Endovascular management of acute critical ischemia secondary to blunt tibial artery injury

Abstract

We report a case of acute limb-threatening ischemia from blunt traumatic tibial arterial disruption managed with endoluminal techniques. An otherwise healthy 37-year-old man involved in a motorcycle crash sustained a compound fracture of his right tibia and fibula. Arterial insufficiency developed after surgical reduction of the orthopedic injuries that warranted selective angiography of the involved extremity. This demonstrated complete occlusion of the infrageniculate circulation at the level of the ankle. Recanalization of the posterior tibial artery was achieved by using coronary balloon-expandable stents, thereby reestablishing in-line flow to the foot. Clinical and noninvasive surveillance at 2 years confirmed patency of the recanalized artery with the absence of any ischemic symptoms. Arterial reconstruction of the infrapopliteal arterial tree poses a formidable challenge in the setting of blunt trauma. Recent improvements in endovascular skills, endoluminal technology, and imaging capabilities have allowed percutaneous reconstruction of challenging arterial pathology. Endovascular treatment of blunt tibial injuries is an alternative to complex open reconstructions. These patients require close long-term postoperative surveillance because the durability of such a repair remains unknown.

Endovascular Management of Peripheral Vascular Trauma

“…Although balloon-expandable stents and covered stents have been used successfully, self-expanding stents are preferred to minimize flexibility limitations in mobile arteries. [6][7][8] Self-expanding stents are oversized by 10 to 20% of the diameter of the injured vessel to optimize apposition. Lastly, informing the trauma team of your facility's endovascular capabilities through presentations or participation in morning report is vital to ensuring that trauma patients have access to endovascular management of their injuries.…”

Endovascular recanalization techniques for popliteal arterial occlusive injury with limb-threatening ischemia secondary to trauma

“…However, in trauma cases, open reconstruction is difficult because of lower-extremity edema and vasospasm of the injured vessels (6). Patient 1 had compound open fractures with contaminated wounds, so surgical bypass was considered to have a high infection risk.…”

“…In particular, balloon angioplasty in combination with surgery, transcatheter embolization of hemorrhagic lesions, and stent or stent graft placement for dissecting or hemorrhagic lesions have been introduced (2,7). However, reports of treatment of occlusive lesions are limited (6). …”

Traumatic Disruption of Saphenous Vein Graft Bypassed to the Dorsalis Pedis Artery

“…Alvarez-Tostado, et al reported a successful treated case of acute critical ischemia secondary to blunt tibial artery injury by endovascular maneuver. 4) Recanalization of the injured posterior tibial artery was achieved by using coronary balloon-expandable stents. In this case, we did not consider endovascular treatment because surgical exposure and revision of the saphenous vein graft was considered to be easy.…”