Endovascular repair of brachial artery transection associated with trauma

Resuscitation and Preparation of the Emergency General Surgery Patient

Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.

Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.

Life and Limb: Current Concepts in Endovascular Treatment of Extremity Trauma

Traumatic injury is the leading cause of death worldwide in younger patient populations and extremity trauma with associated vascular injury accounts for many trauma-related deaths. Iatrogenic injury is also a common cause of extremity vascular trauma and the incidence of iatrogenic injury will likely increase as endovascular techniques continue to become more ubiquitous. For many vascular injuries involving the extremities, surgical repair is viewed as the standard of care. Historically, endovascular techniques did not play a role in the treatment of these vascular injuries, rather they were utilized only as part of the diagnostic assessment; however, there is an increasing trend toward endovascular management of extremity vascular trauma. No validated, widely implemented algorithm to select patients for endovascular intervention exists. Transcatheter techniques, however, play an important role in the management of these patients. For arterial injuries, embolization can be used to rapidly achieve hemostasis if the vessel can be sacrificed. More advanced endovascular techniques such as stent-graft placement may be best employed in the context of isolated, proximal extremity injuries, although there is increasing literature supporting the use of advanced techniques for more distal arterial injuries. The management of peripheral venous trauma remains controversial; however, there is growing data describing successful endovascular management of some peripheral venous injuries. The purpose of this article is to review extremity vascular trauma, concepts of injury triage, endovascular techniques, and intraprocedural considerations.

Penetrating Extremity Trauma Endovascular versus Open Repair?

Penetrating extremity trauma (PET) accounts for an estimated 5-15% of trauma with vascular injury and these injuries are accountable for a significant percentage of trauma-related deaths. Historically, vascular injuries were best treated by open repair. While a defined selection criteria and a comprehensive algorithm have not been validated, the advancement of endovascular techniques, embolotherapy, and stent grafting have become viable options for the treatment of penetrating arterial extremity trauma in select patients. Advantages endovascular repair offers include decreasing mortality and morbidity associated with open repair, decreasing blood loss, decreasing iatrogenic injury such as nerve injury, and lower rate of wound infection. Patients stability, type of vascular injury, and lesion location are main factors help deciding between endovascular and open repair. Patient selection between endovascular and open repair should be determined by on a case-by-case situation, individual hospital guidelines, a multidisciplinary approach, and technical expertise.

Traumatic Lesion of the Brachial Artery in a Pediatric Patient: Treatment With Bioresorbable Vascular Scaffold

Purpose:

Neurovascular injuries and hand ischemia can occur in up to 20% of cases of supracondylar fractures of the humerus (SCH) in children, and their management is still controversial.

Case report:

We report a case of a brachial artery acute occlusion related to a SCH fracture in a child, successfully treated by endovascular implantation of a bioresorbable vascular scaffold.

Conclusions:

Bioresorbable vascular stent represents an alternative solution in treatment of traumatic children vascular lesions.

The elimination of anastomosis in open trauma vascular reconstruction: A novel technique using an animal model

BACKGROUND

The standard approach to vascular trauma involves arterial exposure and reconstruction using either a vein or polytetrafluoroethylene graft. We have developed a novel technique to repairing arterial injuries by deploying commercially available vascular stents through an open approach, thus eliminating the need for suture anastomosis. The objective of this study was to evaluate the feasibility, stent deployment time (SDT), and stent patency of this technique in a ewe vascular injury model.

METHODS

After proximal and distal control, a 2-cm superficial femoral arterial segment was resected in 8 Dorper ewes to simulate an arterial injury. Two stay sutures were placed in the 3- and 9-o'clock positions of the transected arterial ends to prevent further retraction. Ten milliliters of 10-IU/mL heparinized saline was flushed proximally and distally. An arteriotomy was then created 2.5 cm from the transected distal end through which we deployed Gore Viabahn stents with a 20% oversize and at least 1-cm overlap with the native vessel on either end. The arteriotomy was then closed with 3 (1) interrupted 6-0 Prolene sutures. The ewes were fed acetylsalicylic acid 325 mg daily. Duplex was performed at 2 months postoperatively to evaluate stent patency. SDT was defined as time from stay suture placement to arteriotomy closure.

RESULTS

The 8 ewes weighed a mean (SD) of 34.4 (4.3) kg. The mean (SD) superficial femoral arterial was 4.3 (0.6) mm. Six 5 mm × 5 cm and two 6 mm × 5 cm Gore Viabahn stents were deployed. The mean (SD) SDT was 34 (19) minutes, with a trend toward less time with increasing experience (SDTmax, 60 minutes; SDTmin, 10 minutes). Duplex performed at 2 months postoperatively showed stent patency in five of eight stents. There was an association between increasing SDT and stent thrombosis.

CONCLUSION

Open deployment of commercially available vascular stents to treat vascular injuries is a conceptually sound and technically feasible alternative to standard open repair. Larger studies are needed to refine this technique and minimize stent complications, which are likely technical in nature.

Endoluminal occlusion devices: technology update

Endoluminal occlusion has been performed since the early beginning of interventional radiology. Over recent decades, major technological advances have improved the techniques used and different devices have been developed for changing conditions. Most of these occlusion devices have been implemented in the vascular territory. Early embolization materials included glass particles, hot contrast, paraffin, fibrin, and tissue fragments such as muscle fibers and blood clots; today, occlusion materials include metallic devices, particles, and liquid materials, which can be indicated for proximal or distal occlusion, high-flow and low-flow situations, and in large-caliber and small-caliber vessels, based on need. Technological progress has led to a decreased size of delivery catheters, and an increase in safety due to release systems that permit the withdrawing and replacement of embolization material. Furthermore, bioactive embolization materials have been developed to increase the efficacy of embolization or the biological effect of medication. Finally, materials have been modified for changing indications. Intravascular stents were initially developed to keep an artery open; however, by adding a covering membrane, these stents can be used to occlude the wall of a vessel or other endoluminal structures. This article gives an overview of the devices most utilized for occlusion of endoluminal structures, as well as their major purpose in the endovascular territory.

The role of interventional radiology in trauma

Since the development of angiography and transcatheter techniques, interventional radiology has played an important role in the management of trauma patients. The ability to treat life-threatening hemorrhage with transcatheter embolization has spared countless patients the morbidity of surgery. Advances in cross-sectional imaging and increases in understanding of which patients will best benefit from embolization promise to further refine the interventional radiologist's role. As the applications of transcatheter therapy broaden to include embolization of unstable patients with solid organ injuries and endovascular repair of major arterial injuries, the interventional radiologist must be increasingly prepared to provide prompt, efficient, and high-quality service.

Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience

PURPOSE

To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries.

MATERIALS AND METHODS

Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly.

RESULTS

Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%.

CONCLUSIONS

Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Peripheral endografts for the treatment of traumatic arterial injuries

Catheter-based endovascular techniques for vascular trauma management are being increasingly reported. Covered stents may be inserted and deployed through a remote site of percutaneous access under local anesthesia and are ideal for treating arterial ruptures and pseudoaneurysms and to seal off arteriovenous communications. Advantages of endovascular stent-graft repair of peripheral traumatic arterial injuries include less blood loss and tissue damage, reduced operative time and morbidity, shortened hospital stay and recovery periods, and reduced healthcare costs. The present report provides an overview of the role of balloon-expandable and self-expandable covered stents in the minimally invasive treatment of various types of traumatic arterial injuries.