0:01

So let's review this learning case.

0:02

We have a 47-year-old female.

0:04

She presents with left supraclavicular swelling.

0:06

And this occurs after she had a left

0:08

subclavian venous surgical port placed.

0:12

So the surgeon gave the IR a call after the

0:15

left subclavian arterial port was placed,

0:18

which he actually realized after the fact

0:20

when he accessed the port and realized

0:23

that there was pulsatile blood flow.

0:24

He removed the port and then subsequently placed a

0:28

port in the subclavian vein as initially intended.

0:32

Unfortunately, as we know, the subclavian is

0:35

a very hard site to hold pressure on, being

0:38

sort of subclavicular, and the hemostasis

0:42

that he intended to achieve was not achieved.

0:45

So therefore the IR was called in order to

0:47

evaluate this rapidly expanding hematoma, which

0:52

was secondary to this inadvertent arterial injury.

0:56

So what was performed?

0:57

What would you do in this setting?

0:59

Well again, when we have active hemorrhage,

1:01

we need to consider our options.

1:02

Conservative management?

1:03

Oh, you know, let's just watch and wait.

1:05

This doesn't quite strike me

1:07

as a watch and wait situation.

1:08

Could we embolize?

1:09

Alright, well, are we going to embolize the

1:12

extremity, sort of across this particular point,

1:15

this vessel that feeds the upper extremity?

1:17

Ah, probably not a good idea.

1:20

Are we going to call our surgical colleagues?

1:22

Well, our surgical colleagues actually called us.

1:24

So, the final answer is, maybe

1:26

exclude this with a stent.

1:28

And what kind of stent are we going to use?

1:29

Maybe this little guy here,

1:30

which is a stent graft.

1:32

A nice, sort of very cylindrical

1:35

structure that has almost like a little

1:37

sort of chicken wire appearance that

1:39

has impermeable cloth throughout, okay?

1:43

This impermeable cloth allows it to

1:45

exclude and repair the vessel so that

1:48

now it serves as almost functioning like

1:50

a native conduit, excluding that bleed.

1:55

So after this was placed, what do we see here?

1:59

Looks pretty good.

2:00

Contrast flowing throughout, no longer

2:02

seeing that bleed that we initially saw.

2:04

We'll play that again, and we're happy with it.

2:09

CT scan was then performed, of

2:10

course, to evaluate the patient.

2:12

Here we see this nice curve in the patient's

2:14

neck, without evidence of hematoma.

2:17

Fat planes looking pretty good on the right side.

2:19

On the left side, where the enlarging hematoma

2:22

was noted, here we see some residue

2:25

of course, from his prior hematoma that has

2:27

deformed the curvature of the neck.

2:29

And here we see our stent alive

2:31

and well with patent blood flow

2:33

throughout the subclavian artery.

2:37

So what we want to know and what we want

2:38

to sort of recognize is that vasospasm

2:40

is a potential complication in any

2:42

interventional radiology procedure, or any

2:44

endovascular procedure for that matter.

2:46

Active conscious extravasation can also

2:47

be seen subclinically during an angiogram.

2:50

What we also want to recognize is that arterial

2:52

rupture may occur inadvertently during both

2:54

arterial, as well as venous access.

2:57

We want to manage coagulopathy and we

2:59

want to consider stent placement in

3:01

challenging cases of arterial extravasation.

3:03

And of course, this is a tool, a bird in the

3:06

hand, an ace in the hole, which is digital

3:08

compression should be applied with or without

3:11

protamine sulfate to neutralize heparin.