Endovascular repair of external iliac vein injury caused by acetabular screw penetration during total hip arthroplasty: a case report

Introduction: Total hip arthroplasty (THA) is a common orthopedic procedure with low complication rates. However, vascular injuries, though rare (0.1%–0.3%), can lead to life-threatening hemorrhage and hemodynamic instability. External iliac vein (EIV) injuries during THA are exceptionally uncommon, and optimal management remains a clinical challenge. Presentation of case: We report a 62-year-old woman with diabetes and hypertension who underwent right THA for severe osteoarthritis. Intraoperatively, a significant hemorrhage occurred due to the acetabular screw penetration into the right EIV. Despite initial control with a balloon-expandable stent, persistent extravasation required urgent re-intervention. Multiple overlapping balloon-expandable stent grafts were deployed, achieving definitive hemostasis and restoring venous patency. The patient stabilized, recovered uneventfully, and was discharged on anticoagulation. At 1-week follow-up, she demonstrated satisfactory recovery without complications. Discussion: Vascular injuries during THA often result from acetabular screw overpenetration. While open repair has traditionally been the standard, it poses challenges due to limited exposure and increased morbidity. Endovascular stenting offers a minimally invasive, rapid, and effective alternative, particularly in unstable patients. Literature reports of iliac venous injuries treated with stent grafts are limited, making this case noteworthy. Our experience highlights the importance of careful preoperative planning, intraoperative vigilance, and multidisciplinary collaboration to reduce risk and improve outcomes. Conclusion: EIV injury during THA is a rare but potentially fatal complication. Endovascular repair with multiple overlapping stent grafts can provide a safe and effective treatment, serving as a valuable alternative to open repair in emergency settings.