AJR 2002; 178:1180
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Potentially Life-Saving Role for Temporary Endovascular Balloon Occlusion in Atypical Mediastinal Hematoma
Muneer Desai1,
Alexander B. Baxter1,
Riyad Karmy-Jones2 and
John J. Borsa1
1 Department of Radiology, University of Washington School of Medicine,
Harborview Medical Center, 325 9th Ave., Box 359728, Seattle, WA
98104-2499.
2 Department of Thoracic Surgery, University of Washington School of Medicine,
Harborview Medical Center, Seattle, WA 98104-2499.
Received June 25, 2001;
accepted after revision July 3, 2001.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee
B. Talner.
Address correspondence to F. A. Mann.
Introduction
A 43-year-old man sustained extensive polytrauma in a high-speed motor
vehicle crash. An initial chest radiograph showed a widened mediastinum
(Fig. 1A). Because of a
decreasing hematocrit (26%) and a grossly positive finding at diagnostic
peritoneal lavage, the patient underwent emergency splenectomy and repair of a
mesenteric laceration.
After surgical stabilization, a thoracic aortogram showed extravasation
from a laceration of the distal brachiocephalic artery extending into the
origin of the right subclavian artery (Fig.
1B). Emergent temporary tamponade with a 20-mm occlusion balloon
that was inflated proximal to the laceration provided proximal vascular
control (Fig. 1C). The patient
was returned to the operating room for patch-graft repair of a 1-cm
brachiocephalic artery laceration via a median sternotomy.
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Fig. 1B. —43-year-old man after high-speed motor vehicle crash. Early
arterial phase image from left anterior oblique digital subtracted aortogram
shows pseudoaneurysm near origin of right subclavian artery with at least 2-cm
length of intact brachiocephalic artery proximal to injury. At surgery, tear
was identified in distal brachiocephalic artery just proximal to its
bifurcation.
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First described by Binet et al.
[1], traumatic laceration of
the brachiocephalic artery is a rare diagnosis. Associated injuries are
usually severe, and preoperative and intraoperative survival rates are low.
However, patients can reach a trauma center with minimal clinical signs
[2], necessitating a high level
of suspicion based on mechanism of injury and thoracic imaging findings. These
signs include all findings seen with acute traumatic aortic injury, and
diagnostic evaluation is usually aimed at excluding this injury. Proximal
great vessel laceration is found much less frequently and is generally found
during angiography. In this patient, the localized abnormality in the right
superior mediastinum suggested the presence of a great vessel injury. Bone
injuries such as rib fractures, manubrial fractures, sternoclavicular
dislocation, and scapulothoracic dissociation may also be seen with injury to
the mediastinal vasculature.
Definitive repair is operative via median sternotomy, with possible
cardiopulmonary bypass. Temporary balloon occlusion has been used in the
setting of arterial trauma [3,
4] and in the repair of leaking
abdominal aortic aneurysms [5].
For injuries to the brachiocephalic artery, this technique permits easier,
less invasive operative dissection and may eliminate the need for clamping the
artery proximal to the injury. Risks of balloon occlusion are significant and
include aggravating the tear, persistent retrograde bleeding from distal
collaterals, and cerebral or limb ischemia from prolonged inflation. To avoid
aggravating the tear and to safely place the balloon, the normal vessel
proximal to the injury must be sufficently long. Preoperative balloon
occlusion should be considered for brachiocephalic artery injuries with
imaging evidence of active bleeding.
References
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Binet JP, Langlois J, Cormier JM, et al. A case of recent traumatic
avulsion of the brachiocephalic artery at its origin from the aortic arch.
J Thorac Cardiovasc Surg
1962;43:670
-676
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Weiman DS, McCoy DW, Haan CK, Pate JW, Fabian TC. Blunt injuries of
the brachiocephalic artery. Am Surg
1998;64:383
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Rieger J, Linsenmaier U, Euler E, Rock C, Pfeifer KJ. Temporary
balloon occlusion as therapy of uncontrollable arterial hemorrhage in multiple
trauma patients [in German]. Rofo Fortschr Geb Rontgenstr Neuen
Bildgeb Verfahr
1999;170:80
-83[Medline]
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Joseph N, Levy E, Lipman S. Angioplasty-related iliac artery
rupture: treatment by temporary balloon occlusion. Cardiovasc
Intervent Radiol
1987;10:276
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Greenberg RK, Srivastava SD, Ouriel K, et al. An endoluminal method
of hemorrhage control and repair of ruptured abdominal aortic aneurysms.
J Endovasc Ther
2000;7:1
-7[Medline]
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Introduction
References
