BEST CASE OF MY CAREER- PART THREE COMPLETION

Tue Jul 1 06:49:20 BST 2008

Sal

You are an artist of the highest order. I'm just glad my thought was a
good one.

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: 01 July 2008 03:47
To: trauma-list at trauma.org
Subject: Re: BEST CASE OF MY CAREER- PART THREE COMPLETION

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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