EJVES Extra
Volume 15, Issue 4 , Pages 33-36, April 2008

Stenting in Zone II Stab Wounds of Carotid Arteries

  • T.B. Rangaka

      Affiliations

    • Department of General Surgery, University of Limpopo, Medunsa Campus, Pretoria, Gauteng, South Africa
    • Department of Radiology, University of Limpopo, Medunsa Campus, Pretoria, Gauteng, South Africa
    • Corresponding Author InformationCorresponding author. Dr. T.B. Rangaka, Department of Surgery, P O Box 231, Medunsa, Gauteng 0204, South Africa. Tel.: +27 12 5214153; fax: +27 12 5214467.
    • ,
  • M.C.M. Modiba

      Affiliations

    • Department of General Surgery, University of Limpopo, Medunsa Campus, Pretoria, Gauteng, South Africa
    • Department of Radiology, University of Limpopo, Medunsa Campus, Pretoria, Gauteng, South Africa
    • ,
  • A. Scheepers

      Affiliations

    • Department of Radiology, University of Limpopo, Medunsa Campus, Pretoria, Gauteng, South Africa

Received 24 July 2007; accepted 11 March 2008. published online 21 May 2008.

Article Outline

Abstract 

We present three cases of endovascular treatment of a cervical Zone II carotid artery pseudoaneurysm and arteriovenous fistulae following stab wounds using covered Wall-graft stents in three male patients. All three were clinically stable with no other associated aerodigestive injuries or neurological deficit. Angiography revealed pseudoaneurysms and arteriovenous fistulae. Under local anaesthesia, using Seldinger technique and femoral approach, a covered Wall graft stent (Boston Scientific) was inserted using the standard endovascular technique. No cerebral protective devices were used in our patients. Patients received aspirin before the procedure. Patients were discharged on aspirin 24 hours later. Patients were followed up with duplex ultra sound at 3, 6 and 9 months intervals, with good patency.

Keywords: Stenting, Stab wounds, Carotid arteries, Zone II

 

Back to Article Outline

Introduction 

Penetrating trauma to the carotid arteries accounts for more than 90% of all carotid injuries. Carotid injuries constitute 5–10% of all arterial injuries.1 These injuries are classified according to the level of injury. The neck is divided into 3 zones. Zone I refers to the area between the sternal notch and the cricoid cartilage – Zone II is the area between the cricoid and the angle of the mandible; Zone III refers to the area above the angle of the mandible.2, 3 It is accepted practice to image (angiography) injuries in Zone I and Zone III because of the difficulty in surgical exposure.2, 4, 5

It is also recommended that Zone II injuries be explored.4, 6, 7, 8, 9 The recommendation stems from the fact that the area is accessible and deemed to be safe. There is limited published experience in the stenting of stab wounds in Zone II.2 Most published experience in the literature on endovascular stenting of carotid injuries relates to Zone I and III.10 We present three male patients who were stabbed on the lateral aspect of the neck (Zone II) and treated successfully with endovascular stents for arteriovenous fistulae and pseudoaneurysms. All these patients were haemodynamically stable with no neurological deficit or aerodigestive injuries.

Back to Article Outline

Case 1 

A 21 year old male with a stab wound to the neck (Zone II). The patient was reported to have bled significantly at the scene which required a blood transfusion.

On physical examination the patient had a 2cm laceration on the left side of the neck Zone II that had already been sutured. He had no expanding haematoma but a palpable thrill. The laboratory values showed a haemoglobin of 7,4mmol/l (after 2 Units packed cells). The patient had no other organ injuries in the neck. Clinically, the patient had no tracheo-oesophageal injury. Gastrografin swallow showed no injury. The remainder of the examination was unremarkable with no neurological deficit. Given the stable haemodynamic status of the patient, an angiogram was done. This showed an arteriovenous fistula (carotid artery – jugular vein) Fig. 1.

Twenty hours later the patient was taken for endovascular stenting. Fig. 2 shows a post stent result.

Through the femoral approach, using a Seldinger technique, a 7mm covered Wall graft stent (Boston Scientific) was inserted without any complications. Heparin was used intravenously during the procedure, with clotting time monitored. No cerebral protective device was used during the procedure and no complications were noted. The patient was discharged 2 days later on aspirin. He was reviewed at 3, 6 and 9 months intervals and the duplex Dopplers done showed good patency.

Back to Article Outline

Case 2 

A 31 year old male was brought to the casualty department after being stabbed on the neck.

On physical examination he had a 2cm laceration on the lateral neck that had already been sutured. He had a non expanding haematoma on the injury site. The rest of the examination was unremarkable. Oesophageal injury was excluded clinically and radiologically. The laboratory values were normal. An angiogram was performed which demonstrated a pseudoaneurysm in the common carotid artery and an arteriovenous fistula Fig. 3.

The patient was later taken for endovascular stenting 24hrs later Fig. 4.

Through the femoral approach using the Seldinger technique, an 8mm covered Wall stent graft (Boston Scientific) was inserted using routine endovascular technique. There were no complications during the procedure. The patient was discharged 2 days later on aspirin. The patient was followed up to 9 months. The Duplex doppler done showed good patency and there was still no neurological deficit.

Back to Article Outline

Case 3 

A 25 year old male stabbed on the neck. The examination revealed a 2cm laceration on the lateral side of the neck Zone II, with a haematoma and a palpable thrill. An angiogram was performed which showed a pseudoaneurysm (Fig. 5A). Fig. 5B shows intact blood flow into the brain through the opposite carotid artery.

Endovascular stenting was done 48 hours later without any complications and the patient was discharged 24 hours later on aspirin. Fig. 6 shows the post stent angiogram. Follow-up at 3, 6 and 9 months intervals showed good patency on ultrasound.

Back to Article Outline

Discussion 

The most common cause of carotid injuries is penetrating trauma. Most of the patients are young males. The mortality and morbidity of these injuries remain high despite advances in diagnosis and treatment. Mortality for carotid injuries ranges from 10–31% with permanent neurological deficit ranging from 16–60%.2, 11 Injuries to Zones I and III pose a management difficulty because of limited access.12 With the advent of endovascular stenting, these injuries tend to be better managed avoiding extensive surgical dissections (with cranial nerve injuries) and long hospital stays.2, 13

Patients with active bleeding and a compromised airway require immediate exploration, while those who are haemodynamically stable and have a patent airway should undergo further investigation: ie. duplex Doppler and angiography.1, 2, 11 Duplex Doppler is recommended for Zone II injuries while angiography is better for Zone I and III injuries.4, 5

Ultrasound sensitivity in these injuries is reported to be 100%.3, 5, 14 Mandatory exploration of all penetrating neck injuries has been replaced by a selective approach in patients with soft signs.2 Soft signs of arterial injury are: history of severe bleeding, diminished distal pulse, injury of anatomically related structures, small non expanding haematoma, multiple fractures and extensive tissue injury and injury in anatomical areas of major blood vessels.

Mandatory exploration remains necessary in patients with hard signs of arterial injury: active pulsatile bleeding, shock with ongoing bleeding, absent distal pulses, symptoms and signs of acute ischaemia, expanding or pulsating haematoma and bruits or thrill over the area of injury.4

Management of carotid injuries in Zone II using endovascular techniques is controversial because it is accessible to open surgery.12 The controversy stems from the occurrence of possible complications such as distal embolism, in-stent stenosis and stent migration, stent breakage and endoleaks, and the fact that patients are young.1

It is known that stents have been used for many years in the treatment of patients with stenosis due to artherosclerosis even though these were older patients. The concern in its widespread usage was the cost and durability especially because patients are young. A study comparing endovascular stenting and open surgery in patients with penetrating vascular injuries in Johannesburg showed costs to favour endovascular treatment.15 This demonstrated increased complication rate in open surgery.

We did not have any immediate complications in the three patients who were treated with endovascular stents. Our patients did not have associated aerodigestive injuries which also supported the decision to stent. It seems that the problem of the vein was solved after stenting in our patient with an arteriovenous fistula. After nine months the vessels were still patent on ultrasound. Even though our sample was small, the results yield a promising and encouraging milestone in the treatment of these injuries. This is also supported by results from Schonholz et al.16

Although the open surgical approach is still the mainstay of therapeutic treatment, the study suggests that minimally invasive management with the utilization of endovascular techniques is a viable option in Zone II carotid injuries in selected patients.

Back to Article Outline

Acknowledgements 

A special thank you to Mrs M Howard and Mrs J C Ferreira for typing the manuscript.

Back to Article Outline

References 

  1. Van Marle J, Le Roux DA. Vascular trauma. In:  Beard Jonathan D,  Gaines Peter A editor. Vascular and endovascular surgery. 3rd ed.. Elsevier Saunders; 2006;p. 174–194
  2. Kumar SR, Weaver FA, Yellin AE. Cervical vascular injuries: carotid and jugular venous injuries. Surg Clin North Am. 2001;81:1331–1344
  3. Saletta JD, Lowe RJ, Lim LT, Thornton J, Delk S, Moss GS. Penetrating trauma of the neck. J Trauma. 1976;16:579–587
  4. Weaver FA, Yellin AE, Wagner WH, Brooks SH, Weaver AA, Milford MA. The role of arterial reconstruction in penetrating carotid injuries. Arch Surg. 1988;123:1106–1111
  5. Corr P, Abdool-Carrim AT, Robbs JV. Colour-flow ultrasound in the detection of penetrating vascular injuries of the neck. S Afr Med J. 1999;80:644–646
  6. Robbs JV. Basic principles in the surgical management of vascular trauma. In:  Greenlalgh RM editors. Vascular and endovascular technique. 4th ed.. London: W B Saunders; 2001;p. 455–465
  7. Robbs JV, Keanin J. Exploration of the neck. In:  Campion HR,  Robb JV,  Trunky D editor. Robbs and Smith's operative surgery. 4th ed.. London: Butterworths; 1989;p. 166–172
  8. Kuehne JP, Waever FA, Papanicolao N, Yellin AE. Penetraint trauma of the internal carotid artery. Arch Surg. 1996;131:942–947
  9. Robbs JV, Human RR, Kajarutanam P, Duncan H, Vawda I, Baker LW. Neurologic deficit and injuries involving the neck arteries. Br J Surg. 1983;70:220–222
  10. Ul Haq T, Yaqoob J, Muner K, Usman MU. Endovascular-covered stent treatment of posttraumatic cervical artery pseudoaneurysms. Australas Radiol. 2004 June;48(2):220–223
  11. McKevitt EC, Kirkpatrick AW, Vertesi L, Granger R, Simons RK. Blunt vascular neck injuries: diagnosis and outcomes of external vessel injury. J Trauma. 2002;53:472–476
  12. Robbs JV. Penetrating injury to the blood vessels of the neck and mediastinum. In:  Brancereai A,  Jacobs M editor. Vascular emergencies. New York: Futura; 2003;p. 39–48
  13. Montalvo BM, LeBlang SD, Nunes DB, Ginzburg E, Klose KJ, Bocerra JL, et al. Color Doppler sonography in penetrating injuries of the neck. AJNR Am J Neuroradiol. 1996;17:943–951
  14. Fry WR, Dot JA, Smith RS, Sayers DV, Morabito DJ. Duplex scanning replaces arteriography and operative exploration in the diagnosis of potential cervical vascular injury. Am J Surg. 1994;168:693–695
  15. Pillai J, Carrim ATO, Britz R, Cluver MDV, Candy G, Veller MG. Johannesburg Hospital, University of the Witwatersrand, South Africa, Presented at VASSA 2006.
  16. Schonholz C, Parodi JC, Uflacker R, Hannegan C, Selby B, Uflacker A. Clinical experience with the treatment of carotrid artery lesions with stent-graft. Vascular (Canada). 2006;14(3):23–29

PII: S1533-3167(08)00006-X

doi:10.1016/j.ejvsextra.2008.03.002

EJVES Extra
Volume 15, Issue 4 , Pages 33-36, April 2008

Article Tools

* Image Usage & Resolution