Bull Horn Injuries: Endovascular Repair of an External Iliac Artery Thrombosis

Every year there are multiple festivities with bull runs in our country that cause injuries and even deaths, especially in amateur bullfights. Wounds caused by bull horns are characterized by presenting important tissue destruction, several trajectories with foreign objects and a high risk of infection. The lesions are variable and the most common location is in the lower extremities, followed by the upper extremities, head and neck, abdomen, perineum, thorax, back and lumbar region (Table 1).^1–7

Table 1.

Number of Vascular Lesions and Distribution. Percentage of Deaths due to Vascular Causes.

Author year	Type of wounded	Number of wounded	% of vascular lesions	% of deaths	% of vascular deaths	Location of vascular lesions
						LE	UE	HN	ABD	PER	TOR	EL
Utrilla (1999)			9.25		37% total 50% since 1975
Ríos (2003)	Professionals	15	15.3	0	0	15	1	1	3	5	1	0
Zamora (2004)	Professionals	223	0.7	2.24	20	211	64	65	31	7	22	3
Martínez (2006)	Professionals	387	1.03	0.77	33.3	244	19	12	44	41	21	6
Rudloff (2006)	Professionals	68	5.05	0	0	63	9	10	6	7	3	0
Miñano (2007)	Professionals	365	–	0	0	199	73	30	15	33	15	0
Vaquero (2008)	Professionals	656	8.53	0	0
TOTAL		1.714	6.65 (0.75–15.3)			752	166	118	101	93	62	9

The number of lesions is higher than the number of wounded because these could present several lesions.

ABD, abdomen; BL, back and lumbar region; HN, head and neck; LE, lower extremities; PER, perineum; TOR, thorax; UE, upper extremities.

The incidence of vascular injury is approximately 7%, but this type of injury is considered more severe, and increases the possibility of serious complications or even death (Table 1). The publication by Utrilla shows us the following data: deaths caused by vascular injuries were 37% and increased to 50% in the last quarter of the XX century; most deaths since 1975 were in the non-professional group and over a third occurred in bull runs; the deaths of runners in popular bull runs were in 82% of cases caused by haemorrhage due to injury of the principal thoraco-abdominal blood vessels and less commonly due to injury in the vessels of the lower extremities.¹

We present the case of a 27-year-old man, who was gored by a bull horn in a non-professional bull run, and presented several wounds with multiple trajectories and muscular lesions in the back of the right thigh, and another wound in the left flank; no femoral pulse was found. He was transferred to our Hospital with a CT scan that revealed a fracture of the 6th rib, without any visible visceral intrathoracic or abdominal lesions; a haematoma in the left flank that extended to the retroperitoneum; and no contrast was visible in the left external iliac artery for approximately 4 cm with distal repermeabilization due to a probable thrombosis or rupture of the artery (Fig. 1). The patient had received tetanus immune globulin and tetanus vaccination, analgesia and antibiotic therapy.

Figure 1.

CT scan, initial diagnosis: thrombosis of the external iliac artery.

After evaluating the patient, a diagnostic angiography was performed with the following aims:

• 1.

  To confirm the diagnosis and characteristics of the lesion.

• 2.

  To perform an endovascular clamping of the iliac artery if necessary.

• 3.

  To attempt an endovascular solution if possible.

The patient was transferred to the endovascular operating room and spinal anaesthesia was used. The right femoral artery was accessed percutaneously, the common iliac artery was reached and in the diagnostic angiography a thrombosis of the external iliac artery with repermeabilization in the external iliac artery proximal to the common femoral artery was observed, without lesions in the femoral tripod and with permeable distal vessels. The external iliac artery was re-canalized and repaired using two covered endoprothesis (viabahn GORE^® 8 mm×50 mm and advanta-Atrium^® 7 mm×38 mm). The control angiography showed permeability without complications of the external iliac artery and permeability of the femoral tripod and distal vessels. Subsequently, the other wounds were cleansed, examined and treated. Postoperative vascular treatment included subcutaneous 40 mg enoxaparin/24 h until the patient recovered full motility, and permanent antiaggregation with clopidogrel. The postoperative course was uneventful. Follow-up in the outpatient clinic revealed a proper perfusion of the extremity, with pulses in all locations, without thrills or bruits. An angio-CT was performed 5 months later and revealed permeability of the iliac artery and no complications (Fig. 2).

Figure 2.

CT scan, control: permeability of the endoprothesis and the external iliac artery.

Patients with bull horn injuries should be classified as major trauma patients and should be treated at the bull-ring or transferred to hospitals depending on the severity of their injuries. Vascular lesions are defined by Miñano as class D, originating an immediate threat to the life of the patient and indicating that the patient should be stabilized at the site, controlling the haemorrhage, and transfer to a hospital for definitive treatment should not be delayed.⁶

Vascular lesions can be treated using different techniques and depending on the type of injury, including simple ligation,⁴ or a by-pass, usually with the internal saphenous vein.^5,7 We have not found any publications in the literature that have used endovascular procedures for the treatment of vascular injuries caused by bull horn wounds. This first case shows that their use is possible with good results, and should encourage us to use them in the future in similar circumstances.

The development and use of covered stents in different locations is common use in vascular surgery departments. Every day more authors believe that the first option for patients with vascular injuries should be endovascular procedures independently of the origin.^8–10 If we can resolve the lesion successfully, we will also have a very low morbimortality. If the lesion cannot be solved with endovascular techniques, they do not hinder the use of conventional surgical techniques, which can always be used.

Vascular lesions caused by bull horn injuries can be severe, and we recommend on site control of the haemorrhage, and subsequent safe transfer of the patient to a hospital with a vascular surgery department with the necessary endovascular infrastructure in order to offer the amateurs and professionals of our ancient festival all the possible solutions to their problem, using either conventional or endovascular surgery.