Endovascular Management of Axillo-subclavian Arterial Injury a Review of Published Experienceã‚â§

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ten.25259/AJIR-1-2019

Endovascular Repair of Axillary Avenue Transection with a Stent Graft following Blunt Trauma

1 Department of Interventional Radiology, OMNY Vein and Cardiovascular, New York

two Department of Surgery, West Virgina, Charleston, United States

3 School of Medicine, Academy of Jordan, Amman, Jordan

Corresponding Writer: Rami Sartawi, Department of Interventional Radiology, OMNY Vein and Cardiovascular, New York 10065, United States. Electronic mail: rsartawi@omnymd.com

Received: 2019-02-01, Accustomed: 2019-05-01, Published: 2019-05-23

©2019 Published by Scientific Scholar on behalf of American Journal of Interventional Radiology

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How to cite this article: Sartawi R, Abu-Halimah S, Abdelhamid S, Yanis A. Endovascular Repair of Axillary Artery Transection with a Stent Graft post-obit Blunt Trauma. Am J Interv Radiol 2019;3(5) 1-4.

Abstract

Transection injuries of the axillary artery are rare and typically involve surgical repair. This case describes an emergent endovascular treatment option, using a stent graft, in a patient that was deemed every bit loftier hazard for open surgery.

Keywords

Axillary artery transection

Endovascular

Retrograde access

Stent graft

Trauma

INTRODUCTION

Traumatic injury of the axillary avenue following blunt injury is rare. Surgical repair is considered the standard approach but can be difficult for anatomic reasons, with consistent limb and life-threatening complications.^[1] Endovascular therapy thus provides an alternative for therapy in the loftier-chance patient. Case reports exist for the direction of pseudoaneurysms with stent grafts, but little to no data exists for the endovascular treatment of transections in the extremities. This report demonstrates the use of a stent graft for repair of a left axillary artery transection using a combination of retrograde and antegrade access.

CASE Written report

A 41-year-old volunteer firefighter was pinned nether a large tree branch while in the line of duty. Prolonged extrication at the site resulted in an 8-h filibuster to presentation to the emergency department. On arrival, he was found to be in hemorrhagic shock. On physical examination, a cold and swollen left arm was identified. Ecchymosis in the left chest wall was also present. Computerized tomography (CT) scan abnormalities demonstrated a left scapular fracture and an associated hematoma in the left axilla/anterior chest wall (Figure ane). No other areas of extravasation were identified in the chest, abdomen, or pelvis. A CT angiogram demonstrated active extravasation in the axilla but could just provide limited boosted information due to poor timing of the bolus and the patient's torso habitus (body mass index 55). Despite aggressive resuscitation with IV fluids and claret products, the patient remained hypotensive and coagulopathic. Interventional radiology and vascular surgery were emergently consulted for assistance.

On initial evaluation, a faint radial pulse could be elucidated in the left manus. The left arm swelling had progressed significantly, and there was at present concern for compartment syndrome. Hemoglobin was 9 and the patient's INR was 1.9 at the time of consultation. Decision fabricated to pursue angiography in an endeavor to more accuratley define the injury, and try to accost it endovascularly if possible. The plan was then to transfer the patient to the OR for emergent fasciotomy with possible surgical exploration/bypass (if needed). Unfortunately, by this signal, well-nigh 10 h passed and the overall prognosis was poor.

The patient was quickly transferred to the interventional radiology suite. Anesthesia was present for the process to assist with hemodynamic support. The patient was still receiving blood products, including fresh frozen plasma and packed cherry blood cells, in an endeavor to attempt to correct his coagulopathies. A central line had already been placed in the right groin and so, the patient'due south left groin was accessed for the angiogram. A 6F ten cm Pinnacle sheath (Terumo) was placed into the left common femoral artery using ultrasound-guided access. Selective angiography through a 4F Glidecath (Terumo) demonstrated complete transection of the left axillary artery with agile extravasation (Figure two). A 5F Fogarty balloon (Edwards) was gently inflated, and very apace, ultrasound-guided retrograde access was performed into small but pulsatile left radial avenue (3 mm in diameter). A 6F Slender sheath (Terumo) was placed into the radial artery after ultrasound-guided access. Angiography demonstrated significant retraction of the stumps of the axillary artery in add-on to the transection injury (Effigy 3).

After a brief discussion of options with vascular surgery, information technology was elected to try to achieve "through and through" across the hematoma if possible. A 6F Atrieve snare catheter (Argon Medical) was placed into axillary hematoma through the radial access. The Fogarty balloon was deflated and removed over a wire. Quickly, a 4F Navicross (Terumo) catheter was placed antegrade through the left groin access. Within a few minutes, an 0.018 wire (Glidewire advantage, Terumo) was successfully snared in the soft tissue/ hematoma, and "body flossing" was performed from the left groin to the left wrist with a 0.018 wire. Next, the existing groin sheath was exchanged for a 6F Cook Shuttle sheath (Cook). Side by side, an 8 mm × xv cm stent graft (Viabahn, Gore Medical) was placed with 3–4 cm overlap into the native arteries on each side followed past angioplasty with a 6 mm balloon (Figure 4). In-line menstruation was at present present with no extravasation (Figures 5 and 6). Thrombosis/spasm of the radial artery was noted, but menses to the mitt was nowadays through the ulnar artery. A radial artery compression device (TR Band, Terumo) was placed at the radial site, and the left groin sheath was left in place, to exist used as an arterial line. The patient subsequently underwent fasciotomy in the OR. The sheath was removed the adjacent day when the patient'due south coagulopathy improved.

Unfortunately, despite successful revascularization, the patient ended upward with a transhumeral amputation 1 week later on due to extensive muscle necrosis. At the time of the amputation, information technology was noted that the flow into the brachial artery remained robust.

DISCUSSION

The axillary artery originates from the subclavian artery, offset at the lateral margin of the first rib and ending in the brachial artery at the inferior border of the teres major muscle. Considerable collateral supply exists effectually it to the shoulder and upper extremity and includes the subscapular and circumflex humeral arteries.

Axillary artery injuries constitute <five% of all major arterial injuries, and the bulk of these are penetrating in nature.^[2] Blunt trauma constitutes 5–8% of axillary artery injury cases.^[iii,four] "Typical" signs of injury can include those of acute limb ischemia, simply those symptoms can sometimes be absent-minded because of the rich collateral supply around the shoulder.

High rates of morbidity and mortality are associated with complex surgical exposure and repair of the axillary artery.^[5] Surgical techniques involve supraclavicular, infraclavicular, median sternotomy, and thoracotomy approaches.^[vi] Information technology is considered hard, however, to reach proximal and distal control due to the need for extensive dissection. In our specific case report, the patient's obesity and coagulopathy would have added boosted complication in an unstable patient, making endovascular methods a compelling alternative when viable. In fact, endovascular therapy for the treatment of pseudoaneurysms with stent grafts has already been described every bit a viable alternative in that setting.^[seven,8] Our case expands the possible role for stent grafts in the periphery.

Long-term viability of covered stents in the axillary artery remains unknown although information exist to support its use. Follow-upwards patency rates of up to 84.4% accept been reported for endovascular direction of peripheral vascular injuries.^[9] The approach described in this case report is non without run a risk, but in patients that are high gamble for surgery, or in whom long-term patency is not the primary business organization, this may serve as a bridging option.

CONCLUSIONS

Endovascular direction of axillary artery transection due to blunt injury should exist considered in patients who are at high risk for surgical intervention. However, there is deficient data most the use of grafts in such cases and its long-term success rates. This case describes a possible culling to surgical exploration for peripheral vascular injuries.

Announcement of patient consent

The authors certify that they have obtained all advisable patient consent.

Financial support and sponsorship

Nil.

Conflicts of involvement

There are no conflicts of interest.

References

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