Urgent endovascular management of a subclavian artery trauma after a gunshot injury

The management of penetrating neck injury

“…The difficulty associated with surgical access to injuries of zones 1 and 3 has led to the expansion of endovascular approaches to injuries in these regions. [35][36][37][38][39] Endovascular procedures have been well documented in the post-traumatic elective setting to treat pseudoaneurysms and arteriovenous fistulas; however, endovascular approaches are now being used in the emergency setting. Studies have documented the successful endovascular control of vertebral, subclavian and axillary artery injuries in hypotensive patients.…”

“…Studies have documented the successful endovascular control of vertebral, subclavian and axillary artery injuries in hypotensive patients. 15,[33][34][35][36][37][38][39] Du toit et al 16,17 described the endovascular approach to subclavian, axillary and proximal carotid artery injuries, using stent-graft deployment, and have demonstrated excellent long-term follow-up results of this approach in small numbers of patients, with only a single late stent occlusion but no strokes or stent graft-related deaths; others report less blood loss and procedure time using an endovascular approach. 38 Difficult surgical access to the proximal part of the vertebral artery has resulted in angiographic embolization now being the treatment of choice for such injuries.…”

Right Axillary Artery Bullet Embolus and the Formation of a Pulmonary Arteriovenous Fistula after a Gunshot Wound to the Back

“…If there is no exit wound identified and if imaging fails to reveal a missile or reveals the missile to be in an unusual location, then bullet embolization should be suspected and appropriate diagnostic tools should be performed. 2 Factors that will affect the migration of the bullet in the systemic arterial system include the anatomy of origin of the arteries from the aorta, the force of blood flow, and gravity. Bullets that enter the left heart and thoracic or abdominal aorta usually embolize to lower extremities, but in our case, the bullet more than likely embolized from the pulmonary vein through the heart to the ascending aorta and eventually lodged in the proximal right axillary artery.…”

“…Because the bullet embolus can result in impaired tissue perfusion, necrosis, gangrene, sepsis, and thrombus formation, it has been reported that early extraction of the bullet and thrombus will provide an excellent outcome. 2 Our patient was taken emergently to the operating room as soon as the formal angiogram revealed the bullet to be in the lumen of the axillary artery. Through an infraclavicular incision, an arteriotomy was made and the bullet and thrombus were removed.…”

“…PAVF can remain asymptomatic in which case it causes a delay in diagnosis. 2 In twothirds of cases reported, there has been some delay varying from 1 to 35 years in diagnosing a PAVF. 1 In our case, the patient presented with fever and leukocytosis while recovering from his initial operation on the ventilator in the intensive care unit.…”