Vascular blow-out syndrome is a life-threatening condition consisting of carotid artery rupture, usually secondary to direct tumor involvement in advanced head and neck cancers, which is rarely described in the peripheral circulation [6]. In this study, a case of peripheral blow-out at a rare site and its endovascular treatment under emergency conditions are presented. In the literature, no case of femoral artery blow-out due to squamous cell carcinoma of the skin has been reported.
There are several case reports of femoral blow-out that were treated with repair of the rupture in the vessel by urgent surgery and then treated with plastic reconstruction [5]. In an ulcerated, edematous and infected area, traditional open surgery carries a risk of poor wound healing in these patients who also have other serious illnesses. Also, curative surgery is not possible in an advanced malignancy environment. Considering the general condition of the patient, a major surgery including vascular reconstruction and extensive excision is required. Instead, in recent years, the minimally invasive endovascular approach, including major vascular occlusion, embolization of vascular damage, or placement of a covered stent, has become an effective alternative to open surgery in these high-risk patients. Endovascular treatment controls bleeding with high success and low complication rates, and minimal ischemic injury has occurred due to the procedure [3, 6].
Stent-grafts are widely used with high success in emergency endovascular treatments including trauma and bleeding of various arterial lesions in the body [7]. Polytetrafluoroethylene coated nitinol stent grafts (Gore Viabahn and Bard Fluency) are the most commonly used coated stents [8, 9]. They are placed to cover the damaged part of the artery to repair the vascular wall. Stent-grafts also have their own complications. These can be counted as stent occlusion, deformation, intimal hyperplasia and loss of branches. The most prominent complication among these is occlusion, which is reported in the literature at a rate of approximately 17% [10]. Balloon expandable stent-grafts provide more accurate positioning and size selection, but are more prone to deformation and crushing [11]. Self-expandable stent-grafts are more flexible and more resistant to crushing with external forces. For this reason, self expandable stent grafts should be preferred in the main femoral artery, which is the joint region as in our patient, and in carotid artery lesions, which have a superficial localization [11]. In addition, self-expandable stent-grafts should be preferred when a longer grip area is required in the vessel [7]. After stent placement, instent balloon angioplasty may be necessary to increase the diameter of the stent and to ensure that the graft fits tightly to the artery wall [12].
In the treatment of an active bleeding secondary to iatrogenic, traumatic or spontaneous arterial lesions at the level of an important vascular structure such as the common femoral artery, the primary goal is always the preservation of the parent artery. In such large vessels, the use of a stent graft should be the first choice in order to protect the outflow in cases where the bleeding point can be passed by the guidewire and a healthy lumen can be reached distally [7]. In cases where the patent lumen distal to the hemorrhage cannot be reached, parent artery occlusion emerges as another endovascular treatment option for life-threatening hemorrhage control.
Stent occlusion is one of the main complication encountered during follow up. Dual antiplatelet therapy is recommended after treatment of non-traumatic peripheral arterial occlusion or stenosis with stent graft. However, optimal antiplatelet therapy in patients with active bleeding treated by using stent graft is not clear [13]. In a meta-analysis, it was reported that in all studies it was recommended that patients should use at least one antiplatelet agent, ranging durations from 3 months to lifelong [14].
