Salvage of the Carotid Artery with Covered Stent after Perforation with Dialysis Sheath

Summary

We present a rare case of carotid tear caused by iatrogenic erroneous insertion of a dialysis sheath into the common carotid artery (CCA). This was treated by placement of a covered stent-graft in the CCA over the puncture site. This treatment achieved hemostasis while preserving the carotid artery with good outcome. The technical details are presented and the relevant literature regarding treatment of carotid blowout syndrome is discussed. This case suggests that placement of a covered stent-graft is a good option not only for the “usual” blowout syndrome due to head and neck tumors, but also for treatment of iatrogenic injury to the carotid artery.

Introduction

Covered stents or stent grafts are not often used in the intracranial circulation since they are difficult to navigate via the tortuous cerebral circulation. Covered stent grafts are however sometimes used for the extracranial cerebral arteries of the head and neck. The most common indication for a covered stent graft in the arteries of the neck is for treatment of a carotid blowout syndrome ^1-4. In this syndrome, hemorrhage is caused by a perforation of the carotid artery or its branches. The most common cause of carotid blowout syndrome is head and neck malignancy and subsequent irradiation. Carotid perforation following trauma to the neck is extremely rare but has been reported ^7,8. Our case represents a rare scenario in which the carotid tear was caused by iatrogenic erroneous insertion of a dialysis sheath into the common carotid artery (CCA).

Case Report

A 59-year-old woman with end stage renal failure and a short thick neck underwent an attempted insertion of a dialysis catheter into the left internal jugular vein. Although puncture was performed under ultrasound guidance, the left CCA was inadvertently punctured, followed by insertion of a 14.5 French dialysis peel away introducer sheath (Bard, Tempe, AZ, USA). The intraarterial sheath position was recognized when pulsatile blood exited the sheath. The sheath was clamped and manual pressure was applied to the puncture site to control the bleeding (this was needed throughout the entire procedure). Five thousand units of IV heparin were immediately given to reduce the risk of thrombus development in the carotid artery. Interventional Neuroradiology was consulted and a decision was made to place a covered stent in the CCA over the rupture site, and to then pull the dialysis sheath.

Under local anesthesia a 5F femoral introducer sheath was placed in the right common femoral artery. A diagnostic arteriogram was performed with a 5F Berenstein catheter (Merit, Medical, South Jordan, UT, USA) placed in the proximal left CCA (Figure 1A). It confirmed the presence of the dialysis sheath in the common carotid artery at the T1 level. There was focal arterial spasm around the sheath, and small amount of thrombus was noted in the lumen of the CCA superior to the sheath entrance point. The diagnostic catheter was advanced over a 0.035 inch flexible angled tip glide wire (Terumo, Tokyo, Japan) distal to the sheath in the CCA. The wire was then exchanged for a 0.035 inch 300cm long extra stiff Amplatz exchange guide wire (Cook, Bloomington, IN, USA). The diagnostic catheter and short femoral introducer were removed and replaced with a 9 French short introducer sheath at the femoral puncture site. A 9 mm diameter × 100 mm long Viabahn self expanding covered stent (Gore, Flagstaff, AZ, USA) was advanced over the Amplatz wire, positioned to traverse the dialysis sheath entry site, and deployed across the sheath. The dialysis sheath was then removed from the outside without evidence of bleeding (Figure 1B). Post stenting CCA arteriogram demonstrated no evidence of leak (Figure 1C); there was normal opacification of the left internal carotid artery and of the intra-cranial circulation without any evidence of gross emboli (Figure 1D). The femoral sheath was removed and hemostasis was obtained with an 8 French Angioseal arterial closure device (St. Jude Medical, Minnetonka, MN, USA). The patient was then treated with a loading dose of 300 mg clopidrogel taken orally immediately after the procedure followed by 75 mg clopidrogel per day for six months, as well as 81 mg aspirin once a day for life. We did not perform anti-aggregation tests.

The patient was hemodynamically stable after this procedure but suffered from mild neurological symptoms that included aphasia, with moderate expressive language deficits and difficulty with comprehension, as well as mild right-sided weakness. CT of the brain showed three tiny cortical and subcortical infarcts at the left occipital and left frontal lobes that were confirmed by MRI (Figure 2A). Given fluctuations in the clinical symptoms over the 24 hours following stent insertion, CTA and Doppler ultrasound examinations were performed the following day and showed complete patency of the stented CCA. Stent patency persisted at six months (Figures 2B-D) and clopidrogel was stopped. The patients' neurological symptoms improved while in hospital and after short rehabilitation she recovered to baseline normal neurological function. The patient's stay in the hospital was complicated by venous thrombosis of the left subclavian and left internal jugular veins around a dialysis line that was eventually inserted into the left subclavian vein. It is possible that the presence of a soft tissue hematoma in the left neck from the previous carotid rupture contributed to the development of this venous thrombosis. It was treated with warfarin. Clopidrogel and aspirin were not stopped during warfarin treatment.

Figure 1.

A) Frontal projection of a left common carotid arteriogram shows the dialysis sheath (arrow heads) placed in the CCA with partial collapse of the CCA distal to the sheath. Filling defects from thrombus are noted superior to the sheath (arrows). B) Frontal plain film of the neck shows the covered stent in the left CCA after removal of the dialysis introducer sheath (arrows). C, D) Frontal left common carotid arteriogram after stenting and removal of the dialysis sheath, demonstrates a patent stent and CCA with no leak and preserved flow into the left internal carotid artery and towards the intracranial circulation.

Figure 2.

DWI image from an MRI performed several days after stenting (A) shows a small lesion of restricted diffusion in the posterior left frontal lobe (arrow in A) in keeping with a small acute embolic infarct. Two more similar lesions were noted in the cortex of the posterior left frontal lobe and in the left occipital lobe. Follow-up Doppler US (B) and CTA (C, D) 6 months after stenting show that the left CCA is patent and that the stent is well opposed against the CCA wall (arrows in B and D).

Discussion

The traditional treatment of an arterial tear is deconstructive with permanent occlusion of the torn artery. This approach is classically used for carotid blowout cases with surgical or endovascular occlusion of the tear and of the carotid artery ^5-7. In these emergency situations, there is often not enough time to evaluate the intracranial collateral circulation of the circle of Willis, nor is there time to perform a carotid artery balloon test occlusion. Therefore a deconstructive approach with permanent occlusion of the carotid artery carries a substantial risk of stroke ^5-7. Furthermore, in non emergent scenarios, when patients pass a balloon test occlusion prior to sacrifice, it does not necessarily indicate that the patient is immune to stroke following carotid sacrifice ^9-11. Thus, when possible, a reconstructive technique to preserve the artery and prevent stroke is preferred. In our case, the patient was relatively young with a near normal life expectancy which further supports preserving the carotid artery. She did suffer minor transient ischemic symptoms after stenting, likely the result of emboli from the clot that was present at the area of perforation prior to stenting (Figure 1A).

A variety of covered stents are available and were reported for carotid blowout treatment ^1-6. These include balloon and self-expandable stents. The procedure described here was influenced by its emergent nature and the necessity to use available materials which were limited since the use of covered stents for cerebral vessels is not common in our institution. The Viabahn stent we used, a self-expandable covered stent, was the only available covered stent that would suite the size of the CCA. We did not have time to measure the artery properly and used an estimation of 6-7 mm diameter to be the diameter of an average common carotid artery in a large adult female. We chose a stent that is slightly larger in diameter in order to achieve good apposition of the stent to the arterial wall, in order to prevent stent dislocation and possible endoleak at the rupture site. The stent we used is relatively long (10 cm) which was the only length available in the desired diameter. In addition, we would have preferred to use a carotid artery long sheath or guiding catheter to deliver the stent, but did not have the required 9F sheath in the cerebral length. Thus we used a short 9F groin sheath and performed the delivery of the stent solely over the Amplatz wire. The stent positioning into the site of deployment was guided by the known entry site of the dialysis sheath, and by the known location of the CCA bifurcation as noted on the pre-stenting arteriogram and on the road map. This was sufficient to deliver the stent with no encountered instability.

Since thrombus was seen in the CCA prior to stenting, it is possible that a filter wire or a balloon guide catheter with aspiration during the critical parts of the treatment could have prevented its embolization towards the brain and the patients' reversible stroke symptoms. We did not use a “filter wire” since it would not have supplied the needed support for delivering a covered stent via a short groin sheath. The required balloon guide catheter was not available in our inventory in 9F.

Conclusions

Covered stent graft is a good option for treatment of iatrogenic tear of the carotid artery. It achieves hemostasis while preserving the parent artery.