Successful fluoroscopy-free extremity endovascular revascularization in an austere environment: a case report

Background. The use of endovascular techniques in military trauma has increased over time. We present a case of stent-graft placement in a far-forward medical treatment facility (MTF). Methods. A 27 year-old male sustained a blast injury to his upper extremities. He was admitted to a Role 2 MTF 7 hours post-injury. On presentation, he was hemodynamically stable, with multiple closed fractures of both hands, a partial amputation of the right forearm, and the absence of right upper-extremity pulses. Plain radiographs revealed two metallic fragments overlying the right humerus head. The patient underwent a completion below-elbow amputation and right brachial artery exploration. Following the insertion of an arterial sheath, a multipurpose 5-Fr catheter was used to obtain a single-shot angiogram, which demonstrated a traumatic sub-total occlusion of the axillary artery. Using a combination of gentle catheter-wire manipulation and serial radiography, the lesion was traversed and access to normal subclavian artery obtained. A Fluency®Stent Graft (6x100 mm) was then deployed, followed by a completion angiogram, which demonstrated the restoration of extremity perfusion. Results.The patient was evacuated to the next echelon of care on day 5 with good perfusion of the extremity. CT-angiography on day 30 demonstrated thrombotic occlusion of the stent-graft; however, the extremity was viable and further revascularization was not clinically indicated. He was discharged on day 78 following conversion to internal osteosynthesis. Conclusion.Endovascular revascularization of extremity trauma is possible in an austere environment, although techniques need to be refined to support a reduced logistical footprint.