Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries

CardioVascular and Interventional Radiology, Dec 2016

Introduction The unintentional arterial placement of a central venous line can have catastrophic complications. The purpose of this systematic review is to assess and analyse the available evidence regarding the use of the various vascular closure devices (VCDs) for the management of iatrogenic thoraco-cervical arterial injuries (ITCAI). Methods A systematic review was performed according to PRISMA guidelines. Results Thirty-two relevant case series and case reports were identified with a total of 69 patients having being studied. In the majority of the studies, plug-based VCDs were used (81%) followed by suture-based devices (19%). The majority of studies reported successful outcomes from the use of VCDs in terms of achieving immediate haemostasis without any acute complications. Long-term follow-up data were only available in nine studies with only one case of carotid pseudoaneurysm being reported after 1-month post-procedure. All other cases had no reported long-term complications. Five studies performed direct or indirect comparisons between VCDs and other treatments (open surgery or stent grafting) suggesting no significant differences in safety or effectiveness. Conclusion Although there is limited evidence, VCDs appear to be safe and effective for the management of ITCAIs. Further research is warranted regarding the effectiveness of this approach in comparison to surgery and in order to identify those patients who are more likely to benefit from this minimally invasive approach.

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Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries

Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries Gregory C. Makris 0 1 2 Rafiuddin Patel 0 1 2 Mark Little 0 1 2 Carina Tyrrell 0 1 2 James Sutcliffe 0 1 2 Kader Allouni 0 1 2 Mark Bratby 0 1 2 Susan Anthony 0 1 2 Raman Uberoi 0 1 2 0 Alfa Institute of Biomedical Sciences , Neapoleos 9, Athens , Greece 1 Interventional Radiology Department, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK 2 G. C. Makris et al.: Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries Introduction The unintentional arterial placement of a central venous line can have catastrophic complications. The purpose of this systematic review is to assess and analyse the available evidence regarding the use of the various vascular closure devices (VCDs) for the management of iatrogenic thoraco-cervical arterial injuries (ITCAI). Methods A systematic review was performed according to PRISMA guidelines. Results Thirty-two relevant case series and case reports were identified with a total of 69 patients having being studied. In the majority of the studies, plug-based VCDs were used (81%) followed by suture-based devices (19%). The majority of studies reported successful outcomes from the use of VCDs in terms of achieving immediate haemostasis without any acute complications. Long-term follow-up data were only available in nine studies with only one case of carotid pseudoaneurysm being reported after 1-month post-procedure. All other cases had no reported long-term complications. Five studies performed direct or indirect comparisons between VCDs and other treatments (open surgery or stent grafting) suggesting no significant differences in safety or effectiveness. Conclusion Although there is limited evidence, VCDs appear to be safe and effective for the management of ITCAIs. Further research is warranted regarding the effectiveness of this approach in comparison to surgery and in order to identify those patients who are more likely to benefit from this minimally invasive approach. Closure device; Iatrogenic injury; Interventional radiology; Vascular - Central venous line insertion is a common medical procedure that can be complicated by inadvertent arterial placement of the catheter. This can be the cause of significant mortality and morbidity for the patient [1]. Treatment options include open surgical repair, compression, off-label use of percutaneous vascular closure devices (VCDs), and/or stent grafts. Some of the potential complications include bleeding, thrombosis, stroke, limb ischaemia, neurologic deficit, and death (Fig. 1). [1]. The use of VCDs in interventional radiology has revolutionised the way we achieve haemostasis offering a safe and effective alternative to manual compression. At the same time they have made endovascular abdominal aneurysm repair a truly minimally invasive (percutaneous) procedure very often without the need for time-consuming groin cut-downs. There are many different types of VCD that offer solutions for a variety of indications and vascular disease profiles. The main types of VCDs include suture based, plug based, and nitinol clips [2]. These sophisticated devices have been shown to have a good safety profile for closure of arteriotomies post endovascular procedures with overall rates of complications similar between manual compression at 13.1% and VCDs at 12.2% [3]. The off-label use of these interventional radiology devices for the treatment of iatrogenic injuries of thoracoFig. 1 Coronal CT (A) and 2D reconstruction (B) of the upper chest and neck demonstrating large haematoma after inadvertent right subclavian artery puncture during right internal jugular vein line placement cervical vascular injuries (ITCVI) post central venous line placement is becoming increasingly common. The location and the local anatomy where these vascular injuries occur (carotid, brachiocephalic, subclavian, or vertebral arteries) make the use of manual compression difficult or even dangerous [3, 4]. Traditionally these cases have been treated with an open surgical repair and more recently with the placement of a stent graft where possible [4]. The purpose of this study is to review the available clinical evidence regarding the safety and effectiveness of the available VCDs for the management of ITCVI. A systematic review was performed according to PRISMA guidelines [5]. The PubMed, Scopus, and Cochrane databases were searched for clinical studies evaluating the short- and long-term clinical outcomes from the use of VCDs for the treatment of iatrogenic thoraco-cervical vascular injuries. The search terms used were: ‘‘closure device’’, ‘‘interventional radiology’’, AND ‘‘subclavian’’ OR ‘‘carotid’’ OR ‘‘vertebral’’ OR ‘‘iatrogenic’’ OR ‘‘thoraco-cervical’’ in various combinations. Two independent reviewers GCM and ML performed the literature search and data extraction. The selected studies were manually searched for relevant publications out of their reference lists. All cli (...truncated)


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Gregory C. Makris, Rafiuddin Patel, Mark Little, Carina Tyrrell, James Sutcliffe, Kader Allouni, Mark Bratby, Susan Anthony, Raman Uberoi. Closure Devices for Iatrogenic Thoraco-Cervical Vascular Injuries, CardioVascular and Interventional Radiology, 2017, pp. 381-387, Volume 40, Issue 3, DOI: 10.1007/s00270-016-1506-z