Cardiovascular Intervention and Therapeutics | 2021
Viabahn stent graft in the treatment of traumatic axillary artery pseudoaneurysm
Abstract
Proximal humeral fractures account for approximately 5% of all fractures, but pseudoaneurysm formation after arterial injuries associated with such fractures is rare. Some previous studies have reported the usefulness of stent graft in the treatment of arterial injuries [1, 2]. The patient was an 89-year-old woman diagnosed with a left proximal humeral fracture after falling into an irrigation canal; the patient was followed under conservative treatment based on her preference. She was referred to our hospital with complaints of pain and swelling in her left shoulder during rehabilitation in a local hospital. Computed tomography (CT) revealed a large pseudoaneurysm (72 × 100 mm) in the left axillary artery (Fig. 1A). Due to the accompanying pain, she was diagnosed with impending pseudoaneurysm rupture and underwent early treatment. In consideration of the need for early therapy, the treatment strategy included surgical revascularization and repair of the fracture that had caused the axillary artery injury; however, the level of activities of daily living based on the Clinical Frailty Scale was 7–8. As emergency therapy, we considered a less invasive approach was endovascular treatment. Not coil embolization and thrombin infusion, stent grafting was chosen because of the large diameters of the pseudoaneurysm and the entry site in the present case. A 7-Fr sheath was inserted in the brachial artery under local anesthesia, and a pigtail catheter was inserted near the pseudoaneurysm to determine the overall features of the vessels (Fig. 1E). Intravascular ultrasound (IVUS) was performed to measure the vessel diameter and identify the entry site into the pseudoaneurysm using the IVUS marking technique. The lumen diameter of the proximal and distal vessel reference diameter was 7.3 mm and 4.6 mm (Fig. 1C). We considered this case was an exceptional case without other treatment. Although oversizing is the potential risk of geometric mismatch, Viabahn stent graft (8 × 25 mm W. L. Gore & Associates) was placed in a position that covered the entry site with an emphasis on the proximal landing zone. Confirmatory IVUS demonstrated no signs of infolding and dissection (Fig. 1D). Finally, the absence of endoleak in the pseudoaneurysm was confirmed by angiography. The TOMETA KUN compression system (Zeon Medical, Tokyo, Japan) was used for hemostasis. The patient’s pain improved the day following the endovascular treatment. She was discharged on dual antiplatelet therapy. One month after endovascular treatment, contrast-enhanced CT performed at the outpatient clinic confirmed the absence of endoleak in the pseudoaneurysm (Fig. 1B, F). The use of stent grafts in the treatment of axillary artery pseudoaneurysm could be less invasive and remarkably effective.