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Acute Endovascular Repair of Right Subclavian Arterial Perforation from Clavicular Fracture after Blunt Trauma
Volume 18
Number 5
Acute Endovascular Repair of Right Subclavian Arterial Perforation from Clavicular Fracture after Blunt Trauma From: Pål J. Stokkeland, MD Kjetil Soreide, MD Lars Fjetland, MD Departments of Interventional Radiology (P.J.S., L.F.) and Surgery (K.S.) Stavanger University Hospital POB 8100, N-4068 Stavanger, Norway Acute Care Medicine Research Network University of Stavanger Stavanger, Norway (K.S.) Editor: Injuries to the subclavian arteries are uncommon and most often attributed to penetrating trauma (1). On rare occasions, blunt trauma may be associated with subclavian vessel injuries with or without the development of a pseudoaneurysm and brachial plexus injury (1,2). Although clavicular fractures are usually uncomplicated, they may, on rare occasions, cause severe subclavian vessel injury—fatal outcomes have been reported. Thus, when a severe subclavian vessel injury is present, prompt repair of the injured vessel is essential. As such, endovascular techniques have emerged as an important potential alternative and may allow for a less invasive repair of vascular injuries by means of stent placement. However, although (chronic) pseudoaneurysms appear to be the most frequent indication, there are very few reports in the literature about the acutely employed endovascular stent-repair of subclavian artery injury from blunt trauma. Herein, we describe the successful acute endovascular repair of a right subclavian artery injury caused by a fractured clavicle after blunt trauma by using a retrograde brachial arterial access with a covered stent. An 80-year-old man with known chronic alcohol dependency, cerebral ischemia, and Wernicke encephalopathy sustained fractures of the right distal humerus, midshaft clavicle (with acromioclavicular dislocation), and 3rd rib after a fall from an unknown height. The fractures were treated conservatively with a collar and cuff sling. Five weeks later, he again presented to the hospital, after a fall, and was suspected of having a cerebral insult. This time, there was a large pulsating tumor overlying the right supraclavicular area. Ultrasonography and computed tomographic (CT) angiography helped confirm an active extravasation from the right subclavian artery, caused by a clavicular bone spike (Figure, parts a and b). At clinical examination, the patient had hypotenson and tachycardia. His hemoglobin level decreased from 125 g/L at admission to 90 g/L after the procedure. Because of the known comorbidities, he was considered a poor candidate for open
DOI: 10.1016/j.jvir.2007.02.027
Letters to the Editor
•
689
surgery. Thus, endovascular treatment was preferred. A covered stent-graft (Hemobahn, 10 –100 mm; W.L. Gore, Flagstaff, Ariz) was placed through a retrograde right brachial arterial access, and the bleeding was immediately occluded (Figure, parts b– d). The patient recovered uneventfully. During a follow-up of 14 months, no events related to the covered stent occurred. Subclavian vascular injuries are rare, especially after blunt trauma. To date, only a handful of cases have undergone endovascular treatment, with indications mainly due to the development of a pseudoaneurysm or penetrating trauma. We are aware of only one previous report about endovascular repair in the acute setting due to arterial subclavian bleeding after blunt trauma (3). The use of a retrograde brachial arterial access in the acute phase is (to our knowledge) not thoroughly described in the literature and poses an alternative route to direct endovascular repair of these injuries. In the particular setting of subclavian artery injury, the potential harm of using the longer, femoral arterial route, with manipulation in the aortic arch (and the common carotid arteries), may cause unnecessary risk for cerebral events. Conversely, the retrograde brachial route poses little risk, is feasible, and, in particular, is also available in the acute setting. It is, however, at the cost of the surgical principle of proximal control of the vascular lesion. Open surgical repair of the subclavian artery can be technically difficult due to the exposure required and the surrounding traumatized structures. Morbidity (eg, chronic upper-extremity neuropathy, reflex sympathetic dystrophy, or brachial plexus injury) may further worsen the clinical course (1). Recently, White et al (4) reported on 18 subclavian injuries treated with endovascular prosthesis, with good 1-year primary patency (86%). None of their patients required surgical bypass procedures. The endovascular approach with covered stents has been used to treat subclavian and axillary artery injuries, with good immediate and longterm results (4), offering an alternative to direct dissection in the zone of injury (5). This type of therapy should be particularly appealing when multiple traumatic injuries or medical co-morbid conditions exist. Moreover, it is feasible in the acute setting with use of the brachial retrograde arterial access, as demonstrated herein. References 1. Katras T, Baltazar U, Rush DS, et al. Subclavian arterial injury associated with blunt trauma. Vasc Surg 2001; 35:43–50. 2. Kidd JN, Drummond-Webb JJ, Vandevanter SH, et al. Proximal left subclavian artery disruption caused by blunt trauma in an adolescent: case report and review of the literature. J Trauma 2005; 58:845– 847. 3. Stockinger ZT, Townsend MC, McSwain NE, Jr, et al. Acute endovascular management of a subclavian artery injury. J La State Med Soc 2004; 156:262–264. 4. White R, Krajcer Z, Johnson M, et al. Results of a multicenter trial for the treatment of traumatic vascular injury with a covered stent. J Trauma 2006; 60:1189 –1195; discussion 1195–1186. 5. Castelli P, Caronno R, Piffaretti G, et al. Endovascular repair of traumatic injuries of the subclavian and axillary arteries. Injury 2005;3 6:778 –782.
690
•
Letters to the Editor
May 2007
JVIR
Figure. (a) Multi-section helical CT scan (anterior-oblique view) obtained with a volume-rendering technique shows a clavicular fracture and extravasation of contrast medium from the subclavian artery (arrow). (b) Digital subtraction angiogram (anteroposterior view) shows active bleeding (arrow) from the subclavian artery injury. (c) Digital subtraction angiogram (anteroposterior view) obtained after placement of a covered stent through a retrograde brachial access shows balloon inflation. (d) Digital subtraction angiogram (anteroposterior view) obtained after stent placement shows an open artery without bleeding.
Retrieval of a Tilted Recovery Filter from a Leftsided Inferior Vena Cava with a Loop Snare From: John R. Kachura, MD Vikram Venkatesh, BSc, MD Department of Medical Imaging Toronto General Hospital 200 Elizabeth St Toronto, Ontario, Canada M5G 2C4 Editor: Herein, we describe a case in which a Recovery nitinol filter (Bard Peripheral Vascular, Tempe, Ariz), positioned in the superior aspect of a left-sided inferior vena cava (IVC), was not amenable to removal with the Recovery Cone Re-
DOI: 10.1016/j.jvir.2007.02.028
moval System (Bard Peripheral Vascular). A loop snare was successfully used to retrieve the filter. A 66-year-old woman scheduled for surgical resection of a Pancoast tumor was discovered at preoperative contrast medium– enhanced computed tomography (CT) of the thorax to have asymptomatic left pulmonary artery thromboembolism. Abdominal and pelvic CT revealed a left-sided infrarenal IVC that emptied into the left renal vein, and no right-sided infrarenal IVC. The suprarenal IVC was rightsided. One day before surgery, a Recovery filter was deployed in the left-sided IVC with its tip at the level of the inferior aspect of the left renal vein. A right femoral approach was used. Nine days after filter insertion, anticoagulant therapy was prescribed and filter removal requested. Cavography revealed that the filter tip had tilted leftward into the inflow of the left renal vein and that at least one of the filter’s right lateral upper arms was now hooked into the inferior aspect of the outflow of the left renal vein (Figure, part a). Considering the anatomy, it was decided that attempts at retrieval using the Recovery Cone Removal Sys-
Number 5
Acute Endovascular Repair of Right Subclavian Arterial Perforation from Clavicular Fracture after Blunt Trauma From: Pål J. Stokkeland, MD Kjetil Soreide, MD Lars Fjetland, MD Departments of Interventional Radiology (P.J.S., L.F.) and Surgery (K.S.) Stavanger University Hospital POB 8100, N-4068 Stavanger, Norway Acute Care Medicine Research Network University of Stavanger Stavanger, Norway (K.S.) Editor: Injuries to the subclavian arteries are uncommon and most often attributed to penetrating trauma (1). On rare occasions, blunt trauma may be associated with subclavian vessel injuries with or without the development of a pseudoaneurysm and brachial plexus injury (1,2). Although clavicular fractures are usually uncomplicated, they may, on rare occasions, cause severe subclavian vessel injury—fatal outcomes have been reported. Thus, when a severe subclavian vessel injury is present, prompt repair of the injured vessel is essential. As such, endovascular techniques have emerged as an important potential alternative and may allow for a less invasive repair of vascular injuries by means of stent placement. However, although (chronic) pseudoaneurysms appear to be the most frequent indication, there are very few reports in the literature about the acutely employed endovascular stent-repair of subclavian artery injury from blunt trauma. Herein, we describe the successful acute endovascular repair of a right subclavian artery injury caused by a fractured clavicle after blunt trauma by using a retrograde brachial arterial access with a covered stent. An 80-year-old man with known chronic alcohol dependency, cerebral ischemia, and Wernicke encephalopathy sustained fractures of the right distal humerus, midshaft clavicle (with acromioclavicular dislocation), and 3rd rib after a fall from an unknown height. The fractures were treated conservatively with a collar and cuff sling. Five weeks later, he again presented to the hospital, after a fall, and was suspected of having a cerebral insult. This time, there was a large pulsating tumor overlying the right supraclavicular area. Ultrasonography and computed tomographic (CT) angiography helped confirm an active extravasation from the right subclavian artery, caused by a clavicular bone spike (Figure, parts a and b). At clinical examination, the patient had hypotenson and tachycardia. His hemoglobin level decreased from 125 g/L at admission to 90 g/L after the procedure. Because of the known comorbidities, he was considered a poor candidate for open
DOI: 10.1016/j.jvir.2007.02.027
Letters to the Editor
•
689
surgery. Thus, endovascular treatment was preferred. A covered stent-graft (Hemobahn, 10 –100 mm; W.L. Gore, Flagstaff, Ariz) was placed through a retrograde right brachial arterial access, and the bleeding was immediately occluded (Figure, parts b– d). The patient recovered uneventfully. During a follow-up of 14 months, no events related to the covered stent occurred. Subclavian vascular injuries are rare, especially after blunt trauma. To date, only a handful of cases have undergone endovascular treatment, with indications mainly due to the development of a pseudoaneurysm or penetrating trauma. We are aware of only one previous report about endovascular repair in the acute setting due to arterial subclavian bleeding after blunt trauma (3). The use of a retrograde brachial arterial access in the acute phase is (to our knowledge) not thoroughly described in the literature and poses an alternative route to direct endovascular repair of these injuries. In the particular setting of subclavian artery injury, the potential harm of using the longer, femoral arterial route, with manipulation in the aortic arch (and the common carotid arteries), may cause unnecessary risk for cerebral events. Conversely, the retrograde brachial route poses little risk, is feasible, and, in particular, is also available in the acute setting. It is, however, at the cost of the surgical principle of proximal control of the vascular lesion. Open surgical repair of the subclavian artery can be technically difficult due to the exposure required and the surrounding traumatized structures. Morbidity (eg, chronic upper-extremity neuropathy, reflex sympathetic dystrophy, or brachial plexus injury) may further worsen the clinical course (1). Recently, White et al (4) reported on 18 subclavian injuries treated with endovascular prosthesis, with good 1-year primary patency (86%). None of their patients required surgical bypass procedures. The endovascular approach with covered stents has been used to treat subclavian and axillary artery injuries, with good immediate and longterm results (4), offering an alternative to direct dissection in the zone of injury (5). This type of therapy should be particularly appealing when multiple traumatic injuries or medical co-morbid conditions exist. Moreover, it is feasible in the acute setting with use of the brachial retrograde arterial access, as demonstrated herein. References 1. Katras T, Baltazar U, Rush DS, et al. Subclavian arterial injury associated with blunt trauma. Vasc Surg 2001; 35:43–50. 2. Kidd JN, Drummond-Webb JJ, Vandevanter SH, et al. Proximal left subclavian artery disruption caused by blunt trauma in an adolescent: case report and review of the literature. J Trauma 2005; 58:845– 847. 3. Stockinger ZT, Townsend MC, McSwain NE, Jr, et al. Acute endovascular management of a subclavian artery injury. J La State Med Soc 2004; 156:262–264. 4. White R, Krajcer Z, Johnson M, et al. Results of a multicenter trial for the treatment of traumatic vascular injury with a covered stent. J Trauma 2006; 60:1189 –1195; discussion 1195–1186. 5. Castelli P, Caronno R, Piffaretti G, et al. Endovascular repair of traumatic injuries of the subclavian and axillary arteries. Injury 2005;3 6:778 –782.
690
•
Letters to the Editor
May 2007
JVIR
Figure. (a) Multi-section helical CT scan (anterior-oblique view) obtained with a volume-rendering technique shows a clavicular fracture and extravasation of contrast medium from the subclavian artery (arrow). (b) Digital subtraction angiogram (anteroposterior view) shows active bleeding (arrow) from the subclavian artery injury. (c) Digital subtraction angiogram (anteroposterior view) obtained after placement of a covered stent through a retrograde brachial access shows balloon inflation. (d) Digital subtraction angiogram (anteroposterior view) obtained after stent placement shows an open artery without bleeding.
Retrieval of a Tilted Recovery Filter from a Leftsided Inferior Vena Cava with a Loop Snare From: John R. Kachura, MD Vikram Venkatesh, BSc, MD Department of Medical Imaging Toronto General Hospital 200 Elizabeth St Toronto, Ontario, Canada M5G 2C4 Editor: Herein, we describe a case in which a Recovery nitinol filter (Bard Peripheral Vascular, Tempe, Ariz), positioned in the superior aspect of a left-sided inferior vena cava (IVC), was not amenable to removal with the Recovery Cone Re-
DOI: 10.1016/j.jvir.2007.02.028
moval System (Bard Peripheral Vascular). A loop snare was successfully used to retrieve the filter. A 66-year-old woman scheduled for surgical resection of a Pancoast tumor was discovered at preoperative contrast medium– enhanced computed tomography (CT) of the thorax to have asymptomatic left pulmonary artery thromboembolism. Abdominal and pelvic CT revealed a left-sided infrarenal IVC that emptied into the left renal vein, and no right-sided infrarenal IVC. The suprarenal IVC was rightsided. One day before surgery, a Recovery filter was deployed in the left-sided IVC with its tip at the level of the inferior aspect of the left renal vein. A right femoral approach was used. Nine days after filter insertion, anticoagulant therapy was prescribed and filter removal requested. Cavography revealed that the filter tip had tilted leftward into the inflow of the left renal vein and that at least one of the filter’s right lateral upper arms was now hooked into the inferior aspect of the outflow of the left renal vein (Figure, part a). Considering the anatomy, it was decided that attempts at retrieval using the Recovery Cone Removal Sys-