Carotid Blowout Syndrome: Endovascular Management of Acute Hemorrhage with Tapering Overlapped Covered Stents

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

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Abstract 016: Endovascular Management of Major Vascular Access Site Complications During Transcatheter Aortic Valve Implantation (TAVI).

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.016 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Muhammad U Majeed ◽

Kelly D Green ◽

Marat Fudim ◽

Mark A Robbins ◽

David X Zhao

Keyword(s):

Vascular Access ◽

Vascular Complications ◽

Covered Stents ◽

Endovascular Management ◽

Access Site ◽

Femoral Access ◽

Access Site Complication ◽

Small Series ◽

Significant Difference ◽

Endovascular Approach

Background: Major vascular access site complications remain a challenge in the field of TAVI and are associated with higher 30 day mortality. However, outcomes following endovascular management with covered stents for such complications are not well established. Methods: We reviewed the one year data of patients who underwent TAVI at our institution with a Sapien valve by percutaneous femoral approach. Identified were patients who suffered major vascular complications according to the definitions set forth by the Valve Academic Research Consortium. We then compared the outcome of patients managed by an endovascular approach with a population whose femoral access site complications were managed surgically/endovascularly (85.7% surgically), as reported from the Partner trial. Results: A total of 16 patients experienced Major Vascular complications. TAVI was aborted on 2 patients due to access site complication. Excluded were 3 patients who had benign small ascending aortic dissections after successful valve deployment and 3 patients who were managed surgically. Ten remaining patients were managed by a pure endovascular approach with covered stents. Four of these patients suffered ilio-femoral dissection, 4 had perforation and 2 had both perforation and dissection. No significant difference was observed in pre and post procedure creatinine (1.01 vs 1.14, p=0.16) and none required dialysis within 30 days, as compared with 8.1% in Partner trial. We observed no statistically significant difference between the Partner trial cohort and our patients in 30 day all cause mortality (14.1% vs 10%, p=1), stroke rate (4.8% vs 0%, p=1), access site hematoma (22.9% vs 0%, p=0.1), retroperitoneal bleed (9.5% vs 0%, p=0.6), pseudoaneurysm (3.4% vs 0%, p=1), and gastrointestinal ischemia (1.6% vs 0%). No access site infection, stent thrombosis, or stenosis leading to limb ischemia were noted clinically at 30 day follow-up. Conclusion: Many patients with major vascular complications during TAVI can be treated with a pure endovascular approach. In our small series we observed no difference in concurrent complications when an endovascular repair can be rapidly initiated as compared to a primary surgical approach.

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Endovascular Management of Unusual Aneurysms of the Axillary and Subclavian Arteries

Journal of Endovascular Therapy ◽

10.1177/152660289600300406 ◽

1996 ◽

Vol 3 (4) ◽

pp. 389-395 ◽

Cited By ~ 6

Author(s):

Timothy M. Sullivan ◽

J. Michael Bacharach ◽

John Perl ◽

Bruce Gray

Keyword(s):

Upper Extremity ◽

Advanced Cancer ◽

Surgical Techniques ◽

Covered Stents ◽

Endovascular Management ◽

The Third ◽

Operative Repair ◽

Brachial Vein ◽

Palmaz Stents

Purpose: Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents. Methods and Results: Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months. Conclusions: Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.

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