Abstract
A male patient aged 49 years presented to the emergency room after sustaining a nail-gun injury to the left neck (Zone III). Computed tomography (CT) angiogram demonstrated retained nail traversing in close proximity to the left internal carotid artery. Catheter angiogram with three-dimensional (3D) reconstruction revealed partial left internal carotid injury without active extravasation and with preserved flow through the vessel. The nail was removed by gentle traction with the simultaneous deployment of stent-graft across the injured segment. Balloon angioplasty of the stent was performed secondary to endoleak and active extravasation. Complete vessel reconstruction with maintained blood flow was achieved. The patient was extubated the following day and was discharged home on hospital day five without neurological deficits. This case report demonstrates the usefulness of endovascular repair of high cervical arterial injuries with special attention to the unique nature of nail gun injuries.
Highlights
Penetrating and blunt trauma of the neck has the potential for catastrophic vascular, airway, digestive and nervous system injury
We present a unique nail gun injury to the neck zone 3 with an injury to the left internal carotid, which was successfully treated with simultaneous nail removal and endovascular repair with a covered stent
Initial angiography did not clearly indicate injury to the carotid artery and the injury was confined to the carotid canal the nail was removed by gentle traction
Summary
Penetrating and blunt trauma of the neck has the potential for catastrophic vascular, airway, digestive and nervous system injury. Limited tissue injury should be expected due to the low velocity of the projectile as compared to gunshots or explosive devices [4] In this case report, we present a unique nail gun injury to the neck zone 3 with an injury to the left internal carotid, which was successfully treated with simultaneous nail removal and endovascular repair with a covered stent. Left common carotid angiography in the neck demonstrated preserved flow through the left internal carotid artery but significant vessel narrowing at the level of the nail (Figure 3). Follow-up angiography demonstrated excellent flow through the stent but with active extravasation secondary to a proximal endoleak related to incomplete apposition of the proximal stent to the vessel wall (Figure 5) At this time, the anaesthesia team noted blood pooling in the oropharynx. The patient stopped his clopidogrel one week after the procedure due to financial reasons but continues on the aspirin regimen
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