OBJECTIVE: To evaluate retrospectively the results, complications and follow-up of patients after endovascular treatment of vascular injuries.
METHODS: Fifty transcatheter embolisation procedures (TCE) were performed in 46 patients between 1999 and 2008 at the Aga Khan University Hospital, Karachi. Injuries in 14 (30.4%) patients were due to road traffic accident; iatrogenic in 13 (28%); accidental in 6 (13%). Firearms, bomb blasts and earthquake contributed to injuries in 8(17%), 4(8.8%) and 1(2.2%) patients respectively. All patients underwent angiography and had evidence of either active haemorrhage, pseudo-aneurysm, abnormal vascularity or arteriovenous fistula. Followup ranged from 1 day to 6 years with mean of 10.5 months. Medical record files, lab results and imaging reports were utilised for the study. Procedure was declared as technically successful when there was cessation of extravasation, occlusion of fistula or exclusion of pseudo-aneurysm in the post-embolisation angiograms. Treatment was deemed clinically successful if there was resolution of the indication for which the procedure was done.
RESULTS: Transcatheter embolisation was technically successful in occluding vascular lesions in all 46 (100%) patients. Lesions recurred in 4 (9%) patients who underwent initially successful TCE. These patients were treated effectively with repeated TCE. Three patients died during the same hospital stay and 3 patients died after being discharged from the hospital. All these patients were treated successfully with TCE and had factors other then TCE contributing to their mortality.
CONCLUSION: Transcatheter embolisation for vascular injuries was found to be a satisfactory procedure, with low morbidity and mortality rates

Tahir, Muhammad Misbah

Tanveer-ul-Haq,

eCommons@AKU

eCommons@AKUDepartment of Radiology Medical College, PakistanMay 2012Role of endovascular treatment in vascular injuriesMuhammad Misbah TahirAga Khan UniversityTanveer-ul-HaqAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationTahir, M., Tanveer-ul-Haq, . (2012). Role of endovascular treatment in vascular injuries. Journal of the Pakistan Medical Association,62(5), 470-3.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_radiol/16IntroductionVascular trauma is a challenging issue for the surgeonsrequiring effective and quick team work. Time delay andinappropriate management can result in significant morbidityand mortality. Worldwide bombings, civilian landmineinjuries, and combat-related injuries are becoming morecommon, and most physicians are expected to encounter thesepatients at some point or the other in their careers.Transcatheter repair takes preference over surgicalrepair in vascular trauma because of several aspects. There isdecrease in morbidity and mortality, especially when there iscoexisting large haematoma, pseudo-aneurysm orarteriovenous fistula.1-5Intraluminally placed stents and stent grafts designedto bridge traumatic lesions as well as various types of moretraditional occlusive devices, such as balloons, coils and otherthrombogenic materials, can be used for transcatheterembolisation. The retrospective study reviewed theendovascular management of patients with vascular traumapresenting at Aga Khan University Hospital, Karachi,between 1999 and 2008. There were 46 patients reportingwith a variety of complex or inaccessible vascular injurieswho were treated successfully, emphasising the utility of theendovascular approach. Cases were performed according tothe institutional guidelines and protocols with interventionalradiologist and doctors from surgical and medical specialtiesworking in collaboration as a team. Patients and MethodsIt was a retrospective descriptive study carried out atthe AKU Department of Radiology. The archives of theangiography suite were used to identify all patients who hadundergone TCE for vascular injuries at the interventionalradiology section between January 1999 and May 2008.Being retrospective in nature, the study did not require theapproval of the institutional review board.In all cases, the patients had been fully briefed aboutthe procedure and only offer their informed consent, basiclaboratory investigations had been performed beforeperforming TCE. These included complete blood count withplatelet counts, serum creatinine, electrolytes, prothromin470 J Pak Med AssocRole of endovascular treatment in vascular injuriesMuhammad Misbah Tahir, Tanveer-ul-HaqDepartment of Radiology, Aga Khan University Hospital, Karachi, Pakistan.Corresponding Author: Tanveer-ul-Haq. Email: tanveerhaq@aku.eduAbstractObjective: To evaluate retrospectively the results, complications and follow-up of patients after endovasculartreatment of vascular injuries.Methods: Fifty transcatheter embolisation procedures (TCE) were performed in 46 patients between 1999 and2008 at the Aga Khan University Hospital, Karachi. Injuries in 14 (30.4%) patients were due to road trafficaccident; iatrogenic in 13 (28%); accidental in 6 (13%). Firearms, bomb blasts and earthquake contributed toinjuries in 8(17%), 4(8.8%) and 1(2.2%) patients respectively. All patients underwent angiography and hadevidence of either active haemorrhage, pseudo-aneurysm, abnormal vascularity or arteriovenous fistula. Follow-up ranged from 1 day to 6 years with mean of 10.5 months. Medical record files, lab results and imaging reportswere utilised for the study.Procedure was declared as technically successful when there was cessation of extravasation, occlusion of fistulaor exclusion of pseudo-aneurysm in the post-embolisation angiograms. Treatment was deemed clinicallysuccessful if there was resolution of the indication for which the procedure was done.Results: Transcatheter embolisation was technically successful in occluding vascular lesions in all 46 (100%)patients. Lesions recurred in 4 (9%) patients who underwent initially successful TCE. These patients were treatedeffectively with repeated TCE. Three patients died during the same hospital stay and 3 patients died after beingdischarged from the hospital. All these patients were treated successfully with TCE and had factors other thenTCE contributing to their mortality. Conclusion: Transcatheter embolisation for vascular injuries was found to be a satisfactory procedure, with lowmorbidity and mortality rates.Keywords: Transcatheter embolisation, Endovascular treatment, Vascular injuries (JPMA 62: 470; 2012).Original Articletime and activated partial thromboplastin time. For stent graftprocedures, Aspirin 325 mg/day was started at least 3 daysbefore the procedure and was advised to be continuedindefinitely. In addition, Clopidogrel 300 mg was given a dayprior and 75 mg a day to be taken for 6 weeks post-procedure(Figure 1-A,B).Selective digital subtraction angiography wasperformed by transfemoral approach. Catheter wasmanoeuvered into a more distal position with guide wire afterthe source of bleeding was identified. In majority of cases a3-F super selective coaxial catheter (Progreat Terumo Japan)had been introduced coaxially in proximity to the bleedingbranch. Coils (Boston Scientific U.S.A) (Cook U.S.A), PolyVinyl Alcohol particles (PVA) (Cordis Johnson and JohnsonU.S.A) Gel foam (Gelita Medical BV Netherlands),detachable balloons (Minvasys France) and Cyanoacrylateglue (Histoacryl, B.Braun Germany) were used alone or incombination for embolisation. In cases of stenting, guide wirewas placed through the diseased segment of the vessel andself-expanding polytetrafluoroethylene (PTFE) coveredstents (Boston Scientific U.S.A) were deployed to excludethe pseudo aneurysm. All embolisation procedures had beenperformed by interventional radiologists who had 5-15 yearsof experience with intra-arterial catheter embolisationtechniques. Follow-up consisted of radiological and clinicalassessment and ranged from 1 day to six years with a meanof 10.5 months. Medical record files, lab results, imagingreports were utilised for the purpose of this study.Fifty TCE procedures were performed in 46 patientsbetween January 1999 and May 2008. Thirty-eight (83%) ofthe patients were male and 8 (17%) were female. Their agesranged from 13 to 79 years (mean 37years). Injuries involvedpredominantly head and face in 17 (37%) patients, pelvis in 9(19.6%), extremities in 5 (10.9%), kidneys in 12 (26.1%), andliver and thorax in 1 (2.2%) patient each. One (2.2%) patientpresented with polytrauma. The lesions encountered included 16 post-traumaticextravasations, 10 pseudo-aneurysms, 12 arteriovenousfistulas (AVFs), 6 AVFs and false aneurysms occurringtogether, and 2 cases of abnormal vascularity (hyperemia).Most injuries were encountered in renal arteries (Table).Injuries in 14 (30.4%) patients were due to road trafficaccident. Four of them with pelvic fractures were unstablewith extravasations from branches of iliac artery.Transcatheter embolisation was performed effectively inthese patients with coils, poly vinyl alcohol and Gelfoam.Two patients suffered renal injuries resulting in avulsion ofinterpolar branches of renal artery and arteriovenousmalformation. They were managed successfully with coilembolisation. Firearms, bomb blasts contributed to injuries in 8(17.4%) and 4 (8.7%) patients respectively. Two patients hadinjury to common iliac artery resulting in development ofarteriovenous fistulae and pseudo-aneurysms which wereexcluded successfully with covered stents. One gunshot victimhad extravasation from the branch of right hepatic arteryresulting in haemobilia. He was cured with coil embolisation ofthe bleeding vessel. One bomb blast victim developed AVFbetween internal jugular vein and internal carotid artery whichwas occluded uneventfully with coil embolisation. Injuries in 13 (28.3%) patients were Iatrogenic. Twoof these 13 had common femoral artery pseudo-aneurysmsand were treated with covered stents. One of them hadexcision of inguinal lymph node and radiotherapy while theother was intravenous drug abuser. Another patient developedpseudo-aneurysm of common carotid artery as a complicationof Joe catheter insertion and was treated with combinationtherapy involving covered stent, coil and glue embolisation(Figure-2 A-B). Five patients had vascular injuries followingpyelolithotomies. Pseudoaneurysms were noted in 3 casesand extravasation was detected in 2. These lesions weretreated with coil embolisation. Two patients developed grossVol. 62, No. 5, May 2012 471Figure-1: A) Digital subtraction angiogram of right internal carotid artery showingmature traumatic direct right carotocavernous fistula. B) Successful detachableballoon embolization of right carotocavernous fistula.Table: Arteries embolized by names & number.Name of artery No. of PatientsRenal 14Internal iliac 6Internal pudendal 3Common iliac 2External iliac 1Common femoral 2Internal carotid 11 including 9 carotid cavernous fistulasExternal carotid 4Common carotid 2Hepatic artery 1Ascending aorta 1Anterior tibial artery 1Posterior tibial artery 1haematuria following transplantation of kidneys. Pseudo-aneurysm and arteriovenous fistula was detected in onepatient, which was taken care of with balloon and coilembolisation. The other had extravasation which was treatedwith coil embolisation. Another coronary artery bypass graft(CABG) patient developed pseudoaneurysm of ascendingaorta during surgery and was immediately shifted to theangiography suite where pseudo-aneurysm was excludedwith detachable coil embolisation. Active extravasation wasnoted in a patient following renal biopsy. He was embolisedsuccessfully with coils, but could not recover from the shockand died during the same hospital stay.Six (13%) patients had accidental vascular injuries.One of them developed priapism due to pseudo-aneurysmand arteriovenous fistula of internal Pudendal artery. He wastreated with poly vinyl alcohol particles and coilembolisation. Another patient had suicidal attempt with kniferesulting in pseudo-aneurysm in the left proximal internalcarotid artery. He was treated with a covered stent. One (2.2%) patient had head injury due to earthquake,resulting in caroto-cavernous fistula and pseudo-aneurysm ofthe internal carotid artery. Balloon embolisation wasperformed with occlusion of fistula and pseudo-aneurysmalong with good cross-flow preserving the cerebralcirculation. Radiologic records and patient charts were reviewedby two of the researchers together to extract information aboutthe technical and medical success of the procedure, andtechnical and medical complications. Technical success of theprocedure was defined as complete occlusion of bleeding,pseudo-aneurysm or AVF with arterial embolisation asdocumented with arterial angiography at the end of theprocedure. Medical success was defined by the disappearanceof indication for which embolisation was performed like theabsence of recurrent haematuria, absence of recurrent need forerythrocyte administration, absence of recurrent decrease ofhaemoglobin by more than 1.5 g/dL (15 g/L), and absence ofneed for angiographic re-embolisation or subsequent surgery.ResultsTranscatheter embolisation (TCE) was technicallyand clinically successful in occluding vascular lesions in all46 (100%) patients. Lesions recurred in 4 patients. Threepatients had recurrence of the carotid cavernous fistula(CCF), while one patient had recurrence of leg arteriovenousfistula (AVF). These patients were treated effectively withrepeated TCE. In one patient there was dislodgment of coil in theprofunda femoris artery without any clinical consequenceswhile attempting embolisation of branches of the externaliliac artery. No other angiographic embolisation-relatedcomplications were encountered. Of the total, 43 patients survived to be dischargedfrom the hospital. Three patients died during the samehospital stay. One patient had a fall from the sixth floor andhad bled profusely before being brought to the angiographysuite. He died of multi-organ failure after being treatedsuccessfully for vascular injuries. Another patient, who hadroad traffic accident, died of intracranial haemorrhage afterbeing treated for pelvic bleed. The third patient had post-renalbiopsy bleed and was brought in shock. He was treatedsuccessfully with embolisation of the renal artery, but couldnot recover from the shock and died five days later. Threepatients had died after being discharged from the hospital. Allthese patients were treated successfully with TCE and hadother concomitant diseases like chronic renal failure, scrotalcarcinoma and cirrhosis which contributed to their death.Six patients had been treated with covered metallicstents. No stent occlusion or infection was noted in ourstudy. The longest stent patency interval noted in the studywas six years. DiscussionEndovascular management of patients with traumaticvascular lesions is an attractive conception with the facility ofdiagnosis and treatment in the same session along withrelatively easy access to difficult locations like the base of theskull, infraclavicular region and the pelvis. Vascular injuries can be treated with transcatheterembolisation by stent grafts, occlusive intervention devicesand combination therapy. For the exclusion of a vascularlesion, stent graft is used. It is made of an impermeableendoluminal graft supported by a metallic stent. One of the largest studies describing the repair ofcarotid injury with stent graft deployment was carried out at472 J Pak Med AssocFigure-2: A) Right brachiocephalic artery digital subtraction angiogram showingcommon carotid stump filling large pseudo aneurysm. (Arrow) and non-filling of thedistal common carotid artery and its branches. This is an iatrogenic injury followingcentral line placement. B) Successful embolization with self expanding metallic stent,coils and histoacryl glue resulting in complete exclusion of the pseudo aneurysm.the Montefiore Medical Center.6 In the initial phase of thestudy six pseudo-aneurysms and one arteriovenous fistulawere treated with seven stent grafts. All the stent grafts weredeployed successfully with 100% patency at a mean follow-up of 6.5 months. A subsequent report defined the outcomefollowing the repair of six subclavian artery injuries.7 Allendografts were patent at a mean follow-up interval of 19months. No stent occlusion was noted in our retrospective,and the study longest patency interval noted was six years. One of the complications of stent graft is infectionthough it has not been clearly described. In our series, no caseof stent graft infection was found.In vessels that can be occluded completely withoutclinical consequences, TCE can be performed withmechanical devices, polymeric solid biomaterials and liquidadhesives. Balloon occlusion has become an acceptedmodality of treating traumatic carotid-cavernous fistulas(CCF).8,9 Our study found that six cases of CCF had beensuccessfully treated with transcatheter detachable balloonocclusion. In 3 of these cases, only micro coils were used asthe embolising material. One patient with traumatic AVF ofthe left leg, and another patient with transplanted kidney andiatrogenic injury to a branch of renal artery resulting inpseudo-aneurysm and AVF formation, were also treatedsuccessfully treated with balloon and coil occlusion. All theseballoons were placed within the fistula withoutcompromising the arterial lumen. One of the very important occlusive modalities for themanagement of endovascular trauma is coil embolisation.1 Inour series, coils were the only embolising agents in 23 of 50TCE procedures. Gelfoam was used primarily for thetemporary control of bleeding before surgical intervention.10,11In two cases, we noticed the use of Gelfoam; one with nasalbleed, and the other with internal iliac artery bleed. PVAexpands up to 15 times in length after coming in contact withblood, making it ideal for occlusion when the catheter can beplaced closed to the area of injury in selected casesHistoacryl glue is an important tool of occlusiveendovascular management. It is a liquid adhesive materialwhich rapidly polymerises after coming in contact with theblood. It can be used effectively to supplement balloonocclusion. In a patient with AVF of posterior tibial artery,our study noted the use of combination of glue and balloonsuccessfully. In another patient with pseudo-aneurysm ofthe common carotid artery, a combination of Histoacrylglue, coils and covered stent had been used for the exclusionof pseudo-aneurysm.ConclusionThe retrospective review of data revealed satisfactoryresults in patients treated with transcatheter embolisation forvascular injuries. TCE has replaced surgery in curing carotid-cavernous fistulas. It is the preferred modality for treatinglesions at sites difficult to approach by conventional surgery.It also becomes the treatment of choice in patients wheresurgery is contraindicated because of patient factors likederanged coagulation profile or inability to endure generalanaesthesia. It also decreases the hospital stay of patient.AcknowledgementWe thank all our teachers, especially Dr Azeemuddin,for their encouragement, help and cooperation.References1. Cook RE, Keating JF, Gillespie I. The role of angiography in the managementof haemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 2002;84: 178-82. 2. Weiss VJ, Chaikof EL. Endovascular treatment of vascular injuries. Surg ClinNorth Am 1999; 79: 653-65.3. Nicholson AA. Vascular radiology in trauma. Cardiovasc Intervent Radiol 2004;27: 105-20.4. Dinkel HP, Danuser H, Triller J. Blunt renal trauma: minimally invasivemanagement with microcatheter embolization experience in nine patients.Radiology 2002; 223: 723-30.5. Qasim ZA, Masood R, Mateen MA. Successful use of angiographicembolisation to control haemorrhage from blunt pelvic trauma in a pediatricpatient. J Pak Med Assoc 2004; 54: 32-3.6. Ohki T, Veith FJ, Marin ML, Cynamon J, Sanchez LA. Endovascularapproaches for traumatic arterial lesions. Semin Vasc Surg 1997; 10: 272-85.7. Patel AV, Marin ML, Veith FJ, Kerr A, Sanchez LA. Endovascular graft repairof penetrating subclavian artery injuries. J Endovasc Surg 1996; 3: 382-8.8. Bavinzski G, Killer M, Gruber A, Richling B. Treatment of post-traumaticcarotico-cavernous fistulae using electrolytically detachable coils: technicalaspects and preliminary experience. Neuroradiology 1997; 39: 81-5.9. Lewis AI, Tomsick TA, Tew JM Jr. Management of 100 consecutive directcarotid-cavernous fistulas: results of treatment with detachable balloons.Neurosurgery 1995; 36: 239-44.10. Hieshima GB, Grinnell VS, Mehringer CM. A detachable balloon fortherapeutic transcatheter occlusions. Radiology 1981; 138: 227-8.11. Katzen BT, Rossi P, Passairello R, Simonetti G. Transcatheter therapeuticarterial embolisation. Radiology 1976; 120: 523-31.Vol. 62, No. 5, May 2012 473

Role of endovascular treatment in vascular injuries

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Role of endovascular treatment in vascular injuries

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