Penetrating abdominal vascular injuries

Traumatic thoracolumbar projectile with concomitant vertebral body and aortic injury

Penetrating subdiaphragmatic aortic trauma is associated with high morbidity and mortality with studies having reported a 50%-70% associated mortality. We describe a case of a patient with a subdiaphragmatic aortic injury caused by a 7.4-cm common nail that traversed through his L1 vertebral body into the aorta. His aortic injury was managed jointly with vascular surgery and neurosurgery teams.

Visceral vascular injuries

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Abdominal vascular injuries: injuries to the aorta

This article discusses injuries to the abdominal aorta at its supra- and infrarenal positions, focusing on the surgical approaches to abdominal aorta injuries and renal vascular pedicles. The controversy regarding the use of bioprosthetic materials and the coLlective experience with these injuries as reported in the literature are reviewed. Primary renal artery repair versus nephrectomy also is examined.

Abdominal vascular injuries

Injuries to major abdominal arteries and veins frequently are associated with exsanguinating hemorrhage and visceral ischemia. Expeditious management is the key to survival and good outcome. Knowledge of anatomic relationships between viscera and vessels forms the basis for directed dissection, optimal exposure, and lasting repair of vessels. Although penetrating mechanism of injury remains the most common cause of these injuries, trauma surgeons must be familiar with patterns of blunt trauma-mediated injury to avoid the devastating consequences of delayed management.

Optimal exposure of the proximal abdominal aorta: a critical appraisal of transabdominal medial visceral rotation

PURPOSE

Adequate exposure of the upper abdominal aorta and its branches is a necessary prelude to safe and durable reconstruction of this aortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we report the results of the transabdominal medial visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta.

METHODS

One hundred eight operations were performed in 104 patients, representing 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smoking (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33) and a similar proportion had abnormal renal function (elevated creatinine level) before operation (n = 40, 37.0%). One third of patients (n = 34) had undergone previous aortic or aortic branch reconstruction. Eighty percent of procedures were elective (n = 87). Seventy-one patients (65.7%) required renal revascularization, usually for hypertension or elevated creatinine levels, whereas 37 patients (34.3%) underwent visceral reconstruction, most often for symptoms of chronic mesenteric ischemia. Only 22 patients required isolated infrarenal aortic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal aortic clamping. The most frequently used reconstruction techniques were bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%).

RESULTS

There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). All intraoperative deaths and four postoperative deaths were related to hemorrhage and its complications. Visceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related to the medial visceral rotation approach included splenic injury (n = 23, 21.3%), one aortic injury, and one adrenal injury. The aortic injury was associated with substantial intraoperative bleeding and subsequent death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19.2%), and infectious (n = 17, 16.3%), were attributed to the procedures performed.

CONCLUSIONS

Transabdominal MVR exposure of the upper abdominal aorta provides unrestricted access to the visceral branch-bearing segment of the aorta and places no limitations on the choice of arterial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repairs, but the frequency of splenic injury and postoperative pancreatitis is increased.

Hepatic vein and retrohepatic vena caval injury

Retrohepatic venous injury presents as a rare but frequently lethal complication of trauma. The anatomic arrangement makes management of these injuries difficult at best. Operative exposure and isolation techniques ranging from cross-clamping the aorta, portal triad, suprarenal vena cava, and suprahepatic vena cava to the use of internal shunts are described in this report. Our experience from 1968 to 1987 with internal shunting techniques includes 27 patients. We have successfully resuscitated 12 patients for an acute mortality of 55%. We believe that this figure is high but compares favorably with published results. Late deaths from sepsis, disseminated intravascular coagulation, or multiple systems organ failure remain as significant causes of overall mortality. Many techniques have been successfully employed over the years in achieving vascular isolation of the liver. The methods all have their own merits, but the key factor in each is the recognition that they need to be employed. Conservative selection of patients is undoubtedly justified, but aggressive approaches should not be delayed until they are the methods of last resort.

Retroperitoneal vascular injury

Retroperitoneal vascular injuries are among the greatest challenges that confront the surgeon. Problems in resuscitation, exposure, and repair are numerous. Techniques to improve such perioperative tactics result in improved survival.

Management of injuries to the suprarenal aorta

During a 12 year period, 79 patients with a diagnosis of a penetrating wound to the suprarenal aorta were treated. An analysis of the records of these patients has led to the following conclusions: With a midline penetrating wound and presence of a supramesocolic hematoma or hemorrhage, injury to the suprarenal aorta should be suspected. If a midline supramesocolic hematoma is present or if hemorrhage can be controlled by direct pressure, a lateral approach with medial mobilization of the intraabdominal viscera on the left side allows rapid vascular control. Although lateral aortorrhaphy is preferred, patch grafting, and end-to-end anastomosis, or insertion of a prosthetic graft was required in 46 percent of the patients who underwent repair. As in all previous series, the insertion of synthetic patches or prostheses was not complicated by infection. The average survival rate for injuries to the suprarenal aorta in series reported since 1974 is 33 percent. Finally, the continuing problem of irreversible shock suggests the need for rapid transport from the field to the hospital for victims of penetrating wounds to the abdomen.

Radiographic and clinical findings in unusual abdominal aortic aneurysms

Atherosclerotic abdominal aortic aneurysms typically present either asymptomatically or with abdominal or back pain. Inflammatory, mycotic, and traumatic aortic aneurysms and aneurysms complicated by venous fistula are less common. The different clinical presentations of these latter aneurysms should raise a suspicion to their diagnosis and appropriate preoperative evaluation. The radiographic and clinical features of inflammatory, mycotic, traumatic, and complicated atherosclerotic aneurysms are presented and discussed.

Penetrating injuries to the iliac arteries

Despite advances in the management of traumatic truncal and peripheral vascular injuries, penetrating trauma to the iliac arteries carries a high mortality. Among more than 600 patients with arterial trauma seen at the Ben Taub General Hospital between January 1958 and December 1977, eighty-three had penetrating injury to the iliac arteries. Thirty-two patients (39 per cent) died within thirty days of injury, none of these dying within 48 hours of injury. Injuries were managed by resection and end-to-end anastomosis (36 per cent), lateral arteriorrhaphy (27 per cent), ligation (20 per cent), and prosthetic interposition (10 per cent). Three perigraft infections occurred with ultimate removal of the graft and ligation of the common iliac artery. Among patients with penetrating injuries who arrive alive at a hospital, iliac artery wounds result in massive intraperitoneal blood loss, in contrast to aortic injuries which frequently have a protective tamponade for a period of time. Delay in surgery, irreversible shock, dilutional bleeding diathesis, and respiratory insufficiency result in a high mortality. A high index of suspicion and prompt aggressive surgery are necessary to improve changes of survival of patients with this highly lethal injury.

Tube graft replacement of the suprarenal aorta with implantation of the superior mesenteric artery

The superior mesenteric artery was successfully implanted to a tube graft replacement of the suprarenal abdominal aorta after a gunshot wound. Although injuries to the abdominal aorta carry a high mortality, adequate management and prompt operation can reduce the mortality rate. In cases like this one the ingenuity of the surgeon is at stake, because arterial anastomoses are not always possible to their natural origin. Death from aortic injuries is most commonly caused by hemorrhage and exsanguination, so appropriate measures must be taken as soon as the diagnosis is made to avoid this possibility. Also, patients should not be hypotensive for any long time, so transfusion should be timed carefully, especially when the aortic clamps are being removed.

Injuries to the inferior vena cava and their management

Injuries to the inferior vena cava are being seen with increasing frequency in the civilian population. A review of the experience at UCLA/Harbor General Hospital Medical Center over a ten year period (1966 to 1976) discloses thirty-four patients with major injuries to the inferior vena cava, with an overall mortality of 53%. The factors that appear critical to patient survival are: (1) level of injury (suprarenal versus infrarenal sites); (2) presence or absence of profound shock on admission; and (3) the speed with which diagnosis is made and treatment carried out. Technical considerations regarding identification and handling of inferior vena caval injuries are presented. The mortality rate for major inferior vena caval injuries remains distressingly high and serves as a challenge for future improvement.