ALBANY — A woman in her 80s presented to an emergency department in Albany with a 16-inch flathead screwdriver protruding from the right side of her neck into her thorax. Approximately 4 inches of the screwdriver shaft was visible in the right lower neck upon arrival.

The patient was using a screwdriver to pop fasteners off a pool cover when she tripped and fell, landing on the tool. Upon her arrival at the emergency department, there was no pulsatile bleeding. CT angiography revealed that the aorta had been nicked by the screwdriver while it remained in place. Medical Student Malena Allbright stated, "The aorta is the biggest artery in your body and, if nicked, that blood will come out with high pressure, and patients can bleed out fairly quickly."

A clinician drove to the scene following a 911 call and arrived before the ambulance to ensure the screwdriver was not moved. Allbright noted, "Had somebody removed it before she got to an emergency room, she probably wouldn't have survived." The patient received 1 unit of blood in the emergency department and an additional 2 units during transport to the operating room. A massive transfusion protocol was enacted, and the patient received 5 units of packed red blood cells in total.

The patient was transferred to a hybrid operating room one hour after her arrival. Trauma, vascular, and cardiothoracic teams were present. The clinical team chose to use thoracic endovascular aortic repair (TEVAR) to repair the patient's aorta from the inside. Allbright explained that TEVAR was chosen over open sternum surgery because older adults do not have the same rehabilitation strength as younger patients. She added, "So seeing it being used in a penetrating injury from a contaminated screwdriver in an older patient kind of pushes the boundaries of what we know about how this procedure can be used."

The team attempted to intubate the patient but was unsuccessful due to edema of the airway, leading to an emergent open tracheostomy. The team gained femoral arterial access through both sides of the groin to visualize bleeding and deliver a stent graft. A stent graft was then inserted and opened in the necessary area to seal off the bleeding. Imaging confirmed no residual bleeding before the screwdriver was removed. The team did not irrigate the wound due to the numerous important vascular structures and anatomy that could not be visualized. Only about 25 published reports of penetrating thoracic aortic injuries have surfaced in the last decade, and none of those were repaired using TEVAR. The infectious diseases team prescribed a one-month course of cefadroxil.

Three days after her operation, the patient developed atrial fibrillation and was given an amiodarone infusion. Twelve days after surgery, while taking a blood thinner, she developed black, tarry stools and acute blood loss anemia. An endoscopy revealed a duodenal bulb ulcer with a clot, and the blood thinner was subsequently stopped. The patient was discharged after successfully completing a repeat swallow study, resuming a normal diet, and having her tracheostomy removed. Yearly imaging surveillance has shown a stable graft without aneurysm or pseudoaneurysm formation.