IATROGENIC LACERATION OF THE BRACHIOCEPHAILIC TRUNK AND RIGHT COMMON CAROTID ARTERY — A CLASSIC EMERGENCY

Abstract

Introduction: Iatrogenic vascular lesions are rare but potential complications of any surgical intervention at cervical level, with catastrophic consequences when not properly contained. Despite the importance of the vascular structures located at this level, literature on this subject is scarce, fact which reinforces its rarity. In a decade in which endovascular options became the standard treatment modalities in a wide range of pathologies, proper open surgical skills are still essential for the resolution of this type of problems.

Methods: The authors present a case report of iatrogenic laceration of the brachiocephalic, right subclavian and common carotid arteries during a cervical lymphadenectomy, successfully controlled and corrected by means of open surgery.

Results: Female patient, 49 years old, with previous medical history of total thyroidectomy and right cervical lymphadenectomy due to thyroid papillary carcinoma. Regular assessment in outpatient consultation was maintained, and at 5 years’ follow-up, bilateral profound lymph node metastasis was diagnosed, and re-intervention was planned.

During the right cervical surgical dissection, heavy arterial hemorrhage from the carotid sheath was noted, with no possibility for proper vascular control. Due to lack of access for tissue dissection and vascular control, sternotomy of the sternal manubrium was performed, and access to the upper mediastinum was granted. Laceration of the brachiocephalic trunk, and proximal segments of both the right subclavian and common carotid arteries were noted. Vascular dissection, isolation and control were rapidly assured.

Taking into account nature of the lesion and the fibrosis and the frailty of the surrounding tissues, direct suture was not possible, and so vascular reconstruction was performed by means of prosthetic grafts. In order to do so, interposition graft between the brachiocephalic trunk and the right subclavian artery was performed, after which new interposition graft was sutured between the right common carotid artery and the previous one. In both cases, PTFE grafts were used. Once arterial flow was restored, lymph node excision was performed as planned. Post-operation evolution was favorable, with no neurological deficits to report nor right arm ischemia, as the right radial pulse was present and strong. Doppler ultrasound evaluation performed at one-month follow-up revealed total integrity of the vascular grafts, with no anastomotic stenosis.

Conclusion: Iatrogenic vascular lesions are important surgical challenges, due to their seriousness, unpredictability, and need for quick intervention and control. In this endovascular era, proper domain of open classic surgical techniques is still essential to the daily practice of any vascular surgeon.