Emergency vascular surgery_a_practical_guide


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Emergency vascular surgery_a_practical_guide

  1. 1. Emergency Vascular SurgeryA Practical Guide
  2. 2. Eric Wahlberg Pär Olofsson Jerry GoldstoneEmergencyVascular SurgeryA Practical GuideWith 68 Figures and 39 Tables
  3. 3. Eric Wahlberg, MD, PhDAssociate ProfessorKarolinska Institute and University HospitalDepartment of Vascular Surgery17176 StockholmSwedenPär Olofsson, MD, PhDAssociate ProfessorKarolinska Institute and University HospitalDepartment of Vascular Surgery17176 StockholmSwedenProfessor Jerry Goldstone, MDUniversity Hospital of ClevelandCase Western ReserveDivision of Vascular SurgeryCleveland, Ohio 44106USAISBN 978-3-540-44393-3 Springer Berlin Heidelberg New YorkLibrary of Congress Control Number: 2006936731This work is subject to copyright. All rights are reserved, whether the whole or part of thematerial is concerned, specifically the rights of translation, reprinting, reuse of illustrations,recitation, broadcasting, reproduction on microfilm or in any other way, and storage in databanks. Duplication of this publication or parts thereof is permitted only under the provisionsof the German Copyright Law of September 9, 1965, in its current version, and permis-sions for use must always be obtained from Springer. Violations are liable for prosecutionunder the German Copyright Law.Springer is a part of Springer Science + Business Mediaspringer.com© Springer-Verlag Berlin Heidelberg 2007The use of general descriptive names, registered names, trademarks, etc. in this publica-tion does not imply, even in the absence of a specific statement, that such names are exemptfrom the relevant protective laws and regulations and therefore free for general use.Product liability: The publishers cannot guarantee the accuracy of any information aboutdosage and application contained in this book. In every individual case the user must checksuch information by consulting the relevant literature.Editor: Gabriele M. Schröder, Heidelberg, GermanyDesk Editor: Stephanie Benko, Heidelberg, GermanyProduction: LE-TeX Jelonek, Schmidt & Vöckler GbR, Leipzig, GermanyDrawings: Medical Art, Gudrun and Adrian Cornford, Reinheim, GermanyTypesetting: am-productions GmbH, Wiesloch, GermanyCover design: Frido Steinen-Broo, eStudio Calamar, SpainPrinted on acid-free paper 24/3180 YL – 5 4 3 2 1 0
  4. 4. PrefaceEmergency Vascular Surgery – A Practical Guide provides a concise guide tomanaging patients with all kinds of emergent vascular problems. It is not in-tended to be a “classic” textbook, so the background information given is veryconcise. The focus is instead on management and treatment, especially opensurgical strategies. The text is written for newcomers to the vascular surgical field, for surgicaltrainees, and for all doctors who treat emergent vascular surgical patients inthe emergency department. We believe the hands-on approach and the practi-cal tips will be appreciated by these readers in the clinical situation, and wehope the book may also serve as a quick review before a physician takes care ofa case. Medical students during surgical clerkships might find parts of thebook valuable, as will experienced vascular surgeons. The book is organized into two sections: specific body areas and generalconcepts. The former covers the body from head to toe and includes separatechapters for injuries and for nontraumatic disease. In the second part, somegeneral principles related to emergency vascular surgical practice are dis-cussed. Management of complications is difficult to cover in a book of thisscope, so the principles given in the chapter pertaining to this area are not verydetailed. The final chapter gives general vascular surgical guidelines for theinexperienced surgeon. All chapters are organized the same way. They start with a brief backgroundthat aims to motivate the reader and give an idea of incidence and pathophysi-ology. The rest of the chapter follows the patient’s course through the hospital:The clinical presentation is followed by suggestions for work-up and diagnosis,and the next part concerns management and treatment – emergency treat-ment, selection of patients for emergency surgery, and ways to perform com-mon vascular surgical procedures. Technical tips on complicated proceduresare also provided. Finally, the chapters end with a brief summary on manage-ment after treatment, with some examples of outcome and results. Most chap-ters also contain illustrations to facilitate the technical description of the surgi-cal procedures and notes to highlight particularly important aspects. A fewreferences for further reading are also suggested; they have been selected togive a better understanding of the issues and do not necessarily refer to infor-mation given in the text. The authors would like to acknowledge and thank a number of people in-volved in the writing of this book. First, we are grateful to the initial authors ofthe Swedish book from 1998 that gave us the idea to expand its contents andwrite an English version of it. Thank you all for letting us continue in thisdirection. We are also very grateful to all the residents, vascular trainees, andvascular surgeons who have read chapters and given us valuable suggestions on
  5. 5. how to improve the content and structure. Last but not least, we acknowledgethe secretaries Annika Johansson and Synnove Nordstrom for all of their helpwith this project. Eric Wahlberg Pär Olofsson Jerry Goldstone Stockholm and Cleveland 2007
  6. 6. ContentsPart A Specific Body AreasChapter 1 Vascular Injuries to the Neck 1Chapter 2 Vascular Injuries to the Thoracic Outlet Area 15Chapter 3 Vascular Injuries in the Arm 31Chapter 4 Acute Upper Extremity Ischemia 41Chapter 5 Abdominal Vascular Injuries 45Chapter 6 Acute Intestinal Ischemia 65Chapter 7 Abdominal Aortic Aneurysms 75Chapter 8 Aortic Dissection 91Chapter 9 Vascular Injuries in the Leg 101Chapter 10 Acute Leg Ischemia 119Part B General ConceptsChapter 11 Vascular Access in Trauma 135Chapter 12 Complications in Vascular Surgery 141Chapter 13 Acute Venous Problems 159Chapter 14 Acute Problems with Vascular Dialysis Access 167Chapter 15 General Principles of Vascular Surgical Technique 179 Subject Index 191
  7. 7. Specific Areas PART A
  8. 8. Vascular Injuries to the Neck 1CONTENTS 1.1 Summary1.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Severe vascular injury after blunt neck1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . 3 trauma can be present even in the absence1.2.1 Causes and Mechanism . . . . . . . . . . . . . 4 of clinical signs. Penetrating Trauma . . . . . . . . . . . . . . . . . 4 Be liberal with duplex or angiography after1.2.1.2 Blunt Trauma . . . . . . . . . . . . . . . . . . . . . . . . 4 blunt trauma when cervical vessel injuries1.3 Clinical Presentation . . . . . . . . . . . . . . . 4 cannot be ruled out.1.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . 5 Associated injuries on the cervical spine,1.3.2 Clinical Signs . . . . . . . . . . . . . . . . . . . . . . . . 6 airway, and digestive tract must always be considered.1.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . 6 Always stabilize the neck of patients in all1.4.1 Penetrating Trauma . . . . . . . . . . . . . . . . . 6 types of severe cervical trauma until the14.4.2 Blunt Trauma . . . . . . . . . . . . . . . . . . . . . . . . 7 entire spectrum of injuries is known.1.5 Management and Treatment . . . . . . 8 If the patient is stable angiography should1.5.1 Management Before Treatment . . . . . 8 always be performed in penetrating inju- Management in the Emergency ries to zones I and III. Department . . . . . . . . . . . . . . . . . . . . . . . . . 8 If available, duplex or angiography is rec- Airway Obstruction . . . . . . . . . . . . . . . . . 8 ommended in zone II injuries in order to1.5.1.3 Immediate Operation select between conservative and surgical or Further Diagnostic Work-up? . . . . . 9 management. Which Patients Can Be Safely Transported? . . . . . . . . . . . . . . . . . 91.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . Preoperative Preparation 1.2 Background and Proximal Control . . . . . . . . . . . . . . . . Exposure and Repair . . . . . . . . . . . . . . . . 11 Traumatic injuries to the cervical vessels are rela- Exploration of Minor Injuries tively uncommon and constitute only about 5–10% and Hematomas . . . . . . . . . . . . . . . . . . . . . 12 of all vascular injuries. In about 25% of patients1.5.2.4 Injuries to the Vertebral Artery . . . . . . 12 with blunt head and neck trauma, the cervical ves- Venous Injury . . . . . . . . . . . . . . . . . . . . . . . . 12 sels are involved. The most common mechanism1.5.2.6 Endovascular Treatment . . . . . . . . . . . . 12 is penetrating injuries, but the incidence of blunt1.5.3 Management After Treatment . . . . . . 12 vascular trauma is probably underestimated be-1.5.4 Results and Outcome . . . . . . . . . . . . . . . 13 cause related symptoms are often vague and not Further Reading . . . . . . . . . . . . . . . . . . . . . 13 recognized. The patients are mostly young, and despite the low incidence, mortality and morbidity are very high. Mortality is, in most series, between 5% and 40%, and persistent neurological conse- quences are reported in up to 80% of patients. Mortality is not only caused by massive bleeding
  9. 9. 4 Chapter 1 Vascular Injuries to the Neck and cerebral ischemia due to embolization or The internal carotid artery is involved in more thrombotic occlusion associated with the vascular than 90% of these injuries, most commonly its injury, but also secondary damage to the aerodi- distal parts. Three to ten percent of all carotid gestive tract (e.g., airway compression from a large injuries are caused by blunt trauma. The true inci- expanding hematoma). dence is unknown, but a few reports cite figures The anatomical location and the often complex in the range of 0.1–1.1% of all blunt head and neck associated injuries make traumatic cervical vascu- injuries. The variation is related to the type of lar injuries extremely challenging. study performed and methodology used; some studies are retrospective, while others use screen- ing with angiography or computed tomography 1.2.1 Causes and Mechanism (CT). Blunt carotid injuries occur in motor vehi- cle, industrial accidents or after assaults. Injuries Penetrating Trauma to the vertebral artery are less common because The most common mechanism for cervical vascu- they are well protected by osseous structures. In- lar injuries is penetrating trauma. As shown in juries to the vertebral arteries are most commonly Table 1.1, the common carotid is the most fre- caused by intraoral trauma dislocated fractures or quently injured major artery. The type of penetrat- penetrating trauma. The mechanisms are the same ing trauma is most often stab wounds by knives, as in the internal carotid artery. but other mechanisms are high- or low-velocity The mechanism of injury is either a direct projectile and gunshot wounds, and bone frag- blow or hyperextension and rotation of the neck. ments from fractures. High-velocity penetrating In the latter type, the internal carotid artery is trauma can also cause secondary “blunt” injuries stretched over the body of the C2 vertebra and by a shock wave. the transverse process of C3, which causes an inti- mal flap with subsequent risk for embolism or dis- Blunt Trauma section and thrombotic occlusion. Other conse- Blunt trauma to the cervical vessels is thought to quences are development of a pseudoaneurysm be less than 0.5% of all blunt traumas to the body, or, in rare cases, even complete disruption of the but recent reports indicate that many blunt vascu- internal carotid at the base of the skull. In some lar injuries go undetected. reports, up to 50% of patients are reported to have bilateral vascular injuries after blunt trauma to the neck. Carotid dissection is also reported to occur after minor head and neck trauma, and to be associated with activities such as unaccustomed Table 1.1. Frequency of vessel and associated organ physical exercise; “heading” a soccer ball and injuries in penetrating injuries to the neck childbirth. Site of injury Major vessels 1.3 Clinical Presentation Arteries Common carotid artery 73% (10–15%) Internal carotid artery 22% External carotid artery 5% Common to all neck trauma is that many patients with severe vascular or other injuries present with Veins External jugular 50% (15–25%) Internal jugular 50% a clinical picture deceptively lacking obvious symptoms and signs of their injuries. Further- Other organs more, significant associated intracranial lesions, Digestive tract 5–15% multiple organ injuries, and alcohol or drug in- Airway 4–12% toxication often confuse the clinical picture. The Major nerves 3–8% history and clinical examination must be per- No involvement 40% formed with a high level of suspicion in order to of important structures achieve a good platform for the diagnostic evalua- tion and management.
  10. 10. 1.3 Clinical Presentation 5 1.3.1 Medical History hours or days from the injury to the appearance of neurological symptoms is common after bluntKnowing the mechanism of injury can provide carotid trauma. A frequent type of symptom is aimportant clues to the type of and potential vascu- typical transient ischemic attack but completelar injury. Information about the type and extent stroke or amaurosis fugax also occurs.of trauma should be obtained from the patient, Because the carotid is the most common in-paramedics, or relatives. In penetrating injuries, jured artery, it is essential to assess the patient’sinformation about external bleeding is important: mental status, including possible alterations dur-the magnitude and volume (brisk and pulsating or ing transport as well as transient, progressive, oroozing), the color (dark venous or bright arterial), permanent focal neurological changes. It is alsoand the duration (initial but stopped or ongoing). important to inquire about symptoms related toIn cases of brisk bleeding, injuries to the carotid associated cranial nerve injuries (see Table 1.2).artery or larger veins are likely. Symptoms of hy- Difficulties or pain with swallowing suggestpovolemia or shock during the course from inci- an esophageal injury and should increase the sus-dent to admission indicate significant blood loss. picion for associated vascular injuries. In bluntRespiratory problems indicates the presence of a carotid injuries, headache and/or cervical painlarge hematoma compressing the airway, which are the most common symptoms, followed bycould require immediate attention and manage- symptoms indicating cerebral or retinal ischemiament. A history of a symptom-free interval of (see Table 1.3). Neck wounds or bleeding from theTable 1.2. Examples of findings and symptoms in neck injuries Injury type Signs Symptoms Vascular penetration Artery or vein Bleeding, hematoma, swelling Bleeding, pain Carotid or vertebral Horner’s syndromea Hanging eye lid, headache Bleeding with tracheal Stridor, supraclavicular Dyspnea compression and intercostal retractions Embolization Hemiplegia/hemiparesis Weakness, numbness Arteriovenous fistula Bruit or thrill Swelling Cranial nerves Glossopharyngeal nerve IX Pharyngeal paresis, soft palate Difficulty swallowing hanging down Vagal nerve X Vocal cord paresis Hoarseness Accessory nerve XI Unable to shrug the shoulders Weakness Hypoglossal nerve XII Tongue deviation toward Difficulty swallowing the injured side Aerodigestive tract Subcutaneous emphysema Shortness of breath. Difficulty or pain with swallowing Hemoptysis Mandibular fracture Tenderness Pain, difficulty speakinga Caused by disruption of the blood supply (vasa vasorum) to the superior cervical ganglion or by direct injury to the sympathetic nerve plexus
  11. 11. 6 Chapter 1 Vascular Injuries to the Neck Table 1.3. Consequences of blunt injuries to the carotid artery Type of injury Mechanism Consequences Symptoms/signs Direct blow Rupture Hematoma Swelling and respiratory problems Pseudoaneurysms Bruit, swelling Intimal tear Thrombosis Stroke, focal neurology Rotation-extension Intimal tear Dissection Stroke, focal neurology Thrombosis Stroke, focal neurology mouth, nose, or ears after severe blunt cervical vascular injury are tenderness over the carotid trauma may be associated with injuries to the ver- artery and in the scalp. The most common associ- tebral artery. ated injury is fracture of the mandible. NOTE 1.3.2 Clinical Signs The physical examination can be negative despite severe vascular injury after blunt A penetrating injury is usually obvious at inspec- cervical trauma. tion of an open wound with signs of recent or on- going bleeding. A “sucking wound” suggesting a connection with the aerodigestive tract indicates 1.4 Diagnostics an increased risk for “proximity” injuries to the major cervical arteries (i.e., the vertebral arteries). 1.4.1 Penetrating Trauma Even minor external signs of penetrating trauma can be associated with a severe underlying vascu- The location of penetrating cervical injuries are lar injury. One example is the expanding hemato- generally divided into three different zones that ma. The reverse however, is also possible – a large are helpful for planning the diagnostic work-up hematoma compressing adjacent structures har- and management (Fig. 1.1). It is therefore impor- bored by the stiff fascial layers of the neck but tant to classify the localization of the injury into undetectable at inspection. Sometimes signs of zones according to this subdivision. The rationale airway obstruction reveal such injuries. Signs and for this lies in difficulties achieving proximal con- symptoms of penetrating cervical vascular trauma trol in zone I injuries and distal control in zone III. are summarized in Table 1.2. Exploration and the possibility of obtaining con- Half of the patients with significant blunt vas- trol are much easier in zone II injuries. cular injuries to the neck lack symptoms at admis- Patients with “hard signs” of major vessel inju- sion but develop symptoms and signs within 24 h. ry – shock, active brisk bleeding, rapidly expand- In blunt trauma, it is therefore important to per- ing hematoma (for discussion about the definition form a careful neurological examination at admis- of “expanding hematoma,” see Chapter 12, p. 149) sion to obtain a baseline for later comparisons at – and those with neurological deficit or severe the mandatory repeated examinations. The neu- airway obstruction should be transported to the rological evaluation should seek signs of central as operating room for immediate exploration and well as peripheral nerve injuries – alertness, motor treatment. and sensory function, reflexes in the extremities Patients with “soft signs” of major vessel injury – as well as signs of cranial nerve dysfunction (Ta- – history of bleeding, stable hematoma, and/or ble 1.2). It is important to thoroughly inspect for cranial nerve injury – usually need further work- signs of contusion, asymmetry, or deformity that up. This is also true for patients who don’t have indicate underlying hematomas and to note the signs, but who have an injury in proximity to ma- hematoma size for later estimation of possible jor vessels. This group constitutes the majority of expansion. Other physical findings indicating a penetrating neck injuries. The following recom-
  12. 12. 1.4 Diagnostics 7 tomas. Altered flow patterns indicating high resis- tance or abnormal turbulence can be associated with a lesion distally in the internal carotid artery. The developing experience of the duplex technique has prompted a policy change in some hospitals, and duplex ultrasound is used as the primary diagnostic tool for all injuries in stable patients. This examination is performed prior to the deci- sion about angiography or surgical exploration and irrespective of anatomic zone. In some cen- ters, therapeutic decisions are based on thin-slice high-speed CT scans instead. Gunshot wounds deserve special comment. All patients with such injuries should be screened with angiography or duplex ultrasound. Because associated injuries are common, CT scanning of the head, surgical spine, and aerodigestive tract should also be included in the diagnostic work- up.Fig. 1.1. Division of the neck into three zones aids in NOTEthe management of penetrating cervical vascular inju- Injuries not penetrating the platysmaries (Monson DO, Saletta JD, Freeark RJ. Carotid-verte- need no further vascular evaluation.bral trauma. J Trauma 1969; 9:987–999). Zone I extendsinferiorly from 1 cm above the manubrium to includethe thoracic outlet; zone II extends from the upper limitof zone I to the angle of the mandible; and zone III is 1.4.2 Blunt Traumabetween the angle of the mandible and the base of theskull The diagnosis of vascular injuries after blunt trau- ma is much more challenging. As previously not- ed, clinical signs and symptoms are frequently subtle or absent, and initial transient or late neu-mendations have been generally accepted in these rological deficits are common. The most com-cases: monly injured vascular segment is the distal inter- Zones I and III: With the exception of unstable nal carotid artery. Dissection, with varying de-patients, angiography is always indicated. The grees of luminal narrowing, is the most commongoals are detecting injury, planning an operation injury. Other types are pseudoaneurysm or evenpossibly requiring special exposures (e.g., intra- total transection of the artery with free extravasa-thoracic clamping), and excluding indications for tion. If an expert ultrasonographer is available,operation. duplex ultrasound can be considered as a primary Zone II: Injuries penetrating the platysma in screening method, but a negative study cannot bethis zone require surgical exploration to identify relied upon to exclude the presence of a clinicallyand treat vascular injuries as well as injuries to the significant injury. For all other patients, the rec-aerodigestive tract unless the patient is asymp- ommendation is angiography as the first option,tomatic and angiography, duplex ultrasound, and as it is still the gold standard.CT have ruled out such injuries. In all patients with basilar skull fractures, un- Duplex ultrasound in the hands of an experi- stable cervical spine fractures, Horner’s syndrome,enced examiner has been shown to be consistent or LeFort-II or-III facial fractures, recent studieswith angiography findings in more than 90% of advocate a more aggressive attitude with angio-cases. It can reveal dissections, thrombotic occlu- graphic screening for blunt carotid injuries. Extra-sion, intimal flaps, pseudoaneurysms, and hema- cranial carotid injuries are also reported to be
  13. 13. 8 Chapter 1 Vascular Injuries to the Neck NOTE A patient with neck trauma and a possible vascular injury who is stable, has stabi- lized after resuscitation, or has a trans- cervical gunshot injury should undergo a selective aortic arch angiography. 1.5 Management and Treatment 1.5.1 Management Before Treatment Management in the Emergency Department As with other major trauma, the Advanced Trau- ma Life Support guidelines should be followed for severe cervical vascular injuries. Consequently, airway and respiration have first priority, followed by control of bleeding. Control of bleeding is best achieved by external finger or manual compres- sion applied directly to the bleeding site. Blindly applied clamps should not be attempted because of the risk of iatrogenic injuries to blood vessels as Fig. 1.2. Angiography showing a dissection of the well as to other organs. internal carotid artery resulting in a narrowing of the lumen with the typical “string sign” appearance (ar- Resuscitation to hemodynamic stability is im- rows) portant. Hypertension may increase bleeding and also induce progress of a dissection, while hypo- tension will increase the risk for thrombosis and more common in patients with a Glasgow coma cerebral malperfusion. scale of 8 or less and thoracic injury. A typical finding at angiography in caroid dissection is a Airway Obstruction stenosis, irregular and often tapered, beginning Patients with neck trauma and airway obstruction 2 or 3-cm distal to the bifurcation and often ex- require meticulous management and close co- tending up to the base of the skull, above which it operation with the anesthesiologist. Intubation is abruptly reconstituted with a normal lumen. should be performed in an anesthetized patient to Occasionally a typical “string sign” can be seen in avoid gagging, which might discharge clots and the stenosed segment (Fig. 1.2). thus cause profuse bleeding or embolization. Cau- CT is not reliable for diagnosing blunt cervical tion should also be taken when the patient’s neck vascular injuries. CT angiography is under devel- is flexed at the intubation because of the risk of opment and is likely to play a greater role in the associated cervical vertebral fractures. There is an future. It has the advantage of short examination obvious risk for dislocation and spinal injury. The times and concurrent diagnosis of other injuries, intubation might also be technically challenging such as brain injuries and skull or facial fractures. because a large hematoma might cause total com- Magnetic resonance imaging (MRI) has a high pression of the trachea. Emergency tracheotomy sensitivity and specificity in relation to angiogra- or coniotomy is then the only alternative, but it phy (95% and 99%, respectively) for detecting may also be complicated by the deranged anatomy blunt carotid injuries, as does MR angiography and risk of bleeding. The risk of profuse uncon- (84% and 99%), but both are time-consuming and trolled bleeding is greatest if the hematoma is complicate monitoring and resuscitation of the located on the anterior aspect of the neck because critically injured patient. the tamponade will be immediately lost when the
  14. 14. 1.5 Management and Treatment 9pretracheal fascia is incised. By using liberal intu- employed. Anticoagulation therapy, antiplateletbation early on and under controlled conditions, therapy, or both should also be initiated.such situations could be avoided. Management of significant carotid artery in- jury existing with major neurological deficit and Immediate Operation coma is controversial. Some surgeons suggest only or Further Diagnostic Work-up? observation and palliation, especially in patientsThe surgeon has to decide in the emergency de- with CT-verified cerebral infarction, because ofpartment whether the patient requires immediate the poor prognosis. Others advocate repair. Thisoperation, further diagnostic examination, or standpoint is based on the difficulties of decidingcontinued observation. whether the vascular trauma, cerebral contusion, It is important to emphasize that although or drugs caused the coma. Some reports, however,standard teaching has been that exploration is re- indicate a possibility of better outcome after ex-quired for all zone-II injuries that penetrate the ploration and repair.platysma, as well as for gunshot wounds that cross When the carotid artery is occluded and therethe midline, the availability of better diagnostic are no neurological symptoms, observation andmodalities has permitted the use of selective ex- anticoagulation with heparin followed by 3 toploration protocols. 6-months of coumadin is a general treatment The following recommendations are given for irrespective of the type of trauma. In patientsthis initial selection: with major neurological symptoms and a verified1. Immediate operation is indicated for unstable infarction on CT, anticoagulation is associated patients with active bleeding not responsive to with a considerable risk for bleeding. The patients vigorous resuscitation or with rapidly expand- prognosis is then poor, and palliation is recom- ing hematoma or airway obstruction, irrespec- mended. tive of anatomical zone. In blunt trauma, indications for exploration2. Injuries in zone II not penetrating the platysma and open repair are rarer due to the mostly distal need no further examination. location of injuries to the internal carotid artery.3. All others require further diagnostic evalua- For asymptomatic injuries, including dissection, tion with angiography, duplex ultrasound, and anticoagulation is usually the only treatment need- CT to determine whether critical structures ed and is indicated to prevent thrombosis of the have been injured. If angiography or high-qual- injured segment and/or embolization from it. Only ity duplex ultrasound is not available, injuries injuries that after angiography appear to be easily in zone II need to be surgically explored. accessible during surgery and are symptomatic should be considered for repair. This is particu-Depending on the results of these diagnostic stud- larly important when there appears to be a highies, the following general recommendations can be risk for embolization. In patients with decreasedgiven regarding management of vascular injuries. consciousness having an occluded internal carotid Repair is recommended in all patients with artery after blunt trauma and with no, or with se-penetrating carotid injuries when there is still evi- vere, neurological symptoms, most reports advo-dence of prograde flow and the patient has no ma- cate only observation without surgical exploration.jor neurological symptoms. For minor injuries to As already mentioned, however, some do recom-the carotid artery, including those with small but mend a more aggressive approach. This strategyadherent intimal flaps, defects, or pseudoaneu- requires extensive experience in carotid surgery.rysms <5 mm in size, repair is recommended insymptomatic patients. If the patient is asymptom- Which Patients Can Be Safelyatic and there is no ongoing active bleeding, a con- Transported?servative approach has proven to be a safe alter- Because cervical vascular injuries often require annative. The patient needs to be followed on an experienced vascular surgeon, a thoracic surgeon,inpatient basis for a couple of days to monitor for an endovascular specialist, and frequently also athe appearance of neurological symptoms. Liberal specialist in head and neck surgery, some patientsindications for repeated duplex examination are would benefit from being transported to a hospital
  15. 15. 10 Chapter 1 Vascular Injuries to the Neck where such expertise is available. A stable patient bectomy catheters is not recommended because of can be transported to another hospital after intu- the risks of mechanical disruption of the throm- bation, or with readiness for emergency intubation bus and bringing fragments up into the circle of in the ambulance, with no major risks. An unsta- Willis. Clamping of the external carotid artery is, ble patient should, of course, remain where he or on the other hand, almost always safe and can be she is. used more liberally. TECHNICAL TIPS 1.5.2 Operation Surgical Exposure of the Carotid Arteries Preoperative Preparation and Proximal Control An incision anterior and parallel to the anterior The management of patients with major external border of the sternocleidomastoid muscle is bleeding is mostly related to penetrating injuries recommended (Fig. 1.3). The incision can be ex- to the carotid artery. Surgical exposure of this tended dorsal to the ear and down to the sternal artery is described in the Technical Tips box. It is notch. As previously noted, preparations need important to prepare and drape the patient for to have been made to allow elongation of the possible median sternotomy, which might be nec- incision into a median sternotomy in order to essary to obtain proximal control. Bleeding can obtain proximal control of, for instance, the bra- usually be controlled by external compression by a chiocephalic trunk on the right side or the com- gloved finger during the preparation and until the mon carotid on the left. After the skin has been complete surgical team is at hand. In the rare and incised, subcutaneous fat is divided and, if need- challenging circumstance in which this is impos- ed, the external jugular vein ligated and divided. sible, a nonspecialist surgeon might be forced to The sternocleidomastoid muscle is retracted attempt exposure and control of the artery proxi- posteriorly, and a dissection plane anterior to mal to the injury through a separate incision with the muscle is identified. The next structure to continued external finger compression over the identify is usually the facial vein and its conflu- lesion by an assistant. During control by direct ence to the internal jugular vein. The former is finger compression of the artery, care must be suture-ligated and divided and is usually a very taken to minimize manipulation because of the good landmark because it is located just above risk of thrombus fragmentation and embolization. the carotid bifurcation. Dividing this vein allows Compression also needs to be balanced with the posterior retraction of the internal jugular vein desire to maintain flow in the artery. Clamping and exposure of the common carotid and its the common or internal carotid artery for control bifurcation. When preparing the carotid arteries, might be necessary but should be avoided unless extreme care must be taken to avoid squeezing the patient’s condition is life-threatening. The rea- of the vessel, and other types of operative ma- son for this is the risk of embolization and cerebral nipulation or trauma because of the risk of em- ischemia due to interrupted flow. Inserting a shunt bolization to the brain. Vessel loops are applied, may be the only way to avoid a major stroke; the and the most cranial clamp is applied first to risk of major stroke in this patient category after avoid embolization when the more proximal carotid clamping may be as high as 50%. Shunting parts are clamped. Important structures to pro- usually requires proximal and distal control, tect are the hypoglossal and vagus nerves. The arteriotomy, and possibly also extraction of the former usually crosses over the internal carotid thrombus before inserting the shunt. Extracting a artery 2–3 cm cranial to the bifurcation and is thrombus requires a delicate technique and spe- best exposed after cranial retraction of the di- cial consideration because it can easily be frag- gastric muscle. The latter runs parallel and dorsal mented and dislodged as embolic masses. The to the common carotid artery. The cervical ansa, safest way is to use traction with forceps and/or often located obliquely over the carotid bifur- suction. If the extraction is followed by brisk back- cation, can be divided to facilitate exposure. flow, the result is satisfactory. The use of throm-
  16. 16. 1.5 Management and Treatment 11Fig. 1.3 a Recommended incision for exposure of the dorsal to the ear. b The normal anatomy and relationscarotid arteries, anterior and parallel to the anterior between major arteries, veins, and important nerveborder of the sternocleidomastoid muscle. The incision structures at exposure of the carotid and jugular ves-can be extended into a median sternotomy or cranially sels Exposure and Repair Resection with end-to-end anastomosis: This isFor larger arterial injuries, proximal and distal possible in limited injuries requiring minor re-control is mandatory. This always requires an in- sections, allowing an anastomosis without anydirect assessment of the cerebral perfusion by tension.checking the backflow from the internal carotid Resection with an interposition graft: Whenartery. Measuring the stump pressure in the inter- larger segments must be excised because of thenal carotid artery is recommended if there is injury, continuity might be restored with an au-sufficient time. This is obtained by first clamping tologous vein graft harvested from the greaterthe common and external carotid arteries and saphenous vein or with prosthetic grafts for un-then puncturing the internal carotid artery with contaminated wounds.a small-caliber injection needle connected to a Transposition of external to internal carotidcatheter filled with saline and a pressure trans- artery: This is a good alternative in special cas-ducer. If the backflow is poor or the mean stump es in which vein grafts are unavailable.pressure is <50 mmHg, shunting is probably nec- Ligation or balloon occlusion: Ligation shouldessary. be reserved for inaccessible injuries that are im- Different repair techniques include the follow- possible to repair. In cases with very distal inju-ing: ries to the internal carotid artery, even ligation Simple suture: Simple sutures are mostly suffi- might be difficult. An occluding balloon cath- cient in minor penetrating injuries or small eter can then be inserted into the artery at the pseudoaneurysms. base of the skull and insufflated until bleeding Patch: A patch can be used for a minor wall de- stops. The balloon catheter can be left in place fect or to compensate for diameter loss after for 1 to 2 days or more and then be deflated and arteriotomy and intimal repair. removed.
  17. 17. 12 Chapter 1 Vascular Injuries to the Neck Exploration of Minor Injuries Endovascular Treatment and Hematomas As already described in sections and, A patient with an injury penetrating the platysma endovascular technique is an alternative to con- in anatomical zone II without a history of bleeding sider in some cervical vascular injuries. Endovas- may be explored by extending the traumatic skin cular treatment is the first option in injuries to the wound to allow inspection of the injured area, vertebral artery due to its location and surgical in- including vessels, trachea, and esophagus. If, how- accessibility. The application of detachable bal- ever, duplex ultrasound or angiography excludes loons, coils, stents, or hemostatic agents is usually a major vascular injury, there is no vascular indi- successful for managing bleeding, aneurysms, and cation for exploration. Patients with a history of fistulas. Endovascular techniques have also been significant bleeding as well as those with large reported to be successful for managing some ca- hematomas should be treated according to what rotid artery injuries (such as traumatic lacera- has been described above for proximal control, tions), pseudoaneurysms, and injuries in some before exploring the wound and evacuating the noncritical and small terminal branches. If endo- hematoma. vascular occlusion of an internal carotid artery is considered in severe traumatic injuries, the neuro- Injuries to the Vertebral Artery logic effect of a temporary occlusion should be Due to its relatively inaccessible location, injuries evaluated prior to occlusion. It is reasonable to be- to the vertebral artery in the cervical region are lieve that the endovascular treatment option will usually best treated by modern endovascular become even more useful in the near future. techniques. The options are intraluminal covered stents or endovascular embolization with coil. Be- sides bleeding and hematomas, pseudoaneurysms 1.5.3 Management After Treatment and arteriovenous fistulas can occur after verte- bral artery trauma and also be successfully treated As in elective carotid surgery, monitoring and cor- by transcatheter embolization. In unstable pa- recting blood pressure is important to minimize tients with life-threatening bleeding, immediate risks for bleeding and cerebral complications. intervention with proximal and distal ligation Most common are thrombosis and reperfusion might be necessary. problems. Acceptable postoperative systolic blood pressure limits are 100–180 mmHg. Venous Injury The patient should be checked for clinical signs Major venous injuries in the neck are almost ex- and symptoms of embolization, and if emboliza- clusively seen after penetrating trauma. The most tion is suspected, the operated artery should be commonly injured veins are the external and in- checked with ultrasound for complications that ternal jugular. Due to the low pressure in veins, might need urgent repair. many such injuries are never recognized. Isolated Antiplatelet and/or anticoagulation therapy venous injuries consequently rarely need explora- should be considered to maintain patency in re- tion or repair. Venous injuries encountered during constructed arteries and to avoid thrombosis in exploration of a neck injury can be treated either bluntly injured but still patent vessels. by repair using simple or running sutures or by Traumatic and surgical wounds should be ligation. In bilateral injuries to the internal jugular checked for signs of a developing hematoma and veins, however, reconstruction of one of the sides infection. The latter is particularly important in is indicated to avoid severe venous hypertension. contaminated wounds and when repair has in- As in all other types of venous surgery, gentle and cluded the use of prosthetic material. Antibiotic meticulous technique must be applied and caution treatment should be given liberally to avoid the taken not to extend the injuries to the veins by a development of severe deep infections in penetrat- traumatic technique. (See Chapter 15 on vascular ing cervical injuries. For the same reason, meticu- surgical technique.) lous wound care is important.
  18. 18. 1.5 Management and Treatment 13Table 1.4. Stroke and mortality rates after different grades of blunt carotid and vertebral artery injuries. (FromBiffl et al. Ann Surg 2002; 235: 699–707) Injury grade/description Carotid artery injury Vertebral artery injury Stroke Death Stroke Death I Luminal irregularity 3% 11% 19% 31% or dissection, <25% narrowing II Dissection or intramural 11% 11% 40% 0 hematoma, >25% narrowing or intraluminal thrombus or raised intimal flap III Pseudoaneurysm 33% 11% 13% 13% IV Occlusion 44% 22% 33% 11% V Transection and free extravasation 100% 100% – – nation of other major injuries. Mortality directly 1.5.4 Results and Outcome related to vertebral artery injuries has been report- ed to be as low as 4%.Several authors report better results after repair ofpenetrating injuries to the carotid artery com-pared with ligation, with regard to neurological Further Readingoutcome (44% vs. 16% neurologically intact) andmortality (5% vs. 11%). Baumgartner RW, Arnold M, Baumgartner I, et al. Ca- The results of conservative treatment of carotid rotid dissection with and without ischemic events;dissection, the most common type of injury after local symptoms and cerebral artery findings. Neu- rology 2001; 57:827–832blunt trauma, are generally good with duplex-veri- Biffl WL, Ray CE, Moore EE, et al. Treatment relatedfied resorption of intramural hematoma within outcomes from blunt cerebrovascular injuries. Ann3 months of anticoagulation. The key to this is Surg 2002; 235:699–707early detection, preferably before the onset of Demetriades D, Theodorou D, Ascentio J. Managementsymptoms, and institution of a heparin infu- options in vertebral artery injuries. Br J Surg 1996;sion followed by oral anticoagulation for at least 83:83–863 months. Table 1.4 above summarizes the experi- Demetriades D, Theodoru D, Cornwell E, et al. Evalua- tion of penetrating injuries to the neck: prospectiveence of Biffl and colleagues at Brown Medical study of 223 patients. World J Surg 1997; 21:41–48School (Rhode Island Hospital, Providence, RI, Gomez CR, May K, Terry J B, et al. Endovascular thera-USA) from 109-patients with carotid injuries. py of traumatic injuries of the extracranial cerebral Recent series report good results in managing arteries. Crit Care Clin 1999; 15:789–809cervical vascular injuries, irrespective of zone, Kreker C, Mosso M, Georgiadis D, et al. Carotid dissec-with only careful physical examination, but the tion with permanent and transient occlusion or se-general impression is that it is too early to elimi- vere stenosis: long term outcome. Neurology 2003;nate angiography and duplex ultrasound from the 28:271–275 Mwipatayi BP, Jeffery P, Beningfield SJ, et al. Manage-work-up. ment of extra-cranial vertebral artery injuries. Eur J As seen, there is a correlation between the inci- Vasc Endovasc Surg 2004; 27:157–162dence of stroke and mortality in carotid injuries Navsaria P, Omoshoro-Jones J. An analysis of 32 surgi-that is not found in injuries to the vertebral artery cally managed penetrating carotid artery injuries.and the posterior circulation. Overall mortality Eur J Vasc Endovasc Surg 2002; 24:349–355after vertebral artery injuries seems to be around Reid J, Weigfelt J. Forty-three cases of vertebral artery20%, but this is usually in patients with a combi- trauma. J Trauma 1988; 28:1007–1012
  19. 19. 14 Chapter 1 Vascular Injuries to the Neck Romily RC, Newell DW, Grady MS, et al. Gunshot Singh RR, Barry MC, Ireland A, et al. Current diagnosis wounds of the internal carotid artery at the skull and management of blunt internal carotid artery in- base: management with vein bypass grafts and a jury. Eur J Vasc Endovasc Surg 2004; 27:577–584 review of the literature. J Vasc Surg 2001; 33:1001– 1007 Sekharan J, Dennis JW, Veldenz H, et al. Continued ex- perience with physical examination alone for evalu- ation of penetrating zone 2 neck injuries; result of 145 cases. J Vasc Surg 2000; 32:483
  20. 20. Vascular Injuries to the Thoracic Outlet Area 2CONTENTS 2.1 Summary2.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Always exclude injuries to the great2.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . 15 thoracic aortic branches after injury to the2.2.1 Magnitude of the Problem . . . . . . . . . . 16 cervical, clavikular and thoracic regions2.2.2 Etiology and Pathophysiology . . . . . . 16 One third of patients who survive thoracic2.2.2.1 Penetrating Trauma . . . . . . . . . . . . . . . . . 16 vascular trauma has minor or lack external2.2.2.2 Blunt Trauma . . . . . . . . . . . . . . . . . . . . . . . . 16 signs of thoracic injury.2.3 Clinical Presentation . . . . . . . . . . . . . . . 17 A plain chest X-ray shall be performed2.3.1 Medical History . . . . . . . . . . . . . . . . . . . . . . 17 in all patients with thoracic injuries2.3.2 Clinical Signs . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate restoration of BP to 100– Physical Examination . . . . . . . . . . . . . . . . 18 120 mmHg is advisable to avoid rebleed- ing2.4 Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . 18 Be liberal with insertion of a chest tube2.5 Management and Treatment . . . . . . 19 in patients with moderate or severe hemo-2.5.1 Management Before Treatment . . . . . 19 thorax2.5.1.1 Management in the Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . Patients in Extreme Shock . . . . . . . . . . . Unstable Patients . . . . . . . . . . . . . . . . . . . 22 2.2 Background2.5.1.4 Control of Bleeding . . . . . . . . . . . . . . . . . Stable Patients . . . . . . . . . . . . . . . . . . . . . . 23 This chapter is focused on injuries to the intratho- Nonsurgical Management . . . . . . . . . . 24 racic parts of the great aortic branches, from their2.5.2 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 origin in the aortic arch to the thoracic outlet. It2.5.2.1 Preoperative Preparation also includes the retroclavicular vessels – the dis- and Proximal Control . . . . . . . . . . . . . . . . 24 tal subclavian and the proximal axillary arteries. Exposure and Repair . . . . . . . . . . . . . . . . 25 These injuries are often difficult to diagnose and2.5.2.3 Endovascular Repair and Control . . . 27 distinguish from aortic arch injuries (i.e., injuries2.5.3 Management After Treatment . . . . . . 28 to the aorta, the pulmonary vessels, and the heart2.6 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 itself). Because cardiothoracic surgeons and not vascular surgeons usually manage the latter, they Further Reading . . . . . . . . . . . . . . . . . . . . 29 will not be covered here. A vascular injury to this region of the body is less common but is associated with high mortality. Many patients die at the scene of the accident or are in extremely bad condition at arrival in the emergency department. Accordingly, they regu- larly require immediate thoracotomy, but many patients are stable and possible to work up and can be treated without surgery. Most hospitals do not
  21. 21. 16 Chapter 2 Vascular Injuries to the Thoracic Outlet Area have a thoracic surgeon on call; therefore, these juries often remain unrecognized. Arteriograms patients are often initially managed by general in patients with a widened mediastinum on plain surgeons with limited experience in thoracic or x-ray after thoracic trauma have been found to be vascular surgical procedures. Basic information negative for arterial injuries in 85%; this suggests about exposure and access routes and ways to that the mediastinal enlargement was caused achieve proximal and distal control of intratho- mainly by venous injury. racic great vessels is important not only in this situation but also to obtain proximal control of NOTE bleeding vessels in cervical and proximal upper Injuries to subclavian and axillary arteries extremity vascular injuries (these areas are dis- are most common after penetrating cussed in Chapters 1 and 3). Good anatomical trauma. knowledge, including that of common variations, is critical, especially for the difficult exposures of the subclavian and axillary vessels, such as when 2.2.2 Etiology and Pathophysiology the right subclavian artery originates directly from the aortic arch or has a common trunk with the right carotid artery. Penetrating Trauma Knife stabbings or missiles from firearms cause a NOTE majority of injuries to the great vessels. In this Anatomical aortic arch and branch type of penetrating trauma, all intrathoracic ves- variations can be expected in 25–35% sels are at risk of being injured. The extent of inju- of cases. ries is related to aspects of the weapon, such as the length of a knife or the velocity (high vs. low) and caliber (small vs. large) of a gun. The innominate 2.2.1 Magnitude of the Problem artery is injured mostly by bullets from firearms. Stab wounds by knives directed inferiorly into the The number of thoracic injuries (all types includ- right clavicular region may also damage the in- ed) is steadily increasing in the United States and nominate artery. The same mechanisms are com- is estimated to be 12 per million inhabitants per mon for injuries to the subclavian and proximal year. In penetrating neck and chest injuries, 3% axillary arteries. Stab wounds are associated with are associated with injuries to the subclavian and a better chance of survival than are injuries from axillary arteries, and in 20% of those injuries, firearms, particularly shotguns. Blood loss after a veins are also injured. In a meta-analysis of 2,642 knife injury is often limited by a sealing mecha- civilian cases of penetrating thoracic trauma, the nism in the wound channel. Furthermore, if the incidence of great vessel injuries was 1% innomi- vascular injury is small, the adventitia also limits nate artery, 5% subclavian, and 6% axillary artery the bleeding. injuries. But because many patients die at the The development of hypotension is another scene, particularly after penetrating trauma, these factor contributing to limited blood loss. Injuries numbers are uncertain. Irrespective of the type of to the major blood vessels in the thoracic outlet are injuries, trauma to the thoracic great vessels is always challenging because they are rare and tech- associated with a high mortality: 80–90% die at nically difficult to expose and control. This is re- the scene. The mortality among patients who flected in the high mortality reported in the litera- survive transport to the hospital is also high. ture. Patients with injuries in the distal parts of the intrathoracic arteries have a better chance of sur- Blunt Trauma vival because these vessels are covered with soft Blunt trauma to the intrathoracic vessels occurs in tissue, providing better prerequisites for sponta- motor vehicle and industrial accidents and in falls neous tamponade. from heights. If it leads to total disruption of the More proximal injuries increase the risk for ex- vessel, the patient will exsanguinate at the scene. sanguination into the pleural cavities. Venous in- When the adventitia remains intact, the possibility
  22. 22. 2.3 Clinical Presentation 17of survival is better. The mechanism is shear motor vehicle, use of a safety belt, or the height ofcaused by acceleration/deceleration or compres- a fall can indicate the risk for intrathoracic vascu-sion forces. Deceleration forces are associated with lar injuries.injuries to the aorta but may also cause injuries to When deciding whether immediate thoracoto-the innominate artery. The innominate and com- my is needed, the course of transport and timemon carotid artery might be exposed to shear elapsed from injury to admission is always offorces at their origin from compression of the an- potential importance.terior chest wall. The subclavian and axillary ar-teries can also be injured by blunt trauma, andthen mostly in association with clavicle or 1st-rib 2.3.2 Clinical Signsfractures. Other possible mechanisms are hyper-extension combined with neck rotation, causing As in other vascular injuries, the following “hardtension and stretching of the contralateral subcla- signs” strongly indicate severe vascular injury:vian vessels. Alternative mechanisms include Severe bleedingstretching over the clavicle. Blunt injuries to the Shock or severe anemiasubclavian artery after deceleration trauma are Expanding hematomarare. There are, however, some controversies re- Absent or weak peripheral pulsesgarding the association between 1st-rib fractures Bruitsand injuries to the subclavian vessels. Two series of49 and 55 patients, respectively, reported an inci- “Soft signs” that also indicate vascular injuries in-dence of 14% and 5% of vascular injuries in asso- clude the following:ciation with rib fractures. On the other hand, in a Local and stable hematomalarge cohort of 466 patients only 0.4% was found. Minor continuous bleeding Mild hypotensionNOTE Proximity to large vessels Injuries to large veins in the thoracic Any periclavicular trauma outlet region are associated with a risk of air embolism and if this occurs, Injuries to the large vessels in the thorax are it significantly increases mortality. frequently associated with injuries to the aero- digestive tract. The following signs and symptoms should alert the responsible surgeon to exclude 2.3 Clinical Presentation underlying severe vascular injuries: Air bubbles in the wound 2.3.1 Medical History Respiratory distress Subcutaneous emphysemaThe diagnosis is obvious in most cases of penetrat- Hoarsenessing vascular trauma, but the following informa- Hemoptysistion is important for management. In injuries Hematemesiscaused by a firearm, the type of weapon used(shotgun, hand weapon, high or low velocity, small NOTEor large caliber) and the distance from where it Patients with periclavicular trauma shouldwas fired are relevant. For knife stabbings, the always be suspected to have intrathoracicblade length and size are important, as well as the great vessel injuries.angle and direction in which it struck the body.Stabbings directed inferiorly in the clavicular re- Intrathoracic injuries to the subclavian and axil-gion or at the base of the neck are associated with lary arteries are associated with high mortality.an increased risk for injuries to the innominate or Like injuries to the thoracic aorta, the presenta-subclavian arteries. tion varies widely, from a fairly stable to a more In blunt trauma, information about the direc- extreme situation with massive bleeding and ex-tion and localization of force, the velocity of the sanguination and death at the scene or during
  23. 23. 18 Chapter 2 Vascular Injuries to the Thoracic Outlet Area transport. The latter is more common after blunt bruits. A systolic bruit over the back and upper trauma that causes avulsion of great vessels and chest usually indicates a false aneurysm in any of penetrating trauma to the subclavian artery or the great intrathoracic vessels. A continuous bruit vein. The consequence of subclavian vessel injury indicates the presence of an arteriovenous fistula. is bleeding into the pleural cavity with or without Peripheral pulses, including axillary, brachial, air embolization. At arrival in the emergency de- and radial, should always be examined. They are partment, a patient with a penetrating intratho- normal in about half of cases with significant racic vascular injury is typically hemodynamically vessel injury. Absence of a radial pulse indicates a unstable, whereas a blunt vessel injury is not injury to the axillary, subclavian, or innominate always immediately apparent. arteries, causing occlusion, dissection, or emboli- Blunt injuries to the innominate artery are rela- zation. The latter is occasionally caused by an em- tively rare, and 75% are combined with other inju- bolizing bullet. ries such as rib fractures, flail chest, hemothorax A thorough neurological evaluation is also rel- or pneumothorax, extremity or facial fractures, or evant when considering the possibility of com- head or abdominal injuries in multitrauma cases. bined brachial plexus and vascular injuries. The Because there are no typical clinical signs or symp- absence of a radial pulse in combination with toms, diagnosis is difficult. The only frequent clin- Horner’s syndrome is suspicious for injury to the ical finding is that 50–70% of such patients have a subclavian artery. weak radial or brachial pulse. Distal extremity Coma or major neurological deficits can also ischemia is uncommon, however, due to good col- occur as a consequence of injuries to the innomi- lateral circulation in the shoulder region. This ex- nate and common carotid arteries leading to plains the possibility of having a palpable distal occlusion or embolization and different levels of pulse despite a severe proximal arterial injury. cerebral ischemia. Therefore, it is important to The subclavian artery is usually injured by evaluate the patient’s mental status upon admis- direct trauma associated with first-rib or clavicu- sion. The result influences the decision about if lar fractures that cause occlusion of the artery. and when to perform emergency surgical repair. About half of the patients have a combined injury This evaluation may also be important during the to the brachial plexus. Accordingly, clinical signs course of management as a baseline for later re- and symptoms indicating such neurological inju- evaluations. ries (see Chapter 3, p. 33) should increase the sus- The management and diagnostic work-up in picion of injuries associated with the subclavian the emergency department are strongly related to artery. the condition in which the patient arrives. In these types of injuries, the patient is often in an extreme Physical Examination condition, requiring immediate transfer to the The entire thorax should be inspected for stab operating room for an emergency thoracotomy wounds. It is important not to forget skin folds, or other surgical repair. Thoracotomy may even the axilla, or areas with thick hair. A penetrating be indicated in the emergency department for a trauma to this region is always obvious at arrival dying patient. in the emergency department. It is also important to remember that one-third of patients who sur- NOTE vive blunt trauma and are taken to the emergency One-third of patients who survive blunt department have minor or even no external signs thoracic vascular trauma have minor or of thoracic injury. no external signs of thoracic injury. A pulsatile mass or hematoma at the base of the neck, with or without a bruit, indicates an injury to the subclavian artery with leakage through the 2.4 Diagnostics vessel wall. At physical examination, auscultation can re- At arrival, most patients are in a condition that veal signs of hemothorax or pneumothorax. The necessitates immediate transfer to the operating entire chest and back should be auscultated for room for surgical exploration and treatment. In
  24. 24. 2.5 Management and Treatment 19the remaining patients, the diagnostic work-up intrathoracic vessels, why it is important that thedepends on the type of trauma and the patient’s angiography visualizes the entire thoracic aortacondition. In a stable patient, such examinations and its branches. The endovascular treatment ofcan provide information of great importance for these injuries is discussed later in this chapter.the management strategy. A good rule is not to Chest tube placement should have liberal indi-start time-consuming examinations while the cations for diagnostic as well as therapeutic pur-patient is still hemodynamically unstable. poses, as a chest tube can reveal the presence of In a stable patient, plain neck and chest x-rays hemothorax or pneumothorax. The technique isshould always be done to see whether he or she has described in detail in the section on managementany of the following: below. Hemothorax or pneumothorax Widened mediastinum NOTE Irregular outline of the descending aorta A plain chest x-ray should be performed Tracheal dislocation in all patients with thoracic trauma. Blurring of the aortic knob Dilatation of the aortic bulb Presence of bullets or fracture fragments 2.5 Management and Treatment Fractures in cervical vertebrae, clavicles, or ribs 2.5.1 Management Before TreatmentDuplex examination has its limitations for detect-ing injuries to the innominate and subclavian ar- Management in theteries because of their deep intrathoracic location, Emergency Departmentparticularly in obese patients. It is also examiner- Management of these often severely injured pa-dependent, but nowadays a first choice in many tients in shock follows the usual Advanced Trau-centers. Transesophageal echocardiography may ma Life Support principles of trauma resuscita-be valuable for diagnosing aortic injuries, but less tion. The first priority is always airway controlso in injuries to the aortic branches. and resuscitation for hypovolemia. Injuries to the Spiral computed tomography (CT) with intra- great vessels in the thoracic outlet frequently re-venous contrast is mostly used to obtain informa- sult in expanding mediastinal hematoma, causingtion about a missile’s direction and trajectory tracheal compression and requiring emergencythrough the body. The trajectory’s vicinity to great endotracheal intubation.vessels is important when selecting patients for 1. Clear and maintain the airway.angiography. The modern multislice CT angio- 2. Secure ventilation by endotracheal intubationgraphy has the potential to become an important and 100% oxygen.diagnostic tool for providing more detailed de- 3. Consider chest tube insertion.scription of thoracic vascular injuries. 4. Place two or three intravenous lines, preferably Angiography can be diagnostic as well as thera- in the legs and/or the opposite arm.peutic. It reveals the presence and localization of 5. Support adequate circulation by rapid volumeocclusions, bleeding, leakage, or pseudoaneu- replacement with 2.000–3.000 ml of a warmrysms as well as intimal tears. To detect potential balanced electrolyte solution and blood prod-tears and other injuries in the innominate artery, ucts.aortography should be performed with posterior 6. Control bleeding. (See below.)oblique projections. A bulbous dilatation at or just 7. Consider putting the patient in Trendelenburgdistal to its origin and the visualization of an inti- position to avoid air embolism when majormal flap in the lumen indicate a tear injury to the venous injuries cannot be excluded.artery. 8. Insert a Foley catheter. In subclavian injuries, a pseudoaneurysm orocclusion can be found. It is important to remem- As in patients with a ruptured abdominal aorticber that 10% of patients with innominate or sub- aneurysm, resuscitation aims at keeping bloodclavian injuries also have other injuries to great pressure around 100–120-mmHg because of the
  25. 25. 20 Chapter 2 Vascular Injuries to the Thoracic Outlet Area risk of sudden massive rebleeding if the blood within minutes) and systolic blood pressure pressure gets too high. Another event posing risk <50 mmHg, and those who experience cardiac ar- for new bleeding during resuscitation is gagging rest in the emergency department. These patients during endotracheal intubation or the insertion of are candidates for thoracotomy in the emergency an esophageal tube. department, aiming at controlling bleeding by If possible, obtain written consent from the pa- manual compression, tamponade, or clamping. tient or his or her family in case emergency sur- This allows more effective resuscitation and is a gery is necessary. The surgical procedure that may last lifesaving effort to improve these patients’ be required often includes clamping of central ar- vital functions enough to allow transfer to the teries, the aorta, or the common carotids, with a operating room for immediate surgery. great risk for severe cerebral and spinal complica- In such an extreme situation, surgeons with no tions. Therefore, it is advisable to alert an experi- or only limited experience in thoracotomy can be enced thoracic and/or vascular surgeon for early forced to choose between the two ultimate alterna- help with management. tives: to open the patient’s chest or to let him or her die. The prognosis for such a patient is, irrespec- NOTE tive of who is performing the thoracotomy, poor, Moderate restoration of blood pressure and the survival rate is only around 5%. This to 100–120 mmHg is advisable to avoid should be weighed against the alternative, which is rebleeding. 100% mortality. More than 20% of patients with injuries to subclavian and axillary vessels are in an Patients in Extreme Shock extreme condition with no vital signs or with im- In this category are patients who, most commonly minent cardiac rest upon arrival to the emergency after penetrating thoracic trauma, have lost con- department. These patients have a very poor prog- sciousness and present with no vital signs despite nosis. resuscitation during the transport but who still show activity on electrocardiography. Other pa- NOTE tients in this category are those with acute thera- Do not hesitate to perform a thoracotomy py-resistant deterioration, those with severe and in the emergency department on a patient persistent shock despite very rapid and aggressive with persistent electrocardiographic volume resuscitation (2.000–3.000 ml of fluids activity but with no detectable vital signs.
  26. 26. 2.5 Management and Treatment 21 TECHNICAL TIPS Chest Tube Insertion Start by determining the desired site of insertion. clamp and then expand it with a gloved finger. The recommended site is the 4th or 5th intercostal This is to take precautions against iatrogenic space, landmark the nipple level just anterior to injury to the lung (Fig. 2.1 c, d). the midaxillary line, which is good for draining air Insert a catheter (32-French or 36-French) with as well as blood. Scrub and drape the predeter- the curved clamp and guide it with a finger. To mined area. Anesthetize the skin, intercostal mus- drain blood, it is best to direct it posterolaterally, cles, pleura, and rib periosteum locally (Fig. 2.1 a). and to remove air, an apical position is preferred. Make a 3 to 4 cm long skin incision over the Correct intrapleural position is indicated by intercostal space, parallel to the ribs (Fig. 2.1 b). “fogging” in the catheter during respiration and Bluntly dissect the subcutaneous tissue over the when the first side hole is 1 to 2 cm inside the cranial aspect of the rib to avoid the intercostal chest wall. Connect the tube to a water-suction vessels. Continue dissection down to the pleura, device. Secure the tube with a separate suture, preferably with a curved clamp or a finger. Then and suture the skin. puncture the parietal pleura with the tip of aFig. 2.1. Steps for chest tube insertion
  27. 27. 22 Chapter 2 Vascular Injuries to the Thoracic Outlet Area TECHNICAL TIPS Emergency Anterolateral 5th-Interspace Thoracotomy for Control of the Aorta The patient must be intubated and ventilated. Incise the skin from the sternum to the axillary line along the upper border of the 5th rib on the left side. In women, the submamillary groove is a landmark. Continue cutting the muscles with scissors or a scalpel all the way down to the pleu- ra. Open the pleural sheath with a pair of scis- sors. The opening should be as large as the hand. One or two costal cartilages can be cut to obtain better access through the thoracotomy. Follow the aortic arch, pass the left subclavian artery Fig. 2.2. Incision for emergency anterolateral thora- and pulmonary artery, and mobilize the heart cotomy slightly to the right. Press the descending aorta manually or with an aortic occluder against the spine and try to achieve the best possible occlu- Unstable Patients sion. This occlusion is maintained under contin- Patients with blood pressure <50 mmHg and in uous fluid resuscitation and while the patient is severe shock are candidates for immediate sur- transferred to the operating room. Alternatively, gery. A rapid infusion of 2–3 l of a balanced elec- place a Satinsky clamp just distal to the origin of trolyte solution over 10–15 min should be given, the left subclavian artery. The proximal blood aiming to keep blood pressure between 70 and pressure must be kept <180 mmHg after clamp 90 mmHg. It is probably important to keep this placement, and it should be removed as soon level of blood pressure to avoid the risk of in- as possible. creased bleeding associated with a higher blood The left subclavian artery is, in contrast to the pressure. If the patient does not respond to this right, an intrapleural structure and can in most volume replacement, he or she should be taken to cases be visualized relatively easy and directly the operating room for immediate surgery. compressed with a finger, clamped, or packed. A Antibiotics covering staphylococci and strepto- left-sided thoracotomy can be extended over to cocci should be administered according to the the right, aiming at a higher interstitium. If, how- local protocols. One suggestion is cephalosporins. ever, it is obvious that the injury is on the right Analgesics, morphine 10 mg intravenously, and, side, the thoracotomy should be performed on in penetrating injuries, prophylaxis against teta- that side. Severe right-sided intrathoracic bleed- nus should also be administered. ing is best controlled by finger compression and packing a tamponade in the apex of the right Control of Bleeding pleural cavity, combined with heavy manual In penetrating injuries with continued external compression in the right supraclavicular fossa. bleeding, control is achieved by finger compres- If resuscitation fails despite adequate fluid sion over the wound. A gloved finger can also be substitution and successful control of bleeding, inserted into the wound to compress the bleeding air embolism should be suspected if there are and stop the outflow of blood. Another recom- injuries to large veins. Puncture and aspiration in mended method is to insert a 24-French Foley the right ventricle is diagnostic as well as thera- catheter into the wound tract and fill the balloon peutic. with water or saline (Fig. 2.3). The catheter is clamped after insufflation of the balloon, and if
  28. 28. 2.5 Management and Treatment 23 >300 ml blood drained through the tube within an hour Deterioration of vital signs when the drain is opened Even in initially unstable patients, this strategy with evacuation of hemothorax and volume re- placement is often successful. It may allow enough time to let the patient undergo emergency work-up under close surveillance. Information obtained from CT scanning and/or angiography facilitates decisions regarding optimal positioning and routes for exposure of the injury at final surgical treatment (see section 2.5.2, p. 25–27). As de- scribed below, in many situations this type of management stabilizes the patient enough to allow continued nonsurgical management. NOTE Be liberal with chest tube insertionFig. 2.3. Temporary balloon tamponade of bleeding in patients with moderate or severeafter penetrating injury to a major subclavian vessel. hemothorax.A Foley catheter is gently inserted to the bottom ofthe wound tract. After the balloon is filled with saline,gentle traction is applied to the catheter, causing com- Stable Patientspression of the vessels against the clavicle Initial management is the same as described above for unstable patients or patients in extreme shock, as summarized in Table 2.1.the wound penetrates into the pleural cavity, it is Diagnostic examinations in stable patients in-gently pulled so the balloon tamponades the pleu- clude repeat plain chest x-ray, angiography or du-ral entrance. If external bleeding persists after this plex ultrasound under close surveillance. Also inmaneuver, a second balloon can be inserted into stable patients chest tubes should be placed on lib-the wound and insufflated to stop external bleed- eral indications for evacuation and monitoring ofing from the wound tract. By applying some trac- bleeding. The following indicate continued bleed-tion to the catheters, the balloon can also compress ing and the possible need for surgical treatment:injured vessels against the clavicle or the ribs. Deterioration of vital signs (i.e., hypotensive If there are clinical indications or radiological reaction) when the drain is startedsigns of moderate or large hemothorax, a chest 1.500–2.000 ml of blood within the first 4–8 htube should be inserted for its evacuation. The ra- Drainage of blood exceeding 300 ml/h for moretionale is that a hemothorax can contribute to con- than 4 htinued intrathoracic bleeding and restrict ventila- More than half of pleural cavity filled withtion and venous return. Depending on the results blood on x-ray despite a well functioning chestwhen the pleural cavity is drained, different ac- tubetions can be taken. In an unstable patient, the fol-lowing are considered strong indicators for emer- All of these factors may indicate thoracotomygency thoracotomy: and should alert the surgeon to consider operation 1.500 ml of blood drained directly after inser- and contact with a cardiothoracic surgeon when tion of the tube needed.