Endovascular management for subclavian atery injury
Case report
Endovascular Management for Subclavian Artery Injury with Aneurysmal Formation after Stab Wound Trauma Mahmoud Shabestari1MD, Aliasghar Moeinipour2 MD, Hamid Hoseinikhah3*MD
Abstract Endovascular intervention is an interesting alternative to conventional open surgical repair for a penetrated peripheral artery that has suitable anatomic criteria for percutaneous device treatment. Carotid and subclavian artery injury, especially at the base of the artery in proximity to the aortic arch, is a challenging anatomic position for surgical exposure. This is a situation where the use of endovascular intervention seems to be a good option. Endovascular treatment decreases the time of surgery, estimated bleeding, and iatrogenic complications, especially peripheral nerve injury, when compared with similar surgical modalities by limiting surgical dissection in the traumatized operative field. We describe a young man with a traumatic stab wound injury to the junction of the left subclavian artery and the carotid artery that was successfully managed with a covered stent. (Iranian Heart Journal 2014; 15(3): 44-46) Keywords:
Endovascular treatment
Angioplasty
Subclavian artery
1
Professor of Interventional Cardiology, Mashad University of Medical Sciences, Mashad, Iran. Assistant Professor of Cardiac Surgery, Mashad University of Medical Sciences, Mashad, Iran. Cardiac Surgeon, Mashad University of Medical Sciences, Mashad, Iran. Department of Cardiothoracic Surgery-Imam Reza Hospital, of Mashad Medical University Corresponding Author: Hamid Hoseinikhah E-mail:
[email protected] Tel:09153046163 Received: July 29, 2014; Accepted: October 4, 2014 2 3
24-year-old man was referred to our center because of a stab wound to the left side of the neck sustained one week earlier. At initial assessment, a thrill and bruit could be heard in the zone of the injury, and there was a pulsatile mass. Neurological and peripheral arterial examinations of the upper extremity were normal. For further evaluation, the patient was referred for computed tomographic (CT) angiography, which showed a huge aneurysm formation at the junction of the subclavian artery and the carotid artery that extended to the left
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hemithorax. After consultation with an interventional cardiologist and given the special site of the aneurysm and arterial injury, we decided to repair this injury via endovascular intervention. A stent graft was used for the repair of the base of the subclavian and carotid arteries in order to cover the injury site and the aneurysmal sac (Figures 1 and 2). At early and long-term follow-up of the patient, there were no neurological and vascular complications in the upper extremity.
Endovascular Management for Subclavian Artery Injury
Figure1. Large aneurysm in the left subclavian artery
Discussion he treatment of the injuries of the carotid and subclavian arteries (penetrating traumas) can pose a great challenge to surgeons even in the selective setting, where surgical exposure may require sternotomy or thoracotomy or a more difficult approach such as the trapdoor incision.1-3 Overall mortality, including deaths at the scene, is reported to be as high as 70% to 80% and, in patients surviving to the hospital, 5% to 15%.9 We and others have previously suggested that the endovascular option for such traumas in selected patients is a safe and effective method with no major complications and that it is a minimally invasive alternative to open repair. A large study confirmed this statement reporting a technical success rate of 100%, no procedure-related deaths or limb loss, and no neurological morbidity. A comparison of endovascular treatment for injury to the carotid and subclavian arteries with conventional open surgical repair demonstrated that early stent graft failure (within 30 days) occurred in 3 of 57 subclavian artery injuries (5%). A review of the literature on the open repair of subclavian artery injuries revealed that early failure rates reported by McKinley et al.6 (12 of 236 repairs) and Degiannis et al.7 (3 of 54 repairs) were about 5%. Overall, the early graft failure rate of the endovascular repair of this vessel compares favorably with open repair.
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Figure 2. Endovascular stent repair for the aneurysm of the subclavian artery
It is concluded that the stent graft management of selected carotid and subclavian artery injuries is safe with minimal morbidity and mortality rates and is as such comparable with open surgery. The long-term results demonstrated in this study are acceptable, and there are no published results available to provide any evidence that open surgery might be better. In fact, many authors believe that any patient stable enough to undergo angiography is a possible candidate for stent graft treatment if a carotid or subclavian artery injury is demonstrated. Emerging clinical contraindications to endovascular management include a large hematoma causing compression symptoms, concomitant injuries that warrant exploration in their own right (e.g. tracheal or esophageal injuries), and grossly infected wounds that might lead to graft sepsis. Technical restrictions include a significant luminal size discrepancy between the proximal and distal parts of the involved artery, leading to graft sizing difficulties, with the possibility of proximal endoleaks, or distal oversizing and vessel damage. This is especially problematic when treating chronic arteriovenous fistulae and can be partly overcome by using tapered stents. Other technical restrictions include an inability to traverse the lesion with a guide wire. This is a potential problem with old arteriovenous fistulae, false aneurysms, and arterial occlusions with widely displaced 45
Endovascular management for subclavian atery injury
proximal and distal arterial lumens.8-10 Femoral and brachial punctures with the snaring of the femoral guide wire in the lesion via the brachial approach may potentially address this problem. We believe that with improving endovascular techniques and increasing general acceptance of this modality, up to 50% of penetrating carotid and subclavian artery injuries can be treated endovascularly. This correlates well with a retrospective evaluation by Xenos et al.,11 demonstrating a 52% suitability rate of their patients for endovascular repair. Stent graft repair is now our first choice in the management of selected, stable patients with carotid and subclavian artery injuries. References 1.
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10. Sitsen ME, Ho GH, Blankensteijn JD. Deformation of self-expanding stent grafts complicating endovascular repair of peripheral aneurysms. J Endovasc Surg 1999;6:288-92. 11. Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J, Goldman D. Covered stents for injuries of the subclavian and axillary arteries. J Vasc Surg 2003;48:451-4.
