Uterine Artery Embolization Results in Transmetatarsal Amputation

Case Summary

This case involves a middle-aged female with a past medical history that includes hypertension and an enlarged 26-week pregnancy-sized fibrous uterus. Due to related problematic symptoms, she underwent uterine fibroid embolization. The procedure was completed successfully without any complications noted.

After the procedure, the patient developed pain in her right lower extremity. Despite these complaints, the Ob/Gyn did not recommend any further testing. The patient then visited her internal medicine physician who ordered a lower extremity Doppler. The internist’s office had no direct contact with the patient and the lower extremity Doppler was read as normal.

The following day, the patient returned to her internist with complaints of worsening lower extremity pain. Upon examination, her right lower extremity was cool and dusky with an absence of the dorsalis pedis and posterior tibialis pulses. She was referred to the Emergency Department where she was found to have a complete dissection of her right iliac artery that resulted in a complete lack of blood flow to the lower extremity through the artery.

In addition to open vascular repair of the iliac artery, the patient underwent fasciotomy to relieve pressure within the muscle compartment of the afflicted limb. Unfortunately, due to the hypoxic ischemia-induced injury, transmetatarsal amputation was also required.

Case Theory

It is estimated that 20 to 40% of women over the age of 35 suffer from uterine leiomyomas (fibroids). Although many women are asymptomatic, problems such as heavy menstrual bleeding, pelvic pain, and infertility may require treatment.

During myomectomy, bleeding is the main concern. Myomectomy bleeding can be reduced in several ways, the most reliable of which is bilateral ligation of the uterine vessels. The uterus is richly vascular, and the primary blood supply originates from the uterine artery, a branch of the internal iliac artery. There is a great deal of blood supply within the myometrium itself.

To reduce blood loss, surgeons may ligate the Iliac artery. Often, iliac injuries are associated with hemorrhage as well as limb ischemia. A damaged or dissected iliac artery will decrease blood flow and result in the presence of acute loss of circulation to the lower extremities. Restoring blood flow to the limb is the priority, followed by prudent post-operative care.

In this case, the failure to recognize the surgical damage and lack of blood flow, along with the negligence in post-operative follow-up care led to a poor outcome for this patient.

Expert Witness Specialties

Obstetrics and Gynecology

An expert in Obstetrics and Gynecology can speak to the risks, the standard of care, and proper procedures, including management of blood loss during uterine fibroid removal, and can opine on the care given in this case.

Internal Medicine

An internal medicine expert can opine on whether a negative Doppler without an in-person visit for the symptomatic patient was below the standard of care.

Questions for the Expert Witnesses

• What is the appropriate management of a patient with complaints of unilateral leg pain following endovascular surgery?
• Should the Ob/Gyn have recognized the potential complications and related symptoms?
• What are some possible differential diagnoses for a patient with unilateral leg pain following endovascular surgery?
• Did the delay in care cause or contribute to the damage caused by the ischemia, the need for a fasciotomy, and the need for amputation?

Expert Witness Involvement

Here is what an expert in Obstetrics and Gynecology had to say about this case:

Expert Witness Response E-339550

I have been in practice since 1996 and I am very familiar with the standard of care for fibroid management and referrals for Uterine Artery Embolization. I regularly refer these patients and take care of them post-procedure. I am qualified to render an expert opinion on these items based on my experience, training, and knowledge with 25 years of clinical practice caring for women of all ages. I also teach medical students and residents as a clinical associate professor of obstetrics and gynecology at UNC School of Medicine, Charlotte Campus. Generally, the interventional radiologist manages the patient overnight in the hospital. Post-procedure visits are uncommon as 95% of patients have no complications. However, if the patient called with complaints of unilateral leg pain, then we would recommend an exam and always a Doppler study due to DVT risks. Most causes of unilateral leg pain would be related to the vascular component of the surgery and would include: hematoma, nerve injury, infection, emboli (DVT) arterial dissection, contrast neuropathy, or necrosis.