P (Patients)
I (Intervention)
C (Comparator)
O (Outcomes)
Patients with cervicothoracic vascular injury
Endovascular repair
Open repair
Technical success, durability
Table 33.2
Summary of literature review
Study | Patients (#) | Follow-up duration (median) | Vessels involved | Procedures | Outcomes | Quality |
|---|---|---|---|---|---|---|
Desai et al. (2014) [9] | 10 | 13 months | Common carotid (1) Internal carotid (2) Subclavian (7) | Stent graft | Patent grafts at follow-up; no complications reported | Low |
Maughan et al. (2013) [4] | 17 | 22.2 months | Vertebral (iatrogenic) | Observation, stenting or coil embolization | 76 % no change in neurological status 2 patients with neurological decline | Low |
Seth et al. (2013) [10] | 47 (53 injuries, 47 blunt, 6 penetrating) | Up to 7 years | Cervical internal carotid | Stent graft, coil emoblization | Technical success 100 % 1 stent occlusion, 1 stent-related false aneurysm, 3 transient ischemic attacks | Moderate |
Rocha et al. (2013) [11] | 8 | 17 months | Subclavian/axillary (5) Carotid (3) | Stent graft | 2 subclavian grafts occluded within one year; no other complications | Low |
Dubose et al. (2012) [15] | 160 (literature review) | Up to 70 months | Axillary/subclavian | Stent graft | 84.4 % durable patency 6.3 % repeat intervention 3.1 % open conversion | Moderate |
Shalhub et al. (2011) [17] | 34 (16 open, 12 endo, 3 converted to open) | 235 days (open) 411 days (endo) | Innominate (11) Subclavian (16) Axillary (7) | Stent graft | 3 immediate conversions 100 % patent at 1 year follow-up both open and endo Endo times and blood loss significantly less than open | Low |
duTroit et al. (2008) [16] | 57 | 48 months | Subclavian/axillary (penetrating) | Stent graft | 3/57 early graft occlusion 2 died within 30 days 5 short-term stenosis | Moderate |
DuBose et al. (2008) [12] | 113 | 2 weeks-2 years | Internal carotid | Unclear (literature review) | 9.7 % occlusion rate, 94 % alive with no neurologic sequelae at follow-up | Low |
Maras et al. (2006) [13] | 20 | Up to 2 years | Internal carotid (20) | Stent graft or bare-metal stents | 3 long-term occlusions Study performed prior to availability of current endografts | Low |
Cothren et al. (2005) [14] | 46 (23 stented, 23 medical management) | 2–35 months | Internal carotid (23) | Bare-metal stent | 21 % complication rate, 45 % occlusion rate for stenting; 5 % complication rate for medical management | Moderate |
Results
While increasing numbers of endovascular repairs are being performed for vascular trauma [1, 2] no randomized trials were identified comparing endovascular to open repair. Similarly, very few data were available regarding long-term outcomes of endovascular repair.
Vertebral Artery
Maughan and colleagues [4] examined vertebral artery injuries occurring in the setting of neck surgery, providing some of the only available data regarding endovascular treatment of these lesions for trauma. Seventeen vertebral artery injuries were identified out of 8213 patients undergoing neck or skull-base surgery over a 15 year period. Nine of the 17 patients underwent endovascular repair of their injuries with either coil embolization or endovascular stenting, and at a median follow-up of 22 months, none of the treated patients had significant neurological sequelae. However, numerous authors [5–8] have noted that management of vertebral artery injuries is controversial, with medical management (antiplatelet agents and/or anticoagulation) often superior to surgical or endovascular management. Anticoagulation and antiplatelet therapies have not been compared head-to-head for medical management purposes. No clear conclusions can be drawn from the literature to recommend routine endovascular management of vertebral artery injuries, regardless of grade, in the absence of ongoing hemorrhage or neurological deterioration.
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