Covered Stents in Peripheral Arterial Trauma: A Word of Caution
Furqan Muqri, MD, Palma Shaw, MD.
SUNY Upstate Medical University, Syracuse, NY, USA.
OBJECTIVES: Endovascular therapies such as coiling and stenting are now frequently used to treat arterial trauma and appear effective with lower morbidity. We reviewed our recent experience with endovascular approach to arterial trauma including early and late results.
METHODS: We reviewed the records of patients with peripheral arterial trauma during 2018. Three patients presented with decreased or absent distal Doppler signals after blunt or penetrating trauma. Patient 1 had a motorcycle collision and a right shoulder injury with an axillary artery transection, Patient 2 had a fall with an axillary artery transection, and Patient 3 had a gunshot wound to left thigh with development of a profunda femoris and common femoral vein fistula. All three cases were treated with angiography and covered stent placement.
RESULTS: Brachial artery cutdown was performed for the first two cases. For Patient 1, due to the dissection present, a self-expanding covered stent was placed without angioplasty to exclude the disrupted and dissected section of the axillary artery. In Patient 2, through brachial cutdown and percutaneous femoral access two kissing Kumpe catheters were used to traverse transected axillary artery, allowing placement of a self-expanding covered stent. In Patient 3, after coiling failed, a self-expanding covered stent was placed to successfully exclude the traumatic arteriovenous fistula.
All 3 limbs were salvaged facilitating treatment of concomitant injuries and recovery. Although the vascular supply of the patients was preserved, there was some remaining nerve and muscle damage as a result of the inciting injuries. Mid-term and early follow up of these patients resulted in one stent thrombosis, however, due to the presence of collaterals, the patient remained asymptomatic. One patient has developed in stent stenosis identified by increased velocities on duplex ultrasound requiring angioplasty. The third patient has been successfully discharged and will be monitored.
CONCLUSIONS: Endovascular treatment of peripheral arterial trauma with stenting is gaining acceptance as a less invasive and faster alternative in peripheral vascular trauma. Covered stents provide a minimally invasive option to address arterial injury, especially in difficult to reach locations minimizing morbidity. Our recent experience suggests that close follow up is critical, as it appears that longer-term, additional interventions to maintain patency will be necessary. This is of more concern in younger patients more typical of the trauma population.
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