Emergency stent-graft implantation for iatrogenic peripheral arterial rupture

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1 DOI /s EMERGENCY RADIOLOGY RADIOLOGIA D URGENZA ED EMERGENZA Emergency stent-graft implantation for iatrogenic peripheral arterial rupture Posizionamento di endoprotesi in emergenza per il trattamento della rottura iatrogena delle arterie periferiche L. Xiao J. Shen J.-J. Tong Department of Radiology, the First Hospital of China Medical University, 155 Nanjing North Road, Shenyang , Liaoning, P.R. China Correspondence to: L. Xiao, Tel.: , Fax: , Received: 9 June 2011 / Accepted: 30 August 2011 Springer-Verlag 2012 Abstract Purpose. We evaluated the experience with and efficacy of stent-grafting for iatrogenic peripheral arterial ruptures. Materials and methods. From 2005 to 2009 we performed stent-grafting on four male patients (age years) with iatrogenic peripheral arterial ruptures. In patient 1, grointissue necrosis followed a subcutaneous injection and led to femoral arterial rupture. Pseudoaneurysms ruptured in patients 2 and 3 who were undergoing femoral arteriotomy. Patient 1 experienced a ruptured carotid artery during neck surgery. Shock occurred in three of the four patients. Four patients underwent self-expanding stent-grafting (8 mm 60 mm or 8 mm 80 mm) under local anaesthesia. Results. Haemorrhages were controlled in all patients. No procedure-related complications occurred. Patient 1 died of lung metastases 13 months after stent-grafting. Follow-up examinations showed that the stent-graft remained patent in patients 1, 2 and 4, whereas stent occlusion occurred after 15 months in patient 3; in this case, a pseudoaneurysm proximal to the stent was identified, and although repeat stent-grafting successfully stopped the bleeding, the patient died of multiple organ failure 1 week later. Conclusions. Emergency stent-grafting is a technically feasible and therapeutically effective modality for treating high-risk patients who experience iatrogenic peripheral arterial ruptures. The efficient treatment of hypotension and early endovascular intervention will improve the prognosis. Keywords Peripheral vascular disease Complication Endoluminal repair Stent-graft Riassunto Obiettivo. Scopo del presente lavoro è valutare la nostra esperienza nell utilizzo di endoprotesi e la loro efficacia nel trattamento delle rotture iatrogene delle arterie periferiche. Materiali e metodi. Dal 2005 al 2009 abbiamo posizionato quattro endoprotesi in altrettanti pazienti (età anni) con rottura iatrogena delle arterie periferiche. Nel paziente 1, la necrosi dei tessuti molli inguinali, sviluppatasi in seguito ad una iniezione sottocutanea, ha portato alla rottura dell arteria femorale. Nei pazienti 2 e 3, che sono stati sottoposti ad arteriotomia femorale, si è verificata la rottura di pseudoaneurisma. Il paziente 4 ha subito la rottura della carotide durante un intervento chirurgico al collo. Tre su quattro pazienti sono entrati in stato di shock. A tutti i pazienti è stata posizionata un endoprotesi autoespandente (8 mm 60 mm or 8 mm 80 mm) in anestesia locale. Risultati. In tutti i casi si è avuto un arresto dell emorragia. Non ci sono state complicanze correlate alle procedure. Il paziente 1 è morto per metastasi polmonari 13 mesi dopo il posizionamento dell endoprotesi. Gli esami di follow-up hanno dimostrato che le endoprotesi nei pazienti 1, 2 e 4 sono rimaste pervie, mentre nel paziente 3 si è occlusa dopo 15 mesi; in quest ultimo caso, è stato individuato uno pseudoaneurisma prossimale allo stent e, nonostante il posizionamento di una nuova endoprotesi abbia bloccato l emorragia, il paziente è morto per insufficienza multiorgano una settimana dopo. Conclusioni. Il posizionamento in emergenza di

2 endoprotesi è una modalità tecnicamente realizzabile e terapeuticamente efficace nel trattamento di pazienti ad alto rischio che hanno subito la rottura iatrogena di un arteria periferica. Un efficiente trattamento ipotensivo e un precoce intervento endovascolare migliorano la prognosi. Parole chiave Arteriopatia periferica Complicazioni Endoprotesi Introduction Increased popularity of surgical and endovascular interventions for vascular disorders has resulted in a significant patient burden due to iatrogenic arterial injuries [1]. Arterial rupture is one of most severe arterial injuries [2]. In partial cases of arterial rupture, shock due to the rapid and excessive blood loss typically occurs. Although it is a conventional therapeutic option for managing arterial injuries, vascular surgery is not appropriate in patients who are in poor physical condition and cannot tolerate the stress of surgery. Percutaneous endovascular stent-grafting was initially used to treat abdominal aortic aneurysms [3]. Stent-grafting has been used for many years to exclude aneurysmatic and iatrogenic lesions of peripheral arteries [4 6]. Patients in poor general condition can typically tolerate emergency stent-grafting, which results in favourable haemostasis. Therefore, stent-grafting is an effective alternative to vascular surgery in those cases. In this article, we describe the clinical experience and median-term follow-up outcomes of four cases complicated by iatrogenic peripheral arterial ruptures. Materials and methods Between October 2005 and October 2009, four patients with iatrogenic peripheral arterial ruptures were treated by stentgrafting in our hospital. The four patients were all male and aged years. The patient in case 1 developed left groin lymph node metastases following penis cancer resection. A Pseudomonas aeruginosa preparation was subcutaneously injected into the metastases over 3 successive days, which resulted in necrosis of the left groin skin and subcutaneous tissue. The wound remained unhealed, and the subcutaneous tissue detached and formed an approximately 3-cm-deep defect. The defect worsened and led to abrupt, massive bleeding from the left groin 3 months after the initial injection. The patient was transferred to our emergency service with continuous gauze compression applied to the left groin. In cases 2 and 3, both patients complained of sudden pain in the right lower limb. Emergency embolectomies of the right iliac artery were performed by vascular surgeons. Blood started to ooze from the incision site 48 h after embolectomy in case 2 and 12 h after embolectomy in case 3. Ultrasonography showed cystic masses located anterior to the right femoral arterial incisions, which were diagnosed as ruptured pseudoaneurysms. Case 4 was a patient who underwent a radical neck dissection for laryngeal cancer, and the procedure was complicated by a ruptured haemorrhagic right carotid artery. With gauze compression, the patient was transferred to the angiography suite. The blood pressures of four patients ranged from 70/30 to 110/80 mmhg and heart rates from 108 to 132 bpm. Percutaneous endovascular stent-grafting was performed with patients informed consent. A 10-cm, 9-F sheath was inserted through the contralateral femoral artery in cases 1, 2 and 3. A 10-cm 9-F sheath was inserted through the right femoral artery in case 4. A 5-F catheter was inserted into the proximal segment of ruptured arteries through the sheath. Digital subtraction angiography (DSA) was performed over the ruptured artery with a Siemens Multistar T.O.P or Siemens Artis DTA C- arm imagery system (Siemens, Germany). Extravasation of contrast media was observed in cases 1, 2, 3. The superficial femoral artery (SFA) was occlusive in cases 1 and 3. Under fluoroscopy, a 5-F catheter along with a in. hydrophilic guide wire (Terumo, Tokyo, Japan) was inserted into the distal segment of the ruptured arteries [profunda femoris artery (PFA) in cases 1 and 3; SFA in case 2; internal carotid artery (ICA) in case 4]. After replacement of the in. stiff guidewire (Terumo, Tokyo, Japan), a polytetrafluoroethylene (PTFE)-covered nitinol stent (Fluency, Bard, USA) was transported through the ruptured section. After verifying the correct position, the stent-graft was deployed across the ruptured arteries within 6 h of rupture. The size of stent-grafts used in cases 2 and 3 was 8 mm 60 mm and in cases 1 and 4 was 8 mm 80 mm. Intraoperatively, 3,000 U of heparin was administered through the sheath. Postoperatively, 75 mg per day of clopidogrel and 100 mg per day of aspirin were administered orally for 12 months. Patients

3 were evaluated at 6-month intervals by ultrasonography of the lower-limb arteries. Results mal end of the graft. An 8 mm 60 mm stent-graft (Fluency, Bard) was implanted. The repeated DSA showed no contrast media extravasation from the right CFA and no distal blood flow. After the guidewire and 5-F catheter were inserted repeatedly into the PFA branches, angiography identified filling thrombus in the right CFA and PFA in addition to partial arterial blood flow (Fig. 3). However, the patient died of multiple organ failure 1 week later due to intractable hypotension. Discussion Postcatheterisation pseudoaneurysms are the most common iatrogenic arterial injury, whereas arterial rupture is one of the most severe and emergent complications. Typically, the standard treatment for postcatheterisation pseudoaneurysm is vascular surgery. However, since 1991, ultrasonographyguided minimally invasive therapy has become the preferred approach for treating uncomplicated femoral pseudoaneurysms [7]. Ultrasonography-guided percutaneous thrombin injection has an overall success rate of 95% in treating iatrogenic femoral artery pseudoaneurysms [8]. However, ruptured pseudoaneurysms could not be treated with percutaneous thrombin injection. The surgical approach achieves a technical success rate Technical success was achieved in all four patients. After stent-grafting, angiography showed that the blood flowed through the stent-graft without contrast media extravasation in cases 1, 2 and 3 (Figs. 1 and 2). There was no haemorrhage recurrence after stent-graft implantation and decompression. Patients blood pressures returned to values ranging from 86.7/43.3 to 120/81.7 mmhg and heart rates from 122 to 80 bpm following infusion of whole blood. No procedure-related complications occurred. Patients were discharged within 5 7 days after stent-grafting. During follow-up (13 36 months), ultrasonography showed that the stent-graft remained patent and the blood supply to the distal extremity was sufficient in cases 1, 2 and 4; femoral stent-graft occlusion occurred after 15 months in case 3. Patient 1 died of lung metastases 13 months after stent-grafting without recurrence of the left femoral arterial bleeding. In case 3, DSA identified an obliteration of the stent-graft in the right common femoral artery (CFA), downstream displacement of the proximal end of the stentgraft and extravasation of contrast media from the proxia b c d Fig. 1a-d Necrosis and ulcerations occurred in the subcutaneous tissue of the groin following subcutaneous injection of a Pseudomonas aeruginosa preparation and resulted in rupture of the femoral artery. a Left common femoral artery (CFA) was compressed and obliterated, whereas the profunda femoris artery (PFA) and the superficial femoral artery (SFA) were not visualised. b The catheter was inserted into the left CFA, and there was extravasation of contrast media. c The catheter was inserted into the PFA. d Following stent-grafting, normal blood flow in the left CFA was maintained, with no contrast media extravasation. Fig. 1a-d Necrosi e ulcere dei tessuti sottocutanei inguinali, conseguenti ad un iniezione sottocutanea di un preparato di Pseudomonas aeruginosa, che hanno portato alla rottura dell arteria femorale. a L arteria femorale comune di sinistra (AFC) è stata compressa ed obliterata e quindi l arteria femorale profonda (AFP) e l arteria femorale superficiale (AFS) non sono visualizzate. b Si è introdotto un catetere nella AFC di sinistra e si è rilevato uno stravaso di mezzo di contrasto. c Si è inserito il catetere nella AFP. d Dopo posizionamento dell endoprotesi permane il flusso ematico nella AFC di sinistra e non si visualizza spandimento di mezzo di contrasto.

4 a b Fig. 2a,b Ruptured pseudoaneurysm following femoral arteriotomy. a Extravasation of contrast media from the defect in the anterior wall of the right common femoral artery CFA. b Following stent-grafting, normal blood flow in the right CFA was maintained, with no contrast media extravasation. Fig. 2a,b Rottura di pseudoaneurisma conseguente ad arteriotomia femorale. a Stravaso di mezzo di contrasto dalla lesione del muro anteriore dell AFC. b In seguito all endoprotesi si è mantenuto un normale flusso ematico nell AFC di destra, senza stravaso di mezzo di contrasto. of almost 100% in treating iatrogenic femoral artery injures. However, in complicated cases, the postoperative morbidity rate is as high as 25% and mortality rate is 3.5% [9]. The surgical approach requires general anaesthesia, which further increases the risk of complications. Additionally, iatrogenic arterial injuries may result in local haematomas and tissue injuries, which adversely affect the healing of surgical incisions and increase the risk of postoperative infections. The surgical approach is mainly used in young patients who are expected to have a long survival and in cases complicated by regional infections; seriously compressed vessels, nerves, or skin; or previous failure of minimally invasive treatment [2]. As an alternative to open surgery, endovascular treatment has been widely used in clinical practice. Simply due to the use of local anaesthesia, endovascular treatment is a welltolerated approach in most cases and results in shortened hospitalisations. Gasparini et al. [4] reported an initial clinical success rate of 100% in the treatment of eight iliac artery aneurysms using percutaneous stent-graft implantation. The patency rate of stent-grafts was 100% (8/8) during 3 12 months of follow-up. Baltacioǧlu et al. [5] reported a technical success rate of 100% in the repair of 17 different iatrogenic vascular lesions by means of endovascular balloonexpandable stent-grafts. Stent-graft patency rate was 94.1% (16/17) in the follow-up period. Adovasio et al. [6] reported that technical success was achieved in both patients who underwent endovascular balloon-expandable stent-grafting for injuries of the external iliac artery during hip surgery. In our study, the technical success rate of self-expanding stentgraft implantation was 100%. The long-term patency rate of stent-grafts was 75% (3/4), lower than in other studies. The major reason for occlusion, in our opinion, may be thrombosis induced by twisting of the stent-grafts during adjacent joint motion and the slow blood flow in the stent-graft due to occlusive lesions in distal arterial branches. Based on our clinical experience, stent-grafting is a major technical advancement and a rapid, effective and minimally invasive therapeutic approach to serious iatrogenic arterial ruptures. In addition to covering the arterial defect, the stent-graft also ensures blood supply to the distal artery, which is equivalent to the surgical ligation and bypass procedures for ruptured arteries. The major complication of stent-grafting is stent occlusion, which is mainly associated with thrombosis, neointimal hyperplasia and stent-graft distortion. Stent-grafting complications include stent-graft migration and leaks. Gasparini et al. [4] reported one patient (12.5%) with a minimal perigraft leak. In Adovasio et al. s study, a patient died of hypovolemic shock 17 months after endovascular treatment [6]. According to the authors analysis, the unfavourable clinical result was a direct result of not replacing the hip prosthesis or implanting an extraanatomical femorofemoral graft to bypass the infected area [6]. In our study, one patient experienced downstream displacement of the proximal end of the stent-graft and injuries to the local vascular wall. We believe the complication may be a result of excessive vascular tension during hip-joint motion. Balloon-expanding stent-grafts are superior because they enable more accurate localisation and result in better matching of the calibre of the injured blood vessels. However, these stents may collapse or deform under extrinsic forces, which results in stent occlusion [10]. Due to their superior flexibility and radial expansion force against the extrinsic forces, self-expanding stent-grafts are more suitable for treating superficial sites, such as the carotid artery and groin [10]. Animal studies have shown that polyethylene terephthalate (PET)-covered stents are associated with

5 a b c d e Fig. 3a-e Ruptured pseudoaneurysm following femoral arteriotomy. a Extravasation of contrast media from the defect in the anterior wall of the right common femoral artery (CFA) occurred, and the right SFA was obliterated. b Following stent-grafting, normal blood flow in the right CFA was maintained, with no contrast media extravasation; right profunda femoris artery (PFA) branches were clearly visible. c The right CFA stent-graft became occluded 15 months after the initial stent-grafting procedure, and extravasation of contrast media was visible at the proximal end of the stent-graft. d Following the repeated stent-grafting procedure, the right CFA showed no extravasation of contrast media, but no blood flow was visible beyond the distal end of the stent-graft. e Following insertion of the guidewire into the PFA branches, minimal blood flow and filling defects were visible in the right CFA and PFA. Fig. 3a-e Rottura di pseudoaneurisma conseguente ad arteriotomia femorale. a Stravaso di mezzo di contrasto dalla lesione del muro anteriore dell arteria femorale comune di destra (AFC) con obliterazione dell arteria femorale superficiale di destra (AFS). b Dopo posizionamento di endoprotesi si è preservato un normale flusso ematico nella AFC di destra, senza stravaso di mezzo di contrasto; i rami dell arteria femorale profonda (AFP) sono chiaramente visibili. c L endoprotesi della AFC di destra si è occlusa 15 mesi dopo il suo posizionamento ed è visibile stravaso di mezzo di contrasto all estremità prossimale dell endoprotesi. d Dopo la ripetizione della procedura di posizionamento di endoprotesi, la AFC di destra non mostra stravaso di mezzo di contrasto ma nè flusso ematico oltre l estremità distale dell endoprotesi. e Dopo l introduzione della guida nei rami della AFP, sono visibili minimo flusso ematico e difetti di riempimento nella AFC e AFP di destra. a higher risk of thrombosis and immunogenicity than are PTFE-covered stents [11]. Multiple studies report that PT- FE-covered self-expanding stents can be used to effectively treat vascular injuries [12 14]. Due to the absence of longterm follow-up study on stent-grafting, the procedure may be associated with unfavourable outcomes in young patients who are expected to have a long survival. Therefore, stentgrafting is not recommended in young patients except in emergent cases. The 38-year-old patient in case 1 in this report underwent emergency stent-grafting due to hypotension, extensive metastases of the malignant tumour and shorter survival expectancy. Additionally, the left groin tissue defect did not allow for surgical incision healing, and the simple ligation of the artery for haemostasis would have impaired the blood supply to the lower limbs. An adjuvant bypass procedure was likely to incur regional infections due to the exposed autologous or artificial vessels at the site of the defect. We used PTFE-covered self-expanding stent-grafts with a calibre of 8 mm and a length of 6 8 cm in all four patients. The interventional procedure was completed within h. In case 1 and 3, DSA did not identify the SFA. Placement of the stent-grafts between CFA and PFA did not cause lowerlimb arterial ischaemia, as documented by the follow-up examinations. In case 4, a larger carotid defect was suspected, and a long stent-graft was used to block the right external carotid artery defect. Stent-grafting was performed within 6 h of arterial rupture in all cases, except for the secondary stent-grafting in case 3, which was performed 22 h after arterial rupture; that patient finally died of multiple organ failure due to intractable hypotension, although the stentgraft successfully controlled the haemorrhage. In summary, we propose some critical measures in stentgrafting procedures used to treat iatrogenic peripheral arterial ruptures. First, DSA should be used to accurately identify the location and diameter of the ruptured artery in addition to its distance from important adjacent arterial branches. Second, self-expanding stent-grafts should be used in superficial and circuitous arterial ruptures that are in close proximity to joints; the stent should have a calibre 1- to 2-mm larger than the diameter of the ruptured artery and a length 3- to 4-cm longer than that of the arterial rupture. Third, implantation of the stent-graft not only avoids more arterial branches but also ensures closure of the arterial rupture. Conclusions Emergency stent-grafting is a minimally invasive, technically successful and therapeutically effective modality for treating iatrogenic arterial ruptures. Such procedures

6 are particularly useful for the rescue of high-risk patients and are considered a favourable alternative to surgical treatment. Endovascular treatment should be performed early if possible and requires prior resolution of hypotension to minimise organ injury. Appropriate size and accurate localisation of the stent-graft contribute to the technical success of the procedure and promote favourable clinical prognosis. Conflict of interest None References/Bibliografia 1. Morgan R, Belli AM (2003) Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol 14: Tsetis D (2010) Endovascular treatment of complications of femoral arterial access. Cardiovasc Intervent Radiol 33: Parodi JC, Palmaz JC, Barone HD (1991) Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vase Surg 5: Gasparini D, Lovaria A, Saccheri S et al (1997) Percutaneous treatment of iliac aneurysms and pseudoaneurysms with Cragg Endopro System 1 stent-grafts. Cardiovasc Intervent Radiol 20: Baltacioǧlu F, Cimşit NC, Cil B et al (2003) Endovascular stent-graft applications in iatrogenic vascular injuries. Cardiovasc Intervent Radiol 26: Adovasio R, Mucelli FP, Lubrano G et al (2003) Endovascular treatment of external iliac artery injuries after hip arthroplasty. J Endovasc Ther 10: Fellmeth BD, Roberts AC, Bookstein JJ et al (1991) Postangiographic femoral artery injuries: nonsurgical repair with US guided compression. Radiology 178: Vlachou PA, Karkos CD, Bains S et al (2011) Percutaneous ultrasoundguided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms. Eur J Radiol 77: Franco CD, Goldsmith J, Veith FJ et al (1993) Management of arterial injuries produced by percutaneous femoral procedures. Surgery 113: Onal B, Kosar S, Gumus T et al (2004) Postcatheterization femoral arteriovenous fistulas: endovascular treatment with stent-grafts. Cardiovasc Intervent Radiol 27: Hussain FM, Kopchok G, Heilbron M et al (1998) Wallgraft endoprosthesis: initial canine evaluation. Am Surg 64: Bates MC, AbuRahma AF, Crotty B (2005) Successful urgent endovascular surgery for symptomatic subclavian artery aneurysmal compression of the trachea. Catheter Cardiovasc Interv 64: Gandini R, Pipitone V, Konda D et al (2005) Endovascular treatment of a giant superior mesenteric artery pseudoaneurysm using a nitinol stentgraft. Cardiovasc Intervent Radiol 28: Jahnke T, Schaefer PJ, Heller M et al (2008) Interventional management of massive hemothorax due to inadvertent puncture of an aberrant right subclavian artery. Cardiovasc Intervent Radiol 31:S124 S127

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