Regarding “Long-term results of stent graft treatment of subclavian artery injuries: Management of choice for stable patients?”

Abstract

We read with interest the article regarding stent graft treatment of 57 traumatic sublcavian arterial injuries.1du Toit D.F. Lambrechts A.V. Stark H. Warren B.L. Long-term results of stent graft treatment of subclavian artery injuries: Management of choice for stable patients?.J Vasc Surg. 2008; 47: 739-743Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar It is surprising that no mention was made of the vertebral artery. Certainly with stent grafts varying from 30 to 60 mm in length, the vertebral artery was covered in many (if not most) of their cases. If this is true, did they first determine if the contralateral vertebral artery was patent all the way to the basilar artery? After all, a hypoplastic vertebral artery is an uncommon, but real, entity. The authors reported that they treated 39% of their subclavian injuries with stent grafts and believe that up to 50% of such injuries could be treated in this fashion. Does proximity of the subclavian injury to the vertebral artery origin play a role in the 50% who cannot be treated endovascularly? Also of interest is the statement that a stent graft cannot be used if there is much of a difference in arterial diameters at the proximal and distal landing zones. Except for their 12 cases of arteriovenous fistulae, the diameter of a subclavian artery should not change much from proximal to distal. Even if it did, Fluency stent grafts (Bard, Tempe, Arizona) have been shown to have minimal infolding when oversized up to 3 mm relative to the vessel. How often would proximal to distal subclavian diameter ever be a problem? Overall, we found this series of 57 subclavian arterial injuries treated endovascularly without limb loss or other incapacitating symptoms to be impressive. However, we would like to have seen a discussion of the vertebral artery and believe that proximal and distal luminal discrepancy of the subclavian artery would be a rare contraindication to stent graft placement. ReplyJournal of Vascular SurgeryVol. 49Issue 1PreviewWe appreciate the interest of Drs Smith and Carlson in our article reporting the long-term results of stent graft treatment of subclavian artery injuries.1 We thank them for the 2 interesting comments. We did not describe all the technical details of the procedure but did refer to our previously published article2 where the issue of the vertebral artery was discussed. We did cover the vertebral artery in many of the cases after confirming by angiography that a patent normal sized contra lateral vertebral artery with good cross flow into the Circle of Willis was present. Full-Text PDF Open Archive