When 15-year-old Mohan (name changed) was rushed to Apollo Hospital Bannerghatta during early – September, with a knife stab injury on the left side of his neck and profuse bleeding hardly did his parents imagine that he would be able to walk out of the hospital, completely fit and fine, within just about four days. Due to loss of 2 litres of blood from the wound, right at the accident spot and the critical positioning of the deep cut, it was a huge challenge to recover the teen from the situation and bring him back to normal life. When Mohan’s family had almost lost hope, the precision, expertise and presence of mind of Dr. Sunder Narsimhan, Senior Consultant, Vascular and Endovascular Surgery from Apollo Hospitals worked wonder and gifted a miracle cure to the young lad.
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Recreation of the entry wound of the stab wound on the patient
Mohan was presented with a stab injury at the left side of his neck along with an injury in the left forearm and nape of the neck. While earlier he received an initial treatment in the form of wound suturing in another hospital, he was shifted to Apollo Hospital for further treatment and management, keeping in mind the severity of his wound where major blood vessel go to the brain and the complex condition that needed an expert’s touch.
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Visual Representation of the Coil Embolization
For the doctor, it was a huge challenge, mostly due to two reasons. First, Mohan had lost a lot of blood and second location of the wound where the left vertebral artery was transected, making it difficult for the doctor to reach the location of the injury as it was inaccessible surgically as the artery runs to the brain through small bony canal of the spine.
Explaining the condition, Dr. Sunder Narsimhan said, “The boy had lost over 2 litres of blood at the accident spot following which he was taken to a nearby hospital where he got his wound sutured which slightly helped in controlling the voracious bleeding. After he was brought to our emergency, we did a quick CT scan that showed that the cut was through the blood vessels of his left vertebral artery. His life could not be saved unless the bleeding was stopped which is why we took him to the operation theatre without wasting any more time. As we removed the sutured wound, the bleeding increased profusely.”
“We had to take immediate measures to tackle the intense bleeding. We used some special material to pack the area of the wound to temporarily stop the bleeding. While we decided to conduct coil embolization, more specifically, an angio-embolisation of the vertebral artery, it was not possible to go forward with the procedure at the theatre. This was because he had not only lost a lot of blood by then but he also had very low blood pressure, only 50 mm of mercury as against the normal rate of 120 mm mercury. As a result, we adopted a noval strategy, sutured his wound again and shifted him to our cath lab to conduct the procedure,” Dr. Narasimhan added.
Apollo Hospital’s cath lab or catheterization laboratory is well-equipped with state-of-the-art diagnostic imaging equipment that the doctors use to visualize the blood vessels and arteries of the heart in order to treat critical anomalies.
Angio-embolisation is a minimally invasive procedure that seals the cut blood vessel. It is an endovascular procedure performed from inside the artery with the help of a steerable catheter inserted into the bloodstream and guided to the blood vessel (Vertebral Artery) going to the brain.
Dr. Narasimhan, Dr. Savith and Dr. Manju said, “After a thorough study, we conducted the procedure on him that enabled us to prevent blood loss completely from the vertebral artery. After three days we took him for a repeat CT scan, the report of which showed that there was no abnormality and he was doing good. Following this he was taken to the operation theatre, the pack was removed and the wound was sutured. During the surgery, we made sure that blood flow to his brain was not compromised. While one of his vertebral arteries was injured, the other vertebral artery and two other carotid arteries were in perfect shape and were functioning adequate enough to make sure that no blood flow to his brain was compromised.”
After the complex procedure, Mohan was in good health, had no neurological complications and was able to do all activities, as normally as anyone else.
Angio-embolisation also helped in preventing the risk of the false aneurysm which occurs in case of injuries to the blood vessel. False aneurysm refers to a collection of blood that forms between the two outer layers of an artery which may result in a blockage to the uninterrupted blood flow. After getting fully cured, Mohan was discharged from the hospital within four days.
Before performing this minimally-invasive procedure, the patient is given sedation. A needle is used to create a tiny surgical hole in the groin area, specifically in the femoral artery. Thereon, a small, flexible tube, also known as a catheter is inserted through the open skin and into the artery. contrast dye is injected through the steerable catheter into the artery which needs to be studied. On placing the catheter appropriately, the surgeon makes use of metal coils to close the bleeding blood vessel. In the case of endovascular embolization, several other materials, apart from metal coils, like small plastic particles, glue, foam can also be used to seal off the bad blood vessel.
Apart from treating deep wounds on the vertebral artery, as in this case, embolisation can be used to treat several other conditions including Arteriovenous malformation (AVM), Brain aneurysm, Carotid artery cavernous fistula and certain tumors.
A relatively new and unique procedure, coil embolization is mostly used to tackle emergency conditions and for medical conditions where open surgery is considered risky and the instruments of the doctor cannot reach the problem area manually. The primary goal of the procedure is to prevent bleeding in the problem area. Not just that, this procedure significantly lowers the risk of rupturing of blood vessels.
The embolisation procedure may take several hours and may involve risk if not conducted by expert hands. Such risks include bleeding at the site of the needle puncture, bleeding in the brain, damage to the artery from where the needle is passed through, dislodged coil, failure to treat the abnormal blood vessel accurately and wholly and post-procedural infection. This is where the need arises for expert endovascular surgeons like Dr. Narasimhan to successfully conduct the surgery with no related complications and risk, thereby saving a precious, young life.
Given the complicated nature of the procedure and tender age of the patient, not many hospitals and surgeons in the country are equipped enough to conduct this. The procedure requires in-depth knowledge, the immediate presence of mind, expertise and experience of doctors along with adequate infrastructure, Apollo Hospital with its pool of stalwart surgeons and the equipped facility has been successfully overcoming the complex crisis and gifting new lives to many.
