Using Stent Grafts for the Treatment of Arterial Injuries Caused by Penetrating Trauma to the Extremities

Using Stent Grafts for the Treatment of Arterial Injuries Caused by

Penetrating Trauma to the Extremities

Mohamed Abd El-Monem Abd El-Salam Rizk, MD

Vascular Surgery Department, Ain Shams University, Cairo, Egypt

Aim: To assess the technical success, primary patency and associated complications in the treatment of acute arterial injuries caused by penetrating trauma using stent grafts through an endovascular maneuver, and to compare these results with a group who were treated surgically.

Patients & methods: Six (6) patients presenting with penetrating trauma of the extremities associated with vascular injury were studied  in the period from August 2013 till August 2015. These patients had arteriovenous fistula or a pseudoaneurysm that occurred due to penetrating trauma. They were treated using stent grafts. This group was compared to another group of (10) patients who were treated surgically by exploration and repair.

Results: The technical success rate was 100% in both groups. The patency rate in 3 months was 100%

for both groups while in 6 months it was 83.3 % for the stent graft group and 100% for the surgical group.

Conclusion: Using stent graft in the treatment of arterial injuries resulting from penetrating trauma is a minimally invasive procedure, time saving, and is not associated with surgical wound infection.

Key words: Stent graft, arterial injury, pseudoaneurysm, arteriovenous fistula.

Introduction

Trauma-related  vascular  injuries  constitute  3% of civilian trauma casualties.1  Vascular injuries to the extremities occur in 0.5% to 1% of injured patients but account for 20% to 50% of all vascular injuries.2,3

As for Egypt there was limited data about the rate of civilian trauma causalities and vascular injury in them. In a study about the pattern and trend of injuries among trauma unit attendants in Upper Egypt in the period of 2002 till 2009, it was found that the number of attendants increased every year from 9.3% from the total cases in all study period in 2002 up to 15.3% in 2009. Young adults aged 20-29 years were the most common group affected  by  injuries  (22.2%),  male  to  female ratio was 3:1. Falls represent one half of injuries (49.6%) from all attended cases, followed by exposure to inanimate mechanical forces (19.5%) and transport accidents (18.3%).4

Another study showed that 1st leading cause of injury in the years 2005-2008 in upper Egypt was Assault/fight representing an average of 23.745 % of all injuries, and 4th leading cause of injury in the years 2005-2007, and 2009 was sharp objects.5

Arterial injuries resulting from penetrating trauma or interventional vascular procedures can lead to the formation of arterial pseudoaneurysms and/or arteriovenous fistulas (AVFs).

Open surgical control and repair remain the mainstay of the management of most extremity vascular  injuries  especially  patients  presenting with hard signs of vascular injury, while those presenting with soft signs still have a time window for further investigations.

Patients and methods

This  study  was  conducted  on  patients attending the vascular outpatient clinic or the emergency departments, this     cohort     study was     done on 6   patients presenting with penetrating trauma associated      with   vascular injury;  they    were    treated    using    covered stents.  This  study  sample  presented    in  the period from August 2013 till August 2015, the results for this study were compared to data collected from patients treated with surgical exploration and repair of vascular injury of the extremities due to penetrating injuries during the same period of time.

The inclusion criteria of the patients in the study group were:

Patients having arteriovenous fistula or arterial pseudoaneurysm after a penetrating injury to the extremities either due to firearm injury (bullet, shots or slugs) or due to a stab by a sharp object.

1.   Vascular injury discovered either immediately after the incident or later during the follow up.

2.   Vitally stable patients with serum hemoglobin of more than 8 gm/dL.

3.   Patient’s approval to be included in the study.

The exclusion criteria of the patients in the study group were:

1.   Patients who had previous history of diabetes mellitus, hypertension, or cardiac disease.

2.   Vitally unstable patients or serum hemoglobin less than 8 gm/dL.

3.   Patients who had hard signs of vascular injury or acute lower limb ischemia.

4.  Patients known to have peripheral vascular disease.

Patients who were vitally unstable, had serum haemoglobin less than 8 gm/dL, had hard signs of vascular injury or having acute lower limb ischemia were treated surgically by exploration and repair.

Every patient was subjected to:

1.   History  taking,  putting  in  mind  the  mode of   trauma,   symptomatology   of   patients’ condition, and the duration since the incident.

2.   Clinical examination with special attention to the presence of thrill or bruit by stethoscope.

3.  Duplex Scanning, CT angiography or direct conventional angiography.

Procedure:

1.   The procedure was done under local infiltration anesthesia with antegrade puncture of the common femoral artery of the affected site while the patient was in the supine position, or retrograde puncture of the common femoral or brachial arteries in case of upper limb injuries.

2.   Seldinger technique was used with introduction of a 8 F (Prelude®, MeritMedical) sheath. Diagnostic angiogram was done to select the area for intervention using non ionic contrast media.

3. A 0.035 J shaped guide wire (Terumo®, Terumo corporation) was manipulated to cross the affected segment, with the help of a 5F guiding catheter (Performa®, MeritMedical).

4. Introductionofaselfexpandlevascularstentgraft (Fluency®, C. R. Bard, Inc.) 6-8 mm in various lengths was done according to the length of the desired site.

5. Completion angiography was done for evaluation of angioplasty results.

6.   Manual  compression  of  the  puncture  site: immediately after removal of the sheath for 15 to 20 minutes (it was done immediately after the procedure).

7.   All patients were maintained on Clopidogre 75 mg once daily, together with acetyl salicylic acid 100 mg for at least 6 months.

8.   The procedure was followed up every 3 months and 6 months using duplex ultrasound.

Resault

This study was conducted on 6 patients with penetrating trauma associated with vascular injury; they were treated using covered stents. The study sample presented in the period from August 2013 till August 2015.

During this period of time another 10 patients were treated through surgical exploration and repair of the arterial injury.

The mean age for our cohort study group was 29.17±6.62, they were all males.

As for the mode of trauma, four (66.7%) of them sustained firearm injury with gun shots, while the other two (33.3%) were subjected to stab using sharp objects.  

Of  the studied group, 5 (83.3%) patients had injuries to the lower extremity, while one (16.7%) had an upper extremity injury. 

Four patients (66.7%) had an arterial pseudoanerysm, while the other two (33.3%) had an arteriovenous fistula.

a                              b

c

Fig 1a,b: A patient having an arteriovenous fistula between superficial femoral artery and vein after a gun shot firearm injury

c: a patient having a pseudoaneurysm of the first

part popliteal artery after a stab injury.

Three patients were diagnosed immediately after they were subjected to the injury, while the other three had late presentation after one to three weeks from being subjected to the traumatic injury. Two of those patients presented with either a pulsating swelling in proximity of the site of injury or diffuse limb swelling. 

All patients were subjected to duplex ultrasound, CT angiography or direct conventional angiography.

As for the patients who underwent surgical exploration and repair in comparison to our cohort group, the following table showed these results.

Table 1: Description of the studied patients

Stent graft group       Surgical group              P value

Number of patients                                6                             10

Age                                29.16667±6.61564       28.1± 7.03088

Male                      6 (100%)                 10 (100%)

Gender

Female                         0                             0

Upper limb                 1 (16.7%)                  2 (20%)                 0.48214286

Site of the injury

Lower limb                 5 (83.3%)                  8 (80%)

Fisher’s exact

Patients who underwent surgical exploration had complete or partial cut of the arterial axis with or without venous injury. Those patients had ahard sign for vascular injury. The following table showed the sites of these injuries in comparison to our cohort group.

Table 2: Description of the site of the lesion in the studied groups. (SFA: superficial femoral artery)

Upper limb

Lower limb

In the stent graft group we treated the vascular injury through an endovascular technique using a stent graft to cover the lesion site, while in the surgical group, repair of the arterial injury was done either through direct repair, vein patch repair or reversed saphenous bypass graft.

Technical success was defined as restoration of the continuity of the arterial access without any residual connection  through  a  fistula  or  a pseudoanerysm.     In     both     groups     this was  successfully  reached  in  all  patients included in the study. The following table showed the type of the procedure done in relation to the mechanism of injury in the surgical group.

a                                   b

Fig 2a,b: A covered stent applied to the site of

an arteriovenous fistula in the lower extremity.

Table 3: The type of surgical repair in relation to the mechanism of injury

Direct repair     Saphenous patch graft

Reversed saphenous bypass

o

Fig 3: The type of surgical repair in relation to the mechanism of injury. In the stent graft group, all patients underwent the procedure under local anesthesia, while patients in the surgical group under- went the procedure under general anesthesia. As for the duration of the procedure, the following table showed these results.

Table 4: Duration of the procedure in both groups

Table 6: Patency rates at 3, 6 months

Stent graft group

Surgical group

Stent graft group

Surgical group

Duration of the procedure

Up to one hour

Direct repair          1-2 hours Saphenous patch graft   1-2 hours Reversed saphenous

bypass              2-3 hours

Patency at

3 months

Patency at

6 months

Yes         6 (100%)     10 (100%)

No               0                  0

Yes        5 (83.3%)     10 (100%) No        1 (16.7%)                      0

As  for  the  postoperative  complications  during the follow up period of the first two weeks, the following table showed these results.

Table 5: Postoperative complications

The patient in the stent graft group who had his stent graft occluded, was admitted to CCU for myocardial infarction. The patient had critical ischemia of his upper limb and underwent axillo- brachial bypass using synthetic graft.

Stent graft group

Surgical group

Discussion

Our study was conducted on patients who were

Hematoma formation              1                   0

Surgical site infection              0                   4

Acute thrombosis                   0                   0

In the surgical group four patients have had surgical site infection, 3 of them were subjected to shot gun injury and one was subjected to stab wound injury through which exploration was done because it was over the course of the vessel. 

This led to extension of the hospital stay of these patients for  a week or more. 

Patients  who underwent  treatment  using stent graft were maintained on clopidogril for at least 6 months.

The following table showed the results of the follow up. 

subjected to penetrating trauma of the extremities that caused either an arteriovenous fistula or a pseudoaneurysm which was treated through an endovascular option using stent grafts. Technical success was 100%, postoperative complications occurred in one patient in the form of puncture site hematoma which was treated conservatively. Patency in 3 months was 100%, while in 6 months was 83.3%, the only patient who had his stent graft occluded has been admitted to the CCU for myocardial infarction.

By comparing the results for our cohort group with a group of patients who were treated surgically, it was found that both groups had no difference as regards  the technical success and patency rate in the 1st 3 months. Using stent graft had been associated with short procedure time in comparison to the surgical option. Also there was no associated surgical site infection for the stent graft group in comparison to the surgical group. 

Our study subjects were all young adult males with a mean age of 29.17±6.62 which goes with the results of multiple studies that  those with extremity vascular injuries tend to be young, with average ages in the 30s, and predominantly (70%-90%) male.6,7