Endovascular management of peripheral arterial trauma in patients presenting in hemorrhagic shock.

AIM: This study investigated patients who sustained peripheral arterial trauma, presented with clinical signs of shock, and underwent urgent endovascular repair (endo-R). METHODS: Eighteen patients (11 men) aged 62.8 ± 17.5 y (range: 24-78 years) with severe peripheral arterial injuries or spontaneous ruptures who presented with clinical signs of shock were treated on an emergency basis at two institutions from August 2003 to August 2009. The injury mechanism and clinical presentation were assessed in all patients. The time interval from the initial event to the procedure, the time interval from hemodynamic instability to endo-R (HI-to-endo-RTI), the artery involved in the approach to the injured vessel, the method of endo-R, and the endo-R duration were recorded. Stent grafting and/or embolization of the injured vessel were performed. The outcome was assessed mainly by clinical examination and duplex scanning. The duration of follow-up ranged from 6 d to 60 mo (27.4 ± 17.8 mo, mean ± SD). RESULTS: Mechanisms of injury included 13 iatrogenic (9 catheter-related) injuries, 2 spontaneous hemorrhages, and 1 case each of gunshot wound, fall injury, and car accident. Traumatic lesions were in the external carotid (N.=1), vertebral (N.=1), subclavian (N.=3), common iliac (N.=1), external iliac (N.=5), internal iliac (N.=3), profunda femoral (N.=1), superficial femoral (N.=2), and popliteal (N.=1) arteries. Stent grafts and embolotherapy were successfully deployed in 12 and 4 patients, respectively, with complete exclusion of the bleeding site. One patient received both treatments and another patient received balloon occlusion therapy. Technical success with no procedural complications occurred in all cases. The mean event-to-procedure time interval, HI-to-endo-RTI, and operative time were 147 min, 42.2 ± 48.2 min (range: 3-180 min), and 40.0 ± 29.6 min (range: 5-110 min), respectively. Thirteen patients had an uneventful postoperative course while three patients died (mortality rate: 17%). One patient had below-knee amputation and another one suffered hemiparesis (morbidity rate: 11%). The durations of the hospital and intensive-care-unit stays were 16.6 ± 19.5 d (range: 2-62 d) and 6.4 ± 14.6 d (range: 0-60 d), respectively. The follow-up duration was 27.4 ± 17.8 mo (range: 0.2-60 mo). Freedom from early or late endo-R major events occurred in 71.4% and 65.6% of cases at 6 mo and 12 mo, respectively, and the rate of primary patency of endografts was 91.7% and 81.8%. CONCLUSION: Endo-R of traumatic non-aortic arterial injuries or spontaneous ruptures might be considered as a treatment option-in preference to open repair-even in emergency settings such as in shock patients. However, the safety of endovascular treatment in unstable trauma patients must be proved after comparison with open surgical treatment.

A case of extraskeletal Ewing sarcoma originating from the visceral pleura.

Extra skeletal Ewing Sarcoma (EES) is a rare entity which predominantly occurs in adolescents and young adults. It usually arises from the soft tissues of the trunk or the extremities. We present a case of EES arising from the left visceral pleura in a 21 year old female patient who presented to the emergency room of our institution with fever, productive cough and sternal pain radiating to the back for the last 3 days. Chest radiograph was firstly performed, followed by chest CT examination. Finally open lung biopsy revealed a small round cell malignancy. The mass was resected and the histological examination revealed Extra skeletal Ewing Sarcoma (EES) of the visceral pleura without involvement of the adjacent lung. Secondary multiple nodules at the lateral wall of the pleura were also noticed and so postoperative multiagent chemotherapy was performed. EES should be considered in the differential diagnosis of any patient, especially adolescents or young adults, with a soft tissue mass of the trunk or the extremities.