[Endovascular Treatment for Vascular Injuries of the Extremities]

Abstract

Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities.

Fig. 1. A 74-year-old male patient involved in a motorcycle accident.

A. CT angiography shows active arterial bleeding (arrow) and hematoma involving the right axillary artery. B. Angiography of the right axillary artery shows arterial rupture and bleeding corresponding to CT findings. C. Final angiography shows disappearance of active bleeding after placement of a 9 mm × 6 cm stent-graft (Covera Plus, Bard, Tempe, AZ, USA) at the injured segment. D. Follow-up CT angiography (maximum intensity projection image) shows disappearance of the peripheral hematoma and preserved distal blood flow.

Fig. 2. A 20-year-old male patient admitted to the trauma center following a motorcycle accident.

A, B. CT angiography (maximum intensity projection image) (A) and conventional angiography of the left subclavian artery (B) show transection of the left subclavian artery and compromised distal flow secondary to trauma. C. Attempt at passing a guidewire through the traumatic lesion via a n antergrade approach was unsuccessful. Therefore, retrograde approach via the brachial artery was tried to pass the lesion and it was successful. Fluoroscopy image shows the guidewire subsequently captured using a snare (arrow) via the femoral access route to establish through-and-through brachial-femoral guidewire access. D. Final angiography obtained after placement of a 7 mm × 10 cm bare-metal stent (SMART Flex, Cordis, Santa Clara, CA, USA) shows recovery of the distal blood flow.

Fig. 3. A 80-year-old male patient involved in a pedestrian traffic accident.

A. CT angiography shows active bleeding (arrow) and hematoma involving the right thigh. B. Conventional angiography of the right common femoral artery shows definitive evidence of an active bleeding focus in a muscular branch (arrow). C. Image shows super-selective catheterization of the bleeding vessel using a microcatheter; embolization was performed using N-butyl cyanoacrylate. D. Final angiographic image shows disappearance of active bleeding.