The world of surgery is constantly changing as new and novel technologies are applied to diagnosis and treatment modalities. Over just the last few years, vascular surgery has seen a major paradigm shift following the endovascular explosion and the minimally invasive trends established in general surgery and gynecology. The reductions in surgical stress, shortened lengths of stay and of convalescence, and equivalent or improved outcomes have made endovascular operations and minimally invasive surgery a standard of care.

Minimally invasive vascular surgery, however, poses even a new set of anatomic and physiologic hurdles beyond even the technical challenges of endovascular surgery. Dealing with not only the injury or disease itself, minimally invasive vascular techniques must be technically sound as to avoid loss of vascular control, sufficiently brief so as to avoid interruption of tissue oxygenation and immediately safe from the devastating vascular complications possible such as embolism or thrombosis.

It is likely that endovascular techniques will replace open surgical techniques (if they have not already replaced) because of the benefits of the minimally invasive approach. Over the next few years, the practice of vascular trauma will likely bear this out and not the scientific outcome parameters. The problem is that the therapeutic interventions are changing at a rapid pace, the surgeons are becoming more facile with the techniques, and the endovascular equipment arena is constantly changing.

The final chapter is unlikely to be written for some time, and in trauma, as always, will never be validated by strict evidence-based medicine. Also looming on the horizon for vascular disease is the possibility of avoiding surgery altogether with gene manipulation. Unfortunately, this modality is unlikely to be temporally adequate to deal with the topic of this chapter, and there will always be a need for immediate vascular intervention in trauma, yet the reconstructions may be manipulated postrepair to assure patency.

Experience with vascular injuries predates any recorded history as our species developed from not only the gatherers but also the hunters. Understanding vascular anatomy for a quick and successful kill is still passed on orally in non-Western and nonliterate cultures. Understanding vascular anatomy is essentially for appropriate dressing of the carcass and understanding vascular anatomy for the harvesting of blood as a renewable food resource in some cultures is necessary. Lastly, the reality of war has driven the knowledge of vascular anatomy not only for killing one’s opponent but also for the salvage of the injured combatant.

The first medical discussions of vascular injury are found in the Edwin Smith Papyrus from approximately 3000 bc. Galen may be the best resource for his descriptions of arterial and venous injuries in the wounds seen by the gladiators. He advises ligature for arterial injuries and styptic for venous wounds. Galen and his remaining theories remained in practice through the Dark Ages, when surgical care was left to the barbers and other tradesman. Through the Napoleonic Age and into the 19th century, vascular surgery was comprised solely of amputation as no other therapy existed. Suffice it to say, any large vessel vascular injury was fatal, and only peripheral extremity injuries would be the vascular trauma that survived to the surgeon’s table. One needs to bear in mind this was the same therapy for open fractures or large soft tissue injury as well. Arteriovenous fistulas (AVFs), which were the sequelae of survivable injuries, were frequent and surgical treatment constituted the literature of this age.

Despite the case reports of Carrel and Hunter, the application of vascular reconstruction for injuries would wait until late in the 20th century. During the Civil War, The Practice of Surgery by Samuel Cooper¹ (the text of choice for the South) and Samuel D. Gross’s A Manual of Military Surgery² (North) both elaborate immediate amputation of any extremity injury with ligation of the artery and often the vein to avoid hemorrhage, gangrene and/or sepsis, and death. The exhaustive reports during World War I by Makins³ and World War II by DeBakey and Simeone⁴ are unfortunate testimonials of logistics and the lack of standard techniques resulting in virtually the same outcomes. Control of life-threatening bleeding and avoiding gangrene and sepsis took preference over limb salvage, exactly the same as the last 2000 years.

Despite the capability of arterial suturing for direct injury, the key problem in trauma during this time period remained finding a suitable vascular replacement. During the Korean War and through today’s latest conflicts, vascular grafts from autogenous vein have been used with documented limb salvage.^5,6,7 Unfortunately, the scourge of interpersonal violence in American cities has had probably more to do with shaping current techniques and therapies for vascular trauma than mankind’s long military experience.⁸

The are no subtle differences in the comparisons of military versus civilian vascular trauma—types of weapons, projectile velocity, transport times, and availability of diagnostic and therapeutic resources are but a few. While the civilian trauma systems may have had their basis in the military, modern vascular treatments are primarily based on that urban experience. Whereas, the majority of survivable war related injuries involve extremity injuries or wounds with devastating soft-tissue trauma as well, the modern “knife and gun club” presents with far more isolated injuries, with injuries that would not be survivable with prolonged transport or delayed resuscitation and in settings where resources are virtually unlimited.

Lastly, a new classification of vascular injuries must be named. With the burgeoning growth of interventional and endovascular techniques, iatrogenic injuries are increasing in frequency. This is not new,^9,10 but now only we see more with the rapidly expanding volume in the diagnostic and therapeutic setting. Also, we see the subsequent need for secondary interventions as medical care improves and allows patients to live longer and with severe disease.¹¹ While many of these injuries are related to the treatment for vascular disease, others are for diagnosis, monitoring, or nonvascular disease therapies and performed by practioners without vascular surgical skills.

Three key issues in the management of the trauma patient suffering vascular injury have come to light recently. We seem to be capable of learning from our past and the laboratory and carrying this to the bedside with improved outcomes. The first is the concept of directed resuscitation—fashioned and now carried down to basic physiologic principles. The second is the concept of the damage control procedure. Short abbreviated interventions reduce the second hit of surgical intervention, and allow restoration of normal physiology between stresses. Lastly, there is a rebirth of delayed repair—temporizing often with “damage control” until definitive intervention is possible—a concept that most often seen with blunt aortic injury (BAI), but applicable to virtually any injury or anatomic region.

The standard resuscitation model was challenged by many researchers seeking to reduce the purely iatrogenic problems of Adult Respiratory Distress Syndrome seen after aggressive resuscitation. Shock is inadequate end-organ perfusion. In today’s molecular nomenclature, however, this amounts to cellular or even subcellular hypoxia. Resuscitation is the restoration of organ perfusion and the restoration of molecular level oxygenation. Aggressive fluid administration was borne out of the wartime experiences, where the renal failure from hypovolemia in World War II and Korea was traded for ARDS or the Da Nang Lung of Vietnam. The choice of crystalloid, colloids, and/or hypertonic solutions remains the constant and current battlefield for the surgical researchers seeking the Holy Grail of resuscitation.

Bickell et al.¹² challenged resuscitation dogma on a different level and demonstrated that preoperative resuscitation of the trauma patient was not to be guided by rigid protocols, but rather by common sense and simple standard markers. Their study marked a “delay” in resuscitation to avoid overzealous fluid until the bleeding could be surgically stopped with improved outcome. Until the arterial injury/venous injury/bleeding is stopped, it makes little sense to pour fluid and resources to the patient until operation can be performed simply to reach an arbitrary physiologic parameter. Such misdirected resuscitation leads to further bleeding and a loss of endogenous clotting factors.

As documented now, most accepted clinical parameters such as blood pressure and pulse are not good indicators of occult hypoperfusion. Many authors have sought the single marker of adequate resuscitation. In the Eastern Association for the Surgery of Trauma’s (EAST) Practice Guideline on the Endpoints of Resuscitation,¹³ it is scientifically supported to monitor lactate and/or base deficit and to gauge adequate resuscitation by the correction of this molecular/cellular level acidosis. Once the vascular injury is fixed, salvage depends more on correcting this physiology rather than technical aplomb.¹⁴

Stemming from both these concepts has been the rebirth of what has been termed “damage control.”¹⁵ In order to again reduce overzealous and futile resuscitative efforts, abbreviated procedures are performed in fitting with the patient’s physiology. Rather than carrying on in the face of the fatal triad of coagulopathy, hypothermia, and acidosis, the arterial bleeding is stopped, often by ligation, the venous bleeding is controlled by packing and enteric soilage is limited. The operative wound is not formally closed, but temporized for reduction of heat and fluid losses, to allow tissue edema without creating a compartment syndrome, and as a window to the area of concern. Many employ some technique, which is homemade or commercially available, that creates a water-tight, compressive temporary closure with great success. The patient is then returned for resuscitation to restore normal physiology—correct hypothermia,¹⁶ restore clotting capacity and reverse the acidosis. This process can be applied anywhere—the chest, the abdomen, and even the extremities.¹⁷

Once the patient’s physiology has been corrected, the patient is returned for definitive procedures—arterial reconstruction, restoration of bowel continuity, osteosynthesis, or whatever. It should be noted that there is a substantial set of these patients in whom the physiologic derangements will not be corrected and the patient will expire. From our experience, this number is approximately 50%.

Traumatic injury is unlike elective surgery in that the patient has already suffered a major systemic stress, and is now faced with secondary stress from surgery. With the realization that there are such risks to emergent operative repair—i.e., the cure is worse than the disease, delayed repair has not only been applied in extremis, but for the stable patient. The best example of this has been BAI.^18,19,20,21

The diagnosis of BAI is derived mostly from the high index of suspicion of the causative mechanism as well as incidental findings on screening radiographs. The diagnosis is confirmed by aortography, today either direct intra-aortic contrast injection, or from rapid acquisition computed tomography (CT),^22,23 which allows evaluation of other key thoracic anatomy as well.^24,25,26

BAI is the result of a rapid acceleration or deceleration, and therefore not exclusive to any particular mechanism or any particular direction of force. The aorta is disrupted usually just distal to the left subclavian artery.²⁷ The incidence of BAI is greater than seen by the clinician as most victims exsanguinate and die at the scene. The fortunate few in whom the adventitia remains intact enter the emergency department with near normal blood pressures.

Findings that are worrisome on the initial chest radiograph during the initial evaluation are widened mediastinum, the loss of the aortic knob, left apical cap, nasogastric tube deviation, or even large left hemothorax.²⁸ These nondiagnostic findings should be followed by diagnostic testing, from obtaining an erect chest radiograph to aortography. With the new generation of CT scanners available, contrasted CT of the chest is a rapid, sensitive and specific test to ascertain if BAI or some other injury is present.²⁹ For many centers, this has replaced aortogram as the diagnostic test of choice and carries with it a sensitivity of 97% to 100%, negative predictive value of 100%, and specificity of 83% to 99%.^23,25

The second interesting facet of BAI is the timing of repair. The natural history of this injury is rapid exsanguinations once the adventia is disrupted. Formerly, this mandated immediate repair, before this nonsurvivable event occurred. Several anecdotal reports of survivors without repair, of increased mortality in the elderly with trauma and thoracotomy, as well as the blossoming concept of maximizing resuscitation altered the immediate repair plan of care. More recently, with the multiply injured patient, in whom a thoracotomy represents a taxing metabolic and physiologic stress, BAI therapy has been delayed. Resuscitation is guided by correcting the immediate life-threatening injuries, restoring perfusion and avoiding hypertension.^23,30 The repair of the stable BAI is turned into an elective procedure and can even be accomplished by endovascular technique to further reduce the surgical insult.^{31,32,33,34,35} For open procedures, the debate continues over the use of bypass^36,37; it remains as an operator-dependent surgical decision based on associated injuries.^38,39

This concept of reducing or delaying additional surgical stresses after acute injury can be applied not only to life-threatening abdominal or thoracic injury, but to other devastating injuries, such as extremity vascular and/or skeletal injuries, or massive soft tissue injuries. The goal remains to restore normal physiology, and use operation as a means to and not an end of resuscitation.

The diagnosis of vascular trauma is generally quite simple—it is based on the clinical manifestations on the physical examination: After the initial assessment, a thorough palpation of all major pulses (radial/ulnar, brachial, dorsalis pedis/posterior tibial, popliteal, femoral, and carotid) is performed as part of the secondary survey. Palpable pulses are sufficient to determine if further testing is needed.³⁹ A thorough history taking is of paramount importance especially in the aging population as vascular disease may have already altered pulses or present reconstructed anatomy. The expectation should be palpable pulses in all sites. Any alteration in pulses is concern for an injury and should be investigated further, with operation and/or confirmatory testing. The decision making for operative exploration depends mostly on the physiologic state of the patient. If they are hypotensive, and the pathway to resuscitation involves stopping the bleeding from the vascular injury, further diagnostic and therapeutic intervention should occur in the operating room (OR). If the patient is physiologically stable, other modes of diagnosis may be employed.

Louis Pasteur is quoted “in the field of observation, chance favors the prepared mind.” The diagnosis of vascular injury also depends on the clinician’s index of suspicion. The clinical manifestations are usually dependent on the mechanism, the location, the time since the injury and the overall severity of the injury, yet there are injuries that have no such manifestations, or the manifestations of such injuries are delayed but devastating. A vascular injury may exist with palpable pulses, so the physician must be acutely aware of such circumstances to reliably diagnose occult injury. Not surprisingly, the outcome of these injuries is often excellent.⁴⁰

Blunt trauma patients are more prone to intimal injury and dissection then full thickness transection injury from penetrating trauma. This type of injury usually involves large vessels like thoracic aorta in a deceleration injury or carotid injury from a direct blow where the elasticity of each layer of the vessel reacts differently.⁴¹ Extremity vessels are more commonly involved in penetrating trauma but may also be injured because of the blunt mechanisms such as fractures and/or dislocations. A knee dislocation is especially worrisome for popliteal injury, which may present as the spectrum of vascular injury, from total occlusion to AVFs.^32,42

Penetrating trauma can present with other clinical manifestations beside pulse alterations, such as external or internal bleeding, pulsatile hematoma, or distal ischemia. The injury may present only as end-organ malperfusion such as altered neurologic states from carotid injury or limb ischemia from superficial femoral artery injuries. On the other hand, other injuries may not cause any clinical signs because of the collaterals such as with the profunda femoris artery. The time of occurrence of the injury should be documented since it directly impacts both the diagnosis and management. The duration of time since injury can dictate the amount of blood loss as well as ischemia time to prevent permanent injury.⁴⁴ The correctable defect in the trauma patient is hypoperfusion and stems either from hypovolemia or impairment of cardiac function. All trauma patients should be treated as having a vascular injury until the physical examination or further testing rules this out. For vascular injuries, further tailoring of the examination can be done to the location of injury and specific clinical signs. We describe the main points of diagnosis and management based on the location of injury for convenience. Both arterial and/or venous injuries are detailed.

Other than the physical examinations, diagnostic adjuncts such as ultrasound and angiography are used to help diagnose vascular injury. Again, the unstable patient with suspected vascular injury needs to be in the operating room. These modalities should be employed only in the stable patient within time constraints for ischemia or potential ischemia. The role of both modalities is changing rapidly as technologic advances are made and now that these same approaches can now offer therapeutic roles as well.

The use of sound energy to detect and describe blood flow and blood vessels is a fundamental part of vascular diagnosis outside of trauma.⁴⁵ It only makes sense that this modality, which is easy, mobile, painless, interpretable by the surgeon and repeatable, would be applied to the trauma victim. The two forms of ultrasound, Doppler flow and B-mode imaging now have been combined within a graphic format of color imaging which makes interpretation intuitive. The details of this modality are covered in depth elsewhere, but the use of ultrasound is playing a larger role in vascular diagnosis. It, however, is limited and has not yet reached “gold standard” applicability for any disease process.⁴⁶

Angiography has advanced technologically to be an excellent diagnostic tool to a means of therapy with reduced complications.⁴⁷ Again the in-depth review of the principle and techniques is described elsewhere. Delineation of the vascular system was formerly accomplished by filling the vessel in question with radio-opaque contrast material and obtaining at the least biplanar radiographs to assess continuity, intimal integrity and anatomy. Today, with advances in technology, contrast angiography can be direct, i.e., with contrast media directly in the vessel, or indirect, i.e., using intrinsic properties of the imaging modality and blood vessels to differentiate the above goals.⁴⁸

Today, digital subtraction angiography offers clear images with lower contrast doses to provide this information with minimal risks of radiation and contrast.⁴⁹ Rapid spiral CT with increasing numbers of detectors now offers a similar digital image that is amenable to computer manipulations to give high quality imaging in three dimensions. Today, these multidetector images are encroaching on the gold standards of contrast angiography.

Magnetic resonance angiograms may also be performed with a noniodinated contrast, gadolinium, and without ionizing radiation. Currently, however, these MRAs are not as accurate for lesions, although if the past development of CT is a comparator, MRA imaging quality will also be improved to produce reliable diagnostic images.⁵⁰

Vascular injuries are managed by four primary techniques:

1. 
   

   Observation: Best for nonocclusive injuries found on diagnostic evaluation.

   
   
2. 
   

   Direct repair (arteriorrhaphy/venorrhaphy): Amenable in only roughly 10% of cases.

   
   
3. 
   

   Patch or interposition grafts: The majority of modern repairs.

   
   
4. 
   

   Ligation.

This applies to open, endovascular, and minimally invasive techniques as well, in which only the technical approach is different. The choice of management technique is fluid and depends on the clinical status of the patient, the extremity, and the resources available. Time is perhaps the greatest factor and must be accounted for in every therapeutic plan. Just as our history reminds us, the goal is survival—life over limb. Restoring blood volume, reducing further blood loss and reestablishing flow are the priorities.

Today’s outcomes from vascular trauma are marvelous. An overall survival of 93% and limb salvage rate of 98% are quoted.⁵¹ These figures are the product of time, frequency, and location of injury. While even a common but relatively minor injury can be fatal, there are virtually fatal injuries that are fortunately infrequent. The surgeon facing any vascular injury, however, must be ready for even the most devastating of injuries, prolonged presentation, and abnormal physiology and rapidly fashion a plan of care that is based upon these goals.

Blunt

Trauma to the scalp comes from unnamed vessels but with significant blood flow that failure to stop bleeding can cause significant hemorrhage, shock, hypothermia, and disseminated intravascular coagulation (DIC) or even death. Temporal artery injury is usually manifested by active bleeding or expanding hematoma on the side of the head. Nonexpanding hematomas and smaller size hematomas although may occur with temporal artery injury are more frequently associated with venous injury. Bleeding from the scalp may be exacerbated when patient is coagulopathic as a result of the significant blood loss or hypothermia. Control of bleeding is the main treatment and is generally effected by suturing the wound closed and direct pressure. The single named vessel which may bleed is the superficial temporal artery and is treated uniformly with ligation. Evacuation of the hematoma prior to intervention reduces infection and deformity as well as exposes bleeding vessels needing direct ligation or clipping. Since the scalp is heavily vascularized, one should not be concerned about ischemic changes form ligation of these vessels, but one must be sure to debride any nonviable tissue prior to definitive closure.

Vascular injuries to the face are usually ligated with the rich collateral flow available from the branches of the external carotid and jugular system.

Basilar skull fracture can be associated with carotid injury. Basilar skull fracture is a clinical diagnosis and suspected when a patient presents with raccoon eyes, hemotympanum and/or Battle’s sign (mastoid contusion). Carotid injury must also be expected after significant force that results in mandibular or Le Fort type fractures.⁵² Blunt carotid injury (BCI) can be from a partial occlusion because of a hematoma in the arterial wall, an intimal flap or a local thrombus as well as wall disruption.

Because of the specific course of the internal carotid artery inside a bony compartment, a fixed point is created and again a difference in elasticity or stretch of the arterial walls is possible. Occlusion from external compression or thrombosis after intimal injury is the rule and presents as significant neurologic deficits unexplained by other anatomic injuries.^54,55 Therefore, internal carotid injury at the skull base level is suspected when focal neurologic impairment is identified. After blunt trauma significant carotid disruption is rare and therefore local hemorrhage or expanding hematomas are very rare or rapidly fatal before definitive diagnosis or repair are made.

Controversy exists in the screening regimen for blunt carotid injury. Although quite rare by some accounts (0.5%–0.004% of trauma victims),⁵⁴ BCI can have devastatingly poor outcomes.⁵⁵ Quite logically, these poor outcomes are reduced by aggressive screening, but the utility of such widespread screening for large populations with such a low incidence of injury remains problematic. Furthermore, generally the treatment for BCI is anticoagulation, which may be difficult or precluded by neurologic bleeding or other associated injuries present in the multisystem trauma victim, and currently experimental methods may be employed based on atherosclerotic therapies.⁵⁶

Penetrating scalp injuries are treated similarly. Large lacerations require expeditious control and injuries from gunshot wounds are generally sufficiently small so as not to require any therapy other than debridement and local wound care. Intracranial vascular injuries are the purview of the neurosurgeon, although embolization may be a useful adjunct for lifesaving control.

Blunt

Blunt vascular injury in the neck although rare can be fatal or even worse, result in a devastating neurologic insult and result from even minimal trauma.^57,58,59 Unfortunately, physical examination may miss many cases because of lack of physical signs or the clinical result is neurologically irreversible. Inspection may show ecchymosis, abrasions, or a seat belt sign at the base of the neck. A large hematoma may cause tracheal compression and deviation, as well as facial swelling caused by impaired venous return. Even a small size hematoma when deep and paratracheal can cause laryngospasm and become a major airway threat. It is always prudent to intubate a patient with a neck hematoma before tracheal compression occurs. Auscultation may reveal a carotid murmur when there is a partial occlusion of the carotid artery because of an intimal flap or dissection, but as in atherosclerotic disease, a near complete occlusion of the carotid artery may not manifest a murmur on auscultation.

A thorough neurologic examination is mandatory for any trauma patient. This is important for isolated neck injuries as well. Finding altered function secondary to an embolic or an occlusive event, i.e., fitting a stroke like pattern initiates the evaluation and treatment for BCI. Vertebral artery injury is associated with cervical vertebral fractures and would be very hard to diagnose on physical examination if one omits the neurologic examination. When arterial injury is suspected, even based on mechanisms alone, physical examination should always be supplemented by Doppler ultrasound or CT angiogram of the neck. Presently, arteriogram is the gold standard to rule out vascular injury,^60,61 but CT technology is likely to eclipse this in the near future.^62,63

One must also be wary of carotid injury from iatrogenic mechanisms as well. Diagnostic angiography, endovascular therapies for virtually any problem at/or above the arch vessels, or cardiac catheterization with or without coronary manipulation places the carotid system at risk. Similarly, the diagnosis my not be evident until neurologic changes have occurred.^64,65,66

BCI can occur more proximally than the base of the skull. Using CT angiography or 4 vessel angiography are the gold standards for diagnosis. Injuries to the carotid around the bifurcation and in the common carotid are also generally managed with anticoagulation unless an easily repairable intimal flap is seen.^67,68 Vertebral injuries are also managed with anticoagulation or embolization.⁶⁹ It is important to note that vascular injuries to the neck in blunt trauma have a very low incidence and the frequency of such diagnosis has been on the rise probably because of the aggressive screening in the recent years.^55,69,70,71 While a constellation of associated injuries are noted in BCI (Seatbelt mark, cervical spine fractures, mandible fracture) routine screening for patients with these injuries is hotly debated.^72,73,74,75 New endovascular alternatives are described frequently.^76,77 Despite this, the outcome is often devastating.^78,79 Vertebral artery injuries are very amenable to angiographic or endovascular treatment with good outcomes.⁸⁰

Injury to the jugular vein can cause an expanding hematoma and may not be controlled by simple compression because of the amount of swelling and bleeding. The development of a hematoma in the neck is worrisome more for potential airway compromise than exsanguination, and early airway control is advisable. Although a constant; jugular vein injury is not differentiated from arterial neck injury by color of the blood, lack of arterial pulsations by palpating a pulsatile mass in the later. If the patient is stable and the hematoma is not expanding or impinging on the airway, nonoperative therapy is possible, otherwise operative ligation is needed.

AVFs are a consequence of injury of both vessels or of failed surgical repair. AVFs were probably more frequent before aggressive surgical repair, and the historical reports spend a great deal of discussion over the only available therapy then of ligation. Classically, the diagnosis is made by a thrill or bruit in the area of injury. High flow vessels may lead to venous congestion, either manifest as edema or even near congestive heart failure. Physical examination reveals a pulsatile mass and confirms the thrill.

Today, AVFs either recognized at the time of injury and repaired or unrecognized until presenting late are managed with both arterial and venous reconstruction. Current management options are dependent on location, as endovascular procedures avoid some very morbid surgical approaches. Beside open repair or ligation, endovascular stenting (both arterial and venous), or embolization are feasible and readily performed.^52,81

Penetrating

Penetrating injury to the neck may present a major threat to life because of the hemorrhage or airway compromise. As with any trauma patient the airway should be secured, breathing maintained and shock treated. Airway control is paramount—it is easier to extubate the uninjured patient than to delay and be faced with a very difficult airway and a potentially impossible surgical airway. Bleeding control is obtained by simple pressure until further definitive treatment can be accomplished in the operating room.

The dynamics of injury is an integral part of the history—a high-velocity missile will cause different injuries than a penknife. On inspection, one should assess the location, the depth, and extent of the injury. Long lacerations made with a knife in a suicide attempt tend to be superficial to the platysma and would cause only superficial bleeding which is easy to control, whereas injuries penetrating the platysma require operative exploration and proximal and distal vascular control. High-velocity projectiles may not only create vascular injuries but result in airway, esophageal, nervous, or bony injuries as well and can be managed in damage control fashion, including the use of shunts.⁸² Operative exploration for trauma is conducted in a similar technical fashion to elective carotid surgery to avoid those iatrogenic injuries intrinsic to the surgical approach such as cranial nerve injuries.

The standard approach to the carotid sheath is the common incision along the anterior border of the sternocleidomastoid muscle. The muscle is retracted laterally and the carotid sheath is visible beneath. Opening the sheath exposed the internal jugular vein medially and the vagus nerve posteriorly as well.

There are clinical manifestations that are an immediate indication for surgical exploration. Such signs and symptoms are active arterial bleeding, expanding hematomas, thrill, or bruit and diminished or absent distal carotid sounds or pulse. Neurologic impairment with a focal deficit is also an indication for exploration. Other signs that constitute an indication for exploration are related to airway injury such as subcutaneous air, stridor, hoarseness, dysphagia, and hemoptysis.

Palpation is useful to assess the extent and size of the hematoma as well as to identify the location of the trachea if swelling occurs. If the wound is not actively bleeding, it is prudent not to probe or expose the wound until definitive control can be established in the operating room.

The location of the injury determined during the physical examination directs the subsequent management. Anatomically the neck can be initially divided into two simple triangles: anterior and posterior triangles divided by the sternocleidomastoid muscle. All major vessels are contained in the anterior triangle. The platysma constitutes the superficial border of the anterior triangle and if not violated a major vessel injury is far less likely.

The neck is also divided into three zones from inferior to superior. Zone I, or the thoracic inlet, extends from the sternal notch to the cricoid cartilage. The proximal location of this zone signifies that the great vessels in the chest or at the base of the neck are injured and prudent planning for the operative approach to assure proximal control is very important. When patient is stable, an arteriogram or high resolution CT angiogram is indicated to identify the extent of the injury.⁸³ When unstable, patient should be explored to control bleeding and a combined median sternotomy and anterior neck approach is best. Most surgeons would begin with the neck incision and extend inferiorly as needed for control. If the arch vessels are involved a thoracic extension into the second rib interspace (i.e., the trap-door incision) is performed.

Zone II, or the midzone, extends from the cricoid cartilage to the angle of the mandible. An injury at this zone is fairly easy to identify by physical examination and the management is dependent on the symptoms. If any of the above signs, the so-called hard signs, is present then exploration is indicated. When no hard signs are present and patient is stable an arteriogram or CT angiogram may be done. This may obviate operation⁸⁴ and the ensuing complications. Additional testing is performed for other structures in the neck such as bronchoscopy and esophagoscopy, to rule out as associated injury.

Zone III is between the angle of the mandible and the skull base. Symptoms and physical examination findings can be very subtle at this location.⁶⁸ An onsite Doppler ultrasound may not rule out injury at this location because of bony structures. Carotid arteriogram or a high resolution CT angiogram employed to determine injury. Because distal control is often impossible, ligation, embolization, or packing of the foramen lacerum with sternocleidomastoid muscle may be the only recourse. The unfortunate outcome is often survival but with a dense neurologic insult for the younger patient without collateralization. Exposure at this location may require a mandibular disarticulation, although endovascular techniques offer both diagnostic accuracy and interventional therapy.

Injury to the neck may not be limited to one zone and may involve two or three zones at the same time especially in gunshot wounds or high-velocity missile injury. When arterial injury is suspected by proximity or mechanism, exploration or arteriogram is indicated to rule out or define the extent of the injury. Recently, CT angiography of the neck defines vascular as well as other system injuries quickly and assists in therapeutic planning. With the newly found interventional skills, adopted from embolization as well as endovascular treatment for carotid occlusive disease, the use of the angiography/endovascular suite is particularly appealing.⁸⁵ For injuries to the vertebral system an area in which the surgical options for approach are virtually impossible and even the open therapy involves ligation, the endovascular route is ideal.⁸⁶

Blunt

History taking again should focus on the mechanism of injury. Blunt injury should be classified between a deceleration injury and a direct impact to heighten the surgeon’s index of suspicion for BAI. Unfortunately, physical examination can be very limited in these types of injuries and not be helpful to identify the location or the extent of the injured vessel. After securing the airway and ventilation, a vascular injury is suspected when a patient is hypotensive or shows signs of shock. Major vascular injuries must always be considered, but usually solid organ injuries are the cause and identified at the time of abdominal exploration. The evaluation for the hypotensive patient undergoing active resuscitation includes a chest radiograph to show if hemothorax, BAI, or pneumothorax is present and Focused Assessment with Sonography for Trauma (FAST) examination of the abdomen to evaluate for free fluid. Each pertinent issue is addressed immediately as it is identified to restore normal physiologic parameters. When stable, patients are evaluated with CT scanning.

On inspection, abrasion, ecchymoses, and “seat belt signs” should be noted. Palpation may reveal crepitus, chest wall instability, or subcutaneous emphysema. Distended jugular veins may indicate a tension hemothorax or pericardial tamponade. Decreased or muffled breath sounds on auscultation may lead to a diagnosis of hemothorax. Unequal blood pressures or pulses in the extremities may indicate an innominate artery injury. Palpable fracture of the sternum is another signs that should raise the suspicion of an innominate artery injury. Some commonly noted signs in patients with BAI are pseudocoarctation and intrascapular murmur.^87,88,89 Unfortunately, physical examination can be very limited as to identify the location or the extent of the injured vessel but represent sufficient energy transfer to create such an injury. A negative finding on physical examination should not rule out aortic injury if suspected by the history.^90,91

Similarly, there may be no external signs of injury and yet an injury may exist. A thoracic vascular injury may not be detected until a chest tube is placed; a CT scan is performed or worse until a hemorrhagic shock has occurred. The presence or absence of restraints does not appear to affect the incidence of BAI.⁹² In the chest, the vessels more prone to injury after a blunt trauma include the thoracic aorta most commonly, followed by innominate artery, pulmonary veins and vena cava. Aortic injuries constitute up to 15% of immediate deaths after a motor vehicle crash with the proximal descending aorta disruption in up to 65% of the cases.^93,94

An initial rush of blood of more than 1500 mL on insertion of chest tube or ongoing hemorrhage of more than 200 mL/h is an indication for exploratory thoracotomy since major vessel injury is clinically suspected and bleeding control is lifesaving. Serial monitoring of chest tube output is also necessary, as continued outputs in excess of 200 mL/h also warrant exploration. As with any trauma patient there must be a concerted effort to maintain end-organ perfusion, maintain euthermia and avoid coagulopathy. When stable, patients can be diagnosed with major thoraco–abdominal vascular injuries by routine contrasted trauma CT scan.^95,96,97,98

Other than BAI, virtually any thoracic vessel can be injured by a blunt mechanism.^99,100,101 Similar to BAI, any free rupture likely leads to rapid death, and only the victims who have contained hematoma or intact adventia survive to hospital. Because of this particular fact, they are amenable again to evaluation with rapid sequence helical acquisition CT with contrast and endovascular repair; venous injuries are diagnosed and treated similarly.^{99,100,102,103} Because these injuries are infrequent, there are no prospective management series, and endovascular or open techniques become interchangeable regardless of mechanism.

Thoracic vena cava injury is very rare but carries a mortality rate greater than 60%. Such injury may be suspected after hemopericardium and cardiac tamponade. Pulmonary vein injury when associated with bronchus disruption may lead to a systemic air embolism when intrabronchial pressure increases to above 60 Torr.¹⁰⁴ As above this usually manifest as mental status changes, seizures, and cardiac arrest.

On the other hand, penetrating injury can have different outcomes depending on the mechanism and location of the injury. Again the type of weapon used, the trajectory of the projectile and the time since injury are all pertinent to the evaluation and therapeutic plans.¹⁰⁵ Approximately 85% of gunshot wounds to the chest on reaching the hospital will require only tube thoracostomy for evacuation of blood and air, and restoration of normal physiologic parameters from bleeding and disruption of lung tissue integrity. For those patients who do not resuscitate or have the same signs of massive ongoing bleeding, major vascular injury is suspected and those patients mandate exploration.

Simply “connecting the dots” between wounds or tracing the presumed trajectory of the missile; either by visual inspection or chest radiography diagnoses the presumed anatomic injury. This is crucial for surgical planning, primarily choosing the incision that is most expedient for control and definitive repair.

The standard thoracotomy must be a mastered skill for any general and vascular surgeon. The transverse incision is made over the inframammary crease starting at the lateral sternal border of the concerned side and extending to the anterior axillary line. The pectoralis and intercostals muscles are divided and the fifth intercostals space is entered. The internal mammary artery and vein are near the lateral border of the sternum so care must be taken to not injure them. The lung is collapsed and a rib spreader is inserted. The lung is retracted upward and the inferior pulmonary ligament is divided. On the left, the descending thoracic aorta is visualized in the posterior mediastinum. The mediastinal pleura is incised. Vascular control is obtained with blunt dissection of the aorta being careful not to injure the esophagus which is anterior to the aorta. The vascular clamp is placed around the aorta to occlude it just above the diaphragm. On the right, access to the superior vena cava, azygos system, inferior vena cava (IVC), and esophagus are subpleural in the posterior mediastinum.

The “cardiac box” is the topographic anatomy that predicts cardiac and major vascular injury. Any penetrating wound within the parallelogram defined by connecting the midclavicular lines at the clavicles and the costal margins is worrisome. Ultrasonography (echocardiography) is a rapid and repeatable noninvasive method to diagnose pericardial fluid. If the patient is hemodynamically unstable, pericardial fluid is present or both are present, median sternotomy is the best approach for control of cardiac and most major vascular injuries. This box applies post trauma as well.

Median sternotomy is the rapid and best approach for most major vascular injuries of the arch and distal vessels—heart, ascending and aortic arch, innominate, carotids and proximal subclavian vessels, vena cava, and jugular veins as well. Sternotomy is performed by incising the skin from the sternal notch to just below the xiphoid process. Blunt finger dissection develops the pretracheal space superiorly and the subxiphiod space inferiorly to allow the power saw or Lebschke knife to cut the sternum vertically. Both halves are retracted laterally and the pericardial sac and great vessels are in plain view.

The sternotomy may be extended into the neck for more distal injuries to the carotids or subclavian vessels. A suspected injury to the more distal left subclavian vessels should be approached by thoracotomy and sternotomy extended up the neck for the right side. If the injury suspected is distal to the arch, a left thoracotomy is the best approach for descending aortic injury. Pulmonary hilar injuries are best controlled through a thoracotomy on the side of suspected injury.

Repair of the injury can be accomplished with continuous size appropriate monofilament suture or interposition grafts. The decision point is extent of the vascular injury and the ability to mobilize uninjured segments together for a tensionless anastomosis. This requires that there be a ready supply of vascular graft material available. The technique of clamp and sew is employed most frequently as the additional time for initiating cardiopulmonary bypass is prohibitive; anticoagulation is inappropriate because of additional injuries or both. Autogenous graft material is also infrequently used because of availability, size mismatch, and time constraints.

The operating team, especially the anesthesiology team, must be ready for the potential massive blood loss encountered when opening and exposing the injury and the changes in physiology resulting from control before repair is effected. Over resuscitation can result in cardiac strain and the anesthesiologist must be ready to rapidly shift from massive transfusion to vasodilating therapy virtually in a heartbeat. Concomitantly, other concerns must be shared. If the left subclavian artery is clamped, blood pressure monitoring is inaccurate on the left side, if the pulmonary hilum is to be clamped, ventilatory adjustments must be made, but most of all, someone must be watching the clock. Hypothermia, coagulopathy, and even likely neurologic injury are time dependent, and with the success of damage control procedures and the aggressive intensive are unit resuscitative capabilities, the initial procedure must be limited. For our patients in extremis, undergoing massive resuscitation, we limit operating room time to 60 minutes—door to door.

Emergency Department Thoracotomy

Emergency department thoracotomy (EDT) is a dramatic surgical display that factually rarely results in salvage.¹⁰⁶ The procedure can consume vast resources and is not without substantial healthcare provider risk,¹⁰⁷ nevertheless, its results can truly be awesome, and it does have role within very strict guidelines. Clear indications for which patient and which practioner performs EDT are facility dependent. First and foremost, there must be the immediately available resources to care for the patient with their chest open and cross clamps in place, and there must be clear decision points for terminating interventions if normal physiology is not reestablished. Well-defined algorithms have been published.¹⁰⁸ For our Trauma Center, even where an operating room, surgeons, anesthesiologists, and laboratory resources are immediately available, we strictly limit EDT based upon our Center’s outcome data. For penetrating chest injury only, we perform EDT only if ECG monitor electrical activity is present, FAST examination shows cardiac motion of any kind and no abdominal fluid, and there have been signs of life within 10 minutes of arrival.

The goal of EDT is to restore sufficient circulation for immediate operation. This is accomplished by relieving cardiac tamponade, cross clamping the descending aorta to restore circulating volume quickly to maintain perfusion, and rapidly controlling active thoracic bleeding until the patient is rapidly transported to the operating room. EDT is simply a left anterolateral thoracotomy. It is performed by making an incision from the midsternum across the chest horizontally just below the nipple to the table. The chest is rapidly entered at the fourth interspace and the surgeon’s hand enters the chest to evacuate hematoma, gain access to the pericardium and find the aorta. The pericardium is opened on the anterior surface and care is taken to preserve the phrenic nerve which runs for superior to inferior along the lateral border of the pericardial sac. The pericardium is tough and difficult to grasp so often it is easier to incise a centimeter size hole with the knife, and then use the scissors to fully open the pericardium and evacuate any clots. Bleeding from the heart or great vessels is controlled by a finger, simple sutures, clamps, temporary ligation, or any other method that allows resuscitation to progress. Open cardiac massage to revive the heart is done, and to try to preserve blood flow to the brain.

Clamping the descending aorta will decrease the volume needed to restore perfusion to the brain and is accomplished by the surgeon hand sliding along the posterior thoracic wall, up onto the vertebral column. The aorta is generally flaccid and feels like a penrose drain; passing a nasogastric tube makes aortic identification easier as the tube can be felt to the right of the aorta. The cross clamp is applied by breaking through the pleura and applying the clamp across all the structures on top of the vertebral column. An injury to the left lung hilum is controlled by simply cross clamping the entire hilum. If no blood is found in the left thorax, the thoracotomy can be extended across the sternum to open the right chest in similar fashion for immediate control of bleeding.

Transmediastinal gunshot wounds are particularly worrisome for major vascular injury. They are also worrisome for aerodigestive tract injury and/or neurologic injury as well. As discussed frequently, the unstable patient needs operation. Current management of the stable patient includes helical CT.^{92,109,110,111,112} Despite normal or easily corrected vital signs, significant major vascular injury may still exist with transmediastinal gunshots.¹¹³

The subclavian vessels broach the neck, the thorax, and the extremity. The surgeon must be prepared to deal with any region and be expected to gain control rapidly and without delay. For the stable patient, arteriography is crucial for operative strategy.^114,115 Endovascular techniques are superior to open procedures which risk multiple incisions, complex approaches and dangerous dissections. Nervous structures at risk for injury include vagus, phrenic, and the brachial plexus. Because of the proximity of these structures to the vessels, preoperative examination is imperative to document the deficits from the injury.

Exposure for the subclavian vessels is different for the right and the left side. On the right, median sternotomy with a cervical extension offers the best approach. On the left, however, a left thoracotomy and potential supra clavicular incision offer the exposure for control. The incisions may be combined through the sternum in the so called trap-door approach. Because of the bony structures and fixed position of the arch, there is insufficient mobility to fashion a tension-free anastomosis and interposition grafts are employed; because of the caliber of the vessel, polytetraflouroethylene (PTFE) grafts are most commonly used.¹¹⁶

In summary, major vascular injuries that reach the hospital; either blunt or penetrating are managed with similar schema—hypotensive patients go to the operating room and stable patients are evaluated with helical CT. Thoracic injuries are particularly amenable to endovascular techniques because of the current technology and surgeon increasing experience. It is beneficial to the patient to avoid thoracotomy as the second insult, temporizing with damage control and definitive repair when the patient is warm, fluid replete, and not coagulopathic.

The data from civilian trauma centers reveal that the incidence of abdominal vascular trauma is significantly higher than that in military injuries, because of the logistics of devastating injuries making it alive to medical care. The Ben Taub General Hospital in Houston published a 30-year review in 1989 that documented civilian inner city abdominal vascular injuries at 33.8%.¹¹⁷ The military, abdominal vascular injury experience demonstrates only an incidence of 2% in the paper by DeBakey and Simeone in 1946,⁴ of 2.3% in Korean conflict⁶ and Rich et al.⁷ reported an incidence of 2.9% in Vietnam due primarily to logistics, and ballistics. The high-velocity, repeating weapons (projectile velocity greater than 2000 feet/s) and other weapons designed to fragment as compared to the single shot low-velocity weapons being used by the civilian population transfer greater injury. The projectiles are designed for stopping power, a military objective, rather than accuracy. Despite remarkable improvements in prehospital care in theater, the simple fact remains that the individual is injured in a “hostile” environment. Intercity violence has forced prehospital system improvements that have resulted in shorter transport times and earlier surgical intervention.

The incidence of abdominal vascular injury sustained after blunt trauma is 5% to 10% while penetrating stab wounds to the abdomen similarly have a low incidence of vascular injury.^117,118 The most commonly injured abdominal vessels were the IVC (25%), the aorta (21%), the iliac arteries (20%), the iliac veins (17%), the superior mesenteric vein (SMV) (11%), and the SMA (10%).¹¹⁹

Iatrogenic injuries to abdominal vessels are caused by laparoscopy (primarily trocar injuries), angiography, cardiac catheterization, abdominal procedures (pelvic and retroperitoneal dissections), and spinal procedures.^{120,121,122,123,124} Injuries created are similar to stab wounds and the only caveat for the operating surgeon is that a major vascular injury has been described even during the most mundane cases.¹²⁵ Early diagnosis and a high index of suspicion must always be maintained when sharp objects are manipulated in proximity to vascular structures. Repair is dependent on the clinical status of the patient and endovascular and minimally invasive techniques are acceptable in the stable patient.^126,127 Patients in extremis require immediate control by whatever means are most expedient.¹²⁸

Diagnosis

Physical examination is relatively inconclusive; decision for operation is made largely depending on the amount of hemorrhage and associated shock, or the presence of peritoneal signs. The usefulness of the physical examination is limited in the trauma patients who are intubated, have altered consciousness or who have other distracting injuries. The physical findings also depend on the location of the injury—contained within the retroperitoneum or intraperitoneal injury/hemorrhage. Contained hematomas may present with a hypotension which responds to a fluid bolus. Active free hemorrhage presents with shock that transiently responds or is refractory to resuscitation. Although there is considerable hemorrhage within the peritoneum there may not be either a distended abdomen or peritoneal signs.

Inspection of the bluntly injured patient may identify a seat belt sign, abrasion or ecchymosis. The EAST practice management guidelines for the evaluation of blunt abdominal trauma recommended that patients with seatbelt sign should be admitted for observation and serial physical examination.¹²⁹ Auscultation is rarely useful, and palpation can elicit peritonitis. When hemorrhage is contained retroperitoneally or in the lesser sac, the patient may show signs of transient hypotension that is usually corrected with fluid resuscitation. In this case hypotension may be delayed, or not seen until the time of exploration. Patients with abdominal vascular injuries, a systolic blood pressure in the emergency department of more than 100 mm Hg and a base deficit of more than -7.2 have been shown to have favorable survival rate of 96.2%.¹³⁰ Equivocal physical examination findings or altered mental status constitute an indication for objective diagnostic measures like CT scan, FAST, etc. FAST offers immediate information that is repeatable and simple. It requires no ionizing radiation and many of the ultrasound machines are portable and lightweight. Because of its high accuracy when used to evaluate hypotensive patients who present with blunt abdominal trauma, every abdominal physical examination should be complemented with FAST when possible. Detection of intraperitoneal fluid is best made by this surgeon performed examination.^131,132,133

In the hemodynamically stable blunt trauma patient, FAST is performed and may be complemented with CT scan. CT offers several additional data to detect injury (retroperitoneum, contrast studies, osseous anatomy) and plan therapeutic maneuvers. Hemodynamically unstable patients may be evaluated initially with FAST to ascertain if the hemorrhage is indeed within the abdomen. The hemodynamically unstable patient with abdominal hemorrhage needs to be taken to the operating room as quickly as possible.

In the emergency department the ATLS regimen is initiated as quickly as is possible—high flow intravenous access, crystalloid and O-negative blood infusion and an active attempt to prevent hypothermia.¹³⁴ Although the only important decision is if and when take the patient to the operating room, being prepared for other contingencies is necessary—assuring the availability of blood and blood products for massive hemorrhage, quickly administering antibiotic/tetanus prophylaxis, and preparing the operating room and associated personnel for impending arrival are crucial system issues. The precise diagnosis is made at operation with the most likely source coming from a solid organ injury, but full exploration is needed to fully evaluate all organs and vessels.

Nonoperative therapy for solid organ injury is now standard. There are cases in which angiographic or endovascular techniques are employed to stop bleeding in the liver and spleen^135,136 identified on CT. These interventions avoid laparotomy and its associated morbidity but are not wholly innocuous.¹³⁷

If the FAST or a CT scan detects free fluid, and there is no evidence of a solid organ injury (spleen or liver) in a patient mandates either deep peritoneal lavage to determine the nature of the fluid or exploratory laparotomy. Laparoscopy in experienced hand may also be an alternative in selected stable patients. The concern here is for hollow viscus injury, but mesenteric injury that devitalizes an intestinal segment, or creates a potential defect for bowel herniation. Hematuria, although is nonspecific, it may be a sign of retroperitoneal injury especially when associated with the pelvic fractures. An unstable pelvic fracture can be associated with pelvic vascular disruption. The control of pelvic hemorrhage associated with pelvic fractures is embolization. There have been reports of packing of the pelvic fractures most recently,¹³⁸ a challenge to the strict policy of never opening a contained retroperitoneal or preperitoneal hemorrhage from a pelvic fracture. Currently, this practice is best left to the experienced surgeons who routinely employ this technique.

Penetrating abdominal vascular injuries are evaluated with physical examination looking for entrance and exit wounds from the nipples to the upper thighs. Other findings on physical findings worrisome for intra-abdominal injury are hematuria and loss of femoral pulses. The trajectory of the missile or stab wound predicts the organ or vessel injured. As in the blunt vascular trauma the physical examination depends on whether the hematoma is contained or active hemorrhage is present. A FAST may be performed to evaluate for cardiac tamponade from cardiac injury. A chest X-ray and an abdominal X-ray are of diagnostic value in revealing a hemothorax and the trajectory of the missile.

In penetrating injury, the location and the number of lacerations or entry points are noted. For most gunshot wounds, intra-abdominal injury occurs frequently, and exploration is generally the next step.¹³⁹ There are some injuries that miss the peritoneum, and for the stable patient evaluation with CT to track the course of the projectile is acceptable and avoids nontherapeutic laparotomy and its consequences.¹⁴⁰ There is a subset of patients with gunshot wounds to the abdomen who can be evaluated with CT and observed despite intra-abdominal injuries.^141,142

For knife wounds, violation of the abdominal wall fascia is a key in decision making. Unlike the cavitary distribution of energy from guns that creates a conical blast injury in the tissue of adjacent organs; only fascial penetration creates the potential for penetrating abdominal injury with sharp objects. If this is not obvious from peritonitis or evisceration, a local wound exploration in a stable patient using local anesthesia may determine the depth of the laceration. Again, selective exploration is performed to avoid unneeded laparotomy. Laparoscopy is often used at our center, not only for diagnosis, but therapy as well. Repair of intra-abdominal injuries requires advanced laparoscopic skills.^143,144

Management

Virtually, an EDT is never indicated to cross clamp the aorta in cases of imminent or cardiac arrest for abdominal injuries. A large series by Feliciano et al.¹⁴⁵ revealed only one of 59 patients with isolated penetrating wounds to the abdomen survived after an EDT. Determining the patients and situations for which this dramatic intervention is undertaken is paramount to performing it.

The management of both penetrating and blunt abdominal vascular trauma depends on the location of the injury. Hematoma when identified by CT scan or at operative exploration are explored for penetrating injury and observed intraoperatively for blunt mechanisms. If the hematoma is expanding, it too is explored to control the bleeding point. The abdomen has been divided into 3 zones to classify the vessel or vessels injured and to help the surgeon in operative decision making: (1) Zone I include the midline retroperitoneum, (2) Zone II include the upper retroperitoneum with renal artery and vein, and (3) Zone III or pelvic retroperitoneum (Figure 49-1 and Table 49-1).