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October 17, 2008
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James E Chalk, Scott Stevens
University of Tennessee Graduate School of Medicine, Knoxville, TN
Background: Exposure to repair injured axillosubclavian vessels is associated with significant morbidity and mortality. Recently, vascular surgeons have successfully used endovascular techniques to repair these injuries. Here we report a case of a blunt axillary artery transection repaired exclusively with percutaneous methods. This strategy combines ultrasound, percutaneous angiography and CT-imaging. To our knowledge, this is the first reported case of percutaneous repair for this injury.
Methods: Patient: A 50-year-old gentleman was evaluated in the emergency department as an activated trauma. He was involved in a timber cutting accident and was struck in the head, right chest, shoulder and upper back regions. On initial presentation he was noted to have inability to move with loss of sensation in the right upper extremity. On exam, the right upper extremity was cool, pale with non-palpable pulses in the brachial, radial or ulnar arteries. Diagnostics: CT chest, abdomen and pelvis, using 120 ml of Omnipaque 300 IV contrast, demonstrated the right subclavian artery was completely transected just distal to the costocervical trunk with a considerable defect between the distal and proximal ends. Distal reconstruction was through the scapular collaterals. A large right chest wall hematoma extended into the axilla with concomitant right third and fourth rib fractures. The right scapula was fractured through the notch as well as through the body. Operative: Considering the morbidity of open repair, an endovascular approach was performed. The right groin was cannulated and an aortic arch angiogram was obtained. The right subclavian was selected and showed an avulsion injury with extensive hematoma. Following this, ultrasound was used to aid in cannulating the right brachial artery for retrograde access. With brachial and femoral wire access into the hematoma, a snare was used to create single wire continuity through the brachial and femoral arteries. Then with guided sheath protection, PTFE covered stents were telescoped to establish continuity.
Results: The covered stent re-established flow through the axillary artery to the hand. Postoperative CT-angiogram demonstrated the graft, inflow and outflow arteries were all patent. No extravasation was noted. He was discharged on his home dose of plavix with good distal pulses.
Conclusion: Traumatic injuries involving the subclavian or axillary artery are relatively uncommon. This is the first reported case of a blunt transection of the axillary artery secondary to trauma repaired in this manner. As vascular surgeons we can expand our treatment options to include, not only the traditional open repair, but also endovascular repair. With appropriate judgment and training, this procedure could be an effective alternative to standard techniques resulting in less operative time and blood loss, shorter postoperative recovery and decreased morbidity.
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Endovascular Repair of a Blunt Traumatic Avulsion of the Axillary Artery
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James E Chalk, Scott Stevens
University of Tennessee Graduate School of Medicine, Knoxville, TN
Background: Exposure to repair injured axillosubclavian vessels is associated with significant morbidity and mortality. Recently, vascular surgeons have successfully used endovascular techniques to repair these injuries. Here we report a case of a blunt axillary artery transection repaired exclusively with percutaneous methods. This strategy combines ultrasound, percutaneous angiography and CT-imaging. To our knowledge, this is the first reported case of percutaneous repair for this injury.
Methods: Patient: A 50-year-old gentleman was evaluated in the emergency department as an activated trauma. He was involved in a timber cutting accident and was struck in the head, right chest, shoulder and upper back regions. On initial presentation he was noted to have inability to move with loss of sensation in the right upper extremity. On exam, the right upper extremity was cool, pale with non-palpable pulses in the brachial, radial or ulnar arteries. Diagnostics: CT chest, abdomen and pelvis, using 120 ml of Omnipaque 300 IV contrast, demonstrated the right subclavian artery was completely transected just distal to the costocervical trunk with a considerable defect between the distal and proximal ends. Distal reconstruction was through the scapular collaterals. A large right chest wall hematoma extended into the axilla with concomitant right third and fourth rib fractures. The right scapula was fractured through the notch as well as through the body. Operative: Considering the morbidity of open repair, an endovascular approach was performed. The right groin was cannulated and an aortic arch angiogram was obtained. The right subclavian was selected and showed an avulsion injury with extensive hematoma. Following this, ultrasound was used to aid in cannulating the right brachial artery for retrograde access. With brachial and femoral wire access into the hematoma, a snare was used to create single wire continuity through the brachial and femoral arteries. Then with guided sheath protection, PTFE covered stents were telescoped to establish continuity.
Results: The covered stent re-established flow through the axillary artery to the hand. Postoperative CT-angiogram demonstrated the graft, inflow and outflow arteries were all patent. No extravasation was noted. He was discharged on his home dose of plavix with good distal pulses.
Conclusion: Traumatic injuries involving the subclavian or axillary artery are relatively uncommon. This is the first reported case of a blunt transection of the axillary artery secondary to trauma repaired in this manner. As vascular surgeons we can expand our treatment options to include, not only the traditional open repair, but also endovascular repair. With appropriate judgment and training, this procedure could be an effective alternative to standard techniques resulting in less operative time and blood loss, shorter postoperative recovery and decreased morbidity.
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