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. Case 2 A nine-year-old boy suffered an injury to the right side of the occipital region, following a fall from a tree, and lost consciousness for 5 minutes. The physician on duty at a nearby health center examined the wound, which did not appear deep. The scalp injury was stitched and a pressure dressing was applied. The case was further referred to a neurologist. A computed tomography scan of the brain was normal, and no fracture of any skull bone was detected. However, after removal of the pressure dressing, a swelling was noted, which progressed in size in two weeks to almost half the size of his head (Figure 2A). The suspected cause was continuous leaking from an artery injured in the fall. A magnetic resonance angiogram reported the presence of a large hematoma, but could not detect the bleeding artery due to the overlapping of different vessels in that region. A selective angiogram revealed free flow of dye into a large pseudoaneurysm, due to injury of the right vertebral artery at the level of 2nd and 3rd cervical vertebrae (Figure 2B). With the location of the leaking vessel within the vertebral canal, and the presence of the large swelling making a surgical approach difficult, an endovascular approach was considered to seal the leaking vertebral artery. Because the vertebral artery was a paired vessel and the leakage site was far proximal to the origin of any branch, embolization was considered. Stainless steel coils were deployed distally as well as proximal to the site of injury.4 After traversing through multiple sharp kinks, the tip of 5F Judkins (Cordis, Miami Lakes, Florida) right catheter was placed just distal to the site of leakage and two coils of 3 mm (1 mm bigger than the size of vessel to avoid travel of the coil to the basilar artery) were deployed (Figure 2C). Then the catheter tip was pulled back proximal to the site of injury, where two more 3 mm coils were deployed (Figure 2D), thus blocking the entry of blood from both sides. An angiogram of the left vertebral artery confirmed intact intra-cranial circulation but revealed cessation of entry of blood via basilar artery into the site of injury of the right vertebral artery (Figure 2E). Coils deployed in the right vertebral artery proximal to the site of leakage occluded antegrade flow as well. At 7-month follow up, the swelling had reduced to a third of the original size, (Figure 2F) and had lost its doughy consistency. It was a hard mass, most likely filled with organized clots. Its surgical evacuation is being considered following an angiogram. Case 3 A 35-year-old healthy male smoker received a stab injury to the right side of the chest, just below the scapula, following an altercation with a mugger. He was immediately hospitalized, where the wound was explored by a surgical team and repaired. On the fifth day, he had a bout of hemoptysis. He was kept under observation but the bloody sputum was continually coughed out at short intervals. The chest X-ray showed a hazy shadow near the right hilum. A pulmonary angiogram of the right side excluded injury to any of its branches communicating with the bronchial tree. Selective angiogram of the bronchial arteries with a 5 Fr Sidewinder catheter (Terumo, Tokyo, Japan) revealed clouding of dye in right sub-hilar region fed by the right lower bronchial artery (Figure 3A). Considering the small size (less than 2 mm) of the artery, it was embolized by transcatheter injection of 300 micron PVA particles. This was accomplished successfully 10 minutes later. While doing a selective angiogram of the target vessel, the patient coughed out bloody sputum, which stopped shortly after a successful embolotherapy (Figure 3b). At 3-month follow up, there was no recurrence of hemoptysis. Case 4 A 25-year-old student was hit by a motorized truck while riding his motorcycle and suffered severe, multiple injuries to his limbs and head, and fractures of the ribs. The patient was kept under artificial ventilation in the intensive care unit. Four days later, he started having bouts of hematemesis and melena. Endoscopic examination of the upper gastro-intestinal system revealed the presence of hemobilia, indicating bleeding of hepatic origin. On angiographic examination, clouding of dye was seen in the left lobe of the liver, fed by the left hepatic artery, which was also most likely injured during the accident. The dye was then discharged into the duodenum after traversing the bile ducts (Figure 4A). Embolotherapy was performed by transcatheter injection of dye/saline soaked gelatin sponge (Ab Gel). This is a temporary measure of embolization that keeps the artery blocked for 72 hrs, followed by gradual restoration of the circulation following dissolution of the gelatin pieces. The tip of the catheter was placed into the lumen of the left hepatic artery, as near as possible to the site of injury (Figure 4B, left), and the pieces of gelatin sponge were injected through the catheter, thus plugging the site of injury. Extravasation stopped within the next few minutes (Figure 4B, right). During his stay for nearly three months in the hospital (due to other injuries), recurrence of hemobilia was not seen, though there was a transitory rise in level of hepatic enzymes. At 24-month follow up, there were further bleeding complications. Discussion We have presented four cases of leaking arteries following injury. The material, technique and site of endovascular treatment were different in each case. Deployment of a covered stent for the first case was considered so that distal circulation would be optimally maintained after successful sealing the leaking site of the femoral artery.5 The diagnostic angiogram was completed by a contralateral approach since the leaking artery was uncertain at that stage. It could have been the profunda artery as well, which could have been overlooked by the ipsilateral approach. Ipsilateral caudal entry for deployment of stent was chosen for easier straight passage of the stiff JOSTENT, hand crimped on a 6 mm peripheral balloon. Therefore, a guiding catheter was not required, and a long, curved route from the contralateral entry was also avoided. The second case was my first experience in tackling an injury of the vertebral artery, and I was not sure about passage of a stiff covered stent through multiple kinks of the artery. After studying the radiological anatomy of the vessel, a possibility of dislodgement of the stent before reaching the site of leakage seemed possible. In about 11.2% of cases, a patient survives with one good size vertebral artery, the other one being present in rudimentary form only. Also, no branch was seen arising from anywhere near the site of injury. So sacrificing one vertebral artery was not seen as unjustified. Also, clinically, the patient had not developed any neurological symptom thus far. Angiographically, the left vertebral artery alone maintained the territory of circulation assigned to vertebro-basilar system. The most important technical aspect of the third case is in detecting the leaking artery, as the bronchial arteries are known for their rather common anomalous origins. Fortunately, in this case, it was not necessary to look for the leaking branch arising from the subclavian or internal mammary artery. The origin of the vessel was from the right wall of the thoracic aorta at the level of D5. As per classification of Cauldwell, it belonged to type 3, with two right and two left bronchial arteries arising separately.6 The right lower branch going to the hilar region could be differentiated from intercostal artery, which takes a cephalic course before taking a course along the undersurface of a rib. Use of a co-axial microcatheter for subselective intubation was not considered as it had no communication with the superior intercostals artery, thus excluding the risk of embolizing any spinal branch. Once the diagnosis was achieved, sealing the vessel was quick and effective. In the bronchial system, if the bleeding vessel is correctly detected, every injection of dye is followed by some cough and hemoptysis if it is actively bleeding, which was noted in this case. Whether or not the hemoptysis caused by the leaking of the bronchial artery was related to the stab injury is undetermined. It could have been due to stress of the thoracic operation on a smoker’s lung eroding the bronchial mucosa from a preexisting bronchiectesis, allowing entry of blood into the bronchial tree. The measure of temporary embolotherapy was used in case 4 to maintain the circulation of the left hepatic artery in the future. The stoppage of blood supply for 72 hours would help in naturally healing the injured wall of the vessel, when restoration of blood supply after disintegration of gelatin sponge may not result in any further leakage.7 This does not happen in all cases. If the bleeding recurs, one has to take a permanent measure by injecting PVA particles or deploying coils, if the size of the vessel permits. If portal circulation is intact (taking charge of 75% of hepatic circulation), one can sacrifice a part of the hepatic arterial circulation without affecting much of the hepatic function. If the laceration is at main or proximal segment of hepatic artery,8 the segment distal to laceration also has to be properly embolized to avoid any back bleeding. We tried to save a kidney that was bleeding following a needle biopsy (Figure 5) by injecting Ab-Gel in the feeder artery. The Ab-Gel sponge failed to do the job, and it had to be tackled with PVA particles after one week. The bleeding recurred, causing fresh episode of hematuria, and we had to accept functional loss of the lower 1/3 of the kidney. The role of the microcatheter (BSX, Cordis, Miami Lakes, Florida), which can traverse co-axially through a 5 Fr catheter, should be always considered. It was useful in cases 2, 3, and 4. But in each case, the 5 Fr catheter alone could reach the site of target, avoiding the use of another hardware. In case 2, coils larger than the vessel size were taken so that they did not slip off distally reaching the basilar artery which could produce disastrous neurological problems. Conclusion Judicious and strategic application of technique and material used for endovascular management of a leaking artery can give optimum results, particularly where open surgical management is time consuming, of high risk, and perhaps impractical, as seen in these four cases. Acknowledgment: We wish to thank Dr. Siddhartha Dhar MDS, for making necessary corrections in the manuscript.
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