Endovascular treatment of a traumatic subclavian artery aneurysm

Pseudoaneurysm of the subclavian artery following clavicle fracture due to blunt traumatism: a case report

The clavicle fractures are frequent, vascular injuries associated with closed fractures of clavicle are rare. The pseudoaneurysms of the subclavian artery constitute an exceptional complication. We report a case of a 40-year-old who presented an expanding hematoma of the right side of the neck after a road traffic accident. Radiography of the right shoulder showed a midclavicular fracture. An arterial doppler of vessels showed a circulating hematoma in the contact of the right subclavian artery with a correct distality flow. Computed tomographic angiogram of the chest confirmed the diagnosis of a false aneurysm in the postvertebral portion of the right subclavian artery. The treatment was surgical and consisted of excision of the false aneurysm and a repair of the arterial injury by an arterial patch, the clavicle was fixed with a reconstruction plate and screws. Early intervention appears to be indicated due to the risk of thrombo-embolic complications. Endovascular repair appears to be the preferred treatment modalities, due to a lower rate of cardiopulmonary complications, but it is reserved for much selected cases.

Endovascular Treatment of a Traumatic Axillary Artery Rupture Using the Dual Bull's-Eye Technique

BACKGROUND

Our purpose is to report a case of an axillary artery rupture treated by endovascular means using the dual bull's-eye technique. An 83-year-old woman with multiple comorbidities was diagnosed with axillary artery rupture after the reduction of a shoulder dislocation.

METHODS

An endovascular repair attempt was made, but, despite the use of a double approach (antegrade and retrograde), reconnecting both ends of the severed artery was deemed not possible. 5-mm Amplatz GooseNeck snares were advanced from each access and superposed in a perpendicular plane. A percutaneous infraclavicular puncture with a lumbar needle was made through both snares, and a V14 guidewire was subsequently introduced. The guidewire was recovered through femoral and brachial accesses, and a 7 × 100 mm covered self-expandable stent was deployed.

RESULTS

The final angiographic control did not show further hemorrhage, and the patient recovered radial pulse. Follow-up showed complete patency and no complications at 9 months after the procedure.

CONCLUSIONS

The dual bull's-eye technique can be used as a resource tool in cases of arterial rupture, when the arterial continuity cannot be re-established by conventional approaches.

Acute subclavian artery occlusion with associated clavicle fracture managed with bypass graft alone

Subclavian artery injury is a rare consequence of clavicle fracture. It most often results from penetrating trauma but can result from blunt trauma with adjacent bone fragments causing rupture, pseudoaneurysm, dissection or thrombosis of the artery. If flow through the subclavian artery is compromised there is a risk of ipsilateral upper limb ischaemia. Life-threatening haemorrhage may result in cases of laceration, and cerebral infarction may result from dissection. Vascular injury in association with clavicle fracture is typically regarded as an indication for internal fixation of the fracture. We present a case of subclavian artery thrombosis in association with a comminuted midshaft clavicle fracture causing limb ischaemia managed by carotid to brachial artery bypass without internal fracture fixation. The fracture united at 4 weeks and there was no sustained vascular or neurological impairment at follow-up. We advocate urgent vascular intervention in subclavian artery injury. There is little discussion in the literature regarding non-operative management of clavicle fractures with subclavian artery injury. We suggest that select clavicle fractures with subclavian artery injury can be safely managed non-operatively.

Vascular trauma

Last century saw a marked increase in vascular injuries and their treatment has been improved from the experience gained in the major conflicts in the latter half of the last century. This trend of increasing numbers of vascular injuries has been perpetuated by a rise in civilian violence.

This article reviews the mechanisms, diagnosis and treatment of vascular injury and outlines some of the advances in endovascular techniques for treating vascular trauma.

Traumatic Subclavian Artery Pseudoaneurysm: Periprocedural Salvage of Failed Stent-Graft Exclusion Using Coil Embolization

Purpose:

To report the exclusion of a subclavian pseudoaneurysm by a combination of covered stent implantation and coil embolization.

Case Report:

A 30-year-old man presented with a posttraumatic pseudoaneurysm of the left subclavian artery. A covered Jostent was inserted via a percutaneous femoral approach and deployed in the injured subclavian artery. Because of tapering of the artery proximally, apposition of the covered stent to the arterial wall was insufficient, leading to persistent filling of the pseudoaneurysm. Exclusion of the pseudoaneurysm was achieved by coil embolization through a gap between the stent-graft and the arterial wall.

Conclusions:

This report illustrates that successful endovascular treatment of a left subclavian pseudoaneurysm may require a combination of catheter-based techniques.

Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment

AIM

To report and analyse our results regarding the endovascular management of blunt axillo-subclavian arterial injuries as the first line treatment.

METHODS

During an eight-year period, seven patients (mean age 56.4±14.1 years, all males) with blunt traumatic axillo-subclavian arterial injuries were presented to the emergency department. All patients suffered also from concomitant other injuries and had a supraclavicular haematoma along with diminished or absent upper limb peripheral pulses, while computed tomography angiography set the diagnosis.

RESULTS

The endovascular procedure was technically successful in all patients. No procedure-related complication was encountered during the in-hospital stay, while none of the patients died. The median hospital stay was 22 days (range 12-46). During a follow-up period spanning an average of 27 months (range 6-44 months) there was one stent-graft thrombosis at 12 months in an otherwise asymptomatic patient that required no further intervention.

CONCLUSION

Endovascular technique seems to constitute a reliable approach for treating blunt axillo-subclavian arterial injuries in the emergent setting. Despite uncertainties in patient selection and optimal management algorithms, it seems that endovascular approach could be the first line treatment for such injuries. Accumulation of data on larger number of patients with longer follow-up is warranted to further define the value of this therapeutic modality in the trauma setting.

Subclavian Artery Pseudoaneurysm Formation 3 Months after a Game of Rugby Union

Pseudoaneurysms of the subclavian artery remain a rare complication after fracture of the clavicle. We report a case of delayed diagnosis of a subclavian artery pseudoaneurysm after a closed fracture of the clavicle in a 15-year-old patient, 3 months after the original injury while playing rugby union. Despite several attendances to the Emergency Department with vague symptoms, the final diagnosis was confirmed by duplex ultrasound and Computed Tomography of the thorax. Surgical repair was indicated due to acute limb ischaemia from distal embolisation from a large pseudoaneurysm, with the patient making a full recovery. This case highlights the need for clinical vigilance when assessing patients, particularly on repeated occasions when their recovery appears to be impaired. A thorough history and clinical examination can raise suspicion of even rare occurrences and aid prompt management.

Late onset acute occlusion of the subclavian artery after clavicle fracture

Vascular injuries after a clavicle fracture are rare. The treatment remains, if possible, conservative. In case of life-threatening bleeding or limb ischemia, endovascular treatment is the treatment of choice. In this case report, we describe a patient who suffered a clavicle fracture five years before and now presented with acute invalidating claudication caused by an acute occlusion superimposed on a brachial artery stenosis. After unsuccessful thrombolytic therapy a surgical exploration of the brachial artery was performed.

Endovascular management of axillo-subclavian arterial injury: a review of published experience

BACKGROUND

The role of endovascular treatment for vascular trauma, including injury to the subclavian and axillary arteries, continues to evolve. Despite growing experience with the utilization of these techniques in the setting of artherosclerotic and aneurysmal disease, published reports in traumatic subclavian and axillary arterial injuries remain confined to sporadic case reports and case series.

METHODS

We conducted a review of the medical literature from 1990 to 2012 using Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of subclavian or axillary artery injuries. Thirty-two published reports were identified. Individual manuscripts were analysed to abstract data regarding mechanism, location and type of injury, endovascular technique and endograft type utilized, follow-up, and radiographic and clinical outcomes.

RESULTS

The use of endovascular stenting for the treatment of subclavian (150) or axillary (10) artery injuries was adequately described for only 160 patients from 1996 to the present. Endovascular treatment was employed after penetrating injury (56.3%; 29 GSW; 61 SW), blunt trauma (21.3%), iatrogenic catheter-related injury (21.8%) and surgical injury (0.6%). Injuries treated included pseudoaneurysm (77), AV fistula (27), occlusion (16), transection (8), perforation (22), dissection (6), or other injuries otherwise not fully described (4). Initial endovascular stent placement was successful in 96.9% of patients. Radiographic and clinical follow-up periods ranging from hospital discharge to 70 months revealed a follow-up patency of 84.4%. No mortalities related to endovascular intervention were reported. New neurologic deficits after the use of endovascular modalities were reported in only one patient.

CONCLUSION

Endovascular treatment of traumatic subclavian and axillary artery injuries continues to evolve. Early results are promising, but experience with this modality and data on late follow-up remain limited. Additional multicenter prospective study and capture of data for these patients is warranted to further define the role of this treatment modality in the setting of trauma.

Late concomitant pseudoaneurysm and arteriovenous fistula of the subclavian artery: a developing country perspective

Concomitant subclavian artery pseudoaneurysm and arteriovenous (AV) fistula has been rarely reported. We report a case of late concomitant pseudoaneurysm and AV fistula of the subclavian artery caused by a gunshot wound. Open surgical approach with an infraclavicular approach was used; subclavian artery was repaired with a Gortex interposition graft and subclavian vein was ligated. The postoperative course was uneventful. In developing countries, where the endovascular expertise is unavailable or if the lesion is large, open surgical approach provides similar results as an endovascular approach.

Complex extremity fractures following high energy injuries: the limited value of existing classifications and a proposal for a treatment-guide

Complex extremity fractures have been described as demanding and associated with an increased risk of complications. Since a treatment-guided classification is not currently available, we recommend a new assessment for complex extremity fractures, categorising them into low, moderate and high risk depending on several fracture-related comorbidities. In our experience, the degree of soft-tissue damage and the overall injury severity are the most critical determinants in deciding whether primary definitive fracture stabilisation is possible or should be delayed. Low-risk complex extremity fractures can be managed according to classic fracture principles, whereas these principles may have limited value in moderate-risk complex extremity fractures. High-risk complex extremity fractures in the polytrauma setting require thorough assessment. In selected cases, primary amputation is a life-saving alternative. We present a new treatment guide taking parameters of local injury severity into account.

Compound and acutely ruptured false aneurysm of the brachial artery: a case report

Introduction

A patient with a neglected, compound acutely ruptured false aneurysm of the brachial artery which developed after a periprosthetic fracture of the right humerus, is reported.

Case presentation

An 84-year-old Greek woman underwent right shoulder hemiarthroplasty 2 years before a periprosthetic fracture which was treated conservatively in another hospital. After removing the U-slab herself, she noticed the development of an ulcer on the mid-humerus, with continuous oozing but no fever. This led to above-elbow amputation in an attempt to save the patient's life.

Conclusion

It is hoped that by awareness of such a possibility coupled with an early diagnosis based on the clinical picture and imaging modalities, such unfortunate results can be avoided in the future. In case of increasing displacement at the fracture site and excessive local swelling, the possibility of the presence of a false brachial aneurysm should be ruled out despite the presence of normal perfusion of the hand and palpable radial and ulnar pulses.

A singular case of iatrogenic axillofemoral bypass disruption: a dramatic event treated by a lucky combined approach

Proximal disruption of an axillofemoral bypass is a catastrophic event rarely caused by a posttraumatic anterior dislocation of the shoulder. Herein, we present a 74-year-old man with a painful dislocation of the right shoulder that was successfully reduced. Three hours later he had hemodynamic shock with an expanding and pulsating hematoma at the level of the right shoulder, pectoral and infraclavicular region. Surgical exposure of the right brachial artery was carried out, and intraoperative angiography revealed a proximal anastomotic leakage. The distal ballooning improved the hemodynamic status, and by a redo infraclavicular incision the hematoma was drained. The arterial leak was repaired by an 8 mm polytetrafluoroethylene interposed graft between the axillary artery and existing graft. The utility of a combined approach (endovascular + open surgical) is discussed.

Radiologische Interventionen bei polytraumatisierten Patienten

The most frequent cause of mortality during the first 4 h following severe trauma is uncontrollable hemorrhage from large arteries and parenchymal organs, whereas traumatic injuries of the heart and aorta are responsible for sudden death occurring at the accident site. It is therefore mandatory to diagnose and treat these injuries rapidly. Multislice spiral computed tomography is a highly useful imaging modality for severely injured patients. In this group of patients, various interventional procedures such as embolisation, stenting and temporary balloon occlusion may contribute to saving lives. In ruptures of the aorta and major arteries, stenting and temporary balloon occlusion may prevent exsanguination. Transcatheter embolisation is useful in hemorrhage from visceral organs, arteriovenous fistulas and secondary onset hemorrhage.

Traumatic false aneurysm of the subclavian artery treated by insertion of Memotherm stent

Traumatic aneurysms of the left subclavian artery and transverse cervical artery, subsequent to penetrating gunshot wound were diagnosed by angiography in 35-year-old patient. Subclavian artery aneurysm was treated by insertion of the Memotherm bare stent, whereas the false aneurysm of the transverse cervical artery was embolized with Gianturco's coils. The follow up examinations at 6 and 12 months showed good patency of subclavian artery.

Subclavian arterial injury associated with blunt trauma

Blunt subclavian artery trauma is an uncommon but challenging surgical problem. The purpose of this study was to retrospectively review the management of blunt subclavian artery injuries treated by the Trauma and Vascular Surgery Services at the East Tennessee State University-affiliated hospitals between 1992 and 1998. Six patients with seven blunt subclavian artery injuries were identified. Physical signs indicating blunt subclavian artery injury were pain or contusion around the shoulder joint; fractures of the clavicle, scapula, or ribs; periclavicular hematomas; and ipsilateral pulse or neurologic deficits. Seven subclavian artery injuries were treated-two arterial transections, two pseudoaneurysms, and three intimal dissections. Associated injuries included four clavicle fractures, one humerus fracture, one combined rib and scapular fractures, and two pneumothoraxes. Vascular surgical treatment included three primary arterial repairs, two saphenous vein interposition grafts, and one polytetrafluoroethylene (PTFE) graft. One patient was treated nonoperatively with anticoagulation. No deaths occurred. Morbidity occurred in two patients with chronic upper extremity neuropathy producing prolonged disability from pain and weakness; one patient had reflex sympathetic dystrophy, and the other had a brachial plexus injury. In conclusion, blunt subclavian artery trauma can be successfully managed with early use of arteriography and prompt surgical correction by a variety of vascular techniques. Vascular morbidity is usually low, but long-term disability because of chronic neuropathy may result from associated brachial plexus nerve injury despite a successful arterial repair.

Endovascular treatment of penetrating thoracic outlet arterial injuries

OBJECTIVES

to establish the feasibility of stent-graft treatment of penetrating thoracic outlet arterial injuries.

DESIGN

prospective study.

MATERIALS AND METHODS

forty-one patients with penetrating injuries to the carotid, subclavian and proximal axillary arteries admitted between August 1998 and May 1999 were studied. Patients requiring urgent surgical exploration for active bleeding (n=26) were excluded. Remaining patients underwent arteriography to assess suitability for stent-graft placement. After successful stent-graft treatment clinical and sonographic follow-up were done at 1 month and thereafter 3-monthly.

RESULTS

of the 15 patients considered, 10 patients qualified for stent-graft treatment (seven male, three female, mean age 27 years). The vessels involved were subclavian artery (seven), carotid artery (two) and axillary artery (one). Seven had arteriovenous fistulae and three, pseudoaneurysms. Stent-graft treatment was successful in all 10 patients with no procedure-related complications. On mean follow-up of 7 months no complications were encountered.

CONCLUSION

endovascular treatment shows promise as a treatment modality for thoracic outlet arterial injuries. Long-term follow-up is required for comparison to the results of standard surgical repair.