Buttock necrosis

Dietz DM, Stahlfeld KR, Bansal SK, Christopherson WA (2004) Buttock necrosis after uterine artery embolization. Obstet Gynecol 104 1159-1161... 

Although the incidence of serious complications such as colonic, lumbosacral plexus, or buttock necrosis is low after IIA embolization, the incidence of claudication and sexual dysfunction is high enough to warrant preservation of the IIA circulation if possible. In final analysis, the decision whether to embolize an IIA or not should be weighed against the potential risks and benefits of the other therapeutic alternatives. The risk of development of such symptoms as claudication or sexual dysfunction may outweigh the hazards of IIA revascularization or aneurysm rupture and death if no action is taken. 

Sodium borate decomposes into borate and peroxide and is less toxic than potassium bromate. From 3 to 6g and from 15 to 30 g boric acid is potentially fatal to children and adults, respectively. Cutaneous manifestations include desquamating, erythematous rash commonly over palms, soles, buttocks, and scrotum. The lesion may progress to exfoliation. Central nervous system (CNS) effects range from irritability, restlessness, and headache to coma and convulsions in severe cases. Gastrointestinal symptoms include anorexia, nausea, vomiting, and diarrhea. Acute renal tubular necrosis may lead to renal failure in moderate to severe cases. 

A spectrum of end-organ ischemic complications can occur with embolotherapy. Bowel infarction can complicate splanchnic embolization targeting bleeding or could result from inadvertent non-target embolization from an upstream source [88]. Gallbladder infarction or bile duct necrosis can complicate hepatic artery embolization or che-moembolization [89, 90]. Splenic abscess and overwhelming sepsis can occurs following splenic embolization [91]. Skin necrosis and nerve injury have been reported as a result of ethanol embolization of vascular malformations [53, 54]. Buttock muscular necrosis, buttock claudication and sexual dysfunction can occur as a result of internal iliac branch embolization, especially when distal or bilateral [92-95]. 

Skin Cutaneous necrosis associated with levamisole-contaminated cocaine has been described in two patients [199], in whom there were mottled non-infiammatory erythematous and purpuric patches on both legs and buttocks, with scattered, punched-out ulcers with central eschars. Biopsies showed extensive vascular thrombosis with no evidence of vasculitis, making cocaine-induced vasculitis highly unlikely. There were strongly positive perinuclear ANCAs in both patients and weakly positive IgM anticardiohpin antibodies in one. There were no coagulopathies. 

An 80-year-old woman with acromegaly developed extensive fat necrosis in both buttocks after three deep subcutaneous doses of lameo-tide 60 mg extended release. The lesions first became apparent about 4 months after the first injection and developed over several months. There was central necrosis with surrounding inflammatory tissue. The CRP concentration and white cell count were normal and bacterial cultures were negative. Once the lesions were clearly demarcated they were excised. 

Embolization, by definition, reduces blood flow distally. Therefore, it is no surprise that distal necrosis is a recognized complication of trauma embolization. However, unintentional reflux of embolization material from the internal iliac into the femoral artery can cause inadvertent ischemia in the leg. Sciatic palsy with associated foot drop and sacral plexus palsy has been reported [57]. Embolization of the superior gluteal artery in a patient vdio will be subjected to prolonged bedrest may cause sacral and buttock ischemia leading to skin break down [58]. Sexual dysfunction seems not to he a complication of bilateral internal iliac artery embolization, but is more likely a result of nerve injury secondary to the fracture or pelvic trauma [59]. 

---