Cath Lab Digest

Introduction
Vascular injury following trauma is seen almost daily in our profession, The bleeding must be stopped as early as possible and this task is usually managed by surgeons. However, there are conditions where the surgical approach involves high risk and is less practical than a swiftly performed endovascular procedure. This may depend on the site, as well as the vessel affected in the process of injury, resulting in leakage that causes blood loss with or without the formation of a pseudoaneurysm.

Angiographic diagnosis followed by transcatheter sealing of the site of leakage is a universally accepted technique that is performed by deploying a covered stent or stainless steel coils, as well as by injecting poly vinyl alcohol particles (PVA). Intra-visceral arteries where future patency is desirable can receive trans-catheter injection of absorbable gelatin sponge, which blocks the circulation for 72 hours before it starts disintegrating. The technique and material used to stop the bleeding depend on the vessel injured and the demand of distal blood supply in the future. We have presented four interesting cases where leakages from injured arteries were tackled with an endovascular approach using these sealing materials.

Case I
A 55-year-old female with a history of arthritis, particularly crippling the knee joints, had failed two operations for replacement of her left knee due to rejection of the artificial joint on both occasions. Two days after a complicated surgery involving femoro-tibial nailing, the patient developed a pulsating hematoma on medial side of the thigh, which grew rapidly in size in the next 24 hours. A needle aspiration performed by the surgeon revealed fresh blood gushing into the aspiration syringe, indicating an arterial injury most likely induced during the passage of a nail. Following her transfer to the cardiovascular unit, an angiogram was performed to obtain the actual diagnosis. The angiogram performed from the contralateral femoral artery revealed free flow of dye from the femoral artery at the third lower level of the thigh, accumulating in a pseudo-aneurysmal sac (Figure 1A). The profunda artery was intact. With the patient encased in an orthopedic metal frame up to the groin, and the site of leakage at a substantially deep level, the leaking site was sealed.¹

Considering the continuation of distal flow of blood in the leg as absolutely vital, transcatheter deployment of a covered stent precisely at the site of leakage stops further blood loss.^2,3 A covered 30 mm JOSTENT® (Abbott Vascular, Redwood City, California) and an ipsilateral approach were selected. The left femoral artery was punctured at the groin with the tip of the needle directed toward the left foot, and a 6F sheath was placed in the femoral artery. A 135 cm 0.35 J tipped Terumo guidewire (Terumo, Tokyo, Japan) was pushed through the sheath, crossing the site of injury and its distal end was parked in the posterior tibial artery. Thereafter, the JOSTENT was manually crimped on a 35 mm x 6 mm peripheral balloon, which could be passed through the lumen of the sheath railing over the Terumo guidewire and placed at the site of blood leakage (Figure 1B). The stent was deployed at 12 ATM for 30 seconds, sealing the site of injury. The angiogram showed an optimum result with complete stoppage of extravasation of dye, and a patent vascular lumen with TIMI III distal flow (Figure 1C). Then 10,000 units of heparin was injected, in addition to the clopidogrel and aspirin that had been started earlier, immediately after the diagnostic angiogram as per the dose schedule. The ipsilateral site of puncture was closed with Angio-Seal™ (St. Jude Medical, St. Paul, Minnesota). The blood accumulated in the pseudo-aneurysmal pocket was evacuated 5 days later. At 9-month follow up, the patient was still physically handicapped and dependent on a wheel chair (for orthopedic reasons), but no clinical recurrence of leaking of the femoral artery was seen, and optimum flow of blood in distal part of the limb was maintained. She is currently taking aspirin and clopidogrel indefinitely.