BEST CASE OF MY CAREER- PART THREE COMPLETION

[KMATTOX at aol.com]

First,   Thank you for the case and your continued honesty and  candor in 
exposing your self to an international group of second guessing  people, but we 
all know that you are the master of the trauma interventional  catheter, coil, 
and stent.     So let the Monday morning  quarterbacks give it their best 
shot.    
 
If the circle of Willis is not intact, we are back to Norman McSwains  
approach.   OPEN PROCEDURE.     I have a couple of  tricks.    First a finger will 
control most things at this level  until one gets thoughts and instruments 
together.   Second, one needs  a needle, suture and needle driver that is of 
appropriate size.    Third, I get my 3.5 power loupes on and  accomidated.        I 
then determine if this  is a reparable injury.   If I have decided to ligate 
, then I DO NOT  PUT A CLAMP on the artery.    I throw a suture into the area 
away  from the lingual nerve and bring it out under tension, AND DO NOT  TIE.  
 I then by yo yo ing the suture, I walk sutures across the area  of bleeding 
using 6 (o) polypropylene suture on the smallest  needle.    I place my finger 
over the bleeding between each  suture.    By about the 3rd or 4th throw of 
the suture, the  bleeding is STOPPED.    I REPEAT,  I DO NOT TIE THIS SUTURE  
(yet).    I now dissect out the neck and look for the vital  structures, 
particularilly the vagus nerve and the lingual  nerve.     If I have incorporated my 
sutures into a nerve, I  will now replace sutures ONE AT A TIME, taking care 
to avoid the nerve while  using tension withot tying to assure hemostasis, yet 
no necrosis by  suture.      I have never had to use bone  wax.     
 
I do believe that ANY acute care surgeon (what we used to call a general  
surgeon) should be able to achieve such control in such an injury.   
 
k
 
 
 
 
 
In a message dated 6/30/2008 8:48:00 P.M. Central Daylight Time,  
sjasmd at aol.com writes:

tim
the foley really wasnt working very well
going from one  vertebral to the other is relatively easy and has been 
reported several times  over the past twenty years. I did one and it took less than 
ten minutes from  decision to completion. but going through the middle of the 
circle of willis  is another thing altogether and is one of the scariest 
scenarios i have  thought about my entire career with, fortunately, no opportunity 
to try it.  

But this case seemed like it was one where this strategy would be a  solution 
to this patient's bleeding. 

That is why i called this my best  case. a difficult problem, trying 
circumstances, few alternatives and a  successful hemostasis

I used a 2.6 French microcatheter that I was able  to get across from the 
left vertebral into the basilar, through the left  posterior communicating artery 
into the distal segment of the internal carotid  artery. Getting down below 
the skull base and introduction of a couple of  coils ended this bleeding 
instantaneously. (see attached)
36 hours later he  is conscious and alert with left arm and leg weakness. He 
is still intubated  so it is difficult to assess thought, speech, etc.

distal carotid  retrograde bleeding has never before occured?in my experience 
of?about 40 ICA  endovascular treatments. Not exposing the transected carotid 
artery probably  contributes to early thrombosis of the distal vessel. I 
guess the hole in the  side of his neck and ear was a ready access to continued 
bleeding. 

A  colleague of mine suggested trying to reenter the distal side before  
embolization but i really didnt expect distal bleeding. I still wonder about  the 
risks of distal thromboembolization during that manipulation.  


I think that Norm's solution is a good one when one has experience  and the 
injury is not too high in the neck near the skull base. In this case  it would 
likely have been a difficult proposition because of four proximal  bleeders 
and a fairly distant bleeding distal ICA. 

I recall a seasoned  vascular surgeon with trauma experience trying to repair 
a laceration of the  ICA as high as this one. when the injury fell apart, he 
was subjected to very  significant blood loss coming from the distal side of 
the vessel. When he  tried to clamp the distal vessel, it retracted into the 
carotid canal and he  could not ligate. eventually he did as norm did and used 
bone wax to plug the  carotid canal although the patient required about 15 
units of blood before  this was accomplished.

Ken
what was your suggestion if his circle of  willis was not intact?


sal


-----Original  Message-----
From: Timothy Craig Hardcastle  <TimothyHar at ialch.co.za>
To: Trauma &amp; Critical Care mailing  list <trauma-list at trauma.org>
Sent: Mon, 30 Jun 2008 8:38  am
Subject: RE: BEST CASE OF MY CAREER- PART  TWO



Sal

Exactly what I asked about / suggested earlier -  distal end backbleeding
- leave the Foley catheter inflated for 48 hours  and try again. It
should clot up. Otherwise move to OR and go and ligate  the distal end.
Obviously there is "adequate" collateral flow!

If  you are really good (like I know you are) you could go through the
circle  of Willis with Micro-catherters and embolise the ICA from inside
the brain  (seen it done once in Tygerberg - crossover from one vertebral
to the other  to coil a vertebral AV fistula. Takes a bit of time though.

What is his  Lactate and temp / pH at this point and how much blood has
he  lost?

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med  (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist:  Trauma and Critical Care
Deputy director: Trauma Unit and Trauma  ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair  Road
Mayville, Durban

Postal: PostNet Suite 27
Private Bag  X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za  


-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of sjasmd at aol.com
Sent: 30 June 2008 14:26
To:  trauma-list at trauma.org
Cc: daniel.levin at downstate.edu;  rick.hoffer at gmail.com;
MICHAEL.HERSKOWITZ at DOWNSTATE.EDU;  huntz.liu at downstate.edu;
ERICH.LANG at DOWNSTATE.EDU
Subject: Re: BEST CASE  OF MY CAREER- PART TWO

I decided that an attempt at stent graft of the  external carotid artery
had merit in order to maintain the ophthalmic  artery collateral and
because this would have treated the occipital,  posterior auricular and
external carotid injuries simultaneously even if it  occluded. I thought
that the graft had low likelihood of success because of  the preexisting
post traumatic vasospasm and the small size of the vessel,  but i didnt
think it would hurt to try.. 

A 5mm? diameter 22mm  Atrium stent graft was placed over the injured
segment of the ECA and the  orifices of both branches. It occluded within
minutes. 

The proximal  ICA occlusion was secured with three gianturco
coils. I
chose NOT to try  to go through the clotted ICA to the other side?of?this
injury for fear of  dislodging and embolizing clot into the brain.? 


There was still  bleeding from the wound but when the balloon was
deflated, there was  torrential bleeding. We intermittently let down the
balloon and repeated  the angiography of the carotid and remaining
external carotid branches  without seeing any extravasation.? So we
repeated angiography of all  remaining three cerebral vessels. The left
vertebral angiogram is  attached.





-----Original Message-----
From:  KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Sun, 29 Jun 2008 10:25  pm
Subject: Re: BEST CASE OF MY CAREER
I have seen the second set of  images.    I would also  consider
DEFLATING the  
tamponading balloon for a few seconds in order to obtain  a  view.   It
may be 
that the internal carotid artery is  occluded ONLY  by the occluding
balloon.  

k


In  a message dated 6/29/2008 9:20:14 P.M. Central Daylight Time,   
jduchesn at tulane.edu writes:

sal-  good save!.........is the  patient awake? Any lateralizing signs?
I agree  with Norm. Based on  this angio view the injury can be approach
thru 
formal   sternocleidomastoid approach........I favor repair before  
ligation........  although looks like the ophthalmic artery  collateral
is open 
like Dr 
Mattox  well mention 
Good  case
j
CharityOne

Juan C Duchesne MD, FACS,  FCCP
Trauma  and Critical Care Surgery Section
Surgical Hospital Center   Director
Director Surgical Intensive Care Unit  
Louisiana ATLS  /  PHTLS State Faculty
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