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Carotid artery injuries, Joel Arudchelvam, SLSC 2022.pptx

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Carotid artery injuries, Joel Arudchelvam, SLSC 2022.pptx

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Carotid artery injuries, Joel Arudchelvam, SLSC 2022, Carotid artery injuries
Causes

Hard signs of vascular injury
Associated signs

Anatomy and neck zones
Management
Factors to consider

Preoperative imaging
Management – changing concepts
Vascular surgical intervention
Open surgery

Carotid artery injuries, Joel Arudchelvam, SLSC 2022, Carotid artery injuries
Causes

Hard signs of vascular injury
Associated signs

Anatomy and neck zones
Management
Factors to consider

Preoperative imaging
Management – changing concepts
Vascular surgical intervention
Open surgery

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Carotid artery injuries, Joel Arudchelvam, SLSC 2022.pptx

  1. 1. Joel Arudchelvam MBBS (Col), MD (Sur), MRCS (Eng), FCSSL(Hon) Consultant Vascular and Transplant Surgeon
  2. 2. Carotid artery injury  Carotid artery injury (CAI) occur in 4.9% to 6% following penetrating neck injuries and in 1% to 2.6% following blunt neck injury  Penetrating carotid injuries (PCI) result in a mortality rate of 22% to 33%  PCI - about 23% stroke Management of carotid artery trauma. Lee TS, Ducic Y, Gordin E, Stroman D. 3, 2014, Craniomaxillofacial trauma & reconstruction, Vol. 7, pp. 175– 189 Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad. 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.
  3. 3. Penetrating carotid artery injury Causes  Road traffic accidents  Industrial injury  Stab  Iatrogenic Penetrating Carotid Injuries, A Single Surgeon Experience . J Arudchelvam, C Gurusinghe, AGAVJ Abeysinghe, N L Mohotti, N Gowcikan, N Harivallavan, R Cassim, M Wijeyaratne. Colombo : s.n., 2022. Sri Lanka Surgical Congress 2022.
  4. 4. Penetrating carotid artery injury  PCI involve common and internal carotid arteries at similar rates  Internal jugular venous injuries associated in about 26% Management of carotid artery trauma. Lee TS, Ducic Y, Gordin E, Stroman D. 3, 2014, Craniomaxillofacial trauma & reconstruction, Vol. 7, pp. 175–189 Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad. 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.
  5. 5. Hard signs of vascular injury  Active haemorrhage  Expanding hematoma  Hypotension not responding to fluid resuscitation  Thrill or bruit  Neurological deficit (PCI- about 23% stroke)  Associated signs  Horner's syndrome (due to associated sympathetic chain injury)  Features of injury to the last four cranial nerves
  6. 6. Anatomy and neck zones
  7. 7. Zone II injury
  8. 8. Anatomy and neck zones  Zone 1  Proximal common carotid  Subclavian arteries  Zone 2  Distal common carotid  Division of the carotid  Internal and external carotid arteries.  Zone 3  Internal carotid arteries.
  9. 9. Management  Factors to consider  Stability of the patient  Signs of vascular injury  Zone of injury  Neurological status  Associated aero- digestive system injury
  10. 10. Preoperative imaging  Stable patients  Can undergo imaging – to assess vascular or aero- digestive tract injury  Unstable patients  Should go to the operation theatre immediately
  11. 11. Management “Changing concepts”  Early period (1950 s) - mandatory exploration in whom the platysma muscle was penetrated (8)  Later (1970 s)- haemodynamic stability and the neck zones  Zone 2 should undergo mandatory exploration irrespective of the haemodynamic stability  Zone 1 / zone 3 needs further imaging if the patients are haemodynamically stable (9). 8. Penetrating wounds of the neck. Fogelman MJ, Stewart RD. 1956, Am J Surg, Vol. 91, p. 581e93. 9. Carotid vertebral trauma. Monson DO, Saletta JD, Freeark RJ. 1969, J Trauma, Vol. 9, p. 987e99
  12. 12. Management – changing concepts  Current  Haemodynamic stability  Presence of aero-digestive injuries.
  13. 13. Vascular surgical intervention Options Open Endovascular
  14. 14. Open surgery  Position  Supine, sand bag in between the scapula  Neck slightly extended, chin tilted upwards, turned to the contralateral side
  15. 15. Open surgery  Skin preparation  Neck, upper chest (to expose the upper chest in zone 1 injury for proximal control)  Mandibular area (for mandibulotomy in zone 3 injury)
  16. 16. Open surgery  Incision along the anterior border of the sternocleidomastoid  For proximal carotid vessel (Zone 1) - sternotomy  For distal control (Zone 3) - mandibulotomy  Proximal and distal control – can use endo-vascular balloon occlusion
  17. 17. Open surgery  Options  Repair  Direct arterial repair (lateral arteriorrhaphy)  Patch repair (venous and synthetic)  End to end repair  Interposition graft repair (venous or synthetic graft)  Ligation Penetrating Carotid Injuries, A Single Surgeon Experience . J Arudchelvam, C Gurusinghe, AGAVJ Abeysinghe, N L Mohotti, N Gowcikan, N Harivallavan, R Cassim, M Wijeyaratne. Colombo : s.n., 2022. Sri Lanka Surgical Congress 2022. Our experience Sidewall laceration and contusion (80%) Direct repair (80%) Interposition graft (20%)
  18. 18. Indications for ligation  Persistent hypotension  Fixed dilated pupils  Signs of irreversible ischemic changes on the computed tomography  Internal carotid artery injury close to the base of the skull  Severe soft tissue injury to the neck  Absent back bleeding during the surgery
  19. 19. Management  Ligation is associated with  Higher stroke rate - 56% vs 10% (13)  Higher mortality - 50% vs 17% (2)  compared to the repair group  Repair should be done whenever possible provided  No contraindications for repair  Haemodynamically stable patient
  20. 20. Endovascular  Endovascular options  False aneurysm  Intimal flaps  Luminal narrowing  To achieve proximal and distal control - zone 1 and 3 injuries
  21. 21. Neurological status and carotid repair  Old believe  Repair of carotid arteries was contraindicated in the presence of a neurological deficit ( believed to convert an ischaemic stroke into a haemorrhagic stroke)  Recent studies showed that the majority died due to cerebral edema due to ischemia than haemorrhagic transformation
  22. 22. Neurological status and carotid repair  In addition studies showed that revascularization after prolonged neurological deficit and infarctions improve after revascularization  Probably due to the resolution of cerebral oedema  Therefore revascularization even in the presence of a neurological deficit is advised
  23. 23. Summary  Repair is associated with  Reduced stroke rate  Reduced mortality  Ligation of carotid artery is associated with  Increased stroke rate  Increased mortality  Even in the presence of neurological status provided the patient is stable and there are no contraindications

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