Successful covered stent-graft treatment of superficial femoral arterial injury due to blunt trauma.

BACKGROUND: Endovascular treatment is used for traumatic arterial injuries in the torso. However, the effectiveness of endovascular covered stent-graft treatment for peripheral artery injury is unclear. We present a case of superficial femoral artery (SFA) injury successfully treated with a covered stent-graft. CASE REPORT: A 68-year-old man presented with traumatic lower limb injury and shock. Computed tomography angiography revealed left subtrochanteric fracture and hematoma with extravasation. Digital subtraction angiography revealed extravasation from a left SFA branch, and a pseudoaneurysm at the SFA trunk. We coil embolized the SFA branch, and treated the pseudoaneurysm with a covered stent-graft. Computed tomography carried out 22 days later showed complete pseudoaneurysm exclusion and sufficient stent patency.
CONCLUSION: We successfully used a covered stent-graft to treat SFA injury due to blunt trauma. A covered stent-graft could be effective for peripheral artery injury.

INTRODUCTION

Arterial injuries in the extremities account for 50% of all arterial trauma cases, with 64–82% resulting from penetrating injury. Traumatic lower extremity arterial injuries cause significant morbidity and mortality, , with amputation rates of 0.95–26.1%.

Arterial injuries are increasingly being treated endovascularly, with covered stent‐grafts generally used for traumatic or iatrogenic aortic injuries. In peripheral arteries, covered stent‐grafts are used to treat stenosis or occlusion, but are rarely used for traumatic injury.

We used a covered stent‐graft to achieve hemostasis after traumatic superficial femoral artery (SFA) injury.

CASE REPORT

A 68‐year‐old man sustained head and lower limb injuries in a 4‐m fall. He was taking medications for hypertension and diabetes mellitus. He was in shock (blood pressure 55/40 mmHg, heart rate 83 b.p.m.) at the accident scene. He received i.v. crystalloid fluids during transportation to hospital.

At arrival, his blood pressure was 106/68 mmHg, heart rate was 81 b.p.m., respiratory rate was 16 breaths/min, oxygen saturation was 100% (on O2 10 L/min), and Glasgow Coma Scale was E4V5M6; the limbs were cold and wet, indicating shock.

Physical examination revealed a 5‐cm‐long occipital wound, left femoral swelling, and right ankle pain. Focused assessment with sonography for trauma was negative. Blood gas analysis showed acidemia (pH 7.28) and elevated lactate (3.7 mmol/L). Hemoglobin was 9.9 g/dL, and coagulation examination revealed elevated D‐dimer (77.08 µg/mL) and decreased fibrinogen (146 mg/dL).

Radiography revealed fractures in the subtrochanteric region of the left femur and the right distal tibia and fibula. Enhanced computed tomography (CT) showed hematoma with extravasation around the femoral fracture (Figs. 1 and 2). We diagnosed hemorrhagic shock due to left SFA injury (injury severity score 10).

Fig. 1

Images obtained on admission of a 68‐year‐old man with superficial femoral arterial injury due to blunt trauma. A, Radiograph showing a left subtrochanteric fracture. B, C, Enhanced computed tomography showing (B) initial left subtrochanteric fracture and (C) subsequent hematoma with extravasation.

Fig. 2

Enhanced computed tomography of a 68‐year‐old man with traumatic lower limb injury showing (A) the pseudoaneurysm of the main trunk of the left superficial femoral artery and (B) extravasation from a branch of the left superficial femoral artery.

We carried out right femoral artery puncture and used a 6‐Fr sheath and 0.018 inch × 200 cm guidewire for anterograde angiography of the left SFA. A delivery catheter was not used because of the emergency situation. Digital subtraction angiography showed extravasation from the proximal muscle branch of the left SFA and a pseudoaneurysm in the main SFA trunk. We carried out balloon occlusion of the proximal SFA branch for 30 min (using a 5.2‐Fr, 9‐mm balloon) and external fixation of the fractures. Extravasation remained after balloon occlusion, and was embolized with two microcoils (Microcoilspiral [2 cm, 2 mm]; Cook Medical Japan, Tokyo, Japan). We used a covered stent‐graft (Viabahn [6 mm × 2.5 cm]; Gore, Newark, DE, USA) to repair the SFA trunk (Fig. 3). Disappearance of the extravasation was confirmed. During angiography, we transfused 2 units of red blood cells and 10 units of fresh frozen plasma. On returning to the emergency room, the patient’s hemoglobin was 6.7 g/dL and lactate was 0.9 mmol/L.

Fig. 3

Digital subtraction angiography images of a 68‐year‐old man with traumatic lower limb injury. The images show (A) extravasation from a branch of the left superficial femoral artery, and (B) angiography after coil embolization, and the pseudoaneurysm of the main trunk of the left superficial femoral artery, (C) the retained covered stent‐graft, and (D) final contrast examination.

The patient received additional transfusions while the hemoglobin and fibrinogen were monitored. Continuous heparin infusion was given to prevent intrastent thrombosis. We carried out internal fixation of the left subtrochanteric and right distal fibular fractures on day 8, and of the right distal tibial fracture on day 14. Two surgical site infections were treated with debridement and systemic antibiotics from day 12 until hospital discharge. Computed tomography showed adequate stent patency on day 22, and we changed the heparin infusion to oral aspirin from day 38. The patient was transferred to another hospital on day 63.

DISCUSSION

We successfully treated traumatic SFA injury with a covered stent‐graft. We carried out the procedure in a short time without vascular complications and obtained sufficient stent patency in the subacute phase.

Lower limb arterial injuries due to blunt trauma are often associated with fractures. Thus, SFA injury should be suspected in all patients with proximal femoral fracture.

Arterial injuries are increasingly being treated endovascularly rather than with open repair. Compared with open repair, endovascular interventions decrease in‐hospital mortality and hospitalization duration, , , and result in lower transfusion requirements and mortality in patients with blunt thoracic aortic injuries.

For the peripheral arteries, injuries are generally treated by surgical approaches, whereas covered stent‐grafts are used for stenosis or occlusion. However, covered stent‐graft implantation for peripheral arterial injury has been reported. , Endovascular repair of peripheral arterial trauma results in fewer wound complications and shorter hospitalization than open repair. The hospitalization was relatively long in the present case, but this was only because the patient needed two fracture fixations and developed surgical site infections.

Compared with open repair, endovascular treatment of SFA injuries has been reported to reduce blood loss, hospital stay, iatrogenic nerve injuries, and recovery time, and to reduce ischemic and operative times for lower extremity injuries. Therefore, endovascular treatment could be beneficial for peripheral arterial injury, particularly in areas that are difficult to expose surgically.

Small pseudoaneurysms with low flow volume can be treated conservatively. However, we selected a covered stent for the main SFA trunk because of the close proximity of the fracture. We would have chosen endovascular treatment even if this patient only had a main SFA trunk pseudoaneurysm.

The disadvantages of the Viabahn are the lack of insurance cover for traumatic peripheral arterial injuries, contraindication in patients with heparin‐induced thrombocytopenia II, and need for long‐term antiplatelet therapy. The Viabahn also has the potential risk of stent thrombosis, although long‐term stenosis and salvage rates remain unreported. Furthermore, information about postoperative anticoagulation is lacking. Our patient had a high bleeding risk because of planned surgeries for the fractures. Thus, we initially selected heparin infusion, and switched from heparin to aspirin after the surgeries. Our patient had no stent stenosis or obstruction at 9 months postoperatively (Fig. 4). Dual antiplatelet therapy is recommended when the Viabahn is used for non‐traumatic SFA stenosis or occlusion. However, the optimal antiplatelet therapy for trauma patients treated with the Viabahn remains unclarified. Furthermore, the reported antiplatelet regimen and duration after Viabahn insertion vary. Although our patient was successfully managed with single antiplatelet therapy after Viabahn insertion, more cases need to be accumulated to determine the optimal antiplatelet regimen and duration for trauma patients treated with the Viabahn.

Fig. 4

Enhanced computed tomography of a 68‐year‐old man with superficial femoral arterial injury due to blunt trauma. The scan was carried out 9 months after the injury and shows adequate stent patency.

There are no reports of infection after covered stent placement, but trauma patients are at higher risk of infection and must be carefully monitored.

In the present case, endovascular treatment only took 1 h and was minimally invasive. Enhanced CT undertaken on day 22 and 9 months postoperatively revealed no stent stenosis and/or obstruction, and we successfully saved the limb. This suggests that endovascular treatment with a covered stent‐graft is effective for peripheral arterial injury; however, it is necessary to accumulate further cases and investigate the hemostatic effect and long‐term outcomes.

DISCLOSURE

Approval of the research protocol: N/A.

Informed consent: Written informed consent was obtained from the patient.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

Conflict of interest: None.