Endovascular management of traumatic cervicothoracic arteriovenous fistula

BACKGROUND: This study evaluated a single-centre experience with endovascular repair of traumatic arteriovenous fistula in the cervicothoracic region. METHODS: Endovascular repair of 27 traumatic cervicothoracic arteriovenous fistulas was attempted between August 1998 and December 2001. Patients with active bleeding or end-organ ischaemia were excluded. Follow-up was accomplished with clinical, duplex Doppler and arteriographic evaluation after 1 month and then every 3 months. RESULTS: Twelve patients with a major vessel injury were treated by stent-graft placement. Vessels involved were the subclavian (eight), common carotid (three) and internal carotid (one) arteries. Subclavian artery side branches were embolized in three of the eight patients. Four patients developed early type 4 endoleaks but all resolved. Treatment with stent-grafts was ultimately successful in all 12 patients. Three patients were lost to follow-up. During mean follow-up of 21 (range 3-36) months, one of the remaining patients developed a graft stenosis. Fifteen patients with minor vessel injuries were treated with arterial embolization. Vessels embolized were subclavian artery branches (four), external carotid artery and branches (seven) and vertebral arteries (four). Successful embolization was accomplished in ten of 15 patients. CONCLUSION: Endovascular therapy is a promising alternative to surgery for selected patients with cervicothoracic arteriovenous fistula.     

Vertebral and carotid artery dissection following chiropractic cervical manipulation

A 50-year-old woman presented a sudden left occipital headache and a posterior circulation stroke after cervical manipulation for neck pain. Magnetic resonance imaging documented a left intracranial vertebral artery occlusive dissection associated with an ipsilateral internal carotid artery dissection with vessel stenosis in its prepetrous tract. This is the first reported case showing an associate vertebral and carotid artery dissection following cervical manipulation. Carotid dissection was asymptomatic and, therefore, its incidence may be underestimated. We emphasize that cervical manipulation should be performed only in patients without predisposing factors for artery dissection and after an appropriate diagnosis of neck pain. Received: 25 October 1997 / Accepted: 19 August 1998     

Vertebral arteriovenous fistula as a result of Swan-Ganz catheter insertion: surgical correction in a symptomatic patient.

A case of a vertebral arteriovenous fistula is reported after being caused by insertion of a Swan-Ganz catheter into the vertebral artery prior to cardiac surgery. The patient's clinical symptoms which precipitated re-admission consisted of multiple episodes of diaphoresis and dizziness. A right carotid bruit was detected in the neck. Four vessel cerebral arteriograms could not accurately identify the origin of the fistula. The proximal carotid artery was considered by several radiologists to be the arterial source of the fistula. During the surgical procedure, a tortuous right vertebral artery was found to be the source of the fistula. Surgical correction of the fistula was successful with preservation of the vertebral artery. Recommendations from a review of the literature are made for the current treatment of this rare complication from an insertion of a Swan-Ganz catheter.     

Treatment of extracranial and intracranial aneurysms and arteriovenous fistulae using stent grafts

OBJECTIVE: Treatment of 11 patients with aneurysms or arteriovenous fistulae of the craniocervical arteries with stent grafts. METHODS: Peripheral stent grafts were deployed in two extracranial internal carotid arteries. Coronary stent grafts were used to treat two giant aneurysms, five direct carotid-cavernous fistulae, one vertebrojugular fistula, and two dissecting aneurysms of the vertebral artery (V2 and V4). RESULTS: Stent grafts were used successfully in two extracranial internal carotid and two extracranial vertebral arteries, one dissecting aneurysm of the intracranial vertebral artery, one giant aneurysm and one pseudoaneurysm of the cavernous internal carotid artery, and five direct carotid-cavernous sinus fistulae. Angiographic follow-up examinations (available in nine patients; obtained at 3 mo to 5 yr; average, 24 mo) revealed normal vessel caliber, and the stent grafts in all 9 of 11 initial patients were patent. There was a recurrent saccular aneurysm adjacent to the stent graft in the patient with the intracranial vertebral artery aneurysm. The following five complications were encountered: transient hemiparesis (n = 2), increased hemiparesis, postprocedural management-related fatality, and ICA dissection. In six patients, stent graft deployment was accomplished without any technical or clinical complication. There were no permanent neurological deficits consequent to stent graft placement. CONCLUSION: Stent grafts are a useful tool for the endovascular treatment of head and neck aneurysms and direct arteriovenous fistulae in selected patients. The major disadvantage of the currently available stent grafts is their lack of mechanical flexibility. Maneuvering stent grafts in the intracranial arteries carries the risk of iatrogenic vessel dissection and may require supportive measures and protection of the target site by conventional stents.     

Unusual fatal stab wounds of head & neck: With examples of unrecognized ice pick wounds of the brain

Four examples of fatal penetrating stab wounds of the head and brain are described. In three of these, the weapon used was probably an ice pick, and in one, a thin-bladed knife. In two of these cases, the small surface wounds on the scalp were concealed by the hair and not detected clinically, and in one case, a small wound on the forehead was mistaken for a superficial laceration.In two examples of stab wounds of the neck and left common carotid artery, a mural thrombus developed in the artery wound and gave rise to an embolus which lodged in the left middle cerebral artery, causing death from cerebral infarction.A fatal stab wound of the neck and left innominate vein and arch of the aorta resulted in an arteriovenous aneurysm which dissected the anterior mediastinum and ruptured into the left pleural cavity where a massive hemothorax was formed.     

Large vertebral arteriovenous fistula treated with stent-grafts--case report

A 24-year-old woman presented with neck bruit and thrill. Neurological examination revealed no focal abnormality. Angiography and magnetic resonance imaging showed an arteriovenous fistula (AVF) at the C4-5 levels of the right vertebral artery (VA). The fistula had a single orifice that drained into the epidural veins via the C4-5 intervertebral foramen. A stent-graft was made of a 3.9 cm balloon-expandable stent and an expandable polytetrafluoroethylene graft sutured outside the stent. The stent-graft was advanced through the femoral artery up to the VA but did not pass far enough distally to seal the entire fistula because of the high friction between the bulky device and the small vessel. Another 2 cm stent-graft was delivered and successfully positioned across the fistula. The AVF completely disappeared and the right VA was well preserved. Follow-up angiography at 3 weeks and 5 months after the treatment showed no fistula and no stenosis inside the stent-grafts. Stent-grafts are useful to treat AVF with a large orifice. The stent-graft is a promising technology to treat neurovascular diseases, although improvement is required for use in smaller vessels.     

Vertebral artery dissection after iatrogenic cervical subcutaneous emphysema

We report a case of spontaneous vertebral artery dissection (VAD) in a patient who developed extensive subcutaneous emphysema following the removal of a chest tube after a cardiac transplant. The pathophysiology and management of this uncommon complication are reviewed. Although vertebral and carotid artery dissections are unusual events occurring in 2.5 to 3 per 100,000 people, they are increasingly acknowledged to be important causes of stroke in the young and middle-aged adult population accounting for up to 25% of such cases. VADs are associated with a variety of minor traumatic mechanisms including painting a ceiling, yoga, chiropractic manipulation of the spine, and driving. These events cause injury to the vessel wall either by shearing forces secondary to rotational injuries or direct trauma to the vessel wall on bony prominences, especially the transverse processes of the cervical vertebrae. We present a case of a patient with documented previously normal vertebral arterial anatomy who developed a VAD after mediastinal tube removal resulted in subcutaneous emphysema tracking through fascial planes into his neck.     

Surgical treatment of the acute stroke caused by proven vertebral-basilar artery insufficiency

Five patients with acute strokes caused by proven vertebral-basilar artery insufficiency had restoration of acutely lost neurologic function with revascularization of ischemic tissue and cells of the hindbrain, including upper and lower motor neurons of the brainstem. This was done with an operation to correct partial extralumenal obstruction of the proximal vertebral artery. The operations were performed three to seven days after the onset of the acute strokes. Patient selection is dependent on angiography of the aortic arch with visualization of the vessels of the neck, the vertebral and carotid arteries. There was no mortality and no significantly morbidity among these patients.     

Chest wall arteriovenous fistula: an unusual complication after chest tube placement

Posttraumatic arteriovenous fistulas can form between vessels of the thorax that have sustained loss of integrity to the vessel wall. Although most are caused by injuries as a consequence of missile penetration or stab wounds, iatrogenic damage is a potential cause. Herein we present a case of a systemic arteriovenous fistula involving an intercostal artery and subcutaneous vein after chest tube placement.     

Stent-graft treatment of pseudoaneurysms and arteriovenous fistulae in the carotid artery

The purpose of this study was to assess the safety and efficacy of stent-graft placement in the management of arteriovenous fistulae (AVF) and pseudoaneurysms (PAs) involving the carotid artery (CA). Twenty-two patients (16 men, 6 women) with a CA AVF (n = 5) or PA (n = 17) owing to a gunshot or stab wound, carotid endarterectomy, blunt trauma, a tumor, spontaneous dissection, or a central venous catheter were treated with percutaneous placement of stent grafts. The patients presented with tumor, bruit, headache, mouth and tracheostomy bleeding, transitory hemiparesis, seizure, or stroke. Diagnoses were made by using computed tomographic angiography (CTA) and digital subtraction angiography. Fourteen lesions were in the common CA; eight were in the internal CA. Homemade devices and stent grafts from a variety of manufacturers were employed. Follow-up evaluations included clinical, CTA, and Doppler ultrasound assessments. All patients had resolution of the PA or AVF. In one patient with a large petrous PA, acute occlusion of the CA developed after placement of three balloon-expandable stent grafts, but there were no neurologic complications because the circle of Willis was functional. During follow-up ranging from 2 months to 13 years, asymptomatic 90% stenosis owing to stent compression was observed on Doppler ultrasound and angiographic examinations in a patient with an autologous vein-covered stent graft in the internal CA. Three other patients died of causes unrelated to stent-graft placement. In all other patients, the stent graft remained patent. Our results indicate that stent grafting is an acceptable alternative to surgery in the treatment of AVF and PAs in the CA.     

Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.     

Fatal intracranial hemorrhage after balloon occlusion of an extracranial vertebral arteriovenous fistula. Case report

A patient is presented who developed a fatal hemorrhage immediately after balloon occlusion of an extracranial vertebral arteriovenous fistula. The fistula was associated with marked retrograde flow not only from the contralateral vertebral artery but also from the carotid artery system through the posterior communicating artery and the basilar artery. The bleeding appeared to be caused by acute hemodynamic effects following abrupt occlusion of the long-standing fistula. A gradual staged occlusion or trapping procedure should be considered for the treatment of such vertebral arteriovenous fistulae.     

Management of penetrating injuries to carotid artery

The diagnosis and management of penetrating injuries to the cervical carotid arteries continue to be controversial. Most patients with stab or gunshot wounds to the common or internal carotid artery in cervical zone II (sternal notch to angle of mandible) are symptomatic with external or intraoral hemorrhage, a rapidly expanding hematoma, evidence of a carotid-jugular arteriovenous fistula at an obvious site, or loss of the carotid pulse with a neurologic deficit. Immediate airway control and arterial repair are indicated in such patients. Other patients present with stab or gunshot wounds with proximity only to the carotid sheath, a stable hematoma, unknown level of a carotid-jugular arteriovenous fistula, or loss of the carotid pulse without a neurologic deficit. Diagnostic options in this latter group include duplex ultrasound, color duplex imaging, and standard arteriography, while the role of CT or MRI angiography in evaluating patients with penetrating cervical wounds is unclear at this time. Certain arterial injuries discovered on diagnostic tests are currently managed with observation, endovascular stenting (for intimal or wall irregularities), and arteriographic embolization (for small pseudoaneurysms or high carotid-jugular fistulas). Operative repairs for injuries in zone II are performed through an oblique cervical incision and include all the options used with peripheral vascular injuries. Patients with penetrating cervical wounds, preoperative neurologic deficits, and immediate transport to the trauma center should have repair rather than ligation of the injured carotid artery. When the patient is truly comatose with a Glasgow Coma Scale score < 8, an unsatisfactory neurologic outcome is likely with either arterial repair or ligation. Injuries to the extracranial internal carotid artery in cervical zone III (above the angle of the mandible) may require innovative approaches to control hemorrhage and then maintain flow to the ipsilateral cerebral cortex.     

胸主动脉夹层动脉瘤腔内隔绝术中椎动脉缺血的预防

目的:探讨腔内隔绝术治疗StanfordB型胸主动脉夹层动脉瘤时椎动脉缺血的预防方法。方法:对136例接受腔内隔绝术治疗的StanfordB型胸主动脉夹层动脉瘤病人,尤其是左锁骨下动脉血流受干扰者的病史资料进行回顾性分析。结果:136例病人中135例手术成功,66例左锁骨下动状脉开口受到干扰,其中5例因左锁骨下动脉距夹层破口太近,而有意将其封堵。8例有椎动脉缺血症,仅1例为急性脑缺血表现。2例术后被迫行颈动脉鄄椎动脉旁路术以缓解椎动脉缺血情况。而术前接受预防性颈动脉鄄椎动脉旁路术的4例病人,完全遮蔽左锁骨下动脉后无不适症状。结论:完全遮蔽左锁骨下动脉可能会引起左侧椎动脉的急性缺血而致严重并发症。根据夹层破口与左锁骨下动脉开口间的距离,术前选择性实施左颈动脉鄄左椎动脉旁路术可预防椎动脉缺血的发生。     

Management of extra-cranial vertebral artery injuries.

OBJECTIVES: To review the management of vertebral artery injuries, and the impact of pre-operative angiography. MATERIALS AND METHODS: A retrospective review was conducted of all patients with vertebral artery (VA) injuries admitted to Groote Schuur Hospital, Cape Town between January 1987 and December 2002. Patients presenting with uncontrolled active bleeding or haemodynamic instability with a poor response to resuscitation were taken immediately to surgery. Stable patients, including those who stabilised after simple resuscitation, with evidence of a vascular injury (a bruit or a large haematoma) or trans-cervical gunshot wounds, underwent routine aortic arch and selective angiography. RESULTS: One hundred and one patients with vertebral artery injuries were included in the study. Ninety-two patients sustained penetrating injuries (41 gunshot, 51 stab), three were iatrogenic and six due to blunt trauma. Angiography was performed as the primary investigation in 88 patients, while seven patients had angiography following surgery. Thirty-nine vertebral artery occlusions, 11 arteriovenous fistulae, two intimal injuries and 36 false aneurysms were identified. Thirty-three radiological interventions were performed. There were 22 associated vascular injuries in 16 patients, 27 nerve injuries in 25 patients, 11 osseous injuries in nine patients and eight aerodigestive injuries. Seven patients died. CONCLUSIONS: Angiography and intervention is of great benefit in the diagnosis and management of traumatic vertebral artery injuries. Angiography often avoids unnecessary exploration and permits endovascular treatment.     

Traumatic aneurysms and arteriovenous fistulas of the extracranial vessels in war injuries

BACKGROUND: Extracranial vessel injuries are potentially devastating complications of penetrating head and neck wounds associated with war conflicts. These vasculopathies may be occlusive or they may lead to formation of traumatic aneurysms (TA) and arteriovenous fistulae (AVF). Even though these penetrating injuries are usually clinically silent and often appear only as small superficial wounds, they may lead to catastrophic hemorrhage or vascular insult. In this study, we attempted to elucidate signs, symptoms and circumstances present in these victims who are at risk of harboring an occult vasculopathy, excluding the occlusive ones and concentrating primarily on TAs and AVFs. MATERIALS AND METHODS: In a prospective study conducted during 8 years of war between Iran and Iraq, we encountered 13 cases of traumatic vasculopathies of the extracranial carotid and vertebral arteries. The type and number of injuries were: carotid-jugular fistula (CJF) 3, carotid trunk or branch aneurysm (CA) 2, superficial temporal artery aneurysm (STA) 3, vertebral artery aneurysm (VA) 2, vertebral arteriovenous fistula (VAVF) 1, ophthalmic artery aneurysm (Oph. An.) 1, and lingual artery aneurysm (Lin. An.) 1. Angiography was performed between the 5th and 30th day after the injury and surgical intervention was performed in all cases. RESULTS: The Glasgow outcome scale (GOS) score was 13-15 in all victims at the time of discharge from the base hospital without any additional neurological deficit. The follow-up period varied from 5 to 8 years in all cases in whom no further morbidity or mortality occurred. Single photon emission computed tomography was the noninvasive tool used for measurement of cerebral blood flow in the cases in which a major vessel ligation was performed; no remarkable change in cerebral blood flow was noted. CONCLUSION: Early recognition of stigmas suggesting possible formation of extracranial traumatic vasculopathies such as TAs or AVFs in the difficult situation of war frontier hospitals should be highlighted for attending physicians or younger neurosurgeons. Performing angiography promptly in suspected cases can pick up such traumatic vascular lesions earlier. Using simpler surgical techniques in situations in which more sophisticated endovascular equipment is unavailable can be life-saving for these usually young victims.     

Assessment of vessel wall thickness in carotid atherosclerosis using spiral CT angiography.

OBJECTIVES: the purpose of this study was to evaluate the amount of vessel wall thickening in the internal and common carotid arteries in patients undergoing spiral CT angiography for the investigation of significant atherosclerotic disease. MATERIALS AND METHODS: forty-five carotid systems in patients with a 70% or greater stenosis (according to carotid duplex) were imaged with CT spiral angiography using a standardised protocol. The vessel wall thickness of the distal common and mid internal carotid artery was measured using axial CT sections. RESULTS: vessel wall thickness was greater and more variable within the common carotid artery than within the internal carotid artery. The mean proportion of total vessel diameter constituted by vessel wall thickness was significantly greater in the common carotid artery as compared to the internal carotid artery: 28+/-12% (SD) vs 15+/-6%, respectively (p < 0.001). CONCLUSIONS: significant and extended wall thickening is commonly present in the internal and common carotid arteries of patients with atherosclerotic disease, but the internal carotid artery is significantly less affected than the common carotid artery. These observations question the validity of using the common carotid artery as a reference vessel for angiographic stenosis measurements.     

Small aneurysm clips for surgery of neck vessels

Surgery of the internal carotid artery and the extracranial vertebral artery is of a fundamentally preventive nature, and justifiable when intra and postoperative complications (intraoperative stroke, postoperative vessel occlusion, postoperative TIA and/or stroke) remain within very low limits (less than 5% according to major case-series'). To minimize damage to the arterial wall that could cause vessel occlusion and even neurological damage, the authors propose the use of intracranial aneurysm clips for temporary closure of the neck vessels, explaining the methods used for selection of these clips.     

Surgical reconstruction for radiation-induced extracranial vertebral artery stenosis: a case report]

We report a case of symptomatic extracranial vertebral artery stenosis after radiation therapy. This 49-year-old female received radiation therapy to the neck for nasopharyngeal carcinoma 11 years earlier, was admitted because of continuous dizziness and a floating sensation. Magnetic resonanse imaging showed no abnormalities, but an aortography demonstrated complete occlusion of the right common carotid artery as well as occlusion of the right vertebral artery and severe stenosis of the left vertebral artery at its origin, which was presumed to be the result of previous radiation therapy. Percutaneous transluminal angioplasty (PTA) for the left vertebral artery was performed using conventional balloon treatment, which resulted in wall dissection. Because of this, she underwent end-to-side vertebral artery to subclavian artery transposition, and she has had no further ischemic events science that time. PTA has been successfully performed as the first treatment of choice for vertebral artery stenosis, but surgical reconstruction can be a therapeutic management of choice for cases of failed PTA.     

Stab wounds at the craniocervical junction

Between 1976 and 1984, 11 patients with stab wounds at the craniocervical junction were seen in the Department of Neurosurgery at Groote Schuur Hospital. The injury usually occurred in males, and the left side was predominantly involved. Because of the anatomical features of this region, the penetrating instrument is deflected by the occipital squama into the atlantooccipital or atlantoaxial interspace, and an almost predictable syndrome occurs. The dura mater is penetrated, so that cerebrospinal fluid leakage and meningitis are common complications (meningitis occurred in 5 patients). A meningocele may develop at this site and did occur in 4 patients, but only 2 required surgical repair. Because of the exposed position of the vertebral artery at this level, this vessel was injured in 4 patients; an arteriovenous fistula developed in 2, vertebral artery occlusion occurred in 1, and a false aneurysm developed in another patient. The neurological deficit varied in magnitude, was often transient, affected the upper limbs more than the lower, was asymmetrical (suggestive of lateralized injury), and at times showed a remarkable tendency to recover. Awareness of the existence of this syndrome may help in forestalling complications. The only warning sign may be an insignificant wound in the suboccipital or retromastoid region.