CASE REPORT
En dova scu la r m a n a ge m e n t of e x t r e m it y a r t e r ia l t r a u m a
Ch a r le s An got t i Fu r t a do de M e de ir osI; Th a is Cr ist in a H a t su m u r aI I; D a n ie l Ra ssi Gu sm ã oI I I; Lu ca s M a r ce lo D ia s Fr e ir eI V; Edu a r do Fa ccin i Roch aI V; An a Te r e z in h a Gu illa u m onV
IPhD st udent in Per ipher al Vascular Surgery, Cent ro de Refer ência em Cir ur gia Endovascular ,
Univer sidade Est adual de Cam pinas ( UNI CAMP) , Cam pinas, SP, Brazil.
I IResident , Peripheral Vascular Surgery, Cent ro de Refer ência em Cirurgia Endovascular, UNI CAMP,
Cam pinas, SP, Br azil.
I I IResident , Peripheral Vascular Surgery, Cent ro de Refer ência em Cirurgia Endovascular, UNI CAMP,
Cam pinas, SP, Br azil.
I VHired physician, Peripheral Vascular Surgery, Cent ro de Referência em Cir ur gia Endovascular ,
UNI CAMP, Cam pinas, SP, Brazil.
VProfessor. Head, Per ipher al Vascular Surgery, Cent ro de Refer ência em Cirurgia Endovascular,
UNI CAMP, Cam pinas, SP, Brazil.
Correspondence
J Vasc Bras. 2008; 7( 1) : 56- 61.
ABSTRACT
Treat m ent of art erial t raum at ic inj ur ies is usually perform ed w it h convent ional revascularizat ion t echniques. How ever , vascular inj ur ies can increasingly be r epair ed efficient ly t hrough m inim ally invasive pr ocedur es. We report four cases of ext rem it y ar t er ial t r aum a t reat ed by endovascular t echniques in a reference cent er. All pat ient s show ed sat isfact or y developm ent ov er a 15- m ont h follow- up. We suggest t hat endovascular t herapy is a pr om ising alt ernat ive t o surgery for select ed pat ient s w it h ext rem it y art erial t raum a.
Ke yw or ds:Vascular t r aum a, pseudoaneur ysm , ischem ia, em er gency t reat m ent .
RESUM O
por m eio de pr ocedim ent os m inim am ent e invasivos. Nós descr evem os quat r o casos de t raum a art erial dos m em br os que foram t rat ados por t écnicas endovascular es num cent r o de r efer ência. Todos os pacient es evoluír am sat isfat or iam ent e dur ant e o seguim ent o de 15 m eses. Nós suger im os que o t rat am ent o endovascular é um a alt er nat iva pr om issor a em relação à cirurgia par a pacient es selecionados com t r aum a ar t er ial dos m em br os.
Pa la vr a s- ch a ve : Traum a vascular, pseudo- aneurism a, isquem ia, t rat am ent o de ur gência.
I n t r odu ct ion
Tr aum at ic art erial lesions w it h acut e lim b ischem ia are usually repaired by t radit ional revascularizat ion t echniques.1 - 4 I n gener al, lim b am put at ion rat e ranges accor ding t o lesion m echanism , w het her penet r at ing or blunt , bet w een 10 and 30% , r espect ively. To im pr ove t hat rat e, it is necessary t o develop new t echniques for cir culat ion r est or at ion.
Due t o it s m inim ally invasive char act er , t he endovascular surgery can have som e advant ages com par ed t o t he convent ional t reat m ent in select ed cases of vascular t raum a. Next , w e report on four cases of lim b art erial t r aum a t hat w er e at t ended at t he Em er gency Room of Hospit al de Clínicas da Univer sidade Est adual de Cam pinas and successfully subm it t ed t o endovascular t reat m ent by t he per ipher al vascular surgery t eam .
Ca se de scr ipt ion
Ca se 1
A 31- year - old m ale pat ient w as vict im of penet r at ing bullet inj ur y ( BI ) w it h ent r ance hole ( EN) in t he r ight subscapular region and exit hole ( EX) in t he r ight infr aclavicular r egion. Physical
Ca se 2
An 18- year- old m ale pat ient w as vict im of a penet r at ing BI w it h EN in t he left cubit al fossa and EX in t he left axillary crease. Physical exam inat ion: st able, w it h signs of ischem ia in t he left upper lim b and brachial- brachial index = 0.6. The pat ient w as subm it t ed t o digit al angiogr aphy t hrough
fem oral appr oach, axillary art ery r ecanalizat ion and lesion r epair by placem ent of a JOMED® balloon st ent gr aft t hrough ret rograde br achial approach at t he sam e t im e ( Figur es 5 and 6) .
Ca se 4
As a result of new opt ions of t reat m ent , car e of pat ient s w it h vascular disease has drast ically changed over t he past years. Endovascular pr ocedur es significant ly cont ribut ed t o m ost of t hese changes. Many m inim ally invasive t echniques have also been adapt ed t o m ult iple t raum a pat ient s. This has been w ell dem onst r at ed in t he t reat m ent of solid or gan lesions and pelvic fract ures, w hich st art ed being em bolized t o cont r ol hem orrhage.5
Now adays, w it h t he grow ing advance of endovascular pr ocedur es, t r aum at ic lesions of lar ge- caliber art eries can be efficient ly r epair ed, in m any cases by endovascular t echniques. These procedures seem part icularly at t r act ive in blunt t r aum a, especially in areas bet w een t he t runk and ext rem it ies, w here proxim al vascular cont r ol is difficult .
Especially in cases of pseudoaneur ysm and art eriovenous fist ulas, endovascular t r eat m ent is of great value. Today, m inim ally invasive t echniques allow r epair of acut e or chronic lesions, t hus avoiding a sur ger y t hat is oft en difficult , at a sit e w her e t her e is change of anat om ic st ruct ures and int ense bleeding.6 - 8
How ever, regarding ar t er ial t raum a of ext rem it ies, t her apy becom es a lit t le m ore challenging. Perhaps for t hat r eason t her e are few r epor t s on endovascular t r eat m ent of t raum a in peripheral art eries, w het her in low er and upper lim bs or in relat ion t o m echanism of lesion, penet r at ing or blunt .9 - 1 5
The m ain advant age of endovascular t echniques in t hese cases is t o avoid ar eas of r ecent t r aum a, in w hich t here is a lar ge anat om ic dist ort ion in an at t em pt t o expose affect ed st ruct ures t o cont r ol bleeding and r est or e blood flow , bot h essent ial for lim b preservat ion. As a direct consequence, inadvert ent lesions, blood loss and incidence of infect ions should be m uch less fr equent . Shor t er hospit alizat ion t im e and possibilit y of t r eat m ent using only local anest hesia are also expect ed.
On t he ot her hand, associat ion w it h venous and lym phat ic lesions is fr equent , as w ell as w it h bone fract ures, soft t issue t r aum a and neur ological lesions. Despit e t he successful t reat m ent of vascular lesions, neur ological lesions det er m ine m aj or funct ional deficit in up t o 40% of cases.1 6
So far , t here has been no evidence in t he lit er at ur e indicat ing t hat endovascular t r eat m ent in t raum a is bet t er t han convent ional sur gical t r eat m ent . Today t here is consensus t hat pat ient s w it h severe hem odynam ic inst abilit y or t hose w it h m aj or act ive bleeding have form al cont r aindicat ion for endovascular t r eat m ent . Also, cases of m ult iple t raum a w it h associat ed cr anial and abdom inal lesions should be subm it t ed t o convent ional sur ger y, especially if t here is cont raindicat ion t o ant icoagulat ion. Pat ient s w it h pr olonged evolut ion t im e ( > 6 hour s) should also be subm it t ed t o open revascularizat ion of t he ischem ic lim b.
I n case of em ergency, lack of t im e for planning is a lim it ing fact or. Due t o t hat difficult y, devices chosen w er e t hose t hat could be used, but t hey also had t o be adapt ed t o each sit uat ion. All four cases r epor t ed above obt ained t echnical success. Mean hospit alizat ion t im e w as 3 days, and during a 15- m ont h follow - up, lim b salvat ion rat e r eached 100% . St ent pat ency is easily assessed by a sim ple physical exam inat ion and, if necessary, Doppler ult rasound can be used for confirm at ion ( Figure 6) .
Re fe r e n ce s
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2. Huynh TT, Pham M, Griffin LW, et al. Managem ent of dist al fem oral and poplit eal art erial inj uries: an updat e. Am J Surg. 2006; 192: 773- 8.
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14. Lönn L, Delle M, Kar lst r öm L, Risber g B. Should blunt ar t er ial t raum a t o t he ext r em it ies be t reat ed w it h endovascular t echniques?J Traum a. 2005; 59: 1224- 7.
15. Alvar ez- Tost ado J, Tulsyan N, But ler B, Rizzo A. Endovascular m anagem ent of acut e crit ical ischem ia secondar y t o blunt t ibial art ery inj ur y. J Vasc Surg. 2006; 44: 1101- 3.
Cor r e spon de n ce :
Charles Angotti Furtado de Medeiros
Rua Izabel Negr€o Bertoti, 101/52 Bairro M. Sto. Ant•nio CEP 13087-508 – Campinas, SP, Brazil
Tel.: (19) 3256.9771
Email: drcharlesangotti@hotmail.com
