Isolated Axillary Artery Injury due to Blunt Trauma in Ice Hockey

ABSTRACT:: We report the first case of a purely isolated axillary artery dissection because of focal blunt trauma to the axilla. A 42-year-old man presented to our outpatient orthopedic clinic 7 days after a fall during a hockey game whereby another player's skate blade struck the patient directly in the axilla without disrupting the skin. The patient denied having any symptoms of shoulder dislocation but experienced some pain and numbness, which subsided rapidly. Then he developed a cool hand with exertional claudication. Physical examination revealed absent radial and brachial pulses. Computed tomographic angiography demonstrated dissection of the distal axillary artery extending to the middle two-thirds of the brachial artery. Following urgent consultation with vascular surgery, the patient was treated operatively with reverse saphenous interpositional grafting and embolectomy. This case illustrates the need to have a heightened index of suspicion to all injuries to the axilla and the importance of performing careful soft tissue and neurovascular examinations in hockey players presenting with shoulder complaints, even when bony injury is not present.     

经右腋动脉选择性脑灌注在主动脉夹层手术中的应用

目的总结右腋动脉插管体外循环(ECC)、选择性顺行脑灌注在主动脉夹层手术中应用的初步经验。方法回顾性分析我院2005年1月—2008年7月采用深低温停循环(DHCA)加右腋动脉插管选择性顺行脑灌注(ASCP)手术治疗I型主动脉夹层10例。男8例,女2例。年龄24~63岁,平均(41.7±12.0)岁。升主动脉+全弓置换+降主动脉术中支架置入术5例,升主动脉+全弓置换2例,升主动脉+右半弓置换3例。结果本组主动脉阻断时间83~258min,平均(132.3±52.8)min。深低温停循环时间8~53min,平均(29.10±18.30)min,选择性脑灌注时间8~58min,平均(33.4±18.5)min。手术死亡2例,1例因术中出血、体外循环时间长不能脱机,1例因术后低心排和多脏器功能衰竭。术后暂时性脑损害2例,均治愈出院,无永久性脑损害发生。结论右腋动脉插管灌注和顺行脑灌注在主动脉夹层手术中可提供有效的脑保护,其操作简便、安全。     

1ml注射器辅助法在桡动脉穿刺置管中的应用

目的探讨一种新型穿刺法即1 ml注射器辅助法在桡动脉置管的应用,观察其置管成功率与穿刺所需时间。方法选取300例重大手术需动脉穿刺置管的患者,随机分为两组,Ⅰ组采用直接穿刺置管法,Ⅱ组采用1 ml注射器辅助穿刺法。结果Ⅰ组穿刺成功123例,Ⅱ组穿刺成功141例,两组相比,有显著统计学意义(P<0.01);前者用时(56±10.4)s,后者(34±9.3)s(P<0.01)。结论1 ml注射器辅助穿刺是简单、快速、安全且损伤较小的动脉穿刺方法。     

Unusual presentation of ulnar artery aneurysm and dissection with associated anomalous radial artery: appearances on multi-detector row CT angiography

We present a case of ulnar artery aneurysm and dissection associated with a congenitally hypoplastic ipsilateral radial artery. We postulate that the aetiology is due to increased blood flow through the ulnar artery as a consequence of the radial artery anomaly, therefore making the ulnar artery more vulnerable to aneurysm formation and traumatic damage. This might represent a variant of the hypothenar hammer syndrome with associated ulnar artery dissection and recurrent distal embolisation manifesting as Raynaud’s phenomenon. Forearm arterial injuries, treatment and the importance of upper limb arterial anatomical variations are also discussed. To our knowledge, this is the first reported case of its type diagnosed by multi-detector row computed tomography angiography.     

Percutaneous Axillary Artery Access in Complex Endovascular Aortic Repair

PurposeThis study was designed to assess the feasibility and safety of percutaneous axillary access in complex endovascular aortic repair (EVAR) with use of a percutaneous closure device.Materials and MethodsAll patients undergoing percutaneous axillary artery access between 2012 and 2017 were included. Left percutaneous axillary access was the sole antegrade aortic approach used. Patient and intervention characteristics were documented. Mortality, procedural success, technical success, peri- and postoperative complications, and repeat interventions were examined. A total of 25 percutaneous axillary access procedures were performed in 23 patients. The mean age of the treated patients was 72.2 years, and 71% were male. Percutaneous axillary access was obtained for a variety of indications (chimney EVAR, thoracoabdominal aortic aneurysm repair, thoracic EVAR, and type B dissections). Vascular access sheath sizes ranged from 6 F to 12 F.ResultsThe procedural success rate was 96%. Technical success of vascular closure was 100%. The perioperative access complication rate was 8%: 1 dissection of the axillary artery and 1 stenosis occurred. No hematoma, hemorrhage, or neuropathies were seen. One access-related repeat intervention had to be performed. The 30-d mortality rate was 4%.ConclusionsDirect puncture and percutaneous closure of the axillary artery for complex aortic procedures is safe and feasible.     

Endovascular Treatment of Iatrogenic and Traumatic Carotid Artery Dissection

This paper reports on the early and midterm results of endovascular treatment of acute carotid artery dissections, its specific problems, and its limitations. We encountered seven patients with symptomatic extracranial carotid artery dissection, three cases of which occurred after carotid endarterectomy, two after carotid angioplasty and stenting, and two after trauma. Balloon-expandable and self-expanding stents were placed using a transfemoral approach. Success in restoring the carotid lumen was achieved in all patients. No procedure-related complications occurred. All patients experienced significant clinical improvement while in the hospital and achieved complete long-term recovery. At follow-up (mean, 22.4 months), good luminal patency of the stented segments was observed. In conclusion, in this small series, primary stent-supported angioplasty seems to be a safe and effective strategy in the treatment of selected patients having acute traumatic extracranial carotid artery dissection, with excellent early and midterm results. Larger series and longer-term follow-up are required before definitive recommendations can be made. Stefan Schulte and Konstantinos P. Donas contributed equally.     

多层螺旋CT对肺动脉栓塞的诊断价值

目的探讨肺动脉栓塞(pu lmonary embolism,PE)的多层螺旋CT(MSCT)表现特征,评价MSCT对PE的诊断价值。方法回顾分析43例临床诊断PE患者的16层螺旋CT肺动脉造影资料的影像学表现,并与其肺动脉造影(DSPA)或随访结果相对照。结果本组43例均与临床诊断相符,中心型16例,周围型23例,混合型4例。多层螺旋CT肺动脉造影(MSCTPA)对叶及叶以上肺动脉的显示率达100%,检出PE阳性20支,段肺动脉清楚显示726支(显示率达84.4%),检出PE阳性109支,亚段肺动脉清楚显示1185支(显示率达68.9%),检出PE阳性61支。PE的直接征象包括血管腔完全闭塞、部分充盈缺损、轨道征和附壁血栓;间接征象有肺梗死灶、“马赛克”征、右室增大和/或肺动脉扩张、胸腔积液、心包积液等。结论MSCTPA诊断PE简便、安全、无创,对亚段肺动脉栓塞的诊断准确、可靠,是诊断早期肺动脉栓塞的首选方法。     

超声心动图在肺动脉栓塞诊断中的价值

目的探讨超声心动图在肺动脉栓塞诊断中的应用价值。方法对临床综合检查而诊断的肺动脉栓塞37例患者,进行经胸超声心动图检查,着重观察右房、右室、肺动脉及其分叉、下腔静脉等处,测量三尖瓣返流速度,估测肺动脉压力,观察肺动脉频谱形态的变化,测量肺动脉峰值流速、加速时间、射血时间等。结果右心系统内可见活动或附壁实质性中低等回声。右房、右室增大,主肺动脉及分支增宽,右室壁增厚,运动幅度减低。右心功能减低,下腔静脉增宽,三尖瓣可见不同程度的返流,肺动脉压增高,肺动脉频谱形态见特征性的“指拳征”。肺动脉频谱加速时间及射血时间缩短。结论超声心动图在诊断肺动脉栓塞中具有重要的临床意义,可提高诊断的正确率。     

Aspiration Therapy for Acute Superior Mesenteric Artery Embolism with an Angled Guiding Sheath and Guiding Catheter

Seven patients with superior mesenteric artery embolism were treated by aspiration with the use of a 6-F angled guiding sheath and a 6-F guiding catheter through an 8-F short sheath by direct advancement using a telescopic and “biting-off” technique. Aspiration of the trunk took between 30 and 60 minutes (median, 44.0 min), and total procedure time ranged from 34 to 94 minutes (median, 60 min). Five of six trunk lesions and six of nine branch lesions were successfully aspirated. One dissection was observed. Six patients underwent bowel resection. Two patients died and the remaining five survived for a median of 868.2 days without complications.     

Complications of Lower-Extremity Outpatient Arteriography via Low Brachial Artery

We retrospectively evaluated low brachial artery puncture for arteriography and its complications as an alternative approach route for bilateral lower extremity run-off. Using the Seldinger technique and catheterization with a sheathless 4-F multiple side-hole pigtail catheter, we performed 2250 low brachial artery punctures in outpatients.The right brachial artery (RBA) was successfully punctured in 2039 patients; the left brachial artery (LBA) in 200. The transfemoral approach was used in 11 patients when catheterizing either of brachial arteries failed. Ten major or moderate complications (2 pseudoaneurysms, 2 thrombosis, 1 dissection and 5 hematomas) were encountered. Surgical intervention was necessary in three cases. There were no transient ischemic attacks. Twenty-one patients suffered temporary loss of radial pulse which returned spontaneously in less than 1 hour. One patient demonstrated prolonged loss of pulse which required heparin. Low brachial artery puncture and catheterization at the antecubital fossa is a very safe and cost-effective alternative to the femoral artery approach for lower extremity intra-arterial arteriography in the hands of experienced operators. The success rate in catheterizing one of the brachial arteries was 99.52% with a low significant complications rate of 0.44%. The transbrachial approach should be used as a standard method for lower extremity IA - DSA in an outpatient setting.     

BAE在治疗支气管扩张所致大咯血中的应用

目的:评价支气管动脉栓塞法(Bronchial Artery Embolism,BAE)对支气管扩张所致大咯血的疗效。材料与方法:支气管扩张致大咯血患者8例,其中男性16例,女性2例,年龄35～78岁,平均51.5岁,经放射造影(5例)与CT扫描(3例)证实后,均接受了支气管动脉栓塞治疗。结果:二年以内的疗效为100％,二年以上疗效为88％。结论:支气管动脉栓塞对支气管扩张所致大咯血具有明显的止血效果和可以反复进行等优点,它在显著改善临床症状方面是一种优于内科保守治疗并可与外科手术相媲美的理想方法。     

急性肠系膜动脉栓塞9例的诊断与治疗分析

目的　探讨肠系膜动脉栓塞易误诊的原因及早期诊断和治疗。方法　总结 1 985— 2 0 0 0年间收治的 9例急性肠系膜动脉栓塞的诊治经验。结果　就诊时明确诊断 1例。9例均行手术治疗 ,抢救成功 3例 ,死亡 6例。结论　该病诊断困难 ,预后较差。只有提高认识 ,早期诊断 ,及时正确施治 ,方能提高疗效     

Vascular diseases of the thorax: evaluation with multidetector CT

The list of vascular diseases in the thorax has been narrowed to three, which are considered essential information for radiologists interpreting CT scans of the thorax: (1) aortic dissection and its variants, intramural hematoma and penetrating atherosclerotic ulcer; (2) acute pulmonary embolism; and (3) coronary artery disease. The spatial resolution of multidetector CT is such that CT has become the imaging modality of choice for aortic dissection and pulmonary embolism. This move away from angiography has transpired over the last decade; perhaps the next decade will see the same occur for evaluation of coronary artery disease.     

Traumatic subarachnoid hemorrhage and the COL3A1 gene: emergence of a potential causal link

We describe two previously unreported associations in four cases. The first two cases demonstrate an association between segmental mediolytic arteriopathy and vascular Ehlers-Danlos syndrome. The second two cases illustrate an association between vascular Ehlers-Danlos syndrome and traumatic subarachnoid hemorrhage. In case 1, there was acute subarachnoid hemorrhage and mesenteric artery dissection. In case 2, there was an acute mesenteric artery dissection with intestinal infarction. In both cases 1 and 2, segmental mediolytic arteriopathy was found in the vertebral arteries. Cases 3 and 4 were sudden deaths from traumatic subarachnoid hemorrhage with intracranial vertebral artery rupture. Genetic testing in all four cases revealed point mutations in the type 3 procollagen gene (COL3A1), as observed in vascular Ehlers-Danlos syndrome. Based on the first two cases, we propose that segmental mediolytic arteriopathy may be a marker for this disease. We further suggest that vascular Ehlers-Danlos syndrome may be related to the pathogenesis of traumatic vertebral artery injury, in some cases. We recommend that cases of segmental mediolytic arteriopathy and traumatic subarachnoid hemorrhage undergo genetic testing for COL3A1 mutations.     

自发性肠系膜上动脉夹层MSCTA诊断

目的通过分析自发性肠系膜上动脉夹层病例资料,提高对该疾病的认识。方法应用MSCT对5例急症患者进行平扫描和增强扫描,结束后将图像传输至工作站后处理,应用容积再现(VR)、曲面重建(CPR)、最大密度投影(MIP)等方法观察血管情况。结果 5例患者在重建图像上均清晰显示出肠系膜上动脉及其分支。轴位示肠系膜上动脉内真假腔影,并能清晰显示低密度的内膜瓣,与主动脉夹层的真假腔相类似。CPR及MPR上可显示条形低密度充盈缺损影,亦可清楚显示内膜瓣。VR图像可以显示双腔改变。MIP图像与VR图像相似。5例均仅显示1处破裂口,而非像主动脉夹层显示两处或多处破裂口。其中1例病例远端肠系膜上动脉栓塞,并合并肝总动脉动脉瘤,1例病例近端、远端肠系膜上动脉栓塞,1例合并右肾动脉分支夹层。结论 MSCTA可早期诊断自发性肠系膜上动脉夹层。     

Traumatic neuroma after neck dissection: CT characteristics in four cases

BACKGROUND AND PURPOSE: Traumatic neuroma, an attempt by an injured nerve to regenerate, may present as a palpable nodule or an area sensitive to touch (trigger point) after neck dissection. The purpose of this study was to identify CT characteristics of traumatic neuroma in four patients after neck dissection. METHODS: Between April 1995 and November 1998, the CT studies in three men and one woman (ages, 45-64 years) who had had a radical neck dissection and a nodule posterior to the carotid artery were reviewed retrospectively. CT was performed 1.5 to 6 years after neck dissection with clinical correlation and/or pathologic examination. Three patients had squamous cell carcinoma of the upper aerodigestive tract and one had a primary parotid adenocarcinoma. RESULTS: Three patients with a traumatic neuroma had a centrally radiolucent nodule with peripherally dense rim and intact layer of overlying fat, which was stable on CT studies for 1 to 2 years. One of these had a clinical trigger point. The fourth patient with a pathologically proved traumatic neuroma mixed with tumor had intact overlying fat, but the nodule lacked a radiolucent center and was not close to the carotid artery. CONCLUSION: The CT findings of a stable nodule that is posterior but close to the carotid artery with central radiolucency, a dense rim, and intact overlying fat, combined with the clinical features of a trigger point and a lack of interval growth, strongly suggest the diagnosis of traumatic neuroma.     

Bilateral extracranial internal carotid artery injury due to non-penetrating trauma--report of three cases.

Angiographic features of three patients with bilateral internal carotid artery injury (spasm/dissection/thrombosis) due to non-penetrating trauma are reported. All three patients were involved in motor vehicle accidents. Focal-localizing neurological signs were present and the patients were suspected of having extracerebral haematomas. The diagnosis of traumatic spasm/dissection/thrombosis of the cervical portion of the internal carotid arteries was made following angiography. The need to include views of the cervical carotid arteries in cases of traumatic hemiparesis is stressed and possible effect of cranial CT scanning in these patients on diagnosis of carotid artery injury discussed.     

Treatment of Internal Carotid Artery Dissections with Endovascular Stent Placement: Report of Two Cases

Extracranial carotid artery dissection may manifest as arterial stenosis or occlusion, or as dissecting aneurysm formation. Anticoagulation and/or antiplatelet therapy is the first-line treatment, but because it is effective and less invasive than other procedures, endovascular treatment of carotid artery dissection has recently attracted interest. We encountered two consecutive cases of trauma-related extracranial internal carotid artery dissection, one in the suprabulbar portion and one in the subpetrosal portion. We managed the patient with suprabulbar dissection using a self-expandable metallic stent and managed the patient with subpetrosal dissection using a balloon-expandable metallic stent. In both patients the dissecting aneurysm disappeared, and at follow-up improved luminal patency was observed.     

外伤性颈内动脉动脉瘤的介入治疗

目的：探讨外伤性颈内动脉动脉瘤介入治疗技术。方法：回顾性分析4例颈内动脉假性动脉瘤,1例蛇形动脉瘤,1例颈内动脉颈段巨大动脉瘤（直径〉25mm）,1例颈内动脉海绵窦瘘并发假性动脉瘤的介入治疗,其中后者采用可脱性球囊、带膜血管内支架介入治疗的方法。结果：5例一次性闭塞颈内动脉,1例颈内动脉颈段的巨大动脉瘤行带膜内支架治疗,保持了颈内动脉通畅,旷置了动脉瘤。另1例海绵窦的假性动脉瘤行球囊栓塞时,球囊滑入假性动脉瘤腔,术中出现鼻腔大出血,经抢救治疗后二次行球囊栓塞闭塞颈内动脉。结论：外伤性颈内动脉动脉瘤的介入治疗效果好、风险小、微创、并发症少。     

Spontaneous Dissection of the Superior Mesenteric Artery

Spontaneous dissection of the superior mesenteric artery (SMA) is a rare occurrence, especially when not associated with aortic dissection [1]. Currently, only 28 cases appear to have been reported. Due to the scarcity of cases in the literature, the natural history of isolated, spontaneous SMA dissection is unclear. CT has been reported to be useful for the initial diagnosis of SMA dissection [2–5]. We present two recent cases of spontaneous SMA dissection in which enhanced spiral CT was instrumental in following the disease process and guiding clinical decision making.