Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 83-85

Delayed thrombectomy firing the last shoot


Department of Vascular and Endovascular Surgery, Assuit University Hospital, Assiut, Egypt

Date of Submission10-Sep-2020
Date of Decision15-Mar-2021
Date of Acceptance03-May-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Mohammed Shahat
Department of Vascular and Endovascular Surgery, Assuit University Hospital, Assiut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_127_20

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  Abstract 


Cervical carotid artery not common entity trauma, especially the blunt one. here, we are presenting a case of animal bite in the neck which caused internal carotid artery (ICA) thrombosis ICA. The patient showed rapid deterioration in the first 24 h that make us obliged to do thrombectomy patient show partial improvement after the surgery. ICA delayed thrombectomy may play role in the management of late ICA thrombosis.

Keywords: Blunt trauma to the internal carotid artery, camel bite, delayed thrombectomy, internal carotid artery delayed thrombosis


How to cite this article:
Shahat M, Elayoon HA. Delayed thrombectomy firing the last shoot. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:83-5

How to cite this URL:
Shahat M, Elayoon HA. Delayed thrombectomy firing the last shoot. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Nov 28];8, Suppl S1:83-5. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/83/324927




  Introduction Top


Cervical vascular injury is difficult to be assessed and managed due to narrow anatomical space filled by complex structure, the injury may be masked by associated injury of the head, thorax, abdomen, also the neurological manifestation may not appear at the time of the trauma its appearance may be delayed. The animal bite is underestimated public health issue especially in developing and tropical, Saharan areas, lack of registration makes this problem hidden and makes the recommended health care delayed for the victim. Camels bite is prevalent in Arabian areas and its teeth usually penetrate deeply with the neck area make approaching the camels very dangerous with a morbid sequel. Camel mandible anatomy makes him deadly weapon when used for biting with its huge teeth with sharp canines large incisors, associated with his bad temper in rutting season make camel bite unique problem which rarely mentioned in literature except in few papers.[1]


  Case Report Top


Male patient 35 years presented to our ER 1 day after camel biting the neck region about 30-h patient was stable 130/80 pulse rate was 85 b/m with oral temperature was 37.2°C. Teeth marks were on the right side of the neck with a small puncture wound.

Carotid pulsation was feeble in the right side in comparison to the other side of the neck. The neurological examination revealed motor aphasia with lt sided hemiparesis 2/5 in both upper and lower limbs. Normal pupillary reflexes, positive Babinski sign. But the patient conscious, awake, aware of surrounding and obey commands. The relatives claim that he was talking and develop progressive weakness of his muscles. He received tetanus toxoid. Computed tomography (CT) scan was done which showed no abnormality in the brain then CT angiography (CTA) of the neck vessel showed complete occlusion of the common carotid artery (CCA) with fresh thrombus inside which is confirmed by duplex us which shoed dissected flab with floating thrombus inside no flow detected inside the internal carotid artery (ICA). Trickling flow in external carotid artery (ECA).

Hematological lab investigation shows no abnormality due to the delayed presentation we decided on initial conservative management by therapeutic dose anticoagulation with low-molecular-weight heparin (LMWH) and follow-up of the patient. The patient then developed deterioration of the conscious level complete hemiplegia, so we choose to do delayed thrombectomy.

Under regional anesthesia the neck explored dissection and isolation of CCA, ICA, ECA was done with great caution to avoid more embolization of the distal intracranial vessels distal healthy free thrombus zone of ICA was identified and clamped then CCA and ECA were clamped after full heparinisation. The site of hematoma and bruising in CCA was identified and opened thrombus evacuation and retrograde flush to make sure of the evacuation of all thrombus excision of the dissected part [Figure 1] and [Figure 2] and replaced by saphenous vein interposition graft we prefer this to avoid usage of the prosthesis in potentially septic field [Figure 3] and [Figure 4].
Figure 1: Neck exploration evacuation of thrombus

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Figure 2: Isolation of dissected segement

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Figure 3: Patch closure of the carotid bulb

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Figure 4: Removal of internal carotid artery clamp after reconstruction

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The incision was closed in layers over negative suction drains.

The 1st postoperative day passed uneventful patient had the same degree of disturbance of consciousness, complete hemiplegia. On the 2nd postoperative day, his neurological condition worsened and he had to be placed on a mechanical ventilator. Neurology consultation and CT revealed hyperperfusion with brain edema that is managed by mannitol and antiedematous measures. This led to improvement in his conscious levels with partial improvement in the motor power 1/5 in both upper and lower limbs.

The patient received antiplatelet, LMWH, metronidazole, amoxicillin-clavulanic, fluoroquinolone.


  Discussion Top


Despite well-established guidelines for surgical management of carotid injury, animal bite management is not well studied because most of it occurs in developing countries and it is a rare and uncommon entity. There is no estimated incidence worldwide but estimated incidence for camel bite at all about 1.5/100.000 in the Arab united emirates.[2]

The mechanism of injury for camel bite is complex it is either penetrating crushing injury from his long sharp teeth. Or blunt injury as the camel can lift his victim and throw them on the ground. Usually, 8% of camel bite is in the neck. In most of the cases, it occurs from March to November due to increase in sexual activity with an accompanying increase in the level of aggression.[3]

Small wound or puncture wound with lack of awareness and lack of symptoms and signs may delay the diagnosis. Neurological manifestation can range from transient ischemic attacks, hemiparesis hemisensory loss, hemiplegia, hemianopsia. Furthermore, the neurological symptoms can be out of proportion to the conscious level.[4]

The patient with hard signs of vascular injury should be managed by immediate exploration and correction these signs are pulsatile or expanding hematoma, a bruit over the vessel, absent pulse, distal ischemia, active bleeding. Hemodynamically, stable patients should be managed by imaging modalities CT is considered the main workhorse in evaluating this kind of injury with CTA for vascular evaluation, CT brain for brain state evaluation.

We should consider early and aggressive use of antithrombotic medication to prevent progression of the deficit reduce the chances of stroke, provided there is no contraindication.[5]

Surgical management should be done promptly delayed management has emerged as a controversial issue as some claim it may produce more harm by reperfusion injury, edema, hemorrhagic transformation, and resultant uncal herniation, death.[6]

There is no marker to predict benefit from revascularization except the time usually <24 h. However, no evidence prohibits the delayed revascularization that is accomplished by appropriate surgical intervention.[7],[8]

The use of great saphenous vein as a conduit is best to replace ICA with liberal applications of antibiotics and tetanus toxoid.


  Conclusion Top


Camels is considered dangerous their bite penetrate deeply and causing fatal consequences.

Delayed ICA thrombectomy may be used for stabilization of neurological condition of the patient but should be used cautiously with keeping an eye on reperfusion syndrome.

Declaration of patient consent

Written informed consent to publish this information was obtained from study participants person “Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient. A copy of the consent form is available for review by the Editor of this journal.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bregman B, Slavinski S. Using emergency department data to conduct dog and animal bite surveillance in New York City, 2003-2006. Public Health Rep 2012;127:195-201.  Back to cited text no. 1
    
2.
Abu-Zidan FM, Eid HO, Hefny AF, Bashir MO, Branicki F. Camel bite injuries in United Arab Emirates: A 6 year prospective study. Injury 2012;43:1617-20.  Back to cited text no. 2
    
3.
Abu-Zidan FM, Hefny AF, Eid HO, Bashir MO, Branicki FJ. Camel-related injuries: Prospective study of 212 patients. World J Surg 2012;36:2384-9.  Back to cited text no. 3
    
4.
Ahmadi J, Levy ML, Aarabi B, Giannotta SL. Vascular lesions Resulting from Head Injury. Neurosurgery. Vol. 2. New York: McGraw-Hill; 1996. p. 2821-40.  Back to cited text no. 4
    
5.
Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr, Johnson JL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 2004;139:540-5.  Back to cited text no. 5
    
6.
Kuehne JP, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal carotid artery. Arch Surg 1996;131:942-7.  Back to cited text no. 6
    
7.
Asensio JA, Vu T, Mazzini FN, Herrerias F, Pust GD, Sciarretta J, et al. Penetrating carotid artery: Uncommon complex and lethal injuries. Eur J Trauma Emerg Surg 2011;37:429-37.  Back to cited text no. 7
    
8.
du Toit DF, van Schalkwyk GD, Wadee SA, Warren BL. Neurologic outcome after penetrating extracranial arterial trauma. J Vasc Surg 2003;38:257-62.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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