Stent graft repair of subclavian and axillary vascular injuries: The Groote Schuur experience

Abstract

Despite the paucity of long-term, durable data, stent graft repair has emerged as a safe and feasible alternative to open repair of trauma-related subclavian and axillary vascular injuries (SAVIs). Surgical treatment is often attended by high morbidity and mortality rates (5-30%). [1,2] Indeed, some have suggested that stent graft repair should be considered as first-line treatment for trauma-related SAVIs. Peripheral stent grafting evolved as a complementary treatment strategy since 2008 at Groote Schuur Hospital, Cape Town, for select patients with vascular trauma. Methods All patients considered endosuitable were counselled about the procedure, and the need for diligent follow-up was emphasised. Consent was obtained from all patients. The procedure was performed either in an interventional angio suite under local anaesthesia or in the operating theatre (OR) under general anaesthesia. Estimation of stent graft diameter and length was obtained from preoperative imaging modalities that included catheter angiography, duplex ultrasound (DUS) or computed tomography angiography (CTA). A range of stent grafts of different diameters and lengths was available at the time of the procedure. Access for deployment was obtained via percutaneous or 'cut-down' (femoral or brachial) approaches. When using femoral access, long systems were utilised (guidewires; balloon and stent catheters; long, appropriately sized sheaths). Heparin was given prior to lesion crossing and stent graft deployment in all cases. We maintained the habit of balloon moulding, a requirement for some older-generation

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients

“…16 However, the literature does not adequately address the role of endovascular therapy in HIV-patients. 17 In the general population, complications are experienced in 5e30% patients with surgically managed axillosubclavian injuries. 18 In their report on axillosubclavian injuries treated by the insertion of covered stent grafts, Naidoo et al 17 included five HIV-patients, two of whom experienced complications after endovascular treatment.…”

“…17 In the general population, complications are experienced in 5e30% patients with surgically managed axillosubclavian injuries. 18 In their report on axillosubclavian injuries treated by the insertion of covered stent grafts, Naidoo et al 17 included five HIV-patients, two of whom experienced complications after endovascular treatment. 17 Their HIVrelated trauma experience mirrors the immediate technical success of the current study in which seven patients with post-traumatic pseudo-aneurysms were managed by stent grafts and/or coiling procedures.…”

“…18 In their report on axillosubclavian injuries treated by the insertion of covered stent grafts, Naidoo et al 17 included five HIV-patients, two of whom experienced complications after endovascular treatment. 17 Their HIVrelated trauma experience mirrors the immediate technical success of the current study in which seven patients with post-traumatic pseudo-aneurysms were managed by stent grafts and/or coiling procedures. 19 The role of endovascular therapy cannot be underestimated in the four patients with delayed clinical presentations due to the challenges associated with achieving safe surgical tissue plane dissections in these patients.…”

“…19 The role of endovascular therapy cannot be underestimated in the four patients with delayed clinical presentations due to the challenges associated with achieving safe surgical tissue plane dissections in these patients. 17,20 While the patients with post-traumatic pseudo-aneurysms had a successful immediate outcome, it may be argued that the traumarelated pseudo-aneurysms are an incidental finding in patients with normal blood vessels who are afflicted concomitantly by HIV infection. Although studies on vessel wall adjacent to aneurysmal lesions demonstrated inflammatory and vasculitic pathology similar to that within the dilated segment, the profile of arterial wall histology from asymptomatic individuals with apparently normal vessels remains undescribed and requires future attention.…”

Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature

“…In some series, the vertebral artery is routinely covered in repair of these injuries. 51 Some centers report verifying an intact circle of Willis 52 prior to vertebral coverage, but others use expectant management, citing the approach to the left subclavian during TEVAR for trauma. 51 Conversely, some centers report not completely covering pseudoaneurysms because of their proximity to a dominant vertebral artery.…”