Contemporary Review of Traumatic Axillary and Subclavian Artery Injuries at an Urban Level One Trauma Center.

OBJECTIVE: Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes. METHODS: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests. RESULTS: Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) (P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) (P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism (P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation. CONCLUSIONS: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization.

Endovascular Management of A Symptomatic Giant Hepatic Artery Aneurysm.

Hepatic artery aneurysms (HAAs) are an uncommon clinical condition. Ruptured hepatic artery aneurysm carries a high incidence of mortality. Traditionally, they are treated with open surgical resection; however, endovascular aneurysm exclusion is an alternative option to open repair in select patients who have suitable anatomy. Here, we present a case of a giant hepatic artery aneurysm treated with a covered stent placement.

Endovascular Treatment of Innominate Artery Bifurcation Injury with Balloon-Expandable Covered Stents Utilizing Kissing Stent Technique.

Major injury of the innominate artery is traditionally treated with an open repair which is technically challenging, associated with large volumes of blood loss and prolonged operative times. Endovascular treatment with covered stent placement across the injury is an attractive alternative. However, placement of a single covered stent across the innominate artery bifurcation into one of its distal branches will not prevent bleeding because of retrograde perfusion from the unstented branch distal to the bifurcation. Here, we report a case of successful endovascular repair of one such injury involving the innominate artery bifurcation with ongoing extravasation into the mediastinum. The injury was successfully treated by utilizing 2 balloon-expandable covered stents placed in kissing fashion from the innominate artery into both of its distal branches. This technique of parallel covered stent placement across a bifurcation could effectively repair bifurcation injuries while maintaining patency of both distal branches.

Inferior vena cava perforation during percutaneous filter removal.

BACKGROUND: Percutaneous Inferior Venacava (IVC) filter retrieval can be challenging when the filter is grossly angulated, embedded in the wall or penetrates through the IVC. When conventional filter removal technique fails, the use of advanced retrieval techniques often improves the chances of percutaneous filter retrieval. These techniques, however, are associated with a high rate of complications. METHODS: We report a case of 26-year-old female who had IVC filter placed on postpartum day 4. Attempted percutaneous filter retrieval 3 weeks later with loop snare technique and endobronchial forceps assisted filter removal technique resulted in gross filter deformity, malposition, and IVC perforation. RESULT: Open IVC filter removal was performed with midline laparotomy and cavotomy with lateral venorrhapy. The deformed filter along with adherent thrombus was completely removed. The patient had an uneventful recovery with no immediate or long-term complications. CONCLUSION: Use of advanced endovascular IVC filter retrieval techniques could result in serious complications like filter fracture, migration and IVC perforation. Since excessive tilt of the filter at the time of placement often results in difficult retrieval, it is important to ensure proper deployment of the filter with minimal tilt. If encountered with excessively tilted or embedded filter, one should refrain from excessive manipulation of the filter and consider open filter removal.

Endovascular Repair of Transected Axillary Artery via Snare Assisted Through and Through Femoral to Brachial Artery Access.

Axillary artery injury is a rare but complex surgical problem that often requires challenging exposures, lengthy operations, and morbid outcomes for repair. For these reasons, endovascular repair is an attractive alternative as it obviates many of the challenges present with open repair. While pseudoaneurysms, dissections, and short segment injuries with limited arterial disruption are regularly treated endovascularly, complete arterial transections are almost exclusively treated with open repair as obtaining wire access across the site of injury is often not possible. Here we report a case of successful endovascular repair of a completely transected axillary artery with the use of snare assistance to obtain through and through femoral to brachial artery access. This ultimately allowed for covered stent deployment across the axillary transection restoring distal blood flow. Snare assistance in obtaining through and through access across areas of complete transection can allow for increased use of endovascular repair.

Use of Indocyanine Green During Repair of a Superior Mesenteric Artery Aneurysm.

Superior mesenteric artery (SMA) aneurysms are rare and associated with a high risk of rupture, with resultant significant morbidity and mortality. During open operative repair of a superior mesenteric artery aneurysm, perfusion of the involved small bowel must be evaluated when determining need for and/or extent of vascular reconstruction. We present a case of a 51-year-old woman who underwent open repair of a non-ruptured superior mesenteric artery aneurysm with ligation and excision, in whom no revascularization was determined to be needed and the involved small bowel was able to be preserved, with intraoperative evaluation of perfusion using indocyanine green (ICG) fluorescence imaging, as an adjunct to more traditional methods of perfusion assessment.

Endovascular Treatment of Giant Celiac Artery Aneurysm in Behcet's Disease.

We report a case of a 17-year-old male with Behcet's disease (BD) with giant celiac artery aneurysm and impending rupture. Over the past 8 weeks, patient began having intermittent back and abdominal pain that worsened and became persistent over the past few days. This was accompanied by anorexia and non-bilious vomiting. Computed tomography angiogram (CTA) demonstrated a wide neck large celiac artery aneurysm (60 mm diameter). Endovascular repair of the aneurysm was performed using stent graft of the aorta and transcatheter coil embolization of the aneurysm sac. Technical success was confirmed by interruption of flow in the aneurysm, and preservation of distal native circulation at the conclusion of the procedure. One-week post-embolization, a CTA demonstrated complete thrombosis of the aneurysm. On follow-up CTA at 3, 6, and 12 months after embolization, the aneurysm has completely thrombosed and decreased in size to 24 mm. Patient remains asymptomatic till date.

Endovascular Rescue of Sheath Perforation During Inferior Vena Cava Filter Retrieval.

INTRODUCTION: Inferior vena cava (IVC) filter retrieval is generally a straightforward procedure but can be challenging with unique complications. A technique used for endovascular rescue of a patient where sheath perforation by the IVC filter occurred during IVC filter retrieval is described. REPORT: A 75 year old man underwent retrieval of an IVC filter that had been in place for 10 months. Using the IVC filter retrieval set from a standard right internal jugular vein approach and the loop-snare technique, the hook and collet were captured, and the filter was collapsed into the retrieval sheath. Approximately halfway through removal of the filter through the sheath, mild resistance was encountered and the tip of the IVC filter was found to have perforated the side of the retrieval sheath. The sheath appeared to have bent slightly in this region, probably weakening the sheath wall and creating angulation, which allowed sheath perforation to occur. From a right common femoral vein approach, an Amplatz wire was used to cannulate the distal end of the perforated sheath. A balloon was then used to pull the perforated sheath with the IVC filter into a larger sheath. After removing the Tuohy-Borst and Luer adapters on the perforated sheath, it was able to be internalised and removed via the femoral vein sheath. DISCUSSION: The endovascular rescue technique described herein may prove useful to other practitioners encountering similar situations, and the complication shows areas of caution when using the loop-snare retrieval technique.

Hybrid Endovascular Treatment of Dysphagia Lusoria: Report of 2 Cases.

Dysphagia Lusoria is a condition when aberrant right subclavian artery (ARSA) causes esophageal compression. We report 2 cases of Dysphagia Lusoria treated by hybrid endovascular technique which included subclavian to carotid transposition and embolization of origin of ARSA. By using this technique, we avoided the need for thoracotomy. Both patients had complete symptom relief without any surgery related complication.

Percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound guidance.

Mural aortic thrombus is a challenging clinical problem with significant potential complications. Particularly precarious are situations with involvement of the visceral segment of the aorta. We describe a technique for percutaneous thrombectomy of mural aortic thrombus using intravascular ultrasound to guide an angled mechanical thrombectomy catheter in conjunction with a continuous aspiration system (Indigo mechanical thrombectomy system; Penumbra, Alameda, Calif). Use of this technique in three patients with challenging cases of mural aortic thrombus is discussed. All patients were treated successfully and without complication using this technique.

Successful Percutaneous Retrieval of IVC Filter with Wide Retroperitoneal Penetration Presenting with Gastrointestinal Bleeding.

Symptomatic penetration of the retroperitoneal structures by inferior vena cava (IVC) filter is a rare clinical entity. Vast majority of these patients require laparotomy and open retrieval of the filter. We report a case of a filter penetrating into the duodenum within two months of implantation resulting in gastrointestinal bleeding. The patient was successfully managed with percutaneous retrieval of the filter, blood transfusion and serial abdominal examination thus avoiding laparotomy.

Anatomic characteristics and natural history of renal artery aneurysms during longitudinal imaging surveillance.

OBJECTIVE: Renal artery aneurysms (RAAs) are uncommon, and rates of growth and rupture are unknown. Limited evidence therefore exists to guide clinical management of RAAs, particularly small aneurysms that are asymptomatic. To further characterize the natural history of RAAs, we studied anatomic characteristics and changes in diameter during imaging surveillance. METHODS: Patients evaluated for native RAAs at a single institution during a 5-year period (July 2008 to July 2013) were identified and analyzed retrospectively. Patients with two or more cross-sectional imaging studies (computed tomography or magnetic resonance imaging) more than 1 month apart were included. Demographic and clinical data were collected from medical records, and anatomic data (including aneurysm diameter, calcification, and location) were obtained from electronic images. Changes in RAA diameters over time were evaluated by plots and Wilcoxon signed rank tests. RESULTS: Sixty-eight RAAs in 55 patients were analyzed. Median follow-up was 19.4 months (interquartile range, 11.2-49.0 months). Mean age at presentation was 61.8 ± 9.8 years, and 73% of patients were women. Hypertension was prevalent among 73% of patients. Multiple RAAs were present in 18% of patients, and 24% also had arterial aneurysms of other splanchnic or iliac vessels. The majority of RAAs were calcified and located at the main renal artery bifurcation. Mean initial aneurysm diameter was 16.0 ± 6.4 mm. Median annualized growth rate was 0.06 mm (interquartile range, -0.07 to 0.33 mm; P = .11). No RAA ruptures or acute symptoms occurred during surveillance, and 10.3% of RAAs were repaired electively. CONCLUSIONS: Risk of short-term RAA growth or rupture was low. These findings suggest that annual (or less frequent) imaging surveillance is safe in the majority of patients and do not support pre-emptive repair of asymptomatic, small-diameter RAAs.

Association of maturation period blood pressure with dialysis access patency.

Problematic dialysis vascular access is a major health issue. The purpose of this study was to evaluate for potentially modifiable factors associated with access patency, particularly, the association of early postoperative, or maturation period, blood pressure with patency. A retrospective review was performed of patients who had undergone placement of an arteriovenous fistula or graft. Demographic, operative, and postoperative factors were evaluated for possible association with access primary patency using univariate and multivariate Cox regression analyses. Seventy-three patients over a 3-year review period were examined. Overall analysis showed a significant association of absence of peripheral vascular disease, aspirin use, and absence of previous permanent dialysis access with higher primary patency rates. Fistula subgroup analysis showed that higher blood pressure during the maturation period relative to preoperative blood pressure was associated with lower patency rates. For grafts, race was significantly associated with patency, with blacks having higher patency rates than whites. Multiple clinical factors were found to have a significant association with dialysis access primary patency. The finding of an association of maturation period blood pressure with fistula patency suggests that the maturation period environment, specifically hemodynamics during this time, may play an important role in dialysis access patency.

Late outcomes of carotid artery stenting: a critical review.

The role of carotid artery stenting (CAS) as an alternative to carotid endarterectomy for the treatment of extracranial carotid occlusive disease for stroke prevention continues to evolve. Although technical and device refinements aimed at making CAS safer continue to this day, safety as measured by 30-day and 1-year outcomes has been the primary recipient of regulatory and practice attention. Relatively less emphasis has been placed on the incidence of recurrent stenosis after CAS and the efficacy of CAS in late stroke prevention. Data on late outcomes of CAS, including factors of potential influence, have been emerging and are addressed in this review.

Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases.

BACKGROUND: Pneumatosis intestinalis (PI) and portal venous gas (PVG) historically mandated laparotomy due to the high mortality rate associated with mesenteric ischemia. Computed tomography (CT) can identify PI/PVG in patients with ischemic emergencies and benign idiopathic conditions. METHODS: A consecutive series of patients with PI or PVG was reviewed from a single institution over 5 years. Eighty-eight cases of PI/PVG were studied: 74 initial patients (year 1-4) were used to generate a treatment algorithm and fourteen additional cases were used to test the algorithm. RESULTS: PI and PVG were associated with three major clinical subgroups: mechanical causes (n=29), acute mesenteric ischemia (n=29), and benign idiopathic (n=26); four were unclassifiable. Patients with acute mesenteric ischemia were associated with abdominal pain (p=0.01), elevated lactate (>or=3.0 mg/dL; p=0.006), small bowel PI (p=0.04), and calculated vascular disease score (p<0.0005). The three subgroups could be distinguished using the generated algorithm with a sensitivity of 89%, specificity of 100%, and positive predictive value of 100%. CONCLUSIONS: With greater sensitivity of modern CT scans, PI and PVG are being detected in patients with a wide range of surgical and non-surgical conditions. This clinical algorithm can identify subgroups to direct surgical intervention for acute ischemic insults and prevent non-therapeutic laparotomies for benign idiopathic PI and PVG.