Endovascular treatment of iatrogenic penetrating trauma of the carotid artery: case report

Carotid trauma demands early diagnosis and treatment. Open repair may be technically challenging if the trauma is at the base of the neck. We present a case of iatrogenic penetrating carotid trauma caused by insertion of a hemodialysis catheter. Treatment was accomplished by placement of a covered stent-graft in the common carotid artery, covering the puncture site. This case suggests that placement of a covered stent-graft is a good option for treatment of iatrogenic injury to the carotid artery.

Later, the patient had a peritoneal dialysis catheter implanted without intercurrent conditions and was discharged in good clinical conditions.

DISCUSSION
The standard treatment for a perforating trauma of an artery is ligature with permanent occlusion of the artery.This technique is traditionally employed in cases of carotid rupture, particularly in cases in which there is insufficient time to evaluate collateral cerebral circulation, and endovascular or surgical

INTRODUCTION
Arterial traumatisms involving the cervical region have a low incidence, but elevated morbidity and mortality.Despite advances in diagnostic and surgical techniques, carotid injuries at the base of the neck are still challenging for vascular and trauma surgeons. 1,24][5] The conventional approach to treating these cases is with open surgery.However, as endovascular techniques have evolved, percutaneous treatment is becoming a lower morbidity and mortality option for treatment of this type of complication.

CASE DESCRIPTION
The patient was a 75-year-old female with chronic renal failure who was on hemodialysis but with difficult vascular access.On the day she was admitted, a catheter for hemodialysis was placed in the femoral vein, without intercurrent conditions.On the day after admission, the Nephrology team attempted to place a catheter in the left jugular vein for hemodialysis, which was inadvertently placed into the left common carotid artery.The catheter was left in the carotid, the patient was heparinized and the Vascular and Endovascular Surgery Team was called.A cervical angiotomography showed the catheter placed in the common carotid artery at the junction between its proximal and mid thirds and with the tip in the ascending aorta (Figure 1).
The decision was taken to attempt endovascular correction of the carotid trauma and to remove the hemodialysis catheter manually.The right common femoral artery was dissected and a 9 French wired introducer sheath was advanced up to the thoracic aorta.A 0.035" × 450 cm jagwire guide-wire (Boston, Natick, MA, USA) was inserted via the hemodialysis catheter, the guide-wire was captured using a GooseNeck snare (EV3, Plymouth, MN, USA) and removed via the common femoral (Figure 2).The 9F introducer sheath was repositioned in the left common carotid artery.Angiography was used to identify the perforation site and the carotid bifurcation.A Viabahn 8 mm × 5 cm endoprosthesis (Gore, Flagstaff, AZ, USA) was positioned at the site of the orifice, the hemodialysis catheter was removed manually and the endoprosthesis released and then post-dilatation was performed using a 7 × 40 mm balloon catheter.Control angiography demonstrated patency of the treated segment with no leakage (Figure 3).occlusion of both carotid and the rupture site are performed. 4,6Vascular ligature or occlusion involves a very high risk of ischemic cerebral events. 4,6,7urgical management should therefore prefer reconstructive techniques or those that preserve cerebral flow, whenever the patient's condition allows. 3In our case, the patient had suffered a perforating carotid trauma that was sealed by the hemodialysis catheter itself, which had not been removed from the placement site (Figure 1).This meant that it was possible to conduct preoperative imaging exams and plan the most appropriate and safest technique for correction of the perforation.In order to avoid embolic complications caused by the large-caliber intra-arterial catheter, the patient was kept on heparin until the catheter had been removed and the endovascular repair accomplished.
Endovascular repair of the perforating carotid trauma was the option chosen in the case described here because of the age of the patient, 75 years, the presence of multiple comorbidities and the elevated surgical risk, and also because of the perforation site, which was located at the base of the neck and involved the proximal segment of the common carotid.It is known that carotid injuries involving the base of the neck are a challenge for surgeons. 1,29]11,12 In the case described here, a self-expanding Viabahn endoprosthesis was used because of its flexibility, since the patient had a tortuous carotid, and because of the simple and rapid release mechanism, which was important because of the need to release it at the same moment that the catheter was removed manually.An 8 × 50 mm endoprosthesis was used in a 7 mm target artery, making correct placement possible and preventing leakage or migration.The long introducer sheath was used to protect the material as it was advanced to the placement site and to provide angiographic control.The hemodialysis catheter (intra-arterial) itself was used to advance the guide-wire and perform the through-and-through technique, for passage and positioning of the sheath in the proximal common carotid.A carotid filter was not used because of incompatibility between the filter guide-wire (0.014") and the wire needed to place the endoprosthesis (0.035").The nature of the injury, which was traumatic and not atherothrombotic, meant that a filter was not absolutely necessary.
The case described here suggests that use of the endovascular technique, with endoprosthesis placement, is a good option for treatment of cases of iatrogenic perforating carotid trauma.

Figure 1 .
Figure 1.Preoperative angiotomography showing the hemodialysis catheter in the left common carotid artery.

Figure 2 .
Figure 2. Fluoroscopy showing the hemodialysis catheter, the guide-wire and the 9 French long introducer sheath.

Figure 3 .
Figure 3.Control angiography showing final appearance after release of the endoprosthesis in the left common carotid artery.