Outcomes of operative and nonoperative management of blunt thoracic aortic injury.

OBJECTIVE: Although the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend has occurred for aggressive endovascular treatment of low-grade BTAIs. Little is known about the natural history of grade 1 and 2 injuries treated nonoperatively. We hypothesized that most of these low-grade injuries would remain stable with nonoperative management. METHODS: We performed a review of BTAIs at a large referral level 1 trauma center from 2004 to 2020. The injuries were graded using a standard 1 to 4 scale. The outcomes of the nonoperative and thoracic endovascular aortic repair (TEVAR) management strategies were compared, including post-trauma morbidity, mortality, reinterventions, and lesion stability. RESULTS: A total of 176 patients with BTAIs and sufficient imaging studies and follow-up data available were identified during the study period, including 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with a grade 4 injury. Of these 176 patients, 112 had undergone TEVAR and 64 had been treated nonoperatively. Most of the patients (90.2%) who had undergone TEVAR had had grade 3 injuries. Nonoperative management was performed for 97.2% of the grade 1 injuries and 62.5% of the grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). The rates of post-trauma morbidity within 30 days (stroke, 3.6% vs 3.1%; myocardial infarction/arrhythmia, 8.9% vs 1.6%; respiratory failure, 31.2% vs 28.1%; acute kidney injury, 9.8% vs 12.5%; urinary tract infection, 2.7% vs 4.8%; gastrointestinal bleeding, 3.6% vs 0.0%; pulmonary embolism, 10.9% vs 4.5%) and 1-year mortality after discharge (1.8% vs 3.1%) were comparable between the operative and nonoperative groups. The median follow-up was 1501 days (interquartile range [IQR], 475.6-2804 days) for the TEVAR group and 1170.5 days (IQR, 317-2173 days) for the nonoperative group. No lesion progression had occurred in the patients with low-grade (grade 1-2) injuries managed nonoperatively. Resolution of grade 1 and 2 injury had occurred in 20% of the patients at 30 days, which had improved to 44% at long-term follow-up. Fourteen patients with grade 3 injuries (12.2% of the grade 3 injuries in our series) were also observed and did not require future intervention. These patients had generally had smaller pseudoaneurysms with minimal periaortic hematoma. None of these 14 patients had experienced progression or rupture during follow-up (median, 454.5 days; IQR, 81-1199 days) using computed tomography. CONCLUSIONS: Nonoperative management of low-grade BTAIs did not result in long-term aortic complications or the need for reintervention. We found that grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma can be safely observed if the patients can be appropriately followed up. Thus, the indications for treatment of select grade 3 injuries merit further consideration.

[Vascular injury associated with knee dislocation]. / La lesión vascular asociada a la luxación de rodilla.

INTRODUCTION: Knee dislocation is a rare injury but considered serious clinically since it can be accompanied by vascular and neurological injuries that if they do not have a timely diagnosis and treatment can lead to the loss of the limb. Regarding vascular injury, the optimal diagnostic method for the identification of this type of lesion is of the utmost importance. OBJECTIVE: To present the literature review on the epidemiology, classification and diagnostic approach of knee dislocation with or without associated vascular injury. METHODS: Report of the literature found in databases and analyses based on clinical experience and synthesis of these documents. CONCLUSION: Vascular injury is not an uncommon finding in the context of knee dislocation, with a high risk of complications and even amputation if an early diagnosis is not made, the authors recommend angio-CT to confirm the suspected diagnosis and not delay treatment.

INTRODUCCIÓN: La luxación de rodilla es una lesión poco común, pero considerada grave clínicamente, ya que puede acompañarse de lesiones vasculares y neurológicas que si no tienen un diagnóstico y tratamiento oportuno pueden llegar a la pérdida de la extremidad. Respecto a la lesión vascular es de suma importancia el método diagnóstico óptimo para la identificación de este tipo de lesiones. OBJETIVO: Presentar la revisión bibliográfica sobre la epidemiología, clasificación y aproximación diagnóstica de la luxación de rodilla con o sin lesión vascular asociada. MÉTODOS: Reporte de la literatura encontrada en bases de datos y análisis basados en experiencia clínica y síntesis de estos documentos. CONCLUSIÓN: La lesión vascular no es un hallazgo infrecuente en el contexto de una luxación de rodilla, tiene un riesgo elevado de complicaciones e incluso de amputación si no se realiza un diagnóstico temprano, los autores recomiendan la angio-TAC para confirmar la sospecha diagnóstica y no retrasar el tratamiento.

Higher Prevalence of Bovine Aortic Arch Configuration in Patients Undergoing Blunt Isthmic Aortic Trauma Repair.

BACKGROUND: The prevalence of a bovine aortic arch configuration is higher in patients treated for thoracic aortic aneurysms and type B dissection; its prevalence in aortic isthmic trauma has not been described. METHODS: A case control study was performed comparing consecutive patients treated at our institution for acute isthmic aortic transection after blunt trauma between 2002 and 2019 and a control group of consecutive sex-matched individuals undergoing imaging for nonaortic disease. Imaging and clinical findings were reviewed. Subjects were divided into bovine and nonbovine groups and prevalence was compared. The length of the aortic segment between the left subclavian artery (LSA) and the next proximal great vessel was measured in the control population and a comparison was performed between bovine and nonbovine aortic arch subjects. RESULTS: Thirty-three consecutive (30 male) patients were reviewed, 66 individuals (60 male) were included in the control group. A higher incidence of bovine arch in trauma patients was found: 57.6% vs. 34.8% (P = 0.007). The median (range, mm) and mean (SD) distance between the bovine trunk and the LSA were 13 mm (2-27) and 12.4 mm (5.9), respectively, compared with 5 mm (1-27) and 7.8 mm (6.1) between the left common carotid and LSA in nonbovine aortic arches (P < 0.005). CONCLUSION: A higher incidence of bovine arch in patients reaching out for surgical treatment for traumatic isthmic aortic transection was found in our population. Clinical interpretation of this finding can lead to several alternatives. Confirmation with larger series and data on prevalence of this anatomic variation in nonsurvivors is needed to provide a better understanding of this finding.

Dissection of the Hepatic Artery: A Rare Cause of Late Ischemia After Liver Transplant.

Hepatic artery dissection is an infrequent vascular complication that can arise after orthotopic liver transplant. Most patients with this complication are diagnosed during the intraoperative period or the first days after liver transplant, with an association shown with living-donor liver transplant. In this study, we discuss a rare case of an extrahepatic artery dissection that was successfully managed through surgical excision and arterial revascularization that was diagnosed 4 years after orthotopic liver transplant. Furthermore, we hypothesize on the potential causes of its occurrence.

Displasia fibromuscular en la Argentina. Registro del grupo de trabajo de Hipertensión Secundaria de la Sociedad Argentina de Hipertensión Arterial (SAHARA-DF): proyecto de protocolo y resultados preliminares / Fibromuscular dysplasia in Argentina. A registry from the Secondary Hypertension working group of the Argentine Society of Hypertension (SAHARA-DF): project protocol and preliminary results

En la Argentina no existen datos epidemiológicos sobre displasia fibromuscular. La realización de un registro nacional puede aportar información que conduzca a una actualización de los consensos y recomendaciones para un correcto diagnóstico, evaluación y tratamiento. El Registro Argentino de Displasia Fibromuscular (SAHARA-DF) inició su actividad de recopilación de datos en octubre de 2015. Al año 2019 se confirmaron 49 pacientes (44 mujeres, 38 hipertensos, edad 45,3 ± 17,2 años, 12 con presentación neurológica). Veintidós pacientes tuvieron lesiones vasculares en más de un sitio, a pesar del sesgo diagnóstico por falta de estudios complementarios en casi la mitad de los casos. El sitio afectado más frecuente fue el renovascular, seguido por el carotídeo y el ilíaco, y las lesiones multifocales fueron más frecuentes que las unifocales (35 versus 14, respectivamente). Se constató la presencia de aneurismas asociados en 13 casos y disección arterial en 4 casos. De las 22 angioplastias renales realizadas, 14 fueron con colocación de stent (endoprótesis). En este estudio preliminar de una población argentina se evidencia el carácter sistémico de la enfermedad y se plantea un llamado a actuar en cuanto a la necesidad de debatir el algoritmo diagnóstico y el método de tratamiento. (AU)

In Argentina there are no epidemiological data regarding fibromuscular dysplasia. Building a National Registry may provide information leading to updated consensus and recommendations for a correct diagnosis, assessment and treatment. Data gathering for the Argentine Registry of Fibromuscular Dysplasia (SAHARA-DF) was initiated in October 2015. By 2019, 49 patients were confirmed (44 women, 38 hypertensives, age 45.3 ± 17.2 years, 12 with a neurological presentation). Twenty-two patients had multi-site vascular lesions, in spite of a diagnosis bias due to lack of supporting studies in almost half of the cases. The renovascular site was the most affected, followed by the carotid and iliac sites, and multifocal lesions were more frequent than unifocal (35 versus 14, respectively). Associated aneurysms were found in 13 cases, and arterial dissection in 4. Twenty-two renal angioplasties were performed, 14 with stent placement. In this preliminary study of an Argentinian population, the systemic nature of the disease is evidenced, and a call for action arises regarding the need for discussing the diagnostic algorithm and treatment method. (AU)

Late neurological deficit after attempted PICC insertion in the arm.

INTRODUCTION:: Insertion of central catheters in peripheral vessels is a common procedure performed for a variety of indications, including parenteral nutrition. Hyperemesis gravidarum may require parenteral nutrition in exceptional situations. Although globally safe, insertion of peripherally inserted central catheters (PICCs) can lead to complications. CASE REPORT:: We describe a case of a pregnant woman who required parenteral nutrition and underwent an unsuccessful PICC insertion attempt resulting in arterial puncture, and who 34 days later presented with right upper limb paresthesia. A pseudoaneurysm with nerve compression was diagnosed and treated by open surgery, without maternal or fetal complications. CONCLUSION:: We recommend active surveillance ultrasound (e.g. in the first 24-48 h) of unsuccessful PICC insertion attempts, because late complications may occur and require invasive procedures for treatment.

Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury.

OBJECTIVE: The traditional approach to stable blunt thoracic aortic injury (BTAI) endorsed by the Society for Vascular Surgery is early (<24 hours) thoracic endovascular aortic repair (TEVAR). Recently, some studies have shown improved mortality in stable BTAI patients repaired in a delayed manner (≥24 hours). However, the indications for use of delayed TEVAR for BTAI are not well characterized, and its overall impact on the patient's survival remains poorly understood. We sought to determine whether delayed TEVAR is associated with a decrease in mortality compared with early TEVAR in this population. METHODS: We conducted a retrospective cohort study of adult patients with BTAI (International Classification of Diseases, Ninth Revision diagnosis code 901.0) who underwent TEVAR (International Classification of Diseases, Ninth Revision procedure code 39.73) from 2009 to 2013 using the National Sample Program data set. Missing physiologic data were imputed using chained multiple imputation. Patients were parsed into groups based on the timing of TEVAR (early, <24 hours, vs delayed, ≥24 hours). The χ2, Mann-Whitney, and Fisher exact tests were used to compare baseline characteristics and outcomes of interest between groups. Multivariable logistic regression for mortality was performed that included all variables significant at P ≤ .2 in univariate analyses. RESULTS: A total of 2045 adult patients with BTAI were identified, of whom 534 (26%) underwent TEVAR. Patients with missing data on TEVAR timing were excluded (n = 27), leaving a total of 507 patients for analysis (75% male; 69% white; median age, 40 years [interquartile range, 27-56 years]; median Injury Severity Score [ISS], 34 [interquartile range, 26-41]). Of these, 378 patients underwent early TEVAR and 129 underwent delayed TEVAR. The two groups were similar with regard to age, sex, race, ISS, and presenting physiology. Mortality was 11.9% in the early TEVAR group vs 5.4% in the delayed group, with the early group displaying a higher odds of death (odds ratio, 2.36; 95% confidence interval, 1.03-5.36; P = .042). After adjustment for age, ISS, and admission physiology, the association between early TEVAR and mortality was preserved (adjusted odds ratio, 2.39; 95% confidence interval, 1.01-5.67; P = .047). CONCLUSIONS: Consistent with current Society for Vascular Surgery recommendations, more BTAI patients underwent early TEVAR than delayed TEVAR during the study period. However, delayed TEVAR was associated with significantly reduced mortality in this population. Together, these findings support a need for critical appraisal and clarification of existing practice guidelines in management of BTAI. Future studies should seek to understand this survival disparity and to determine optimal selection of patients for early vs delayed TEVAR.

Endovascular treatment of penetrating arterial trauma with stent grafts.

BACKGROUND: The endovascular management of arterial injuries has resulted in reduced operating time, blood loss, hospital mortality, lower incidence of sepsis, and decrease in mortality rates. For penetrating trauma, however, the benefits of endovascular therapy are questionable. PATIENTS AND METHODS: Data were obtained by retrospective analysis of electronic medical records. All patients with vascular trauma seeking care at our institution from January 2010 to December 2015 were reviewed. A total of 223 vascular trauma patients were enrolled. Of these, 18 patients (8 %) were treated with endovascular techniques. The data related to clinical presentation, patient characteristics, technical aspects of the treatment, and follow-up were analysed. RESULTS: The mean patient age was 35.4 ± 17.8 years, 94 % were male. The mean injury severity score was 10.4 ± 2.5. The most commonly observed trauma mechanism was a gunshot in 10 cases (55 %), followed by lesions provoked by arterial catheter misplacement in five cases (27 %), and stab wounds in three cases (16.6 %). The main injury site was the subclavian artery, accounting for eight cases (44 %), followed by the superficial femoral artery and the tibiofibular trunk in two cases, respectively (18 %). The anterior tibial, fibular artery, axillary, common carotid, superior mesenteric, and profunda femoris were each affected once. Arteriovenous fistula was detected in nine cases (50 %), pseudoaneurysms in nine cases (50 %), and short occlusion in two cases (11 %). The mean follow-up duration was 753 days. The primary patency rate was 92.3 and 61.5 % after one and two years, respectively. The survival rate was 94.4 % after one and two years. Infection of the stents or limb amputations were not identified at follow-up. CONCLUSIONS: The endovascular treatment of penetrating arterial injuries with covered stents is feasible. However, the criteria used to choose the best method must be individualized.

Endovascular Treatment of Late Aortic Erosive Lesion by Pedicle Screw without Screw Removal: Case Report and Literature Review.

BACKGROUND: Aortic lesions are uncommon complications in spine surgery, but potentially fatal, because they can cause massive bleeding and hemodynamic instability. We report the endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal. METHODS: A breast cancer patient had a pathological fracture on T10, with spinal cord compression, and a pseudoaneurysm of the aorta in contact with an anterolateral pedicle screw. Endovascular surgery corrected the aortic lesion and allowed decompression, a week later, by posterior arthrodesis (T7-L1), with screw maintenance. RESULTS: There was no contrast leakage at thorax angiotomography in 2 years, and she died of meningeal carcinomatosis. CONCLUSION: Screw maintenance was safe in the endovascular treatment of aortic lesion by erosion.

Utilización de la ultrasonografía y aplicación del Doppler para la evaluación de ejes vasculares periféricos y la prevención del síndrome compartimental / Using ultrasonography and doppler application for evaluating vascular axes and prevention of compartmental syndrome

La ultrasonografía es un método de evaluación rápido y eficaz en los departamentos de emergencias, siempre en manos entrenadas. La lesión vascular periférica es un cuadro que en lo que trauma se refiere, debe tener un veloz diagnóstico y tratamiento por los riesgos que significa: En lesiones abiertas, la hemorragia; y en lesiones cerradas se añade el síndrome compartimental. Lograr la evaluación de la indemnidad o no del árbol vascular en los miembros, se torna importante a la hora de prevenir eventos que requieran intervención quirúrgica (reparación y/o fasciotomía). El objetivo de este trabajo consiste en demostrar la utilidad del conocimiento del árbol vascular periférico y su evaluación mediante doppler para el manejo del traumavascular periférico, utilizando listas de verificación para la evaluación sistemática de la vasculatura. Se realiza-ron evaluaciones sistemáticas a 10 residentes de cirugía general, utilizando primero modelos inanimados y animados y luego se evaluaron en situaciones de guardia, dividido en periodos (febrero/abril 2016 y mayo/agosto 2016). Se correlacionaron los hallazgos con lo estipulado en la lista de verificación previamente realizada y se estableció la relación posterior con el desarrollo del síndrome compartimental. Se evaluaron 185 modelos animados: 1era evaluación: Reconocimiento de estructuras >60 %= 6 residentes. >80 %= 4 residentes. 2da evaluación: Reconocimiento de estructuras >60 %= 3 residentes. >80 %= 7 residentes. En la atención del politraumatizado: reconocimiento de estructuras >60 %= 3 residentes. >80%= 7 residentes. Pacientes con riesgo de síndrome compartimental (n=77) = 11 (14,78 %). Resolución: lesión vascular = 1 (1,3 %) síndrome compartimental= 1 (1,3 %) con resolución quirúrgica. La utilización de la ultrasonografía y del doppler para la evaluación vascular periférica es útil para el reconocimiento precoz del riesgo a desarrollar desde una lesión vascular simple hasta un síndrome compartimental. La utilización de listas de verificación durante la simulación para la generación del criterio, son útiles en la formación de residentes de cirugía.

Ultrasonography is with adequate training, a fast and effective evaluation method in emergency departments. Peripheral vascular injury is frequent in trauma and should have a rapid diagnosis and treatment, as risks include: open sores, bleeding; closed injuries and compartmental syndrome. Prompt evaluation of the integrity in the vascular tree becomes important in preventing events that require surgical intervention (repair and / or fasciotomy). The aim of this work is to demonstrate the usefulness of knowledge of peripheral vascular tree, ultrasound evaluation and Doppler for peripheral vascular trauma management,using checklists for the systematic evaluation of the vasculature. Systematic evaluations were realized in 10general surgery residents. Initially, using inanimate and animate models which were then evaluated intrauma situations. Divided into periods (February / April 2016 ­ May/August 2016). The findings with previouscriteria made the verification list and subsequent connection with the development of compartment syndromethat were established by correlation. Evaluation animated models: 1st assessment: Recognition of structures>60 % =6 residents. > 80 % =4 residents. The 2nd assessment: Recognition of structures > 60 % = 3residents. > 80 % = 7 residents. In the care of multiple trauma: recognition structures > 60% =3 residents.>80 % =7 residents. Patients at risk for compartmental syndrome (n=77)=11 (14.78 %). Resolution:Vascular Lesion 1 (1.3 %) compartmental syndrome: 1 (1.3 %) with surgical resolution. The use of ultrasonography and Doppler for peripheral vascular evaluation is useful for early recognition of risk from developing a single vascular lesion, to compartmental syndrome. The use of the checklists during simulation for the generation of criteria is useful in the training of surgical residents

Diagnostic performance of CT angiography in neck vessel trauma: systematic review and meta-analysis.

This study was conducted in order to define the diagnostic performance of CT angiography for vascular injuries compared with angiography in patients with neck trauma. CT angiography is the cornerstone of diagnosis for hemodynamically stable patients with wounds suspicious of vascular trauma in the limbs, chest, or abdomen. Available evidence for the use of CT angiography in neck vascular trauma comes from small case series and few randomized controlled trials, and high-quality information does not exist regarding its performance. A protocol using the recommendations of the Cochrane Collaboration was designed. A systematic search of diagnostic studies without limits on language or time was carried out to December 2014. Studies including patients with neck trauma with retrospective or prospective data collection that assessed CT angiography compared with other methods were selected. Methodological quality was assessed using the QUADAS-2 tool. A hierarchical model ROC curve and a bivariate random effects model were used for the pooled analysis. Sixteen studies were selected and reviewed, and nine studies with 693 patients were included in this review. The overall sensitivity was 97 % (95 % CI 0.77-1.00; I (2) = 65.7 % (41.4-90.0)), while the overall specificity was 99 % (95 % CI 0.93-1.00; I (2) = 0). The hierarchic ROC curve showed an area under the curve of 0.99. Publication bias was not identified in this study. CT angiography can be stated as the gold standard for diagnosing vascular injuries in hemodynamically stable patients with neck trauma.

Aortic iatrogenic perforation during transseptal puncture and successful occlusion with Amplatzer ductal occluder in a case of mitral paravalvular leak closure.

Complications of transseptal puncture are significant and potentially life threatening. Aortic perforation is one of these complications and it needs to be repaired immediately. We report the case of a 48-year-old female with a history of rheumatic mitral valve disease. She underwent three previous mitral valve replacements. Her last echocardiogram reported an anterolateral leak in the mitral prosthesis. Catheterization was performed. During the procedure, when attempting to perform transseptal puncture, catheterization was complicated by a forcefully puncture of the aortic root by the Brockenbrough needle followed by an immediately advancement of an 8-Fr Mullins sheath. We decided to leave the 8-Fr sheath in the aortic root recognizing the danger of removing the sheath and finally we advanced a 6/4 mm Amplatzer ductal occluder (ADO I) through the Mullins sheath and under fluoroscopy and TEE guidance we achieved a successful deployment of the device and closure of the perforation. Subsequently, the paravalvular leak was closed with an Amplatzer Vascular Plug (AVP III 10/5 mm). There are only three cases of a similar technique for the same injury in which the authors describe successful closing of aortic perforation with percutaneous closure devices. Our case is the first described during a mitral paravalvular leak closure. It is also the first to describe a different technique of leaving the Mullins sheath in the aortic root and advancing the Amplatzer device through it to achieve successful closure of the aortic perforation. We preferred the percutaneous closure over open-heart repair. © 2015 Wiley Periodicals, Inc.

Application of 64-slice spiral computed tomography angiography in extremity vascular injuries.

The objective of the current study was to assess the utility of 64-row helical computed tomography angiography (CTA) in the evaluation of extremity vascular traumas. The extremities from 17 clinical cases of suspected traumatic vascular damage were evaluated using 64-row helical CTA. To evaluate extremity vascular traumas using CTA, volume rendering, multiple planar reconstruction, and curved planar reconstruction technology were applied to accurately and rapidly indicate the type and extent of blood vessel damage, as well as any relationship with injuries to adjacent bones, joints, soft tissue swelling, or hematomas. The types of extremity vascular traumas evaluated included damaged arteries, artery spasms or block, blood vessels shifted because of pressure, pseudo aneurysms, arteriovenous fistula, and vein occlusion. The results of the study indicated that 64-row helical CTA could be highly efficient and accurate in the evaluation of extremity vascular traumas, and could aid in making clinical assessments.

[Efficacy of multidetector computed angiotomography in the diagnosis of limb arterial injuries]. / Eficacia de la angiotomografía con multidetectores en el diagnóstico del trauma arterial de extremidades.

OBJECTIVE: To determine the diagnostic usefulness of multidetector computed angiotomography in the diagnosis limb arterial injuries in patients with suspicion of arterial injury with no indication of immediate surgery. METHODS: Non-invasive 64-channel multidetector computed tomography (MDCT) was performed on 99 limbs suspected of having a traumatic vascular injury over a 44-month period between August 2004 and April 2008. The results were interpreted by the duty radiologist and his findings were compared with those from surgery or clinical follow-up. Inter-observer variability was evaluated by comparing the reading of the MDCT by the duty radiologists with the retrospective reading by radiology specialist in trauma. RESULTS: MDCT as a diagnostic method of vascular injury of the limbs, interpreted by a general radiologist showed a sensitivity of 98% (95% CI: 93-100), a specificity of 88% (5% CI: 77-99), a positive predictive value of 91% (95% CI: 82-99), a negative predictive value of 97% (95% CI: 90-100), a positive likelihood radio of 8.24 (3.6-18.7), and a negative likelihood radio of 0.02 (0-0.15). The inter-observer variability by comparing the interpretation of the MDCT by the duty radiologist with that of the radiology specialist in trauma had a kappa of 0.869. CONCLUSION: Multidetector computed angiotomography is a high precision diagnostic imaging method in arterial injury of the limbs, offering a suitable and appropriate therapeutic approach, and could be considered as new gold standard for the diagnosis of arterial injuries of the limbs.

Endovascular treatment of late aortic perforation due to vena cava filter.

Perforation of inferior vena cava (IVC) by filter struts ranges from 9% to 24%, and clinical sequelae and complications are unpredictable. The aim of this article was to report an unusual case of late complication of IVC filter that caused an IVC wall perforation and penetration of the filter's hooks in the aorta, which was treated by endovascular procedure. Molding strut tip by balloon angioplasty, its accommodation with a bare stent, and its coverage and protection with an endoprosthesis is probably the first technique reported so far in this situation.

Endovascular repair of a traumatic arteriovenous fistula involving the iliac bifurcation using an iliac branch device.

Endovascular techniques have shown to be useful in the management of vascular injuries because they transform a complex and potentially dangerous procedure into a safe one. We present the case of a 39-year-old man with congestive heart failure and abdominal bruit 11 years after an abdominal gunshot wound. Imaging studies revealed an arteriovenous fistula involving the left iliac artery bifurcation, and an iliac branch device was used to treat it. Symptoms resolved, and follow-up imaging showed patency of the graft and closure of the arteriovenous communication. To our knowledge, this is the first report of a nonaneurysmal disease treated with this device.

Subclavian crush syndrome: a cause of pacemaker lead fracture.

A 48-year-old male with a symptomatic 2:1 atrio-ventricular block and a dual-chamber pacemaker, implanted one year previously, was admitted due to a syncopal episode. Pacemaker malfunction was identified as the cause of syncope. Subclavian crush syndrome was the cause of the pacemaker malfunction. Its incidence, consequences and management are discussed in this report.

Endovascular treatment of penetrating traumatic injuries of the extracranial carotid artery.

PURPOSE: To describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the extracranial carotid artery. MATERIALS AND METHODS: The clinical and angiographic features of 36 traumatic injuries of the carotid artery during a 12-year period were reviewed. There were 35 male patients (97.2%) and 1 female patient (2.8%) with an average age of 28.8 years (range 13-60 years). Of the 36 lesions of the carotid artery, 29 (80.6%) were the result of gunshot injury, and 7 (19.4%) were secondary to stab wounds. In 24 (66.7%) instances, the injury resulted in a pseudoaneurysm; in 7 (19.4%), in an arteriovenous fistula (AVF); in 4 (11.1%), in a dissection; and in 1 (2.8%), in inactive bleeding. All patients were treated with an endovascular approach using different techniques (balloon occlusion, embolization, or stent deployment). RESULTS: Endovascular therapy resulted in documented lesion occlusion in 34 (94.4%) patients. Two patients declined any follow-up postprocedural imaging; however, they have remained asymptomatic. Clinical improvement was documented in 35 (97.2%) patients, and there was one procedure-related complication with fatal consequences. CONCLUSIONS: In this series, endovascular techniques were an effective method of treatment. It was possible to use different endovascular reconstructive techniques or parent artery occlusion depending on the degree of vessel damage, with resolution of clinical symptoms and avoidance of surgery in most cases.