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Weir A, Kennedy P, Joyce S, Ryan D, Spence L, McEntee M, Maher M, O'Connor O. Endovascular management of pelvic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1196. [PMID: 34430637 PMCID: PMC8350659 DOI: 10.21037/atm-20-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/18/2020] [Indexed: 11/06/2022]
Abstract
Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.
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Affiliation(s)
- Arlene Weir
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Padraic Kennedy
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Stella Joyce
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - David Ryan
- School of Medicine, University College Cork, Cork, Ireland
| | - Liam Spence
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mark McEntee
- School of Medicine, University College Cork, Cork, Ireland
| | - Michael Maher
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - Owen O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
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Tanmit P, Angkasith P, Teeratakulpisarn P, Thanapaisal C, Wongkonkitsin N, Prasertcharoensuk S, Panich C. Treatment Outcome of Traumatic Subclavian Artery Injuries. Vasc Health Risk Manag 2021; 17:481-487. [PMID: 34429608 PMCID: PMC8379483 DOI: 10.2147/vhrm.s322127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Traumatic subclavian artery injuries are associated with high morbidity and mortality. Thoracic cage and clavicle provide a well protection of the underlying subclavian vessels and nerves and also cause a very limited operation space during open surgery. The endovascular modality is less invasive and alternative to conventional open surgical reconstruction. PURPOSE The purpose of this study was to analyze the different therapeutic effects on limb salvage. METHODS A retrospective review of patients who presented with blunt or penetrating injuries to the subclavian arteries between March 2012 and March 2021. RESULTS Endovascular and open repairs were both effective for traumatic subclavian artery injury. There was no statistical difference in the limb salvage, mortality, procedure-related complication, reintervention rate and in-hospital medical complications. Intraoperative blood loss, red blood cell transfusion requirement and length of hospital stay were significantly lower in the endovascular intervention group. CONCLUSION Endovascular treatment represents an attractive alternative to the traditional surgical approach for the treatment of traumatic injuries in the subclavian.
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Affiliation(s)
- Parichat Tanmit
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Phati Angkasith
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Panu Teeratakulpisarn
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chaiyut Thanapaisal
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | | | - Chaiwat Panich
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Endovascular treatment of subclavian artery injury with a complex post-traumatic fistula: Case report. Trauma Case Rep 2021; 32:100400. [PMID: 33665302 PMCID: PMC7900574 DOI: 10.1016/j.tcr.2021.100400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background Endovascular treatment in trauma is a promising strategy to reduce perioperative morbidity and mortality. We report the case of a gunshot wound causing an initially undiagnosed subclavian artery injury, with delayed progression to a complex, difficult-to-manage arteriovenous (AV) fistula. Placement of an encapsulated endovascular stent graft resolved the primary lesion, but persistent cervical arteriovenous communications were only repaired after multiple, sequential embolization procedures. Report A 25-year-old male sustained a gunshot wound to the right neck. Initial treatment failed to identify any vascular injury, and the patient was discharged. Three weeks later, he presented to our facility with headache and a palpable right-sided cervical thrill. Arteriography showed contrast extravasation from the right subclavian artery and an AV fistula with the ipsilateral internal jugular vein. The arterial injury was repaired with an encapsulated stent graft, but residual contrast leak persisted on follow-up angiography. Three months after the first intervention, cervical thrill was still present; a right vertebral–right internal jugular AV fistula was identified and repaired by distal coil embolization. One month later, persistent symptoms prompted repeat arteriography, which again identified contrast extravasation, now involving the thyrocervical trunk. Selective thyrocervical embolization was ultimately successful, with resolution of symptoms and no further evidence of contrast leak. Conclusion Delayed management of neck trauma can be challenging due to neovascularization, which hinders open repair in this delicate region. Post-traumatic arteriovenous fistulas are thus a particularly fearsome complication, and can be very difficult to approach; as in our patient, multiple interventions may be required. This case highlights the importance of detecting vascular trauma as early as possible, as a delay in diagnosis can hinder treatment and eventuate challenging late complications. Further studies are needed to demonstrate the long-term benefits of endovascular management of complex vascular injuries of the neck region. Endovascular treatment of arterial trauma can reduce early morbidity and mortality. Late diagnosis of vascular trauma can be associated with arteriovenous fistula. Post-traumatic repair of arteriovenous fistula can be challenging in the cervical region and require multiple interventions. Endovascular approaches can be an option where open dissection is challenging.
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Kaslow SR, Gurney O, Ascher E. Explore no more: Early experience with a novel minimally invasive approach to penetrating trauma to zone II of the neck. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:595-597. [PMID: 33145471 PMCID: PMC7593346 DOI: 10.1016/j.jvscit.2020.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/28/2020] [Indexed: 12/25/2022]
Abstract
The traditional approach to penetrating injuries to zone II of the neck has included operative neck exploration, extensive enough to allow for proximal and distal vascular control of the potential vascular injury. Few studies have reported cases of entirely endovascular management of penetrating injury to this portion of the neck. In the present case report, we describe the case of a 38-year-old man who had sustained a stab wound to zone II of the neck. The injury to the internal carotid artery was managed endovascularly with placement of a covered stent. The findings from the present case illustrate the potential use of minimally invasive vascular treatment strategies as an alternative to mandated operative intervention.
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Affiliation(s)
- Sarah R Kaslow
- Department of Surgery, New York University Langone Hospital, Brooklyn, NY
| | - Onaona Gurney
- Department of Surgery, New York University Langone Hospital, Brooklyn, NY
| | - Enrico Ascher
- Department of Surgery, New York University Langone Hospital, Brooklyn, NY
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Blitzer DN, Ottochian M, O'Connor JV, Feliciano DV, Morrison JJ, DuBose JJ, Scalea TM. Timing of intervention may influence outcomes in blunt injury to the carotid artery. J Vasc Surg 2020; 71:1323-1332.e5. [DOI: 10.1016/j.jvs.2019.05.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
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Elkbuli A, Shaikh S, McKenney M, Boneva D. Subclavian artery avulsion following blunt trauma: A case report and literature review. Int J Surg Case Rep 2019; 61:157-160. [PMID: 31376736 PMCID: PMC6677780 DOI: 10.1016/j.ijscr.2019.07.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/15/2019] [Accepted: 07/18/2019] [Indexed: 11/29/2022] Open
Abstract
Subclavian artery injuries are rare, highly fatal, and constitute less than 2% of all vascular injuries. Surgical repair of these injuries can be technically challenging due to their anatomic location. Therapeutic approaches include surgical repair, endovascular repair, or a hybrid approach depending on the severity of the injury and the patient’s hemodynamic status.
Introduction Subclavian artery injuries are rare and are associated with a high morbidity and mortality. The majority of patients with blunt trauma to the subclavian artery succumb to their injury before reaching a hospital. In-hospital mortality remains high. Presentation of case We report the case of a 30-year-old male who presented with complete traumatic subclavian artery avulsion after a motorcycle collision. He presented in hemorrhagic shock. Temporary hemostatic control was achieved with endovascular balloon occlusion followed by operative intervention. Discussion Prompt diagnosis and meticulous management including early transfusion, when indicated, are necessary to salvage both the patient’s life and limb from such severe injuries. Intra-operative diagnosis of subclavian artery injury is most common due to the hemodynamic instability of most patients with such injuries; however, conventional angiography and computed tomography angiography are useful diagnostic modalities as well. Temporizing measures such as endovascular balloon occlusion to obtain vascular control may serve as a valuable adjunct to surgical repair. Conclusion Repair of a subclavian artery injury is challenging for even the most experienced of surgeons. Endovascular techniques can be therapeutic or used as an adjunct to control bleeding ad allow an open repair.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; University of South Florida, Tampa, FL, United States.
| | - Saamia Shaikh
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; University of South Florida, Tampa, FL, United States
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; University of South Florida, Tampa, FL, United States
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, United States; University of South Florida, Tampa, FL, United States
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Reva VA, Morrison JJ, Denisov AV, Seleznev AB, Zhabin AV, Bozhedomova ER, Samokhvalov IM. Development of an ovine model of occlusive arterial injury for the evaluation of endovascular interventions. Vascular 2015; 24:501-9. [PMID: 26546598 DOI: 10.1177/1708538115615779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular intervention for occlusive arterial trauma is becoming more common in clinical practice. The aim of this study is to present an ovine model of extremity arterial injury for use in future endovascular translational research. Animals under general anesthesia had their left superficial femoral artery exposed, which was bluntly injured over a 2-cm section using a hemostat and injection of air. Occlusion was confirmed on angiography and the flow characteristics measured by ultrasonography. Of five animals enrolled, four occluding lesions were created successfully. Post injury, there was a significant reduction in the median (interquartile range) systolic velocity (cm/sec) on the left (injury) compared to the right (control) side (3.5 (0-16.5) vs. 29 (23.8-43.3); p < 0.001). The ovine superficial femoral artery can be used to consistently produce an occlusive lesion that is suitable for use in the future evaluation of endovascular trauma interventions.
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Affiliation(s)
- Viktor A Reva
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Jonathan J Morrison
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK and The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Alexey V Denisov
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Alexey B Seleznev
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Anatoly V Zhabin
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Elvira R Bozhedomova
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
| | - Igor M Samokhvalov
- Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia
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