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Number 12
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2013
used bare stents. We chose the EXCLUDER iliac stentgraft (W.L. Gore and Associates) in both cases because of its availability and because it has proven to have low permeability when used in abdominal aortic aneurysm repair. The graft provided an effective seal across the perforation, with creation of a new intact flow lumen. In conclusion, the use of covered stents for treatment of traumatic venous injuries provided a safe and effective way to address the acute extravasation. It may prove to be a first-line approach in this setting to maintain vessel patency and avoid iatrogenic complications.
Iatrogenic Type A Aortic Dissection: Conservative Treatment after Complicated Left Subclavian Artery Recanalization From: Anna M.H. Sailer, MD Vincent G.A. van Ommen, MD Jan H. Tordoir, MD, PhD Geert Willem H. Schurink, MD, PhD Willem H. van Zwam, MD, PhD Departments of Radiology (A.M.H.S., W.H.v.Z.), Cardiology (V.G.A.v.O.), and Surgery (J.H.T., G.W.H.S.) Maastricht University Medical Centre P. Debyelaan 25 6229 HX Maastricht, The Netherlands
1923
REFERENCES 1. Qi Y, Gillespie DL. Venous trauma: new lessons and old debates. Perspect Vasc Surg Endovasc Ther 2011; 23:74–79. 2. Dale J, Dolmatch B, Duch J, et al. Expanded polytetrafluoroethylene– covered stent treatment of angioplasty-related extravasation during hemodialysis access intervention: technical and 180-day patency. J Vasc Interv Radiol 2010; 21:322–326. 3. Ko SF, Ng SH, Fang FM, et al. Left brachiocephalic vein perforation: computed tomographic features and treatment considerations. Am J Emerg Med 2007; 25:1051–1056. 4. Avery LE, Stahlfeld KR, Corcos AC, et al. Evolving role of endovascular techniques for traumatic vascular injury: a changing landscape? J Trauma Acute Care Surg 2012; 72:41–46. 5. Zieber SR, Mustert BR, Knox MF, Fedeson BC. Endovascular repair of spontaneous or traumatic iliac vein rupture. J Vasc Interv Radiol 2004; 15: 853–856.
Vascular access was achieved with a 5-F sheath introduced into the right common femoral artery. Aortography showed a normal ascending aorta and confirmed the CT angiographic diagnosis of ostial LSA occlusion (Fig 1). As antegrade recanalization of the LSA was not successful, a 4-F sheath was introduced into the left brachial artery, and retrograde recanalization with a soft 0.035-inch hydrophilic guide wire (Terumo, Somerset, New Jersey) was performed. During retrograde recanalization, the guide wire and catheter came into a subintimal position in the ascending aorta. No connection with the true lumen was achieved. Contrast medium injection through the transbrachial catheter showed a type A dissection with subintimal deposition of contrast
Editor: Iatrogenic aortic dissections account for 5% of aortic dissections, with type A dissections being the most common (1). During thoracic endovascular aortic repair, retrograde type A dissections occur in 2% of procedures (1,2). The decision how to manage this potentially lethal complication can be difficult. We report a case of a 72-year-old woman with progressive claudication of her left arm and previous history of hypertension who was seen at our hospital’s vascular outpatient clinic. She presented with pain in the left arm during exercise and numbness and cramping of her fingers. No vertigo or other symptoms of subclavian steal syndrome were present. Diagnostic computed tomographic (CT) angiography showed an ostial occlusion of the left subclavian artery (LSA) 25 mm in length, whereas the other aortic arch branches were patent. There was an anatomic variant with the left vertebral artery (LVA) arising directly from the aorta, explaining the absence of subclavian steal symptoms. The patient was scheduled for endovascular recanalization of the LSA occlusion.
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.08.001
Figure 1. Aortography shows proximal LSA occlusion (black arrow) and a patent LVA (white arrow) arising directly from the aorta.
1924
’
Letters to the Editor
Sailer et al
’
JVIR
Figure 4. Axial view of first control CT angiogram after the intervention confirms type A aortic dissection. Contrast medium is visible in the false lumen at the outer border of the ascending aorta (arrow).
Figure 2. Contrast medium injection via the transbrachial catheter (black arrow) shows subintimal contrast stain (white arrow) and subintimal position of the catheter tip (black arrowhead) in the ascending aorta. Transfemoral catheter is visible in the true aortic lumen (white arrowhead).
Figure 5. Coronal view of second control CT angiogram shows shrinkage of the false lumen (black arrow) and patent LVA (white arrow). Figure 3. Aortography via the transfemoral catheter (white arrow) shows an occluded LVA (black arrow). Transbrachial catheter is visible in the occluded LSA (black arrowhead).
medium as well as proximal occlusion of the LVA (Fig 2). There was normal flow of contrast medium in the true aortic lumen, brachiocephalic trunk, and left common carotid artery (Fig 3). The patient was in
stable cardiovascular condition and was transferred to the medium care unit for further observation. No dyspnea, thoracic pain, or neurologic symptoms were present. The patient had a normal electrocardiogram and regular heart rate of 62 beats per minute. Blood pressure was 152/72 mm Hg, and control with labetalol and irbesartan was initiated. No cardiac tamponade or aortic valve regurgitation were found on
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2013
Figure 6. Third control CT angiogram 2 months after the intervention shows a healed ascending aorta. The proximal LSA occlusion is still visible (arrow).
echocardiography. The first follow-up CT angiogram 3 hours after the intervention showed an unchanged type A aortic dissection and LVA occlusion (Fig 4). There was no extension of the dissection to the coronary arteries, no significant compression of the true aortic lumen, and no pericardial effusion. A second follow-up scan 3 days after the intervention showed regression of the false lumen and an open LVA with antegrade flow (Fig 5). There was no connection between the true and the false lumen. A third follow-up CT angiogram after 2 months showed a normal ascending aorta and open supraaortic vessels except the proximal LSA occlusion (Fig 6). At an outpatient clinic visit 6 months after the intervention, the patient reported no symptoms besides the preexisting claudication. The aortic dissection injury
Biliary Cardiac Tamponade as a Result of Iatrogenic Biliary-Pericardial Fistula From: Andrew M. Surman, BS Miles B. Conrad, MD, MPH Christopher F. Barnett, MD, MPH John S. MacGregor, MD, PhD Sujal Nanavati, MD Mark W. Wilson, MD Department of Radiology and Biomedical Imaging (M.B.C., S.N., M.W.W.)
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.08.003
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and LVA occlusion had resolved spontaneously and uneventfully. The patient in the present case was in stable cardiovascular condition after the dissection. No cardiac complications were present that would have indicated immediate intervention. As the patient had a patent right vertebral artery, no cerebrovascular ischemia had occurred. In a similar reported case, Tochii et al (3) performed subacute aortic arch replacement to avert potential risk of fatal complications. This is in line with common recommendations for surgical ascending aorta and arch graft replacement after retrograde iatrogenic type A aortic dissection (4). We decided to refrain from surgical repair and treated the patient conservatively. Our decision was based on the consideration that there was only retrograde poststenotic flow and no direct aortic blood pressure feeding the false lumen originating from the LSA. We therefore did not expect further expansion of the false lumen, nor development of cardiac complications. Follow-up CT angiograms confirmed our hypothesis, showing shrinkage and complete healing of the aortic dissection. As the present case shows, for evaluation of treatment after iatrogenic type A aortic dissection, precise analysis of the blood supply to the false lumen can help in making the proper therapeutic decision.
REFERENCES 1. Jonker FHW, Schlosser FJV, Indes JE, et al. Management of type A aortic dissections: a meta-analysis of the literature. Ann Thorac Surg 2010; 89:2061–2066. 2. Langer S, Mommertz G, Koeppel TA, Schurink GW, Autschbach R, Jacobs MJ. Surgical correction of failed thoracic endovascular aortic repair. J Vasc Surg 2008; 47:1195–1202. 3. Tochii M, Ando M, Takagi Y, et al. Iatrogenic type A aortic dissection after catheter intervention for the left subclavian artery. Ann Thorac Cardiovasc Surg 2010; 16:451–453. 4. Piffaretti G, Mariscalco G, Tozzi M, Bruno VD, Sala A, Castelli C. Acute iatrogenic type A aortic dissection following thoracic aortic endografting. J Vasc Surg 2010; 51:993–999.
Department of Medicine, Division of Cardiology (C.F.B., J.S.M.) School of Medicine (A.M.S.) University of California, San Francisco 505 Parnassus Avenue San Francisco, CA 94122
Editor: Puncture of a nontarget organ during percutaneous liver biopsy is a rare complication (1). We present a case of pericardial injury during image-guided biopsy of a caudate lobe mass complicated by hemopericardium. The importance of considering biliary dilatation during pericardial drain placement is supported by the following report of a biliary-pericardial fistula. This rare
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Number 12
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December
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2013
used bare stents. We chose the EXCLUDER iliac stentgraft (W.L. Gore and Associates) in both cases because of its availability and because it has proven to have low permeability when used in abdominal aortic aneurysm repair. The graft provided an effective seal across the perforation, with creation of a new intact flow lumen. In conclusion, the use of covered stents for treatment of traumatic venous injuries provided a safe and effective way to address the acute extravasation. It may prove to be a first-line approach in this setting to maintain vessel patency and avoid iatrogenic complications.
Iatrogenic Type A Aortic Dissection: Conservative Treatment after Complicated Left Subclavian Artery Recanalization From: Anna M.H. Sailer, MD Vincent G.A. van Ommen, MD Jan H. Tordoir, MD, PhD Geert Willem H. Schurink, MD, PhD Willem H. van Zwam, MD, PhD Departments of Radiology (A.M.H.S., W.H.v.Z.), Cardiology (V.G.A.v.O.), and Surgery (J.H.T., G.W.H.S.) Maastricht University Medical Centre P. Debyelaan 25 6229 HX Maastricht, The Netherlands
1923
REFERENCES 1. Qi Y, Gillespie DL. Venous trauma: new lessons and old debates. Perspect Vasc Surg Endovasc Ther 2011; 23:74–79. 2. Dale J, Dolmatch B, Duch J, et al. Expanded polytetrafluoroethylene– covered stent treatment of angioplasty-related extravasation during hemodialysis access intervention: technical and 180-day patency. J Vasc Interv Radiol 2010; 21:322–326. 3. Ko SF, Ng SH, Fang FM, et al. Left brachiocephalic vein perforation: computed tomographic features and treatment considerations. Am J Emerg Med 2007; 25:1051–1056. 4. Avery LE, Stahlfeld KR, Corcos AC, et al. Evolving role of endovascular techniques for traumatic vascular injury: a changing landscape? J Trauma Acute Care Surg 2012; 72:41–46. 5. Zieber SR, Mustert BR, Knox MF, Fedeson BC. Endovascular repair of spontaneous or traumatic iliac vein rupture. J Vasc Interv Radiol 2004; 15: 853–856.
Vascular access was achieved with a 5-F sheath introduced into the right common femoral artery. Aortography showed a normal ascending aorta and confirmed the CT angiographic diagnosis of ostial LSA occlusion (Fig 1). As antegrade recanalization of the LSA was not successful, a 4-F sheath was introduced into the left brachial artery, and retrograde recanalization with a soft 0.035-inch hydrophilic guide wire (Terumo, Somerset, New Jersey) was performed. During retrograde recanalization, the guide wire and catheter came into a subintimal position in the ascending aorta. No connection with the true lumen was achieved. Contrast medium injection through the transbrachial catheter showed a type A dissection with subintimal deposition of contrast
Editor: Iatrogenic aortic dissections account for 5% of aortic dissections, with type A dissections being the most common (1). During thoracic endovascular aortic repair, retrograde type A dissections occur in 2% of procedures (1,2). The decision how to manage this potentially lethal complication can be difficult. We report a case of a 72-year-old woman with progressive claudication of her left arm and previous history of hypertension who was seen at our hospital’s vascular outpatient clinic. She presented with pain in the left arm during exercise and numbness and cramping of her fingers. No vertigo or other symptoms of subclavian steal syndrome were present. Diagnostic computed tomographic (CT) angiography showed an ostial occlusion of the left subclavian artery (LSA) 25 mm in length, whereas the other aortic arch branches were patent. There was an anatomic variant with the left vertebral artery (LVA) arising directly from the aorta, explaining the absence of subclavian steal symptoms. The patient was scheduled for endovascular recanalization of the LSA occlusion.
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.08.001
Figure 1. Aortography shows proximal LSA occlusion (black arrow) and a patent LVA (white arrow) arising directly from the aorta.
1924
’
Letters to the Editor
Sailer et al
’
JVIR
Figure 4. Axial view of first control CT angiogram after the intervention confirms type A aortic dissection. Contrast medium is visible in the false lumen at the outer border of the ascending aorta (arrow).
Figure 2. Contrast medium injection via the transbrachial catheter (black arrow) shows subintimal contrast stain (white arrow) and subintimal position of the catheter tip (black arrowhead) in the ascending aorta. Transfemoral catheter is visible in the true aortic lumen (white arrowhead).
Figure 5. Coronal view of second control CT angiogram shows shrinkage of the false lumen (black arrow) and patent LVA (white arrow). Figure 3. Aortography via the transfemoral catheter (white arrow) shows an occluded LVA (black arrow). Transbrachial catheter is visible in the occluded LSA (black arrowhead).
medium as well as proximal occlusion of the LVA (Fig 2). There was normal flow of contrast medium in the true aortic lumen, brachiocephalic trunk, and left common carotid artery (Fig 3). The patient was in
stable cardiovascular condition and was transferred to the medium care unit for further observation. No dyspnea, thoracic pain, or neurologic symptoms were present. The patient had a normal electrocardiogram and regular heart rate of 62 beats per minute. Blood pressure was 152/72 mm Hg, and control with labetalol and irbesartan was initiated. No cardiac tamponade or aortic valve regurgitation were found on
Volume 24
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Number 12
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December
’
2013
Figure 6. Third control CT angiogram 2 months after the intervention shows a healed ascending aorta. The proximal LSA occlusion is still visible (arrow).
echocardiography. The first follow-up CT angiogram 3 hours after the intervention showed an unchanged type A aortic dissection and LVA occlusion (Fig 4). There was no extension of the dissection to the coronary arteries, no significant compression of the true aortic lumen, and no pericardial effusion. A second follow-up scan 3 days after the intervention showed regression of the false lumen and an open LVA with antegrade flow (Fig 5). There was no connection between the true and the false lumen. A third follow-up CT angiogram after 2 months showed a normal ascending aorta and open supraaortic vessels except the proximal LSA occlusion (Fig 6). At an outpatient clinic visit 6 months after the intervention, the patient reported no symptoms besides the preexisting claudication. The aortic dissection injury
Biliary Cardiac Tamponade as a Result of Iatrogenic Biliary-Pericardial Fistula From: Andrew M. Surman, BS Miles B. Conrad, MD, MPH Christopher F. Barnett, MD, MPH John S. MacGregor, MD, PhD Sujal Nanavati, MD Mark W. Wilson, MD Department of Radiology and Biomedical Imaging (M.B.C., S.N., M.W.W.)
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.08.003
1925
and LVA occlusion had resolved spontaneously and uneventfully. The patient in the present case was in stable cardiovascular condition after the dissection. No cardiac complications were present that would have indicated immediate intervention. As the patient had a patent right vertebral artery, no cerebrovascular ischemia had occurred. In a similar reported case, Tochii et al (3) performed subacute aortic arch replacement to avert potential risk of fatal complications. This is in line with common recommendations for surgical ascending aorta and arch graft replacement after retrograde iatrogenic type A aortic dissection (4). We decided to refrain from surgical repair and treated the patient conservatively. Our decision was based on the consideration that there was only retrograde poststenotic flow and no direct aortic blood pressure feeding the false lumen originating from the LSA. We therefore did not expect further expansion of the false lumen, nor development of cardiac complications. Follow-up CT angiograms confirmed our hypothesis, showing shrinkage and complete healing of the aortic dissection. As the present case shows, for evaluation of treatment after iatrogenic type A aortic dissection, precise analysis of the blood supply to the false lumen can help in making the proper therapeutic decision.
REFERENCES 1. Jonker FHW, Schlosser FJV, Indes JE, et al. Management of type A aortic dissections: a meta-analysis of the literature. Ann Thorac Surg 2010; 89:2061–2066. 2. Langer S, Mommertz G, Koeppel TA, Schurink GW, Autschbach R, Jacobs MJ. Surgical correction of failed thoracic endovascular aortic repair. J Vasc Surg 2008; 47:1195–1202. 3. Tochii M, Ando M, Takagi Y, et al. Iatrogenic type A aortic dissection after catheter intervention for the left subclavian artery. Ann Thorac Cardiovasc Surg 2010; 16:451–453. 4. Piffaretti G, Mariscalco G, Tozzi M, Bruno VD, Sala A, Castelli C. Acute iatrogenic type A aortic dissection following thoracic aortic endografting. J Vasc Surg 2010; 51:993–999.
Department of Medicine, Division of Cardiology (C.F.B., J.S.M.) School of Medicine (A.M.S.) University of California, San Francisco 505 Parnassus Avenue San Francisco, CA 94122
Editor: Puncture of a nontarget organ during percutaneous liver biopsy is a rare complication (1). We present a case of pericardial injury during image-guided biopsy of a caudate lobe mass complicated by hemopericardium. The importance of considering biliary dilatation during pericardial drain placement is supported by the following report of a biliary-pericardial fistula. This rare
