Letter to the Editor: Bare metal stents in upper extremity arterial trauma - rethinking an underused solution for complex injuries

Abstract

Upper extremity arterial trauma remains a challenging clinical entity, often complicated by concomitant orthopedic, neurologic and soft-tissue injuries. In this issue, Chen et al published in World Journal of Cardiology present a decade-long retrospective analysis evaluating the clinical performance of bare metal stent (BMS)-assisted endovascular repair for upper limb arterial injuries, offering compelling evidence that BMS may play a more significant role than previously appreciated. They describe a refined “working track” technique to restore luminal continuity across traumatic arterial disruption, followed by overlapping BMS placement. In their cohort, BMS-assisted repair demonstrated durable patency over long-term follow-up. Importantly, the BMS group achieved better functional recovery, reflected by significantly lower Disabilities of the Arm, Shoulder and Hand scores than controls. These findings highlight not only the mechanical resilience of modern stent platforms in anatomically mobile segments but also the potential of BMS to minimize thrombosis risk, challenging the traditional bias favoring graft interposition or covered stents in trauma settings. Despite limitations inherent to retrospective and incomplete follow-up data, this study adds important real-world insights to an underexplored domain of endovascular trauma management. The work by Chen et al underscores the need for prospective, randomized controlled studies to clarify the optimal role of BMS in upper extremity revascularization and invites the interventional community to reconsider long-standing paradigms in limb-salvage strategies.

Key Words: Upper extremity arterial trauma; Bare metal stent; Endovascular repair; Vascular reconstruction; Stent overlap; Trauma revascularization

Core Tip: Long-term outcomes of bare metal stent (BMS)-assisted repair for upper limb arterial trauma using a “working track” end-to-end technique with strategic stent overlap. Their BMS cohort achieved 100% patency and better functional recovery by Disabilities of the Arm, Shoulder and Hand score compared with non-BMS repairs. By preserving branches and demonstrating durability in mobile arterial segments, BMS may be an underused, limb-salvaging option in selected traumatic injuries. Prospective studies are needed to define patient selection, antithrombotic regimens and comparative effectiveness.

TO THE EDITOR

Major vascular injuries of the extremities remain among the most consequential problems in trauma care, carrying substantial risks of death, limb loss and long-term disability[1]. They arise through penetrating, blunt, or iatrogenic mechanisms, with the injury pattern reflecting the mode of trauma. Blunt force typically produces closed arterial damage ranging from intimal disruption with secondary thrombosis to more severe intimal tears that can propagate dissection, aneurysmal change, luminal occlusion and distal ischemia. When combined intimal/medial injury leads to arterial dilation, traumatic true aneurysms may form. In contrast, penetrating trauma more often causes partial or complete transection, sometimes evolving into pseudoaneurysms or arteriovenous fistulas[2].

As upper limb trauma becomes increasingly common, management of major arterial injuries must prioritize both survival and durable limb salvage[3]. Alongside conventional surgical options, such as primary anastomosis, graft interposition and vessel transposition, endovascular methods have been adopted more frequently in recent years[4]. Yet the literature still lacks robust, systematic comparisons of reconstruction strategies, particularly with respect to long-term functional recovery after revascularization[5]. Against this background, Chen et al[6] published in World Journal of Cardiology provide an interesting case-control analysis evaluating bare metal stent (BMS)-assisted endovascular repair for upper limb arterial trauma, with follow-up extending beyond three years. In their decade-long retrospective cohort (n = 79 arterial injuries), 15 patients underwent BMS-assisted reconstruction and long-term follow-up data were available in 54 patients (including 13 BMS-treated).

Two aspects of the report deserve emphasis[6]. First is the pragmatic technical innovation. Building on end-to-end anastomosis, the authors describe creation of a “working track” bridging transected ends to facilitate controlled intraluminal stent alignment. They then intentionally overlap BMS to reinforce the repair and modestly reduce the effective lumen diameter at the overlap zone, aiming to lessen flow separation and stent-related thrombosis.

In traumatic transections, luminal discontinuity and jagged edges create turbulence, platelet activation and early occlusion[7]. At the same time, the “working track” approach prioritizes coaxiality and a low-shear scaffold, a concept familiar to coronary chronic total occlusion operators[8]. The overlap strategy also echoes multilayer flow-modulation principles used in other vascular beds, potentially compensating for the lack of a sealing membrane while preserving branch flow.

Second are the unexpectedly strong clinical signals. Among patients with long-term follow-up, the BMS cohort achieved 100% patency, no observed deformation or fracture and superior limb salvage and functional recovery compared with non-BMS surgical repairs. Most strikingly, Disabilities of the Arm, Shoulder and Hand (DASH) scores were markedly lower in the BMS group, suggesting that durable perfusion translated into better real-world arm and hand use rather than being a purely angiographic success. Prior endovascular trauma evidence is largely limited to small series, often mixing covered and bare platforms and focusing on patency alone. Chen et al[6] extend the literature by incorporating functional endpoints (DASH) alongside durability and limb salvage outcomes[9-12]. The field has lacked functional data at multi-year horizons following traumatic upper limb revascularization, making this contribution clinically meaningful.

BMSs have historically been treated as second-line tools in peripheral trauma, commonly reserved for dissections, intimal flaps, or as adjuncts to pseudoaneurysm repair. Several biases fuel this pattern: Concern about stent fracture near joints, skepticism about incomplete sealing in frank ruptures, and preference for conduit interposition in contaminated wounds. Supporting data also exist beyond the present series. Li et al[12] reported 16 patients with arterial injuries at joint levels treated with nitinol BMSs, with a mean follow-up of 73 ± 14 months, and observed no migration, deformation, or fracture despite the mechanically dynamic anatomy. Although one acute thrombosis and two late restenosis occurred, these findings reinforce that modern BMS can remain durable across joint-adjacent segments when appropriately sized and deployed. Chen et al[6] challenge each assumption. Their use of flexible nitinol platforms with no fatigue failures during long follow-up speaks to the mechanical durability of modern stents in mobile arterial beds when landing zones and sizing are appropriate.

Moreover, in small-caliber, branch-rich upper limb arteries, BMS may offer practical advantages over covered stents by preserving side-branch patency and maintaining physiologic flow patterns. With appropriate sizing, deployment technique and antiplatelet therapy, modern nitinol BMS can achieve durable remodeling with acceptable thrombotic risk. The authors’ overlap technique is an intuitive attempt to mitigate the chief weakness of BMS, residual turbulence at irregular lesions, without paying the branch-occluding price of a covered stent. Finally, the endovascular approach shortened operative time and limited soft-tissue disruption, a nontrivial advantage in mangled limbs and unstable trauma physiology. However, interpretation should still be tempered by design limits. The retrospective nature and the incomplete follow-up, as well as the BMS cohort that was also small, leaving uncertainty about uncommon late events, are important. These caveats do not negate the findings, but they define the questions that need prospective testing.

This study does not claim that BMS supersede open surgery or covered stents for all upper extremity arterial injuries. Instead, it makes a sharper and more useful point: When paired with thoughtful intraluminal alignment and overlap reinforcement, modern BMS can deliver excellent long-term patency with measurable functional benefit in selected traumatic reconstructions. Chen et al[6] invite the interventional and trauma communities to reconsider legacy heuristics and to individualize repair choices based on mobility, branch preservation, wound biology and overall physiologic context.

FUTURE DIRECTIONS

The work by Chen et al[6] ultimately reopens an important conversation in limb-salvage strategy: In upper extremity trauma, should open conduit repair remain the default, or should BMS-assisted reconstruction be more actively considered when anatomy allows? Prospective, multicenter studies are needed to reduce selection bias and to define which lesion morphologies benefit most from BMS vs covered stents or open conduit repair. Future protocols should standardize peri-procedural imaging, quantify joint-adjacent mobility and incorporate biomechanics-focused surveillance for stent fatigue or fracture[13]. Equally important, trials or structured registries should test optimized antithrombotic regimens tailored to trauma patients, balancing stent patency against bleeding risk. Finally, functional endpoints such as DASH[14], adjusted for nerve and orthopedic injury severity, should become core outcomes, ensuring that revascularization success is measured where it matters most: Durable limb use.

CONCLUSION

Chen et al[6] provide real-world evidence that BMS-assisted repair, when executed with meticulous intraluminal alignment and strategic stent overlap, can achieve excellent durability and meaningful functional advantages in selected upper extremity arterial injuries. Their data challenge the reflexive preference for graft interposition or covered stents in all trauma settings and suggest that modern BMS platforms may be an underused tool for limb salvage. The study reframes BMS as a credible, branch-preserving and mechanically resilient option that deserves a defined place in contemporary upper limb trauma algorithms. However, given the retrospective design, modest stented cohort and incomplete follow-up, these findings should be regarded as hypothesis-generating and warrant validation in larger prospective, multicenter comparative studies.