Emergency Endovascular Stent Grafting of an Innominate Vein Injury Causing Hemothorax: The Double Balloon on a Single Wire Technique

Introduction

Arterial stent grafting has been extensively documented in the literature as a treatment for occlusive diseases ¹ or to exclude hemorrhages.^2,3 The application of stent graft in stenotic disease of central veins^4,5 has also been described; however, there are few reports on the use of stent grafts in emergency situations due to acute venous bleeding. Typically, central vein bleeding tends to self-limit, so intervention is rarely necessary. Landolff et al ⁶ described a case in which an injury to the right iliac vein, caused during percutaneous left atrial appendage occlusion, was treated with a 10-mm Bentley BeGraft. Gupta et al ⁷ previously reported the use of a stent graft to seal an iatrogenic injury of the innominate vein, which occurred during dialysis catheter placement; in that case, however, the patient was hemodynamically stable with the primary concern being catheter dysfunction. A systematic review by Smeets et al ⁸ reported very good outcomes for iatrogenic and traumatic venous injuries to the inferior vena cava and iliac veins treated with stent grafts.

Azizzadeh et al ⁹ described the use of 10-mm VIABAHN^® to treat an injury to right innominate vein and Altuwaijri et al ¹⁰ reported the employment of a GORE^® EXCLUDER (W.L. Gore & Associates, Flagstaff, AZ, USA) to exclude a rupture of the superior vena cava.

The GORE VIABAHN VBX balloon-expandable endoprosthesis (W.L. Gore & Associates) is a very versatile balloon-expandable stent graft which can be customized to a desired diameter but also overdilated beyond its nominal diameter according to the manufacturer indications. However, the pre-mounted balloon can dilate the stent graft only to its nominal measure, and a second, larger balloon is typically needed to further dilate the device. In case of stenosis, the chance of stent migration during the balloon exchange is minimal. However, if the device is deployed in a patent’s vein to manage a bleeding defect, blood flow could potentially push the stent graft away, leading to migration into the heart. Although rare, stent migration has been already described in central veins,^11–13 more commonly during the treatment of hemodialysis fistulae, and it could lead to severe valvular regurgitation, acute heart failure, arrhythmias, endocarditis, and tamponade. ¹⁴ In this report, we described our technique to treat a life-threatening injury of the left innominate vein (LIV) using the “double-balloon on a single wire” (double-BLOW) technique to adapt a VIABAHN VBX endoprosthesis.

Technique

A 61-year-old patient with heart failure with reduced ejection fraction (5/12) was deemed unsuitable for heart transplantation due to comorbidities. The patient was initially implanted with an implantable cardioverter defibrillator (ICD) in 2011. In 2023, he experienced multiple hospitalizations due to a progressive worsening of his clinical condition. By 2024, he was referred for ICD replacement to upgrade to a cardiac resynchronization therapy defibrillator.

Following the procedure, a chest X-ray revealed minimal pleural effusion. However, the patient’s hemoglobin level continued to drop from 10.5 to 7.9 g/dL, and he developed thrombocytopenia. One day later, a chest X-ray indicated an increase in the right-sided pleural effusion and the patient began to experience severe respiratory distress and desaturation. A contrast-enhanced computed tomography (CT) scan revealed active bleeding from a large defect (7 mm) in the LIV, with a significant blood collection extending behind the superior vena cava and along the wall of the right atrium into the right pleural cavity (Figure 1). The diameter of the LIV on CT was 15 mm. The patient was referred to the Interventional Radiology Department for diagnostic phlebography and treatment. The patient could not assume a supine position due to the worsening of the respiratory distress and desaturation; a 10F drainage catheter was positioned in the right pleura under ultrasound guidance, allowing for the immediate evacuation of approximately 1200 mL of blood, which improved the patient’s respiratory distress. An 8Fr venous access was placed in the left basilic vein. The phlebographic exam revealed a large defect with active extravasation of the contrast medium in the LIV.

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Figure 1.

(a) Axial contrast-enhanced CT revealed the presence of a small defect in the left innominate vein (red arrow); in this image we can also appreciate that the contrast media density in the defect is similar to those in the left axillary vein (white arrow), suggesting a probable venous origin of the bleeding. (b) Sagitta-reformatted CT effectively shows the defect (red arrow) on its large neck (yellow dotted line), while (c) a coronal reformatted maximum intensity projection reconstruction demonstrated the extravasation of contrast media (red arrows). (d) A phlebographic acquisition from the left arm confirmed the presence of an injury (red arrow) in the left innominate vein. CT, computed tomography.

Subsequently, a second operator established an 8F access via the right femoral vein, allowing access to the left subclavian vein through a hydrophilic guidewire and angled catheter to perform a rendezvous procedure. The guidewire was snared with a goose-neck catheter and externalized through the left arm access. A long catheter was used to replace the hydrophilic guidewire with a 0.035″, 260-cm super-stiff guidewire (Amplatz Super Stiff; Boston Scientific, Marlborough, Massachusetts, U.S.). The first operator placed a 11 × 59 mm GORE VIABAHN VBX in the LIV to cover the defect from the access in the left arm (Figure 2a). Simultaneously, a second 16 × 40-mm balloon catheter (AltoSa XL PTA Balloon; AndraTec GmbH, Koblenz, Germany) was positioned through the femoral access, in contact with the tip of the stent graft by the second operator. The first operator gradually dilated the VIABAHN VBX to the maximum diameter allowed by the pre-mounted balloon (11 mm, pressure = 12 atm) and then gradually deflated (Figure 2b). During the removal of the pre-mounted balloon, the partially inflated 16 × 40-mm balloon, was gradually pushed into the stent by the second operator and then inflated to the proper position to reshape the stent graft and effective sealing at the proximal and distal end of stent graft was obtained (Figure 2c and d). Final imaging confirmed complete exclusion of the previously identified defect and adequate blood flow through the stent (Figure 3a).

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Figure 2.

(a) After the externalization of the guidewire from the second access, the balloon-expandable stent graft (yellow arrow) and the larger balloon (blue arrow) were positioned using the same guidewire (arrowheads). (b) The balloon installed on the stent graft was inflated to its rated burst pressure which corresponded to a diameter of 11 mm. (c) The second balloon was gently advanced into the proximal part of stent and inflated (blue arrow) until its nominal pressure, which corresponded to a diameter of 16 mm, (d) to guarantee complete adhesion to the wall of the vein.

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Figure 3.

(a) Final phlebographic exam demonstrated complete sealing of the bleeding and an overdilated stent graft (red dotted arrow). (b) Contrast-enhanced CT performed 3 weeks from the procedure showed a good adherence of the stent-graft (red dotted arrow) to the left innominate vein and complete resorption of the right hemothorax. CT, computed tomography.

Compressive hemostasis was applied to the arm access site, and the femoral access was replaced with a quadrilumen central venous catheter. A follow-up CT scan showed no signs of venous bleeding (Figure 3b), and subsequent hematocrit testing revealed an increase in hemoglobin levels to 94.0 g/L.

Discussion

Innominate vein perforation is a rare mechanical complication reported during the placement of central venous catheters ¹⁵ and dialysis catheters ¹⁶ as well as during electrophysiologic procedures; such complications are more common when the left internal jugular is the site of access. ¹⁷

Most of these injuries do not result in extensive bleeding due to the low pressure in the venous system and can be managed conservatively; for more severe injuries, surgical sternotomy, or thoracotomy ¹⁸ as well as endovascular coiling have been described. ¹⁵ In 1 case by Zhou et al, ¹⁹ an injury created during catheterization for hemodialysis was addressed with selective embolization using cyanoacrylate and coils.

In our case, we believe that the combination of a large defect, a severe venous hypertension due to cardiac dysfunction and the intrathoracic negative pressure of the pleural space contributed to an “aspiration mechanism” that worsened the bleeding. Prompt diagnosis and treatment are crucial in such emergency situations. Given the diameter of the defect, we determined that a stent graft was the most effective solution to preserve the vein’s patency and control the bleeding. Direct catheterization and coiling of the defects, due to their wide necks, could have been challenging and might have resulted in suboptimal bleeding control outcomes.

The LIV typically measures 6 cm in length and 11 to 13 mm in diameter and present a distinctive curve in the mediastinum. ²⁰ Stent grafting of the LIV requires a device which is short in length and large in diameter, possibly with an additional 20% to 30% oversizing to seal-off bleeding; however, such devices are seldom available off-the-shelf for emergency. While aortic endoprosthesis have an adequate diameter, they are usually too long for central veins ¹⁰ and they should be custom-made to obtain the desired length as already described by Lee et al. ²¹

Although considered off-label, the employment of balloon-expandable stent graft in treating central vein occlusion or stenoses has already been described in literature ⁴ and in our case was justified by the life-threatening condition. In our case, the chronic heart condition has probably overdilated the central vein due to severe venous hypertension and our patients needed a larger stent graft to properly treat the bleeding.

The characteristics of the GORE VIABAHN VBX permit to over dilate the devices by more than 30% of its nominal diameter, but the pre-mounted balloon must be exchanged with a larger one. During this exchange, if the device is not ensnared in a stenosis, the polytetrafluoroethylene membrane may create a large surface area for blood flow that could lead to device migration. Additionally, during overdilation, the stent graft has a progressive shortening in length which is esteemed to be 25% to 30% by the manufacturer; these characteristics imposes a very high degree of precision during deployment.

In our case, we employed a novel technique to improve stability, prevent migration, thereby enhancing the accuracy of the stent graft’s deployment. The cores of the double-BLOW technique are the externalization of the guidewire through both accesses and the employment of a single guidewire for the stent graft and the larger balloon. Externalizing the guidewire enhances the stability of the system and serves as a “safety net” to prevent migration of the stent into the heart^11–13: even if undersized, the device would remain on the guidewire, and it could be pushed in a less troublesome area or recover through a surgical access in the femoral vein. This externalization technique also allows for the mounting of 2 devices from 2 different access points onto the same guidewire, even if the combined lengths of the 2 shafts exceed the guidewire’s length; this approach offers the chance to perform the balloon exchange in a very short time and to avoid stent migration with the larger balloon, which should be positioned always against blood flow.

Nevertheless, our technique has drawbacks: first, during the exchange, the second balloon may displace the stent graft. Second, compared to selective embolization, inadequate sealing, may result in suboptimal control of the bleeding.

In conclusion, stent grafting of the central vein is an effective method for controlling bleeding. In these situations, the VIABAHN VBX serves as a handy device. The “double-BLOW” design provides additional stability, reduces the time needed for balloon exchange, and enhances the precision of stent-graft deployment.