Selective Use of Endovascular Techniques in the Management of Vascular Trauma

The Characteristics and Results of Endovascular Devices in Trauma (CREDiT) study: Multi-institutional results

INTRODUCTION

Endovascular techniques are increasingly used to repair major traumatic vascular injuries, but most endovascular implants are not designed/approved for trauma-specific indications. No inventory guidelines exist for the devices used in these procedures. We aimed to describe the use and characteristics of endovascular implants used for repair of vascular injuries to allow for better inventory management.

METHODS

This CREDiT study is a six-year retrospective cohort analysis of endovascular procedures performed for repair of traumatic arterial injuries at five participating US trauma centers. For each treated vessel, procedural and device details were recorded and outcomes assessed with the aim of defining the range of implants and sizes used for these interventions.

RESULTS

A total of 94 cases were identified; 58 (61%) were descending thoracic aorta, 14 (15%) axillosubclavian, 5 carotid, 4 abdominal aortic, 4 common iliac, 7 femoropopliteal, and 1 renal. Vascular surgeons performed 54% of cases, trauma surgeons 17%, IR/CT Surgery 29%. Systemic heparin was administered in 68% and procedures were performed a median of 9 h after arrival (IQR 3-24 h). Primary arterial access was femoral in 93% of cases, 49% were bilateral. Brachial/radial access was used primarily in 6 cases, and secondary to femoral in 9. The most common implant was self-expanding stent graft; 18% used >1 stent. Implants ranged in diameter and length based on vessel size. Five of 94 implants underwent reintervention (1 open surgery) at a median of 4d postop (range 2-60d). Two occlusions and 1 stenosis were present at follow-up at a median of 1 month (range 0-72 m).

CONCLUSIONS

Endovascular reconstruction of injured arteries requires a broad range of implant types, diameters, and lengths which should be readily available in trauma centers. Stent occlusions/stenoses are rare and can typically be managed by endovascular means.

Penetrating Vertebral Artery Injuries: A Literature Review and Proposed Treatment Algorithm

BACKGROUND

Penetrating vertebral artery injuries (VAIs) are rare but devastating trauma for which the approach to treatment varies greatly. The literature on treatment modalities is limited to case reports, case series, and 1 review, with the majority of cases being treated surgically. However, with the advent of digital subtraction angiography, treatment has shifted toward less invasive endovascular modalities that allows one to assess the flow and risks of sacrificing the vertebral artery (VA).

METHODS

In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review of VAI was performed. Two case reports were also detailed. Using a multidisciplinary team, a decision algorithm was proposed for approaching penetrating VAIs.

RESULTS

We identified 169 patients. Of the penetrating VAI, the majority were occlusions, most commonly managed conservatively. Other injuries including pseudoaneurysm, dissection, transection, and arterial-venous fistula were treated predominantly endovascularly and occasionally with the surgical exploration/ligation. Most endovascular treatments included embolization without significant stroke or complication from VA sacrifice. However, there are incidences in which VA sacrifice should be avoided and these scenarios can be better delineated with digital subtraction angiography to assess flow and anatomy.

CONCLUSIONS

This systematic review not only details the updated treatment options but also provides a decision algorithm for the treatment of penetrating VAI. It highlights the shifting treatment options of penetrating VAI to endovascular therapy, as well as details VAI variants that may suggest stenting over embolization.

Endovascular Therapy And Controversies In The Management Of Vascular Trauma

Aim:

To review the advent of endovascular treatment of vascular injuries and its controversies.

Methods:

Literature review over the past 13 years using the PubMed search engine.

Results:

The management of vascular trauma has changed dramatically over the last decade. This is mainly due to the advent of advanced endovascular techniques and technologies. There are, however, a limited number of publications with a correspondingly small number of patients and lack of long-term follow-up. In this article, we discuss the injuries to different vessel groups and their respective endovascular approaches. Of the literature available, the endovascular management of aortic injuries still holds the most experience and has shown favorable results.

Conclusion:

Endovascular management of vascular injuries is a new addition to the armamentarium of the surgeon. The fact that it is minimally invasive is a major advantage and the published data are encouraging. However, in order to determine which anatomical sites and circumstances are most appropriate for this method versus open surgery, more reports are necessary.