[Trauma-associated vascular injuries and the vascular surgical/interventional options for vascular reconstruction]. / Traumaassoziierte Gefäßverletzungen und deren gefäßchirurgische/interventionelle Rekonstruktionsmöglichkeiten.

AIM: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations. METHOD: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options. RESULTS: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival. CONCLUSION: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

Nasopharyngeal Migration of Coils Following Embolization of a Traumatic Pseudoaneurysm of the Internal Carotid Artery: A Case Report.

Post-traumatic pseudoaneurysms of the internal carotid are a rare but potentially fatal cause of epistaxis; they are associated with fractures of the base of the skull with involvement of the carotid canal. Endovascular management is the preferred therapeutic strategy, with optimal long-term results and low complication rates. Complications may include thromboembolic events, infarction of perforating arteries, and rupture of the pseudoaneurysm. We present a case of a 28-year-old male with a post-traumatic pseudoaneurysm of the internal carotid who was managed with endovascular therapy. A late complication was the extrusion of the embolization material into the nasal cavity and nasopharynx, which was safely and effectively treated through endovascular and endoscopic approaches.

Predictors of Middle Meningeal Artery-Related Vascular Diseases Associated with Blunt Head Trauma.

OBJECTIVE: Traumatic middle meningeal artery (MMA)-middle meningeal vein (MMV) fistula (MMA-MMV fistula) and MMA pseudoaneurysm are the 2 main MMA-related vascular diseases occurring after blunt head trauma. These are rare but known causes of delayed intracranial hemorrhage. This study investigated predictors that may aid in the diagnosis of these diseases. METHODS: In our department, screening digital subtraction angiography (DSA) is performed for patients with blunt head trauma accompanied by intracranial hemorrhage and skull or facial bone fracture. This study included 87 patients who underwent screening DSA without craniotomy from January 2019 to June 2023. The patients' clinical characteristics were retrospectively collected from the database. Statistical analysis was performed to examine the associations of various evaluation items with MMA-related vascular diseases. RESULTS: The first DSA examination revealed 34 MMA-MMV fistulas and 1 MMA pseudoaneurysm. The second follow-up DSA examination revealed 13 MMA-MMV fistulas and four MMA pseudoaneurysms. Temporal/parietal bone fracture (odds ratio, 5.33; P = 0.0005; 95% confidence interval, 1.95-14.60) was significantly associated with MMA-related vascular diseases. Endovascular treatments were performed in 9 patients. All procedures were successfully completed without complications; no delayed bleeding was observed. CONCLUSIONS: Temporal/parietal bone fracture in patients with blunt head trauma is a likely predictor of MMA-related vascular diseases. When initial head computed tomography reveals this pathology, we recommend careful imaging follow-up (e.g., DSA) and treatment as needed, while considering the possibility of MMA-related vascular diseases.

Combining Endovascular Coiling and Open Evacuation for a Delayed-Onset Ruptured Post-traumatic Pseudoaneurysm of the Distal Paracentral Pericallosal Artery Branch.

Cerebrovascular pseudoaneurysm development and rupture is a rare, delayed sequelae of trauma. We present a case of a female patient in her sixties who presented after a fall without evidence of vascular injury on imaging. However, after one week, repeat imaging due to an abrupt change in mental status revealed a ruptured pseudoaneurysm, which was treated with a combination of coil embolization and open surgical evacuation of associated intracranial hematoma. This case illustrates the importance of continued surveillance beyond the acute traumatic period to identify late-onset complications in trauma patients requiring emergent treatment.

Development of Anterior Cranial Fossa Dural Arteriovenous Fistula and Supraclinoid Internal Carotid Artery Pseudoaneurysm Following Frontobasal Trauma: A Case Report and Literature Review.

Cerebrovascular injuries resulting from frontobasal head trauma represent a range of imaging and clinical presentations. Severe cerebrovascular injuries such as vessel transection commonly present with profound neurological deficits and are often easily identified with routine imaging. However, small intimal injuries and dissections may be challenging to detect and may be clinically silent or masked by additional injuries in the setting of polytrauma. The onset of symptoms and complications from cerebrovascular injuries may be delayed from the time of initial presentation, and failure to recognize and diagnose these injuries may result in devastating outcomes if management is delayed. In this case report, we present a case of frontobasal craniofacial trauma that resulted in an anterior cranial fossa dural arteriovenous fistula (ACF-dAVF) and supraclinioid segment internal carotid artery (ICA) pseudoaneurysm.

Repeated coil embolization of traumatic basilar artery pseudoaneurysm accompanied by bilateral traumatic internal carotid artery stenosis following severe head injury in a pediatric patient: A case report and literature review.

Background: Few cases of pediatric traumatic intracranial aneurysms (pTICAs) in the posterior circulation involving the basilar artery (BA) following severe head trauma have been reported. Here, we describe a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic internal carotid artery (ICA) stenosis following blunt head trauma. Case Description: A 16-year-old boy presented to our emergency department after being hit by a car. The patient was initially diagnosed with multiple skull base fractures underlying traumatic subarachnoid hemorrhage and left acute epidural hematoma. Seven days following emergency craniectomy, magnetic resonance imaging revealed bilateral ICA stenosis, BA stenosis, and BA pseudoaneurysm. We decided to perform coil embolization, resulting in body filling and a volume embolization ratio of 15.7%. Twenty-eight days after coil embolization, digital subtraction angiography revealed aneurysmal rupture. We performed repeated coil embolization, resulting in body filling and a volume embolization ratio of 20.9%. Conclusion: We reported a pediatric case of traumatic BA pseudoaneurysm accompanied by bilateral traumatic ICA stenosis following a severe head injury treated with repeated coil embolization. Considering the risk of further brain injury due to high incidence of rupture, early vascular survey and appropriate treatment may be the most important prognostic factors in pTICAs.

Traumatic Pseudoaneurysm of the Occipital Artery Treated with Open Surgical Ligation: 2-Dimensional Operative Video.

Scalp pseudoaneurysms occur most commonly because of trauma and are often in the superficial temporal artery due to the lack of soft tissue coverage between skin and bone, making it more vulnerable anatomically.1,2 Pseudoaneurysms of the occipital artery (OA) also occur but are extremely rare.2-4 An 80-year-old man presented with scalp bleeding and a small left-sided posterior scalp laceration after a fall and head strike 10 days prior. He was admitted and during his 2-week hospital stay, the occipital laceration continued to rebleed (Video 1). He developed a 2-cm pulsatile ulcerative mass with central necrosis on the left nuchal ridge. Computed tomography angiography revealed an ovoid left occipital lesion measuring 1.3 × 2.5 × 2.3 cm with delayed contrast filling and partial thrombosis. The base of the lesion had dense contrast filling continuous with the OA, diagnostic of OA pseudoaneurysm. OA pseudoaneurysm may be treated endovascularly or surgically. While surgical resection is the most common treatment, minimally invasive techniques have been successfully done through direct injection of N-butyl cyanoacrylate or endovascular embolization. The clinical presentation of this case was unique because this patient had an ulcerated lesion with central necrosis overlying the pseudoaneurysm. Endovascular management alone would not address the open lesion, which is at high risk for infection. The risk of infection would increase after embolization of the occipital artery, causing further necrosis of the tissue.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients.

OBJECTIVE: Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS: This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS: Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS: Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Blunt aortic injury-traumatic aortic isthmus pseudoaneurysm with right iliac artery dissection aneurysm: A case report.

BACKGROUND: Blunt aortic injury is a special type of aortic disease. Due to its low incidence, high prehospital mortality and high probability of leakage diagnosis, the timely identification of patients with blunt aortic injury who survive the initial injury has always been a clinical challenge. CASE SUMMARY: We report a case of traumatic aortic pseudoaneurysm with right iliac artery dissection aneurysm that was diagnosed 3 mo after a traffic accident. The patient is a 76-year-old male who was knocked down by a fast-moving four-wheel motor vehicle while crossing the road (the damage mechanism was side impact). He received chest, cranial computed tomography (CT) and whole abdomen enhanced CT in the local hospital. The images suggested subarachnoid hemorrhage, right frontoparietal scalp hematoma, fracture of the right clavicle and second rib, lump-shaped mediastinal shadow outside the anterior descending thoracic aorta (mediastinal hematoma), mesenteric vascular injury with hematoma formation, pelvic fracture, and subluxation of the left sacroiliac joint. After the pelvic fracture was fixed with an external stent, he was sent to our hospital for further treatment. In our hospital, he successfully underwent partial resection of the small intestine and CT-guided screw internal fixation of the left sacroiliac joint and returned to the local hospital for rehabilitation treatment. However, since the accident, the patient has been suffering from mild chest pain, which has not aroused the attention of clinicians. During rehabilitation, his chest pain gradually worsened, and the thoracic aorta computed tomography angiography performed in the local hospital showed a pseudoaneurysm in the initial descending segment of the aortic arch. After transfer to our hospital, a dissecting aneurysm of the right external iliac artery was incidentally found in the preoperative evaluation. Finally, endovascular stent graft repair was performed, and he was discharged on the 10th day after the operation. No obvious endo-leak was found after 4 years of follow-up. CONCLUSION: We highlight that emergency trauma centers should consider the possibility of aortic injury in patients with severe motor vehicle crashes and repeat the examination when necessary to avoid missed diagnoses.

Flow Preserving Endovascular Treatment of Traumatic Pseudoaneurysms of the Distal Anterior Cerebral Artery-Case Reports and Review of Literature.

Traumatic intracranial pseudoaneurysms (tIPAs) are a very rare pathology caused by blunt or penetrating head trauma. Diagnostic and therapeutic challenges of tIPAs are due to their unpredictable onset during the initial injury, or in a delayed manner, their unclear traumatic mechanism. Moreover, the presence of subarachnoid, subdural, or intraventricular hematoma may often cause them to be overlooked, which can potentially be followed by lethal rebleeding. Treatment of these lesions is controversial and on a case-by-case basis with regard to endovascular therapy or open surgery. We report two cases of three tIPAs of the distal anterior cerebral artery (dACA) with immediate and delayed onset after the trauma. Endovascular therapy resulted in complete obliteration of lesions with flow preservation in the parent artery using the flow diverter-assisted coiling strategy. The aim of this manuscript is to discuss the mechanism, angioanatomical characteristics, and current treatment options for these exceptional lesions.

Use of covered stent (CGuard) in the treatment of post-traumatic internal carotid artery pseudoaneurysm.

Post-traumatic internal carotid artery pseudoaneurysm (ICA PSA) is a rare occurrence with high mortality rates, and with the advent of endovascular therapy, its treatment has shown drastic improvement in clinical as well as radiological outcomes. Here we are describing our experience with the CGuard embolic protection system (InspireMD, Tel Aviv, Israel) for the treatment of post-traumatic left ICA PSA in a 49-year-old male. New improved biomechanics and navigability have proven it to be a safe and efficient treatment modality for ICA PSA. However, a multicentric large-scale randomized trial is recommended to support this modality.

Branch retinal artery occlusions after balloon sinuplasty due to formation of a traumatic pseudoaneurysm in the internal carotid artery and embolization treatment.

PURPOSE: To describe a case of multifocal branch retinal artery occlusions due to a traumatic internal carotid artery pseudoaneurysm and endovascular treatment after a balloon sphenoid sinuplasty procedure. OBSERVATIONS: A 62-year-old female with no significant past medical history underwent an elective outpatient balloon sinuplasty of the right frontal sinus and bilateral sphenoid sinuses. Shortly after the balloon sinuplasty device was inflated in the left sphenoid sinus, acute, severe, pulsatile bleeding was encountered from the posterior wall of the sinus. The patient underwent emergent catheter angiography and a traumatic pseudoaneurysm was noted in the left internal carotid artery that required endovascular embolization. After the procedures, the patient's visual acuity was 20/40 in the right eye and 20/200 in the left eye. The pupil exam revealed a left relative afferent pupillary defect. Visual field testing showed a central scotoma and an inferior nasal quadrant defect in the left eye. On fundus exam, there were multiple retinal emboli seen with ischemic retinal whitening in the left superior macular and superior temporal segments consistent with multifocal branch retinal artery occlusions in the left eye. CONCLUSIONS AND IMPORTANCE: The dilation of paranasal sinuses using a balloon instrument is a fairly new technique in the surgical management of chronic sinonasal inflammatory disease, and serious adverse effects have not been widely reported. To our knowledge, this is the first case of multifocal branch retinal artery occlusions due to a traumatic internal carotid artery pseudoaneurysm and endovascular treatment after balloon sinuplasty to be reported in the English language ophthalmic literature.

A rare case of a right ventricular Pseudo-aneurysm, related to an attempted suicide.

We present the case of a 74-year-old female who attempted suicide by stabbing repeatedly with a nail scissor in the sub-sternal chest. Chest Computed Tomography (CT) performed at her arrival at our emergency department detected the presence of massive pericardial effusion. A follow-up cardiac CT after the pericardial drainage showed a Pseudo-aneurysm of the anterior wall of the right ventricle. .

The diagnosis of delayed expanding traumatic pseudoaneurysm of thoracic aorta caused by self-inflicted penetrating injury with crossbow bolt: A case report.

INTRODUCTION AND IMPORTANCE: Penetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up. CASE PRESENTATION: A 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day. CLINICAL DISCUSSION: Emergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury. CONCLUSION: This case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection.

Management of a delayed, post-traumatic rupture of splenic artery pseudoaneurysm in a patient with life threatening co-morbidities: A treatment challenge.

INTRODUCTION: Splenic artery embolization (SAE) is an accepted intervention for patients with traumatic injury AAST III-IV in hemodynamically stable patients, splenic artery aneurysm and pseudoaneurysm (Brian and Charles, 2012). Unusual circumstances may pose different challenges in individual cases. CASE PRESENTATION: A 52-year-old male on anticoagulants for past mitral valve replacement presented to us with history of blunt trauma sustained a month prior, was found to have grade IV splenic injury with delayed pseudo-aneurysmal rupture. In addition, his cardiac evaluation revealed an ejection fraction of 20%. A potential life threatening unstable cardiac status and hemodynamic irregularities accentuated due to the hemoperitoneum was an unusual challenge to deal with. After initial stabilization in ICU, the option of distal embolization of splenic artery was undertaken in a well-planned manner. DISCUSSION: Unstable cardiac condition, anticoagulant therapy and delayed pseudo aneurysmal bleed led us into undertaking this procedure as a semi-emergency with calculated risks. We discuss this case due to the complexities and dilemmas on various aspects which we faced in his management. CONCLUSION: Patient tolerated the procedure well and was discharged on the third day of embolization. Our experience taught us the judicious implementation of a viable and only lifesaving option for an otherwise inoperable patient due to multiple co-morbidities and would strongly recommend this interventional radiological, relatively innocuous procedure for salvaging such patients.

Endovascular Repair of Thoracic Aortic Pseudoaneurysms in Children.

Pediatric aortic pseudoaneurysms are rare and can result in life-threatening sequelae. We describe 2 cases of exclusion of descending thoracic aortic pseudoaneurysm by different approaches, chosen based on the anatomy and cause of the lesions. (Level of Difficulty: Beginner.).

Endovascular treatment of traumatic carotid pseudoaneurysm with Tubridge flow diverter: A case report.

Traumatic pseudoaneurysm is a rare lesion with a high risk of rupture, and represents one of the most difficult lesions to treat, either surgically or endovascularly. Herein, we describe the case of a 32-year-old man with a traumatic pseudoaneurysm of the internal carotid artery, which was treated by overlapped flow diverters (Tubridge). The patient recovered well, and the follow-up angiography at four months showed complete occlusion of the pseudoaneurysm and patency of the internal carotid artery and the ophthalmic artery.

Post Traumatic Pseudoaneurysm of Left Anterior Descending Artery Presenting as Acute Coronary Syndrome.

Penetrating cardiac injuries are highly lethal and carry high mortality rate. Both blunt and penetrating cardiac injuries in patients who survive are known to present with well-known sequelae that often appear days to weeks after the initial insult. In the literature there have been documented cases of cardiac injury induced myocardial infarction, ventricular aneurysms, valvular dysfunction and even fistulous tracts between the coronary vessels and chamber. Although the most commonly injured vessel is the left anterior descending (LAD) coronary artery, traumatic injuries to the left coronary artery result in early death in the majority of cases. We present a unique case of LAD pseudo aneurysm and stenosis presenting as acute coronary syndrome (ACS) months after the initial penetrating cardiac injury successfully managed by stenting. There are only few isolated case reports of coronary artery pseudoaneurysm following penetrating chest trauma published in English literature.

A Time Bomb Defused, In Time! A Traumatic Optic Neuropathy To Be Wary Of.

Authors describe a case of traumatic pseudoaneurysm of cavernous internal carotid artery in a young male who presented with complaints of progressive decrease in vision, inability to move the eye, and delayed epistaxis 8 months after the head injury sustained during a motor vehicle accident. The presence of optic atrophy and epistaxis in the setting of head trauma alerted the authors to look for this potentially life-threatening condition. Timely intervention in the form of endovascular coil occlusion of the internal carotid artery was performed and the epistaxis stopped without any ischaemic or thromboembolic sequaelae.

Endovascular treatment of a traumatic carotid pseudoaneurysm with the Tubridge stent; A case report / 中国脑血管病杂志

Traumatic intracranial pseudoaneurysm is usually caused by blunt or penetrating head injuries. It lacks of real blood vessel wall and is covered only by a fragile connective tissue layer. Traumatic intracranial pseudoaneurysm mainly occurs in the carotid, cavernous and petrous segments of the internal carotid artery. A case of traumatic internal carotid artery pseudoaneurysm successfully treated with Tubridge flow diverter device was reported. The 32-year-old male patient was diagnosed as a pseudoaneurysm of the left internal carotid artery after a traffic accident, and received treatment with Tubridge flow diverter device one month later. After stents release, angiography showed obviously retained contrast agent in pseudoaneurysm, decreased aneurysm size and well-opened stents. The size of the pseudoaneurysm was found reduced by magnetic resonance angiography reexamination on the 4th day after the operation,and a further decrease on the 10th day by digital subtraction angiography (DSA) reexamination. Four months after the operation, DSA showed the aneurysm was completely cured.