Migration of doctors: should we apply the index of happiness?

The use of a covered stent is a safe minimally invasive endovascular procedure, which can be performed under a local anaesthetic. On reviewing the literature1, arterial injuries treated with endovascular repair were associated with a shorter operative time, less blood loss and one year patency rates. New results were similar to those following open repair. Schoder et al2 reported successful deployment of covered stent, with a complete seal achieved in all cases. Though less invasive, the endovascular procedure is not risk free. Our patient recovered without developing any complication, however, literature reports about 17% procedural complication rate.2 Groin haematoma, transient ischaemic attack and stroke are possible risks. These patients need regular follow up to check stent patency. Clinical assessment by checking brachial blood pressure on both arms is safe and accurate. If there is any doubt, CT angiogram should be considered. Dannetz et al3 presented series of 46 patients of penetrating injuries of the axillosubclavian artery; 50% were treated with endovascular techniques. Bartorelli et al4 presented a case report on two iatrogenic subclavian artery injuries which were both treated by endovascular techniques without endograft occlusion, migration, deformation or fracture during follow up at 12 and 10 months respectively. Subclavian artery injury is a known complication of Hickman line insertion, but actual incidence of this is unknown. In many cases, the injury might be undetected unlike this case, where the coagulation profile was deranged. Trauma related arterial injuries can be managed successfully by endovascular covered stent. Based on our case report, it appears to be an appropriate treatment in comparison to open surgical repair, as it has less complications like decreased blood loss and reduced requirements for anaesthesia. However, in patients with deranged coagulation profile, prior correction followed by open surgical insertion of HL may be safer than insertion under fluoroscopic guidance.