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250 Section 12: Vascular Trauma
Correct Answer D Stent graft collapse
Reference
Gennai, S., Leone, N., Andreoli, F., et al. (2020). Influence of thoracic endovascular repair on aortic
morphology in patients treated for blunt traumatic aortic injuries: long-term outcomes in a multicentre study. Eur J Vasc Endovasc Surg, 59(3), 428–436. PMID: 31911139
8. RATIONALE
Management of abdominal vascular trauma is determined by the mechanism of injury and
zone of injury. There are three zones within the abdomen and pelvis; zone I is the center portion
of the abdomen and contains the aorta, mesenteric vasculature, and the inferior vena cava; zone
II involves bilateral flanks and contains renal vasculature; and zone III involves the pelvis with
iliac arteries and veins. Blunt abdominal trauma in the absence of instability and/or expanding
hematoma does not necessitate operative intervention, while all penetrating trauma warrants
operative exploration. Zone I injury is managed by laparotomy for aortic repair or replacement.
Primary repair with or without patch angioplasty should be performed if the tear in the vessel in question involves <50% diameter and the quality of the edges of the vessel are satisfactory. Replacement should be performed if the diameter of the injury is >50% or the length of
injury mitigates against primary repair. Gunshot wounds require debridement prior to repair.
If replacement is necessary in a contaminated field, use of a synthetic conduit for repair is not a
desirable option. Small-diameter blood vessels can be replaced by the greater saphenous vein as
a conduit. For aorta and inferior vena cava, femoral and popliteal veins (deep veins) harvest may
be necessary. However, this procedure is time consuming, and if there is concomitant arterial
or venous injury in the extremity, the deep vein harvest should not be performed. Other options
include a rifampin-soaked Dacron graft or cryopreserved aortic homograft. The patient may
need lifelong antibiotics in this type of clinical scenario.
Correct Answer D Repair of aorta with bovine pericardial patch angioplasty and interposition bovine carotid graft for inferior vena cava injury
Section 12: Vascular Trauma 251
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Reference
Chapellier, X., Sockeel, P., & Baranger, B. (2010). Management of penetrating abdominal vessel inju-
ries. J Vasc Surg, 147(2), e1–12. PMID: 20638931
9. RATIONALE
Iatrogenic arterial injury occurs in less than 1% of patients following total knee arthroplasty.
The mechanism of injury involves direct trauma (heat injury or instrumental injury) or indirect
(arterial stretching during retraction). Diagnostic testing should be done with CT angiography
if the patient is outside the operating room or arteriogram from the contralateral femoral artery
in patients who are still in the operating room undergoing knee arthroplasty. Most patients have
thrombosis or a laceration of the popliteal artery, and open repair is required. If the injury is suspected in the operating room, the patient should be kept supine and the popliteal artery exposed
via the medial approach. The drawback of this approach is the relative inaccessibility of the middle
portion of the popliteal artery, which is directly behind the knee, and the potential risk of skin incision breakdown, as the medial incision is quite near the anterior incision for the knee arthroplasty.
If the injury is discovered after the patient has left the operating room, an emergent operation
should consider using the posterior approach. Direct repair, patch angioplasty, or interposition
graft may be necessary depending on the extent of involvement of the popliteal artery. In patients
with prolonged ischemia, a lower-extremity four-compartment fasciotomy is often required.
Correct Answer C CTA lower extremity
Reference
Hans, S. S., Shepard, A. D., Reddy, P., et al. (2011). Iatrogenic arterial injuries of spine and orthopedic
operations. J Vasc Surg, 53(2), 407–413. PMID: 21055898
10. RATIONALE
Right popliteal pseudoaneurysm following right knee
ar thropla sty.
Covered stent placement for repair of right popliteal
pseudoaneurysm.
252 Section 12: Vascular Trauma
The pseudoaneurysm involving the popliteal artery without arteriovenous fistula is best managed
by a covered stent, preferably using contralateral femoral access. Pseudoaneurysm is probably the
result of a partial laceration of the popliteal artery. Excessive bleeding following tourniquet release
should be suspicious for arterial injury. Complete transection of the popliteal artery is relatively
uncommon. Patients at increased risk of arterial injury are those with peripheral arterial disease
with or without prior arterial bypass and patients who are undergoing redo joint arthroplasty.
Correct Answer C Covered stent via contralateral femoral approach
Reference
Hans, S. S., Shepard, A. D., Reddy, P., et al. (2011). Iatrogenic arterial injuries of spine and orthopedic
operations. J Vasc Surg, 53(2), 407–413. PMID: 21055898
11. RATIONALE
This presentation is highly suggestive of radial artery pseudoaneurysm, which can be easily confirmed by duplex imaging. The Allen test will help in evaluation of the integrity of the
palmar arch and the patency of the ulnar artery. If the ulnar artery and palmar arch are not
patent, repair of the right radial artery pseudoaneurysm, if complicated by postoperative radial
artery thrombosis, will result in severe ischemia in the hand. Catheter-based arteriography and
CTA are usually not necessary unless arteriovenous fistula or other vascular injury is suspected.
Diminished radial artery flow or thrombosis associated with radial artery line placement
(arterial line) has been reported in 25%–33% of patients after decannulation, but hand ischemia occurs in <1% of patients. Treatment of distal thromboembolism from atherosclerosis or
catheter-related debris with a patent radial artery would require catheter removal, anticoagulation/antiplatelet medications, or both if clinically appropriate. For patients who present with
thrombotic radial artery occlusion, they may undergo radial artery exploration or thromboembolectomy followed by patch angioplasty. Pseudoaneurysm is the most common nonischemic
complication. The patient may undergo primary repair, vein patch angioplasty, or ligation in
the setting of a ruptured pseudoaneurysm. Mycotic pseudoaneurysms should be treated with
antibiotics, excision, and wide debridement of infected tissues.
Correct Answer C Duplex imaging of the ulnar artery with Allen test
Reference
Garg, K., Howell, B. W., Saltzberg, S. S., et al. (2013). Open surgical management of complications from
indwelling radial artery catheters. J Vasc Surg, 58(5), 1325–1330. PMID: 23810262
Section 12: Vascular Trauma 253
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12. RATIONALE
The patient has a hematoma in close proximity to the left femoral vessels. Ankle-brachial index
is very useful when the physical signs are not definitive (hard signs) of arterial injury. An ankle
brachial index of >0.9 approaches 100% predictive value for home discharge, and an ABI of <0.9
has a sensitivity of 95% and a specificity of 97% for the diagnosis of arterial trauma. Patients
with an ABI of <0.9 should undergo CT angiography or catheter-based arteriography.
Correct Answer D Measurements of ankle-brachial index
Reference
Fox, N., Rajani, R. R., Bokhari, F., et al. (2012). Evaluation and management of penetrating lower
extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg, 73(5 Suppl 4), S315–S320. PMID: 23114487
13. RATIONALE
Tracheoinnominate artery fistula is a potentially life-threating iatrogenic complication that is
typically associated with percutaneous or surgical placement of a tracheostomy tube. It has also
been described in cases of tracheal resection and tracheal stenting. The incidence after
surgical tracheostomy has been reported to be 0.1%–1%, with a peak incidence typically seen
7–14 days after the procedure, but it can be seen as early as 3 days and as late as 6 weeks after the
procedure. Risk factors for fistula development include high cuff pressure, necrosis, mucosal
trauma from a malpositioned cannula, low tracheal incision, excessive neck motion, or radiation therapy. Most patients manifest minor bleeding episodes prior to a massive hemorrhage.
For the successful management of tracheoinnominate fistula, treatment should be initiated
immediately for control of bleeding before contemplating definitive surgical management. The
tracheostomy cuff should be overinflated to help tamponade the bleeding from the fistula; flexible bronchoscopy should be performed through the tracheostomy tube to clear and secure the
airway. Digital compression should be applied around or through the tracheostomy incision.
No attempt should be made to manipulate the tracheostomy tube. Once the bleeding can be
controlled locally, operative intervention is the treatment of choice. A medial sternotomy is performed to gain access to the innominate artery. Ligation and resection of the fistulous segment
of the innominate artery without vascular reconstruction is the recommended treatment. The
condition is fatal if not immediately recognized.
Correct Answer B 7–14 days
Reference
Grant, C. A., Dempsey, G., Harrison, J., & Jones, T. (2006). Tracheo-innominate artery fistula after per-
cutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth, 96(1), 127–131.
PMID: 16299043
14. RATIONALE
If tracheoinnominate artery fistula (TIF) is suspected, placement of a finger in the stoma to
compress the innominate artery should be the first maneuver. Temporizing measures can be
useful for patients who present with tracheoinnominate artery fistula until definitive repair
is performed. Manual pressure or a pressure dressing in the neck may be helpful. Suction via
bronchoscopy may be necessary to prevent aspiration of the blood. In a few reported cases the
endovascular approach has afforded a faster hemorrhage control than thoracotomy or median
254 Section 12: Vascular Trauma
sternotomy, but there is potential for stent graft infection. Stent graft deployment can be performed using the brachial artery, axillary artery, or femoral artery access with placement of a
covered stent at the site of the fistula. Open surgical repair is associated with a mortality rate of
approximately 50%. Operative management includes a median sternotomy to expose the aortic
arch vessels and trachea with repair sutured over pericardial pledgets. Innominate artery exclusion and extra-anatomic graft such as carotid-carotid, axillo-axillary, or femoral-axillary artery
bypass may offer a less morbid option than direct revascularization.
Correct Answer D 50% mortality
Reference
Hamaguchi, S., & Nakajima, Y. (2012). Two cases of tracheoinnominate artery fistula following trache-
ostomy treated successfully by endovascular embolization of the innominate artery. J Vasc Surg,
55(2), 545–547. PMID: 21958569
15. RATIONALE
(a) An angiographic image demonstrating AP views in the arterial phase and with two vessel opacification and delayed
filling of the pseudoaneurysm. (b) Lateral projections demonstrate the arteriovenous fistula communication to the
venous pseudoaneurysm.
Bleeding, infection, and deep venous thrombosis have been reported following knee arthroscopy. Uncommon complications include arterial nerve injury and injury to articular cartilage.
During knee arthroscopy, laceration of a genicular artery and vein may result in the formation of a fistula with high pressure in a dilated (aneurysmal) popliteal vein. During meniscectomy with manipulation and external rotation of the knee, the neurovascular bundle in close
approximation to the posterior horn of the meniscus may get injured, which may result in the
formation of an arterial venous fistula. Vascular injury should be considered in the differential diagnosis in a patient with new onset of pain with fullness or mass in the popliteal fossa
Section 12: Vascular Trauma 255
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following knee arthroscopy or surgery. It is important to obtain a lateral view during arteriography to confirm the site of fistula and location of the pseudoaneurysm before undertaking repair.
In low-risk patients open repair via the posterior approach is preferable; if the site of the fistula
is very close to the knee joint line, the medial approach is a satisfactory option. Endovascular
options are reserved for high-risk patients.
Correct Answer D Direct open repair
Reference
Hans, S. S. (2020). Popliteal venous pseudoaneurysm and associated arteriovenous fistula follow-
ing knee arthroscopy in challenging arterial reconstructions. In S. S. Hans (Ed.), Challenging
arterial reconstructions: 100 clinical cases (pp. 265–267). Cham, Switzerland: Springer Nature
Switzerland AG.
16. RATIONALE
Coil embolization with coaxial microcatheter using access from the brachial artery, basilic vein, and cephalic vein and
placement of a covered stent at the origin of the feeding branches of the axillary artery (femoral access).
256 Section 12: Vascular Trauma
Iatrogenic injuries to the branches of the axillary artery may result from orthopedic operations
on the shoulder joint, pacemaker wire manipulation, lead extraction, or insertion of a largebore catheter (hemodialysis). Duplex imaging is readily available for confirming the diagnosis,
and CT angiography is extremely helpful in identification of inflow and outflow vessels; 3D
rendering is useful in selecting treatment options and preplanning for obliteration of traumatic
arteriovenous fistulas. Most traumatic fistulas require open repair, as spontaneous resolution
occurs in less than 2% of patients. Depending on the location of the fistula, many patients with
arteriovenous fistula have minimal symptoms or may be completely asymptomatic. Surgical
closure may be the only option available for closure of traumatic fistulas involving axial vessels
in younger patients. Other treatment options are now available that include covered stents,
coil embolization, glue, alcohol ablation, etc. An endovascular solution provides a less invasive
choice with less morbidity and is especially suitable in hemodynamically unstable patients.
Long-standing fistulas may have multiple smaller draining channels that would be difficult
to visualize if a power injector is not used. To satisfactorily achieve endovascular repair, coil
embolization of the draining vein using a coaxial microcatheter system by puncture of the
cephalic and basilic vein should be performed. Any small branches of the axillary artery should
also be coil embolized using percutaneous brachial access. For covered stent placement to
obliterate large circumflex humeral branches at their origin, femoral artery access may be
preferable, as a large-size sheath is necessary to deploy a large-diameter covered stent (6 mm
or 8 mm). Coverage of the axillary artery in isolation at the site of the main arterial inflow to the
fistula is not effective in obliteration of the traumatic arterial venous fistula.
Correct Answer D Coil embolization with coaxial microcatheter using access from brachial
artery, basilic vein, and cephalic vein and placement of a covered stent at the origin of the feeding branches of the axillary artery
Reference
Hans, S. S., Shepard, A. D., Reddy, P., et al. (2011). Iatrogenic arterial injuries of spine and orthopedic
operations. J Vasc Surg, 53(2), 407–413. PMID: 21055898
SECTION 13: VENOUS DISEASE
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MCQs 1–52
Q1. The most common nerve injured during
endovenous ablation of the lesser saphenous vein is:
A. Saphenous nerve
B. Sural nerve
C. Posterior tibial nerve
D. Common peroneal nerve
Q2. The incidence of superficial burns follow-
ing endovenous ablation is:
A. <0.2%
B. 0.2%–3.7%
C. 3.8%–4.5%
D. 4.6%–5%
Q3. Following endovenous ablation of the
greater saphenous vein, a 28-year-old
woman presents with class IV endothermal heat-induced thrombosis (EHIT). The
optimal treatment is:
A. Heparin
B. Warfarin
C. Apixaban
D. Lovenox
Q4. Arteriovenous fistula following endove-
nous thermal ablation occurs in:
A. <0.2%
B. 0.2%–0.4%
C. 0.5%–0.8%
D. 0.9%–1.0%
Q5. Recanalization following endovenous
thermal ablation occurs in:
A. <2% of patients
B. <4% of patients
C. 4%–6% of patients
D. 7%–8% of patients
Q6. A 44-year-old woman with a BMI of 44
undergoes laparoscopic Roux-en-Y gastric
bypass. On postoperative day 3, she has a
swollen, mottled, slightly cooler left lower
extremity. Duplex venous study shows a left
femoral-popliteal venous thrombosis with
probable extension into the left external
iliac vein. CT venography shows thrombosis of the left common and external iliac
vein. The next best step in management
besides intravenous heparinization is:
A. Continue heparin for 2 weeks followed by
warfarin
B. Apixaban
C. Retrievable inferior vena cava filter
D. Catheter-based mechanical pharmaco-
logic venous thrombectomy
Q7. The incidence of arterial puncture during
access of the internal jugular vein in the
neck during insertion of a central venous
catheter is:
A. <4.0%
B. 4.2%–9.3%
C. 9.4%–10%
D. 11%–12%
Q8. Which of the following statements is true
regarding central line–associated bloodstream infection (CLABSI)?
A. Peripherally inserted central catheters
(PICC-line) are associated with increased
catheter-associated thromboembolism in
the upper extremity
B. The adherence to an insertion checklist
or bundles has no effect on central line
associated–bloodstream infection rates
C. The infection rate in the outpatient set-
ting is higher with a PICC-line than with
central venous catheters
D. The PICC-line is associated with a lower
in-hospital infection rate as compared
with central venous catheters
DOI: 10.1201/9781003389897-13
258 Section 13: Venous Disease
Q9. A 22-year-old woman who is 18 weeks
pregnant presents 8 days after an uncomplicated laparoscopic ovarian cystectomy
with a markedly swollen left lower extremity without any pain. Clinical examination
and duplex venous study reveal left femoropopliteal acute deep venous thrombosis
with extension into the left external iliac
vein. The optimal management for acute
deep venous thrombosis is:
A. IVC filter via right IJ vein placed at supra-
renal level
B. Catheter-directed mechanical-pharma-
cological thrombolysis
C. Subcutaneous low molecular weight
heparin during the entire pregnancy
D. Unfractionated heparin intravenously
followed by oral warfarin
Q10. The incidence of stent thrombosis follow-
ing stent placement for acute iliac vein
thrombosis is:
A. <5%
B. 6%–7%
C. 8%–9%
D. >10%
Q11. The incidence of stent thrombosis follow-
ing venous stenting for post-thrombotic
syndrome is:
A. 1%–3%
B. 4%–5%
C. 6%–7%
D. 8%–10%
Q14. During resection of a pancreatic adeno-
carcinoma with involvement of the portal
vein, the most satisfactory conduit for
reconstruction of the portal vein is:
A. PTFE graft
B. Femoral vein
C. External iliac vein
D. Internal jugular vein
Q15. Resection of a retroperitoneal sarcoma
with inferior vena cava includes en-bloc
resection and inferior vena cava reconstruction. The most satisfactory conduit
for inferior vena cava reconstruction is:
A. Aortic homograft
B. Cryopreserved inferior vena cava
C. Superficial femoral vein (femoral vein)
D. Externally reinforced PTFE graft
Q16. Tilt of the IVC filter (defined as greater
than 15 degrees angulation from the long
axis of IVC) is least common with:
A. Gunther-Tulip filter
B. Trapease
C. Vena tech
D. Bird nest
Q17. The venogram shown in this figure is
diagnostic of:
Q12. The incidence of pulmonary embolism
following iliofemoral venous stent placement is:
A. <1%
B. 1%–2%
C. >2% but <3%
D. Pulmonary embolism is not a known
complication of venous stenting
Q13. The incidence of clinically significant
bleeding following endovascular iliocaval
procedures is:
A. 0.3%–1.1%
B. 1.2%–1.5%
C. 1.6%–1.8%
D. 2%
A. Left-sided inferior vena cava
B. Duplicated inferior vena cava
C. Normal vena cava with large left gonadal
vein
D. Nutcracker syndrome
Q18. Filter fracture after 1 year of implantation
of an IVC filter occurs in:
A. <2%
B. <5%
C. 5.9%–27%
D. 28%–30%
Section 13: Venous Disease 259
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Q19. Symptomatic perforation of the
IVC after filter placement occurs in
approximately:
A. <5% of patients
B. 5%–7% of patients
C. 8%–9% of patients
D. >10% of patients
Q20. The reported incidence of IVC thrombosis
after IVC filter placement is:
A. <2%
B. 2%–30%
C. 31%–35%
D. 36%–40%
Q21. The reported incidence of recurrent
pulmonary embolism following IVC filter
placement is:
A. <3%
B. <6%
C. 6%–9%
D. 10%–12%
Q22. The incidence of deep venous thrombosis
as a late complication of an indwelling
IVC filter is as high as:
A. 12%
B. 22%
C. 33%
D. 43%
Q23. A 74-year-old man is scheduled for
removal of a retrievable IVC filter for
deep venous thrombosis of the common
femoral vein and pulmonary embolism with a prior history of craniotomy.
Venacavogram at the time of retrieval
showed a significant amount of thrombus
within the filter. The best management
option is:
A. Remove the filter and place the patient
on low molecular weight heparin
B. Remove the filter and start the patient on
apixaban
C. Cancel the retrieval, continue anticoagu-
lation, and reevaluate for clearance of the
thrombus in 4–6 weeks
D. Cancel the retrieval, anticoagulation
for 2 weeks, followed by removal of the
filter
Q24. Retrieval rates for retrievable IVC filters
has been reported as:
A. 10%
B. 20%–23%
C. 24%–30%
D. 31%–40%
Q25. All are known complications of IVC filter
retrieval except:
A. Device fracture
B. Caval intussusception
C. Dissection and hemorrhage
D. Perforation of duodenum
Q26. An advanced strategy to facilitate
retrieval of a removable IVC filter by snaring the retrieval hook of the filter is not
successful. The next best option is:
A. Use of a CloverSnare
B. Division of struts by biopsy forceps fol-
lowed by removal
C. Benson wire and a snare catheter are
maneuvered so that the wire passes
through the opposite interstices of the
filter then snaring the wire with EN Snare™
(Merit Med, South Jordan, UT) with a
“lasso” pulled below the filter collar
D. Photothermal tissue ablation with an
excimer laser
Q27. The incidence of post-thrombotic syn-
drome following deep venous thrombosis
of the lower extremity occurs in:
A. 20% of patients
B. 30% of patients
C. 40% of patients
D. 50% of patients
Q28. The normal luminal diameters of the
common iliac, external iliac, and common
femoral veins are:
A. Common iliac vein 18 mm, external iliac
vein 16 mm, common femoral vein 14 mm
B. Common iliac vein 16 mm, external iliac
vein 14 mm, common femoral vein 12 mm
C. Common iliac vein 14 mm, external iliac
vein 12 mm, common femoral vein
10 mm
D. Common iliac vein 12 mm, external iliac
vein 10 mm, common femoral vein
10 mm
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