Pessoa Thaís Duarte Baião, Araujo Walter Junior Boim de, Caron Filipe Carlos, Ruggeri Viviane Gomes Milgioransa, Erzinger Fabiano Luiz, Brandão Adriana Buechner de Freitas, Mazzoni Camila de Almeida, Cunha Afonso Henrique Venco Teixeira da
Medical Residency Program in Vascular and Endovascular Surgery, Hospital Angelina Caron, Rodovia do Caqui, 1150, 83430000 Campina Grande do Sul, PR, Brazil.
Hospital Santa Madalena Sofia, Rua Fulvio José Alice, 381, 82820450 Curitiba, PR, Brazil.
Trauma Case Rep. 2021 Feb 11;32:100400. doi: 10.1016/j.tcr.2021.100400. eCollection 2021 Apr.
Endovascular treatment in trauma is a promising strategy to reduce perioperative morbidity and mortality. We report the case of a gunshot wound causing an initially undiagnosed subclavian artery injury, with delayed progression to a complex, difficult-to-manage arteriovenous (AV) fistula. Placement of an encapsulated endovascular stent graft resolved the primary lesion, but persistent cervical arteriovenous communications were only repaired after multiple, sequential embolization procedures.
A 25-year-old male sustained a gunshot wound to the right neck. Initial treatment failed to identify any vascular injury, and the patient was discharged. Three weeks later, he presented to our facility with headache and a palpable right-sided cervical thrill. Arteriography showed contrast extravasation from the right subclavian artery and an AV fistula with the ipsilateral internal jugular vein. The arterial injury was repaired with an encapsulated stent graft, but residual contrast leak persisted on follow-up angiography. Three months after the first intervention, cervical thrill was still present; a right vertebral-right internal jugular AV fistula was identified and repaired by distal coil embolization. One month later, persistent symptoms prompted repeat arteriography, which again identified contrast extravasation, now involving the thyrocervical trunk. Selective thyrocervical embolization was ultimately successful, with resolution of symptoms and no further evidence of contrast leak.
Delayed management of neck trauma can be challenging due to neovascularization, which hinders open repair in this delicate region. Post-traumatic arteriovenous fistulas are thus a particularly fearsome complication, and can be very difficult to approach; as in our patient, multiple interventions may be required. This case highlights the importance of detecting vascular trauma as early as possible, as a delay in diagnosis can hinder treatment and eventuate challenging late complications. Further studies are needed to demonstrate the long-term benefits of endovascular management of complex vascular injuries of the neck region.
创伤的血管内治疗是一种有望降低围手术期发病率和死亡率的策略。我们报告一例枪伤导致最初未被诊断出的锁骨下动脉损伤的病例，该损伤随后进展为复杂且难以处理的动静脉瘘。置入带膜血管内支架移植物解决了原发性病变，但持续性颈动静脉交通仅在多次序贯栓塞术后才得以修复。
一名25岁男性右颈部遭受枪伤。初始治疗未发现任何血管损伤，患者出院。三周后，他因头痛和右侧颈部可触及震颤前来我院就诊。动脉造影显示造影剂从右锁骨下动脉外渗，并与同侧颈内静脉形成动静脉瘘。使用带膜支架移植物修复了动脉损伤，但随访血管造影仍有残留造影剂渗漏。首次干预三个月后，颈部震颤仍存在；经远端弹簧圈栓塞术识别并修复了右椎动脉-右颈内静脉动静脉瘘。一个月后，持续的症状促使再次进行动脉造影，造影再次显示造影剂外渗，此次累及甲状颈干。选择性甲状颈干栓塞最终成功，症状缓解且无造影剂渗漏的进一步证据。
由于新生血管形成，颈部创伤的延迟处理具有挑战性，这阻碍了在这个精细区域进行开放修复。创伤后动静脉瘘因此是一种特别可怕的并发症，且处理起来可能非常困难；如我们的患者所示，可能需要多次干预。该病例强调了尽早发现血管创伤的重要性，因为诊断延迟会阻碍治疗并最终导致具有挑战性的晚期并发症。需要进一步研究来证明血管内治疗颈部复杂血管损伤的长期益处。
