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Endovascular Covered Stent Repair of an Iatrogenic Subclavian Artery–to–Pulmonary Artery Fistula and Pseudoaneurysm
Endovascular Covered Stent Repair of an Iatrogenic Subclavian Artery–to–Pulmonary Artery Fistula and Pseudoaneurysm Shane C. Wheeler, MD, Kenneth M. Zinn, MD, and Terence W. Hughes, MD
An iatrogenic fistula and consequent pseudoaneurysm developed between the right subclavian artery and right pulmonary artery as a result of misplacement of a hemodialysis access catheter. The patient, who was considered to be at high risk for surgical repair, successfully underwent endovascular treatment that involved insertion of two nitinol stents covered with expanded polytetrafluoroethylene (stent-grafts), one into the right subclavian artery and the other into a right upper lobe pulmonary artery. Multi– detector row computed tomographic angiography played an integral role in the evaluation of the patient’s vascular injury and treatment planning. J Vasc Interv Radiol 2007; 18:775–779
THE placement of central venous and arterial catheters is associated with several types of complications, although catheter-induced fistulas and pseudoaneurysms are uncommon (1– 4). Successful endovascular repair (stent-grafting) of iatrogenic vascular injuries and vascular injuries resulting from trauma (ie, gunshot wounds or motor vehicle accidents) has been reported (2,3,5– 8). Herein, we describe a case in which a catheter-induced subclavian artery–to–pulmonary artery fistula with an associated large pseudoaneurysm was successfully treated percutaneously, in a staged fashion, with the placement of two covered stent-grafts. Multi– detector row computed tomographic (CT) angiography was crucial in the evaluation and treatment of the patient.
From the Department of Interventional Radiology, Bridgeport Hospital/Yale New Haven Health, 267 Grant St, Bridgeport, CT 06610. Received August 11, 2006; final revision received February 20, 2007; accepted February 22, 2007. Address correspondence to S.W.; E-mail:[email protected] None of the authors has identified a conflict of interest. © SIR, 2007 DOI: 10.1016/j.jvir.2007.02.029
CASE REPORT Given that this case report involved the collection of existing data, documents, and records in a retrospective manner, it was exempt from internal review board approval at our institution. A 77-year-old woman with a history of enterococcal endocarditis and associated mitral valve disease, endstage renal disease, hypertension, and diabetes was transferred to our hospital from another institution for evaluation and management of a vascular complication related to the placement of a hemodialysis catheter. She had initially presented to the other institution with diarrhea and other nonspecific complaints and was subsequently found to have methicillin-resistant Staphylococcus aureus bacteremia. During that admission, a dialysis catheter was placed, at the bedside, into the right subclavian vein; however, it did not function. A chest radiograph showed that the catheter tip was not in its expected location, projecting too medially in the chest. The catheter was removed, and the patient became hemodynamically unstable. Because this occurred at another institution, the exact steps in stabilizing the patient are not known. It can be assumed that the
patient was stabilized before further imaging. Subsequently, a magnetic resonance (MR) angiogram was obtained. An MR angiogram was likely chosen secondary to the patient’s endstage renal disease. The study revealed a large mediastinal hematoma and suggested the presence of a fistula between the right subclavian artery and the right pulmonary artery. The patient was transferred to our institution for management of this complication. Hard-copy films from the transferring institution were not available at transfer. Thus, shortly after the patient’s admission to our hospital, multi– detector row CT angiography of the chest was performed to assess the complications. The CT angiogram demonstrated the presence of a fistulous tract between the right subclavian artery and the right pulmonary artery (Fig 1). Along this tract, a large irregular mediastinal pseudoaneurysm, with a maximum transverse diameter of 4.3 cm, was observed posteromedial to the superior vena cava and ascending aorta. The pseudoaneurysm was directly adjacent to a branch of a right upper lobe pulmonary artery. Treatment options were discussed with the patient’s primary physician and cardiothoracic surgery and interventional
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Repair of a Subclavian Artery–to–Pulmonary Artery Fistula
June 2007
JVIR
Figure 3. Arteriogram (delayed imaging) shows direct communication between the proximal right subclavian artery and the right pulmonary artery. Contrast medium is seen in a superior branch of Figure 1. Coronal multi– detector row CT angiogram shows a the right pulmonary artery (arrows). fistula (arrow) from the right subclavian artery to the right pulmonary artery.
Figure 4. Arteriogram shows the stent-graft in the proximal right Figure 2. Arteriogram shows extravasation of contrast medium subclavian artery after balloon dilation. The arrow is pointing to from the proximal segment of the right subclavian artery (arrow). the stent-graft in the region of previous extravasation.
radiology physicians. The consensus was that the patient was a poor surgical candidate because of her underlying valvular heart disease and that percutaneous management should be pursued. The patient presented to the interventional radiology suite for assessment and possible management. Informed consent for diagnostic arteriography and possible intervention, including stent placement
or coil embolization, was obtained after a detailed discussion with the patient and her family. An arteriogram demonstrated extravasation of contrast medium from the proximal segment of the right subclavian artery, just distal to the thyrocervical trunk and the right internal mammary artery (Fig 2). As the earlier CT angiogram had indicated, the extravasation extended centrally into the
mediastinum. At delayed angiographic imaging (Fig 3), the branches of the right pulmonary artery were faintly visualized, proving the presence of a direct communication between the two vessels, that is, the fistula. The associated large pseudoaneurysm was clearly evident and was also shown on the CT angiogram (Figs 5 and 6). On the basis of these findings, it was decided that insertion of a cov-
Volume 18
Number 6
Wheeler et al
•
777
Figure 5. Coronal CT angiogram shows a large mediastinal pseu- Figure 6. Arteriogram shows filling of the pseudoaneurysm (ardoaneurysm from the right upper lobe pulmonary artery. The thin rows) with contrast medium in a superior segment of the right arrow indicates the neck of the pseudoaneurysm, and the thick pulmonary artery. arrow indicates the pseudoaneurysm itself.
ered stent would be the most appropriate management for the subclavian arterial injury. It was thought that treating the high-pressure subclavian artery injury might permit the lowerpressure pulmonary artery defect to close. Therefore, under fluoroscopic guidance through a left common femoral sheath (9-F Pinnacle sheath; Boston Scientific, Natick, Mass), an 8 mm ⫻ 2.5-cm nitinol self-expanding, polytetrafluoroethylene-covered stent (Gore Viabahn Endoprosthesis; WL Gore, Flagstaff, Ariz) was advanced to the right subclavian artery and deployed. The stent was then dilated to 8 mm by using an 8 mm ⫻ 4-cm balloon dilation catheter (Ultrathin SDS; Boston Scientific Vascular, Natick, Mass). A postdeployment arteriogram showed no residual extravasation of contrast medium from this site (Fig 4). Forty-eight hours after the insertion of the covered stent, a follow-up CT angiogram showed that the large mediastinal pseudoaneurysm had slightly increased in size, from 2.4 to 2.9 cm in the transverse dimension (Fig 5). The patient presented to the interventional radiology suite for treatment, and informed consent was again obtained. A selective right pulmonary angiogram
was obtained with a right femoral vein approach. The study demonstrated the specific site of extravasation from a proximal right upper pulmonary artery, filling the large mediastinal pseudoaneurysm observed at CT angiography (Fig 6). With use of a directional catheter (4.1-F Davis catheter; Merit Medical, South Jordan, Utah), multiple attempts were made to cannulate the vascular defect in the pulmonary artery for possible embolization. However, the catheter could not be safely seated within the neck of the pseudoaneurysm to proceed with embolization. Therefore, stent-graft placement was believed to be the best treatment option. A second Viabahn stent-graft (6 mm ⫻ 2.5 cm) was advanced over a 0.025-inch stiff guide wire and deployed across the region of extravasation. The covered stent was then dilated with a 6 mm ⫻ 2-cm balloon dilation catheter (Ultrathin SDS) to its maximal diameter, which had been deemed an appropriate size for this pulmonary artery (Fig 7). Postdeployment arteriography showed no residual filling of the pseudoaneurysm sac. The patient tolerated the procedure well, with no associated complica-
tions. Chest CT angiography performed 48 hours later showed no persistent filling or increase in the size of the pseudoaneurysm (Fig 8). Subsequent follow-up CT angiograms obtained the next week continued to demonstrate that both of the stent-grafts were patent and that the pseudoaneurysm had stabilized. The patient was discharged home, able to return to her pretreatment lifestyle. She died about 3 months later of cardiac valvular disease.
DISCUSSION In our patient, an iatrogenic injury resulting from insertion of a venous access catheter for dialysis access was repaired successfully with an endovascular stent-graft. Before advancements in endovascular technique, most iatrogenic fistulas and pseudoaneurysms due to central line placement were treated by means of direct surgical ligation after a median sternotomy, thoracotomy, or clavicular resection. Especially in patients who are poor surgical candidates, perhaps because of multiple concomitant disorders, a minimally invasive approach is the only option. Multi– detector row CT angiography, used with recon-
778
•
Repair of a Subclavian Artery–to–Pulmonary Artery Fistula
Figure 7. Arteriogram from a right upper pulmonary artery injection shows the pulmonary artery stent-graft (arrow) after balloon dilation.
Figure 8. Coronal CT angiogram obtained 48 hours after the placement of the stent-graft in a superior segment of the right pulmonary artery. There is no further evidence of contrast medium filling the pseudoaneurysm (arrows).
structed and reformatted images, is evolving to be the method of choice for the pre- and posttreatment evaluation of both traumatic and disease-related vascular abnormalities (1). Endovascular stent-grafts have been used successfully to treat a variety of lesions of the major vessels, including fistulas due to trauma. Du Toit et al (8) used a Viabahn or Wallgraft (Boston
Scientific) endoprosthesis in 12 patients with a stab or gunshot wound affecting the subclavian, common carotid, or internal carotid arteries. All but one of the covered stents remained patent during a mean follow-up period of 21 months. Successful stentgraft treatment of iatrogenic injury to the subclavian artery related to placement of a central venous catheter was
June 2007
JVIR
described by Bartorelli et al (7) (who also used a Viabahn device) and by Nicholson et al (3). Wicky et al (9) reported the use of a covered endoprosthesis to treat a large subclavian artery pseudoaneurysm that resulted from several unsuccessful attempts to catheterize the right subclavian vein for dialysis access. Parodi (10) treated six patients who had systemic artery– to–systemic vein arteriovenous fistulas with percutaneous insertion of a stent-graft. An extensive literature search found no previous reports of elective placement of a stent-graft in the native pulmonary artery, as was done during the second endovascular procedure in our patient. The advantages of covered stent repair of arterial lesions include the elimination of risks associated with surgery, especially hemorrhage and injury to surrounding structures. Avoidance of surgery is especially important in patients who have multiple underlying medical problems or serious injuries. Although the follow-up in our case was limited, previous reports have indicated that stent-grafts used to treat injuries of major arteries have good patency (5– 8,10). Determination of the precise role of endovascular treatment of traumatic vascular lesions would require a randomized trial comparing this therapy with surgery. The advantages of CT angiography in the assessment of vascular disorders include its reliability, speed, safety, and noninvasive nature (1). Shorter scanning times, combined with three-dimensional volume rendering, provide excellent simultaneous visualization of contrast-enhanced vessels and surrounding tissues. This can facilitate early diagnosis, eliminating the risk associated with the alternative of conventional angiography, and decrease costs. CT angiography has been shown to be an excellent method for detecting pulmonary artery pseudoaneurysms, mediastinal hematomas, and subclavian artery injuries (1). CT angiography was crucial in this case in that it provided information as to the presence of the fistula to the right pulmonary artery. This was only faintly seen at digital catheter angiography and could have been overlooked if not suggested at CT angiography. In addition, CT angiography permitted noninvasive monitoring of the size and extent of the pseudoaneurysm as well as the presence of any persistent extravasation. As
Volume 18
Number 6
stated, CT angiography played a crucial role in the treatment and care of this patient. References 1. Alkadhi H, Wildermuth S, Desbiolles L, et al. Vascular emergencies of the thorax after blunt and iatrogenic trauma: multi– detector row CT and threedimensional imaging. Radiographics 2004; 24:1239 –1255. 2. Finlay DJ, Sanchez LA, Sicard GA. Subclavian artery injury, vertebral artery dissection and arteriovenous fistulae following attempt at central line placement. Ann Vasc Surg 2002; 16: 774 –778. 3. Nicholson T, Ettles D, Robinson G. Managing inadvertent arterial catheterization during central venous access
Wheeler et al
4.
5.
6.
7.
procedures. Cardiovasc Intervent Radiol 2004; 27:21–25. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331: 1735–1738. Patel AV, Marin ML, Veith FJ, Kerr A, Sanchez LA. Endovascular graft repair of penetrating subclavian artery injuries. J Endovasc Surgery 1996; 3: 382–388. Auf der Maur, Chatterjee T, Erne P. Percutaneous transcatheter closure of coronary-pulmonary artery fistula using polytetrafluoroethylene-covered graft stents. J Invasive Cardiol 2004; 16:386 – 388. Bartorelli AL, Trabattoni D, Agrifoglio M, Galli S, Grancini L, Spirito R.
•
779
Endovascular repair of iatrogenic subclavian artery perforations using the Hemobahn stent-graft. J Endovasc Ther 2001; 8:471– 421. 8. DuToit DF, Leith JG, Strauss DC, Blaszczyk M, Odendaal J de V, Warren BL. Endovascular management of traumatic cervicothoracic arteriovenous fistula. Br J Surg 2003; 90: 1516 –1521. 9. Wicky S, Meuwly JV, Doenz F, Uské A, Schnyder P, Denys A. Life-threatening vascular complications after central venous catheter placement. Eur Radiol 2002; 12:901–907. 10. Parodi JC. Endovascular repair of aortic aneurysms, arteriovenous fistulas, and false aneurysms. World J Surg 1996; 20:655– 663.
An iatrogenic fistula and consequent pseudoaneurysm developed between the right subclavian artery and right pulmonary artery as a result of misplacement of a hemodialysis access catheter. The patient, who was considered to be at high risk for surgical repair, successfully underwent endovascular treatment that involved insertion of two nitinol stents covered with expanded polytetrafluoroethylene (stent-grafts), one into the right subclavian artery and the other into a right upper lobe pulmonary artery. Multi– detector row computed tomographic angiography played an integral role in the evaluation of the patient’s vascular injury and treatment planning. J Vasc Interv Radiol 2007; 18:775–779
THE placement of central venous and arterial catheters is associated with several types of complications, although catheter-induced fistulas and pseudoaneurysms are uncommon (1– 4). Successful endovascular repair (stent-grafting) of iatrogenic vascular injuries and vascular injuries resulting from trauma (ie, gunshot wounds or motor vehicle accidents) has been reported (2,3,5– 8). Herein, we describe a case in which a catheter-induced subclavian artery–to–pulmonary artery fistula with an associated large pseudoaneurysm was successfully treated percutaneously, in a staged fashion, with the placement of two covered stent-grafts. Multi– detector row computed tomographic (CT) angiography was crucial in the evaluation and treatment of the patient.
From the Department of Interventional Radiology, Bridgeport Hospital/Yale New Haven Health, 267 Grant St, Bridgeport, CT 06610. Received August 11, 2006; final revision received February 20, 2007; accepted February 22, 2007. Address correspondence to S.W.; E-mail:[email protected] None of the authors has identified a conflict of interest. © SIR, 2007 DOI: 10.1016/j.jvir.2007.02.029
CASE REPORT Given that this case report involved the collection of existing data, documents, and records in a retrospective manner, it was exempt from internal review board approval at our institution. A 77-year-old woman with a history of enterococcal endocarditis and associated mitral valve disease, endstage renal disease, hypertension, and diabetes was transferred to our hospital from another institution for evaluation and management of a vascular complication related to the placement of a hemodialysis catheter. She had initially presented to the other institution with diarrhea and other nonspecific complaints and was subsequently found to have methicillin-resistant Staphylococcus aureus bacteremia. During that admission, a dialysis catheter was placed, at the bedside, into the right subclavian vein; however, it did not function. A chest radiograph showed that the catheter tip was not in its expected location, projecting too medially in the chest. The catheter was removed, and the patient became hemodynamically unstable. Because this occurred at another institution, the exact steps in stabilizing the patient are not known. It can be assumed that the
patient was stabilized before further imaging. Subsequently, a magnetic resonance (MR) angiogram was obtained. An MR angiogram was likely chosen secondary to the patient’s endstage renal disease. The study revealed a large mediastinal hematoma and suggested the presence of a fistula between the right subclavian artery and the right pulmonary artery. The patient was transferred to our institution for management of this complication. Hard-copy films from the transferring institution were not available at transfer. Thus, shortly after the patient’s admission to our hospital, multi– detector row CT angiography of the chest was performed to assess the complications. The CT angiogram demonstrated the presence of a fistulous tract between the right subclavian artery and the right pulmonary artery (Fig 1). Along this tract, a large irregular mediastinal pseudoaneurysm, with a maximum transverse diameter of 4.3 cm, was observed posteromedial to the superior vena cava and ascending aorta. The pseudoaneurysm was directly adjacent to a branch of a right upper lobe pulmonary artery. Treatment options were discussed with the patient’s primary physician and cardiothoracic surgery and interventional
775
776
•
Repair of a Subclavian Artery–to–Pulmonary Artery Fistula
June 2007
JVIR
Figure 3. Arteriogram (delayed imaging) shows direct communication between the proximal right subclavian artery and the right pulmonary artery. Contrast medium is seen in a superior branch of Figure 1. Coronal multi– detector row CT angiogram shows a the right pulmonary artery (arrows). fistula (arrow) from the right subclavian artery to the right pulmonary artery.
Figure 4. Arteriogram shows the stent-graft in the proximal right Figure 2. Arteriogram shows extravasation of contrast medium subclavian artery after balloon dilation. The arrow is pointing to from the proximal segment of the right subclavian artery (arrow). the stent-graft in the region of previous extravasation.
radiology physicians. The consensus was that the patient was a poor surgical candidate because of her underlying valvular heart disease and that percutaneous management should be pursued. The patient presented to the interventional radiology suite for assessment and possible management. Informed consent for diagnostic arteriography and possible intervention, including stent placement
or coil embolization, was obtained after a detailed discussion with the patient and her family. An arteriogram demonstrated extravasation of contrast medium from the proximal segment of the right subclavian artery, just distal to the thyrocervical trunk and the right internal mammary artery (Fig 2). As the earlier CT angiogram had indicated, the extravasation extended centrally into the
mediastinum. At delayed angiographic imaging (Fig 3), the branches of the right pulmonary artery were faintly visualized, proving the presence of a direct communication between the two vessels, that is, the fistula. The associated large pseudoaneurysm was clearly evident and was also shown on the CT angiogram (Figs 5 and 6). On the basis of these findings, it was decided that insertion of a cov-
Volume 18
Number 6
Wheeler et al
•
777
Figure 5. Coronal CT angiogram shows a large mediastinal pseu- Figure 6. Arteriogram shows filling of the pseudoaneurysm (ardoaneurysm from the right upper lobe pulmonary artery. The thin rows) with contrast medium in a superior segment of the right arrow indicates the neck of the pseudoaneurysm, and the thick pulmonary artery. arrow indicates the pseudoaneurysm itself.
ered stent would be the most appropriate management for the subclavian arterial injury. It was thought that treating the high-pressure subclavian artery injury might permit the lowerpressure pulmonary artery defect to close. Therefore, under fluoroscopic guidance through a left common femoral sheath (9-F Pinnacle sheath; Boston Scientific, Natick, Mass), an 8 mm ⫻ 2.5-cm nitinol self-expanding, polytetrafluoroethylene-covered stent (Gore Viabahn Endoprosthesis; WL Gore, Flagstaff, Ariz) was advanced to the right subclavian artery and deployed. The stent was then dilated to 8 mm by using an 8 mm ⫻ 4-cm balloon dilation catheter (Ultrathin SDS; Boston Scientific Vascular, Natick, Mass). A postdeployment arteriogram showed no residual extravasation of contrast medium from this site (Fig 4). Forty-eight hours after the insertion of the covered stent, a follow-up CT angiogram showed that the large mediastinal pseudoaneurysm had slightly increased in size, from 2.4 to 2.9 cm in the transverse dimension (Fig 5). The patient presented to the interventional radiology suite for treatment, and informed consent was again obtained. A selective right pulmonary angiogram
was obtained with a right femoral vein approach. The study demonstrated the specific site of extravasation from a proximal right upper pulmonary artery, filling the large mediastinal pseudoaneurysm observed at CT angiography (Fig 6). With use of a directional catheter (4.1-F Davis catheter; Merit Medical, South Jordan, Utah), multiple attempts were made to cannulate the vascular defect in the pulmonary artery for possible embolization. However, the catheter could not be safely seated within the neck of the pseudoaneurysm to proceed with embolization. Therefore, stent-graft placement was believed to be the best treatment option. A second Viabahn stent-graft (6 mm ⫻ 2.5 cm) was advanced over a 0.025-inch stiff guide wire and deployed across the region of extravasation. The covered stent was then dilated with a 6 mm ⫻ 2-cm balloon dilation catheter (Ultrathin SDS) to its maximal diameter, which had been deemed an appropriate size for this pulmonary artery (Fig 7). Postdeployment arteriography showed no residual filling of the pseudoaneurysm sac. The patient tolerated the procedure well, with no associated complica-
tions. Chest CT angiography performed 48 hours later showed no persistent filling or increase in the size of the pseudoaneurysm (Fig 8). Subsequent follow-up CT angiograms obtained the next week continued to demonstrate that both of the stent-grafts were patent and that the pseudoaneurysm had stabilized. The patient was discharged home, able to return to her pretreatment lifestyle. She died about 3 months later of cardiac valvular disease.
DISCUSSION In our patient, an iatrogenic injury resulting from insertion of a venous access catheter for dialysis access was repaired successfully with an endovascular stent-graft. Before advancements in endovascular technique, most iatrogenic fistulas and pseudoaneurysms due to central line placement were treated by means of direct surgical ligation after a median sternotomy, thoracotomy, or clavicular resection. Especially in patients who are poor surgical candidates, perhaps because of multiple concomitant disorders, a minimally invasive approach is the only option. Multi– detector row CT angiography, used with recon-
778
•
Repair of a Subclavian Artery–to–Pulmonary Artery Fistula
Figure 7. Arteriogram from a right upper pulmonary artery injection shows the pulmonary artery stent-graft (arrow) after balloon dilation.
Figure 8. Coronal CT angiogram obtained 48 hours after the placement of the stent-graft in a superior segment of the right pulmonary artery. There is no further evidence of contrast medium filling the pseudoaneurysm (arrows).
structed and reformatted images, is evolving to be the method of choice for the pre- and posttreatment evaluation of both traumatic and disease-related vascular abnormalities (1). Endovascular stent-grafts have been used successfully to treat a variety of lesions of the major vessels, including fistulas due to trauma. Du Toit et al (8) used a Viabahn or Wallgraft (Boston
Scientific) endoprosthesis in 12 patients with a stab or gunshot wound affecting the subclavian, common carotid, or internal carotid arteries. All but one of the covered stents remained patent during a mean follow-up period of 21 months. Successful stentgraft treatment of iatrogenic injury to the subclavian artery related to placement of a central venous catheter was
June 2007
JVIR
described by Bartorelli et al (7) (who also used a Viabahn device) and by Nicholson et al (3). Wicky et al (9) reported the use of a covered endoprosthesis to treat a large subclavian artery pseudoaneurysm that resulted from several unsuccessful attempts to catheterize the right subclavian vein for dialysis access. Parodi (10) treated six patients who had systemic artery– to–systemic vein arteriovenous fistulas with percutaneous insertion of a stent-graft. An extensive literature search found no previous reports of elective placement of a stent-graft in the native pulmonary artery, as was done during the second endovascular procedure in our patient. The advantages of covered stent repair of arterial lesions include the elimination of risks associated with surgery, especially hemorrhage and injury to surrounding structures. Avoidance of surgery is especially important in patients who have multiple underlying medical problems or serious injuries. Although the follow-up in our case was limited, previous reports have indicated that stent-grafts used to treat injuries of major arteries have good patency (5– 8,10). Determination of the precise role of endovascular treatment of traumatic vascular lesions would require a randomized trial comparing this therapy with surgery. The advantages of CT angiography in the assessment of vascular disorders include its reliability, speed, safety, and noninvasive nature (1). Shorter scanning times, combined with three-dimensional volume rendering, provide excellent simultaneous visualization of contrast-enhanced vessels and surrounding tissues. This can facilitate early diagnosis, eliminating the risk associated with the alternative of conventional angiography, and decrease costs. CT angiography has been shown to be an excellent method for detecting pulmonary artery pseudoaneurysms, mediastinal hematomas, and subclavian artery injuries (1). CT angiography was crucial in this case in that it provided information as to the presence of the fistula to the right pulmonary artery. This was only faintly seen at digital catheter angiography and could have been overlooked if not suggested at CT angiography. In addition, CT angiography permitted noninvasive monitoring of the size and extent of the pseudoaneurysm as well as the presence of any persistent extravasation. As
Volume 18
Number 6
stated, CT angiography played a crucial role in the treatment and care of this patient. References 1. Alkadhi H, Wildermuth S, Desbiolles L, et al. Vascular emergencies of the thorax after blunt and iatrogenic trauma: multi– detector row CT and threedimensional imaging. Radiographics 2004; 24:1239 –1255. 2. Finlay DJ, Sanchez LA, Sicard GA. Subclavian artery injury, vertebral artery dissection and arteriovenous fistulae following attempt at central line placement. Ann Vasc Surg 2002; 16: 774 –778. 3. Nicholson T, Ettles D, Robinson G. Managing inadvertent arterial catheterization during central venous access
Wheeler et al
4.
5.
6.
7.
procedures. Cardiovasc Intervent Radiol 2004; 27:21–25. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331: 1735–1738. Patel AV, Marin ML, Veith FJ, Kerr A, Sanchez LA. Endovascular graft repair of penetrating subclavian artery injuries. J Endovasc Surgery 1996; 3: 382–388. Auf der Maur, Chatterjee T, Erne P. Percutaneous transcatheter closure of coronary-pulmonary artery fistula using polytetrafluoroethylene-covered graft stents. J Invasive Cardiol 2004; 16:386 – 388. Bartorelli AL, Trabattoni D, Agrifoglio M, Galli S, Grancini L, Spirito R.
•
779
Endovascular repair of iatrogenic subclavian artery perforations using the Hemobahn stent-graft. J Endovasc Ther 2001; 8:471– 421. 8. DuToit DF, Leith JG, Strauss DC, Blaszczyk M, Odendaal J de V, Warren BL. Endovascular management of traumatic cervicothoracic arteriovenous fistula. Br J Surg 2003; 90: 1516 –1521. 9. Wicky S, Meuwly JV, Doenz F, Uské A, Schnyder P, Denys A. Life-threatening vascular complications after central venous catheter placement. Eur Radiol 2002; 12:901–907. 10. Parodi JC. Endovascular repair of aortic aneurysms, arteriovenous fistulas, and false aneurysms. World J Surg 1996; 20:655– 663.