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Stafforini NA, Singh N. Management of Vascular Injuries in Penetrating Trauma. Surg Clin North Am 2023; 103:801-825. [PMID: 37455038 DOI: 10.1016/j.suc.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).
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Affiliation(s)
- Nicolas A Stafforini
- Division of Vascular Surgery, Department of Surgery, University of Washington, 325 9th Avenue, Box 359908, Seattle, WA 98104, USA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, 325 9th Avenue, Box 359908, Seattle, WA 98104, USA.
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2
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WANG P, SONG C, LU Y. Isolated superior mesenteric artery rupture caused by abdominal trauma. J Zhejiang Univ Sci B 2022; 23:1065-1068. [PMID: 36518058 PMCID: PMC9758718 DOI: 10.1631/jzus.b2200288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The superior mesenteric artery (SMA) is one of the visceral branches of the abdominal aorta. It has multiple branches to supply blood and nutrition to the intestinal segment, and these form an anastomosis with each other. SMA injuries are usually classified as major visceral artery injuries, and have an incidence of <1%. The clinical manifestations of patients with SMA injuries include intra-abdominal bleeding and peritoneal irritation. The compromised blood supply can lead to intestinal ischemia and perforation. These injuries are often not diagnosed in time and have significant mortality rates of 25%-68% due to the lack of specific features (Maithel et al., 2020). Not only that, but patients with less severe trauma or no visible damage on initial examination may still have clinically significant intra-abdominal injuries (Nishijima et al., 2012). Emergency departments often encounter multiple cases that require urgent diagnosis and treatment (Li et al., 2021; Zhang et al., 2021; Zhou et al., 2021), and therefore, it is imperative to diagnose and manage these rare injuries expeditiously.
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Affiliation(s)
- Ping WANG
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou310003, China,The Key Laboratory for Diagnosis and Treatment of Aging and Physicochemical Injury Diseases of Zhejiang Province, Hangzhou310003, China
| | - Congying SONG
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou310003, China,The Key Laboratory for Diagnosis and Treatment of Aging and Physicochemical Injury Diseases of Zhejiang Province, Hangzhou310003, China
| | - Yuanqiang LU
- Department of Emergency Medicine, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou310003, China,The Key Laboratory for Diagnosis and Treatment of Aging and Physicochemical Injury Diseases of Zhejiang Province, Hangzhou310003, China,Yuanqiang LU,
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Melmer PD, Clatterbuck B, Parker V, Castater CA, Klingensmith NJ, Ramos CR, Busby S, Hurst SD, Koganti D, Williams KN, Grant AA, Smith RN, Benarroch-Gampel J, Dente CJ, Rajani RR, Todd SR, Sciarretta JD. Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes. Vasc Endovascular Surg 2021; 56:40-48. [PMID: 34533371 DOI: 10.1177/15385744211042491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.
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Affiliation(s)
- Patrick D Melmer
- Grand Strand Medical Center, University of South Carolina, Myrtle Beach, SC, USA
| | - Brant Clatterbuck
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Christine A Castater
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan J Klingensmith
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Christopher R Ramos
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Stephanie Busby
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Stuart D Hurst
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Keneesha N Williams
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - April A Grant
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Randi N Smith
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Jaime Benarroch-Gampel
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Christopher J Dente
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Ravi R Rajani
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Samual R Todd
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
| | - Jason D Sciarretta
- Emory University School of Medicine, Marcus Trauma Center, 71741Grady Memorial Hospital, Atlanta, GA, USA
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Abukhalaf SA, Mohammed KA, Imam A, Ashker AM, Gabri EM, Abusada M, Khalayleh H, Khalaileh A. Splenic Vein as an Autologous Graft in Traumatic SMV Injuries: A Missed Valuable Alternative. Ann Vasc Surg 2021; 74:521.e1-521.e7. [PMID: 33556513 DOI: 10.1016/j.avsg.2021.01.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 01/04/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
Traumatic superior mesenteric artery (SMA) and vein (SMV) injuries are rare but often lethal. The ideal management options of traumatic SMV injury are still controversial. Management options include venous repair and ligation. Splenic vein turndown procedure (SVTP) is a rare procedure that has been described in only 6 cases in the literature. Here, we reviewed the literature on the usage of the splenic vein turndown procedure (SVTP) as an alternative option in patients with traumatic SMV injury. METHODS We performed a narrative review for the available literature on the usage of the splenic vein as an autologous graft in the management of the SMV injury. We included all studies of SVTP in traumatic SMV injuries only. RESULTS We included only 5 studies. In total, 7 patients underwent SVTP. Five patients presented with a penetrating abdominal vascular trauma (AVT) and 2 patients with a blunt AVT. The advantages of the SVTP include no need for additional incisions to harvest potential autologous grafts, minimally increased operative time, and 1 less anastomotic site compared to other conduit options. CONCLUSIONS In cases of traumatic SMV injuries with associated splenic or pancreatic injuries that need distal pancreatosplenectomy, surgeons may consider SVTP as an ideal management option rather than primary repair or ligation.
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Affiliation(s)
| | | | - Ashraf Imam
- Department of General Surgery, Hadassah Medical Center and Hebrew University, Jerusalem, Israel
| | - Ashraf M Ashker
- Department of General Surgery, Al Shifa Medical Complex, Gaza, Palestine
| | - Eyad M Gabri
- Department of General Surgery, Shuhada Al Aqsa Hospital, Gaza, Palestine
| | - Marwan Abusada
- Department of General Surgery, Al Shifa Medical Complex, Gaza, Palestine
| | - Harbi Khalayleh
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; The Department of Surgery, Kaplan Medical Center, Israel
| | - Abed Khalaileh
- Department of General Surgery, Hadassah Medical Center and Hebrew University, Jerusalem, Israel.
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5
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Maithel S, Grigorian A, Fujitani RM, Kabutey NK, Sheehan BM, Gambhir S, Chen SL, Nahmias J. Incidence, morbidity, and mortality of traumatic superior mesenteric artery injuries compared to other visceral arteries. Vascular 2019; 28:142-151. [DOI: 10.1177/1708538119893827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
ObjectivesCeliac artery, superior mesenteric artery, and inferior mesenteric artery injuries are often grouped together as major visceral artery injuries with an incidence of <1%. The mortality rates range from 38–75% for celiac artery injuries and 25–68% for superior mesenteric artery injuries. No large series have investigated the mortality rate of inferior mesenteric artery injuries. We hypothesize that from all the major visceral artery injuries, superior mesenteric artery injury leads to the highest risk of mortality in adult trauma patients.MethodsThe Trauma Quality Improvement Program (2010–2016) was queried for patients with injury to the celiac artery, superior mesenteric artery, or inferior mesenteric artery. A multivariable logistic regression model was used for analysis. Separate subset analyses using blunt trauma patients and penetrating trauma patients were performed.ResultsFrom 1,403,466 patients, 1730 had single visceral artery injuries with 699 (40.4%) involving the celiac artery, 889 (51.4%) involving the superior mesenteric artery, and 142 (8.2%) involving the inferior mesenteric artery. The majority of patients were male (79.2%) with a median age of 39 years old, and median injury severity score of 22. Compared to celiac artery and inferior mesenteric artery injuries, superior mesenteric artery injuries had a higher rate of severe (grade >3) abbreviated injury scale for the abdomen (57.5% vs. 42.5%, p < 0.001). The overall mortality for patients with a single visceral artery injury was 20%. Patients with superior mesenteric artery injury had higher mortality compared to those with celiac artery and inferior mesenteric artery injuries (23.7% vs. 16.3%, p < 0.001). After controlling for covariates, traumatic superior mesenteric artery injury increased risk of mortality (OR = 1.72, CI = 1.24–2.37, p < 0.01) in adult trauma patients, while celiac artery ( p = 0.59) and inferior mesenteric artery ( p = 0.31) injury did not. After stratifying by mechanism, superior mesenteric artery injury increased risk of mortality (OR = 3.65, CI = 2.01–6.45, p < 0.001) in adult trauma patients with penetrating mechanism of injury but not in those with blunt force mechanism (OR = 1.22, CI = 0.81–1.85, p = 0.34).ConclusionsCompared to injuries of the celiac artery and inferior mesenteric artery, traumatic superior mesenteric artery injury is associated with a higher mortality. Moreover, while superior mesenteric artery injury does not act as an independent risk factor for mortality in adult patients with blunt force trauma, it nearly quadruples the risk of mortality in adult trauma patients with penetrating mechanism of injury. Future prospective research is needed to confirm these findings and evaluate factors to improve survival following major visceral artery injury.
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Affiliation(s)
- Shelley Maithel
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Areg Grigorian
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Roy M Fujitani
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Nii-Kabu Kabutey
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Brian M Sheehan
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Sahil Gambhir
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Samuel L Chen
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Jeffry Nahmias
- Irvine Department of General Surgery, University of California, Orange, CA, USA
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Karaolanis G, Moris D, McCoy CC, Tsilimigras DI, Georgopoulos S, Bakoyiannis C. Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma. Front Surg 2018; 5:7. [PMID: 29516005 PMCID: PMC5826055 DOI: 10.3389/fsurg.2018.00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 01/29/2018] [Indexed: 12/17/2022] Open
Abstract
The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.
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Affiliation(s)
- Georgios Karaolanis
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Hospital, Durham, NC, United States
| | - C. Cameron McCoy
- Department of Surgery, Duke University Hospital, Durham, NC, United States
| | - Diamantis I. Tsilimigras
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Georgopoulos
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Chris Bakoyiannis
- First Department of Surgery, Division of Vascular Surgery, National and Kapodistrian University of Athens, Athens, Greece
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7
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Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries. World J Surg 2017; 42:713-726. [DOI: 10.1007/s00268-017-4212-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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8
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Leppäniemi A, Savolainen H, Salo J, Aarnio P. Proximal superior mesenteric arterial and venous injuries. Int J Angiol 2011. [DOI: 10.1007/bf02042916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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9
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Time Course Study on the Use of Temporary Intravascular Shunts as a Damage Control Adjunct in a Superior Mesenteric Artery Injury Model. ACTA ACUST UNITED AC 2010; 68:409-14. [PMID: 19826313 DOI: 10.1097/ta.0b013e31819ea416] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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McLaughlin DF, Wade CE, Champion HR, Salinas J, Holcomb JB. Thromboembolic complications following trauma. Transfusion 2009; 49 Suppl 5:256S-63S. [DOI: 10.1111/j.1537-2995.2008.01989.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Temporary intravascular shunting improves survival in a hypothermic traumatic shock swine model with superior mesenteric artery injuries. Surgery 2009; 147:79-88. [PMID: 19744445 DOI: 10.1016/j.surg.2009.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2008] [Accepted: 05/18/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND Repairs of superior mesenteric artery (SMA) injuries are difficult and often result in high mortality. Our group has employed temporary intravascular shunts (TIVS) as a damage control procedure in a SMA transection model and hypothesized that TIVS would improve survival when compared with primary vascular anastomosis in the setting of a damage control surgery. METHODS The SMA was clamped and completely transected while pigs were hemorrhaged to a mean arterial pressure of 40 mmHg and maintained in shock for 30 minutes. Cold lactated Ringer's solution was gradually infused while the abdomen was open to induce hypothermia. Animals were randomized to control (no resuscitation), primary anastomosis (PA), or temporary shunting (TS) of the SMA. Animals were resuscitated for 6 hours with the shed blood and lactated Ringer's solution. Delayed anastomosis was performed in TS animals after resuscitation. Surviving animals were humanely killed 2 days after operation. Systemic hemodynamic parameters were recorded hourly. The ileum was harvested at the end of resuscitation and experiment for pathologic evaluation. RESULTS All animals suffered extreme physiologic conditions: hypothermia, severe acidosis, hypotension, and depressed cardiac output and oxygen delivery. Control animals suffered 100% mortality. Compared with the PA group, TS animals required less resuscitation fluid, retained higher SMA flow rates, normalized lactate levels faster, suffered less severe intestine histopathology, and had greater early survival. CONCLUSION Damage control surgery in the setting of SMA transection seems better managed with TS than with PA. Further validation of this model is required before generalization to human applications.
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Asensio JA, Petrone P, Garcia-Nuñez L, Healy M, Martin M, Kuncir E. Superior mesenteric venous injuries: to ligate or to repair remains the question. ACTA ACUST UNITED AC 2007; 62:668-75; discussion 675. [PMID: 17414345 DOI: 10.1097/01.ta.0000210434.56274.7f] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.
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Affiliation(s)
- Juan A Asensio
- Division of Trauma and Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
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Asensio JA, Petrone P, Kimbrell B, Kuncir E. Lessons learned in the management of thirteen celiac axis injuries. South Med J 2005; 98:462-6. [PMID: 15898524 DOI: 10.1097/01.smj.0000136239.16913.c2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Celiac axis injuries are rare. The purposes of this study were to (1) review institutional experience, (2) determine additive effect on death of associated vessel injuries, and (3) correlate mortality rates with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury. METHODS This was a retrospective, 132-month study (January 1992 to December 2002) of patients with celiac axis injuries. RESULTS Thirteen patients were included in the study. Mean revised trauma score was 5.35+/-2.63; mean injury severity score was 25+/-12. The mechanism was penetrating in 12 (92%) and blunt in 1 (8%); 3 of 13 had Emergency Department thoracotomy (100% mortality rate). Treatment included ligation in 11 and primary repair in 1; 1 exsanguinated. Overall survival was 5 of 13 (38%). Adjusted survival excluding patients who had Emergency Department thoracotomy was 5 of 10 patients (50%). Those surviving with isolated injuries included 57% of patients. Mortality rate versus AAST-OIS was grade III, 43% (3 of 7 patients); grade IV, 50% (1 of 2 patients); and grade V, 100% (4 of 4 patients). CONCLUSIONS Celiac axis injuries are rare. Patients with isolated injuries have better survival rates. Mortality rate correlates well with AAST-OIS for abdominal vascular injury.
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Affiliation(s)
- Juan A Asensio
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles County-University of Southern California Medical Center, Los Angeles, CA 90033-4525, USA.
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14
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Weinstein D, Wiener Y, Bass A, Halevy A. Traumatic laceration of the superior mesenteric artery: report of a case and review of the literature. THE JOURNAL OF TRAUMA 2002; 53:568-70. [PMID: 12352499 DOI: 10.1097/00005373-200209000-00029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Daphna Weinstein
- Department of Surgery "B", Assaf Harofeh Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Zerifin, Israel
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15
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Asensio JA, Forno W, Roldán G, Petrone P, Rojo E, Ceballos J, Wang C, Costaglioli B, Romero J, Tillou A, Carmody I, Shoemaker WC, Berne TV. Visceral vascular injuries. Surg Clin North Am 2002; 82:1-20, xix. [PMID: 11905939 DOI: 10.1016/s0039-6109(03)00138-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Juan A Asensio
- Trauma Surgery Service A, Division of Trauma Surgery and Surgical Critical Care, Los Angeles County and University of Southern California Medical Center, 90033, USA
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16
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Asensio JA, Berne JD, Chahwan S, Hanpeter D, Demetriades D, Marengo J, Velmahos GC, Murray J, Shoemaker WC, Berne TV. Traumatic injury to the superior mesenteric artery. Am J Surg 1999; 178:235-9. [PMID: 10527446 DOI: 10.1016/s0002-9610(99)00166-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Superior mesenteric artery (SMA) injuries are rare and devastating injuries incurring very high mortality rates. It is the purpose of this study to review our experience with these injuries, to analyze Fullen's classification based on anatomical zone and injury grade for its predictive value, and to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality. METHODS Retrospective study was made over a 65-month period of all patients sustaining SMA injuries in an urban level I trauma center. RESULTS Thirty-five patients, mean age 31, had a mean Revised Trauma Score of 5.86 and a mean Injurity Severity Score of 23. Mechanisms of injury were penetrating 27 (77%) and blunt 8 (23%). Mean admission systolic blood pressure was 85 mm Hg. Mean estimated blood loss was 8,500 mL and mean total fluid replacement 17,000 mL. Operating room findings were retroperitoneal hematoma in 34 (97%) and "black bowel" in 2 (6%). Number of associated injuries was nonvascular, mean 4.2, and vascular, mean 1.5. Surgical management consisted of ligation in 18 (51%), primary repair in 14 (40%), and interposition graft in 2 (6%). Overall mortality was 19 of 35 (54%). Mortality versus Fullen's zones was zone I, 100%, zone II, 43%, and zones III and IV, 25%. Mortality versus Fullen's ischemia grade was grade 1, 89%, grade 2, 58%, grade 3, 100%, and grade 4, 19%. Mortality versus AAST-OIS: was grade 1, 0%, grade II, 20%, grade III, 0%, grade IV, 59%, and grade V, 88%. CONCLUSIONS SMA injuries are highly lethal. Most deaths are due to exsanguination. A higher number of associated vascular injuries increases mortality. "Black bowel" is an uncommon finding. Both Fullen's anatomical zones and the AAST-OIS for abdominal vascular injuries correlate with mortality. Fullen's ischemia grade does not.
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Affiliation(s)
- J A Asensio
- Department of Surgery, University of Southern California, and the Los Angeles County and the University of Southern California Medical Center, 90033-4525, USA
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Patel S, Zabel DD, Fulda G. Isolated avulsion of the middle colic artery with colonic infarction after blunt abdominal trauma. THE JOURNAL OF TRAUMA 1997; 43:137-9. [PMID: 9253925 DOI: 10.1097/00005373-199707000-00033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- S Patel
- Department of Surgery, Medical Center of Delaware, Wilmington, USA
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18
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Carrillo EH, Bergamini TM, Miller FB, Richardson JD. Abdominal vascular injuries. THE JOURNAL OF TRAUMA 1997; 43:164-71. [PMID: 9253935 DOI: 10.1097/00005373-199707000-00043] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Trauma surgeons are occasionally faced with patients with abdominal vascular injuries. Important surgical issues in the successful management of these injuries require a thorough knowledge of the abdominal vascular anatomy and techniques of vascular repair, that surgical exploration be performed without delay, that the vascular injury be exposed rapidly with control of hemorrhage upon entering the abdomen, that efforts be made to reestablish perfusion initially to the structures at the highest risk of anoxic injury, and an understanding that it is occasionally necessary to perform temporary procedures while the general condition of a patient is being stabilized, with subsequent definitive care. The primary goal in the management of these patients should be hemorrhage control rather than maintenance of blood flow. The principles of abbreviated laparotomy with planned reoperation should be used in some patients with major abdominal vascular injuries. The decision to reestablish vascular continuity at a later time should balance anticipated functional outcome against potential complications.
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Affiliation(s)
- E H Carrillo
- Department of Surgery, University of Louisville School of Medicine, Kentucky 40292, USA.
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Morris JA, Eddy VA, Rutherford EJ. The trauma celiotomy: The evolving concepts of damage control. Curr Probl Surg 1996. [DOI: 10.1016/s0011-3840(96)80010-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
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.
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Affiliation(s)
- R J Mullins
- Oregon Health Sciences University, Portland, USA
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Reilly PM, Rotondo MF, Carpenter JP, Sherr SA, Schwab CW. Temporary vascular continuity during damage control: intraluminal shunting for proximal superior mesenteric artery injury. THE JOURNAL OF TRAUMA 1995; 39:757-60. [PMID: 7473971 DOI: 10.1097/00005373-199510000-00028] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
"Damage control" is an accepted technique for the treatment of the patient with exsanguinating injuries to the abdomen and intraoperative coagulopathy. We describe the use of an intraluminal shunt to maintain temporary vascular continuity of the superior mesenteric artery during rewarming and correction of coagulopathy in the intensive care unit following a gun shot wound to the abdomen. Successful complex reconstruction was achieved at definitive laparotomy using an autogenous vein interposition graft.
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Affiliation(s)
- P M Reilly
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Medical Center, Philadelphia 19104, USA
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Udekwu OP, Jannetta J, Udekwu AO, Peitzman AB. Disruption of the gastroduodenal artery and right gastric artery following blunt trauma. Injury 1993; 24:225-6. [PMID: 8325677 DOI: 10.1016/0020-1383(93)90173-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Abdominal vascular injuries and specifically injury to the visceral arteries occur uncommonly as the result of blunt trauma. This is a report of disruption of both the gastroduodenal and right gastric arteries as the result of blunt trauma.
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Affiliation(s)
- O P Udekwu
- Department of Surgery, University of Pittsburgh School of Medicine, PA
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Ritchey ML, Lally KP, Haase GM, Shochat SJ, Kelalis PP. Superior mesenteric artery injury during nephrectomy for Wilms' tumor. J Pediatr Surg 1992; 27:612-5. [PMID: 1320674 DOI: 10.1016/0022-3468(92)90460-o] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Iatrogenic injury to the aorta or its major branches during nephrectomy for Wilms' tumor in children is rarely reported but may be more common than is currently acknowledged. We identified four patients with ligation of the superior mesenteric artery (SMA) that occurred during nephrectomy for nephroblastoma and another child in whom SMA thrombosis developed postoperatively. All of the tumors were on the left side. Interruption of the SMA was recognized intraoperatively in all four children, and primary repair was done. In three patients, appearance of the bowel remained normal before repair of the injury. Three of the arteries were repaired by primary reanastomosis, and one was joined with an interpositioned hypogastric artery graft. None of these patients had gastrointestinal complications postoperatively. In the fifth patient, SMA thrombosis developed after repair of an aortic tear during nephrectomy. This patient required subsequent small bowel resection for bowel infarction and died in the perioperative period. Every surgeon treating children with Wilms' tumor should be aware of the possibly distorted vascular anatomy and take precautions to avoid such a significant injury. Attempts at early ligation of the vessels may not be justified until the renal vasculature is clearly identified.
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Affiliation(s)
- M L Ritchey
- Department of Urology, Wilford Hall USAF Medical Center, Lackland AFB, TX
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Abstract
Small bowel injuries are becoming more commonplace. Difficult to diagnose and treacherous when missed, small bowel injuries should be searched for assiduously in all patients at risk. Use of DPL or CT scanning, coupled with a low threshold for exploration, improves the diagnosis and treatment of small bowel injuries. A delayed diagnosis results in a progressive septic insult and markedly increased mortality. Early diagnosis is the key. After addressing life-threatening problems, the operation should include a thorough and systematic exploration to identify all injuries. Sound surgical technique includes debridement of nonviable tissue, restoration of small bowel continuity, generous irrigation, and placement of enteral feeding catheters. By adhering to the preceding principles and by exercising meticulous postoperative care and maintaining a low threshold to reoperate, catastrophic complications can be avoided.
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Affiliation(s)
- S L Stevens
- Department of Surgery, University of Tennessee Medical Center, Knoxville
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Affiliation(s)
- G Louridas
- Department of Surgery, Witwatersrand Medical School, Johannesburg, South Africa
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Abstract
Civilian vascular trauma is not uncommon. Prompt treatment with modern vascular surgical techniques produces good results.
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Affiliation(s)
- P F Blacklay
- St. Bartholomew's Hospital, West Smithfield, London, UK
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Chirurgische grundsätze bei der behandlung von bauchschußverletzungen mit besonderer berücksichtigung militärchirurgischer fragen. Eur Surg 1985. [DOI: 10.1007/bf02656041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gauderer MW, Wolkoff JS, Izant RJ. Traumatic aneurysm of the suprarenal abdominal aorta: surgical reconstruction in a 7-yr-old patient. J Pediatr Surg 1982; 17:940-3. [PMID: 7161683 DOI: 10.1016/s0022-3468(82)80471-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
A 7-yr-old sustained a gunshot wound of the upper abdomen lacerating the portal vein and liver requiring immediate repair. Postoperative angiograms demonstrated two false aneurysms of the aorta between the renal arteries and the superior mesenteric artery. On the thirteenth postoperative day the aneurysms were resected and a Dacron graft interposed between the level of the renal arteries and the celiac axis. The superior mesenteric artery was reattached utilizing a short segment Dacron graft. The boy made a good recovery and is normal after a 3-yr follow-up.
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