A 28-year-old female presented to our level one trauma center after being ejected 20 yards during an MVC. On arrival she had a Glasgow Coma Score of 14 and was complaining of inability to feel and move her lower extremities, and of back pain worse with movement. She was transported from the trauma bay to the computed tomography (CT) scanner for trauma imaging workup. Her initial CT chest, abdomen, and pelvis with intravenous contrast revealed multiple thoracic injuries including a mediastinal and periaortic hematoma with several areas of contrast blushing, the largest adjacent to the azygos vein suggestive of venous hemorrhage (Fig. 1). Additionally, a sternum fracture, multiple rib fractures, complex T4 and T5 vertebral body fractures with osseous fragment within spinal canal, and concurrent perched facets at this level with multilevel spinous process and transverse process fractures were found. There were trace bilateral hemopneumothoraces and bilateral pulmonary contusions.
Interventional radiology (IR) was then consulted to address the mediastinal hemorrhage concerning for arterial and/or venous injuries. In the interim the patient was transferred to the trauma intensive care unit (TICU) and during this transfer she experienced bradycardia and loss of respirations requiring one round of advanced care life support (ACLS) that resulted in return of spontaneous circulation after intubation. She was also hypotensive to 74/55 mmHg, requiring 5 units of intravenous fluid (IVF) and 3 units of packed red blood cells (pRBC).
Patient arrived in the interventional suite in in class III hypovolemic shock. The right common femoral artery was accessed in standard retrograde fashion. Thoracic aortography was performed in orthogonal left anterior oblique (LAO) and right anterior oblique (RAO) projections. This confirmed normal course and caliber of the thoracic aorta, proximal great vessels, and internal mammary arteries and no extravasation or arterial injury to any of these structures.
After exclusion of a thoracic arterial injury, the right common femoral vein was accessed in standard antegrade fashion. Superior venocavogram was performed in the LAO and RAO orthogonal projections. Due to CT findings suspicious for azygous vein injury, a 5Fr Cobra catheter was introduced over an 035 Glidewire and manipulated across the azygous/superior vena cava (SVC) junction into the distal azygous vein. With an 0.018″ V-18 wire in place, pullback azygous venogram was performed in steep RAO and LAO projections confirming a pseudoaneurysm at the superior aspect of the azygous arch and extravasation from the inferior aspect of the azygous arch (Fig. 2).
Based on these injuries, the decision to place a stent-graft across this azygous arch segment was made. The Cobra catheter was advanced back into the azygous vein and the V18 microwire was removed for an exchange length 0.035″ Rosen wire. The Cobra catheter and 5Fr sheath were then removed and an 8Fr × 45 cm Pinnacle Destination sheath was advanced over the Rosen wire and positioned in the mid superior vena cava. Over the Rosen wire, an 8 mm × 5 cm Viabahn stent-graft was positioned across the azygous arch and deployed. Spot fluorography of the chest was obtained, confirming good stent-graft coverage of the areas of injury. Repeat azygous venography with pullback was performed confirming good coverage of the injury sites, no further extravasation, and good antegrade flow of contrast through the azygous arch into the SVC (Fig. 3). The catheter was then removed. The arterial and venous sheaths were removed, and hemostasis was achieved with manual pressure.
The patient tolerated all aspects of the procedure well and there were no immediate complications. She left the procedure suite in guarded condition. The patient had a repeat episode of hypotension after she returned to the TICU, at which time she was started on vasopressors. She was slowly weaned off of all pressors by post-procedure day 6. She underwent several other surgeries and procedures with a variety of services including neurosurgery, general surgery, pulmonology, and insertion of an abdominal drain with IR. She had no complications related to the azygous stent placement which was patent on follow-up CT chest performed on post-procedure day eight. Unfortunately, she remained paraplegic due to her severe spinal injuries.
Additional follow-up was obtained 2 years post-procedure, at which time the stent continued to appear intact and without evidence of endoleak or other malfunction. Patient has had no further medical care or imaging within our system related to her azygous injuries.