Cardiovascular Journal of Africa: Vol 26 No 2 (March/April 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 2, March/April 2015 AFRICA e9
Case Report
Removal of broken catheter piece with snare device
during endovascular treatment of post-traumatic
brachial artery pseudo-aneurysm
Veysel Temizkan, Alper Ucak, Ibrahim Alp, Murat Fatih Can, Gokhan Arslan, Ahmet Turan Yilmaz
Abstract
Post-traumatic pseudo-aneurysm is a rare complication of
penetrating vascular injury. Endovascular stent implanta-
tion has become an alternative approach in the management
of this pathology. In our case, we present a brachial artery
pseudo-aneurysm that was treated with endovascular stent
implantation, and removal of a broken catheter part with a
three-dimensional snare device.
Keywords: pseudo-aneurysm, endovascular, stent, catheter
Submitted 16/2/13, accepted 10/2/15
Previously published online 9/4/15
Cardiovasc J Afr 2015; 26: e9–e11
DOI: 10.5830/CVJA-2015-025
The aetiology of pseudo-aneurysms includes blunt or penetrating
trauma, iatrogenic injury during vascular procedures, or
dehiscence of a vascular graft. Pseudo-aneurysms can be treated
in a variety of ways and treatment decisions often depend on
their size and location.1 The frequency of peripheral artery
pseudo-aneurysms is much lower in the upper than the lower
extremities.2
Although gold-standard treatment is still the surgical
approach, endovascular methods have become more frequently
used in recent decades. The technological development of
new-generation devices allows a short processing time, quick
recovery and less traumatic process.3-5 Nevertheless, some
complications such as rupture, dissection, catheter breakage,
and thrombo-embolism during endovascular procedures may
be seen.6-8 In this case, we present treatment of a post-traumatic
brachial artery pseudo-aneurysm and the management of
iatrogenic breakage of the catheter.
Case report
A 20-year-old male patient was admitted to the emergency
department one hour after a 9.65-mm (38-cal) gunshot bullet
wound to the right arm. The entrance and exit wounds were
directly one-third proximal-lateral and medial of the right upper
extremity. There was no active bleeding.
Vital signs on admission included blood pressure of 130/70
mmHg in the right arm and 120/60 mmHg in the left arm, and
a heart rate of 90 beats per minute. The patient had palpable
brachial, radial and ulnar pulses. The Allen test for vascular
integrity of the radial and ulnar arteries was normal at the
extremities. Capillary filling time was two seconds. The right
arm was larger than the left arm. There was a pulsatile mass and
murmur on auscultation.
Colour Doppler scanning showed a brachial artery pseudo-
aneurysm of 14 × 13 mm in diameter in the proximal segment
of the vessel (Fig. 1A). Brachial angiography was planned seven
hours after hospitalisation.
A 6-Fr introducer sheath was placed in the right common
femoral artery (CFA) and a 0.035-Fr guide wire was advanced
through the right proximal brachial artery. A pigtail catheter was
advanced over the guide wire. Angiography showed a pseudo-
aneurysm sac in the proximal part of the right brachial artery.
Extravasation was not observed (Fig. 1B). The pseudo-aneurysm
was stented using a 6 × 50-mm stent (Gore, WL, Arizona, USA)
(Fig. 1C).
Control angiography showed however that the stent could
not be opened completely because of external compression of
a haematoma (Fig. 1B). A 5 × 30-mm Viatrac (Abbott Vascular,
Santa Clara, CA, USA) dilatation balloon over the guide wire
was advanced through the guiding catheter to the target lesion.
When the lesion was reached, it was dilated successfully with a
maximum of 9 atm. There was no residual stenosis afterwards.
The pseudo-aneurysm sac was observed to be closed, with
normal passage of contrast distally.
During removal of the balloon catheter, the guide wire was
difficult to manipulate at the level of the abdominal aorta and
we had to force it. Although removal of the whole system was
achieved, the distal part of the catheter was not found. We
Department of Cardiovascular Surgery, Haydarpasa
Training Hospital, Gulhane Military Medicine Academy,
Istanbul, Turkey
Veysel Temizkan, MD,
Alper Ucak, MD
Ibrahim Alp, MD
Murat Fatih Can, MD
Ahmet Turan Yilmaz, MD
Department of Cardiovascular Surgery, Gulhane Military
Medicine Academy, Ankara, Turkey
Gokhan Arslan, MD