Successful management of traumatic false

Transcription

1 CASE REPORT Successful management of traumatic false aneurysm of the extracranial vertebral artery by duplex-directed manual occlusion: A case report Richard L. Feinberg, MD, Kathryn Sorrell, BSN, RVT, Jock R. Wheeler, MD, Roger T. Gregory, MD, Stanley O. Snyder, Jr., MD, Robert G. Gayle, MD, and F. Noel Parent III, MD, Bethesda, Arid., and Norfolk, Va. A 32-year-old man was transferred to our hospital after a 2.0 by 2.5 cm traumatic false aneurysm of the distal extracranial vertebral artery was noted after a stab wound of the posterior side of the neck. To obviate the need for operative exposure of the distal vertebral artery at the base of the skull, we elected to perform duplex-directed manual occlusion of the lesion. Angiography before and after the procedure, as well as 10-month follow-up duplex ultrasonography, demonstrated satisfactory thrombosis of the false aneurysm without evidence of a residual arterial defect. There was no morbidity associated with the procedure. We conclude that duplex-directed manual occlusion, a new technique recently described for the nonoperative management of postcatheterization femoral false aneurysms, can be applied safely and effectively to false aneurysms in other locations in which the risks and technical difficulties of operative repair render surgery less desirable. (J VAse SURG 1993;18: ) Compared with its larger counterpart, the carotid artery, the extracranial vertebral artery (VA) is relatively infrequently affected by cervical trauma, in large part because of its protected location within the deep planes of the neck. Nevertheless, as a result of the widespread use of four-vessel angiography in the evaluation of both blunt and penetrating neck trauma, injury to the VA is now being increasingly recognized. Trauma to the extracranial VA may result in thrombosis, hemorrhage, arteriovenous fistula, or, less commonly, pseudoaneurysm. The traditionally accepted standard of management for posttraumatic false aneurysm of the extracranial VA has been direct surgical repair;"7 however, the difficulty of obtaining adequate surgical exposure, particularly when the From the Department of Surgery, Division of Vascular Surgery, Eastern Virginia Graduate School of Medicine, Norfolk. Reprint requests: Joe& R. Wheeler, MD, 250 W. Brambleton Ave., Norfolk, VA Copyright 1993 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter /93/$ /4/44845 distal portion of the vessel is involved, has often resulted in suboptimal results and a consequent lack of enthusiasm for operative repair of such lesions. At our institution we have successfully performed duplex-directed manual occlusion (DDMO) of selected false aneurysms resulting from femoral catheterization. We now present the case of a posttraumatic false aneurysm of the distal portion of the third segment of the extracranial vertebral artery successfully treated by DDMO, with satisfactory results on long-term follow-up. CASE REPORT A 32-year-old white man was admitted to a local community hospital after sustaining a stab wound to the left posterolateral side of the neck. Initial evaluation, consisting of local wound exploration by the emergencydepartment physician, revealed bright red bleeding from within the depths of the wound that seemed to abate after the placement of several muscular mass-ligation sutures. The wound was then closed over a Penrose drain and the patient was admitted for overnight observation. Fourvessel cervical arteriography, performed the following morning, demonstrated a 2.0 by 2.5 cm pseudoaneurysm 889

2 890 Feinberg et al. November 1993 Fig. 1. Digital subtraction angiogram, lateral view, right vertebral artery, demonstrates false aneurysm projecting posteriorly near base of skull. of the third portion of the extracranial right VA (Fig. 1), and the patient was immediately transferred to our institution for further evaluation and treatment. On initial evaluation at our hospital, the patient appeared to be a healthy young male in no acute distress who was alert and cooperative and fully oriented. Blood pressure was 130/60 mm Hg, and the heart rate was 70 beats/min and regular. There was a freshly sutured posterior neck wound to the left of midline at the level of the spinous process of the third cervical vertebra. A Penrose drain remained in place, and there was no bleeding and no palpable mass. The neurologic examination result was completely normal, including test results of cranial nerve function. Review of the angiograms accompanying the patient confirmed the presence of a 2.0 by 2.5 cm traumatic aneurysm of the distal portion of the extracranial right VA, with the point of arterial injury identified as the vertical portion of the third segment of the artery, adjacent to the lateral mass Of the first cervical vertebra, as it begins its posteromedial ascent toward the base of the skull (Fig. 1). The left VA was patent throughout its extracranial and intracranial course, with excellent cross-filling demonstrated through the basilar artery. Because of the absence of neurologic symptoms and the patient's stable hemodynamic state, a color-flow duplex scan of the distal VA was performed (ATL Ultramark 9) (Advanced Technology Laboratories, Bothell, Wash.). Color-flow imaging readily identified the pseudoaneurysm with its characteristic swirling to-and-fro pattern of blood flow, s and the point of origin of the neck of the pseudoaneurysm from the distal VA (Fig. 2). With steady manual compression with the ultrasound probe applied directly over its neck, the pseudoaneurysm was occluded and thrombosed under real-time duplex visualization (Fig. 3), by a technique that we have used successfully in the treatment of postcatheterization femoral false aneurysms and have reported previously. 9 After DDMO of the vertebral pseudoaneurysm, the patient was hospitalized for an additional 24 hours during which he remained free of neurologic deficits. Before discharge, repeat duplex scanning and vertebral arteriography were performed. These studies confirmed both thrombosis of the pseudoaneurysm and maintenance of VA patency, while demonstrating the presence of a small residual defect at the site of the arterial injury (Fig. 4). At 10-month follow-up, the patient remains free of symptoms, and repeat color-flow duplex scan (Fig. 5) reveals a completely normal distal VA with no residual evidence of the previous intimal injury.

3 JOURNAL OF VASCULAR SURGERY Volume 18, Number 5 Feinberg et al. 891 Fig. 2. Color-flow duplex image, sagittal view, of distal right vertebral artery demonstrates neck of false aneurysm. Fig. 3. Color-flow image of distal right vertebral artery after successful manual occlusion. Note absence of flow within thrombosed false aneurysm cavity. DISCUSSION Injury to the extracranial VA has long been considered an exceedingly rare sequela of cervical trauma. A review of the cumulative U.S. military experience with arterial trauma during World Wars I and II, as well as the Korean and Vietnam conflicts, revealed that VA injuries constituted only 0.2% ofau arterial injuries.1 As a consequence of the rarity with

4 892 Feinberg et al. November 1993 Fig. 4. Follow-up selective right vertebral angiogram immediately after DDMO. Note small residual outpouching of contrast material at site of neck of thrombosed false aneurysm. which such injuries have been demonstrated, their true incidence has remained unknown and the natural history of such injuries has been incompletely documented. Pseudoaneurysm formation remains among the least frequent of the potential consequences of VA trauma, with VA thrombosis and arteriovenons fistulization constituting the bulk of such lesions in most recent reports. 2"3'1 12 As a result, the true natural history of traumatic vertebral aneurysm remains obscure, and the infrequent reports of such lesions betray a lack of consensus regarding strategies for, and appropriateness of, treatment. Recent trends favoring a more aggressive diagnostic approach to patients with cervical trauma, however, have led to an increased recognition of many vertebral injuries that had previously gone undetected. After the implementation of a protocol employing routine four-vessel cervical angiography in the evaluation of cervical trauma, Meier et al.~0 noted that the incidence of VA injuries increased from 3% to 19% of all cervical vascular injuries identified. At our institution we concur with such an approach and adhere to a routine policy of performing four-vessel cervical arteriography, with complete visualization of the extracranial course of both carotid and vertebral arteries, in the evaluation of penetrating neck trauma. In this patient the performance of complete four-vessel cervical arteriography before arrival at our hospital enabled the prompt detection of the pseudoaneurysm and provided important anatomic information regarding the status of the contralateral artery. In 1893, Matas, 4 as part of a larger review of vertebral trauma, presented a series of 20 traumatic aneurysms of the extracranial VA, carrying an overall mortality rate of 70%, including two deaths among four patients in whom operative repair was attempted. A European review collating the experience of several countries during World War I described 60 traumatic aneurysms of the extracranial VA, with a 57% mortality rate overall. 13 Based on the significant mortality rate associated with simple observation in these early reports, operative repair emerged as the widely accepted standard for the management of traumatic aneurysm of the extracranial VA, once identified. Heffetz s reported the successful treatment of a pseudoaneurysm of the first portion of the VA after a stab wotm_.d to the base of the neck by means of proximal

5 Volume 18, Number 5 Feinberg et al. 893 Fig. 5. Follow-up color-flow duplex image, 10 months after occlusion, demonstrates patency of right vertebral artery with no evidence of residual arterial wall defect. subclavian artery ligation and packing the interior of the aneurysm cavity. Pseudoaneurysm of the more distal portions of the extracranial VA, however, frequently presents a formidable technical challenge in terms of both operative approach and repair. Consequently, nonoperative alternatives such as coil, balloon, or gel embolization have been suggested for managing these lesions, although such techniques have had mixed results, and numerous complications have been reported. 2,3,6,1 Still others have elected to observe such aneurysms of the distal extracranial VA, preferring repeated angiographic follow-up studies to a potentially difficult operative endeavor.7,14 In one such report a traumatic vertebral aneurysm occurring as a result of a small-caliber gunshot wound of the neck was demonstrated to undergo progressive expansion during a 7-month observation period, eventually requiring delayed operative repair, with an occipital infarction as a consequence. 7 In the case we now report, the patient was seen at our institution more than 24 hours after injury and was hemodynamically stable, without evidence of hemorrhage or neurologic deficit. Angiography demonstrated patency of the contralateral VA that was continuous with the basilar artery, thus rendering unlikely the possibility ofischemic complications as a result of the eventual thrombosis of the injured VA from compression by the pseudoaneurysm. Never- theless, we felt compelled to attempt obliteration of this patient's lesion in view of the unpredictable incidence of serious complications that have been reported as a result of distal embolization and arteriovenous fistulization (a consequence of erosion of the aneurysm into the adjacent vertebral veins) 2,6,7,10,14 Because of the distal origin of this pseudoaneurysm from the extracranial VA near the base of the skull, and the anticipated technical difficulty of obtaining surgical control of the distal VA beyond the aneurysm to enable surgical reconstruction, we opted for a nonoperative approach as the initial strategy in this patient. Although an attempt at angiographic embolization was considered briefly, the technical difficulty of obtaining satisfactory angiographic control in lesions of the third portion of the artery (i.e., after the vessel has exited from the bony canal formed by the foramina of the transverse processes of the cervical vertebrae and begins its posteromedial course around the lateral mass of the first cervical vertebra) has been well documented. 2 As a result, we decided to perform a preliminary duplex ultrasonographic examination of the pseudoaneurysm with an eye toward attempting transcutaneous DDMO. This technique, which we and others have previously reported to be a safe and successful method for managing selected false aneurysms of the

6 894 Feinberg et al. November 1993 femoral artery, 9'is consists of manual compression of the neck of the pseudoaneurysm with the ultrasound probe during real-time color-flow visualization of both the aneurysm and its parent artery. In this manner the pressure exerted by the manually controlled probe can be continually readjusted so as to achieve complete cessation of blood flow within the aneurysm (and ultimately thrombosis) while maintaining continuous antegrade flow through the parent artery. Although the application of this technique to the vertebrobasilar circulation raises theoretic concerns regarding the potential for inducing serious thromboembolic complications, the use of this technique in the case presented here resulted in immediate and complete thrombosis of the pseudoaneurysm with no patient discomfort, no sequelae, and no recurrence documented at follow-up to 10 months. We believe this to be the first and only report describing the successful application of DDMO to an aneurysm in a location other than the femoral artery. Similar to its demonstrated efficacy in selected femoral false aneurysms, DDMO offered an effective, completely noninvasive therapeutic option in this patient who would otherwise have faced the risks of either superselective catheterization and embolization or operative exposure of the distal VA at the base of the skull through a recently traumatized field. Although the precise applications, indications, and appropriate case selection criteria remain to be defined for this nascent technique, we believe that this case suggests the potential utility of DDMO as a noninvasive alternative for the management of a variety of pseudoaneurysms in which the potential risks or technical difficulties of surgical repair may render operation less desirable. REFERENCES 1. Rich NM, Spencer FC. Carotid and vertebral injuries. In: Vascular trauma. Philadelphia: WB Saunders, 1978: Goluecke P, Sclafani S, Phillips T, et al. Vertebral artery injury: diagnosis and management. J Trauma 1987;27: Frye RE. Penetrating and blunt vertebral trauma. In: Ernst CB, Stanley JC, eds. Current therapy in vascular surgery. Philadelphia: BC Decker, 1991: Matas R. Traumatisms and traumatic aneurysms of the vertebral artery and their surgical treatment, with a report of a cured case. Ann Surg 1893;18: Heifetz CJ. Traumatic aneurysm of the first portion of the left vertebral artery. Ann Surg 1945;122: Roper PR, Guinto FC, Wolma FJ. Posttraumatic vertebral artery aneurysm and arteriovenous fistula: a case report. Surgery 1984;96: Wiener I, Flye MW. Traumatic false aneurysm of the vertebral artery. J Trauma 1984;24: Wilkinson DL, Polak JF, Grassi CI, Whittemore AD, O'Leary DH. Pseudoaneurysm of the vertebral artery: appearance on color-flow Doppler sonography. AJR Am J Roentgenol 1988;151: Sorrell KA, Feinberg RL, Wheeler JR, et al. Color-flow duplex-directed manual occlusion of femoral false aneurysms. J VAsc Su~ 1993;17: Meier DE, Brink BE, Fry WJ. Vertebral artery trauma. Arch Surg 1981;116: Reid JD, Weigelt JA. Forty-three cases of vertebral artery trauma. J Trauma 1988;28: Buscaglia LC, Crowhurst HD. Vertebral artery trauma. Am 1 Surg 1979;138: Perrig H. Zur anatomie, klinik und therapie der vedetzungen und aneurysmen der arteria vertebralis. Beitr Klin Chir 1931;154: Davidson KC, Weiford EC, Dixon GD. Traumatic vertebral artery pseudoaneurysm following chiropractic manipulation. Radiology 1975;115: Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: non-surgical repair with US-guided compression. Radiology 1991;178: Submitted May 12, 1992; accepted Dec. 2, 1992.