts using endovascular intervention techniques.

PURPOSE: To report the long-term follow-up of previously reported cases of salvaging failing or failed in situ bypass grafts using endovascular techniques, to include previously unreported cases, and to include the results of thrombolysis for the salvage of occluded in situ venous bypass grafts. MATERIALS AND METHODS: Between 1985 and 1995, 352 patients underwent distal bypass via the in situ saphenous vein. Seventy-three of these patients underwent endovascular interventions for (i) graft stenoses (65 lesions in 40 patients) treated by balloon angioplasty (PTA), (ii) AV residual fistulas to veins (AVF) (23 patients) occluded by coil embolotherapy, (iii) graft occlusion (21 occluded grafts in 19 patients) treated by catheter-directed high-dose thrombolytic infusion and PTA or surgical revision of uncovered stenoses, and (iv) retained valve leaflets causing stenoses (five patients) treated by valvectomy and/or PTA. Cumulative patency rates were determined by the Kaplan-Meier method. Twenty-nine of 73 patients had been previously reported by the authors. RESULTS: PTA was successful in 39 of 40 patients, cumulative patency after bypass PTA was 0.79 (SE +/- 0.07) for 12 months and 0.63 (SE +/- 0.12) for 5 years. The only complication of PTA was a graft anastomotic disruption that was successfully treated by surgery. Longer lesions and lesions requiring repeated PTA were more likely to restenose. For thrombolysis, there were 13 of 19 successful infusions and five delayed occlusions. The cumulative patency for both 12 months and 5 years was 0.43 (SE +/- 0.12). AVF embolization was successful in 21 of 23 patients. Cumulative patency for 12 months and 5 years was 0.87 (SE +/- 0.07) and 0.81 (SE +/- 0.09), respectively. Five successful valvectomy procedures were performed by stripping residual valves with endocardial forceps. CONCLUSION: In experienced hands, PTA and AVF embolization can be performed on failing in situ saphenous vein bypass grafts with good long-term patency. Thrombolysis results were less favorable but can prolong patency of grafts.

Inferior vena cava filters--percutaneous insertion?

The incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) among Chinese is much lower than in Caucasians. The total number of inferior vena cava (IVC) filters inserted in regional hospitals in Canada (about 700 beds in Toronto General Hospital) and Hong Kong (about 1,250 beds in Pamela Youde Nethersole Eastern Hospital) also reflects this. Thirty-six IVC filters were deployed in Toronto General Hospital, compared to 8 IVC filters inserted in Pamela Youde Nethersole Eastern Hospital from August 1997 to September 1998. Despite this, the physician may encounter patients with thromboembolic disease who require inferior vena cava interruption. The usual indication will be pulmonary embolism with contraindications to, or failure or complications of, anticoagulation therapy. It is important for angiographers to be familiar with the technique of percutaneous insertion of IVC filters. The types of IVC filters, techniques of insertion and guidelines relating to the choice of a filter would be discussed.

A practical approach to vascular access for hemodialysis and predictors of success.

PURPOSE: The long-term results and predictors of success for vascular access at The Toronto Hospital were studied. This report describes the access program and emphasizes the role of the vascular access coordinator. METHODS: A total of 384 consecutive patients underwent 466 vascular access procedures. The access program is centered around a dedicated, full-time vascular access coordinator, who is a registered nurse and is responsible for all aspects of access care, including follow-up. Outcome variables were collected prospectively. Primary, primary-assisted, and secondary success was determined by means of Kaplan-Meier analysis, and the stepwise Cox proportional hazards model was used for multivariate analysis of the factors that were independently predictive of primary success. RESULTS: There were 235 autogenous arteriovenous fistulae (AVFs) and 231 arteriovenous grafts (AVGs). The cumulative primary, assisted-primary, and secondary success (patent and functional for effective dialysis) at 24 months for all 466 cases combined was 36% +/- 3%, 54% +/- 3%, and 66% +/- 3%, respectively. The primary success for AVFs and AVGs at 2 years was 54% +/- 4% and 18% +/- 4%, respectively (P <.001; log-rank test); the primary-assisted success for AVFs and AVGs at 2 years was 62% +/- 4% and 44% +/- 6%, respectively (P <.001; log-rank test); and the secondary success for AVFs and AVGs at 2 years was 70% +/- 4% and 60% +/- 5%, respectively (P =.331; log-rank test). Stratification of variables revealed significant benefit for AVFs (P =.001), the female sex (P =.014), and the absence of diabetes mellitus (P =.001). Multivariate analysis with Cox regression determined that access type (AVF vs AVG; P =.001) and diabetes mellitus (P =.024) were independently predictive of primary success. The improved clinical coordination of access patients with the initiation of the vascular access program resulted in a significant reduction in length of hospital stay before and after the program was organized (2.5 +/- 0.06 vs 1.1 +/- 0.03 days; P =.001). CONCLUSION: The organization of a vascular access program in a practical and cost-effective way for reduced length of hospital stay is streamlined through a dedicated access coordinator, who ensures an integrated, multidisciplinary approach. The results for the Cox model is useful when discussing the anticipated results of access procedures with individual patients.

Reoperative parathyroidectomy in the era of localization technology.

BACKGROUND: Recurrent and/or persistent hyperparathyroidism (HPT) is an uncommon disease. Relatively few cases are seen by any one center or surgeon. Most of the prior reviews of this problem were done in the era prior to potentially accurate magnetic resonsance imaging (MRI) and sestimibi scan localization and do not reflect current preoperative localization technology. METHODS: All cases of recurrent or persistent parathyroidectomy seen in our institution between 1992 and 1996 were reviewed retrospectively to assess the predictive value of preoperative MRI, selective venous sampling, sestimibi scanning, ultrasound examination, and computerized tomography (CT) scanning. The preoperative localization studies were compared with the findings at operation, the pathology report, and the patient's long-term calcium status. RESULTS: Twenty-eight patients were operated upon at our institution for recurrent or persistent HPT during this time interval. The final pathology turned out to be: adenoma, 24; hyperplasia, 2; carcinoma, 2. The site at which the reoperative pathology was found was in the neck in 22 patients and intrathoracic requiring sternotomy in 6. The long-term outcome, i.e., serum calcium level at > 6 months postoperatively, was normocalcemia in 22 of 28 (85%), persistent hypocalcemia in 2 of 28, and persistent hypercalcemia in 2 of 28. Some combination of MRI, sestimibi, selective venous sampling, ultrasound, and CT scan was performed on all patients preoperatively. Preoperative MRI scans were performed on 26 of 28 patients. They correctly localized the side and site of the pathology in only 12, yielding a sensitivity of 66%. There were, however, no false positives; therefore, the positive predictive value of this test was 100%. Selective venous sampling was carried out on 26 of 28 patients and correctly localized in only 8 (sensitivity, 50%). Again, there were no false positives, yielding a positive predictive value of 100%. Sestimibi scanning was performed in 16 of 28, localizing in 8 (sensitivity, 50%). The positive predictive value of this test was 80%. Ultrasound was performed in 26 of 28 patients and localized in only 3, yielding a sensitivity of 17%, with a positive predictive value of 75%. Computerized tomographic scan was performed preoperatively only when all other investigations turned out to have been nonlocalizing and was therefore done in only four patients, one of whom had a positive CT scan showing an intrathoracic, intrapericardial adenoma. CONCLUSIONS: These data demonstrate that despite the availability of what are putatively accurate preoperative localizing tests for previously unoperated cases, no one localizing test is particularly sensitive in reoperative parathyroid surgery. Magnetic resonance imaging and selective venous sampling, however, are complementary and when positive do accurately predict the site of the persistent/recurrent parathyroid pathology. Use of these preoperative localizing studies resulted in a successful outcome, i.e., normocalcemia or hypocalcemia in 93% of patients operated on.

The renal sympathetic and renin-angiotensin response to lower body negative pressure in well-compensated cirrhosis.

BACKGROUND & AIMS: Certain antinatriuretic hormonal systems may be involved in the subclinical sodium handling abnormality in preascitic cirrhosis. The aims of this study were to determine the following in preascitic cirrhosis: (1) basal activity of the renal sympathetic and renin-angiotensin systems and (2) the relationship between the response of these systems to lower body negative pressure and sodium excretion. METHODS: Seven preascitic cirrhotic patients and 9 age- and sex-matched controls were studied on a 150 mmol sodium per day diet. Systemic and renal hemodynamics, renal neurohormonal secretion rates, and sodium excretion were assessed before, during increasing levels of, and after lower body negative pressure, each for 30 minutes. RESULTS: Both groups responded with a significant decrease in central venous pressure (P < 0.01) that remained higher in the cirrhotics than in the controls throughout the study. Cirrhotics showed significant increases compared with controls in renal renin and angiotensin II secretion rates at -20 mm Hg of lower body negative pressure, which was associated with significant renal sodium retention (96 +/- 17 micromol/min vs. 218 +/- 21 micromol/min at baseline, P < 0.05), but there was no change in renal sympathetic activity. CONCLUSIONS: In preascitic cirrhosis, sodium retention occurs in response to lower body negative pressure, which was associated with increased renal renin-angiotensin activity. Stimulation of the intrarenal renin-angiotensin system may be the initial renal pathophysiological change causing sodium retention in cirrhosis.

Management of upper extremity central venous obstruction using interventional radiology.

Upper extremity central vein stenosis/occlusion is responsible for significant morbidity. The objective of this report is to review our management using interventional radiological techniques and to determine the long-term clinical results. All radiological interventions for central vein stenosis/occlusion (n = 59) between July 1991 and July 1996 at our institution were reviewed. The interventions consisted of thrombolytic therapy alone in 10 cases, PTA in 40 cases (combined with initial thrombolytic therapy in 6 cases), and deployment of a venous stent in 9 cases. At follow-up, the cumulative success (patency and relief of symptoms) was determined (Kaplan-Meier method). The involved vein was the subclavian, axillary, or innominate (SUB-AX-INN) in 45 cases and the superior vena cava (SVC) in 14 cases. The etiology was secondary to an indwelling foreign body (catheter, pacemaker lead) in 53 cases (90%), and spontaneous in only 6 cases (10%). The average follow-up after intervention was 17.2 months, with a cumulative success of 70 +/- 7.5% at 2 years, with rapid decline thereafter. Analysis of the failure quantiles revealed that 25% failed by 17 months, 50% failed by 26.6 months, and 75% failed by 33.8 months. There were no subgroup differences (log-rank test) for stenosis versus occlusion (p = 0.526), SUB-AX-INN versus SVC (p = 0.744), or if the intervention was begun < 5 days versus > or =5 days after symptom onset (p = 0.240), or whether or not a stent was deployed (p = 0.893). Interventional radiological techniques should be considered when symptoms from upper extremity central vein stenosis/occlusion are severe and disabling, or when veno-access or maintenance of patency of an ipsilateral arteriovenous (A-V) access is necessary. These results suggest an acceptable short-to medium-term solution.

Image-guided insertion of the Uldall tunneled hemodialysis catheter: technical success and clinical follow-up.

PURPOSE: To evaluate the technical success, complication rates, and survival time of the Uldall double-lumen catheter placed by interventional radiologists in patients presenting to a hemodialysis clinic. MATERIALS AND METHODS: Patients eligible for this study included those with end-stage renal disease (ESRD) who had failed peripheral vascular access or who were awaiting access at a hemodialysis unit between June 1993 and March 1996. All catheters were placed under fluoroscopic and ultrasound guidance in the angiography suite. RESULTS: Attempts were made to insert 130 catheters into jugular veins in a consecutive series of 61 patients with ESRD. The accumulated catheter experience in this cohort was 15,380 days and the median survival time was 141 days (95% confidence interval [CI]; 116 days-166 days). One hundred twenty-one catheters (93%) were successfully inserted, mainly (94%) into the internal jugular vein. Excellent dialysis blood flow rate was obtained-on average 365 mL/min (95% CI; 350-379 mL/min). The overall infection rate, including exit site (n = 13), sepsis (n = 19), and clavicular osteomyelitis (n = 1), was 2.1 episodes per 1,000 catheter days. CONCLUSIONS: This catheter is recommended for acute and longer term hemodialysis for patients without peripheral vascular access. It can be inserted percutaneously, the same internal jugular vein can be used repeatedly with few complications and good blood flow, and the technique can be easily learned by any experienced angiographer.

The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt.

BACKGROUND & AIMS: The pathogenesis of the delayed natriuresis after transjugular intrahepatic portosystemic shunt (TIPS) insertion is unknown. This was studied to elucidate the mechanism involved. METHODS: In 12 patients with cirrhosis and refractory ascites after TIPS, systemic and renal hemodynamics, renal sodium handling, central blood volume, neurohumoral factors, and hepatic function were studied weekly after the shunt with the patients receiving a diet of 20 mmol sodium/day. RESULTS: Two weeks after TIPS, the initial natriuresis (4 +/- 1 to 18 +/- 3 mmol/day; P < 0.05) was associated with significant reductions in corrected sinusoidal pressure (24.4 +/- 1.8 to 7.5 +/- 0.4 mm Hg; P < 0.001), proximal renal tubular reabsorption of sodium (P = 0.05), and renin-angiotensin-aldosterone activity (P < 0.05), but with significant systemic vasodilatation (P < 0.05). At 4 weeks, negative sodium balance was achieved (52 +/- 21 mmol/day; P < 0.01), despite continued systemic arterial vasodilatation, associated with significant increases in total central and cardiac volumes (P < 0.05) and normalization of serum aldosterone levels (P < 0.01). Four late responders were significantly older (P = 0.01) and had significantly lower baseline glomerular filtration rates (P = 0.02). CONCLUSIONS: In cirrhosis, sinusoidal portal hypertension and an activated renin-angiotensin-aldosterone system seem to be important in the pathogenesis of sodium retention. Systemic vasodilatation without arterial underfilling does not prevent natriuresis. Delayed natriuresis after TIPS is associated with increasing age and pre-TIPS renal impairment.

Pulmonary arteriography for the assessment of technical feasibility of sleeve resection in lung cancer.

BACKGROUND: Pulmonary arteriography has been reported to be useful in the preoperative assessment of patients with lung cancer to determine the technical resectability and feasibility of pneumonectomy by imaging the main right and left pulmonary arteries. In this report, we describe the use of selective pulmonary arteriography in the assessment of lobar resectability. METHODS: Selective pulmonary arteriography provides a detailed anatomic view of the lobar branches and has been used at our institution for the past 30 years to preoperatively investigate patients who are candidates for a sleeve lobectomy. RESULTS: Three cases are described that demonstrate the usefulness of selective pulmonary arteriography in the assessment of the technical feasibility of sleeve resection in patients with lung cancer. CONCLUSIONS: Arteriographic findings may accurately show whether a sleeve lobectomy is technically possible, that only a pneumonectomy is possible, or that the only safe way to ensure clearance of the pulmonary artery is to perform arterioplasty. This information may obviate an unnecessary thoracotomy in patients who are judged on the basis of a physiologic assessment to be unable to tolerate a pneumonectomy.

Noncoronary vascular stenting.

The aim of this report is to review the current state of the art with respect to noncoronary vascular stenting. A review of the literature was performed, examining the historical aspects of stent design and usage, as well as the currently available designs and their respective functions. When appropriate, we note our personal experience with stent placement in each anatomic site. Currently available stents take many forms: balloon-expandable, self-expanding, and shape-memory alloy. Varied design modifications have been made to maximize the open area, to limit the surface area of the prosthesis, to increase (or decrease) flexibility, and to increase (or decrease) stent plasticity and elasticity. Modifications to minimize thrombogenicity are also underway. The clinical uses of the currently available stents in multiple anatomic locations will be discussed. Intravascular stents are an addition to the arsenal available for prolonging blood vessel patency.

Indications and results of balloon angioplasty for arterial occlusive lesions.

This paper describes the current techniques for percutaneous transluminal angioplasty (PTA) of peripheral arteries, summarizes the long-term results of the procedure, and identifies the variables that are predictive of long-term success of PTA performed in the iliac and femoropopliteal segments.

Management of total parenteral nutrition-related superior vena cava obstruction with expandable metal stents.

Catheter-related thrombotic and stenotic obstructions are the second most common serious complication of long-term total parenteral nutrition. Subsequent venous access problems have profound implications because of immediate and long-term requirements of nutrition support. Although improved understanding of pathogenesis has led to improved prophylaxis and treatment of thrombosis, some patients will have refractory obstructions that threaten venous access and lead to severe clinical sequelae, including superior vena cava (SVC) syndrome. We describe two cases of patients with SVC syndrome refractory to anticoagulant, thrombolytic, and balloon angioplasty therapy, managed successfully with percutaneous placement of expandable metal stents. A discussion of the current understanding of prophylaxis and treatment of catheter-related thrombosis and the role for interventional measures to restore venous patency and avoid permanent venous access problems accompanies the case descriptions.

Case report: avascular necrosis of the femoral head as a complication of complex embolization for severe pelvic haemorrhage.

We present a case of avascular necrosis of the femoral head following embolization of the right medial femoral circumflex artery with alcohol after a failed prior internal iliac artery ligation to control benign pelvic haemorrhage in a 41-year-old woman. No case of late necrosis of the head of the femur as a complication of iliac artery vessel embolization to control haemorrhage has been documented previously. The problems associated with therapeutic pelvic embolization following ligation of the internal iliac artery and the disruption of the femoral head arterial supply are discussed.