Endovascular Treatment of Traumatic Vascular Injuries in the Head and Neck Region

Background and Objectives: Traumatic vascular injuries of the head and neck pose significant treatment challenges due to the complex anatomy, diverse clinical presentation, and mostly emergent nature. Endovascular treatment increasingly complements traditional surgical approaches. This study aimed to report our 10-year experience in treating traumatic vascular injuries of the head and neck with endovascular therapy and to determine the effectiveness of endovascular treatment. Materials and Methods: A retrospective analysis of 21 patients treated for head and neck vascular injuries between May 2011 and April 2021 was performed. Patients' medical histories, clinical presentations, imaging findings, treatment materials, and clinical outcomes were reviewed. Treatments included stenting, coil embolization, and other endovascular techniques focused on hemostasis and preservation of the parent vessel. Results: The most common injuries involved the internal maxillary artery branches (n = 11), followed by the common or internal carotid artery (n = 6), vertebral artery (n = 3), and others. Endovascular treatment achieved successful hemostasis in all but one case. In five of six carotid artery injuries and two of three vertebral artery injuries, we achieved successful hemostasis while preserving the parent vessel using covered and bare stents, respectively. Conclusions: Endovascular therapy might be a useful treatment modality for traumatic vascular injuries in the head and neck region, offering efficacy, safety, and a minimally invasive approach.

Same Clinical Reality of Spontaneous Rupture of the Common Iliac Artery with Pseudoaneurysm Formation-Comparison of Two Therapeutical Solutions, Endovascular Stent-Graft and Open Surgical Correction, for Two Cases and Review of the Literature

The incidence of isolated iliac artery aneurysms is approximately 2% and common iliac artery pseudoaneurysms are even rarer. A pseudoaneurysm is a localized hemorrhage as opposed to an actual aneurysm, which affects the entire vascular wall. They are typically asymptomatic and only detectable accidentally while looking for other causes. If large and symptomatic, they typically exhibit pressure symptoms as a result of the compression of the structures around them. Common symptoms include generalized stomach pain, urological problems, gastrointestinal bleeding, and neurological symptoms such as leg paralysis or sciatica-like back pain. Rarely, they may exhibit hemodynamic instability together with an aneurysm rupture, which has a high fatality rate. Due to the unique presentation, the diagnosis is typically rarely made and there is little experience with treating it. We report two cases of common iliac artery pseudoaneurysm found in two patients who had no notable medical history and who we chose to repair through the endovascular technique in the first case, an approach that has gained more ground for vascular repair worldwide, making it the current go-to method, and for the second case we chose a more traditional approach, through open surgery.

Civilian vascular trauma, treatment and outcome at a level 1-trauma centre

BACKGROUND

Outcomes after vascular injuries in wartime are well documented, but studies on vascular injuries in a civilian European populations are scarce.

METHODS

A retrospective study on all adults admitted to a North-European level 1-trauma centre 2009-2018 with The Abbreviated Injury Scale-codes for non-iatrogenic vascular trauma (VT). Data were extracted from both national and regional trauma-registries, as well as patient charts. Patient demographics, mechanism, and location of vascular injury were registered as well as its treatment. Incidence and injury scores (ISS, NISS and TRISS) were calculated and overall survival (Kaplan-Meier) estimated.

RESULTS

Of 4042 trauma-patients, 68 (1.7%) (median age 44 years, 76% males) sustained 81 vascular injuries (69 arterial; 12 venous); 46 blunt and 22 (32%) penetrating injuries. The total incidence of vascular injuries was 1.45/100,000 inhabitants and did not change over the study-period (95% confidence interval 1.13-1.82). The injuries were located in thorax (n = 17), neck (n = 16) and abdominal region (n = 15); most of the blunt injuries followed traffic (n = 31) or falling accidents (n = 10), and with 17 of the 22 penetrating injuries due to stabbing. The median ISS and NISS-scores were 22 and 33, with 50 (74%) and 55 (81%) patients having scores > 15, respectively. Forty-three (63%) patients had open surgical repair and 8 (12%) received endovascular treatment. Twenty-one patients died within 30-days (31%), 33% and 27% after blunt and penetrating injuries, respectively. Half of the patients that died within 24 h sustained aortic injury.

CONCLUSIONS

Traumatic vascular injuries are rare in civilian settings and are less than 2% of major trauma admissions. These patients are often seriously injured and their treatment can be challenging with high 30-day mortality.

TRIAL REGISTRATION

Retrospectively registered.

Repair of a high-flow superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis

A 50-year-old patient had presented with recalcitrant right lower extremity venous stasis ulceration, atrial fibrillation, and congestive heart failure. He had a history of a gunshot wound to the right thigh >30 years previously, which had been managed without surgery. Computed tomography angiography indicated a fistulous communication between the right superficial femoral artery and vein with massively dilated right iliofemoral venous and arterial systems. He was treated with stent-graft coverage of the superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis. This stent-graft accommodated the diameter asymmetry in the superficial femoral artery caused by the long-standing fistula and ameliorated the symptoms that had afflicted him for decades.

Covered Endovascular Repair of Innominate Artery Bifurcation After Thoracic Blunt Trauma

Innominate artery (IA) injury is a rare entity with most patients dying before reaching the hospital. While open surgery remains the standard treatment, the endovascular approach is attractive as it may reduce perioperative morbidity and mortality. We report a case of IA blunt injury extending to the subclavian artery with pseudoaneurysm formation successfully treated with covered stenting of IA and its bifurcation. A 49-year-old male was admitted after suffering multiple trauma due to a high energy impact motorcycle crash. In the emergency room, the patient was hypotensive with a Glasgow coma score of 15. On physical examination, he had right peri-orbital ecchymosis, left otorrhagia and an open patella fracture. The computed tomographic angiography (CTA) revealed enlargement of the mediastinum and a 29 mm pseudoaneurysm involving the right brachiocephalic trunk and its bifurcation. Under general anesthesia, a covered balloon-expandable stent (CBES) was then placed in the IA followed by kissing stent of its bifurcation with an additional 2 covered balloon-expandable stents. Final subtraction angiography demonstrated complete pseudoaneurysm exclusion and stent patency without additional complications. No neurologic deficits or other intervention-related complications were found in the postoperative period. At 10 months follow-up, the patient remained asymptomatic and with palpable distal pulses. Endovascular management of IA injury may provide a good alternative to open surgery with low perioperative morbidity and mortality.

Blunt Traumatic Injury to the Superficial Femoral Artery in a Morbidly Obese Female: Case Report Using Endovascular Covered Stent Repair

Lower extremity vascular injuries following trauma are rare events that require prompt identification and management in order to prevent ischemia and limb loss. Endovascular approaches, rather than traditional open procedures, are increasingly used to treat a wide range of vascular disease. The use of endovascular repair for revascularization in the trauma setting is not routine but may provide an appealing alternative in select trauma patients and injuries. We present a case of successful endovascular repair with stent grafting of a superficial femoral artery intimal injury following a femur fracture in a 35-year-old morbidly obese female and review the current literature regarding the use of endovascular therapy in the trauma setting.

Blunt Aortic / Inferior Vena Cava Injury: Are We Consistently Providing the Same Level of Care?

Major vascular traumatic injuries have a higher pre-hospital and in-hospital mortality rate. The different mechanisms of injury and anatomy of the aorta and inferior vena cava (IVC) make the management a constant challenge to surgeons and clinicians. Blunt traumatic aortic injury (BTAI) can occur at the thoracic or abdominal level, each of which possesses different considerations. Blunt traumatic inferior vena cava injury (BTIVCI) also has important diagnostic challenges since the lesion may not be as evident in the IVC as compared to the aorta, possibly due to lower caval pressures or the ability to self-tamponade from adjacent structures. Endovascular management has significantly increased in the past years, and despite an improvement in mortality, the approach to aortic and IVC injuries is not well standardized. Diagnostic imaging helps to classify the extent of the lesions and guide towards the best therapeutic options for each case. Conservative management, in some cases, has shown to reduce mortality, and close follow-up has proven good outcomes. Future research will provide more evidence to determine the best approach to BTAI and BTIVCI for better long-term outcomes. This article aims to provide an updated review of the current literature regarding diagnosis, classification, and management of BTAI and BTIVCI.

In-hospital outcomes of patients with non-iatrogenic civilian vascular trauma

Background: Morbidity, lesion pattern, management and short-term outcomes of civilian vascular trauma are rarely evaluated. Therefore, analysis of in hospital results in patients with non-iatrogenic vascular trauma in a tertiary referral hospital was performed. Patients and methods: Retrospective evaluation of patients with vascular trauma from 2007-2017 was done. 48 patients (34 male, 14 females, mean age 56 years) were included. Excluded were patients with iatrogenic vascular complications. Major cause of vascular trauma were traffic accidents in 43.8 %, fall from great heights in 27.1 %, sport and home related injuries in 16.8 %, suicidal injuries in 4.2 % and gunshot wounds in 2.1 % (other 6.3 %). 60.4 % of patients presented with blunt, 39.6 % of patients with penetrating vascular trauma. More than half of the cases included polytraumatized patients (54.4 %). Results: Most commonly affected were the popliteal (25.0 %) and the axillar artery (18.8 %). Aortic injuries were present in 14.6 % of cases, whereas the femoral and subclavian artery were involved in 12.6 % and 10.4 %. Vascular reconstruction was performed by interposition graft in 45.9 %, direct suture in 18.8 %, patchplasty in 10.4 %, ligation in 12.4 %, and implantation of stentgraft in 12.5 %. Postoperative complication rate was 54.2 %. Rate of in-hospital major amputation was 14.6 % and in-hospital mortality was 14.6 % as well. Comparison between blunt and penetrating trauma as to postoperative complication (p = 0.322), blood transfusion (p = 0.452) and amputation (p = 0.304) showed no significant differences, whereas lethality in blunt trauma was 20.6 % vs. 5.2 % in penetrating trauma. Injury severity score (ISS) was significantly elevated for blunt trauma patients (mean ISS Score blunt 32 vs 21 penetrating, p = 0.043). Conclusions: The majority of vascular lesions is caused by blunt trauma. Blunt lesions do also show a severe injury pattern, compared to penetrating trauma, and the complication rate remains high. However, by means of vascular reconstruction, limb salvage is feasible in a high percentage of cases.