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Rich’s Vascular Trauma
This page intentionally left blank
Rich’s Vascular
Trauma
FOURTH EDITION

Todd E. Rasmussen, MD, FACS

Colonel (Ret.) USAF MC
Professor of Surgery and Senior Associate Consultant
Division of Vascular and Endovascular Surgery
Mayo Clinic
Rochester, Minnesota

Nigel R.M. Tai, MB, BS, MS, FRCS

Colonel, Late RAMC
Consultant Trauma & Vascular Surgeon
Royal Centre for Defence Medicine (Research & Clinical Innovation)
HQ Defence Medical Services
Birmingham, United Kingdom;
Vascular Clinical Lead
Barts Health NHS Trust
London, United Kingdom
Elsevier
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RICH’S VASCULAR TRAUMA, FOURTH EDITION ISBN: 978-0-323-69766-8

Copyright © 2022, by Elsevier Inc. All Rights Reserved.

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Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 List o­f C­on­tributors
Christopher Aylwin, MBBS, MA, FRCS Ravi Chauhan, FRCA, FCAI, MBChB, Dip IMC, RCSEd
Consultant Vascular and Trauma Surgeon Intensive Care and Anaesthesia Consultant
Major Trauma Centre Intensive Care
Imperial College Healthcare NHS Trust Royal Centre of Defence Medicine
London, United Kingdom Birmingham, United Kingdom

Ed B.G. Barnard, BM, BS, BMedSci(Hons), PhD, FRCEM, Kenneth J. Cherry, MD

FIMC, RCSEd Edwin P. Lehman Professor of Surgery
Senior Lecturer Emeritus University of Virginia Medical Center
Academic Department of Military Emergency Medicine Charlottesville, Virginia;
Royal Centre for Defence Medicine (Research & Clinical Consultant, Sentara Vascular Specialists Sentara
Innovation) Norfolk General Hospital Eastern Virginia Medical
Birmingham, United Kingdom; School
Honorary Consultant in Emergency Medicine Norfolk, Virginia
Cambridge University Hospitals NHS Foundation Trust
Cambridge, United Kingdom Kevin K. Chung, MD
Professor and Chair
Andriy I. Batchinsky Department of Medicine
Director, Autonomous Reanimation and Evacuation Uniformed Services University of the Health Sciences
Program Bethesda, Maryland
Brooks City Base
San Antonio, Texas;
Senior Principal Investigator Ian D. Civil, MBChB, FRACS, FACS
Director of Trauma Services
The Geneva Foundation
Auckland City Hospital
Tacoma, Washington;
Auckland, New Zealand
Manager, Extracorporeal Life Support Capability Area
U.S. Army Institute of Surgical Research
Battlefield Health and Trauma Research Institute Jon Clasper, CBE, DSc, DPhil, DM, LLM,
Fort Sam Houston, Texas FRCSEd(Orth)
Professor Emeritus & Consultant Orthopaedic Surgeon
Kenneth Boffard, MB, BCh, FRCS, FRCS(Edin), Visiting Professor in Bioengineering
FRCPS(Glas), FCS(SA), FACS Imperial College London;
Professor Emeritus Clinical Lead
Department of Surgery The Royal British Legion Centre for Blast Injury Studies
University of the Witwatersrand London, United Kingdom
Johannesburg, South Africa;
Professor and Academic Head William Darrin Clouse, MD
Trauma and Critical Care Professor of Surgery
Milpark Academic Trauma Centre Chief, Division of Vascular & Endovascular Surgery
Johannesburg, South Africa University of Virginia
Charlottesville, Virginia
Jeremy W. Cannon, MD
Associate Professor of Surgery Lazar B. Davidovic, MD, PhD, FETCS
Department of Surgery Head of the Clinic
Perelman School of Medicine at the University of Clinic for Vascular and Endovascular Surgery
Pennsylvania Clinical Center of Serbia
Philadelphia, Pennsylvania; Belgrade, Serbia;
Adjunct Associate Professor of Surgery Full Professor of Vascular Surgery
Department of Surgery Faculty of Medicine
Uniformed Services University of the Health Sciences University of Belgrade
Bethesda, Maryland Belgrade, Serbia

v
vi List o­f C­on­tributors

David L. Dawson, MD Elon Glassberg, MD, MHA, MBA

Clinical Professor Medical Corps Israeli Defense Forces
Texas A&M University Bar-Ilan University Faculty of Medicine
Temple, Texas; Safed
Vascular Surgeon Israel
Baylor Scott & White Health The Uniformed Services University of the Health
Temple, Texas Sciences
Bethesda, Maryland
Demetrios Demetriades, MD, PhD, FACS
Professor of Surgery Peter Gogalniceanu, MEd, FRCS
University of Southern California Senior Surgical Registrar
Los Angeles, California Departments of Trauma and Vascular Surgery
The Royal London Hospital
London, United Kingdom
Joseph J. Dubose, MD, Col, MC, USAF
Professor of Surgery Matthew A. Goldshore
University of Maryland School of Medicine Department of Surgery
Baltimore, Maryland; Perelman School of Medicine at the University of
Director, C-STARS Pennsylvania
R Adams Cowley Shock Trauma Center
Philadelphia, Pennsylvania
University of Maryland Medical Center
Baltimore, Maryland
Eitan Heldenberg, MD
Head Department of Vascular Surgery
Philip M. Edmundson, MD Hillel Yaffe Medical Center
Division of Trauma and Emergency Surgery Hadera, Israel
UT Health San Antonio
San Antonio, Texas Joseph A. Herrold, MD, MPH
Assistant Professor
Timothy Fabian, MD R Adams Cowley Shock Trauma Center
Professor Emeritus Baltimore, Maryland
University of Tennessee Health Science Center
Memphis, Tennessee Shehan Hettiaratchy, MA, DM,
FRCS(Plast)
David V. Feliciano, MD Lead Surgeon
Clinical Professor Imperial College Healthcare NHS Trust
Department of Surgery St Mary’s Hospital
University of Maryland School of Medicine London, United Kingdom
Baltimore, Maryland;
Attending Surgeon Tal M. Hörer, MD, PhD
Shock Trauma Center Associate Professor Surgery
University of Maryland Medical Center Department of Cardiothoracic and Vascular
Baltimore, Maryland Surgery
Örebro University Hospital and Univeristy
Faculty of Life Sceince
Charles James Fox, MD Örebro, Sweden
Associate Professor of Surgery
Baltimore Shock Trauma Center Division of Vascular Kenji Inaba, MD, FACS
Surgery Professor of Surgery
University of Maryland School of Medicine University of Southern California
Baltimore, Maryland Los Angeles, California

Michaela Gaffley, MD Robert H. James, BSc, FRCEM, FIMC, RCSEd, RAF

General Surgery Resident Consultant in Emergency Medicine & Pre-hospital
Wake Forest University School of Medicine Emergency Medicine
Winston-Salem, NC, United States JHG(SW), University Hospitals Plymouth & Devon Air
Ambulance;
Shaun M. Gifford, MD, MS, RPVI Honorary Lecturer in Military Emergency Medicine and
Chief, Vascular Surgery Pre-hospital
David Grant Medical Center Retrieval and Transfer Medicine
Travis Air Force Base Royal Centre for Defence Medicine & University of Plymouth
California Devon, United Kingdom
 List o­f C­on­tributors vii

Jan O. Jansen, MBBS, PhD Clinic for Vascular and Endovascular

Center for Injury Sciences, Department of Surgery Surgery
University of Alabama at Birmingham Clinical Center of Serbia
Birmingham, Alabama Belgrade, Serbia

Donald H. Jenkins, MD Ernest E. Moore, MD

Professor of Surgery, Division of Trauma and Emergency Distinguished Professor and Vice Chair
Surgery for Research
UT Health San Antonio University of Colorado Denver
San Antonio, Texas; Denver, Colorado;
Betty and Bob Kelso Distinguished Chair in Burn and Director of Research
Trauma Surgery Surgery
Division of Trauma and Emergency Surgery Ernest E Moore Trauma Shock Center
Associate Deputy Director, Military Health Institute Denver, Colorado
Division of Trauma and Emergency Surgery
UT Health San Antonio Laura J. Moore, MD
San Antonio, Texas Professor of Surgery & Chief of Surgical
Critical Care
Michael Jenkins, BSc, MS, FRCS, FRCS, FEBVS The University of Texas McGovern
Consultant Vascular Surgeon Medical School
Regional Vascular Unit Houston, Texas;
Imperial College Medical Director
Healthcare NHS Trust Shock Trauma Intensive Care Unit
London, United Kingdom The Red Duke Trauma Institute
Memorial Hermann Hospital—Texas Medical
David S. Kauvar, MD, MPH Center
Vascular Surgery Service Houston, Texas
Brooke Army Medical Center
Fort Sam Houston, Texas;
Associate Professor Jonathan J. Morrison, PhD, FRCS, FEBVS, FACS
Department of Surgery Assistant Professor and Chief of Endovascular
Uniformed Services University of the Health Sciences Surgery
Bethesda, Maryland R Adams Cowley Shock Trauma
University of Maryland
Alexander Kersey, MD Baltimore, Maryland
General Surgery Resident
Walter Reed National Military Medical Center Sanjeewa Heman Munasinghe, RWP, RSP,VSV, USP,
Bethesda, Maryland MBBS, MD, FSLCR
Secretary to the Ministry of Health and Indigenous
Alexis Lauria, MD Medical Services
General Surgery Resident Colombo, Sri Lanka;
Walter Reed National Military Medical Center Consultant Radiologist
Bethesda, Maryland Army Hospital
Colombo, Sri Lanka
Gregory A. Magee, MD, MSc
Assistant Professor of Surgery Rossi Murilo, superior, mestrado
Department of Surgery Professor of Surgery
University of Southern California University of Valença School of Medicine
Los Angeles, California Valença–UNIFAA
Rio de Janeiro, Brazil;
Director Executive of FES
James E. Manning, MD State Health Foundation
Professor of Emergency Medicine (Ret.) Rio de Janeiro, Brazil;
Emergency Medicine Master’s
University of North Carolina Vascular Surgery UFRJ (Federal University of Rio de
Chapel Hill, North Carolina Janeiro)
Rio de Janeiro, Brazil
Miroslav Markovic, MD, PhD, FETCS, FIUA
Professor of Surgery David M. Nott
Faculty of Medicine Consultant Vascular and Trauma Surgeon
University of Belgrade Regional Vascular Unit and Major Trauma Centre
Belgrade, Serbia; Imperial Healthcare NHS Trust
Vascular Surgeon London, United Kingdom
viii List o­f C­on­tributors

Carlos A. Ordoñez, MD, FACS Assistant Professor

Chief, Division of Trauma and Acute Care Surgery Department of Polytrauma
Fundación Valle del Lili Dzhanelidze Research Institute of Emergency Medicine
Cali, Colombia; Saint-Petersburg, Russian Federation
Professor of Surgery, Trauma and Critical Care
Trauma and Acute Care Surgery Fellowship Norman Minner Rich, MD, DMCC
Universidad del Valle Professor Emeritus in Surgery
Cali, Colombia USU Walter Reed Surgery
Uniformed Services University of the Health Sciences
Allan Pang, MBChB, FRCA Bethesda, Maryland
Academic Department Military Anaesthesia and Critical
Care Igor M. Samokhvalov, MD, PhD, Prof., Colonel MC (Ret)
Royal Centre for Defence Medicine Deputy Chief Surgeon of the Russian Army
Birmingham, United Kingdom; Ministry of Defense of the Russian Federation
Specialist Anaesthesia Trainee Moscow, Russian Federation;
Anaesthestic Department Professor and Chair
James Cook University Hospital Department and Clinic of War Surgery
Middlesbrough, United Kingdom Kirov Military Medical Academy
Saint-Petersburg, Russian Federation;
Michael W. Parra, MD Senior Scientific Researcher
Trauma Research Director Department of Polytrauma
Trauma-Critical Care Dzhanelidze Research Institute of Emergency Medicine
Broward Health Level I Trauma Center Saint-Petersburg, Russian Federation
Fort Lauderdale, Florida

Douglas M. Pokorny, MD James B. Sampson, MD

Division of Trauma and Emergency Surgery Colonel USAF MC
UT Health San Antonio Air Force Medical Readiness Agency
San Antonio, Texas San Antonio, Texas

Rina Porta, MD, PhD Stephanie Savage, MD, MS

Vascular Interventionist Radiology Professor of Surgery
Vascular Surgery Department of Surgery
Department of Vascular and Endovascular Surgery University of Wisconsin
Clínicas Hospital—School of Medicine University of São Madison, Wisconsin
Paulo—FMUSP
São Paulo, Brazil Thomas M. Scalea, MD, FACS
Francis X. Kelly Professor of Trauma
Brandon W. Propper, MD Surgery, Director of Program in Trauma,
Vascular Surgery Program Director Physician-in-Chief
Walter Reed National Military Medical Center The University of Maryland School of Medicine
Associate Professor of Surgery R Adams Cowley Shock Trauma Center
Uniformed Services University Baltimore, Maryland
Bethesda, Maryland
David Schechtman, MD
Amila Sanjiva Ratnayake, MBBS, MS General Surgery Resident
Consultant General Surgeon Department of General Surgery
Military Hospital Brooke Army Medical Center
Colombo, Sri Lanka; San Antonio, Texas;
Adjunct Associate Professor Teaching Fellow
Uniformed Services University of the Health Sciences Department of Surgery
Bethesda, Maryland Uniformed Services University
Bethesda, Maryland
Viktor A. Reva, MD, PhD
Assistant Professor Daniel J. Scott, MD, RPVI
Department of War Surgery Deputy Chief, Vascular Surgery
Kirov Military Medical Academy San Antonio Military Medical Center
Saint-Petersburg, Russian Federation; Texas
 List o­f C­on­tributors ix

Niten Singh, MD Pirkka Vikatmaa, MD, PhD

Professor of Surgery Section Chief Vascular Emergencies
Division of Vascular Surgery Department of Vascular Surgery
University of Washington Helsinki University Hospital and University of Helsinki
Seattle, Washington Helsinki, Finland

Michael J. Sise, MD , FACS

Senior Trauma and Vascular Surgeon Matthew Vuoncino, MD
Scripps Mercy Hospital Integrated Vascular Surgery Resident
San Diego, California University of California—Davis and Travis Air Force
Base
Jason E. Smith, MBBS, MSc, MD, Sacramento, California
FRCP, FRCEM
Consultant in Emergency Medicine Carl Magnus Wahlgren, MD, PhD
Defence Medical Services Chief, Senior consultant
United Kingdom; Department of Vascular Surgery
Defence Professor of Emergency Medicine Karolinska University Hospital
Academic Department of Military Emergency Adjunct Professor
Medicine Karolinska Institute
Royal Centre for Defence Medicine Stockholm, Sweden
Birmingham, United Kingdom;
Honorary Consultant in Emergency Medicine
Emergency Department Fred A. Weaver, MD, MMM
University Hospitals Plymouth NHS Trust Professor and Chief
Plymouth, United Kingdom Division of Vascular Surgery and Endovascular
Therapy
Ian J. Stewart, MD Keck School of Medicine, University of Southern
Deputy Vice Chair of Research California
Department of Medicine Los Angeles, California
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Joseph M. White, MD, FACS, FSVS
Peep Talving, MD, PhD, FACS Associate Professor of Surgery
Professor of Surgery The Department of Surgery
Institute of Clinical Medicine Uniformed Services University of the Health
University of Tartu Sciences and Walter Reed National Military
Tartu, Estonia; Medical Center
Director Bethesda, Maryland
Division of Acute Care Surgery
North Estonia Medical Center
Tallinn, Estonia Paul W. White, MD
Program Director, Vascular Surgery Fellowship
Sujeewa P.B. Thalgaspitiya, MBBS, MS Walter Reed National Military Medical Center
Head, Senior Lecturer Bethesda, Maryland;
Department of Surgery Associate Professor
Faculty of Medicine and Allied Sciences Uniformed Services University of the Health Sciences
Rajarata University of Sri Lanka Bethesda, Maryland
Anuradhapura, Sri Lanka; Consultant to the Surgeon General for Vascular
Consultant Surgeon Surgery
Teaching Hospital Anuradhapura United States Army
Anuradhapura, Sri Lanka

Timothy K. Williams, MD
Rebecca Joy Ur, MD Associate Professor
Vascular Surgery Vascular and Endovascular Surgery
Vascular Institute of the Rockies Wake Forest Baptist Health
Denver, Colorado Winston-Salem, NC, United States
x List o­f C­on­tributors

Tom Woolley, MD, FRCA, MBBS Jeniann A. YI, MD, MSCS

Defence Professor Senior Fellow
Anaesthetics and Critical Care Department of Surgery
Academic Department Military Anaesthesia and Critical University of Colorado Anschutz Medical Campus
Care Aurora, Colorado
Royal Centre for Defence Medicine
Birmingham, United Kingdom
 Foreword
EMILY MAYHEW*
Imperial College London, 2021
HARRY PARKER**
London, 2021

One day, this comprehensive, up to date, and carefully The features that make this work essential for vascular
refreshed (see Preface) account of the management of vas- specialists also secure its particular interest for medical
cular trauma in the second decade of the 21st century will historians. It pays respectful attention to the practices of
move from the shelves of volumes that constitute the medi- the past that would eventually coalesce into the discipline
cal school curricula around the world to the quieter library of vascular surgery and the formal management of vascu-
stacks of medical history. The emerging hot topics explored lar injury. The historical review picks up the first signs of
on its pages will have been resolved and incorporated into the integration of military and civilian medical practice
the clinical mainstream. The innovations and new assess- in vascular repair to show that it is a fascinating constant
ments described in each of its chapters will have become of vascular surgery that alliances forged by military med-
common practice, and the evolving systems will have ics in times of war were consolidated in peace. Despite the
been consolidated and implemented as standard. The calls unprecedented scale and pace of military casualty, lessons
for new management strategies to fill the gaps in current from field surgery were learned, transmitted, and applied
capabilities will have been answered. Vascular surgery, the consistently in civilian practice. Within the medical sector,
youngest of the 10 surgical specialties, will have grown into it is rare to see progress maintained and stabilized across
all its potential. periods of transition. A key consequence of this extraor-
Rich’s Vascular Trauma, in this current and three pre- dinary success is that both clinician and patient expecta-
vious editions, provides the textual infrastructure that tions of survivability were revised significantly, and remain
has enabled this remarkable disciplinary growth. When, undiminished. This work provides evidence and exemplar
eventually, it is replaced by successor volumes, its value of disciplinary progress and good historical practice, as well
will be transformed. Its contents will assume a different as a crucial reminder that there are responsibilities to be
responsibility: that of providing a definitive historical respected when the stakes of survival are renegotiated.
record of the creation of vascular surgery in the modern One element will never change no matter the century
era. Each revised edition contributes to the challenging or the mechanism of vascular injury. Survivors, whether
task of focused and sustained tracking of an intricate, unexpected or anticipated, will seek to understand the
highly technical surgical specialty that has developed process by which their lives were secured. This is a useful
at extraordinary speed. Additionally, this fourth edition dimension of the work that we suggest might receive addi-
contributes a truly international dimension, drawing on tional consideration. Rich’s Vascular Trauma is a resource
testimony and evidence from vascular specialists with that enables professional development, historical reflection,
regional and national specificities in their provision that and, above all, answers to that most important and compli-
has contributed to the global development of the disci- cated question asked by the patient from their life beyond
pline and its community of practice. survival: “what happened to me?”

* Emily Mayhew is Historian in Residence in the Centre for Blast Injury Studies, Department of Bioengineering at Imperial College London. She is the author of
Wounded: From Battlefield to Blighty, 1914-1918 published by Vintage and The Four Horsemen: War, Pestilence, Famine and Death and the Hope of a New Age,
published by Riverrun.
** Harry Parker is a writer and artist and lives in London. He joined the British Army when he was 23 and served in Iraq in 2007 and Afghanistan in 2009 as a
Captain in 4th Battalion The Rifles. His debut novel, Anatomy of a Soldier is published by Faber and Faber.

xi
Preface to the Fourth Edition of
Rich’s Vascular Trauma
NORMAN M. RICH and KENNETH J. CHERRY

The first two decades of the 21st century saw the military surgical readiness, with the cost of that inertia shored up
surgical communities of the United States of America, the and eventually born by those injured in wars of the future.
United Kingdom, and other allied counties respond with More than ever, we are convinced that the answer to this
determination and innovation to the challenges faced by conundrum lies in purposeful collaboration and shared
those caring for patients with life-and-limb threatening endeavors across all stakeholders charged with the respon-
vascular trauma. Air superiority during the Afghanistan sibility of surgical care: civilian and military surgical com-
and Iraq Wars, combined with sophisticated field and en- munities, trauma and vascular surgeons, prehospital and
route treatment protocols, allowed rapid evacuation of in-hospital specialists, global health, humanitarian and
the injured to definitive surgical centers within the the- military providers, and across international borders.
ater of war. Stabilized patients were repatriated rapidly to We are delighted to see that, in the Fourth Edition, the
military hospitals back home, half-way around the world Editors have again assembled contributions from an array
from their original point of injury. Deployed teams cared of talented practitioners and leaders who have wedded
for patients who, in previous conflicts, may never have state-of-the-art technical insight to hard-won wisdom,
reached surgical care alive. Killed-in-action and case- divined from a range of practice settings: an approach
fatality rates decreased as clinical experience and new which sees the Fourth Edition endorsed and adopted by
systems of care and innovative approaches and products the Society for Vascular Surgery. Todd Rasmussen of the
were applied. United States Air Force and Uniformed Service University
Implementing a process that the National Academy of has been an effective leader, role model, and respected
Medicine referred to as focused empiricism, military surgeons mentor in all of this experience, forging an effective part-
managed a once-in-a-generation burden of vascular injury nership with his counterpart Nigel Tai of the British Army
within a new and evolving global trauma system.1 Newly and UK Defence Medical Services—a partnership borne
designed tourniquets, balanced transfusion of blood prod- out of the recent wars that has now served two Editions
ucts, damage control surgery, including the use of tempo- of this textbook.
rary vascular shunts, and selective venous and tibial artery These two Editors continue the important work of
repair were among the approaches that became standard forerunners Frank Spencer, Ken Mattox, and Asher
during the wars. For the first time a closed, negative pres- Hirschberg, whose foundational Editorship proved to be
sure wound dressing technology was used to control soft the shoulders upon which subsequent editions rest. The
tissue injuries associated with vascular trauma and endo- work of the contributors within these pages consolidates
vascular devices were applied to select injury patterns in and continues the themes and perspectives that Michael
frontline surgical hospitals. E. DeBakey, Carl W. Hughes, and others took from their
Unable to perform traditional randomized, controlled respective service in World War II, the Korean Conflict,
research on these approaches, surgeons relied on registry- and Vietnam, and that Colonels Todd Rasmussen3 and
based study and international collaboration to develop Nigel Tai took from theirs.
real-world evidence that was applied within a system Finally, with the publication of this Fourth Edition we
of data-driven performance improvement. Throughout would like to acknowledge our friend and military surgical
this period, military techniques and protocols for vascu- colleague Surgeon Vice-Admiral Alasdair Walker CB OBE
lar trauma were scrutinized, adjusted based on the best QHS FRCS, who died in 2019. Admiral Walker completed
available evidence, and shared with civilian surgeons, as his surgical research fellowship at the Uniformed Services
part of the constructive exchange of breakthroughs that University and was a key mentor and contributor to the
accompanies the unearthing of fresh knowledge in either Third Edition of this textbook. As Surgeon General to
setting.1 the UK Armed Forces, Admiral Walker worked tirelessly to
The challenge now is to preserve and sustain the progress mitigate the insidious effects of the phenomenon that he
in vascular trauma care made since the beginning of this defined (The Walker Dip). Admiral Walker was a lion of
century; progress that the Third Edition of Rich’s Vascular military surgery who had immense character and unri-
Trauma did much to capture when it was published in valed experience in a career spanning the 1982 War in
2015, toward the closure of the Iraq and Afghanistan the South Atlantic to the 2009 fighting season in Hel-
Wars. Six years on, this carefully refreshed Fourth Edition is mand Province, Afghanistan. Despite daunting bona fides
a commendable addition to the toolbox required to address and ascension to the highest levels of military leadership,
that ever-urgent task of avoiding the so-called Walker Dip2; Admiral Walker was unpretentious in conversation, reas-
where peacetime or inter-war periods see atrophy of military suring in mentorship, and ever the advocate for the next

xii
 Preface to the Fourth Edition of Rich’s Vascular Trauma xiii

generation of physician and surgeon. His untimely death References

is a loss to current and future generations of surgeons and 1. National Academies of Sciences, Engineering, and Medicine. A National
those whom they serve. Trauma Care System: Integrating Military and Civilian Trauma Systems to
The success that we have no doubt will accompany this Achieve Zero Preventable Deaths After Injury. Washington, DC: National
latest edition of Rich’s Vascular Trauma was, to a large Academies Press; 2016.
2. Expounded on at the 2013 meeting of the Military Health Ser-
degree, set by Admiral Walker’s tireless groundwork in vices Research Symposium meeting in Fort Lauderdale, FL using the
strengthening and renewing the bonds of surgical kinship example of the Crimean War to illustrate his point. The phenom-
between his country’s military, ours, and that of countless enon can be found in almost all historical antecedents. Military Med.
allies along the way. He leaves us a rich legacy of union and 2014;179:477–482.
3. Rich NM, Carl W, Hughes CW, De Bakey ME. Recognition of Air
friendship, upon which this and future Editions of this text- Force surgeons at Wilford Hall Medical Center-supported 332nd
book will surely capitalize in the pursuit of ever-better out- EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. J Vasc Surg.
comes for our deserving patients. 2007;46(6):1312–1313.

Vice-Admiral Alasdair Walker, CB, OBE, QHS, FRCS, RN

22 June 1956–1 June 2019

Alasdair Walker qualified from the University of Glasgow in 1979. He deployed to the South Atlantic during the Falklands
War in 1982 and led Commando Forward Surgical Goup 2 during the Iraq War in 2003. He was Senior Surgeon in the
Role 3 Hospital at Camp Bastion in 2009. Subsequent appointments included Medical Director (2009), Director of Medical
Policy and Operational Capability for the Surgeon General (2011), Assistant Chief of the Defence Staff for Health (2014),
Medical Director General (Navy), and Surgeon General in 2015. He retired from the Royal Navy in May 2019 as Surgeon
Vice-Admiral.
The portrait above was taken during his time as International Scholar in the Department of Surgery at Uniformed Ser-
vices University of Health Sciences, Bethesda, Maryland, United States in 1992.
Table of Contents

Surgical Trainee’s Perspective, 1 12 Endovascular Variable Aortic Control, 137

ALEXANDER KERSEY and ALEXIS LAURIA MICHAELA GAFFLEY and TIMOTHY K. WILLIAMS

SECTION 1 13 Selective Aortic Arch Perfusion, 144

JAMES E. MANNING and ED B.G. BARNARD
Setting the Stage, 11
14 Endovascular to Extracorporeal Organ Support
1 The Vascular Injury Legacy, 12 for Vascular Trauma and Shock, 158
NORMAN M. RICH and KENNETH J. CHERRY
KEVIN K. CHUNG, ANDRIY I. BATCHINSKY, and IAN J. STEWART

2 Epidemiology of Vascular Trauma, 23 15 Gathering the Evidence: Clinical Study of New

PETER GOGALNICEANU, TODD E. RASMUSSEN, and NIGEL R.M. TAI
Technologies, 166
LAURA J. MOORE and JAN O. JANSEN
3 Systems of Care in the Management of Vascular
Injury, 34
DONALD H. JENKINS, DOUGLAS M. POKORNY, and PHILIP M. SECTION 4
EDMUNDSON The Management of Vascular Trauma, 170
4 Training Paradigms for Vascular Trauma, 42 16 Cardiac, Great Vessel, and Pulmonary
PAUL W. WHITE and JAMES B. SAMPSON Injuries, 171
DAVID V. FELICIANO and JOSEPH J. DUBOSE

SECTION 2 17 Blunt Thoracic Aortic Injury, 199

Immediate Management and Diagnostic DEMETRIOS DEMETRIADES, PEEP TALVING, and KENJI INABA
Approaches, 55 18 Abdominal Aortic Trauma, Iliac and Visceral Vessel
5 Prehospital Management of Vascular Injury, 56 Injuries, 212
ROBERT H. JAMES and JASON E. SMITH CHRISTOPHER AYLWIN and MICHAEL JENKINS

6 Damage Control and Immediate Resuscitation for 19 Inferior Vena Cava, Portal, and Mesenteric Venous
Vascular Trauma, 70 Systems, 226
TIMOTHY FABIAN and STEPHANIE SAVAGE
TOM WOOLLEY, RAVI CHAUHAN, and ALLAN PANG

7 Diagnosis of Vascular Injury, 82 20 Neck and Thoracic Outlet, 241

GREGORY A. MAGEE and FRED A. WEAVER
MICHAEL J. SISE
21 Upper Extremity and Junctional Zone Injuries, 252
8 Imaging for the Evaluation and Treatment of MATTHEW VUONCINO, JOSEPH M. WHITE, and WILLIAM DARRIN
Vascular Trauma, 91 CLOUSE
DAVID L. DAWSON
22 Lower Extremity Vascular Trauma, 273
DAVID S. KAUVAR and BRANDON W. PROPPER
SECTION 3
Emerging Technologies and New Approaches 23 Surgical Damage Control and Temporary Vascular
to Vascular Trauma and Shock, 107 Shunts, 288
DANIEL J. SCOTT and SHAUN M. GIFFORD
9 Endovascular Suites and the Emergency Vascular
Service, 108 24 Considerations for Conduit Repair of Vascular
JOSEPH A. HERROLD, THOMAS M. SCALEA, and JONATHAN J. Injury, 300
MORRISON NITEN SINGH and REBECCA JOY UR

10 Stent-Grafts, Coils, and Plugs, 114 25 Management of Pediatric Vascular Injury, 312
DAVID SCHECHTMAN and BRANDON W. PROPPER MATTHEW A. GOLDSHORE and JEREMY W. CANNON

11 Resuscitative Endovascular Balloon Occlusion of 26 Soft-Tissue and Skeletal Wound Management

the Aorta, 126 in the Setting of Vascular Injury, 321
JENIANN A. YL, CHARLES JAMES FOX, and ERNEST E. MOORE SHEHAN HETTIARATCHY and JON CLASPER

xiv
 Table of Contents xv

27 Vascular Surgery in the Austere 32 Russia, 374

Environment, 332 IGOR M. SAMOKHVALOV and VIKTOR A. REVA
DAVID M. NOTT
33 Serbia, 377
LAZAR B. DAVIDOVIC and MIROSLAV MARKOVIC
SECTION 5
Global Perspectives on Vascular Trauma, 352 34 Israel, 388
EITAN HELDENBERG and ELON GLASSBERG
28 Australia and New Zealand, 353
IAN D. CIVIL 35 South Africa, 391
KENNETH BOFFARD
29 Sri Lanka, 357
AMILA SANJIVA RATNAYAKE, SANJEEWA H. MUNASINGHE, and 36 Colombia: Don’t Dread the Popliteal and Axillary
SUJEEWA P.B. THALGASPITIYA Fossa, 396
CARLOS A. ORDOÑEZ and MICHAEL W. PARRA
30 Vascular Trauma in Finland, 365
PIRKKA VIKATMAA 37 Brazil, 401
ROSSI MURILO and RINA PORTA
31 Sweden, 370
TAL M. HÖRER and CARL MAGNUS WAHLGREN Index, 407
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 Surgical Trainee’s Perspective
ALEXANDER KERSEY and ALEXIS LAURIA

Introduction (pRBC), 6U fresh frozen plasma (FFP), 1 pack of

platelets [which contains 6U])
The aim of this section is to provide a concise, resident- n Consider tranexamic acid (TXA) as part of the resuscita-
focused, overview of a select number of chapters in the tion protocol based on local practice.
textbook. For each of the selected chapters, the topics are n Consider broad spectrum antibiotics and tetanus where
broken down by a general introduction (contextualizing indicated.
the subject), ­surgical approach (detailing patient evalu- n Match anesthesia-induction strategy to patient physiol-
ation and prioritization) and tactics (providing helpful ogy (use cardio-stable induction agents to avoid cata-
tips – the “Do’s and Don’ts” of safe surgical care) needed to strophic loss of cardiac output).
get the best outcomes. n Keep patient warm.
The section will be most useful for the busy Resident
needing to quickly review the fundamentals of a vascular
trauma topic, priming them for a later and more compre-
hensive review of the relevant chapters when their sched- SURGICAL TACTICS IN THE ED
ule permits. n Do:
n Familiarize yourself with the type of tourniquet and
hemostatic dressings used by your prehospital care
Subject: Critical First Steps and providers – how they are applied and released.
n Understand how long the warm ischemia time has
Damage Control Resuscitation been and ensure it is recorded.
(Chapters 5 and 6) n Release tourniquets only for specific purpose (e.g.,
immediately prior to diagnostic angiography; to assess
GENERAL likelihood of arterial injury, etc.). If no gross hemor-
rhage, leave down but be prepared to tighten again if
n Damage control resuscitation (DCR) begins in the pre-
further hemorrhage occurs.
hospital arena and is continued via reception into the
n Remove dressings if ineffective or if examining wound
Emergency Department (ED), transfer to surgery or
will change operative decision-making.
interventional radiology (IR) suite, and within the Criti-
n Re-assess tourniquets/hemostatic dressings after
cal Care Unit.
patient movement to ensure proper function.
n DCR prioritizes use of tourniquets, hemostatic dressings,
n Monitor coagulopathy through early use of thrombo-
temporizing procedures (resuscitative endovascular bal-
elastography (TEG)/rotational thromboelastometry
loon occlusion of the aorta [REBOA]) and balanced trans-
(ROTEM); monitor physiology through multiple feeds
fusion of blood products to mitigate the consequences of
(trends in hemodynamic variables, lactate, urine out-
hemorrhage and shock.
put, etc.).
n DCR generates surgical options by restoring physiologi-
n Refine anticipated management plan as results from
cal normality.
examination and investigations accrue and commu-
nicate accordingly.
SURGICAL APPROACH n Establish and maintain hierarchy of open, closed-
n Prior preparation in the ED is essential: muster team loop communication and task allocation (i.e., identify
members, assign roles, pre rehearse likely scenarios, pre- team lead but enable all to have a voice).
pare equipment and drugs, order blood products, don n Use checklists and regular, formalized briefing
PPE, forewarn onward destinations (operating room opportunities (SNAP brief, STACK brief, ‘time outs’)
(OR), IR suite, intensive care unit (ICU), etc.) and antici- to review progress and before major interventions
pated consultants. (Chapter 6, p. 68)
n Use C-ABC framework to prioritize immediate steps in n Do Not:
management: n Lose situational awareness and become task fixated.
n (C) Control of catastrophic bleeding – tourniquet, n Become distracted by a prominent injury and fail to
hemostatic dressings, REBOA appropriately assess whole patient in stepwise fashion.
n (A) Airway management n Fail to obtain and document a brief but thorough
n (B) Breathing – ensure adequate ventilation extremity motor and sensory examination prior to
n (C) Circulation – vascular access, hemorrhage con- intubation if safe to do so.
trol, restore circulatory volume n Fail to consider ethics issues and/or fail to set ceilings
n Replace volume with a 1:1:1 ratio of red cells, of care for patients where continued medical inter-
plasma and platelets (6U packed red blood cells vention is likely to be futile.
1
2 • Surgical Trainee’s Perspective

n Fail to consider requirements of associated members of n Discuss injury concerns with radiologist so that vas-
the attending trauma team (e.g., Orthopedics) and not cular workup can be integrated with planned imaging
integrate these points in to the overall DCR strategy. to avoid multiple trips to the radiology suite.
n Frequently reassess for changes in pulse examination
throughout the resuscitation as hypotension, vaso-
Subject: Injury Identification and pressors may confound examination.
n Do Not:
Diagnostic Workup (Chapters 7 n Take an unstable patient to imaging.

and 8) n Delay operative intervention for imaging if the imag-

ing will not add to or change decision-making.
n Hesitate to confirm questionable pulse examinations –
GENERAL
either with second provider or Doppler examination.
n Early identification of vascular injury is crucial to pre- n Fail to consider the risks associated with each imag-
venting long-term morbidity, loss of limb, or loss of life ing modality (contrast reactions, renal dysfunction,
n Chapter 7, Box 7.1 (Checklist for Prompt Recognition access site complications, time requirements, risks of
of Vascular Injury) radiation).
n Modalities for diagnosis include detailed injury his-
tory, bedside examinations (pulse examination, Doppler
examination, point-of-care ultrasound, Ankle Brachial
Index (ABI)), radiographic imaging (CT angiography
Subject: Resuscitative
[CTA]) and formal angiography. Endovascular Balloon Occlusion of
n Approach is based on: (1) patient stability, (2) concom­ the Aorta (REBOA) (Chapter 11)
itant injuries, and (3) availability/feasibility of diagnos-
tic modalities (i.e., contrast allergies). GENERAL
n Minimally invasive alternative to thoracotomy and aor-
DIAGNOSTIC APPROACH tic clamping for temporization of exsanguinating sub-
n Any exsanguinating hemorrhage should be temporized diaphragmatic hemorrhage.
per C-ABC with adjuncts (as described previously). n Carries systemic consequences due to lower body and
n Hard signs of vascular injury, CTA or angiography posi- visceral ischemia but these are probably less than stan-
tive for vascular injury→to the OR dard emergency department thoracotomy (EDT) and
n Chapter 7, Fig. 7.5 (Algorithm of the indications for
cross-clamping. These consequences may be off-set
immediate operation and the role of imaging modalities) through the development of partial occlusion or inter-
n Hard signs of vascular injury include: mittent occlusion techniques.
n Pulsatile hemorrhage
n Expanding hematoma
SURGICAL APPROACH
n Bruit or thrill over area of injury n The first step is percutaneous femoral artery cannula-
n Absent pulse tion, which should be done under ultrasound (US) guid-
n ABI < 0.9 ance to maximize chances of success and minimize
n Soft signs of vascular injury include: complications.
n History of hemorrhage at scene n The artery is accessed via hollow-needle and wire 2 to 3 cm
n Wounds of neck/extremities with unexplained hem- below the mid-inguinal ligament. Seldinger technique is
orrhagic shock used to place a sheath, which is used to position a guide-
n Neurologic deficit in peripheral nerve in proximity to wire over which a compliant occlusion balloon can be
vessels placed into zone I or III as required, using predetermined
n High risk fracture, dislocation, or penetrating proxim- standard insertion lengths (Chapter 11, Fig. 11.1). The
ity wound wireless ER REBOA system (Prytime Medical; Chapter 11,
n Presence of a pulse does not rule out a vascular injury. Fig. 11.2) does not require wire guidance and employs a
Conversely, a normal ABI makes the likelihood of a vas- 7-Fr sheath.
cular injury much lower. n The aorta is divided into three zones; zone I ((left subcla-
n Consider use of checklist adjuncts to “clear” the patient vian to celiac), zone II (celiac to lowest renal artery) and
of vascular injuries in various cavities or prompt further zone III (infrarenal aorta). Chapter 11, Fig. 11.4).
imaging. n The length of catheter insertion needed to reach each
n Chapter 7, Box 7.3 (Clearing Trauma Patients for zone can be approximated using anatomic landmarks:
Presence of Vascular Injury) n Zone I: femoral access site to sternal notch
n Zone III: femoral access site to umbilicus
n The occlusion balloon is positioned in zone III for pelvic
TACTICS
hemorrhage and distal zone I for intraabdominal bleeding.
n Do: n Position of the balloon may be confirmed with plain x-ray.
n Consider injury mechanism when evaluating for n The balloon is inflated with a contrast/saline mix:
occult injury. n Inflate balloon until recognizable hemodynamic
n Be cognizant of additive use of contrast. response (increased central/upper extremity blood
 • Surgical Trainee’s Perspective 3

pressure, absent or decreased distal pulses, step-up in n Consider shunting when definitive repair must be
waveform proximal to balloon) deferred due to:
n Tactile feedback during inflation is important in n physiological instability (i.e., damage control surgery)
recognizing aortic wall tension and avoiding injury – n need to complete other life-saving interventions
if resistance is met, inflation should stop n requirement to perform skeletal fixation
n The REBOA is secured to prevent balloon migration and n absence of sufficient expertise or materials
the patient can be taken to the right place to stop the n Shunting is applicable to both arteries and veins.
hemorrhage (IR suite, OR). n Shunt dwell times of 2 to 5 hours are typical; however,
n Balloon time must be assiduously tracked. Zone I aortic some scenarios require longer times. The goal should be
occlusion time must be kept to less than 30 minutes to to remove shunts and perform definitive revasculariza-
reduce the chances of spinal cord or visceral ischemia/ tion as early as the patient’s status, resources, and tech-
tissue infarction. Longer occlusion times may be toler- nical expertise allow.
ated for zone III inflation.
SURGICAL APPROACH
SURGICAL TACTICS n Shunts should be used as part of a comprehensive vascu-
n Do: lar management plan and require a technically experi-
n Match the need for REBOA to a good understanding of enced team with adequate resources.
patient physiology:
n Physiologically stable patients with potential for
SURGICAL TACTICS
sudden deterioration may have a sheath inserted
as a prelude to REBOA deployment if there is n Do:
deterioration. n Get the preliminaries right: adequate proximal and
n Unstable patients may have sheath insertion distal vascular exposure; injury definition/débride-
and balloon inflation to allow safer transfer to ment; assessment of inflow and backflow; Fogarty
IR/OR. sweep; heparinized saline flush.
n Deflate the balloon slowly (consider 1–2 mL every n Ensure that vascular injury downstream of the shunt
2–3 minutes) to prevent rapid hemodynamic changes has been ruled out to prevent hemorrhage once flow
and catastrophic ischemia-reperfusion injury to restored – consider angiography.
the heart, giving plenty of warning to anesthetic n Choose a shunt and position that is right for the vessel
colleagues. caliber and injury:
n Consider adding medications or common rescue needs n In-line – short segmental defect or small working
(bicarb, blood and/or crystalloid, pressors, manage- area (Chapter 23, Figs. 23.3 and 23.4)
ment of hyperkalemia) in anticipation of reperfusion n Looped – long segment defect, large working area
injury after balloon deflation. (Chapter 23, Fig. 23.5).
n Employ REBOA as part of a comprehensive DCR n Remember standard sequencing: [Shunt]→[Fracture
paradigm. Reduction and Fixation]→[Definitive Vascular
n Do Not: Repair]→[Fasciotomy].
n Use REBOA as a “bridge” if the destination is not n Have a plan for definitive management, know when/
determined or the hemorrhage control strategy not where necessary resources are available.
clear – always have a plan as to next steps (including n Be aware of and have a plan for shunt-related com-
definitive hemorrhage control). plications (dislodgement, luminal injury, thrombosis,
n Persist at multiple attempts at groin cannulation. kinking, etc.) and communicate this to other relevant
Resort to surgical cutdown early if groin cannulation members of the patient care team.
is not possible. n Do Not:
n Longitudinal incision extending inferiorly from the n Inadequately secure the shunt.
midpoint between the pubic symphysis and ante- n Fail to consider collaterals and branch points within
rior superior iliac spine (ASIS). the injury/shunt zone and ligate these as needed.
n Use REBOA for intrathoracic hemorrhage. n Fail to give anesthesia colleagues warning of reperfu-
n Fail to evaluate the patient for complications, particu- sion prior to shunt clamp removal.
larly lower limb ischemia due to peri-sheath thrombo- n Routinely employ systemic anticoagulation.
sis, and have a plan for dealing with them. n Routinely use shunts to bridge defects in small vessels
below the elbow or the knee (increased likelihood of
thrombosis).
Subject: Temporary Vascular
Shunts (Chapter 23)
Subject: Neck Injury (Chapter 20)
GENERAL
GENERAL
n Use of shunts is a desirable option to bridge damaged
vessels in the extremities, junctional areas, and trunk to n A unique, compacted and congested anatomical zone
enable early reperfusion of tissue. with multiple vital structures.
4 • Surgical Trainee’s Perspective

n Neck trauma is divided into three zones based on ana- n Options for carotid repair include:
tomic landmarks (Chapter 20, Fig. 20.1): n Primary repair with monofilament suture (rarely
n Zone I – sternal notch to cricoid cartilage advisable)
n Zone II – cricoid cartilage to angle of mandible n Patch angioplasty with bovine pericardium or vein
n Zone III – angle of mandible to base of skull graft
n Wide spectrum of presentation from exsanguinating n Interposition graft with saphenous vein preferably
hemorrhage to subtle clinical or imaging findings that or PTFE (graft generally required for >2-cm length
can lead to delayed stroke. defects)
n Carotid injuries may present with contralateral n Use of a Fogarty occlusion balloon, carefully inflated, is a
extremity weakness, aphasia, or Horner’s syndrome. facile means of gaining distal control in zone III injuries.
n Vertebral injuries are rarely symptomatic on presen- If possible, repairs of the internal carotid artery (ICA)
tation. should be undertaken using a shunt to maintain pro-
n Increased prevalence of CTA has resulted in more blunt grade flow. If backflow cannot be obtained after gentle
injuries (blunt carotid and vertebral injury – BCVI) being Fogarty thrombectomy, there is little advantage attempt-
identified. ing repair and ligation is advisable.
n Risk factors for BCVI that should prompt screening n Vertebral artery injuries are challenging to repair due
include: to difficult access; management concentrates on injury
n Head and neck trauma associated with severe neck definition (CTA), and control of hemorrhage (ligation,
hyperextension and rotation or hyperflexion embolization) where this is significant, accepting the risk
n Lefort II or III fracture of posterior circulation stroke.
n Basilar skull fracture involving the carotid canal n Injuries to the vertebral artery as it passes through
n Closed head injury consistent with diffuse axonal the transverse processes of the cervical vertebra are
injury presenting with Glasgow coma scale (GCS) approached by the same route as exposure of the carotid
score <6 artery. Hematoma will displace the carotid sheath ante-
n• Cervical vertebral body or transverse foramen frac- riorly; the carotid artery and internal jugular vein must
ture, subluxation, or ligamentous injury at any level or be displaced to allow access to the injury tract, longus
any fracture of C1–C3 colli muscle, and injured vertebral artery. Gaining proxi-
n A seat-belt or other clothesline-type injury with signif- mal and distal control requires removal of the anterior
icant cervical pain, swelling, or altered mental status tubercle of the transverse process which is difficult to
accomplish in the midst of hemorrhage.
n Alternatively, tamponading the surgically exposed injury
SURGICAL APPROACH
tract with hemostatic material or the balloon of a Fog-
n Physical examination is extremely important with iden- arty catheter while addressing balanced transfusion and
tification of hard vascular signs an indication for airway judicious use of time may be sufficient to allow bleeding
control and operative exploration. For stable patients, to stop as a prelude to follow-up catheter-based emboli-
CTA is the next step. It is crucial to pick-up pathologic zation.
neurological signs prior to intervention.
n Repair of penetrating carotid trauma in a patient with SURGICAL TACTICS
neurological deficit has attracted controversy, but there
are no absolute contraindications. However, a delay of n Do:
more than 3 hours from coma onset and large areas of n Screen aggressively for BCVI; management is almost
cerebral infarct seen on initial CT scan are reasons to always nonoperative with antithrombotic therapy
consider what reperfusion is likely to achieve. and follow-up CTA the mainstay of treatment. Enlarg-
n Catheter-based angiography and endovascular stenting ing pseudoaneurysms that develop during follow-up
is suited to distal carotid (zone III) hemorrhage where can be selectively managed with stenting or coiling.
surgical access is difficult. Similarly, very proximal
lesions (zone I) that would otherwise mandate median Grade Description Management
sternotomy for proximal control may be managed via
I Intimal injury with <25% Antithrombotic therapy
covered stents. luminal narrowing
n Operative positioning and draping should take into II Dissection or hematoma with Antithrombotic therapy
account the potential need to open the chest and possible >25% luminal narrowing
vein harvest. III Pseudoaneurysm Antithrombotic therapy;
n Carotid injuries are exposed via a standard sternal consider endovascular
notch to mastoid process incision, via a plane that lies management
medial to the sternocleidomastoid muscle. The inter- IV Occlusion Antithrombotic therapy
nal jugular vein should be mobilized laterally away V Transection Operative interven-
from the carotid; dividing the facial vein facilitates tion (endovascular if
this. Exposing the upper parts of the internal carotid inaccessible)
(zone III) requires preservation of the XII cranial
nerve, division of the occipital artery, and mobilization n Antithrombotic therapy (either anticoagulation or anti-
of the posterior belly of the digastric, protecting the IX platelet) is chosen empirically based on injury pattern,
and XI cranial nerves. provider experience, and institutional guidelines.
 • Surgical Trainee’s Perspective 5

n Do Not: n Ligation of the SCA or axillary is unlikely to lead to limb

n Fail to assess penetrating injuries of the neck for pres- loss or crippling ischemia due to collaterals but may
ence of tracheal and esophago-pharyngeal injury, result in functional impairment; repair or shunting is
through rigorous surgical exploration at the time of advised if possible. Brachial artery injuries should be
vascular repair and combination of rigid esophagos- repaired.
copy + esophagography + tracheo-laryngoscopy if n Injuries to single forearm arteries may be ligated if there
any doubt exists. is good flow in the intact remaining vessel verified intra-
n Fail to repeat CTA 7 to 10 days after injury for nonop- operatively via Doppler.
eratively managed patients to assess for resolution or
progression SURGICAL TACTICS
n Do:
n Prep widely considering all possible approaches for
Subject: Upper Extremity and proximal and distal control. Include the hand and
Junctional Zone Injuries (Chapter 21) forearm to allow for intraoperative Doppler interroga-
tion and possible fasciotomy.
n Be cognizant of critical structures (brachial plexus,
GENERAL
vagus, phrenic nerves).
n Upper limb vascular trauma can lead to life-threatening n Use CTA to confirm site of probable junctional vascu-
hemorrhage and tissue ischemia, neuropathy and isch- lar injury if the patient is stable.
emia reperfusion injury. n Make liberal use of shunts for complex injuries,
n Junctional trauma may require control from within the especially where conjoined orthopedic fixation is
chest; is technically challenging to manage and may be anticipated.
associated with gross shock. n Remember to perform forearm fasciotomy if compart-
n Where possible, injuries to the subclavian artery (SCA) ment syndrome is anticipated (Chapter 21, Box. 21.1
can be managed with covered stents. and Fig. 21.15).
n Do Not:
n Use limb viability trauma scoring systems (Chapter 21,
SURGICAL APPROACH
Tables 21.2 and 21.3) as an absolute driver of deci-
n Junctional penetrating trauma may present with a com- sion-making, but instead as a cue/prompting mea-
bination of upper limb signs (loss or function, reduced sure to consider all elements contributing to injury
pulse through to obvious ischemia), local signs (pulsatile burden.
periclavicular hemorrhage or expanding hematoma), n Hesitate to gain the second opinion of a colleague
chest signs (massive hemothorax). when considering amputation.
n A variety of surgical approaches exist for management n Cover a dominant vertebral artery when stenting
of junctional injury: the SCA, or fail to follow-up on patients with covered
stents (where long-term outcomes are unknown).

Location Approach Adjuncts Subject: Blunt Thoracic Aortic

Right proximal
SCA
Median sternotomy Supraclavicular extension,
resection of clavicular
Injury (Chapter 17)
head
Left proximal Anterolateral Extend with median ster- GENERAL
SCA thoracotomy notomy and supracla-
vicular incision (may be n Blunt thoracic aortic injury (BTAI) typically occurs in the
referred to as trapdoor aorta distal to the origin of the left subclavian artery, and
incision) ranges from intimal tear only (minimal aortic injury) to
Mid-distal SCA, Supraclavicular incision Clavicular resection, pseudoaneurysm and complete transection (with lethal
Proximal (divide sternocleido- ­infraclavicular incision and unconstrained hemorrhage). CTA is the standard
axillary mastoid and anterior diagnostic tool.
scalene)
n Most cases that survive to reach surgical care can be
Distal axillary, Lateral infraclavicular Lateral extension onto arm
Proximal incision (split pec
temporized through vigorous blood pressure control
brachial major, divide pec (beta blockade) and careful monitoring while arrange-
minor) ments are optimized for definitive management or other
Mid-distal Incision over medial more life-threatening injuries addressed.
brachial bicipital groove n In general, goal SBP <120 mm Hg
Ulnar, radial Longitudinal forearm S-shaped extension over n Esmolol drip is most commonly used due to rapid
incision antecubital crease to onset, ease of titration
expose distal brachial n Aortic endovascular stenting (thoracic endovascular
artery
aortic repair (TEVAR); Chapter 17, Figs. 17.9, 17.10)
SCA, Subclavian artery. has become a prevailing mode of treatment, with open
6 • Surgical Trainee’s Perspective

or hybrid repairs reserved for injuries involving the aor- emergent endotracheal intubation in the ER and transfer
tic arch or where endovascular resources are limited. expeditiously to the OR for surgery.
n Where physiology becomes agonal, perform EDT (left
anterolateral thoracotomy or clamshell thoracotomy if
SURGICAL APPROACH
suspected right-sided injury) (Chapter 16, pp. 4–6, Figs.
n Open repair is accomplished by the clamp and sew 16.1–16.4) with the aim of:
approach via left posterolateral thoracotomy and distal n Confirming the diagnosis.
perfusion of the aorta to reduce the chance of spinal n Performing pericardiotomy if tamponade is present.
cord ischemia (Chapter 17, pp. 5–7, Fig. 17.8). n Via longitudinal incision in the pericardium above
n Proper sizing of stents is key in preventing TEVAR-related the left phrenic nerve.
complications (Chapter 17, Table 17.3 and Figs. 17.11– n Controlling hemorrhage from a wound to the heart,
17.13). Bird’s neck deformity can be avoided by using great vessels, or lung.
new generation devices that allow for the curvature of n Catastrophic lung hemorrhage may be temporized
the aorta in young patients. with use of hilar clamping or lung twist (Chapter
n Most patients tolerate covering of the origin of the left 16, p. 25). These require division of the inferior
subclavian well. Carotid-subclavian bypass can be pulmonary ligament.
undertaken for patients who develop subclavian steal. n Clamping the descending thoracic aorta to preserve
circulating volume and perfuse the coronary and
carotid arteries.
SURGICAL TACTICS
n The inferior pulmonary ligament can be taken
n Do: down to aid in visualization.
n Base the timing of definitive management on the n Undertaking internal cardiac massage.
nature and extent of the BTAI lesion, other associated n Less critically disturbed patients whose physiology stabi-
injuries, and facility expertise. lizes with resuscitation can be more thoroughly worked
n Consider conservative management (with early CTA up (CT chest, CTA arch vessels) and then moved to criti-
follow-up) for patients with minor lesions (intimal cal care for close observation. Conservative management
tear, small pseudoaneurysm). should be abandoned if tube thoracostomy output con-
n Consider screening for blunt cardiac injury with elec- tinues (>200 mL/h over 2–4 hours) or if volume require-
trocardiogram (EKG) monitoring. ments become elevated.
n Do Not:
n Fail to ensure that all TEVAR patients are submitted to SURGICAL TACTICS
life-long surveillance programs to ensure stent com- n Do:
plications are identified. n Make use of the subxiphoid pericardial window tech-
nique to rule out tamponade during trauma laparot-
omy (Chapter 16, p. 8).
Subject: Cardiac, Great Vessel and n Match the repair technique to the location of the
Pulmonary Injuries (Chapter 16) heart injury: clamp and suture (permanent monofila-
ment) for atria; unpledgeted repair to right ventricle;
GENERAL pledgeted repair to left ventricle.
n Consider temporizing cardiac injuries in extremis with
n Surgery is infrequently needed for thoracic injury; skin staples, Foley balloon, or other adjuncts (Chapter
patients with penetrating injuries to the heart and great 16, Table 16.2).
vessels usually do not reach the surgeon alive. n Use partial isolation (Satinsky clamp) to deal with
n The most common indications for thoracotomy are simple penetrating arch injury.
hemorrhage from the lung, major arterial injury in the n Use debranching techniques to manage complex injuries
arch or root-of-neck vessels, or a penetrating cardiac to the branch vessels (i.e., control the injury→sew proxi-
wound. mal end of prosthetic graft onto arch→sew distal end of
graft to cut distal end of the disrupted arch vessel).
SURGICAL APPROACH n Use lung-sparing techniques (suture, stapled wedge,
tractotomy) when dealing with pulmonary hemor-
n Any penetrating injury between the nipples from rhage (Chapter 16, pp. 25–26).
the sternal notch to xiphoid process (known as the n Consider endovascular techniques to manage great
“cardiac box”) or encompassing the left chest, should be vessel injuries.
evaluated for potential cardiac injury. n Do Not:
n Site large-bore access venous access sites on the n Undertake futile resuscitative thoracotomy (blunt
contralateral side to any injury, and consider using the mechanism of injury [MOI] with no signs of life in ER,
common femoral veins. penetrating MOI with no signs of life in the field).
n Critically shocked patients with evidence of massive n Fail to consider packing the chest as a damage control
hemothorax (chest x-ray appearance, immediate drain- measure.
age of 1200–1500 mL of blood via tube thoracostomy); n Injure the intercostal arteries arising from the pos-
or cardiac tamponade (diagnosed on US); or visible terior aspect of the thoracic aorta when applying a
hemorrhage from the root of the neck should undergo cross-clamp.
 • Surgical Trainee’s Perspective 7

n Lose sight of location of coronary arteries and inad- the lesser sac or left medial visceral rotation; approach
vertently ligate or disrupt coronary arteries while the SMA via the lesser sac (with stapled division of the
attempting to repair a cardiac injury. pancreas in-extremis), via left medial visceral rotation
n Forget to get postop echocardiography to evaluate for or via the root of the small bowel mesentery. The infe-
valvular injury post cardiac repair. rior mesenteric artery can be ligated. Injuries to the
renal arteries usually result in ligation and probable
nephrectomy.
n Mobilize the cecum or sigmoid colon to visualize the
Subject: Aortic, Iliac and Visceral common and external iliac vessels, avoiding the ure-
Arterial Injuries (Chapter 18) ter, and be prepared to achieve distal control at the
groin if unfavorable pelvic anatomy is present.
n Do Not:
GENERAL
n Fail to consider endovascular treatment of pelvic ves-
n Wide variety of presentation with potential for rapid sel injury (covered stent) if the situation permits (i.e.,
deterioration and exsanguination. consider operating in a hybrid room if possible).
n Vascular injuries in the abdomen are categorized accord- n Fail to consider preperitoneal packing as a means to
ing to anatomical location, defined within three retro- temporize pelvic bleeding associated with pelvic frac-
peritoneal zones: zone I – midline, zone II – lateral, zone tures prior to embolization.
III – pelvic (Chapter 18, Fig. 18.1). n Fail to consider the likelihood of abdominal compart-
n CTA is the gold standard investigation for stable casu- ment syndrome and the advantage of temporary lapar-
alties; exploratory laparotomy for unstable patients ostomy to prevent this and allow assessment of visceral
(i.e., no or short-lived response to initial resuscitation). viability at a subsequent planned relook procedure.

SURGICAL APPROACH
n Skin preparation and draping should take account of
Subject: Inferior Vena Cava, Portal
the potential need for left anterolateral thoracotomy and and Mesenteric Venous Injuries
vascular control at the groins. (Chapter 19)
n Evisceration, four-quadrant packing, and sequential
removal of packs removes blood and allows a methodical GENERAL
start to challenging surgery.
n Any zone I retroperitoneal hematoma will require explo- n As with injury to the aorta and its branches, injuries to
ration as there is a high chance of it involving the aorta the IVC, portal vein, and mesenteric vessels are highly
or its branches, or the inferior vena cava (IVC). Left or lethal.
right medial visceral rotation respectively for aorta n CTA is the investigation of choice, with hematomas
(hematoma biased to left of midline) and IVC (hematoma around the ascending colon and duodenum fairly spe-
biased to right of midline) are the key maneuvers to cific for IVC injuries as well as caval filling defect.
expose the injury, though consideration should be given n Resuscitative thoracotomy or zone I REBOA are valid
to obtaining supraceliac aortic control in very unstable means of controlling aortic inflow in order to manage
patients beforehand (Chapter 18, Figs. 18.2–18.4). the critically deteriorating patient.
n Large zone I hematomas that are present in the supra- n Selected patients, without hemodynamic disturbance,
colic compartment may be better controlled through and where the hematoma is small-to-moderate on CT
clamping of the thoracic aorta via left anterolateral scan, may be monitored and observed; assuming there is
thoracotomy. no other reason to pursue laparotomy (e.g., blunt injury;
n Zone II and zone III hematomas may be managed more or, if penetrating, no violation of peritoneum or signs of
judiciously, with exploration reserved for ongoing bleed- peritonism).
ing (expanding hematoma or the presence of physiologi-
cal instability). Some also include penetrating trauma as SURGICAL APPROACH
an indication, particularly for pelvic hematoma where
the iliac vessels may have been injured. n Cava:
n Utilize right medial visceral rotation (Chapter 19,
Fig. 19.2), with extensive kocherization of the duo-
SURGICAL TACTICS
denum, for infra- and suprarenal IVC and control.
n Do: Use digital pressure or careful application of swabs/
n Do consider preplacement of a REBOA catheter sponges on sticks to occlude the IVC either side of an
prelaparotomy to enable rapid aortic control should injury rather than attempting encirclement with risk
this be required. to the lumbar vessels.
n Branches of the celiac artery can be ligated proxi- n Retrohepatic injuries to the cava, heralded by dark
mally with low risk of end-organ ischemia; injury to blood continuously welling up from behind the liver,
the peripancreatic superior mesenteric artery (SMA) should be managed via manual compression of the liver
should be repaired or shunted in order to avoid cata- against the cava and thence appropriate packing and/
strophic mid-gut infarction. Approach the celiac via or clamping of the portal triad (Pringle maneuver).
8 • Surgical Trainee’s Perspective

n If this fails to control bleeding, the laparotomy inci- n Documenting a complete lower extremity neurovascular
sion should be extended to the right chest via right examination prior to intervention assists in determina-
anterolateral thoracotomy, with control of the supra- tion of injury pattern as well as evaluation of possible
hepatic IVC from within the pericardium, prior to full postoperative complications.
mobilization of the liver, and exposure of the injured n High energy mechanisms of injury, especially explosions,
retrohepatic cava. Alternatively, seek to place occlu- result in complex multisegmental injury with disruption
sion balloons in the cava via percutaneous means to of soft tissue, bone, and skin.
isolate the liver prior to mobilization. n Limb salvage and vascular reconstruction must only be
n Portal Vein considered in the context of the totality of injury and
n Approach by clamping the portal triad proximal to associated physiological disturbance. Interventions that
the injury, taking down the hepatic flexure of the save life and restore homeostasis should be prioritized
colon, and performing a wide Kocher maneuver, then accordingly.
releasing the clamp to facilitate digital control of the n The presence of a vascular injury can be discerned from
injury and gentle dissection of the vein away from the hemorrhage, ischemia, or signs found on CTA. The
hepatic artery and common bile duct to allow injury latter, as a preprocedural investigation, is especially
definition and placement of vessel loops. useful in situations where several levels of vascular
n Be prepared to divide the neck of the pancreas (to damage may be present (shotgun injury, multiple long
the left of the SMA/superior mesenteric vein [SMV]) bone fracture).
using a linear cutter stapler in order to expose the n Warm ischemic time is very important and must be
most proximal portion of the portal vein if proximal carefully monitored, driving urgency of revasculariza-
control is not achievable otherwise. tion. Aim to restore perfusion within 3 hours of injury –
n Superior Mesenteric Vein although classic teaching is 6 hours, recent data
n Injuries are associated with central hematoma at the indicates this is too long.
base of the small bowel mesentery (at the fusion of n Primary amputation is a difficult decision to undertake –
the peritoneum overlying junction of the transverse a second opinion, obtained from an experienced col-
colon mesentery). league brought to the OR for this purpose can help in
n Medial visceral rotation from the right with kocher- decision-making.
ization allows the operator to place a hand behind the
mesentery containing the injured vein. This allows for SURGICAL APPROACH
application of digital control and dissection of the vessel/
clamping/repair, or ligation prior to hematoma entry. n Proximal tourniquet for control of ongoing hemorrhage
until proximal control is achieved via exposure of vessels
above the injury zone, with subsequent distal control
SURGICAL TACTICS
and thence entry into the hematoma and evaluation of
n Do: the injury. Prep tourniquet into field to allow for intraop-
n Consider getting aortic control before opening a large erative manipulation.
central hematoma. n Injuries at the groin may not be amenable to tourni-
n Handle the portal vein and SMV carefully; they are quet control; sponge-stick or digital control of external
thin-walled and tear easily. hemorrhage should be maintained while a retroperi-
n Anticipate the splanchnic sequestration effects of toneal approach is used to effect access to the external
portal vein or SMV ligation and ensure aggressive vol- iliac artery (EIA). A curvilinear skin incision, from the
ume resuscitation in the postoperative period. Plan for mid-inguinal point superior to the anterior superior
early relook laparotomy to assess for potential bowel iliac spine, can be employed, dividing aponeurosis of the
infarction. external oblique, splitting the underlying fibers of the
n Do Not: internal oblique and transversus abdominis, reaching
n Expect to see contrast extravasation on the initial CT the preperitoneal plane, and developing this medially to
abdomen in venous injury. reach the EIA.
n Ligate the suprarenal IVC – this is not tolerated and n In general, standard vascular axial exposures (mid-
will lead to acute renal failure. inguinal, anteromedial thigh, medial calf; Chapter 22,
n Spend too much time attempting complex repair of pp. 9–13) can be used to deal with injuries to the com-
the portal vein – damage control adjuncts such as mon, profunda and superficial femoral arteries, and the
ligation or shunting should be considered early to popliteal and posterior tibial vessels. There should be no
avoid extensive bleeding. hesitation in extending these incisions proximally or dis-
tally as the situation dictates.
n The orthodox preliminaries of injury definition,
Subject: Lower Extremity Vascular evaluation of inflow and backflow, and Fogarty
Trauma (Chapter 22) catheter thrombectomy of upstream and downstream
vessels are required before considering whether the
GENERAL patient requires a shunt or immediate definitive
repair.
n The lower limb is the most frequent site of arterial injury n Ensure adequate healthy tissue coverage over any shunt/
in both civilian and military trauma. repair after the wound is appropriately débrided.
 • Surgical Trainee’s Perspective 9

SURGICAL TACTICS to IIIA to IIIC – vascular repair required; Chapter 26,

n Do: Table 26.1).
n Consider coil embolization for the treatment of n Options include: primary amputation; defer primary
CTA-identified bleeds emanating from branches of the amputation to a later date once patient has been coun-
profunda. selled; or attempt surgical intervention with the aim of
n Bias toward use of end-to-end interposition with great limb salvage (i.e., revascularization, fracture fixation,
saphenous vein for short defects, or formal by-pass for soft tissue coverage).
longer defects. The latter option, combined with vessel n Tailor decisions to individual patient, overall injury bur-
exclusion, is very applicable for popliteal artery injuries den, and future functional goals.
and avoids surgical division of medial knee ligaments. n Shunts are a key part of the armamentarium in decision-
n Repair the popliteal and common femoral veins, if making concerning sequencing.
possible, in order to avoid the morbidity of ligation. n The viability of the distal soft-tissue envelope defines the
n Avoid ligation of the external iliac, superficial femoral, level of the amputation, with preservation of viable soft
or popliteal artery when possible due to high risk of tissue a critical goal of initial débridement to preserve
limb loss. options for later stump closure on re-look surgery 2 to 5
n Default to four-quadrant calf fasciotomy unless: days later.
n Ischemia time <2  hours
n Lower limb hourly observations (pain, tissue
SURGICAL TACTICS
laxity, perfusion, pulses) can be assured in the
postoperative period, with concurrently avail- n Do:
able surgical capacity for rapid fasciotomy should n Save detailed wound evaluation for the OR once it is
compartment syndrome develop. Pain out of pro- clear that surgery is required.
portion to examination and/or pain with passive n Appraise skin, muscle, and nerve loss as well as a bony
motion are commonly first signs of compartment skeleton assessment during evaluation. Check for
syndrome. degloving injury.
n Do Not: n Work superficial-to-deep and peripheral-to-central
n Zealously repair single calf vessel injuries if there is when performing débridement, extending wounds
good evidence of foot perfusion from the uninjured along fasciotomy (axial) lines where required. Pre-
vessels. serve bony fragments that have a contiguous soft
n Fail to verify that all four compartments were opened tissue attachment. Liberally irrigate.
during calf fasciotomy. n Utilize viable soft tissue to cover vascular repairs,
n anterior/lateral – visualize and palpate septum mobilizing local flaps if necessary (e.g., Sartorius flap
between the two compartments ensuring both for common femoral vessels).
opened via H-type incision n Plan for later definitive orthopedic fixation at the
n deep posterior – visualization of the posterior tibial same time as definitive wound coverage (e.g., the Fix
neurovascular bundle and Flap approach) to reduce risk of deep infection
n Injure the superficial peroneal nerve during the lat- and allow for resolution of soft tissue edema.
eral incision or the great saphenous vein during the n Be familiar with the variety of soft tissue coverage
medial incision. solutions (local and distal fasciocutaneous and mus-
n Be falsely reassured by a normal compartment cle flaps, free flaps (Chapter 26, pp. 8–10).
pressure – this can be used as an adjunct in diagnosis n Do Not:
but not unilaterally to rule out compartment n Compromise skin perforators when performing calf
syndrome. fasciotomy.
n Submit patients to complex soft tissue reconstruction
until they are physiological stable.
Subject: Soft-Tissue and Skeletal n Fail to involve the patient in the discussion regarding
Wound Management in the Setting reconstruction options, particularly when consider-
of Vascular Injury (Chapter 26) ing the place of early amputation.

GENERAL Subject: Management of Pediatric

n Multidisciplinary input that is timely, coordinated, and Vascular Injury (Chapter 25)
coherent is vital in order to achieve good functional out-
comes in complex limb trauma in both the civilian and GENERAL
military settings.
n Secondary, or delayed amputation is part of the n Pediatric vessel size, propensity for spasm and infre-
spectrum of treatment options. quency of presentation combine to make management
challenging; 50% iatrogenic.
n Diagnosis is difficult in the shocked child; continuous
SURGICAL APPROACH
wave Doppler and injury extremity index are useful
n Categorize open lower-limb fractures using the Gustilo- adjuncts to clinical diagnosis; CT angiography is a main-
Anderson system (I–III, where III is subcategorized in stay of localization if Duplex is not available.
10 • Surgical Trainee’s Perspective

n Abnormal ABI 2 years or younger: < .88, Abnormal long-term outcomes are unknown and open repair is
ABI > 2 years: < 0.9 (Chapter 25, p. 2) the default for blunt thoracic aorta injury.
n The use of intraoperative systemic heparin, and short-
term postoperative anticoagulation is permissible to
SURGICAL APPROACH
prevent vessel thrombosis, as is longer-term antiplatelet
n Extremities: therapy.
n Standard repair techniques (primary repair, vein
patch angioplasty, interposition grafting with reversed SURGICAL TACTICS
saphenous vein) should be employed.
n Synthetic grafts are avoided where possible due to n Do:
lack of potential for conduit growth and concern for n Respect the propensity of pediatric vessels to
long-term patency. spasm and employ the gentlest of handling tech-
n Veins should be repaired to avoid edema, improve niques; use vessel loops to achieve control; employ
patency of concomitant arterial repairs, and improve high-magnification loupes and microvascular
functional outcomes. instrumentation.
n Interrupted sutures permit circumferential anasto- n Remember to employ long-term imaging follow-up
motic expansion with growth; vessel ends should be for any stent grafts to assess for device migration as
maximally spatulated to the same end. vasculature enlarges over time.
n Topical papaverine and lidocaine to vessels may n Do Not:
reduce spasm and permit a less technically challeng- n Delay in achieving the best imaging solution that the
ing repair. child will tolerate; early liaison with anesthetic and
n Trunk and neck: pediatric colleagues and generation of sedation/anal-
n Blunt carotid vertebral artery injury (BCVI) rarely gesia options to permit imaging is advisable.
benefit from surgical exploration. Antithrombotic n Delay in intervening where there is evidence of
medications should be considered based on injury ischemic compromise to a limb and simple measures
severity. These should be followed up as per adult such as fracture reduction have not restored perfusion.
practice to ensure complications do not develop. n Forget that fasciotomy is a vital part of the manage-
n Stent graft repair of arch vessel injury or distal extra- ment of pediatric extremity vascular injury and use
cranial carotid injury is feasible in older children but this liberally.
SECTION 1
Setting the Stage

11
 1 The Vascular Injury Legacy
NORMAN M. RICH and KENNETH J. CHERRY

Although the first crude arteriorrhaphy was performed servicemen who sustained vascular trauma in Vietnam.5
more than 250 years ago, it is only within the past 50 years An interim Registry report that encompassed 1000 major
that vascular surgery has been practiced both widely and acute arterial injuries showed little change from the overall
consistently with anticipation of good results. Historically, statistics presented in the preliminary report.6 Considering
it is of particular interest that by the turn of the 20th cen- all major extremity arteries, the amputation rate remained
tury, many if not most of the techniques of modern vascu- near 13%. Although high-velocity missiles created more
lar surgery had already been explored through extensive soft-tissue destruction in injuries seen in Vietnam, the
experimental work and early clinical application. In retro- combination of a stable hospital environment and rapid
spect, it is therefore almost astonishing that it took nearly evacuation of casualties (similar to that in Korea) made
another 50 years before the work of such early pioneers as successful repair possible. Injuries of the popliteal artery,
Murphy, Goyanes, Carrel, Guthrie, and Lexer was widely however, remained an enigma, with an amputation rate
accepted and applied in the treatment of vascular injuries. remaining near 30%.
However, adoption of the thought processes and practices In the past 50 years, civilian experience with vascu-
of these enlightened surgeons was hampered by the tech- lar trauma has developed rapidly under conditions much
nological limitations of their era and had to await the dra- more favorable than those of warfare. Results are better
matic advances in graft materials and imaging seen during than those achieved with military casualties in Korea and
the 1950s and beyond.1,2 Vietnam.
Since the days of Ambroise Paré in the mid–16th century,
major advances in the surgery of trauma have occurred
during times of armed conflict, when it was necessary to Initial Control of Hemorrhage
treat large numbers of severely injured patients, often under
far-from-ideal conditions. This has been especially true with Control of hemorrhage following injury has been of prime
vascular injuries. concern to man since his beginning. Methods for control
Although German surgeons accomplished arterial have included various animal and vegetable tissues, hot
repairs in the early part of World War I (WWI), it was not irons, boiling pitch, cold instruments, styptics, bandaging,
until the Korean War and the early 1950s that ligation of and compression. These methods were described in a his-
major arteries was abandoned as the standard treatment torical review by Schwartz in 1958.7 Celsus was the first
for arterial trauma. The results of ligation of major arteries to record an accurate account of the use of ligature for
following trauma were clearly recorded in the classic manu- hemostasis in CE 25. During the first three centuries, Galen,
script by DeBakey and Simeone in 1946, who found only 81 Heliodorus, Rufus of Ephesus, and Archigenes advocated
repairs in 2471 arterial injuries among American troops in ligation or compression of a bleeding vessel to control hem-
Europe in World War II (WWII).3 All but three of the arte- orrhage.
rial repairs were performed by lateral suture. Ligation was Ancient methods of hemostasis used by Egyptians about
followed by gangrene and amputation in nearly half of the 1600 BCE are described in the Ebers’ papyrus, discovered by
cases. The pessimistic conclusion reached by many was Ebers at Luxor in 1873.7 Styptics prepared from mineral or
expressed by Sir James Learmonth, who said that there was vegetable matter were popular, including lead sulfate, anti-
little place for definitive arterial repair in the combat wound. mony, and copper sulfate. Several hundred years later dur-
Within a few years, however, in the Korean War, the pos- ing the Middle Ages in Europe, copper sulfate again became
sibility of successfully repairing arterial injuries was estab- popular and was known as the hemostatic “button.” In
lished conclusively, stemming especially from the work of ancient India, compression, cold, elevation, and hot oil
Hughes, Howard, Jahnke, and Spencer. In 1958, Hughes were used to control hemorrhage, while about 1000 BCE,
emphasized the significance of this contribution in a review the Chinese used tight bandaging and styptics.
of the Korean experience, finding that the overall ampu- The writings of Celsus provide most of the knowledge of
tation rate was lowered to about 13%, compared to the methods of hemostasis in the first and second centuries CE.7
approximately 49% amputation rate that followed ligation When amputation was done for gangrene, the prevailing
in WWII.4 surgical practice was to amputate at the line of demarcation
During the Vietnam hostilities, more than 500 young to prevent hemorrhage. In the first century CE, Archigenes
American surgeons, who represented most of the major was apparently the first to advocate amputating above the
surgical training programs in the United States, treated line of demarcation for tumors and gangrene, using liga-
more than 7500 vascular injuries. In 1969, Rich and ture of the artery to control hemorrhage.
Hughes reported the preliminary statistics from the Rufus of Ephesus (first century CE) noted that an artery
Vietnam Vascular Registry, which was established in 1966 would continue to bleed when partially severed, but when
at Walter Reed General Hospital to document and follow all completely severed, it would contract and stop bleeding
12
 1 • The Vascular Injury Legacy 13

within a short period of time.7 Galen, the leading physician understanding of vascular injuries.7 Although Rufus of
of Rome in the second century CE, advised placing a finger Ephesus apparently discussed arteriovenous communi-
on the orifice of a bleeding superficial vessel for a period of cations in the first century CE, it was not until 1757 that
time to initiate the formation of a thrombus and the cessa- William Hunter first described the arteriovenous fistula as
tion of bleeding. He noted, however, that if the vessel were a pathological entity.8 This was despite the fact that, as early
deeper, it was important to determine whether the bleeding as the second century CE, Antyllus had described the physi-
was coming from an artery or a vein. If coming from a vein, cal findings, clinical management (by proximal and distal
pressure or a styptic usually sufficed, but ligation with linen ligation), and the significance of collateral circulation.9
was recommended for an arterial injury. The development of the tourniquet was another advance
Following the initial contributions of Celsus, Galen, and that played an important role in the control of hemorrhage.
their contemporaries, the use of ligature was essentially for- Tight bandages had been applied since antiquity, but subse-
gotten for almost 1200 years in Western medicine. A ten- quent development of the tourniquet was slow. Finally, in
sion developed between traditional church teachings and 1674, a military surgeon named Morel introduced a stick
enlightened thought, perhaps holding back any advance- into the bandage and twisted it until arterial flow stopped.7
ment in Western medicine or surgery. Use of the knife on The screw tourniquet came into use shortly thereafter. This
living tissue was considered to be wrong; consequently, method of temporary control of hemorrhage encouraged
amputation was below the line of ischemic demarcation. more frequent use of the ligature by providing sufficient
Abu al-Qasim al-Zahrawi, a prominent Arab physician from time for its application. In 1873, Freidrich von Esmarch, a
Moorish Spain (10th century CE), advocated ligation in his student of Langenbeck, introduced his elastic tourniquet
great work Kitab Al-Tasrif almost 600 years before Paré.7 bandage for first aid use on the battlefield.10 Previously it
Throughout the Middle Ages, cautery was used almost was thought that such compression would injure vessels
exclusively to control hemorrhage. Jerome of Brunswick irreversibly. His discovery permitted surgeons to operate
(Hieronymus Brunschwig), an Alsatian army surgeon, electively on extremities in a dry, bloodless field.
actually preceded Paré in describing the use of ligatures as Ligation was not without its complications, as British
the best way to stop hemorrhage.7 His recommendations Admiral Horatio Nelson discovered after amputation of his
were recorded in a textbook published in 1497 and provided right arm after the attack at Tenerife, “A nerve had been
a detailed account of the treatment of gunshot wounds. taken up in one of the ligatures at the time of the opera-
Ambroise Paré, with wide experience in the surgery of tion,” causing considerable pain and slowing his recovery.11
trauma, especially on the battlefield, firmly established the Furthermore, the long ligatures meant delayed wound heal-
use of ligature for control of hemorrhage from open blood ing. It was Haire, an assistant surgeon at the Royal Naval
vessels. In 1552, he startled the surgical world by ampu- Hospital Haslar, who took the risk of cutting sutures short
tating a leg above the line of demarcation, repeating the (rather than leaving them long) to allow suppuration,
demonstration of Archigenes 1400 years earlier. The ves- necrosis, and granulation before the suture was pulled
sels were ligated with linen, leaving the ends long. Paré away. He observed that “the ligatures sometimes became
also developed the bec de corbin, ancestor of the modern troublesome and retarded the cure,” and that cutting them
hemostat, to grasp the vessel before ligating it (Fig. 1.1).7 short allowed stumps to heal in the course 10 days.
Previously, vessels had been grasped with hooks, tenacu- In addition to the control of hemorrhage at the time of
lums, or the assistant’s fingers. He designed artificial limbs injury, the second major area of concern for centuries was
and advanced dressing technique. During the siege of Turin the prevention of secondary hemorrhage. Because of its
(1536), Paré ran out of oil, which was traditionally used to great frequency, styptics, compression, and pressure were
cauterize. He mixed egg yolk, rose oil, and turpentine and used for several centuries after ligation of injured vessels
discovered this dressing had better outcomes than oil. became possible. Undoubtedly, the high rate of secondary
In the 17th century, Harvey’s monumental contri- hemorrhage after ligation was due to infection of the
bution describing circulation of blood greatly aided the wound, often promoted by dressing choices or infection
spread by well-meaning attendants. Although John Hunter
demonstrated the value of proximal ligation for control of a
false aneurysm in 1757, failure to control secondary hem-
orrhage resulted in the use of ligature only for secondary
bleeding from the amputation stump.12 Subsequently, Bell
(1801) and Guthrie (1815) performed ligation both proxi-
mal and distal to the arterial wound with better results than
those previously obtained.13,14
Some of the first clear records of ligation of major arter-
ies were written in the 19th century and are of particu-
lar interest. The first successful ligation of the common
carotid artery for hemorrhage was performed in 1803 by
Fleming, but was not reported until 14 years later by Coley
(1817), because Fleming died a short time after the opera-
Fig. 1.1 Artist’s concept of the bec de corbin, developed by Paré tion was performed.15 A servant aboard the HMS Tonnant
and Scultetus in the mid–16th century. It was used to grasp the ves- attempted suicide by slashing his throat. When Fleming
sel before ligating it. (From Schwartz AM. The historical development of saw the patient, it appeared that he had exsanguinated.
methods of hemostasis. Surgery. 1958;44:604.) There was no pulse at the wrist and the pupils were dilated.
14 SECTION 1 • Setting the Stage

It was possible to ligate two superior thyroid arteries and through Pasteur and Lister. Subsequently, Halsted (1912)
one internal jugular vein. A laceration of the outer and demonstrated the role of collateral circulation by gradually,
muscular layers of the carotid artery was noted, as well as completely occluding the aorta and other large arteries in
a laceration of the trachea between the thyroid and cricoid dogs by means of silver or aluminum bands that were grad-
cartilages. This allowed drainage from the wound to enter ually tightened over a period of time.18
the trachea, provoking violent seizures of coughing,
although the patient seemed to be improving. Approxi-
mately 1 week following the injury, Fleming recorded: “On Early Vascular Surgery
the evening of the 17th, during a violent paroxysm of
coughing, the artery burst, and my poor patient was, in an About two centuries after Paré established the use of the lig-
instant, deluged with blood!”15 ature, the first direct repair of an injured artery was accom-
The dilemma of the surgeon is appreciated by the follow- plished. This event more than 250 years ago is credited as
ing statement: “In this dreadful situation I concluded that the first documented vascular repair. Hallowell, acting on
there was but one step to take, with any prospect of success; a suggestion by Lambert in 1759, repaired a wound of the
mainly, to cut down on, and tie the carotid artery below brachial artery by placing a pin through the arterial walls
the wound. I had never heard of such an operation being and holding the edges in apposition by applying a suture
performed; but conceived that its effects might be less for- in a figure-of-eight fashion about the pin (Fig. 1.2).19 This
midable, in this case, than in a person not reduced by hem- technique (known as the farrier’s stitch) had been utilized
orrhage.”15 The wound rapidly healed following ligation of by veterinarians but had fallen into disrepute following
the carotid artery, and the patient recovered. unsuccessful experiments. Table 1.1 outlines early vascular
Ellis (1845) reported the astonishing experience of suc- techniques.
cessful ligation of both carotid arteries in a 21-year-old Unfortunately, others could not duplicate Hallowell’s
patient who sustained a gunshot wound of the neck while successful experience, almost surely because of the mul-
he was setting a trap in the woods in 1844, near Grand tiple problems of infection and lack of anesthesia. There
Rapids, Michigan, when he was unfortunately mistaken was one report by Broca (1762) of a successful suture of a
for a bear by a companion.16 Approximately 1 week later, longitudinal incision in an artery.20 However, according to
Ellis had to ligate the patient’s left carotid artery because of Shumacker (1969), an additional 127 years passed follow-
hemorrhage. An appreciation of the surgeon’s problem can ing the Hallowell-Lambert arterial repair before a second
be gained by Ellis’ description of the operation: “We placed instance of arterial repair of an artery by lateral suture in
him on a table, and with the assistance of Dr. Platt and a man was reported by Postemski in 1886.20
student, I ligatured the left carotid artery, below the omo-
hyoideus muscle; an operation attended with a good deal of
difficulty, owing to the swollen state of the parts, the neces-
sity of keeping up pressure, the bad position of the parts
owing to the necessity of keeping the mouth in a certain Figure-of-eight suture
position to prevent his being strangulated by the blood, and Laceration
the necessity of operating by candle light.”16 Pin
There was recurrent hemorrhage on the 11th day after
the accident, and right carotid artery pressure helped con- Brachial artery
trol the blood loss. It was, therefore, necessary also to ligate
the right carotid artery 4½ days after the left carotid artery
had been ligated. Ellis remarked: “For convenience, we had
him in the sitting posture during the operation; when we Fig. 1.2 The first arterial repair performed by Hallowell, acting on a
tightened the ligature, no disagreeable effects followed; no suggestion by Lambert in 1759. The technique, known as the farrier’s
fainting; no bad feeling about the head; and all the percep- (veterinarian’s) stitch, was followed in repairing the brachial artery
tible change was a slight paleness, a cessation of pulsation by placing a pin through the arterial walls and holding the edges in
in both temporal arteries, and of the hemorrhage.”16 The apposition with a suture in a figure-of-eight fashion about the pin.
patient recovered rapidly with good wound healing and (Drawn from the original description by Mr. Lambert, Med Obser and Inq
returned to normal daily activity. There was no perceptible 1762;2:30–360.)
pulsation in either superficial temporal artery.16
The importance of collateral circulation in preserv-
ing viability of the limb after ligation was well understood Table 1.1 Vascular Repair Before 1900
for centuries, as identified by Antyllus nearly 2000 years Technique Year Surgeon
ago.9 The fact that time was necessary for establishment of Pin and thread 1759 Hallowell
this collateral circulation was recognized. Halsted (1912) Small ivory clamps 1883 Gluck
reported cure of an iliofemoral aneurysm by application of
Fine needles and silk 1889 Jassinowsky
an aluminum band to the proximal artery without seriously
Continuous suture 1890 Burci
affecting the circulation or function of the lower extrem-
ity.17 Asepsis had been recognized, and the frequency of Invagination 1896 Murphy
secondary hemorrhage and gangrene following ligation Suture all layers 1899 Dörfler
promptly decreased as an understanding of transmission Adapted from Guthrie GC. Blood Vessel Surgery and its Applications.
of infectious disease and its management was developed New York: Longmans, Green and Co; 1912.
 1 • The Vascular Injury Legacy 15

With the combined developments of anesthesia and

asepsis, several reports of attempts to repair arteries
appeared in the latter part of the 19th century. The work
of Jassinowsky, who is credited in 1889 for experimentally Femoral artery
proving that arterial wounds could be sutured with preser-
vation of the lumen, was later judged by Murphy in 1897 Femoral vein Posterior
as the best experimental work published at that time.21,22 Anterior
In 1865, Henry Lee of London attempted repair of arterial
lacerations without suture.23 Glück, in 1883, reported 19
experiments with arterial suture, but all experiments failed
because of bleeding from the holes made by the suture nee-
dles.24 He also devised aluminum and ivory clamps to unite Aneurysmal pockets
longitudinal incisions in a vessel, and it was recorded that on the anterior and
the ivory clamps succeeded in one experiment on the femo- posterior surface of
ral artery of a large dog. Von Horoch of Vienna reported B the femoral artery
six experiments, including one end-to-end union, all of
which thrombosed.23 In 1889, Bruci sutured six longitu-
dinal arteriotomies in dogs; the procedure was successful
in four.20 In 1890, Muscatello successfully sutured a par-
tial transection of the abdominal aorta in a dog.20 In 1894, A
Heidenhain closed by catgut suture a 1-cm opening in the
axillary artery made accidentally while removing adherent
carcinomatous glands.25 The patient recovered without any
circulatory disturbance. In 1883, Israel, in a discussion of
a paper by Glück, described closing a laceration in the com-
mon iliac artery created during an operation for perityph-
litic abscess.24,26 The closure was accomplished by five silk
sutures. However, from his personal observations, Murphy
(1897) did not believe it could be possible to have success in
this type of arterial repair.22 In 1896, Sabanyeff successfully
closed small openings in the femoral artery with sutures.20
The classic studies of J.B. Murphy of Chicago (1897) con- C
tributed greatly to the development of arterial repair and
culminated in the first successful end-to-end anastomosis
of an artery in 1896.22 Previously, Murphy had carefully Fig. 1.3 (A–C) The first successful clinical end-to-end anastomosis of
reviewed earlier clinical and experimental studies of arte- an artery was performed in 1896. Sutures were placed in the proximal
rial repair and had evaluated different techniques exten- artery, including only the few outer coats; three sutures were used to
sively in laboratory studies. Murphy attempted to deter- secure the final repair. (From Murphy JB. Resection of arteries and veins
mine experimentally how much artery could be removed injured in continuity—end-to-end suture-experimental clinical research.
and still allow an anastomosis. He found that 1 inch of a Med Record. 1897;51:73.)
calf ’s carotid artery could be removed and the ends still
approximated by invagination suture technique because Hospital in Chicago on September 19, 1896, approximately
of the elasticity of the artery. He concluded that arterial 2 hours after wounding. There was no hemorrhage or
repair could be done with safety when no more than 3/4 increased pulsation noted at the time. Murphy first saw the
inch of an artery had been removed, except in certain patient 15 days later, October 4, 1896, and found a large
locations, such as the popliteal fossa or the axillary space, bruit surrounding the site of injury. Distal pulses were
where the limb could be moved to relieve tension on the barely perceptible. When demonstrating this patient to
repair. He also concluded that when more than half of the students 2 days later, a thrill was also detected. An opera-
artery was destroyed, it was better to perform an end-to- tive repair was decided on. Because of the historical signifi-
end anastomosis by invagination rather than to attempt cance, the operation report is quoted:
repair of the laceration. This repair was done by introduc-
ing sutures into the proximal artery, including only the Operation, October 7, 1896. An incision five inches long was
two outer coats, and using three sutures to invaginate the made from Poupart’s ligament along the course of the femoral
proximal artery into the distal one, reinforcing the closure artery. The artery was readily exposed about one inch above
with an interrupted suture (Fig. 1.3).22 Poupart’s ligament; it was separated from its sheath and a
In 1896, Murphy was unable to find a similar recorded provisional ligature thrown about it but not tied. A careful
case involving the suture of an artery after complete divi- dissection was then made down along the wall of the vessel to
sion, and he consequently reported his experience (1897) the pulsating clot. The artery was exposed to one inch below
and carried out a number of experiments to determine the the point and a ligature thrown around it but not tied: a careful
feasibility of his procedure. Murphy’s patient was a dissection was made upward to the point of the clot. The artery
29-year-old male shot twice with one bullet entering the was then closed above and below with gentle compression
femoral triangle. The patient was admitted to Cook County clamps and was elevated, at which time there was a profuse
16 SECTION 1 • Setting the Stage

hemorrhage from an opening in the vein. A cavity, about the femoral artery aneurysm in 31 patients. Billroth reported
size of a filbert, was found posterior to the artery communicat- secondary hemorrhage from 50% of large arteries ligated
ing with its caliber, the aneurysmal pocket. A small aneurysmal in continuity. Wyeth collected 106 cases of carotid artery
sac about the same size was found on the anterior surface of the aneurysms treated by proximal ligation, with a mortality
artery over the point of perforation. The hemorrhage from the rate of 35%.
vein was very profuse and was controlled by digital compres- In 1897, Murphy summarized techniques he considered
sion. It was found that one-eighth of an inch of the arterial necessary for arterial suture. They bore a close resemblance
wall on the outer side of the opening remained, and on the to principles generally followed today:
inner side of the perforation only a band of one-sixteenth of
an inch of adventitia was intact. The bullet had passed through 1. Complete asepsis
the center of the artery, carried away all of its wall except the 2. Exposure of the vessel with as little injury as possible
strands described above, and passed downward and backward 3. Temporary suppression of the blood current
making a large hole in the vein in its posterior and external side 4. Control of the vessel while applying the suture
just above the junction of the vena profunda. Great difficulty 5. Accurate approximation of the walls
was experienced in controlling the hemorrhage from the vein. 6. Perfect hemostasis by pressure after the clamps are
After dissecting the vein above and below the point of lacera- taken off
tion and placing a temporary ligature on the vena profunda, the 7. Toilet of the wound
hemorrhage was controlled so that the vein could be sutured.
At the point of suture the vein was greatly diminished in size, Murphy also reported that Billroth, Schede, Braun,
but when the clamps were removed it dilated about one-third Schmidt, and others had successfully sutured wounds in
the normal diameter or one-third the diameter of the vein above veins.22 He personally had used five silk sutures to close an
and below. There was no bleeding from the vein when the clamps opening 3/8-inch long in the common jugular vein.
were removed. Our attention was then turned to the artery. Several significant accomplishments occurred in vascular
Two inches of it had been exposed and freed from all surround- surgery within the next few years. In 1903, Matas described
ings. The opening in the artery was three-eighths of an inch his endoaneurysmorrhaphy technique, which remained
in length; one-half inch was resected and the proximal was the standard technique for aneurysms for over 40 years.27
invaginated into the distal for one-third of an inch with four In 1906, Carrel and Guthrie performed classic experimental
double needle threads which penetrated all of the walls of the studies over a period of time with many significant results.28
artery. The adventitia was peeled off the invaginated portion for These included direct suture repair of arteries, vein trans-
a distance of one-third of an inch: a row of sutures was placed plantation, and transplantation of blood vessels as well as
around the edge of the overlapping distal end, the sutures pen- organs and limbs. In 1912, Guthrie independently pub-
etrating only the media of the proximal portion; the adventitia lished his continuing work on vascular surgery.14 Following
was then brought over the end of the union and sutured. The Murphy’s successful case in 1896, the next successful repair
clamps were removed. Not a drop of blood escaped at the line of an arterial defect came 10 years later when Goyanes used
of suture. Pulsation was immediately restored in the artery a vein graft to bridge an arterial defect in 1906.22,29 Work-
below the line of approximation and it could be felt feebly in the ing in Madrid, Goyanes excised a popliteal artery aneurysm
posterior tibial and dorsalis pedis pulses. The sheath and con- and used the accompanying popliteal vein to restore conti-
nective tissue around the artery were then approximated at the nuity (Fig. 1.4).29 He used the suture technique developed
position of the suture with catgut, so as to support the wall of by Carrel and Guthrie of triangulating the arterial orifice
the artery. The whole cavity was washed out with a five percent with three sutures, followed by continuous suture between
solution of carbolic acid and the edges of the wound were accu- each of the three areas. A year later in 1907, Lexer in
rately approximated with silk worm-gut sutures. No drainage. Germany first used the saphenous vein as an arterial substi-
The time of the operation was approximately two and one-half tute to restore continuity after excision of an aneurysm of
hours, most of the time being consumed in suturing the vein. the axillary artery.29 In his 1969 review, Shumacker com-
The artery was easily secured and sutured, and the hemorrhage mented that within the first few years of the 20th century,
from it readily controlled. The patient was placed in bed with the the triangulation stitch of Carrel (1902), the quadrangula-
leg elevated and wrapped in cotton.22 tion method of Frouin (1908), and the Mourin modification
(1914) had been developed.20
The anatomic location of the injuries, the gross pathol- By 1910, Stich had reported more than 100 cases of
ogy involved, and the detailed repair contributed to Mur- arterial reconstruction by lateral suture.30 His review
phy’s historically successful arterial anastomosis. Murphy included 46 repairs, either by end-to-end anastomosis or by
mentioned that a pulsation could be felt in the dorsalis pedis insertion of a vein graft.31 With this promising start, it is
artery 4 days following the operation. The patient had no curious that over 30 years elapsed before vascular surgery
edema and no disturbance of his circulation during the was widely employed. A high failure rate, usually by throm-
reported 3 months of observation.22 bosis, attended early attempts at repair, and few surgeons
Subsequently, Murphy (1897) reviewed the results of were convinced that repair of an artery was worthwhile. In
ligature of large arteries before the turn of the century.22 1913, Matas stated that vascular injuries, particularly arte-
He found that the abdominal aorta had been ligated 10 riovenous aneurysms, had become conspicuous features of
times, with only 1 patient surviving for 10 days. Lidell modern military surgery, and he felt that this class of injury
reported only 16 recoveries after ligation of the common must command the closest attention of the modern mili-
iliac artery 68 times, a mortality of 77%.20 Balance and tary surgeon: “A most timely and valuable contribution to
Edmunds reported a 40% mortality following ligation of a the surgery of blood vessels resulted from wounds in war.
 1 • The Vascular Injury Legacy 17

attempted repair of acutely injured arteries and were suc-

Artery cessful in more than 100 cases.31 During the first 9 months
of WWI, low-velocity missiles caused arterial trauma of
a limited extent. In 1915, however, the widespread use of
high explosives and high-velocity bullets, combined with
mass casualties and slow evacuation of the wounded, made
arterial repair impractical.
In 1920, Bernheim went to France with the specific intent
of repairing arterial injuries.32 Despite extensive prior expe-
rience and equipment, however, he concluded that attempts
A V at vascular repair were unwise. He wrote: “Opportunities
for carrying out the more modern procedures for repair or
reconstruction of damaged blood vessels were conspicuous
by their absence during the recent military activities. Not
that blood vessels were immune from injury; not that gap-
ing arteries and veins and vicariously united vessels did not
g
cry out for relief by fine suture or anastomosis. They did,
most eloquently, and in great numbers, but he would have
been a foolhardy man who would have essayed sutures of
arterial or venous trunks in the presence of such infections
as were the rule in practically all of the battle wounded.”32
The great frequency of infection with secondary hemor-
rhage virtually precluded arterial repair. In addition, there
were inadequate statistics about the frequency of gangrene
following ligation, and initial reports subsequently proved
Fig. 1.4 The first successful repair of an arterial defect utilizing a vein to be unduly optimistic. In 1927, Poole, in the United States
graft. Using the triangulation technique of Carrel with endothelial Army Medical Department History of WWI, remarked that
coaptation, a segment of the adjacent popliteal vein was used to repair if gangrene were a danger following arterial ligation, pri-
the popliteal artery. A, Artery; V, vein; g, graft. (From Goyanes DJ. Nuevos mary suture should be performed, and the patient should be
trabajos chirugia vascular. El Siglo Med. 1906;53:561.) watched very carefully.
Despite the discouragement of managing acute arte-
Unusual opportunities for the observation of vascular rial injuries in WWI, fairly frequent repairs of false aneu-
wounds inflicted with modern military weapons … based rysms and arteriovenous fistulas were carried out by many
on material fresh from the field of action, and fully con- surgeons. These cases were treated after the acute period
firmed the belief that this last war, waged in close proxim- of injury, when collateral circulation had developed with
ity to well-equipped surgical centers, would also offer an the passage of time and assured viability of extremities. In
unusual opportunity for the study of the most advanced 1921, Matas recorded that the majority of these repairs
methods of treating injuries of blood vessels.”27 consisted of arteriorrhaphy by lateral or circular suture,
Matas described Soubbotitch’s experience of Serbian with excision of the sac or endoaneurysmorrhaphy.33
military surgery during the Serbo-Turkish and Serbo- In 1919, Makins, who served in WWI as a British sur-
Bulgarian Wars at the 1913 London International Con- geon, recommended ligating the concomitant vein when it
gress.27 He reported that 77 false aneurysms and arteriove- was necessary to ligate a major artery.34 He thought that this
nous fistulas were treated. There were 45 ligations, but 32 reduced the frequency of gangrene by retaining within the
vessels were repaired, including 19 arteriorrhaphies, 13 ven- limb for a longer period the small amount of blood supplied
orrhaphies, and 15 end-to-end anastomoses (11 arteries and by the collateral circulation. This hypothesis was debated
4 veins). It is impressive that infection and secondary hemor- for more than 20 years before it was finally abandoned.
rhage were avoided. In 1915, Matas, in discussing Soubbot- Payr in 1900, Carrel, and the French surgeon Tuffier
itch’s report, emphasized that a notable feature was the described temporary arterial anastomoses with silver and
suture (circular and lateral repair) of blood vessels, and the glass tubes that were inserted with some success by Makins
fact that it had been utilized more frequently in the Balkan and other WWI military surgeons, but patency was limited
conflict than in previous wars.27 He also noted that, judging to 4 days, merely allowing some collateral development.20,34
by Soubbotitch’s statistics, the success obtained by surgeons
in the Serbian Army Hospital in Belgrade far surpassed those
obtained by other military surgeons in previous wars, with World War II Experience
the exception perhaps of the remarkably favorable results in
the Japanese Reserve Hospitals reported by Kikuzi. Experiences with vascular surgery in WWII were well
recorded in the classic review by DeBakey and Simeone in
1946, analyzing 2471 arterial injuries.3 Almost all were
World War I Experience treated by ligation, with a subsequent amputation rate near
49%. There were only 81 repairs attempted—78 by lateral
During the early part of WWI, with the new techniques suture and 3 by end-to-end anastomosis—with an amputa-
of vascular surgery well established, the German surgeons tion rate of approximately 35%. The use of vein grafts was
18 SECTION 1 • Setting the Stage

even more disappointing: they were attempted in 40 cases of Blakemore (Vitallium) tubes, two bulldog forceps, and a
with an amputation rate of nearly 58%. That review cov- 2-mL ampoule of heparin!
ered the time period ending in December 1944. The conclusion that ligation was the treatment of choice
More recently, Barr, Cherry, and Rich35 reported on for an injured artery was summarized by DeBakey and
research analyzing the original records of WWII military Simeone in 1946: “It is clear that no procedure other than
medical units in the Mediterranean and European the- ligation is applicable to the majority of vascular injuries
aters, with emphasis on the treatment of vascular inju- which come under the military surgeons’ observation. It is
ries subsequent to December 1944 and going through the not a procedure of choice. It is a procedure of stern neces-
War’s end in May 1945. These authors found that there sity, for the basic purpose of controlling hemorrhage, as
was a change in practice from ligation to repair. Whereas well as because of the location, type, size and character of
DeBakey and Simeone had reported a 3.3% repair rate, most battle injuries of the arteries.”3
surgeons in the last half year of the War repaired arter- In retrospect, it should be remembered that the aver-
ies at an increased rate. The Second Auxiliary Surgical age time lag between wounding and surgical treatment
Group repaired 9% of injured vessels, a threefold increase. was over 10 hours in WWII, virtually precluding success-
Surgeons in the Third Auxiliary Surgical Group repaired ful arterial repair in most patients. Of historical interest is
22% of the injured arteries they encountered, a sevenfold the nonsuture method of arterial repair used during WWII
increase. The amputation rate of the Second Auxiliary was (Fig. 1.5).
25%, contrasting with the 50% rate noted with ligation.
The 107 cases of repair reported by the Third Auxiliary
was a greater total than the entirety (81) of the DeBakey
and Simeone report through 1944.
A similar shift to repair was not seen in the Pacific the-
aters.36 Only five reports of attempted repair came from the
War in the Pacific. The surgeons there were aware of the
need for something other than ligation, but the island bat- 1
tlefields, the vast oceanic distances, the jungle terrain and
climate, the lack of stable supply lines, the lack of estab-
2
lished nearby evacuation hospitals, and the lack of rapid Saline Proximal
methods of evacuation all contributed to the static nature Rubber shod
of surgery for injured vessels there. It simply was not pos- Artery clamp
sible in the Pacific.
The controversial question of ligation of the concomitant Vein
Kelly clamp
vein remained, though few observers were convinced that
the procedure enhanced circulation. The varying opinions 3 Distal end of
4
were summarized by Linton in 1949.37 vein placed into
A refreshing exception to the dismal WWII experience in proximal end of artery
Distal
regard to ligation and gangrene was the case operated on by 5
Dr. Allen M. Boyden—an acute arteriovenous fistula of the
femoral vessels repaired shortly after D-Day in Normandy.
The following comments are taken by Boyden from his own
original field notes (approximately 26 years later in 1970)
and emphasize the value of adequate records, even in mili-
tary combat:

High explosive wound left groin, 14 June 1944, at 2200 6 7

hours. Acute arteriovenous aneurysm femoral artery.
Preoperative blood pressure 140-70; pulse 104. Fig. 1.5 The various steps of a nonsuture method of bridging arterial
Operation: 16 June 1944, nitrous oxide and oxygen. defects designed during World War II. (1) The Vitallium tube with its
Operation: 1910 to 22 hours. two ridges (sometimes grooves). (2) The exposed femoral artery and
One unit of blood transfused during the operation. vein, with the vein retracted and clamps placed on a branch. (3) The
Arteriovenous aneurysms isolated near junction with pro- removed segment of vein is irrigated with saline solution. (4) The vein
funda femoris artery. has been pushed through the inside of the Vitallium tube, and the two
Considerable hemorrhage. ends have been everted over the ends of the tube held in place with
Openings in both artery and vein were sutured with fine silk. one or two ligatures of fine silk. (5) The distal end of the segment of
Postoperative blood pressure 120-68; pulse 118. Circulation the vein is placed into the proximal end of the artery and held there
of the extremity remained intact
by two ligatures of fine silk. (6) The snug ligature near the end of the
until evacuation.
Vitallium tube is tied to provide apposition of the artery and the vein.
(7) The completed operation, showing the bridging of a 2-cm gap in
As this case demonstrated Boyden’s interest in vascu-
the femoral artery. (Modified description of the original drawings from
lar surgery, the Consulting Surgeon for the First Army
presented him with half of the latter’s supply of vascular Blakemore AH, Lord JW Jr, Stefko PL. The severed primary artery in war
instruments and material. This supply consisted of two sets wounded. Surgery. 1942;12:488.)
 1 • The Vascular Injury Legacy 19

Experiences During the Korean effect on the overall results, for patients with severe injuries
from high-velocity missiles survived to reach the hospital
War but often expired during initial care. These patients would
never have reached the hospital alive in previous military
In pleasant contrast to the experiences of WWII, the suc- conflicts.
cessful repairs of arterial injuries in the Korean War were Between October 1, 1965 and June 30, 1966, there
due to several factors. There had been substantial progress were 177 known vascular injuries in American casualties,
in the techniques of vascular surgery, accompanied by excluding those with traumatic amputation, as reported by
improvements in anesthesia, blood transfusion, and antibi- Heaton and colleagues.46 There were 116 operations per-
otics. Perhaps of greatest importance was the rapid evacu- formed on 106 patients with 108 injuries. These results
ation of wounded men, often by helicopter, which often included the personal experience of one of us (NMR) at the
allowed their transport from time of wounding to surgical 2nd Surgical Hospital. The results reported included a short-
care within 1 to 2 hours. In addition, a thorough under- term follow-up of approximately 7 to 10 days in Vietnam. In
standing of the importance of débridement, delayed pri- Vietnam, amputations were required for only 9 of the 108
mary closure, and antibiotics greatly decreased the hazards vascular injuries—a rate of about 8%. Subsequently, follow-
of infection. ing detailed analysis of the Vietnam Vascular Registry by
Initially in the Korean War, attempts at arterial repair Rich and colleagues in 1969, and then in 1970, the ampu-
were disappointing. During one report of experiences at a tation rate was found to be approximately 13%—identical
surgical hospital for 8 months between September 1951 to that of the Korean War.5,6 Almost all amputations were
and April 1952, only 11 of 40 attempted arterial repairs performed within the first month after wounding.
were thought to be successful, as reported by Hughes in The Vietnam Vascular Registry was established at Walter
1959.38 Only 6 of 29 end-to-end anastomoses were con- Reed General Hospital in 1966 to document and analyze all
sidered initially successful, and all six venous grafts failed. vascular injuries treated in Army Hospitals in Vietnam. A
In another report from a similar period of time, only 4 of preliminary report by Rich and Hughes in 1969 involved
18 attempted repairs were considered successful. In 1952, the complete follow-up of 500 patients who sustained 718
Warren emphasized that an aggressive approach was vascular injuries (Table 1.2).5 Although vascular repairs
needed, with the establishment of a research team headed on Vietnamese and allied military personnel were not
by a surgeon experienced in vascular grafting.39 Surgical included, the Registry effort was soon expanded to include
research teams were established in the army, and there all American service personnel, rather than limiting the
was improvement in results of vascular repairs by 1952. effort to soldiers.
Significant reports were published by Jahnke and Seeley in In 1967, Fisher collected 154 acute arterial injuries in
1953; Hughes in 1955 and 1958; and Inui, Shannon, and Vietnam covering the 1965–1966 periods.47 There were
Howard in 1955.4,40–42 Similar work in the navy was done 108 arterial injuries with significant information for the
with the US Marines during 1952 and 1953 by Spencer initial review from Army hospitals. In 1967, Chandler and
and Grewe and reported in 1955.43 These surgeons worked Knapp reported results in managing acute vascular inju-
in specialized research groups under fairly stabilized condi- ries in the US Navy Hospitals in Vietnam.48 These patients
tions, considering that they were in a combat zone. Briga- were not included in the initial Vietnam Vascular Registry
dier General Sam Seeley, who was chief of the Department report, but, after 1967, an attempt was made to include all
of Surgery at Walter Reed Army Hospital in 1950, had the military personnel sustaining vascular trauma in Vietnam.
foresight to establish Walter Reed Army Hospital as a vas- This included active-duty members of the US Armed Forces
cular surgery center, and this made it possible for patients treated at approximately 25 Army hospitals, 6 Navy hospi-
with vascular injuries to be returned there for later study. tals, and 1 Air Force hospital.
In a total experience with 304 arterial injuries, 269 were As with any registry, success of the Vietnam Vascular
repaired and 35 ligated, as reported by Hughes in 1958.4 Registry has depended on the cooperation of hundreds of
The overall amputation rate was 13%, a marked contrast individuals within the military and civilian communities. In
to that of about 49% in WWII. Because amputation rate is the initial report from the Registry, 20 surgeons who had
only one method of determining ultimate success or failure done more than five vascular repairs were identified. As can
in arterial repair, it is important to emphasize that Jahnke be seen by the list of more than 500 surgeons within the
revealed in 1958 that, in addition to the lowered rate of front and back covers of the first edition of this textbook,
limb loss, limbs functioned normally when arterial repair many surgeons in every training program in the United
was successful.44 States contributed to the generally good results obtained in
Vietnam.5
EXPERIENCE IN VIETNAM In addition to the surgeons already cited, hundreds of
individuals have been directly contacted through the Reg-
In Vietnam, the time lag between injury and treatment was istry. The cooperative effort that has been obtained has not
reduced even further by the almost routine evacuation by only provided long-term follow-up information for the indi-
helicopter, combined with the widespread availability of vidual surgeon, but it has also given the names of additional
surgeons experienced in vascular surgery. In a 1968 study patients who have previously been missed, and additional
by Rich, 95% of 750 patients with missile wounds sus- specific information has been added where needed regard-
tained in Vietnam reached the hospital by helicopter.45 This ing individual patients. A major success in the Registry
promptness of evacuation, however, created an adverse effort was obtained at the American College of Surgeons’
20 SECTION 1 • Setting the Stage

Table 1.2 Management of Arterial Trauma in Vietnam Casualties Preliminary Report from the Vietnam Vascular Registrya
Artery End-to-End Anastomosis Vein Graft Lateral Suture Prosthetic Graft Throm-Bectomy Ligation
Common carotid 2 6 (2) 3 (2) 1
Internal carotid 2 1
Subclavian 1
Axillary 6 (3) 12 (3) 2 (3) (1) (3) (1)
Brachial 57 (8) 32 (10) 2 (1) 1 (9) 1 (2)
Aorta 3 (1)
Renal 1
Iliac 1 1 1 (1) (1) (1)
Common femoral 4 (2) 11 (1) 4 (1) 1 (2) (2) (4)
Superficial femoral 63 (5) 37 (14) 7 (7) (4) 2 (6) (4)
Popliteal 31 (5) 28 (13) 6 (4) (10) 2 (4)
Total 165 (23) 127 (43) 29 (17) 2 (8) 3 (33) 6 (16)
a
Numbers in parenthesis represent additional procedures performed after the initial repair in Vietnam and repair of major arterial injuries not initially treated in
Vietnam.
Modified from Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery. 1969;65(1):218–226.

Clinical Congress in Chicago in 1970, where 110 surgeons Vietnam via Gulf War 1991 to
who had previously performed arterial repairs in Vietnam
signed in at the Vietnam Vascular Registry exhibit. The
Afghanistan and Iraq
exhibit attempted to represent some of the activities and
presented some of the interim results of the combined effort Since Vietnam, there have been many minor conflicts
of all of the surgeons. around the world. In the British Falklands campaign of
The fact that significant problems continue to confront 1982, despite excellent surgical outcomes for those who
the surgeon managing combat vascular injuries is empha- reached field hospitals, there was little vascular experi-
sized by the report by Cohen and co-workers in 1969, which ence. The relative paucity of surgical cases during the mul-
evaluated a 6-month period of experience in Vietnam.49 tinational Gulf War of 1991 similarly did not influence
The following list represents some of the major remaining advances in military vascular surgery.
problems: The decade and a half of war that followed the events
of September 11, 2001, resulted in a significant bur-
1. Arterial injuries associated with massive damage to soft den of injury including vascular trauma. Studies from
tissues White, Stannard, and, more recently, Patel have shown
2. Major venous obstruction that the recorded rate of this injury pattern in modern
3. Repeated vascular operations with a viable limb combat is 7% to 15%, which is considerably higher than
4. Associated unstable fractures that reported in previous wars.50–52 The reasons behind
5. Inadequate tissue débridement the increased rate of vascular trauma are discussed in
6. Calf wounds with small vessel injury Chapter 2, but suffice it to say the recent wartime expe-
rience forms the basis for much of the text that fol-
Through the Vietnam Vascular Registry, identification lows. Providing details on vascular trauma managed in
cards have been sent to the majority of the patients whose Afghanistan and Iraq is beyond the scope of this particu-
names and records are included in the long-term follow- lar chapter; however, strategies such as topical hemostatic
up.1,2,5 The responses from the individual patients through agents, the reemergence of tourniquets, temporary vascu-
this media have been extremely encouraging, and the typi- lar shunts, smarter transfusion and resuscitation strategies,
cal response that is frequently received is that the patients and even catheter-based endovascular techniques will be
appreciate the fact that “someone still cares.” Nearly 1500 highlighted throughout the text. Finally, the vexing injury
patients have been evaluated by one of the authors (NMR) pattern from these wars—that is, vascular disruption with
in the Peripheral Vascular Surgery Clinic and Registry at noncompressible torso hemorrhage—will be redefined with
Walter Reed Army Medical Center over the past 50 years. a call for new management strategies.
Preliminary plans are presently being made to maintain
an extended long-term follow-up. This will be important
in determining the long-term results of the repairs and in Civilian Experience
determining the incidence of such problems as the early
development of arteriosclerosis in the repair sites of these The frequency of arterial injuries in civilian life has
young men. Personal contact has been made through the increased greatly in the past decade. This is due to more
Registry with approximately 300 other surgeons who have automobile accidents, the appalling increase of gunshot
performed vascular repairs in Vietnam, and the support of and stab wounds, and the increasing use of therapeutic and
these surgeons has been solicited in helping with this long- diagnostic techniques involving the cannulation of major
term follow-up project. arteries.
 1 • The Vascular Injury Legacy 21

As recently as 1950, most general surgeons had little 2. Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2nd ed.
experience or confidence in techniques of arterial repair. Philadelphia: WB Saunders; 2004.
3. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War
The experiences in the Korean War, combined with the II: an analysis of 2471 cases. Ann Surg. 1946;123:534–579.
widespread teaching of techniques of vascular surgery 4. Hughes CW. Arterial repair during the Korean War. Ann Surg.
in surgical residencies, resulted in a great increase in fre- 1958;147(4):555–561.
quency of arterial repair between 1950 and 1960. This is 5. Rich NM, Hughes CW. Vietnam vascular registry: a preliminary
report. Surgery. 1969;65(1):218–226.
well-illustrated in the report by Ferguson and co-authors 6. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam:
in 1961 of experiences with 200 arterial injuries treated in 1000 cases. J Trauma. 1970;10(5):359–369.
Atlanta over the 10-year period beginning in 1950.53 The 7. Schwartz AM. The historical development of methods of hemostasis.
proportion of patients treated by arterial repair increased Surgery. 1958;44(3):604–610.
from less than 10% in 1950 to more than 80% in 1959. In 8. Hunter W. The history of an aneurysm of the aorta, with some remarks
on aneurysms in general. Med Obs Soc Phys Lond. 1757;1:323.
the latter part of the study, ligation was done only for inju- 9. Antyllus. Oribasius 4: 52 (Daemberg Edition). Cited by Olser in Lancet
ries of minor arteries, such as the radial or ulnar, or certain 1915;1:949.
visceral arteries. The mortality rate was reduced by one- 10. Esmarch F. The Surgeon’s Handbook of the Treatment of the Wounded in
third and the amputation rate by half when two consecu- War. New York: LW Schmidt; 1878.
11. Owen E. Nelson as a patient. The Lancet. 1897;3856:195–197.
tive 5-year periods were compared. The rate of success of 12. Hunter J. Cited in Power, D-Arcy. Hunter’s operation for the cure of
arterial repair improved from 36% to 90%. aneurysm. Brit J Surg. 1929;17:193–196.
In 1964, Patman and associates reported experiences 13. Bell J. Principles of surgery. Discourse. 1801;9:4.
with 271 repairs of arterial injuries in Dallas.54 In the 14. Guthrie GJ. On Gun Shot Wounds to the Extremities, Requiring the
past decade, a series of reports from large urban centers Different Operations of Amputation with Their After Treatment. London:
Longman and Others; 1815.
throughout the United States have appeared, all document- 15. Coley RW (Translation for Fleming J). Case of rupture of the carotid
ing the effectiveness of current techniques of arterial repair. artery and wound of several of its branches successfully treated by
Reference will be made to these reports in specific discus- tying off the common trunk of the carotid itself. Med Chir J (Lond).
sions in the following chapters. Two large series from the 1817;3:2.
16. Ellis J. Case of gunshot wound, attended with secondary hemorrhage
early 1970s are those of Drapanas and colleagues in 1970 in which both carotid arteries were tied at an interval of four and a
from New Orleans, which included 226 arterial injuries, half days. NY J Med. 1845;5:187.
and the cumulative report by Perry and associates from Dal- 17. Halsted WS. The effect of ligation of the common iliac artery on the
las in 1971, which included 508 arterial injuries.55,56 circulation and function of the lower extremity. Report of a cure of
In 1974, Smith and co-workers reported a survey of iliofemoral aneurysm by the application of an aluminum band to the
vessel. Bull Johns Hopkins Hosp. 1912;23:191–220.
268 patients in Detroit with 285 penetrating wounds of 18. Halsted W. Discussion in Bernheim, BM. Bull Johns Hopkins Hosp.
the limbs and neck.57 There were 127 peripheral arterial 1916;27:93.
injuries identified. In 1975, Cheek and coauthors reviewed 19. Hallowell (1759). Extract of a letter from Mr. Lambert, surgeon at
200 operative cases of major vascular injuries in Memphis Newcastle upon Tyne, to Dr. Hunter, giving an account of new method
of treating an aneurysm. Med Obser Inq. 1762;30(360).
that included 155 arterial injuries.58 Kelly and Eiseman, in 20. Shumacker HB Jr, Muhm H. Arterial suture techniques and grafts:
1975 from Denver, found 116 arterial injuries among 175 past, present and future. Surgery. 1969;66(2):419–433.
injuries to major named vessels in 143 patients.59 Hardy 21. Jassinowsky A. Die arteriennhat: eine experimentelle studie. Inaug
and associates, in 1975, reviewed 360 arterial injuries in Diss Dorpat. 1889
353 patients in Jackson.60 Bole and colleagues, in 1976, 22. Murphy JB. Resection of arteries and veins injured in continuity end-
to-end suture. Exp Clin Res Med Rec. 1897;51:73–104.
reported 126 arterial injuries in 122 patients in New York 23. von Horoch C. Die gefässnaht. Allg Wien Med Ztg. 1888;33:
City during 1968–1973.61 263–279.
During the Troubles in Belfast in the 1970s and 1980s, 24. Glück T. Uber zwei fälle von aortenaneurysmen nebst bemerkungen
Baros D’Sa combined the skills required of civilian and mili- uber die naht der blutgefässe. Arch Klin Chir. 1883;28:548.
25. Heidenhain L. Über naht von arterienwunden. Centralbl Chir.
tary vascular surgeons in managing vascular injuries and 1895;22:1113–1115.
developed an international reputation for the use of shunts 26. Israel. Cited in Murphy, JB. Resection of arteries and veins injured in
in terrorist-induced, complex vascular trauma.62,63 continuity–end-to-end suture–experimental clinical research. Med
Rec. 1897;51:73.
27. Matas R. An operation for radical cure of aneurysm based on arterio­
Conclusion graphy. Ann Surg. 1903;37:161–196.
28. Carrel A, Guthrie CC. Uniterminal and biterminal venous transplan-
tations. Surg Gynecol Obstet. 1906;2:266–286.
Advances in the management of vascular trauma have 29. Lexer E. Die ideale operation des arteriellen und des arteriell-venosen
been driven by the requirements of warfare. This is no less aneurysma. Arch Klin Chir. 1907;83:459–477.
30. Stich R. Ueber gefaess und organ transplantationen mittelst gefaess-
true now than it was in medieval times. In the last 50 years, naht. Ergeon Chir Orth. 1910;1:1.
concomitant technological improvements in resuscitation, 31. Nolan B. Vascular injuries. J Roy Coll Surg. 1968;13(2):72–83.
anesthesia, and endovascular technologies within the civil- 32. Bernheim BM. Blood vessel surgery in the war. Surg Gynecol Obstet.
ian sector have contributed further. The difficult decisions 1920;30:564–567.
of when to repair, how to repair, damage-control vascular 33. Matas R. Military Surgery of the Vascular System. Philadelphia: WB
Saunders; 1921.
surgery, and when to amputate will be covered in the fol- 34. Makins GH. Gunshot Injuries to the Blood Vessels. Bristol, England: John
lowing chapters of this textbook. Wright and Sons; 1919.
35. Barr J, Cherry K, Rich N. Vascular surgery in World War II: the shift to
repairing arteries. Ann Surg. 2016;263(3):615–620.
References 36. Barr J, Cherry K, Rich N. Vascular surgery in the Pacific theaters of
1. Rich NM, Spencer FC. Vascular Trauma. Philadelphia: WB Saunders; World War II: the persistence of ligation amid unique military medical
1978. conditions. Ann Surg. 2019;269(6):1054–1058.
22 SECTION 1 • Setting the Stage

37. Linton RR. Injuries to major arteries and their treatment. NY J Med. 51. Stannard A, Brohi K, Tai N. Vascular injury in the United Kingdom.
1949;49:2039. Perspect Vasc Surg Endovasc Ther. 2011;23(1):27–33.
38. Hughes CW. Vascular surgery in the armed forces. Milit Med. 52. Patel JA, White JM, White PW, Rich NM, Rasmussen TE. A contempo-
1959;124(1):30–46. rary, 7-year analysis of vascular injury from the war in Afghanistan.
39. Warren R. Report to the Surgeon General. Washington, DC: Department J Vasc Surg. 2018;68(6):1872–1879.
of the Army; 1952. 53. Ferguson IA, Byrd WM, McAfee DK. Experiences in the management
40. Jahnke EJ Jr, Seeley SF. Acute vascular injuries in the Korean War: an of arterial injuries. Ann Surg. 1961;153:980–986.
analysis of 77 consecutive cases. Ann Surg. 1953;138(2):158–177. 54. Patman RD, Poulos E, Shires GT. The management of civilian arterial
41. Hughes CW. The primary repair of wounds of major arteries; an injuries. Surg Gynecol Obstet. 1964;118:725–738.
analysis of experience in Korea in 1953. Ann Surg. 1955;141(3): 55. Drapanas T, Hewitt RL, Weichert RF III, Smith AD. Civilian vascular
297–303. injuries: a critical appraisal of three decades of management. Ann
42. Inui FK, Shannon J, Howard JM. Arterial injuries in the Korean Surg. 1970;172(3):351–360.
conflict: experiences with 111 consecutive injuries. Surgery. 1955; 56. Perry MO, Thal ER, Shires GT. Management of arterial injuries. Ann
37(5):850–857. Surg. 1971;173(3):403–408.
43. Spencer FC, Grewe RV. The management of arterial injuries in battle 57. Smith RF, Elliot JP, Hageman JH. Acute penetrating arterial injuries of
casualties. Ann Surg. 1955;141(3):304–313. the neck and limbs. Arch Surg. 1974;109(2):198–205.
44. Jahnke EJ Jr. Late structural and functional results of arterial injuries 58. Cheek RC, Pope JC, Smith HF, Britt LG, Pate JW. Diagnosis and
primarily repaired. Surgery. 1958;43(2):175–183. management of major vascular injuries: a review of 200 operative
45. Rich NM. Vietnam missile wounds evaluated in 750 patients. Mil cases. Am Surg. 1975;41(12):755–760.
Med. 1968;133(1):9–22. 59. Kelly GL, Eiseman B. Civilian vascular injuries. J Trauma. 1975;15(6):
46. Heaton LD, Hughes CW, Rosegay H, Fisher GW, Feighny RE. Military 507–514.
surgical practices of the United States Army in Vietnam. Curr Probl 60. Hardy JD, Raju S, Neely WA, Berry DW. Aortic and other arterial
Surg. 1966:1–59. injuries. Ann Surg. 1975;181(5):640–653.
47. Fisher GW. Acute arterial injuries treated by the United States Army 61. Bole PV, Purdy RT, Munda RT, Moallem S, Devanesan J, Clauss RH.
Medical Service in Vietnam, 1965–1966. J Trauma. 1967;7(6): Civilian arterial injuries. Ann Surg. 1976;183(1):13–23.
844–855. 62. Barros D’Sa AAB. Management of vascular injuries of civil strife.
48. Chandler JG, Knapp RW. Early definitive treatment of vascular injuries Injury. 1982;14(1):51–57.
in the Vietnam conflict. JAMA. 1967;202(10):960–966. 63. Barros D’Sa AAB. The Rationale for Arterial and Venous Shunting in
49. Cohen A, Baldwin JN, Grant RN. Problems in the management of the Management of Limb Vascular Injuries. Belfast, Northern Ireland:
battlefield vascular injuries. Am J Surg. 1969;118(4):526–530. Grune & Stratton Ltd; 1989.
50. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH,
Rasmussen TE. The epidemiology of vascular injury in the wars in
Iraq and Afghanistan. Ann Surg. 2011;253(6):1184–11849.
 2 Epidemiology of Vascular
Trauma
PETER GOGALNICEANU, TODD E. RASMUSSEN, and NIGEL R.M. TAI

Repair the vessel without compromising the lumen determinants of health-related states or events in human
DR. RICHARD LAMBERT (1759) populations, and the application of this study to the preven-
tion and control of health problems.1 The global burden
and impact of trauma as an agent of death and disability is
Lambert’s dictum describes “what” vascular surgeons do. increasingly well characterized (Table 2.1). However, while
This has remained constant throughout the centuries. the prevalence and incidence of individual vascular injury
However, “why” and “how” surgeons do this has changed patterns have been well depicted in local situations, the
drastically from decade to decade. The vascular trauma sub- epidemiological study of vascular trauma is a relatively
specialty in particular has experienced changing practices underexploited field.2 Possible reasons for this include the
with regard to fluid versus blood products resuscitation, heterogeneity of the circumstances in which vascular
tourniquet use, point-of-care imaging and endovascular injury may be sustained, the protean direct and indirect
innovations, such as REBOA and the covered stent. consequences of vascular trauma to bodily systems, and the
The true purpose of epidemiological study should not unsuitability of modern scoring methodologies to capture
be limited to the listing of injury patterns by mecha- the specific effects of vascular injury on patient outcome.
nism of injury (MOI), anatomical location or geography. In the first edition of Rich’s Vascular Trauma, Geza de Takats
These provide interesting facts but are somewhat artificial summarized richness and complexity of traumatic mecha-
academic exercises that have limited clinical applications. nisms of injury as follows:
The real purpose of epidemiology is to understand how
society changes and the mechanisms by which human suf- From time immemorial, hungry or suspicious cavemen,
fering occurs. Epidemiology serves the surgeon by provid- frustrated and jealous lovers, violent criminals, and, more
ing an understanding of how injury patterns arise from recently… machinery and automobiles, have inflicted serious
the patient’s and the surgeon’s broad social and political and often irreparable injury on the human body and soul.
context. More importantly, it allows anticipation of how
different infrastructures can serve to mitigate or exacer- Consequently, understanding the historic and contem-
bate this harm. Vascular trauma is both catastrophic and porary epidemiology of vascular trauma is important.
complex. Studying its origins and patterns provides a more Box 2.1 lists the generic components of epidemiological
subtle representation of health-care issues, which have a endeavor. With respect to trauma, recognizing the preva-
far greater reach than the routines of the operating room. lent populations underpins the alignment and targeting
Furthermore, the evolution of the vascular surgeon’s arma- of hospital resources, as well as education of health-care
mentarium, from the cauterizing iron to the endovascular providers. In essence, this informs the design of trauma
stent, has itself impacted on the landscape of vascular inju- and vascular-care systems. More widely, the standard-
ries as the range of iatrogenic injuries has grown. ized and open-access description of the incidence, mech-
Contemporary drivers of epidemiological change in vas- anisms, and demography of traumatic injury empowers
cular injury include: comparison of properly stratified outcomes from injury.
In turn, these aid not only research, but also clinical gov-
1. Military conflict. ernance, quality-improvement initiatives, and fair reim-
2. Civilian trauma and urban unrest, including accidental bursement for treating hospitals. Subsequently, these
injury, terrorism, and gang-related civilian violence. provide knowledge of socioeconomic realities and influ-
3. Trauma at the extremes of age. ence the design and assessment of preventative public
4. Iatrogenic vascular injury as a result of minimally inva- health interventions, thus informing health and social
sive or endovascular procedures. policy.
If vascular and trauma clinicians are to anticipate
injury patterns, to track changes, and to put into place
effective programs to prevent or to mitigate the effects
Principles of Vascular of vascular trauma, then the study of injury epidemiol-
Epidemiology ogy is an essential function of practice. The aim of this
chapter is to provide the context to more-detailed illus-
Epidemiology (from the Greek: the study of that which befalls trations of specific anatomical injuries given elsewhere
the people) is defined as the study of the distribution and in the text.

23
24 SECTION 1 • Setting the Stage

Table 2.1 Summary: Deaths (000s) by Cause, in WHO Regions (a), Estimates for 2010 and 2016.
Cause World (2016) World (2010)
Population
(thousands) 7,461,884 6,140,789
000 % total 000 % total Change (000)
Injuries 297,394 11 290,806 10 6589
A. Unintentional 215,158 8 209,494 7 5664
injuries
1. Road injury 82,538 3 69,837 2 12,701
2. Poisonings 6269 0 8341 0 −2073
3. Falls 38,162 1 30,431 1 7731
4. Fire, heat, and hot substances 10,610 0 12,876 0 −2266
5. Drowning 20,134 1 28,715 1 −8581
6. Exposure to mechanical forces 13,225 0 14,057 1 −832
7. Natural disasters 361 0 670 0 −309
8. Other unintentional injuries 43,860 2 44,567 2 −707
B. Intentional 82,236 3 81,311 3 924
injuries
1. Self-harm 37,564 1 39,194 1 −1630
2. Interpersonal violence 31,237 1 32,174 1 −938
3. Collective violence and legal 13,436 1 9943 0 3492
intervention
From the World Health Organization (WHO) Global Health Observatory Data Repository. Accessed May 2019. https://www.who.int/healthinfo/
global_burden_disease/estimates/en/.

different denominators, and inflating or deflating preva-

Box 2.1 Core Purposes of Epidemiological lence accordingly. Outcomes are defined differently and with
Programs (1) varying degrees of accuracy. For instance, mortality rates
may variously be built on definitions such as death while
Identifying risk factors for disease, injury, and death an inpatient, ignoring those who expire before reaching
Describing the natural history of disease the hospital. Epidemiology is dependent on data; countries
Identifying individuals and populations at greatest risk for disease with mature trauma systems and mandatory data-collection
Identifying where the public health problem is the greatest infrastructures offer a more fruitful perspective on injury
Monitoring diseases and other health-related events over time
rates and causes. Similarly, while wartime populations often
Evaluating the efficacy and effectiveness of prevention and
treatment programs have higher vascular injury rates than peacetime cohorts,
Providing information that is useful in health planning and the presence of detailed injury data (with accurate descrip-
decision making for establishing health programs with tion of the denominator populations) is directly related to
appropriate priorities whether a trauma systems approach to data collection is
Assisting in carrying out public health programs deployed by the medical services of the combatant parties.
It is fair to say that countries without a “trauma systems”
approach to injury management are usually unable to
describe the effect of vascular trauma in populations-at-risk.
Context and Categorization of Because most developing countries fall into such categories,
it is correct to assume that the global burden of vascular
Vascular Trauma trauma is unknown.
Vascular trauma may be broadly categorized according to:
The epidemiological study of vascular injury is hampered by
the protean nature of trauma and the multiple and interre- 1. MOI: e.g., iatrogenic, blunt, penetrating, blast, combina-
lated factors that determine functional outcome. Examples tion injuries
include co-injury to critical soft tissue, as well as bony and 2. Anatomical site of injury: e.g., compressible versus
neurological structures. This difficulty is made more acute noncompressible hemorrhage
by the lack of uniformity among authors as to appropriate 3. Contextual circumstances: e.g., military versus civilian
injury descriptors, outcome metrics, and follow-up peri-
ods. Most studies in both the military and civilian domains Each of these domains may be further stratified, with
offer descriptions of cohorts comprising specific vascular military injury being subdivided by patient status (combat-
regions (extremities) or anatomical areas (e.g., calf vessels); ant vs. noncombatant) and category of conflict (civil war,
this provides detail at the expense of proper epidemiologi- counter-insurgency warfare, maneuver warfare). Civilian
cal perspective. Rates of vascular trauma are conflicted by injuries may be similarly contextualized by local circum-
use of different definitions of population-at-risk, invoking stances (e.g., urban trauma vs. rural trauma).
 2 • Epidemiology of Vascular Trauma 25

carried a lower mortality in the military setting (4.2% vs.

1. MILITARY CONFLICT 12.16%). This was potentially attributed to the use of body
Warfare since the 2000s has lost many of the character- armor and implementation of combat casualty care strat-
istics that defined previous engagements, such as World egy. This includes advanced military resuscitative strategies
War I (WWI), World War II (WWII), Korea, and Vietnam. and the necessary infrastructures that allow rapid evacua-
Current conflict is a “war among the people,” where “people tion and prehospital care.
in the streets and houses and fields… are the battlefield. Military A comprehensive study summarizing recent US military
engagements can take place anywhere, with civilians around, experience (13,076 cases) analyzed vascular injuries from
against civilians, in defense of civilians. Civilians are the targets, the United States Joint Theater Trauma Registry (JTTR)
objectives to be won, as much as an opposing force.”3 As such, (2002–09).21 It defined battle-related injuries as those suf-
vascular trauma inflicted by high-energy military ballistic ficiently severe to prevent return to duty into the combat
projectiles and purpose-built or improvised blast weaponry theater. The specific incidence of vascular injury (“total
can affect two populations-at-risk: combatants and non- incidence injury”) was found to be 12%, while the inci-
combatant (civilians). dence of injuries requiring surgery (“operative incidence”)
was found to be 9%. The study also identified differences
Vascular Trauma in Combat Troops in vascular injury rates between troops deployed to Iraq
It is important to remember that military combatants repre- (12.5%) and Afghanistan (9%). Other differences included
sent a specific demographic group. Compared with civilian causative mechanism, with blast accounting for 74% and
injuries, military arterial injury occurred predominantly 67% of injuries in Iraq and Afghanistan, respectively (with
in males in their twenties (25 vs. 32 years and 98.7% vs. an overall contribution of 73%). There was no difference
82% males, respectively).4 Furthermore, the predominant in the anatomical distribution of the injuries, nor the “died
mechanisms of injury to US and UK soldiers (Afghanistan) of wounds” (DOW) rate (6.4%) between theaters. Wounds
are either improvised explosive devices (48%) or gunshot were principally sustained to the extremities (79%), torso
wounds (29%).5 Contemporary data confirms that exsan- (12%), and cervical regions (8%). In the torso, the most
guination is the major cause of death in fatally wounded commonly injured vessels were the iliac arteries (3.8%), fol-
soldiers.6–9 It is also estimated that 80% of arterial injuries lowed by the aorta (2.9%), the subclavian arteries (2.3%),
sustained in combat affect the extremities.10 More than and the inferior vena cava (IVC) (1.4%). In the neck, 109
70% of these are associated with blast injuries. carotid injuries accounted for 7% of injuries. It was noted
Vascular injury rates seem only to have increased as war- that the vascular injury burden borne by the extremities
fare has become more sophisticated: allied surgeons in WWI was remarkably similar to that noted by DeBakey in WWII.
noted vascular trauma rates of 0.4% to 1.3%11; DeBakey In contrast, the higher contemporary rate of cervical and
characterized the vascular injury burden in WWII as affect- aortic injury was attributed to increased survivability and
ing 0.96% of all patients; later, in the Korean and Vietnam far-shortened medivac times.
wars, the rate of vascular injury was judged to be higher, Overall, the authors concluded that the rate of vascular
at 2% to 3%.12–16 Coalition militaries engaged in combat injury in these wars was five times that previously reported
operations in Afghanistan and Iraq have invested substan- from Vietnam and Korea. The early reported incidence of
tially in detailed trauma registries in order to capture injury vascular injury was estimated at around 4.4% to 4.8%,
data. Such databases have been used to characterize miscel- based on data published from US military hospitals in
laneous injury patterns so that force protection (e.g., body Iraq.17,18 However, when this analysis includes nonoperated
armor or vehicle design) and treatment protocols can be cases and vascular injury that was unrecognized on recep-
continually updated and aligned to contemporary trauma tion, the prevalence can be as high as 7%.18 This marked
archetypes. Interestingly, present rates of wartime vascular increase in vascular injury rates is striking and not entirely
trauma confirm a much higher prevalence than in previous clear. In addition to increased wound survivability, possible
campaigns,17–20 with arterial injury rates being reported by reasons include:
some as high as 7.1%.10
A comparative study of the outcomes of major arterial 1. the very high rate of blast-related injury etiology in these
injuries in military and civilian populations was under- campaigns,
taken by Markov et al.4 One-quarter of all military arterial 2. overestimation of the population-at-risk in earlier
injuries were not amenable to control by tourniquet appli- reports (thus deflating the denominator), or
cation or compression (noncompressible arterial injuries 3. more accurate capture of “minor” nonoperated vascular
[NCAIs]). Military arterial injuries were shown to have a wounds (adding to the numerator).
lower incidence of NCAIs compared with the civilian pop-
ulations (28% vs. 61%). These differences were attributed In a similar but smaller British study, Stannard et al.
to a higher rate of blunt trauma to the torso in the civilian scrutinized the records of 1203 UK servicemen injured
setting, as a result of motor vehicle collisions. Blast injuries through enemy action between 2003 and 2008.20 Unlike
were the predominant mechanism of injury in military the US JTTR, the British JTTR dataset also included patients
settings (69%), while the civilian population was equally who were killed in action (KIA)—that is, who died before
affected by either blunt or penetrating trauma (50% and reaching a medical treatment facility22 (an aspect of injury
50%, respectively). No difference in mortality was found burden not scrutinized in US accounts). Characterization of
between matched military and civilian cohorts where com- injury was made from clinical data and from postmortem
pressible arterial injuries were involved (2% military vs. examinations conducted by the UK Coroner system. It was
4.1% civilian). However, their study suggested that NCAIs determined that 9.1% of this cohort sustained injuries to
26 SECTION 1 • Setting the Stage

named vessels. Blast wounds accounted for 54% torsocer- 40% of those admitted to the facility were of Iraqi origin,
vical injuries and 76% of extremity wounds, respectively. they made up to 51% of the vascular injury cohort.
Critically, the study showed that more than half of patients Deployed military hospitals are primarily configured and
who sustained an injury to a named vessel died before any resourced for the care of their own nation’s soldiers, so
surgical intervention could be undertaken. Injury to named understanding the additional burden presented with a large
vessels in the thorax and aorta proved almost universally local national population of injured civilians, insurgents,
fatal. Cervical vascular injuries also proved highly lethal, and military remains important. In a supplementary report
with 13 of 17 patients affected eventually succumbing. from the Air Force Theater Hospital in Balad, Iraq,24 it was
Two-thirds of the vascular injuries sustained involved the determined that the incidence of vascular trauma among
extremities. Almost half of these patients survived, albeit 4323 locals treated at the facility was 4.4%. The authors
with eventual amputations in a significant proportion. The focused on extremity injuries—which affected 70% of vas-
limb salvage (primary assisted patency) rate was 84%. This cular casualties—and observed that the median length of
UK group concluded that while favorable limb-salvage rates stay from presentation to definitive wound closure was 11
are achievable in casualties able to withstand revasculariza- days. Casualties underwent a median of three operations.
tion, torso vascular injury is not usually amenable to suc- Notably, the age range was 4 to 68 years and included 12
cessful surgical intervention. pediatric injuries. Mortality was 1.5% with significant com-
The rate of lower limb amputation following vascular plications in 14% but despite this a 95% limb salvage rate
injury to the extremities is important, being a major cause was recorded.
of disability and avoidable mortality. Lower limb arterial This experience matches earlier reports. Sfeir et al.25
injuries are thought to be caused predominantly by blast described a population of 366 lower limb–wounded vas-
injuries (70%) or gun-shot wounds (30%). The common- cular cases, sustained by a mixed population of combatant
est affected vessels in penetrating limb injuries include the and noncombatants during the Lebanese civil war over a
superficial femoral artery, the popliteal artery and the pos- 16-year period ending in 1990. Two-thirds of patients had
terior tibial arteries, each being affected in around 20% of received gunshot wounds. Patients included 118 who had
cases.10 Perkins et al. studied 579 injured extremities in popliteal arterial injuries, 252 with femoral injuries and
US service members from the wars in Iraq and Afghani- 16 who had tibial vessel injuries. The overall mortality rate
stan.23 Their primary amputation rates were 8.5%, with was 2.3% with no mortality in the popliteal and tibial injury
salvage attempts occurring in 91% of patients. Tissue loss group whereas there were nine deaths in the femoral inju-
and damage control were the principal reasons for primary ries group. The overall amputation rate was 6% (11.7% for
amputations. Secondary amputations occurred in 15.5% the popliteal injuries group). Mirroring more contemporary
of limbs. Early secondary amputations were associated by experience, the authors associated failure of limb salvage
nonviable or infected tissue, while late ones with poor limb with physiological instability, delay in repair (of more than
function. 57% of amputations were transtibial, while 30% 6 hours from injury), and presence of long bone fracture.
were transfemoral. It is also important to note that 82.7%
of those undertaking limb salvage were amputation free at 2. CIVILIAN VASCULAR INJURY
10 years. This highlights the significant threat that military
vascular injuries pose to the lower limbs, but also the value The overall impact of vascular trauma in civilian society is
of attempting limb revascularization within adequately largely unknown in societies without recourse to large pop-
prepared trauma infrastructures.10,23 ulation datasets. Even in the United States, which is served
by the National Trauma Data Bank (NTDB),b large-scale
Vascular Trauma among Local National Populations studies are few. Overall, regional variations in incidence and
Few studies have examined the burden and impact of vas- MOI of vascular trauma occur based on socioeconomic and
cular trauma in civilians injured in time of war. The regis- political challenges faced by the populations studied. Vas-
tries of military trauma systems may be biased toward data cular trauma in the civilian setting is also seen as a major
collection among their own troops, or in such cases where consumer of hospital resources,26–28 being associated with
information is captured there is usually no data on long- longer hospital stay, greater use of critical care resources,
term outcomes due to lack of follow-up in war-afflicted as well as higher blood transfusion requirements.28 Rapid
societies. In a study by Clouse et al. analyzing vascular access to adequate trauma care facilities is universally
casualties treated at a Level IIIa US facility in Iraq, 30% were considered to be of major importance in achieving good
civilians while and 24% were local national combat outcomes.26,27
forces.17 Extremity vascular injuries were significantly more In 2010, Demetriades et al. attempted to characterize the
prevalent in US forces compared with the local popula- nature of vascular trauma in 22,089 patients—including
tion (81% vs. 70%). Vascular injury to the torso was sig- children—drawn from a general trauma population of
nificantly less common in US forces (4% vs. 13%), but neck more than 1.8 million case files recorded on the NTDB
injuries occurred with similar prevalence (14% vs. 17%). system.29 Accepting the almost inevitable reporting bias
The authors hypothesized that the lack of protective body that accompanies analysis of such retrospective data, it was
armor might increase the nonextremity vessel injury rate determined that the overall incidence of vascular injury
in the Iraqi population. Interestingly, vascular injuries were during the study period (2002–06) was 1.6%. Four-fifths
noted to be overrepresented in the local nationals: although of the injured were male, and the average age was 34 years.

NTB: a national trauma registry administered by the American College

b

Level III facility is equivalent to a major trauma center (MTC).

a
of Surgeons and receiving data from more than 900 trauma facilities.
 2 • Epidemiology of Vascular Trauma 27

It was reported that 51% sustained a penetrating mecha- vascular trauma occurred in 8.6% of explosion casualties
nism; the top four mechanisms of injury were motor vehi- and was associated predominantly with penetrating inju-
cle collisions, firearm injuries, stab wounds, and falls from ries.27 Individuals with vascular trauma also had a higher
height. Just under one-quarter were shocked on admission, injury severity score and a mortality rate five times greater
and over half had an Injury Severity Score of more than 15. than those with nonvascular trauma (22.9% vs. 4.9%,
Abdominal injuries and chest injuries accounted for more respectively). The lower-extremities and head/neck areas
than 24.8% and 23.8% of the trauma burden, respectively, were the most common anatomic regions to suffer vas-
with arm and leg injuries accounting for 26.5% and 18.5%. cular trauma (37% and 25%, respectively). Data from the
Adult mortality was 23.2%; vessels associated with the Boston Marathon bombing also showed that 66% of
highest amputation rates were the axillary artery (upper patients admitted to hospital had suffered lower extremity
limb amputation rate of 6.3%) and popliteal artery (lower injuries, with 22% undergoing amputation.32
limb amputation rate of 14.6%).29 This impressive dataset These studies concluded that vascular trauma is associ-
summarized national epidemiological data; but what is of ated with poorer outcomes in the civilian population26,27
concern to individual trauma and vascular surgeons is the and that the higher incidence of vascular injuries in terror-
local epidemiology of vascular injury among their patients, related scenarios requires integration of a vascular surgeon
because this will determine workload, case mix, and as part of the trauma team.
outcome.
Another American cohort of 5858 patients from NTDB Urban Populations
(2012) analyzed traumatic abdominal and pelvic vascu- Inner-city populations in countries such as the United
lar injuries. The overall mortality for this group was 25%. States and South Africa experience high rates of interper-
Blunt trauma accounted for 57% of injuries, while 40% sonal violence, often mediated by low-energy handgun or
were caused by penetrating trauma. Those with penetrat- bladed weaponry. South Africa has an intentional homicide
ing injuries were 1.72 more likely to die than those with rate of 32 per 100,000. In the United States this is 4.8 per
blunt trauma. Men had a higher incidence of penetrating 100,000, while in the UK it is considerably less, at 1.7 per
trauma compared with women (48% vs. 17%). This study 10,000.35–37 However, there is significant regional variation
highlighted once again the poor outcomes of vascular trun- in violence rates even within societies where violent injury
cal injuries, especially when associated with penetrating is common. For instance, in South Africa, Limpopo expe-
trauma.30 rienced 762 murders in 2009–10, while Gauteng experi-
Data from a major UK trauma center suggested that enced 3444 murders over the same time frame.35 Similarly,
vascular injury occurred in 4.4% of consecutive trauma the murder rate in non-suburban US cities is approximately
admissions between 2005 and 2010.28 Vascular injuries in twice that of suburban areas.36 Of course, the relationship
this cohort had a 18% death rate, with the highest mortality between urban concentration and population homicide
being seen in those with blunt injuries to junctional areas. rates is not universal. Australia has an overall murder rate
In this UK-specific cohort, stab wounds were the common- of 1.2 per 100,000, yet the homicide rate in the sparsely
est cause of vascular injury, being five times more com- populated Northern Territories is 3.96 per 100,000, com-
mon than gun-shot wounds. However, patients with blunt pared with 0.8 in Victoria State.38 The degree to which
injuries were more severely injured. Arterial injuries repre- national and urban murder statistics translate to violent
sented 87% of the vascular trauma, while 13% were venous vascular injury is difficult to quantify, but it is unsurpris-
in nature. 47% of injuries were central in nature, with 35% ing to note that the majority of classical reports detailing
affecting the extremities and 20% junctional areas. the burden, type, and outcomes from vascular trauma
Civilian trauma has also been changed by the fact that ter- come from urban institutions serving inner-city and poorer
rorism is now no longer an isolated phenomenon associated populations. As described earlier, population-wide data
with the developing world. An estimated eightfold increase garnered from the National Trauma Data Bank suggests
in terrorist attacks was noted between 2000 and 2014.31 the contemporary overall prevalence of vascular injury in
Recent attacks, including the Boston Marathon bomb- patients is 1.6%21 whereas that presenting for treatment in
ing,32 the Paris attacks,c,33 as well as the recent UK terrorist urban areas has been quoted as 2.3% in a New York Level I
attacks,d,34 have provided an evolving picture of terror- trauma center39 and 3.4% in a Level II center in El Paso,
related vascular injuries in civilian populations. Many of Texas.40 These reports typify the perceived demographic as
these have been associated with a multitude (and often com- almost always male and usually young. Mortality is approx-
bined) mechanism of injuries, including improvised explo- imately twice that of nonvascular patients39 and penetrat-
sive devices (IED), stabbing, and motor vehicle-induced ing trauma is overrepresented in vascular patients, with the
injuries. Injury patterns in this population are different El Paso authors recording a 40% penetrating injury mecha-
from those seen in military circumstances, as civilians lack nism in vascular patients against a rate of 10% in the gen-
ballistic-proof equipment and communities may not be pre- eral trauma population.
pared for these attacks. Different studies of civilian trauma The largest US single center study of vascular trauma to
in Israel (2000–2005) showed that vascular trauma was date was published in 1988 and emanated from Houston.41
more common in terrorist-related compared with non– It typifies the experience of many large inner-city urban
terrorist-related scenarios (10% vs. 1%).26 Specifically, trauma facilities and was undertaken with the aim of deriv-
ing epidemiological conclusions that would guide trauma-
c
Paris terror attacks (2015): Charlie Hebdo and Bataclan. center and health logisticians. The study encompassed a
d
UK terror attacks (2017): Manchester Arena bombing, London Bridge 30-year period, describing 5760 cardiovascular injuries
attack, and Westminster Bridge attack. in 4459 patients. The authors set themselves the task of
28 SECTION 1 • Setting the Stage

accounting for the entire vascular injury cohort, rather a national trauma registry and trauma systems approach
than restricting themselves to specific vessels, utilizing in the UK National Health Service will allow better plotting
multiple corroborative documentary sources rather than of the impact of vascular trauma, especially with regard to
a single registry. Their study confirmed that the burden inner-city “hot spots.”49
of vascular trauma in the city was being borne by young
men (86% male, average age 30 years), 90% of whom had Rural Populations
been injured by firearms (gunshot wound 51.5%; shot- Large vascular series are dominated by urban centers,
gun injury 6.8%) or knives (31.1%). The study once again but non-urban and rural populations have discrete epide-
demonstrated that the wound pattern in civilian circum- miological injury profiles and patients who have bespoke
stances, even where ballistic penetrating injury is the norm, requirements, particularly regarding timely access to
does not follow that seen in wartime. Torso and neck inju- vascular care. Endeavors by North American research-
ries accounted for two-thirds of all injuries treated, while ers studying trauma systems serving rural populations
lower extremity injuries (including the groin) comprised have shed light on injury patterns in these more isolated
only a fifth. Whereas very few soldiers with injuries to the settings.
large vessels of the abdomen are seen by military surgeons, In 1982, Koivunen et al. reviewed 89 Missourians, one-
trauma to the abdominal vasculature accounted for 33.7% third of whose injuries were farm related, and found that
of the total vascular injury cohort seen in Houston—a fact the delay between injury and arrival at the center aver-
attributed to the maturation of the city’s Emergency Medi- aged 3.4 hours. Their study also found that 82% of the
cal Services. Trends in epidemiological factors—including injuries involved extremities, and 35% of the injuries were
changes in the local population, changes in local crime ligated, with an overall amputation rate of 16.4% and a
patterns (noting the increased burden of trauma that mortality rate of 5.6%. The complication rate associated
accompanied criminal narcotic activity), and provision of with vascular repair was 12.4%. The authors noted that
health-care infrastructure—were carefully described. The the majority of complications and all deaths and amputa-
authors noted a sixfold surge in vascular trauma, with 163 tions were in patients suffering trauma from farm, indus-
and 1069 injured patients in the first and last respective 5 trial, and motor-vehicle accidents.50 In the largest North
years of the study period, although as they did not detail the American series to date, Oller examined 1148 vascu-
denominator data (total number of trauma patients treated lar injuries suffered by 978 patients reported from eight
for each time period), it was not possible to assess for trends trauma centers in a largely rural state. Over the course
in the proportion of patients with vascular trauma. Fur- of the study, vascular trauma accounted for 3.7% of all
thermore, trauma scores, physiology, and crude outcome trauma cases entered on the trauma registry. The amputa-
measures such as mortality were not given, thereby limiting tion rate was 1.3% among those with extremity injuries,
characterization of case mix and reducing the utility of this which accounted for 47% of the total cohort. The authors
impressive dataset for the purposes of comparison. Despite reached broadly similar conclusions to the Missouri group
these drawbacks, this classic study serves as template for with respect to rural vascular injury patients—four-fifths
other investigators seeking to describe vascular trauma epi- of whom were transferred in from peripheral facilities—in
demiology among their communities.42 that these patients were older, had a higher incidence of
South Africa urban centers have reported a number of blunt trauma, had longer inpatient admissions, and had
large series of vascular injuries pertaining to individual ves- higher mortality rates (14.2%). They argued that, for opti-
sels and bodily regions,43 though overall burdens of impact mum care, trauma services catering to rural patients with
are less clear. Data from Sydney and Perth in Australia have vascular injuries must configure their systems to enable
reported vascular trauma rates of 1% to 1.8% with pen- prompt identification, resuscitation, and early transport
etrating trauma mechanisms contributing up to 42% of of vascular injury patients to major trauma centers for
cases.44,45 Reports from individual centers in the UK empha- definitive care.51
size the relative rarity of noniatrogenic vascular trauma in
the general and university hospital setting alike46–48; how- Lifestyle and Socioeconomic Factors
ever, the rates of vascular trauma among certain inner-city Obesity. Obesity is an ever-growing problem in developed
populations may approach those seen in North American societies and one associated with poor outcome in polytrauma
centers. In 2011, a 6-year study in the lead trauma cen- patients.52–55 Simmons et al. studied 115 patients with lower-
ter for London determined that 256 patients (4.4%) out extremity vascular injuries over a 5-year period ending in
of 5823 trauma admissions sustained vascular injury.28 2005 and dichotomized the group by a body mass index
Penetrating trauma caused 135 vascular injuries (53%), (BMI) of 31 or more.54 Interestingly, they found that obese
while the remainder resulted from blunt trauma patients, patients in general exhibited no difference in amputation
who were more severely injured (median Injury Sever- rate or mortality, although a BMI of greater than 40 was
ity Score [ISS] 29) compared with those with penetrating not associated with a favorable outcome.
trauma (median ISS 11) and had greater mortality rates Ethnicity. A study by Moreira et al.56 identified racial
(26% vs. 10%) and higher limb amputation rates (12% vs. disparities in mortality outcomes after arterial trauma.
0%). These differences remained when comparing injuries They suggested that minority populations sustaining vas­cu­
in each anatomical zone. Blunt vascular trauma patients lar arterial injuries have a higher rate of adjusted mortality
were twice as likely to require massive blood transfusions compared with Caucasian victims. A different study by
(47% vs. 27%) and had a fivefold longer hospital stays Hicks et al. also suggested that older Afro-Caribbean victims
(median 35 days vs. 7 days) when compared with patients (>65 years) of vascular trauma “were nearly five times more
with penetrating vascular trauma. Recent development of likely to experience death or amputation after vascular trauma
 2 • Epidemiology of Vascular Trauma 29

than their Caucasian counter-parts.”57 This may be related to This offers a unique perspective of the outcome differences
access to adequate trauma facilities, although Moreira’s in pediatric vascular injuries in the context of armed con-
study suggested that the use of open and endovascular flict, where the pediatric vascular injury rate is almost six
techniques was similar across the different groups studies. times higher than in the civilian setting (3.5% vs. 0.6%).29,64
Poverty. In North America, poverty is increasingly recognized In the civilian population, vascular injury rates are simi-
as a determinant of outcomes from trauma.58–60 It is unclear larly low in children65–70 accounting for 0.6%–1% of pedi-
to what extent these factors are intrinsic drivers of outcome atric trauma.62 The predominant mechanism of vascular
and to what extent they represent summary descriptors injury in children is penetrating trauma.69,70 In the United
of multiple competing and compounding subfactors. In States, this is associated with firearm trauma and motor
order to answer this, Crandall sought a more homogeneous vehicle collisions (MVC) (36.9% and 34%, respectively).62
trauma grouping and thus examined the fate of patients Upper limb trauma was most frequent anatomic site of vas-
with lower-extremity vascular injury to investigate the cular injury (35%). Mortality in this patient group was asso-
impact of race and insurance status.61 Using a large NTDB ciated with shock at presentation and penetrating injuries.
population of 4928 patients, the authors found that those In a 12-year-long study by Klinker et al.,70 1.1% of all
who were of Latino, African American, Asian American, or trauma admissions in patients younger than 18 years were
Native American origin had a significantly higher odds ratio associated with vascular injury. The prevalence of vascu-
of death (1.45), as did the uninsured cohort (1.62). The lar trauma with blunt injury was 0.4%, whereas that with
African American and Latino cohorts made up 51.1% and penetrating trauma was 4.5%. Notably, there were as many
19%, respectively, of penetrating vascular patients, but wounds caused by glass injury as there were by gunshots.
these groups only contributed 12.1% and 10.5% to the The burden of extremity vascular trauma resulted in a 10%
blunt-injury cohort. When the outcomes were stratified by overall amputation rate, most of whom had mangled extremi-
mechanism of injury, no difference was found with respect ties secondary to train or lawnmower accidents. Mortality
to mortality in bluntly injured patients, whatever their reached almost 10% (frequently associated with head injury),
insurance status or race. Penetrating trauma patients who but unlike pediatric vascular injury in armed conflict, there
were uninsured had significantly worse mortality, but race was a virtual absence of thoracic aortic injury in this cohort.70
only trended toward statistical significance in the prediction Barmparas et al. analyzed pediatric vascular injury
models studied. among 251,787 US National Trauma Data Bank patients
15 years of age or younger29 and compared them with
an adult vascular trauma patient cohort. The prevalence
3. TRAUMA AT THE EXTREMES OF AGE of pediatric vascular injury was noted to be 0.6% against
an overall rate of 1.6%. Pediatric patients had lower ISS
Pediatric Trauma scores with a high, but less frequent, incidence of penetrat-
Pediatric vascular trauma is a rare phenomenon, account- ing injury (41.8% vs. 51.2%). There were clear differences
ing for less than 2% of pediatric hospital admissions.62 Nev- in injury patterns. In contrast to adults, pediatric patients
ertheless, it has a large potential for long-term functional exhibited significantly more blunt and penetrating upper
consequences. Therapy in this patient group, whether extremity vascular injuries but sustained less penetrat-
surgical or conservative, requires the surgeon to take into ing chest and abdominal vascular injuries. The upper arm
account the developmental needs of the child. Interest- bore the brunt of pediatric vascular injury; brachial ves-
ingly, the majority of vascular arterial injuries in this group sel trauma occurred in 13.2%, with forearm vessel injury
appear to be treated by vascular rather than pediatric sur- in 22%. The incidence of blunt thoracic aortic injury was
geons. This highlights potential clinical and training chal- much lower in children, involving 8.9% of all blunt pediat-
lenges as non–pediatric-trained vascular surgeons have to ric vascular trauma cases versus 26.1% in bluntly injured
adapt adult techniques to children in the absence of subspe- adults, with a linear relationship between age and inci-
cialist training, national guidelines, or long-term outcomes dence of aortic injury. Mortality was significantly lower in
data.63,64 the pediatric cohort when compared with adults (13.2%
Specific challenges are posed by children receiving care vs. 23.2%)—a difference that persisted even after correct-
in war zones, where sophisticated armed conflict occurs in ing for compounding differences such as ISS, low GCS, and
the proximity of civilian populations. Over 4000 children mechanism. There was no difference in the frequency of
were treated in US Military Hospitals in Iraq and Afghani- lower-extremity amputation between adult and pediatric
stan between 2002 and 2011,64 of which 3.5% had a vas- patients (9.1% in children vs. 7.5% in adults). The authors
cular injury. The majority of these were boys (79%) who drew attention to the fact that, despite the survival advan-
had suffered penetrating trauma (95.6%), predominantly tage observed in pediatric patients, the rate of penetrating
to the limbs (38% upper and 28% lower limbs) or the injury was sobering and a fifth of children who had been
torso (25.4%). Blast injuries (58%) and gunshot wounds shot died from their injuries.
(37%) were the predominant mechanism of injury. For- In summary, the incidence of pediatric vascular injury
tunately, limb salvage rates were 95%. Nevertheless, the is thankfully low. Nevertheless, this represents a high-risk
consequences of these injuries need careful consideration, area of surgical practice, where vascular surgeons may
as almost 1 in 10 children died. Of the children that died encounter unfamiliar clinical circumstances.
the majority (71.4%) had sustained vascular injuries to the
chest, abdomen, or pelvis. These included trauma to the Geriatric Trauma
major abdominal vessels or injuries to the hepatic and mes- There have been fewer studies of the epidemiology of vas-
enteric arteries leading to nonsurvivable visceral ischemia. cular injury in geriatric patients. Patients over the age of 65
30 SECTION 1 • Setting the Stage

represent a relatively small proportion (7.6%) of all individ- endovascular aneurysm repair (EVAR), thoracic endovas-
uals suffering traumatic vascular injury. The mechanism cular aneurysm repair (TEVAR), and transcatheter aortic
of injury in this population is predominantly blunt trauma, valve replacement (TAVI). Newer iatrogenic injuries are
sustained in the majority of cases by MVCs and falls (59.2% also associated with failed percutaneous closure devices
and 14.0%, respectively, compared with 23.6% and 3.6% in and heavy-duty cannulation for ECMO. Future challenges
individuals <65 years of age).71 Despite the relatively rare confronting the trauma vascular surgeon may also result
occurrence of vascular injury, these individuals do pose from the rapid insertion of REBOA catheters.
significant clinical challenges due to the associated burden Arterial complications associated with retrograde cath-
of occlusive vascular disease, stiffer vasculature, less resil- eterization of the common femoral artery carry a major
ient physiology, and concurrent polypharmacy. Addition- complication rate under 1%.74,75 Minor complication (e.g.,
ally, geriatric patients display higher ISS scores compared puncture site hematoma) have been reported in up to
with the nongeriatric adult population sustaining vascular 12.5% of patients,76 although the majority of studies report
trauma. Cumulatively, these factors are reflected in a mor- these in less than 10% of cases.77 Variation in this com-
tality rate that is four times higher in the geriatric vascular plications rate depends on whether vascular catheteriza-
trauma patient compared with the adult one. Anatomically, tion is diagnostic in nature or followed by an intervention
vascular injury in patients over 65 predominantly affected using a large bore device (10-fold difference in complication
the thoracic vasculature (40%) with 33% displaying dam- rate).78 Irrespective of incidence, femoral and external iliac
age to the thoracic aorta. Other differences in injury pattern injuries carry nontrivial morbidities, leading to increased
included higher rates of penetrating neck and arm injury hospital stay (2.7 vs. 4.5 days)79 and increased blood trans-
and more blunt chest and abdominal vascular injuries. The fusion requirement (39%). Furthermore, one study sug-
authors described a linear increase in thoracic aortic injuries gested that retroperitoneal bleeding from femoral arterial
with increasing age and a corresponding decrease in inju- punctures is associated with a 6.6% rate of mortality.80 In
ries to the forearm vessels and femoropopliteal axis. Inter- addition, major femoral bleeding in the context of percuta-
estingly, no significant difference in amputation rates was neous coronary intervention has been associated with an
described between older (2.5%) and younger (3.0%) patient increased 30-day mortality, as well as a decreased long-term
cohorts in terms of overall, upper limb, or lower limb injury survival.79
patterns. The younger patient cohort was significantly more Overall, the incidence of femoral arterial puncture site
likely to undergo fasciotomy (9.6% vs. 2.8%), although the bleeding is thought to have reduced over time. A large
authors were unable to account for this. Overall mortality series reports a reduction from 8.4% to 3.5% over a 10-year
was significantly higher in the older cohort when compared period.79 This may be associated with a large number of
with younger adults (43.5% vs. 21.6%). Being over 64 factors, including color Doppler ultrasound–guided access,
years was associated with an odds ratio of death of 3.9 after transition to a radial approach in coronary catheterization,
adjusting for sex, ISS, low GCS, presence of shock, mecha- and the replacement of post-procedural manual compres-
nism of injury, and body region of injury. Unsurprisingly, sion with vascular closure devices (VCD). Nevertheless,
older patients had longer intensive care unit stays, although as coronary intervention is increasingly performed thr­
overall inpatient length of stay of 10.2 days did not differ ough the radial approach, a degree of deskilling should be
significantly compared with the younger cohort. expected when radial operators attempt unavoidable femo-
ral access. This may lead to a future rise in the prevalence
of groin complication. In the context of transfemoral cath-
4. IATROGENIC VASCULAR INJURY
eterization for coronary interventions, risk factors for com-
Vascular surgeons are increasingly encountering vessel plications include female gender, the presence of peripheral
trauma resulting from inadvertent iatrogenic misadven- arterial disease, and left-sided punctures.75
ture during open surgery or endovascular intervention. Less common complications of femoral arterial access
This may represent the chief cause of vascular trauma in include pseudoaneurysms (0.1%–0.2% for diagnostic pro-
peaceful countries where percutaneous cardiac, neurologi- cedures; 3.5%–5.5% for interventional procedures),81 AV
cal, and endovascular therapies are practiced. One Euro- fistula formation (<1%),82 and arterial dissections (0.2%).75
pean review of the burden of iatrogenic vascular trauma Vascular rupture is usually associated with angioplasty
estimated incidence of 35% to 42%.72 However, even in and stenting in the context of balloon overinflation, device
developing countries, this may account for a significant oversizing, and intrinsic arterial pathology, such as arteri-
proportion of the vascular injury workload.73 The advent tis or infiltrating calcified plaque.74 Although rare (0.1%),
of coronary angiography and angioplasty has created a this can have catastrophic consequences, especially when
new niche of traumatic vascular injuries, mainly related to occurring in the aortoiliac segment.
bleeding and pseudoaneurysm formation in the iliofemoral In Sweden, where repairs for vascular trauma constitute
segment. Traditional injury patterns resulting from high 1.3% of all emergency and elective vascular workloads, a
femoral punctures led to noncompressible bleeding from review of national vascular registry data revealed that iat-
the external iliac artery in the pre-peritoneal and retroperi- rogenic etiology accounted for 48% of all vascular injuries,
toneal spaces. Low-puncture sites are similarly associated with penetrating trauma and blunt trauma accounting for
with arteriovenous fistula formation.74 With the advent of 29% and 23%, respectively.83 The most commonly injured
micropuncture access and a shift to radial approaches to vessel was the right femoral artery, in keeping with compli-
the coronary vessels, a new generation of iatrogenic iliac cations from endovascular interventions. As expected the
injuries have arisen. These are associated with large bore iatrogenic group was older, with a median age of 68 and had
access for endovascular reconstructive procedures, such as a higher incidence of comorbid conditions such as cardiac
 2 • Epidemiology of Vascular Trauma 31

disease (58%) and renal dysfunction (18%) than patients complication, made worse by concomitant anticoagulation
injured by noniatrogenic etiologies. Mortality was approxi- or damage to other organs in the pericaval space, such as
mately double that of noniatrogenic patients (4.9% vs. the duodenum.94 Prompt removal of IVC filters remains
2.5%). The authors noted that iatrogenic vascular trauma therefore the wisest strategy for vascular surgeon wishing
had increased over the 1993–2004 study period by 150% to avoid caval trauma.
and attributed this to the increased uptake of endovascular Venous angioplasty poses a final category of venous
procedures. Two small but recent studies from both provin- injury. This is often related to the treatment of central venous
cial and tertiary referral vascular centers in England, where or upper limb venous stenosis. Post-procedural bleeding due
71% to 73% of all vascular injuries were found to be iatro- to vein rupture is reported as occurring in 2% to 6% of cases,
genic in nature,48,84 echoed these results. Both studies found with the highest morbidity associated with intrathoracic
worse outcomes in the iatrogenic group compared with the venous rupture that cannot be externally compressed.95,96
noniatrogenic cohorts, with patients undergoing noncar- In summary, the broad advances in endovascular tech-
diac or peripheral vascular interventions faring the worst nology, often deployed by nonvascular or training physi-
following their iatrogenic injury. cians, can create a multitude of vascular injuries which
Vascular trauma following ECMO is often associated with can result in noncompressible hematomas, formation of AV
the large 16 to 20 Fr cannulas used for accessing the com- fistulae, and pseudoaneurysms, as well as vessel rupture.
mon femoral artery. These increase the risk of thromboem- While the incidence of these injuries is thankfully low, their
bolic events, especially in women and those with peripheral occurrence has a veritable traumatic etiology with all its
arterial disease. The rate of ECMO-related lower limb isch- associated catastrophic outcomes. This makes endovascu-
emia is thus reported as being anything between 10% and lar iatrogenic injury a worthy target of the skills specific to
70%85, while local complications (dissections, pseudoan- the vascular trauma surgeon.
eurysms, or retroperitoneal bleeds) occur in 7% to 14% of
patients.86 While the risk-benefit balance of this interven-
tion is justifiable, vascular surgeons should be aware of this Summary
new cohort of patients requiring adaptation of their vascu-
lar trauma skills. Vascular injury remains a costly consequence of contem-
Vascular closure devices have provided advances in reduc- porary trauma burden—both in human and material met-
ing time to hemostasis and facilitating early ambulation rics. Current trauma epidemiology confirms that this injury
after percutaneous arterial puncture.87 Although generally type remains a global blight. The contribution of vascular
considered to be safe, VCDs have nevertheless created addi- injury to mortality and morbidity is relatively well under-
tional opportunities for arterial damage if improperly used. stood within discrete populations, such as the coalition
In a combined cohort of coronary and peripheral interven- forces fighting in Afghanistan and Iraq (12%). Incidentally,
tions, VCDs were shown to have a complication rate of 3.9% this represents a much higher rate than that encountered
(2.2% major and 1.7% minor complications) and a device in historical armed conflicts, such as Korea and Vietnam.
failure rate of 7.8%.88 These are not infrequent errors which However, granularity of data for the same injury types in
can lead to bleeding, as well as femoral artery occlusion. the civilian populations is much lower due to a lack of sys-
Differences in vessel-closure technologies between various tematic data collection and analysis.
devices, operator experience, re-do interventions and ath- It is important to note that the incidence and prevalence
eromatous vessels walls all play a role in arterial damage of vascular trauma is not well investigated worldwide.
following VCD use. It is important to note however that a Available data suggests that the prevalence of vascular
Cochrane review found no differences in vascular injuries trauma is lower in civilian trauma cohorts, who exhibit dif-
between VCD use and manual compression.87 Furthermore, ferent patterns of injuries from military populations. Iatro-
the complication profile of VCDs is superior to the traditional genic trauma is an evolving niche for the vascular surgeon,
alternative of manual compression alone.78 which remains in a dynamic state as a result of technologi-
Venous iatrogenic injury is most commonly encountered cal innovation and novel applications of endovascular tech-
in the placement of central venous catheters (CVC). It is esti- niques. Pediatric and geriatric vascular trauma pose further
mated that 5 million CVCs are inserted annually.89 Consid- population-specific challenges to the trauma-vascular sur-
ering that 2% of CVC suffer from misplacement (even with geon. Vascular surgical care is particularly challenging in
ultrasound guidance) these result in a significant number children that have been the victims of armed conflict. Con-
of venous injuries.90–92 Furthermore, CVCs are seen as train- sequently, if vascular injury is to be managed in a holistic
ing procedures, consequently being placed by practitioners manner, robust trauma systems and systematic collection
with a various degree of experience. While the majority of of metadata is needed in order to obtain accurate epide-
CVC-associated venous injuries are related to puncture site miological knowledge. More importantly, if this data is to
hematomas, insertion of lines in the internal jugular and be analyzed in a context-adjusted manner, an understand-
subclavian veins can be associated with inadvertent punc- ing of social, political and economic circumstances is man-
ture of adjacent major arteries or mediastinal structures, datory. These will ultimately inform resource utilization,
leading to potentially noncompressible arterial hemorrhage. system design and trauma prevention strategies that will
Inferior vena cava filters are a second major area of impact favorably on patient outcomes.
venous injuries, with complications occurring during
insertion and retrieval, as well as during use (IVC penetra- References
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2010;45:1404–1412. 60. Maybury RS, Bolorunduro OB, Villegas C, et al. Pedestrians struck by
30. Talbot E, Evans S, Hellenthal N, et al. Abdominal and pelvic vas- motor vehicles further worsen race- and insurance-based disparities
cular injury: a National Trauma Data Bank study. Am Surg. in trauma outcomes: the case for inner-city pedestrian injury preven-
2019;85(3):292–293. tion programs. Surgery. 2010;148:202–208.
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62. Eslami MH, Saadeddin ZM, Rybin DV, et al. Trends and outcomes of treated at the Mayo Clinic from 1994 to 2005. JACC Cardiovasc Interv.
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65. Whitehouse WM, Coran AG, Stanley JC, et al. Pediatric vascular genic femoral arteriovenous fistulas: implications for risk stratifica-
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 3 Systems of Care in
the Management of
Vascular Injury
DONALD H. JENKINS, DOUGLAS M. POKORNY, and PHILIP M. EDMUNDSON

Trauma Systems Overview vascular-trauma service can save lives and limbs. Addition-
ally, there tends to be considerable overlap in the personnel,
Managing severe injuries requires the timely intervention expertise, resources, and infrastructure required to deliver
of multidisciplinary teams, as well as the coordination of complex trauma care and complex vascular care. These
prehospital care and resuscitation begun at the point of synergies can improve outcomes for both trauma and non-
injury. Fundamentally, trauma systems save lives by rapidly trauma emergency vascular patients alike.
delivering critically injured patients in optimal condition
to specialist surgical teams. The delivery of these patients
to specialized trauma centers has repeatedly demonstrated Key Components of a Trauma
significant reductions in mortality compared with non- System
specialist centers.1
A regional trauma system is a public health model that The purpose of a regional trauma system is to reduce death
seeks to optimize outcomes among injured patients for a and disability following injury, while ensuring efficient use
defined population.2 A true trauma system treats trauma as a of resources and personnel. Not all hospitals can be staffed
disease entity. The system covers the whole patient pathway, and equipped to manage all injuries. Major trauma patients
from prehospital care, transportation, and the acute man- must be identified early in their clinical course and directed
agement of injury through the reconstruction and rehabili- to definitive care in a flexible and error-tolerant system that
tation phases. Included in this public health approach is a can deliver high quality clinical outputs. Key facets of a
responsibility for injury prevention in order to actively reduce trauma system therefore include the following:
the burden of disease in the population. This approach also
includes a strong commitment to system-wide data collec- 1. A prehospital care system that is closely integrated into
tion and analysis, which is utilized for performance improve- the trauma system, with defined protocols to expedite
ment across the entire spectrum of patient care. patient triage
A trauma system goes beyond simply designating one 2. A regional trauma coordinating system integrating
hospital as a “Level I trauma center” conjoined with bypass prehospital and hospital care to identify and deliver
protocols that send all injured patients to this institution. patients to a place of definitive care quickly and safely
While this model may improve care for the severely injured, with proper notification to the hospital team
it has the potential to worsen outcomes for less seriously 3. A network of hospitals with defined capability and
injured patients treated at the same center. Patients with capacity, and with predetermined transfer agreements
mild to moderate injuries—who constitute 85% of all for optimizing casualty flow
trauma patients—will suffer from de-prioritization within 4. Specialized and designated regional trauma centers
an overloaded hospital. Systems that comprehensively that have responsibility for the management of injured
address the needs of patients within a given area (so-called patients in the region
“inclusive trauma systems”) incorporate all acute hospi- 5. Acute rehabilitation services to improve outcomes and
tals in a region and have been shown to produce better restore casualties back to productive roles in society
outcomes for a patient population.3,4 Hospitals in an inclu- 6. A continuous process of system evaluation, gover-
sive system are designated according to their capabilities nance, and performance improvement across the
and institutional commitments. In the United States, lev- trauma network
els of capability are designated with a system from level I 7. Ongoing training and education for all healthcare
to level IV. In the United Kingdom, centers are designated professionals involved in the care of injured patients
as major trauma centers (MTCs), which manage severely 8. An active injury prevention program to reduce the
injured patients, and trauma units (TUs), which manage burden of injury for the population that the trauma
mild and moderately injured patients. Other countries and system serves
military entities have similar tiered levels of care. 9. A responsibility toward research into trauma and its
Patients with vascular injuries are among the prime effects, to continuously improve care and outcomes
beneficiaries of the organized delivery of trauma care. The following injury
prompt resuscitation and early delivery of patients with 10. A system-wide plan for response to disaster and mass
active hemorrhage or ischemic limbs to a multidisciplinary casualty incidents

34
 3 • Systems of Care in the Management of Vascular Injury 35

The primary function of the system is to identify each developed by the broader community of trauma specialists,
trauma patient as soon as possible in the clinical course, to both regionally and nationally.
render appropriate treatment, and to ensure swift transfer Travuma QI is not only the province of mature trauma
to the most appropriate facility. In the case of major trauma, systems in well-resourced settings, the principles of QI are
this will involve directing the patient from the point of equally applied to trauma care across the entire range of
injury to the nearest trauma center that can care for the trauma systems, including those with minimal resources
patient, while beginning resuscitation at the point of injury. and austere environments. Importantly, a regional system
In the event that a patient arrives at a facility that is not delivers trauma care that achieves these benchmarks with
equipped to provide definitive care within the trauma sys- local solutions that reflect its own particular geography,
tem because triage protocols are inadequate or misapplied, resources, and capabilities.6–10
or because the patient arrives unannounced, the local facil- Within the trauma system, the provision of quality care
ity must maintain sufficient trauma capabilities in early is linked to both designation status and financial reimburse-
resuscitation to optimize patients for secondary transfer ment. It is possible for trauma centers to lose their status
to a higher level of care. The regional trauma center must and for previously undesignated institutions to gain status
maintain the ownership of these patients and help coor- as trauma centers depending on their ability to demonstrate
dinate their timely disposition and early resuscitation. In quality care and a commitment to performance improve-
these scenarios, patients may be transferred in unstable ment. An independent team that periodically reviews the
conditions, and there must be expertise within the system quality, quantity, and capacity of the institution determines
to provide ongoing resuscitation during transport, as well designation status. These periodic reviews also allow for the
as continued coordination with the receiving institution identification of areas for improvement and function as part
in order to expedite care. This is particularly important for of the broader quality improvement and standardization of
patients with demonstrated vascular injuries. The rapid therapy across institutions.
resuscitation and control of hemorrhage, particularly from There is a growing body of evidence that the institution
an extremity, can stabilize patients for transport to definitive of dedicated trauma centers can improve outcomes for
care that otherwise would not survive transport. trauma patients across a variety of metrics.11 In addition to
Once injured patients arrive at regional trauma centers, demonstrably more lives saved, trauma centers by virtue of
the infrastructure of the institution must ensure timely increased knowledge, experience, resources, and personnel
availability of the trauma team, ancillary staff, blood prod- are able to provide higher quality and more efficient care,
ucts, operating room capabilities, and required specialist even to those patients without fatal injuries. The upfront
and consulting services. The primary trauma team should cost is significant and varies by region, but the provision of
maintain the ownership of these patients throughout their expert and efficient care represents overall a cost savings to
hospitalization and coordinate between consulting and the community served. Around the world, the implementa-
ancillary services as needed. tion of trauma systems has resulted in consistent mortality
The system also includes acute and chronic rehabili- reductions, and ongoing quality improvement within these
tation services both in the hospital and beyond. Patients systems should yield increasing cost effectiveness as these
managed at a trauma center should eventually be repatri- systems mature.12 Patients with vascular injury are the
ated to the local community as soon as possible following most likely to benefit from robust and well-integrated
definitive care. This maintains the capacity of the trauma trauma systems, as this patient population is at high risk
center, while ensuring that patients can access appropriate for rapid decline due to hemorrhage and the necessity of
community services and rehabilitation teams. urgent surgical intervention.
Additionally, the primary trauma team must continu-
ously engage in quality improvement across the entire
spectrum of care in order to continue to deliver the best Trauma Center Function
care possible, from the point of injury to rehabilitation and
return to preinjury status. Quality improvement (QI) can be When a hospital is designated as a regional trauma center,
conceptualized as follows: it accepts responsibility for the delivery of injury care to all
people living and working within its catchment area. The
A method of evaluating and improving processes of patient trauma center has a duty to ensure that injured patients will
care which emphasizes a multidisciplinary approach to problem receive high-quality trauma care at the most appropriate
solving, and which focuses not on individuals but on systems of hospital and in a timely manner. Furthermore, it is respon-
patient care that may be the cause of variations. QI consists of sible for the continuum of care, from the first prehospital
periodic scheduled evaluation of organizational activities, poli- response through completion of rehabilitation, including
cies, procedures and performance to identify best practices and the quality of care received at other trauma-receiving hos-
target areas in need of improvement and includes implementa- pitals within its region. The center also has a public health
tion of corrective actions or policy changes where needed.5 duty to reduce the injury burden through injury prevention
activities for its population.
This involves feedback as appropriate to the prehospital Trauma centers have all surgical specialties required
team, transferring facilities, and consulting services, as for the care of multisystem trauma patients, as well as on-
well as internal review of quality and performance of the site and in-house trauma team coverage 24 hours a day.
trauma team and the trauma center. This also includes There is capacity and expert support from diagnostic and
periodic review and accreditation by independent reviewers interventional radiology, transfusion services, critical care,
to ensure compliance with best practices and benchmarks rehabilitation, and other allied services. However, the mere
36 SECTION 1 • Setting the Stage

presence of these services will not be sufficient for the desig- was essentially isolated from the hospitals and tertiary/
nation of a regional trauma center, because improvements quaternary care facilities.14 Hoping to recreate the positive
in outcomes and the process of care are only seen when the impact of civilian trauma systems on patient outcomes, a
overall responsibility of the care of trauma patients is man- group of military physicians advocated for a theater trauma
aged by a specialist trauma service.13 system based on the civilian model.
The function of the trauma service is to provide expert In late 2004 to early 2005, US Central Command (CENT-
care for trauma patients, integrating the care of multiple COM) implemented an inclusive system of trauma care for
teams and advocating for patients, both within the hospital its entire area of operations designated as the Joint Theater
system and during ongoing community care. The service Trauma System (JTTS).15 Simultaneously, the UK Defense
is responsible for trauma education to all staff involved in Medical Services began an independent, yet strikingly simi-
trauma care, ensuring appropriate certification and ensur- lar, endeavor to build an ad hoc trauma system for its forces
ing that best practice guidelines are understood and imple- engaged in Iraq and Afghanistan.16 The stated vision of the
mented. Typically, the service will receive all new trauma JTTS was to ensure that every soldier, marine, sailor, and
patients and direct their early resuscitation and assessment. airman injured on the battlefield had the optimal chance
Additionally, the trauma team will determine their observa- for survival and had maximal potential for functional
tion or admission status and will perform a tertiary survey recovery—“the right patient to the right care in the right
and radiology review on all evaluated patients to ensure no place at the right time.”17 Although the epidemiology of
injuries are missed. military trauma differs from civilian centers, the American
Patients with a single system injury (e.g., isolated brain College of Surgeons Committee on Trauma (ACS COT) text
injury or isolated tibia fracture) may be signed over to the entitled Resources for the Optimal Care of the Injured Patient
appropriate specialist team, but patients with combined served as a useful model for the structure, function, and role
injuries (e.g., brain injury and a tibia fracture) remain of the JTTS.2 This document, commonly referred to as “the
under the care of the trauma service with appropriate spe- Orange Book,” identifies criteria for civilian trauma care
cialty input. The final responsibility to ensure delivery of resources and practices in an effort to optimize standards of
quality trauma care remains with the trauma service for all care, policies, procedures, and protocols for care of the trau-
admitted trauma patients. matically injured patient. The content of the manual provides
The trauma service is a multidisciplinary team made guidance for medical care personnel from the prehospital
up of surgeons, specialist nurses, occupational therapists, arena through hospital and subspecialist care. The ACS COT
physical therapists, respiratory therapists, pharmacists, Verification Review Committee (VRC), initially developed in
data collection staff, and administrative staff. Trauma- the early 1970s, functions as the oversight process and veri-
trained general surgeons with experience or additional cer- fying entity for the American trauma care system.
tification in critical care lead most trauma teams. Trauma Following the example of the ACS COT, the JTTS iden-
program managers, trauma nurse coordinators, and nurse tified and integrated processes and procedures to enable
case managers are also essential to the daily activities of recording of trauma patient–related data at all levels of
the service, whereas the data collection staff monitors the care to promote continual process improvement. Establish-
health of the system and compliance with quality improve- ment of the Department of Defense (DoD) Trauma Regis-
ment initiatives. try (DoDTR) provided a comprehensive resource for the
Turning a multispecialty hospital into a specialist trauma collection of all DoD trauma injury data. These essential
center is not a trivial task, and it involves a significant data were used to predict needed resources, evaluate out-
investment in staff and resources, as well as changes in the comes, educate staff, and identify training needs in order
delivery of health care and clinical governance. Managing to improve continuity of care across the combat care con-
the interface between other hospitals in the region and pre- tinuum. It was essential in facilitating real-time, evidence-
hospital care providers requires commitment, communica- based changes in these conflicts. Oversight and direction
tion, education, and intense coordination. Despite this, the for the theater trauma system above level I is directed by
cost to implement trauma centers and regional systems is the CENTCOM surgeon. The US-based parent organization,
relatively cheap and the potential savings from minimized now known as the Joint Trauma System (JTS), was founded
disability and loss of life represent a large net gain for the primarily to manage the DoDTR. JTS embraced the system
community and region served. concept for providing continuity of care from the point
of injury to medical treatment facilities to rehabilitation
centers in the continental United States. A philosophy of
Trauma Systems in Combat continuous improvement drove and matured the system.
The JTS now exceeds the capabilities of the US trauma care
Casualty Care system on which it was modeled.
Prior to 2016, the JTS was a directorate within Joint Base
At the time of this publication, US, UK, and other NATO Sam Houston; in the fall of 2016, the recommendation was
military medical forces deployed in support of operations made by the Under Secretary of Defense to establish the JTS
in Iraq and Afghanistan have provided continuous combat as an independent authority and lead agency for trauma
casualty care for nearly two decades. This medical response in the DoD. With the realignment of US military medicine
initially lacked a cohesive and structured approach. Com- and the incorporation of the Defense Health Agency (DHA)
munication lines between individual medics/corpsmen, in 2017, the JTS was finally named as the governing body
forward operating bases (FOB), combat hospitals, and evac- of trauma care in military medicine. The National Defense
uation facilities did not exist: the prehospital environment Authorization Act of 2017 (NDAA17) established the
 3 • Systems of Care in the Management of Vascular Injury 37

Combatant Command Trauma System (CTS) as the succes- Table 3.1 Comparison of US Trauma Center Levels:
sor of the JTTS. NDAA17 also granted JTS the power to serve Civilian Versus Military
as the reference body for all military trauma in an effort to
establish standards of care for trauma services provided at US Civilian
Military Designation Description Designation
military medical treatment facilities (MTFs). Additionally,
JTS was directed to coordinate the translation of research V (e.g., BAMC/ISR, Major trauma center with I
WRNNMC) teaching and research
from the DoD centers of excellence into standards of clinical
trauma care and to coordinate the incorporation of lessons IV (e.g., LRMC) Major Trauma Center II
learned from the trauma education and training partner- III (e.g., In-theater Regional trauma III
hospitals, CSH, TAH) center, limited capability,
ships into clinical practice.18,19 Experiences from prior US 30-day ICU holding
wars and conflicts were largely lost as providers retired and capability
time passed. Establishment of the JTS ensured that corpo- IIB (e.g., FRSS, FST Community hospital with IV
rate memory is preserved, and that benefits of the current EMEDSs, CRTS, limited emergency
system will be available to future surgeons/conflicts. CVN) surgery capability
IIA (e.g., BAS) Basic aid station, outpatient —
clinic
Organization of the Joint Theater I EMS/corpsman/medic —
Trauma System BAMC, Brooke Army Medical Center; BAS, battalion aid station; CRTS,
casualty receiving and treatment ship; CSH, combat support hospital; CVN,
There are five levels, or “roles,” (known as echelons in aircraft carrier battle group; EMEDSs, expeditionary medical services; FRSS,
most NATO nations) of care in the US military trauma- forward resuscitative surgical system; FST, forward surgical team; ISR, US
care system. Each role has progressively greater resources Army Institute of Surgical Research; LRMC, Landstuhl Regional Medical
Center; TAH, US Navy hospital ships; WRNNMC, Walter Reed National Naval
and capabilities (Tables 3.1 and 3.2). Role I care provides Medical Center.
aid at or near the point of injury. Role II care consists of
surgical resuscitation provided by forward surgical teams
that directly supports combatant units in the field. Role III and to scrutinize the efficacy of care via access to
care provides a much larger and resource-capable facility databases depicting performance metrics across the
and serves as the highest level of care within the theater of continuum of care.
operation. Generally speaking, military role III centers offer n Key policy/guideline development: includes comprehen-
advanced medical, surgical, subspecialist, and trauma care: sive authority to maintain trauma system infrastructure
they are similar to civilian level I trauma centers or MTCs. as well as planning, oversight, and command authority
Transfer of casualties between roles I and III is generally via to create and enforce policy and guidelines on behalf of
rotary or fixed-wing tactical airframes. the welfare of the injured.
Role IV care is the first level at which more definitive n Assurance: includes education and coalition building
surgical management is provided outside the combat zone. with leaders and participants across the system to fos-
For US forces in the Afghanistan (and Iraq) theater, this is ter cohesion and collaboration. Also includes the use of
Landstuhl Regional Medical Center (LRMC) in Germany. analytical tools to monitor performance, promote injury
Role V care is the final stage of evacuation to one of the prevention, and to evaluate and verify that system com-
major military centers in the continental United States ponents meet agreed-upon criteria.
(CONUS). At a role V facility, there is not only definitive care,
there are also more comprehensive rehabilitation services. Successful implementation of these functions with regard
Transfer of casualties between role III and role IV/V facili- to military trauma care capabilities in Operation Iraqi Free-
ties is by specialist strategic aeromedical evacuation or by dom (OIF), Operation Enduring Freedom (OEF), and Opera-
Air Force Critical Care Air Transport Team (CCATT). The tion Inherent Resolve (OIR) led to the lowest case-fatality
UK military system has similarly structured in-theater care rates recorded for combat casualty populations.
from echelon 1 through to echelon 3—generally analogous A major challenge arising from the conflicts has been
to US level I to III, with the Royal Centre for Defence Medi- determining how to turn the past successes of the JTTS
cine at Queen Elizabeth Hospital Birmingham (University approach, developed in Afghanistan and Iraq, into strate-
Hospitals Birmingham NHS Foundation Trust), United gies that will assure care to military populations deployed
Kingdom acting as their highest tier. on future operations. JTTS was built around a very static
The elements that comprised JTS were bound by an over- and stable network of medical facilities backed up by robust
arching leadership that was tasked to continually assess and largely guaranteed aeromedical evacuation routes. The
system structure, function, and outcomes, while creating system dealt with large volumes of injured combatants over
policy and guidelines based on the analysis of their assess- several years, often being treated by seasoned clinicians
ments. An understanding of the epidemiology behind who served on multiple tours. Such enduring conditions
specific injury mechanisms and casualty injury burden is were fertile for systemization and quality improvement.
essential to placing these functions in proper context.20–22 Future operations, predicted to involve near-peer threats,
Each of the following functions is central to adjudicating are likely to be lighter and shorter, take place in areas where
trauma system efficacy: we will not have established infrastructure, and involve less
assured logistic and evacuation options. The “opportunity
n Assessment: includes the ability to thoroughly describe cycle” within which it is possible to characterize problems,
the epidemiology of injury within the theater jurisdiction launch improvement initiatives, observe for effect, and
38 SECTION 1 • Setting the Stage

Table 3.2 US Trauma System Organization

Civilian Trauma System Components Military Trauma System Components
National/Federal American College of Surgeons, Committee on Trauma Department of Defense, Military Health System, Defense Health
Level Agency, Combat Support Agency
■ Registry (National Trauma Data Bank)
■ Academic organizations influencing trauma care ■ Joint Trauma System
(American Association for Surgery of Trauma/Eastern ■ DoD Trauma Registry
Association for Surgery of Trauma/Western Association for ■ Defense Medical Readiness Institute/Committee on Tactical
Surgery of Trauma Combat Casualty Care/Committee on Surgical Combat Casualty
Care/Committee on En Route Combat Casualty Care
State/Command State trauma system COCOM
Level ■ State director (Texas: Governor’s EMS and Trauma ■ COCOM surgeon
Advisory Committee chair) ■ CTS-derived COCOM data
■ State registry
■ CTS; COCOM-specific
■ State trauma system plan

Regional Level Regional trauma areas AOR (Operation Inherent Resolve)

■ Registry ■ CTS-derived AOR data
Local Level Local trauma center JTS leadership
■Trauma registry
Local/Regional Regional advisory council Command surgeon
Components ■ RAC chair ■ JTS director
■ Rural/urban organizations ■ Level II/III facilities
■ EMS (ground/air) ■ Level I/Medevac Btln
■ Hospital representatives, all levels ■ PI/Comm/Prev
■ PI/Comm/Rehabilitation/Prev
AOR, Area of responsibility; Btln, battalion; COCOM, combatant command; CTS, combatant command trauma system; EMS, emergency medical service; JTS,
joint trauma system; PI, performance improvement; RAC, regional advisory council.

revise accordingly may be much less favorable than during the aneurysm screening, stroke prevention, and limb revascu-
JTTS era. Developing swifter, more agile systemization meth- larization and are familiar with rigorous study and quality
odologies and improvement mechanisms that not only take improvement.23,24 Efforts to improve outcomes from vascu-
account of new operational realities but thrive within them is lar trauma should leverage this expertise accordingly.
an emerging problem that must be tackled successfully by It is essential that both vascular and trauma surgeons
DHA and JTS in order to continue delivering the best results. serving a region or population take every opportunity to
jointly champion the benefits of a systemized approach.
Even with mature trauma systems, internal and external
Challenges of Vascular Injury Care pressures may degrade the ability of the system to function,
and these must be anticipated and countered. Challenges
If it is clear that the outcomes for injury can be improved such as cost containment, resourcing of administration, cli-
by a systemized approach, what are the barriers and chal- nician disengagement, and competing health policy agen-
lenges faced by surgeons wishing to address the specific das must be managed without losing sight of the patients
problem of vascular injury within a trauma system? and their needs.

OWNERSHIP AND RESPONSIBILITY DATA COLLECTION AND COMPARISON

With increasing concentration of tertiary-level clinical ser- Generic data should be collected as part of the baseline
vices, vascular centers are now often collocated with trauma performance dataset as part of a broader trauma registry,
centers. “Ownership” of the vascular trauma patient will but there are a few guidelines on the specific data fields
depend on local circumstances but must be clearly defined. that should be maintained for vascular patients. In gen-
Trauma surgical teams may be the traditional leaders of the eral, data collected for utility as measures of performance
system and may be best placed to ensure that the system should be readily measurable, should reflect or be associ-
works holistically. However, vascular surgeons embody the ated with outcomes, should be set at a threshold that mir-
technical subject matter expertise, particularly with regard rors current standards of practice, should be amenable to
to endovascular treatments. The principle province of vas- risk stratification, and should signal system-wide quality.6
cular surgery is age-related degenerative disease. Noni- Clearly, such discrete metrics are required if the vascular-
atrogenic vascular trauma represents a small amount of specific processes and outcomes are to be monitored and
vascular emergency workload, and interest and enthusiasm included in feedback mechanisms. A suggested list of
among vascular surgeons to lead system improvements potential date fields—in addition to usual data pertain-
and novel research may be variable. Nonetheless, vascular ing to trauma epidemiology, indices of physiology, and
surgeons have led on improvements to systems addressing resuscitative measures—is included in Box 3.1. Judgments
 3 • Systems of Care in the Management of Vascular Injury 39

Surgery.25,26 The London trauma system has also published

Box 3.1 Candidate Vascular–Specific Process its own guidelines. Implementation of guidelines should
and Outcome Fields for a Vascular-Injury not occur in isolation but should be followed up by impact
Database analysis and regular review by the broader trauma and vas-
Quality cular communities. Clinical practice guidelines (CPGs) may
Provider gain effective traction among the clinical community when
championed by senior decision makers and introduced
Training level of provider (revascularization; amputation) alongside associated programs of provider education. It is
Specialty of provider (revascularization; amputation) important that all stakeholders participate in the process,
Training level of anesthesia provider
as unannounced implementation of CPGs frequently fail to
Institution gain traction in clinical practice.
Accredited vascular teaching program
Accredited endovascular program INTRODUCTION AND TRACKING OF NEW
Vascular quality assurance program TECHNOLOGY
Process All trauma systems should have defined and governed
Time Interval: point of injury to vascular imaging means of reviewing applicant candidate technologies, filter-
Time Interval: point of injury to surgical vascular control ing out those which are a liability, introducing new thera-
Time Interval: point of injury to reperfusion of limb pies, and assessing for impact on patient care. Both vascular
Time Interval: point of injury to definitive vascular repair of limb and trauma surgeons are familiar with the research para-
Time Interval: from point of consent/assent to amputation or to dox encompassed by the increasingly rapid development
surgery
of exciting new adjuncts to management of their patients.
Provision of definitive rehabilitation prescription
Time to definitive limb fitting The endovascular revolution has allowed multiple types of
devices and of techniques to be introduced to practice—
Outcome with a varying degree of governance and data to support
this. A well-worn narrative implies that developments have
Postoperative compartment syndrome (rate)
Postoperative vascular repair perfusion failure/end organ occurred at such a pace, that lengthy efforts to properly trial
ischemia (rate) the novel intervention are not practical, as the results do not
Postoperative wound or graft infection (rate) reflect emerging or even established practice by the time the
Postoperative amputation (within 30 days) (rate) results are disseminated. Countless examples from multiple
domains run counter to this view—including well-run and
informative trials such as CRASH-2 and multiple random-
ized trials scrutinizing the benefits of carotid stenting for
stroke prevention.27,28 However, in the absence of trial data,
must be made regarding which process data should be and recognizing that new treatments emerge continuously,
used as measures of system efficacy. This decision should leaders must have local policies regulating the introduction
be based on evidence. Similarly, outcome data should be and surveillance of new treatments that enable follow-up
based on agreed definitions. For instance, the terms “early,” and tracking. Properly run device or therapy registries (con-
“late,” “primary,” “secondary,” “emergent,” and “elective” taining prospectively gathered data) are feasible and vital
amputation are defined differently among institutions and knowledge-generating tools and should be managed at the
contexts. The goal is standardized, evidence-based bench- regional or national level.
marks and outcomes of functional recovery that enable
population-stratified comparisons of process and outcomes REBOA
with respect to time and institution. The challenge is not
only to develop the data that describe performance, but to One such new technology has led to renewed interest in
ensure that the data are collected over a large enough popu- endovascular balloon occlusion of the aorta or REBOA.
lation to ensure a sufficient volume of information is avail- First described as a therapy for trauma during the Korean
able for meaningful analysis of infrequent injury patterns. War, recent vascular surgery experience with endovas-
cular devices has led to renewed interest in this mode of
therapy, with commercial devices now available for expedi-
CLINICAL PRACTICE GUIDELINES
tious placement by both surgical and nonsurgical trauma
The JTTR approach to the conflicts in Afghanistan and Iraq providers. Moore et al. evaluated REBOA versus resusci-
led to the dissemination of vascular injury clinical prac- tative thoracotomy and found improved overall survival
tice guidelines to reduce heterogeneity of practice and to and fewer early deaths due to hemorrhage in patients who
improve standardization of therapy, which was widely suc- underwent REBOA.29 The American Association for the
cessful. This military experience should serve as a model for Surgery of Trauma’s AORTA registry demonstrated a trend
civilian organizations to develop and refine their own ver- toward improved survival with REBOA but failed to reach
sion of these, taking into account local and regional specific statistical significance.30 Despite trends toward improved
factors and the broader capabilities of local trauma sys- survival, these studies continue to demonstrate significant
tems. Those with the most utility use a systematic review morbidity and mortality in this patient population. Addi-
methodology such as those provided by the Eastern Associ- tionally, access to the common femoral artery and place-
ation for the Surgery of Trauma or the Society for Vascular ment of catheter have been associated with significant
40 SECTION 1 • Setting the Stage

complications including aortic dissection, rupture, perfo- underway to evaluate the effectiveness of civilian training
ration, embolization, air emboli, and peripheral ischemia.31 and further refine the process.35
Proper patient selection and deployment zone continue to
be an area of ongoing research. Furthermore, although
nonsurgical physicians have been demonstrated to safely Conclusion
place REBOA, several studies from Japan have demonstrated
the importance of early surgical intervention for definitive The development, implementation, and maturation of
control once the balloon is placed, as aortic occlusion for trauma systems within the civilian and military communi-
a prolonged period (>60 minutes) is associated with poor ties have resulted in reduced morbidity and mortality from
outcomes.32 Thus the ultimate utility of this device in the severe injury. Because of its unique capacity to cause death
context of a modern trauma system for control of major and major disability, vascular trauma as a specific injury
vascular hemorrhage is still being evaluated. pattern warrants unique consideration within this dis-
cussion. Furthermore, it is likely that skilled coordination
and application of evidence-based management of vascu-
WHOLE BLOOD
lar trauma within an environment of continuous process
Field resuscitation of trauma patients continues to evolve, improvement will lead to the greatest gains reducing pre-
and the recent US military experience from the conflicts in ventable death following injury.
the Middle East has spurred renewed interest in both whole
blood resuscitation as well as product resuscitation at the References
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Patients with vascular injury are some of the primary ben- meta-analysis comparing outcome of severely injured patients treated
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significant physiologic derangement and subsequent mor- Patient. Chicago: Chicago ACS; 1999.
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vascular injury, as is typical for patients with penetrating a province-wide trauma system on motor vehicle collision process of
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13. Davenport R, Tai N, West A, et al. A major trauma centre is a specialty
geons to help mitigate the strain these events can have on a hospital not a hospital of specialties. Br J Surg. 2010;97:109–117.
trauma system. Campaigns such as “Stop the Bleed,” which 14. Department of Defense Center of Excellence for Trauma. History
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15. Eastridge B, Jenkins D, Flaherty S, Schiller H, Holcomb JB. Trauma
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in an effort to limit blood loss in the field and deliver patients tion Iraqi Freedom and Operation Enduring Freedom. J Trauma.
to the trauma system with less physiologic derangement.34 2006;61:1366–1372.
Other efforts including local, regional, and national efforts 16. Hodgetts T, Davies S, Russel R, McLeod J. Benchmarking the UK
in support of safe gun practices and safe gun storage are military deployed trauma system. JR Army Med Corps. 2007;153(4):
237–238.
hoped to also mitigate the overall burden of vascular injury 17. Eastridge BJ, Costanzo GS, Jenkins DH, et al. Impact of joint theater
as a result of ballistic injury in the community. The effec- trauma system initiatives on battlefield injury outcomes. Am J Surg.
tiveness of these programs is hard to judge, but efforts are 2009;198(6):852–857.
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18. Department of Defense Center of Excellence for Trauma. Joint 28. Meier P, Knapp G, Tamhane U, et al. Short term and intermediate term
Trauma System Clinical Practice Guidelines. Available from: https:// comparison of endarterectomy versus stenting for carotid artery ste-
jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs. nosis: systematic review and meta-analysis of randomized controlled
19. S. 2943—114th Congress. National Defense Authorization Act for clinical trials. BMJ. 2010;340:c467.
Fiscal Year 2017 (Public Law 114–328). Washington: US Govern- 29. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscita-
ment Publishing Office. tive endovascular balloon occlusion of the aorta as an alternative to
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Ann Surg. 2007;245:986–991. 30. Dubose JJ, Scalea TM, Brenner M, et al. The AAST prospective Aor-
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RF. Understanding combat casualty care statistics. J Trauma. (AORTA) registry: data on contemporary utilization and outcomes
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lower-extremity-arterial-trauma,-evaluation-and-management-of. cold-stored, low titer O+ whole blood. Transfusion. 2019;59:1429–
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 4 Training Paradigms for
Vascular Trauma
PAUL W. WHITE and JAMES B. SAMPSON

Introduction and impractical to meet the demand. Surgical educators

have also responded by developing short courses involving
The issue of surgical training—whether vascular or gen- both didactic and simulation training to meet the demand
eral—faces a number of significant current and future for additional training in the management of vascular
challenges. Firstly, the advent of vascular surgical residen- injuries.
cies in the United States and Great Britain has widened
the gap between vascular surgery and general surgery as
specialties, and it has specifically limited the exposure of Graduate Medical Education
vascular surgeons to major trauma and constrained the
general surgeons experience with regard to the fundamen- Training in surgery has traditionally followed an appren-
tals of diagnosis and management of perfusion abnor- ticeship model, with the trainee undergoing supervised
malities, techniques of vascular imaging, exposure, and exposure to decision-making and technical skills under the
surgical or endovascular intervention. Secondly, the intro- tutelage of a “craft” master. Historically, the acquisition of
duction of work-hour restrictions in the United States, the vascular techniques—whether by master or apprentice—
United Kingdom, and the European Union has led to dra- has followed a model whereby the development of new
matically decreased opportunities for professional contact skills occurs via adaption and remolding of previously
with patients and clinical material for all trainees.1–7 The learned skill sets. However, with the increased adoption of
full impact of these work-hour directives is only now being multimodal imaging in the diagnosis and minimally inva-
assessed. However, a recent study by the Royal College of sive techniques in the management of general surgical and
Surgeons of England suggests that the quality of patient vascular disease, the opportunity to transfer previously
care has sharply declined because of the lack of continuity learned skills to these new realms of practice is concor-
of care, and it further suggests that operative exposure is dantly lower. Image acquisition and interpretation at the
insufficient to ensure competency in an adequate range of point of care and new endovascular therapies pose sub-
procedures for independent practice.8 Thirdly, the develop- stantial technical challenges, similar to those experienced
ment of ever–increasingly complex procedures, including by practitioners of laparoscopic and minimally invasive
endovascular techniques, has strained the ability of sur- surgery (MIS). These include reduced tactile sensation, a
gical residency or fellowship programs to endow compe- two-dimensional (2-D) (rather than a three-dimensional
tence and proficiency in all the required areas of practice. [3-D]) perspective, and the need to overcome propriocep-
Fourthly, the extensive adoption of minimally invasive tech- tive and visual issues.15,16 Additional data sources and new
niques, both endovascular and laparoscopic, has decreased decision-making algorithms and treatment opportunities
the opportunities for trainees to develop the open surgical often require new training models and educational cur-
skills needed to treat traumatic injuries.9 Fifthly, there is ricula—applicable to both established specialists and sur-
increasing scrutiny of the quality of health care, brought gical trainees—while paying heed to new restrictions in
about by a number of high-profile cases involving medical duty hours. The relentless and inevitable drive to subspe-
errors, such as the Bristol Enquiry in the United Kingdom cialize has concurrently required practitioners to master
and the Institute of Medicine’s “To err is human” report new techniques at the cost of narrowing clinical focus and
in the United States.10–14 This increasing scrutiny has led constraining the surgical armamentarium required for
to closer supervision and less independence during surgi- trauma injury management. With these issues in mind, it
cal training, which in turn can impede the development of is timely to consider new and emerging ways of deliver-
confident and decisive surgical trainees. ing training to surgeons expected to manage patients with
As a result of these challenges, current training para- vascular trauma.
digms for both general and vascular surgery are inadequate The current trend in surgical training within the United
for expert management of traumatic vascular injury, and States is toward a structured, competency-based cur-
they each provide a different foundation on which to build riculum with objective and ongoing documentation of
with additional training. This has led some individuals who proficiency within residency training and then going into
are particularly interested in vascular injury management independent practice. Toward this end, national organiza-
to seek additional training or experience in both trauma tions including the American College of Surgeons (ACS),
management and vascular disease management. This dual the American Board of Surgery (ABS), the Residency
training has resulted in some true experts, but it is inefficient Review Committee–Surgery (RRC-S) of the Accreditation

42
 4 • Training Paradigms for Vascular Trauma 43

Council for Graduate Medical Education (ACGME), the available on the operative experience of residents. Exam-
American Surgical Association, the Association for Pro­ ining ACGME case logs from 1999 to 2017, Cortez et al.
gram Directors in Surgery, and the Association for Surgical found a 10% decrease in vascular case volume reported
Education have established a national consortium called by general surgery residents.26 A more detailed analysis
the Surgical Council on Resident Education (SCORE) to of ACGME case data by Drake et al. found that case vol-
reform general surgical residency education.17 The SCORE ume declined by 50% in the chief resident year, arguably
has developed a national curriculum. The SCORE portal the most important year to consolidate and firmly estab-
provides a modular curriculum that combines learning lish the knowledge, skills, and abilities (KSAs) of surgical
objectives, discussion questions, text resources and videos, practice.27 Open arterial cases are clearly those most nec-
and self-assessment quizzes in a single online format. Pro- essary to develop competence in treating vascular trauma,
gram directors can track a trainee’s progress by self-study and those have also declined at an alarming 38% over
through the curriculum over the course of a residency.18 the first two decades of the 21st century.28 The average
The Association for Program Directors in Vascular Surgery number of vascular cases for trauma that were reported
has nearly completed a similar curriculum specific to vas- by graduating residents to the ACGME as being performed
cular surgery (VSCORE). The aim is to ensure alignment of over the entire residency program in general surgery
the core content of the training program, the core compe- decreased from 5.2 in 1999–2000 to 1.5 in 2008–09 to
tencies expected as learning outcomes, and the assessment 1.1 in 2017–18 (Table 4.1).29,30 It is important to bear in
practices. This will confirm that—no matter what program mind that these data reflect average experience, and as
or tract a resident completes—measurable and acceptable such there are significant numbers of trainees who have
levels of competence are achieved in all required areas.19 no experience caring for patients with major vascular
Unfortunately, experiential learning through case volume trauma. Furthermore, the reported experience of all upper
has suffered significantly since the late 1990s, and the extremity vascular cases by graduating general surgery
decline in case volume threatens the effectiveness of our residents averaged 2.0 cases per trainee in 2017–18.29,31,32
current training paradigms. These reports reveal extremely limited experience in the
management of vascular injury and very limited experi-
ence in open vascular surgery in specific anatomic regions.
GRADUATE MEDICAL EDUCATION/RESIDENCY
This is particularly concerning to the military commu-
TRAINING IN GENERAL SURGERY nity because of experience from operations in Iraq and
The increasing specialization of vascular surgeons and Afghanistan where the brachial artery was a frequently
their training, especially with the advent of stand-alone injured structure. The decline in case volume is multi-
GME programs in vascular surgery, has diluted the available factorial, and many of the relevant changes in training
training opportunities for general surgery residents with have occurred nearly simultaneously. In addition to the
the majority of open vascular cases being done by vascular transition to laparoscopic, endoscopic, and endovascular
surgeons and vascular residents/fellows.20–23 In a study of techniques, an increasing trend toward conservative man-
22 general surgery residencies, the opening of a vascular agement of solid organ injury has contributed to signifi-
surgery fellowships was associated with a 17% decline in cantly fewer opportunities for trainees to undertake open
vascular surgery cases for general surgery residents.24 Simi- surgical procedures.33–35
larly, the opening of a 0-5 integrated vascular surgery resi- The advent of duty hour restrictions has also had a
dency was associated with a 20% decline in vascular case deleterious effect. Although overall case numbers have
numbers for general surgery residents at the University of remained stable for general surgery residents, the breadth
South Florida.25 and variety of operative experience has declined. Increases
Overall, and in spite of the fact that many still consider in laparoscopic and alimentary tract procedures have off-
vascular surgery to be an integral part of general sur- set significant declines in trauma and vascular cases.36
gery training, trainees are getting less experience in this The 80-hour workweek has also increased the variability
area. Surgical residents in the United States are required of residents’ experience. Whereas average case numbers
to self-report the number and nature of the cases they remain the same, the difference in case volume between
perform during their training to the ACGME. Although residents has increased suggesting that the quality of
the quality of these case logs is limited by the nature of graduating residents may be more variable.37 The hope
self-reporting, they remain the best quantitative data that many of the KSAs needed to treat vascular injuries

Table 4.1 The Average Number of Selected Cases over the Duration of Training
1999–2000 2002–03 2005–06 2008–09 2011–12 2014–15 2017–18
Major vascular cases for trauma— 5.2 4.9 4.6 4.7 1.5 1.2 1.1
General Surgery Residents
Major vascular cases for trauma— 7.2 8.1 10.7 12.5 10.7 12.2 12.0
Vascular Surgery 5+2 Fellows
Major vascular cases for trauma— NA NA NA NA NA 11.0 10.1
Vascular Surgery 0+5 Residents
Note: This data was reported by graduating chief residents and was supplied as part of the case log submitted to the American Board of Surgery from 1999 to
2018.
Numbers represent the mean for each procedure; and, if missing (NA), that procedure was not reported during that particular year.
Data collated from https://www.acgme.org/Data-Collection-Systems/Case-Logs-Statistical-Reports.
44 SECTION 1 • Setting the Stage

in trauma patients can be gained by elective operative (SVS) voted in 1979 to develop accredited vascular train-
experience is unfounded. The concurrent decrease in total ing programs. Initially, 17 programs were approved, ris-
vascular cases, open arterial cases, and trauma cases after ing to 52 programs by 1982.48 In 1982, the first 14 ABS
duty-hour restrictions calls in to questions the prepared- Certificates of Special Qualifications in General Vascular
ness of general surgery trainees to treat trauma.38 Surgery were issued, each earned after successful comple-
Based on the data presented, it is clear that general tion of a written examination. In the 1990s, leading vas-
surgery residents in the United States have a suboptimal cular surgeons pushed for recognition of vascular surgery
experience with the surgical management of vascular as a specialty distinct from general surgery, based on the
trauma. In Canada, vascular surgery has been removed underlying premise that patient outcomes were improved
from the Canadian general surgery training objectives. In when care was provided by a specialist in vascular surgery
a survey of 29 Canadian surgical residents, 90% reported rather than a general surgeon who occasionally performed
an intention to perform vascular procedures after train- vascular operations.49–51 Subsequently, vascular surgery
ing despite the same cohort self-reporting of inadequate became a distinct specialty of surgery on March 17, 2005,
training in 10 of the 13 procedures surveyed.39 Unsur- when (with approval of the American Board of Medical
prisingly, the authors of this study concluded that cur- Specialties) the ABS agreed to offer a Primary Certificate
rent trainees may lack the skills and abilities to deal with in Vascular Surgery.46 In October 2005, training program
vascular emergencies. requirements for this certificate were approved, and the
In spite of the growing prevalence of specialist-trained traditional requirement for 5 years of training and certifi-
vascular surgeons, there are still many areas in the world cation in general surgery was eliminated. Effective July 1,
(developed and underdeveloped) where the primary sur- 2006, the ABS converted its certificate in vascular surgery
geon may not be a vascular surgical specialist and where from a subspecialty certificate to a specialty (primary) cer-
opportunities to practice a vascular skill set are infre- tificate. These landmark changes heralded the development
quent. Ensuring that a fully trained vascular surgical spe- of new training paradigms. Two pathways have evolved:
cialist is available for each and every trauma case is not the traditional Independent (5+2) 2-year vascular surgery
practical in many hospitals, and is certainly unfeasible in fellowships following a 5-year general surgery program and
the austere domains of military and humanitarian surgi- Integrated (0+5) vascular surgery residency immediately
cal practice. Thus, the need to train competent practitio- following medical school. 5+2 graduates are eligible for
ners who can handle vascular trauma is universal.40–43 dual board certification by the ABS in general and vascular
The development of vascular damage control techniques surgery while 0+5 graduates are only eligible for vascular
such as vascular shunting, which require a less refined surgery certification.
set of KSAs, offers a potential solution wherein vascular Vascular trauma is increasingly funneled toward spe-
injuries can be temporarily managed by general surgeons cialist trauma or vascular surgeons, but opportunities to
with shunting followed by evacuation or transport to a gain experience in vascular trauma are still limited.42 The
vascular specialist.44 numbers of major vascular repairs for trauma that were
reported to the ABS by vascular surgery fellows—though
significantly greater than that reported by graduates of
GRADUATE MEDICAL EDUCATION/RESIDENCY
general surgery residencies—are small, with the average
TRAINING IN VASCULAR SURGERY number of cases reported as 7.2 in 1999–2000 and 12.0
Within the United Kingdom, the vascular curriculum is in 2017–18 (see Table 4.1).29 Furthermore, more than 60%
set by the Intercollegiate Surgical Curriculum Programme of these procedures were peripheral in nature with surgical
(ISCP).45 The ISCP benefits from the input of specialty advi- experience of vascular trauma in the thorax and neck being
sory committees (SACs) representing each of the 10 surgi- particularly low, averaging less than one case in each area
cal specialties. It is also informed by and collaborates with per resident.
the Surgical Royal Colleges of Great Britain and Ireland and Integrated and Independent GME programs seem to
other professional bodies, including the Local Education provide a similar volume of vascular trauma cases to
and Training Boards (established in 2013) and the General trainees although long-term data is not available yet (see
Medical Council (GMC). In 2012, vascular surgery became Table 4.1). In addition, overall case numbers in most
established as a fully-fledged surgical specialty and left the categories of vascular surgery are similar between gradu-
aegis of the General Surgery SAC, with a dedicated training ates of integrated and independent programs.52 Nonethe-
pathway leading to specialist certification, separate from less, there may be important differences in the experiences
that of general surgery. of graduates from these different types of programs.
In the United States, vascular surgery has been (and is Graduates of independent programs have a more concen-
still considered by many to be) an integral part of general trated operative experience performing more open and
surgery training and practice.46 Before 1960, no specific major cases during their final years of training.53 The
training programs existed in vascular surgery, and vascu- advantages of completing general surgery residency may
lar surgery was practiced by general and cardiothoracic also be significant. Between 2012 and 2014, graduating
surgeons. The first vascular surgery–specific training pro- general surgery residents performed more than twice as
grams, including the vascular surgery fellowship at Walter many open abdominal procedures on average than inte-
Reed Army Medical Center, were, in essence, apprentice- grated vascular surgery residents.54 Integrated vascular
ships directed by some of the pioneers of vascular sur- surgery residents do pursue open surgical procedures
gery.47 Training opportunities were advanced considerably during their general surgery rotations, but these cases are
when the membership of the Society for Vascular Surgery most often minor, nonabdominal procedures.55
 4 • Training Paradigms for Vascular Trauma 45

Endovascular surgery has had a mixed effect on case vol- information and to construct a strategy that enables the
ume in vascular training programs. Open peripheral case best use of the relevant skill. In other words, cognitive ori-
volume has remained stable, whereas endovascular case entation is needed in order to make appropriate decisions.59
volume has exploded.56 Open aortic case volume, however, Didactic lectures, textual material, and, more recently, case-
has decreased dramatically. Of the approximately 45,000 based training have been used for transfer of information
abdominal aortic aneurysms (AAA) repaired in the United and cognitive skills. Technical and cognitive components
States each year, only 15% are repaired with open tech- of clinical training are inseparable; they inform each other.
niques.57 The effect of this on vascular surgical trainees’ Since Dewey’s 1938 pioneering work,60 experiential learn-
ability to care for vascular trauma is unknown. ing has been recognized as an important part of how adults
After training, experience with vascular trauma remains acquire new knowledge and skills (i.e., “learning by doing”
limited for many surgeons. US vascular surgeons seeking is a particularly effective method for advancing cognitive
recertification have reported the following data: in 2003, and technical skills). Modern theory emphasizes the prob-
only 46% of surgeons reported having undertaken any lem-centered approach and the need to understand the
trauma cases in the previous 12 months; in 2009, this contextual orientation of the adult learner.61 Effective and
proportion had diminished to 23%. In both cohorts, the systematic training is a byproduct of the quality of the cur-
accumulated annual experience amounted to an average of riculum that is developed to enhance that training.
four procedures.58 Though it is difficult to judge proficiency As yet, the ideal curriculum for training in vascular
and competence by volume data alone, it is certain that the trauma has not been delineated and will likely be specific
experience of trainees is anything but uniform, and the lim- to national situations as well as the needs of and learning
ited experience raises the question whether these specialists styles of individual learners. However, the ideal curricula
have the requisite skill set to ensure the best outcomes when will clarify goals and objectives in unambiguous terms,
called to care for patients with vascular injuries. Likewise, driven by consensus of expert opinion. The obvious goal is
only a small minority of vascular specialists report that to produce competent and proficient practitioners who can
management of vascular trauma comprises part of their appropriately diagnose and apply cognitive, technical, and
clinical practice. teamwork skills to the management of patients presenting
It is clear that the experiential approach cannot be relied with vascular trauma, aided by a thorough understand-
on as a means of endowing surgical trainees with the ing of anatomy and current open-surgical and endovas-
required KSAs to expertly manage vascular injuries. As cular techniques. The remainder of this chapter will focus
such, there is a critical need to improve the way training is on the wide variety of tools that are currently employed to
conducted in order to secure the best care for patients with train in vascular surgery in general and vascular trauma in
vascular trauma. The remainder of this chapter explores particular.
the evolving challenges faced by those tasked with training
the surgeon of the future and discusses current and near- VASCULAR TRAUMA TRAINING TOOLS
term modalities that are likely to improve the uniformity of
training in the management of vascular trauma. The tools currently available to teach the management of
vascular trauma include the following:

1. Clinical case material—care of patients

Ways Forward for Vascular Trauma 2. Didactic lectures
Training 3. Textbook and digital media
4. Case-based discussion
As previous chapters demonstrate, effective trauma man- 5. Team-based training
agement presents specific challenges, with the requirement 6. Animal-model–based training
for rapid, systematic assessment and decision making to 7. Human-cadaver–based training
prevent patient deterioration. However, every injury pat- 8. Simulation-based training
tern is unique with some factors coming to light only in the a. Synthetic models—low and high fidelity
operative phase of management, and it is not always pos- b. Virtual reality
sible to rehearse and preplan all aspects of surgical man-
agement. This mandates that any training algorithm must The ideal vascular trauma curricula will incorporate sev-
include core principles that can be adapted and can be flex- eral of these tools ordered to the goals and objectives of the
ibly deployed to deal with the individual situation at hand. educational program. Clinical case material has long been
Training must be set at two distinct levels: (1) the KSAs the mainstay of vascular trauma training, but, as discussed
required by nonvascular specialists to prevent deterioration, previously, can no longer be counted on to provide sufficient
to surgically stabilize the patient, and to set the conditions experience. Didactic lectures, textbook and digital media,
for further specialist intervention and (2) the advanced and case-based discussion represent the bulk of traditional
specialist skills necessary to deal with complex injuries, methods to convey information, but have limited effective-
postoperative issues, complications, and guide long-term ness if not focused by and incorporated within a meaning-
management. Clinical educators generally consider surgical ful curriculum. Likewise, simulation training using animal
training to have the following two separate components: (1) models and human cadavers have proved extremely useful
a “hands-on” practical learning of technical skills and (2) in the training of surgeons, but their use must be based on
the acquisition of knowledge and cognitive skills. Cognitive a thorough needs assessment and on a good understanding
orientation centers around the ability to organize relevant of their inherent limitations.
46 SECTION 1 • Setting the Stage

The use of animals for training has several advantages pump system and injuries created in the heart, lung, liver,
and a number of distinct limitations. Animals provide excel- and inferior vena cava, allowing for repair in a “bleeding
lent approximations of human physiology, necessitating human model.”70 Though this technique improves the fidel-
careful and appropriate choices and executions of surgical ity of the cadaveric model, it requires significant preprocess-
maneuvers in order to avoid excess hemorrhage and death. ing and equipment, as well as very fresh cadaveric material,
Animal tissues require standard operating equipment and making it impractical for widespread use and adoption.
supplies; they bleed when cut; and they exhibit damage if
not handled, dissected, and sutured carefully.62,63 However, TEAM-BASED TRAINING FOR VASCULAR TRAUMA
maintenance of an animal laboratory is expensive and
logistically intensive, requiring veterinary support, animal Since the turn of the century, there has been an explosion
care facilities, sterile operating rooms (OR), and humane of interest in training hospital teams using methods similar
and sanitary disposal of the animals. Animal laboratories to those utilized by the aviation industry.71–76 Nontechnical
are rightly subject to stringent care standards in order to skills are the cognitive and social skills that enable people
ensure animal welfare. The use of animals is a highly visible working in safety-critical industries to function effectively
and emotionally charged issue decried by very active and and safely. Decision-making and nontechnical skills signifi-
vocal animal rights groups.64 Another key disadvantage of cantly influence the quality of care afforded to the injured
animal models concerns differences in anatomy such that patient. It is abundantly clear that the surgeon is just one
they are usually inadequate for teaching anatomic vascular part of the health-care team and that the team as a whole
exposures. The availability of live animal models for train- that must function optimally to secure the best possible
ing purposes is highly variable across the world and is pro- outcome. No amount of technical virtuosity on the part
hibited in many areas. Though still available in the United of the surgeon will overcome such errors, which can only
States, the US Department of Defense (DoD) has directed be addressed through effective training in teamwork, deci-
that medical simulation and other alternative methods of sion making, and communication. As such, crew resource
training are to be utilized to the maximum extent practica- management (CRM) is now high on the clinical agenda
ble before the use of animals for the training of physicians with the UK House of Commons Health Committee recently
and combat medics.65 The surgical community must there- acknowledging the critical influence of human factors on
fore be proactive in searching for replacements to live-tissue patient safety.77 Examples of CRM skills include the following:
training as this model is unlikely to be universally available
in the future. n Teamwork/team coordination
Cadaver-based training is particularly useful for teach- n Communication
ing vascular exposures in humans, a skill essential to the n Leadership/followership
effective treatment of vascular injuries.64,66 The availability n Decision making
and cost of cadavers is highly variable, as is the cultural n Conflict resolution
acceptability of using cadaveric material around the world. n Assertiveness
For instance, the cost of obtaining cadavers for one such n Management of stress and fatigue
trauma course (the Advanced Surgical Skills for Exposure n Workload management
in Trauma [ASSET] course) is highly variable, ranging up to n Prioritization of tasks
$8000, depending on the US state concerned. Even in areas n Situational awareness
where it is possible to obtain cadaveric material, the num-
ber of adequate specimens may not be sufficient to meet the CRM skills-training significantly improves teamwork and
need. Of interest is the low willingness of medical profes- communications skills and there is increasing evidence
sionals to donate their own bodies for medical education. In that it improves patient outcomes.74,78,79 A Veterans Affairs
a recent survey of medical professionals in India, only 22% (VA) study reported a 50% reduction in surgical mortality
of physicians stated that they were willing to donate their between CRM-trained surgical teams versus non–CRM-
bodies for medical education (though only 7% had already trained surgical teams.72 Further studies in the VA system
registered to do so), but 68% expected the public to do the showed a reduction of 18% in mortality rates in 74 facili-
same.67 ties that received training compared to a 7% reduction in 34
Though cadavers give an excellent representation of control facilities.80 The US DoD has implemented a program
human anatomy, they have some limitations. Most cadav- called TeamSTEPPS to address CRM issues in DoD facilities,
ers are elderly and deconditioned—translating the lessons and it is currently used widely both in civilian and military
learned on an 80-year-old woman with diminished mus- settings.76 US military units have undergone and imple-
cle mass to a muscular 20-year-old male may be difficult. mented CRM training in deployed environments.81 This
Cadaver tissue preserved in formalin has very different approach has also been used in Norway, using a live porcine
characteristics than tissue found in a fresh or fresh-frozen model, to develop team skills in damage control surgery in
cadaver. Cadavers have no blood flow and do not bleed. a rural setting.82 In general, CRM within both military and
Attempts have been made to improve the fidelity of cadaveric civilian trauma systems is under-researched, although a
specimens by cannulating the vessels of very fresh cadavers set of related studies from the aviation, the organizational
and perfusing them with artificial blood in a pulsatile fash- sciences, and the social psychology domains illustrates the
ion.68–70 Initially developed for neurosurgical training, such potential for future study in this area.83
perfused cadaver models have been modified as potential Clinical CRM training should involve the whole team so
tools for training on trauma surgical procedures. Pulsatile that all members share a common purpose and develop a
flow can be obtained using a modified intraaortic balloon full understanding of individual and team roles. Although
 4 • Training Paradigms for Vascular Trauma 47

likely to be important in civilian settings, there is no doubt near-instant feedback that is informed by objective assess-
that exceptional nontechnical skills are essential for the ment data, which has been captured during the simulated
military trauma team practicing in austere circumstances. procedure, would seem desirable.104,105 In contrast to the
As such, CRM training was a core feature of the UK Defence traditional “learning by doing” model (where assessment is
Medical Services predeployment Military Opera­tional Surgi- often subjective and biased toward individual supervisors),
cal Training (MOST). performance data obtained from simulators allow mentors
to objectively evaluate problems and to address these sys-
tematically before moving on to the next stage. Appropriate
SIMULATION-BASED TRAINING FOR VASCULAR
mentorship within the curriculum is crucial.106
TRAUMA Simulation is a tool within a curriculum and is not its
Simulation-based training is becoming widely established end98,107; the curriculum developers set the context with
within surgical education, and simulation centers dedi- regard to subject matter and schedule of learning.108 How-
cated to teaching the technical aspects of surgical skill have ever, in order to make the best use of simulated training,
become increasingly popular.64,84 This training offers obvi- it is best that educators and simulation experts align their
ous benefits to novice surgeons who are learning invasive efforts from the outset and work in tandem.109 Certainly the
procedural skills and to practicing surgeons who need skill potential for use of simulation for technical skills is signifi-
refreshment. Simulation-based training provides a safe, cant for vascular trauma training. Simulations may include
structured environment for motor skills acquisition, with both open and endovascular skills and may cover the fol-
the aim of preparing trainees for real-life OR experience. lowing learning outputs:
Trainees may improve their performance, may overcome
learning curves, and may manage simulated procedural n Assessment, planning, and prioritization
complications without risk to patients.85–88 The importance n Surgical approaches and anatomy
of simulation in training has been recognized by the Resi- n Control of hemorrhage
dency Review Committee for Surgery, with the most recent n Repair of vascular structures
ACGME Program Requirements for General Surgery stating
that resources should include “simulation and skills labo- Simulators applicable to vascular surgery range from
ratories.” The Agency for Healthcare Research and Quality partial-task trainers to high-fidelity mock operating rooms.
supports the effectiveness of simulation training “especially The key to successful simulation is “willing suspension
for psychomotor and communication skills,” although it of disbelief ” on the part of the learner—in that he or she
is recognized that supportive data is limited.89 However, finds it difficult to distinguish between the simulator and
the available evidence suggests that technical skills gained a live patient or scenario. Simulators designed to mimic
in the simulation laboratory do transfer to the OR43,90—a endovascular or laparoscopic procedures are better able to
benefit also demonstrated for endovascular simulators in accomplish this, whereas those designed to represent open
animal91 and human92 studies. Practice of open surgical vascular surgical procedures are generally of lower fidelity
skills on low-fidelity models (e.g., synthetic models) has and may suffer from inadequate face and content validity—
also been shown to improve technical skill acquisition and which can directly affect applicability of simulator-acquired
retention.93–95 skills to real world scenarios.
Current trends in medical and surgical skills training Sidhu et al. studied a group of surgical residents learn-
confirm movement away from the traditional apprentice- ing vascular anastomoses skills and found that skill trans-
ship model of graded responsibility to a more structured fer was better when they were trained on a higher-fidelity
approach, with stepwise progress toward the attainment of model (human cadaver brachial arteries) when compared
technical competence.96,97 The concept of the “pretrained with those training on a lower-fidelity (plastic models) vari-
novice” used by educational psychologists refers to a ant.93 This lesson must not be overlooked by those respon-
learner who has automated the required suite of basic psy- sible for developing simulation models—it is not enough
chomotor skills and spatial judgments.98 Enabling a trainee to incorporate a simulator into a curriculum without first
to reach this position via simulation is attractive because ensuring that it has the appropriate level of fidelity to meet
subsequent OR training is likely to be a higher-yield experi- the goals and objectives required.
ence for the learner and is likely to be safer for the patient. Like endoscopy and laparoscopy, practitioners of endo-
Simulation-based training should commence with initial vascular surgical techniques use screen-based technologies,
cognitive training,99 should include predefined proficiency enabling more opportunity for faithful simulation as com-
levels that trainees must reach before moving to the next pared with open surgery. Several endovascular simulators
level,100,101 and should offer distributed practice sessions are currently commercially available, providing a variety
to reinforce acquired skills.102,103 This structured approach of training options, such as angioplasty and stenting of the
avoids the random presentation of cases typical of experien- carotid, renal, iliac, and superficial femoral arteries; caval
tial Halstedian learning. Cases should include complicated filter deployment; and aortic aneurysm stent repair. These
and crisis scenarios, so that correct management of poten- are classified as high-fidelity simulators as haptic (touch),
tial problems is therefore practiced. Simulation programs aural, and visual interfaces are simulated, providing near-
should guard against overtraining, should include validated realistic representations.110,111
methods of assessment, and should have protected time for Chaer et al. conducted the first randomized study exam-
feedback and error analysis88 because this has been shown ining the transfer of simulator-trained endovascular skills
to improve performance. Although the optimal type of to the clinical environment.92 Twenty general surgery
feedback has not been established, the facility to undertake residents without prior endovascular experience were
48 SECTION 1 • Setting the Stage

randomized to a 2-hour period of simulator training versus

no training. Participants were then supervised through two
VASCULAR TRAUMA SURGERY SHORT COURSES
endovascular interventions in patients with lower extrem- A number of courses and curricula have been developed to
ity occlusive disease. Using a global performance rating teach basic and advanced vascular trauma skills. The fol-
scale, the residents who received simulation training scored lowing section highlights a selection of such courses that
higher by their supervisors than the control group in the are embraced by leading surgical organizations designed to
first endovascular case, and this finding persisted with meet this challenge.
second case performance. A separate review performed
by the Best Evidence Medical Education (BEME) collabora- The Definitive Surgical Trauma Care Course
tion found that “the weight of the best available evidence The Definitive Surgical Trauma Care (DSTC) course traces
suggests that high-fidelity medical simulations facilitate its origins to a meeting of five internationally known trauma
learning under the right conditions.”112 It also found that surgeons from the United States, Canada, France, and
the quality of the supportive literature was generally poor Australia. These five members of the Societé International
and was based around narrative and qualitative analyses. de Chirugie (SIC) and the International Association for the
Further studies are required to determine how degree of Surgery of Trauma and Surgical Intensive Care (IATSIC)
exposure to simulation relates to benefit, to investigate the determined that there was a worldwide need to enhance
optimal strategy for incorporation into training curricula, surgical training in the technical aspects of trauma care.118
and to better understand for which interventional proce- DSTC is designed to teach qualified surgeons and advanced
dures endovascular simulation is best suited. surgical trainees strategic thinking and decision making in
The European Board of Vascular Surgery (EBVS) has the management of severely injured patients, and provide
been the vanguard of using simulation as an assessment them with the surgical skills required to manage major
tool (probably out of necessity due to the wide spectrum organ injury. Taught by experienced trauma-trained sur-
of differences in training among the countries of the Euro- geons, it is an intensive 2-day course comprising lectures,
pean Union). Qualification as a vascular surgeon by the interactive case discussions, and laboratory-based surgi-
EBVS requires a demonstration of knowledge and cogni- cal skills training. The surgical skills laboratory is variably
tive ability coupled with a technical and endovascular skills comprised of cadaver, animal (pig or goat), or both animal
assessment.113 Validation studies of the EBVS skills assess- and cadaver models, depending on local availability and
ment have been conducted, which have promoted accep- cultural sensitivities regarding the use of such models. In
tance and continued use of simulation in the evaluation of 2014, DSTC courses were taught in 41 centers around the
vascular surgical candidates.114,115 world at sites including Spain, Israel, Canada, Denmark,
However, in spite of advances in simulation for training the Netherlands, Australia, New Zealand, South Africa,
in endovascular therapy, it is important to note that the Austria, Portugal, Norway, Sweden, Germany, France,
vast majority of vascular trauma is (and will likely continue Greece, Singapore, and Argentina. This truly international
to be in the near future) treated using open surgical tech- course provides a broad overview of techniques applicable
niques. As such, there is an unmet need to develop open to the patient who requires surgery and intensive care for
skills simulation and assessment for the management of major trauma. The flexibility of the course ensures that it
vascular trauma. Sidhu and colleagues116 have developed a can be adapted to local conditions although some degree
comprehensive vascular skills assessment (CVSA) for surgi- of standardization is lost. The course includes vascular
cal trainees. Candidates undergo a series of four 20-minute exposures and hemorrhage control but does not set out to
vascular skills stations where control and repair of inferior teach repair or advanced management of vascular trauma
vena cava injury, a femoral embolectomy, a graft-to-artery injuries.
anastomosis, and an ultrasound-guided line insertion are
assessed by a vascular surgeon using a previously validated Definitive Surgical Trauma Skills
global rating scale.117 The CVSA has excellent construct Definitive Surgical Trauma Skills (DSTS) is a 2-day (origi-
validity and correlates well with postgraduate-year level, nally 3-day) hands-on practical cadaveric workshop course
although the actual performance scores obtained by the for civilian surgeons who are required to perform life-
residents were low (with a mean score of 50%), reinforcing preserving surgery on severely injured patients, as part
the need for improved and targeted training. of their on-call duties, and for military and humanitarian
Several barriers to widespread integration of endovascu- surgeons who may deploy to conflict zones.119 This course
lar simulators into training programs exist. The devices are was a collaborative effort between the Royal College of Sur-
expensive (in excess of $100,000) and require regular cali- geons of England, the UK Defence Medical Services, and the
bration, maintenance, and updating as reliability remains Uniformed Services University of the Health Sciences in the
problematic. Current training on the simulator is also lim- United States. Though there is significant content overlap
ited by realism with regard to tactile feedback and graphical with the DSTC course, DSTS was developed specifically to
interfaces. Transferability of endovascular and open skills meet local needs and to include an emphasis on cardio-
from the virtual reality realm to the OR remains to be defini- thoracic injuries and vascular surgical techniques. In the
tively proven. However, there is little doubt that the concept words of the original conveners:
of simulation is here to stay. As technology continues to
advance, more sophisticated simulators will become avail- To manage trauma competently there is a need to master opera-
able to help surgeons achieve clinical competence, thereby tive skills that cover the whole of the abdominal cavity, includ-
reducing the number of errors and ultimately improving ing the pelvis and the retroperitoneum. General surgeons should
patient safety. be competent and confident to carry out trauma thoracotomies
 4 • Training Paradigms for Vascular Trauma 49

and able to cope with central and peripheral vascular trauma.

Advanced Surgical Skills for Exposures in Trauma
Further skills and knowledge are also required … encompassing
trauma epidemiology, critical decision making and, not least, a (ASSET)
detailed knowledge of surgical anatomy.118 ACSCOT established a Surgical Skills Committee in 2005
that was tasked to develop a standardized, skills-based
Taught by an experienced international faculty of civil- course targeted at surgical exposure of those vital struc-
ian and military surgeons, the course emphasizes the con- tures most likely to be involved following potentially or
cepts of damage control resuscitation and surgery using immediately life- or limb-threatening injuries. This resulted
limited didactic material, multiple case discussions, and in the establishment of a new educational course known
extensive “bedside” exposure in the human cadaver lab. as ASSET. The committee established the following three
These scenario-driven sessions are supported by surgical educational objectives for the course participants: to
anatomy tutorials using the extensive prosected specimen gain knowledge in the proper surgical exposure of life-
preparations of the Royal College of Surgeons of England, threatening injuries, to improve self-confidence in opera-
under the supervision of a senior clinical anatomist. tive exposure, and to promote technical competence in
DSTS covers all of the techniques required for vascular accessing vital structures. The intended audience include
exposure of the vessels in the torso, as well as the junctional senior surgical residents (postgraduate years [PGY]-4
and proximal extremities. Techniques such as shunting, and PGY-5), trauma and acute care surgery fellows, and
primary repair, and vessel patching are taught, although practicing general surgeons involved with trauma care.
the course emphasizes damage control over definitive vas- To develop the curriculum, the committee developed a
cular repair. As such, DSTS in its current form provides comprehensive list of life- and limb-threatening injuries
familiarization with the essence of vascular repair, but it is for potential inclusion. Using a modified-Delphi process,
not designed to formally teach vascular surgery. The use of the committee members ranked each item for priority and
fresh frozen cadavers, combined with excellent anatomic relevance in the practice of trauma surgery; a specific sur-
prosections and the real-time input of a senior anatomist, gical exposure had to be endorsed by at least 90% of the
provides a level of anatomic accuracy and tactile realism committee membership for inclusion. The various injuries
unique to this course. were then grouped by anatomic region as follows: (1) head
and neck, (2) thorax, (3) abdomen and pelvis, (4) retroperito-
Advanced Trauma Operative Management neum, and (5) extremities. Course materials were generated
The Advanced Trauma Operative Management (ATOM) for each of these areas and vetted by members of the commit-
course uses standardized porcine models to teach the repair tee to achieve a consensus view of the materials taught. The
of penetrating trauma. It is offered in over 26 sites in the ASSET course was piloted in March 2008 at the Uniformed
United States, Canada, Africa, the Middle East, and Japan. Services University in Bethesda, MD, USA. Four beta courses
The ATOM course was developed at Hartford Hospital were then conducted to further codify and refine ASSET,
(Hartford, CT, USA) and uses a standardized simulation which began to be formally offered by the ACS in March
in which proper methods of repairing severe penetrating 2010. This course rapidly gained a foothold with a total of
trauma are taught and evaluated.120 ATOM employs a 1:1 19 course sites established in the United States and Canada
faculty-to-student ratio and a rigidly standardized curricu- by the end of 2011, with 54 courses offered and over 500
lum to teach the surgical management of injuries to the students and 100 instructors trained.
bladder, small intestine, kidney, ureter, spleen, pancreas, The ASSET course in its final form is conducted over a
stomach, diaphragm, duodenum, liver, lung, inferior vena 6- to 7-hour time period using fresh or fresh-frozen cadav-
cava, and heart. Though it is an excellent primer in the ers with a student-to-faculty ratio of four to one. The entire
management of penetrating trauma, the vascular-specific course is conducted in the cadaver dissection lab at the
component of the course is limited to the inferior vena cava table side with minimal didactics. The course is designed
(IVC) and the heart, where injuries bleed profusely and specifically to teach vascular exposure for management
must be managed correctly if the pig is to survive. A survey of trauma. The dissections are guided by a case-based
of perceptions among ATOM participants was reported in approach, wherein a few PowerPoint slides are used to pres-
2005 and documented post-course improvement in partici- ent a case (e.g., a patient shot in the upper arm with loss of
pant self-confidence with regard to repairing penetrating pulses and a presumed brachial artery injury), followed by
injuries.121 A worldwide follow-up survey of 1001 ATOM a few slides of relevant anatomy and a brief narrated video
course participants conducted in 2008 found that partici- showing step by step how to do the procedure. The students
pants perceived the course allowed them to identify injuries are then urged to rapidly perform the exposure with the
more rapidly, to have a more organized operative approach, help of the faculty who seek to instill a sense of urgency as
and to control bleeding more quickly.122 if this were an actively bleeding patient. Faculty are guided
The ATOM course is now managed by the surgical skills by a manual with the specific goals and objectives for each
subcommittee of the ACS Committee on Trauma (ACSCOT). dissection, but they are also encouraged to engage the stu-
Limitations of the course include the associated costs, dents in additional dialog reinforcing the dissections with
the lack of exposure to human anatomy, and the lack of their personal clinical pearls and tips. A richly illustrated
emphasis regarding exposure and repair of vascular trauma laboratory manual and a DVD containing all the vascular
(other than the IVC and heart). Additionally, the use of live exposures are also provided to the students. Both the man-
animals limits utility in certain areas of the world, and it ual and the DVD can be purchased outside the course.123
should be anticipated that such use will be further restricted In an analysis of the first four beta courses, it was noted
in the future. that the general level of trauma experience was low, even
50 SECTION 1 • Setting the Stage

Table 4.2 Comparison of Mean Pre-ASSET and Post-ASSET

Surgical Self-Assessed Confidence (SSAC) and Mean
Instructor-Assessed Participant Evaluation
Instructor
Region/Level Pre-SSAC Post-SSAC Difference* Evaluation
Neck 2.76 3.69 0.93 4.12
Chest 2.49 3.71 1.22 4.03
Abdomen 3.28 4.00 0.72 4.00
Pelvis 2.97 3.97 1.00 4.02
Lower extremity 2.88 3.97 1.09 4.07
Upper extremity 2.63 3.96 1.33 3.93
Note: A five-point Likert scale is used for these scores.
* = P < .05.
A

among senior course participants.124 Participants were

asked to assess comfort level in performing the vascular
exposures both before and after attending ASSET. As seen
in Table 4.2, there was a significant improvement in confi-
dence; additionally, when asked to rate the course using a
five-point Likert scale, participants had an average response
of 4.8 to the statement “I learned new knowledge”; 4.8 to
“I am better prepared to obtain exposure of injured struc-
tures”; and 4.91 to “I would recommend this course to a
colleague.”
The ASSET course was developed to teach vascular expo-
sure and specifically does not teach vascular repair. This
factor, course expense, variability in cadaveric availability,
and the fact that the cadaveric model does not bleed com-
prise the major limitations of ASSET. Nonetheless, it would B
appear that the course is tailored to meet the needs of sur-
geons wishing to learn how to perform the vascular expo-
sures key to the management of vascular injury.
The US military is considering ASSET+ as an assessment
of the readiness of general surgeons before deployment to
a combat zone. ASSET+ will utilize a reduced student-to-
faculty ratio, and it will incorporate a second session of dis-
section in which the students’ abilities to perform the vas-
cular exposures taught in the first session will be assessed.
In addition, material covering emergent cesarean section,
craniotomy for head trauma, and lateral canthotomy for
retrobulbar hematoma is included. The first pilot was held
at the University of Maryland in April 2019 (Fig. 4.1).
European Vascular Masterclass
In response to work-hour restrictions imposed by the C
European Working Time Directive and in an attempt to
standardize vascular training in the European Union, lead- Fig. 4.1 The ASSET+ Course. (A) Students and faculty review a brief
ing European vascular centers developed a European Vas- video of an exposure before performing the procedure on a fresh
cular Masterclass (EVM) course with the specific aim to cadaver. (B) The reduced student-faculty and student-cadaver ratios
train vascular surgeons on realistic open and endovascular ensure students can perform each exposure and give faculty the
simulators using a standardized teaching approach.94,125 opportunity to closely observe and assess each student. (C) Students
This approach uses stepwise teaching of a consensus- perform an exposure under the observation and instruction of expe-
formulated approach to performing open vascular proce- rienced faculty.
dures. Task-specific learning processes are understood to
be acquired in the following two phases: fast-phase learn-
ing and slow-phase learning. Fast-phase learning is set endovascular aortic reconstruction, carotid endarterec-
within individual skill sessions, with complementary slow- tomy, and distal bypass surgery) and virtual simulators (for
phase learning occurring between sessions during times of carotid, iliac, and renal interventions). The physical models
rest.126 The EVM provides hands-on experience with pulsa- have been developed by Synbone (www.synbone.ch), but
tile realistic models (open simple and complex aortic repair, they are not currently widely available, nor have they been
 4 • Training Paradigms for Vascular Trauma 51

validated as effective teaching tools. The EVM is meeting a in the training of vascular trauma specialists. The fidelity
perceived educational need to train basic and advanced vas- of endovascular simulators is excellent, but simulators that
cular surgical techniques, but once again it was not devel- allow for the training of open surgical procedures are in
oped to address vascular injuries from trauma. their infancy. Several excellent physical models that approx-
imate human tissue characteristics are currently in devel-
Basic Endovascular Skills for Trauma (BEST) opment, and they will no doubt make a big impact on future
With the development of endovascular techniques such as training. Comprehensive curricula must teach the manage-
resuscitative endovascular balloon occlusion of the aorta ment of vascular trauma incorporating surgical exposure
(REBOA) and most general and trauma surgeons’ lack of blood vessels (as is done with the DSTS, ASSET, MOST,
of training in endovascular skills and techniques, mul- and some DSTC courses), control of bleeding (as is taught
tiple courses have arisen to equip these surgeons with the in limited fashion in the ATOM and some DSTC courses),
needed basic endovascular skills necessary to safely employ and basic vascular techniques (both open and endovascu-
new technologies. The BEST course uses a cadaveric model lar). Such a comprehensive vascular trauma curriculum
to teach REBOA, percutaneous and open femoral access, does not currently exist, and it is incumbent on the commu-
and common femoral artery repair. The course is primar- nity of surgeons caring for patients with vascular trauma
ily offered to fully trained trauma and acute care general to address this deficit in the near future in order to ensure a
surgeons. Developed by surgeons at the University of legacy of highly skilled surgeons who are able to manage all
Maryland, the one-day course is now offered under the aspects of vascular trauma.
auspices of the ACSCOT.127,128
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89. Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness lation in vascular surgery education. J Vasc Surg. 2010;52:1072–
of continuing medical education: evidence report/technology 1080.
assessment No. 149 (prepared by the Johns Hopkins Evidence- 114. Pandey VA, Wolfe JHN, Lindahl AK, et al. on behalf of the Euro-
Based Practice Center, under contract No. 290-02-0018) (Agency pean Board of Vascular Surgery. Validity of an exam assessment
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90. Seymour N. VR to OR: a review of the evidence that virtual real- 115. Pandey VA, Wolfe JH, Liapis CD, Bergqvist D. European Board of
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54 SECTION 1 • Setting the Stage

116. Sidhu RS, Chen J, Baxter K, Wu H. Development of a comprehen- 124. Kuhls DA, Risucci DA, Bowyer MW, et al. Advanced Surgical Skills
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2009;197:591–594. course for surgery residents and fellows. JACS. 2013;74(2):664–
117. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing 670. 2012 submitted unpublished data.
technical skill via an innovative “bench station” examination. Am J 125. European Vascular Course. http://www.vascular-course.com/.
Surg. 1997;173:226–230. Accessed 25 October 2019.
118. Ryan JM, Roberts P. Definitive surgical trauma skills: a new skills 126. Walker MP, Brakefield T, Hobson J, Stickgold R. Dissociable stages
course for specialist registrars and consultants in general surgery of human memory consolidation and reconsolidation. Nature.
in the United Kingdom. Trauma. 2002;4:184–188. 2003;425:616–620.
119. Royal College of Surgeons of England. https://www.rcseng.ac.uk/ 127. Brenner M, Hoehn M, Pasley J, Dubose J, Stein D, Scalea T. Basic
education-and-exams/courses/search/definitive-surgical-trauma- endovascular skills for trauma course: bridging the gap between
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120. Jacobs LM, Burns KJ, Kaban JM, et al. Development and evaluation Acute Care Surg. 2014;77(2):286–291.
of the Advanced Trauma Operative Management course. J Trauma. 128. American College of Surgeons. Basic Endovascular Skills for
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123. American College of Surgeons. Advanced Surgical Skills for Expo- 2014;76(4):929–935, discussion 935-936.
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SECTION 2
I­mm­ed­iate Management and
Diagno­st­ic A­pp­roaches

55
 5 Prehospital Management of
Vascular Injury
ROBERT H. JAMES and JASON E. SMITH

Introduction Stopping the Bleeding

Major hemorrhage is the leading cause of preventable death EXTREMITY HEMORRHAGE
in both civilian and military trauma patients.1,2 However,
since the beginning of the twenty-first century improve- Principles
ments have been made in the care of trauma patients with The extremities are the most commonly injured anatomi-
major hemorrhage. For the purposes of this chapter the cal regions in those patients wounded on the battlefield.5 In
terms vascular injury and major hemorrhage will be used patients with battlefield injury in more than one body area,
interchangeably. 82% will have an injury to at least one limb.5 As a result
These improvements are, perhaps, best demonstrated of this, much of the guidance pertaining to management
by examining the survival of wounded military personnel of exsanguinating extremity injury is from military experi-
during recent operations in Iraq and Afghanistan. The New ence and literature. Although caution should be used when
Injury Severity Score (NISS) associated with a 50% risk of translating experience from one sphere to another, a man-
death increased from 32 to 60 over the period 2003–12 gled or amputated limb caused by a motor vehicle collision
(Fig. 5.1).3 This improvement in survival is largely attrib- or industrial accident requires similar management to that
utable to advances in the care of patients with major caused by an improvised explosive device (IED).6 Equally it
hemorrhage.3 should be noted that “military” mechanisms of injury can
In order to effectively manage vascular injury in the be experienced in civilian practice.7
prehospital environment, there are two key components. During American combat operations in Vietnam, exsan-
Firstly (and most crucially), where possible, stop the bleed- guination from wounded extremities was the most com-
ing. Secondly, mitigate blood loss with an appropriate vol- mon cause of preventable death.8 This was in contrast to
ume replacement strategy, ideally with blood and blood the experience of American Special Forces personnel dur-
products, which may include the use of pharmacological ing combat operations in Somalia in the late 1990s. Here
adjuncts. The advances seen during recent conflicts were US special forces used TQs for patients with catastrophic
due to several factors, but these can be grouped into these extremity hemorrhage, which was not standard practice
two key areas. The near universal training in, and avail- during the Vietnam war or among the wider military or
ability of, devices such as tourniquets (TQs) and hemostatic civilian populations in the late 1990s. Case reports from
dressings allowed the control of hemorrhage at the earliest the conflict credited the use of TQs with preventing death
possible time, and the forward deployment of medical teams from exsanguination.9 The potential value of TQ use was
with the capability to provide advanced resuscitative tech- recognized and in the later conflicts in Iraq and Afghani-
niques ensured that replacement of lost blood volume was stan, there was a resurgence in the use of TQs for extremity
managed in line with the latest resuscitation strategies.4 injury, along with improvements in design. The UK military
In this chapter we will discuss the lessons learned dur- were also early adopters of the new style TQs. In April 2006
ing these conflicts and attempt to translate their relevance they became personal issue for all UK personnel deploying
to the wider readership of this book. We will also explore to operational areas. This adoption of TQs was one part of
potentially life-saving techniques that have continued to a larger paradigm shift in care for battlefield casualties from
evolve since the cessation of major combat operations in the familiar “ABC” to a revised “<C>ABC”.10 This placed the
Afghanistan and those that may continue to evolve in the control of catastrophic hemorrhage as the primary consid-
future. In order to do this, we will consider bleeding com- eration when treating a wounded casualty. Reviews of the
ing from three distinct pseudoanatomical zones: extremity use of tourniquets, as part of this new paradigm, by both
hemorrhage, junctional hemorrhage (the groins, axillae, the British and American militaries again found them to be
and neck) and noncompressible torso hemorrhage (NCTH); life-saving.11,12
and discuss the current and future prehospital manage- The UK military’s approach to the management of
ment of each of these types of bleeding. We will also briefly extremity injury was further conceptualized in a hemostatic
discuss the management of maxillofacial hemorrhage, ladder (Fig. 5.2).13 This ladder covers the whole spectrum
which can be life-threatening and requires specific, prehos- of the management of catastrophic hemorrhage, including
pital, management steps but does not fit neatly into these in-hospital care. It should be noted that only the first four
categories. Finally, we will analyze current thinking related rungs on the ladder are applicable to prehospital care and,
to volume replacement in the bleeding trauma patient, when viewed through today’s lens, the ladder could be con-
explore the scientific rationale behind this thinking, and sidered to be incomplete or even incorrect due to the omis-
attempt to provide some practical guidance for those trying sion of tranexamic acid and the inclusion of recombinant
to resuscitate bleeding trauma patients. activated Factor VII (rFVIIa).14,15 Notwithstanding these
56
 5 • Prehospital Management of Vascular Injury 57

0.9

0.8 Year
2003
0.7 2004
Probability of Survival 2005
0.6 2006
2007
0.5 2008
2009
0.4
2010
2011
0.3
2012
0.2

0.1

0
0 15 30 45 60 75
NISS

Fig. 5.1 Cumulative probability of survival versus new injury severity score (NISS) for patients treated in Afghanistan and Iraq, 2003 to 2012. (With
permission from Penn-Barwell, et al. Improved survival in UK combat casualties from Iraq and Afghanistan: 2003–2012. J Trauma and Acute Care Surg.
2015;78(5):1014–1020.)

concerns, the principles of the hemostatic ladder remain

valid and provide a good representation of the care provided
to injured personnel, and remain as a guide to the manage-
ment of casualties today.
A stepwise approach starting with direct pressure and
elevation, using a First Field Dressing (FFD) or equivalent, is
usually the first technique that should be used in the man-
agement of bleeding extremity injuries. If necessary, this
can then be followed by the use of hemostatic agents (see
later). If these measures fail to control hemorrhage, a TQ
should then be applied.
In addition to allowing easy conceptualization of the
principles of management of catastrophic hemorrhage,
there are other great strengths to this model. First, there
is an acknowledgement that there are times when the
stepwise approach advocated should not be followed.
One example is during “care under fire” (CUF) when a TQ
should be applied immediately due to the tactical situation.
However, it can be extrapolated that there are also clinical
situations where moving straight to TQ application may
be appropriate. This may be due to the state of the limb
itself, i.e., mangled or amputated with catastrophic hem-
orrhage, or due to competing priorities in the care of the
patient, e.g., concomitant airway obstruction or complete
ventilatory failure requiring emergency management. In
other words, there are occasions when the use of a TQ
is the most expeditious way to manage exsanguination
and thus should be used in order to allow timely manage-
ment of other injuries, even if a more time-consuming
Fig. 5.2 The hemostatic ladder for the management of hemorrhage. approach, such as direct pressure with or without hemo-
rFVIIa, Recombinant activated Factor VII. (With permission from static gauze, may also work.
Moorhouse I, et al. A realistic model for catastrophic external This is a situation where expert clinical judgement is
hemorrhage training. J R Army Med Corps. 2007;153(2):99–101.) required. Another example of when it may be advisable to
58 SECTION 2 • Immediate Management and Diagnostic Approaches

jump some rungs of the ladder is if the number of patients TQs are routinely used in elective surgery. It should also be
outmatches the number of clinicians available to deal with noted that injury to the limb is rare if a TQ is in place for
them – the National Ambulance Resilience Unit recom- less than 2 hours, although this evidence relates to elective
mends the use of TQs to manage extremity hemorrhage in a surgical patients and may not be applicable to hypovolemic
major incident.16 The final situation where TQ use is appro- trauma patients.20,21 Application of a TQ for longer than
priate, without escalating through the hemostatic ladder, 6 hours is likely to lead to muscle damage necessitating
is when operating in a chemical, biological, radiological, amputation.21
or nuclear (CBRN) environment. Here the requirement Appropriate removal of a TQ is another area for consid-
to keep the casualty as well protected as possible from the eration – see Box 5.2 for the key principles. If the TQ has
CBRN hazard, as well as the encumbrance for the clinician been in place for more than 6 hours, removal should only be
of operating in personal protective equipment (PPE), neces- undertaken with cardiac monitoring and with appropriate
sitates the use of TQs.17 equipment for resuscitation to hand.
In addition, the decision to use a TQ should be reviewed at
the earliest appropriate point and de-escalated back down
the hemostatic ladder if appropriate.13 JUNCTIONAL HEMORRHAGE
Practicalities Principles
Simple measures often save lives. Direct pressure can often Junctional hemorrhage, or bleeding from a junction
stop significant bleeding, at least until a more definitive between the torso and the extremities, is by definition not
means of controlling the bleeding is possible. If simple amenable to traditional extremity TQ use. This is either
direct pressure is not successful, hemostatic dressings because it is not possible to get proximal to the wound in
should be considered. This is likely to be especially helpful order to apply a TQ (in the axillae and groins) or because an
in situations where there is a wound cavity to pack, e.g., ischemic zone distal to the TQ is not feasible (in the neck).
a gunshot wound. UK military guidelines suggest a two- Once again much of the data and experience related to the
person approach to the application of their hemostatic management of injuries to these areas comes from military
dressing of choice (Celox). One person removes the FFD, evidence and experience. A review of US fatalities during
which was applied in order to manage the wound with Operations IRAQI FREEDOM (OIF) and ENDURING FREE-
direct pressure, as the other tightly packs the hemostatic DOM (OEF) found that by the end of OEF junctional hemor-
dressing into the wound cavity. The first operator then rhage had surpassed extremity hemorrhage as the leading
reapplies direct pressure through another FFD for three cause of potentially avoidable death from compressible hem-
minutes.18 The direct pressure here is key: the hemostatic orrhage.1 These deaths are avoidable because, although not
dressing should be seen as an adjunct to direct pressure, amenable to TQ use, bleeding in junctional areas is easily
not as an alternative. Further discussion about hemostatic accessible and potentially compressible. Therefore, relatively
dressings can be found below in the “Junctional Hemor- straightforward treatment options, which can be employed
rhage” section. by nonspecialist physicians and, indeed, by nonvocational
As discussed previously, TQs have been shown to be life- medics, exist for managing hemorrhage in these areas. This
saving.11,12 Whereas the manner of application depends on is particularly the case with the widespread adoption of
the exact model of TQ used, certain principles are ubiqui- hemostatic agents. The widespread use of these dressings,
tous (Box 5.1). along with the resurgence of TQs, must be considered one
When TQs are applied for the correct indication, the risk of the positive legacies of these conflicts.
of ischemic injury to the limb is outweighed by the risk of
death from exsanguination. It should be noted that arterial
Practicalities in the Management of Junctional
Hemorrhage
There are additional complexities in managing vascular
Box 5.1 General Principles for Applying an injury in the neck. Therefore, the management of the neck
Arterial Tourniquet (TQ)19 will be considered separately to the management of bleed-
ing in the axillae and groins.
1. Application of a TQ should occur in:
a. Limb amputation with bleeding
b. Catastrophic hemorrhage
c. In the additional situations outlined in the text Box 5.2 Principles for Removal of an Arterial
2. Unless involved in CUF or in a CBRN environment, apply the TQ
Tourniquet (TQ)18
5–7.5 cm above the bleeding site directly to skin.
3. Tighten the TQ until bleeding stops. Remember, some oozing
from bone ends may continue, but this will be low pressure 1. An alternative method of hemorrhage control should be in
and amenable to pressure control. place prior to removal of a TQ.
4. If bleeding is not controlled or the TQ is being applied for an 2. This should only be undertaken in a controlled environment
above-knee amputation, apply a second TQ proximal to the where the casualty can receive careful assessment and rapid
first one. treatment if they were to deteriorate.
5. Note TQ application time. 3. Do not remove the TQ; merely loosen it.
4. If alternative methods of hemorrhage control are not success-
ful, re-tighten the TQ.
CBRN, Chemical, biological, radiological, or nuclear; CUF, care under fire.
 5 • Prehospital Management of Vascular Injury 59

Axillae and Groins. The basic principles of controlling Patients with these signs, especially expanding hema-
hemorrhage from these areas again follow the hemostatic toma or stridor, will require definitive airway control.
ladder in Fig. 5.2, although TQ use is not an option. There is Irrespective of the difficulty that this airway is likely to
little difference in the requirement for direct pressure with present, there is a strong argument for prehospital intu-
or without the addition of a hemostatic dressing. However, bation of these patients. This is true despite the lack of
the severity of injuries caused by IED blasts, especially access to both additional support (e.g., from anesthet-
during the conflict in Afghanistan, sometimes exceeded the ics and ENT) and the full complement of difficult airway
capacity for management by direct pressure ± hemostatic equipment. Exceptions to this rule are if transfer time
dressing. As such, novel techniques and devices have been to a facility equipped to manage the injury is extremely
investigated and, in some cases, have begun to be used. short or appropriately skilled and equipped personnel
Neck. Vascular injury in the neck occurs in 3% of blunt are not available to definitively secure the airway pre-
and 20% of penetrating craniocervical injuries.22,23 The hospital.24 This is because these airways will, with time,
number of important anatomical structures in the neck deteriorate, sometimes rapidly. This is another decision
makes this a unique and challenging area in which to requiring expert clinical judgement.
manage vascular injury. There is a spectrum of clinical When considering intubating these patients, the most
syndromes that need to be considered: experienced and skilled intubator should undertake the
first attempt.25 The patient should be optimized and posi-
1. Injury to neck vessels may lead to exsanguination due to tioned, and all appropriate procedures to ensure the high-
external catastrophic hemorrhage. est chance of first pass success should be undertaken,
2. Contained hemorrhage from an injury to a neck ves- e.g., adequate paralysis, the use of checklists, and use of
sel, especially an artery, may lead to development of a a bougie.25 The intubator should be prepared for blood
hematoma that compresses other structures in the neck, in the airway and, as such, adequate suction should be
crucially the airway, leading to life-threatening airway available. Equally, all members of the team should be
obstruction. prepared for a failed intubation and a well-rehearsed and
3. Dissection of neck vessels may lead to neurological robust plan for this eventuality must be in place.25
sequelae, ranging from subtle findings on neurological 3. Prehospital management of vessel dissection is limited
examination to profound deficit or stroke. to having an index of suspicion, supportive measures
including Prehospital Emergency Anesthesia (PHEA)
To discuss the management of each of these syndromes dependent on the patient’s neurological state, and trans-
in turn: fer to an appropriate facility capable of managing the
patient’s holistic care.
1. For external catastrophic hemorrhage, direct pres-
sure ± a hemostatic dressing is again the approach Hemostatic Dressings
of choice. However, the pressure applied may in itself We have already introduced the subject of hemostatic dress-
cause airway compromise. Therefore, if the option to ings, so will now explore in more detail what these items are
definitively secure the airway (with a cuffed tube in the and examine the pros and cons of individual formulations.
trachea) is available, then this should be considered as Hemostatic dressings can be grouped by their mecha-
part of the initial management. An additional or alter- nism of action into26:
native method for control of hemorrhage is Foley cath-
eter balloon tamponade. This requires the insertion of 1. Those that concentrate clotting factors
a Foley catheter into the wound track and the inflation 2. Muco-adhesive agents
of the balloon with 10 to 15 mL of water. The catheter 3. Procoagulant factor supplements
is clamped to ensure there is no bleeding through the
lumen of the catheter. It may then be advisable to close Factor concentrators were the original hemostatic
the neck wound around the catheter.22 Successful ces- agents. They are presented as loose or encapsulated gran-
sation of bleeding in as many as 85% of patients has ules and act by rapidly absorbing water, bringing platelets
been reported with this technique, although it should and clotting factors into closer contact with each other and
be noted that in this case series the neck wounds were therefore stimulating coagulation. The agent most com-
caused by a low velocity mechanism.22 There is a pos- monly used initially was QuickClot. However, there were
sibility of patient deterioration following the insertion concerns about an exothermic reaction from the activated
of the balloon (usually due to excessive vagal stimula- agent causing burns, and also concern about difficulty
tion), so if this happens the balloon should be deflated, removing the product from the wound further along the
and alternative methods of hemorrhage control care pathway, and so the use of this agent has declined.27
sought.24 Muco-adhesive agents form a seal around the bleeding
2. The first requirement for the successful management site and thus encourage coagulation.26 These products are
of neck vascular injury with contained hemorrhage is usually made from chitosan impregnated gauze and include
a high index of suspicion. Very small entry wounds can Celox and HemCon.
cause significant vascular injury. The symptoms and Procoagulant factor supplements such as QuickClot
signs of neck vessel injury may at first be subtle. Poten- Combat Gauze deliver a high local concentration of clotting
tial indicators of a neck vessel injury are a wound deep factors and thus activate the coagulation cascade.26
to platysma, hoarse voice, expanding hematoma, pulsa- Agreed criteria that make an ideal hemostatic dressing
tile mass, and stridor. can be found in Box 5.3.
60 SECTION 2 • Immediate Management and Diagnostic Approaches

Box 5.3 Features That Make an Ideal

Hemostatic Dressing27,28
  1. The ability to stop large vessel bleeding within 2 minutes
  2. Approved by national medical device/drug licensing agency
  3. Effective on wounds not amenable to a tourniquet
  4. Flexible and easily removable
  5. Be ready to use without mixing or preparation
  6. Be simple to apply with minimal training, including by the
casualty
  7. Be lightweight and durable
  8. Have a minimum 2-year shelf life and stable at extremes of
temperature
  9. Be safe to use
10. Be relatively inexpensive
11. Be nontoxic with no side-effects
12. Is biodegradable and bioabsorbable

Three recent systematic reviews have examined the effi-

cacy of the different types of hemostatic dressing.29–31 All
were narrative reviews due to the heterogeneity of included
studies, and all found that the hemostatic dressings were
effective. However, evidence comparing one particular for- Fig. 5.3 The XSTAT 30 from RevMedX. (Personal correspondence James/
mulation to another was both scarce and contradictory. Musho. With Permission.)

Complex or Novel Options

Given that there are described instances of hemostatic
dressing failure, further options are potentially required for
the management of junctional hemorrhage. These options
can again be considered in two broad camps. Those meth-
ods relying on local effect to control hemorrhage and those
methods aimed at gaining proximal control of bleeding.

Methods Relying on Local Effect. Several devices are

either being trialed or have recently started being used
clinically for the management of junctional hemorrhage.
Most are unlikely to be of use in managing vascular
injury in the neck, although there are promising results
for their use in axillary or groin hemorrhage. Whereas
the devices themselves are new, the principle they rely on
is the augmentation of direct pressure with or without the
additional use of hemostatic dressings.32 One of the more
novel solutions is a device, much like a large syringe, which
allows chitosan-soaked, cellulose sponge to be injected into
an axillary wound (Fig. 5.3) and then secured with normal
bandages. This has Food and Drug Administration (FDA)
approval for use in axillary wounds, and has undergone
initial clinical trials with promising results, but intrathoracic,
intrapelvic, or intraabdominal use is contraindicated.33,34 Fig. 5.4 The SAM JT. A junctional tourniquet. (With permission from van
Other devices (the Combat Ready Clamp [CRoC], the Oostendorp SE, et al. Prehopsital control of life-threatening truncal and
Junctional Emergency Tool [JETT], the SAM Junctional junctional hemorrhage is the ultimate challenge in optimizing trauma
Tourniquet [SAM-JT], and the Abdominal Aortic Junctional care; a review of treatment options and their applicability in the civilian
Tourniquet [AAJT]) use clamps or inflatable bladders to pro- trauma setting. Scand J Trauma Resusc Emerg Med. 2016;24:110–123.)
vide direct pressure over the wound. There have been some
case reports of their use in both axillary and groin hemor-
rhage with good effect. Many of the devices were deemed to The final device worthy of mention is the iTClamp. This
be too bulky or fragile to be an ideal solution for prehospi- is unique in that it may be used in neck wounds as well as
tal use, but the SAM-JT (Fig. 5.4), essentially a SAM pelvic groin or axillary wounds. It is a mechanical clamp with
binder with the addition of an inflatable bladder, received needle-like teeth that is applied to a wound and approxi-
positive feedback from US armed forces medics in a preclini- mates the skin edges in order to tamponade bleeding. In
cal trial.35 one trial, when used in this manner, it failed to adequately
 5 • Prehospital Management of Vascular Injury 61

control bleeding from a neck wound, but when the cav- The timing of prehospital RT is also an area worthy of
ity was packed with hemostatic gauze and the iTClamp discussion. Many patients in TCA are in fact in a low cardiac
re-applied, bleeding was controlled.36 There are also case output state (LCOS).45 Thus ascertaining how far into their
reports of successful use in groin hemorrhage.37,38 apparent TCA thoracotomy should be undertaken is chal-
lenging. Traditionally, prehospital RT is only undertaken in
Methods for Gaining Proximal Control of Blee-ding. patients in TCA, as defined by a lack of a central pulse. How-
There is cross-over between these techniques and the ever, the disease process may already be very advanced by
techniques used for management of NCTH. Here a discussion this time, resulting in a pathophysiological and biochemical
of the implications of the use of these methods in junctional milieu that is resistant to attempts at resuscitation. There
hemorrhage will be undertaken, with further detail in the certainly seems to be some physiological rationale to inter-
management of NCTH provided in the relevant section. vening earlier in patients in whom RT may be the definitive
The first and most widely used prehospital technique is procedure in reversing their disease process. Equally this is
resuscitative thoracotomy (RT). In the management of groin supported by the literature base, with reduced time from
hemorrhage, the aim of RT is to access and compress the arrest to RT associated with improved survival.43
descending aorta. This is usually only performed once the As described previously, the use of REBOA instead of RT
patient has suffered a traumatic cardiac arrest (TCA). The for proximal aortic control has been advocated by various
role of prehospital RT in penetrating trauma, especially stab authors. A more detailed discussion of REBOA is available
wounds in the “cardiac box,” is well-established in both the in Chapter 11, but we will mention the specific prehos-
literature and practice.39,40 A simple technique for opening pital implications of REBOA. It has only been performed
the chest using the “clamshell” approach is advocated in the prehospital environment by one service, London’s
giving excellent exposure to the thoracic contents, although Air Ambulance (LAA). They have demonstrated that with
the most cranial structures are still difficult to access.41 the correct equipment and training, it is feasible to under-
Notwithstanding the consensus regarding prehospital RT take REBOA in the civilian prehospital setting.46 Prehospi-
for penetrating trauma, the situation in blunt injury or for tal REBOA is limited to zone 3 placement only (where the
obtaining proximal aortic control in groin hemorrhage REBOA balloon is landed between the caudal renal artery
is controversial, with resuscitative endovascular balloon and the aortic bifurcation). As such there is only prehospital
occlusion of the aorta (REBOA) being the more commonly experience of using REBOA for pelvic or more distal hemor-
described technique for achieving hemorrhage control.42 rhage. Its use in the prehospital environment is challenging.
This position contrasts somewhat with the military evidence. There is a failure rate of up to 32%, and significant concerns
In his review of RT following wartime injury, Morrison about the risk of arterial thrombus formation exist wherever
reports 21.5% survival following RT; just over 46% of REBOA is carried out as a percutaneous technique.46 How-
these patients had an extremity injury with an abbreviated ever, in case series those patients in whom REBOA was suc-
injury score greater than 2, and 97% of them had aortic cessful had an improvement in systolic BP of 66 mm Hg, and
control as part of their resuscitation.43 These data suggest both prehospital cardiac arrest and death from exsanguina-
that RT for exsanguinating junctional hemorrhage may tion were significantly reduced (0% vs. 50% P = .021; 0% vs.
not be futile. However, it should be noted that this study 67% P = .004, respectively).46 There was also a suggestion
describes in-hospital resuscitative thoracotomy.43 They found of improved survival (62% vs. 33%), although this failed to
worse survival in those patients sustaining cardiac arrest reach statistical significance (P = .350) and due to the study
prehospital (0%) compared to those arresting en-route to a design attributing this to REBOA, is not appropriate.46
medical treatment facility (MTF) (10%) or arresting within
the MTF (42%). However, they also found that survivors had NON-COMPRESSIBLE TORSO HEMORRHAGE
a significantly shorter time from arrest to thoracotomy (6.15
vs. 17.7 minutes).43 Patients in this case series had to wait Bleeding within the torso is arguably one of the greatest
until ED arrival for thoracotomy to be undertaken. Although challenges facing prehospital providers. To facilitate the
Morrison suggests that RT in patients arresting in the field discussion of this pathology, it can be subdivided into three
is futile, it is difficult to ascertain whether it was the arrest broad sections: thoracic, abdominal and pelvic hemorrhage.
in the prehospital environment that led to poor outcomes or However, given the noncompressible nature of hemorrhage
the delay in thoracotomy being performed, and as such we in these body cavities there are certain principles that apply
cannot conclude from this paper whether prehospital RT to all areas, which will be discussed initially.
would have been of benefit or whether it should necessarily
preclude the use of prehospital thoracotomy for control Considerations for All Torso Hemorrhage
of junctional hemorrhage.43 As such it is important to be Even in the most advanced prehospital services there is a
realistic about the likely success of prehospital RT and be limit to the amount of resources that can be carried. This
cognizant of the reduced resources available to clinicians means an extremely finite supply of blood products, when
in the prehospital environment, the relative lack of surgical considering the volume that is likely to be required in order
expertise of prehospital physicians (who are usually not to treat exsanguinating hemorrhage, and a limited range of
surgeons) compared to in-hospital surgeons, and the less possible interventions.
favorable environment in which prehospital physicians are One of the keys for prehospital personnel managing
forced to operate. Further evidence guiding TCA management patients with NCTH is early recognition of the pathology.
suggests that RT should be part of the management of patients When assessing patients for concealed, life-threatening
with TCA, many of whom will have suffered exsanguinating bleeding, an over-reliance on physiological parameters and
junctional hemorrhage, and not merely viewed as a last- monitoring is potentially harmful. Patients do not always
ditch attempt in those destined to die.44
62 SECTION 2 • Immediate Management and Diagnostic Approaches

demonstrate the classic picture of hypotension and tachy- It should be noted that tamponade can occur following
cardia, which was identified as long ago as the First World blunt injury, typically secondary to tearing the right atrial
War.47 Further study during the Second World War dem- appendage.54 Theoretically, this should be equally amenable
onstrated that only 27% of shocked patients displayed the to RT, although the overall physiological insult is likely to
classic picture of tachycardia and hypotension in the first be greater in blunt trauma with, as in this case, injuries to
hour following injury – the time when they are likely to be other structures in the chest, as well as concomitant inju-
seen by prehospital providers.48 A global overview of the ries to other body areas more likely. In addition, the most
patient, taking into account their mechanism of injury, recent consensus statement from the Faculty of Pre-Hos-
features found on clinical examination such as the state of pital Care of the Royal College of Surgeons of Edinburgh
their peripheral vasculature, their color (especially of the sees blunt injury as a contraindication to RT.55 However, the
gums), presence of sweating, how they feel to touch, and same document acknowledges the difficulty of diagnosing
finally physiological parameters, may allow more accurate tamponade in the prehospital setting, a pathology proven to
recognition of a bleeding patient.49 A simple algorithm be amenable to RT, and conflicts with accepted practice by
has been suggested with high accuracy (91%) for prehos- several well-respected prehospital organizations.56
pital physicians to predict the requirement for in-hospital As well as the relief of tamponade, there are other pro-
blood transfusion, a surrogate of significant blood loss. This cedures that can be performed to aid the management of
involves an assessment of whether the patient is bleeding, intrathoracic hemorrhage. In particular bleeding from the
if the systolic blood pressure is less than 90 mm Hg, and if lung can be managed by hilar clamping, lung twist, or com-
the patient fails to respond to initial crystalloid infusion.50 pressing the lung with an “inco pad.”
However, the first criterion within this algorithm is clearly When considering the appropriateness of prehospi-
subjective, as this study evaluated the performance of left tal RT, access to timely and expert onward care must be
atrial appendage physicians. This group has regular expo- considered. There is little benefit in undertaking RT if the
sure to bleeding trauma patients and access to a wealth of nearest ED is several hours away. Particularly in the case
institutional knowledge about accurate recognition of these of the patient with life-threatening hemorrhage, aggres-
patients. As such, this algorithm may not work in a different sive damage control resuscitation is likely to be required
situation. This study may suggest that the judgement of an concomitantly, or at least very shortly after RT.43
experienced clinician may be the key in recognition of the
bleeding trauma patient. Abdominal Hemorrhage
As mentioned, definitive treatment for this type of bleed- RT with aortic control is also an option for the management
ing is difficult on scene. Even temporizing measures are of intraabdominal hemorrhage. Again, some survivors have
challenging (see later). However, a package of care has been been reported from the use of this procedure in-hospital.43
described that should be applied to all bleeding patients, Prehospital laparotomy to allow four quadrant packing is
which has elements that are applicable to those with NCTH.51 not routinely performed, and is probably not feasible. This
One of the key principles is the minimization of scene times. is due to the requirement for large blood volumes once any
However, if there is treatable pathology that can be managed tamponading effect of the abdominal wall is released, a lack
by the prehospital team, a universal “scoop and run” philos- of surgical expertise, and limitations of equipment in the
ophy may lead to harm.52 Correctly managing this dilemma prehospital environment.
again suggests the requirement for expert on-scene clinical Zone 1 REBOA, where the balloon is placed between the
decision-making. Interestingly, there is a lack of literature left subclavian artery and the coeliac artery, has been sug-
describing how to ensure shorter scene times, although we gested as a technique for the control of abdominal hemor-
would suggest that the crucial elements are rapid decision- rhage.57 This has never been performed prehospital and
making and excellent nontechnical skills.53 therefore all data regarding its use must be extrapolated
Coupled to short on-scene times, careful patient handling from the in-hospital setting. Prehospital zone 1 REBOA is
is important and simple changes can lead to a significant feasible: access to the femoral vessels should be no more
improvement in this area. This means minimizing forces that difficult than for zone 3 REBOA. A fuller discussion of the
could lead to disruption of clots. For example, in one study, a physiological effects of zone 1 versus zone 3 REBOA is
change in practice from the use of longboards to using a split beyond the scope of this chapter, but further information is
orthopedic scoop stretcher for patient transfer reduced the available in Chapter 11.
amount of rotational movement experienced by a patient In terms of the desirability of undertaking zone 1 REBOA,
from 510 degrees to 170 degrees during the course of their the evidence is mixed. One Japanese case series describes
transfer from incident scene to the resuscitation room bed.51 the use of REBOA as a temporizing measure, pending
The final interventions are the administration of blood prod- angioembolization of abdominal solid viscus bleeding.
ucts and the use of tranexamic acid (TXA) (see later).51 Numbers are small (seven patients) but they report an 86%
survival with no complications of REBOA.58 One patient
Thoracic Hemorrhage died as a result of head injury.58 Interestingly, however,
The primary on-scene intervention that can be performed they also describe how they let the balloon down every
for the management of life-threatening bleeding in the 20 minutes and rapidly transfused blood products: this
chest is RT. As discussed previously, this is usually only per- would not be possible in the prehospital environment due
formed once the patient is in TCA, although there may theo- to the inability to carry large amounts of blood. Another
retically be a role for earlier intervention. Most survivors of Japanese study reported worse survival in patients treated
prehospital RT suffer from cardiac tamponade, usually due with REBOA, although this could be due to the manner in
to a low-velocity, penetrating injury to the right ventricle.40 which REBOA was employed as a last-ditch technique.32,59
 5 • Prehospital Management of Vascular Injury 63

Timely and accurate decision-making again seems key in Pelvic Hemorrhage

the effective use of REBOA. It must be considered in the Prehospital management of pelvic hemorrhage can again
appropriate patient group and, when necessary, employed be challenging. There are two key techniques. First is the
as early as is feasible; as with RT, it should be seen as an use of a pelvic circumferential compression device (PCCD).
integral part of the resuscitation effort, and not something This term encompasses both specifically designed pelvic
to try once all else has failed.44 binders and improvised devices such as bed sheets.71
As with junctional hemorrhage there are some novel Although a full description of the classification of pelvic
techniques for the management of intraabdominal hem- fractures is outside the remit of this chapter, some under-
orrhage. Once more, most of these techniques involve the standing is necessary to understand the utility of these
use of pressure to tamponade bleeding. There is a theoreti- devices. A simple explanation of pelvic fracture mecha-
cal possibility that an externally applied tourniquet could nisms is that they can occur due to anteroposterior (AP),
help to tamponade intraabdominal bleeding.32 In both lateral, or vertical force, or indeed due to a mixture of these.
preclinical trials and in fields other than trauma, external This underpins the Young-Burgess classification. These can
abdominal pressure has been shown to effectively arrest lead to different fracture patterns. The fracture most ame-
aortic blood flow or massive obstetric hemorrhage, respec- nable to pelvic binder use is that resulting from an AP force,
tively.60,61 However, This is likely to be more applicable to which causes the pelvis to fracture in an “open-book” pat-
pelvic bleeding due to the most likely sources of significant tern with disruption of the symphysis pubis and sacroiliac
intraabdominal bleeding being relatively proximal, espe- joint(s). Application of a pelvic binder in this situation aims
cially in blunt injury. to reduce intrapelvic volume and thus tamponade bleed-
Internal compression of abdominal hemorrhage can ing, which is often of low-pressure, venous origin. On the
be applied via gas insufflation or self-expanding foam.62,63 other hand, if the injury has been caused by a lateral force
Porcine models of intraabdominal hemorrhage have found it is easy to see that a pelvic binder may simply replicate the
reduced bleeding in both visceral and vascular models initial force that caused the injury. There are also concerns
of injury.62,64 This has been shown to be plausible in the about the possibility of PCCDs causing pressure necrosis or
prehospital environment with the use of a portable CO2 even peroneal nerve palsy.72,73 Therefore, PCCDs should not
insufflator.62 There are theoretical risks associated with be applied thoughtlessly to all trauma patients. Box 5.4 out-
abdominal insufflation. Amongst them are the risk of ten- lines criteria for major trauma patients, with a mechanism
sion pneumothorax if concomitant diaphragmatic injury consistent with pelvic injury, who do not require PCCD
is present and, in patients with head injury, raised intraab- application.74 If a PCCD is used it should be seen as a treat-
dominal pressure potentially leading to raised intracranial ment for bleeding and not merely a packaging device. Thus,
pressure (ICP).65 It should be noted that in elective surgery, if they are applied, they should be applied early, if possible
abdominal insufflation with CO2 in patients with diaphrag- prior to extrication.74
matic defects has not led to physiologically compromising The second prehospital technique for managing pelvic
pneumothorax.66 bleeding is zone 3 REBOA. The principles of REBOA in pelvic
Intraabdominal foam is a second option for intraab- bleeding are identical to those in junctional hemorrhage.
dominal pressure control of hemorrhage. Once injected,
the foam expands up to 35 times, engulfs the organs, and
becomes solid, thus tamponading the bleeding.32,67 So far MAXILLOFACIAL HEMORRHAGE
this has proved effective in both porcine and cadaveric The final area from which exsanguinating hemorrhage can
models of solid viscus and vascular injury.68–70 Again this occur is the face. Successfully controlling massive maxillofa-
is potentially feasible within the prehospital environment. cial hemorrhage requires specific equipment and expertise.
However, in addition to the concern about raised ICP However, control is possible in the prehospital environment.
already outlined, there are specific concerns related to the Maxillofacial hemorrhage is usually associated with sig-
use of foam. First, once the foam has been deployed, the nificant blunt force; for example, following a motor vehicle
patient requires a laparotomy to remove it. It is usual at collision or a fall from height.
this point that there is some injury to the bowel requiring The first consideration when dealing with maxillofacial
repair or even resection.68,70 Second, similar to concerns hemorrhage is to secure the airway with a cuffed tube in
about air entering the pleural cavity in abdominal insuf- the trachea. The airway is almost always at risk because of
flation, if a diaphragmatic injury is present, there are con- the large amounts of blood that will be within it. All PHEA
cerns that foam could enter the pleural cavity and cause should be undertaken with the aim of maximizing the
a “foamothorax.”67 Experimental results suggest that this
may be a problem in larger diaphragmatic tears, which
are usually associated with blunt rather than penetrat-
ing injury. As such, caution may need to be exercised Box 5.4 Major Trauma Patients Not Requiring
when using foam for patients with blunt intraabdominal a Pelvic Binder
hemorrhage.67 A pelvic binder need not be applied if all of the following criteria
The final category of possible prehospital treatments for are met:
intraabdominal hemorrhage proposed in the literature base
are energy-based hemostatic devices. All seem to be some 1. Patient has a Glasgow Coma Score >13
way from being in a format that could be reliably deployed 2. Patient is not shocked
3. Patient does not have a distracting injury
prehospital, and there are significant challenges with their 4. No pain on clinical assessment of the pelvis
use in the prehospital environment.65
64 SECTION 2 • Immediate Management and Diagnostic Approaches

chance of first-pass success. However, along with patients If the patient deteriorates as a result of this intervention,
with neck hematomas, this is a case where especial care and the devices should be removed. It is possible to manually
preparation are required. It is advisable to preoxygenate the replace the maxilla either as a temporizing measure prior
patient in whatever position allows optimal blood drain- to the complete package of care being delivered, or if the
age. This is most likely to be sitting up or in the left lateral necessary equipment is not available.
position. Further information about optimizing the chances
of intubation success is available in the section discussing
SUMMARY
neck injury.
Having secured the airway, the facial skeleton must then Bleeding is a significant cause of death in trauma. Sim-
be realigned. This is done using three different devices. First, ple interventions, such as direct pressure and the use of
nasal epistats (Fig. 5.5) should be inserted bilaterally. Do not extremity tourniquets, can help in many cases. Application
inflate the epistats at this stage. Next, place appropriately of these simple interventions should follow a hemostatic
sized McKesson props (Fig. 5.6) and tie the chains together ladder similar to the example given in this chapter.
to prevent them being accidentally displaced, ingested, or If bleeding is not directly compressible, the management
inhaled. Secure a rigid cervical collar in the usual way. is more difficult and controversial. Expert clinical decision-
At this point, the epistats can be inflated, starting with the making is often required in these cases. Depending on the
posterior balloon.75 This aims to restore normal anatomy, available skill set and geography, it may be appropriate to
especially of the maxilla, and thus tamponade any bleeding. treat these patients using a “scoop and run” approach.
Some on-scene interventions have been shown to work in
specific groups of patients. Innovative treatments for the
most difficult patients are being developed, but most are
some way from being ready for universal adoption.

Replacing Lost Volume

GENERAL CONCEPTS
Understanding the physiological principles behind volume
resuscitation of the trauma patient is probably the most
robust way to ensure optimized resuscitation for an indi-
vidual trauma patient in front of a prehospital clinician.
There is a requirement for a nuanced approach to resusci-
tation that defies simple application of protocols. As such,
some time will be spent exploring the scientific rationale
behind how patients are resuscitated. There is evidence of
improved outcomes in bleeding patients treated prehospital
by expert teams.4
The lethal triad is a concept familiar to most involved in
Fig. 5.5 Nasal epistats for the management of maxillofacial hemor- trauma care. The dangers of acidosis, hypothermia, and
rhage. The white, 10-cc port is for inflation of the distal balloon and the coagulopathy have been understood for some time.76 Given
green, 30-cc port is for inflation of the proximal balloon. (With permis- the universal acceptance of these factors as deleterious, a
sion from Dr K Sharpe, personal photos.) sound resuscitation strategy must seek to minimize them.
Hypothermia is difficult to reverse in the prehospital envi-
ronment. However, steps should be taken to minimize heat
loss, including minimizing exposure and packaging of the
patient with appropriate covering. It is worth mentioning
that this must be balanced by the requirement for access to
the patient, especially during the initial assessment of the
patient. On the other hand, the management of acidosis and
coagulopathy are more complex; both are caused by tissue
hypoperfusion. With respect to trauma patients, this hypo-
perfusion is predominantly secondary to bleeding. The best
way to prevent acidosis and coagulopathy is still somewhat
uncertain, and in order to understand why, it is necessary to
understand two competing theories. The first is the paradigm
of care that states we should keep blood pressure low in
order to avoid “popping the clot”; the second is to ensure
maximum perfusion and thus prevent the undesirable
Fig. 5.6 McKesson props for the management of maxillofacial hemor- sequelae of hypoperfusion, such as acute traumatic coagu-
rhage. The smooth surface is placed against the buccal mucosa. (With lopathy (ATC; see later). Pressure and flow are linked but
permission from Dr K Sharpe, personal photos.) are not analogous. If you consider these priorities, it is
 5 • Prehospital Management of Vascular Injury 65

immediately apparent that the ideal is a high-flow but low- defines the relationship between oxygen delivery (DO2),
pressure system. This is very difficult to achieve in the early arterial oxygen carriage (CaO2), and cardiac output (CO).82
stages of resuscitation, especially in the prehospital environ- As well as demonstrating how reduced cardiac output due
ment. The normal physiological response to blood loss will to permissive hypotension leads to reduced DO2, it also helps
ensure a high systemic vascular resistance, and thus a rela- to explain why replacing lost blood volume with crystalloid
tively high-pressure but low-flow system will predominate. simply does not work. Aside from the deleterious effect of
being a nonphysiological fluid, which is acidotic and often
cold, it does not carry oxygen. This leads to a reduction in
PERMISSIVE HYPOTENSION
CaO2 and therefore DO2. Crystalloid-based resuscitation also
Some early suggestion of the value of permissive hypoten- leads to a dilutional coagulopathy. This has been termed
sion comes from the First World War.77 Cannon suggested “resuscitation coagulopathy.” This is one component of
that: trauma induced coagulopathy (TIC), the other being ATC.
This equation also demonstrates the fundamental con-
Injection of a Fluid that will increase blood pressure carries cern with a prolonged period of permissive hypotension;
danger in itself. Haemorrhage in the case of shock may not have CO is significantly diminished and, as a result, tissue oxygen
occurred to a large degree because the blood pressure is too low, delivery is reduced.
and the flow too scant to overcome the obstacle offered by a clot.
If the pressure is raised before the surgeon is ready to check any Acute Traumatic Coagulopathy
bleeding that may take place, blood that is sorely needed may The harms of coagulopathy in trauma patients have been
be lost. well demonstrated (Fig. 5.7).83 This graph shows that a
trauma patient with a prothrombin ratio of 1.3 to 1.4 has
A very similar theory was espoused 80 years later.78 a mortality approximately twice that of a trauma patient
Worse survival for patients with penetrating torso injury with a prothrombin ratio less than 1.3. Mortality contin-
who received aggressive, preoperative, crystalloid resusci- ues to increase with prothrombin ratio greater than 1.4 in
tation was demonstrated in a large randomized controlled a nonlinear manner.83
trial.78 This formed the bedrock of the arguments for per- There are two key drivers to the development of ATC,
missive hypotension in the subsequent decades. Although as demonstrated in Fig. 5.8. Significant tissue disruption,
methodologically rigorous, several things should be con- represented by the injury severity score (ISS) on the X-axis,
sidered about this study that limits its external validity and and marked hypoperfusion, represented by base deficit on
must be interpreted with caution when applied to how we the Z-axis, are associated with a raised prothrombin ratio
should resuscitate patients today. First is the patient demo- (Y-axis). There is little that can be done after injury to limit
graphic. On the whole they were young men with, presum- tissue damage. However, ensuring adequate perfusion is
ably, few comorbidities.78 Second is the mechanism of injury; possible, but this conflicts with the concept of permissive
by definition all these patients sustained penetrating injury, hypotension.
with approximately 30% stabbed and the remainder receiv- The harm of prolonged permissive hypotension has
ing relatively low-velocity gunshot wounds – given that the been demonstrated in animal models.82 In pigs exposed to
injuries occurred outside of military conflict, it is likely that a model of either hemorrhage and blast or hemorrhage
the weapons involved were, on the whole, low velocity rather and sham blast, those resuscitated to normotension had
than high-velocity military-style weapons.78 These mecha- improved survival compared to those resuscitated following
nisms mean that the amount of overall tissue damage was a regimen of permissive hypotension.82 Although the effect
likely to be low, certainly in comparison to patients with
significant blunt injury. Finally, the fact that patients in the
early resuscitation group received large volumes of crystal- 35 *
loid may have caused harm due to the type of fluid they were *
receiving, rather than the timing or, indeed, the amount.79–81 30 *
If examined in isolation there is excellent evidence sup-
porting the findings, suggesting that permissive hypoten- 25
Mortality (%)

sion is the appropriate strategy for resuscitation in trauma. 20 *

However, there is also evidence that this is not the case,
especially in injury caused by blast.82 15

10
ALTERNATIVE RESUSCITATION STRATEGIES
5
Much of the literature supporting permissive hypotension
is based on models of uncontrolled hemorrhage of arterial 0
0.8–0.9 1 1.1–1.2 1.3–1.4 1.5–1.6 1.7–1.8 1.9–2.0
lesions; these are the most likely to re-bleed if blood pressure
is raised, and are likely to be the type of injury that benefits Prothrombin ratio
most from a permissive hypotension approach.82 The fun- Fig. 5.7 The effect of coagulopathy on mortality in trauma. Prothrom-
damental problem with permissive hypotension is reduced bin ratio is a measure of coagulopathy. The higher the ratio, the worse
oxygen delivery to the tissues.82 The equation: the coagulopathy. (With permission from Frith D, et al. Definition and
drivers of acute traumatic coagulopathy: clinical and experimental
DO2 = CaO2 × CO investigations. J Thromb Haemost. 2010;8(9):1919–1925.)
66 SECTION 2 • Immediate Management and Diagnostic Approaches

was most marked in pigs exposed to blast (and thus with the tension ensures improved perfusion and hopefully improved
greatest degree of tissue injury), the effect was also seen in oxygen delivery, leading to, at best, a reversal of the nega-
those pigs with sham blast.82 This was despite the fact that tive effects of permissive hypotension. In further work, in
the only resuscitative fluid used was 0.9% normal saline.82 a mixed arteriovenous porcine model of hemorrhage, this
Interestingly, there was no difference in survival at 1 hour strategy showed a significant improvement in survival com-
(Fig. 5.9). These findings led to the suggestion that a combi- pared to prolonged hypotensive resuscitation in the blast
nation approach may be most appropriate.82 injured group, but no significant difference in the sham
blast group.82 There was no evidence of increased re-bleed-
Novel Hybrid Resuscitation ing in novel hybrid resuscitation compared to prolonged
This strategy consists of an initial period of an hour with permissive hypotension.82
a hypotensive resuscitation target followed by a period of
resuscitation to normotension, even if definitive control of Practical Application
bleeding has not been achieved. The physiological rationale In terms of resuscitation strategy, current evidence sug-
for this is sound and its efficacy is supported by the avail- gests that novel hybrid resuscitation is likely to be the best
able literature, albeit in a porcine model.82 The initial hour option.84 There are greater risks of resuscitation to normo-
allows time for any clot to form and stabilize prior to chal- tension in penetrating injury, and the reduction in burden
lenging it with increased pressures. The return to normo- of tissue damage means that there is less chance of develop-
ing ATC, certainly in low-velocity penetrating injury. Even
so, prolonged hypoperfusion is still likely to be detrimental.
As such an initial period of hypotension to avoid “popping
2 the clot”, followed by resuscitation to normotension or near
1.9 normotension, is advisable. Exact durations and blood pres-
1.8 sure values are more uncertain. However, best available evi-
* * dence would point toward a BP target of 100 mm Hg, and
Prothrombin ratio

1.7
1.6 * never lower than 90 mm Hg, for the period of permissive
1.5 hypotension, with resuscitation to 110 mm Hg subsequent
* * to this period.84
1.4 *
1.3 *
Even this guidance may need to be adjusted when dealing
with an individual patient. Given that the primary driver in
1.2 > 12 resuscitation is to ensure good oxygen delivery to tissues,
1.1 6.1–12
some account must be taken of a patient’s normal physi-
1 0.1–6
ological state. For example, in a usually hypertensive arte-
< 16 0 Base deficit riopath, the blood pressure target for both the hypotensive
16–24 (mmol L–1)
25–35 and normotensive period may be higher still.
ISS > 35

Fig. 5.8 Causes of the acute coagulopathy of trauma. This demon-

strates that both tissue damage, represented by injury severity score WHAT TO USE DURING RESUSCITATION
(ISS), and tissue hypoperfusion, represented by base deficit, are
required for coagulopathy to occur. (With permission from Frith D, et al. Choice of Fluid
Definition and drivers of acute traumatic coagulopathy: clinical and exper- The concept that patients who are bleeding should receive
imental investigations. J Thromb Haemost. 2010;8(9):1919–1925.) blood as replacement fluid during resuscitation is now well
established. However, although a large systematic review
on the use of prehospital blood product resuscitation dem-
1.00
onstrated that prehospital blood transfusion was safe and
feasible, it failed to find any short- or long-term mortality
benefit, improvement in biochemical markers, or reduction
0.75
in in-hospital blood transfusion in those getting prehospital
blood.85 This review was significantly handicapped by both
Survival

the paucity of evidence available at that time and the poor

0.50
quality of the evidence that was available.85
S Normot Transfusion of blood products to bleeding trauma
B Normot patients is the standard of care in-hospital. Given the lack of
0.25
S Hypot available evidence specifically looking at prehospital blood
B Hypot product administration, it seems reasonable to extrapolate
that prehospital blood transfusion is appropriate. Further
0.00
evidence from clinical trials focusing on prehospital blood
0 100 200 300 400 500
product administration is emerging on this subject.
Time after onset of resuscitation (min)
There are potential difficulties with prehospital blood
Fig. 5.9 Survival following different resuscitation strategies in pigs transfusion. As has been described in the section on “stop-
exposed to a combined hemorrhage and blast or hemorrhage and ping the bleeding,” the first priority in managing the
sham blast. (From Kirkman E, et al. Blast injury research models. Philos bleeding patient must be to stop the bleeding; it is almost
Trans R Soc Lond B Biol Sci. 2011;366(1562):144–159.) impossible to definitively control hemorrhage prehospital,
 5 • Prehospital Management of Vascular Injury 67

and delaying definitive treatment is deleterious. Therefore, of major hemorrhage protocols. Recent work demonstrates
the administration of blood products must not be allowed to that 55% of major trauma patients who have not received
prolong on-scene times. pRBC are hypocalcemic.92 Given the vital role calcium plays
Both packed red blood cells (pRBC) and plasma have been in the clotting cascade we would contend that it should be
carried prehospital. The logistics of carrying prehospital routinely administered to bleeding, trauma patients.
platelets are such that it is not currently feasible. Given that
pRBCs do not contain clotting factors, transfusion of them TRANSPORT DESTINATION
alone may contribute to coagulopathy. The gold standard
in theory would be replacement of whole blood. However, The final responsibility of a prehospital team managing
reduced mortality from exsanguination in patients receiv- a patient with vascular injury is to ensure they are trans-
ing a balanced transfusion of pRBCs, plasma, and platelets ported to an appropriate center. Since the introduction of a
in a 1:1:1 ratio compared with patients receiving twice trauma system in the UK, survival from major trauma has
as many units of pRBCs compared with plasma has been significantly improved.93 Decision-making around a desti-
shown in-hospital.86 Therefore, a 1:1 transfusion of plasma nation for a patient is especially challenging when long dis-
to pRBC is currently seen as a reasonable compromise tances are involved.
when replacing lost intravascular volume. Due to the logis-
tical burden of carrying plasma, many services are choos- SUMMARY
ing to carry lyophilized plasma rather than frozen plasma.
The lyophilization process seems to have minimal effect on The optimum resuscitation strategy is likely to vary from
the biological function of the plasma, with no difference patient to patient depending on their own premorbid state
in thrombin generation assays and extensive clinical use and their mechanism of injury. If giving volume for resus-
suggesting equivalence.87 Work is ongoing to determine citation of a bleeding patient, then balanced transfusion or
whether the early addition of cryoprecipitate to pRBCs and ideally fresh whole blood should be used in preference to
plasma would be beneficial.88 crystalloid. TXA should be given to bleeding patients and
The administration of fresh, warmed, whole blood to calcium should be considered, especially if patients are
trauma patients is now being explored and, in some cir- receiving citrated blood products.
cumstances, implemented.89 Administering this prehospital
is a significant challenge, although it has been achieved in References
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 6 Damage Control and Immediate
Resuscitation for Vascular
Trauma
TOM WOOLLEY, RAVI CHAUHAN, and ALLAN PANG

Introduction point of wounding to definitive treatment in order to mini-

mize blood loss, maximize tissue oxygenation, and optimize
Hemorrhage occurs when there is disruption of the blood outcome.”3 DCR reflects advances in combat casualty care
vessel wall after an injury, i.e., vascular trauma. Hemor- made in the recent military campaigns in Afghanistan and
rhage remains a leading cause of death in trauma patients, Iraq and spans the spectrum of vascular trauma manage-
accounting for 40% of deaths.1 In order to reduce mortality ment. This practice has evolved as an overarching con-
from hemorrhage there must be early and effective control cept that draws together all those interventions. It starts
of the bleeding, with concurrent replacement of blood vol- from immediate first aid measures delivered at the point of
ume. There remains debate as to the most effective fluid with injury, such as application of tourniquets and optimization
which to resuscitate patients, but resuscitation is equally as for surgical intervention by effective volume resuscitation,
important as any operative maneuvers required to expose, through to the critical care unit with the management of
control, and reconstruct an injured blood vessel. coagulopathy, systemic inflammatory response, and any
New understanding of the pathophysiology of trauma has associated organ dysfunction, which is encompassed by the
influenced the military approach to resuscitation, which is emerging concept of endotheliopathy.
centered around the prevention and mitigation of acidosis, DCR includes damage control surgery (DCS). DCS is the
hypothermia, and coagulopathy while maintaining tissue operative stage of DCR that sacrifices the completeness
oxygenation.2 In particular, novel transfusion protocols have of the immediate surgical repair in order to address the
been developed to counter the lethal triad; these protocols physiological consequences of the injury. DCS has come to
adopt early blood transfusion, increased red cell to plasma mean a time-limited surgical procedure (i.e., abbreviated
transfusion ratios, dynamic monitoring of coagulopathy, and operation) where the imperative is the minimal interven-
tailoring of transfusion to the individual’s need. tion to save life and limb before the trauma triad of death
This chapter will focus on the early management of the of hypothermia, coagulopathy, and metabolic acidosis
physiological insult caused by major vascular trauma, with becomes established.
a particular emphasis on trauma team response, transfu- Currently there is no universally agreed time period where
sion therapy, safe anesthetic practice, and circulatory sup- surgical intervention must be complete. Previously this was
port. Resuscitation end points are discussed, as are other thought to be time limited to a maximum of 60 minutes.
handrails that provide guidance during complex clinical As our understanding and delivery of resuscitation has
scenarios. The ethics of trauma resuscitation are also delib- improved, so this arbitrary 60-minute rule has become less
erated, recognizing that these decisions are more pressing critical. Patients with significant injury severity are arriv-
when resources (clinicians, operating-theater capacity, crit- ing to theatres with less physiological derangement, and so
ical care capacity, blood products) are constrained. increasing the options available to surgeons for their opera-
tive repairs. The main determinate of surgical time should
be the physiological state of the patient. The more effective
DAMAGE CONTROL DEFINITIONS
and coordinated the early resuscitation, the more options
The term “damage control” originates from maritime termi- become available to the surgeon.
nology, relating to the emergency measures used to manage Once the initial surgery is complete, the resuscitation
during the emergency crisis of the sinking of a ship. This is must continue and this will likely occur in the critical
the principle that action taken is that which is necessary to care unit. Unlike DCS, DCR is not time limited and is com-
keep the ship “afloat” in times of crisis rather than compre- plete once a patient’s physiology is returned to normal. It
hensively completing the repair. When applied to trauma, is often thought that once a patient has arrived in Criti-
“damage control” incorporates a mosaic of interventions cal Care that the job is done. This is not the case and DCR
that collectively provide an effective hematological and principles, especially the use of blood products, should
mechanical “plug” to arrest blood loss and keep the patient continue until the patient is fully resuscitated. Thus, from
“afloat.” the anesthetist’s perspective, DCR occurs from the point of
Damage control resuscitation (DCR) is formally defined injury by minimizing the insult, through the initial resus-
as “a systematic approach to major trauma combining the citation, to optimize the patient for the further insult of
<C>ABC (catastrophic bleeding, airway, breathing, circu- surgery, and on to critical care until the patient’s physiol-
lation) paradigm with a series of clinical techniques from ogy is returned to normal.

70
 6 • Damage Control and Immediate Resuscitation for Vascular Trauma 71

Pathophysiology of Coagulopathy/ the military, for many years, have used whole blood in the
sickest patients. Whole blood for bleeding trauma patients
Trauma-Induced Coagulopathy (TIC) has increased in civilian practice in recent years, particu-
larly in the United States, where the American Association
Within the context of major vascular trauma, the patho- of Blood Banks recently endorsed the use of whole blood.
physiology of coagulopathy is multifactorial and is still not Whole blood in civilian trauma has less uptake outside of
fully understood. Traditionally, teaching of the trauma the United States, but is now used in the United Kingdom,
triad of death of acidosis, hypothermia, and coagulopathy Israel, and Norway.
fed into each other as a vicious cycle. Although acidosis and
hypothermia do play a role in exacerbating coagulopathy, ACIDOSIS
our understanding of trauma science has shown that there
are more nuanced factors at play that lead to coagulopathy Trauma to vasculature leads to significant blood loss, which
in the context of trauma. itself will lead to hypovolemia and therefore hypoperfusion,
along with reduced oxygen delivery to peripheral tissues. At
the cellular level, anaerobic respiration becomes the pre-
HYPOTHERMIA
dominant means of energy production, which leads to the
The activation of the coagulation cascade is an enzymatic production of lactic acid and therefore a metabolic acidosis.
process and therefore requires two physiological conditions Within animal studies, acidosis has shown to have multiple
to function. Tissue factor (Factor VIIa) activity decreases by effects on coagulation, such as reducing the activity of clot-
50% at 28°C4 and platelet adhesion to Von Willebrand Fac- ting factors (50% at pH 7.2, 70% at pH 7.0, and 90% at pH
tor is essentially absent below 30°C.5 Trauma patients have 6.8) and increasing degradation of fibrinogen, i.e., hyperfi-
often suffered a period of exposure during the prehospital brinolysis.15
phase and, when combined with significant blood loss, are
extremely prone to hypothermia. Combined with interven- TISSUE TRAUMA
tions such as fluid resuscitation with nonwarmed fluids or
cold blood products, the vasodilatory effect of general anes- Although acidosis does play a significant part in trauma
thesia, and the exposure of body cavities during surgery, it coagulopathy, it is not the only factor, as significant clinical
becomes easy to see how hypothermia is an ever-present coagulopathy is detected even with mild degrees of acido-
risk during this initial phase of DCR. sis,16 and coagulopathy can still occur even when acidosis
Clinically significant effects of coagulopathy have been is corrected.15 It is now apparent that tissue damage and
shown where core temperature is below 34°C4,6 and mor- disruption of the endothelium, which leads to the exposure
tality from hemorrhage is markedly increased when core of the subendothelial layer and release of tissue factor, also
temperature is below 32°C7; however, what is not clear is has implications for coagulation.
whether the hypothermia in itself is an independent factor The exposure of subendothelial layer leads to activation
or merely a marker of the severity of shock and physiologi- of plasma proteases, which leads to the activation of the
cal compromise. coagulation cascade and so the formation of thrombin and
fibrin. In significant trauma, where there are multiple sites
of endothelial disruption, there is activation of procoagu-
HEMODILUTION
lation factors such as X, II, V, and VIII. These factors then
Where there is significant disruption to the vasculature, subsequently enter the systemic circulation and generate
larger clots are required, consuming coagulation prod- thrombin, affecting macro and microvascular flow as well as
ucts such as platelets, coagulation factors, and fibrinogen. giving rise to a process where platelets, coagulation factors,
Within earlier versions of advanced trauma life support and fibrinogen are consumed and coagulopathy develops.
(ATLS) teaching, liberal fluid resuscitation was advocated, Tissue disruption also leads to release of tissue-type plas-
which aimed to improve tissue perfusion, but risked worsen- minogen activator (tPA) and increased tissue expression of
ing coagulopathy by diluting coagulation factors within an tPA. tPA activates plasmin from plasminogen, which lyses
already depleted blood volume. Dilution has been shown to the clot, i.e., fibrinolysis. Within the context of hemorrhagic
have detrimental effects on coagulation and impair hemo- trauma, hypoperfusion leads to further release of tPA from
stasis.8 the Weibel-Palade bodies within endothelium17,18 and fur-
For the same reason, the sole use of packed red cells as ther weakening of the clot.
a means of volume replacement will also lead to a dilu- The combination of excessive activation of coagulation
tional coagulopathy as platelets, coagulation factors, and with hyperfibrinolysis has led to trauma-induced/-associ-
fibrinogen are not replaced.9 Mathematical models have ated coagulopathy described as the “fibrolytic phenotype”
suggested that use of 1:1:1 ratio with red cells, plasma, and of disseminated intravascular coagulation.
platelets will minimize the dilution and provide a solution
closest to whole blood.10,11 Experience from recent military ENDOTHELIAL DYSFUNCTION
campaigns in Afghanistan and Iraq have shown that this
ratio is possible and does have better outcomes12—findings The formation of lactic acid and other metabolites can be seen
also replicated in a civilian setting in the PAMPER Trial.13 as a surrogate for oxygen debt, which needs to be addressed
Of note, component therapy itself has a dilutional effect as and “repaid” in a timely manner, or else excessive morbid-
each component has its own additive solutions.14 In order ity and mortality due to multiorgan failure19–21 is risked.
to minimize the dilutional effects of component therapy, Multiorgan failure is traditionally viewed as dysfunction
72 SECTION 2 • Immediate Management and Diagnostic Approaches

of one or more of the respiratory, cardiac, renal, and viduals who may not have worked with each other before
hepatic systems. The blood and endothelium unit should and have their own competing priorities for the patient.
also be considered an organ, which may also suffer from the The team leader will need to manage multiple information
effects of prolonged hypoxia and acidemia and thus oxygen streams about the patient and clinical trajectory while also
debt. This concept has been described as “blood failure” by weighing up options for the next place and phase of care.
the Trauma Hemostasis and Oxygenation Research (THOR) Preparation prior to patient arrival is important. The use of
Network.22 pre-alerts based from the prehospital team can in turn acti-
In health, the endothelium undertakes a range of physi- vate members of the trauma team to the ED prior to patient
ological functions including control of vasomotor tone, arrival, to assign roles, pre-rehearse likely scenarios, and
maintenance of blood fluidity, and regulated transfer of prepare equipment/drugs.
water, nutrients, and leukocytes across the vascular wall, This may include drawing up induction and maintenance
as well as regulation of immunological cell migration.23 anesthetic drugs, anticipating necessary procedures, prim-
The inner endothelial wall has anticoagulative properties ing universal donor red cells (O negative) and plasma (AB
via various systems such as the thrombomodulin/protein C positive) for administration using a rapid transfusion device
system, heparinoid-lined glycocalyx, and potential release with or without a warming mechanism, and informing the
of tPA and urokinase plasminogen activator.24,25 Although CT radiographer/radiologist and the theatre coordinator.
not fully understood, it has been proposed that damage to Performing these actions can not only smooth out transi-
the endothelium, either by direct damage by trauma or by tions of care and enhance the patient flow, but also allow for
hypoperfusion, leads to the release of these anticoagulative more mental bandwidth such that task-critical operators
factors and the glycocalyx into the systemic circulation, can rehearse and concentrate on relevant procedures, i.e.,
leading to global hypocoagulability should the insult be of the anesthetist performing rapid sequence induction (RSI).
significant magnitude.26 Traditional resuscitation protocols emphasized a linear/
Other factors may lead to further endothelial dysfunc- 2-D approach, where the patient arrives in ED, undergoes
tion. The initial procoagulative state leads to microemboli initial assessment and resuscitation, is transferred to CT
and therefore microvascular occlusion, compromising flow Scan for imaging, and then undergoes surgical correction or
and oxygen delivery. There is also increased paracellular intervention in the theatre or interventional suite. Another
permeability due to loss of endothelial integrity and tissue approach, however, is to bypass ED and transfer directly
edema—compounding the impairment of oxygen delivery to theatre in order to save time in a severely compromised
and increasing oxygen deficit. In the face of global hypo- patient.
perfusion, there will be hyperstimulation of the sympa- So-called 3-D resuscitation is a concept that has been
thetic-adrenal system leading to high circulating levels of developed in the deployed military hospital and in select
catecholamines. High levels of catecholamines have been civilian trauma centers. In this scenario, advanced notifi-
implicated as a proposed mechanism of endothelial dam- cation from the field or en-route care platform allows the
age known as shock-induced endotheliopathy,27 which may team leader to identify the small number of patients who
be common to other acute critical illness syndromes such will benefit from direct transfer from the ambulance or heli-
as postcardiac arrest syndrome, sepsis, and myocardial copter to the operating theatre or Hybrid Suite. In the war-
infarction. time setting, these patients are often injured from explosive
As a better understanding of the mechanisms of trauma- events, have single or multiple amputations, or have torso
related coagulopathy is developed, we will find better tools injuries and are in pending cardiovascular collapses from
to quantify the contributory factors described previously. hypovolemia.
Although the extent of tissue damage and therefore the
extent of endothelial damage is not a reversible factor, try- INITIAL PRIORITIES IN MANAGEMENT
ing to limit endothelial dysfunction and further damage
by ensuring adequate oxygen delivery and limiting oxygen The use of a C-ABC framework allows identification and pri-
debt is desirable. Currently, there is no way of measuring oritization of the immediate steps in stabilization and man-
or quantifying oxygen debt and, although lactate clear- agement.
ance has been quoted as a useful marker for resuscitation
end point in the critically ill28 (and probably our best widely C—Catastrophic Hemorrhage Control
measurable marker), it does not signal whether oxygen debt Catastrophic hemorrhage is significant bleeding which
has been repaid. requires immediate management to stop exsanguination.
For the patient suffering catastrophic hemorrhage to arrive
into the ED alive, there will be some form of catastrophic
Emergency Department Reception hemorrhage control, which may or may not be com-
plete, or may have become ineffective between application
Patient evaluation in the Emergency Department (ED) and arrival. Verbal handover and visual checks should be
allows assessment from both a surgical and a physiologi- made of:
cal point of view. There is a balance that needs to be struck
between early surgical intervention and the need to optimize n Tourniquet—Check positioning and adequacy (i.e., needs
the patient physiologically, which is situation dependent. tightening/requires second). Consider judicious release
The role of the trauma team is to enforce a systematic (after primary survey, and assuming physiology is stable)
approach to patient assessment and action, but the nature if wound pattern suggests it is not required (controlled
of medical rotas means that the team will consist of indi- release).
 6 • Damage Control and Immediate Resuscitation for Vascular Trauma 73

n External Dressings—appropriate packing, consider use When considering the need for C-Spine immobilization,
of hemostatic agent impregnated dressings. the mechanism of injury and pros and cons of immobili-
n REBOA—Time to balloon deflation is critical, particu- zation must be weighed up and considered. Immobilization
larly in zone 1 deployment. Consider timing, extent, and increases the difficulty of managing the airway, raises the
place of deflation as per Chapter 11. risk of aspiration in the event of vomiting, and increases
intracranial pressure. Blanket immobilization has been de-
A—Airway (and C-Spine Protection) emphasized in favor of a risk-stratified approach in both
Most anesthetists would consider airway management the military31 and civilian32 practice.
most important early priority in the treatment of the criti-
cally unwell patient—as without adequate oxygenation B—Breathing: Optimizing Gas Exchange
the patient will quickly deteriorate. Ultimately, the patient As part of the primary survey, the emphasis of detection
with major vascular trauma will require a definitive airway and immediate treatment of life-threatening thoracic inju-
as part of general anesthesia and operative intervention, ries can be summarized with the mnemonic ATOM FC (Air-
although the timing and place of RSI will be dictated by way obstruction/disruption, Tension pneumothorax, Open
case specifics. It has become common practice to secure the pneumothorax, Massive hemothorax, Flail Chest).
airway to facilitate transfer either to CT or theatre. Other The place of supplemental oxygen in critically unwell
indications include: patients is changing. The unmitigated use of supplemen-
tal oxygen for every patient is not necessary and, in some
n Significant hypoxia/respiratory failure cases, is potentially harmful due to hyperoxia.33 National
n Loss of protective airway reflex due to reduced Glasgow guidelines in the United Kingdom, Australia, and New Zea-
Coma Score (GCS) ≤8 land now dictate careful titration of supplemental oxygen
n Significant chest trauma to target pulse oximetry (SpO2) between 92% and 96%.34,35
n Airway soiling A recent systematic review36 concerning supplemental oxy-
n Dropping GCS gen in the military trauma population made a number of
n Requirement for sedation/analgesia for humanitarian recommendations on indications (Table 6.1).
reasons Mechanical ventilation has physiological implications
that are counterproductive to the shocked patient’s resus-
From the team leader’s perspective, securing the airway citation goals. By introducing positive pressure within the
has to be balanced with other pressing priorities in the intrathoracic cavity, venous return to the heart is impeded
patient’s care (i.e., hemorrhage control and volume resus- and cardiac filling reduced, diminishing cardiac contractil-
citation). The airway can be interim managed using less ity and cardiac output. PPV also negatively affects the lungs
invasive measures such as airway maneuvers and adjuncts by reducing alveolar perfusion, reducing O2 transfer/CO2
(ora-/nasopharyngeal airways), providing these enable suc- clearance and inducing atelectasis by contributing to V/Q
cessful ventilation. mismatching. Inadvertent attempts to compensate for this
Securing the airway itself is not a risk-free intervention. by increasing positive end expiratory pressure (PEEP) and
Induction of anesthesia and the introduction of positive raising ventilatory pressures to achieve a higher minute
pressure ventilation (PPV) are fraught with risk, especially in volume will worsen the cardiovascular insult and may pre-
the context of hemorrhagic shock. Securing the airway may cipitate a cardiac arrest.
be technically challenging and may need multiple attempts The vascular trauma patient will undergo significant
at laryngoscopy and/or specialist airway equipment. The fluid shift during volume resuscitation, increasing the risk
“can’t intubate, can’t oxygenate” scenario, which can rap- of lung injury in the form of acute respiratory distress
idly lead to life-threatening hypoxia, is an ever-present con-
cern. Securing the airway in a more controlled manner in
a patient who has progressed to a safer physiological state
after a short period of resuscitation, where RSI can be con- Table 6.1 Use of Supplementary Oxygen in Emergency
ducted in a dedicated environment, is preferable to an over- Patients36
hasty or under-prepared attempt at intubation. Supplemental O2 Required Supplemental O2 May Be
RSI comprises rapid induction and swift intubation with Regardless of SpO2 Required Based on SpO2
the use of cricoid pressure, without the use of bag-mask Chest injuries Evidence of hypotension without
ventilation. Although these components make sense in an hypovolemia
unfasted patient to prevent aspiration, there are associated Injuries at altitude Truncal injuries
drawbacks in the critically unstable patient. These include Decompression injuries GCS <15
impaired view at laryngoscopy, reducing the ability to bag- Smoke inhalation and carbon Return of spontaneous circulation
mask ventilate in a failed laryngoscopy, and increasing monoxide poisoning following cardiac arrest
the risk of hypoxia and risk of cardiovascular collapse. A Cardiopulmonary resuscitation
concept known as controlled sequence induction offers the Preoxygenation prior to RSI
operator a gentler approach. This technique allows rapid Ventilated patients
intubation and gentle bag-mask value ventilation during
GCS, Glasgow Coma Score; RSI, rapid sequence induction.
the apneic phase of induction, reducing the risk of hypoxia. Adapted from Cottey L, Jefferys S, Woolley T, Smith JE. Use of supplemen-
The concept is well-established within pediatric practice,29 tary oxygen in emergency patients: a systematic review and recommenda-
and is gaining traction amongst critical care practitioners.30 tions in military clinical practice. J R Army Med Corps. 2019;165(6):416–420.
74 SECTION 2 • Immediate Management and Diagnostic Approaches

syndrome (ARDS) or transfusion-related acute lung injury fresh frozen plasma, and 1 unit of pooled platelets, giving
(TRALI), impairing gas exchange. These syndromes tend a near 1:1:1 ratio.
to occur 24 to 48 hours following the initial trauma insult This ratio is a useful starting point but only an approxi-
and, although there are various ventilatory strategies aim- mation of what the individual patient requires—tailoring
ing to prevent/minimize the effect of these syndromes, they of the mix requires trend analysis of physiological, hema-
lie outside the scope of this chapter. tological (and thromboelastogram) data. Close liaison with
the lab-support is essential in the effective delivery of major
C—Circulation: Volume Resuscitation hemorrhage protocols (MHP), as well giving them context
This concerns the processes of achieving hemostasis and to anticipate further blood product requirements. In the
volume resuscitation, which should occur simultaneously. author’s experience, allowing approximately 30 minutes
Peripheral large bore lines (14–16 G) offer the greatest of lead time of likely requirements will give the laboratory
flow rates (even compared to most conventional central team enough time to prepare blood products for the follow-
venous catheters) and are the preferred means of imme- ing shock pack. Transfusion services vary in their ability to
diate IV access. Gaining access can be challenging in the surge blood products to the ED or Theatre in this manner,
shocked patient, especially if there is associated major with less mature services, or those situated in the devel-
extremity trauma. The subclavian and axillary veins offer oping world, less able to support the shock pack or MHP
an alternative route and resist collapse even in significant approach.
hypovolemia. Intraosseous (IO) routes can be quickly and Other adjuncts to MHP have included off-license use of
easily accessed; rapid infusion of fluid requires pressure recombinant factor VIIa,39,40 although RCT data has failed
(i.e., the manual use of a syringe) but good flow rates can to demonstrate any mortality benefit41,42 with increased-
be achieved. Drugs administered via the IO route reach the risk thromboembolic events.43 Conversely, there is good
central circulation just as quickly as the IV route.37 evidence around early administration of tranexamic
A higher pressure to drive IV infusions can be obtained acid. This antifibrinolytic agent has been shown to reduce
by simply raising the infusion bag or directly applying pres- mortality in both the civilian (CRASH-2)44 and military
sure to the bag. The use of a pressure bag allows continuous (MATTERs)45 setting. There appears to be an enhanced
pressure and is a readily available low-tech option; other effect when given early in the treatment pathway (less
infusion systems such as the Level One and Belmont systems than 3 hours from injury, ideally less than 1 hour).46
have the advantage of allowing a second bag of fluid to be This is now reflected in clinical practice as the initial
primed while an infusion is ongoing, preventing interrup- loading dose is routinely delivered within the prehospital
tion of volume resuscitation and allowing for in-line warm- setting.
ing of the fluid to reduce the risk of iatrogenic hypothermia.
The benefits of using early blood products versus crys- D—Disability and “Cardio-Stable” Induction
talloids as a volume replacement in traumatic hypovole- Strategies
mic shock have now been widely described in the military Assessment of disability involves being aware that by
population. Two recent randomized controlled trials (RCTs), inducing general anesthesia, the team will be unable to
PAMPER and COMBAT, studied the outcome of shocked assess neurological status, which is often the first and most
patients following early, en-route resuscitation with plasma sensitive sign of a neurological injury. Prior to induction,
versus standard fluid resuscitation. COMBAT was conducted attempts should be made to gauge the best GCS and neuro-
in an urban setting, with short prehospital times (less than logical status, with a rapid assessment for signs suggestive
20 minutes)—and no mortality difference was observed. of gross upper or lower motor neuron injury.
There was a high proportion of penetrating trauma and Inducing anesthesia in a hypovolemic patient is fraught
most patients did not get their plasma treatment prehospital with risk—and careful thought and team discussion/
due to the rapidity of transfer to the ED.38 briefing should precede expedited intubation to check
PAMPER,14 on the other hand, was a multisite study optimal timing and location. These patients rely on their
with longer prehospital times (median 40 to 42 minutes in increased sympathetic drive to maintain adequate cardiac
each study arm) where the control arm protocol defaulted output in a relatively underfilled state. Conversely, induc-
to local resuscitation standard operating procedures (SOPs) tion agents are generally negatively inotropic and inhibit
(including some services where administration of red cells the sympathetic nervous system, which will compromise
and crystalloid was the standard of care). In this study any compensation the patient is trying to mount. This will
there was a significant reduction in mortality for the plasma invariably lead to a low cardiac output state or cardiac
group, with most benefit in those patients who received arrest if the induction technique is not modified by alter-
both plasma and red cells. The PAMPER and COMBAT data ing the ratios of medications or by changing the medica-
sets were designed to be combinable, and aggregate analy- tions used. These techniques are known as “cardio-stable”
ses revealed that where prehospital times were greater than induction strategies.
20 minutes, there was a mortality benefit in the plasma One such technique is to employ high-dose opiate (i.e.,
group, and this was more significant in blunt, rather than 10 mcg/kg fentanyl), which allows a reduced dose of propo-
penetrating, trauma. fol for induction. This strategy is used routinely in elective
“Shock packs” or major hemorrhage packs are a system patients with compromised cardiac function where mini-
improvement that makes balanced trauma resuscitation of mizing suppression of cardiac drive is vital. This approach
blood products easier to conduct from a logistical perspec- will be familiar to the general (non-trauma) anesthetist but
tive. The components of shock packs vary but typically will takes more time to achieve conditions suitable for intuba-
include 4 units of O negative packed red cells, 4 units of tion, and so carries a higher risk for aspiration.
 6 • Damage Control and Immediate Resuscitation for Vascular Trauma 75

Ketamine with short acting opiates (alfentanil/fentanyl) MANAGEMENT BEYOND THE EMERGENCY
is the preferred choice of most trauma anesthetists and pre-
hospital practitioners, particularly within the UK setting.
DEPARTMENT
Ketamine has the advantage of maintaining sympathetic The operating theatre is fraught with human factor chal-
drive and cardiac inotropy, thereby maintaining cardiac lenges that pose hazards to the unstable patient. Urgency
output. It also has analgesic properties due to its action as an for intervention combined with clinical uncertainty and
N-methyl-D-aspartate (NMDA) antagonist, which reduces patient instability serve to compound stress and the poten-
pain burden during recovery. Ketamine is not frequently tial for error. Good communication—not just between
used in day-to-day anesthetic practice and, unlike the other the surgeon and anesthetist, but amongst all team mem-
induction agents, it achieves anesthesia by disassociation. bers—is an essential attribute of good surgical and anes-
Dosing errors, inadequate or overzealous hypnosis, and thetic management. Both sides of the surgical drape need
increased risk of adverse outcomes are potential hazards to understand each other’s roles and how they may help
when used by those who are unfamiliar with ketamine. It each other. Surgeons and anesthetists are equally prone to
increases cerebral blood flow and raises intracranial pres- task fixation, which leads to the loss of global situational
sure, which would be detrimental in head injured patients. awareness. Although consultants have authority to direct
Hallucinations, particularly on emergence, are a possibility the flow of care, the team should be managed with as flat a
and therefore the operator should maintain a calm environ- hierarchy as possible, such that all are empowered to speak
ment during induction/emergence, as well as having readily up, fully participate in decision-making, and anticipate
deployable rescue strategies to deal with associated combat- their own requirements to perform optimally.
iveness. Checklists can enhance team function. Although some
Etomidate has a very advantageous cardio-stability pro- checklists have arguably become cumbersome, when used
file, as well as providing rapid onset of anesthesia. When correctly they reduce the incidence of never events.49 A
first introduced in the 1970s, it rapidly gained in popular- well-drilled and rehearsed team will use the checklist as
ity as the “ideal” induction agent.47 However, by the 1980s an opportunity to give everyone an insight into the global
it was noted that that etomidate inhibits 11β-hydroxylase, picture and allow voicing of concerns. Momentum can be
a key enzyme in adrenal cortisol production, and was maintained by using an abbreviated version of the well-
shown to lead to poorer mortality outcomes in critically ill described WHO surgical safety checklist known as a Snap
patients.48 For this reason, it is often avoided in routine clini- Brief:
cal practice and certainly would be particularly harmful in
a patient who is likely to undergo a prolonged period within n Patient
critical care. n Confirm patient ID
n Clinical findings
E—Everything Else (Including Transfer) n Surgical
Hypothermia worsens coagulopathy. Efforts must be made n Surgical plans
not only to deliver heat, but also to limit heat loss. The n Time required
removal of wet clothing, ensuring adequate ambient tem- n Anesthetic
peratures as well as the use of forced air warmers/blankets n STACK brief (physiological status)
will help prevent loss, whereas the use of warmed fluids will n Systolic BP
aid in the delivery of heat. Other more invasive techniques n Temperature
such as intravesical washout and extracorporeal warming n Acidosis/base excess
are available in theory, but in practice are rarely used, par- n Coagulation/calcium
ticularly in the acute setting. n Kit (blood products/drugs given)/potassium
The primary survey should also be completed to ensure
all other major life-threatening injuries are found, with the Intraoperatively, this same format can be used to facili-
head-to-toe examination (secondary survey) conducted tate regular team briefs, with the “S” standing for “surgical
only once all issues found during the primary survey have progress.”
been addressed. During surgery, anesthetic concerns fall broadly in to (1)
This patient will need an escorted transfer (to CT or The- ensuring cardiovascular stability; (2) optimizing coagula-
atres), which will require an anesthetist, particularly if the tion through the treatment of coagulopathy; and (3) facili-
patient is under general anesthesia. The same standard of tating surgical treatment.
care (i.e., monitoring and physiological support) should
be adhered to throughout the process of the transfer. This Cardiovascular Management
means there must be the means to maintain safe anesthesia Blood pressure—readily available and measurable—is often
(i.e., infusions and oxygen, with resilience in case of entrap- used as a resuscitation end point during the early stage of
ment), as well as emergency drugs and equipment at hand resuscitation. Mean arterial pressure (MAP) is intimately
for the transferring team to respond to patient deteriora- linked to cardiac output and systemic vascular resistance as
tion at any point during the transfer. A good rule of thumb demonstrated by the equation below:
is to take double the amount of drugs and oxygen antici-
pated for the expected duration of transfer. Throughout the MAP = Cardiac Output × Systemic Vascular Resistance
transfer, the team must be mindful of the location of the
nearest places of safety, which includes returning to ED if This equation forms the basis of how pharmacologi-
required. cal cardiovascular support can be provided in the form of
76 SECTION 2 • Immediate Management and Diagnostic Approaches

vasopressors, which cause vasoconstriction, and inotropes, any hospital and offers real time feedback. Severe acidosis
which increase heart muscle contractility. impedes coagulation and is negatively inotropic, which com-
Vasopressors predominately have an effect on the capaci- pounds inadequate tissue perfusion63; correction of acidosis
tance vessels (i.e., arterioles) by increasing the vasomotor (“lactate clearance”) is a useful predictor of mortality.31,64
tone (therefore vascular resistance), leading to greater per-
fusion pressure. The vasopressor of choice is noradrenaline, Optimizing Coagulation
which is easily titratable and widely used; however, this does Optimization of coagulation comes in two parts: the man-
require central access, and phenylephrine or metaraminol agement of TIC and the mitigation of the untoward effects
may be used to bridge the period until central access is avail- of blood product administration and massive transfusion.
able. At some point, however, vasopressors alone can lead The pathophysiology of TIC is multifaceted and not
to excessive vasoconstriction, inhibiting global flow, which fully understood. Coagulation function is conventionally
may cause end organ damage.50 The early use of vasopres- measured using established assays such as prothrombin
sors in trauma has proven controversial. In theory, the use time and international normalized ratio. These tests were
of vasopressors may limit the amount of volume required initially developed for the screening of heritable coagu-
to maintain a higher blood pressure and thereby reduce lopathies such as hemophilia, and as means to monitor
the risk of TIC and other deleterious effects of excessive anticoagulant therapy.65 The results of these tests represent
fluid. A recent systematic review of predominantly obser- the time, in seconds, until the earliest formation of fibrin is
vational studies found a lack of suitably robust evidence detected. They do not assess the maturity of the clot beyond
to determine whether vasopressors are of benefit in early the formation of the first strands of fibrin and correlate
trauma.51 Vasopressors were associated with worse out- poorly with risk of bleeding in elective general and vascular
comes and increased use of fluids, indicating that patients surgeries.66
requiring vasopressors are more likely to be physiologically New approaches include point of care (POC) testing in
deranged.52–54 Similarly, the single RCT included in this the form of viscoelastic assays such as thromboelastogra-
review did not find any benefit with vasopressor use when phy (TEG) and rotational thromboelastometry (ROTEM). In
compared to placebo, although it was underpowered and the trauma setting, TEG was first used as a research tool to
prone to methodological bias.55 The results of ongoing RCTs investigate trauma coagulopathy67; it is now an increasingly
examining this therapeutic question are awaited. important technique in managing TIC.68–70 TEG and ROTEM
Inotropes increase cardiac contractility, thereby increas- both measure clot strength, thereby allowing functional
ing stroke volume and cardiac output. Increased contrac- assessment of coagulation. Both employ a vertical pin held in
tility incurs an increased demand for oxygen and potential a blood sample contained within a cup (cuvette). In TEG, the
for oxidative stress in the cardiac myocytes, which increases cup oscillates clockwise and anticlockwise as the blood clots’
the risk of ischemia. Many inotropes are chronotropic (act viscosity increases and the degree of frictional torque force
to increase the rate of contraction), which not only adds to on the pin changes, allowing a dynamic picture of clot devel-
oxygen demand but also potentiates arrhythmia, decreas- opment and strength to be obtained (Fig. 6.1).71 In ROTEM,
ing cardiac efficiency and therefore reducing cardiac out- the oscillatory force is applied to the pin rather than the
put. cuvette—the latter is held stationary—and as the clot devel-
Though important, blood pressure is only a surrogate ops, pin movement is reduced; this is measured by the angle
marker for tissue perfusion and is not a particularly reliable of deflection of a beam of light directed at the pin. Newer TEG
metric in hemorrhagic shock. Perfusion may deteriorate as technology assesses clot formation using a different, innova-
compensatory increases in vascular resistance maintain tive approach where the blood vibrates at a fixed frequency,
measured blood pressure and the latter can mislead.56 Ide- and a light detector measures meniscus motion to generate
ally, oxygen delivery, which is calculated as: the clot formation tracing.72 TEG and ROTEM depict changes
in viscosity (and thus clot strength) via a trace, characterized
O2 Delivery = Arterial O2 Content ×Cardiac Output by a number of descriptors (Fig. 6.2).73
R-Time. The reaction (R)-time represents the time from
is the variable that is of most utility as an end point. Cardiac the beginning of the test to the establishment of a fibrin
output is the most influential component of this formula as mesh with measurable rigidity of amplitude of 2 mm. This
arterial oxygen content is usually not deficient if appropri- variable has also been referred to as the clot initiation time.
ate transfusion has been rendered. The gold standard for R-time is measured in minutes and reflects coagulation
cardiac output measurement utilizes pulmonary artery factor activity. This variable is currently used in clinical
catheterization, which in itself divides opinion. Suggestions algorithms and protocols to trigger plasma transfusion.74
of increased complication rate,57 difficulties with interpreta- Alpha (α) Angle. This is thought to signify the clot
tion of data,58 and the lack of mortality benefit59 have led strengthening, which in this phase of clotting is mostly
to calls for less invasive means to measure cardiac output.60 achieved by fibrinogen cleavage and fibrin polymerization.
These may include bioimpedance, esophageal Doppler, and A lower angle represents a decreased rate of clot strength
pulse waveform analysis, which have shown to be reason- growth, whereas a higher angle represents a greater rate
ably accurate,61 with the latter applicable within the prehos- of clot strength growth. The α-angle is used clinically as a
pital phase,62 although whether availability of these metrics marker of fibrinogen concentration and is currently used in
affects outcomes is unknown. trauma protocols to trigger fibrinogen replacement in the
Other markers for adequacy of oxygen delivery include way of cryoprecipitate or fibrinogen concentrate.75,76
acid-base status and serum lactate. Although lactate is Maximal Amplitude (MA). This represents the maximal
affected by many other factors, it is widely available in strength achieved by the clot, depicted by the width in
 6 • Damage Control and Immediate Resuscitation for Vascular Trauma 77

More tailored use of blood products may also incur less

complications, such as immunosuppression (where the
mechanism is not fully understood)83; citrate toxicity with
hypocalcemia (mitigated via intravenous calcium supple-
mentation with every shock pack and measurement of
ionized calcium levels), hypomagnesaemia, and alkalosis;
hypothermia (mitigated with blood warming devices); and
hyperkalemia. Regarding the latter, whereas prolonged
storage (more than 10 days) or irradiated blood is thought
to increase the risk of hemolysis, there is no evidence that
mortality is significantly affected by the age of stored blood
that is used prior to standard expiry times.84 Regular POC
testing and timely dextrose/insulin infusion interven-
tion for hyperkalemia (greater than 7.0 mmol/L or 6.0 to
6.9 mmol/L + ECG changes) represents the best means of
Fig. 6.1 Normal thromboelastography trace.71 managing this sequela of massive transfusion.
Facilitating Surgical Treatment
Clot
propagation
Keys to good anesthetic planning (and thus facilitating the
Clot Clot surgical agenda) include (1) a realistic appraisal of the likely
strength lysis length of surgery; (2) likely blood loss; and (3) potential for
Clot
formation deviation from the surgical plan. Regular situation reports
(STACK brief) on progress or difficulty allows the anesthetist
Amplitude (Mm)

and the wider team to gain a global view about the direc-
0 angle
MA (mm) LY30,% tion of management and the rationale for the surgical plan.
Knowing when surgical hemostasis has been achieved pre-
R time (min)
vents over-resuscitation. Similarly, the forewarning of key
surgical steps (clamping and de-clamping of major vessels)
allows the anesthetist to pre-emptively manage circulating
volume, inotrope strategy, and deal with ischemia-reperfu-
sion and washout of metabolites.
Time (min) Another consideration for the anesthetist is to decide
on the merits of waking the patient following completion
Fig. 6.2 Viscoelastic trace and parameters of the various stages of the of surgery. Physiological stability (acid-base status, vaso-
clotting process.73 See text for explanation. pressor support), probability of returning to theatre, and
likelihood of a successful analgesia plan are some of the
factors that are considered. In the authors’ experience, DCS
millimeters of the widest space in the TEG tracing. Clinically, patients, by definition, remain physiologically deranged and
MA reflects a combination of platelet count and function, will require further surgical exploration. Therefore, in vas-
as well as fibrinogen activity and the interaction between cular trauma patients, a period of sedation in critical care
the two. Although not solely reflecting platelet function, and preparations for transfer of an anesthetized patient will
MA is currently used in clinical algorithms and protocols to need to be made.
trigger platelet transfusion.
Amplitude at 30 Minutes (LY30). This is the standard
measure of fibrinolysis by TEG. LY30 is determined Ethics of Resuscitation
by calculating the percent reduction of clot strength
(amplitude) 30 minutes after reaching MA. The ethics of resuscitation following major vascular trauma
Fig. 6.377 gives examples of traces, their explanations, and hemorrhagic shock presents challenges, particularly so
and suggested treatment options to guide coagulation when set against the resource-constrained environment of a
optimization. Being a POC test, viscoelastometry assess- military field hospital or humanitarian surgical team. Deci-
ments can be continued from the trauma bay to theatre, sions surrounding initiation of resuscitation or surgery in
recovery, and critical care. There is some evidence that the gravely injured, declaration of futility following cardiac
better outcomes are obtained when these tests are used arrest, and the definition of ceilings of care and/or blood
to inform transfusion practice78 in trauma, guiding the product expenditure are vexing and cannot be satisfactorily
hemostatic resuscitation79 and reducing blood product answered by the application of a triage algorithm. Senior
consumption as compared to standard assays.80 As such, clinical decision-makers, who can navigate the often-emo-
uptake has increased accordingly; in 2014 the American tional pressures of these conundrums, are an important
Association for the Surgery of Trauma noted that only 9% resource in implementing an evidence-based approach.
of institutions used TEG,81 but it is now endorsed by The For instance, knowing that the outcome from cardiac
American College of Surgeons Trauma Quality Improve- arrest following vascular trauma and cardiovascular collapse
ment Program82 and is included in the general surgical is likely to be an adverse outcome can help guide the dura-
resident curriculum. tion of resuscitation attempt. Even in the best well-resourced
78 SECTION 2 • Immediate Management and Diagnostic Approaches

Fig. 6.3 Abnormal viscoelastometry values/traces and their explanations.76 D.I.C., Disseminated intravascular coagulopathy; N/S, 0.9% normal saline.

civilian series, a survival rate of 7% (physician-led London challenges in advance with their own teams. The goals are
Helicopter Emergency Medical Service) was observed.85 to manage expectations, maintain organizational norms,
Results in well-resourced and staffed role 3 hospitals, work- respect the conventions of ethical clinical management,
ing in a mature military trauma system, are better (24% and deliver humane and respectful medical care that allevi-
survival in a select group of injured, in whom the dominant ates suffering.
cause of cardiac arrest was hypovolemia1), but the likelihood
of achieving these results during warfare, characterized by
remote and dispersed medical facilities, is not high. Future Development of DCR
Context is therefore the foundation for approaching
many of these questions. Context will dictate expectations Whole blood transfusion was established in World War II
and inform boundary setting, as will a clear understanding and the Vietnam War; however, the need for a more tailored
of the organizational Medical Rules of Eligibility for treat- approach and longer storage times leads to development of
ment. Similarly, the professional obligations of the physi- the standardized component therapy that is a highly effec-
cian (mandated through national law, statutory policy, tive and efficient treatment in elective surgical circum-
and professional regulation) and their duty to the chain of stances. In military major trauma settings, especially those
command form part of a decision framework for conten- that cannot access component platelet therapy, the case for
tious issues. Any appraisal of potential ethical challenges whole blood is increasingly clear.86,87 The risk of increased
caused by the necessity to treat the civilian population must risk of plasma-associated transfusion reactions can be miti-
also consider the capacity and capability of host nation gated using leuko-reduction filters. The logistics of provid-
health systems; familial, cultural, and societal expectations; ing a prescreened, low-titer emergency donor panel are
and the spectrum of opinion that will be held by Medical complicated but feasible. Evidence from civilian trials is
Treatment Facility staff. The threshold for sustaining local awaited.
patients and transferring them to their own health-care The early use of high-dose fibrinogen concentrates
facilities is often an ethical quandary. (cryoprecipitate) as a treatment option for TIC is also being
Answers to these dilemmas are beyond the scope of this investigated. Following encouraging results from a feasibil-
chapter, but it is appropriate for those who manage major ity study (CRYOSTAT,88 which suggested that early use of
vascular trauma in the resource-constrained or deployed cryoprecipitate and maintaining fibrinogen levels may lead
setting to consider these questions and then discuss the to reduced mortality), a multicenter RCT (CRYOSTAT-2) is
 6 • Damage Control and Immediate Resuscitation for Vascular Trauma 79

being conducted to investigate benefit, with results expected 8. Brummel-Ziedins K, Whelihan MF, et al. The resuscitative fluid you
by 2021. choose may potentiate bleeding. J Trauma. 2006;61:1350–1358.
9. Ho AM, Karmakar MK, Dion PW. Are we giving enough coagu-
Another aspect of tailoring DCR and personalizing trans- lation factors during major trauma resuscitation? Am J Surg.
fusion strategy to the individual patient is to make better 2005;190:479–484.
diagnostic and prognostic predictions, whether these arise 10. Hirshberg A, Dugas M, Banez EI, Scott BG, Wall Jr MJ, Mattox KL.
from more sophisticated assays or via insights generated Minimizing dilutional coagulopathy in exsanguinating hemorrhage:
a computer simulation. J Trauma. 2003;54:454–463.
from application of computer science. Health-care systems 11. Ho AM, Dion PW, Cheng CA, et al. A mathematical model for fresh
generate huge quantities of structured and unstructured frozen plasma transfusion strategies during major trauma resuscita-
data pertaining to all manner of input and outcome cri- tion with ongoing hemorrhage. Can J Surg. 2005;48:470–478.
teria. The use of artificial intelligence (AI) technologies to 12. Borgman M, Spinella PC, Perkins JG, et al. The ratio of blood products
develop machine-learning algorithms to better understand transfused affects mortality in patients receiving massive transfusions
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 7 Diagnosis of Vascular Injury
MICHAEL J. SISE

Introduction a variety of injury patterns. They can only be found with fur-
ther imaging studies. Thus, considering both the mechanism
Vascular trauma presents in a variety of settings and results in and setting of injury will lead to the appropriate diagnostic
findings that range from life-threatening hemorrhage second- evaluation. Further consideration of injury patterns will also
ary to major torso or extremity vessel disruption to no detect- prompt appropriate early workup and timely recognition,
able signs in occult injuries. Effective management is based and result in successful management.
upon early diagnosis and prompt treatment. Isolated vascular Penetrating vascular injuries are rarely occult and usu-
injuries are becoming less common at modern urban trauma ally present with clear signs of hemorrhage including local
centers. There is a growing prevalence of multisystem trauma hematoma, active bleeding, and shock.7 The nature of bleed-
that includes vascular injury, making early diagnosis more of ing at the scene should always be determined. Initial pulsatile
a challenge.1–3 Successfully identifying vascular trauma in a flow or large amounts of blood at the scene may be indica-
timely fashion requires an organized approach with attention tive of significant vascular injury. Bleeding during prehos-
to the mechanism of injury, presence of hemorrhage at the pital transport should also be considered a sign of vascular
scene or during transport, a thorough physical examination trauma. This information may not be readily available when
augmented, when needed, with Doppler extremity pressure patients are transported by bystanders or if they flee the scene
measurements, and finally, the effective use of multidetector of the injury. In the shocked patient, redirecting attention to
CT angiography (MDCTA). Imaging techniques are discussed apparently nonbleeding wounds may reveal an underlying
at length in subsequent chapters. extremity vascular injury which has ceased bleeding.
Several analyses of human error suggest that three fac-
tors play a role in most major errors: familiarity, distraction,
and fatigue.4 The modern trauma center creates an envi- Injury Pattern Recognition
ronment where all three factors are constantly interplaying.
Trauma care is, therefore, an error prone process. Avoiding The early diagnosis of vascular injuries requires a high
error in the care of the injured requires not only an orga- index of suspicion based upon both mechanism of injury
nized approach, but the use of short but effective checklists and injury patterns. The following discussion reviews each
which assure the application of that organized approach. anatomic area and the important considerations of both
Unfortunately, most physicians are overly familiar with mechanism and injury pattern that will lead to attention
long, detailed, and all-inclusive checklists that were not to diagnostic measures that identify vascular injuries in a
developed in conjunction with them or by colleagues who timely fashion. The goal of this review is to generate pattern
actually provide trauma care. Most physicians do not find recognition and decisive action.
these types of checklists useful and they are not often used.
In contrast, the experience of military and civilian aviation HEAD AND NECK VASCULAR INJURIES
communities strongly supports the use of short and prac-
tical checklists created by experienced air crews and thor- The neck and face are areas of relatively superficial major
oughly tested at the point of service until they are effective.4 vascular structures. Additionally, the neck is a zone of
The essential history and physical elements that lead to multiaxis motion with cerebrovascular arterial structures
the prompt diagnosis of vascular injury are displayed as a in close proximity to boney prominences. This is a high-
checklist in Box 7.1. risk zone for both blunt and penetrating vascular injury.2
Although penetrating injuries are usually obvious because
of hemorrhage, blunt injuries are almost always occult. Low
The Mechanism, Setting, and velocity gunshot wounds may cause injuries other than the
Patterns of Injury typical penetrating laceration hemorrhage. Partial arterial
wall disruption from bullets passing in proximity may cause
The evaluation of an injured patient must begin with a con- arterial thrombosis. Pattern recognition of both blunt force
sideration of the mechanism of injury and the setting in loading and associated injuries is essential for prompt diag-
which that injury occurred.5 This is particularly important nosis of blunt cerebrovascular injury.
in patients injured in high-speed motor vehicle crashes. The The most common underlying mechanism of significant
advent of modern automobile passenger restraint systems blunt cerebrovascular injury in the neck and at the skull base
resulted in many occupants surviving what were previously is stretching of the vessel, often across a boney prominence,
fatal crashes. However, this also resulted in a rising incidence or from direct compression by a fracture fragment.6,8 Less
of blunt cerebrovascular and thoracic arterial injuries.6 likely is focal blunt force with direct compression and partial
These injuries are often asymptomatic, associated with few arterial rupture. There are key anatomic areas where these
physical findings on presentation, and occur in the setting of events occur. At the base of the skull, fracture of the temporal

82
 7 • Diagnosis of Vascular Injury 83

Box 7.1 Checklist for Prompt Recognition of THORACIC VASCULAR INJURIES

Vascular Injury Penetrating trauma to the thorax with major vascular
Review following questions in the trauma bay and consider fur- injury presents with life-threatening hemorrhage that
ther evaluation for vascular injury for any positive answer requires immediate operative intervention to identify the
injury and control hemorrhage. In contrast, blunt injuries
1. High-Risk Mechanism of Injury
are often occult and early diagnosis requires attention to
n Significant blunt force loading and anatomic extent across
major vessels? both mechanism and injury pattern. Rapid deceleration
n Penetrating path in area of major vessels?
or acceleration can create visceral rotation and stretch of
the mediastinal structures, causing sheer stress at transi-
2. Blood Loss at the Scene tion points between relatively mobile and fixed vessel seg-
n History of pulsatile bleeding from wound?
ments.2,9 The heart and proximal great vessels have been
n Significant blood at scene, on clothing, trail of blood?
n Fled the scene and history of significant bleeding from
described as moving like a “bell clapper” in the chest in
wounds? certain high-speed impacts, with the result that the aorta
is partially torn at the isthmus, a transition point between
3. Bleeding Indicators mobile and fixed elements.9 This type of movement can also
n Prehospital hypotension present and trauma in area of
stretch and partially tear the branches of the aortic arch.
major vessel?
n Shock unexplained with nonbleeding extremity or neck
Direct trauma from compression and fracture of the ster-
lacerations? num, manubrium, or clavicles can cause vascular injuries.
This type of direct compression may injure the aortic arch
4. Physical Examination and its proximal branches or the pulmonary artery at its
n Pulsatile bleeding, copious venous bleeding, or large
bifurcation area (Fig. 7.3).
hematoma?
n Extremity pulses absent, Doppler signals absent, or injured
A variety of fracture patterns have been described with
extremity index <0.9? blunt thoracic aortic injury. Although first rib fracture is
n Bruit or thrill over injury site? often described as a harbinger of blunt aortic injury, tho-
n Major deficit in peripheral nerve located in proximity to racic spine fracture is the most commonly associated frac-
major vessel? ture finding.9,10 This type of fracture is the result of major
5. High-Risk Fractures, Joint Dislocations? force loading on the thorax and indicative of the risk of
n Cervical spine fracture—vertebral artery injury
great vessel injury. Although clavicle fractures are very
n Thoracic spine fracture—thoracic aortic injury common, blunt subclavian artery and venous injuries are
n Supracondylar humerus fracture—brachial artery injury rarely associated with this finding.1,2
n Knee dislocation—popliteal artery injury The portable anterior-posterior chest radiograph is an
n Tibial plateau fracture—calf compartment syndrome important tool in the early recognition of occult mediastinal
vascular injury. Despite a wide variety of findings described
to be associated with thoracic aortic injury, two are of
bone in the area of the carotid canal may be associated with particular importance.9,10 Increased width of the superior
internal carotid artery dissection. Hyperextension of the neck mediastinum and the absence of a normal left side aortic
may stretch the internal carotid artery across the transverse contour are both indications of a mediastinal hematoma
process of C2, also causing dissection. Hyperflexion may lead and warrant additional CT scan imaging to rule out vascu-
to compression of the internal carotid between the angle of lar injury. Finding of rib fractures, thoracic spine fractures,
the mandible and the transverse process of C2 with arterial and sternal fractures are less strongly associated with tho-
thrombosis (Fig. 7.1). Hyperrotation of C1 on C2 can cause racic aorta and great vessel injuries, but should also prompt
a stretch injury of the vertebral artery, resulting in dissection additional imaging with CT scanning.
and thrombosis. Any cervical spine fracture that involves
transverse processes may cause vertebral artery injury. At ABDOMINAL VASCULAR INJURIES
the prominent transverse process of C6, direct blunt force
trauma may compress the common carotid artery, creating Penetrating abdominal vascular injuries present in a man-
a partial wall disruption and pseudo-aneurysm. ner similar to thoracic vascular injuries.10,11 Intraabdomi-
Direct trauma to the neck also requires attention to the nal hemorrhage and shock require immediate operative
possibility of vascular injury.6,8 Handlebar trauma and other intervention to both identify and control the site of hem-
direct blows to the neck may disrupt the carotid artery. orrhage. Blunt vascular injuries occur in a fashion similar
Attempted hanging or strangulation may cause blunt carotid to thoracic injuries.11 The major difference in the abdomen
disruption. The shoulder harness of an automobile passen- is the paucity of motion segments in major arteries due to
ger restraint system may also compress the common carotid the retroperitoneal location of the aorta and its proximal
artery and cause disruption and thrombosis. Signs of direct branches. The renal hilum is an exception and blunt stretch
neck trauma should direct attention to the possibility of injuries of the renal arteries are not uncommon.2,10,11 The
carotid injury. Particular attention should be paid to direct abdominal aorta and proximal mesenteric arteries may be
lower neck trauma and hoarseness in the absence of direct injured by direct blunt force trauma such as a lap belt pas-
laryngeal trauma. The vagus nerve lies adjacent to the com- senger restraint compression of the distal aorta against the
mon carotid artery and trauma sufficient to cause injury to sacral promontory in a high-speed motor vehicle crash.
the vagus proximal to the take-off of the recurrent laryngeal Survivable blunt tears of the celiac and superior mesenteric
trauma may also injure the common carotid artery (Fig. 7.2). artery occur infrequently.2,10,11
84 SECTION 2 • Immediate Management and Diagnostic Approaches

Right

1.91cm Right

Fig. 7.1 Internal carotid artery thrombosis from gunshot wound transiting retromandibular area and lodging adjacent to mastoid process. There was a
lack of hemorrhage or hematoma and the patient had a normal neurologic examination.

UPPER EXTREMITY VASCULAR INJURIES injury can result in tearing and thrombosis of the axillary
artery with absent pulses at the wrist. Proximal fracture of
Penetrating upper extremity vascular injuries typically pro- the humerus or humeral head dislocation rarely causes bra-
duce either significant external hemorrhage or acute limb chial artery occlusion. However, supra-condylar humeral
ischemia and are usually obvious at initial presentation fracture is associated with distal brachial artery occlusion
(Fig. 7.4). Blunt injuries, although less obvious, are usually and forearm ischemia.1,2 Other fractures of the upper arm
associated with musculoskeletal injuries.1,2 Blunt posterior are infrequently associated with major vascular injuries
distraction of the shoulder with brachial plexus stretch unless they involve a crush injury.
 7 • Diagnosis of Vascular Injury 85

LOWER EXTREMITY VASCULAR INJURIES

Penetrating injuries of the groin and leg produce findings
similar to the upper extremity with either obvious hemor-
rhage or distal ischemia.2,10 Although proximal femur frac-
tures and hip dislocations rarely result in vascular injury,
distal femoral fracture may be associated with superfi-
cial femoral arterial injury. The distal superficial femoral
artery and proximal popliteal artery are relatively fixed by
the transition through the adductor canal. Stretch injury
and thrombosis may occur. The most common musculo-
skeletal injury associated with vascular trauma is knee
dislocation.1,2,10 The popliteal artery is fixed proximally by
the adductor canal and distally in the upper calf by the
trifurcation into the anterior tibial, peroneal, and poste-
rior tibial arteries. Posterior displacement of the tibial pla-
teau stretches and disrupts the popliteal artery, resulting
in thrombosis and distal ischemia; and knee dislocation is
associated with as high as a 30% incidence of popliteal vas-
cular injury.1,3,10
Crush injuries of the lower extremity may cause arterial
disruption at any level. Bumper strike trauma in pedestrians
struck by a motor vehicle are particularly high risk for blunt
vascular injury. Compartment syndrome is also a risk in
this type of injury. All below-knee fractures of the leg must
lead to suspicion of compartment syndrome. However, tib-
ial plateau fracture is the most commonly associated frac-
ture with calf compartment syndrome.3,12 Tibia and fibula
fracture often involve significant distraction and angulation
Fig. 7.2 Pseudoaneurysm common carotid artery in patient who suf- of fracture segments with ripping of compartment fascial
fered blunt trauma from striking neck on handle bars of a motorcycle. planes. An “auto fasciotomy” and decompression of the
He presented to the emergency department complaining of hoarse- compartments often results. Tibial plateau fracture usually
ness. Examination revealed a contusion at the base of the neck and a requires significant force loading but does not result in dis-
bruit over the carotid artery. traction of fracture segments and the fascial planes remain

A B

Fig. 7.3 (A) CT angiogram coronal reconstruction demonstrating innominate artery pseudoaneurysm in a patient with blunt force compression of the
anterior chest from a high-speed motor vehicle crash. (B) Posterior volume rendering technique view of innominate artery pseudoaneurysm.
86 SECTION 2 • Immediate Management and Diagnostic Approaches

A B

Fig. 7.4 (A) Transiting gunshot wound of volar aspect of the right forearm (outlined by arrow) in patient with distal pulses absent. (B) The patient was
taken directly to the operating room, where the bullet tract was found to transect the brachial artery and both ends were thrombosed and retracted
(arrows). The median nerve was intact.

intact. Intracompartment hemorrhage results with a risk Box 7.2 Hard and Soft Signs of Vascular Injury
for compartment syndrome.
Hard Signs
n Pulsatile hemorrhage
OTHER HIGH-RISK INJURY PATTERNS n Expanding hematoma
A high index suspicion for either torso or extremity vascu- n Bruit of thrill over area of injury

lar injury should also attend the evaluation of a variety of n Absent extremity pulses
n Injured extremity index <0.9
other injuries. High-speed side impacts may be particularly
high risk for thoracic vascular injuries, as well as falls from Soft Signs
significant height.9,10 Aircraft crash survivors should all be n History of hemorrhage
evaluated for thoracic aorta and great vessel injuries. Vic- n Wounds of neck or extremities and unexplained hemorrhagic
tims of motor vehicle crash with prolonged entrapment shock
should have careful evaluation for extremity arterial occlu- n Neurologic deficit in peripheral nerve in proximity to vessels
sion and compartment syndrome. All crush injuries are n High-risk fracture, dislocation, or penetrating proximity wound

similarly at risk and should prompt a careful evaluation for

the presence of vascular injury.1,2,10

Life-threatening torso hemorrhage requires immediate oper-

Physical Examination ative intervention. Control measures are directly applied to
extremity bleeding, including direct manual pressure and
Vascular trauma very quickly sorts itself into three major tourniquet application. Timely operative control and repair
categories with implications for physician examination and should immediately follow. During the secondary survey, a
adjunctive diagnostic measures. First, life-threatening hem- thorough physical examination should identify most extrem-
orrhage requires immediate action and diagnosis is relatively ity vascular injuries. In patients with injury mechanisms and
quickly made in conjunction with control measures. Second, patterns placing them at risk for occult injuries, appropriate
limb-threatening arterial occlusive injuries are successfully imaging studies should be promptly obtained.
diagnosed with an appropriate extremity examination.7 The Pulse examination at the wrist and foot must be care-
third category, occult injuries, is not easily found on physical fully performed. There is a very common error in “over call-
examination.7,10 Adjunctive measures, often based upon pat- ing” pedal pulses as present when they are in fact absent.
tern recognition of mechanism and associated injuries, are The doralis pedis and posterior tibial pulses should only be
required to identify these less-than-obvious injuries. There called present when they are clearly palpable and as easily
are commonly described hard and soft signs of vascular found as a normal radial pulse. The “1+ to 2+” pedal pulses
injury which must always be recalled and carefully consid- noted in patients with complete proximal arterial occlu-
ered during physical examination (Box 7.2). sion and ischemia are often either palpation of the exam-
The Advance Trauma Life Support guidelines for ini- iner’s own pulsation in finger tips or simply imagined. The
tial and definitive patient assessment are extremely useful chain of error that is initiated by calling a pulse present in
in the evaluation of patients at risk for vascular injury.5 error directly threatens limb viability in the presence of a
Acute hemorrhage is addressed during the primary survey. proximal traumatic arterial occlusion. Conversely, missing
 7 • Diagnosis of Vascular Injury 87

a pulse that is, in fact, present by calling it absent leads to dressings.10 However, it is very useful for subsequent outpa-
further investigation which confirms adequate flow. The tient follow-up following vascular reconstruction.
erroneous palpation of pedal pulses in an ischemic limb is
an unfortunately common event. The need for attention to
detail in this portion of the physical examination and the Clearing the Trauma Patient for
need for adjunctive measures when there is not a clearly the Presence of Vascular Injury
present pulse are crucial elements of early diagnosis and
successful management of vascular injuries.7,10,13 The physical examination has proven valuable in ruling
The problem of inaccurate pulse examination is perva- out spine injuries in stable trauma patients who can be
sive throughout trauma and emergency care.10 Preventing adequately examined. This process has been dubbed “clear-
these errors in diagnosis calls for an organized approach ing the spine.” Similarly, physical examination and adjunc-
to the education of the trauma team members, emergency tive tests can clear each of the major anatomic areas for the
department staff, critical nursing staff, and medical-­surgical presence of clinically significant vascular injury. Numerous
floor staff in the priorities of peripheral vascular examina- studies have proven the value of a normal pulse examina-
tion. This includes not only careful pulse examination, tion in the extremity without active hemorrhage or hema-
but also demonstrating the techniques of adjunctive Dop- toma.3,7,13,16,17 In the hemodynamically stable patient with
pler pressure measurements. This education effort should a normal extremity neurovascular examination, vascular
be repeated at regular intervals to refresh the knowledge injury is not present. Further imaging studies are not needed.
base of the team members who are essential in recognizing This includes proximity penetrating trauma not associated
extremity vascular compromise. with significant hemorrhage, hematoma, or distal neuro-
logic deficit.3,16–18 Box 7.3 outlines the process of clearing for
major vascular injury in each anatomic area. Further evalu-
DOPPLER ULTRASOUND ADJUNCTIVE MEASURES
ation with imaging studies is reserved for patients who do not
The primary adjunctive measure in the examination of meet the criteria for clearance. Proceeding with those studies
extremity blood flow is the use of the Doppler ultrasound in the absence of indications risks delay in treatment of other
and a blood pressure cuff at the wrist or ankle.14 There are injuries and, increasingly more important, unnecessary
Doppler “myths” that need to be considered. The first is that exposure to radiation. The burden of unnecessary CT imag-
the presence of arterial signals is equal to the presence of ing in young trauma patients and the resultant cancer risk
adequate perfusion. The more dangerous myth is that the should not be ignored.19 Each CT imaging study must be indi-
presence of Doppler signals indicates the absence of injury. cated by the real risk of injury and the absence of alternative
Although an experienced Doppler ultrasound operator diagnostic approaches. Thoughtful serial physical examina-
can identify the triphasic characteristics of a normal pat- tions, adjunctive m ­ easures, and judicious use of plain film
ent extremity artery, most physicians and nurses cannot
distinguish the differences between normal and abnormal
Doppler signals. Collateral flow around an occluded artery
may produce Doppler signals of a diminished quality over Box 7.3 Clearing Trauma Patients for Presence
the pedal vessels and may be misinterpreted as the absence of Vascular Injury
of injury.
Head and Neck
The only valid use of the Doppler ultrasound in the early
n Alert, hemodynamically stable patient
evaluation of the trauma patient for extremity vascular
n Absence of high-risk mechanism
injury who has distal Doppler signals present is in conjunc- n Normal neurologic examination
tion with a blood pressure cuff at the wrist or ankle.14 The n Negative physical examination head and neck
Doppler probe is placed over the distal artery and the cuff n Absence of cervical spine or basilar skull fractures
slowly inflated. The pressure at the cessation of Doppler
signals equals the systolic blood pressure at the cuff, not at Chest and Abdomen
the distal probe. The ankle or wrist pressure is then com- n Normal chest and abdominal examination
n Absence of high-risk mechanism
pared with the other extremity if it is not injured, and to
n Normal chest x-ray, pelvis x-ray and negative FAST
an uninjured arm. The ratio of the injured extremity dis-
tal arterial pressure compared to a normal extremity is the Upper Extremity
injured extremity index (IEI) and should be 0.9 or greater.14 n Alert, hemodynamically stable patient
Normal ankle–brachial index (ABI) in an uninjured healthy n Normal upper extremity neurovascular examination
young person is 1:1.14,15 Caution should be used in inter- n Upper extremity fracture or penetrating proximity injury
preting the IEI in patients who are hypotensive, in severe n absence of significant hematoma or hemorrhage

pain, or hypothermic. Vasoconstriction not associated with n absence of neurologic deficit in distal arm or hand
n normal pulse examination or injured extremity index ≥0.9
injured vessels may falsely depress the ABI. Reassessment
after resuscitation, adequate pain control, or re-warming Lower Extremity
should be performed.10 n Alert, hemodynamically stable patient
Duplex color flow imaging, although highly accurate, is n Normal lower extremity neurovascular examination
not practical for the acute assessment of vascular injury.16 n Lower extremity fracture or penetrating proximity injury
This technology is highly operator dependent and the ability n absence of significant hematoma or hemorrhage
to obtain satisfactory images is impaired by wounds, hema- n absence of neurologic deficit in distal leg or foot

toma, the presence of air in the tissue, and the p

­ resence of n normal pulse examination or injured extremity index ≥0.9
88 SECTION 2 • Immediate Management and Diagnostic Approaches

radiography can ­significantly reduce the radiation exposure from a penetrating wound or complete ischemia second-
without missing or delaying diagnosis of vascular injuries. ary to either penetrating or blunt trauma are the two most
frequent indications for immediate operation.3 If a patient
has a tourniquet placed on an extremity for hemorrhage,
Definitive Diagnosis of Vascular the next stop should be the operating room. The value of
Injury immediate operation for either hemorrhage or ischemia
has significantly increased in the era of vascular damage-
The final diagnostic steps to confirm or definitively rule out control techniques. Rapidly establishing vascular continu-
vascular injury include immediate operation and direct ity with shunts and obtaining control of bleeding allows
examination of vessels, emergency center or intraopera- time for treatment of other injuries and subsequent imag-
tive angiography, MDCTA, and formal catheter angiogra- ing studies for further workup without negatively impact-
phy.3 Each has its role in the definitive diagnosis of vascular ing outcome. Fig. 7.5 outlines the indications for immediate
injury. Every trauma center must have the capability and operation and the role of imaging modalities.
the practice guidelines to perform each of these definitive
steps. The following discussion provides the context for each PORTABLE ANGIOGRAPHY IN THE TRAUMA BAY
of these diagnostic techniques and presents a practice rec-
ommendation that can serve as a template for your trauma OR OPERATING ROOM
practice group’s guideline. Severely injured patients with severe life-threatening associ-
ated injuries who must be taken to the operating room pose a
SURGICAL EXPLORATION FOR VASCULAR INJURY challenge if vascular injury is suspected but hard signs are not
present. MDCTA may not be possible. An arteriogram can be
When should we take our patient at risk for major vascu- obtained in the trauma resuscitation bay or in the operating
lar injury directly to the operating room? Maybe the more room by cannulating the artery proximal to the suspected vas-
important question in an era of aggressive application of cular injury, injecting 20 to 25 mL of full-strength contrast,
MDCTA is when do we not need an imaging study before and taking an x-ray or using fluoroscopy.21,22 The timing from
we operate? The simple answer to these questions is that a a rapid injection to shooting a single plain film is important.
direct trip to the operating room without imaging is called If these studies are inconclusive and major concern remains
for when physical examination clearly indicates the location about the presence of a vascular injury, there is a limited role
and extent of injury and imaging adds nothing of significant for operative exploration and direct assessment of the artery.3
decision-making value or incurs a delay that risks worsen- However, in the absence of hard signs, these patients are bet-
ing the patient’s outcome.3,20 Active arterial hemorrhage ter served by obtaining MDCTA when they are stable.

Active arterial, major

venous hemorrhage
from wound
Take directly to the
Hard signs of Ischemia, obvious operating room.
vascular injury site of occlusion

Unstable patient

CT angiography and Take to the operating

positive for major injury room ASAP.

Perform orthopedic
Multilevel extremity repairs as needed.
CT angiography and
injury, unclear vascular Follow closely for
positive for minimal injury
status (i.e., soft signs) compartment syndrome
and late thrombosis.
CT angiography
Formal catheter angiography
nondiagnostic

Perform single-injection
Unclear vascular status Pressure index < 0.9 local angiography and
and there is a need for operative repair, if indicated.
immediate operation
for other injuries Pressure index ≥ 0.9 Serial examinations

Fig. 7.5 Algorithm of the indications for immediate operation and the role of imaging modalities.
 7 • Diagnosis of Vascular Injury 89

MULTIDETECTOR CT ANGIOGRAPHY of preventable limb loss following injury. The most common
location is in the calf, with the anterior compartment particu-
The advent of 64-slice MDCTA has changed the time course larly vulnerable to this complication. Forearm compartment
of definitive radiologic imaging for vascular trauma diagnosis. syndrome is the next most common. However, compartment
This imaging technique has largely replaced catheter angiog- syndrome can occur in the thigh, upper arm, foot, hand, and
raphy.23 It is a very accurate and easy-to-obtain study with buttocks. This syndrome most commonly occurs secondary
excellent diagnostic imaging.24 MDCTA is discussed at length to prolonged ischemia or crush injury. A high index of sus-
in a subsequent chapter. However, patients with unequivocal picion, including checking for compartment syndrome as
evidence of active hemorrhage or complete arterial occlusion part of an organized approach to the workup of all injured
well localized by physical examination should not undergo patients plus frequent physical examination (augmented
MDCTA. The delay to the operating room, the small but real with compartment pressure measurements), is necessary to
risk of contrast-induced nephropathy, and radiation exposure detect this complication in its early stage.
are not worth the expense in terms of time delay and morbid- Although the first clinical finding is loss of light touch sen-
ity. Unfortunately, the widespread availability of MDCTA leads sation in the distribution of the nerve in the relevant com-
to a very high rate of unnecessary studies. Each MDCTA must partment (e.g., peroneal nerve in the anterior compartment
be justified by balancing the value of diagnostic information of the lower leg), this finding is difficult to identify in many
against the cost in time and morbidity. patients due to distracting injury or altered mental status
from injury, alcohol, or drug intoxication.12,25,26 The more
useful initial finding is pain on passive stretch of the extensor
CATHETER ANGIOGRAPHY
hallucis longus muscle, elicited by pulling the great toe down
There is a definite role for catheter-based diagnostic imag- and placing its extensor muscle on stretch. Less specific is ten-
ing—often described as formal angiography. This technique derness on direct compression. In the young and physically fit
is particularly relevant when endovascular treatment of patient, the turgor and tautness (as opposed to suppleness) of
arterial injury is an option. It is also an important step in the compartment during direct digital compression is a dis-
definitive diagnosis when MDCTA does not adequately criminating physical finding. Extremity sensory and motor
image vessels at risk (see Fig. 7.5). The presence of multiple examination is also not specific enough to be helpful in ruling
metallic fragments, such as those seen in shotgun injuries, out the diagnosis of compartment syndrome. Similarly, the
compromises the quality of MDCTA. Formal angiography loss of arterial pulses is a very late and relatively uncommon
is required for definitive imaging in this setting. This tech- finding unless there is underlying arterial injury.12
nique is also discussed in a subsequent chapter. The most The diagnosis of compartment syndrome should be con-
important consideration in formal angiography is the time sidered in: all fracture dislocations at or below the knee
required to mobilize the personnel to complete this study. and elbow; all extremity crush injuries; and in any patient
The 1-to-2–hour or more time period required for this study complaining of increasing pain following injury. In view
must be carefully weighed against the overall priorities in of the nonspecific nature of the physical examination find-
the care of the injured patient. ings and the multiple distracting factors, it is not surprising
that delay in diagnosis is unfortunately very common. Early
diagnosis is only possible through measurement of com-
Compartment Syndrome partment pressures. Normal tissue compartment pressure
ranges from 0 to 9 mm Hg. Although controversy exists
Compartment syndrome may occur shortly after injury, about the pressure that defines compartment syndrome, the
in the subsequent initial resuscitation phase after life-­ safest approach is to perform fasciotomy when the compart-
threatening hemorrhage, or 12 to 24 hours after reperfusion ment pressure exceeds 25 mm Hg.12,25,26
following vascular repair.12,25,26 Failure to diagnose and treat There is a variety of methods used to measure compart-
compartment syndrome is one of the most common causes ment pressure. The Stryker Pressure Monitor (Fig. 7.6A) is

A B

Fig. 7.6 (A) Stryker Pressure Monitor for compartment pressure monitoring. (B) Alternative device for pressure monitoring constructed from blood pres-
sure cuff gage, pressure tubing, a stopcock, and syringe. Saline is flushed through the line to the 18-gauge needle. The compartment is entered with
the needle and three to five cc of saline are flushed into the compartment. The stopcock is turned to the gage to measure the compartment pressure.
90 SECTION 2 • Immediate Management and Diagnostic Approaches

the most practical and commonly used device. If not avail- 8. Miller PR, Fabian TC, Bee TK, Timmons S, Laneve L, Alexander RH.
able, an alternative device can be created with a blood pres- Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma.
2001;51:279–286.
sure cuff manometer and saline flush tubing (Fig. 7.6B). 9. Wall MJ, Tasi PI, Mattox KL. Heart and thoracic vascular injury. In:
The pressure is measured in the four calf compartments or Moore EE, Feliciano DV, Mattox KL, eds. Trauma. 8th ed. New York:
the appropriate compartments in other areas of the extrem- McGraw-Hill; 2017.
ities. If borderline elevation is noted, frequent serial mea- 10. Shackford SR, Sise MJ. Extremity vascular trauma. In: Moore EE, Feli-
ciano DV, Mattox KL, eds. Trauma. 8th ed. New York: McGraw-Hill;
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of extremity compartment swelling. Fasciotomy techniques 11. Dente CJ, Feliciano DV. Abdominal vascular trauma. In: Feliciano DV,
are discussed elsewhere in this text. Mattox KL, Moore EE, eds. Trauma. 6th ed. New York: McGraw-Hill;
2004.
12. Whitesides TE, Heckman MM. Acute compartment syndrome:
Summary update on diagnosis and treatment. J Am Acad Orthop Surg. 1996;4:
209–218.
13. Frykberg ER, Vines FS, Alexander RH. The natural history of clini-
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ognition of high-risk injury patterns, thorough physical J Trauma. 1991;31:515–522.
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to major limb arteries. J Vasc Surg. 1990;11:85–93.
19. Brenner DJ, Hall EJ. Computed tomography – an increasing source of
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Recoveries. Surrey, England: Ashgate Publishing Ltd; 2008. 24. Inaba K, Branco BC, Reddy S, et al. Prospective evaluation of mul-
5. American College of Surgeons. Advanced Trauma Life Support. 10th ed. tidetector computed tomography for extremity vascular trauma. J
American College of Surgeons; 2018.http://www.facs.org/trauma/ Trauma. 2011;70:808–815.
atls/index.html. 25. Wallin D, Yaghoubian A, Rosing A, Walot I, Chauvapun J, de
6. Biffl WL, Moore EE, Ryu RK, Offner PJ, et al. The unrecognized Virgilio C. Computed tomographic angiography as a primary diagnos-
epidemic of blunt carotid arterial injuries: early diagnosis improves tic modality in penetrating lower extremity vascular injuries: a level I
neurologic outcome. Ann Surg. 1998;228:462–470. trauma experience. Ann Vasc Surg. 2011;25:620–623.
7. Frykberg ER, Dennis JW, Bishop K, et al. The reliability of physical 26. Feliciano DV, Cruse PA, Spjut-Patrinely V, Burch JM, Mattox KL.
examination in the evaluation of penetrating extremity trauma for Fasciotomy after trauma to the extremities. Am J Surg. 1988;156:
vascular injury: results at one year. J Trauma. 1991;31:502–511. 533–536.
 Imaging for the Evaluation and
8 Treatment of Vascular Trauma
DAVID L. DAWSON

Background or by injection through a catheter that is manipulated into

the desired position from a remote access site. Angiographic
The evolution of imaging for the diagnosis and treatment techniques are standard parts of general, trauma, and vas-
of vascular injury has evolved with the development of cular surgery practice and may be applied in the resuscita-
imaging technologies, increased availability of advanced tion suite or operating room (OR). Diagnostic studies and
modalities, and changing treatment paradigms. Diagnos- interventions are also performed by radiologists in special-
tic arteriography was first used in 1927 by Egas Moniz, a ized imaging suites. Transcatheter angiography provides
neurologist. The technique for percutaneous access and the highest-resolution imaging of most vascular beds. It
catheter exchange over a wire was developed in 1953 by provides anatomic definition and a road map for surgical
Sven-Ivar Seldinger, a radiologist. For a time, radiology was planning or intervention (Tables 8.1 and 8.2)
the dominant specialty to perform angiography, but image- Interpretation of angiography requires knowledge of
guided therapies are now commonly used by other special- anatomy, physiology, and consideration of injury mecha-
ties, including surgery. The use of angiography has been nisms. Vascular injury associated with hemorrhage can be
broadened and inextricably melded with treatment. demonstrated by extravasation of contrast when bleeding is
Medical practice has evolved with the development of brisk and ongoing, but extravasation may not be visualized
new imaging capabilities. Arteriography was once the stan- if the bleeding is slow or under tamponade. Bleeding may
dard for nonsurgical evaluation of penetrating extremity also be overlooked on an imaging study if the injected con-
wounds in the absence of “hard signs” of vascular injury, trast bolus is too small, if it is injected into a different vessel,
but noninvasive tests became widely adopted with the intro- or if image acquisition is terminated too soon.
duction of Doppler and ultrasound imaging options. The Angiographic interruption of vessel continuity indi-
increased availability of point-of-care ultrasound (POCUS), cates vessel disruption or thrombosis. With sufficient con-
including affordable hand-held systems, has provided trast injected, distal reconstitution of flow (i.e., beyond
advanced imaging capabilities at the bedside and in the the disrupted segment) from collateral vessels may be
field. Computed tomography (CT) scanning was first intro- demonstrated. Imaging of distal arterial beds can be com-
duced to clinical practice in 1972, but it took more than two promised by hypoperfusion and vasoconstriction, typical
decades of innovation, including helical acquisition with manifestations of hemorrhagic shock. Vasospasm, with
high-resolution multidetector arrays and the development tapering of arteries (sometimes to occlusion) and slow
of image postprocessing capabilities, to develop systems flow, can be more prominent in young patients who have a
that could be used for detailed vascular evaluations. greater degree of vasomotor reactivity. These findings are
Computed tomography angiography (CTA) is now a stan- not necessarily indicative of injury or increased compart-
dard for evaluation of extremity vascular injuries as well as ment pressure.
for potential injuries in the torso or cervical region.1,2 The Early filling of the venous circulation following contrast
widespread use of CT imaging for trauma has led to fun- injection into the artery is a sign of an arteriovenous fis-
damental changes in trauma management paradigms, with tula. Traumatic pseudoaneurysms result from focal disrup-
less invasive or nonoperative treatment strategies becoming tion of arterial-wall integrity, with blood flow contained
more common.3 Table 8.1 and the following paragraphs only by the adventitia or surrounding tissues. A pseudoan-
provide an in-depth description of the various imaging eurysm appears as a focal outpouching of contrast beyond
modalities used in the diagnosis, management, and follow- the normal artery wall. Intimal flaps and focal segments of
up of vascular trauma. nonocclusive thrombosis may be detected as filling defects
or lucencies within the contrast column, sometimes with a
delay in distal contrast flow.
Imaging Modalities Indications
Transcatheter angiographic evaluation is a useful tool for
ANGIOGRAPHY
trauma patients, both to diagnose and to localize and treat
Angiography is the term for direct imaging of any vascular vascular injury. Conventional angiography may be neces-
structure. Arteriography and venography refer more spe- sary when images on CTA are obscured by artifacts caused
cifically to imaging of arteries or veins, respectively. Intra- by metallic fragments, by soft-tissue air, or streak artifacts.
vascular injection of contrast agents allows visualization Thus, shotgun or wounds with multiple metallic fragments
of vascular anatomy and can be accomplished after direct are often best evaluated with direct catheter angiography
vascular puncture and placement of a needle or a catheter, (Fig. 8.1). With complex wounding mechanisms, such as

91
92 SECTION 2 • Immediate Management and Diagnostic Approaches

Table 8.1 Comparisons of Diagnostic Tests for Vascular Injuries

Diagnostic Modality Advantages Disadvantages Notes
POINT-OF-CARE TESTING
Doppler (continuous wave) • Limb pressure measurements • Indirect, provides only rough localization • Serial examinations may be useful for
effectively screen for extremity of injuries monitoring
arterial injury
• Real-time assessment of vascu-
lar patency or shunt function
Ultrasound (POCUS) • Rapid • User dependent results • Available through all phases of care
• Safe • Applicable to prehospital use
• May add vascular assessment
to FAST
ULTRASOUND
Vascular laboratory • Follow-up after screening tests • Most centers lack 24/7 availability • Follow-up after screening tests
ultrasound • May be used for serial exami- • Not for unstable patients • Intraoperative assessment of grafts
nation of minor injuries • Follow-up after vascular repairs
ARTERIOGRAPHY
Direct injection • Simple • Limited views • May be used to assess results of
• May be performed with por- revascularization procedures
table C-arm or static images
Digital subtraction • Diagnostic • Risk of vessel injury from access or cath- • May be performed with portable
angiography • Guides interventional eter manipulation system, imaging suite, or hybrid OR
therapies • Contrast risk
VOLUMETRIC IMAGING
Computed tomography • Standard assessment tool in • Contrast risk, especially with multiple • 24/7 availability in most trauma care
trauma studies settings
• Provides anatomic information • May be overused
about vascular and nonvascu- • Appropriate protocol and timing needed
lar injuries for optimal vascular imaging
Magnetic resonance • Specialized applications only • Long acquisition times • Rarely used for trauma assessment
imaging • Secondary role for trauma • Many contraindications
• Magnetic field limits support equipment
that can be used during imaging
FAST, Focused assessment with sonography for trauma; OR, operating room; POCUS, point-of-care ultrasound.

Table 8.2 Angiographic Findings With Common Vascular Injuries

Lesion Findings Notes
Arterial stenosis • Narrowing of contrast column • Intimal flap
• Delayed distal filling • Extrinsic compression
• Focal area of lucency with intimal flap • Spasm
• Smooth, tapered stenosis with spasm
Arterial occlusion • Occluded segment is not visualized • Presence of prominent collaterals suggests
• Limited collateral may be present with acute occlusion preexisting occlusion
• Meniscus sign with embolic occlusion
Active hemorrhage • Contrast seen tracking into extravascular tissues • Patient may be hemodynamically unstable
Pseudoaneurysm • Saccular aneurysm appearance • Extravasation may be active if pseudoaneu-
• May have appearance of outpouching or bubble aris- rysm is not contained
ing from artery wall
Arteriovenous fistula • Early filling of adjacent arteries • May have reduced or absent distal arterial
• Contrast moving into more central venous circulation flow

high-energy explosives, vascular injuries needing repair amenable to endovascular treatment. Thus, arteriography
may be missed during early phases of care. For combat- should be considered in cases of complex trauma involving
injured soldiers evacuated through several echelons of high-energy, penetrating mechanisms or wounds in prox-
care, physical examination and clinical assessment may imity to named vessels.4
be insufficient. Routine arteriography at centers providing Transcatheter angiography is often used as part of a strat-
higher-level care can identify vascular injuries that may be egy for endovascular therapy of vascular injury. As one
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 93

A B

C D

Fig. 8.1 (A) CT overview scan in AP projection demonstrates multiple metallic pellets from a shotgun. (B) Metallic fragments create CT streak artifacts
that degrade imaging and interfere with postprocessing. (C) Digital subtraction arteriography is useful after shotgun or blast injuries with multiple frag-
ments because there is a risk of significant injury to major arteries or branches. (D) Arrows highlight locations of several pseudoaneurysms that appear
as outpouchings from the artery.

example, if angiography demonstrates significant arterial failure, advanced age (older than 75 years), anemia,
injury, low-pressure inflation of a compliant balloon may diabetes, preexisting renal insufficiency, and increasing
be used to occlude flow into the damaged area. In these volume of contrast. Commonly used criteria for the diag-
types of cases, endovascular techniques may be used both nosis of PC-AKI or CIN include either a greater than 25%
to control bleeding and accomplish definitive treatment of increase of serum creatinine or an absolute increase in
the injury. serum creatinine of 0.5 mg/dL after administration of a
contrast agent.
Preparation Baseline renal function should be assessed prior to con-
As intravascular contrast agents are used for transcath- trast administration, when possible. Patients at risk for
eter arteriography and CTA and have the potential for allergic reactions to contrast may be premedicated with
nephrotoxicity, it is important to be aware of the risk fac- intravenous (IV) corticosteroids and histamine blockers.
tors for renal injury. Post-contrast acute kidney injury Although allergies to shellfish do not predict risk of a con-
(PC-AKI) is the general term used for a decline in renal trast reaction, atopy or a history of prior contrast reac-
function within 48 hours of intravascular administra- tions may. Avoiding use of large doses of contrast (as may
tion of iodinated contrast medium. PC-AKI is a correla- occur in patients undergoing multiple imaging procedures),
tive diagnosis. It does not indicate that the contrast was avoiding hypovolemia (a practical concern in many trauma
the cause of the observed deterioration in renal function. patients), and monitoring renal function are recommended.
Contrast-induced nephropathy (CIN) is the specific term Use of iso-osmolar contrast (e.g., iodoxinol) and reduced
used when the cause of decline in renal function was volumes of contrast reduce CIN risk. There is limited evi-
caused by the contrast administration. Factors associ- dence suggesting that the use of N-acetylcysteine, theoph-
ated with PC-AKI in trauma patients include hypoten- ylline, sodium bicarbonate, and statins further reduce the
sion (systolic blood pressure less than 80 mm Hg), heart incidence of CIN.5
94 SECTION 2 • Immediate Management and Diagnostic Approaches

reduction of the time of exposure, increase of the distance

Pitfalls and Danger Points from the source of the scattered radiation, and effective use
The risks of contrast angiography include the following: of shielding (including lead garments and glasses).

n Vascular access site complications, such as vessel injury Operative Strategy

(e.g., hematoma, pseudoaneurysm, embolization, throm- There are three tiers of technical sophistication for trauma
bosis) arteriography, as follows: (1) simple “on table”; (2) por-
n CIN table C-arm; and (3) fixed, floor, or wall-mounted sys-
n Anaphylactic response to the contrast agent tem either in a dedicated suite (i.e., radiology department
n Technical and time requirements unit) or in a “hybrid” OR space. Resource availability and
n False-negative studies clinical circumstances typically dictate which approach
n Risks of ionizing radiation is used. Patients who are hemodynamically or physiologi-
cally unwell may need to be taken immediately to the OR for
Catheterization for angiography poses a small risk of management of their injuries. Although modern trauma
iatrogenic vascular injury at the site of access. The risk of centers are moving to building fixed imaging systems in
access site injury is minimized with the use of ultrasound many of their trauma or resuscitative ORs,6 these advanced
guidance, direct operative exposure, and/or the initial use capabilities may not be available in most centers. As such,
of small-caliber access needles and wires (i.e., micropunc- on-table angiography using several single-picture x-rays or
ture devices). Diagnostic yield depends on the angiographic with a portable C-arm using basic cine loop angiography
technique used and the size and location of the vessel being (with or without digital subtraction) may be required.
imaged. Injuries may be missed in high-flow vessels (such Traumatic injuries of the descending thoracic aorta are
as the aorta) due to rapid washout of contrast, or an injury preferentially managed with thoracic endovascular aortic
may be overlooked if imaging is performed in only a single repair (TEVAR) (Fig. 8.2).7–9 Early experience with TEVAR
plane. Improper timing or an insufficient contrast bolus highlighted shortcomings of first-generation graft devices,
may result in poor quality imaging, especially if the con- which were designed primarily to treat aortic aneurysms.
trast is not directly administered into the vessel of interest However, current devices are available in sizes that better fit
via selective or subselective catheterization. a normal-caliber aorta, and that better appose to the distal
There is attendant risk with the use of ionizing radiation transverse arch and proximal descending thoracic aorta.
(x-rays) for angiography, though the risks to most patients Endovascular techniques can be used to manage hemor-
are usually negligible. Surgeons and staff who have regu- rhagic shock and certain patterns of vascular trauma,
lar exposure to x-rays during procedures should have spe- including pelvic fractures with associated retroperitoneal
cific training in radiation safety and practices to minimize hemorrhage. Temporary deployment of an endovascular
their own occupational radiation exposures. It is important balloon can provide proximal occlusion of the aorta for
to note that scatter from the patient is the main source of hemorrhage control during open operative resuscitation
radiation to which medical personnel are exposed. Practices or surgical management of vascular injuries.10 In selected
to maintain exposure to levels as low as reasonably achiev- cases, transcatheter management can provide definitive
able (ALARA) should be mandated. Radiation doses may be therapy (Fig. 8.3).11
affected by factors that cannot be readily modified, includ- The yield of angiographic identification of a pelvic source
ing the size of the patient and the part of the body being of bleeding ranges from 43% to 78%.12 Sources of hemor-
imaged. Specific actions to reduce radiation doses include rhage include injuries to major pelvic arterial and venous

A B

Fig. 8.2 Blunt aortic injury. A pedestrian struck by an automobile arrived in the emergency department with hypotension (systolic BP 60 mm Hg), bilateral
pneumothoraces, and an open femur fracture. (A) Surface-shaded three-dimensional (3-D) rendering of CT angiogram of the chest demonstrated blunt aortic
injury (BAI). There is a pseudoaneurysm of the proximal descending thoracic aorta (yellow arrow). (B) Digital subtraction arteriography in left anterior oblique
projection demonstrates the aortic pseudoaneurysm (left image – yellow arrow) on the initial contrast injection. The follow-up aortogram (right image) after
placement of self-expanding covered stent (TAG Thoracic Aortic Graft, W.L. Gore and Associates) shows complete coverage of the injured segment.
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 95

A B C D

E F
Fig. 8.3 Pelvic crush injury with external iliac artery dissection. (A) A 25-year-old man sustained a crush injury to the pelvis. three-dimen-
sional (3-D) computed tomography angiography (CTA) (left) and digital subtraction angiography (DSA) (right) demonstrate interruption of
the external iliac artery due to dissection and thrombosis. (B) After recanalizing the occluded external iliac artery with self-expanding bare metal
nitinol stents, intimal flap and thrombus are seen at the level of the inguinal ligament, distal to the stents. (C) Extravasation of contrast is seen
after placement of an overlapping stent. This was successfully treated with a covered stent. (D) Embolization of thrombus to the anterior tibial
and peroneal arteries is demonstrated with DSA. Acute arterial occlusion results in a sharp cut off of the contrast and almost no collateral flow.
Aspiration thrombectomy cleared the distal vessels of thrombus. (E) The final arteriogram (left) shows the stented left external iliac artery to be
patent. The distal vessels show smooth tapering, consistent with vasoconstriction. Vasospasm is commonly seen in younger patients, as trauma
patients often are. The posterior and anterior elements of the fractured pelvis were subsequently stabilized with compression screws (right).
(F) Follow-up CTA (left) and duplex scan (right) confirm patency of the injured segment and normal flow patterns after treatment with stenting.

structures, but a small vessel disrupted by fractures can occlusion. Covered stents and other endovascular strate-
bleed substantially and transcatheter angiography often gies can be used for extremity vascular injuries (although
directly identifies these sources of bleeding. Endovascular the benefit of peripheral artery endovascular therapy is
treatment with embolization is effective for management of less obvious than the superiority of endovascular treat-
hemodynamically unstable patients with pelvic fractures, ment of blunt traumatic aortic injuries).15 Because injuries
though external fixation and pelvic packing may be better in patients who are in shock require immediate attention
initial therapies.13,14 and because extremity vascular injuries are often associ-
As detailed in another chapter of this textbook, selective ated with skeletal, soft-tissue, or other trauma, open sur-
catheterization with flow-directed particulate embolization gical repair remains the more common approach. Still,
is one method of controlling bleeding from small arteries at endovascular techniques may be advantageous when the
sites of injury.14 Embolic coils may be deployed to proximally extremity exposure is difficult or associated with consider-
occlude an injured vessel, but temporary occlusion alone able morbidity, as with injuries to the subclavian or axil-
may be inadequate for pelvic trauma. As such, catheter- lary arteries.
directed use of inexpensive and readily available materials, Operative strategy may vary with the situation. Factors to
such as Gelfoam pledgets or slurry into the source vessels consider include the patient’s hemodynamic and physiologic
(Upjohn, Kalamazoo, MI) can also be effective. status, the level of endovascular expertise, the quality of the
Angiographic findings indicative of extremity vascular available imaging systems, and the inventory. Endovascular
injury or disruption include uncontained extravasation maneuvers may be used to temporize or definitively control
of contrast, pseudoaneurysm or contained extravasation hemorrhage (e.g., balloon catheter occlusion or emboliza-
of contrast, arteriovenous fistulae, intimal tear, spasm, or tion). Some endovascular treatments may be safely delayed
96 SECTION 2 • Immediate Management and Diagnostic Approaches

and not performed for hours, or even days after the original
injury, for example, TEVAR for mild or moderate blunt trau-
matic aortic injury (BTAI) (see Fig. 8.2).9
Surgeon training and experience (or the availability
of an interventional specialist) may determine whether
an open surgical therapy, an endovascular treatment, or
a mixed or hybrid approach is most practical for a given
injury scenario. Simple endovascular maneuvers for arte-
rial access and pressure monitoring, hemorrhage control
and resuscitation (i.e., resuscitative endovascular balloon
occlusion of the aorta [REBOA]), and arteriography should
be in the armamentarium of general and trauma surgeons.
Advanced endovascular techniques, subselective catheter-
ization, use of aortic endografts, and other complex inter-
ventions require additional training and credentialing.
When possible, complex vascular interventions should be
performed with optimal imaging equipment.
Angiography and simple endovascular interventions can
be performed with a relatively limited inventory of access
needles, wires, and sheaths as well as catheters, working
wires, balloons, and stents. As more complex interventions
are contemplated, sufficient inventory of endovascular
devices and supplies is needed to ensure success. Supplies
needed for trauma interventions may include aortic endo-
graft systems, large sheaths and compliant aortic balloons,
snares, microcatheters, embolic devices and agents, and Fig. 8.4 Intraoperative arteriography can confirm the presence of and
covered stents. It is also important to have an appropriate can localize vascular injuries in injured extremities. This example dem-
range of device sizes to meet a variety of needs. The avail- onstrates disruption and occlusion of the proximal left popliteal artery
ability of anticipated implants and supplies must be con- in a patient with a comminuted supracondylar femur fracture.
firmed before embarking on a plan of endovascular therapy.
Operative Technique for Angiography
On-table angiography does not require advanced skills or bone, from the vessels of interest. Because of this advantage,
specialized equipment. Contrast is injected by hand, and a DSA generally requires less contrast than nonsubtracted
single radiograph is obtained. This technique may be of prac- angiography, including that of the aorta and visceral vessels.
tical use during operative management of extremity injuries Intraoperative use of a C-arm fluoroscopy system can pro-
when the presence, location, or extent of an injury is uncer- vide the real-time imaging needed for selective catheteriza-
tain (Fig. 8.4). It can also be used to evaluate the technical tion with shaped wires and catheters as well as guidance for
result of a vascular repair. Vascular access is obtained, either interventions, such as placement of an occlusion balloon,
in a percutaneous manner or after open surgical exposure of therapeutic embolization, or placement of covered stents. In
the vessel. The artery in question is accessed using a hollow- order to use fluoroscopy, the patient must be positioned on a
tip needle, a butterfly set, a catheter, or a sheath placed using radiolucent operating table. Use of a surgical table designed
the Seldinger over-the-wire exchange technique. The imag- for endovascular procedures is helpful. The surgeon can
ing plate can be inserted in a sterile wrap and positioned on move the endovascular table to position the anatomic area
the surgical field under a limb to be imaged. of interest in the field of view while the fluoroscopy unit
Although this simple and useful arteriographic technique is remains stable. Many other tables used for trauma surgery
available for use in any situation, it has limitations. First, the and orthopedic procedures (including the Jackson table) are
delay between contrast injection and imaging must be esti- radiolucent and suffice for basic fluoroscopic imaging and
mated, and errors in timing the transit of contrast to the area endovascular intervention. Use of a fixed table, however,
of interest will result in failure to opacify the vascular segment often requires a radiology or equipment technician to be
of interest. Second, this technique provides only one image per more actively involved in C-arm positioning to center the
injection. Each individual image must be processed for evalua- field of view.
tion of the adequacy of the technique, the projection, and the Fixed imaging systems are standard in larger hospitals
field of view. This approach can be time consuming. with busy vascular surgery and interventional radiology
The limitations of single-image, on-table angiography can programs. These have wall, ceiling, or floor mounted sys-
be overcome by the use of a portable C-arm fluoroscopy sys- tems, typically integrated with a contrast management or
tem with cine loop recording and digital subtraction capa- injection system. Fixed imaging units have table mounted
bilities. By using cine loop angiography, timing of imaging controls for use by the operating surgeon. They are pro-
is less critical. Multiple images can be recorded with each grammed with various image acquisition protocols and
single contrast injection. Digital subtraction angiography have features to facilitate intravascular catheter navigation.
(DSA) provides superior definition of vessels as it removes Fixed imaging systems provide larger imaging fields and
the image of overlying or surrounding structures, including magnification capabilities, which provide high resolution
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 97

imaging of the vessels of interest (Fig. 8.5). Centers that checks in the upper and lower extremities are needed to
have invested in fixed imaging suites in the OR (i.e., hybrid confirm that there has not been coverage of the left sub-
ORs) also have a more extensive inventory of catheters, clavian artery or infolding of the graft resulting in distal
guidewires, and other endovascular supplies, and accessory ischemia. CT angiography is generally used for endograft
equipment. imaging and surveillance in the days and weeks follow-
ing placement. It is important to note that for many endo-
Patient Care Following Angiography vascular therapies, postprocedure noninvasive imaging
Removal of arterial catheters and sheaths should be done with duplex ultrasound is sufficient to confirm patency of
by trained personnel following correction of coagula- treated segments. Because duplex scans are inexpensive,
tion abnormalities. Use of percutaneous arterial closure avoid the use of contrast, and do not expose patients to
devices may decrease the time to hemostasis, but closure radiation, they are also appropriate for long-term surveil-
device use should be considered contraindicated if there lance applications.
has been a break in sterile technique. The presence of
foreign material in or on the vessel wall (e.g., suture, col- Complications
lagen plug) increases the risk of subsequent infection at Inadequate hemostasis at the arterial puncture site leads
the vascular access site.16 to bleeding and hematoma, and any communication
The arterial access site and the extremity in which the between the access artery and adjacent vein can result in
access was obtained should be monitored for evidence of an arteriovenous fistula. An intimal flap, distal emboliza-
injury following sheath removal. Access site and distal tion, or de novo thrombosis at the arterial access site can
extremity examinations should look for signs of bleed- lead to varying degrees of limb ischemia with or without
ing, neurologic change, or other complications. Of note, neurologic deficit. As such, vascular access sites should be
embolic or thrombotic complications appear to be more carefully assessed for the presence of ecchymosis, a mass,
common after emergency endovascular procedures for or bruit; and the distal limb should be examined for signs
trauma, as hypercoagulability from shock and performing of ischemia.
procedures without systemic heparin may increase the
risk of pericatheter thrombosis. Postprocedure laboratory ULTRASOUND
tests should include serum creatinine and hemoglobin
measurements. Ultrasound imaging has many advantages.17 It is nonin-
Patients who have had interventions for hemorrhage vasive, inexpensive, and increasingly available for point-
control or ischemia require careful observation to ensure of-care examinations. It can be used to image numerous
that there has been sustained technical success. Such organs or regions of interest. It can also be used for the eval-
patients should be serially monitored with physical exami- uation of late complications of vascular injury. Good image
nation. Objective and quantifiable measures of technical quality, a selection of imaging modes and processing fea-
success of the endovascular procedure, such as ankle/bra- tures, and a range of transducer options are now available
chial index, are particularly useful to identify unexpected with most ultrasound systems. Imaging without the use
changes in limb perfusion. In some situations, repeat mea- of ionizing radiation allows ultrasound systems to be used
surements of hematocrit should be performed to ensure without concern for patient or provider radiation exposure.
the absence of bleeding. The introduction of compact systems for POCUS has
Stent grafts placed for traumatic aortic injury are evalu- made it possible to perform examinations in prehospital
ated with intraoperative imaging, but postoperative pulse locations (including austere or remote environments), as
well as in a range of clinical settings (including emergency
rooms, ORs, and intensive care settings). Early generations
of compact, portable ultrasound systems were substantially
inferior to the larger, heavier, full-featured systems used by
radiology departments and vascular laboratories. However,
evolution of beam-forming and image-processing tech-
nologies narrowed the capability and quality gap between
compact, highly portable devices and traditional high-end
systems. As such, size and mass of ultrasound systems has
continued to decrease, making for smaller devices and less
expensive systems. As a result, use of POCUS for trauma has
become increasingly common.
B-mode imaging provides a two-dimensional (2-D) gray
scale representation of tissue in the scan plane. Blood
A B
is hypoechoic. The lumen of vessels will appear dark on
B-mode imaging. Real-time imaging can demonstrate
Fig. 8.5 (A) Arch aortogram (left anterior oblique projection). (B) Selec-
dynamic features of vessels, including the pulsatile expan-
tive left subclavian arteriogram. Digital subtraction arteriography pro-
sion of arteries and collapsibility of patent veins if external
vides better vascular definition. In this example, the aorta is uninjured, pressure is applied with the probe (scan head) during the
but blunt trauma has resulted in occlusion of the left axillary artery examination (Table 8.3). The resolution of B-mode ultra-
(arrow), which is best demonstrated with selective catheterization and sound is related to transducer frequency and the depth
direct contrast injection into the left subclavian artery. of the imaged structure. Resolution decreases with the
98 SECTION 2 • Immediate Management and Diagnostic Approaches

Table 8.3 Ultrasound Findings With Common Vascular Injuries

Lesion B-Mode Image Color Doppler Pulsed Doppler Notes
Arterial stenosis • Flap may be visualized in • Color aliasing (speckled • Increase in peak systolic veloc- • Intimal flap
superficial vessels pattern) ity (velocity ratio ≥ 2.0) • Extrinsic compression
• Spectral broadening • Spasm
Arterial occlusion • Echogenic material may be • No color filling in • Absent flow or preocclusive • Distal pulse absent
visualized in lumen occluded segment thump • Arterial Pressure Index
• Proximal or distal col- • Damped waveform distal to <0.90
laterals may be seen occluded segment
Pseudoaneurysm • Hypoechoic area extrinsic to • Flow extrinsic to artery • Bidirectional to-fro flow in • Extravasation from
artery • Alternating red and blue pseudoaneurysm or its arterial actively bleeding vessel
• Moving blood may be directly color (yin-yang pattern) connection may not be seen with
visualized in pseudoaneurysm ultrasound
due to increased echogenicity
of rouleaux aggregate
Arteriovenous fistula • Hematoma may be present near • Color aliasing • High-velocity jet at arterial
site of injury • Tissue bruit (speckling injury
overlying tissue) • Spectral broadening
• Pulsatile flow pattern and
increased velocity in outflow
vein
Venous thrombosis • Vein does not collapse with • Absence of flow • Absence of flow • Calf veins may be dif-
probe compression • No augmentation with ficult to visualize
• Echogenic material in vein distal limb compression
lumen

use of lower-frequency transducers, which are used for prerequisite for vascular surgery board certification. Vascu-
the examination of deeper structures. When superficial lar ultrasound may be useful for trauma care, even if vas-
anatomic features are evaluated with high-frequency cular specialty expertise is not available. Most radiologists
transducers, details of vessel walls can be seen, including have training in general ultrasound, and many general and
atherosclerotic plaque, dissection, or intimal flap. Con- trauma surgeons have skills with the use of POCUS. Mea-
versely, use of B-mode ultrasound as a stand-alone modal- surements of vessel size (detection of aneurysms), detection
ity may be insensitive for detection of vascular injury when of arterial or venous flow, assessment for deep-vein patency,
deeper vessels are evaluated. In these instances, the only mapping of superficial veins, and other simple evaluations
abnormal B-mode finding may be a hematoma in proxim- can be learned without extensive formal training. Provid-
ity to the vascular injury. Patient discomfort or agitation, or ers may seek voluntary certification for POCUS competency
the presence of wounds, external fixators, or dressings, may through professional societies or the Point-of-Care Ultra-
limit ultrasound examinations for trauma. sound Certification Academy (an APCA spin-off) https://
Duplex ultrasound scanning (DUS), adding Doppler www.pocus.org.
flow detection to the B-mode image, increases the utility of
diagnostic vascular ultrasound. Flow information from a Indications
specific point of interest is displayed by the pulsed Doppler Focused assessment with sonography for trauma (FAST)
flow velocity waveform. Color flow duplex scanning dis- can be a part of the secondary survey of the injured patient,
plays areas with flow in color overlying the B-mode image used to identify pericardial effusion and hemoperitoneum.
of anatomy. Color flow imaging assigns colored (rather The extended FAST (eFAST) includes ultrasound assessment
than gray scale) pixels in regions where moving tissue of both thoraces looking for pneumothorax or hemotho-
(e.g., blood) returns a Doppler-shifted echo. The color flow rax.18 Although not typically included in a FAST exami-
display provides information about the location of the flow, nation, ultrasound can also confirm endotracheal tube
its direction, and its velocity. In addition, a speaker pro- positioning and can provide an indication of intravascular
vides an audio output of the Doppler signal (see Table 8.3). volume by evaluating ventricular filling and the dimensions
With experience, users can learn to recognize characteris- of the inferior vena cava. A practical aspect of POCUS is its
tic “signatures” of abnormal flow, including higher pitch ability to be repeated over time to confirm initial impres-
with elevated velocities; abrupt blunted signal proximal to sions or to show trends.
an occlusion; course sound with spectral broadening from Ultrasound is of particular utility in evaluation of
turbulence; or continuous low-resistance, diastolic flow neck19,20 and extremity vessels21,22 following trauma due
associated with an arteriovenous fistula. to their relative superficial location. Dissection, stenosis,
Use and interpretation of vascular ultrasound is integral thrombosis, and arteriovenous fistula can all be demon-
to the training of surgeons. The Registered Physician in strated using this imaging modality. Because duplex is
Vascular Interpretation (RPVI) credential of the Alliance safe, inexpensive, and noninvasive, it is especially useful
for Physician Certification and Advancement (APCA) is a to confirm a normal physical examination in patients who
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 99

have extremity injury mechanisms associated with a risk POCUS with probe compression to see if the popliteal
of vascular injury, including penetrating trauma, poste- and common femoral veins collapse under manually
rior knee dislocation, hyperextension, and supracondylar applied pressure can serve as a quick screening test. With
fracture (Fig. 8.6). this basic bedside maneuver, one can accurately identify
In the absence of hard signs, the presence of an extrem- major proximal limb DVT.26 To diagnose iliac vein throm-
ity vascular injury can be excluded with a combination of bosis, nonocclusive DVT, limited segmental DVT, or calf
physical examination and noninvasive pressure measure- vein thrombosis, a complete examination should be per-
ment to calculate the injured extremity index (IEI). Using formed by a vascular technologist. If limited thrombosis
continuous-wave Doppler, this cuff occlusion technique (e.g., isolated calf vein DVT) is observed and is not treated
measures the systolic blood pressure in the injured limb and with anticoagulation, repeat duplex examination 5 to 7
compares it to the cuff occlusion pressure in the uninjured days later may be used to look for proximal thrombus
contralateral limb.23 An IEI of less than 0.90 suggests that progression.
a flow-limiting arterial stenosis or occlusion is present. DUS Intraoperatively, ultrasound can be useful for local-
complements the measurement of the IEI; however, in the ization of vessel injuries (Fig. 8.7) and for evaluation of
absence of clinically evident ischemia or bleeding, with a technical results after repair of vascular trauma. DUS can
normal IEI, there is little risk in delaying the duplex scan by identify defects that may lead to early thrombosis or late
several hours or even days. complications including abnormalities of the intima at
When minor vascular injuries are detected, most may be the site of vascular clamp placement (i.e., clamp injury).
managed nonoperatively with expectation of spontaneous DUS can also detect flow-limiting stenosis at the anasto-
healing. Injuries with low risk of late complications include mosis of a vascular repair or the presence of intraluminal
intimal injuries (intimal flap) that are associated with less thrombus. By detecting these injuries or technical defects
than 50% stenosis. The absence of a pressure gradient intraoperatively, surgical revision can be performed before
across the injured segment (i.e., a normal injured extremity leaving the OR.
index) or a duplex finding of peak systolic velocity increased
by less than a factor of two suggest the absence of a hemo- Preparation
dynamically significant injury. The noninvasive nature No specific preparation is needed for most ultrasound
of duplex allows for serial examinations to confirm that a examinations. However, fasting before abdominal DUS
given injury has healed over time. may reduce the amount of bowel gas that obscures the
Severely injured patients are at risk for venous thrombo- view of deeply positioned abdominal, retroperitoneal, and
sis and pulmonary embolism.24,25 The presence of significant pelvic vessels.
injury causes thrombophilia (a procoagulant condition).
DUS is the diagnostic test of choice for the detection of venous Pitfalls and Danger Points
thrombosis of the extremities. New unilateral limb swelling The hazards related to, or limitations of, ultrasound are
is the best clinical sign that predicts deep vein thrombosis negligible but include:
(DVT), but clinical evaluation alone lacks the sensitivity or
specificity. Thus, duplex scanning to evaluate for DVT is indi- n Results are operator dependent, requiring a basic knowl-
cated when there are signs or symptoms of DVT, or to screen edge and some technical skill
for DVT in asymptomatic high-risk patients. n Tissue disruption, obesity, or edema may limit imaging

Fig. 8.6 Popliteal artery injury from posterior knee dislocation. A 24-year-old man was involved in a motor vehicle crash, which resulted in posterior disloca-
tion of the right knee. The right foot was pulseless and pale. CT angiography (A, three-dimensional [3-D] reconstruction) and digital subtraction angiography
(DSA) (B, subtracted DSA image; C, nonsubtracted image) show occlusion of the infragenicular (P3) segment of the popliteal artery. This was reconstructed
with a bypass graft from the distal superficial femoral artery to the tibioperoneal trunk. Patency of the vein graft was confirmed at 1-month follow-up with
duplex ultrasound scanning (D) that showed a hyperemic arterial flow pattern (forward flow through mid and late-diastole).
100 SECTION 2 • Immediate Management and Diagnostic Approaches

Intima separated
Aorta from adventitia

A B

Fig. 8.7 (A) A seat belt–restrained 15-year-old girl injured in a car crash presented with a Chance fracture, a bowel injury, and a right lower extremity
ischemia. Intraoperative ultrasound imaging demonstrates patency of the aorta at the level of the inferior mesenteric artery. (B) The seat belt injury to
the terminal aorta resulted in an extensive intimal tear, which is seen in this intraoperative transverse B-mode image.

n Ultrasound transmission through air is poor; imaging of Focal pseudoaneurysms of extremity arteries may be man-
intrathoracic structures is limited; and bowel gas may aged with real-time, ultrasound-guided thrombin injec-
obscure abdominal and pelvic imaging tion, a technique that is used to treat iatrogenic femoral
n Bowel gas may be increased in nonfasting patients and in artery pseudoaneurysms, but can be used for other arterial
trauma patients who have been ventilated with a mask pseudoaneurysms. Finally, ultrasound can be used for the
before intubation real-time assessment of surgical outcomes, either during a
n Ultrasound transducers should be appropriately disin- procedure (when corrective action can be taken if a techni-
fected to prevent transmission of infectious agents cal defect is found) or later, if surveillance is indicated.
Strategy Technique
Providers at the point of care can perform vascular-specific The hand-held transducer (probe) transmits ultrasound
examination or a registered technologist may perform an energy and receives reflected echoes. Because air has high
ultrasound during the tertiary survey (or at any subse- acoustic impedance, a water-based gel is used for acoustic
quent step of a patient’s care). Ultrasound can be used as a coupling between the transducer and the skin for routine
screening tool to detect injuries or vascular complications applications, but blood or saline irrigation are suitable cou-
that are not evident from clinical assessment. Examples of pling media during intraoperative use. A transducer that
screening examinations include evaluation of limbs with is appropriate for the depth and the location to be evalu-
“soft” or no signs of vascular injury that sustained trauma ated is selected. Deeper structures require the use of lower
with mechanisms known to injure vessels. ultrasound frequencies (1 to 5 MHz). High-frequency trans-
Ultrasound can be used as a diagnostic tool, either alone ducers (6 to 12 MHz) provide better imaging resolution
or in combination with other testing modalities. Arterial but with limited imaging depth. Transducer elements can
disruption, intimal dissection or flap, thrombosis, and arte- be mounted in a curved or linear array to create a sector
riovenous fistula can be definitively diagnosed using ultra- or boxlike image. Phased array transducers can provide a
sound, especially in the extremities. If DUS is combined compact footprint, with a sector-like scan. Probes designed
with thorough physical examination, including calculation specifically for intraoperative use may have a T-shaped or
of the IEI, additional imaging, such as CTA or angiography “hockey-stick” design to facilitate use in the operative field.
may be unnecessary. Transducers are typically designed to operate over a range
DUS may also be used as a complement to other diag- of frequencies (broadband) for greater versatility and better
nostic tests or screening maneuvers (e.g., Doppler pressure imaging. Specifics of transducer design vary among manu-
measurements and calculation of the IEI). In many cases, if facturers and systems used.
the initial examination is normal and there is no hard sign Vessels in the neck and extremities can be imaged
of vascular injury, a more thorough evaluation with DUS directly. Because air in the lungs and viscera interferes with
can follow on an elective basis (see Table 8.3). ultrasound transmission, ultrasound imaging to evaluate
Ultrasound imaging is also an important tool to guide for truncal vascular injury is limited. Subcostal and para-
real-time certain vascular or endovascular proce- sternal views or “windows” allow for evaluation of the
dures. For example, ultrasound has become the standard heart and pericardial sac, but the thoracic aorta cannot
to guide health care providers as they accomplish percu- be visualized with a transthoracic approach. The presence
taneous arterial or venous access.27,28 Ultrasound can also of intraabdominal fluid (i.e., blood) on a FAST examina-
help with localizing vascular structures or injuries during tion is indirect evidence of vascular disruption or solid
an operation to repair a vascular structure or other injuries. organ parenchymal injury. Direct vascular examination
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 101

of intraabdominal vessels is seldom performed in the acute

phases of trauma evaluation and management (i.e., not
part of the FAST).
Vascular access is facilitated with routine use of ultra-
sound for venous and arterial punctures. When ultrasound
is used for procedural guidance or intraoperative assess-
ment, the transducer is placed in a sterile sleeve. Acoustic
coupling gel needs to be placed inside the sleeve, with no air
gap or bubbles between the transducer face and the inner
portion of the sleeve. Sterile gel is used on the field. An 18- or
21-gauge needle can be seen with ultrasound as it is directed
through the soft tissues into the vessel lumen. Needles with
a stippled surface may be more echogenic and easier to visu-
alize with B-mode ultrasound. Imaging the vessel in a lon-
gitudinal scan plane allows the site of vascular entry to be
selected, while changing to a transverse image ensures that
vessel entry is precisely at the 12 o’clock position. Ultra-
sound imaging can also confirm intraluminal positioning of
catheters and guidewires once access is achieved.
Some ultrasound applications such as transesophageal
echocardiography (TEE) used to evaluate the thoracic aorta,
require specialized capabilities.1,29 TEE in the setting of
trauma requires endotracheal intubation for airway con-
trol. Intraoperative TEE may provide the initial diagnosis of
BTAI for patients who have been brought directly to the OR
for surgical stabilization, bypassing the CT scanner. Intra-
vascular ultrasound (IVUS) is an invasive technology requir-
ing vascular access, catherization of a target vessel, and
introduction of an imaging catheter over a guidewire. The Fig. 8.8 Intravascular ultrasound (IVUS) evaluation of aortic pseudoa-
aorta can be evaluated with an 8-French IVUS catheter over neurysm. An endovascular graft was used to treat a 51-year-old woman
a 0.035-inch wire. Although IVUS is not appropriate as a who was found to have a pseudoaneurysm of the infrarenal aorta found
screening test, it can provide detailed morphologic informa- after a roll-over accident while using a riding lawnmower. The abnormal
tion to guide the choice of an appropriately sized endograft segment is shown on the digital subtraction angiography (DSA) image (A).
for treatment of BTAI (Fig. 8.8).30 IVUS allows real-time IVUS was used to measure the dimensions of the aorta at the left renal
imaging and diameter measurements in both systole and vein (B), to assess the aneurysmal segment (C), and to evaluate the distal
diastole while the patient is on the OR table. Routine use of abdominal aorta (D), proximal to the bifurcation.
IVUS prior to TEVAR for BTAI is recommended, as CTA mea-
surements may underestimate the diameter of the aorta if
the CTA was performed in the setting of intravascular hypo- (EDs) found CT use increased by 330% between 1996 and
volemia.31 2007.33 The availability and convenience of CT scanning
has reduced reliance on FAST imaging in the emergency
Complications departments.34
Ultrasound is safe, noninvasive, and not associated with CT is routine for the evaluation of injuries to the brain,
direct risk of complications. The primary hazards associ- face, chest, abdomen, and pelvis, as well as spine and skeletal
ated with diagnostic ultrasound are the risks of interpreta- injuries. Routine single-pass, whole-body computed tomog-
tion errors. Without attention to cleaning and disinfection, raphy (WBCT, or “pan scan”) has been advocated by some
ultrasound equipment can be a potential vector for trans- for its high diagnostic yield and potential to identify missed
mission of health care–associated infection.32 Tissue heat- injuries.35 The alternative of a more targeted use to avoid
ing is negligible with diagnostic ultrasound applications, unnecessary health care costs and radiation-exposure risks
and there is essentially no risk of injury in typical clinical may be more appropriate for most patients, though. From
applications. the standpoint of vascular trauma, contrast-enhanced CTA
can reliably confirm and characterize clinically evident
problems (e.g., occluded extremity vessel with ischemia), as
COMPUTED TOMOGRAPHY
well as detect subclinical injuries (e.g., asymptomatic arte-
Computed tomography (CT) is the workhorse imaging tech- rial injuries or minor BAI) (Fig. 8.9).36
nology in contemporary emergency medicine and trauma Magnetic resonance imaging (MRI) and magnetic reso-
care including vascular trauma. Multidetector CT (MDCT) nance angiography (MRA) may be used as alternatives to CT
with high-speed helical scanning has reduced imaging and CTA, with the potential advantages of avoiding CT arti-
times to minutes. The availability of CT scanning is nearly facts and radiation exposure. However, MRI is not as read-
ubiquitous, even in relatively austere locations on the battle- ily available and has slower image acquisition times. There
field. Data from a US survey of nearly 100 million patients are also a greater number of contraindications for the use
who underwent CT scanning in emergency departments of MRI, including the presence of metallic implants. Also
102 SECTION 2 • Immediate Management and Diagnostic Approaches

of practical importance, there are many pieces of medical penetrating injuries to the neck (zones I, II, and III), cervical
equipment that are not compatible with use in the presence spine or spinal cord injuries, and thoracic injuries. CTA for
of a strong magnetic field and thus cannot accompany a suspected arterial injuries of the neck without initial indi-
patient during an MRI scan. cations for immediate operation allows characterization of
lesions, such as partial or complete occlusion, pseudoan-
Indications eurysm, intimal flap, dissection, and arteriovenous fis-
The indications for CTA are broad. Any patient with a tula (Fig. 8.10).37 With the same examination, CT provides
known or suspected vascular injury may be a candidate for information about the cervical soft tissues, the aerodigestive
CTA, though CTA may not be needed if there is sufficient tract, the spinal canal, and the spinal cord. In cases of pen-
information from clinical assessment (i.e., hard signs of vas- etrating injuries, the bullet or fragment trajectories and the
cular injury). Other noninvasive imaging modalities may locations of fragments may be assessed.
suffice to make the correct diagnosis of vascular injury and The most common indication for thoracic CTA for
may allow for appropriate management. trauma is evaluation of known or suspected BTAI, usually
Indications for CTA of the head and neck after blunt or in the setting of high-energy deceleration injuries. CTA of
penetrating trauma include unexplained or incongruous the chest is also useful in the setting of penetrating trauma
central or lateralizing neurological deficit. This modality with possible great vessel injury. Chest x-ray findings that
is also indicated for complex facial or mandible fractures, suggest BTAI or other vascular injury include a widened
mediastinum, an apical cap, and a displacement of the tra-
chea, left main bronchus, or nasogastric tube. However, a
normal chest x-ray does not exclude BTAI.
BTAI has been characterized based on findings on CTA as
follows: type I, intimal flap; type II, intramural hematoma;
type III, pseudoaneurysm; and type IV, aortic disruption.7
This grading scheme separates those patients who may be
managed without an operation (type I), from those with
more severe injuries (types II, III, and IV), who require oper-
ative or endovascular treatment.
CT scanning of the abdomen and pelvis is an established
modality for the evaluation of blunt trauma. Standard
imaging protocols are often employed, but contrast-
enhanced CTA provides additional information for the
evaluation of suspected vascular injuries that may not
have been clinically apparent (Fig. 8.11). In addition, the
vascular injuries may be associated with other injury pat-
terns. For example, patients with truncal vascular injuries
may have associated spine or spinal cord injury, or injury
to the viscera or solid organs.38
Fig. 8.9 Mid-shaft humerus fracture with brachial artery disruption.
The indications for CTA for the evaluation of extremity
Long bone fractures, such as this mid-shaft humerus fracture, can result in
trauma are similar to those for conventional arteriography.
intimal disruption and arterial occlusion, as seen in the three-dimensional However, the availability and diagnostic accuracy of CTA
(3-D) rendering of the CT angiography (A) and the maximum intensity has made it the imaging modality of choice for extrem-
projection (B). ity trauma in most centers.39 Adding extremity CTA to an

Fig. 8.10 Carotid artery dissection from blunt trauma. Images from a CT scan done to evaluate a 25-year-old man who was severely beaten about the head
and neck. Axial reconstruction (A) demonstrates dissection flap in the cervical portion of the left internal carotid artery, dilation of the segment, and luminal
irregularity (yellow arrow). Coronal display of maximum intensity projection facilitates visualization of pseudoaneurysm (B, yellow arrow), with proximal and
distal irregularity. The 3-D rendering (C) shows the vasculature and bony anatomy together.
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 103

B C
Fig. 8.11 Traumatic renal artery occlusion. Chest and abdominal injuries were sustained by a 14-year-old boy who was thrown from a motor bike traveling
35 miles per hour. (A) CT scan with contrast demonstrates left renal artery occlusion – likely from dissection (yellow arrow). The right kidney (R) is enhanced
with contrast, but no contrast appears in the left kidney (L). (B) Color flow duplex scanning of the kidneys demonstrates flow in arcuate arteries and veins in the
right kidney (top) but no flow in the left kidney (bottom). (C) Normal pulsed Doppler arterial waveforms can be obtained from the right kidney (top), but only
slow velocity venous flow can be detected in the left renal hilum (bottom).

already-planned scan of the chest, abdomen, and pelvis recommended to reduce the risk of CIN. As experienced
adds little time, and provides detailed information useful in clinicians are aware, transporting critically ill or injured
the polytrauma patient. Studies of CTA in the evaluation of patients to an imaging suite is associated with risks. This
extremity vascular trauma have shown high rates of sensi- may require suspension of specific therapies and may initi-
tivity and specificity (90% to 100%).40 ate a transition of care. Additionally, movement of a seri-
ously injured patient to the CT scan area and scanning
Preparation table may result in interruption of cardiovascular monitor-
Reliable IV access is needed for contrast administration. ing and may increase the risk of displacement of lines or
Planning the sequence of imaging may help limit the vol- tubes. Thus, coordination and planning are needed anytime
ume of iodinated contrast agents (by limiting multiple diag- patients are moved to the CT scanner from the resuscitation
nostic imaging procedures). Avoiding hypovolemia is also room, OR, or intensive care unit.
104 SECTION 2 • Immediate Management and Diagnostic Approaches

equipment malfunction can be eliminated by regular pre-

Pitfalls and Danger Points ventive maintenance and timely repairs.
Risks associated with CTA are similar to conventional arte- Beam attenuation is proportional to the average attenua-
riography but without the risks of arterial catheterization. tion coefficient in each volume element (voxel). Resolution
CTA hazards include: may be degraded when tissues with different absorption
densities are in the same voxel. Partial-volume effects are
n CIN minimized by the use of thin sections or “cuts” and by the
n Anaphylactic reaction to contrast selection of a section that lies in the center of the object of
n Contrast extravasation outside of the vein interest for attenuation measurements. Beam-hardening
n Late effects of exposure to ionizing radiation (cancer) artifacts result from preferential absorption of low-energy
n Venous injuries may be missed if single-phase acquisi- photons from the x-ray beam. The effect may be pronounced
tion is performed in areas of high attenuation, such as bone. Specific to CTA,
n Diagnostic (interpretation) errors inadequate vascular opacification due to delayed contrast
n Imaging limitations due to artifact medium transit times in patients in shock may render CT
n Movement of the patient from a treatment area to the CT angiography (arterial or venous) nondiagnostic. Timing
imaging suite delays may be most problematic for CTA of distal vessels or
for more central venous structures.
From a population-based perspective, the risk of radia-
tion exposure from diagnostic CT scans is considerable. Strategy
However, on an individual basis, radiation-associated risks CT scanning has become nearly ubiquitous in the manage-
are low and usually not major considerations in the con- ment of the severely injured patient, with demonstrated
text of a potentially life- or limb-threatening injury. The efficacy for detection of occult injuries and characterization
most practical way to keep radiation exposures as ALARA of known injuries. Standard imaging protocols detect most
in trauma care is to perform only those studies needed for vascular injuries, but dedicated CT angiographic studies are
patient management. Routine CT imaging for low-risk often needed to better characterize some patterns of vascular
injury mechanisms is discouraged. This is particularly trauma, especially those to medium- and smaller-sized vessels.
important for children, as they are at greater lifetime risk
for cancer due to radiation exposure.41 Since 2006, the Technique
“Image Gently Alliance” (https://www.imagegently.org), CT angiography is performed in targeted regions with
which began as a committee of the Society for Pediatric IV contrast infusion. A typical contrast bolus volume is
Radiology, has advocated to decrease radiation doses to 100 mL, with an infusion rate of 4 mL/s. The imaging delay
children, primarily through more selective use of imaging, is typically estimated, but most systems will time the arte-
but also by the use of dose-limiting imaging protocols and rial phase acquisition with bolus tracking, starting when
up-to-date equipment. the contrast arrives at a preselected region of interest. A
Of note, overall radiation dose may be decreased with the technologist performs CT scans, typically with predefined
initial performance of a quality CTA, as its high diagnostic protocols. The technologist positions the patient, adminis-
yield may obviate the need for other radiographic studies. ters contrast materials, prepares and operates the CT scan
Technology advances (detector design, image-processing equipment, then sends image data in Digital Imaging and
systems) have decreased radiation dose and other proce- Communications in Medicine (DICOM) format to the pic-
dure-specific changes (adjustments in tube current [mA], ture archiving and communication system (PACS).
tube potential [kVp], gantry rotation time, helical pitch) can Conventional CT displays show the density of the imaged
further limit exposure. Other pitfalls of CTA include sources tissue (the degree to which x-rays are attenuated) in gray
of artifact that can degrade image quality or one's ability to scale. CT densities are measured in Hounsfield units (HU),
interpret the image. which range from −1024 to +3071. As the human eye can
During the evaluation of a trauma patient, motion can discern only 30 to 40 gray scale levels, the image display
also degrade image quality, creating black or white bands, can be varied to include HU ranges across a small or broad
dark spots, loss of resolution, or anatomic distortion. Strate- window, centered on a particular level of interest.
gies to reduce motion artifact include fast scanning, gating Modern MDCT scanners have isotropic resolution, with all
(e.g., to reduce motion artifact from the cardiac cycle), tube three dimensions of the individual image volumes (voxels)
alignment, corrective reconstruction, and postprocessing being the same (X = Y = Z). Because of this, the CT dataset
techniques. The presence of high-density foreign materials can be considered a three-dimensional (3-D) represen-
can also be problematic. Metal can create streak artifacts tation of the image volume scanned, and these data can be
by causing the detectors to operate in a nonlinear response displayed in several ways. Postprocessing of the volumetric
region, and even small fragments can create a star-pattern imaging data from CTA can greatly facilitate image inter-
artifact. Patient body habitus also affects image quality with pretation. Some postprocessing may be done automatically,
more image distortion occurring in larger patients. but technologists, radiologists, and other clinicians are able
Performance of a CT scan relies on geometric precision to manipulate the dataset to yield the views and projections
and measurement quality. Inaccurate geometry, inaccurate of specific diagnostic interest. Postprocessing techniques can
alignment of the x-ray tube with the detectors, or incorrect create 2-D or 3-D images.
data can produce artifacts and blurring that limit spatial The use of dual energy levels (kVp) during imaging can
resolution. Detector calibration errors and balance can also facilitate removal of bone from images or can help distinguish
occur, detracting from image quality. Artifacts caused by calcium from contrast-enhanced blood.42 The thickness
 8 • Imaging for the Evaluation and Treatment of Vascular Trauma 105

of the imaging slice through the imaged volume can be

selected. Thin-slice reconstructions have better edge defi-
Postexamination Care
nition, better high-contrast resolution, and fewer partial- There are few specific concerns after CTA, although hypovo-
volume artifacts at the cost of greater noise and poorer lemia should be avoided to reduce the risk of kidney harm.
low-contrast resolution. Urine output and renal function should be monitored.
Two-dimensional CTA postprocessing techniques include
multiplanar reformatting (MPR) of images, as well as Complications
curved reformatting. MPR displays volumetric data in CTA is generally safe, noninvasive, and associated with few
orthogonal planes (axial, sagittal, coronal), as well as in direct risks of complications. Early complications of CTA
oblique planes selected and manipulated by the user. Sam- are primarily those associated with contrast administration
ples through the volume dataset can be thin slices or thick (extravasation, renal failure, allergic-type reactions). Other
slabs. Curved reformats (CR) are used to view vessels over risks associated with CTA are those associated with errors in
their entire course, which facilitates evaluation of segment image interpretation. The late risks associated with radiation
patency or stenosis. exposure are modest for most patients, but children may be at
Three-dimensional postprocessing includes maximum increased lifetime risk for radiation-associated cancers.
intensity projections (MIP) and surface shaded volume
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13. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic
fractures. Injury. 2009;40(10):1023–1030.
14. Niola R, Pinto A, Sparano A, Ignarra R, Romano L, Maglione F. Arte-
rial bleeding in pelvic trauma: priorities in angiographic embolization.
Curr Probl Diagn Radiol. 2012;41(3):93–101.
15. Katsanos K, Sabharwal T, Carrell T, Dourado R, Adam A. Peripheral
endografts for the treatment of traumatic arterial injuries. Emerg
Fig. 8.12 Axillary artery gunshot wound. Maximum intensity projec- Radiol. 2009;16(3):175–184.
tions (MIP) can create images that resemble conventional arteriography. 16. Cherr GS, Travis JA, Ligush Jr. J, et al. Infection is an unusual but
The thickness of the tissue in the image can be varied. This thick MIP slab serious complication of a femoral artery catheterization site closure
device. Ann Vasc Surg. 2001;15(5):567–570.
(44-mm reconstruction) in steep right anterior oblique projection shows
17. Gaitini D, Razi NB, Ghersin E, Ofer A, Soudack M. Sonographic evalu-
the abrupt cut off of flow in the left axillary artery after a gunshot wound to ation of vascular injuries. J Ultrasound Med. 2008;27(1):95–107.
the left shoulder. Metallic fragments from the bullet are seen in the large 18. Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of
hematoma on the anterior chest wall. eFAST in the trauma patient: a systematic review and meta-analysis.
Cjem. 2019;21(6):727–738.
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19. Larsen DW. Traumatic vascular injuries and their management. Neu- sizing in the management of blunt thoracic aortic injury. J Vasc Surg.
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LM. Point-of-care ultrasound and Doppler ultrasound evaluation of fection and hygiene practices: WFUMB Global Survey Results. Ultra-
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2017;9(1):5. 33. Kocher KE, Meurer WJ, Fazel R, Scott PA, Krumholz HM, Nallamothu
21. Peck MA, Rasmussen TE. Management of blunt peripheral arterial BK. National trends in use of computed tomography in the emergency
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Semin Ultrasound CT MR. 1997;18(1):39–56. gency ultrasound-based algorithms for diagnosing blunt abdominal
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28. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous 2009;29(3):863–876.
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Trauma. 2008;64(6):1415–1418. discussion 1418–1419. estimated radiation-associated cancer risk among injured children
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matic aortic injury. J Vasc Surg. 2011;53(3):608–614. 42. Wortman JR, Uyeda JW, Fulwadhva UP, Sodickson AD. Dual-energy
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NT. Intravascular ultrasound is a critical tool for accurate endograft 602.
SECTION 3
E­me­rg­ing Technologies and
New Approaches to Vascular
Trauma and Shock

107
 9 Endovascular Suites and
the Emergency Vascular Service
JOSEPH A. HERROLD, THOMAS M. SCALEA, and JONATHAN J. MORRISON

Introduction This chapter aims to discuss all of these issues and the evi-
dence surrounding HTOR and the clinical teams required to
Hemorrhage control is a critical component of any facility deliver an integrated trauma vascular service. Much of this
that manages trauma patients. This core capability exists in data is borne out of the experience of establishing such a
many forms, from mechanical devices, such as tourniquets service at the R Adams Cowley Shock Trauma Center at the
for extremity hemorrhage to invasive surgical procedures. University of Maryland, Baltimore.
Within the domain of hospital care, operative exploration is
the gold standard for hemodynamically unstable patients, Endovascular Suites
whereas catheter-based endovascular techniques are
reserved for stable patients who can tolerate transfer to a PRINCIPLE
remote interventional radiology (IR) suite.
This paradigm has largely been a product of geography The concept of the HTOR takes its origins from vascular
and specialty boundaries. IR suites tend to be remote to surgery. Once vascular surgeons introduced endovascular
resuscitation personnel and equipment, such as anesthesi- procedures into their practice and training, the integration
ology support and blood banking. The option of converting of radiological imaging into their ORs became essential.
from an endovascular to an open surgical approach is often This has enabled the full spectrum of hybrid operations,
limited by the logistical difficulty of transferring patients where open surgery (e.g., femoral endarterectomy) can be
back and forth to the operating room (OR) from the IR suite. combined with endovascular interventions (e.g., iliac stent-
Furthermore, in a conventional model of separated IR ing) in a single setting.
and OR suites, there is often little cross-discipline appre- Trauma surgery is similar to vascular surgery in several
ciation of the burden of disease. The personnel perform- important ways, as it pertains to the HTOR and endovascu-
ing the endovascular procedure may not promptly discern lar interventions: the need for timely intervention, the risk
the physiology of a declining trauma patient and recog- of significant blood loss, and pathologies that may traverse
nize when a truncated procedure or conversion to an open multiple anatomic planes and compartments. For these
approach is desirable. Equally, the requestors of the endo- reasons and more, endovascular techniques have become
vascular approach may not appreciate the limitations of increasingly essential components of trauma patient man-
endovascular technology and interventions. agement.5 For example, endovascular interventions are
To address this gap, a new concept is starting to emerge, being used more and more as adjuncts in the treatment
where operative hemorrhage control can be augmented of pelvic and solid organ hemorrhage, and BTAIs are now
with endovascular adjuncts by a single, multidisciplinary treated almost exclusively endovascularly.4,6–8
team in one location.1 This is especially useful in certain The extension of the hybrid vascular OR concept to
anatomically challenging locations, such as noncompress- trauma surgery solves the issue of geography by allow-
ible torso hemorrhage, or to preserve tissue plains to pre- ing interventions to be delivered in a single location, while
vent cross contamination between fields, such as protecting maintaining active resuscitation, and providing the full
retroperitoneal vascular structures from an intraperitoneal spectrum of operative capability. Thus, the HTOR is the opti-
hollow viscous injury.2,3 Similarly, some injuries may be mal destination for most trauma patients with hemorrhage.
optimally managed by endovascular means with an opera-
tive approach held in reserve, such as blunt thoracic aorta ROOM DESIGN
injuries (BTAI).4
The limitations of a conventional model of noninte- The minimum recommended size for an HTOR is 55 m2,
grated IR and OR management can be addressed by a com- although many would argue that 70 m2 is a more appropri-
bination of technological and system solutions. The issue of ate figure. An HTOR requires space for the four traditional
geography can be addressed by the development of a hybrid zones of an operating room, plus an additional imaging
trauma operating room (HTOR) which colocates operative zone: sterile field, circulation pathway, moveable equip-
and endovascular capability. Although a specialist room ment, anesthetic, and imaging zone. The imaging zone is
such as an HTOR is necessary for integrated care, it is not where the imaging system is located when not in operation,
sufficient to provide said care without the addition of a and must not interfere with the movement of patients, per-
seamlessly integrated service. Personnel who are trained in sonnel, or equipment.
both disciplines and the physical workings of the rooms are The biggest HTOR design decision relates to the type of
required to make the integrated concept work. imaging system to be installed. When considering a fixed

108
 9 • Endovascular Suites and the Emergency Vascular Service 109

imaging system, these can either be floor or ceiling mounted. The optimal system type is often dependent on local
Although such a difference may seem small, there are big issues. A floor-mounted system offers the greatest flexibil-
implications to this decision. In general, a floor-mounted ity for the room configuration, especially if the room is used
system offers the greatest flexibility to the HTOR configura- by multiple different specialty groups, such as vascular and
tion (Fig. 9.1). A floor-mounted system allows for imaging trauma. A ceiling-mounted system can make OR setup
to occur over a greater floor space, allowing for the bed to be more straightforward by limiting options. As with many
positioned anywhere within that area. Furthermore, such complex clinical issues, planning is key.
a system does not encroach on the ceiling, leaving this free
for the positioning of surgical lights, monitors, and other ORGANIZATIONAL ISSUES
such devices.
The drawback of a floor-mounted system is complexity. The organization of an HTOR can be complex due to the
Whereas the ability to freely position the OR table and imag- involvement of multiple teams: the scrub team, circulat-
ing system can accommodate the widest variety of proce- ing staff, radiography, as well as the surgical and anesthetic
dures, the long list of procedure-specific configurations can teams. For straightforward cases, where a single interven-
be overwhelming for the OR staff and lead to confusion tion or serial procedures are being performed, leadership can
about the room set-up, especially in hospital settings that come from the senior clinician performing the procedure.
lack dedicated endovascular OR staff. This becomes prob- When procedures are being done in parallel with multiple
lematic for complex patients, which is discussed in more teams, delivery of patient care in the HTOR can become
detail later. hampered if clear leadership is not established. In such sce-
A ceiling-mounted system consists of a gantry which narios, it is the trauma surgeon’s role to step forward and
allows for an imaging system to travel from a parked loca- command the room, as they have the greatest appreciation
tion, up and down the length of an OR bed, with limited for the pathophysiology of the injured patient. However, this
side-to-side translation (Fig. 9.2). This type of system per- requires the trauma surgeon to also have a working knowl-
mits full body imaging, but the bed position is relatively edge of the room’s operation, the endovascular techniques at
fixed, limiting the flexibility of the room configuration. hand, and all of the clinical factors in play.
Furthermore, as the ceiling is occupied with the gantry, the The most complex of trauma patients can require the
location of surgical lighting and monitors can be limited. use of an imaging system, power injection, suction reser-
voirs, energy devices, cell salvage, and—on rare occasion—
extra-corporeal circuits for venous bypass, renal replace-
ment therapy, or membrane oxygenation. The arrival of all
of this ancillary equipment can rapidly crowd and reduce
the functionality of the room and requires forward planning.
Such scenarios are both a strength and weakness of HTORs. If
managed well, combined open and endovascular techniques
can make a huge difference in the management of complex
injury, but if the room functionality is not optimized, HTORs
can become a liability and hinder effective care.
The planning for these extraordinary cases should ide-
ally happen at the room planning stage, where the most
complex clinical scenarios are simulated and practiced.
This rarely happens in modern health care, so a deliberate

Fig. 9.1 An example of a floor-mounted hybrid trauma operating room Fig. 9.2 An example of a ceiling-mounted hybrid trauma operating
fixed imaging system. room fixed imaging system.
110 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

effort must be made by the teams using these rooms to sim- The mounting of FPDs onto a robotic arm has led to the
ulate extremes of operation. This reduces the risk of critical current generation of fixed systems, which are inherently
errors during actual patient care. more complex and capable than mobile c-arms. The resolu-
Many solutions to efficient operations are local, but in tion is greater and higher energy imaging can be acquired
Baltimore, we have developed a number of HTOR procedure- (Fig. 9.3). As the detector is on a robot arm, the position rel-
specific configurations. We have identified the most common ative to the OR table is always known, allowing for images
room configurations, which consist of three different bed to be stored with their spatial data.
and imaging system positions. This covers 95% of our opera- This allows for automation of certain imaging sequences,
tions, and a drawing of these arrangements is prominently such as stepped digital subtraction angiography, where a sin-
displayed at both the booking desk and in the HTOR, so that gle bolus of contrast can be tracked down an entire extremity.
staff are aware of how the room should be configured. Additionally, image-specific bed and detector positions can
For any case where open and endovascular surgery be stored and recalled for later use, which has the combined
is anticipated, we use a larger, double-decker instrument effect of reducing both radiation and contrast use.
table. On the lower deck, we place open instruments, and on A specific advantage of fixed systems is the availability
the upper deck, long catheters, wires, and sheaths can be of cone-beam computed tomography (CBCT), which is an
laid out. This allows for the ease of identification of catheter advanced axial imaging protocol. CBCT obtains volumet-
types and for preparing long devices for deployments, such ric imaging data from a single 200-degree planar rotation
as thoracic aortic stent-grafts. by projecting x-ray beams from a central voltage tube in a
Finally, we have deliberately elected to make endovascu- cone-shaped projection through the object and onto a high
lar surgery part of our standard scrub teams’ remit, and not resolution two-dimensional FPD.
that of a specialist endovascular scrub team. This is to mini- This is in contrast to multidetector CT (MDCT), which
mize the need for specialty call schedules, but does require collects data across multiple one-dimensional detector ele-
a significant investment in training. We have yet to master ments, scanning body cavities across a full 360 degrees in
this program of education but recognize that a single train- a helical manner as the patient passes through the detec-
ing event is inadequate, and recurrent top-down training tor. CBCT detector panels are smaller and do not move
of scrub teams is crucial for sustainable skills in the HTOR. with respect to the anatomical plane of the patient. The
volume of acquisition is limited to the size of FPD. Addi-
tionally, increased radiation scatter creates increased
IMAGING CAPABILITY
image artifact and decreased image quality when com-
Initially, imaging for endovascular interventions consisted pared to MDCT.
of stand-alone c-arm systems, which use an x-ray tube and However, despite these limitations, CBCT has the advan-
image intensifier to produce dynamic images. Although tage of providing axial imaging capability in the HTOR,
still common in orthopedic practice, image intensifiers have which we use in two ways. Firstly, to perform a noncontrast
largely been superseded by flat panel detectors (FPD) in vas- head CBCT on the OR table as a screening test for intracra-
cular surgery, which increase the available image size and nial space-occupying lesions (Fig. 9.4). Secondly, to further
dynamic range, while possibly reducing overall radiation assess suspected vascular lesions (e.g., pseudoaneurysms,
dose.9–11 arterio-venous fistulas) in order to plan the strategy for

Fig. 9.3 Images of (A) a pre- and (B) postthoracic endoluminal stent grafting for a blunt thoracic aortic injury.
 9 • Endovascular Suites and the Emergency Vascular Service 111

Unfortunately, hemorrhage is rarely isolated and is always

time-sensitive, rendering the hemostasis-by-consultation
model inadequate for efficacious treatment of trauma
patients. However, as previously mentioned, endovascu-
lar hemostasis has become increasingly useful, if not the
norm, for certain injuries, placing definitive injury manage-
ment under the jurisdiction of other specialties.5 Examples
include the use of interventional radiology to embolize
solid organ vascular injury and vascular surgery to deploy
thoracic stent-grafts for BTAI. In hemorrhaging patients,
time to hemostasis is the metric of utmost importance with
a strong correlation to mortality, as empirically shown in
several studies.12,13 However, most trauma systems are
designed to expedite delivery of injured patients to the care
of a trauma surgeon but not necessarily the subspecialists
providing definitive hemostasis. Although this horizontal
model is presented as responsible clinical practice, where
everyone has the opportunity to provide expertise, we
believe that this model often provides cumbersome, com-
mittee-based care without clear leadership in a setting that
mandates prompt decisiveness.
We have instead adopted a vertically integrated system,
where a subset of our trauma faculty are dual-trained in
vascular and trauma surgery. These individuals provide
a 24/7 hemostasis service as part of a dedicated vascular
trauma service. Under this model, expedited delivery of
injured patients to the trauma surgeon is delivery to defini-
tive hemostasis. This hastens and simplifies access to early
Fig. 9.4 Noncontrast cone-beam CT scan of the head demonstrating a hemorrhage control, as there are no consultants providing
right subdural hematoma. an ancillary layer of decision-making from a frequently
off-site location. Furthermore, as the patient remains
within the sphere of trauma surgeons who understand the
hemostasis. Both of these applications provide vital diag- pathophysiology at hand, decision-making becomes more
nostic information in patients otherwise deemed too unsta- stream-lined and holistic in the context of the patient’s
ble to undergo imaging prior to the OR. As it is an emerging injury pattern. For example, complex subselective embo-
technology, the evidence base for the use of CBCT imaging lizations are not attempted in hemodynamically unstable
in trauma is currently sparse; however, this represents fer- patients—damage control hemostasis and comprehensive
tile ground for future clinical research. resuscitation in the ICU are prioritized instead.
This service model was adopted at our institution in
Emergency Vascular Service 2015. Prior to adoption, catheter-based therapies were
delivered by an IR service, and the average time to pelvic
embolization was over 5 hours. With the advent of the
CLINICAL NEED
new service model, time to pelvic embolization has been
The HTOR holds much promise for the judicious applica- reduced by over an hour to around 3.5 hours.14 Fig. 9.5 is
tion of technology to improve trauma patient outcomes by an illustrative case of the workflow efficiencies created by
integrating endovascular techniques and advanced imag- an HTOR that can be achieved in critical trauma patients.
ing into active resuscitation and operative management. Although this model is neither feasible nor appropriate at
This concept is not new, having been around since the early every institution, the virtues of this system of care are still
2000s, but few institutions have capitalized on the poten- highly relevant to those providing hemostasis to injured
tial it offers. The requisite technology is constantly improv- patients (Box 9.1).
ing and readily available, placing the responsibility for slow
adoption elsewhere. PRACTICAL IMPLEMENTATION
In our view, the biggest barrier to successful HTOR use is
the system of care built around the trauma service. The most The implementation of a vascular trauma service depends
common model of trauma patient care is that of the classic upon numerous local factors that relate to access to person-
in-patient “primary team and consultation service” archi- nel, trauma system resources, and patient volume. To justify
tecture. A patient is admitted under the primary team and, a dedicated service, the patient volume has to be adequate.
as patient pathology extends beyond the scope of their disci- Although the volume-outcome relationship is well estab-
pline, relevant specialists are consulted for further evaluation lished in surgery, the appropriate threshold for such service
and management. This model of care works well when the is unknown.15 At Shock Trauma, we see between 6000 and
problem at hand is isolated and not time dependent. 8000 trauma activations a year and perform roughly 500
112 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Conventional Model of Care

MCC
Shocked Stabilize Pelvis Pan CT Scan
Insertion of IVD
Low GCS Angioembolization & DC-Ortho
Repeat Head CT
Unstable Pelvis SI Screw Plain Films
Femur & SFA Injury

Hybrid Trauma Operating Room Model of Care

MCC
Shocked Stabilize Pelvis
CBCT of Head Insertion of IVD
Low GCS Angioembolization DC-Ortho
Plain Imaging Repeat Head Imaging
Unstable Pelvis SI Screw
Femur & SFA Injury

Fig. 9.5 Example of a patient pathway using both a conventional and hybrid operating room approach. The patient in question was a motor cyclist
involved in a crash who presented in hemorrhagic shock with a pelvic fracture, femur fracture, and superficial femoral arterial (SFA) injury. In a conven-
tional model of care, the pelvis would have been managed initially in a radiology suite, followed by transfer to the operating room for exploration of the
SFA. Once stabilized, a pan-CT would have been undertaken, followed by the insertion of an intraventricular drain (IVD) for a brain injury and damage
control orthopedics (DC-Ortho). With a hybrid room model of care, all of this imaging can be undertaken in a single location. CBCT, Cone-beam com-
puted tomography; GCS, Glasgow coma score; MCC, major complication and comorbidity; SI, iliosacral.

Box 9.1 Top 10 Lessons of Hybrid Trauma Operating from general surgery training, which is the foundation of
Room Use trauma surgery. In the United Kingdom, vascular surgery
1. Use the largest room possible.
training is a separate pathway from general surgery, with
minimal overlap. The United States has developed both
2. Train the team who will use the room, in its operation.
integrated programs as well as the classic general surgi-
3. Engage all of the disciplines that will use the facility (radiology,
vascular, trauma, etc.).
cal followed by vascular fellowship pathway. It is unclear
whether the latter will be continued into the long term.
4. If possible, employ trauma surgeons who are also trained vascular
surgeons. Other countries training programs are in similar states of
5. Track your case utilization – case number and when do they
evolution.
happen? The end result is that both vascular- and trauma-interested
6. Think big – this is a new frontier with enormous room for innova- trainees are struggling to gain adequate exposure to both
tion and study. disciplines short of completing fellowship training in both.
7. Be practical – try and consolidate operating sets that include This arduous and time-consuming training path has pro-
endovascular tools as well as open. duced predictably few dual-trained practitioners. The lack
8. Rehearse specific scenarios – e.g., the management of hemody- of surgeons with sufficient training in trauma and vascular
namically unstable pelvic fracture. surgery is of significant concern for many of the reasons
9. Have a champion for the facility within the nursing and surgical listed previously. Our favored solution is the creation of a
groups, who can identify and solve problems. trauma vascular training module that would consist of a
10. Have a specific plan for when the room has technical problems cross-specialty curriculum that is available to both vascular
and an alternative facility is required. and trauma trainees. This is at an early stage of develop-
ment, although cross-discipline training has been success-
fully delivered in the United Kingdom via trauma training
vascular procedures a year. We believe that this is sufficient interface groups.
volume to justify three dual-trained surgeons, who also Whereas a core curriculum would serve both trauma
participate in the trauma service. and vascular trainees, the emphasis of the training would
need to differ between groups. For example, vascular train-
ees would need an emphasis on trauma decision-making,
TRAINING ISSUES
whereas trauma trainees would need to focus on the devel-
In both the United States and the United Kingdom, vascular opment of procedure-based skills. This area remains con-
surgery training had followed a pathway of general surgical tentious, but a comprehensive strategy to fill this training
training followed by additional vascular training. However, gap is badly needed to provide trauma vascular training
vascular surgery training is becoming increasingly isolated ­sufficient to meet the demand for such providers.
 9 • Endovascular Suites and the Emergency Vascular Service 113

5. Branco BC, DuBose JJ, Zhan LX, et al. Trends and outcomes of endo-
Conclusions vascular therapy in the management of civilian vascular injuries.
J Vasc Surg. 2014;60:1297–1307.
6. Tesoriero RB, Bruns BR, Narayan M, et al. Angiographic embolization
HTORs have the potential to bring advanced imaging and for hemorrhage following pelvic fracture: is it “time” for a paradigm
concomitant open and endovascular procedures to trauma shift? J Trauma Acute Care Surg. 2017;82:18–24.
care. The environment of an HTOR is complex and requires 7. Adnan SM, Wasicek PJ, Crawford A, et al. Endovascular control of
pelvic hemorrhage: concomitant use of resuscitative endovascu-
trained personnel who are familiar with trauma manage- lar balloon occlusion of the aorta and endovascular intervention.
ment and HTOR technology. A dedicated service consist- J Trauma Acute Care Surg. 2019;86:155–159.
ing of dual-trained trauma and vascular surgeons is one 8. Bhullar IS, Tepas JJ, Siragusa D, Loper T, Kerwin A, Frykberg ER. To
way to deliver HTOR operations. Although this model nearly come full circle: nonoperative management of high-grade IV-V
blunt splenic trauma is safe using a protocol with routine angioembo-
may not work in all institutional environments, it seems lization. J Trauma Acute Care Surg. 2017;82:657–664.
clear that the synergy of the HTOR combined with capable 9. Weis M, Hagelstein C, Diehm T, Schoenberg SO, Neff KW. Comparison
staff with a unified decision-making structure optimizes of image quality and radiation dose between an image-intensifier sys-
delivery of hemostasis to injured patients. This system can tem and a newer-generation flat-panel detector system — technical
provide more expeditious and comprehensive care, lead- phantom measurements and evaluation of clinical imaging in chil-
dren. Pediatr Radiol. 2016;46:286–292.
ing to improved patient outcomes. It is likely that a specific 10. Spira D, Kirchner S, Blumenstock G, et al. Therapeutic angiographic
trauma-vascular training pathway will be needed in the procedures: differences in dose area product between analog image
future to deliver the care required in HTOR environments in intensifier and digital flat panel detector. Acta Radiol. 2016;57:
the quantity in which it is needed. 587–594.
11. Livingstone RS, Chase D, Varghese A, George PV, George OK. Tran-
sition from image intensifier to flat panel detector in interventional
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 ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­10 Stent-Grafts, Coils, and Plugs
DAVID SCHECHTMAN and BRANDON W. PROPPER

Introduction endovascular hemorrhage control is evidence of bleeding,

such as active extravasation from a liver, splenic, renal, or
Hemorrhage is the leading cause of preventable death in pelvic injury. Other indications include high-grade solid
trauma patients, with 96% of those patients dying from non- organ injuries or moderate hemoperitoneum. Additionally,
compressible torso or junctional hemorrhage.1 As endovas- patients who have an injury to a junctional vessel as evi-
cular techniques have become more ubiquitous for elective denced by contrast extravasation, dissection flap, or pseu-
and emergent vascular cases, there has been a shift toward doaneurysm on imaging may be appropriate for stent-graft
endovascular interventions for trauma patients. Angioem- placement, which maintains distal perfusion while exclud-
bolization devices, such as particulate, plug, or coil embo- ing the injured segment. For trauma patients managed in
lization have been the standard of care for nonoperative a hybrid operating room, there is the option for concur-
management of hemodynamically normal trauma patients rent or sequential open and endovascular interventions.
with solid organ injury and contrast extravasation on imag- Several considerations that must be addressed when plan-
ing. More recently, endovascular stent-grafts have become an ning endovascular hemorrhage control include vascular
adjunct for control of hemorrhage from axial vessels while site of access, size of the target vessels, urgency of treat-
maintaining antegrade flow to distal structures. The accep- ment, blood supply, collaterals, distal perfusion, emboliza-
tance and use of endovascular adjuncts in trauma patients tion agent, and potential for migration of occlusive agent.
with arterial injury have been rapidly increasing. Only 3% Age remains another factor of continued debate. There is
of vascular injuries captured in the National Trauma Data minimal data looking at endovascular technology when
Bank (NTDB) in 2004 were managed with endovascular deployed in growing vessels. Each of these considerations
therapy. Ten years later, 9% of vascular injuries were being will be addressed in the following anatomic sections.
managed with an endovascular approach.2 It is especially
appealing to use endovascular interventions for injured junc-
tional vessels including subclavian, innominate, axillary, and Embolization Agents
iliac arteries, where the morbidity from a high thoracotomy,
median sternotomy, or laparotomy may be avoided. Endo- The ability to perform catheter-directed mechanical occlu-
vascular interventions may decrease the physiologic penalty sion to a vascular territory or affected parenchyma within
on these patients with polytrauma, avoid the need to enter a a specific organ has been an adjunct to open surgery for
second body cavity, limit vessel exposure with possible dam- trauma since the 1970s.3 These catheter-directed tech-
age to adjacent structures or nerves, and possibly spare the niques have evolved with the expansion of nonopera-
need for general anesthesia. This chapter reviews the current tive management for solid organ injury. Over the past five
literature for management of solid organ, pelvic, junctional, decades, embolization has moved from improvised embolic
and peripheral vascular injuries. Resuscitative endovascular agents, such as guidewires, suture material, or autologous
balloon occlusion of the aorta (REBOA) and endovascular clots to commercially available permanent and temporary
management of aortic injuries will be discussed elsewhere in embolic agents (Table 10.1).
this textbook.
TEMPORARY EMBOLIZATION AGENTS
Principles of Endovascular Historically, biologic material such as autologous clots or
Hemorrhage Control soft tissue were used as temporary embolization agents. In
current practice, Gelfoam (Pharmacia & Upjohn, Kalama-
Appropriate patient selection is fundamental to optimiz- zoo, MI) is the commercially available option most com-
ing outcomes in trauma patients undergoing endovascular monly used in trauma. Gelfoam is an insoluble porous
interventions for hemorrhage. Patients who are hemody- product made from purified porcine skin, gelatin granules,
namically unstable, have diffuse peritonitis, or evidence and water. Although its use as an embolization agent is
of hollow viscus injury should be taken for emergent open off-label, clinical experience using Gelfoam embolization
intervention. Patients who are hemodynamically normal extends back to the 1970s.3 During the embolization pro-
or responders to fluid resuscitation may undergo multi- cedure, a slurry of 1 to 2 mm cubes of Gelfoam sponge
detector computed tomography (MDCT) with IV contrast. and contrast medium is combined using two syringes with
Based on the results of imaging, these patients may require a three-way stopcock. The contents are alternated between
urgent operative intervention, endovascular hemorrhage the two syringes until a homogenous slurry is formed with
control, or observation. The most common indication for the consistency of pudding. This may then be used for
114
 ­­ • Stent-Grafts, Coils, and Plugs 115
­­­
Table 10.1 Commonly Used Embolization Agents for
used for elective vessel ablation and embolization of targeted
Trauma tissue. Experience in trauma is currently limited for these
agents, given the delivery systems can be difficult to control,
Embolization resulting in unintended distal ischemia or reflux into central
Agent Size Vessel Tips
vessels delivering embolization agent to other unintended
Temporary locations. They are not without advantages, however, as
– Gelfoam Large or Gelfoam slurry can be used for liquid adhesives function independent of the clotting cas-
small large vessels
cade and can occlude a vessel of a coagulopathic patient. In
Gelfoam powder can be used for the setting of trauma, large-vessel embolic agents are most
small vessels
commonly used. In this setting, large vessels are considered
Recanalization is highly variable
any vessel that can be seen on angiography.
– Fibrillated Small Recanalization of vessels in 2–3
collagen months Thrombin
Permanent
– Coils Large Microcoils are also available
Although not commonly used for catheter-directed therapy,
thrombin is used routinely for treatment of pseudoaneu-
Concern for distal embolization if
not anchored or when used for rysms at arterial access sites. Thrombin directly acts on
arteriovenous fistula fibrinogen, converting it to fibrin monomers thereby allowing
– Amplatz Large Multiple different shapes and it to cross-link and polymerize. This reaction results in almost
Vascular Plug lengths available immediate clot production with administration of thrombin.
Can be used to make a backstop It is approved as a topical agent, and intraarterial use is off-
for coils label, though there has been extensive experience using this
– Particles Small Limited role in trauma agent.4–6 When treating a postcatheterization pseudoaneu-
Tends to cause more ischemia rysm or posttraumatic peripheral pseudoaneurysm, the tar-
and necrosis than large vessel get is accessed by direct puncture and a small syringe is used
occlusion to administer small aliquots of thrombin until thrombosis of
– Liquid adhesive Small Risk of gluing catheter to vessel pseudoaneurysm is achieved. This generally takes less than
wall 1000 units (1 mL of 1000 unit per mL preparation). Extreme
Delivery can be challenging with care must be taken when injecting thrombin, as emboliza-
mixing of glue
tion of an unintended target can have severe consequences,
– Thrombin Small May cause nontarget including irreversible ischemia. Although there are reports
embolization
of using thrombin to treat posttraumatic solid organ pseu-
Most commonly used for narrow
neck pseudoaneurysms
doaneurysms, we do not advocate this practice.7
Coils
Coils are the most common agent for permanently embo-
embolization of proximal vessels by administering puffs lizing large vessels, given their ease of use and availabil-
of the slurry under fluoroscopy. The contrast medium in ity. They may be used alone or in combination with other
the slurry allows for visualization of the Gelfoam cast in the agents that provide scaffolding for coils and prevent distal
target vessel. Once vessel occlusion is achieved, no addi- embolization. When selecting a coil for embolization, the
tional agent is injected, as it may reflux into a more cen- size of the target vessel, sheath size, and flow in the target
tral vessel and cause unintended embolization elsewhere. vessel must be considered. Coils were originally a curled seg-
Recanalization typically occurs within 3 weeks but may ment of steel guidewire. These needed to be tightly packed
take up to 3 months. The rate of recanalization is very because they were minimally thrombogenic. Now coils have
unpredictable with Gelfoam. A powdered form of Gelfoam a thrombogenic adjunct attached, such as nylon fiber, poly-
is also available but has a small diameter of only 10 to ester, or biologically active material that promotes clotting
100 µm. This and other small diameter temporary occlusive and allows for fewer coils needed for the desired effect. Mod-
such as starch microspheres and fibrillated collagen tend ern coils are made mostly of a platinum alloy, as it is more
to travel more distally, increasing the likelihood of tissue malleable than steel and easier to see under fluoroscopy. To
ischemia, and have limited utility in controlling the injured achieve their final configuration, coils may have a built-in
larger parenchymal vessels in solid organ trauma. “memory” to which they assume after being released. There
is also a class of surface-modified coils that have a coating,
that when hydrated, expands and configures the wire and
PERMANENT EMBOLIZATION AGENTS
increases the diameter of the coil for more efficient pack-
Permanent embolization agents include coils, plugs, and ing. The deployment method is also variable among differ-
particles. The decision of which agent to use is based on ent coils and commercial brands. Some coils may be pushed
the size of the target vessel, the blood supply to the affected through the deployment catheter, chased with a saline
organ, and if ischemia is desired. In the setting of severe flush, or advanced on a deployment system from which the
injury, tissue ischemia should be minimized, which makes coils must be detached. Detachable coils offer the greatest
the use of a large number of permanent small-particle control and offer the possibility of repositioning prior to
embolic agents less desirable. Polyvinyl alcohol (PVA) par- final deployment to prevent migration in high-flow systems.
ticles, tris-acryl gelatin (TAGM), and other types of micro- Multiple diameters from 0.010- to 0.052-inch are
spheres, and liquid adhesives or sclerosants are frequently available for different applications. The combination of coil
116 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

composition and diameter will determine the stiffness of the Medical Corporation). AVPs are a series of four different
coil, often reported as “softness.” Manufacturers also report generations of self-expanding occlusive devices made of
the recommended catheter inner diameter, number of loops, nitinol mesh available in several shapes so that emboliza-
extended coil length, and coiled diameter. This allows for tion/occlusion may be achieved in a variety of target ves-
appropriate/accurate selection based on vessel size. Correct sels. These devices are available in a variety of diameters.
sizing is crucial. Stiffer coils should not be oversized more There are four distinct plugs. The AVP, AVP II, AVP III, and
than 1 mm, whereas softer coils can be oversized by 20% to AVP 4 have different numbers of segments, sizes of deliv-
30%. Oversizing of coils prevents distal migration, especially ery catheter, and deployed sizes ranging from 3 to 22 mm.
in young patients who are vasoconstricted at the time of the When choosing a device, it should be oversized by 30% to
procedure. The drawback to oversizing is that too large of 50% to the target vessel diameter. The AVPs are deployed
a coil can push the delivery catheter backward, leading to by unsheathing and can be withdrawn into the sheath for
unintended proximal embolization or dislodgement from repositioning if necessary. Once in position, the device is
the target vessel or failure of the coil to assume its intended detached by unscrewing the plug device from the delivery
shape. In lower-volume trauma centers or if a dedicated system. The large nature of AVPs makes it ideal for large
team is not available 24 hours a day, we favor selecting one vessels such as the proximal splenic artery or for AVF, where
size of macrocoils and microcoils that works with the diag- there is concern for embolizing into the systemic system. The
nostic catheters that are pulled for the trauma setup. This size and stiffness of the system does make it challenging to
prevents having to find additional delivery catheters dur- deploy after an acute angle or in a tortuous vessel.
ing the procedure. For simplicity, 0.035-inch coils can be
deployed through 4- or 5-Fr diagnostic catheters without
difficulty. If smaller vessels are being selected, microcoils Stents-Grafts
are available that can be deployed through a 0.014- or
0.021-inch lumen (i.e., through a microcatheter). Micro- When the injured or target vessel provides inline flow to a
coils may jam or start to form their deployed configuration vital structure without good collateral circulation, occlu-
in a larger catheter, leading to obstruction of the catheter. sion with an embolization device is often not a viable option.
When deploying coils, it is important to ensure the deliv- In many of these scenarios, such as with an injured periph-
ery system is well-positioned and stable. This allows for pre- eral vessel, there is minimal morbidity associated with an
cise deployment without proximal migration of the catheter open surgical approach to primary repair, or placement of
and coil. The authors recommend that the catheter being an interposition or bypass graft. In contrast, open surgical
used for delivery of the coil be placed through a sheath or an repair of injured vessels in the chest, abdomen, or pelvis is
additional catheter that will not be moved during deploy- associated with a greater degree of morbidity, which may
ment. This gives the operator the ability to remove the entire be particularly precarious in severely injured patients with
deployment catheter without losing purchase. Testing the compromised physiology. As such, the use of catheter-based
stability can be performed by advancing a wire several cm reconstructive options such as covered stents (i.e., stent-
from the tip of the delivery catheter to ensure the system grafts) to manage vascular disruption in these anatomic
remains in place. There are several techniques for emboli- locations is often beneficial. Deployed inside of the injured
zation. The two most common are the “anchor” technique, vessel, covered stents or stent-grafts exclude or “seal” the
which involves anchoring the end of the coil in a small vascular disruption, while maintaining antegrade flow in
branching vessel, with the body of the coil remaining in the the affected artery or vein. Historically, stents could be mod-
target vessel preventing migration of subsequently placed ified by the surgeon by using vein to make a covered stent
coils. The second is the “scaffold” technique, which initially from a bare metal stent. Currently, there is a wide range
uses a large coil to create a scaffold so that smaller coils can of commercially available balloon-expandable and self-
subsequently be packed proximally to form a dense coil nest. expanding covered stents that can be used for the manage-
If no branching vessel, is present, or it is a high-flow sys- ment of vascular trauma.
tem and there is concern for embolization of the initial coil,
a plug device can be deployed. Detachable coils afford the BALLOON-EXPANDING STENTS
operator greater control/accuracy for deployment. These
systems allow for advancement, retraction, and reposition- Balloon-expandable stents are stored in a crimped state in
ing of the coil before it is finally released from the delivery the delivery catheter and are expanded by inflating a bal-
wire. This can be an advantage when in a high-flow system loon within the stent, expanding it to the vessel diameter or
or if an arterial venous fistula (AVF) is present that would slightly larger. These stents are often stainless steel and have
allow for a misplaced coil to migrate to the venous system higher radial stiffness. Radial stiffness describes how much
and cause a pulmonary embolus. Detachable coils are the diameter of the stent is reduced by a certain amount of
released by an electrical current, a mechanical switch, or a external pressure. Balloon-expanding stents have greater
wire to break the bond of the coil to the deployment device. degrees of radial stiffness or “hoop strength” and there-
fore require a higher amount of force to buckle. However,
Plugs balloon-expandable stents often lack the flexibility or
When no branching vessel is present to place an “anchor” elasticity to recover once buckling occurs.8 The deployment
coil, or in a high-flow system where there is concern of balloon-expandable stents tends be more precise than
for embolization of the initial coil, a plug device can self-expanding stents, though the technology for accurately
be deployed. A commerically available vascular plug is deploying all types of stents continues to improve. The
Amplatzer Vascular Plugs (AVPs) (St. Jude Medical, AGA higher radial stiffness of balloon-expandable stents tends to
 ­­ • Stent-Grafts, Coils, and Plugs 117

be ideal for preventing migration, and this feature coupled injuries in hemodynamically normal patients has been pur-
with the precise delivery capability make them preferred sued as a standard of care since the 1990s, with a goal of
for placement in the ostia of large branch vessels. Due to preserving splenic function and lowering the risk of post-
their relative inflexibility, balloon-expandable stents are less splenectomy spesis.16 Although nonoperative management
commonly used in tortuous vessel or in vessels located in is well-accepted, the optimal application of splenic angio-
highly mobile anatomic areas (e.g., behind the knee). embolization (SAE) remains unsettled.12,16,17
The Eastern Association for the Surgery of Trauma
(EAST) guideline on splenic trauma recommends angiogra-
SELF-EXPANDING STENTS
phy for patients with Association for the Surgery of Trauma
Self-expanding stents are manufactured at the desired size (AAST) grade III or higher injury, contrast extravasation,
and are then collapsed or constrained using a covering moderate hemoperitoneum, or ongoing splenic bleeding.12
delivery device. When the constraining or covering device This guideline is in agreement with a large metaanalysis
is removed, the stent expands and reconforms to its original showing a decrease in the failure of nonoperative manage-
manufactured shape. This physical property is accomplished ment when SAE was used as an adjunct in patients with
through a spring mechanism inherent to the structure of grade IV or V injuries. In this report, SAE had a failure rate
the stent, or by using a temperature-driven method using of 12% for grade IV or V injuries, whereas nonoperative
the “shape memory” of the metal.9 Self-expanding stents management alone failed 50% of the time. The beneficial
are most commonly made from the metallic alloy called effect of SAE was not observed in the lower, grade I to III
Nitinol, and they tend to have less radial stiffness than bal- groups, although there was likely selection bias, as many of
loon-expandable stents. However, self-expanding Nitinol these patients had a separate indication for arteriography
stents or stent-grafts have greater degrees of elasticity to and/or embolization.16 The authors’ practice is to perform
recover their original configuration when the external force catheter-directed arteriography for stable patients or tran-
is removed. These qualities make self-expanding stents ideal sient responders with extravasation on initial CT imaging
to use in tortuous or flexible anatomic areas, such as those (Fig. 10.1A), or those with a moderate hemoperitoneum
crossing joints, or in areas of movement, such as the cervical and a grade IV or higher splenic injury. Embolization is only
vessels. An additional consideration is accurate placement performed at the time of arteriography if there is evidence
or deployment of the self-expanding stents. As it resumes of bleeding (see Fig. 10.1B), pseudoaneurysm, or a concern
the manufactured shape upon removal of the covering or for secondary rupture (Fig. 10.2).
constraining deployment device, self-expanding stents may Once the decision is made to proceed with SAE, the next
migrate or “jump,” thus making their precise placement step is selecting where, along the course of the splenic
more challenging. Newer deployment systems used with artery, embolization should occur. Anatomically, the
the most modern self-expanding stents or stent-grafts have options include the proximal splenic artery, distal arteries
improved the ability to accurately land the proximal extent near or in the hilum of the spleen, or a combined proximal
of these devices in the desired location. and distal approach. There is no consensus as to the opti-
mal technique, but there are recognized patterns of success
and failure.18,19 For example, proximal SAE is likely a bet-
Management of Solid Organ Injury ter approach in patients with multiple areas of extravasa-
tion, a high risk of secondary splenic rupture, or as a rapid
Starting in the 1980s, there was a push for the nonopera- intervention if the patient has hemodynamic deterioration
tive management of intraabdominal solid organ injuries in during the procedure. Proximal embolization also allows
patients who were hemodynamically stable on presentation collateral flow from the short gastric, gastroepiploic, and
or who responded appropriately to resuscitation.10,11 Initial pancreatic arteries to maintain some degree of splenic per-
protocols for nonoperative management included catheter- fusion and function. In the case of proximal, large-vessel
based contrast arteriography for hemodynamically stable embolization, the driving pressure of the main artery is
patients with an injury to the spleen, kidney, or liver on CT attenuated, which promotes hemostasis and decreases the
imaging. If extravasation was observed at the time of arte- rate of splenic rupture, while allowing for some degree of
riography, an embolic agent could be deployed to increase splenic function via small-vessel collateral flow.
the likelihood of splenic salvage or the nonoperative man- The splenic artery is 5.6 mm ± 1.3 mm for both adult men
agement of splenic injury (versus open splenectomy). The and women, and embolization is best achieved with appro-
management of solid organ injury has evolved as newer priately sized coils or plugs.20 Distal embolization is indicated
CT imaging technology provides quick, contrast-enhanced in patients with a single or several small parenchymal inju-
imaging during the immediate diagnostic phase of care. ries. This allows for preservation of antegrade flow from
Advances in diagnostic imaging allow for a more selective the splenic artery to the remainder of the spleen and pres-
use of catheter-based arteriography in certain patients with ervation of functional parenchyma. Distal embolization has
extravasation, high-grade injuries, and/or hemoperito- higher rates of infarction, abscess, and cyst formation.18 The
neum on the initial CT scan (Table 10.2).12 authors do not recommend the technique of distal subselec-
tive embolization followed by proximal embolization, with or
without use of a particulate embolization agent between the
SPLENIC INJURY
coils, except in patients who are rebleeding after distal embo-
The spleen is the second most commonly injured abdomi- lization and in whom the proximal embolization is being
nal organ but the most common source of massive bleeding performed as a salvage maneuver. Combining proximal and
in blunt trauma.13–15 Nonoperative management of splenic distal embolization has the highest complication rate, with
118 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Table 10.2 AAST Organ Injury Scale Imaging Criteria (CT Findings)
Injury
Grade Spleen Liver Kidney
I – Subcapsular hematoma <10% – Subcapsular hematoma <10% surface area – Subcapsular hematoma and/or parenchymal
surface area – Parenchymal laceration <1 cm in depth contusion without laceration
– Parenchymal laceration <1 cm
depth
– Capsular tear
II – Subcapsular hematoma – Subcapsular hematoma 10%–50% surface – Perirenal hematoma confined to Gerota fascia
10%–50% surface area; intrapa- area; intraparenchymal hematoma <10 cm – Renal parenchymal laceration ≤1 cm depth with-
renchymal hematoma <5 cm in diameter out urinary extravasation
– Parenchymal laceration 1–3 cm – Laceration 1–3 cm in depth and ≤10 cm
length
III – Subcapsular hematoma >50% – Subcapsular hematoma >50% surface – Renal parenchymal laceration >1 cm depth
surface area; ruptured subcap- area; ruptured subcapsular or parenchymal without collecting system rupture or urinary
sular or intraparenchymal hema- hematoma extravasation
toma ≥5 cm – Intraparenchymal hematoma >10 cm – Any injury in the presence of a kidney vascular
– Parenchymal laceration >3 cm – Laceration >3 cm depth injury or active bleeding contained within Gerota
depth fascia
– Any injury in the presence of a liver vas-
cular injury or active bleeding contained
within liver parenchyma
IV – Any injury in the presence of – Parenchymal disruption involving – Parenchymal laceration extending into urinary col-
a splenic vascular injury or 25%–75% of a hepatic lobe lecting system with urinary extravasation
active bleeding confined within – Active bleeding extending beyond the liver – Renal pelvis laceration and/or complete uretero-
splenic capsule parenchyma into the peritoneum pelvic disruption
– Parenchymal laceration – Segmental renal vein or artery injury
involving segmental or hilar
– Active bleeding beyond Gerota fascia into the
vessels producing >25%
devascularization retroperitoneum or peritoneum
– Segmental or complete kidney infarction(s) due to
vessel thrombosis without active bleeding
V – Any injury in the presence of – Parenchymal disruption >75% of hepatic – Main renal artery or vein laceration or avulsion of
splenic vascular injury with lobe hilum
active bleeding extending – Juxtahepatic venous injury to include – Devascularized kidney with active bleeding
beyond the spleen into the retrohepatic vena cava and central major – Shattered kidney with loss of identifiable paren-
peritoneum hepatic veins chymal renal anatomy
– Shattered spleen

AAST, American Association for the Surgery of Trauma; CT, computed tomography.

Fig. 10.1 (A) High-grade splenic injury with active arterial extravasation seen on CTA. (B) The same patient with contrast extravasation seen on
angiography.
 ­­ • Stent-Grafts, Coils, and Plugs 119

Fig. 10.3 High-grade liver injury involving the medium-sized ves-

sels. Extravasation seen on CTA and was subsequently treated with
Fig. 10.2 Delayed splenic rupture after a high-grade blunt splenic injury embolization.
that was not managed with endovascular adjuncts.

embolization is performed, it is not uncommon to see

up to one in three patients having infarction, abscess, or revascularization from distal branches. For this reason,
cyst.21 Other complications include splenic atrophy, postpro- if super-selective embolization distal and proximal to the
cedure bleeding, pleural effusion, and splenic abscess.22 The injury with microcoils is not possible, Gelfoam may be
authors favor the use of coils over particulate in most cases needed to control the distal bleeding and coil embolization
of splenic embolization, as there tends to be less reaction and used to control the proximal or inflow artery. Embolization
pain with coils alone. Additionally, if proximal coils are used of the liver is generally well tolerated, given the dual arte-
to attenuate antegrade flow, the operator should expect to rial and portal venous blood supply. With this in mind, Gel-
see a pseudoaneurysm on subsequent imaging with CT and foam or particle embolization should be avoided proximal
should have a plan with that in mind. or just distal to the cystic artery, as there is concern for
refluxing of the agent into the cystic artery causing infarc-
tion of the gallbladder. Although the common or proper
LIVER
hepatic arteries may be embolized, stent-graft placement
The liver is the most commonly injured intraabdominal to exclude the injury is often a better option that main-
organ, and severe liver injury carries mortality rates of up tains inline arterial flow to the liver parenchyma.
to 40%.14,15,23 Nonoperative management of liver injuries There should be a high index of suspicion for a concomi-
has been a standard method of treatment since a 1996 tant venous injury in patients with high-grade liver injury
review of 13 level I trauma centers in the United States who require continued fluid resuscitation after embolization.
reported high rates of success with this approach.24 As with These injuries are often difficult to visualize on angiogra-
splenic injury, patients who are hemodynamically unstable phy and may require operative exploration and packing. For
with evidence of severe liver injury or those who have dif- patients who have undergone successful embolization of liver
fuse peritonitis should undergo surgical exploration. In bleeding, there are several mid- and long-term complications
the early days of nonoperative management, high-grade which need to be considered, if not anticipated. These include
injuries (AAST IV or V), altered neurologic status, contrast hepatic necrosis, abscess formation (Fig. 10.4), gallblad­der
extravasation on CT, moderate- to large-volume hemoperi- infarction, bile leak, and hemobilia (i.e., bleeding into the
toneum, or age greater than 55 were seen as an indica- bile system) after a combined ductal and vascular injury.
tion for operative exploration.24,25 Although these factors Although abscess and necrosis are most common, the rate
still contribute to decision making, none are considered a attributable to the embolization procedure itself is not clear,
contraindication to nonoperative management, and over as the liver injury alone contributes to a significant portion of
85% of liver trauma is now managed without open opera- this complication. With no intervention, these complication
tive intervention.26,27 At least one study describes the use of rates have ranged from 5% to 24% for simple nonoperative
endovascular embolization after open surgical intervention, management and from 0 to 40% in patient’s managed with
as a number of patients who undergo damage control lapa- angiography.23,29
rotomy for hepatic injury continue to have bleeding after
leaving the operating room.28 RENAL
The majority of livery injuries are minor, with 68%
having an AAST grade I or II injury, with the average The kidneys are the most commonly injured genitourinary
liver grade of patients undergoing angioembolization organ in trauma.14,15,30 Similar to other solid organ injuries,
being 3.7.29 These tend to be parenchymal injuries involv- selective nonoperative management of blunt renal injury
ing small or medium branches (Fig. 10.3). If proximal is well-tolerated, and the majority of all kidney injuries are
120 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

traversed with a wire. If the area of injury is able to be

crossed, a balloon-expandable stent-graft can be deployed.
In these cases, balloon-expandable stents are preferred
because of their radial force and because they tend to be
deployed with greater degrees of control and precision. Fol-
lowing renal stent-grafting, thrombosis of the repair can
occur resulting in kidney loss.37 If concomitant injuries do
not preclude, it is the authors’ practice to give the patient an
antiplatelet medication at the time of the procedure, and for
a number of weeks afterwards as a way to assist stent-graft
patency. However, successful stent patency has also been
reported in patients who are unable to receive antiplatelet
agents or coagulation.38 Complications related to endovas-
cular management of renal trauma include impaired renal
function, urinoma, persistent hematuria, abscess, renal
failure, AVF, pseudoaneurysm, and urinary tract infection.
The rates of complication between patients undergoing
Fig. 10.4 Liver abscess that occurred after angioembolization of
nonoperative management with and without angioembo-
medium sized hepatic arteries for high-grade blunt liver injury. lization have been reported to be similar.32

managed nonoperatively. Patient selection for nonoperative POSTINTERVENTION MANAGEMENT

management is similar to other intraabdominal solid organ
injuries, and is based on the patient’s physiology, associated After successful embolization of an abdominal solid organ
injuries, and anatomy. One unique factor of the kidney is its injury, close monitoring is necessary to assess for rebleed-
retroperitoneal location, which makes the finding of hemo- ing. Up to 13% of patients will require either additional
peritoneum less common, as Gerota fascia may tampon- embolization or splenectomy after initial SAE for splenic
ade bleeding from the injury. The majority of blunt renal trauma.39 Similar rates exist for patients undergoing embo-
injuries are the result of sudden deceleration which applies lization for liver or renal injury. No consensus exists at this
sheer forces to the renal pelvis or pedicle, as it is the only time for a monitoring algorithm after the procedure. We rec-
fixed attachment point of the kidney. ommend trending hemoglobin/hematocrit every 6 to 8 hours
Renal injuries that are amenable to angioemboliza- and monitoring in an ICU for at least the first 24 hours after
tion include parenchymal injury with arterial contrast the procedure. Once discharged from the ICU, these patients
extravasation, pseudoaneurysms, arteriovenous fistulas, remain in the hospital for a minimum length of stay of at least
and nonself-limiting gross hematuria.31 Successful use of 3 days while we continue to trend hemoglobin and hemato-
embolization in the setting of blunt kidney injury ranges crit at less frequent intervals. There is no evidence to suggest
from 63% to 100%.31–34 Initial failure of embolization does pharmacologic prophylaxis for venous thromboembolism
not mandate operative intervention, and a second attempt (VTE) increases failure of nonoperative management of
may prove successful.32,35 If embolization of the injury is to solid organ injuries. We initiate VTE prophylaxis after two
be undertaken, a super-selective approach should be under- consecutive stable hemoglobin checks and if there is no
taken to limit scarring and to preserve renal function. The other evidence of bleeding.12,40 Repeat imaging during the
use of microcoils is preferred in these cases, as embolic patient’s hospital course should be guided by clinical status.
agents are prone to reflux into neighboring arteries and Some groups advocate for reimaging of the solid organ 48
adversely affect uninjured parts of the kidney. If an emboli- to 72 hours after the injury to assess for latent pseudoaneu-
zation or sclerosing agent is to be used, we recommend using rysms or AVF that may benefit from intervention, but this
a balloon catheter to deliver the agent, as it can be inflated practice is clinician and institution-dependent.
to occlude the injured branch and prevent reflux of mate-
rial. Blind angioembolization or more proximal emboliza-
tion should be avoided, as this will result in necrosis of the Pelvic Bleeding
renal parenchyma and other complications.36 If during the
endovascular procedure the patient becomes unstable or the Pelvic injuries with associated bleeding present a chal-
injury is deemed to require operative intervention, balloon lenge for surgeons and the resuscitation team. It takes a
occlusion of the main renal artery is a useful maneuver to significant amount of energy to cause a pelvic fracture,
reduce bleeding until open surgical control can be achieved. and as such, these injuries are often associated with other
Injuries to the renal artery or vein in hemodynamically life-threatening findings requiring acute intervention. Of
stable patients may be managed with revascularization these patients, 15% will have an associated injury in the
maneuvers including placement of a covered stent across chest, 32% an intraabdominal injury, and 40% a long
the area of vascular disruption to preserve flow to the renal bone fracture.41 A multiplicity of injuries can confound
parenchyma. Unlike other solid organs of the abdomen, the initial workup and management of these critically ill
there is no collateral flow to the kidney and the organ does patients, whose risk of death is as high as 40%.42 A rel-
not tolerate proximal, large-vessel embolization/occlusion. atively small proportion of bleeding associated with pel-
In order to place a covered stent in the main renal artery, vic fractures is secondary to an arterial source (15%). In
the injured portion of the vessel must be able to be safely contrast, venous or osseous sources are responsible for up
 ­­ • Stent-Grafts, Coils, and Plugs 121

to 85% of the bleeding that occurs in conjunction with possible, as each hour of delay has been shown to be asso-
this injury pattern.42 When arterial bleeding is present, ciated with increased mortality.45
it is most commonly from a named branch vessel of the If obtained prior to the pelvic arteriogram, CT imaging
internal iliac artery, such as the superior gluteal, internal can direct or help improve the efficiency of the catheter-
pudendal, lateral sacral, iliolumbar, or inferior gluteal. based intervention. It is important to understand the vas-
Arterial bleeding is present in more than 60% of patients cular anatomy of the pelvis, including collateral pathways
who die from pelvic fractures.43 It is important to remem- that may contribute to bleeding. These include the contra-
ber that the volume of the pelvis can increase by 20% with lateral internal iliac, lumbar, inferior mesenteric, inferior
a 5-cm pubic diastasis, allowing for potentially fatal hem- epigastric, medial and lateral circumflex, median sacral,
orrhage in what is normally a confined space.44 and deep circumflex iliac arteries. This anatomy is variable,
As with the management of other injury patterns, and beginning the procedure with a pelvic arteriogram is
patient selection is important to optimize success. Hemo- often beneficial if there has been no preceding CT imaging.
dynamically unstable patients should be initially managed Next, selective catheterization of the internal iliac artery is
by advanced trauma life support guidelines including pel- performed and digital subtraction angiography obtained to
vic x-ray, external reduction of the pelvic fracture using a delineate the vascular anatomy. Once the bleeding source is
binder or sheet, and performance of a focused assessment localized, embolization may be performed.
with sonography for trauma (FAST) examination to assess In these cases, selective embolization of the bleeding
for hemoperitoneum. If the patient is hypotensive, and arteries is ideal and can be achieved using either coil embo-
there is no hemoperitoneum, the patient should undergo lization which causes permanent occlusion or a temporary
arteriography if the capability exists in that given medical agent such as Gelfoam. Angioembolization in the pelvis is
center. In settings where these capabilities are not pres- a risk factor for orthopedic interventions to the pelvic ring
ent or there is a significant hemoperitoneum, the patient to have higher complications rates.46 However, in hemody-
should undergo preperitoneal packing and laparotomy. If namically unstable patients, less selective embolization is
hemorrhage continues with preperitoneal packing, angi- often employed, including Gelfoam, which can be used as
ography/angioembolization may be used as an adjunct for an embolic agent for larger portions of the internal iliac
hemostasis after open surgery (Fig. 10.5). artery circulation. Because of extensive collateral circula-
If on initial presentation the patient is hemodynami- tion, it is often necessary to complete embolization of ves-
cally normal, he or she may undergo the usual trauma sels in the contralateral internal iliac system to achieve a
evaluation including contrast-enhanced CT imaging of more complete hemostasis. If the patient continues to have
the abdomen and pelvis, with a delayed phase to assess for evidence of bleeding after initial selective embolization
bleeding and injuries to pelvic or genitourinary structures. maneuvers, occlusion of bilateral internal iliac arteries may
If contrast extravasation is identified on CT imaging, diag- be performed in an attempt to decrease flow (i.e., pressure
nostic and potentially therapeutic arteriography should head) through the system and allow for tamponade of small
be performed. This should be undertaken as quickly as arterial and venous bleeding.

Fig. 10.5 (A) Patient with active extravasation of contrast from the mid left internal iliac artery that was not controlled with per-peritoneal packing
(retractor and radio-opaque laparotomy pads seen in negative on digital subtraction angiography). Laparotomy was performed and proximal control
of distal aorta (zone III) was performed while awaiting endovascular support. (B) Image after embolization without additional extravasation.
122 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

In certain hemodynamically unstable patients, when sur- changes, or loss of distal pulse require operative exploration
gical fixation of the pelvic fracture is necessary, temporary irrespective of the zone of injury. Although not the primary
balloon occlusion of the internal iliac arteries may be per- therapy, endovascular adjuncts such as proximal balloon
formed to slow bleeding. Definitive angioembolization may occlusion may be used to gain temporary bleeding control of
then be performed after the anatomy of the bony pelvis is the great vessels or at the skull base.
restored. These interventions are not without complica- In patients with proximal zone I injuries, the area of
tions. The most common complications are at the vascular injury may be accessible through a cervical incision. How-
access site or involve contrast-induced nephropathy. Com- ever, many patients with zone I injuries will need a median
plications related to the embolization include pelvic infec- sternotomy to obtain proximal control to perform a repair. If
tion, poor bone healing, skin sloughing, skin or muscle the patient’s physiology permits and there are endovascular
necrosis, rectal ischemia, and neurologic effects on the capabilities, a transfemoral approach with balloon occlusion
bladder and/or sexual function.43,44,47 using a compliant balloon may spare the patient the morbid-
ity of a thoracic exposure. Once the balloon is in place, angi-
ography may be performed to locate the injury for surgical
Cervical Vascular Injury planning. If there is adequate proximal vessel length after
open exposure, the balloon may be replaced with a clamp.
Trauma to vessels at the thoracic outlet and in the cervical If proximal length is not adequate, the balloon can be main-
region may be preferentially managed with endovascular tained for proximal control during the repair.
techniques depending on the size of the vessel and its acces- Zone III injuries located above the angle of the mandible
sibility via an open surgical approach. In hemodynamically are often difficult to expose and control. The use of self-
stable patients with penetrating neck injuries or a concern expanding covered stents has been described to treat acute
for blunt cerebral injury, the workup begins with contrast- injuries that are not amenable to open exposure.49 Zone III
enhanced CT imaging to assess for extravasation, vessel dis- is also the most common site for blunt carotid artery injury.
ruption, dissection, intimal flap, pseudoaneurysm, AVF, or Blunt cerebrovascular injury (BCVI) occurs in 3% of trau-
thrombosis. Once the defect is identified in this scenario, the mas and is the result of hyperextension or hyperflexion
choice of management is based on the anatomic location of of the neck in the setting of a high-speed deceleration
the injury. The location of neck injuries is described in one injury.50 The Denver group proposed screening criteria in
of three zones reported by Monson et al. in 1969. Zone I is the 1990s and revised them in 2012. The new guidelines
below the cricoid cartilage, zone II is located between the cri- contain indication for screening as well as a grading sys-
coid cartilage and the angle of the mandible, and zone III is tem (Table 10.3). The mainstay of treatment for low-grade
above the angle of the mandible.48 Zone II injuries are readily BCVI is anticoagulation. For patients who are not eligible
accessible via a cervical incision, which has the added ben- for anticoagulation due to other injuries, either bare or cov-
efit of direct visual inspection of adjacent aerodigestive tract ered stents have been used as an alternate therapy for these
structures. This accessibility and the low morbidity of a cervi- injures.51 Pseudoaneurysms may result from blunt or pen-
cal incision make open repair the approach of choice for zone etrating trauma. When present, they can be treated using
II injuries. Patients with hard signs of vascular injury includ- endovascular coiling or exclusion with a covered stent.52–54
ing expanding hematoma, pulsatile bleeding, neurologic Studies reporting the use of stents for BCVI have reported

Table 10.3 Blunt Cerebral Vascular Injury (BCVI)

Denver Screening Criteria for BCVI Denver Grading Scale for BCVI
Signs/Symptoms of BCVI Grade I: Irregularity of the vessel wall or a dissection/intramural hematoma with
Arterial hemorrhage <25% luminal stenosis
Cervical bruit Grade II: Intraluminal thrombus or raised intimal flap is visualized, or dissection/
intramural hematoma with 25% or more luminal narrowing
Expanding cervical hematoma
Grade III: Pseudoaneurysm
Focal neurologic deficit
Grade IV: Vessel occlusion
Neurologic examination incongruous with CT scan findings
Grade V: Vessel transection
Stroke on secondary CT scan
Risk factors for BCVI
High-energy transfer mechanism with:
– LeForte II or III fracture
– Cervical-spine fracture patterns: subluxation, fractures
extending into the transverse foramen, and fractures of
C1–C3
– Basilar skull fracture with carotid canal involvement
– Petrous bone fracture
– Diffuse axonal injury with GCS score <6
– Near hanging with anoxic brain injury
Adapted from Burlew et al. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg.
2012;72(2):330–337.
 ­­ • Stent-Grafts, Coils, and Plugs 123

a stroke rate of 0% to 5%, but the rate of cerebrovascular safely be repaired endovascularly with a covered stent or
events may be higher given the paucity of quality long-term open if easily accessible. This hybrid approach reduces the
follow-up data with this injury pattern.54,55 morbidity of an open repair for this pattern of injury.62
Vertebral arteries may also be injured from penetrating While experience using stent-grafts for axillo-subclavian
or blunt trauma resulting in free hemorrhage, pseudoaneu- pseudoaneurysm, iatrogenic injury, and trauma extends
rysm, AVF, dissection, or occlusion. Encompassing only 0.5% back to the 1990s, its overall use in trauma remains
of vascular trauma, the rarity of injury and the relationship low.59,61,63 In 2012, it was reported that 9% of subclavian
to the cervical spine can make treatment a challenge.56 The arterial trauma cases were managed using endovascular
first portion of the vertebral artery may be readily accessible techniques.64 In a 2017 multicenter trial, 17% of patients
via open exposure, whereas the second and third portions with axillo-subclavian injuries were treated with endovas-
are within the cervical spine foramina and skull base, respec- cular intervention alone, and an additional 6% had hybrid
tively, making endovascular intervention preferred. In a ret- procedures.59 As hybrid operating rooms become more
rospective review of 101 patients with extracranial vertebral common, we anticipate an increasing role for endovascular
artery injuries (95 of which were penetrating injuries), 81 therapy in the management of junctional vascular injuries.
patients were treated with endovascular intervention, with This may assist in both proximal and definitive control of
the majority being coil embolization. Of these, six patients the injury. At this time, endovascular intervention offers
had failed intervention and required open surgery. Primary hope of decreasing the morbidity of a thoracotomy or ster-
open surgery was performed in 20 patients, with 10 of those notomy in patients appropriate for endovascular hemor-
patients subsequently undergoing endovascular procedure rhage control. Postprocedure, there are reports of using
for bleeding or AVF.57 Embolization of the vertebral arteries anticoagulation or antiplatelet agents over variable time
has a complication rate of 0% to 5%, with the most feared periods to maintain stent patency.55 No consensus exists at
complication being stoke, reported at less than 1%.57 this time, and it is our practice to use antiplatelet therapy
with 81 mg aspirin daily for life in these patients.
Lower extremity junctional trauma often requires
Junctional Vascular Trauma intraabdominal proximal control which is easily obtained
by vascular or general surgeons at the infrarenal aorta or
Junctional trauma includes injury to vessels in the axillo- through endovascular techniques such as REBOA. With
subclavian and iliac/femoral regions. Injuries to these this injury pattern, the transabdominal approach is often
vessels are not amenable to tourniquet control and are dif- used, as there is concern for concomitant intraabdominal
ficult, if not impossible, to control with direct pressure. As injuries. If the injury is more distal, a single iliac artery may
such, patients with these injuries are at high risk of bleed- be isolated with a retroperitoneal dissection via hockey stick
ing to death.58 The challenge of managing injuries in the incision or bilateral iliac vessels may be exposed via mid-
thoracic outlet is obtaining proximal control. Using the line extraperitoneal incision.65 An exception is in military
open surgical approach requires a median sternotomy to trauma, as these patients are wearing body armor that may
control the innominate and right subclavian arteries or protect from intraabdominal injuries, while still leaving the
high, left anterolateral thoracotomy with or without cla- wearer susceptible to lower extremity junctional injury.58
vicular resection for left subclavian artery. Even with the
associated morbidity of exposure, open surgery remains
a standard for hemodynamically unstable patients with Extremity Vascular Trauma
junctional hemorrhage.59,60 Proximal control for pelvic
outlet junctional trauma is less problematic for the general Extremity vessel trauma is almost always amenable to control
or vascular surgeon, as it is accomplished via laparotomy. with manual pressure or a tourniquet. A proximal tourniquet
Penetrating injury to the axillo-subclavian vasculature is generally easily placed for the majority of these injuries and
often has the added morbidity associated with injury to the may be replaced with a pneumatic tourniquet on arrival to
brachial plexus that runs adjacent to the artery and vein. the hospital. This allows full workup of life-threatening torso,
Blunt injury to this region is similarly challenging due to the junctional, thoracic, abdominal, or pelvic sources of bleeding
shear and/or traction forces applied to the vessels and nerve while the tourniquet is in place. Extremity vascular injuries
bundles. When evaluating vascular injury in the axillo- causing exsanguination or profound ischemia should be man-
subclavian (i.e., junctional) region, it is especially important aged in an open fashion. There is a limited role for endovas-
to consider concomitant nerve, aero-digestive tract, boney, cular interventions for extremity vascular trauma. Delayed
or lymphatic injury.61 In stable patients, CT angiography sequalae from extremity vascular trauma such as pseudoan-
can aid in identifying the location and extent of vascular eurysms or AVF may be managed with open, endovascular,
injury. Once the area of injury is identified, an operative or, in the case of pseudoaneurysms with a small neck, with
plan can be formulated based on accessibility of the vessel ultrasound-guided thrombin injection.
and if balloon proximal control is needed to prevent exsan-
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57. Mwipatayi BP, Jeffery P, Beningfield SJ, Motale P, Tunnicliffe J, Navsaria 64. Assenza M, Centonze L, Valesini L, Campana G, Corona M, Modini C.
PH. Management of extra-cranial vertebral artery injuries. Eur J Vasc Traumatic subclavian arterial rupture: a case report and review of
Endovasc Surg. 2004;27(2):157–162. literature. World J Emerg Surg. 2012;7(1):18.
58. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001- 65. Radowsky JS, Rodriguez CJ, Wind GG, Elster EA. A surgeon’s guide to
2011): implications for the future of combat casualty care. J Trauma obtaining hemorrhage control in combat-related dismounted lower
Acute Care Surg. 2012;73(6 suppl. 5):431–437. extremity blast injuries. Mil Med. 2016;181(10):1300–1304.
 Resuscitative Endovascular
11 Balloon Occlusion of the Aorta
JENIANN A. YL, CHARLES JAMES FOX, and ERNEST E. MOORE

Introduction History of REBOA

Uncontrolled hemorrhage is the leading cause of prevent­ REBOA provides an alternative to EDT and aortic clamping
able death in both the civilian and military settings.1 by using endovascular technology to accomplish the same
Thus, to achieve zero preventable deaths following trauma, physiologic effects. The use of REBOA for the exsanguinat­
prompt and effective control of noncompressible torso ing trauma patient dates back to the Korean War when, in
hemorrhage is essential.2 This may require aortic occlusion 1954, Dr. Carl Hughes described aortic occlusion using a
to prevent exsanguination and allow for resuscitative 20-mL balloon catheter to control traumatic hemorrhage
efforts. Historically, this has involved emergent thoraco­ in two moribund casualties.9 Though ultimately unsuc­
tomy with aortic cross clamping. However, advances in cessful in these patients, Dr. Hughes proposed the potential
medical technology have resulted in a new method for utility of this intervention in the setting of massive hemor­
aortic occlusion via resuscitative endovascular balloon rhage. Although intraaortic balloon occlusion continued to
occlusion of the aorta (REBOA). This minimally invasive, be intermittently revisited in the literature, it had generally
endovas­cular technique provides aortic occlusion without poor outcomes and failed to gain support as a means for
req­uiring thoracotomy in patients with life-threatening hemorrhage control.10–12
hemorrhage. The evolution of vascular surgery to include endovascular
techniques led to a renewed interest for balloon occlusion
of the aorta. This resulted in refinement of the technique
History of Thoracic Aortic as well as increased operator familiarity with improved
patient outcomes. One of its most popularized applications
Occlusion for Resuscitation was as a life-saving measure for ruptured aortic aneurysm
patients.13,14 Its successful implementation in this setting
Thoracic aortic clamping was first shown to be beneficial suggested a similar utility for patients suffering from hem­
in a canine acute massive hemoperitoneum model by pre­ orrhagic shock of other etiologies; thus, it was revisited as a
venting precipitous circulatory decompensation at the potential resuscitative measure in trauma.15,16
time of laparotomy.3 Since then, the use of aortic cross
clamping during massive hemorrhage has long been
reported in the literature as a technique to allow for resus­ Physiologic Limitations
citation of the in-extremis patient following severe injury.4,5
Overall outcomes have been favorable when considering Several studies using hemorrhagic shock porcine models
the otherwise fatal nature of the pathology, and it has have been performed to elucidate the physiologic impact
allowed for survival of patients when employed in the of REBOA. One early study compared thoracotomy with
appropriate scenario. Cross clamping of the aorta is usually cross clamping to REBOA and suggested that REBOA was
enacted as part of an Emergency Department thoracotomy superior. This was based on diminished acidosis (serum lac­
(EDT), undertaken for a range of scenarios (chest, abdominal, tate levels, partial pressure of carbon dioxide) and lowered
or extremity injury) where preservation of threatened requirement for volume replacement and inotrope in the
coronary and cerebral circulation is paramount. Military REBOA group.17 The impact of prolonged occlusion time
data report overall survival rates of up to 11% for EDT has also been studied in large animal models but impact
(and 17% when EDT and aortic cross clamping has been with relation to occlusion time is variable. One study dem­
performed as a prelude to laparotomy for hemorrhage onstrated diminished return of flow in the aortic branch
control).6 Civilian data report EDT survival rates approach­ing vessels even following proximal balloon deflation (sug­
8%.7 In both populations, EDT for penetrating thoracic injury gesting an additional mechanism of ischemia/reperfusion
seems to confer greatest benefit whether by assisting with injury that exerts its effect beyond the initial occlusion).18
the control of bleeding, decompression of the pericardium, A further investigation found that 90 minutes of occlusion
preventing bronchovenous air embolism, or administration produced a higher lactate burden but no major differences
of internal cardiac massage.6–8 EDT is necessarily a very in renal, cerebral, spinal, or myocardial organ dysfunction
invasive pro­cedure; it places a significant morbidity on the as compared with 30 minutes of balloon time, with other
patient in addition to the potential complications of aortic evidence suggesting that liver necrosis is the consistent
occlusion.8 sequela of longer aortic occlusion times.19 Lack of defined

126
 11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 127

experimental agreement around the dose-response curve factor is the difference in time to aortic occlusion between
between visceral complications and balloon time may be the two modalities; aortic cross clamping via thoracot­
due to significant collateralization20 and the tolerance of dif­ omy can be accomplished at a median of 317 seconds as
ferent systems to aortic occlusion: for instance, 60 minutes opposed to REBOA at a median of 474 seconds. It seems
of aortic occlusion resulted in a 12.5% rate of spinal cord that gaining vascular access accounts for a good part of this
injury-related mortality in one animal study.21 Prolonged time; once this step is achieved, time to aortic occlusion is
REBOA times have also been associated with decreased (median) 245 seconds.32 Part of the difficulty in assessing
FiO2:PaO2 ratios, potentially mediated through the release the benefit of REBOA is that most published studies docu­
of inflammatory cytokines such as interleukin-6.22 Col­ ment institutional use for different indications, in different
lectively, these studies demonstrate that REBOA does carry populations, within different care systems, with different
systemic consequences but these may be less marked than equipment. Drawing conclusions as to benefit and risk in
those associated with EDT-mediated aortic cross clamping. individual patients and settings are difficult; the results of
Large animal studies are of great use in assessing potential the UK REBOA study,33 a randomized controlled study set in
benefit but translating the end-organ consequences must multiple major trauma centers within the United Kingdom,
always be caveated: for instance, prior clinical experience may help discern benefit when completed.
with high thoracic aortic occlusion for postinjury aortic
repair indicate a progressive risk of spinal cord injury after
30 minutes23,24—a significantly shortened time compared Technical Aspects of REBOA
to representative large animal models.
TOOLS AND MATERIALS
Clinical Outcomes Prior to the introduction of wireless, fluoroscopy-free sys­
tems, establishing balloon occlusion of the aorta required
Aortic occlusion and supradiaphragmatic clamping of the an arterial access kit, a sheath, a wire, and a balloon
aorta can improve patient outcomes, particularly after mas­ (Fig. 11.1). In some places, cost considerations may per­
sive bleeding from penetrating trauma, with survival rates suade surgeons to continue to use these tools. Regardless
from 17% to more than 20% in certain populations.6,25,26 of the supplier, access of the femoral artery can be obtained
The clinical evidence concerning efficacy of REBOA is using a micropuncture set, which will include a micronee­
mixed. A retrospective analysis of a Japanese trauma data dle, microwire, and a 4- or 5-Fr transitional dilator. The
bank series found 625 patients who had been treated with benefit of a micropuncture set is minimization of dam­
REBOA; matched patients who did not undergo REBOA age from inaccurate punctures while attempting access.
group had a survival advantage despite longer times to Through this transitional dilator, a 0.035-inch introducer
surgery.27 However, a further observational study from wire can be advanced retrograde into the femoral vessel in
Japan revealed lower mortality with REBOA compared with order to exchange over wire for an initial sheath. Alterna­
matched patients who underwent aortic cross clamping.28 tively, a 21-gauge hollow needle can be used for access and
Similarly, the Aortic Occlusion in Resuscitation for Trauma will allow passage of a 0.021-inch introducer wire directly.
and Acute Care Surgery (AORTA) registry reported improved Over this wire, a sheath can then be advanced into the
survival to discharge (9.6% of REBOA patients vs. 2.5% artery to establish secure access. Sheaths should be chosen
of thoracotomy patients), although REBOA patients were based on length and French size. Longer sheaths are typi­
more likely to present with intact vital signs.29,30 REBOA cally not required, and therefore standard sheath lengths
certainly elevates central blood pressure, but confirmatory of 10 to 15 cm is adequate. The French size of the sheath
evidence of impact on mortality is absent.31 One complicating reflects the inner diameter and indicates the maximum

Fig. 11.1 Basic endovascular tools required to accomplish aortic balloon occlusion prior to availability of commercial REBOA kits: (left to right) a micro-
puncture set for initial arterial entry, a sheath for stable arterial access, a stiff wire, and an appropriately sized compliant occlusion balloon.
128 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

size of an item that can be passed through it. As such, the

French size is determined by the balloon chosen for aortic
occlusion.
Commercial kits are now available for REBOA to stream­
line the insertion process, and their lower profile design
has replaced the larger 12- and 14-Fr sheath systems that
required arterial repair in favor of 7-Fr sheath systems. The
Rescue Balloon (Tokai Medical Products, Japan) and the
REBOA Balloon Kit (REBOA Medical, Norway) are preas­
sembled kits with 7-Fr–compatible compliant balloons of
sufficient diameter for aortic occlusion. These devices are
still intended to be passed over-the-wire. In contrast, the
ER-REBOA catheter (Prytime Medical, Arvada, CO) utilizes
a peel-away sheath for rapid insertion on a wireless cath­
eter with a curved P-tip to position and avoid branch can­
nulation without wire exchanges (Fig. 11.2). Positioning is
confirmed radiographically, but insertion does not require
fluoroscopic guidance as length markers allow the physi­
cian to advance the catheter with or without imaging to
the desired distance. Furthermore, the smaller sheath size
eliminates the need for adjunct procedures to close the arte­
riotomy, as manual pressure alone is typically adequate to
achieve hemostasis.
Although blind insertion techniques will be discussed,
imaging guidance is preferred. An ultrasound machine
with a linear probe should be used while obtaining arterial
access to visualize the femoral vessels. Additionally, a por­
table radiograph machine can be used to aid in placement
by verifying wire and balloon locations within the patient.
The presence of these technologies within the trauma bay
should be established prior to patient arrival for maximal
efficiency of REBOA.

STEP-BY-STEP PLACEMENT
Herein we describe the steps to successfully insert an endo­
vascular balloon for aortic occlusion. REBOA is placed con­
ceptually in five steps: arterial access, balloon positioning,
balloon inflation, balloon deflation, and sheath removal Fig. 11.2 The ER-REBOA catheter (Prytime Medical, Arvada, CO) with
(Box 11.1).34 mounted compliant balloon on a 7-Fr sheath–compatible catheter
(A), utilized in a patient with presumed pelvic injury with sheeting for
Arterial Access temporary stabilization (B).
The first step for REBOA is to establish arterial access, which
is accomplished percutaneously. The vessel may be palpable
in a patient who is able to sustain a systolic blood pressure Box 11.1 Technical Steps for REBOA
(SBP) above 70 mm Hg. However, a patient in extremis
may not have a palpable pulse to guide access. In an emer­ 1. Arterial access and placement of sheath
gent situation, this can be accomplished by using ana­ 2. Balloon selection and positioning within the aorta
tomic landmarks to identify the common femoral artery. 3. Balloon inflation
The inguinal ligament can be approximated by connecting 4. Balloon deflation
the anterior superior iliac spine and the pubic tubercle. The 5. Removal of balloon and sheath
artery should be accessed approximately 2 to 3 cm below
the inguinal ligament, where it overlies the middle third of REBOA, Resuscitative endovascular balloon occlusion of the aorta.
the femoral head (Fig. 11.3A). Following these landmarks
should result in vessel cannulation above the bifurcation in
an easily compressible area, thereby minimizing potential associated with uncontrolled bleeding because direct pres­
access complications of ischemia and uncontrolled hemor­ sure cannot be applied in this area.
rhage. Accessing below the inguinal crease typically results In any circumstance, routine ultrasound guidance for
in cannulation at a lower level, namely the superficial vessel cannulation is recommended. Ultrasonography is
femoral artery, and should be avoided due to higher risks used to directly visualize the common femoral artery and
of thrombosis and pseudoaneurysm. On the other hand, ensure that it is accessed above the femoral bifurcation and
cannulating too cephalad in the external iliac artery may be below the inguinal ligament (Fig. 11.3B). Using routine
 11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 129

Fig. 11.3 Anatomic landmarks used to identify the common femoral artery for percutaneous access at approximately 2 to 3 cm below the inguinal
ligament where it overlies the middle third of the femoral head (A) and the ultrasound landmarks used to identify the common femoral artery for per-
cutaneous access by viewing the femoral bifurcation and accessing above this level but below the inguinal ligament (B). CFA, Common femoral artery;
CFV, common femoral vein; FV, femoral vein; L, lateral; M, medial; PFA, profunda femoris artery; SFA, superficial femoral artery.

ultrasound has been shown to improve operator success in need for imaging guidance. This sheath serves as a stable
cannulation as well as to minimize arterial complications.35 point of arterial access through which one can advance the
Therefore, when possible it is recommended to obtain arte­­ REBOA catheter and perform further endovascular inter­
rial access with ultrasound guidance in REBOA. It is impor­ ventions. Based on current specifications of aortic occlusion
tant to note that if arterial access cannot be accomplished balloons, a 7-Fr sheath is adequate for REBOA placement;
using these minimally invasive methods, femoral cutdown however, a larger 8-Fr sheath is preferred if simultaneous
for direct vascular exposure is an option and may be preferred contrast administration is planned.
in a patient undergoing cardiopulmonary resuscitation.
Once initial access to the common femoral artery with Positioning of the Balloon
a needle is accomplished, a starter wire with a floppy tip is The next step is introduction of the balloon and its posi­
introduced into the vessel. In our practice, this is a 0.021- tioning within the aorta. A compliant balloon of adequate
inch wire over which a sheath can be directly inserted. Of diameter to occlude the aorta should be selected along with
note, this is best accomplished using two operators so that an appropriate sheath to accommodate the balloon. Several
one can stabilize the needle while the other handles the compliant balloons that are compatible with a 6- or 7-Fr
wire until secure access is established. If no resistance is sheath are now commercially available for aortic occlusion
­encountered with passage of this wire, an arterial sheath as described previously. In our practice, the ER-REBOA
can then be advanced into the artery over the wire without catheter is used (Prytime Medical, Arvada, CO); this wireless
130 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

catheter has an atraumatic P-tip with mounted compliant Table 11.1 Approximate Length of Catheter Insertion
balloon between radiopaque marker bands and a distal Per Zone for Average Height Patients with Corresponding
arterial line port for monitoring blood pressure. Aortic Diameter and Balloon Inflation Volume for the
In relation to REBOA, the aorta is divided in three zones: ER-REBOA Catheter (Prytime Medical, Arvada, CO) as
zone 1 is from the left subclavian artery to above the celiac Guidelines for Fluoroscopy-Free Insertion and Inflation
trunk; zone 2 represents the visceral aorta from the celiac
Catheter Insertion Aortic Diameter Balloon Inflation
artery to the lowest renal artery; and zone 3 is the infra­ Length (cm) (mm)   Volume (cc)
renal aorta (Fig. 11.4). Based on the pattern of injury, the
Zone 1 50 21 13
balloon is positioned in the appropriate zone of the aorta
Zone 3 30 15 8
and its location confirmed radiographically. Optimally, a
zone 3 REBOA should be positioned just above the aortic
bifurcation. Zone 2 REBOA is generally avoided due to the
risk of visceral malperfusion. Zone 1 REBOA should be just
above the celiac axis, so as to minimize risk of spinal cord fill the balloon until its outer walls are opposed and parallel
­ischemia. to the aorta. This contrast dilution is important because of
Balloon positioning can be performed based on estima­ its viscosity, which can impede facile balloon inflation and
tions of aortic lengths without fluoroscopic guidance. deflation. Tactile feedback as a marker of aortic wall tension
A cadaver model was used to demonstrate feasibility of during balloon inflation is critical, and resistance should
accurate balloon placement and inflation based on visu­ prompt cessation of inflation. A stopcock can be used to
alized anatomic landmarks on ultrasound.36 However, then lock off the syringe at a certain volume of inflation.
this method is limited by user proficiency with ultraso­ Again, notice of the external length of the balloon can be
nography in addition to patient habitus. Scott et al. dem­ used as a reference to intermittently check its position and
onstrated in a swine model that an “all-in-one” catheter minimize migration. Known volumes corresponding with
deployed based on an external estimate of length from external diameters can be used to guide balloon inflation
the inguinal ligament to the midsternum had a successful based on typical aortic diameters per zone (see Table 11.1).
placement rate of 87% in the distal thoracic aorta.37 Fixed A plain x-ray is important to verify the balloon position.
distance models rely on population-based computed tomo­ Constant awareness of overall occlusion time is important,
graphic measurements to then determine standard inser­ as prolonged occlusion beyond 30 minutes in zone 1 may
tion lengths to zone 1 and zone 338–40 (Table 11.1). Such have adverse consequences.
guidelines are of particular utility in prehospital, combat,
or austere settings, where imaging technology is not easily Balloon Deflation
accessible. Following resuscitation of the patient with subsequent
improvement of hemodynamics, the occlusive balloon
Balloon Inflation should be deflated as soon as possible. Similar to release of
After confirming position of the occlusive balloon, it is then an aortic cross clamp, restoration of flow with reperfusion
inflated while also monitoring SBP. An appropriately sized can result in a number of events including acidosis, hypo­
syringe with a mix of 1/3 contrast and 2/3 saline is used to tension, hyperkalemia, and cardiac arrest. The decision

Fig. 11.4 Aortic zones related to resuscitative endovascular balloon occlusion of the aorta (REBOA). Zone 1 extends from the origin of the left subclavian
artery to the celiac artery and is a potential zone of occlusion. Zone 2 extends from the celiac artery to the lowest renal artery and is not an occlusion
zone. Zone 3 is defined from the lowest renal artery to the aortic bifurcation. REBOA in this zone may be effective for pelvic and junctional femoral (con-
tralateral) hemorrhage.32 (Reproduced with permission from Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta
(REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71:1869–1872.)
 11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 131

to begin balloon deflation must be actively communicated Treatment Algorithm

and coordinated across the multidisciplinary trauma care
team. The balloon is deflated by releasing the stopcock and Our institutional algorithm incorporates clinical assess­
applying negative pressure, while manually holding and ment, extended focused abdominal sonographic examina­
maintaining its position within the aorta as a number of tion for trauma, and basic radiographic imaging obtained in
attempts at deflation with intermittent re-inflation may the trauma bay to determine areas of primary hemorrhage
be necessary. Slow deflation of the balloon by removing 1 and level of hemodynamic compromise in order to guide
to 2 mL every 2 to 3 minutes is preferred to prevent rapid management (Fig. 11.5). Patients arriving to the trauma
changes in hemodynamics.41 bay while receiving cardiopulmonary resuscitation undergo
emergent thoracotomy if within the time constraints for
Balloon and Sheath Removal known benefit.43 Exceptions are patients with isolated pelvic
After deflation, the balloon can be removed from the aorta or extremity trauma undergoing short-term cardiopulmo­
once no longer required. Sheath removal should also be nary resuscitation where REBOA may be preferred. How­
done as soon as possible, but after reversal of any coexis­ ever, there is a risk of missed thoracic or abdominal injury
tent coagulopathy. Large-bore sheath access can promote with ongoing bleeding that must be acknowledged.
arterial clot formation, and this can be increased among Patients presenting in hemorrhagic shock due to thoracic
trauma patients with associated coagulopathy that is typ­ trauma should undergo thoracotomy, either emergently in
ically dynamic.42 Therefore, intermittent flushing of the the trauma bay or in the operating room (OR). REBOA in these
sheath with heparinized saline is recommended until its patients may, in fact, worsen their injury due to increased
removal. A 7-Fr sheath can be removed without arterial aortic pressure with accelerated blood loss and increased
repair. Generally, any access of 9 Fr and above requires ventricular afterload. Therefore, if REBOA is employed with
closure of the arteriotomy, as manual pressure will not a thoracic injury, the SBP should be maintained at less than
reliably accomplish hemostasis. Groin cutdown with 100 mm Hg to minimize this risk. This is critically important
direct exposure of the vessels can be performed by mak­ in those with a potential thoracic aortic injury. The desired
ing an incision along the sheath and using this as a guide pressure in the setting of a concomitant traumatic brain
to dissect down to the femoral vessels. The artery can then injury is poorly understood but must also be considered.
be primarily repaired after flushing the vessel thoroughly With presumed abdominal hemorrhage, patients with a
and allowing for back-bleeding to remove any clots. Alter­ SBP of 80 mm Hg or greater should be transferred to the
natively, percutaneous closure devices can also be used to OR without delay to avoid further complications. A sheath
provide arterial closure. Wire access is maintained follow­ should be inserted in responders with a SBP of 80 to 90 mm
ing balloon and sheath removal, and the closure device is Hg so that a REBOA may be inserted quickly in the event of
advanced over-the-wire into the vessel and then deployed. rapid deterioration. In patients with a SBP less than 80 mm
However, this should be limited to operators familiar with Hg, REBOA in the emergency department may temporize
this technique and a cutdown should be performed if it major visceral bleeding and stabilize the patient for trans­
fails. port to the OR.

Pattern of CPR SBP <60 SBP 60–80 SBP >80

injury mm Hg mm Hg mm Hg

OR for
Thoracic EDT EDT EDT vs. OR
thoracotomy

OR for
Abdominal EDT REBOA REBOA
laparotomy

EDT vs. OR for pelvic

Pelvic REBOA REBOA
REBOA packing

EDT vs.
Extremity REBOA REBOA OR
REBOA

Fig. 11.5 Algorithm for utilization of emergent thoracotomy versus endovascular balloon occlusion to accomplish aortic cross clamping for resuscita-
tion. Systolic blood pressure (SBP) should be maintained less than 100 mm Hg with possible thoracic aortic injury and less than 120 mm Hg with pos-
sible traumatic brain injury. CPR, Cardiopulmonary resuscitation; EDT, emergency department thoracotomy; OR, operating room; REBOA, resuscitative
endovascular balloon occlusion of the aorta.
132 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Patients in hemorrhagic shock secondary to pelvic trauma Finally, patients with significant lower extremity
represent a unique scenario where we selectively place a zone trauma resulting in shock may also benefit from zone 3
3 REBOA with a SBP between 80 and 90 mm Hg to permit REBOA. Our institutional algorithm utilizes REBOA in
a rapid total body CT scan prior to the OR. All patients with these patients for SBP less than 80 mm Hg; once stabi­
a SBP less than 80 mm Hg should undergo prompt REBOA lized, they can be transferred either for additional imag­
placement. At our institution, control of pelvic bleeding is ing or the OR for treatment. Thus far, the only literature
accomplished by preperitoneal pelvic packing in the OR,44 supporting REBOA for extremity trauma is select case
whereas other institutions may perform pelvic angioembo­ reports. The impact of the ischemia incurred from zone
lization. Alternatively, the REBOA catheter may be used to 3 occlusion on injured extremities is unknown, but cer­
facilitate angiography via contralateral access, and endovas­ tainly periods greater than 90 minutes are well tolerated
cular treatment for pelvic hemorrhage accomplished in the and some have reported inflation for 120 minutes with­
OR45 (Fig. 11.6). out problems.46

Fig. 11.6 Zone 3 aortic occlusion (red arrow) in a hemodynamically unstable patient with a pelvic ring disruption (yellow arrow) on plain radiography (A)
and corresponding three-dimensional pelvic computed tomography (B) with sagittal reformatted image depicting successful aortic balloon occlusion
(C) exemplifies an ideal candidate for resuscitative endo­vascular balloon occlusion of the aorta (REBOA).
 11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 133

the passage of wires, catheters, or other devices can result

Extended Applications of REBOA in intimal dissection. Small, non–hemodynami­cally signifi­
cant dissections may be observed without con­sequence; flow-
Partial REBOA (P-REBOA) is a described alternative to com­ limiting dissections must be addressed, but these can usually
plete balloon occlusion of the aorta.47 Either a designed be treated with an en­dovas­cular approach.
catheter with partial occlusion or intermittent release have
been described. In doing so, one can reduce the total isch­
emic time and extent of reperfusion injury while allowing
for longer time to definitive intervention with subsequent
balloon removal. Similarly, the development of an endovas­
cular variable aortic control (EVAC) system to autoregulate
aortic flow in a continuous manner as an alternative to
P-REBOA with extension of occlusion times has also been
demonstrated in animal models.48 An alternative applica­
tion of this method is intermittent REBOA with planned
intervals of deflation in between periods of inflation; this
method has been shown in swine models to extend the tol­
erance of zone 1 occlusion up to 120 minutes.49 Further­
more, lower extremity cooling reduced ischemic muscle
injury and compartment pressures following prolonged
zone 3 occlusion in a swine hemorrhagic model.50 These
techniques may extend physiologically tolerable occlusion
times when utilized in patients.
Additionally, REBOA in other clinical settings has been
explored. Its use in a swine model with combined hemor­
rhagic shock and traumatic brain injury (TBI) was associ­
ated with poor outcomes due to worsened shock, arguing
against the benefit of REBOA for patients with TBI.51
Further excessive SBP may increase cerebral edema when
cerebral autoregulation is compromised. Thus, the role of
REBOA has yet to be defined for patients with known TBI.
REBOA has proven beneficial in other settings of massive
hemorrhage such as among peripartum women with
abnormal placentation52 as well as mitigating major venous
injuries when deployed in the inferior vena cava.53 As such,
the application of REBOA may expand to other clinical
settings with hemorrhagic shock as a resuscitative measure
until definitive treatment can be accomplished.

Complications of REBOA
ARTERIAL ACCESS COMPLICATIONS
Access site complications occur in 1% to 9% of percuta­
neous interventions, with reduced rates of complications
when using routine imaging guidance.35 The most common
complication related to arterial access is failure to achieve
hemostasis at the puncture site, resulting in hematoma
and/or pseudoaneurysm. Their clinical significance var­
ies and ultimately open repair of the vessel may be required
for resolution (Fig. 11.7A). Arteriovenous fistula is another
potential access site complication. This is the rarest of such
complications and is due to simultaneous ipsilateral vein
and artery access as well as inadvertent access of the vein
when attempting arterial access or vice versa. Up to 38% of Fig. 11.7 Example of arterial access complications. (A) Classic “yin-
acquired arteriovenous fistulae will spontaneously resolve yang” sign demonstrating mixed flow on color wave ultrasonogra-
within 1 year.54 phy from a femoral artery pseudoaneurysm due to failed access site
Arterial dissection can be caused by disruption of plaque hemostasis. (B) Right common femoral arterial dissection following
in atherosclerotic vessels following access (Fig. 11.7B). Ultra­ arterial access. (Reproduced with permission from Biffl W, Fox CJ, Moore
sound guidance can be used to identify and avoid areas of EE. The role of REBOA in the control of exsanguinating torso hemorrhage.
significant calcific disease to minimize this risk. Addi­tionally, J Trauma. 2015;78:1054–1058.)
134 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Thrombosis with or without distal embolization follow­ temporary re-inflation much like releasing an aortic cross
ing REBOA is a potential life- and limb-threatening com­ clamp.59 The release of ischemic metabolites may also result
plication. Systemic heparinization is typically suggested in in acidosis and hyperkalemia, impacting numerous physi­
patients with large sheaths in place; unfortunately, this may ologic processes including cardiac contractility, systemic
not be possible in patients with an ongoing coagulopathy. vascular resistance, and coagulopathy. Prolonged ischemia
However, flushing with heparinized saline prior to sheath can lead to progressive organ dysfunction and tissue loss.
removal is recommended. A thorough vascular examina­ This can clinically manifest as acute lung, liver, and kidney
tion should be performed following arterial access and
sheath removal; concerning examination findings such as
discrepant pulses, pallor, paresthesias, or poikilothermia
should prompt further investigation.
For such complications, sheath size directly relates to the
risk of ischemic events. Large sheath sizes have reported
complication rates of up to 30%,55 whereas smaller sheaths
(<9 Fr) have been shown to have a lower incidence of arte­
rial access-related complications.56,57 Saito et al. reported
a 21.3% amputation rate among survivors in their series
using a 10-Fr commercial REBOA device.58 However, in
their recent review of the AORTA registry, Brenner et al.
found an overall rate of distal embolism to be 4.8% and
an amputation rate of 1.2%.30 Similarly, Matsumara et al.
found that small sheaths resulted in minor complications
that did not require intervention. In contrast, large sheaths
were associated with a 4% intervention rate, and sheaths
upsized for therapeutic needs and/or additional ipsilateral
arterial access were associated with a 67% amputation
rate.56

PLACEMENT-RELATED COMPLICATIONS
Though not required for placement of the ER-REBOA cath­
eter, wire management is important when being used for
placement of the occlusion balloon. Whereas most wires
have an atraumatic tip by design, the stiff wires necessary to
pass a balloon can cause significant damage if placed incor­
rectly. Wire passage into branch vessels or too proximal across
the aortic valve can result in damage to these structures with
major consequences. Similarly, malposition of the balloon
can occur, particularly as currently about 30% of REBOA
are placed using blind insertion30 (Fig. 11.8). Although such
models used to determine these insertion lengths have a high
reported accuracy, variations in torso length and arterial tor­
tuosity may result in inaccurate deployment from “standard”
lengths, particularly of zone 3.37 Inflation of a malpositioned
balloon can cause significant damage. Firstly, inaccurate
balloon occlusion can result in unintended visceral malper­
fusion, inadequate hemorrhage control with ongoing bleed­
ing, or worsening of proximal injuries. Furthermore, blind
inflation based on aortic diameter at the presumed balloon
position can result in overinflation of the vessel, leading to
intimal injury or rupture. Finally, the pulsation of the aorta
can result in migration of the balloon or wire; therefore,
constant monitoring of their position based on external
landmarks in addition to securing these once appropriately
positioned is recommended.

REPERFUSION COMPLICATIONS
Fig. 11.8 Plain radiographs showing a malpositioned aortic occlusion
Balloon deflation results in reestablishment of systemic balloon found in zone 2 along the visceral plate (A) and into the right
circulation with resultant ischemia/reperfusion injury. hypogastric artery (B). (Reproduced with permission from Davidson A, et
Patients may experience vasodilation and hypotension, al. The pitfalls of REBOA: risk factors and mitigation strategies. J Trauma
and slow deflation is recommended with possible need for Acute Care Surg. 2018;84(1):192–202.)
 11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 135

injury, as well as neurologic compromise. Moreover, the ruptured abdominal aortic aneurysms: a meta-analysis and meta-
release of inflammatory mediators from this process com­ regression analysis. Cardiovasc Intervent Radiol. 2015;38:1425–1437.
15. Hörer TM, Skoog P, Pirouzram A, Nilsson KF, Larzon T. A small case
bined with increased proximal blood flow can cause damage series of aortic balloon occlusion in trauma: lessons learned from its
due to hyperperfusion such as cerebral edema, intracranial use in ruptured abdominal aortic aneurysms and a brief review. Eur J
hemorrhage, and myocardial dysfunction. Trauma Emerg Surg. 2016;42:585–592.
16. Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative
endovascular balloon occlusion of the aorta for hemorrhage control
and resuscitation. J Trauma Acute Care Surg. 2013;75:506–511.
Future Advances 17. White JM, Cannon JW, Stannard A, Markov NP, Spencer JR, Rasmus­
sen TE. Endovascular balloon occlusion of the aorta is superior to
As we strive to achieve zero preventable deaths from uncon­ resuscitative thoracotomy with aortic clamping in a porcine model of
trolled hemorrhage, the ability to establish aortic occlu­ hemorrhagic shock. Surgery. 2011;150:400–409.
18. Hoehn MR, Teeter WA, Morrison JJ, et al. Aortic branch vessel flow
sion for resuscitation both efficiently and safely is critical. during resuscitative endovascular balloon occlusion of the aorta.
Though not novel, the utilization of an endovascular bal­ J Trauma Acute Care Surg. 2019;86:79–85.
loon for aortic occlusion in trauma is a recent phenomenon 19. Markov NP, Percival TJ, Morrison JJ, et al. Physiologic tolerance of
with increasing popularity as the technology improves and descending thoracic aortic balloon occlusion in a swine model of
hemorrhagic shock. Surgery. 2013;153:848–856.
practitioners become more familiar with the technique. 20. Wasicek PJ, Shanmuganathan K, Teeter WA, et al. Assessment of
Future directions for REBOA include evolution of its tech­ blood flow patterns distal to aortic occlusion using CT in patients with
nique to prolong physiologically tolerable occlusion times resuscitative endovascular balloon occlusion of the aorta. J Am Coll
such as via variable aortic occlusion methods and adjunct Surg. 2018;226:294–308.
procedures to minimize reperfusion injury. The successful 21. Long KN, Houston IV R, Watson DB, et al. Functional outcome after
resuscitative endovascular balloon occlusion of the aorta of the proxi­
application of REBOA for traumatic noncompressible torso mal and distal thoracic aorta in a swine model of controlled hemor­
hemorrhage has led to its consideration in other clinical sce­ rhage. Ann Vasc Surg. 2015;29:114–121.
narios of hemorrhagic shock as well. Ongoing controver­ 22. Morrison JJ, Ross JD, Markov NP. The inflammatory sequelae of aor­
sies such as its use in patients undergoing cardiopulmonary tic balloon occlusion in hemorrhagic shock. J Surg Res. 2014;191:
423–431.
resuscitation as well as in patients with nontruncal injuries 23. Read RA, Moore EE, Moore FA, Haenel JB. Partial left heart bypass
should continue to be examined as increasing clinical data for thoracic aortic repair: survival without paraplegia. Arch Surg.
becomes available. 1993;128:746–750.
24. Moore EE, Burch JM, Moore JB. Repair of the torn descending thoracic
aorta using the centrifugal pump for partial left heart bypass. Ann
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11. Gupta BK, Khaneja SC, Flores L, Eastlick L, Longmore W, Shaftan GW. shock. J Trauma Acute Care Surg. 2016;80:324–334.
The role of intra-aortic balloon occlusion in penetrating abdominal 32. Romagnoli A, Teeter W, Pasley J, et al. Time to aortic occlusion: it’s all
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12. Okazaki K, Katama Y, Tohdoh Y, Tsuchida H, Namiki A. Intra- 33. UK-REBOA Trial. https://W3.Abdn.Ac.Uk/Hsru/REBOA/Public/Pub­
aortic balloon occlusion of the descending thoracic aorta for intra- lic/Index.Cshtml. Accessed October 14, 2019.
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13. Veith FJ, Lachat M, Mayer D, et al. Collected world and single center balloon occlusion of the aorta (REBOA) as an adjunct for hemor­
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tic aneurysms. Ann Surg. 2009;250:818–824. 35. Kalish J, Eslami M, Gillespie D, et al. Routine use of ultrasound guidance
14. Karkos CD, Papadimitriou CT, Chatzivasileiadis TN, et al. The impact in femoral arterial access for peripheral vascular intervention
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citative endovascular balloon occlusion of the aorta. J Trauma Acute control versus complete aortic occlusion in a swine model of hemor­
Care Surg. 2017;82:204–207. rhage. J Trauma Acute Care Surg. 2017;82:694–703.
37. Scott DJ, Eliason JL, Villamaria C, et al. A novel fluoroscopy-free, resus­ 49. Kuckelman JP, Barron M, Moe D, et al. Extending the golden hour
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hemorrhagic shock. J Trauma Acute Care Surg. 2013;75:122–128. improved survival and reperfusion injury with intermittent versus
38. Pezy P, Flaris AN, Prat NJ, et al. Fixed-distance model for balloon continuous resuscitative endovascular balloon occlusion of the aorta
placement during fluoroscopy-free resuscitative endovascular bal­ in a porcine severe truncal hemorrhage model. J Trauma Acute Care
loon occlusion of the aorta in a civilian population. JAMA Surg. Surg. 2018;85:318–326.
2017;152:351–358. 50. Simon MA, Tibbits EM, Hoareau GL, et al. Lower extremity cooling
39. Eliason JL, Derstine BA, Horbal SR, et al. CT correlation of skeletal reduces ischemia-reperfusion injury following zone 3 REBOA in a por­
landmarks and vascular anatomy in civilian adult trauma patients: cine hemorrhage model. J Trauma Acute Care Surg. 2018;85:512–518.
implications for resuscitative endovascular balloon occlusion of the 51. Williams AM, Bhatti UF, Dennahy IS, et al. Traumatic brain injury
aorta (REBOA). J Trauma Acute Care Surg. 2019;87:S137–S145. may worsen clinical outcomes after prolonged partial resuscitative
40. Stannard A, Morrison JJ, Sharon DJ, Eliason JL, Rasmussen TE. endovascular balloon occlusion of the aorta in severe hemorrhagic
Morphometric analysis of torso arterial anatomy with implica­ shock model. J Trauma Acute Care Surg. 2019;86:415–423.
tions for resuscitative aortic occlusion. J Trauma Acute Care Surg. 52. Ordoñez CA, Manzano-Nunez R, Parra MW, et al. Prophylactic use of
2013;75:S169–S172. resuscitative endovascular balloon occlusion of the aorta in women
41. Kim DH, Chang SW, Matsumoto J. The utilization of resuscitative with abnormal placentation: a systematic review, meta-analysis, and
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and the implementation of a novel approach to stabilizing hemor­ 53. Reynolds CL, Celio AC, Bridges LC, et al. REBOA for the IVC? Resuscita­
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42. Moore HB, Moore EE, Liras IN, et al. Targeting resuscitation to hemorrhage in retrohepatic cava injuries. J Trauma Acute Care Surg.
normalization of coagulating status: hyper and hypocoagulability 2017;83:1041–1046.
after severe injury are both associated with increased mortality. Am J 54. Kelm M, Perings SM, Jax T, et al. Incidence and clinical outcome of
Surg. 2017;214:1041–1045. iatrogenic femoral arteriovenous fistulas: implications for risk stratific
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44. Burlew CC, Moore EE, Stahel PF, et al. Preperitoneal pelvic packing occlusion of the aorta (REBOA). Am J Surg. 2019;217:1126–1129.
reduces mortality in patients with life-threatening hemorrhage due to 56. Matsumura Y, Matsumoto J, Kondo H, et al. Fewer REBOA complica­
unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82:233–242. tions with smaller devices and partial occlusion: evidence from a mul­
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pelvic hemorrhage: concomitant use of resuscitative endovascular 57. Teeter WA, Matsumoto J, Idoguchi K, et al. Smaller introducer sheaths
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46. Ogura T, Lefor AT, Nakano M, Izawa Y, Morita H. Nonoperative man­ 58. Saito N, Matsumoto H, Yagi T, et al. Evaluation of the safety and fea­
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with angioembolization and resuscitative endovascular balloon occlu­ J Trauma Acute Care Surg. 2015;78:897–903.
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47. DuBose JJ. How I do it: partial resuscitative endovascular balloon endovascular balloon occlusion of the aorta: risk factors and mitiga­
occlusion of the aorta (P-REBOA). J Trauma Acute Care Surg. tion strategies. J Trauma Acute Care Surg. 2018;84:192–202.
2017;83:197–199.
 12 Endovascular Variable
Aortic Control
MICHAELA GAFFLEY and TIMOTHY K. WILLIAMS

Introduction In addition, complete aortic occlusion with REBOA poses

challenges at the time of balloon deflation, where abrupt
Resuscitative endovascular balloon occlusion of the aorta washout of ischemic metabolites during reperfusion can
(REBOA) is increasingly utilized for patients with exsan­ produce life-threatening electrolyte abnormalities and
guinating truncal hemorrhage.1 This treatment has acid-base disturbances. Additionally, balloon deflation may
proven effective at rapidly restoring perfusion to the heart result in profound hemodynamic instability, in part due to
and brain, while simultaneously minimizing hemorrhage the loss of distal vascular tone, which is compounded by the
below the level of occlusion. However, this intervention ensuing ischemia reperfusion injury (Table 12.1).2 How­
is encumbered by the progressive ischemic burden that ever, this currently remains the most expeditious manner
begins at the moment of balloon occlusion.2 To address of managing NCTH, particularly in austere environments.
these issues, partial flow strategies have been developed
and tested in applied research models and are increasingly PARTIAL FLOW AS A STRATEGY TO ADDRESS
being utilized in the care of patients. To date, these partial
flow modalities have been performed manually, which rep­ LIMITATIONS OF REBOA
resents a significant limitation to widespread adoption.3 To address these limitations of REBOA, partial REBOA
These limitations include the demand for continuous (pREBOA) has been proposed as an alternative to complete
monitoring of the balloon and the difficulty in maintain­ occlusion, to avoid both hypotension and hypertension.
ing a stable degree of partial aortic flow. To address some Additionally, this technique can minimize ischemic injury
of the fundamental limitations surrounding real-world to downstream organs by allowing some variable amount
implementation of these partial flow strategies, the con­ of blood flow beyond the balloon. In principle, pREBOA
cept of endovascular variable aortic control (EVAC) has involves partial deflation of the balloon catheter, typically
been developed.4 EVAC is an automated technology that via means of manual syringe, thereby allowing some blood
controls aortic flow by precisely regulating inflation and flow beyond the balloon.7 Titration of the balloon can be
deflation of a balloon catheter. As it applies to hemor­ performed to target a blood pressure goal above or below
rhage control, EVAC can specifically be used to achieve a the balloon. To date, this procedure remains ill-defined and
low-­volume distal aortic flow to strike a delicate balance is performed manually in the clinical setting, with no firm
between ongoing hemorrhage and progressive ischemic consensus on how it should be implemented to ensure opti­
injury, a therapeutic modality we have termed regional mal outcomes.
perfusion optimization (REPO).5 Performing pREBOA has significant limitations regard­
less of the methodology used. One principle limitation
stems from the inherent challenge of carefully titrating
The Problems With REBOA aortic blood flow using a conventional aortic balloon
catheter. As an aortic balloon is deflated from the state of
REBOA prolongs survival prior to definitive surgical hemo­ complete occlusion (no downstream flow), a steep inflec­
stasis by decreasing distal hemorrhage below the level tion point is reached where small changes in balloon filling
of occlusion and augmenting proximal perfusion to the volume result in large changes in downstream aortic blood
heart, lungs, and brain. However, the benefits of REBOA flow.8 Additionally, the concurrent decrease in vascular
are quickly offset by progressive ischemia below the level tone below the balloon induced by even brief periods (less
of occlusion (limiting its duration of use to 40 to 60 min­ than 5 minutes) of complete aortic occlusion can result in
utes; Fig. 12.1).6 Severe hypertension above the balloon ­significant decrease in the blood pressure above the balloon
may be detrimental to patients with noncompressible torso during deflation. This observation reflects the fundamental
hemorrhage (NCTH) and concomitant traumatic brain hemodynamic principle known as Poiseuille’s Law, where
injuries. It has been reported that the mortality rate in flow is proportional to the radius of the vessel to the fourth
brain-injured patients requiring REBOA as a resuscitative power. This exponential return of aortic blood flow there­
adjunct approaches 50%,6 with case reports demonstrating fore necessitates precise titration of balloon filling volume
increased intracranial hemorrhage volumes after brief peri­ to maintain stable flow rates. Even when balloon titration
ods of REBOA. Physicians within the trauma community is performed while already at a partial flow state, very small
have hypothesized that the supraphysiologic blood pressure balloon volume changes (less than 10 µL) can result in mea­
and carotid blood flow created by REBOA may account for surable change in aortic flow, highlighting the need for high
these early clinical findings. fidelity in this process.4 Achieving this level of fidelity with

137
138 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Peak lactate pREBOA can be targeted using the EVAC approach; however,
14
there are fundamental differences that differentiate the two
12 strategies. Most importantly is that EVAC represents an auto­
mated process to control aortic flow as opposed to the man­
10
Lactate (mg/dL)
ual aortic flow control achieved with pREBOA. Conceptually,
8 EVAC can be envisioned as a spigot or valve, where flow can
be controlled across the full spectrum, from zero flow to full,
6
unimpeded flow. When applied to hemorrhage control, EVAC
4 can achieve very stable hemodynamics below the level of
flow restriction, thereby avoiding sudden and abrupt changes
2
in downstream blood flow that could result in clot destabili­
0 zation and exacerbation of hemorrhage.
es es es From our robust experience in performing manual pRE­
ut ut ut
in in in BOA, frequent “titrations” are required to maintain a stable
m m m
45 60 90 degree of aortic flow, on the order of every few seconds to
Fig. 12.1 Resuscitative endovascular balloon occlusion of the aorta several times a minute even during steady state conditions.
results in progressive ischemic burden over time. This frequency can be increased by other factors such as
medication administration, fluid or blood administration,
or acute blood loss. By automating this process of balloon
titration, EVAC reduces the burden on the provider from
Table 12.1 Consequences of Prolonged Complete what can be a very time-intensive and task-focused inter­
Aortic Occlusion vention. This cognitive and procedural offloading using
Proximal Effects Distal Effects Systemic Effects
automation enables the provider to engage in higher level
aspects of direct patient care. Additionally, this capability is
↑ Aortic afterload ↓ Cardiac preload Washout of toxic
metabolites
appealing for resource-constrained environments because
it creates the potential for the provider to intensively sup­
↑ Blood pressure ↓ Blood pressure Altered vascular tone
port multiple patients simultaneously, thereby serving as a
↑ Blood flow ↓ Blood flow Hemodynamic instability
force multiplier.
End organ End organ Dysregulated immune
dysfunction dysfunction response
REGIONAL PERFUSION OPTIMIZATION
EVAC can be conceptualized as a technique to regulate aor­
a manual syringe is challenging at best. Optimized balloon tic flow across the full spectrum, yet the therapeutic goals
designs may improve the deflation profile during pREBOA of EVAC are defined by the context and methods of how this
and allow for larger volume changes with lower degrees of technique is applied. With respect to hemorrhage control
change in aortic flow; however, these devices have not made and hemodynamic support for hypovolemic patients, our
it into clinical practice as of yet. group and others have postulated that delivering a stable,
For these reasons, manual pREBOA requires a skilled end low amount of aortic flow can be used to mitigate the effects
user, which represents a significant limitation to broader of sustained aortic occlusion.9 This conceptual therapy,
adoption within the trauma community for users with termed regional perfusion optimization (REPO), embodies
infrequent exposure to this technology. It is also not a prac­ physiologic and hemodynamic effects both above and below
tical solution in environments where providers represent a the level of occlusion, with preference given to the main­
scarce resource, as the constant need to attend to the bal­ tenance of low-volume flow to distal vascular beds. The
loon detracts from other vital aspects of patient care and therapeutic goals of REPO are to (1) minimize tissue isch­
negates the possibility of simultaneously caring for mul­ emia below the level of occlusion, (2) promote hemostasis
tiple injured patients. Therefore, alternate approaches are or minimize ongoing hemorrhage to prevent exsanguina­
needed to enable extending the duration of REBOA-like tion, and (3) minimize adverse effects on proximal vascular
technologies. beds, specifically severe hypertension and excessive cardiac
afterload. The aggregate effect of this therapy is to produce
less secondary injury, thereby minimizing the impact of the
EVAC Concept—Automated Partial intervention at the time of reperfusion. In doing so, REPO
Aortic Flow Control seeks to minimize subsequent resuscitation requirements
and ideally improve survival. Additionally, REPO could be
To overcome the limitations associated with manual p
­ REBOA applied prior to the threshold at which one would utilize
being performed with a conventional compliant aortic occlu­ REBOA as a means of impacting the morbidity associated
sion balloon, our group developed the concept of EVAC. The with large-volume transfusions, vasopressors, and crystal­
EVAC concept was initially developed to further refine our loids that may be required in the context of higher levels of
management of NCTH in austere military environments, hemorrhage and ischemic injury. We have found that utiliz­
where delayed transport or prolonged field care is antici­ ing the EVAC technique to achieve REPO results in signifi­
pated or required, enabling extended duration of interven­ cant decreases in resuscitation requirements (Fig. 12.2).10
tion beyond what is survivable with sustained complete REPO embodies a flow-based approach to resuscitation,
aortic occlusion. Some of the same fundamental benefits of which is optimizing blood flow to downstream tissue beds
 12 • Endovascular Variable Aortic Control 139

based on the patient’s unique physiology. This represents clinically available metrics, specifically utilizing blood
a departure from pressure-based resuscitation paradigms, pressure measurements. It is important to understand how
where blood pressure support or augmentation is the prin­ these two distinct hemodynamic values relate and extrinsic
ciple focus of the resuscitative effort. The REPO concept factors that influence this relationship. Under certain
makes the assumption that controlling and optimizing blood conditions, blood pressure and flow correlate in a predictable
flow within a vessel as opposed to blood pressure represents fashion; however, certain situations make this relationship
a more valuable surrogate marker for tissue perfusion, the unpredictable and/or unreliable.
sustainer of organ viability. By delivering a low level of distal Various interventions influence this relationship, includ­
blood flow (approximately 10%–20% of native visceral and ing fluid, blood, or medications. Additionally, it is important
lower extremity blood flow) to injured tissue beds, our group to recognize that partial aortic occlusion creates unique
and others have demonstrated that the ischemic burden of hemodynamic relationships not present in a healthy native
aortic occlusion can be substantially mitigated (Fig. 12.3).11 aorta. For instance, proximal blood pressure and distal
Additionally, this approach has been shown to result in tol­ blood pressure tend to directly correlate with blood flow
erable levels of hemorrhage in the context of severe liver during active volume administration or from volume loss,
and major vascular injury. Taken together, these beneficial in the absence of any aortic occlusion or in the presence
effects of REPO serve to extend the maximal duration of of a statically held balloon. However, administration of a
intervention for REBOA well beyond what can be expected pure alpha agonist such as phenylephrine (with or without
from equivalent durations of complete aortic occlusion. a static balloon) will variably increase systemic vascular
Although REPO represents a flow-based therapy, it is resistance, thereby raising blood pressure, yet decreasing
important to emphasize that direct blood flow measure­ blood flow. Active balloon titration results in yet a different
ments are not currently easily obtained, making a flow- hemodynamic effect, producing an increase in proximal
based resuscitation challenging outside of experimental blood pressure, a decrease in distal pressure, and a decrease
models. Therefore, it becomes necessary to model flow from in aortic flow. Inversely, balloon deflation tends to result in
a decrease in proximal blood pressure, and an increase in
both distal pressure and aortic flow.
Although general trends are predictable, meaningful
9000
Total resuscitation fluids
60
Total vasopressors quantification of blood flow based on changes in blood
REBOA REBOA pressure due to these interventions is not feasible in most
8000 REPO REPO
50 instances. Nonetheless, our group has evaluated these
Norepinephrine (ng/kg)

7000
hemodynamic relationships in a rigorous fashion, reveal­
Plasmalyte (mL)

6000 40 ing some clinically useful insights. We have found that

5000 the aortic blood pressure below the balloon correlates in
30
4000 a fairly linear fashion with blood flow beyond the balloon
3000 20 at low-flow states (0%–40% of baseline aortic flow), over
2000
an array of hemorrhage volumes (0%–40% total circu­
10 lating blood volume) (Fig. 12.4).12 Such an approach can
1000
be implemented clinically by first measuring the pressure
0 0
A B below the occlusion balloon at full occlusion (by definition
a zero-flow state), then targeting a distal blood pressure of
Fig. 12.2 Resuscitation requirements: Regional perfusion optimization approximately 7 to 10 mm Hg above the occlusion value,
(REPO) resulted in less than half the amount of (A) fluids and (B) vaso- which experimentally results in approximately 5% to 10%
pressors during automated critical care as compared to resuscitative of native distal aortic flow. It is important to emphasize that
endovascular balloon occlusion of the aorta (REBOA). the interventions above may influence this relationship,
thereby requiring periodic assessment of the distal blood
pressure at full occlusion, to again re-establish the zero-flow
state. Using this principle of targeting a flow range based on
Lactate the pressure below the level of the balloon enables clinical
12
REBOA implementation of REPO in the absence of direct aortic flow
10 REPO measurements.
REPO has been explored in multiple large animal models
8 with varying durations of controlled and uncontrolled hem­
Lactate mg/dL

orrhage and ischemia. In our initial proof-of-concept exper­

6
iments, REPO was performed using a largely experimental
4
construct, whereby blood was shunted through a custom
extracorporeal flow circuit in order to tightly regulate flow.
2 This study utilized a highly lethal liver injury model, that
resulted in uniform demise in the absence of interven­
0
Peak lactate Final lactate tion. Following a brief period of complete aortic occlusion
(20 minutes), animals underwent either 70 minutes of con­
Fig. 12.3 Ischemic burden: Regional perfusion optimization (REPO) tinued complete aortic occlusion or REPO (150–300 mL
resulted in lower peak and final lactate levels than resuscitative endo- per minute blood flow; approximately 5%–10% of baseline
vascular balloon occlusion of the aorta (REBOA). native aortic flow). This prolonged i­ntervention period was
140 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Fig. 12.4 Relationship of proximal and distal mean arterial blood pressure to aortic flow beyond the level of flow restriction. Note that distal mean
arterial pressure (MAP) and aortic flow correlate across iterative levels of hemorrhage. This correlation does not exist between proximal mean arterial
pressure and aortic flow across various levels of hemorrhage.

chosen to simulate the reality of modern tactical evacuation Kaplan-Meier survival estimates
100
on the battlefield, recognizing that application of complete
REBOA is not feasible in scenarios where prolonged inter­
vention (greater than 60 minutes) is required. Following Animals surviving (%) 80
the uncontrolled hemorrhage period, animals underwent
definitive hemorrhage control and a protocolized critical 60
care period, where fluid or vasopressor administration/ Damage
control
titration was determined autonomously via an algorithm surgery
based on continuous hemodynamic monitoring. The dif­ 40
REBOA
ferences were striking. All but one REPO animal survived
REPO
the intervention period, with the remainder surviving the 20
duration of the critical care period, compared to only 50% CONTROL
survival for the group who was subjected to 90 minutes of
0
complete aortic occlusion (Fig. 12.5).11 0 1 2 3 4 5 6
Importantly, this study demonstrated that blood flow to Time (hours)
the lower torso as low as 10% of baseline flow using the
REPO approach was sufficient to offset the deleterious effects Fig. 12.5 Kaplan-Meier survival estimates. Regional perfusion optimi-
of sustained aortic occlusion, including distal ischemia and zation (REPO) resulted in a 90%-survival at the end of the study period,
the supraphysiologic proximal aortic pressure and cardiac compared to only 50% of the complete aortic occlusion arm resuscita-
afterload induced by sustained complete aortic occlusion. tive endovascular balloon occlusion of the aorta (REBOA). The time of
To evaluate for benefit of REPO for durations of interven­ damage control surgery is denoted by the dashed vertical line. The liver
tion closer to what could be anticipated during a typical in- injury was uniformly fatal in the absence of intervention, with rapid
hospital scenario, we investigated REPO over a 45-minute death of all control animals.
intervention period using a controlled hemorrhage model. In
this study, critical care interventions were delivered entirely
autonomously based on protocolized computer-controlled with ischemia-reperfusion injury. Similarly, REPO reduced
algorithms and programmable infusion pumps.13 Addition­ the resuscitation requirements for fluid and vasopressors
ally, through continued technological development, REPO substantially and resulted in lower peak and final lactate
was performed using a computer-controlled syringe pump levels, providing both indirect and direct evidence of a lower
and a readily available, off-the-shelf compliant aortic balloon ischemic burden with this approach.
catheter. Even for this shorter intervention duration, we saw Another group has provided data in support of our find­
significant improvement with REPO over complete REBOA ings, showing that 500 mL per minute could be tolerated
for a host of outcome measures. During intervention, REPO with acceptable hemorrhage volumes over extended dura­
animals experienced proximal mean aortic pressures (MAP) tions of REPO, with uniform survival following hemorrhage
closer to normal physiologic range as compared to REBOA. control and resuscitation.14
During the critical care phase, REPO animals maintained Beyond the effects on distal vascular beds, REPO may pro­
an average proximal MAP within the goal range and had a vide beneficial effects on proximal organs as well. In a 2019
higher overall MAP throughout this time period compared to study, our group explored the effects of REPO with EVAC
REBOA animals. REPO also resulted in aortic flow rates closer compared to complete REBOA on cardiac performance
to baseline values, thereby minimizing the hyperemia from as measured via preload recruitable stroke work (PRSW;
low systemic vascular resistance commonly experienced a preload-independent measure of cardiac contractility),
 12 • Endovascular Variable Aortic Control 141

obtained using high fidelity pressure-volume loop measure­ is clear from our experience that the distal pressure/flow
ments from the left ventricle. This study demonstrated sig­ relationship is imperfect and will only serve as an estimate of
nificantly reduced cardiac strain with REPO (Table 12.2).15 aortic flow, yet it is equally unclear if the fidelity achieved in
It is hypothesized that REPO reduces overall cardiac work the lab is required to achieve acceptable clinical outcomes.
and strain in part by reducing cardiac afterload. Our obser­ Further work is needed in this regard.
vations also suggest that catecholamines elaborated sys­ Other groups have also proposed the use of intermittent
temically in response to profound distal hypotension may REBOA (iREBOA) as a viable clinical strategy to overcome
result in a disproportionate increase in cardiac output dur­ some of the technical demands imposed by REPO with
ing complete occlusion, further magnifying the adverse EVAC, namely the need to achieve stable low-volume flow.
impact on cardiac function.16 Although beneficial effects on This approach involves cyclically deflating and re-inflating
proximal vascular beds have been demonstrated with REPO, the balloon based on either a specified duration or by the
it should be emphasized that a strategy to specifically target resulting hemodynamic response. Reassuring large animal
optimization of proximal hemodynamics will compromise studies have suggested iREBOA may significantly expand the
the ability to tightly regulate distal blood flow. For example, duration of intervention to at least 120 minutes; however,
if severe proximal hypertension is still present despite allow­ the ability of humans to tolerate the massive hemodynamic
ing low-level downstream blood flow with REPO, further fluctuations that occur with this approach is of significant
balloon deflation to mitigate this proximal hypertension concern.17,18 Moreover, there is significant risk that any sta­
will inherently increase downstream blood flow and may ble clot may become disrupted with an immediate return to
incite rebleeding. This may be an acceptable tradeoff based a full flow state upon balloon deflation. Whereas the binary
on the scenario, such as when there is concomitant vascu­ state of this approach (inflated or deflated) is technically
lar or pulmonary injury above the diaphragm and when simple to achieve, there remains a significant demand by
ready access to blood products allows for the increased risk the provider to constantly assess the balloon and the resul­
of recurrent hemorrhage. tant hemodynamics. It also creates a challenge in terms
of negotiating the management of unstable hemodynam­
ics. It would be challenging to distinguish if hypotension
LIMITATIONS OF REPO WITH EVAC AND
upon deflation was secondary to low distal vascular tone,
ALTERNATE APPROACHES whereby balloon inflation and/or vasopressor administra­
The experience with EVAC and REPO to date has been in tion would be appropriate or if there was re-bleeding that
applied research models. It remains unclear if the results warranted immediate blood transfusion. This instability
of these early studies will translate into beneficial outcomes and uncertainty does not simplify the process and may cre­
for human victims of trauma. Nonetheless, it is clear that ate a more unpredictable situation from a clinical decision-
REBOA has limitations and requires refinement in order making standpoint. Nonetheless, this approach may serve
to optimize outcomes, which renders approaches such as to unburden the provider from the manual aspects of bal­
REPO with EVAC the rational next step for technologic devel­ loon manipulation. Automated technology such as EVAC
opment. It is also unclear as to whether or not modeling has been employed experimentally to achieve this type of
flow based on pressure will be sufficient for clinical use. It cyclical balloon inflation and deflation.

Table 12.2 Cardiac Function of Animals in the Zone 1 REBOA, Zone 1 REPO, and Control Groups
Parametric data presented as mean ± standard deviation and nonparametric data presented as median (interquartile range)
Control Group (n = 6) Zone 1 REBOA Group (n = 6) Zone 1 REPO Group (n = 6) P Value
CARDIAC OUTPUT
At end hemorrhage, L/min 4.3 ± 2.4 4.8 ± 2.0 5.0 ± 1.4 0.93
At end intervention, L/min 8.2 ± 2.1 11.3 ± 5.1 6.7 ± 2.8 0.11
End of study, L/min 6.8 ± 6 11.2 ± 6.5 7.1 ± 3 0.37
EJECTION FRACTION
At end hemorrhage, % 52 ± 11 49 ± 12 58 ± 8 0.93
At end intervention, % 57 ± 5 49 ± 12 46 ± 9 0.14
End of study, % 45 ± 11 58 ± 15 52 ± 12 0.13
ESPVR
Baseline 1.03 (0.87–1.11) 0.81 (0.68–1.33) 1.13 (0.90–1.50) 0.50
Time 74 minutes 1.85 (1.31–2.11) 2.73 (1.79–3.59) 2.45 (2.42–3.41) 0.08
End of study 1.09 (0.74–2.02) 1.39 (0.93–2.29) 2.04 (1.55–4.08) 0.28
PRSW
Baseline 44.4 (42.0–62.6) 49.1 (42.1–56.4) 51.8 (40.1–63.7) 0.85
Time 74 min 67.1 (62.7–87.9) 111.2 (102.5–148.6) 116.7 (116.6–141.4) 0.04
End of study 65.8 (41.9–80.2) 66.0 (38.8–77.1) 105.3 (84.0–119.5) 0.01
ESPVR, End systolic pressure volume relationship; PRSW, preload recruitable stroke work; REBOA, resuscitative endovascular balloon occlusion of the aorta;
REPO, regional perfusion optimization.
142 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Fig. 12.6 Endovascular variable aortic control (EVAC) hardware platform. (A) External view of the custom wireless EVAC controller. (B) Internal view.
(C) Automated EVAC syringe pump in use during a representative experiment. (Reprinted from Williams et al. A novel automated endovascular variable
aortic control device to expand function of standard REBOA catheters. JEVTM. 2019;3:3–10.)

Future Directions 2. Russo RM, Neff LP, Johnson MA, Williams TK. Emerging endovascu­
lar therapies for non-compressible torso hemorrhage. Shock. 2016;
46(3 suppl 1):12–19.
Our group has refined a viable strategy to achieve controlled, 3. Russo RM, Neff LP, Lamb CM, et al. Partial resuscitative endovascular
titrated distal aortic flow using conventional compliant bal­ balloon occlusion of the aorta in swine model of hemorrhagic shock.
loon catheters inflated with a prototype-grade automated J Am Coll Surg. 2016;223:359–368.
4. Williams T, Neff LP, Tibbits EM, et al. A novel automated endovascular
syringe pump. This pump and its associated controller, which variable aortic control device to expand function of standard REBOA
automate the process of balloon inflation and deflation using catheters. JEVTM. 2019;3:3–10.
closed-loop feedback, represent a major advancement for­ 5. DuBose RJ. “What’s in a name?”: A consensus proposal for a common
ward (Fig. 12.6).4 The automated syringe pump is capable nomenclature in the endovascular resuscitative management and
of making microliter-sized balloon volume adjustments in a REBOA literature. JEVTM. 2017;1(1).
6. Johnson MA, Williams TK, Ferencz SE, et al. The effect of resuscitative
near continuous fashion. However, further technique refine­ endovascular balloon occlusion of the aorta, partial aortic occlusion
ment and technological development is required to translate and aggressive blood transfusion on traumatic brain injury in a
REPO with EVAC into a clinically viable therapy. swine multiple injuries model. J Trauma Acute Care Surg. 2017;83:
EVAC is imminently achievable using conventional pressure- 61–70.
7. Johnson MA, Neff LP, Williams TK, DuBose JJ, Group ES. Partial
based hemodynamic monitoring, yet the process would be resuscitative balloon occlusion of the aorta (P-REBOA): clinical
more streamlined if it were feasible to directly measure technique and rationale. J Trauma Acute Care Surg. 2016;81:S133–
flow beyond the balloon. There are a variety of established S137.
catheter-based technologies that could be employed to enable 8. Davidson AJ, Russo RM, Ferencz SE, et al. Incremental balloon defla­
this. With a broader endorsement of the merits of flow-based tion following complete resuscitative endovascular balloon occlusion
of the aorta results in steep inflection of flow and rapid reperfusion in
resuscitation strategies, this technologic development may a large animal model of hemorrhagic shock. J Trauma Acute Care Surg.
become justified. 2017;83:139–143.
9. Russo RM, Williams TK, Grayson JK, et al. Extending the golden hour:
partial resuscitative endovascular balloon occlusion of the aorta in
Disclosure a highly lethal swine liver injury model. J Trauma Acute Care Surg.
2016;80:372–378.
10. Williams TK, Tibbits EM, Hoareau GL, et al. Endovascular vari­
Dr. Williams is a co-founder of and consultant for Certus able aortic control (EVAC) versus resuscitative endovascular
Critical Care, Inc., actively developing EVAC technology and balloon occlusion of the aorta (REBOA) in a swine model of hem­
other critical care robotics. orrhage and ischemia reperfusion injury. J Trauma Acute Care Surg.
2018;85:519–526.
11. Williams TK, Neff LP, Johnson MA, et al. Automated variable aortic
References control versus complete aortic occlusion in a swine model of hemor­
1. Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of rhage. J Trauma Acute Care Surg. 2017;82:694–703.
exsanguinating torso hemorrhage. J Trauma Acute Care Surg. 12. Johnson MA, Davidson AJ, Russo RM, et al. Small changes, big effects:
2015;78:1054–1058. the hemodynamics of partial and complete aortic occlusion to inform
 12 • Endovascular Variable Aortic Control 143

next generation resuscitation techniques and technologies. J Trauma is mitigated by endovascular variable aortic control (EVAC). J Trauma
Acute Care Surg. 2017;82:1106–1111. Acute Care Surg. 2019;87:590–598.
13. Johnson MA, Tibbits EM, Hoareau GL, et al. Endovascular perfusion 16. Hoareau GL, Williams TK, Davidson AJ, et al. Endocrine effects of
augmentation for critical care: partial aortic occlusion for treatment simulated complete and partial aortic occlusion in a swine model of
of severe ischemia-reperfusion shock. Shock. 2019;51:659–666. hemorrhagic shock. Mil Med. 2019;184:e298–e302.
14. Forte D, Do WS, Weiss JB, et al. Titrate to equilibrate and not 17. Kuckelman JP, Barron M, Moe D, et al. Extending the golden hour
exsanguinate! characterization and validation of a novel partial for Zone 1 resuscitative endovascular balloon occlusion of the aorta.
resuscitative endovascular balloon occlusion of the aorta catheter in J Trauma Acute Care Surg. 2018;85:318–326.
normal and hemorrhagic shock conditions. J Trauma Acute Care Surg. 18. Morrison JJ, Ross JD, Houston Rt, Watson JD, Sokol KK, Rasmussen
2019;87:1015–1025. TE. Use of resuscitative endovascular balloon occlusion of the aorta
15. Beyer CA, Hoareau GL, Tibbits EM, et al. Resuscitative endovascular in a highly lethal model of noncompressible torso hemorrhage. Shock.
balloon occlusion of the aorta (REBOA) induced myocardial injury 2014;41:130–137.
 13 Selective Aortic Arch Perfusion
JAMES E. MANNING and ED B.G. BARNARD

Introduction steady infusion of perfusate to maintain aortic valve closure

(Fig. 13.3). This step is important, as failure to close the aor-
Selective aortic arch perfusion (SAAP) is an emerging tic valve can lead to regurgitation of the perfusate into the
endovascular resuscitation technique that provides tem- left ventricle, left atrium, and pulmonary venous system lim-
porary extracorporeal perfusion to the heart and brain iting the beneficial effects of SAAP therapy in cardiac arrest.
during cardiac arrest.1 The aim of SAAP is to reverse the After the initial bolus, the infusion rate requi­red to main-
cardiac arrest, resulting in restoration of intrinsic cardiac tain closure of the aortic valve can be lower: 10 mL/kg/min
output with a palpable pulse (a return of spontaneous cir- has been used in most of the laboratory research studies to
culation [ROSC]), with a good neurological outcome. SAAP date. The key to maintaining competent aortic valve closure
was developed specifically as a cardiac arrest therapy and is that the subsequent infusion must begin immediately
is applicable to both medical cardiac arrest (sudden cardiac after the bolus, thereby not allowing the aortic pressure to
death) and hemorrhage-induced (including traumatic) drop and the aortic valve to open.
cardiac arrest. The series of SAAP interventions (SAAP The initial perfusate is preferably an exogenous oxygen
modalities) provides a stepwise escalation of aortic bal- carrier, such as stored (allogeneic) whole blood or packed
loon occlusion and extracorporeal perfusion that generates red blood cells, or a non-blood product, such as a hemo-
higher blood flow than that achieved by closed-chest car- globin-based oxygen carrier (HBOC) or a perfluorocarbon
diopulmonary resuscitation (CPR). The sequence of SAAP (PFC) emulsion. The perfusate is passed through an oxygen-
modalities are used to achieve a ROSC, or to provide bridging ator and infused using a pump system. Centrifugal pumps,
heart and brain perfusion support until cannulation for pro- roller-wheel pumps, and peristaltic pumps have all been
longed venoarterial extracorporeal life support (VA-ECLS) if used successfully to perform SAAP in laboratory models.
required. The ability to escalate sequentially through these Limited experiments to date have also shown that rapid
SAAP modalities has potential utility to better inform the serial boluses performed manually are also effective, but
complex risk:benefit decision-making of resuscitation inter- the overall perfusion rate is lower than mechanical pump
ventions in states of severe hemorrhagic shock and car- continuous infusion and the time required to achieve ROSC
diac arrest. This chapter will include a description of SAAP is generally longer. Nonetheless, in austere environments—
and its sequential escalating interventions, the rationale such as military theaters and some prehospital settings—
for SAAP in clinical practice, a summary of large-animal manual infusion for SAAP may prove to be most practical.
laboratory data, an explanation of how SAAP complements
other endovascular resuscitation techniques, and the impli-
cations for trauma and vascular surgery. The Rationale for SAAP
CARDIAC ARREST SURVIVAL
A Description of SAAP
Cardiac arrest is a major public health problem in the
SAAP uses a large-lumen, balloon occlusion catheter United States and throughout the world. According to a
inserted into a femoral artery and advanced to the level 2015 Institute of Medicine Report, there are an estimated
of the descending thoracic aorta with an insertion length 600,000 cardiac arrests each year in the United States
based on body surface measurement (femoral insertion site- alone.2 This includes cardiac arrest due to primary cardiac
to-umbilicus-to-xyphisternal junction). This method posi- causes as well as trauma, poisonings, and other etiologies.
tions the SAAP catheter balloon in the aorta between the Of these, approximately 395,000 occur outside of a hospi-
diaphragm and the left subclavian artery (Fig. 13.1). This tal setting and the survival rate overall for this population
leeway in balloon position within the descending thoracic is less than 8%.2,3 There are an estimated 200,000 in-hos-
aorta allows for insertion and initiation of resuscitative per- pital cardiac arrests each year with a survival rate of about
fusion without the need for imaging technology to verify 24%.2,4 The major limiting factors in achieving a ROSC in
balloon location (Fig. 13.2A,B). When the SAAP catheter medical cardiac arrest are the inadequate myocardial blood
balloon is inflated, the aortic arch vessels, including the cor- flow produced by closed-chest CPR, delays in initiation of
onary, carotid, and vertebral arteries, are relatively isolated bystander CPR, and lack of early defibrillation.
for perfusion with an oxygenated perfusate via the central The incidence of cardiac arrest secondary to trauma is esti-
infusion lumen of the SAAP catheter.1 mated to be 60,000 cases/year in the United States.5 Reported
After the SAAP catheter balloon is inflated, an initial rapid survival in traumatic cardiac arrest (TCA) is improving but
bolus of perfusate (50 mL/2–3 seconds) into the aortic arch may be even lower than medical cardiac arrest—many of the
is used to close the aortic valve, followed immediately by a potentially survivable deaths are due to exsanguination.5,6

144
 13 • Selective Aortic Arch Perfusion 145

Carotid
Vertebral artery arteries

Subclavian artery

Aortic valve Occlusion balloon

Thoracic arteries
Coronary arteries intercostal
bronchial
esophageal

Diaphragm

SAAP catheter

Femoral artery

Fig. 13.1 Diagram of a selective aortic arch perfusion (SAAP) catheter inserted in a femoral artery and advanced to the thoracic aorta with balloon
inflated to isolate the aortic arch vessels for perfusion via the catheter lumen. (From Manning JE, Murphy CM, Hertz CM, Perretta SG, Mueller RA,
Norfleet EA. Selective aortic arch perfusion during cardiac arrest: a new resuscitation technique. Ann Emerg Med. 1992;21:1058–1065.)

The major limiting factors in achieving a ROSC in hemor- minutes. Trauma is the leading cause of severe uncontrolled
rhage-induced TCA (HiTCA) are the diminished effectiveness hemorrhage that is responsible for much of the morbidity
of closed-chest CPR in the setting of hypovolemia, the del- and mortality in both military and civilian trauma popula-
eterious effects of CPR chest compressions in the presence of tions.6,7 Uncontrolled hemorrhage due to noncompressible
chest trauma, the lack of hemorrhage control, and the lack torso hemorrhage (NCTH) is the leading cause of reported
of high-volume fluid resuscitation required to revive the non- preventable death in military combatants and civilian
beating, or inadequately beating, heart. trauma patients with otherwise survivable injuries (pre-
Severe uncontrolled hemorrhage rapidly leads to a state dominantly the lack of devastating traumatic brain injury).
of profound hypovolemia and shock that, if left untreated, Survival from HiTCA is currently extremely low, estimated
can result in cardiovascular collapse and death within to be between 1% and 5%.5,8,9
146 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Fig. 13.2 (A) Fluoroscopic image of a selective aortic arch perfusion (SAAP) catheter balloon inflated with contrast agent, positioned in the thoracic
aorta in a porcine model. (B) SAAP catheter balloon inflated in the thoracic aorta during cardiac arrest in a porcine model.

rapidly and is often due to uncontrolled severe hemorrhage,

but other etiologies include pericardial tamponade, tension
pneumothorax, and hypoxemia related to airway, brain, or
cervical spinal cord injury.11,12
Standard cardiac arrest therapy, developed over the past
60 years, has primarily included closed-chest CPR, electrical
therapies (defibrillation and cardiac pacing, when appropri-
ate), and intravenous administration of drugs (including
epinephrine and antiarrhythmics).10,13 Although identifi-
cation and treatment of a specific cause is emphasized in
cardiac arrest algorithms, the reality is that in most cases
of cardiac arrest a rapidly reversible etiology is not found
and resuscitation interventions follow an algorithmic
approach (e.g., American Heart Association guidelines for
Advanced Cardiac Life Support) with little or no tailoring
of interventions to the individual patient. A major limita-
Fig. 13.3 Fluoroscopic image of contrast infusion into the aortic arch tion in this regard is the lack of physiological parameters to
vessels during selective aortic arch perfusion resuscitation. The image guide resuscitation interventions (pulse quality and pupil-
demonstrates competent closure of the aortic valve with no regurgitation lary response are inadequate guides). Continuous end-tidal
into the left ventricle and effective perfusion of the coronary arteries. carbon dioxide measurement is the most promising nonin-
vasive measure readily available, but even this is at best a
semi-quantitative guide to therapy.14
LIMITATIONS OF CPR AND STANDARD Closed-chest CPR has been widely taught since its land-
mark description in 1960 and has helped save many lives
RESUSCITATION
by creating a coronary perfusion pressure (CPP) gradient
Cardiac arrest is the abrupt, or rapidly progressive, loss of (defined as aortic pressure minus right atrial pressure dur-
cardiac function needed to sustain survival. Sudden cardiac ing the relaxation or diastolic phase of CPR chest compres-
death can be due to a lethal dysrhythmia (i.e., ventricular sions) high enough to perfuse the myocardium.15,16 CPR
fibrillation) resulting in abrupt loss of blood flow, often with- performed with good technique and without time delay can
out any preceding global hypoperfusion or global ischemic generate up to 25% to 33% of normal physiological car-
deficit. Other etiologies of medical (nontraumatic) cardiac diac output.17,18 Although this can be sufficient to result in
arrest involve an acute insult with rapid decompensation, ROSC, survival data over the decades have been relatively
for example: hypoxemia (airway obstruction), heart fail- dismal. Important factors that influence survival outcome
ure (myocardial infarction), circulatory obstruction (mas- are: (1) decline in CPR blood flow over time (even with good
sive pulmonary embolus), or hypovolemia (nontraumatic CPR technique) and (2) time delay to initiation of CPR
hemorrhage).2,10 Traumatic cardiac arrest can also occur which leads to lower CPP and lower CPR blood flow due to
 13 • Selective Aortic Arch Perfusion 147

peripheral arterial vasodilation. In HiTCA, the problems of The endovascular interventions, other than SAAP, that
CPR are magnified. In states of severe hypovolemia, CPR can be used in resuscitation are briefly described later;
has been shown to generate lower aortic diastolic pressure REBOA, ECLS, and EPR are more thoroughly covered in
and therefore CPP, starving the myocardium of oxygen- other chapters.
ated perfusate.19,20 In the setting of thoracic trauma, the Thoracic aortic catheterization can be used to continu-
mechanics of CPR may be less effective and chest compres- ously measure CPR-diastolic aortic pressure (or CPP, if a
sions may even cause further injury. Furthermore, in all central venous pressure catheter is also inserted) and allow
causes of traumatic cardiac arrest, it is likely that CPR will for adjustments in CPR mechanics to optimize aortic pres-
hamper other interventions aimed at reversing the arrest sure and CPP.23 The aortic catheter can also be used to
etiology, for example, endotracheal intubation for hypoxia, deliver resuscitation drugs, such as epinephrine, allowing
thoracostomy for pneumothorax, and vascular access for for rapid titration to therapeutic effect while avoiding exces-
volume replacement in hypovolemia; the risk to providers sive doses that could prove deleterious.24
of inadvertent needle-stick injury is significant. REBOA has been shown to be effective in uncontrolled
Another major limitation of standard cardiac arrest ther- hemorrhage below the diaphragm (zone 1 REBOA, thoracic
apy is that the intravenous administration of resuscitation aortic occlusion) or isolated to the pelvic region (zone 3
drugs is usually ineffective. Epinephrine is most commonly REBOA, infrarenal aortic occlusion).25 Clinical reports show
used, given for its peripheral arterial vasoconstrictor effects. favorable survival in patients with severe hemorrhagic
Epinephrine increases aortic pressure and CPP to improve shock, particularly if initiated before cardiac arrest with
CPR blood flow.21 Both laboratory and clinical studies have loss of cardiac contractility has developed.26–30 However,
shown that the higher the CPP, the greater the myocardial the exact physiological state (i.e., the patient’s place on the
blood flow and higher the rate of ROSC.22 However, during spectrum of hemorrhage) at which the potential benefits of
the low blood flow state of CPR, the circulation of epineph- aortic balloon occlusion outweigh the potential risks of the
rine from a peripheral venous injection site to the periph- procedure is not currently well understood. REBOA cath-
eral arterial system is highly variable. Paradoxically, cardiac eters allow for central aortic pressure monitoring, which
arrest victims with very low CPR blood flow, who most need is valuable in guiding intravenous fluid resuscitation and
the vasoconstrictor effect, are the very patients in whom could potentially be used for intraaortic drug delivery. There
epinephrine is most ineffectively circulated from the periph- is some evidence that REBOA may have utility in medical
eral vein to the peripheral arterial effector sites. This leads to cardiac arrest.31,32
excessive doses of intravenous epinephrine that have been ECPR involves the implementation of femoro-femoral
associated with lower survival rates. VA-ECLS during cardiac arrest to achieve a ROSC. ECPR
The dilemma of present cardiac arrest resuscitation has been reported both in-hospital and prehospital for
includes: (1) closed-chest CPR that provides only a fraction the treatment of medical cardiac arrest deemed to have
of normal cardiac output which diminishes with delay in a good chance of neurological recovery.33–35 Clinical
CPR initiation and with increasing duration of CPR, (2) lack reports of ECPR show high survival rates with favorable
of a noninvasive method of effectively assessing blood flow neurological recovery in the patients meeting criteria for
during CPR so that resuscitation efforts can be individual- this intervention.
ized, (3) resuscitation medications are ineffectively circulated The Impella device is an endovascular rotational pump
when given intravenously, and (4) the time frame allowing that is inserted across the aortic valve with an intake port at
for ROSC is short, and therefore often exhausted prehospital. the distal tip situated in the left ventricle and an outlet port
in the aorta. Impella was developed for the treatment of
severe left ventricular failure. It has also been suggested as a
potential intervention for perfusion support during cardiac
Rationale for Endovascular arrest, but it is not well established.36 A potential limitation
Resuscitation in cardiac arrest is the present need for imaging for inser-
tion to verify proper placement in the left ventricle.
The limitations of standard cardiac arrest resuscitation EPR is experimental and involves the rapid induction
attributable to inadequate CPR blood flow, ineffective drug of profound hypothermia in trauma patients with exten-
delivery, and inadequate parameters to guide therapy are sive injuries who cannot be resuscitated prior to surgical
all addressed to varying degrees by emerging endovascu- intervention.37 The current method for performing EPR is
lar resuscitation interventions that allow for continuous or thoracic aortic cannulation via a thoracotomy with the
intermittent invasive pressure monitoring, extracorporeal infusion of 4°C crystalloid until the target core tempera-
perfusion support, and effective drug delivery during cardiac ture (about 10°C) is achieved. The right atrial appendage is
arrest. Endovascular interventions reported in the literature incised to allow blood and fluid to drain during the induc-
for cardiac arrest resuscitation are set out in Table 13.1 and tion of profound hypothermia.
include: (1) aortic catheterization for hemodynamic moni- One of the major challenges for endovascular resuscita-
toring and intraaortic drug delivery, (2) resuscitative endo- tion is obtaining vascular access in a time-critical manner,
vascular balloon occlusion of the aorta (REBOA), (3) SAAP, often under suboptimal circumstances. A 2018 report from
(4) extracorporeal perfusion support (ECLS/ECMO—these the R Cowley Adams Shock Trauma Center, arguably the
terms are interchangeable, and when used in the setting of most experienced aortic balloon occlusion facility, demon-
cardiac arrest can also be referred to as extracorporeal-CPR strated a significant difference in the median time to com-
[ECPR]), (5) Impella intravascular rotor-flow device, and (6) mon femoral artery access in severe traumatic hemorrhage
emergency preservation and resuscitation (EPR). compared to traumatic cardiac arrest—141 seconds versus
 148
SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock
Table 13.1 Comparison of Characteristics of Endovascular Resuscitation Interventions
Aortic Pressure
Endovascular Placement Monitoring With Distal/Caudal Extracorporeal Post-ROSC
Resuscitation Without Closed-Chest Aortic Pressure Support Arterial Drug Hemorrhage Perfusion to Perfusion Easily Withdrawn
Intervention Imaging CPR With Closed-Chest CPR Delivery Control Achieve ROSC Support Post-ROSC
Aortic pressure Yes Yes No Yes No No No Yes
catheter AoP (±CPP) Epinephrine
(±central venous titration
catheter)
REBOA catheter Yes Yes Potentially increased SVR Yes Yes No No Yes
AoP with aortic occlusion Aortic balloon
occlusion
SAAP catheter Yes Yes Yes Yes Yes Yes Limited, temporary Yes
AoP (intermittent) Aortic arch perfusion (but Aortic balloon Aortic arch or bridge to ECMO,
CPR not needed) occlusion perfusion if needed
Impella device No No Yes No No Yes Yes Potentially
Aortic perfusion (but CPR Whole body
not needed) perfusion
ECLS/ECMO/ECPR Yes Yes Yes Yes via ECMO No Yes Yes No
(arterial side of Aortic perfusion (but CPR circuit Whole body Generally,
ECMO circuit) not needed) perfusion requires
surgical
decannulation
EPR procedure N/A N/A N/A Potentially N/A N/A N/A N/A
Thoracotomy for No CPR No CPR Drugs to limit Induction
aortic access ischemia/ of profound
reperfusion hypothermia
AoP, Aortic pressure; CPP, coronary perfusion pressure; CPR, cardiopulmonary resuscitation; ECLS, extracorporeal life support; ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal-CPR;
EPR, emergency preservation and resuscitation; REBOA, resuscitative endovascular balloon occlusion of the aorta; SAAP, selective aortic arch perfusion; SVR, systemic vascular resistance.
 13 • Selective Aortic Arch Perfusion 149

300 seconds respectively, P < .001.30 Cardiac arrest com- The effectiveness of SAAP may be more limited with thoracic
plicates femoral arterial access due to arterial vasomotor trauma, depending upon the vascular injuries and the rate of
contraction that is unopposed by normal distending pul- bleeding.
satile pressure. This is particularly true with hemorrhage-
induced hypovolemia. Rapid and reliable cannulation of a CLINICAL DECISION-MAKING IN ENDOVASCULAR
contracted femoral artery is likely to be the most variable
component of an endovascular resuscitation procedure, RESUSCITATION
and ideally is secured in all at-risk patients prior to cardiac Endovascular resuscitation is not without risk to the
arrest. The increasing use of ultrasound-guided percuta- patient. In the early management of medical cardiac arrest
neous vascular access and improvements in ultrasound and hemorrhagic shock, the benefit:risk of ECPR and
technology are important advances, but there may still be REBOA, respectively, are not well understood. In traumatic
circumstances in which surgical vascular access is needed hemorrhage, this clinical dilemma is best illustrated by the
to initiate time-critical endovascular resuscitation to pro- clinical decision-making around which patients require
mote survival. The optimal approaches for percutaneous, REBOA in order to survive to the operating theater for
surgical cutdown, and hybrid vascular access techniques definitive surgical hemostasis and which patients will sur-
is an area of ongoing study and discussion. Proper proce- vive to surgical hemostasis without REBOA and its potential
dural skills training and sustained proficiency with vascular risks. Identifying the patients who will rapidly progress to
access are central to the evolution of endovascular resusci- a state of impending cardiac arrest (heart still beating but
tation. no discernible blood pressure) leading to true cardiac arrest
The endovascular resuscitation era that is emerging (heart no longer contracting) is a significant challenge. In
offers a set of interventions that can be applied in both med- medical cardiac arrest, the optimal time for initiation of
ical and traumatic cardiac arrest where standard noninva- VA-ECLS/ECPR after standard therapies have failed remains
sive resuscitation therapies have either failed or are entirely unclear and is likely variable on an individual patient basis.
inadequate to address the complex pathophysiology and ECPR followed by extended post-ROSC VA-ECLS can lead to
injuries of the patient. These endovascular resuscitation complications and potentially burden ICU services.
interventions provide extracorporeal perfusion support, Although it is expected that more advanced interven-
hemorrhage control, physiological monitoring, and drug tion (e.g., SAAP compared to REBOA) confers a greater
delivery beyond the capabilities of present standard resusci- potential risk to the patient, it is also more likely to result
tation. These interventions may be used alone, in series, or in a ROSC and a good outcome, and can be used when the
in combination depending upon the needs of the individual risk:benefit is clearer. SAAP modalities may present a neat
patient, allowing for more precisely tailored care to promote solution to help navigate this theoretical dilemma, via their
survival. Endovascular resuscitation requires a high level logical, sequential, escalating (both in terms of interven-
of skill and a significant commitment of resources. How- tion level and risk) perfusion interventions. The ability to
ever, endovascular interventions offer the best hope for a sequentially escalate interventions, as needed, based on the
substantial improvement in survival from medical cardiac patient’s response to therapy has the potential to clarify the
arrest and HiTCA. risk:benefit decision-making process of endovascular inter-
vention. The aim of this escalation is to achieve ROSC as
rapidly as possible with the fewest resources and the lowest
Sequential SAAP Interventions risk to the patient, while providing vital brain perfusion.

SAAP was developed specifically for the treatment of car-

diac arrest and is applicable to both medical cardiac arrest
SEQUENTIAL ESCALATING SAAP INTERVENTIONS
and HiTCA. In medical cardiac arrest, the balloon occlusion The use of these sequential SAAP interventions and the
isolates the flow of perfusate to the aortic arch (to preferen- timing of deflation of the SAAP catheter balloon will vary
tially achieve optimal heart and brain perfusion) and theo- depending on whether the cause is medical cardiac arrest
retically increases cardiac afterload and CPP. SAAP with or HiTCA. There are three perfusion support modalities that
an exogenous oxygenated perfusate is a volume-loading can be employed using the SAAP catheter leading to transi-
intervention. However, SAAP with exogenous perfusate is tion to VA-ECLS (Fig. 13.4).
time/volume-limited—excessive loading risks circulatory
overload and pulmonary edema. In HiTCA, the volume
loading by SAAP is beneficial as a means of rapidly restor- SAAP With an Oxygenated Exogenous Oxygen Carrier
ing the intravascular volume loss associated with severe This initial SAAP intervention allows for rapid initiation of
hemorrhage. If the major source of hemorrhage is sub- heart and brain perfusion because it only requires femoral
diaphragmatic, the SAAP catheter balloon inflated in the arterial access and insertion of the SAAP catheter to begin
thoracic aorta serves to limit further arterial hemorrhage perfusion support. Stored (allogeneic) whole blood, diluted
caudal to the balloon in the same way as zone 1 (thoracic allogeneic packed red blood cells, HBOC, and fluorocarbon
aortic) REBOA. However, the principal aim of SAAP with emulsion (PFC) are potential exogenous oxygen carriers; all
exogenous perfusate is to provide heart and brain perfu- of these have been studied as SAAP perfusates with favor-
sion to achieve ROSC just as in medical cardiac arrest. The able results. The use of whole blood or packed red blood cells
immediate need to achieve ROSC in HiTCA means that with standard citrate anticoagulant requires the concomi-
SAAP is not contraindicated in the setting of intratho- tant administration of calcium mixed with the blood product
racic hemorrhage even if it may lead to additional bleeding. in a proportion to normalize the ionized calcium just before
150 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

D
C

Fig. 13.4 Modalities of selective aortic arch perfusion (SAAP) resuscitation beginning with (A) SAAP with exogenous oxygen carrier followed sequen-
tially, if needed, by (B) SAAP with autologous blood and (C) partial venoarterial (V-A) extracorporeal perfusion support via the SAAP catheter with the
balloon deflated, either temporarily until stabilization or as a bridge until cannulation for full V-A extracorporeal membrane oxygenation (ECMO) sup-
port (D). IVC, Inferior vena cava; RA, right atrium. (A, B, and D, From Manning JE, Rasmussen TE, Tisherman SA, Cannon JW. Emerging hemorrhage control
and resuscitation strategies in trauma: endovascular to extracorporeal. J Trauma Acute Care Surg. 2020;89(2S):S50–S58.)
 13 • Selective Aortic Arch Perfusion 151

infusion via the SAAP catheter. An HBOC in a balanced salt blood modality is most likely to be used in medical cardiac
solution, such as HBOC-201, does not require concomitant arrest victims in whom initial SAAP exogenous perfusate
calcium. The administration of intraaortic epinephrine dur- was time-limited and additional extracorporeal perfusion
ing this initial SAAP phase may be beneficial for its periph- support is needed to achieve ROSC, although use in HiTCA
eral vasoconstrictor effects or for its inotropic effects. SAAP with post-ROSC hemodynamic instability might also be
with an exogenous oxygen carrier is a volume-loading inter- considered up to the time limit for aortic balloon occlu-
vention and the duration of this modality depends upon the sion. This modality is similar to VA-ECLS but the perfusion
volume status of the patient at the time of cardiac arrest. is limited to the aortic arch and uses smaller catheters,
In HiTCA, SAAP with exogenous perfusate can ­continue and therefore lower infusion rates, to accomplish perfu-
until ROSC and normal intravascular volume has been sion support. When ROSC is achieved, the SAAP catheter
restored. With continuous SAAP infusion, this could be balloon is deflated as soon as possible while observing for
4 to 6 minutes or longer depending on the total blood hemodynamic decompensation, and the catheter removed
volume lost, the presence of ongoing hemorrhage, and
­ as soon as it is apparent that endovascular resuscitation is
the volume of exogenous perfusate available. Once ROSC no longer required. As already noted, the total SAAP bal-
and volume recovery have been achieved, the SAAP ­infusion loon inflation time should be less than 30 minutes. How-
is stopped, but can quickly be re-started if required. The ever, every effort should be made to deflate the balloon as
deflation of the SAAP catheter balloon is dependent upon soon as possible. If ROSC is achieved but intrinsic perfu-
the presence or absence of ongoing hemorrhage caudal to the sion and arterial blood pressure are inadequate, transition
inflated balloon. If hemorrhage control is needed, the SAAP to the next SAAP modality proceeds.
catheter balloon can remain inflated, serving to function as
zone 1 REBOA. However, the time limit for SAAP catheter
balloon inflation should probably be no longer than about Limited Whole Body SAAP Catheter Perfusion
20 minutes. The shorter time limit than that recommended Support
for REBOA is necessary owing to the expected ischemic bur- The third SAAP modality is essentially the continuation
den from the physiological insult of HiTCA as compared to of SAAP with autologous blood but with the SAAP cath-
severe hemorrhagic shock. The cumulative ischemia time for eter balloon deflated. As the perfusion is not restricted to
the abdominal viscera includes the cardiac arrest time period the aortic arch in this modality, it is technically no longer
plus the balloon occlusion time. Thus, SAAP balloon occlu- SAAP but simply using the SAAP catheter to provide a
sion time in HiTCA needs to be shorter than for zone 1 REBOA. limited degree of whole body venoarterial perfusion sup-
For medical cardiac arrest without hypovolemia, SAAP port. The maximum perfusion support in this modality is
with exogenous perfusate will likely be more time-limited. approximately 1 L/min. This SAAP modality is indicated in
This SAAP modality can be used for up to about 4 minutes patients who have achieved a ROSC but are not hemody-
before transition to the next modality. If this SAAP modal- namically stable post-ROSC and may need to be transitioned
ity is used intermittently (e.g., SAAP for 1 minute alternat- to VA-ECLS for prolonged perfusion support. If the patient
ing with CPR for 1–2 minutes), this phase can be extended improves hemodynamically over the short term (approxi-
to about 8 to 10 minutes. During this initial SAAP with mately 30 minutes), the SAAP modality may be withdrawn
exogenous oxygen-carrier intervention, femoral venous without the need for transition to VA-ECLS. However, this
access should be obtained to allow for transition to the next SAAP modality primarily serves as bridging support until
SAAP modality if ROSC has not been achieved or post-ROSC larger cannulas can be placed for transition to VA-ECLS.
hemodynamics are not sufficiently stable. If a ROSC occurs The time period for transition to VA-ECLS will depend upon
during initial SAAP with exogenous perfusate and there is a various factors. This SAAP modality may be used for longer
stable post-ROSC intrinsic perfusion and arterial blood pres- if the patient needs to be transported to the hospital or to
sure, the SAAP catheter can be flushed with crystalloid (to another location to initiate VA-ECLS. If anticoagulation has
prevent clot formation and allow further use) and the SAAP not been initiated up to this point, it should be considered
catheter balloon deflated. As soon as hemodynamic stabil- again during this phase. The use of this SAAP modality to
ity is achieved, the SAAP catheter can be removed. allow for cardiac catheterization and coronary intervention
is theoretical at this time.
SAAP With Oxygenated Autologous Blood
The next SAAP modality requires femoral venous catheter Transition From SAAP Catheter to VA-ECLS
access in order to withdraw the patient’s autologous blood Patients requiring extracorporeal perfusion support for a
to continue SAAP therapy using a closed venoarterial cir- prolonged time period (days to weeks) will need to be tran-
cuit. Therefore, in anticipation of the need for this SAAP sitioned to VA-ECLS. The role of SAAP ends with ROSC and
modality, femoral venous access is obtained during the early temporary post-ROSC perfusion support. The transi-
initial SAAP exogenous perfusate phase. The autologous tion to VA-ECLS can either be accomplished by cannulation
blood is circulated through an oxygenator and pumped of the femoral artery and vein contralateral to the SAAP
back into the aortic arch via the SAAP catheter with the catheter (allowing seamless transition and uninterrupted
balloon still inflated. The benefits and risks of heparin anti- perfusion support), or by removal of the SAAP catheter
coagulation should be considered at this point and may be over a guidewire and upsizing the same artery to an arte-
influenced by the cause of cardiac arrest and the availabil- rial ECLS cannula (with a brief loss of perfusion support).
ity of heparin-bonded circuits. As there is no further vol- The choice may be influenced by factors such as anatomi-
ume loading with this modality, it can be continued for a cal considerations and the circumstances under which the
longer time period. The SAAP with oxygenated autologous SAAP catheter was inserted.
152 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

Advantages and Limitations of If stored (allogeneic) blood is used as the exogenous per-
fusate for SAAP, it must be accurately matched with cal-
SAAP cium to assure the perfusate has a normal ionized calcium
at aortic infusion. The perfusion support provided by SAAP
Compared to standard resuscitation with closed-chest CPR is temporary and intended to achieve a ROSC. If a patient
and other endovascular resuscitation techniques, SAAP resuscitated by SAAP requires ongoing post-ROSC perfu-
has both advantages and limitations that vary depending sion support for many hours or days, the patient needs to
upon the cause of cardiac arrest. be transitioned to ECLS—SAAP cannot provide prolonged
support. However, as previously explained, the paradigm
of sequential, escalating SAAP modalities potentially
SAAP IN MEDICAL CARDIAC ARREST
clarifies the risk:benefit decision-making of endovascular
The principal advantage of SAAP over closed-chest CPR resuscitation.
is the scale of myocardial perfusion that can be generated.
Whereas closed-chest CPR at best generates a fraction of
normal myocardial blood flow, SAAP generates myocardial Laboratory Animal SAAP Studies
perfusion that is even greater than normal physiological
blood flow generated by a healthy beating heart. Closed- The concept of SAAP evolved in the late 1980s from an
chest CPR aims to increase aortic pressure and generate a effort to develop a minimally invasive resuscitation tech-
CPP gradient sufficient to drive myocardial blood flow (as nique to treat medical cardiac arrest that could (1) provide
well as providing cerebral perfusion). SAAP is an extracor- heart and brain perfusion support similar to cardiopulmo-
poreal perfusion therapy that provides a known, predeter- nary bypass using an exogenous oxygen carrier, (2) be initi-
mined level of perfusion. The aortic pressure generated is ated quickly using a single arterial system catheter, and (3)
secondary to the SAAP infusion and can be adjusted using be adaptable for use in the prehospital care setting where
intraaortic epinephrine. the time window allowing for survival is lost in most cardiac
Compared to VA-ECLS, SAAP can be initiated more arrests.1 Thus, the idea of a large-lumen thoracic aortic bal-
quickly by a single provider because it only requires arte- loon catheter that would limit infusion of an exogenous
rial access to begin perfusion support. VA-ECLS requires oxygen carrier to the vessels of the aortic arch, including
both arterial and venous access with larger cannulas and the heart and brain, was pursued. Although SAAP perfu-
a closed perfusion circuit to initiate perfusion. The SAAP sion is not limited solely to the heart and brain, this tech-
catheter has a smaller outer diameter than an arterial ECLS nique offers the closest approximation of that effort using a
cannula and does not require serial dilation steps for inser- single catheter that can be rapidly inserted without the need
tion. The larger ECLS cannulas generally require removal for imaging guidance.
in the operating theater with surgical vascular repair. The SAAP methodology has undergone large-animal labora-
smaller SAAP catheter can be removed quickly and should tory research over the past three decades and efforts to initi-
typically not require surgical intervention. Because SAAP ate clinical trials in both HiTCA and medical cardiac arrest
can be removed quickly and does not commit the patient to are presently being pursued. The earliest laboratory studies
several days of extracorporeal perfusion support, it could on SAAP were in ventricular fibrillation models of medical
be initiated earlier in resuscitation with fewer concerns for cardiac arrest. However, the applicability and advantages of
excessive intervention, and iatrogenic complications. SAAP in HiTCA soon led to study in models of severe hem-
The major limitation of SAAP with an exogenous oxygen orrhage mimicking traumatic cardiac arrest.
carrier is that it is a volume-loading procedure and is time-
limited, particularly in euvolemic or volume-overloaded SAAP IN VENTRICULAR FIBRILLATION CARDIAC
patients—most applicable in medical cardiac arrest. Poten-
tial adverse effects of volume overload due to SAAP are ARREST
most relevant in medical cardiac arrest and least likely in The first SAAP experiments investigated infusion rates to
severe hemorrhage. gain insight into the effective flow rates and limits to vol-
ume loading.1 Fluoroscopic experiments identified the need
for the initial rapid bolus to pressurize the aorta and close
SAAP IN HEMORRHAGE-INDUCED TRAUMATIC
the aortic valve.38 Myocardial blood flow during SAAP was
CARDIAC ARREST measured by colored microspheres and was demonstrated
In HiTCA, SAAP provides resuscitative perfusion to achieve to be greater than baseline myocardial blood flow when the
ROSC, rapid intravascular volume restoration, and aortic heart was beating normally prior to induction of cardiac
balloon occlusion distal hemorrhage control. Thus, SAAP arrest, in the range of 120% to 150% of baseline on aver-
accomplishes three of the aims of resuscitative thoracotomy age. The reason for this supranormal blood flow is that the
using a single balloon catheter, and in doing so reduces the heart in cardiac arrest can be perfused continuously com-
risk to providers, the additional physiological insult in the pared to the normal state of the beating heart which only
patient of a major surgical procedure, and can be employed receives blood flow during the diastolic phase of the cardiac
earlier in the hemorrhage spectrum (impending vs. true cycle. Continuous SAAP infusion without CPR chest com-
cardiac arrest) with a greater expectation of survival. In pressions and pulsed SAAP infusion timed with the diastolic
addition, intermittent aortic pressure measurement can be phase of CPR chest compressions did not show any signifi-
quickly performed to assess for ROSC and determination if cant difference in myocardial blood flow during cardiac
SAAP needs to be continued or stopped. arrest by colored microsphere measurements. Given the
 13 • Selective Aortic Arch Perfusion 153

importance of avoiding aortic valve incompetence, subse- the issue of citrate anticoagulant-related ionized hypocal-
quent research studies have performed SAAP without CPR cemia was not addressed in these experiments. Nonetheless,
chest compressions to avoid potential inadvertent compro- these first experiments in a HiTCA model demonstrated that
mise of aortic valve closure. oxygenated whole blood could effectively achieve ROSC.
Controlled laboratory comparisons of SAAP using PFC In recognition of the potential for limited blood product
emulsions as the oxygen carrier showed improved ROSC availability prehospital and the favorable characteristics
compared to control using standard noninvasive resuscita- of a room temperature, stable HBOC with a long shelf-
tion therapy.39,40 The time limit for infusion of an exogenous life, SAAP was subsequently examined using HBOC-201
oxygen carrier in medical cardiac arrest with euvolemia led compared to lactated Ringer’s solution in a model of liver
to the second SAAP modality of using autologous blood as trauma resulting in a brady-asystolic HiTCA.42 This study
the oxygenated perfusate. This required the addition of a fem- showed that SAAP with oxygenated HBOC-201 without
oral venous blood withdrawal catheter advancing the con- CPR or intraaortic epinephrine resulted in consistent ROSC
cept that femoral venous access would be obtained during after about 2 minutes of therapy. Two animals receiving
the initial SAAP-exogenous oxygen-carrier therapy.41 Thus, SAAP with lactated Ringer’s solution had very brief ROSC
SAAP with autologous blood does not prolong the time to aided by the addition of intraaortic epinephrine. This study
initiate SAAP but adds a means of sustained SAAP without further emphasized the need for a perfusate with adequate
further volume loading. SAAP with autologous blood is simi- oxygen-carrying capacity.
larly effective at achieving ROSC from ventricular fibrillation The lack of regulatory approval of any nonblood oxygen
cardiac arrest (Fig. 13.5). Intraaortic epinephrine adminis- carrier over time led to a renewed interest in blood products
tration has been studied alone and as an adjunct to SAAP serving as the SAAP oxygen-carrying perfusate. Although
during cardiac arrest.24,39 The use of small doses of intraaor- the early experiments using SAAP with oxygenated whole
tic epinephrine during cardiac arrest has been shown to be blood achieved ROSC, the correction of ionized calcium in
useful for promoting ROSC.23 More recently, a comparison of citrate anticoagulated blood had not been demonstrated. It
standard noninvasive resuscitation and SAAP with oxygen- was recognized that citrate anticoagulated blood has a non-
ated HBOC-201 in a ventricular fibrillation model showed detectable ionized calcium level and perfusion of the heart
improved ROSC with SAAP-HBOC. with such blood without correction of the ionized calcium
would result in refractory ventricular fibrillation. To address
this issue, a series of experiments was performed utilizing
SAAP IN HEMORRHAGE-INDUCED TRAUMATIC
stored, citrate anticoagulated whole blood and packed red
CARDIAC ARREST cells as the SAAP perfusate combined with calcium infu-
Laboratory studies in porcine models for severe HiTCA sion to yield ionized calcium levels in the normal range.43
have demonstrated the efficacy of SAAP with both blood The combination prevented hypocalcemia-induced ven-
products and HBOC-201, and also tested the SAAP modali- tricular fibrillation and demonstrated the ability to achieve
ties as an escalating paradigm.42–45 The first experiments ROSC with the concomitant administration of calcium with
defined the translation of SAAP in medical cardiac arrest to citrate anticoagulated blood products (Fig. 13.6). These
HiTCA, and the use of shed autologous blood was found to experiments provided data for the methods and quantifica-
be efficacious. In these experiments, the shed blood was hep- tion of concomitant calcium administration for SAAP with
arinized to prevent clot formation before reinfusion. Thus, both whole blood and packed red blood cells.

Fig. 13.5 Selective aortic arch perfusion (SAAP) in a porcine model of ventricular fibrillation (VF) cardiac arrest showing increasing energy of the VF
waveform followed by successful defibrillation (second arrow) to spontaneous circulation.
154 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

100
FWB-SAAP
80

Percent survival
60
LR-SAAP
40

20
CPR
REBOA
0
Fig. 13.6 Selective aortic arch perfusion (SAAP) in a porcine model of 0 10 20 30 40 50 60
hemorrhage-induced traumatic cardiac arrest showing return of QRS Time from start of arrest (minutes)
complexes with increasing rate on electrocardiogram (ECG) followed
by return of spontaneous circulation (ROSC). (From Manning JE, Ross JD,
McCurdy SL, True NA. Aortic hemostasis and resuscitation: preliminary Fig. 13.7 One-hour survival for selective aortic arch perfusion (SAAP) with
experiments using selective aortic arch perfusion with oxygenated blood fresh whole blood (FWB), SAAP with lactated Ringer’s (LR), cardiopulmo-
and intra-aortic calcium coadministration in a model of hemorrhage- nary resuscitation (CPR) alone, and resuscitative endovascular balloon
induced traumatic cardiac arrest. Acad Emerg Med. 2016;23:208–212.) occlusion of the aorta (REBOA) alone in a porcine model of hemorrhage-
induced traumatic cardiac arrest. (From Barnard EBG, Manning JE,
In order to characterize the level of hemorrhagic injury Smith JE, Rall JM, Cox JM, Ross JD. A comparison of selective aortic arch
that SAAP could effectively resuscitate and to make com- perfusion and resuscitative endovascular balloon occlusion of the aorta
parison with current and evolving resuscitation strate- for the management of hemorrhage-induced traumatic cardiac arrest:
gies, SAAP with fresh whole blood (FWB) was evaluated a translational model in large swine. PLoS Med. 2017;14(7):e1002349.)
against SAAP with oxygenated lactated Ringer’s solution,
zone 1 REBOA with intravenous FWB, and CPR with intra-
venous FWB.44 The porcine model was a hybrid of liver The use of SAAP in thoracic trauma has not been ade-
injury and controlled arterial hemorrhage that resulted in quately studied to date. One small series of experiments
a brady-asystolic arrest; 30% of the animals were in elec- evaluated SAAP in a porcine model of HiTCA with associ-
trocardiographic asystole (a very severe HiTCA). SAAP ated large pericardial tamponade resulting in electrical and
with oxygenated FWB resulted in significantly higher rates mechanical cardiac asystole (Fig. 13.9). SAAP restored
of ROSC and significantly higher 60-minute survival than an organized ECG rhythm and cardiac contractility when
the other three interventions (Fig. 13.7). In addition, SAAP 200 mL tamponade was still in place. The aortic arte-
with FWB was demonstrated to be capable of resuscitating rial pressure was low with the tamponade, but sequential
hemorrhage-induced cardiac asystole in large swine. removal of 50 mL from the pericardial sac resulted in cor-
More recent experiments have examined the use of sequen- responding increases in central aortic pressure (Fig. 13.10).
tial, escalating endovascular intervention in HiTCA: zone 1
REBOA with intravenous FWB (REBOA), followed by SAAP
with exogenous FWB (SAAP), followed by a SAAP circuit with
autologous blood (SAAP-circuit) as required. This paradigm Where Does SAAP Fit in
resulted in two animals (unexpectedly) achieving ROSC in Endovascular Resuscitation
the REBOA phase, two animals achieving ROSC in the SAAP
phase, and four animals achieving ROSC in the SAAP-circuit SAAP is an endovascular resuscitation therapy developed
phase—all eight survived the 60-minute simulated prehospi- specifically for cardiac arrest that has features in common
tal period. This set of experiments demonstrated two important with both VA-ECLS and REBOA. SAAP is primarily an extra-
concepts in HiTCA resuscitation: (1) that even in laboratory corporeal heart and brain perfusion technique to promote
conditions it is challenging to predict whether REBOA with ROSC from cardiac arrest. However, the thoracic aortic bal-
intravenous blood will result in a ROSC, and (2) that a para- loon occlusion integral to SAAP therapy provides hemor-
digm of escalating intervention improves the risk:benefit of rhage control caudal to the balloon consistent with zone
endovascular intervention by only exposing the subject to the 1 REBOA. These shared features make SAAP applicable to
risk of the intervention(s) required to achieve a ROSC, while both medical cardiac arrest and HiTCA, but SAAP is not the
providing vital brain perfusion after a prolonged arrest. same as either VA-ECLS or REBOA. This raises the question
Most recently, renewed interest in HBOCs for austere envi- of how SAAP should be integrated into both medical and
ronments, such as the battlefield, led to further investigation trauma resuscitation strategies.
of SAAP with oxygenated HBOC for resuscitation of HiTCA. In severe hemorrhagic shock leading to impending or true
In a laboratory model of liver injury and HiTCA, SAAP using cardiac arrest, SAAP is an intervention that bridges the gap
oxygenated FWB was compared with SAAP using oxygen- between REBOA hemorrhage control and resuscitative thora-
ated HBOC-201 to evaluate ROSC and 5-hour post-ROSC cotomy with manual cardiac compression to generate myo-
survival and physiological status.45 This study found that cardial perfusion. REBOA (zone 1 or zone 3) is an effective
ROSC rates were not statistically different and physiological means of hemorrhage control that allows for intravenous
recovery was similar for the two groups over the 5-hour post- volume resuscitation and transfer to the operating theater or
ROSC observation period; for example, the similar spectrum interventional radiology suite for definitive hemorrhage con-
of 5-hour lactate levels as an indicator of hemodynamic sta- trol. REBOA, particularly in zone 1, increases systemic vas-
bility, perfusion status, and metabolic recovery (Fig. 13.8). cular resistance and supports mean arterial pressure while
 13 • Selective Aortic Arch Perfusion 155

Lactate levels at end of post-surgery observation period

Two failed Defib

Large IVC clots Died before 4 hours

25

20 Poor / worsening

15
Post-DCS bleed/
Improving after
control
10
Contained pelvic hematoma Post-DCS bleed
Fair - Good / Improving

Excellent recovery

0
FWB + Ca2+ HBOC-201

Fig. 13.8 Final lactate levels showing similar recovery for selective aortic arch perfusion with fresh whole blood (FWB) plus calcium versus hemoglobin-
based oxygen carrier -201 (HBOC-201) at 5 hours after resuscitation from hemorrhage-induced traumatic cardiac arrest in a porcine model. DCS, Damage
control surgery; IVC, inferior vena cava.

Fig. 13.10 Hemodynamic response to selective aortic arch perfusion

Fig. 13.9 Illustration of selective aortic arch perfusion (SAAP) in peri- (SAAP) in a porcine model of hemorrhage-induced traumatic cardiac
cardial tamponade. arrest with an associated 200 mL pericardial tamponade. SAAP infu-
sion results in return of electrocardiographic activity and spontaneous
cardiac contractility with measurable arterial pressure while the peri-
intravenous fluid and blood resuscitation catch-up with cardial tamponade remains. The central aortic pressure progressively
hemorrhage-induced intravascular volume loss. REBOA increases with removal of the pericardial tamponade blood in 50 mL
is most effective when deployed while the heart is still beating increments. Right atrial pressure drops with relief of the pericardial
well and there is a discernible arterial blood pressure. When tamponade. FWB, Fresh whole blood.
patients become bradycardic and lose measurable blood pres-
sure, this is a state of impending cardiac arrest. REBOA can
be effective at this point but only if the heart continues to SAAP offers extracorporeal perfusion to aortic balloon
beat and intravenous blood transfusion rapidly corrects the occlusion hemorrhage control in the setting of true cardiac
volume and perfusion deficit. Traditionally, this is the point arrest due to hemorrhage or impending cardiac arrest with
at which resuscitative thoracotomy is either performed, or at rapidly dropping heart rate and extremely low, nonviable blood
least considered, before cessation of resuscitation efforts. pressure. The combination of thoracic aortic balloon occlusion
156 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

(functional aortic cross-clamp), extracorporeal perfusion with to ECMO. Therefore, in the setting of medical cardiac arrest,
exogenous oxygen carrier (more effective than manual cardiac SAAP is an intervention between closed-chest CPR and
compression), and rapid intravascular volume replacement VA-ECLS that can potentially achieve ROSC and prevent
(equivalent to or better than intravenous infusion) provided unnecessary prolonged ECLS support.
for by the SAAP technique can serve to promote ROSC with-
out the need for a thoracotomy and bridge survival until the
patient can be transferred to the operating theater for definitive
hemorrhage control. Therefore, in the setting of hemorrhage- Implications for Trauma and
induced cardiac arrest, SAAP is an intervention between Vascular Surgery
REBOA and resuscitative thoracotomy that can potentially
achieve ROSC and obviate the need for thoracotomy. The emergence of endovascular resuscitation in both medi-
In medical cardiac arrest, the potential role of SAAP lies cal cardiac arrest and severe hemorrhagic shock will lead
between standard resuscitation therapies of the present to many more emergency vascular access procedures being
day, the foundation of which is closed-chest CPR, and the performed under time pressure in suboptimal conditions.
implementation of VA-ECLS during cardiac arrest or ECPR. This reality can be expected to result in a growing number
A proportion of medical cardiac arrest victims can be resus- of vascular access–related and endovascular resuscitation
citated with closed-chest CPR and defibrillation, if bystander intervention–related complications that will require the
CPR is initiated without delay and an automated defibril- expertise and care of vascular surgeons. It is unrealistic to
lator is nearby and used appropriately. However, these two think that these time-critical endovascular resuscitation pro-
conditions are infrequently met. Delays in CPR and defibril- cedures will be performed by vascular surgeons. Indeed, the
lation lead to decreased effectiveness of CPR and degraded vast majority will not be performed by vascular surgeons and
electrical energy, respectively, that result in preventable it is likely that many of these procedures will be performed by
deaths just as uncontrolled hemorrhage with severe hypo- non-surgeons. For example, prehospital ECMO cannulations
perfusion does in trauma. VA-ECLS/ECPR provides extra- in Paris for ECPR and prehospital REBOA catheterizations in
corporeal perfusion that can effectively reverse the ischemic London for uncontrolled hemorrhage are performed by pre-
debt that occurs during cardiac arrest and lead to ROSC and hospital emergency physicians. In the United States, emer-
long-term survival. Clinical reports are very promising with gency department cannulations for ECPR are performed by
remarkably high survival with good neurological recovery emergency physicians in some hospitals.
in the patients that meet criteria for ECPR. The positive approach to the emerging endovascular
An important aspect of VA-ECLS is that once a patient resuscitation era is to foster collaboration between resuscita-
has been cannulated during cardiac arrest for ECPR and tion physicians who will be performing these interventions
had achieved ROSC, the patient remains on VA-ECLS. The and vascular surgeons who may be involved in training and
duration of VA-ECLS support after ROSC is typically several will likely manage complications. The active involvement of
days. In general, VA-ECLS is not an intervention that can be vascular surgeons in vascular access training, procedure
quickly discontinued. It usually requires surgical decannu- protocols, and case reviews will serve to improve care and
lation and vascular repair in an operating theater. Although limit vascular complications for these endovascular resus-
some resuscitated patients need ongoing perfusion support citation interventions. It should be kept in mind that these
post-ROSC, some do not. This issue is faced when trying interventions are an effort to save the lives of patients who
to determine the appropriate criteria for committing the presently almost invariably die. Success in this arena will be
resources required to perform VA-ECLS/ECPR. In some sys- a major advance in resuscitation medicine, one that may
tems, standard therapy is continued for 20 minutes before impact us personally someday.
the patient is considered for VA-ECLS/ECPR in an effort to
avoid overutilization. There is a tension between waiting too
long to initiate VA-ECLS/ECPR and overutilization without Summary
any clear parameters to distinguish the appropriate choice.
Temporary heart and brain perfusion during cardiac SAAP has been developed over three decades of large animal
arrest may be adequate to achieve ROSC and promote long- laboratory research as an advanced endovascular resusci-
term survival without the need for prolonged ECLS support. tation technique aimed at transforming the survivability
This is the niche that SAAP is designed to fill. The sequence of both medical cardiac arrest and hemorrhage-induced
of SAAP interventions previously described could be initi- cardiac arrest. SAAP is presently being advanced toward
ated early in resuscitation after initial CPR and defibrillation clinical trials and implementation. During the develop-
have failed without committing to prolonged ECLS support. ment of SAAP, endovascular resuscitation technology has
If ROSC is achieved and the patient is hemodynamically sta- significantly advanced, which has both helped to under-
ble post-ROSC, SAAP can be withdrawn rapidly. However, stand the need for this innovation and made it important
if the patient’s condition shows a need for ongoing ECLS to define how SAAP segues with other interventions. The
support, SAAP interventions can be used to provide bridg- use of escalating SAAP modalities complements REBOA,
ing support until cannulation for VA-ECLS can be accom- VA-ECLS/ECPR, and EPR by providing a logical step-wise
plished. Thus, SAAP in medical cardiac arrest may promote approach that assists with clinical decision-making while
ROSC and favorable neurological recovery without commit- reducing the potential risks to the patient of endovascular
ting patients to extended ECLS support post-ROSC. However, intervention by only delivering the least invasive interven-
if ongoing ECLS support is needed, SAAP serves as a bridge tion required for survival in a timely fashion.
 13 • Selective Aortic Arch Perfusion 157

References 27. Sadek S, Lockey DJ, Lendrum RA, et al. Resuscitative endovascular
balloon occlusion of the aorta (REBOA) in the pre-hospital setting: an
1. Manning JE, Murphy CM, Hertz CM, Perretta SG, Mueller RA, Nor- additional resuscitation option for uncontrolled catastrophic haemor-
fleet EA. Selective aortic arch perfusion during cardiac arrest: a new rhage. Resuscitation. 2016;107:135–138.
resuscitation technique. Ann Emerg Med. 1992;21:1058–1065. 28. Belenkiy SM, Batchinsky AI, Rasmussen TE, et al. Resuscitative endo-
2. Institute of Medicine. Strategies to Improve Cardiac Arrest Survival: vascular balloon occlusion of the aorta for hemorrhage control: past,
A Time to Act. Washington, DC: The National Academies Press; 2015. present, and future. J Trauma Acute Care Surg. 2015;79:S236–S242.
3. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival 29. Brenner M, Inaba K, Aiolfi A, et al. Resuscitative endovascular bal-
from out-of-hospital cardiac arrest: a systematic review and meta- loon occlusion of the aorta and resuscitative thoracotomy in select
analysis. Circ Cardiovasc Qual Outcomes. 2010;3(1):63–81. patients with hemorrhagic shock: early results from the American
4. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac Association for the Surgery of Trauma’s Aortic Occlusion in Resus-
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5. Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378:370–379. 30. Brenner M, Teeter W, Hoehn M, et al. Use of resuscitative endo-
6. Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a vascular balloon occlusion of the aorta for proximal aortic con-
review with contemporary definitions and management strategies. trol in patients with severe hemorrhage and arrest. JAMA Surg.
Surg Clin North Am. 2012;92:843–858. 2018;153:130–135.
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2011): implications for the future of combat casualty care. J Trauma effects of the intra-aortic balloon pump during experimental cardiac
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achievable goal. J Trauma Acute Care Surg. 2017;82(Suppl):S2–S8. intra-aortic occlusion balloon in external thoracic compressions dur-
9. Beck B, Tohira H, Bray JE, et al. Trends in traumatic out-of-hospital ing CPR in pigs. Am J Emerg Med. 2002;20:453–462.
cardiac arrest in Perth, Western Australia from 1997 to 2014. Resus- 33. Bellezzo JM, Shinar Z, Davis DP, et al. Emergency physician-initi-
citation. 2016;98:79–84. ated extracorporeal cardiopulmonary resuscitation. Resuscitation.
10. Soar J, Callaway CW, Aibiki M, et al. Advanced Life Support Chapter 2012;83:966–970.
Collaborators. Part 4: Advanced life support: 2015 international con- 34. Lamhaut L, Jouffroy R, Soldan M, et al. Safety and feasibility of
sensus on cardiopulmonary resuscitation and emergency cardiovas- prehospital extra corporeal life support implementation by non-
cular care science with treatment recommendations. Resuscitation. surgeons for out-of-hospital refractory cardiac arrest. Resuscitation.
2015;95:71–120. 2013;84:1525–1529.
11. Barnard E, Yates D, Edwards A, Fragoso-Iniguez M, Jenks T, Smith 35. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated
JE. Epidemiology and aetiology of traumatic cardiac arrest in Eng- with mechanical CPR, hypothermia, ECMO and early reperfusion (the
land and Wales—a retrospective database analysis. Resuscitation. CHEER trial). Resuscitation. 2015;86:88–94.
2017;110:90–94. 36. Vase H, Christensen S, Christiansen A, et al. The Impella CP device
12. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma for acute mechanical circulatory support in refractory cardiac arrest.
outcome: an overview of epidemiology, clinical presentations, and Resuscitation. 2017;112:70–74.
therapeutic considerations. J Trauma. 2006;60:S3–11. 37. Tisherman SA, Alam HB, Rhee PM, et al. Development of the emer-
13. Perkins GD, Travers AH, Berg RA, et al. Basic Life Support Chapter gency preservation and resuscitation for cardiac arrest from trauma
Collaborators. Part 3: Adult basic life support and automated exter- clinical trial. J Trauma Acute Care Surg. 2017;83:803–809.
nal defibrillation: 2015 international consensus on cardiopulmonary 38. Manning JE, Batson DN, Murphy Jr CA, Perretta SG, Norfleet EA.
resuscitation and emergency cardiovascular care science with treat- Selective aortic arch perfusion during cardiac arrest: rapid aor-
ment recommendations. Resuscitation. 2015;95:43–69. tic arch pressurization is required to consistently achieve compe-
14. Paiva EF, Paxton JH, O’Neil BJ. The use of end-tidal carbon dioxide tent aortic valve closure and coronary perfusion. Crit Care Med.
(ETCO2) measurement to guide management of cardiac arrest: a sys- 1994;22:A129.
tematic review. Resuscitation. 2018;123:1–7. 39. Manning JE, Batson DN, Payne FB, et al. Selective aortic arch perfu-
15. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac sion during cardiac arrest: enhanced resuscitation using oxygenated
massage. JAMA. 1960;173:1064–1067. perflubron emulsion with and without aortic arch epinephrine. Ann
16. Niemann JT, Rosborough JP, Ung S, et al. Coronary perfusion pressure Emerg Med. 1997;29:580–587.
during experimental cardiopulmonary resuscitation. Ann Emerg Med. 40. Manning JE, Batson DN, Gansman TW, Murphy Jr CA, Perretta SG,
1982;11:127–131. Norfleet EA. Selective aortic arch perfusion using serial infusions of
17. Bellamy RF, DeGuzman LR, Pedersen DC. Coronary blood flow during perflubron emulsion. Acad Emerg Med. 1997;4:883–890.
cardiopulmonary resuscitation in swine. Circulation. 1984;69:174–180. 41. Barton CW, Manning JE, Batson DN. Effect of selective aortic
18. Ditchey RV, Winkler JV, Rhodes CA. Relative lack of coronary arch perfusion on median frequency and peak amplitude of ven-
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19. Luna GK, Pavlin EG, Kirkman BS, et al. Hemodynamic effects of exter- 42. Manning JE, Katz LM, Pearce LB, et al. Selective aortic arch per-
nal cardiac massage in trauma shock. J Trauma. 1989;29:1430–1433. fusion with hemoglobin-based oxygen carrier-201 for resuscita-
20. Mattox KL, Feliciano DV. Role of external cardiac compression in trun- tion from exsanguinating cardiac arrest in swine. Crit Care Med.
cal trauma. J Trauma. 1982;22:934–936. 2001;29:2067–2074.
21. Michael JR, Guerci AD, Koehler RC, et al. Mechanisms by which epi- 43. Manning JE, Ross JD, McCurdy SL, True NA. Aortic hemostasis and
nephrine augments cerebral and myocardial perfusion during cardio- resuscitation: preliminary experiments using selective aortic arch
pulmonary resuscitation in dogs. Circulation. 1984;69:822–835. perfusion with oxygenated blood and intra-aortic calcium coadmin-
22. Paradis NA, Martin GB, Rivers EP, et al. Coronary perfusion pressure istration in a model of hemorrhage-induced traumatic cardiac arrest.
and the return of spontaneous circulation in human cardiopulmo- Acad Emerg Med. 2016;23:208–2012.
nary resuscitation. JAMA. 1990;263:1106–1113. 44. Barnard EBG, Manning JE, Smith JE, Rall JM, Cox JM, Ross JD.
23. Manning JE. Feasibility of blind aortic catheter placement in the A comparison of selective aortic arch perfusion and resuscitative
prehospital environment to guide resuscitation in cardiac arrest. endovascular balloon occlusion of the aorta for the management
J Trauma Acute Care Surg. 2013;75:S173–S177. of hemorrhage-induced traumatic cardiac arrest: a translational
24. Manning JE, Murphy Jr CA, Batson DN, Peretta SG, Mueller RA, Nor- model in large swine. PLoS Med. 2017;14(7):e1002349. https://doi.
fleet EA. Aortic arch versus central venous epinephrine during CPR. org/10.1371/journal.pmed.1002349.
Ann Emerg Med. 1993;22:703–708. 45. Hoops HE, Manning JE, Graham TL, McCully BH, McCurdy SL, Ross
25. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular JD. Selective aortic arch perfusion with fresh whole blood or HBOC-
balloon occlusion of the aorta (REBOA) as an adjunct for hemor- 201 reverses hemorrhage-induced traumatic cardiac arrest in a
rhagic shock. J Trauma Acute Care Surg. 2011;71:1869–1872. lethal model of non-compressible torso hemorrhage. J Trauma Acute
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 14 Endovascular to Extracorporeal
Organ Support for Vascular
Trauma and Shock
KEVIN K. CHUNG, ANDRIY I. BATCHINSKY, and IAN J. STEWART

Introduction devices.7 These machines were based on technology from

chronic dialysis, but were a major advance from prior CRRT
Mechanical trauma to major arteries often leads to signifi- therapies that relied on an assortment of pumps and dialyz-
cant vascular compromise to large tissue beds which then ers that were not an integrated unit.7 This was followed by
results in the reduction in oxygen delivery, cellular dysoxia, machines designed for the care of critically ill patients with
and cell death. This occurs in varying degrees, depending acute kidney injury (AKI), such as the PRISMAFLEX (Bax-
on the robustness of collateral blood flow to every anatomic ter International, Deerfield, IL), and the NxStage System
region and organ in the body (e.g., muscle, kidney, lungs, One (NxStage Medical Inc., Lawrence, MA). These devices
liver, intestines, etc.). Regardless, it has been well docu- were relatively simple to set-up and maintain, leading to
mented that the degree and extent of tissue injury directly widespread adoption of the technology. Another major
correlates with the duration of the ischemic insult.1–3 As advancement was the clarification of the proper “dose” of
arterial vessels are repaired and blood flow is restored via RRT in the setting of AKI in two, large randomized con-
a variety of open and endovascular techniques described trolled trials (RCTs) involving a mixed critically ill popula-
in chapters throughout this textbook, varying degrees of tion.8,9 Based on these data, the Kidney Disease: Improving
metabolic and end-organ consequences can be expected Global Outcomes (KDIGO) guidelines recommends a mini-
and are widely characterized as “ischemia-reperfusion” mum dose of 20 to 25 mL/kg per hour with CRRT therapy.10
injury.4,5 Reperfusion of damaged skeletal muscle often There are three major modalities of RRT used to treat
results in profound metabolic and inflammatory derange- patients with AKI: intermittent hemodialysis (IHD), CRRT,
ments secondary to the release and circulation of cellular and slow low-efficiency dialysis (SLED). Prior to discussing
contents. This often is compounded by concomitant direct the nuances between the modes of RRT, an explanation of
tissue injury, such as blunt force injury or crush, which how clearance is achieved is important. The first method by
can augment the metabolic derangement several fold. Glob- which the blood is cleared is by diffusion, or hemodialysis.11
ally, the dysregulated immune-inflammatory cascade that With diffusion, the blood and dialysate are separated in a
ensues can trigger a distributive shock characterized by hollow fiber dialyzer by a semipermeable membrane. The
capillary leak, hemodynamic instability, coagulopathy, and difference in concentration of a particular solute between
end-organ failure (Fig. 14.1). Recent disruptive advances the two compartments drives clearance and manages meta­
in the field of vascular surgery in the form of endovascular bolic disturbances. For example, patients with ischemia-
occlusion techniques for hemorrhage control and a variety reperfusion injury often have hyperkalemia and metabolic
of endovascular repair options have pushed the physiologi- acidosis. Compared to the blood, the dialysate is low in
cal limits of what is humanly possible to sustain life after potassium. Therefore, potassium goes down its concentra­
severe injury. As such, an increasing number of severely tion gradient from the blood into the dialysate and is thus
injured patients are surviving longer into the hospitaliza- cleared from the body. Conversely, the dialysate has a rela­
tion and are more metabolically deranged than ever with tively high concentration of bicarbonate compared to the
varying degrees of end-organ injury.6 Fortunately, the field blood. This results in a net transfer from the dialysate to the
of critical care has experienced an equally formidable leap blood, which improves acid-base status. The second method
in medical innovation in the form of various extracorporeal of clearance in RRT is convection, or hemofiltration.11 With
organ support technologies.6 This chapter will review the this method of clearance, there is no dialysate. Instead,
latest advances and techniques to assist vascular trauma the semipermeable membrane is used only to remove fluid
specialists in the management of metabolic derangements and electrolytes from the blood. Separately, a replacement
and organ failure, with a focus on renal and lung support. fluid is infused into the blood line. Similar to dialysate, the
replacement fluid is low in concentration of things that need
to be removed (e.g., potassium) and high in concentration
Advances in Renal Support of things that need to be added (e.g., bicarbonate).
The first type of RRT used to treat patients with AKI is IHD
Over the last three decades, major advancements have which primarily uses hemodialysis or diffusive clearance.
been made in renal replacement therapy (RRT). The early This method utilizes machines that are designed for use in
1990s saw the first generation of continuous RRT (CRRT) patients with end-stage renal disease and are on chronic

158
 14 • Endovascular to Extracorporeal Organ Support for Vascular Trauma and Shock 159

Heart
Inflammatory
insult
↑ Oxidative stress
↓ Myocardial perfusion
Lung Myocardial infarction
Inflammatory
insult
↑ Oxidative stress
↓ O2 transport Kidney
Hypoxia Inflammatory
Pulmonary HTN insult
↑ A-a gradient ↑ Oxidation abcess
Edema Direct dissect damage
ARDS ↑ Endothelial dysfunction
Imperial GFR
Kidney failure

Continued
ischemia Reperfusion
↓ SVR
Distributive shock

End organ failure

or organ support technologies Ischemia
↑ IL-6
↑ IL-8
↑ TNF-α
↑ CK
↑ LDH

Fig. 14.1 Anatomic schematic representing the cascade of events that occurs during an ischemia reperfusion insult. Ischemia results in cellular dysoxia
which leads to cell death and the local release of intracellular enzymes, inflammatory cytokines, and chemokines into the local tissue. Upon reperfusion
of the tissue bed, the compilation of the enzymes is released into the systemic circulation resulting in direct and indirect inflammatory injuries to vari-
ous organs including the kidneys, heart, lungs, liver, and gastrointestinal tract. This ultimately leads to end-organ failure that can occur in isolation or
in combination. ARDS, Acute respiratory distress syndrome; CK, creatine kinase; GFR, glomerular filtration rate; HTN, hypertension; IL, interleukin; LDH,
lactate dehydrogenase; SVR, systemic vascular resistance; TNF-α, tumor necrosis factor-α.

RRT. With IHD, dialysate is made using concentrated elec­ to 25 mL/kg per hour.14 For example, the proper dose for a
trolyte solutions and tap water that has been thoroughly 70-kg patient would be 1400 to 1750 mL/hour of replace­
processed and purified.12 The second type of RRT is ment fluid (if using CVVH), dialysate (if using CVVHD), or
CRRT, which can be subdivided into continuous veno- a combination of the two (if using CVVHDF). The primary
venous hemofiltration (CVVH), continuous veno-venous difference between CRRT and IHD is time and clearance.
hemodialysis (CVVHD), and continuous veno-venous IHD typically lasts 3 to 4 hours, requiring a large amount of
hemodiafiltration (CVVHDF).13 These techniques utilize clearance over that time period to meet the patient’s meta­
devices that were designed to be used in critically ill patients bolic demand. Conversely, CRRT runs continuously, allow­
with AKI. The primary difference between the modes of ing time for much slower clearance. In contrast to IHD,
CRRT is the method of clearance that is employed. CVVH uses which generates dialysis using tap water and concentrated
replacement fluid for convective clearance (hemofiltration), electrolyte solutions, CRRT therapies utilize prepackaged
whereas CVVHD uses dialysate for diffusive clearance sterile solutions for dialysate or replacement fluid.
(hemodialysis). CVVHDF is a combination therapy that uses The third type of RRT used to treat AKI is SLED.15,16
both convective and diffusive clearance (hemodiafiltration). SLED is also sometimes referred to in the literature as pro-
CVVH, CVVHD, and CVVHDF are all dosed relative to the longed intermittent RRT or extended daily dialysis. SLED
patient’s body weight, and prescribed in mL/kg per hour. As uses standard IHD machines, but operates at lower blood
noted previously, the recommended minimum dose is 20 and dialysate flow rates. Whereas a typical IHD session has
160 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

blood and dialysate flow rates of 200 to 400 and 400 to unstable patients, whereas IHD is the preferred modality for
700 mL/min, respectively, SLED treatments have dialysate hemodynamically stable patients.10
and blood flows of 100 to 200 mL/min. Although most SLED The timing of RRT is controversial in the nephrology
treatments last 8 hours, sessions lasting 24 hours have been and critical care fields. Early observational evidence was
described.17 The major advantage of SLED is that because mixed due primarily to different definitions of “early.” One
it leverages traditional IHD, it is relatively easy to institute study did not find a difference on timing of RRT when
in hospitals that do not have sufficient patient volume for early was defined by blood urea nitrogen concentration,
formal CRRT programs. However, there are some concerns but found that when RRT was started within 2 days of ICU
regarding SLED when compared to CRRT and IHD. The first admission there was an association with lower mortality
is electrolyte disturbances, particularly hypophosphatemia, compared with patients who started RRT after ICU day 5.26
which can make it difficult to wean patients from mechani- Similar findings were observed in another retrospective
cal ventilation.18 The second is that the optimal dosing of cohort, in which a lower risk of mortality was present
antibiotics is unclear, especially when SLED treatments are when RRT was initiated within 24 hours of the diagnosis
longer than 8 hours.19 of severe AKI.27 This study found that early RRT was asso-
There are two theoretical benefits to CRRT over IHD in ciated with decreased days on mechanical ventilation and
hemodynamically unstable patients. The first is the slower less time on RRT.27
rate of volume removal. As noted previously, an IHD ses­ Recently, three RCTs have examined the optimal timing
sion typically lasts 3 to 4 hours. Over this relatively short of RRT. The first of these was the Artificial Kidney Initiation
period of time, the entire amount of fluid prescribed to be in Kidney Injury (AKIKI) trial.28 The AKIKI trial random-
removed that day must be taken off the patient. As CRRT ized 620 subjects with severe AKI to early (within 6 hours)
can remove the required volume over a 24-hour period, or late (when the subject developed metabolic disturbances,
the rate at which volume is removed is lower. For example, pulmonary edema, or oliguria) RRT. There was no differ-
if 3 L must be removed, the hourly rate would be 750 mL ence in the primary end point of 60-day mortality. The
with a 4-hour IHD treatment. With a 24-hour CRRT treat­ second study was the Effect of Early vs Delayed Initiation
ment, the hourly rate would be much lower at 125 mL. This of Renal Replacement Therapy on Mortality in Critically
reduced hourly rate is postulated to improve hemodynamic Ill Patients with Acute Kidney Injury (ELAIN) trial.29 The
stability. A second theoretical benefit to CRRT over IHD in ELAIN trial was a single center study of 231 patients with
hemodynamically unstable patients is the slower rate of moderate AKI and an elevated plasma neutrophil gelatin-
clearance. The high clearances of IHD result in a decrease ase-associated lipocalin (a biomarker for AKI). Early was
of plasma osmolality.20 When this occurs, an osmotic gra­ defined as initiating RRT within 8 hours of moderate AKI
dient is established between the intravascular space and and late as initiating RRT within 12 hours of severe AKI. In
the extra­ vascular space, drawing water into the extra­ contrast to the AKIKI study, ELAIN found a decrease in mor-
vascular compartment. This reduces blood volume and may tality when RRT was initiated early. The third study was the
adversely impact hemodynamics. Another situation where Initiation of Dialysis Early Versus Delayed in the Intensive
the slow clearance of CRRT can be advantageous is for Care Unit (IDEAL-ICU).30 This multicenter trial randomized
patients with traumatic brain injury (TBI). In patients with 488 patients with severe AKI to an early strategy (within
TBI, the osmotic shifts involved with the greater clearance 12 hours) or a late strategy (after a delay of 48 hours if
of solute with IHD can result in increased intracranial the patient did not recover renal function). Similar to the
pressure and cerebral edema.21 Although solute is removed AKIKI study, the IDEAL-ICU trial did not find a difference in
quickly from the intravascular space with IHD, there is mortality between the two arms. Although there is another
a lag before it can re-equilibrate across the blood-brain large multicenter trial ongoing,31,32 the preponderance of
barrier, resulting in the intracranial compartment having evidence currently points against the generalizability of
a higher osmolarity than the vascular compartment. This an early approach. However, it is important to note that
concen­tration gradient results in the transfer of water to the only trial to show a benefit (ELAIN) started RRT much
the intracranial compartment via osmosis.22 The slower earlier than either the AKIKI study or the IDEAL-ICU study.
clearances provided by CRRT minimize this gradient and Furthermore, ELAIN involved mostly surgical patients and
may decrease cerebral edema.23 included a novel biomarker to risk-stratify patients. It is
Despite these theoretical benefits, the results from obser­ therefore possible that some patients could benefit from an
vational and clinical trials have been mixed. A recent early initiation strategy, especially when a biomarker is used
metaanalysis of 21 studies (16 comparing CRRT with IHD to stratify patients.
and 5 comparing CRRT with SLED) did not demonstrate A variety of other extracorporeal treatment techniques
a difference between the modalities in terms of mortality, have been examined in an effort to improve mortality in
dialysis dependence, or length of hospital and intensive care critically injured and ill patients with AKI. One of these
unit (ICU) stays.24 In contrast, a previous metaanalysis of is high-volume hemofiltration (HVHF). There is some evi-
23 studies found that IHD was associated with higher rates dence from small studies that HVHF improves surrogate
of dialysis dependence than CRRT.25 These results were outcomes. For example, HVHF has been demonstrated
largely driven by the results from the 16 observational stud- to decrease vasopressor dependency index and multiple
ies. The seven RCTs did not demonstrate a significant ben- organ dysfunction syndrome score in critically ill patients
efit to CRRT. However, the total number of patients in the with burn injury.33 In the largest RCT done to date in 140
RCTs was small (N = 240 for IHD and N = 232 for CRRT). critically ill patients, no difference was observed in 28-day
Despite this paucity of evidence, current opinion in the field mortality or hemodynamic profiles.14 What is clear is
is that CRRT is the preferred modality for hemodynamically that this technique is relatively well-tolerated. Thus, in
 14 • Endovascular to Extracorporeal Organ Support for Vascular Trauma and Shock 161

select patients with profound metabolic derangements 12 mL/kg IBW.49 This strategy, known as lung-protective
being treated with CVVH, increasing the dose of therapy ventilation, has become an important tool for treating ARDS,
to achieve metabolic control seems reasonable and should but it has not been a panacea. Studies have shown that
be requested. despite using the ARDSNet strategy, lung hyperinflation,
Since the early 2000s, CRRT has gained widespread and thus VILI, still occur in approximately 30% of patients.50
acceptance and has saved countless lives. Despite these Furthermore, for patients in whom a lung-protective strat-
advances, the mortality rate of injured patients with AKI egy is implemented, second-order consequences such as
requiring RRT is high at 40% to 67%.34–36 Early initiation or hypoventilation, hypercarbia, and acidosis often complicate
HVHF may have benefit in postsurgical patients with pro- management. This is particularly challenging in severely
found metabolic derangements. However, the effect sizes injured trauma patients, acute or chronic renal failure, con-
are likely to be small and these are difficult to generalize. comitant brain injury, and in those with severe cardiovas-
RRT will always have a role in the management of elec- cular or peripheral vascular disease.51
trolyte disturbances and volume overload; however, future Extracorporeal life support (ECLS) for adult lung failure
advances in patient care will need to couple it with support has become an increasingly valuable tool for the clinical
to other organs (such as extracorporeal membrane oxygen- management of ARDS. In a practical sense, the role of ECMO
ation [ECMO]) and other forms of blood purification tar- off-loads the lungs and spares pulmonary parenchyma from
geted at immune-modulation and pathogen removal. exposure to VILI. As they apply to treatment of lung failure
and ARDS, the terms ECMO and ECLS are interchangeable.
Currently, ECMO is used to extend survival by providing for
Advances in Lung Support both oxygenation and carbon dioxide clearance in critically
ill patients who have failed to improve on less invasive tech-
Acute lung injury and acute respiratory distress syndrome niques such as ARDSNet strategies. Ultimately, the goal of
(ARDS) are well-recognized problems following vascular ECMO is to provide adequate time for the underlying clinical
trauma and shock. In the United States, 200,000 patients condition to be resolved and, consequently, allow the ARDS-
develop ARDS each year and it is anticipated that, by inciting inflammatory insult to abate.
2025, 300,000 cases will be seen per year.37 The causes of Functionally, ECMO is a miniaturized form of cardio­
ARDS are varied and classically include pneumonia, sepsis, pulmonary bypass. Although there are multiple modes of
inhalation injury, thermal injury, chemical exposure, and ECMO, all modes require cannulation of major vascular
iatrogenesis in the form of overzealous mechanical venti­ structures, by either open or percutaneous means. Large
lation and over exuberant fluid resuscitation.38,39 Similarly, 23- to 32-Fr catheters drain circulating blood into an
trauma, particularly, military unique trauma such as extracorporeal circuit and an artificial membrane lung
vascular trauma with shock, burns, blast injury,40 chemical which carries out gas exchange (delivers O2 and removes
weapons,41 and the medical care rendered to treat these CO2). Following gas exchange, oxygenated blood is returned
injuries42,43 also are common causes of ARDS. Although the to the body via a return circuit. The most common modes
precise molecular mechanism that initiates ARDS remains of ECMO are venovenous (VV) ECLS and venoarterial
enigmatic, the shared phenomenon of intense inflammation (VA) ECLS. Although both techniques rely on the use of
among these causes of ARDS is compelling. For this reason an exchange membrane, VV ECLS returns the oxygenated
it is not surprising that ischemia-reperfusion injuries also blood to the venous circulation, whereas VA ECLS returns
produce ARDS. Unfortunately, despite decades of research oxygenated blood to the arterial circulation.52,53 The major-
and numerous clinical trials, the reported mortality for ity of ECMO circuits augment flow with a centrifugal pump
ARDS remains high, ranging from 11% to 44%.37,44 and heat the returning blood with an integral heating ele-
At present, mechanical ventilation is the standard sup- ment.
portive intervention for ARDS and is highly effective in Use of ECMO was shown to be beneficial in adult trauma
most patients with mild ARDS. However, as the severity of victims as early as 197254 but subsequently received nega-
injury increases, lung function decreases. This is evidenced tive publicity after clinical trials from 1980 to 1990 showed
clinically by impairment of oxygenation, ventilation, and poor outcomes.55,56 Criticisms of the early ECLS stem largely
reductions in lung compliance. These changes often prompt from an inadequate appreciation of interactions between
increases in ventilator pressures and/or volumes which, in the mechanical ventilation and ECLS, and an inadequate
turn, place the patient at risk for ventilator-induced lung reduction of mechanical ventilation settings which con-
injury (VILI).45 Also referred to as barotrauma or volu­ tributed to iatrogenic VILI that likely increased mortal-
trauma, this mechanical insult is the result of increased ity. Furthermore, modern ECMO circuits avoid the use of
ventilator volumes and pressures delivered to a poorly com­ silicone-based membrane lungs and long, cumbersome
pliant lung. This overstretching of the lung parenchyma circuits made of biologically unfriendly polymers. These
provokes activation of the inflammatory cascade and leads technological differences led to unsustainable management
to multisystem organ failure.46–48 challenges such as transfusion of 1 to 2 L of blood and blood
Typically, early treatment of ARDS is focused on prevent- products per patient per day in the early clinical studies.57
ing VILI and was the focus of the landmark ARDSNet trial. Whereas the blood losses alone could explain the adverse
ARDSNet demonstrated that reduction in ventilator set- outcomes observed in the early studies, ECMO patients were
tings to a VT of 6 mL/kg of ideal body weight (IBW) and a also subjected to iatrogenic VILI and exposed to a high risk
maximum end-inspiratory plateau pressure (Pplat) of 30 cm of transfusion-related lung injury (TRALI).42,58 Today these
H2O was able to decrease mortality to 31%, compared complications are largely avoided with modern circuits. In
with 39.8% in the conventional arm treated with a VT of fact, today’s ECLS systems bear little physical resemblance
162 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

to their nascent predecessors (Fig. 14.2) and are clinically experience have produced laudable improvements in out-
separated by generations of technological advancement. comes for severely injured patients treated with ECLS.52,58,59
Lastly, access-related bleeding complications and subse­ Data from the ELSO registry shows that the number of
quent transfusion-related coagulopathies in up to 70% of ECMO cases performed annually is increasing (Fig. 14.3).59
patients led to a staggering rate of cerebral hemorrhage as At the same time reported survival has increased to 70%
a cause of death.55,56 For a combination of these reasons, to 80% in patients with severe ARDS in whom mechanical
ECLS before the year 2000 (and in some centers still to date) ventilation was no longer effective.59 These improvements,
was often started too late and in patients who were older interestingly, have occurred despite a continued bias favor-
and sicker, making them unlikely to benefit from therapy. ing last-resort ECMO and are a direct reflection of using bet-
Although early ECMO trials raised concerns of its efficacy ter technology.
prior to the 2000s, more recent trials have supported the In trauma-induced ARDS, which is more analogous to
lifesaving capabilities of modern ECLS centers. Two promi- vascular patients who have sustained shock and ischemia-
nent trials have since evaluated ECMO for lung support. The reperfusion, similar improvements in outcomes have been
CESAR trial (conventional ventilatory support vs. extracor- reported.60,61 In a review of ECLS for cardiopulmonary fail-
poreal membrane oxygenation for severe adult respiratory ure in trauma from 1994 to 2015, survival to discharge
failure)58 and the H1N1 trial.59 The H1N1 study was espe- ranged from 50% to 79%.62 These improvements in sur-
cially important for the renaissance of ECLS, as providers vival have not gone unnoticed by those caring for the most
were eager to initiate ECLS early when encountering ful- severely ill and injured in whom multisystem organ failure is
minant ARDS due to the H1N1 virus in otherwise healthy highly morbid and mortal. Evidence suggests combination
patients. Advancements in technology and increased user therapy with renal support may continue trends toward

Fig. 14.2 Representative images of early extracorporeal life support (ECLS) technology. Left panel shows first trauma patient treated using ECLS. In the
middle panel, a typical ECLS system from the 1990s is depicted. Right panel depicts the modern modular Xenios/Fresenius family of membrane lungs
and ECLS tools. Arrow on the left points to the membrane lung used in the Hill study in 1972 which had a 30-L priming volume; arrow on the right panel
points to the smallest pediatric membrane lung in the modern modular NovaLung (Xenios/Fresenius) system which has a 0.19-L priming volume. (Left
panel, Picture adopted from the manuscript describing the first trauma patient treated using ECLS by Hill et al., ASAIO. 1972;18(0):546–552. Middle panel,
Picture courtesy Luciano Gattinoni and Antonio Pesenti, Milan University, Italy.)

3000 16000

14000
2500
12000
2000
Cumulative runs

10000
Annual runs

1500 8000

6000
1000
4000
500
2000

0 0
19
19
19 8
19 9
19 0
19 1
19 2
19 3
19 4
19 5
19 6
19 7
19 8
20 9
20 0
20 1
20 2
20 3
20 4
20 5
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20
20 9
20 0
20 1
20
20 3
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87
8
8
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9
9
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08
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17

Annual runs Cumulative runs

Fig. 14.3 Sharp increase in extracorporeal life support cases for respiratory failure since the CESAR and H1N1 studies in 2006–2011. (Figure courtesy
Extracorporeal Life Support Organization [ELSO].)
 14 • Endovascular to Extracorporeal Organ Support for Vascular Trauma and Shock 163

In fact, there is potential to avoid intubation altogether for

select patients suffering exacerbations of CO2 retention.70
Currently, at the cutting edge of ECLS technology are
recently developed devices capable of partial ventilatory
lung support. These devices provide extracorporeal CO2
removal (ECCO2R), function at dialysis-like low blood flows
(350–500 mL/min), and now have CE approval for use in
Europe.68,69,71,72 To date, however, there are no ECCO2R
devices approved by the US Food and Drug Administration
(FDA). ECCO2R is to be distinguished from full ECMO, which
utilizes 23- to 32-Fr catheters and blood flows in the 2- to
7-L/min range. The primary role of the ECCO2R system is to
remove CO2, which is why it is particularly suited for reduc­
tion in mechanical ventilator settings during ARDS. To date,
studies have shown that ECCO2R can be performed safely
and effectively enabling low-tidal-volume ventilation, while
preventing deleterious shifts in pH and PaCO2.53,67 ECCO2R
is also effective in reducing pulmonary artery pressure and
reduces the work of the right heart in ARDS.73 ECCO2R is an
effective way to control hypoventilation, hypercarbia, and
acidosis, the main sequelae of the lung-protective ventila­
tion in ARDS patients.66 ECCO2R has been used as a means
Fig. 14.4 Xenios-AG console and hot-swappable membranes of to minimize, replace, and avoid the use of mechanical venti­
neonatal, pediatric, and adult sizes. Circle denotes MiniLung. (Image lation.69,70,74 This new approach is important for mitigation
courtesy Xenios AG.) of VILI as an increase in peak inspiratory pressure or in
driving pressure (ΔP), even in patients receiving lung-
protective ventilation. Conversely, unloading the lung by
improved survival.6,63 However, in chronically ill patients reducing mechanical ventilator settings and decreasing
with vascular disease, tempered hopes may be warranted. ΔP is associated with survival in ARDS.75,76 Batchinsky
Evidence from combat casualties shows an improved prob- et al. demonstrated the ability to reduce ventilator settings in
ability of benefit from ECMO relative to their civilian coun- healthy animals, an approach that is behind the “respiratory
terparts; a finding that is most likely attributable to their dialysis” concept for modern ECCO2R devices.69,77
relative youth, normal baseline physiology, and minimal An example of this approach is the study by Terragni
preexisting medical comorbidities.64 et al., who achieved control of ventilatory pressures, hyper­
Modern ECLS is also less invasive and more efficient in carbia, and pH in patients with mixed causes of ARDS.66
gas exchange than devices even one generation older. Per- These authors studied two groups: (1) patients treated using
cutaneous vascular access using 13- to 19-Fr catheters ARDSNet ventilation alone, and (2) patients receiving both
has become the preferred method of cannulation in spe- low-tidal-volume ventilation and ECCO2R as an adjunct.
cialized ECLS centers and has broadened the appeal of In group 2, Terragni et al. minimized ventilator settings
ECMO initiation to nonsurgeon physicians.58,65 Enhance- using reductions of VT down to circa 4.2 mL/kg (below
ments in efficiency are owed to new highly exchange- the ARDSNet-recommended 6 mL/kg). This resulted in an
permeable polymethylpentene (PMP)-based membrane increase in PaCO2 and a concomitant decrease in pH in these
lungs that more closely mimic the abilities of native lung. patients, but permitted plateau pressures under 25 cm H2O,
In the 2010s, the latest-generation mini-ECLS devices compared to 28 to 30 cm H2O in patients in group 1. Upon
have been developed, based on reengineering of old tech- initiation of ECCO2R, the PaCO2 and pH were normalized,
nology (Fig. 14.4). Although the functional principles and patients had a lower level of circulating inflammatory
are identical to ECMO, the logistical burden, safety, and mediators.66 The Terragni study substantiates the concept
efficiency of the new-generation mini-ECLS devices are that ECCO2R can be effectively used as adjunct to mechanical
in a class of their own.53,66–68 These simplified devices are ventilation in humans with ARDS. Together with work from
comparable to existing bedside dialysis in both usability translational research laboratories, this lung protective
and invasiveness. strategy at dialysis-like invasiveness will be a promising new
Simplification of the machinery has lowered the bar to therapy in hospitals around the world.69,74,78–80
early ECLS and expanded the settings where cannulation
and initiation of ECMO is acceptable. More facile cannu-
lation, portable mini-ECMO devices, lower access-related Combining Techniques
morbidity, and improved membrane lung efficiency has led
to availability, though admittedly not widespread, of ECLS As in many other critically ill or injured populations, the
in emergency departments, ICUs, and even in select prehos- support of patients having sustained major vascular trauma
pital and medical transport settings across the nation. In continues to evolve. Extracorporeal organ support is rapidly
turn, the potential patient population who may benefit from culminating in an ability to support multiple failing organ
ECLS is increased and, consequently, the number of patients systems at the same time.6 The ultimate goal of multior-
exposed to VILI-producing ventilator settings is reduced.66,69 gan support therapy would be to link all of these therapies
164 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

(RRT, blood purification, as well as lung and cardiovascular 16. Kitchlu A, Adhikari N, Burns KE, et al. Outcomes of sustained low
support) into one multifaceted intervention and delivery efficiency dialysis versus continuous renal replacement therapy in
critically ill adults with acute kidney injury: a cohort study. BMC
platform. Of note, the device used in the Terragni study Nephrology. 2015;16:127.
combined a unique approach to multiorgan failure mitiga­ 17. Salahudeen AK, Kumar V, Madan N, et al. Sustained low efficiency
tion in that it combined an ECCO2R and dialysis membranes dialysis in the continuous mode (C-SLED): dialysis efficacy, clinical
in a single set up.66 This is fortuitous and likely more exter­ outcomes, and survival predictors in critically ill cancer patients. Clin
J Am Soc Nephrol. 2009;4:1338–1346.
nally valid among vascular patients whose complex patho­ 18. Alsumrain MH, Jawad SA, Imran NB, et al. Association of hypophos­
physiology often results in multiorgan failure which will phatemia with failure-to-wean from mechanical ventilation. Ann Clin
most benefit from a multiorgan support strategy. Combin­ Lab Sci. 2010;40(2):144–148.
ing extracorporeal modalities in the management of mul­ 19. Scoville BA, Mueller BA. Medication dosing in critically ill patients
tiple organ failure is not new. RRT is already often combined with acute kidney injury treated with renal replacement therapy. Am
J Kidney Dis. 2013;61(3):490–500.
with ECMO and recent reports have demonstrated that 20. Henrich WL, Woodard TD, Blachley JD, et al. Role of osmolality in
therapeutic plasma exchange and molecular adsorbent blood pressure stability after dialysis and ultrafiltration. Kidney Int.
recirculating system may be helpful for acute liver support 1980;18(4):480–488.
(i.e., a form of “liver dialysis”).81,82 The concept of a multiorgan 21. Davenport A. Renal replacement therapy in the patient with acute
brain injury. Am J Kidney Dis. 2001;37(3):457–466.
extracorporeal support platform is within reach and further 22. Osgood M, Muehlschlegel S. POINT: Should continuous venove­
advances in these technologies will push the physiologic nous hemofiltration always be the preferred mode of renal replace­
limits of what is possible in efforts to save the lives of severely ment therapy for the patient with acute brain injury? Yes. Chest.
ill and injured patients. 2017;152(6):1109–1111.
23. Ronco C, Bellomo R, Brendolan A, et al. Brain density changes dur-
ing renal replacement in critically ill patients with acute renal fail-
ure. Continuous hemofiltration versus intermittent hemodialysis.
Acknowledgments J Nephrol. 1999;12(3):173–178.
24. Nash DM, Przech S, Wald R, O’Reilly D. Systematic review and meta-
The authors would like to thank Dr. John Fletcher for his analysis of renal replacement therapy modalities for acute kidney
injury in the intensive care unit. J Crit Care. 2017;41:138–144.
assistance with manuscript formatting, editing, and refer- 25. Schneider AG, Bellomo R, Bagshaw SM, et al. Choice of renal
ence management. replacement therapy modality and dialysis dependence after acute
kidney injury: a systematic review and meta-analysis. Intensive Care
Med. 2013;39:987–997.
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59. Beurtheret S, Mastroianni C, Pozzi M, et al. Extracorporeal membrane exchange in liver failure: assessments of clinical and laboratory
oxygenation for 2009 influenza A (H1N1) acute respiratory distress parameters. J Clin Gastroenterol. 2008;42(5):517–521.
syndrome: single-centre experience with 1-year follow-up. Eur J 82. Hanish SI, Stein DM, Scalea JR, et al. Molecular adsorbent recirculat-
Cardiothorac Surg. 2012;41(3):691–695. ing system effectively replaces hepatic function in severe acute liver
60. Bonacchi M. Extracorporeal life support in polytraumatized patients. failure. Ann Surg. 2017;266(4):677–684.
Int J Surg. 2016;33(Pt B):213–217.
 15 Gathering the Evidence: Clinical
Study of New Technologies
LAURA J. MOORE and JAN O. JANSEN

Why This Chapter? It is, of course, true that we would never perform a random-
ized trial of parachutes – so why do we have to conduct clini-
Vascular and endovascular trauma management is a rap- cal trials? Many clinicians are flummoxed by this argument.
idly developing field, which is dominated by medical devices. Unfortunately, the parachute metaphor is almost never appli-
The preceding chapters in this section have highlighted key cable in medicine.3 Humans are complex, and most therapies
developments, such as stentgrafts, coils, plugs, resuscita- and devices have multiple unintended consequences (some
tive endovascular balloon occlusion of the aorta (REBOA), of which may even be harmful) that complicate the intended
selective aortic arch perfusion (SAAP), and extracorporeal effect.3 This is not true of parachutes. Even more importantly,
life support (ECLS) systems. New devices (and modifications a parachute has a number needed to treat that comes very
of existing ones) are being developed and brought to market close to 1.4 Although some people have survived falls from
with astonishing speed. planes without parachutes, or complete malfunctions of
This presents challenges for the clinical evaluation their parachutesa; and although there are deaths despite a
and adoption of these new technologies. Medical devices parachute being used, the risk is very low,b,5 and the absolute
are not subject to the same regulatory requirements as reduction in mortality is therefore very close to 100%. There
new medicines, which have to be proven to be effective, are no medical therapies that offer comparable benefits.4
or at least be as effective as existing treatments. Medical Simply put, medical devices are not parachutes – and there-
devices, in contrast, only have to be shown to be “safe” fore have to be carefully and thoroughly evaluated.
before they can be marketed and used. This makes it dif-
ficult for researchers to “keep up,” particularly as indica-
tions expand, and devices are modified. In addition, these The Evaluation of Surgical
new devices may also mandate acquisition of new skills Innovation
by the clinicians utilizing them. Buxton’s Law of Health
Services Research which states, “it is always too early to COMPLEX INTERVENTIONS
evaluate, until it is too late,” is highly applicable to endo-
vascular technology. The aim of this chapter is to provide Vascular surgery and endovascular therapies are “complex
the reader with an understanding of the process of evalu- interventions,”6 defined as procedures consisting of several
ating new technologies, and the options available to clini- interacting components or involving the use of difficult
cians and researchers. or complex techniques, which may be applied in various
ways.6 Although the evaluation of surgical and interven-
tional techniques in general proceeds through stages simi-
Medical Devices Are Not lar to those for drug development, there are important
differences. Indeed, some aspects of the evaluation of surgi-
Parachutes cal technique and technology have more in common with
the evaluation of psychological and physical therapies,
Medical students are often taught that multicenter, pro- than drug development.6
spective, randomized clinical trials represent the highest Several bodies have made recommendations regarding the
quality evidence, and that new treatments should, when- study of complex interventions. The UK Medical Research
ever possible, be evaluated in this way. However, in reality, Council recommends that the assessment should be phased;
clinical trials are difficult to design, expensive, and take a include the use of experimental rather than observational
long time to plan and execute. As a result, some innovators designs whenever possible; measure outcomes as well as
like to invoke the “parachute metaphor,” particularly when process; and report detailed descriptions of interventions to
innovations are conceptually attractive, or have shown improve reproducibility, as well as evidence synthesis. The
great promise in the preclinical setting, or in small case IDEAL Collaboration – an international group of surgeons,
series. The arguments usually revolve around statements
such as “we know that it works,” and “you would never
perform a randomized trial of parachutes – it wouldn’t be a
Modern parachute rigs consist of two canopies, a main and a reserve,
ethical.” These claims often reference two satirical articles, although evaluations of the effectiveness of these devices usually refers
by Smith and Pell (2003) and Yeh et al. (2018), published to the system as a whole.
in the Christmas editions of the British Medical Journal.1,2 b
In 2018, there were 13 deaths related to civilian skydiving in the United
Both of these are worth reading, as they make important States, out of an estimated 3.5 million jumps. Four of these deaths were
points (albeit tongue-in-cheek). “medical,” rather than related to trauma.

166
 15 • Gathering the Evidence: Clinical Study of New Technologies 167

researchers, journal editors, methodologists, and statisti- clinical trial that compares the new procedure or device with
cians committed to producing, disseminating, and evalu- traditional management is feasible. Data should be captured
ating quality research in surgery – describes five stages of systematically for every patient having the procedure, paying
innovation, tailored to the surgical setting, with each stage careful attention to adverse outcomes and patient safety. A
defined by a set of recommendations.6 prospective research database is usually the best approach.
Carefully planned, prospective but uncontrolled clinical stud-
ies could run as parallel additions to smaller feasibility or
THE IDEAL STAGES OF SURGICAL INNOVATION
explanatory randomized clinical trials.6
The five stages of surgical innovation are shown in Previous stages focused on the development of a new tech-
Table 15.1.6 It is easy to see how this scheme applies to nique and the description of its outcomes; stage 3 (assess-
the study of new vascular and endovascular technolo- ment) aims to assess effectiveness against current standards.
gies although, in practice, there is overlap, and evaluation Randomized trials of surgical techniques are not always nec-
rarely proceeds linearly. Nevertheless, the underlying con- essary, particularly when an advance is clear and substantial.
cepts are helpful. Alternatives include parallel group nonrandomized studies,
Stage 1 (innovation) is about proof of concept (such as such as those using propensity scores. However, these stud-
the first use of an aortic occlusion device), with the aim at ies are prone to unmeasured confounding and are regarded
this point being description, highlighting technical achieve- as problematic in trauma patients. For example, if a propen-
ment, as well as dramatic successes (“parachutes”) – or sity score only includes admission vital signs, and does not
disasters. Only a small number of patients will be involved, account for the response to resuscitation, matched patients
and the results are conveyed using structured case reports.6 (and groups) may not be comparable after all. Interrupted
Stage 2a (development) involves the planned use of the time series analyses are another option. These designs allow
procedure or device in an initial small group of patients, to rapid and simple comparison with a preinterruption group,
support experience with its first use and often to refine or but cannot eliminate selection bias. However, as stated pre-
modify the precise technique or technology, sometimes lead- viously, most new innovations are not parachutes, and only
ing to technical modifications. The IDEAL Collaboration rec- offer marginal improvements, which are prone to overly
ommends that protocols for prospective development studies optimistic assessment by their developers. Randomized trials
be registered before patient recruitment begins, describing should therefore be the default option at this stage.6
patient selection principles, operative methods, and outcomes
to be measured. Similarly, the nature and timing of technical
modifications should be meticulously recorded.6 Methodological and Practical
Evaluation progresses to exploration, stage 2b, once tech- Challenges
nical issues have been resolved. Experience with the pro-
cedure may still be scarce at this stage, and outcomes with Clinical trials in trauma patients, and clinical trials of medi-
larger numbers of patients are needed before a randomized cal devices in particular, face a number of challenges. Firstly,

Table 15.1 Stages of Surgical Innovation

1: Idea 2a: Development 2b: Exploration 3: Assessment 4: Long-Term Study
Purpose Proof of concept Development Learning Assessment Surveillance
Number Single digit; highly Few; selected Many; may expand to Many; expanded indica- All eligible
and types of selected mixed; broadening tions (well defined)
patients indication
Number Very few; Few; innovators and Many; innovators, early Many; early majority All eligible
and types of innovators some early adopters adopters, early majority
surgeons
Output Description Description Measurement, comparison Comparison; complete Description; audit,
information for non-RCT regional variation;
participants quality assurance; risk
adjustment
Intervention Evolving; proce- Evolving; procedure Evolving; procedure refine- Stable Stable
dure inception development ment; community learning
Method Structured case Prospective develop- Research database; RCT with or without Registry; routine
reports ment studies explanatory or feasibility additions/modifications; database (e.g., Surgical
randomized clinical trial alternative designs Clinical Outcomes
(RCT) (efficacy trial); disease Assessment Program,
based (diagnostic) National Surgical Quality
Improvement Program)
Outcomes Proof of con- Mainly safety; techni- Safety; clinical outcomes Clinical outcomes (specific Rare events; long-term
cept; technical cal and procedural (specific and graded); and graded); middle- and outcomes; quality
achievement; success short-term outcomes; long-term outcomes; assurance
disasters; dramatic patient-centered patient-centered
successes (reported) outcomes; (reported) outcomes;
feasibility outcomes cost-effectiveness
Abbreviated from McCulloch P, et al. No surgical innovation without evaluation: the IDEAL recommendations. Lancet. 2009;374(9695):1105–1112.
168 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock

there is the issue of equipoise. If an intervention has already of the trial – such as discontinuing arms, or changing the
been approved by the Food and Drug Administration, and is allocation ratio. Bayesian trials rely on an alternative ana-
therefore available for use, and in use, clinicians may have lytical framework. Bayes' theorem mathematically combines
formed opinions regarding its benefit, and may no longer prior information (data and beliefs) with new data (e.g., the
have sufficient equipoise to enroll patients in a trial which results of a new trial) to yield an updated summary of knowl-
will result in half of the participants not receiving the inter- edge and the remaining uncertainty.11–13 The key advantages
vention. In the case of new technologies, it is likely that high include greater efficiency and power to detect differences,
volume, high acuity centers may be early adopters of a new and a more interpretable output. Bayesian inference directly
technology. If they believe this technology to be a benefit to estimates the probability that a conclusion is true, given the
patients, they may implement the technology as standard of data observed in an experiment, without any requirement
care in their center, even in the absence of randomized clini- for a binary conclusion.11,12 Traditional (also known as “fre-
cal trial data. If a randomized clinical trial of the technol- quentist”) statistics, in contrast, focus on the probability that
ogy was designed and funded a later date, that high-volume the observed differences in outcomes between two groups,
center would be desirable in terms of study patient recruit- or differences more extreme, could have occurred by chance
ment, but might lack equipoise and be unable to participate. alone. If the “P-value” is less than .05, the usual conclu-
A comprehensive cohort design, with randomized arms as sion is that chance alone cannot account for the differences
well as patient (or physician) “preference” arms can help to seen.11,13 This approach, although familiar, is open to misin-
overcome this issue – but these designs are difficult to ana- terpretation, and wastes information.
lyze, and if all or most of the patients (or clinicians) choose a A recent Bayesian post-hoc analysis of the Extracor-
“preference” arm, the study is unlikely to be successful. poreal Membrane Oxygenation (ECMO) to Rescue Lung
The next big issue for trauma trials is obtaining informed Injury in Severe Acute Respiratory Distress Syndrome
consent. Most vascular trauma patients require urgent or (EOLIA) trial,14 by Goligher et al., highlights the limitations
even emergent treatment, and frequently lack capacity to of the frequentist framework, and the value of the Bayes-
consent for themselves. There is often not enough time to ian approach.15 This trial, which examined whether early
seek informed consent from patients, or their surrogate deci- ECMO reduced mortality for patients with severe ARDS,
sion makers, for them to be enrolled in the trial. Although was stopped early for futility, concluding that ECMO did not
most countries now have a legal and ethical framework to reduce 60-day mortality (P = .09). In contrast, Goligher
conduct research in emergency settings, while safeguard- et al.’s Bayesian analysis, which incorporated a range of
ing patients’ rights and safety, securing the necessary per- “informative priors” to quantify existing beliefs and evi-
missions can be complex, costly, and time-consuming. dence, found it highly probable that ECMO does lower mor-
In the United States, it is possible to conduct a trial using tality. For example, using a minimally informative prior, the
exception from informed consent (EFIC) rules. This allows posterior probability of any reduction in the relative risk of
clinician-scientists to perform much needed research on death at 60 days was 96%. Conversely, the posterior prob-
emergent patients. However, such trials must meet strict cri- ability of an absolute reduction in mortality of at least 2%
teria. Although each institution varies, receiving approval was 92%. However, the posterior probability of an abso-
for EFIC requires a number of community consultation lute risk reduction of 20% or more, which is what the trial
meetings and public notification via advertisements, tradi- had been designed around, was only 2%. This latter result
tional media, and social media, informing members of the is in keeping with the original, frequentist analysis.15 The
community about the trial.7–9 Individuals can then opt out Bayesian analysis, therefore, provided a more informative
of the trial, if desired. set of interpretations than that provided by the frequentist
Another challenge area is patient availability. The num- analysis, demonstrating the power of a Bayesian analysis.
ber of trauma patients with vascular injuries who could The UK-REBOA trial, a randomized trial of REBOA in
participate in a clinical trial is often small. Even when all exsanguinating trauma patients, which is currently being
eligible patients are enrolled (which is rarely possible), the conducted in the United Kingdom, uses a similar frame-
numbers may not be sufficient to demonstrate “statistical work, although the design of this trial was Bayesian from
significance,” even when a genuine difference exists. There the outset.13
are a number of options available to reduce sample size.
Lengthening the accrual time, broadening the eligibility cri-
teria, and adding trial sites are the most common, and most Conclusion
intuitive. Other possibilities include using a continuous
outcome, which is more “information-heavy,” accepting Innovations in vascular and endovascular technology have
lower power, relaxing α, or moving to one-sided significance transformed, and will continue to transform, the care of
tests.10 However, even with these measures, calculated min- patients with vascular injuries. However, most treatments
imum sample sizes may still be unworkable. have adverse as well as intended effects – REBOA is a case in
point – and the rigorous evaluation of these new technologies
is more important than ever. The IDEAL framework usefully
The Role of Innovative Clinical describes the stages of innovation, and the types of studies
Trial Designs that may be helpful at each stage. Although not all interven-
tions require a randomized clinical trial for their evaluation,
Innovative clinical trial designs include adaptive and Bayesian most eventually do. Furthermore, when clinical trials are
trials. Adaptive trials are trials in which interim analyses are required, these will often require innovative designs, which
used to trigger predetermined modifications to the c­ onduct are more complex, but also more interpretable.
 15 • Gathering the Evidence: Clinical Study of New Technologies 169

References public disclosure in exception from informed consent trials. Circula-

tion. 2013;128(3):267–270.
1. Smith GC, Pell JP. Parachute use to prevent death and major trauma 9. Stephens SW, Williams C, Gray R, Kerby JD, Wang HE, Bosarge PL.
related to gravitational challenge: systematic review of randomised Using social media for community consultation and public disclosure
controlled trials. BMJ. 2003;327(7429):1459–1461. in exception from informed consent trials. J Trauma Acute Care Surg.
2. Yeh RW, Valsdottir LR, Yeh MW, et al. Parachute use to prevent death 2016;80(6):1005–1009.
and major trauma when jumping from aircraft: randomized con- 10. Parmar MK, Sydes MR, Morris TP. How do you design randomised tri-
trolled trial. BMJ. 2018;363:k5094. als for smaller populations? A framework. BMC Med. 2016;14(1):183.
3. Morgenstern J. Most medical practices are not parachutes 2018 11. Lewis RJ, Angus DC. Time for clinicians to embrace their inner
[3/3/2019]. Available from: https://first10em.com/parachutes/. Bayesian? Reanalysis of results of a clinical trial of extracorporeal
4. Hayes MJ, Kaestner V, Mailankody S, Prasad V. Most medical practices are membrane oxygenation. JAMA. 2018;320(21):2208–2210.
not parachutes: a citation analysis of practices felt by biomedical authors 12. Berry DA. Bayesian clinical trials. Nat Rev Drug Discov. 2006;5(1):27–36.
to be analogous to parachutes. CMAJ Open. 2018;6(1):E31–E38. 13. Jansen JO, Pallmann P, MacLennan G, Campbell MK. Investigators
5. Crouch J. A record low – the 2018 fatality summary. Parachutist. U-RT. Bayesian clinical trial designs: another option for trauma trials?
2019;714. J Trauma Acute Care Surg. 2017;83(4):736–741.
6. McCulloch P, Altmann DG, Campbell WB, et al. No surgical inno- 14. Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxy-
vation without evaluation: the IDEAL recommendations. Lancet. genation for severe acute respiratory distress syndrome. N Engl J Med.
2009;374:1105–1112. 2018;378(21):1965–1975.
7. Harvin JA, Podbielski JM, Vincent LE, et al. Impact of social media on 15. Goligher EC, Tomlinson G, Hajage D, et al. Extracorporeal membrane
community consultation in exception from informed consent clinical oxygenation for severe acute respiratory distress syndrome and poste-
trials. J Surg Res. 2019;234:65–71. rior probability of mortality benefit in a post hoc Bayesian analysis of
8. Stephens SW, Williams C, Gray R, Kerby JD, Wang HE. Preliminary a randomized clinical trial. JAMA. 2018;320(21):2251–2259.
experience with social media for community consultation and
SECTION 4
T­he M­an­ag­em­ent of
Vascular Trauma
 16 Cardiac, Great Vessel, and
Pulmonary Injuries
DAVID V. FELICIANO and JOSEPH J. DUBOSE

Introduction and the direction of impact, the innominate, carotid, subcla­

vian, or vertebral arteries may also be prone to injury. Blunt
Penetrating injuries to the heart and great vessels result in thoracic vascular injury has also been reported as a result
significant prehospital mortality (50% to 75% for cardiac of air-bag inflation and is more prone to occur in women of
wounds), so the numbers of patients undergoing opera­ small stature or in children.
tions for such injuries are small even in the busiest civilian
centers or wartime hospitals. The presentation is different ADVANCED TRAUMA LIFE SUPPORT (ATLS):
for penetrating wounds to the nonhilar vessels of the lung PRIMARY SURVEY, INITIAL RESUSCITATION,
parenchyma. With a systolic pressure of 25 mm Hg in the
pulmonary artery and its branches, bleeding from injury to EMERGENCY CENTER THORACOTOMY
pulmonary parenchymal vessels requires thoracotomy in Profoundly hypotensive patients with external hemorrhage
only 5% to 10% of patients. After blunt thoracic trauma, at or near the thoracic outlet, those with hemorrhage into
the majority of injuries involve the chest wall (i.e., frac­ the pericardial sac or pleural cavity, or those with cardiac
tured ribs) or lung (i.e., pneumothorax, hemothorax). As tamponade (diagnosis by ultrasound) should undergo rapid
such, only 7% to 8% of patients with this injury pattern sequence or emergent endotracheal intubation in the emer­
require thoracotomy or median sternotomy. In all patients gency department. Awake patients with more normal hemo­
with thoracic trauma, the most common indications for dynamics with intrapleural blood or a pneumothorax, with
thoracotomy are hemorrhage from the lung, major arterial or without tension physiology, should have a thoracostomy
injury in the superior mediastinum or supraclavicular area, tube inserted in the 5th intercostal space at the midaxillary
or a penetrating wound of the heart. line. If this maneuver drains 1000 mL or more of blood in
the first 15 minutes after tube insertion, the patient should
be moved emergently to the operating room (OR). In this
Evaluation and Management in scenario, the patient should be placed on the operating table
the Emergency Center in the supine position with the anesthesiologist and operat­
ing team present. If another 200 mL of blood drains out of
the thoracostomy tube in the next 15 minutes, the patient
MECHANISM OF INJURY
should be intubated in preparation for operation.
Penetrating wounds that injure the heart, the thoracic great The decision as to whether the incision should be an
vessels, or the hilum of the lung are often in a location referred anterolateral thoracotomy or a median sternotomy will
to as the “cardiac box,” which is the area between the nipples depend on the entrance location and trajectory of any pen­
from the sternal notch to the xiphoid process. Based on an etrating wound, the results of the thoracic and pericardial
autopsy study in 2017, this definition should be expanded ultrasound, and the hemodynamic condition of the patient.
to the posterior midline of the left hemithorax.1 Other pen­ If the amount of bloody drainage stops before 1200 mL and
etrating wounds that increase the likelihood of injuries to the patient has normal or near-normal hemodynamics, he
these structures are those that traverse the mediastinum (i.e., or she should be moved to the intensive care unit (ICU) for
transmediastinal wounds) and those to the thoracic outlet. close observation. Resumption of bleeding from the thora­
With blunt trauma to the chest, particularly from motor costomy tube at a rate of 100 to 200 mL/h over the next
vehicle crashes, significant injuries to the heart and great 2 to 4 hours should prompt urgent thoracotomy or median
vessels (and, occasionally, the lung) may occur whether sternotomy.
or not the victim is restrained. Unrestrained victims with Any patient who is hypotensive from a pneumothorax,
frontal or lateral impact can sustain all of the previously bleeding, or cardiac tamponade requires large-bore intra­
described deceleration or direct blunt injuries to the chest venous access for resuscitation, including placement of
wall or intrathoracic structures. The most classic example either 14-gauge extremity vein catheters, large-bore 7.5-
of a deceleration injury is when the forward motion of the Fr central venous catheter(s), or both. If there is concern
victim's thorax stops abruptly on contact with the hub of the about the original wounding mechanism having injured
steering wheel. This mechanism may cause varying degrees one of the subclavian veins, a contralateral upper extremity
of traumatic disruption of the descending thoracic aorta, or subclavian vein should be used for venous access. Tho­
most commonly at the level of the ligamentum ­arteriosum. racic wounds in the expanded cardiac box or those with
Depending on the position of any shoulder-harness restraint a ­transmediastinal trajectory that might have injured the

171
172 SECTION 4 • The Management of Vascular Trauma

superior vena cava should prompt placement of resuscita­ the field and blunt trauma with no signs of life on arrival in
tion lines into the common femoral veins. the emergency center.8
Although the resuscitation fluid for patients with tho­ A left anterolateral thoracotomy at the lower edge of the
racic trauma was lactated Ringer's solution for many years, male nipple is performed when a penetrating left thoracic
hypotensive patients (systolic blood pressure less than wound is present in an agonal or arrested patient. When a
90 mm Hg) are now managed with a strategy referred to penetrating right thoracic wound is present and the patient
as “damage control resuscitation” (DCR).2 In essence, this is agonal on arrival, a bilateral anterolateral thoracotomy
protocol involves avoiding administration of any crystalloid (i.e., clamshell thoracotomy) is performed. If intrapleural
solutions if the patient is awake and has a recordable blood exsanguination from a suspected injury to a subclavian ves­
pressure. Initial application of this hypotensive resuscita­ sel is believed to be present, an anterolateral thoracotomy at
tion strategy allows for the fact that needless administration a higher intercostal space is appropriate. The primary goals
of any fluid aimed at achieving an arbitrary systolic blood of either a unilateral anterolateral or a bilateral antero­
pressure may lead to or worsen bleeding that has otherwise lateral thoracotomy are to control bleeding from a wound
nearly stopped (i.e., “pop the clot” phenomenon). to the heart, a great vessel, or the lung, release a cardiac
Avoidance of crystalloid solutions such as normal saline tamponade, or perform internal cardiac massage. Whether
or lactated Ringer's also stems from recognition that even suture repair of the injured organ or vessel is appropriate
small amounts of these fluids may dilute clotting fac­ in the emergency department will depend on the following
tors and may lead to a condition referred to as dilutional factors: (1) magnitude of the injury; (2) success of tempo­
coagulopathy. DCR is based on the early and balanced use rary bleeding control maneuvers; (3) quality of lighting;
of packed red blood cells (pRBC), thawed plasma, and plate­ and (4) availability of instruments and sutures.
lets. Studies initiated from the wars in Iraq and Afghanistan An additional and important goal of resuscitative thora­
demonstrated that the balanced use of pRBC, plasma, and cotomy is to cross-clamp the descending thoracic aorta to
platelets in a 1:1:1 ratio as part of a DCR strategy conveyed maintain any remaining central aortic pressure and perfu­
a mortality benefit to severely injured patients. Recent mili­ sion to the coronary and carotid arteries. One must be mind­
tary studies have reported a mortality benefit with the use ful in these scenarios that applying a cross-clamp to the
of the antifibrinolytic medication tranexamic acid (TXA), descending thoracic aorta is more difficult through a higher
as well as administration of supplemental cryoprecipitate left-sided thoracotomy incision. Thoracic aortic clamping is
as part of the DCR strategy. performed by first lifting the posterolateral edge of the left
Resuscitative endovascular balloon occlusion of the lung out of the hemithorax. Once the mediastinal pleura
aorta (REBOA) passed through the common femoral artery over the descending thoracic aorta and vertebral bodies is
has replaced emergency center thoracotomy for resuscita­ visualized, it is opened with scissors. Next, the descending
tion in patients with trauma isolated to the abdomen, pel­ thoracic aorta is encircled with the surgeon's left index fin­
vis, or lower extremities. Emergency center thoracotomy for ger before the cross clamp is applied. Subsequent maneu­
resuscitation and bleeding control continues to be indicated vers for cardiac massage or repair include a longitudinal
in a highly selected group of patients. This maneuver with pericardiotomy above the left phrenic nerve, exposure of the
thoracic trauma, also referred to as resuscitative thoracot­ cardiac wound or rupture, and the use of fingers, staples,
omy, is performed in hospitals that do not have an OR in or sutures, or balloons for bleeding control (Figs. 16.1–16.4).
immediately adjacent to the emergency department. Algo­ Because of the cost and low survivability of emergency
rithms, quality improvement data, and reviews of outcomes center thoracotomy, the technique has been used more selec­
have helped refine the indications for this procedure.3–5 tively in recent years. The reported survival rate of 7% to
Reasonable indications to perform an emergency center 10% is deceptive as it includes patients with a variety of inju­
thoracotomy in an injured patient are as follows3–7: ries, while patients with penetrating cardiac wounds have
significantly better outcomes.9 In an old report by Ivatury
1. Penetrating thoracic wound with agonal physiology or et al., 16 of 22 patients with penetrating cardiac injury who
recent cardiac arrest arrived in the emergency center without “detectable vital
2. Uncontrolled bleeding from the thoracic inlet or a thora­ signs, cardiac activity, or spontaneous respirations” were
costomy tube able to have restoration of cardiac function with resuscita­
3. Suspected subclavian vessel injury with intrapleural tive thoracotomy.10 In this same report, eight patients (36%)
exsanguination survived without neurologic sequelae. A more recent (2009)
4. Need for open cardiac massage or occlusion of the report on 283 patients undergoing emergency center thora­
descending thoracic aorta before laparotomy in the OR cotomy for penetrating injury to the heart and great vessels
(REBOA not available) documented worse outcomes including a survival rate of
5. Need for open cardiac massage or clamping of the de­scend­ 24% in those with stab wounds and only 3% in those with
ing thoracic aorta when countershock or closed-chest gunshot wounds.11 The injury scenario with the highest sur­
cardiac massage is ineffective (i.e., cardiopulmonary vival rate following emergency center thoracotomy is cardiac
arrest) tamponade from an isolated, anterior cardiac stab wound in
a patient presenting with measurable vital signs following a
Relative indications include a recent cardiac arrest asso­ short prehospital transport.
ciated with a flail or other chest wall abnormality (difficult For patients with penetrating wound(s) that may involve
external cardiac massage) or pregnancy (to save the child). the heart, thoracic aorta, or great vessels and who are
Strong contraindications for the use of resuscitative thora­ hemodynamically normal, it is appropriate to image the
cotomy include penetrating trauma with no signs of life in thorax to better characterize the presence and location of
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 173

injury. This can be accomplished with a chest x-ray, which Alabama, is credited with the first successful delayed repair
may demonstrate a hematoma in the superior mediastinum of a stab wound to the left ventricle in the United States in
or in the supraclavicular area, a surgeon-performed ultra­ 1902.12,13,16 In the modern era, the vast majority of car­
sound, or a contrast-enhanced CT scan or CT arteriography. diac injuries are from penetrating wounds and are treated
in urban trauma centers.17 Blunt cardiac injuries occur
mostly after head-on motor vehicle crashes, can be caused
The Injured Heart by air bags, and have a significant mortality that is often
related to a delay in diagnosis.18–20
HISTORY
INCIDENCE
Asensio et al. have reviewed the unsuccessful attempts at
cardiac repair by Cappelen in Norway and Farina in Italy Penetrating Trauma
that preceded Ludwig Rehn's successful repair of a wound Patients with penetrating cardiac injuries, especially from
to the right ventricle in 1896.12–15 L.L. Hill of Montgomery, gunshot wounds, have a 50% to 75% mortality rate at the

Phrenic nerve

Pericardial sac

Left
A lung

Sternum Left
Right (cut) lung
lung

Pericardial
B sac

Fig. 16.1 (A) A left anterolateral thoracotomy incision is made at the inferior edge of the male left nipple. In women, the left breast is retracted supe-
riorly and the incision is made at the midaspect of the left hemithorax. The Finochietto retractor is placed with the handle facing the left side of the
patient. (B) Bilateral anterolateral thoracotomy.
174 SECTION 4 • The Management of Vascular Trauma

Left lung
Phrenic nerve
Aorta
Pericardial sac

Left
lung

Fig. 16.2 In a patient with profound hypotension (or who has suffered Fig. 16.3 In the patient with a wound through the pericardial sac, with
a cardiac arrest), the left lung is lifted out of the left chest by the left blood underneath the pericardium, or with asystole, a left longitudinal
hand of the surgeon or by an assistant on the other side of the table. pericardiotomy is made 1 to 2 cm above the left phrenic nerve from the
Having used the tip of an aortic clamp to spread the pleura above and great vessels superiorly to the left hemidiaphragm inferiorly. (Adapted
below the mid-descending thoracic aorta, the surgeon is using the left from Copyright, Baylor College of Medicine, Houston, 1980.)
index finger to encircle the aorta and pull it to the left so that the clamp
can be applied under direct vision. (Adapted from Copyright, Baylor
College of Medicine, Houston, 1980.)

Swing heart into

left chest

Repair 1

Cardiac
massage

Repair 2

B Repair 3 C

Fig. 16.4 (A) After the left pericardiotomy, the heart is swung into the left chest. (B) Atrial wounds are repaired over a Satinsky clamp, whereas ven-
tricular wounds are repaired by sewing under a finger and under adjacent coronary arteries. (C) Patients with profound hypotension, electromechanical
dissociation, or asystole undergo two-handed internal cardiac massage. (Adapted from Copyright, Baylor College of Medicine, Houston, 1980.)
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 175

scene or on arrival at the hospital.20–22 This is secondary to sounds is present in less than 10% of patients with tampon­
acute cardiac tamponade if the lateral walls of the pericar­ ade, whereas the incidence of Kussmaul's sign or jugular
dial sac are intact or to exsanguination when there is com­ venous distension with inspiration is difficult to determine.
munication with a pleural cavity. Only rapid transport to a Bleeding from the injured heart into a pleural cavity most
trauma center or acute care hospital will save the lives of often results from a gunshot wound, and the classic signs of
patients with repairable cardiac injuries and signs of life in hypovolemic shock are typically present. Depending on the
the field.23 This is because therapeutic procedures such as patient’s hemodynamic status, an early resuscitative thora­
pericardiocentesis, an open pericardial window, or an emer­ cotomy rather than a diagnostic test will be necessary.
gent anterolateral thoracotomy are not performed in the
prehospital setting in the United States or during military Blunt Trauma
conflicts. Blunt cardiac injury (BCI) encompasses a spectrum of
trauma including myocardial bruising (myocardial contu­
Blunt Trauma sion), transmural infarction, or a rupture of the free wall
In a review from the American College of Surgeons or septum. The spectrum of cardiac injury is described in
National Trauma Data Bank, blunt cardiac rupture had the American Association for the Surgery of Trauma's
an incidence of 1/2400 admissions and occurred most (AAST) Organ Injury Scale reported in 1994.25 Clinical
commonly after motor vehicle crashes (73%) followed by manifestations that the trauma team must treat in rare
automobile–­pedestrian accidents (16%). In this study, blunt patients include unexplained hypotension, new-onset
cardiac injury was determined to have an overall mortality arrhythmias, or cardiac tamponade. Mechanical problems
of 89%.18 This is most commonly due to rupture of one or that have occurred after a BCI include injury to papillary
more cardiac chambers, tears at the right atrial-caval junc­ muscles, choradae tendineae, cardiac valves, and coro­
tions, or a blunt coronary artery dissection or tear.19 nary arteries.19

PRESENTATION DIAGNOSIS
Penetrating Trauma Penetrating Trauma
Patients with stab wounds to the heart may present with Other than the physical examination, diagnostic options
cardiac tamponade (60% to 90%), intrapleural hemor­ for patients with penetrating injuries (or blunt ruptures)
rhage (10% to 40%), or both. In contrast, patients with with secondary tamponade include the following: (1) an
gunshot wounds present with cardiac tamponade (20%), electrocardiogram to assess for a “J” wave; (2) measure­
intrapleural hemorrhage (80%), or both. Cardiac tampon­ ment of central venous pressure; (3) pericardiocentesis;
ade is caused by blood in an intact pericardial sac which (4) subxiphoid pericardial window; (5) formal transtho­
compresses the atria and impairs venous return and car­ racic (TTE) or transesophageal (TEE) ultrasound; and (6)
diac filling.24 The cardiovascular response to decreased surgeon-performed TTE as part of focused assessment for
stroke volume is progressive tachycardia. Pulsus paradoxus the sonographic evaluation of the trauma patient (FAST)
is present in essentially all patients, as well. Whereas blood examination.
pressure decreases by as much as 10 mm Hg with inspira­ A “J” wave (small positive reflection at the R-ST junction)
tion secondary to a decrease in left ventricular stroke vol­ as a sign of an occult cardiac injury after a penetrating
ume, this decrease may be 15 mm Hg or more in the setting thoracic wound was described by Nichol and Navsaria in
of cardiac tamponade. In the setting of tamponade, there is 2014.26 In a group of 174 patients with penetrating tho­
a simultaneous progressive rise in central venous pressure racic wounds, the specificity to detect a hemopericardium
secondary to the impaired venous return. In this scenario, was 85%, sensitivity 44%, and positive predictive value
patients often present with a dusky or deathlike appearance 91% (P < .001).
that is noticeable regardless of race. Alert patients express Measurement of central venous pressure is invasive,
extreme anxiety (“Am I going to die?”) and frequently com­ time-consuming, and may not confirm the diagnosis of
plain of a “heaviness” or pressure in the chest. cardiac tamponade immediately. It is appropriate to use
If the diagnosis of cardiac tamponade is delayed, myo­ when there is no desire to anesthetize the stable patient
cardial ischemia and continued decreases in cardiac out­ to perform a diagnostic subxiphoid pericardial window or
put occur. This spiral leads to cardiovascular collapse and when the ultrasound machine is broken or unavailable.
cardiac arrest in minutes in patients with wounds or ven­ Any 10 mm Hg increase in central venous pressure over
tricular rupture. In patients with wounds or ruptures of time in the relaxed supine patient receiving only mainte­
the atria, compression of the hole by the extravasated blood nance intravenous fluids should prompt a subxiphoid peri­
in the pericardium may stop further hemorrhage and pro­ cardial window or median sternotomy or thoracotomy.
gressive tamponade. The main hemodynamic finding in A pericardiocentesis may have a therapeutic effect in
such patients is the aforementioned progressive rise in cen­ the patient with tamponade and hemodynamic instabil­
tral venous pressure to 20 to 30 mm Hg with profound ity; however, the diagnostic sensitivity of this maneuver in
hypotension or a cardiac arrest as the terminal event. The the stable patient with a small tamponade has always been
diagnosis of a compressed atrial wound may be delayed for questioned.27 To rule out aspiration of intracardiac blood
12 or more hours until clinical suspicion prompts a peri­ mistaken as an early tamponade, the long spinal needle
cardial ultrasound, a pericardial window, a sternotomy, or used for the pericardiocentesis should be attached to a mon­
a thoracotomy. In most reports, the classic Beck's triad of itor lead to rule out a current of injury as the cardiac wall
hypotension, distended cervical veins, and muffled heart is penetrated.
176 SECTION 4 • The Management of Vascular Trauma

An open surgical subxiphoid pericardial window is per­

formed under general anesthesia and mandates a bloodless
operative approach.28 It is most helpful during an emergency
laparotomy after a gunshot or stab wound when the track of
the missile or knife appears to be in proximity to or appears Liver
to penetrate the pericardial sac. Also, it is used in many cen­
ters when non-surgeon or surgeon-performed ultrasound is
unavailable or when there is not acceptable accuracy with Blood
the technique. The operative approach is through a 5- to Heart Vena cava
10-cm midline abdominal incision starting on the xiphoid
process, which may be excised as needed for exposure. The
linea alba is divided, and extraperitoneal dissection is per­
formed bluntly in a superior direction toward the pericar­
dium. Exposure is enhanced by lifting the xiphoid process
(if still in place) and the lower sternum up with one medium
Richardson retractor or two Navy-Army retractors. Once
cardiac pulsations are palpated, the inferior pericardial sac is
grasped with two long Allis clamps, and a 2-cm vertical peri­
cardiotomy is made between the clamps. If this maneuver Fig. 16.5 Cardiac tamponade detected on surgeon-performed ultra-
results in the release of blood from the pericardial sac, most sound using a 3.5-MHz transducer.
surgeons transition to a median sternotomy followed by a
longitudinal pericardiotomy, evacuation of the tamponade,
and control of bleeding. Patients who manifest progressive Table 16.1 Accuracy of Transthoracic Ultrasound in
Diagnosing Cardiac Tamponade.
hemodynamic deterioration during the subxiphoid pericar­
dial window should undergo left anterolateral thoracotomy Number of
and opening of the pericardium through that approach. Author Patients True-Positives Accuracy
Following the lead of the Trauma Centre faculty at the Rozycki et al., 236 10 100%
University of Cape Town, South Africa, some centers choose 199633
to wash blood out of the pericardial sac after a positive win­ Rozycki et al., 313 22 99.4%a
dow in the reasonably stable patient and observe for further 199834
bleeding without opening the pericardial sac.29–32 The ratio­ Rozycki et al., 261 29 97.3%b
nale for this is that pericardial wounds only or wounds that 199935
injure the cardiac wall superficially (epicardium and outer Nichol et al., 172 — 86.7%c
201536
myocardium) may have stopped bleeding by the time the
pericardial window has been performed. Should there be no a
Two false-positives, no false-negatives.
further bleeding during a period of intraoperative observa­
b
Seven false-positives, no false-negatives.
c
18 false-negatives.
tion with the pericardial sac open, a few groups around the
world close the incision without performing a median ster­
notomy or anterolateral thoracotomy.
A formal TTE or TEE ultrasound performed by a cardiolo­ adjacent to the liver. Should tamponade be present, a black
gist or anesthesiologist is an accurate technique to detect stripe will separate the beating heart from the liver. The
cardiac tamponade. This maneuver can also diagnose intra­ black or anechoic stripe with an ultrasound density that is
cardiac lesions such as septal defects or valvular injuries the same as blood in the inferior vena cava represents blood
and can calculate an ejection fraction. Unfortunately, the outside the heart, i.e., a tamponade. Failure to visualize an
majority of penetrating cardiac injuries come to the emer­ adequate sagittal view through the subxiphoid window is
gency department on weeknights or weekends when the often secondary to the patient's complaining about pain or
specialists who perform formal TTE or TEE ultrasound may discomfort. Also, this cardiac window may be diminished in
not be available. Additionally, the sedation required to prop­ obese patients.
erly perform TEE would be contraindicated in the unstable The ultrasound probe is next placed in a horizon­
patient with this injury scenario. tal direction in the 4th or 5th left parasternal space to
Over the past 25 years, reports have documented that obtain a coronal view of the same cardiac structures. In
limited TTE performed in the emergency center by surgeons the study by Rozycki et al., 246 patients with penetrating
or specialists in emergency medicine using a 3.5-MHz gen­ thoracic wounds were evaluated by surgeon-performed
eral access transducer is the diagnostic test of choice33–35 ultrasound.33 There were 236 true-negative results and
(Fig. 16.5; Table 16.1). The FAST examination begins with 10 true-positive results. In the latter group, the mean
a pericardial view in patients with either penetrating or time from ultrasound to operation was 12 minutes and
blunt trauma. During the FAST, the probe is placed in a lon­ all patients survived after repair of their cardiac wounds.
gitudinal direction in the subxiphoid area at an angle of 30 A follow-up study by Rozycki et al. in 313 patients with
degrees off of the epigastrium with firm pressure. This usu­ penetrating precordial or transthoracic wounds resulted
ally results in a clear view of the apex of the heart, the peri­ in 289 true-negative examinations, 2 false-positive exami­
cardium, and the left lobe of the liver. The beating heart in nations, and 22 true-positive examinations.34 In the latter
this real-time ultrasound approach should lie immediately group, all patients survived when surgery was immediately
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 177

performed by the surgeon-sonographer. Finally, Rozycki infarction, arrhythmias, coronary revascularization); (2)
et al. completed a multicenter study in which emergency unexplained hypotension; and (3) new onset arrhythmia
pericardial sonograms were performed by ultrasound or conduction disturbance on an admission ECG. A patient
technicians, cardiologists, or surgeons.35 In a series of with blunt thoracic trauma and a history of cardiac disease
261 patients with penetrating precordial or transthoracic or the presence of non–life-threatening arrhythmias such
wounds evaluated at five level I trauma centers, 29 (11%) as sinus tachycardia or atrial fibrillation should be admitted
had true-positive studies, and 28 survived after emergency to a telemetry unit for monitoring and observation. When
cardiac repair. The accuracy (97%), specificity (97%), and hypotension is present or when the ECG change is poten­
sensitivity (100%) were equivalent to those reported in the tially lethal (i.e., ventricular tachycardia, ventricular fibril­
previous study from Grady Memorial Hospital.33 lation, third-degree heart block), treatment is initiated in
Some centers around the world have not had the same the emergency center before transfer to the ICU.
accuracy of surgeon-performed ultrasound in detecting When an operation for another injury is indicated in a
intrapericardial blood,36,37 and all centers recognize the patient with blunt cardiac injury, not including cardiac rup­
compromised accuracy of surgeon-performed pericardial ture, the prognosis is generally excellent. In a 1986 report
ultrasound when a left hemothorax is present. Nichol et al., by Flancbaum et al., 19 patients with BCI had an emer­
using a similar description of the expanded cardiac box as gency operation, including 15 on the day of admission.42
later described by Jhunjhunwala et al., offered a new man­ Pulmonary artery catheters were placed in 12 patients, and
agement algorithm for the hemodynamically stable patient inotropes were used in 11. The duration of anesthesia was
in 2015.1,36 First, a patient with a “screening ultrasound” 6 hours, and there were no cardiac-related complications
positive for intrapericardial blood would be taken to the OR or deaths.
for a subxiphoid pericardial window under general anes­
thesia. Second, a patient with an equivocal screening ultra­ OPERATIVE MANAGEMENT IN THE EMERGENCY
sound would undergo a pericardial window or a CT scan of DEPARTMENT AND OPERATING ROOM
the chest. And, third, a patient with a negative screening
ultrasound should have an immediate CT scan of the chest Incisions
or a repeat ultrasound in 24 hours. As previously noted, a left or bilateral anterolateral thora­
cotomy (i.e., clamshell thoracotomy) is performed in the
Blunt Trauma emergency department for release of suspected or docu­
As previously noted, 90% of blunt cardiac injuries are mented tamponade, for control of cardiac hemorrhage,
caused by precordial trauma sustained during motor vehi­ and for resuscitation. The same incision(s) would be used
cle or automobile–pedestrian crashes. Arrhythmias such as in the OR for agonal patients or for those in cardiac arrest.
sinus tachycardia, premature atrial or ventricular contrac­ These incisions allow for expedited control of hemorrhage
tions, and heart block are the most common manifestations from cardiac perforation(s) and for cross-clamping of the
of blunt cardiac injury.38 For this reason, the admission electro­ descending thoracic aorta. The anterolateral thoracotomy
cardiogram (ECG) is the most logical diagnostic tech­nique approach may also be kept separate from any abdomi­
of choice. The usefulness of an ECG is often discounted by nal midline incision needed to address an intraabdominal
studies advocating radioisotope scanning, TTE, and TEE injury. The median sternotomy is performed in the OR in
as diagnostic modalities for blunt cardiac injury. Multiple patients who are more hemodynamically stable and who
reports, however, have documented that an ECG is an excel­ have solitary anterior stab wounds. In such patients, mul­
lent initial test when evaluating patients with blunt thoracic tiple cardiac perforations are unlikely and cross-clamping
trauma.20,39 In essence, these studies have shown that a nor­ of the descending thoracic aorta is usually not needed.
mal ECG in the emergency department effectively excludes
significant blunt cardiac injury. Pericardiotomy
There is continued interest in using a measure of serum Opening the left chest via an anterolateral thoracotomy and
cardiac troponin I (TnI) in addition to the admission ECG to insertion of a Finochietto retractor are followed by a lon­
detect blunt cardiac injury.40 In one study from Los Angeles gitudinal left lateral pericardiotomy performed anterior to
County Hospital, 27 of 80 patients (34%) with an abnor­ the left phrenic nerve. In obese patients where fat obscures
mal ECG and TnI level after blunt chest trauma developed the phrenic nerve, the accompanying pericardiacophrenic
significant BCI.41 BCI in this and other studies is defined as vessels mark the location. Even if the pericardium is diffi­
arrhythmias requiring treatment or the presence of cardio­ cult to grab with a forceps secondary to distention of the
genic shock or cardiac structural injury. The authors con­ sac with blood, the surgeon should resist performing a peri­
cluded that a normal ECG and serum TnI on admission and cardiotomy with a scalpel. This is a particularly dangerous
8 hours after injury excluded blunt cardiac injury. TTE or as right-sided tamponade from a wound to the atrium or
TEE may be used as an adjunct in patients with persistent ventricle may push the heart to the left so that it lies imme­
ECG abnormalities or with unexplained hypotension after diately underneath or abuts the left pericardial sac. In this
blunt chest trauma. position, the left anterior descending coronary artery is at
risk of injury if a scalpel is passed too deeply while opening
the pericardium. A better technique is to lift the pericardium
NONOPERATIVE MANAGEMENT OF BCI
with a toothed forceps and to open the sac with the tip of a
Admission to the hospital for a possible or likely BCI is justi­ straight Mayo scissors. Once it has been opened, the peri­
fied when the following are present after thoracic trauma: (1) cardium generally lifts away from the surface of the heart
history of cardiac disease (i.e., angina pectoris, myocardial allowing the incision to be extended in a superior direction
178 SECTION 4 • The Management of Vascular Trauma

until the pericardial fold on the great vessels is reached. The suturing, the surgeon should consider placing a cross-clamp
longitudinal left pericardiotomy is completed in an inferior on the descending thoracic aorta to preserve central pres­
direction until the left hemidiaphragm is reached. Exposure sure and cerebral circulation. This will, however, increase
of the injured heart is enhanced by making a transverse bleeding through the cardiac wound.
pericardial incision to the right as well. This pericardial inci­ A finger or compression with fingers will control hemor­
sion is made at a right angle to the left lateral pericardiot­ rhage from a cardiac perforation or cardiac rupture in 95%
omy and extends to 1 cm anterior to the right phrenic nerve. of patients. This is because patients with larger defects die at
In patients undergoing bilateral anterolateral thoracot­ the scene or in transit. Suture repair of a ventricular wound
omy, either the pericardiotomy described previously or the can be performed under the occluding finger. When a finger
midline pericardiotomy described later can be used. After a is not successful in controlling bleeding or when more defin­
median sternotomy and insertion of a Finochietto retractor, itive control is needed, the techniques in Table 16.2 may be
the fat anterior to the pericardium and the anterior exten­ applied. Disposable skin staplers with long rotating heads
sions of the parietal pleura are swept laterally with the can be used to quickly close atrial or ventricular defects.43–45
fingers over laparotomy pads. This maneuver exposes the Whether staple repair lines placed in the emergency depart­
anterior surface of the pericardial sac which is grasped with ment should be buttressed or replaced with sutures in the
toothed forceps and opened in a midline longitudinal direc­ OR is controversial. The safest policy is to buttress any left
tion from the great vessels to the diaphragm. ventricular repair with Teflon pledgets in the OR in patients
who stabilize after the initial hemorrhage control and resus­
Control of Hemorrhage From the Heart (Table 16.2) citation maneuvers.
After the pericardiotomy is performed, blood and clots are Elevation of an atrial wound with the fingers, forceps, or
removed from the pericardial sac manually and with irriga­ Allis clamps will frequently allow placement of a Satinsky
tion and suction. Inspection of the anterior surface of the vascular clamp under the perforation. Atrial wounds or
heart and great vessels is performed. If no anterior perfora­ ruptures in the lateral aspect adjacent to the pericardium
tion or blunt rupture is noted, the surgeon should note the cannot be controlled with a Satinsky clamp. With such
patient's blood pressure on the monitor. A profoundly hypo­ injuries, Allis clamps grabbing both sides of the defect are
tensive patient may not tolerate inspection of the posterior placed in a row similar to the method described for wounds
aspect of the heart, which requires elevation of the apex. to the vena cava for the past 100 years. For atrial wounds
Lifting the heart to inspect the underside compresses or kinks adjacent to the ventricle or other difficult cardiac lacera­
the vena cavae, restricting right-sided filling. This maneuver tions, use of a Foley balloon catheter to control hemorrhage
also carries with it a risk of sucking air into an open hypovo­ was first described in 1966.46 Insertion of the tip and bal­
lemic ventricle. With left ventricular perforation, air has the loon of the catheter into the defect is followed by inflation
potential to rapidly move into the coronary arteries causing of the balloon and gentle traction on the end of the catheter
an air embolism and cardiac arrest. As such, manual palpa­ hanging out of the heart.
tion of the posterior surface of the heart without elevation of On rare occasions, the length of a ventricular laceration
the apex is all that is advised until the patient is resuscitated will lead to exsanguinating hemorrhage that will preclude
with a relatively normal blood pressure. Palpation of a pos­ the use of the stapler or the balloon catheter. With manual
terior defect or jet of blood as a ventricle contracts mandates compression of the defect, a horizontal mattress suture is
leaving the finger in place for control of hemorrhage until the rapidly placed on either side of the defect, the two ends on
patient’s hypovolemia is corrected. each side are placed in the hands, and the hands holding
Once the patient has been stabilized and the surgeon is the suture ends are crossed. This should prevent exsangui­
ready to lift the apex of the heart to inspect the posterior nation as a continuous over-and-over suture row or a row
aspect, he or she should notify the anesthesia team so that of staples is placed. A temporary closure as described would
they are aware and can assist in managing any associated then be buttressed with Teflon pledgets in the OR.
hypotension. If there is bleeding from the posterior aspect Because few surgeons are familiar with the manual tech­
of the heart that will require prolonged elevation and/or nique for control of hemorrhage from the heart described over
a century ago by Ernst Ferdinand Sauerbruch (1875–1951),
the related technique of inflow occlusion is used occasionally
Table 16.2 Techniques for the General Surgeon to to control major hemorrhage from the heart. Inflow occlu­
Control Hemorrhage From a Cardiac Perforation or sion slows the heart and improves one’s ability to control car­
Rupture. diac bleeding.47 With difficult-to-visualize cardiac wounds or
Finger Atrium/ventricle
in the case of large ventricular wounds, as described previ­
ously, application of vascular clamps to the superior and
Stapler Atrium/ventricle
inferior vena cavae is appropriate. This maneuver decreases
Satinsky vascular clamp Atrium
hemorrhage from the injured heart and rapidly causes a pro­
Row of Allis clamps Lateral atrium adjacent to found bradycardia which together allow for clamp or suture
pericardium
control of hemorrhage from complex cardiac wounds. Prior
Foley balloon catheter Atrium/ventricle
to tying down the last suture of a ventricular repair, the
Crossed mattress sutures Ventricle clamps on the cavae are removed to allow refilling of the ven­
Inflow (superior vena cava/inferior Large ventricular hole or tricle. Evacuation of ventricular air is accomplished by eleva­
vena cava) occlusion multiple chamber wounds
tion of the apex of the heart as refilling occurs and before the
3-mg intravenous adenosine to Large ventricular hole or final suture of the repair is tied down. The exact time limit on
induce 10–20 s asystole multiple chamber wounds
inflow occlusion is unknown, but 1 to 2 minutes will usually
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 179

allow for restoration of a cardiac rhythm after the repair has With a wound of the ventricle being controlled by the
been completed. surgeon or the assistant's finger, horizontal mattress 3-0
There have been several reports about the administra­ or 4-0 polypropylene sutures can be placed under the fin­
tion of 3 mg of adenosine intravenously to aid in the repair ger and tied. When a Foley balloon catheter has been used
of cardiac injuries.48,49 Approximately 20 seconds after to control hemorrhage from a ventricle, the surgeon must
administration of adenosine, the heart will stop beating be mindful that placement of the sutures for the cardiac
(i.e., induced asystole) for 10 to 25 seconds allowing for ini­ repair can rupture the underlying balloon. Therefore, as
tiation of a rapid suture repair. Further intravenous doses the continuous 3-0 or 4-0 polypropylene suture is placed
are given to complete the repair as needed. The annoying around the controlled defect, the balloon must be tempo­
side effects associated with adenosine use, including facial rarily pushed down into the ventricle with each passage of
flushing, thoracic discomfort, dyspnea, and headache, are the needle. Hemorrhage will occur with this maneuver, but
not noticeable under general anesthesia. rupture of the balloon is prevented.
Teflon pledgets are used to buttress left ventricular repairs
Restoring a Cardiac Rhythm performed with sutures alone in the emergency department
After hemorrhage has been controlled, patients with pre­ and any repairs performed in the OR. Commercially avail­
terminal bradycardia or new onset asystole need immediate able pledgets or pledgets cut from Teflon strips may be used.
cardiac resuscitation. If the heart feels empty, the descending When synthetic pledgets are not available, pieces of the
thoracic aorta should be cross-clamped if this has not been pericardium may be used. The technique is to first pass the
performed previously. If a median sternotomy was the origi­ two needles of a 4-0 polypropylene suture through a pledget
nal approach, a left anterolateral thoracotomy will have to be 6-  to 10-mm long and 3-  to 5-mm wide. The same needles
performed to complete this maneuver. Cardiac resuscitation are separately passed through both sides of the ventricu­
would then include administration of blood components as lar perforation under the surgeon or assistant's finger as
part of DCR, along with bimanual cardiac massage to perfuse described earlier. The two needles are then passed through
the coronary and carotid arteries. It is critical not to lift the another Teflon pledget of similar size and then cut off. As
apex of the heart because this may cause impingement of the the two ends are pulled up tight, the second pledget is moved
vena cavae or air embolism from the partially empty cardiac down to its side of the ventricular wound aided by ample
chamber with perforation if resuscitation has preceded repair. irrigation on the monofilament sutures. Tying the polypro­
When the heart does not respond to the infusion of pylene suture with appropriate tension will bring the Tef­
volume and internal cardiac massage, cardioactive medi­ lon pledgets in apposition, will seal the cardiac perforation,
cations should be administered. These include 1 mg intra­ and prevent the sutures from tearing through edematous
venous atropine for bradycardia, 1 to 3 mg intravenous myocardium.
epinephrine for bradycardia and hypotension, or 1 mg of One technique for a cardiac surgeon to repair a wound
intracardiac (into left ventricle) epinephrine for profound is the use of a sutureless patch and bioglue. This technique
bradycardia or asystole. The onset of ventricular fibrillation appears to be most useful for small wounds in difficult-to-
is treated with internal electrical defibrillation using two repair areas of the heart, such as the coronary sinus.51
paddles in contact with the heart anteriorly and posteriorly Cardiac wounds adjacent to a coronary artery are repaired
and 10 to 20 J as the initial electrical charge. After resto­ with pledgets as described previously, but the needles are
ration of a satisfactory cardiac rhythm and blood pressure, passed through both sides of the ventricular perforation and
suture repair of the cardiac perforation may be performed if under the adjacent coronary artery. Even with this modified
not completed previously. technique, tying the pledgets together to control hemor­
rhage may cause compression of the coronary artery and
Suturing Techniques ischemia of the distal myocardium. A direct, but limited,
Suturing of the injured heart is often complicated by tachy­ laceration of a proximal coronary artery may be repaired
cardia and the side-to-side motion of the heart in the peri­ with interrupted single 6-0 or 7-0 polypropylene sutures on
cardial sac. A most helpful maneuver to stabilize the beating rare occasions. In contrast, a laceration of a distal coronary
heart as repair is being performed is “clamp control of the artery near the apex of the heart is treated with ligation
right ventricular angle” as described at Temple University.50 and a 15-minute period of observation to assess myocardial
To accomplish this maneuver, a Satinsky clamp is applied to ischemia.
the apex of the right ventricle, and an assistant holding this
clamp will eliminate much of the side-to-side motion of the Acute Need for Cardiopulmonary Bypass
beating heart. The majority of patients who reach the hospital with signs
Repair of an atrial perforation or rupture above a Satin­ of life despite a cardiac perforation or rupture have a limited
sky clamp is performed with a purse string or continuous injury that can be repaired by a general surgeon, trauma
4-0 or 5-0 polypropylene suture. An alternate approach fellow, or a senior surgical resident. Approximately 1% to
to a hole in the atrial appendage is to place a 2-0 silk tie 3% of such patients have a more complex injury that can
under the Satinsky clamp much like in performing a decan­ only be repaired by a cardiac surgeon using cardiopulmo­
nulation maneuver following cardiopulmonary bypass. As nary bypass (Table 16.3; Fig. 16.6).22,52
noted, Allis clamps are used to control hemorrhage from
atrial wounds in the lateral aspect adjacent to the pericar­ Treatment in the Operating Room
dium. Repair is accomplished with a continuous or inter­ After Cardiorrhaphy
rupted mattress technique using 4-0 polypropylene suture If a left anterolateral or bilateral anterolateral thoracotomy
passed under the row of Allis clamps. has been performed, the superior and inferior transected
180 SECTION 4 • The Management of Vascular Trauma

Table 16.3 Indications for Cardiopulmonary Bypass for

patients who will not tolerate wire closure of the sternum
Cardiac Injuries. after a cardiac repair, a plastic silo (a genitourinary irriga­
tion bag opened on three seams) should be sewn to the skin
Acute
edges of the median sternotomy with continuous sutures of
Unable to complete repair because of size and location
2-0 nylon as a temporary closure maneuver. As the patient
Repair fails after blood pressure stabilizes or inotropes are administered
enters the diuretic phase of recovery in the subsequent 48
Injury to proximal coronary artery treated by ligation (off pump bypass to 72 hours, the silo is removed, and the sternum is closed
appropriate in certain patients)
at a reoperation.
Delayed
Injury to cardiac valve, papillary muscle, chordae tendineae, or atrial or
ventricular septum MAJOR COMPLICATIONS
Intracardiac fistula Cardiac Failure
Late pseudoaneurysm of ventricular repair
Cardiac failure after repair of a traumatic injury may require
the use of inotropic medications and/or an intraaortic bal­
loon pump. Possible causes of cardiac failure are: (1) tam­
ponade from a coagulopathy, hemorrhage from the repair,
Left anterior or hemorrhage from a missed injury; (2) cardiac compres­
descending sion from closure of the sternum; (3) posttraumatic myo­
coronary artery
cardial infarction without injury to a coronary artery53; (4)
posttraumatic myocardial infarction with injury to a coro­
nary artery; and (5) undiagnosed injury to a cardiac valve,
a papillary muscle, the chordae tendineae, or the atrial or
ventricular septum. An immediate ECG and TTE or TEE will
assist in making the diagnosis. Cardiac compression from
closure of the sternum is usually diagnosed at the comple­
tion of the first operation and is easily reversed by removing
Emergency the sternal wires.
aortocoronary
bypass Delayed Diagnosis of Intracardiac Lesions
For more than 55 years, it has been recognized that patients
Left who survive acute repair of a wound or rupture of the atrium
Left lung or ventricle may also have an internal cardiac injury.54 Post­
ventricular
stab wound
operative cardiac failure or the presence of a murmur on
repair auscultation in a previously healthy patient is a clinical sign
of such an internal injury. Other patients, particularly those
Fig. 16.6 Repair of left ventricular stab wound compressed the adja- with internal fistulas (i.e., right atrium to left ventricle) may
cent left anterior descending coronary artery and prompted an emer- be asymptomatic in the postoperative period.55 There is dis­
gency aortocoronary bypass to restore perfusion. agreement about studying all surviving patients with TTE
before discharge. In the 2016 report from Grady Memorial
Hospital, only 25 of 46 patients who survived after a pene­
trating cardiac wound from 2000 to 2010 had a post-repair
ends of the internal mammary arteries should be clamped two-dimensional TTE.22 All three of the patients who had
and ligated with 3-0 silk ties. If the heart is edematous after “positive” echocardiograms (two ventricular septal defects;
a repair, the pericardial sac is not closed. On occasion, there one cardiac failure) were symptomatic at the time.
may appear to be a risk of postoperative cardiac herniation An abnormal or inconclusive TTE would usually be fol­
through a left lateral pericardiotomy performed through a lowed by a TEE or cardiac catheterization. A patient with
left anterolateral thoracotomy. Closure of this lateral defect a hemodynamically significant injury to a valve, papil­
with interrupted 2-0 silk sutures would then be appropri­ lary muscle, chordae tendineae, or a septum should have
ate. The pericardial sac is drained with a right-angle 36-Fr delayed repair on cardiopulmonary bypass.56
thoracostomy tube inserted through the epigastric area of
the abdominal wall. A second 36-Fr thoracostomy tube SURVIVAL
is placed anterior to the heart. If either pleural cavity has
been opened, one or two 36-Fr thoracostomy tubes are Survival after penetrating cardiac trauma depends on the
placed through the 5th intercostal space between the ipsi­ mechanism of injury (stab vs. gunshot), the number of signs
lateral anterior and middle axillary lines. of life on admission (cardiovascular and respiratory com­
On occasion, epicardial pacing wires may have to be ponents of trauma score), the location of the thoracotomy
sewn to the heart when arrhythmias continue despite car­ (emergency department vs. OR), the cardiac rhythm at the
diac repair and resuscitation. An unstable patient who is time of the pericardiotomy (rhythm vs. asystole), the
not fully responsive to continuing resuscitation and ino­ number of chambers injured, and the associated inju­
tropes may benefit from the transfemoral insertion of an ries.12,22,57 Survival rates from two large series are listed
intraaortic balloon pump before transfer to the ICU. For in Table 16.4.
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 181

Table 16.4 Survival Rates After Penetrating Cardiac Table 16.5 Thoracic Vascular Organ Injury Scale.
Injuries.
Gradea Injury Descriptionb ICD-9 AIS-90
Asensio et al.a Morse et al.b I Intercostal artery/vein 901.81 2–3
1994–96 1975–85 1986–96 2000–10 Internal mammary artery/vein 901.82 2–3
Patients 105 113 79 79 Bronchial artery/vein 901.89 2–3
SW/GSW 37/68 77/36 53/26 34/45 Esophageal artery/vein 901.9 2–3
Survival SW 24/37 (65%) 59/77 47/53 26/34 Hemiazygos vein 901.89 2–3
(77%) (89%) (76%) Unnamed artery/vein 901.9 2–3
Survival GSW 11/68 (16%) 23/36 15/26 20/45 II Azygous vein 901.89 2–3
(64%) (58%) (44%)
Internal jugular vein 900.1 2–3
Survival 35/105 (33%) 82/113 62/79 46/79
Subclavian vein 901.3 3–4
overall (73%) (78%) (58%)
Innominate vein 901.3 3–4
Survival EDT 10/71 (14%) 2/23 (9%) 13/28 9/16
(46%) (56%) III Carotid artery 900.01 3–5
Innominate artery 901.1 3–4
EDT, Emergency department thoracotomy; GSW, gunshot wound; SW, stab
wound. Subclavian artery 901.1 3–4
a
Data from Asensio JA, Berne JD, Demetriades D, et al. One hundred five IV Thoracic aorta, descending 901.0 4–5
penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma.
Inferior vena cava (intrathoracic) 902.10 3–4
1998;144:1073–1082.
b
Data from Morse BC, Carr JS, Dente CJ, et al. Penetrating cardiac injuries: a Pulmonary artery, primary intrapa- 901.41 3
36-year perspective at an urban, level I trauma center. J Trauma Acute Care renchymal branch
Surg. 2016;81:623–631. Pulmonary vein, primary intrapa- 901.42 3
renchymal branch
V Thoracic aorta, ascending and arch 901.0 5
Injuries to the Great Vessels Superior vena cava 901.2 3–4
Pulmonary artery, main trunk 901.41 4
DEFINITION/CLASSIFICATION Pulmonary vein, main trunk 901.42 4
VI Uncontained total transection of 901.0 5
The great vessels in the chest and thoracic outlet are vari­ thoracic aorta or pulmonary hilum
ously defined, but most consider this category to include the 901.41 4
large vessels originating from the aortic arch and those in 901.42 4
what is traditionally considered zone I of the neck. In this AIS-90, Abbreviated Injury Scale; ICD-9, International Classification of
context, the terminology includes the ascending, trans­ Diseases.
verse, and descending thoracic aorta as well as the innomi­ a
Increase one grade for multiple grade III or IV injuries if >50% cir-
cumference. Decrease one grade for grade IV and V injuries if <25%
nate (brachiocephalic), common carotid, and subclavian circumference.
arteries. Because of their sizes and proximal locations, the b
Based on most accurate assessment at autopsy, operation, or radiologic
innominate and central jugular veins may also be included study.
as great vessels of the chest. Table 16.5 provides the AAST From Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV.
Thoracic Vascular Organ Injury Scale for vascular trauma Thoracic vascular, lung, cardiac, and diaphragm. J Trauma. 1994;36:
299–300.
in this region.25

HISTORY
cases.17 The mechanism of these injuries is overwhelm­
Several authors have cited the repair of a stab wound of the ingly penetrating (90%). Of patients who undergo emer­
ascending aorta in 1922 by Dfhanelidze in Russia as one of gent thoracotomy after penetrating thoracic injury, less
the earliest examples of a repair of a great vessel injury.58,59 than one-third have a great vessel injury as the cause of
Emergency ligation of injured great vessels and delayed hemorrhage.
repair of aneurysms and arteriovenous fistulas of the same
were described in reports after World War II.60–62 The earli­ Blunt Trauma
est civilian reports on techniques of exposure and repair of Blunt injuries to the great vessels (exclusive of the descending
great vessel trauma (exclusive of blunt rupture of the tho­ thoracic aorta, which will be described in Chapter 17 of this
racic aorta) were from Johns Hopkins and Baylor College of textbook), are uncommon. When they do occur, these injuries
Medicine.63–65 almost always involve the proximal innominate or subclavian
artery. In an older series describing 43 patients with injury to
INCIDENCE the innominate artery from 1960 to 1992, a blunt mechanism
was the cause in 17% of patients.66 Another even-older series
Penetrating Trauma on 93 patients with subclavian vascular trauma from 1955 to
If wounds to the heart and coronary arteries (#553) are 1978 noted that only 2% of patients had a blunt mechanism
excluded from the 30-year review of 5760 cardiovascu­ of injury.67 Both of these reviews, however, included periods
lar injuries at Ben Taub Hospital in Houston, injuries to of time when shoulder-harness restraints either were not
the great vessels accounted for approximately 10% of available on passenger vehicles or were not commonly used.
182 SECTION 4 • The Management of Vascular Trauma

ETIOLOGY some patients will be asymptomatic with a normal blood

pressure, but will have a contained hematoma in the supra­
Penetrating Trauma sternal, mediastinal, or supraclavicular area. This otherwise
A gunshot wound to the chest has less than a 5% chance asymptomatic hematoma may be seen on physical exami­
of injuring a thoracic great vessel.59 This low incidence nation, chest x-ray, or both (Fig. 16.9). The third group
in patients arriving at trauma centers reflects the lethal of patients will have proximity of a penetrating wound to
nature of penetrating wounds in this region. Stab wounds zone I structures with hard signs of vascular trauma such
are also uncommon and are reported to injure a great vessel as external bleeding, expanding hematoma, hemorrhagic
in only 2% of instances.59 This low percentage reflects the shock, a hemothorax on a surgeon-performed ultrasound,
fact that a stab wound causing a great vessel injury must or a lung outlined by blood or a hematoma visible on a
fall within a limited parasternal, thoracic outlet, or supra­ chest x-ray (Fig. 16.10). Those in the latter two groups with
clavicular area. injuries to the subclavian artery may have a difference in
blood pressure between upper extremities with the affected
Blunt Trauma side notably less than the unaffected side. Because of the
Blunt injuries to the innominate and subclavian arteries extensive collateral flow around the subclavian and axillary
most commonly occur in individuals wearing shoulder- arteries, a patient with proximal thrombosis of the subcla­
harness restraints in frontal motor vehicle crashes. The pro­ vian artery may still have palpable pulses in the ipsilateral
posed mechanism for this injury is direct compression to the upper extremity (Figs. 16.11 and 16.12). Measurement and
upper sternum or clavicle/first rib with partial or complete comparison of upper extremity blood pressure using either
avulsion off the aortic arch (innominate artery) or throm­ a stethoscope or the continuous wave Doppler has enough
bosis (subclavian artery) (Fig. 16.7). Another mechanism sensitivity for the clinician to identify this type of injury.
involves hyperextension and lateral rotation of the cervi­
cal spine away from the side of the shoulder harness. This Blunt Trauma
mechanism occurs as the victim slides under the shoulder If the injured patient was not wearing a restraint and there
harness and may cause stretching and avulsion of the ves­ was no deployment of an air bag, a sternal contusion may
sel. Either mechanism may lead to disruption of the intima suggest a blunt injury to the descending thoracic aorta.
with or without injury to part or all of the media and adven­ Patients with partial avulsion of the innominate artery
titia. Similar mechanisms have been proposed to explain from the aortic arch may present with hypotension, dimin­
blunt injury to the carotid and vertebral arteries. Disruptive ished or absent pulses in the right upper extremity, and a large
injuries to cervical vertebrae contribute to select patterns of hematoma in the superior mediastinum seen on a chest x-ray.
zone I vascular trauma, as well. A less severe injury would be an intimal tear of the innomi­
nate or subclavian artery without ­thrombosis. Therefore,
PRESENTATION
Penetrating Trauma
Patients with penetrating wounds to the thoracic outlet and
superior mediastinum will present with one of three differ­
ent clinical scenarios. First, some will be asymptomatic with
normal vital signs and a normal chest x-ray. These patients
may have proximity of the penetrating wound only to zone I
of the neck and to the great vessels (Fig. 16.8). Second,

Fig. 16.8 An arteriogram that was performed in an asymptomatic

Fig. 16.7 Shoulder-harness restraint caused proximal occlusion of the patient with a stab wound to the thoracic outlet demonstrated a 5-cm
right subclavian artery. traumatic false aneurysm of the right common carotid artery (arrows).
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 183

Fig. 16.9 (A) Chest x-ray of a patient with a gunshot wound in proximity to the left subclavian artery and a palpable hematoma in the left supraclavicular
area. (B) Computed tomography angiogram reconstruction of injury to the left subclavian artery in same patient as (A). Also, note injury to left scapula.
(C) Intraoperative angiogram performed with combined contrast through thoracic aorta and left brachial artery prior to insertion of endovascular stent.

it is external markers of mediastinal injury, asymmetric a shoulder-harness restraint on the lower neck or supra­
upper extremity blood pressures, and/or an abnormal chest clavicular area. Also, a blunt injury to the carotid artery
x-ray that should prompt further imaging. Of interest, some should be suspected in patients who present with abnormal
patients with injury to the proximal innominate artery have neurological findings with a normal CT scan of the brain.
a particular pointed appearance to the right side of the supe­ In those with a proximal (zone I of the neck) injury to
rior mediastinum on chest x-ray (Fig. 16.13). the common carotid artery, there may also be a widened
As previously noted, a blunt injury to the proximal superior mediastinum on the initial chest x-ray. Other clas­
subclavian artery typically causes a flow-limiting intimal sic findings associated with blunt cerebrovascular injury
abnormality or thrombosis. Although most blunt injuries include cervical spine fracture, LeFort II or III facial frac­
to the common carotid artery occur in zone II of the neck, tures, Horner syndrome, and skull-base fracture. The pres­
more proximal injuries to the common carotid artery (i.e., ence of one or more of these findings should heighten the
zone I) can occur. Indicators of such an injury include trauma team's suspicion of the presence of a blunt injury to
the previously mentioned external mark of trauma from the common or internal carotid artery.
184 SECTION 4 • The Management of Vascular Trauma

Fig. 16.10 A profoundly hypotensive patient with superior mediastinal

hematoma from a gunshot wound to posterior transverse aortic arch
and the left common carotid artery was taken to the operating room
directly. (With permission from Feliciano DV. Vascular injuries. In: Maull KI,
Cleveland HC, Strauch GO, et al., eds. Advances in Trauma, Vol. 2. Chicago: Fig. 16.12 The same patient as in Fig. 16.11. Delayed film demon-
Mosby-Year Book; 1987:179–206.) strates reconstitution of the left axillary artery in this patient with an
intermittently normal left radial pulse. (With permission from Graham
JM, Feliciano DV, Mattox KL. Combined brachial, axillary, and subclavian
artery injuries of the same extremity. J Trauma. 1980;20:899–901.)

Fig. 16.13 A patient with a pointed appearance of the right side of

Fig. 16.11 A patient with thrombosis of the proximal left subclavian the widened superior mediastinum had blunt rupture of the innomi-
artery on arteriogram after sustaining a gunshot wound to the lateral nate artery on a computed tomography arteriogram. (With permission
left arm. (With permission from Graham JM, Feliciano DV, Mattox KL. from Feliciano DV, Burch JM, Graham JM. Vascular injuries of the chest and
­Combined brachial, axillary, and subclavian artery injuries of the same abdomen. In: Rutherford RB, ed. Vascular Surgery. 3rd ed. Philadelphia: WB
extremity. J Trauma. 1980;20:899–901.) Saunders; 1989:588–603.)
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 185

DIAGNOSIS a range of vascular thoracic injuries when endovascular

approaches were applied. Other studies on this topic sup­
Penetrating Trauma port these findings.71,73
In the first two groups described earlier (i.e., normotensive Although comparatively less well-studied, endovascular
patient with proximity of wound and normotensive or hypo­ capabilities can also be utilized to support open repair in
tensive patient with hematoma on examination or on chest a “hybrid” approach. For example, endovascular balloons
x-ray), further radiologic studies are necessary. Patients in can provide temporary control of arteries both proximal
the hypotensive group will require judicious resuscitation and distal to the injury site during open exposure (see Chap­
in the emergency department before further imaging stud­ ter 11). Once in position, these balloons can frequently be
ies. Depending on the degree of hypotension, resuscita­ palpated within the operative field, facilitating rapid iden­
tion should be limited to maintain the patient's mentation tification of vascular structures in what can be a severely
and urine output and not a specific blood pressure to avoid disrupted field of exposure due to the injury. It is important
restarting bleeding or increase ongoing bleeding. to remember, however, that these approaches require the
The purpose of additional imaging studies in this scenario availability of specialized providers and imaging capabili­
is to verify and localize the aortic or arterial injury and to ties, “luxuries” that are not often afforded in the setting of
help determine the most appropriate management. CT arte­ an unstable patient.
riography (CTA) is indicated because of convenience, speed, Although the application of endovascular approaches
and improved accuracy. Should the CTA be compromised by appears to have improved outcomes in select patients, there
scatter from metallic bullet fragments, a transfemoral digi­ also remains a paucity of data on long-term outcomes. The
tal subtraction aortogram is performed. need to collect these data is critical to defining the optimal
Regardless of chest x-ray findings, no additional diag­ indications and techniques in the management of injuries
nostic studies are indicated in the third group of patients to the great vessels.
with profound hypotension. Instead, patients with this
injury pattern and clinical presentation should have man­ OPERATIVE MANAGEMENT IN THE EMERGENCY
ual compression of any bleeding from the suprasternal or DEPARTMENT AND OPERATING ROOM
supraclavicular area, initiation of blood component–based
resuscitation and be transported directly to the OR. Patients Finger Control of External Hemorrhage
with a systolic blood pressure less than 70 mm Hg or with On rare occasions, external hemorrhage from either the
a recent cardiac arrest should have a resuscitative thoracot­ suprasternal notch or the supraclavicular fossa may be the
omy in the emergency department as described in previous sole manifestation of a major thoracic vascular injury from
sections. a stab or gunshot wound. If no pleural connection is pres­
ent, insertion of a finger, balloon catheter, or pack into the
Blunt Trauma stab or gunshot wound site may control bleeding until the
Diagnosis of a blunt injury to the innominate, subclavian, patient can be transferred to the OR.
or common carotid artery proceeds in much the same man­
ner as with patients who have a penetrating injury. An
initial chest x-ray is useful as a screening test to assess for
the presence of a hemothorax and/or a widened mediasti­
num indicative of a hematoma. Once again, CTA is used to
determine the presence and extent of a suspected injury in
a patient who is hemodynamically normal.

ENDOVASCULAR MANAGEMENT
The use of endovascular techniques to treat blunt and
penetrating thoracic aortic and side branch injuries has
increased exponentially since the early 2000s.68–74 (Fig.
16.14). A growing body of evidence suggests that, among
appropriately selected patients, endovascular treatment
is associated with improved outcomes for injuries in these
areas which are often associated with challenging expo­
sures for control and repair.
In the study by Branco et al., investigators found that
endovascular treatment for injuries to the axillary or
subclavian arteries was associated with lower in-hospital
mortality and fewer surgical site infections compared with
those managed with open repair.74 A subsequent report
utilizing data from the American College of Surgeons
National Trauma Data Bank compared matched cohorts
of patients with injuries at these locations who under­
went either open or endovascular repair.72 In this study, Fig. 16.14 A patient with blunt trauma to the chest had a traumatic
the authors found that outcomes were improved across false aneurysm of the innominate artery on an arteriogram.
186 SECTION 4 • The Management of Vascular Trauma

middle one-third of the clavicle may be useful in facilitating

Incisions control and repair (Fig. 16.16). Before claviculotomy or par­
The emergent approach to a patient who is hypotensive or tial resection of the clavicle, circumferential stripping of the
who has had a recent cardiac arrest from a wound to a great periosteum is performed to separate away the often tightly
vessel is a unilateral or bilateral anterolateral thoracotomy. adherent subclavian vein. At the completion of the vascular
The only change that may be needed from the previously
described approach is to place the thoracic incision or inci­
sions above the male nipple if there is an obvious wound, Compressed
subclavian
a pulsating hematoma, or external bleeding in proximity artery
to the subclavian vessels. Although it is more difficult to Clamped
spread the ribs at this level, it does allow for rapid insertion subclavian
of a finger or pack to control intrapleural hemorrhage from artery
an injury to a subclavian vessel. After the bilateral antero­
lateral thoracotomy is performed, bimanual dissection is
performed to separate the upper chest flap and sternum
from the underlying thymus and pericardium. Finochietto
retractors are placed bilaterally, and a finger or clamp is
used to control bleeding.
A median sternotomy is performed in the OR in patients
who are more hemodynamically stable and when the track
of a stab or gunshot wound is in proximity to the superior
mediastinum (i.e., supraclavicular notch or zone I of the Chest
neck). The same incision is used when the initial chest x-ray incision
documents a hematoma in the superior mediastinum. A
sternotomy provides great exposure to the ascending and
transverse thoracic aorta, innominate artery and veins,
the first portion of the right subclavian artery, the proximal
right common carotid artery, and the proximal left common
carotid. A high left anterolateral thoracotomy is the pre­
ferred emergency approach to an injury to the first (intra­
thoracic) portion of the left subclavian artery, though this
can be visualized with some effort through a sternotomy by Fig. 16.15 A high left anterolateral thoracotomy, cross-clamping of
experienced surgeons. (Fig. 16.15). the first portion of the left subclavian artery, and external compres-
Injury to the second portion of either subclavian artery sion to control exsanguinating hemorrhage from the second portion.
(posterior to the scalenus anticus muscle) is approached via (With permission from Feliciano DV, Graham JM. Major thoracic vascular
a supraclavicular incision. If the injury is directly behind the injury. In: Champion HR, Robb JV, Trunkey DD, eds. Robb & Smith's Operative
clavicle or at its midpoint, a claviculotomy or resection of the Surgery. London: Butterworth & Co.; 1989.)

Subclavian
artery

Clavicle (cut)

Fig. 16.16 Subperiosteal resection of the middle one-third of the clavicle improves exposure of the second portion of the subclavian artery and of the
adjacent subclavian vein. (Copyright, Baylor College of Medicine, Houston, 1985.)
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 187

repair, the claviculotomy may be repaired by drilling holes in incisions and dividing the clavicle, if necessary, allows for
an anteroposterior direction in the ends. With this maneuver, distal control at the first portion of the axillary artery.
a sternal wire is curved into the letter “U,” is placed postero­
anterior, and the two ends are twisted to align or approxi­ Control of Hemorrhage/Vascular Repair
mate the divided ends of the bone. Another repair technique Penetrating Wound of the Ascending Aorta or
is to use a dynamic compression plate across the anterior Transverse Aortic Arch. After opening the pericardium,
aspect of the fracture. When a segment of clavicle has been pulsatile hemorrhage from the thoracic aorta is controlled
removed, inserting a sternal wire across each “fracture” site with a finger or a Satinsky or a large Wiley “J” clamp.75
is the quickest repair. Repair of the divided clavicle should be Either of these clamps may be placed as a partial occlusion
performed in patients who are hemodynamically stable. clamp isolating the vascular injury for débridement and
Should there be a need to expose the junction of the first repair. Aortorrhaphy is performed with a continuous or
and second portions of the subclavian artery on the right interrupted row of 4-0 polypropylene sutures placed under
side, it may be necessary to perform a median sternotomy the surgeon's finger or above the Satinsky clamp. During
connected to a right supraclavicular incision. On the left these maneuvers it is useful to reduce the patient's blood
side, a high left anterolateral thoracotomy, a left supracla­ pressure and stroke volume to avoid dislodgment of the
vicular incision, and a connecting partial upper median clamp and tearing of the sutures. The use of Dacron or
sternotomy may occasionally need to be performed (Fig. Teflon pledgets as previously described may also assist in
16.17). This rarely used “book thoracotomy” will, of course, repairing arterial injuries in this location.
not open like a book. Rather, it slides open once a Finochi­ Repair of Penetrating Wound of the Innominate
etto retractor is inserted. The disadvantages of this incision Artery. After performing a pericardiotomy, the crossover
include multiple sharp bony ends that catch the gloves of left innominate vein is rapidly mobilized and elevated
the surgical team and significant postoperative pain. superiorly or inferiorly with a Silastic vessel loop. This
Injury to the third portion of either subclavian artery vein may be ligated if necessary if it has been injured or is
(lateral edge of scalenus anticus muscle to anterior edge of obstructing exposure of the injured artery. Finger control
first rib) cannot always be approached through the supra­ on a perforation of the artery is maintained until proximal
clavicular incision. An infraclavicular incision may also and distal vascular clamps (e.g., DeBakey, Satinsky, or Wiley
need to be performed adjacent to the lateral 1/3 of the J) are applied. A wound near the distal bifurcation of the
clavicle, as well. Connecting the supra- and infraclavicular innominate artery may be difficult to visualize through a
standard median sternotomy. In such a patient, the median
sternotomy may be extended cephalad with an oblique right
cervical incision or laterally with a right supraclavicular
incision, as previously noted. These extensions of the
sternotomy will allow for distal control of the right common
carotid and right subclavian arteries, respectively.
Dissection around the proximal right subclavian artery
should be done with care as the right recurrent laryngeal
nerve loops around this vessel within 1.5 to 3.0 cm of its
origin. Once vascular control has been obtained, an effort
should be made to convert clamping of the right subclavian
and common carotid arteries to just the distal innominate if
there is room. This maneuver allows for temporary perfusion
of the right upper extremity via backflow through the right
common carotid artery from the circle of Willis in the brain.
If a short segmental resection of the innominate is neces­
sary for a through-and-through gunshot wound, an end-
to-end and often pledgeted anastomosis is performed with
5-0 polypropylene suture. A longer segmental resection
mandates the insertion of an 8- or 10-mm ringed polytetra­
fluoroethylene (PTFE) or knitted Dacron interposition graft.
As previously noted, temporary vascular shunts are not
usually inserted during end-to-end anastomoses or inser­
tion of interposition grafts in this location or the common
carotid arteries unless a “damage control” operation is per­
formed (Fig. 16.18). This is because there is almost always
Fig. 16.17 Multiple incisions used for wounds to the great vessels. adequate cerebral crossover flow in young patients if vascu­
Exposure of the first portion of right subclavian artery may require a lar clamp time is under 30 minutes.
median sternotomy and right supraclavicular incision. Exposure of the As the end-to-end anastomosis or suture line on the distal
junction of the first and second portions of the left subclavian artery graft is completed, proximal and distal flushing is necessary
may require a high left anterolateral thoracotomy, a partial upper to remove air before the final sutures are tied. The proxi­
median sternotomy, and a left supraclavicular incision—the so-called mal clamp and a clamp on the right common carotid are
“book thoracotomy.” (Copyright Baylor College of Medicine 1980. With then reapplied as backflow from the right subclavian artery
permission.) completes the evacuation of air. Antegrade flow is first
188 SECTION 4 • The Management of Vascular Trauma

e­ stablished into the right subclavian artery by removing the top of the trachea. An effort should be made to interpose
clamp on the innominate artery. Flow into the right com­ thymic tissue or pericardial fat between these structures so
mon carotid artery is established 10 seconds later by remov­ as to prevent development of a tracheo-innominate artery
ing the clamp on this vessel. Depending on the location of fistula.
an interposition graft, the proximal suture line may lie on Repair of a Blunt Tear of the Innominate Artery
Origin. The proximal ascending aorta inferior to the origin
of the innominate artery is first exposed, and an 8-mm knitted
Dacron graft is sewn to it using a partial occlusion clamp
(Satinsky or Wiley J) and a 4-0 polypropylene suture (Fig.
16.19). The hematoma (true or false traumatic aneurysm)
around the proximal innominate artery is not entered until
the aortic arch at the origin of the artery and its bifurcation
in the right superior mediastinum have been dissected free.
At this point a partial occlusion clamp is again placed on the
arch, this time around the origin of the innominate artery.
Another vascular clamp is placed around the distal artery,
or the right subclavian and common carotid arteries are
clamped individually. The hematoma is then entered, and the
distal innominate is transected.
At this juncture, the previously inserted PTFE or Dacron
graft, which has been cut longer than necessary, is sewn
end-to-end to the distal innominate artery (Fig. 16.19)
using 4-0 or 5-0 polypropylene suture. No shunt is used in
the “routine” operation as previously noted. On rare occa­
sions, profound intraoperative hypotension may force the
surgeon to insert a temporary intraluminal shunt through
the proximal graft anastomosis and then withdraw it before
completion of the distal anastomosis. Systemic doses of
intravenous heparin are not generally used in patients
with this pattern of vascular trauma, especially those who
Fig. 16.18 Patient with near-exsanguination from a gunshot wound to have suffered blunt injuries. The final step in this approach
the proximal right common carotid artery had insertion of a temporary is the oversewing of the proximal innominate artery over
intraluminal shunt during the initial “damage control” operation. the partial occlusion clamp on the aortic arch. This suture

Fig. 16.19 Operative technique of bypass grafting for repair of blunt injury to proximal innominate artery. (Copyright, Baylor College of Medicine,
Houston, 1981.)
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 189

line is easily visualized by moving the somewhat redundant to see if a fasciotomy is needed there, as well. If a clavicu­
Dacron graft away from the arch. lotomy or partial clavicular resection has been performed,
Repair of a Blunt Tear of the Left Common Carotid care must be taken to ensure that the tips of the screws used
Artery Origin. After performing a pericardiotomy, the for a bony repair do not protrude posteriorly near the artery,
crossover left innominate vein is mobilized and elevated vein, or repair.
superiorly or inferiorly with a Silastic vessel loop. This vein Superior or Inferior Vena Cava. After performing a
may be ligated if it has been injured or is obstructing an pericardiotomy, DeBakey forceps are used to elevate the
otherwise challenging dissection. A Satinsky or Wiley J perforated edges of the lacerated vein. A Satinsky clamp
clamp is applied in a longitudinal direction to the transverse is then placed under the perforation. As previously noted,
aortic arch just under the origin of the left common carotid a row of Allis clamps may also be used to control bleeding
artery. The type of repair will depend on the amount of local and elevate the edges of a long anterior, medial, or lateral
disruption of the intima and media at the junction of the laceration. A through-and-through wound to the cava
left common carotid artery and transverse arch. An obvious mandates clamp control around the lacerations and repair
extensive disruption of the origin of the left common carotid of the posterior perforation through the anterior opening,
artery is repaired as described for proximal blunt disruption followed by repair of the anterior injury. Venorrhaphy using
of the innominate artery using a separate inflow site for an 4-0 or 5-0 polypropylene suture in a continuous fashion is
interposition graft. the favored method of repair for the vena cava.
Right and Left Subclavian Vessels. When penetrating When clamp control of an extensive posterior perforation
wounds of the subclavian vessels communicate with the of the inferior vena cava is impossible, the patient will need
corresponding pleural cavity, rapid exsanguination will to be placed on cardiopulmonary bypass. In this scenario,
occur. In such patients, a high anterolateral thoracotomy at the inferior cannula is placed in the inferior vena cava in
the level of the 3rd or 4th intercostal space above the nipple the abdomen via the femoral vein and a balloon cath­
should be performed. Finger or pack control at the apex of eter occludes the inferior vena cava beyond the injury.59
the right pleural cavity through the high right thoracotomy Posterior repair with 4-0 or 5-0 polypropylene suture is
coupled with manual pressure on the right supraclavicular completed through a right atriotomy.
fossa will tamponade almost all major subclavian bleeding Crossover Left Innominate Vein. After performing a
until vascular control can be obtained in the OR. pericardiotomy, vascular clamps are placed around any
As the proximal left subclavian artery is an intratho­ perforation in the left innominate vein. Either a lateral
racic structure (in contrast to the mediastinal course of the venorrhaphy or end-to-end anastomosis is performed with
proximal right subclavian), it can be visualized and directly a 5-0 polypropylene suture. Ligation may be performed with
clamped through a high left anterolateral incision. If back- more extensive injuries or as an expedited damage control
bleeding from the distal artery or bleeding from the left sub­ maneuver. If the vein has been ligated, the pressure is then
clavian vein continues, finger or pack pressure through the measured in the superficial volar compartment of the left
thoracotomy incision should be combined with supracla­ forearm as previously described. In these instances, it may
vicular pressure, as described for the right side. be useful to place the left upper extremity in a stockinette
Proximal and distal control of the subclavian artery is to facilitate intermittent elevation to reduce swelling during
obtained after mobilizing the phrenic nerve away and divid­ the postoperative period.
ing the scalenus anticus muscle. Depending on the location
of the injury, it may be necessary to ligate and divide the MAJOR COMPLICATIONS
thyrocervical trunk and, on occasion, the vertebral artery.
For future cardiac surgery, it is worthwhile to preserve the Cardiac Compression with Sternal Closure
ipsilateral internal mammary artery if possible. Experi­ As previously noted, temporary coverage of the heart can
enced trauma vascular surgeons know that the subclavian be accomplished by sewing a plastic silo to the skin edges of
artery is fragile and that tension on an end-to-end anasto­ an anterolateral thoracotomy or median sternotomy. Once
mosis or graft anastomosis will lead to partial or complete the patient's physiology improves and diuresis occurs, the
disruption of the suture line when flow is reestablished. If silo is removed and the sternum closed at a reoperation.
an end-to-end anastomosis cannot be performed because of
tension after a segmental resection, an 8-mm ringed PTFE Cerebral Ischemia
or knitted Dacron interposition graft should be used as the Cross-clamping of the innominate or left common carotid
method of reconstruction. artery in the hypotensive patient has the risk of leading to
Proximity and adherence of the subclavian vein to the cerebral ischemia and stroke. Fortunately, this complica­
clavicle and the many venous branches in this area make tion is uncommon if control of hemorrhage, innominate
obtaining venous control and a satisfactory vein repair or carotid clamp time, and vascular repair are performed
challenging. If control of the subclavian vein is too difficult quickly. If a patient has a persistently depressed Glasgow
or if repair results in extensive narrowing, ligation may be coma scale score in the ICU after a repair of an injured
a better choice. After ligation has been performed, the pres­ innominate, right or left common carotid artery, he or she
sure should be measured in the superficial volar compart­ should undergo a CT scan of the brain. Ipsilateral cerebral
ment of the ipsilateral forearm. A compartment pressure ischemia on the CT is treated with the avoidance of hypo­
greater than 35 mm Hg is followed by forearm fasciotomies tension and hypoxia. Secondary cerebral edema is managed
of the mobile wad and superficial and deep volar compart­ with elevation of the patient's head, intravenous mannitol
ments through a volar–ulnar incision.76 The pressure is (1 g/kg), drainage of cerebrospinal fluid, and, on rare occa­
then measured in the dorsal compartment of the forearm sions, with pentobarbital coma.
190 SECTION 4 • The Management of Vascular Trauma

Associated Neurological Deficits HISTORY

The proximity of the brachial plexus to the supraclavicular Asensio et al. have comprehensively reviewed the history of
area explains the fairly high incidence of neurological defi­ the management of pulmonary injuries.79 After the intro­
cits associated with subclavian vascular trauma. Transected duction of median sternotomy by Duval in 1897 and left
trunks, divisions, or cords noted at the time of operation anterolateral thoracotomy by Spangaro in 1906, it was
should be tagged with long 0 or 2-0 polypropylene sutures American surgeons who developed operative repair of
to allow for identification at a subsequent operation. A care­ major injuries to the lung during World War I. The over­
ful neurological examination should be performed and doc­ whelming number of penetrating chest wounds in World
umented once swelling and pain from the acute injury and War II prompted use of drainage with thoracostomy tubes
operation have resolved. Persistent and severe deficits in the as primary treatment.80,81 This continues today with the
ipsilateral upper extremity mandate referral to a neurosur­ more invasive thoracoscopy or thoracotomy reserved for a
geon with experience in neural grafting. If this is not possible, selected group of patients to be described.
referral of the patient to an upper extremity or hand surgeon
for possible tendon transfers in the forearm is appropriate. INCIDENCE
Penetrating Trauma
SURVIVAL
Penetrating injury, 70% to 75% of which is gunshot related,
Much as with cardiac injuries, survival after injuries to accounts for 75% to 88% of thoracotomies for thoracic
the great vessels depends on multiple factors, including trauma in the United States.79,82 When all patients with
mechanism (penetrating vs. blunt), number of signs of penetrating wounds to the chest are considered, only 5%
life on admission, location of thoracotomy, presentation to 10% have bleeding from the lung as the indication for a
(hemorrhage vs. hematoma), number of vessels injured, thoracotomy as previously noted.
and number of associated injuries. Survival figures
in large series over the past five decades are listed in
Table 16.6.66,68,74,77,78 Table 16.7 Lung Organ Injury Scale.25
Injury
Gradea Injury Type Descriptionb ICD-9 AIS-90
Injuries to the Lungs I Contusion Unilateral, <1 lobe 861.12/861.31 3
II Contusion Unilateral, single 861.20/861.30 3
CLASSIFICATION lobe
Laceration Simple 860.0/1 3
Injuries to the lungs are classified according to the AAST pneumothorax
Lung Organ Injury Scale described in 1994 (Table 16.7).25 860.4/5
III Contusion Unilateral >1 lobe 861.20/861.30 3
Laceration Persistent 860.0/1 3–4
Table 16.6 Survival Rates After Injuries to the Great (>72 hours), air leak
Vessels. from distal airway
860.4/5
Injuries Survival Rates
862.0/861.30
Injury to innominate artery, 1964–92 (penetrating 34/
Hematoma Nonexpanding
blunt 7/other 2)66
intraparenchymal
Gunshot/stab 72%
IV Laceration Major (segmental 862.21/861.31 4–5
Blunt 86% or lobar) airway
Penetrating injury to subclavian artery, 1991–2001 leak
(gunshot 46/stab 5/shotgun 3)77 Hematoma Expanding
Gunshot 73% intraparenchymal
Stab 80% Vascular Primary branch 901.40 3–5
Shotgun 80% intrapulmonary
Penetrating injury to subclavian artery, 1997–2007 vessel disruption
(stab 53/gunshot 4)68—all stentgraft V Vascular Hilar vessel 901.41/901.42 4
Survival 98% (#56) disruption
Early occlusion 5% (#3) VI Vascular Total, uncontained 901.41/901.42 4
transection of
Late occlusion 5% (#3)
pulmonary hilum
Late stenosis 9% (#5)
AIS-90, Abbreviated Injury Scale; ICD-9, International Classification of
Penetrating injury to innominate, carotid, 85%
Diseases.
subclavian, and axillary arteries, 2000–1378 a
Advance one grade for bilateral injuries; hemothorax is graded according
Injury to axillosubclavian arteries, 2003–13 to the thoracic vascular OIS.
(penetrating 41, blunt 112)74 b
Based on most accurate assessment at autopsy, operation, or radiologic
Overall survival 78% (119/153) study.
Endovascular survival 94% (17/18) From Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV.
Thoracic vascular, lung, cardiac, and diaphragm. J Trauma. 1994;36:
Open survival 76% (102/135) 299–300.
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 191

Blunt Trauma (πr2h), a decrease in the radius of 10 to 8 cm in a structure

Only 12% to 25% of patients undergoing a thoracotomy for 30 cm in height would decrease volume by 36%.
trauma to the lung have a blunt mechanism of injury.79 A patient with an open pneumothorax or what is some­
times referred to as a “sucking chest wound” has an opening
ETIOLOGY in the chest wall and pleura that is larger than the opening in
the glottis. In this scenario, when the patient takes a breath,
Penetrating Trauma air will enter the pleural space around the lung rather than
Gunshot and/or stab wounds lacerate the parenchyma of enter into the lung through the tracheobronchial tree (i.e.,
the lung. Exsanguinating hemorrhage from a lung injury is breathing through the chest wall). Such a patient will pres­
uncommon, especially if the wound is in the periphery of a ent with the sound of air movement through the chest wall
lobe. The relatively low incidence of bleeding from a pulmo­ defect, shortness of breath, and possibly hypotension related
nary parenchymal injury is a reflection of the relatively low to tension physiology including mediastinal shift.
systolic pressure in the branches of the pulmonary artery. A patient with a true tension pneumothorax is rare in
This may also be due to a tamponade effect as the visceral the emergency department presumably because of the
and parietal pleura come into contact with one another prehospital lethality of such an injury. In the modern era,
after insertion of a thoracostomy tube. most patients with this entity are in the ICU on a volume
Penetrating wounds that injure the more central, hilar ventilator and often with ventilator-associated pneumonia
area of a lobe or the lung are more likely to cause life-­ that predisposes to pulmonary rupture. A tension pneumo­
threatening bleeding. The obvious reason relates to the larger thorax leads to anxiety and a sense of doom, absent breath
size of more central vessels as well as the increased likelihood sounds, hyperresonant percussion on the affected side, and
that branches of both the pulmonary artery and vein will be deviation of the trachea away from the pneumothorax.
injured. It is also true that central vessels are extraparenchy­ Cyanosis is an ominous sign often manifest shortly before
mal, making them more prone to free bleeding if lacerated. cardiovascular collapse secondary to tension physiology.
Blunt Trauma Hemothorax
It is unusual for an adult to have an injury to the lung with Hemothorax or blood in the pleural cavity results from
an associated pneumothorax or hemothorax without an injury to a vessel in the pulmonary circulation, a vessel in
injury to the overlying ribs. In other words, most blunt pul­ the systemic circulation (e.g., intercostal or internal mam­
monary injuries are associated with rib fractures. The same mary vessel), or an injury to the heart. In all three instances,
is not true for children, who are more susceptible to blunt symptoms from a hemothorax will be related to its volume
pulmonary injury without rib fracture due to the elasticity and whether any bleeding is ongoing. As such, both respira­
of the thoracic cage. In addition to the mechanism of direct tory (e.g., shortness of breath) and hemodynamic compro­
laceration from the end of a fractured rib, there are two mise (e.g., hypotension) may occur.
other proposed mechanisms for blunt pulmonary injury.
The second is the valsalva-compression scenario in which DIAGNOSIS
a patient inspires and holds his or her breath just before
compression occurs during a motor vehicle crash. This A patient with significant thoracic trauma, shortness of
phenomenon is thought to be associated with rupture of breath, and decreased or absent breath sounds over one
the pulmonary parenchyma and pneumothorax. The third hemithorax has a presumed pneumo- or hemothorax. In
mechanism relates to the differential deceleration of the the presence of all three symptoms, no further diagnostic
fixed (hilum and inferior pulmonary ligament) versus study is indicated other than insertion of a thoracostomy
the mobile (peripheral parenchyma and lobes) aspects of tube. In a patient with an altered sensorium, traumatic
the lung in frontal deceleration or lateral impact. In these brain injury, or multiple injuries, or one in whom bilateral
scenarios, the pulmonary vasculature at these junction breath sounds are difficult to assess, a surgeon-performed
points is prone to tearing or disruption. transthoracic ultrasound of the lungs should be performed.
This extended FAST examination (EFAST) is accomplished
PRESENTATION with a 3.5-mHz general transducer probe positioned over
the lateral thorax, superior to the 10th and 11th inter­
Pneumothorax costal spaces. This technique can be used to quickly deter­
Either penetrating or blunt thoracic trauma can cause a sim­ mine the presence of a pneumo- and/or hemothorax.83–85
ple, tension, or open pneumothorax. A patient with a simple Blood in the thoracic cavity appears as a V-shaped stripe on
pneumothorax (does not expand with inspiration) is likely to ultrasound that is isoechoic compared to the blood in the
present with pain from an associated rib fracture and with inferior vena cava and often results in a “fluttering” par­
shortness of breath. The severity of the dyspnea is related tial collapse of the lower lobe.83 A pneumothorax results in
to the size of the pneumothorax and extent of injury to the loss of a finding referred to as the lung “sliding sign” which
underlying lung. Trainees have historically underestimated is a hyperechoic line with to-and-fro movement between
the three-dimensional magnitude of a pneumothorax with a lung and chest wall. A pneumothorax may also result in
collapsed lung. For example, should the radius of an injured an ultrasound finding referred to as a “comet-tail artifact”
lung decrease from 10 to 8 cm secondary to a pneumothorax, which is related to the partially compressed visceral pleura.
the volume of the lung as a sphere (πr3) would decrease by Similar to examination of the pericardial sac and heart in the
50%. If one prefers to consider the injured lung as a c­ ylinder standard FAST, pleural ultrasound looking for an effusion
192 SECTION 4 • The Management of Vascular Trauma

or pneumothorax can be performed quickly and is highly 6. Open, operative rib fixation with metal or absorbable
accurate.83–85 plates.91–93
An anteroposterior chest x-ray performed with the
patient in the supine or semirecumbent position in the Supportive Care After Pulmonary Contusion
trauma room remains the standard for diagnosis in trauma The presence of blood in alveoli and the interstitium of
centers that do not use surgeon-performed ultrasound. the lung after penetrating or blunt chest trauma causes a
Although gross intraparenchymal and pleural abnormali­ ­ventilation/perfusion mismatch and hypoxia. Oxygen by
ties are readily seen, small pneumothoraces may be missed a nasal cannula or by a close-fitting mask with judicious
with this basic technique. The incidence of missed injuries administration of maintenance fluids based on hemody­
can be reduced by performing a posteroanterior chest x-ray namic status are the mainstays of treatment in patients
in the upright position or by repeating the film with the without early onset respiratory failure. Placement of a cen­
patient in expiration. tral venous catheter to measure venous pressure may be
It has long been recognized that a small percentage of useful in older patients with a pulmonary contusion. Signs
pneumothoraces will be recognized in a delayed fashion of respiratory failure (e.g., pO2 less than 70 torr on oxygen,
hours after an injury. This fact has led to repeating a chest pCO2 greater than 55, respiratory rate of greater than 25,
x-ray at 3 hours (i.e., “a 3-hour rule”) as there is little risk poor negative inspiratory force, or worsening chest x-ray)
of a delayed pneumothorax after this.86 Although much mandate intubation. A significant pulmonary contusion
has been written about the benefits of CT scanning in can progress in a short period of time to become every bit as
patients with suspected thoracic trauma, many of the serious as other forms of acute lung injury and adult respi­
injuries detected with this sensitive imaging modality do ratory distress syndrome (ARDS).
not require treatment. Examples include incidentally dis­
covered fractured rib(s), asymptomatic pulmonary contu­ OPERATIVE MANAGEMENT IN THE EMERGENCY
sion, and small pneumo- or hemothoraces.87 The major DEPARTMENT AND OPERATIVE ROOM
advantage of chest CT is in the diagnosis of blunt injury
to the thoracic aorta. Indications
The indications for emergent or resuscitative thoracotomy
NONOPERATIVE MANAGEMENT with or without cross-clamping of the descending thoracic
aorta have been discussed elsewhere in this chapter and are
Tube Thoracostomy also provided in Box 16.1 (Fig. 16.20).
Adults with a pneumo- or hemothorax who have a systolic
blood pressure of 90 mm Hg or greater are usually treated Incisions
with insertion of a 36- or 38-Fr thoracostomy tube. The When there is hemorrhage likely to be from the right pulmo­
chest tube is placed in the ipsilateral midaxillary line in the nary hilum or lung, the patient is placed in the supine posi­
4th or 5th intercostal space under sterile conditions and tion, and a right anterolateral thoracotomy incision is made
with local infiltrative anesthesia. It has been documented on the inferior edge of the right male nipple. As previously
that 28- to 32-Fr tubes have the same success rates as larger noted, the right breast of a female is retracted superiorly to
tubes in treating traumatic pneumo- and hemothoraces.88 allow for a skin incision at the same level as in the male,
More recently, 14-Fr pigtail catheters have been shown to but without damaging the breast. A suspected or confirmed
have reasonable success rates in treating traumatic pneu­ injury to the tracheobronchial tree at the level of the carina
mothoraces.89,90 or right mainstem bronchus is approached through a right
The role of prophylactic antibiotics in conjunction with posterolateral thoracotomy at the 4th intercostal space.
tube thoracostomy is controversial. If given, a first-gener­ When hemorrhage is suspected from the left pulmonary
ation cephalosporin is the antibiotic of choice and should hilum or lung, the patient is placed with the left chest ele­
be administered intravenously before the incision to insert vated 30 degrees on a rolled sheet or beanbag. This allows
the tube.
Analgesia Box 16.1 Indications for Emergency or Urgent
Pain control following rib fracture(s) is extremely impor­ Thoracotomy in Patients With Trauma to the
tant and allows patients to cough, use an incentive spirom­ Lung
eter, and reduce the risk of atelectasis and pneumonia. The n 1200 mL to 1500 mL of blood evacuated through thoracostomy
options for local and regional analgesia for patients include tube in the first 15 to 30 minutes
the following: n 100 mL of blood per hour evacuated through a thoracostomy
tube after the initial 1000 mL drainage in the first 30 minutes
1. Lidoderm (Lidocaine Patch 5%, Endo Pharmaceuticals, n Refractory hypotension in the presence of continued evacua-
Malvern, PA)—three 10- × 14-cm patches applied for up tion of blood through a thoracostomy tube
to 12 hours n Recent or in-emergency department cardiac arrest after a pen-
2. Intercostal nerve block with 3 to 5 mL 0.25% bupiva­ etrating wound to the chest, but away from the mediastinum
caine per rib n Need for reconstruction of the chest wall in the patient with
3. Continuous intercostal nerve block open pneumothorax
n Massive air leak through the thoracostomy tube (presumptive
4. Intrapleural regional analgesia with 20 mL 0.25% evidence of injury to the trachea or the bronchus)
­bupivacaine n Retained foreign body (knife near hilum of lobe or lung)
5. Continuous epidural analgesia
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 193

Box 16.2 Techniques for the General Surgeon

to Control Hemorrhage From a Perforation or
Rupture of the Pulmonary Artery or Lung
Proximal Vascular Control
Intrapericardial clamping of the right or left pulmonary artery
Cross-clamping of the hilum of the lung
Hilar snare
Hilar twist
Control of Hemorrhage From the Lung
Suture pneumonorrhaphy
Stapled-wedge resection
Pulmonotomy (“pulmonary tractotomy”)
Lobectomy
Pneumonectomy (hilum ligated or stapled)

pleural cavity, retracts the lower lobe laterally, divides the

inferior pulmonary ligament, and assumes manual control
Fig. 16.20 Patient with gunshot wound to left midaxillary line (skin clip) of the hilum. The surgeon then places the aortic cross-clamp
had exsanguinating hemorrhage from perforations to the left lung. across the hilum in whichever direction allows for best
exposure of the injuries.
Hilar Twist. The group at Ben Taub Hospital in Houston
for easier cross-clamping of the descending thoracic aorta described the “hilar twist” in 2003 as a maneuver to be
if this should become necessary. The standard anterolateral considered “when appropriate clamps are lacking or difficult
thoracotomy incision is then made on the inferior edge of to place due to exposure or bleeding.”96,97 This maneuver is
the male nipple. A suspected or confirmed injury to the left performed after division of the inferior pulmonary ligament
mainstem bronchus is approached through a left postero­ by rotating or twisting the lung and the hilum 180 degrees
lateral thoracotomy at the 5th intercostal space. to occlude vessels and the mainstem bronchus.
Proximal Vascular Control (Box 16.2) Control of Hemorrhage From the Lung (See Box 16.2)
Intrapericardial Clamping of Pulmonary Artery. An Suture Pneumonorrhaphy. With wounds or lacerations
injury to the pulmonary hilum is highly lethal, and it on the periphery of a lobe, hemorrhage and air leaks can
is rare for a patient with this type of injury to reach the be controlled by placing a continuous 2-0 or 0 absorbable
trauma center with signs of life. If the hilum adjacent to suture through the edges of the defect. If hemorrhage
the pericardium is injured, it will be necessary to obtain is excessive and the defect on the edge is long, a DeBakey
intrapericardial control of the pulmonary artery. An aortic clamp can be placed underneath the laceration, and
anterolateral thoracotomy incision made to expose the the continuous suture row can be placed over the clamp.
hilum and the lung will need to be extended across the Stapled Wedge Resection. Larger defects involving the
sternum in a transverse direction to allow for exposure outer half of a pulmonary lobe may be excised using one
of the mediastinal and intrapericardial structures. The of the standard staplers (4.8-mm staples) up to 90 mm in
intrapericardial right pulmonary artery is exposed by length. The pulmonary or lobar hilum is clamped in these
retracting the superior vena cava to the right and the cases if a double lumen endotracheal tube has not been
ascending thoracic aorta to the left. This vessel passes placed. Standard lung clamps are then used to elevate the
transversely at this level and is clamped in the space as injured segment into good view and an appropriate length
the other vessels are separated. The intrapericardial left staple row is placed through normal parenchyma. It is
pulmonary artery is exposed by retracting the ascending possible to perform a partial lobectomy with two staple lines
thoracic aorta to the right and superiorly. This vessel at right angles to one another. This creates an oddly shaped,
passes transversely under the transverse aortic arch and but hemostatic and functional, remainder of a lobe. Deep
proximal descending thoracic aorta and is clamped in this absorbable sutures are placed around areas of the staple
space. row when bleeding occurs. The major disadvantage of large
Cross-Clamping of the Hilum of the Lung. Ex­sangui­na­­ staple resections is that a bleeding intraparenchymal vessel
ting hemorrhage from the hilum outside of the pericardial sac may not be ligated or excised. Continued bleeding from
or from the parenchyma is controlled with cross-clamping such a vessel may enter the tracheobronchial tree through
of the pulmonary hilum.94 In order to place a DeBakey aortic an adjacent bronchial injury and lead to intraoperative
clamp across the hilum of the lung in the anteroposterior aspiration and asphyxia.
direction, the inferior pulmonary ligament must be divided. Pulmonotomy (Pulmonary Tractotomy) (Fig. 16.21).
Van Natta el al. have described an innovative technique in Pulmonotomy or pulmonary tractotomy was derived from
which the surgeon grips and manually controls the pulmonary the technique of hepatotomy and selective ligation of vessels
hilum.95 The left hand is used when a right thoracotomy following severe hepatic trauma. With deep lobar missile
is performed, and the right hand is used when a left tho­ tracks or lacerations and significant bleeding, neither suture
racotomy is performed. An assistant evacuates blood from the pneumonorrhaphy nor stapled wedge resection is appropriate.
194 SECTION 4 • The Management of Vascular Trauma

Properly performed, pulmonotomy with selective vascular of the lobe (i.e., shotgun wound), devascularization of
ligation will control parenchymal hemorrhage without the the lobe, or a lobar hematoma causing life-threatening
need for lobectomy.79,82,98,99 ventilation–perfusion mismatch.100 Prior to performing
With exsanguinating hemorrhage from vessels in the deep lobectomy, the residual tissue in the fissures around the
parenchyma after a gunshot or stab wound, a hilar clamp is injured lobe is divided with a linear stapling device or
applied after division of the inferior pulmonary ligament. A divided between clamps and then sutured. A DeBakey
linear stapling device is then passed through the entrance aortic clamp is then placed across the entire lobe just
and exit wounds in the same lobe, and the outer pulmonary outside the hilum to stop bleeding or respiratory expansion
parenchyma is divided. When hemorrhage is coming from during lobectomy. The pleura over the hilar structures is
one gunshot or stab wound in a lobe, a finger or clamp is divided, and the lobar artery and proximal branches are
placed into the hole to determine the direction of the track. divided between 2-0 silk ties. The lobar vein and branches
The linear stapler can be used again to open the parenchyma, are divided in a similar manner. Minimal skeletonization
or two DeBakey aortic clamps can be placed in apposition and of the lobar bronchus is performed to preserve bronchial
the parenchyma between them divided with a scalpel or with blood flow before stapling and dividing the bronchus. An
electrocautery. Injured vessels in the now-open track are airtight staple line is verified by filling the pleural cavity
ligated or repaired with 3-0 or 4-0 polypropylene suture. with normal saline and having the anesthesiologist hand
After bleeding has been controlled, edema of the paren­ bag the patient. A three-sided pleural flap is elevated off of
chyma almost always precludes closing the pulmonotomy the paravertebral area and sewn over the bronchial stump
site. Individual suture ligation is used to control remain­ with 3-0 absorbable sutures. Prior to insertion of two
ing vessels under the rows of staples. If DeBakey clamps 36-Fr thoracostomy tubes, the remaining lobe or lobes are
were used to divide the parenchyma, 3-0 or 4-0 absorbable hyperinflated. This maneuver will confirm that no damage
or polypropylene suture is placed in a continuous basting has occurred to other bronchi during the lobectomy and
stitch under each clamp. After a clamp is removed, the same that torsion of the remaining lobe or lobes is not present
continuous suture is returned to the starting point in an and is unlikely to occur in the postoperative period. If there
over-and-over fashion and tied to the original suture. is a risk of torsion, either suturing or stapling the lobes
Lobectomy. Anatomic lobectomy is indicated when there together or suturing the lobe to the mediastinal pleura at
is significant injury to the vessels or bronchus in the hilum another point is performed.
of the lobe, injury to greater than 75% of the parenchyma Pneumonectomy. A pneumonectomy is only indicated
when there is a significant penetrating wound or shearing
injury to the vessels or bronchus in the hilum of the lung or a
major injury encompassing more than 75% of all lobes.101–103
As most patients requiring a trauma pneumonectomy are
in extremis, the “simultaneously stapled pneumonectomy”
has been suggested as an alternate approach to formal
hilar dissection and ligation/stapling.101 First described in
1995, the technique is to place a 55- or 90-mm stapler
across all hilar structures simultaneously for temporary
vascular control or fired for permanent control of the
hilum. Reexploration for possible further stapling of a long
bronchial stump and coverage with a vascularized tissue
pedicle were recommended as well.101 Right heart failure is
common in patients who survive trauma pneumonectomy,
Left lung and postoperative management is quite intensive, often
including infusion of nitric oxide and/or inotropic support.104

Stapler Thoracic Damage Control

Originally described for patients with penetrating wounds
of the abdomen, damage control operative principles have
now been described for patients with injuries to the neck,
chest, extremities, vessels, and bones.105 Similar principles
are now applied to patients undergoing emergency opera­
tions on the general surgery and obstetrics services as well
as those undergoing emergency procedures in the interven­
tional radiology suite. The most fundamental principle of
Fig. 16.21 Linear stapling device passed through gunshot entrance damage control surgery is that the patient with profound
and exit sites to divide parenchyma (pulmonotomy or pulmonary trac- hypothermia, a significant metabolic acidosis, or a marked
totomy) and to expose bleeding vessels. (With permission from Asensio coagulopathy should have a limited first operation or proce­
JA, Demetriades D, Berne JD, et al. Stapled pulmonary tractotomy: a rapid dure to control bleeding and contamination. For injuries to
way to control hemorrhage in penetrating pulmonary injuries. J Am Coll the heart, great vessels, or lungs, many of the techniques
Surg. 1997;185:486–487.) described in this chapter fit the definition of thoracic damage
 16 • Cardiac, Great Vessel, and Pulmonary Injuries 195

control. Phelan et al. have reviewed these principles as sum­ best diagnostic. Starting empiric antibiotic therapy based
marized in Box 16.3.106 on risk factors and local patterns of infection while patient-
specific cultures are pending is an accepted standard.
COMPLICATIONS
Pulmonary Pseudocyst
Air Leak A posttraumatic pulmonary pseudocyst is a parenchymal
An air leak that persists after pulmonary injury is caused cavity that may have an air-fluid level. A chest x-ray or
by necrosis of the parenchyma at the site of sutures or sta­ ­thoracic CT scan confirms the diagnosis. Observation and
ples, failure of an injured lung to heal, or a missed bron­ serial imaging studies are appropriate in asymptomatic
chial injury. Once technical problems have been excluded patients, although antibiotics and even catheter drain­
including leaks in the thoracostomy tube circuit outside of age may be needed for an infected pseudocyst (pulmonary
the chest, some centers choose to lower suction pressure abscess).107
on the underwater seal system or even take the patient's
thoracostomy tube off suction. Failure of this approach Retained Hemothorax
after 5 to 7 days is followed by wedge resection of the A retained hemothorax greater than an estimated 300 mL
remaining lung, pleural abrasion, or chemical pleurodesis after thoracic trauma or after a trauma thoracotomy should
by thoracoscopy with a double-lumen endotracheal tube be evacuated to reduce the incidence of empyema.108 When
in place with timing depending on the cause of the pneu­ a suspected retained hemothorax is present, a chest CT scan
mothorax. should be performed to assess the location, volume, and
presence of an adjacent significant injury to the lung. After
Ventilator-Associated Pneumonia a double lumen endotracheal tube is inserted, the patient
Ventilator-assisted pneumonia (VAP) is a nosocomial com­ is placed in a full lateral position. The 30-degree thoraco­
plication seen in both trauma and nontrauma patients in scope is inserted through a previous tube thoracostomy site,
the ICU. New onset purulent sputum, elevation of temper­ the collection is visualized, and the sites for insertion of two
ature, leukocytosis (occasional leukopenia), infiltrate on more trocars selected. The retained hemothorax is evacu­
chest x-ray, and an increasing oxygen requirement are sug­ ated with a combination of manual traction using thora­
gestive, but not diagnostic of VAP. Fiberoptic bronchoscopy coscopic graspers, irrigation, and suction. Most current
with lavage or protected specimen brush for culture is the reviews recommend that video-assisted thoracoscopic sur­
gery (VATS) evacuation of a retained hemothorax be per­
formed in the first 4 to 7 days after injury.109–111 In contrast,
the “management of post-traumatic retained hemothorax”
Box 16.3 Damage Control for Thoracic Trauma study of the AAST (2012) demonstrated “no relationship
Heart between timing of VATS and success rate.”108 Of interest,
Sauerbruch maneuver to control hemorrhage the same study noted that 26% of patients undergoing
Inflow occlusion to control hemorrhage VATS required a second procedure and that thoracotomy
Restore rhythm before suture repair was ultimately required in 20% of patients.
Leave pericardial sac open/leave incision open.
Empyema
Great Vessels
In one multicenter study, empyema or a purulent infec­
Foley balloon catheter tamponade
Claviculectomy for injury to subclavian vessels
tion of the pleural space developed in 27% of patients with
Insertion of temporary intraluminal shunt a retained traumatic hemothorax.112 As the overlapping
Ligation of major injured veins stages of empyema include exudative, fibrinopurulent, and
organizing, both VATS and thoracotomy with decortication
Lungs
have a role depending on the stage encountered. Should
Hilar twist to control hemorrhage thoracotomy be necessary, goals of the procedure include
Pulmonotomy (pulmonary tractotomy) for through-and-through
evacuation of purulent collections, division of pleural adhe­
or deep lobar injuries
Simultaneously stapled pneumonectomy
sions, decortication of any entrapped lung, and drainage of
Pack pleural cavity/leave incision open the pleural space with thoracostomy tubes.113

Adapted from Phelan HA, Patterson SG, Hassan MO, et al. Thoracic SURVIVAL
damage-control operation: principles, techniques, and definitive
repair. J Am Coll Surg. 2006;203:933–941. Survival figures in large series of patients with injuries to
the lungs since 1980 are listed in Table 16.8.

Table 16.8 Survival After Injuries to the Lungs.

Author Suture/Wedge Pulmonotomy Lobectomy Pneumonectomy
Thompson et al., 1988100 97% — 45% 0%
Wall et al., 199899 — 83% — —
Karmy-Jones et al., 200182 91%/70% 87% 57% 50%
Huh et al., 200397 76.1/80% 90.9% 65% 30.3%
196 SECTION 4 • The Management of Vascular Trauma

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 17 Blunt Thoracic Aortic Injury
DEMETRIOS DEMETRIADES, PEEP TALVING, and KENJI INABA

Introduction the scene and are not captured in hospital-based datasets.

The incidence of aortic injuries in fatal traffic injuries is
The screening, definitive diagnosis, and the method and very high. In a recent analysis of 304 deaths due to blunt
timing of definitive management of blunt thoracic aortic trauma in the county of Los Angeles, 102 patients (33%)
injuries (BTAI), have undergone revolutionary changes had a rupture of the thoracic aorta. About 80% of the
over the last few years. A routine chest CT scan has deaths occurred at the scene and only 20% in the hospital10
replaced plain x-rays for screening purposes; CT angi- (Fig. 17.1).
ography (CTA) has replaced formal angiography as a In another autopsy analysis of 25 fatalities in a 2008 train
method of definitive diagnosis; semielective definitive crash in Los Angeles, thoracic aortic rupture was found in
repair of BTAI instead of emergency repair has now eight cases (33%). All mortalities occurred at the scene.11
become the new standard; endovascular stent grafts have The incidence of aortic trauma increases with age, and
largely replaced open surgical repair. All these changes it is rare to find this injury in the pediatric population. In a
have resulted in a significant reduction of early mortality National Trauma Databank analysis, the incidence of tho-
and complications. racic aortic injury in children younger than 16 years old
was seven times lower than in adults (0.03% vs. 0.21%).12
In an analysis of 5838 auto versus pedestrian injuries,
History there were no aortic injuries in the age group 14 years or
younger. The incidence increased to 0.2% in the group
The first case of blunt thoracic aortic injury was reported 15 to 65 years, 0.5% in the group 56 to 65 years, and 1.5%
by the anatomist Andreas Vesalius in a man who fell from in the group older than 65 years.7
a horse in 1557.1 The first reported repair of an acute
repair of a BTAI occurred in the late 1950s.2 In the 1970s,
there was the development and widespread use of various
shunting techniques and graft materials.1 In the 1990s,
we saw the first reports supporting routine use of CT scan
as a screening method in patients with a suspicious mech-
anism of injury3, and soon afterward CTA was advocated
as the preferred method of definitive diagnosis of BTAI. In
1997, the first endovascular repair of a patient with BTAI
was reported4 and in the 2000s endovascular aortic repair
(EVAR) became the new preferred therapeutic approach.

Epidemiology
It is estimated that 8000 to 9000 blunt trauma victims
suffer thoracic aortic injury every year in the United States.5
The majority of these injuries are due to motor vehicle
collisions (approximately 70%) followed by motorcycle col-
lisions (13%), fall from height (7%), auto versus pedestrian
(7%), and other mechanisms.6 The overall incidence of tho-
racic aortic injuries in patients reaching the hospital alive
is less than 0.5%. In a series of 5838 pedestrian injuries
reaching hospital care, the incidence of BTAI was 0.3%.7 In
another study of 613 admissions following high-level falls,
the incidence of BTAI was 0.1%.8 The presence of a pelvic
fracture is a marker of an associated thoracic aortic injury.
In an analysis of 1450 pelvic fractures, aortic injury was
diagnosed in 1.4%.9 However, it seems that this is the tip of
the iceberg and the real incidence of BTAI is much higher.
The vast majority of patients with this type of injury die at Fig. 17.1 Transected thoracic aorta noted at autopsy.

199
200 SECTION 4 • The Management of Vascular Trauma

Approximately 40% of patients with aortic rupture have Site and Type of Aortic Injury
at least one very severe associated injury (body area abbrevi-
ated injury Score of 4 of greater), the most c­ ommon being the The most common anatomical site of the aortic injury is
head and the abdomen. The mean injury severity score is 40, the medial aspect of the lumen, distal to the left subclavian
a strong indicator of the grave condition of the victims.6 artery (Fig. 17.2). In a prospective analysis of 185 cases of
thoracic aortic injuries, the rupture involved the isthmus
in 75%, followed by the descending aorta in 22% and the
ascending aorta in 4%.6 Computer simulation and cadaver
studies have shown that the combination of increased
intraaortic pressure (mean 1149 mm Hg) and rotational
forces exerts a highly focused stress at the isthmus. In addi-
tion, the tensile strength at the isthmus was found to be
only 63% of that of the proximal aorta.13,14 The most com-
mon type of injury is a false aneurysm (58%), followed by
dissection (25%) and intimal tear (20%)6 (Fig. 17.3).

Natural History of BTAI

The majority of patients with BTAI die at the scene, before
reaching hospital care. In an analysis of 242 fatal BTAI,
Burkhart et al. reported that 57% of the deaths occurred at
the scene or on arrival to hospital, 37% died within the first
4 hours of admission, and 6% died more than 4 hours after
admission.15 In another autopsy study of 102 victims with
BTAI, about 80% of the deaths occurred at the scene and
only 20% in the hospital.10

Screening and Diagnosis

The supine chest x-ray has been extensively used as the
initial screening tool for the diagnosis of BTAI. Numerous­
Fig. 17.2 Classic site of the blunt thoracic aortic injury: medial aspect of radiological findings have been described as suspicious
the aorta, distal to the left subclavian artery.
markers for aortic trauma. They include a widened upper

A B

Fig. 17.3 (A) Aortography: traumatic false aneurysm of the proximal descending aorta (see circle) is the most common type of injury. (B) CT angiogram:
sagittal view of blunt thoracic aortic injury with extensive dissection (see arrows).
 17 • Blunt Thoracic Aortic Injury 201

mediastinum (greater than 8 cm on an anterior-posterior diagnosis of BTAI. The new generation multislice CT
supine chest film at the level of the aortic knob) (Fig. 17.4A) scanners with 3-D reformation have been shown to have
obliteration of the aortic contour, loss of the perivertebral almost 100% sensitivity and specificity, a 90% posi-
pleural stripe, depression of the left mainstem bronchus, tive and 100% negative predictive value, and an overall
deviation of the nasogastric tube to the right, a left apical diagnostic accuracy of 99.7%,20,24 and allow classifica-
pleural hematoma (apical cap), a massive left hemotho- tion of the type of injury (Figs. 17.5 and 17.6). Formal
rax, and the presence of fractures of the sternum, scapula, angiography still has a limited diagnostic role in the rare
upper ribs, or clavicle in a multitrauma patient.5,16–18 The cases where the CT scan findings are suspicious but not
widened mediastinum is the most common finding but it diagnostic.
still has a low sensitivity and specificity. Many conditions, Transesophageal echocardiography (TEE) is another
such as a fracture of the sternum or the thoracic spine or diagnostic modality in the evaluation of suspected BTAI.25–27
supine position in an obese patient, may cause a widened The initial enthusiasm for this imaging modality has been
mediastinum. The most specific signs are loss of the aor- replaced by skepticism. It has failed to gain popularity
tic knob, abnormality of the aortic arch, and deviation of because of conflicting reports about its accuracy and con-
the nasogastric tube, but the sensitivity is very low. Tradi- cerns regarding its availability 24 hours a day.28 The dra-
tionally, a normal chest x-ray had been considered reliable matic shifting from angiography and TEE to CT scanning
in excluding BTAI.19,20 However, numerous studies have in the diagnosis of BTAI is demonstrated by a multicenter
shown that chest radiography is a poor screening tool and study sponsored by the American Association for the Sur-
a significant number of aortic injuries may not show any gery of Trauma (AAST).6 The use of angiography and TEE
mediastinal abnormalities3,21,22 (Fig. 17.4B,C). On the basis for the diagnosis of thoracic aortic injuries decreased from
of these chest x-ray limitations, many centers now use CT 87% and 12%, respectively, in 1997 to only 8% and 1% in
scan of the chest as the primary screening tool for BTAI, 20076 (Table 17.1).
irrespective of x-ray findings.3,21,22 The sensitivity and nega- Other diagnostic modalities such as magnetic resonance
tive predictive value of the CT scan in the diagnosis of BTAI imaging (MRI) or intravascular ultrasound may be useful in
approaches 100%.23 rare patients where the CTA findings are not definitive.
Aortography remained the gold standard for the defini- In summary, the new generation scanners have made
tive diagnosis of BTAI until the late 1990s. However, it CTA the standard modality for screening and definitive
is invasive, takes time, and the angiographic team is not diagnosis of BTAI. Formal aortography may have a rare
always readily available after hours. In the last few years, diagnostic role in patients undergoing angiography for
CT scan has replaced formal angiography for the definitive other injuries such as pelvic fractures, comple x liver inju-

A B

Fig. 17.4 (A) Chest x-ray shows a very widened mediastinum due to blunt thoracic aortic injury. (B) Chest x-ray with a normal mediastinum in an occult
blunt thoracic aortic injury. (C) CT-angiography in the same patient demonstrating blunt thoracic injury.
202 SECTION 4 • The Management of Vascular Trauma

ABSENT EXTERNAL CONTOUR ABNORMALITY PRESENT EXTERNAL CONTOUR ABNORMALITY

Type of aortic injury Definition Example Type of aortic injury Definition Example
Intimal tear No aortic external Pseudoaneurysm Aortic external contour
contour abnormality: abnormality: contained
tear and/or associated
thrombus is <10 mm

Large intimal flap No aortic external Rupture Aortic external contour

contour abnormality: abnormality: not
tear and/or associated contained, free rupture
thrombus is >10 mm

Fig. 17.5 Classification of blunt thoracic injury. (From Starnes, BW, Lundgren RS, Gunn M, et al. A new classification scheme for treating blunt aortic injury.
J Vasc Surg. 2012;55:47–54.)

Table 17.1 Changing Perspectives: Diagnostic

Modalities for Blunt Thoracic Aortic Injury: AAST1 (1997)
vs. AAST2 (2007).
AAST1 AAST2 P-value
n 253 193
Aortogram 207 (87%) 16 (8.3%) <.001
CT scan 88 (34.8%) 180 (93.3%) <.001
TEE 30 (11.9%) 2 (1.0%) <.001
From Demetriades D, et al. Diagnosis and treatment of blunt thoracic
aortic injuries: changing perspectives. J Trauma. 2008;64;1415–1419.
AAST, American Association for the Surgery of Trauma; CT, computed
tomography; N, number; TEE, transesophageal echography.

BTAI. Prevention of free rupture of a contained BTAI

until definitive repair is performed is the most urgent
priority. The risk of free rupture is highest in the first
few hours after the injury, with more than 90% of rup-
tures occurring within the first 24 hours. In an AAST
multicenter study by Fabian et al.,5 24 (8.8%) of the 274
Fig. 17.6 CT angiogram with 3-D reconstruction provides reliable and patients in the study population progressed to free rup-
detailed information about the site, size, and type of aortic injury. ture. However, rigorous blood pressure control reduces
the risk of rupture to about 1.5%.29 Blood pressure con-
trol is best achieved with a combination of judicious fluid
ries, etc. TEE might be useful in critically ill patients in the restriction and pharmacological intervention. The sys-
intensive care unit who cannot be transferred safely to the tolic blood pressure should be kept as low as tolerated,
radiology suite for CT scan. which in most patients will range from 90 to 110 mm
Hg. In elderly patients the optimal systolic pressure may
be slightly higher. Cautious restriction of intravenous
Management fluids and administration of beta-blockers such as an
esmolol drip are the most commonly used modalities for
INITIAL MANAGEMENT OF THORACIC AORTIC blood pressure control. In the presence of an associated
severe brain or spinal cord injury, the systolic blood pres-
INJURIES
sure should be maintained at a slightly higher level (110
Prompt diagnosis and early appropriate treatment to 120 mm Hg) in order to reduce the risk of secondary
remain the cornerstone for survival of patients with neurological damage.
 17 • Blunt Thoracic Aortic Injury 203

TIMING OF DEFINITIVE MANAGEMENT major associated injuries (see Table 17.4). The incidence of
Untreated, the risk of rupture of a BTAI is highest in the paraplegia was similar in the two groups (early repair 1.8%,
first 24 hours after injury although it does not disappear delayed repair 1.4%).
altogether, with late rupture a possibility weeks later.30 In Subsequent studies confirmed that delayed repair is an
the AAST multicenter study by Fabian et al.,5 24 (8.8%) independent factor protective against mortality.37,38 The
patients of the study population progressed to free rupture. current evidence supports that, with adequate medical
Ninety-two percent of the ruptures died within 24 hours blood pressure control, delayed repair is not only safe but
of the injury, one at 30 hours, and one at 6 days. In the may be preferable to emergent repair in select patients. This
group of 13 free ruptures with precise time of rupture, 46% allows for optimizing patient risk factors and operative con-
occurred within 4 hours and another 38% within 8 hours. ditions and ensures that other more life-threatening inju-
For these reasons, the definitive management of BTAI has ries can be prioritized. The practice management guidelines
been considered as an emergency and this policy remained from the Eastern Association for the Surgery of Trauma
the standard of care for many years. However, subsequent suggest delayed repair of BTAI, with the stipulation of effec-
studies showed that the early initiation of vigorous blood tive blood pressure control.39
pressure control via restrictive fluid resuscitation and phar- The optimal time from injury or admission to repair is
macological agents decreases wall stress in the region of unknown and should be individualized, taking into account
the injury29,31,32 and reduces the risk of rupture to approxi- many factors, such as the presence of other severe injuries or
mately 1.5%.29 For patients with contained ruptures who comorbid conditions, the physiological status of the patient,
survive out past 4 hours, with medical treatment, in-hos- and the type and severity of the aortic injury. Delayed repair
pital free rupture and death are now rare.29 The successful should not be attempted in cases with active leaking from
management of these injuries therefore hinges on the early the aortic injury (Fig. 17.7). Also, it might be advisable that
diagnosis and careful blood pressure control. in cases with large contained injuries, the repair should be
In the late 1990s and early 2000s, some studies sug- done urgently, within a few hours of the diagnosis.
gested that selected patients with major associated injuries
could safely be managed with delayed repair until after sta- DEFINITIVE MANAGEMENT OF THORACIC AORTIC
bilization of other major trauma, provided that the blood
pressure was adequately controlled.29,31,33,34 The concept of INJURIES
delayed repair was subsequently applied more liberally in Operative repair remained for many decades the only stan-
patients with no severe associated injuries or major comor- dard definitive management of all BTAI. However, in the
bidities. 21st century there has been a dramatic shift to endovas-
The safety of delayed repair of BTAI and its effect on out- cular techniques. This shift is clearly demonstrated by two
comes remained controversial for many years. Most studies large prospective studies by the AAST in 19975 (AAST1)
included in their analysis only patients with major associ- and 20076 (AAST2). In 1997, all 207 cases with BTAI were
ated injuries and reported contradictory results. Some stud- managed with open repair, whereas in 2007, 65% of the
ies showed improved outcomes with delayed repair, whereas 193 cases were managed with endovascular stent grafts and
others failed to show any benefits. Wahl et al.,35 in a retro- only 35% with open repair (Table 17.2). Currently, the only
spective review of 48 cases, reported that delayed aortic indication for open repair is an injury involving the aortic
repair (more than 24 hours) was safe, but it was associated arch, where placement of an endograft might be technically
with a longer hospital stay and direct costs than early repair.
A similar study of 78 cases by Hemmila et al.29 reported a
higher complication rate and a longer hospital stay in the
delayed (more than 16 hours) group. However, other studies
suggested that delayed repair was associated with improved
outcomes.33,36 An AAST multicenter, prospective study Extravasation
analyzed outcomes in 178 patients with BTAI, according
to the timing of definitive repair (early less than 24 hours,
delayed more than 24 hours).6 The two groups were similar
with regards to injury severity, major associated injuries,
type of aortic injury, and type of aortic repair (operative
vs. endovascular). The mean time from injury to repair was
10.2 hours in the early group and 126.2 hours in the delayed
group. The overall mortality in the delayed repair group
was significantly lower than the early repair group (5.8%
vs. 16.5%, P = .034). Multivariate analysis adjusting for
injury severity, severe extrathoracic injuries, Glasgow coma
scale (GCS), hypotension on admission, age, and method of
aortic injury repair, showed a significantly increased risk of
death in the early repair group (adjusted odds ratio [95%
confidence interval] 7.78 [1.69–35.70], adjusted P-value =
.008). The survival benefits in the delayed repair group were Fig. 17.7 CT angiogram demonstrating active extravasation from a
confirmed in the subanalysis of the groups with or without traumatic throacic aortic aneurysm.
204 SECTION 4 • The Management of Vascular Trauma

Table 17.2 Changing Perspectives: Methods of Definitive Treatment of Thoracic Aortic Injuries: AAST1 (1997) vs. AAST2 (2007).
AAST1 AAST2 P-value
n 207 193
Open repair 207 (100%) 68 (35.2%) <.001
Clamp and sew 73/207 (35.3%) 11/68 (16.2%) 0.003
Bypass 134/207 (64.7%) 57/68 (83.8%) 0.003
Endovascular repair 0/207 (0%) 125/193 (64.8%) <.001
From Demetriades D, et al. Diagnosis and treatment of blunt thoracic aortic injuries: changing perspectives. J Trauma. 2008;64;1415–1419.
AAST, American Association for the Surgery of Trauma.

difficult or impossible. A third evolving therapeutic option vascular clamp placed on the aortic arch is subsequently
for selected cases with minor aortic injuries is observation transferred distal to the origin of the left subclavian artery
combined with medical therapy. to minimize cardiac afterload and spinal cord ischemia
during cross-clamp time. The periaortic dissection plane
Open Surgical Repair is identified and the aortic lesion is exposed. A transverse
The first successful surgical repair of BTAI was performed aortotomy is performed to allow inspection of the aortic
by DeBakey and Cooley in 1953.40 The clamp-and-sew tear and subsequently decide whether primary repair or
technique, as it was known, became the standard of care interposition graft placement is required. The intercostal
for many decades. Advantages of this technique included arteries in proximity of the aortic lesion are preferentially
a relatively expeditious repair and lack of requirement for not ligated nor oversewn, but incorporated into the tailored
systemic heparinization. The clamp-and-sew technique aortic repair. A cell-saver device can be successfully utilized
was initially practiced without distal aortic perfusion and for autotransfusion of blood from the chest in the case of
resulted in a significant rate of paraplegia when aortic major hemorrhage. The aortic injury is repaired utilizing
cross-clamp times exceeded 30 minutes. In more recent 2-0 or 3-0 polypropylene suture material and a collagen-
years, open surgical repair, performed with the use of roller/ coated or preclotted Dacron interposition graft that reduces
centrifugal pumps to provide active distal aortic perfusion in bleeding from the graft. The size of the interposition graft
an effort to reduce the risk of paraplegia, has become the ranges from 22 to 40 mm and is chosen to match the size of
standard of care.41,42 the aorta. Primary repair is utilized only in exceedingly rare
There are multiple techniques for active distal aortic per- pediatric blunt aortic injuries to avoid coarctation with the
fusion during open repair and aortic cross-clamping. The graft as the child grows.
most common configuration is the left heart partial bypass In the AAST1-sponsored prospective multi-institutional
with the inflow into the pump achieved through a cannula study of 1997, the clamp-and-sew technique (without
inserted into the left atrium through the left atrial append- distal aortic perfusion) was performed in 35% (n = 73) of
age or left pulmonary vein. The outflow cannula is inserted all patients undergoing operative repair. In these instances,
in the femoral artery or into distal aorta beyond the distal the paraplegia rate was 16.4%. In comparison, in the 134
aortic clamp using a purse-string controlled aortotomy. patients undergoing repair using distal aortic perfusion, the
Alternatively, right atrial to distal aortic cannulation is used paraplegia rate was significantly lower at 4.5%. The most
in conjunction with an oxygenator; this requires full hepa- important independent risk factor for paraplegia was cross-
rinization (i.e., bolus of 300 to 400 units/kg and mainte- clamp time of more than 30 minutes (odds ratio 15).5
nance of activated clotting time [ACT] above 400 seconds). A decade later, a second AAST-sponsored multiinstitu-
This configuration is used very infrequently in trauma set- tional prospective study (AAST2), including 193 patients
tings due to the risk of hemorrhage from associated inju- subjected to definitive repair of BTAI, was published.6 The
ries (Fig. 17.8). Debate over the preferential distal perfusion incidence of clamp-and-sew technique without bypass
technique is still evolving. between 1997 and 2007 had decreased from 35% to 16%.
In patients who present with free rupture, especially in Likewise, the overall incidence of procedure-related para-
settings with limited resources, the clamp-and-sew tech- plegia in patients undergoing open surgical repair had
nique might be the only option. In these cases, during fallen significantly from 8.7% to 1.6% (P = .001). Currently,
surgery, double-lumen intubation and independent lung approximately 85% of thoracic aortic injuries treated with
ventilation is instituted. The patient is placed in the right open surgery are managed with bypass techniques.
lateral decubitus position and access to the aorta is obtained Numerous studies have demonstrated that active dis-
through a left posterolateral thoracotomy in the fourth or tal perfusion is superior to “passive perfusion” in reducing
fifth intercostal space. The proximal aorta above the area the incidence of procedure-related paraplegia.5,41,42,44,45 A
of the injury and the left subclavian artery are identified, meta-analysis of mortality and risk of paraplegia following
isolated, and controlled with vessel loops. The thoracic aorta repair of traumatic aortic rupture in 1492 patients showed
distal to the injury is identified and likewise isolated with a an overall postoperative paraplegia rate of 9.9%. Among
vessel loop. Aortic clamps are applied proximal and distal to patients treated with simple aortic cross-clamping, case
periaortic hematoma and the subclavian artery. Decision- fatality and incidence of paraplegia were reported as 16%
making with regard to the location of clamp placement can and 19.2%, respectively. With passive shunting, mortality
be greatly aided by the use of two-dimensional and three- was 12.3% and the incidence of paraplegia 11.1%, and
dimensional reconstructions of CTAs.43 When feasible, the with active perfusion the rate of paraplegia was 2.3%.41,42
 17 • Blunt Thoracic Aortic Injury 205

Adult

a Pediatric

Fig. 17.8 Surgical treatment options for blunt thoracic aortic injury. (A) Partial left heart bypass to distal aorta or femoral artery. (B) “Clamp-and-sew”
technique with interposition graft in adult patients. (C) “Clamp-and-sew” with primary repair in selected pediatric patients.

Although open surgical repair is far less common in of only 284 patients with traumatic aortic injury treated
today’s practice secondary to the advent of endovascular with endovascular repair.47 However, the more recent
stent grafts, there are instances in which EVAR is prohibi- AAST2 study in 2007 reported that almost 65% of the
tive, such as in aortic arch injuries, in young patients with 193 patients with BTAI were managed definitively with
small aorta, hemodynamic instability, active extravasation EVAR. Furthermore, 60% of patients with no major extra-
from the aorta seen on CTA (see Fig. 17.7), and patients thoracic injuries, and 57% of patients under 55 years of age
with occlusive disease at vascular access routes. Distal per- with no major associated trauma were treated with endo-
fusion is strongly associated with better outcomes when vascular techniques.
open repair is required. Endovascular repair is associated with significantly
better early outcomes than open repair. In the AAST2 study,
Endovascular Aortic Repair multivariate analysis (adjusting for age over 55, GCS 8 or
EVAR (Figs. 17.9 and 17.10) for traumatic thoracic aortic less, hypotension on admission, and critical extrathoracic
injuries was first utilized in 1997 by Kato and colleagues.4 injuries) showed a significantly lower adjusted mortality
Initially, endovascular repair was recommended only for and fewer blood transfusions in the endovascular group
high-risk patients sustaining BTAI with severe associated as compared to the open repair group. In the subgroup of
injuries or with comorbid conditions.46 The next decade patients with no critical extrathoracic injuries, endovas-
saw a steady increase in the use of endovascular stents in cular repair was associated with a significantly lower case
the management of BTAI. In the AAST1 study in 1997, no fatality and fewer blood transfusions than open repair. A
patient was treated with the EVAR technique.5 A systematic significant survival benefit was likewise identified in the
review of the published literature up to 2006 found a total subgroup of victims with associated critical e­ xtrathoracic
206 SECTION 4 • The Management of Vascular Trauma

Fig. 17.9 Illustration of deployed endovascular stent graft for blunt

thoracic aortic injury.

injuries.6 In a more recent meta-analysis of 699 proce-

dures in which 370 patients were treated with endovas-
cular repair and 329 patients were managed with open
repair, the observed mortality rates were 7.6% and 15.2%
(P = .008), respectively, in favor of EVAR. The incidence of
procedure-related paraplegia was 5.6% in the open repair
group and 0% in the endovascular group. The incidence of
stroke was likewise significantly lower in the EVAR group
B
(0.8% vs. 5.3%, P = .003).48
Despite the improved early outcomes with the endovascu-
lar repair, there is a significant concern because of the high Fig. 17.10 (A and B) CT scan shows a successfully deployed ­endovascular
incidence of device-related complications. In the AAST2 stent graft on sagittal and axial images.
study, 20% of patients subjected to EVAR developed device-
related complications, including endoleaks, access-site
vessel complications, occlusion of the left subclavian or left cause collapse of the device with potentially catastrophic
common carotid arteries, device collapse, and stroke (Table consequences. These problems have been addressed with
17.3). The most common complication was the presence the improvement of stent-graft design, which are now
of an endoleak, observed in 14% of patients. The proper available in smaller sizes and in curved shapes more suited
sizing of the stent is essential in avoiding complications such to the younger aorta.
as endoleaks (Fig. 17.11A) or stent collapse (Fig. 17.11B). The other major concern with endovascular treatment of
Optimal deployment of the stent requires oversizing the BTAI is the lack of long-term follow-up, especially in young
device by 10% to 20%.47,49,50 However, in earlier years, individuals undergoing EVAR. Because of this paucity
this was not always possible (especially in young patients) of data, it is unclear how these devices will behave when
because commercially available devices were only available the aorta becomes tortuous, atherosclerotic, and dilated
in a limited range of sizes. Another factor that increased the with advancing age. Furthermore, the durability of endo-
risk of endoleak was the anatomy of the aorta, especially grafts over time is unknown. Medium-term results are now
the angle between the left subclavian artery and the dis- available and show significant device-related complica-
tal aorta (which can be up to 90 degrees). This resulted in tions. Fernandez et al.52 in a follow-up study (range 5.5 to
poor apposition between stent graft and aortic wall, espe- 108 months) of 20 patients with BTAI treated with EVAR
cially in the inner corner (Fig. 17.12).51 Excessive oversizing reported significant problems: two patients with left subcla-
of the stent (in order to reduce the risk of endoleak) may vian artery occlusion needed late revascularization for steal
 17 • Blunt Thoracic Aortic Injury 207

Table 17.3 Device-Related Complications in Patients Treated with Endovascular Repair in AAST2 Study.
Complications n 125 (%)
Endoleak 18 (14)
Access vessel injury 4 (3)
Subclavian artery occlusion 4 (3)
Stroke 2 (1.6)
Paraplegia 1 (0.8)
Carotid artery occlusion 1 (0.8)
Partial collapse of the device 1 (0.8)
Insertion site infection 1 (0.8)
From Demetriades D, et al. Operative treatment or endovascular stent graft in blunt thoracic aortic injuries: results of American
Associations for the Surgery of Trauma multicenter study. J Trauma. 2008;64;561–571.

A B

Fig. 17.11 CT scan showing stent-graft–related complications. Poor apposition between the graft and the aortic wall may cause (A) endoleak (arrows)
and (B) partially collapsed stent graft.

syndrome; one case developed stent collapse at 6 months person should be considered as a serious adverse event that
and needed re-intervention; in one case the stent fractured is associated with significant complications, such as iatro-
at 4 years; and in one case the stent thrombosed at one year. genic injury to the phrenic nerve, the recurrent laryngeal
Forbes et al.,53 in a series of 17 patients treated with EVAR nerve, and axillary nerve. Despite these very real concerns,
and with a minimum of one-year follow up, reported that the low early mortality rates observed in patients with BTAI
the proximal thoracic aorta, just distal to the left subclavian treated with endovascular repair (Table 17.4) has proven
artery, expanded at a greater rate than the aorta distal to the very attractive to surgeons, and it has become the new stan-
graft. The clinical significance of this finding is unknown. dard of care. For optimal results, it is essential that these
Currently, the most common complication of endovas- procedures are performed in centers of excellence staffed
cular stenting of BTAI is occlusion of the left subclavian with well-trained multidisciplinary teams with experience
artery (Fig. 17.13). Khoynezhad et al.,54 in a prospective in the management of the multitrauma patient. It has
trial of 50 patients treated with EVAR, reported a complete been shown that high-volume centers have significantly
or partial occlusion of the left subclavian artery in 58%. fewer systemic and local complications and shorter hospital
DuBose et al.,55 in a database study of 190 patients treated lengths of stay than low-volume centers.6 Results, especially
with EVAR, reported occlusion of the left subclavian artery device-related complications, should be monitored closely
in 41% of cases. Although most patients tolerate subcla- and reported through the quality improvement process.
vian artery occlusion well, a significant number develop
subclavian steal syndrome or arm claudication and require Advances in Endograft Design
revascularization with carotid-subclavian bypass graft.52,56 Since the introduction of stenting as a definitive treat-
A carotid-subclavian artery bypass procedure in a young ment for BTAI in the mid-1990s, endograft technology
208 SECTION 4 • The Management of Vascular Trauma

Fig. 17.13 Occlusion of the left subclavian artery by a deployed stent

graft (arrow).
Fig. 17.12 Poor apposition between the stent graft and the aortic wall
may occur in the inner corner of the graft (arrow).
on the inner corner. This may over time result in a “bird’s
beak deformity” with the propensity to develop into a type I
endoleak or, if sufficiently severe, may result in migration or
has evolved with several improvements specific to trauma graft collapse. New generation devices incorporate this cur-
patients. One of the most clinically relevant differences vature into the design and can better conform to the natural
between the injured aorta and the chronically diseased contours of the injured aorta.
aorta is anatomic size differential. The often-young, pre- As discussed previously, aortic stenting may result in
viously healthy injured thoracic aorta is much smaller in occlusion of a major aortic arch branch. Whereas pres-
diameter with a well-defined, distal taper. This size discrep- ervation of antegrade flow to the left subclavian can be
ancy continues down into the ilio-femoral region as well, maintained through the use of follow-on left common
impacting the capacity of this segment to accept a deploy- carotid to subclavian by-pass graft, where injuries involve
ment device, which may result in major iatrogenic injury to sealing across the more proximal arch, the at-risk branch
the femoral or the iliac artery. Implantation of an oversized vessels will need to be accessed by median sternotomy and
graft can lead to endoleak, in-folding, and even collapse. In reimplanted upstream of the proximal sealing zone prior
response to this, grafts that can be utilized in patients with to stenting (Fig. 17.14); chimney grafts can also be used
aortic diameters even as small as 16 to 24 mm have been to preserve perfusion.57 Recent advances with the use of
developed. Smaller-sized deployment sheaths have reduced advanced branched grafts may eliminate the need for reim-
the incidence of complications at the insertion site. In plantation (Fig. 17.15). These engineering advances have
addition to the size considerations, the aorta in the young the potential to improve stent delivery and seating, thereby
trauma patient may not be fully unfolded and as such, the reducing the complications associated with endovascular
acute angle prevents close apposition of the graft, especially treatment.58.

Table 17.4 Open Versus Ensovascular Aortic Repair (EVAR) of Thoracic Aortic Injuries in AAST2 Study.
All Patients Open Repair EVAR P-value
n 193 58 125
Mean ISS 39.5 38.9 39.4 .83
Severe associated injuries 39.2% 31.3% 43.4% .10
Mortality 13.0% 23.5% 7.2% .001
Paraplegia 1.6% 2.9% 0.8% .28
Systemic complications 45.1% 50.0% 42.4% .31
From Demetriades D, et al. Operative treatment or endovascular stent graft in blunt thoracic aortic injuries: results of American Associations for the Surgery of
Trauma multicenter study. J Trauma. 2008;64;561–571.
AAST, American Association for the Surgery of Trauma; ISS, injury severity score.
 17 • Blunt Thoracic Aortic Injury 209

Minimal aortic injury (MAI) is defined as a small inti-

mal flap with no periaortic hematoma, occurs in about
10% of BTAI, and is diagnosed with high-resolution
techniques.62 These injures may be managed with blood
pressure control and observation, without surgical or
endovascular interventions. Conservatively managed
patients need regular CT scan follow-up until resolution
of the aortic lesion. Traumatic aortic injury can also be
classified as grade I (intimal tear), grade II (intramural
hematoma), grade III (pseudoaneurysm), and grade
IV (rupture),63 where grade I injuries are equivalent
to MAI.
The available literature consists of mainly small case
series and the preliminary results are encouraging, with
no cases progressing to delayed rupture. In a study by
Malhotra et al.,64 six patients with MAI were observed. In
two, the flap completely resolved, and in one it remained
stable. The remaining three patients formed small pseu-
doaneurysms. The authors concluded that many intimal
injuries heal spontaneously and hence may be managed
nonoperatively. In another study, Akins et al. success-
fully managed nonoperatively five patients with MAI.59
Kepros et al.,65 in another small series of five traumatic
internal tears of the thoracic aorta, reported complete
resolution in all of them within 3 to 19 days. In a larger
series of 27 cases treated with blood pressure control and
Fig. 17.14 Debranching and reimplantation of arch-branches (arrow) with a mean follow-up of 107 days, Caffarelli41 reported
prior to stenting may be required ahead of stent-graft placement stable lesions in 19, complete resolution in 5, progres-
where the blunt thoracic aortic injury zone is at or proximal to the ori- sion requiring open repair in 1, with need of endovas-
gin of the left subclavian artery. cular stenting in 2. It has been suggested that small false
aneurysms have the similar relatively low risk of rupture
as their true aneurysmal counterparts.60 However, the
long-term natural history of these injuries is not known,
and caution should be exercised when considering this
form of treatment.

Summary
The screening, definitive diagnosis, and treatment of
traumatic blunt thoracic aortic injuries have undergone
major evolution in the last two decades. Routine CT scan
of the chest in suspicious mechanisms of injury has
replaced plain chest x-rays as a screening tool. CT angi-
ography has largely replaced invasive angiography for
definitive diagnosis. Delayed repair of the aortic injury
is now the preferred approach in most cases. Endovas-
cular repair has largely replaced open repair. Finally, it
seems that there is a role for conservative management
of selected cases. These new approaches have resulted
in a significant reduction of mortality, paraplegia, and
other complications in patients with BTAI reaching hos-
Fig. 17.15 Arch branch grafts can address injuries to the aortic arch. pital care. Improvement of the endovascular devices has
reduced some device-related complications. However,
there is still concern about remaining device-related
complications, such as the high incidence of subclavian
NONOPERATIVE MANAGEMENT
artery occlusion and limited long-term follow up. These
Experience with nonoperative treatment of BTAI is very lim- injuries should be managed in centers of excellence by
ited and offered mostly to selected patients with advanced multidisciplinary teams with significant experience in
age and minor aortic injuries.59–61 this field.
210 SECTION 4 • The Management of Vascular Trauma

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term outcomes of thoracic endovascular aortic repair focused on bird
 18 Abdominal Aortic Trauma, Iliac
and Visceral Vessel Injuries
CHRISTOPHER AYLWIN and MICHAEL JENKINS

Introduction weapon. The type of injury that results from firearms is

variable depending on the nature of the firearm. Gunshot
Major vascular injuries may be seen in up to 25% of abdom- wounds may be high velocity or low velocity. Low-velocity
inal trauma and are associated with a high mortality.1,2 Fol- gunshot wounds are defined as wounds caused by projectiles
lowing penetrating abdominal trauma, vascular injuries such as bullets or missiles with speeds of less than 600 m/s.12
are the most common causes of death.3 Intra-abdominal Low-velocity gunshot wounds such as those that occur with
hemorrhage can be catastrophic due to the difficulty of rap- handguns cause localized injury to the structures that lie in
idly accessing the retroperitoneal vessels. It is for this rea- the paths of the projectiles. They are associated with a lower
son that early recognition of a possible vascular injury is transfer of energy compared with high-velocity gunshot
essential and transfer to a center capable of early surgical wounds. Military wounds are more often a result of high-
intervention is vital. The early diagnosis of these injuries velocity (greater than 600 m/s) projectiles. A high-velocity
has been facilitated with the increasing use of computed projectile carries with it a significant amount of kinetic
tomography (CT) angiography and with its availability close energy that is transferred to the surrounding tissue and
to the resuscitation room. results in extensive injury around the path of the projectile
Civilian vascular injury comprises approximately 1% as well as the immediate damage to any tissue in the path
to 5% of all trauma4,5 with data from the PROOVIT (PRO- of the projectile. The amount of energy transferred to the
spective Observational Vascular Injury Treatment) registry patient will be decided by a combination of factors including
revealing the incidence of abdominal arterial injuries to be the energy carried by the missile, the cross-sectional area of
7.8% of all of vascular trauma.6 The relative rarity there- the missile that comes into contact with the tissue, and the
fore makes it difficult for a trauma center and its surgeons degree of retardation of the missile within the patient, that is,
to accumulate large caseloads of specific arterial injuries. whether the missile passes through the tissue (delivering less
Although blunt trauma is the most common mechanism energy) or comes to rest within the tissue (delivering all of its
of all vascular injury in the PROOVIT registry, there are kinetic energy). When military weapons are used in civilian
huge variations in the role of penetrating trauma causing settings with no body armor, mortality from abdominal vas-
abdominal vascular injury. In urban US trauma centers this cular injury may approach 100%.13
is reported to be as high as 88%,7 whereas in Germany, over The injury that results from shotgun wounds is depen-
a 16-year period, the incidence of penetrating trauma was dent on the range at which the shotgun is fired. If the range
only 5% in 760 patients with abdominal vascular injury.2 is less than 5 m, the chance of survival is approximately
The incidence of injuries differs between military and civil- 10%. At this range, although the shotgun cartridge con-
ian trauma. During the Vietnam War and World War II, tains multiple pellets (shot), the pellet mass has yet to dis-
the incidence of penetrating abdominal vascular injuries perse and thus acts as a more focused mass on impact with
was less than 3%,8 but in the recent conflicts in Iraq and tissue. When the shotgun is fired from a greater distance
Afghanistan, iliac injuries were found in 3.9% of injuries, (e.g., 5 –15 m) the shot has spread, with each pellet carry-
and aortic injuries in a further 2.9%.9 In civilian popula- ing lower kinetic energy secondary to retardation from the
tions with a high incidence of knife crime, the incidence air – behaving as a low-energy missile, generally resulting
approaches 10%; and this figure doubles to more than 20% in less destruction to tissue. At close range, vascular injuries
in populations with gun crime.10 For aortic penetrating tend to be multiple, complex, and frequently contaminated
injuries, the incidence still remains low, and it is less than either with bowel contents or external contaminants such
3% for penetrating trauma.11 as the victims clothing.14

BLUNT INJURY
Mechanism of Injury Blunt abdominal vascular injury is rarely isolated, is often
associated with high injury severity scores (ISS) in compet-
PENETRATING INJURY
ing injured body regions, and incurs significant mortality.2
In the context of noniatrogenic injuries, penetrating injuries The mechanism by which blunt trauma results in vascular
usually occur either from stab wounds or firearms. Injuries injury is either by severe deceleration, by crush injuries, or
resulting from explosions (e.g., bomb blast) are complex, by direct laceration from a fractured bone fragment. Severe
resulting in mixed patterns of penetrating and blunt trauma. deceleration can occur in the context of high-speed road
Stab wounds (e.g., knife wounds) result in localized inju- traffic accidents or falls from significant heights. Crush inju-
ries whereby the path of injury follows the track of the ries also occur in road traffic accidents and may result in an
212
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 213

anteroposterior crush injury as seen in a seatbelt-restrained Zone II Zone I Zone II

passenger. This can also be associated with shearing inju-
ries of the aortic branches. Fractures of the spine or pelvis
can result in direct laceration to the aorta and iliac vessels,
respectively. Renal vessels may be damaged with accelera-
tion – deceleration-type injuries causing shearing forces to
be applied to the renal pedicle.
Whereas the adventitia is the most durable part of the
arterial wall, the intima remains the least elastic and there-
fore most likely to be torn during blunt injury. Hence the
artery is frequently injured from “inside to outside,” and the
adventitia may remain intact. This creates a thrombogenic
environment within the artery resulting in thrombosis and
occlusion. Alternatively, the intima may be sheared result-
ing in a dissection. If the adventitia remains intact, the
artery may still be weakened, contributing to delayed aneu-
rysmal degeneration. Total transmural injury can lead to
perforation, hemorrhage, and false aneurysms.

Anatomy
Vascular injuries in the abdomen are classified according to
geographical location (Fig. 18.1). These are usually defined
within three zones, albeit a fourth zone is occasionally Zone III
included.
Zone I begins at the point of entry of the aorta through
the diaphragm (i.e., the aortic hiatus) and extends down
to the sacrum. The aorta enters the abdomen at the level
of the twelfth thoracic vertebra passing behind the median
arcuate ligament of the diaphragm. The aorta descends to Fig. 18.1 The three anatomical zones of the retroperitoneum used to
the level of the fourth lumbar vertebra where it bifurcates describe the locations of vascular injuries presenting as retroperitoneal
into the left and right common iliac arteries. Zone I includes hematomas. Zone I extends from the aortic hiatus to the sacrum and
the central retroperitoneal area and the base of the mesen- includes the midline vessels and origins of the visceral branches. Zone II
tery. The area is further divided into the supramesocolic and exists on either side of Zone I and includes the kidneys, renal vessels,
inframesocolic areas. The supramesocolic and inframeso- and paracolic gutters. Zone III lies inferior to the level of the sacral
colic areas are defined by the levels of the renal arteries. The promontory and includes the iliac vessels and pelvic retroperitoneum.
suprarenal aorta, celiac axis, superior mesenteric artery Zone IV is not depicted in the diagram.
(SMA), renal arteries, inferior vena cava (IVC), and superior
mesenteric vein all lie within this supramesocolic area. The
inframesocolic area contains the infrarenal aorta, the infe- may provide some idea of the vessels and organs injured. Do
rior mesenteric artery, and the IVC. not assume that the injury is localized to the missile path.
Zone II exists either side of zone I and contains the para- The presentation of arterial injuries may be early or late
colic gutters, kidneys, and renal vessels. It is also referred to depending on the artery involved, as well as the type and
as the upper lateral retroperitoneum. mechanism of injury.
Zone III, containing the iliac vessels, is also known as the Early presentation is usually in the form of hemorrhage
pelvic retroperitoneum. and hypovolemic shock. Urgent laparotomy will reveal either
The hepatic artery, portal vein, retrohepatic IVC, and blood in the peritoneal cavity or a retroperitoneal hematoma.
hepatic veins all lie within an area occasionally referred to The zone should be defined according to Fig. 18.1. Some
as zone IV. patients may respond to resuscitation but presentation with
a distended abdomen should raise the suspicion of a vascular
injury. Patients who are stabilized and taken for trauma CT of
Clinical Presentation the abdomen revealing vascular injury may also be included
as early presenters. Thrombosis, dissections, and occlusions
The patient should be inspected for signs of penetrating may present with lower limb ischemia (absent or diminished
injury. Stab wounds in the abdomen should be obvious but femoral pulses; cold, pale limbs). This should be considered
be aware that stab wounds in the chest, back, and gluteal in the context of blunt injury resulting in pelvic fractures or
regions can result in injury to abdominal and pelvic ves- abdominal crush. Be aware that the presentation may not be
sels. With both penetrating and blunt trauma, examine for immediate with intimal tears, and repeated examinations are
bruising in the flanks. This can be a sign of a retroperitoneal mandatory. Injuries to the renal pedicles may present with
bleeding. With gunshot wounds, examine the patient for hematuria. Anuria as a result of bilateral renal artery throm-
entry and exit wounds. An attempt to predict the trajectory bosis is rare.
214 SECTION 4 • The Management of Vascular Trauma

Both penetrating and blunt trauma can result in vas- the pubis. If further access is required, the incision may be
cular injuries that present late. With the increasing use of extended in the midline to include a median sternotomy or
CT angiography, arterial injuries are being detected early, through the sixth or seventh intercostal spaces for a lateral
reducing the incidence of late presentation. Pseudoaneu- thoracotomy.
rysms frequently present late. They may each present as a On initiating the laparotomy the surgeon may be pre-
pulsatile mass compressing adjacent structures. Compres- sented with an abdominal cavity containing free blood. At
sion of the duodenum may present as bowel obstruction. this stage it may be difficult to establish the source of bleed-
The false aneurysm may erode into the bowel resulting in ing and the principles of damage control surgery should
massive gastrointestinal hemorrhage. Similarly, internal be applied. In order to identify the source of bleeding, the
iliac pseudoaneurysms have presented with rectal bleed- surgeon should proceed with small bowel evisceration and
ing.15,16 Pseudoaneurysm of the renal artery can pres- packing of the abdominal cavity, using large packs to either
ent with hematuria. Arterial fistulas have been seen with stop or slow the bleeding. These packs are then removed
hepatic artery injuries and penetrating liver injuries. These from each compartment until the source of bleeding is iden-
fistulas may present with hemobilia, right upper quadrant tified. The four-quadrant packing technique requires packs
pain, and upper gastrointestinal hemorrhage. Injuries to be placed in the right upper quadrant over the right lobe
involving both arteries and veins can cause arteriovenous of the liver, the left upper quadrant, the infracolic compart-
fistulas. The clinical manifestation may be obvious or ment (elevate the greater omentum and pack either side of
subtle. Aortocaval fistulas are associated with lower limb the small bowel mesentery), and the pelvis. Pelvic packing is
edema and an abdominal bruit. Other arteriovenous fistu- performed by lifting the small bowel out of the pelvis before
las may present later with high-output cardiac failure and applying the packs into the pelvis.
lower limb chronic venous skin changes. Exposure of the aorta and its branches is best achieved
using the technique of a medial visceral rotation. This can
be performed from either the left or right side; the decision
Investigations will be dependent on which vessels need to be exposed. The
medial visceral rotation can be a time-consuming technique,
The choice of investigation will depend on the patient's even in experienced hands, and temporary control may be
physiologic status and the available local facilities. CT has required, especially if active hemorrhage is occurring from
become the gold standard investigation. Availability close to the supramesocolic aorta. Direct manual compression of
the resuscitation room is an important factor in the plan- the aorta against the spine may control the bleeding but
ning of a major trauma center. Catheter angiography still frequently restricts exposure of the aorta and therefore sub-
maintains an important role in trauma and has the advan- sequent repair. It can be a useful technique to control the
tage of being coupled with therapeutic options such as stent- inflow, but the ultimate aim should be to apply a clamp.
ing and embolotherapy. Early availability of experienced Division or creation of a window within the lesser omen-
interventional radiologists and the location of the radiology tum enables exposure of the supraceliac aorta. This tech-
suite often limit use to the hemodynamically stable patient. nique is aided by retracting the stomach and the esophagus
The use of ultrasound in trauma has increased in the form to the left. The liver is retracted in a cephalad direction. Divi-
of focused assessment with sonography for trauma (FAST) sion of the diaphragmatic crura further aids exposure, and
scans. Bedside ultrasonography is able to detect intraab- then a supra celiac aortic clamp can be applied. This is the
dominal free fluid, facilitating the decision for early explor- quickest way to apply a supraceliac clamp and to gain con-
atory laparotomy. The exploratory trauma laparotomy trol of the bleeding abdominal aorta. Although inflow will
remains an important diagnostic tool and is coupled with be controlled, back-bleeding from the visceral vessels and
the techniques of damage control surgery. Duplex scanning lumbar arteries may be significant. The presence of visceral
is less useful in the acute trauma presentation. It has a role branches can make distal control challenging.
in assessing neck trauma and can be used for surveillance to In order to perform a left-sided medial visceral rotation,
detect late pseudoaneurysms and arteriovenous fistulas. In the peritoneal attachments of the sigmoid and the descend-
the context of abdominal vascular injuries, its use is limited. ing colon are divided. The incision is started in the lateral
avascular peritoneal reflection of the sigmoid colon and is
continued proximally along the left paracolic gutter. The
Surgical Techniques plane is developed by mobilizing the sigmoid colon and the
descending colon to the midline. The retroperitoneal attach-
The operative approach will be dependent on the location ments of the left kidney, pancreatic tail, and spleen can be
of the hematoma and the degree of urgency. The latter is divided, mobilizing these organs to the midline and hence
dictated by the degree of hemodynamic shock. facilitating complete exposure of the abdominal aorta from
When a decision is made to proceed to surgery, the patient its origin at the diaphragm to its bifurcation at the level of
should be prepared with sterile drape application allowing the fourth lumbar vertebra (Figs. 18.2 and 18.3). This tech-
exposure of the abdomen, chest, and groins. This allows nique carries a significant risk of damage to the spleen, left
for incisions to be extended into the chest; and, if deemed kidney, and left renal vessels. Developing a dissection plane
necessary, a left anterolateral thoracotomy can be utilized anterior to the left kidney can reduce the risk of intraopera-
to gain control of the descending aorta prior to entry to tive renal injury.
the abdomen. To facilitate distal control, exposure of the If rapid proximal control of the abdominal aorta is
common femoral arteries may be required. The initial inci- required before the medial visceral rotation, a clamp can
sion is a long midline laparotomy from the xiphisternum to be applied to the distal descending thoracic aorta. This is
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 215

Liver
Stomach

Pancreas
Spleen

Celiac trunk

Transverse Superior mesenteric artery

colon
Left renal artery

Aorta

Descending
colon
Left kidney

Small
intestine IVC

Left ureter

Fig. 18.2 Left-sided medial visceral rotation. The

peritoneum is incised lateral to the descending
Sigmoid colon allowing the colon, left kidney, and spleen
colon to be mobilized to the right. This allows exposure
of the left renal artery, the superior mesenteric
artery, and the celiac artery. IVC, Inferior vena cava.

especially useful with an expanding zone I hematoma. The and an infrarenal aortic clamp applied. More proximal
aorta is exposed by division of the left crus of the diaphrag- application of an infrarenal aortic clamp can be facilitated
matic aortic hiatus. Incision is made at the 2 o'clock position by ligation and division of the left renal vein, preferably pre-
exposing the descending thoracic aorta and hiatal aorta. serving its adrenal and gonadal tributaries.
This is the quickest way to achieve proximal control during Surgical exposure of the celiac artery is either via a medial
a medial visceral rotation. The presence of celiac nerves and visceral rotation or via a direct dissection through the lesser
lymphatic tissue around the aorta, together with dense dia- sack. Fullen's anatomical classification can be used for the
phragmatic muscle fibers, makes careful dissection of the purpose of describing injuries to the SMA. Exposure of the
most proximal abdominal aorta difficult, time consuming, proximal SMA (Fullen's zone I) is via a left medial visceral
and hence unsuitable for the severely hypotensive patient. rotation. If severe bleeding dictates very rapid exposure, this
The advantage of this technique is that, after mobilizing part of the SMA can be exposed by dividing the neck of the
the spleen and the tail of the pancreas, the anterior midline pancreas. The easiest and quickest way of doing this is by
visceral branches of the aorta are well exposed and can be using a stapling device, but, if this is not available, intestinal
controlled, repaired, or ligated. clamps should be applied before the division of the pancreatic
A right-sided medial visceral rotation is performed by divid- neck to control any bleeding. The proximal infrapancreatic
ing the peritoneal reflection lateral to the ascending colon SMA can be exposed through root of the small bowel mesen-
(Fig. 18.4). A dissection plane is developed anterior to the kid- tery, and this may be facilitated further by mobilization of the
ney, facilitating mobilization of the colon and terminal ileum duodenum and retraction of the pancreas. The more distal
to the midline. This allows exposure of the duodenum, which SMA may be exposed directly in the bowel mesentery.
can then be kocherized. The duodenum and the pancreatic The inferior mesenteric artery origin is easily exposed via
head are mobilized to the left, and the retroperitoneal tissue an infrarenal approach to the aorta. The renal arteries can
left of the IVC is divided to expose the suprarenal aorta, the be exposed through respective medial visceral rotation tech-
celiac axis, and the SMA. If exposure of the diaphragmatic niques. In the presence of a large retroperitoneal hematoma,
hiatal aorta is required, this technique should be avoided. the application of a supraceliac aortic clamp should be used
If injury is isolated to the infrarenal aorta, exposure for proximal control. If the renal artery is bleeding from a
to this part of the aorta can be achieved via an anterior more distal point (e.g., renal hilum), the renal artery can be
approach that resembles that for an infrarenal abdominal exposed at its origin without the need for a visceral rotation.
aortic aneurysm. Peritoneal incision is made left of the duo- The small bowel is eviscerated to the right, and the aorta is
denojejunal flexure, the peritoneum dissected off the aorta, approached anteriorly. The duodenojejunal flexure is mobilized
216 SECTION 4 • The Management of Vascular Trauma

Stomach

Pancreas

IVC

Spleen

Left kidney
A Aorta

Kidney

Fig. 18.3 (A) Plane of dissection for left-sided visceral rotation indi-
cated by the arrow and dotted line. (B) The lateral retroperitoneal
attachments are divided to facilitate medial mobilization of the spleen,
descending colon, and kidney. IVC, Inferior vena cava. B

as p
­ reviously described. The left renal vein can be either divided the artery in the patient with multiple injuries. Achieving
as previously described or retracted proximally. The latter can hemostasis during combined venous and arterial bleeding
be facilitated by division of the left gonadal and adrenal veins. can be challenging. The application of clamps to a large vein
This will allow exposure of the origin of the renal arteries. can further tear the vein and therefore should be avoided
The left renal artery can be seen following dissection of or used with extreme caution. Using mounted sponges or
the surrounding peritoneal tissue. The right renal artery swabs to apply pressure above and below the injury can
may require lateral retraction of the IVC to identify its ori- achieve hemorrhage control and is less likely to damage
gin. Additionally, medial rotation of the duodenum and the vein. With the aid of an experienced assistant, the sur-
then of the pancreas may be required to visualize the right geon can repair or ligate the vein. An alternative technique
renal vein, which will need to be looped and retracted before is using Foley catheters within large veins to control the
the remaining right renal artery can be exposed. The pres- inflow and back-bleeding.
ence of a large retroperitoneal hematoma around the right
kidney and juxtarenal IVC can make this a challenging dis-
section. Identifying the IVC distally and then dissecting in a Aortic Injuries
proximal direction along the course of the IVC through the
hematoma is an alternative approach. The majority of injuries to the aorta are consequences
Although the focus of this chapter is on arterial injuries of penetrating traumas. Blunt injuries are rare and may
due to their close proximity, the veins may be injured with be associated with seatbelt injuries and t­ horacolumbar
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 217

Small
Cecum
intestine

Ascending
colon

Duodenojejunal
flexure

Descending
colon

Right
kidney
Ureter

IVC
Fig. 18.4 Right-sided medial visceral
Aorta rotation. This shows the Kocher and
Cattell-Braasch maneuvers. The retro-
peritoneal attachment of the cecum,
ascending colon, duodenum, and
Sigmoid small bowel mesentery are divided.
colon This allows exposure of the inferior
vena cava (IVC), the right renal vessels,
and the right iliac vessels.

f­ractures of the spine. The majority of patients who INVESTIGATIONS

experience a rupture do not survive transport to
hospital. Physiologically abnormal patients who do not respond to
The complex forces that are associated with blunt initial resuscitation should be taken immediately to the oper-
trauma can damage the aortic intima resulting in aor- ating room for a trauma laparotomy. Patients whose physi-
tic dissection, thrombosis, and consequently end-organ ology allows can be investigated with a trauma CT scan.
ischemia or limb ischemia. This may not be apparent at This will identify significant bleeding or retroperitoneal
the initial presentation, and a high index of clinical sus- hematomas. With the increasing availability of CT angiog-
picion is vital. Less commonly, patients may have delayed raphy, the use of catheter angiography as a diagnostic tool
presentation with a pseudoaneurysm or arteriovenous has diminished. Catheter angiography does, however, offer
fistula. the possibility of combining both diagnostic and therapeu-
An aortic branch may be avulsed and present as a large tic options with the use of endovascular stents, occlusion
retroperitoneal hematoma during the trauma laparotomy. balloons, and embolization techniques.
Gunshot wounds appear to be associated with a higher
incidence of aortic injuries than knife wounds.17 The clini-
cal presentation will be dependent on a number of factors. TREATMENT
If the injury results in bleeding into the peritoneal cavity, The choice of treatment is dependent on patient factors
the patient presents in severe shock with peritonitis and a and institutional factors. Patient factors include physi-
distended abdomen. Frequently these patients do not sur- ologic status, injuries to other intra-abdominal organs,
vive transfer to the hospital. If the injury is to the l­ateral and degree of intra-abdominal contamination. Institu-
wall and bleeding is confined to the retroperitoneum, tional factors include the availability of local facilities
hemorrhage may tamponade temporarily within the­ (e.g., interventional radiology, CT imaging, and medical
retroperitoneum. expertise).
218 SECTION 4 • The Management of Vascular Trauma

Injuries to the infrarenal aorta have been successfully

treated with endovascular techniques. These include endo-
Injuries to the Visceral Arteries
vascular stent grafts for dissection flaps and aortocaval fis- CELIAC ARTERY AND BRANCHES
tulas, as well as embolization (e.g., coiling) of aortic visceral
branches. Isolated injuries to the celiac artery are rare.6 The majority
The trauma laparotomy may reveal a retroperitoneal of patients have other vascular injuries. It is for this reason
hematoma. Central hematomas require exploration, and that these injuries are associated with a high mortality. The
the principles of gaining both proximal and distal arterial majority of injuries to the celiac artery are a consequence
control should be applied. Exposure of the aorta and its of penetrating trauma.
branches has been previously described. Small aortic lacer- Bleeding from the celiac trunk or its branches close to
ations may be closed with a 3-0 or 4-0 Prolene suture using their origin can be difficult to control. This is because of the
the technique of lateral aortorrhaphy. If there is a defect in small size of the vessel, especially in a shocked patient where
the aorta and lateral aortorrhaphy is likely to narrow the vasoconstriction makes exposure all the more difficult. The
aorta, consideration should be given to repairing the defect surrounding connective tissue and the location of the celiac
using a prosthetic patch or tube graft (Fig. 18.5). Consider- trunk contribute to a difficult dissection. Urgent control
ation must always be given to the principles of damage con- may be needed with a supraceliac aortic clamp. This is best
trol surgery. The surgeon should avoid prolonged complex achieved as previously described via a window through the
arterial repairs in the patient who is acidotic, hypothermic, lesser omentum. Exposure of the celiac axis is best achieved
and coagulopathic. via a left medial visceral rotation but this is time consuming
The decision to use prosthetic grafts will be affected by and dependent on the hemodynamic status of the patient.
the degree of intraabdominal contamination from other Injuries to the left gastric or splenic artery should not be
injuries. Many surgeons will opt for an extraanatomical repaired as these are small vessels and are better managed
bypass in the presence of abdominal contamination. Some with ligation. The surgeon should be aware that the left
surgeons do not consider mild contamination as a con- hepatic artery may arise entirely from the left gastric artery
traindication to the use of prosthetic grafts in the trauma in up to 10% of patients.18 If there is an injury to the celiac
patient. Instead, the contamination is dealt with, the peri- trunk, this can also be managed by ligation provided the
toneum is washed out, and a graft is used if needed. Like SMA is patent and the ligation is proximal to the branches
many controversies in vascular trauma there is a lack of of the celiac trunk. Evidence from elective endovascular
evidence in the literature to either support or negate the use aneurysm repairs suggests that the risk of ischemic foregut
of prosthetic grafts in this setting. complications is low in most patients.19
If the common hepatic artery is injured, there are a num-
ber of options. The artery can be identified in the lesser
FOLLOW-UP omentum and its exposure facilitated by retracting the
Young patients treated with endovascular stents will need duodenum inferiorly. At the epiploic foramen, it lies ante-
to be in a long-term surveillance program, as the durability rior to the portal vein and medial to the common bile duct;
of these grafts in young patients remains unknown. If there and hence the Pringle maneuver may facilitate control of
has been abdominal contamination and a prosthetic graft bleeding when the injury is at the porta hepatis. Ligation
used, the patient should be followed up for signs of graft of the common hepatic artery proximal to the origin of the
infection. gastroduodenal artery is possible, again dependent on
the patency of the inferior pancreaticoduodenal branch of
the SMA. The common hepatic artery may have a sufficient
diameter so that it is possible to perform arteriorrhaphy.
Alternatively, limited resection and an end-to-end anasto-
mosis may be attempted. If end-to-end anastomoses is not
possible, reconstruction with autologous vein graft or even
prosthetic graft may be considered; however, in the young
resuscitated patient with patent SMA, circulation and a
well-developed gastroduodenal artery, primary ligation or
embolization is unlikely to cause any long-term sequelae.18
If the patient’s physiology allows it and local facilities and
expertise permit, endovascular options may be considered.
Catheter angiography can be used to identify bleeding, and
this procedure can be combined with coil embolization.

SUPERIOR MESENTERIC ARTERY

The most common mechanism of injury to the SMA is pen-
etrating trauma. This is frequently associated with other inju-
Fig. 18.5 Exposure of the suprarenal aorta through a left-sided medial ries. With the exception of the renal artery, the SMA is the
visceral rotation and replacement with a Dacron prosthetic graft. This most commonly injured aortic visceral branch following blunt
was to repair a pseudoaneurysm of the aorta at the level of the SMA trauma.20 Rapid deceleration can result in either avulsion of
after a penetrating aortic injury. SMA, Superior mesenteric artery. the SMA at its origin (Fig. 18.6), or alternatively deceleration
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 219

of hypothermia, acidosis, and coagulopathy. If there is sig-

nificant small bowel necrosis, consideration may be given to
ligation of the proximal SMA. Collateral flow may preserve
the proximal jejunum. However, this decision should not be
taken lightly as it is not without its complications, including
short bowel syndrome.
When considering definitive repair of the SMA using an
interposition graft, the distal anastomosis is to the distal
stump of the SMA and the proximal anastomosis is to the
anterior surface of the disease-free infrarenal aorta. If there
are associated pancreatic injuries or small-bowel contami-
nation, the graft should be covered with either omentum or
surrounding soft tissue to protect the graft from pancreatic
enzymes and to reduce the risk of enteral-arterial fistulas.
Aim to pass the graft to the posterior surface of the small
bowel mesentery and to ensure the graft does not kink when
the bowl is returned to the abdomen.
Fig. 18.6 Superior mesenteric artery (SMA) disruption after a rapid Injuries to the SMA distal to the middle colic artery (Fullen's
deceleration injury. The image indicates a central hematoma and zone III) may be treated with ligation but are likely to result
hemorrhage into the small bowel mesentery. in segmental bowel ischemia. Hence the decision to ligate will
be dependent on how proximal the injury is. More proximal
injuries should be revascularized to avoid significant midgut
Table 18.1 Fullen’s Classification of SMA Injuries. ischemia. Injuries to the segmental SMA branches (Fullen's
zone IV) are treated by ligation and bowel resection.
Fullen's Zones SMA Region A low threshold for a second-look laparotomy at 24 hours
I From the SMA origin to the inferior pancreatico- should be maintained. If temporary intraluminal shunts
duodenal artery are used, the surgeon must always consider the possibility
II From the inferior pancreaticoduodenal artery to of shunt occlusion or dislodgement when a patient fails to
the middle colic artery improve or clinically deteriorates. When segmental SMA
III Distal to the middle colic artery branches are ligated, a second-look laparotomy should be
IV Segmental branches considered mandatory. If damage control techniques are
SMA, Superior mesenteric artery. applied at the primary surgery, small-bowel resections can
be anastomosed at the time of the second-look laparotomy
provided the physiology permits.
injuries may present as an intimal tear, dissection, and throm-
bosis. This comes as no surprise when consideration is given to INFERIOR MESENTERIC ARTERY
the mobility of the small bowel and its mesentery. These inju-
ries can present either early or late as intestinal ischemia. Injuries to the inferior mesenteric artery are rare and cer-
Injuries may occur at any level. When describing the man- tainly far less common than those to the SMA or celiac
agement of SMA injuries, it is useful to consider Fullen's clas- trunk. They are almost always a consequence of penetrat-
sification whereby four zones are described (Table 18.1). ing trauma.
Exposure of the SMA has been previously described. The Exposure of the inferior mesenteric artery is easy com-
decision to perform a rapid left medial visceral rotation will pared with the exposure of the SMA or the celiac trunk.
depend on the state of the patient and the experience of the Injuries are managed by ligation; and in the absence of
surgeon. The presence of a large expanding central hema- associated injuries to the SMA or internal iliac arteries,
toma during a trauma laparotomy may require a supraceliac ischemic complications are rare. There are no reports of
clamp in the severely hypotensive patient. Time permitting, ischemic colon in trauma cases although this is possible if
the medial visceral rotation will provide the best exposure there is coexisting occlusive arterial disease. Any deteriora-
of the SMA at its origin. Ligation of the SMA at any point tion in the patient postoperatively should warrant a second-
between its origin and the middle colic branch is likely to look laparotomy and bowel viability confirmed.
result in massive ischemia of the small bowel, the cecum, and
the ascending colon. Consequently, injuries to this part of the RENAL ARTERY INJURIES
SMA (Fullen's zones I and II) should be repaired. Penetrating
injuries resulting in a partial transection may be amenable to There is a slightly higher incidence of injury to the left renal
primary repair with 6-0 Prolene suture. If a direct repair is artery compared with the right renal artery. Half of the
not possible, an interposition graft using saphenous vein or a cases of blunt injury to the renal artery result in thrombo-
prosthetic graft should be used. sis and/or dissection. Complete avulsion occurs in approxi-
If the overall condition of the patient dictates that a dam- mately one in ten cases.21 Injuries to the distal renal artery
age control procedure is required, prolonged reconstruction may present with a hematoma or hemorrhage in zone II
can be avoided by the placement of a temporary intralu- (lateral compartment or perirenal area); most injuries to
minal shunt. This will allow for a delayed reconstruction the proximal renal arteries present with a more central or
after a period of appropriate resuscitation and correction supramesocolic hemorrhage.
220 SECTION 4 • The Management of Vascular Trauma

When considering treatment of the injured renal artery, vein prosthetic graft can be performed. Another option is
it is important to remember the potential for a solitary func- to translocate the splenic artery onto the left renal artery
tioning kidney and also that one-third of the population or interpose a graft between the right renal artery and the
have an accessory renal artery. The latter anatomical varia- hepatic artery.
tion is more commonly to the inferior pole of the kidney. Other options for renal revascularization include a bypass
The diagnosis of renal artery injury may be made follow- graft directly from the aorta and autotransplantation of the
ing CT scanning, or at laparotomy, with hypertension sug- kidney into the pelvis.
gestive of renal ischaemia. If the diagnosis is delayed, nonoperative management
There appears to be some controversy regarding explora- for a stable injury is an option and should be considered in
tion of perirenal hematomas. Most would advocate explora- patients with multiple injuries.
tion following penetrating trauma; however, stable lateral Overall, the results of revascularization have tended to
perirenal hematomas that do not encroach the midline (i.e., be poor, which has led to a conservative approach in many
unlikely to involve the hilum) in a patient who is hemody- centers. The absolute indications for revascularization
namically stable can be managed by close surveillance. are solitary functioning kidney injuries or bilateral renal
Management of injuries resulting from blunt trauma artery injuries. Delayed hypertension remains a problem in
will be dependent on the duration of renal ischemia. up to half of the patients who undergo revascularization.
Diagnostic delays and late presentation in this group of Patients who are managed conservatively can also develop
patients may result in significant loss of function in the this delayed hypertension, and this has been seen in at least
affected kidney. A kidney ischemic for more than 6 hours one-third of patients managed conservatively.23
is unlikely to improve with revascularization, although
this has been challenged with successful endovascular
revascularization reported after 25 days22; however, if ENDOVASCULAR TREATMENT
they present within 4 to 6 hours, revascularization may Stable patients presenting after blunt trauma and iden-
be attempted, although the majority of stable patients are tified as having intimal flaps, fistulas, pseudoaneurysm,
managed nonoperatively (assuming that contralateral and occlusion should be considered for endovascular
renal function appears sufficient). treatment.
Zone II hematomas should always be explored if the If local facilities and expertise allow, stenting should be con-
hematoma is expanding, if the patient remains hypotensive, sidered although the long-term outcome remains unknown.
or if the kidney has been shown to be nonfunctioning. If the These patients will need long-term surveillance. Emboliza-
hematoma is significantly lateral, control may be achieved tion may be considered as an alternative to nephrectomy.
by exposing the proximal renal artery at the aortic origin. However, delayed nephrectomy may be required because the
With the left renal artery, proximal exposure can be patient may suffer from resistant hypertension.24
achieved as previously described by retracting the trans-
verse mesocolon superiorly, eviscerating the small bowel
to the right, mobilizing the duodenojejunal flexure, and MORTALITY
retracting the left renal vein in a cephalic direction. The majority of blunt trauma results in occlusive injuries
The origin of the right renal artery may also be con- and consequently isolated renal artery injuries have a low
trolled in this way; however, due to the dense retroperito- mortality rate. As expected, mortality is higher when asso-
neal tissue, rapid exposure of the proximal renal artery may ciated with other injuries.
not always be possible. Kocherization of the duodenum
with lateral retraction of the IVC may be needed to expose
the right renal artery. If more rapid control is required in a Injuries to the Iliac Artery
hypotensive patient with an expanding hematoma or hem-
orrhage, supraceliac clamping is likely to be the quickest ANATOMY
option. Injury to the proximal renal artery should always be
considered in patients with expanding central hematoma, The bifurcation of the abdominal aorta into the left and
and the quickest and safest technique for control of bleed- right common iliac arteries occurs at the level of the fourth
ing is to apply a supraceliac clamp. lumbar vertebra. The common iliac arteries continue infero-
When a patient presents with multiple injuries and dam- laterally and bifurcate into the internal and external iliac
age control surgery is indicated, ligation of the renal artery arteries over the sacroiliac joints. It is at this point that the
and nephrectomy are reasonable options provided the kid- ureter crosses from lateral to medial. The common iliac veins
ney is not solitary. The experienced trauma surgeon should merge to form the IVC posterior to the right common iliac
be able to divide the overlying renal fascia, elevate the kid- artery at the level of the fifth lumbar vertebra. Whereas the
ney, and apply a vascular clamp proximal to the hilum to external iliac artery courses beneath the inguinal ligament
control bleeding from a distal renal artery injury. This may to become the common femoral artery, the internal iliac
be possible without applying a supraceliac clamp. artery passes medially and divides into anterior and poste-
If the patient has a single functioning kidney, nephrec- rior divisions. Posteromedial to the left common iliac artery
tomy is contraindicated and repair should be performed. courses the left common iliac vein while the right common
With small lacerations from penetrating trauma, a suture iliac vein passes inferoposterior to the right common iliac
repair may be possible. With larger lacerations, the segment artery bifurcation. The close proximity of the iliac arteries
may require resection. Reconstruction with an end-to-end and veins is the reason for the high incidence of combined
anastomosis or interposition grafting using long saphenous injuries.
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 221

who is at risk of becoming physiologically decompensated

MECHANISM OF INJURY to a radiology department that is remote from the operating
The most common mechanism of injury is penetrat- room and that lacks optimal resuscitation facilities.
ing trauma, usually involving injury to the common iliac As well as identifying and treating the source of bleed-
arteries, with blunt trauma being a rare cause of arterial ing, angiography is also useful in diagnosing intimal flaps
injury. With blunt trauma, the injury is more commonly of the common and external iliac arteries. Some of these
associated with pelvic fractures, causing either direct lac- can be treated with stents. In addition, massive bleeding
eration or intimal tears (associated with thrombosis), and can be controlled by the proximal placement of intralumi-
more commonly affects the internal iliac artery and its nal occlusion balloons, following which the patient can be
branches. One-quarter of patients have combined arterial transferred to the operating room for surgery.
and venous injuries. Angiography should be considered early in patients with
pelvic fractures subsequent to blunt trauma especially
if there is evidence of bleeding. Box 18.1 lists the radio-
CLINICAL PRESENTATION
graphic findings on pelvic films that are associated with
Injury to the iliac vessels should always be suspected in a increased risk of vascular injury and should prompt early
severely hypotensive patient with a low-abdominal pen- angiography.
etrating injury. The index of suspicion should be raised in
the presence of abdominal distension, and, if the femoral
pulse is weak or absent, it is almost diagnostic of a common Surgical Management
iliac or external iliac arterial injury. The presence of signs
suggesting pelvic visceral injuries such as hematuria should In the context of penetrating trauma, laparotomy may iden-
also raise the index of suspicion. tify free intraperitoneal bleeding or a large zone III (pelvic)
The majority of cases will be diagnosed during the hematoma, or both. Traditionally, all zone III hematomas
trauma laparotomy or, if the patient is sufficiently stable, caused by penetrating injury merited surgical exploration.
by trauma CT. Injuries associated with blunt trauma fre- If the patient is hemodynamically unstable, this is still the
quently accompany pelvic fractures. Infrequently, they may recommended action. However, in the patient whose physi-
have delayed presentation with an ischemic leg secondary ology allows it – and if facilities permit – consideration may
to an intimal tear and subsequent thrombosis. be given to intraoperative angiography and an endovascu-
lar treatment option. Bleeding from branches of the inter-
nal iliac artery can be managed by embolization.
INVESTIGATIONS The zone III hematoma resulting from blunt injury
Not all patients should undergo radiological investigations. should not be routinely explored. The exception to this is in
This is dictated by the patient's physiology. Physiologically the presence of an absent or reduced femoral pulse suggest-
abnormal patients with penetrating injury should be taken ing either common iliac or external iliac arterial injury. It is
immediately for a trauma laparotomy. The pelvic x-ray important to remember that blunt injuries may be associ-
taken as part of the initial Advanced Trauma Life Support ated with arterial intimal tears and thrombosis, and hence
(ATLS) resuscitation series may show fragments suggesting the absence of a zone III retroperitoneal hematoma does
foreign bodies (e.g., gunshot wounds, blast injuries), and not exclude a major vascular injury.
consideration should be given to the possibility of iliac vas- Active bleeding is managed according to the principles
cular injuries. of damage control surgery. This involves the application of
With blunt injuries, examine the pelvic x-ray for sacro- direct compression and then proximal and distal exposure
iliac joint disruption, widening of the symphysis pubis, and of the artery to control inflow and back-bleeding.
for bilateral fractures of both superior and inferior pubic In the presence of a large pelvic hematoma, it may be dif-
rami. These radiological findings are associated with an ficult to determine the site of bleeding in the iliac artery, and,
increased risk of iliac vascular injuries. if rapid proximal control is required, aortic cross-clamping
The two most-utilized investigations are CT angiography can be achieved as previously described. The clamp may be
and catheter angiography. CT angiography is performed rou- applied just above the level of the aortic bifurcation. Similarly,
tinely in most if not all trauma centers. The CT images should if the injury is close to the proximal common iliac artery, con-
be examined for pelvic hematomas, extravasation of contrast, trol is best achieved by cross-clamping the distal aorta. If the
false aneurysms, intimal flaps, and thrombosis (suggested by injury is more distal (e.g., external iliac artery), the common
the absence of contrast within the arterial lumen). iliac artery can be exposed by dividing the overlying peri-
Catheter angiography still has a vital role in the manage- toneum. Proximal control can be gained by using a nylon
ment of pelvic hematomas. It has both a diagnostic role and vascular tape to encircle the artery, carefully avoiding dam-
a therapeutic role. Its use is dependent on the availability age to the neighboring common iliac vein. Exposure of the
of local expertise and is dictated by local facilities. If the
interventional radiology suite is close to the operating room
or the trauma center has the ability to perform interven- Box 18.1 Pelvic Radiographic Findings
tional techniques within the operating room (e.g., a hybrid Associated With Increased Risk of Vascular Injury
theater), catheter angiography provides an ideal means of
identifying the source of arterial bleeding and treating it Pubic diastasis greater than 2.5 cm
by using embolization techniques; however, careful consid- Sacroiliac joint disruption
eration must always be given when transferring a patient Butterfly fractures (bilateral superior and inferior rami fractures)
222 SECTION 4 • The Management of Vascular Trauma

c­ ommon iliac and external iliac vessels may require mobi- Burch et al. describes the use of PTFE grafts in the presence
lization of the cecum or sigmoid colon and care should be of colonic and urological contamination without subse-
taken to avoid overlying ureters. With external iliac injuries, quent graft infection.25
proximal control will also require exposure and control of the Injuries to the internal iliac artery and its branches can
internal iliac artery. This is achieved by proximal and distal be difficult to manage. Due to cross-filling from branches of
vascular retraction and by dissecting medially. Distal control the contralateral internal iliac artery, ligation of the injured
may be difficult with a large hematoma. If direct exposure is internal iliac artery (or its branches) may not provide hem-
not possible (e.g., a narrow pelvis), consider either adding a orrhage control. Additionally the surgical exposure is dif-
transverse lower abdominal incision or exposing the artery at ficult. If the hematoma is not expanding, do not explore.
the groin. Longitudinal incision and division of the inguinal Angiography and embolization are the best options. Always
ligament may be required. Exposure of the artery in the groin consider pelvic packing with subsequent angiography and
can be combined with the passage of occlusion balloon cath- embolization as a potential option.
eters to gain proximal control. However, if there is a complete Bleeding may persist even after vascular repair or ligation
transection of the artery or a large defect, the catheter may of internal iliac branches. This is not infrequent after gun-
pass out of the artery rather than into the artery proximal to shot wounds. The safest options are to pack the pelvis and
the site of injury. arrange angiography with subsequent embolization.
The choice of repair will be dependent on the size and
location of the injury and the degree of contamination.
Small arterial injuries (e.g., stab wounds) can undergo pri- Complications of Vascular Trauma
mary repair with a 5-0 or 4-0 Prolene suture. If a patch is
required, either a venous or prosthetic patch may be used The most common early complication following arterial
(e.g., polytetrafluoroethylene [PTFE]; bovine pericardium). reconstruction is thrombosis. The use of meticulous surgical
In the presence of contamination, a venous patch is pre- technique, embolectomy balloon extraction of clots, intraop-
ferred. Complete transection may be repaired by mobiliza- erative local heparinization, and angiography can all reduce
tion of the arterial ends and an end-to-end anastomosis. the incidence of this complication. Postoperative monitoring
Most patients with blunt injury or gunshot wounds of the limb is essential. Lower limb compartment syndrome
require end-to-end anastomosis or interposition grafting. remains a common postoperative problem, and the sur-
Gunshot injuries may be associated with significant intimal geon should have a low threshold for performing fascioto-
damage. The ends of the artery should be carefully exam- mies. Some centers advocate prophylactic fasciotomies, but
ined. Débridement is usually required and an appropriate this remains a topic of debate. An awareness of abdominal
section of normal artery selected for the anastomosis of the compartment syndrome should be maintained. Monitoring
interposition graft. Embolectomy catheters should always intraabdominal pressure, urine output, and ventilatory pres-
be passed distally to remove any residual clot. sure can alert the team of this possibility and the need for
It is best to avoid complex arterial reconstructions requir- abdominal decompression. The use of prosthetic grafts raises
ing extra-anatomical bypasses and mobilization of the inter- the possibility of graft infections. Late complications can also
nal iliac arteries. These are time consuming and are best occur, with delayed presentations of pseudoaneurysms, arte-
avoided in the context of major trauma. If the patient is criti- riovenous fistulas, and aortoenteric fistulas.
cal and requires damage control, arterial continuity may be
temporarily established with the use of intraluminal shunts.
If a vascular shunt is not available, an alternative is to
construct one using a wide bore sterile gastric tube, an intra-
venous tube, or a urethral catheter. These should be secured
Endovascular Treatment of
with distal and proximal ligatures. Later, once the patient's Intra-abdominal Trauma
condition has stabilized, a definite arterial reconstruction
can be performed. Shunts frequently thrombose, and there- Interventional radiological techniques in trauma may include
fore the limb should be monitored for ischemia. Ideally the embolization, stent deployment,26 or balloon occlusion.27
patient should be prophylactically anticoagulated. How-
ever, the critical patient is frequently coagulopathic, and
hence systemic anticoagulation is contraindicated. CONTROL OF BLEEDING BY EMBOLIZATION
Beyond the most critical of situations, the common and Endovascular embolization techniques are especially
external iliac arteries should never be ligated without some useful for hemorrhage control. The decision to embark
means of ensuring distal perfusion (shunt or extraanatomic on an interventional treatment plan will depend on the
reconstruction) due to the high incidence of limb loss and availability of local expertise and interventional facilities.
the risk that the ischemia will result in general deterioration These factors must also be balanced against the hemody-
of the patient. Subsequent reperfusion attempts that cause namic stability of the patient. An unstable patient should
severe reperfusion injury and organ failure are associated not be treated in an interventional radiology suite that
with high mortality. is located away from resuscitating facilities or the oper-
If the physiology is normal, interposition grafting can be ating theater. Should physiology become deranged, it is
performed. Extraanatomical bypass should be considered vital that quick and easy transfer to an operating theater
if there is significant enteric contamination, purulent peri- is possible. The interventional radiologist should be con-
tonitis, or infection in the injured zone. It is worth noting, fident of his or her technical ability to perform selective
however, that one case series of 16 patients reported by embolization.
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 223

A number of principles need to be considered before does appear brisk, further coils will need to be packed into the
embarking on embolization. A detailed understanding of region. Embolization may not always be successful in control-
the anatomy is essential, including variations in arterial ling bleeding. Equally a patient may become hemodynami-
anatomy. It is important to recognize whether a feeding cally compromised during the procedure, necessitating open
vessel or an entire vascular bed requires embolization. The surgery. If a decision is made to convert to open surgery, a
presence of anastomoses and collaterals between arterial temporary occlusion balloon can be placed in the artery proxi-
territories must be appreciated as this will require embo- mal to the injury (e.g., in the common iliac artery or aorta).
lization of both inflow and outflow arteries. Finally the Care needs to be applied when transferring the patient but this
effect on the end organ or vascular territory must also be technique is the endovascular equivalent of arterial clamping
considered. – restoring blood pressure and providing time for the surgeon
Embolization agents used in trauma can be divided into to proceed with damage control techniques.
those that result in permanent vessel occlusion or those
where occlusion is temporary. Agents can be further divided ENDOVASCULAR TREATMENT OF SOLID ORGANS
into mechanical occlusion devices (e.g., coils), particulate
agents (e.g., gel foam), and liquid agents (e.g., sclerosants, AND PELVIC TRAUMA
adhesives).28 The decision to use a type of agent is dictated Pelvic bleeding as a consequence of blunt trauma is most
by the duration of occlusion required, the number of bleed- commonly associated with pelvic fractures. The first-line
ing points, the size of the artery, and whether an individual treatment is to stabilize the fracture through application
feeding vessel or an entire vascular bed is the target. of a pelvic binder, and this frequently results in cessa-
Gelfoam results in temporary occlusion, which can last up tion of venous bleeding. Continued instability suggests
to a few weeks – a useful property in trauma that allows time arterial bleeding, and gelfoam angioembolization of the
for the vessel to heal. Gelfoam is available as either a powder internal iliac arteries is usually indicated. Internal iliac
or a sheet. The powder form is made up of small particles and artery embolization carries a risk of pelvic ischemia; if
hence facilitates occlusion down to the capillary level. The angiography reveals extravasation from isolated branches,
sheet form is more useful for larger vessels and is cut into small selective embolization is preferable as the ischemic burden
pledgets of 1- to 2-mm diameter that are soaked in contrast is lower (Fig. 18.7). Stabilization of the bony pelvis may
media before syringing and injecting. Gelfoam is suitable for require urgent external fixation either before or during
multiple bleeding points and is frequently the choice in pel- concomitant laparotomy. Control of pelvic bleeding dur-
vic trauma. Coil embolization results in permanent occlusion ing the trauma laparotomy can be challenging, and intra-
through both a mechanical obstruction and a thrombogenic operative hemostasis can be facilitated via the technique
effect. The coils are made from stainless steel or platinum and of preperitoneal packing in order to facilitate tamponade.
are available in a range of sizes, usually coated with throm- Preperitoneal packing can be combined with follow-on
bogenic fibers. To be effective, they must be tightly packed in embolization to ensure cessation of hemorrhage. Mortal-
a stable position within the artery. When using coils it is vital ity from major pelvic bleeding still remains high, exceed-
to consider the supply to the bleeding vessel. If the vessel is ing 30%.29
an end artery (e.g., renal), only inflow requires embolization; Although this chapter has focused on the management of
but where this is not the case, both inflow and outflow vessels arterial injuries, the techniques of angioembolization are also
must be embolized to prevent back-bleeding and to gain hem- applied to the nonoperative management of solid abdominal
orrhage control. organ injury, which therefore warrants brief discussion. The
Before embolization, a preliminary angiogram is always spleen remains one of the most commonly injured organs fol-
performed. If contrast extravasation is confirmed, the degree lowing blunt abdominal trauma.30 Angiography is indicated
of extravasation must be matched to the hemodynamic sta- for active bleeding (extravasation), pseudoaneurysms, hemo-
tus of the patient. If the amount of extravasation does not peritoneum on CT (Fig. 18.8), and high-grade splenic inju-
correlate with the shock, other sources of bleeding should ries. Embolization is required if angiography confirms active
be sought before embarking on embolization. The end-organ bleeding. There is controversy regarding the use of proximal
ischemic effects of embolization should always be anticipated. embolization over more distal selective embolization. It has
For instance, embolization of a renal artery should never be been postulated that distal embolization (Fig. 18.8) may offer
performed without confirming the presence of two function- benefits with regard to preserving splenic function – coupled
ing kidneys. Use of “end-hole only” catheters passed by the with a higher risk of rebleeding – though the authors of a
shortest and straightest possible path and maintained in a meta-analysis31 were not able to confirm these differences in
stable position facilitates accurate delivery of the embolization outcome. Blunt trauma to the liver results more frequently
agent to the target vessel and prevents inadvertent occlusion in parenchymal venous than arterial injury. Liver trauma
of nontargeted arteries. If using particulate agents, a test can usually be managed conservatively in the first instance
injection with contrast is usually sufficient to confirm that the given patient stability and the absence of a contrast blush
catheter tip is not displaced during the injection. If using coils, or active extravasation on CT.30 With renal trauma, it is vital
passage of a guide wire will allow the operator to see whether to ensure two functioning kidneys before proceeding with
the delivery catheter tip is not in a stable position. During any embolization. Renal extravasation, arterial lacerations,
delivery of the agent, continuous fluoroscopy is essential, and pseudoaneurysms, and arteriocalyceal fistulae can be treated
completion angiography should be performed to confirm the with embolization. Selective embolization can facilitate renal
effect on flow. After coil embolization, provided the flow is not salvage and can reduce the volume of renal infarction. Other
too brisk, patience and a delay of a couple of minutes may be injuries such as dissection flaps can be managed with endo-
all that are required to facilitate vessel thrombosis. If the flow vascular stents.32
224 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 18.7 (A) Branch of left internal iliac artery showing extravasation of contrast. This patient presented following a stab injury to the buttock. The arrow
shows the extravasation of contrast. (B) Postembolization of iliac artery bleeder.

A B

Fig. 18.8 (A) CT imaging of splenic injury following blunt abdominal trauma. The perisplenic hematoma is arrowed. (B) Selective coil embolization of
the splenic artery.

release of vasoactive agents. The patient will require anal-

COMPLICATIONS OF EMBOLIZATION
gesia and supportive treatment, but, assuming there is no
Misplacement of coils or gelfoam can result in nontargeted abscess, the symptoms are usually self-limiting with reso-
embolization; the consequences will depend on the territory lution after about 3 days. Renal embolization can result in
supplied by the misembolized artery. It is feasible to retrieve hypertension, and, if uncontrollable by antihypertensive
errant coils, but this is not an option with gelfoam. Emboli- medication, it may warrant delayed nephrectomy.
zation of the common or external iliac artery may require
urgent bypass in order to restore limb perfusion. Even prop-
erly targeted selective embolization may result in unantici- ENDOVASCULAR BALLOON OCCLUSION
pated and massive tissue infarction in solid organs such as Occlusion of the aorta with endovascular balloons for
the liver. Clinically, the presentation is of early abdominal exsanguinating haemorrhage is not new and was first
pain and delayed fever, nausea, and vomiting caused by the described in the 1950s.27 In recent years this technique has
 18 • Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 225

been championed again, with several reports in the litera- 17. Davis TP, Feliciano DV, Rozycki GS, Bush JB. Results with abdomi-
ture. Gaining access via the femoral vessels, the resuscita- nal vascular trauma in the modern era/Discussion. Am Surg.
2001;67(6):565.
tive endovascular balloon occlusion of the aorta (REBOA) 18. Burdick TR, Hoffer EK, Kooy T, et al. Which arteries are expendable?
is placed either in the thoracic aorta, or just above the aor- The practice and pitfalls of embolization throughout the body. Semin
tic bifurcation depending on the zone of injury. Despite Intervent Radiol. 2008;25(3):191–203.
some promising results, no clear mortality benefit has 19. Mehta M, Darling III RC, Taggert JB, et al. Outcomes of planned
celiac artery coverage during TEVAR. J Vasc Surg. 2010;52(5):
been shown in a systematic review,33 with some reporting 1153–1158.
adverse outcomes.34 Further evidence is likely to be required 20. Mattox KL, Feliciano DV, Burch J, Beall AC, Jordan GL, De Bakey
before there is widespread adoption of the technique, and ME. Five thousand seven hundred sixty cardiovascular injuries in
randomized trials are undwerway.35 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg.
1989;209(6):698–705, discussion 706.
21. Clark DE, Georgitis JW, Ray FS. Renal arterial injuries caused by blunt
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Perler BA, eds. Rutherford’s Vascular Surgery and Endovascular Therapy. Bultitude MF. Contemporary management of renal trauma. Rev Urol.
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of vascular trauma. In: Sidawy AN, Perler BA, eds. Rutherford’s Vas- vascular injuries: recent experience with 233 consecutive patients.
cular Surgery and Endovascular Therapy. Philadelphia: Elsevier; 2019. J Trauma. 1990;30(12):1450–1459.
2350-2364.e3. 26. Zealley IA, Chakraverty S. The role of interventional radiology in
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miology and outcome of vascular trauma at a british major trauma 27. Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, et al. A sys-
centre. Eur J Vasc Endovasc Surg. 2012;44(2):203–209. tematic review and meta-analysis of the use of resuscitative endo-
6. DuBose JJ, Savage SA, Fabian TC, et al. The American Associa- vascular balloon occlusion of the aorta in the management of major
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lar Injury Treatment (PROOVIT) registry. J Trauma Acute Care Surg. 28. Kessel D, Robertson I. Embolization. In: Kessel D, Robertson I, eds.
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7. Asensio JA, Chahwan S, Hanpeter D, et al. Operative manage- 29. Thorson CM, Ryan ML, Otero CA, et al. Operating room or angiog-
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II; an analysis of 2,471 cases. Ann Surg. 1946;123:534–579. cal CT to visualize arterial extravasation after blunt abdominal
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2005.
 19 Inferior Vena Cava, Portal, and
Mesenteric Venous Systems
TIMOTHY FABIAN and STEPHANIE SAVAGE

Introduction and shock. Aggressive options such as venovenous bypass

and liver explantation are mostly anecdotal and uncom-
Injury to the large veins of the abdominal cavity, including mon, often impractical, methods to manage the bleeding
the inferior vena cava (IVC) and the portal and the superior patient.
mesenteric veins is uncommon occurring in 5% of pene- The infrequent nature of abdominal venous injury is due
trating and 1% of blunt trauma cases.1 Because prehospital to the relatively small size of the vessels and the fact that
mortality associated with injury to these large veins ranges they are hidden or protected by the surrounding inferior
between 30% and 50%, there are relatively few patients costal margin, the viscera, and the retroperitoneum. Pen-
who survive to have surgical repair. As such, even experi- etrating trauma accounts for 95% of injury to intraabdomi-
enced trauma and vascular surgeons have a relatively lim- nal veins, with outcomes following stab wounds slightly
ited practice with the operative management of these injury better than those following injury from firearms or blunt
patterns.2 The literature has consistently reported mortality mechanisms.4,12,13 The American Association for the Sur-
rates of 50% to 70% for injuries to the superior mesenteric gery of Trauma (AAST) includes injuries to the major
vein (SMV), portal vein, and IVC.3–6 The mortality figures abdominal veins in the Organ Injury Scale for Abdominal
have been unchanging over several decades and thought Vascular Trauma (Table 19.1). Not surprisingly, the most
to be refractory because of the difficulty in accessing the common cause of death in these situations is exsanguina-
venous injury, both exposing and controlling, as well as tion, whether in the prehospital setting or in the resuscita-
the likelihood of torrential hemorrhage from these low- tion or operating room.
pressure, high-flow structures.4,7 The principles of operative Patients with major venous injuries who survive to the
exposure and repair that will be reviewed in this chapter hospital often present in shock, although some will have
have remained fairly consistent, though newly developed reached a precarious state of equilibrium as the hypoten-
endovascular techniques offer promise in creating more sion will have reduced the rate of bleeding. In situations in
effective approaches to certain of these highly lethal pat- which permissive hypotension is effective, the patient may
terns of vascular trauma. appear relatively stable. One report of patients sustaining
Historical references to abdominal venous injuries are these types of injuries documented an average hospital
limited mostly to case reports and oblique references in admission systolic blood pressure of 90 mm Hg and heart
clinical series of combat injured.4,8,9 Some of the most rate of 95 beats per minute.14 In addition to lower blood
comprehensive reviews among civilian patients have been pressure, those who died also had higher overall injury
published from the Baylor College of Medicine registry. In a severity (i.e., ISS), a greater number of associated injuries,
1982 review of 312 patients with vascular injury, venous were older, and had more blood loss at the time of laparot-
injuries most commonly occurred to the internal jugular omy.13 A 7-liter blood loss has been shown as a threshold
vein (5.7% of vascular injuries), with the SMV injured 2% associated with higher mortality, while patients with major
of the time and the IMV injured in 0.4% of patients.4,10 An venous injuries require an average of 19 units of packed red
additional review of 4459 patients over 30 years found blood cells and 7 liters of crystalloid.12,15 Given these daunt-
that 34% of the vascular injuries were to the abdominal ing numbers, one should be in a damage control mindset
vasculature and roughly 4% of these were to the mesenteric when tackling this type of vascular trauma, looking for
vessels.11 ways to expeditiously control or temporize bleeding while
As noted, the mortality associated with abdominal coordinating with the resuscitation team to maintain key ele-
venous injuries has changed little in the last 30 years, ments of the patient’s overall physiology (e.g., temperature,
despite advances in other areas of trauma care. Though acid/base status, coagulation profile, oxygenation).
comprehensive reviews are uncommon, case reports of Given the intimate anatomic proximity, patients with
heroic efforts to save patients using specialized techniques central venous trauma commonly have injuries to other
have been published. The military’s experience using tem- intraabdominal structures such as viscera, solid organ, or
porary vascular shunts has become a standard in civilian ductal structures of the hepatobiliary or urogenital tracts.
practice, providing a unique opportunity to control and The liver and stomach are most commonly associated with
temporize certain forms of venous injury while component- intraabdominal venous trauma, although patients with
based resuscitation occurs. At the same time, resuscitative injury to the vena cava or portal or superior mesenteric
endovascular balloon occlusion of the aorta (REBOA) has veins have, on average, between two and four additional
become more common as an adjunct to quickly restore cen- injuries, including those to other large vessels.4,5 Concomi-
tral aortic pressures (i.e., coronary and cerebral pressures) tant liver injuries are especially challenging as attempts
and stem bleeding in certain patterns of torso venous injury to mobilize the organ can place torque on the vena cava

226
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 227

Table 19.1 American Association for the Surgery of

were injured. Injury to more than three intraabdominal
Trauma: Organ Injury Scale for Abdominal Vascular Injury.a vessels was u­ niformly fatal.17
Complication rates are also high in the setting of intraab-
Grade Description dominal venous trauma. The genesis of these is multifac-
Grade 1 Non-named superior mesenteric artery or superior mesen- torial, attributable to associated injuries, patient age and
teric vein branches comorbidities, and severity of blood loss and shock. Com-
Non-named inferior mesenteric artery or inferior mesenteric mon complications include but are not limited to pulmonary
vein branches failure, renal failure, wound infection and dehiscence, and
Phrenic artery or vein sepsis. Intraabdominal complications include thrombosis
Lumbar artery or vein of the venous repair, abdominal compartment s­ yndrome,
Gonadal artery or vein reoperation for bleeding, a prolonged intensive care unit
Ovarian artery or vein stay, including need for vasopressor support and gastro-
Other non-named small arterial or venous structures requir- intestinal complications. In those who survive operative
ing ligation repair, delayed gut or liver ischemia resulting from vessel
Grade 2 Right, left or common hepatic artery ligation or thrombosis (or just prolonged ischemia prior to
Splenic artery or vein the vessel repair) can result in postoperative complications
Right or left gastric arteries and prolonged intensive care unit admissions.4,18
Gastroduodenal artery
Inferior mesenteric artery or inferior mesenteric vein, trunk
Primary named branches of mesenteric artery or vein
Preoperative Preparation
Other named abdominal vessels requiring ligation or repair
The most important component of preoperative preparation
Grade 3 Superior mesenteric vein, trunk is beginning the operation with a thorough understand-
Renal artery or vein ing of anatomy and knowledge about how to expose and
Iliac artery or vein control the abdominal vascular injury. In many instances
Hypogastric artery or vein of central venous trauma, preoperative imaging is limited
Vena cava, infrarenal to only a focused assessment with sonography for trauma
Grade 4 Superior mesenteric artery, trunk (FAST) examination as the unstable patient must be taken
Celiac axis proper directly to the operating room. In these cases, it is often use-
Vena cava, suprarenal and infrahepatic ful to enter the operation in a damage control mindset, look-
Aorta, infrarenal
ing for opportunities to expeditiously control bleeding and
ways to restore flow, but also a willingness to ligate or shunt
Grade 5 Portal vein
vessels and stage operations to optimize the patient’s resus-
Extraparenchymal hepatic vein
citation and physiological condition. In many instances a
Vena cava, retrohepatic or suprahepatic “second look” operation 12 to 24 hours after the first sur-
Aorta, suprarenal, subdiaphragmatic gery is needed to assess for bleeding, viability of the viscera,
a
This classification system is applicable to extraparenchymal vascular and the need to perform definitive vascular repair.
injuries. If the vessel injury is within 2 cm of the organ parenchyma, refer Not all patients with intraabdominal venous trauma are
to specific organ injury scale. Increase one grade for multiple grade III or hemodynamically unstable. The hematoma surrounding
IV injuries involving >50% vessel circumference. Downgrade one grade if
<25% vessel circumference laceration for grades IV or V.
the injury may be contained within the retroperitoneum
From Moore EE, Cogbill TH, Malangoni M, Jurkovich GJ, Champion resulting in tamponade and a patient with normal vital
HR. Scaling systems for organ specific injuries. Curr Opin Crit Care. signs or one who responds to small amounts of resuscita-
1996;2(6):450–462. tion.19 The utility of computed tomography (CT) depends on
the nature and mechanism of injury. CT scan has less of
a role in the immediate management of patients who have
sustained penetrating abdominal trauma, especially those
and/or portal vein and extend or worsen the primary venous in who are hemodynamically normal or lacking peritoneal
injury. Injury to a major venous structure is frequently signs and in whom the penetrating injury is thought to be
accompanied by damage to the adjacent artery, including extraperitoneal. In contrast, CT is invaluable in the diag-
the aorta and the hepatic and superior mesenteric arteries nosis and management of patients with significant blunt
(SMA).5 trauma, especially those with injury to a major abdominal
In a review by Coimbra, 94% of patients with portal vein such as the IVC. In the appropriate patient, detailed CT
and superior mesenteric venous trauma had associated imaging allows the surgeon to gauge the need for an aggres-
intraabdominal injuries, with 61% of these being to other sive resuscitation and to develop a treatment plan that may
major blood vessels (most commonly the IVC and SMA).3 range from nonoperative management, to a damage control
Just over one-third of SMA injuries (35%) have an associ- operation, to the use of endovascular techniques.
ated injury to the of SMV.16 Additional findings from that Identifying an injury to the vena cava on CT may be chal-
clinical experience showed the impact of multiple vascular lenging as contrast extravasation is often not seen, espe-
injuries on survival. From a cohort of 302 patients with cially in the patient with relatively normal vital signs. The
abdominal vascular trauma, a single vessel injury had a most common radiographic finding associated with a large
mortality rate of 45%; when two vessels were injured, the vein injury is a retroperitoneal hematoma. Between 75%
mortality increased to 60%, and 73% when three vessels and 91% of retroperitoneal hematomas develop in zone I
228 SECTION 4 • The Management of Vascular Trauma

of the abdomen (i.e., central or midline), whereas 18% of to a terminal degree of shock. Endovascular access to place
patients will have a zone II hematoma (i.e., lateral spaces). the balloon catheter is achieved using a percutaneous or
Approximately 1 in 10 patients with abdominal venous open femoral artery approach. In either instance, ultra-
injury will have radiographic evidence of a zone III or pel- sound can be used to identify the common femoral artery
vic hematoma.4,14 The presence of retroperitoneal blood just below the inguinal ligament. The length of REBOA
should raise suspicion for injury to a large abdominal ves- catheter to be inserted is estimated by placing the catheter
sel, remembering that the zone of the hematoma may not on the outside of the patient and measuring the distance
correspond anatomically to the injured vessel. One consis- between the femoral artery and the desired aortic occlusion
tent anatomic association is that between a right lateral ret- zone. For a suspected subdiaphragmatic, intraabdominal
roperitoneal hematoma (zone II) near the ascending colon bleeding source, the balloon should be placed and inflated in
and duodenum and an injury to the IVC. As noted previ- aortic zone 1 which is between the origin of the left subcla-
ously, the retroperitoneum and surrounding visceral or vian and the celiac arteries (i.e., supraceliac aorta).26 Zone
solid organ structures often serve to contain and tampon- III balloon positioning and inflation is indicated for patients
ade low-pressure venous bleeding. with a pelvic bleeding source (e.g., severe pelvic fracture),
Another CT finding that points to, or should raise suspi- and occurs between the renal arteries and the aortic bifur-
cion regarding, a large venous injury is “flat” IVC which is cation (i.e., infrarenal aorta).
an indicator of hypovolemia. A flat IVC is defined as having Significantly less invasive than resuscitative thoracotomy,
a maximal transverse-to-anteroposterior ratio of less than inflation of the REBOA balloon has the same hemodynamic
4:1. The flat IVC can also be detected in the trauma bay and bleeding control effects as cross-clamping the aorta.
using ultrasound and is a useful indicator of caval injury REBOA limits or stops bleeding below or distal to the inflated
and/or pending hemodynamic collapse. Subtle findings, balloon and increases central aortic pressure and perfu-
particularly in relation to IVC injury, include an irregular sion to the coronary arteries and brain. Like other forms
contour to the cava or a filling defect within the lumen on of external aortic cross-clamping, REBOA is only a tempo-
CT imaging.20,21 In rare cases, herniation of surrounding rizing maneuver that can be applied for 20 to 30 minutes
fat into the lumen of the vena cava may be present as an until resuscitation can begin and efforts made at definitive
indication of vessel laceration.20,22 Nonoperative manage- hemorrhage control. Preclinical, large-animal studies have
ment (i.e., observation) of some retroperitoneal hematomas shown that REBOA is effective in decreasing blood loss, sta-
is indicated as open exposure of these injuries can release bilizing central venous pressures, and improving survival in
the tamponade and result in torrential hemorrhage.23 the setting of major venous injury.27
The most hemodynamically depleted patients with
abdominal venous trauma may deteriorate too rapidly for
CT or ultrasound imaging or even transport to the oper- Operative Management
ating room. In these cases, a resuscitative thoracotomy,
either in the emergency department or in the operating THE INFERIOR VENA CAVA
room, should be considered as means to restore central
aortic pressure and coronary and cerebral perfusion. Of the three major abdominal veins discussed in this chap-
This maneuver reduces or stops bleeding below the aortic ter, the IVC is the most frequently injured and requires
clamp and maintains left ventricular afterload, preventing some of the most complex decision-making. The incidence
cardiac arrest until hemostasis can be obtained and the of IVC injury ranges from 0.5% to 5% of penetrating inju-
clamp slowly removed. Indications for thoracotomy are ries and 0.6% to 1% of blunt trauma.9 Approximately
limited because of the low likelihood of survival in these 30% to 50% of patients with this injury pattern die prior
scenarios. However, thoracotomy should be considered in to reaching the hospital, either from exsanguination or
patients who have penetrating trauma and a witnessed associated injuries.2,9 Of those who survive to the hospi-
cardiac arrest (pre- or in-hospital), and in those having tal, 20% to 57% will not survive to discharge, dying from
sustained blunt injury and who arrest after arrival to bleeding in the operating room or during the early postop-
the hospital. One literature review on the topic showed erative period.2
a 10.5% (4 of 38) survival rate in patients undergoing Penetrating injury to the vena cava is slightly more com-
resuscitative thoracotomy in the setting of abdominal vas- mon. However, the vena cava is relatively fixed in the ret-
cular injury.13,24,25 roperitoneum and in the setting of blunt trauma, there
Although a left thoracotomy provides relatively easy is torque and tearing of the vessel at one or more of the
access to the aorta for clamping, the exposure comes at a venous tributaries attached to the IVC. The retrohepatic
cost to the patient’s temperature, pulmonary function, and cava is especially fixed in place, protected by the hepatic lig-
acid-base status, not to mention the morbidity of the inci- aments, the retroperitoneum, and the hepatic parenchyma.
sion itself. One alternative is a midline laparotomy with Significant force is required to tear or avulse the vena cava
supraceliac clamping of the aorta at the diaphragmatic in this location, often resulting in a catastrophic injury.28
crus. This approach can be more anatomically constrained Of all major abdominal veins, injury to the IVC, whether
and difficult for those not familiar with the supraceliac blunt or penetrating, is the most amenable to nonoperative
exposure, but if performed quickly, it does accomplish the management. As the IVC is a low-pressure (3–5 mm Hg)
desired effects of resuscitative aortic occlusion and avoids retroperitoneal structure, bleeding is initially contained
opening the thoracic cavity. within the confines of the retroperitoneum, allowing for
REBOA is an appealing, less-invasive alternative to resusci- tamponade of bleeding. Studies with swine have found that
tative thoracotomy for unstable patients or those progressing nonoperative management of IVC lacerations is effective in
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 229

selective circumstances, especially instances in which the

hematoma is contained and the patient’s hemodynamic
status is stable.29,30 When the retroperitoneum is violated,
the tamponade can be released into the peritoneal cavity
resulting in much higher rates of bleeding and shock.
To minimize the likelihood of releasing the retroperito-
neal tamponade, one should opt for permissive hypoten-
sion and avoid over resuscitation and arbitrarily increasing
the patient’s blood pressure. Administering large volumes
of resuscitation fluid (blood or crystalloid) will increase Suprahepatic
the venous pressure, enlarge the vena cava, including the
injured segment, and increase the likelihood of bleeding.
Similarly, patients with penetrating injuries are likely to
benefit from fluid restriction and hypotensive resuscita-
Retrohepatic
tion, a strategy which reduces the chances that hydro-
static pressure will force the clot off the tear in the vena
cava. Patients in whom there is a suspicion for vena cava
(or other major abdominal vein) injury, should not have
resuscitation fluids administered through femoral venous
Suprarenal
or other lower extremity sites. Overt signs of deteriora-
tion, including worsening shock, peritonitis, and ominous
changes in acid base status, indicate the need for surgical
exploration.29
The distal IVC arises from the confluence of the common
iliac veins and as it courses cephalad through the right ret-
roperitoneum, it receives venous flow from several tribu- Infrarenal
taries including lumbar and the right gonadal veins, both
renal veins, the right adrenal vein, and the inferior phrenic
veins. More cephalad, the vena cava traverses posterior to
the liver parenchyma (i.e., retrohepatic). In many cases, the
liver completely engulfs the vena cava, making retrohepatic
exposure more challenging. At, or immediately below, the
diaphragmatic hiatus, the hepatic veins feed into the cava,
including small branches entering the lateral retrohepatic
cava from the liver. After traversing the diaphragm, the
proximal IVC enters the pericardium and drains into the
right atrium. Fig. 19.1 Inferior vena cava anatomy with subsegments—infrarenal,
For operative considerations, the IVC is divided into four suprarenal, retrohepatic, and suprahepatic.
anatomic segments: infrarenal, suprarenal, retrohepatic,
and suprahepatic (Fig. 19.1). Injuries to the infrarenal IVC
have the highest likelihood of survival, due to the relative Exposure and Mobilization
ease of access and tolerance to ligation, when necessary. Access to the IVC depends on the anatomic segment that
The suprarenal IVC remains relatively accessible but is more is injured. Upon identification of a retroperitoneal hema-
intimately associated with structures such as the kidneys, toma suspicious for caval injury, the vena cava should
the pancreatic head, and portal structures. Suprarenal liga- be approached from the patient’s right side. Specifically,
tion of the IVC is poorly tolerated.12 The retrohepatic IVC the white line of Toldt is divided along its length and the
is approximately 7 cm in length and is directly behind, or ascending colon, hepatic flexure, and transverse colon are
within, the liver parenchyma. Injury to this segment almost mobilized and reflected cephalad and to the patient’s left
invariably includes damage to the liver parenchyma, allow- side or midline. An extensive Kocher maneuver is then per-
ing free bleeding from the vein into the peritoneum via the formed, mobilizing the duodenum and pancreatic head to
injury tract through the liver. Exposure of the retrohepatic the patient’s left, using visualization of the left renal vein
IVC is difficult, and survival from injuries in this location less as the cue that mobilization is adequate (Fig. 19.2). Often,
likely.31 The suprahepatic IVC includes the course of the ves- these maneuvers will expose a hematoma overlying the
sel from the dome of the liver to the right atrium, including area of injury. Although proximal and distal control of the
the hepatic veins and the transition across the diaphragm. IVC is advisable in most cases, this is not always possible.
Mortality from injuries in this region approaches 100%, Even in instances where proximal and distal control can
due to difficulty gaining proximal and distal control in this be achieved, significant bleeding may occur from lumbar
high-flow region. Due to the large diameter of the IVC in veins and other posterior tributaries. When hemorrhage is
this location and difficulty of surgical access, in the rare encountered, direct pressure on the area of injury should be
circumstances when this injury is identified preoperatively, applied. Control may then be achieved by starting proximal
percutaneous endovascular techniques will likely provide and distal to this region and “marching” toward the defect.
better salvage than open approaches. In this manner, the site of injury may be localized without
230 SECTION 4 • The Management of Vascular Trauma

Posterior duodenum
Liver

Gallbladder

IVC
Right kidney

Small
intestine

Ascending
colon
Fig. 19.2 Medial visceral rotation exposing
the inferior vena cava (IVC) in situ.

intermittent episodes of profuse bleeding. A common to avoid dislodging thrombus from the injury or disrupt-
­mistake is in not dissecting down to the actual substance ing the thin-walled hepatic veins inserting into the cava.
of the IVC and attempting to sew the peritoneal tissues that As mentioned, percutaneous approaches that involve use
overlie the vena cava in a hurried effort to achieve hemo- of compliant endovascular balloons for inflow and outflow
stasis. Division of the overlying filmy retroperitoneal tissues occlusion may be helpful in visualizing and repairing inju-
will expose the actual wall of the IVC that needs to be seen ries to this portion of the IVC.
to be débrided and repaired.
Control of the retrohepatic and suprahepatic portions of Bleeding Control
the IVC is particularly difficult to achieve given their friable If massive hemorrhage is encountered at the time of lapa-
nature and their anatomic location.32 Cephalad retraction rotomy, temporary aortic occlusion may be required to sup-
of the liver will allow access to the most proximal portion port left ventricular afterload, avoid end stage shock, and
of the infrahepatic IVC.33 Complete mobilization of the liver prevent onset of a terminal cardiac rhythm. This can be
by division of the suspensory ligaments, including the right accomplished by compressing or clamping the supraceliac
triangular, coronary, and falciform ligaments, will provide aorta at the diaphragmatic hiatus or using REBOA inserted
mobility to access the retrohepatic portion of the cava. through one of the femoral arteries. The principles of proxi-
However, attempts to mobilize the liver in this region often mal and distal control apply, regardless of size and location
result in increased bleeding from the retrohepatic wound, of the vessel injury. Initial manual compression of the IVC
as torque on the liver and IVC can increase the size of the allows visualization of the field of injury, to begin dissection.
laceration. Though lobar resection may seem appropri- The traditional teaching is to apply sponge sticks above and
ate, especially in cases of damaged liver parenchyma, this below the venous injury for proximal and distal control.2,12
maneuver is discouraged and should be one of last resort. This technique can be problematic if not accomplished
Removal of the overlying liver removes the possibility of with great care as forceful application may widen or create
tamponade by the organ and adds disrupted liver paren- an iatrogenic injury or avulse a venous branch. Applying
chyma as a source of bleeding. Endovascular approaches, direct pressure with one’s fingers is often gentler and easier
including balloon occlusion of the IVC through remote to control while localization of the injury is underway.
femoral and/or jugular venous access, can offer a quick and After localization of the injury, proximal and distal con-
safe alternative for temporary hemostasis to facilitate repair trol with atraumatic blunt instruments should be achieved
of caval injury in any of its anatomic segments.15,34 to free one’s hands for more detailed dissection of the ves-
Approach to the suprahepatic IVC will almost always sel and eventual repair. Transitioning smaller, more focal
require division of the diaphragm for exposure. Addition- instruments such as the low-profile Kittner dissectors (i.e.,
ally, a sternotomy to access the intrapericardial IVC may be “peanut”) to compress proximal and distal to the injury
indicated for proximal control, as the infradiaphragmatic is less likely to obscure or block key parts of the operative
section of the IVC is not amenable to easy clamping and field from view. The smaller Kittner dissectors are a reason-
repair.35 Care must be taken when working in this region able choice for control, as they can be gently placed directly
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 231

on top of, or above and below, the source of bleeding. The

objective in this setting is to work back from the use of one’s
fingers or hand to a visible and workable operative space
to allow clearer dissection, visualization, and repair of the
injury. The initial use of one’s hand, the sponge stick, or
the Kittner dissectors avoids having to place larger metallic
clamps in the field before the vena cava or the edges of the
injury have been clearly defined.
The importance of good lighting, well-set and wide
retraction, and multiple suction devices cannot be over- Judd-Allis clamp
stated in accomplishing these steps. In the case of linear
IVC
injuries to the major abdominal veins, the vein edges may
be grasped with Judd-Allis clamps and closed with either a
Satinsky clamp or 4-0 polypropylene sutures (Fig. 19.3A).
A simple stitch placed at the proximal and distal extent of
the laceration, with accompanying gentle upward trac-
tion, will also elevate and collapse the laceration. This
controls the bleeding and facilitates exposure for primary
suture closure.36
Another consideration when going to repair the IVC or
other large venous injuries is to use a larger noncutting
needle (e.g., 4-0 polypropylene on an SH needle). A larger
needle is easier to visualize and direct in the presence of con-
siderable amounts of blood. Although well-intended, too
small of a needle is often submerged in blood and not able A
to be seen or appropriately guided which can prolong the
repair and potentially extend the original injury. Another
common misstep is in not dissecting down to the actual sub-
Liver
stance of vein wall and attempting to blindly place a clamp
or to sew the overlying peritoneal tissues in an attempt to
achieve hemostasis. Division of the overlying filmy tissues
leads to identification of the substance of the wall of the IVC
IVC
and allows for control and suture repair of the injury.
Hemorrhage control presents unique challenges in the
case of blunt retrohepatic and suprahepatic IVC injuries.
The IVC injury is usually combined with significant hepatic
parenchymal disruption. Hemorrhage results from both
the disrupted liver and from the retroperitoneum. Visu-
alization and identification of the exact area of injury is
difficult. In this circumstance, direct pressure consists of
compressing the liver parenchyma to reapproximate its
anatomic form and pressuring posteriorly onto the injured
and underlying vena cava as a means of tamponade until
anesthesia can catch up with blood loss. A Pringle maneu- Left renal vein
ver, in which a finger is introduced into the foramen of
Winslow to encircle and occlude the structures of the porta
hepatis, should be utilized if the liver parenchyma is con-
tributing to the bleeding.19 B
Complete mobilization of the liver, including division of
the triangular and coronary ligaments and retroperitoneal Fig. 19.3 (A) Judd-Allis clamps approximating an inferior vena cava
attachments, should be carefully weighed in the circum- (IVC) laceration. (B) Intraluminal repair of a backwall, IVC laceration.
stance of retrohepatic caval injuries. When hematoma is
identified behind the hepatic suspensory ligaments, divi-
sion of the ligaments should be avoided. With the liver com-
pletely mobile, existing tamponade is released and will not obtain more direct proximal and distal control of the v ­ essel
be possible to reestablish with a freely floating liver.37 with loops or clamps, or even allow immediate primary
Control by direct pressure may be difficult or incomplete repair. If circumstances permit, occlusive balloons should
and adjunctive endovascular techniques may be beneficial be introduced and positioned via percutaneous access from
in these circumstances. Specifically, the use of endovascular above (i.e., transjugular) and below (i.e., transfemoral) prior
occlusion balloons may provide a better option for bleeding to exposing the caval injury to lessen bleeding and keep the
control. Inflation of the balloons proximal and distal to the site free for repair. The balloon catheters may be introduced
injury site can provide a bloodless field, allowing time to through both femoral veins, or using a combined femoral
232 SECTION 4 • The Management of Vascular Trauma

and internal jugular vein approach.38 In some cases, inser- polypropylene) with enough purchase so that the suture
tion and inflation of a balloon through the site of injury does not pull through the wall. If primary repair is going
may be more expeditious. Endovascular stent grafts (i.e., to result in significant luminal narrowing, then one should
covered stents) are also an option for hemorrhage control consider using a synthetic or biologic patch angioplasty. As
in the multiply injured patient. In these cases, the stent graft previously noted, in a bloody field, one should use a larger
may be inserted to cover or seal the injury from within and needle with the monofilament suture to be able to see and
control bleeding while other injuries are addressed.39,40 effectively maneuver.
In the setting of profound bleeding from the perihe- The type of vascular reconstruction (primary repair
patic IVC or liver parenchyma, total vascular exclusion versus patch angioplasty versus interposition graft) will
may be necessary. This maneuver requires control of the depend on the location and extent of the venous injury and
supra- and infrahepatic IVC which may require a partial associated injuries. One should be mindful that in damage
sternotomy or right thoracoabdominal incision to expose control scenarios, venous ligation may be the most appro-
and clamp the limited length of vena cava between the dia- priate approach. Although repairing the venous injury to
phragmatic cruse and the liver itself.23 A Pringle maneuver maintain flow is appealing, any significant vascular recon-
to occlude portal vein and hepatic artery inflow completes struction will take time, resources and more resuscitation.
vascular isolation and should stop all bleeding. In reality, It is a difficult call to make, and one that should be made
total hepatic isolation may only stem the bleeding by 40% in conjunction with the anesthesia or resuscitation team,
to 60%, but it should allow enough control to facilitate but in patients who are cold, coagulopathic, and acidotic,
parenchymal or vascular injury repair.41 Because this series foregoing venous repair in favor of ligation may be the bet-
of operative steps induces warm ischemia, they can only be ter part of valor.
held for 45 to 60 minutes before inducing irreversible dam-
age to the liver and hepatic failure.18,23 Intermittent release Ligation
of the Pringle clamp to allow periods of perfusion should As a rule, ligation of the infrarenal vena cava, and the iliac
be performed if the occlusion time must be longer. Broering and left renal veins, is well tolerated. In contrast, ligating
et al. have proposed extending a safe ischemic time period the portal or superior mesenteric veins is poorly tolerated
by infusing cold preservation solution with or without topi- and ligating the right renal vein often results in loss of
cal cooling of the liver.18 However, in these unstable, often kidney function.17 As expected, ligation is better tolerated
hypothermic, patients such complex maneuvers are often when there is an abundant collateral circulation.
not possible and are rarely successful. As a damage control maneuver, ligation of the vena cava
If hepatic isolation is inadequate to allow visualization has been well-described in clinical reports throughout the
and repair, total abdominal vascular exclusion is required. literature. Although the operation is associated with a high
In addition to occlusion of the IVC and performance of a degree of mortality, death is often due to associated injuries
Pringle maneuver, a supraceliac aortic clamp or REBOA is and the degree of shock in which patients present. Initially
placed to prevent all arterial inflow into the abdomen and described from wartime experiences in the 20th century,
distal structures. The loss of venous return in an already ligation remains a contemporary option for managing these
hypotensive patient often leads to full arrest.41,42 Although complex injury scenarios.9 A few notable reports include
mortality is very high, an occasional patient in this extreme Navsaria et al. who used ligation in two-thirds of inju-
situation will survive. ries, and Huerta et al. who described a 42% survival rate
among 36 patients with caval trauma, one-third of whom
Considerations for Venous Repair underwent ligation.12,36 Sullivan et al. reviewed 100 inju-
After controlling the bleeding, attention is turned towards ries over a 13-year period, noting that almost half (43%)
repairing the vessel. Thorough exposure, proximal and dis- were ligated. In that report, patients undergoing ligation
tal control, and careful dissection of enough vessel length had a 41% early and a 59% longer-term mortality. Whereas
on which to work are all important steps. Careful inspec- patients in the repair group fared better, with a mortality of
tion for, and control of, branch vessels facilitates mobiliza- 21%, the patients in the ligation group were more severely
tion and prevents “back-bleeding” into the injured artery injured.9 Ligation of the suprarenal cava is poorly tolerated
or vein. In most cases, prior to repair, the vessel should and associated with higher mortality, unless the patient
be opened with Potts scissors to inspect the backwall and happens to have existing generous collaterals via the azy-
intima and débride injured parts of the wall. The intima of gous and lumbar systems.12,43 Ligation of the vena cava at
the vessel should then be irrigated vigorously with heparin- or above the retrohepatic segment is uniformly fatal.
ized saline to remove platelet aggregate and thrombus and Hesitation to ligate the major abdominal veins stems
allow further inspection of the lumen. not only from mortality concerns but from the poten-
Primary repair is one method should the vessel have a tial sequelae of ligation. A major consideration follow-
sharp injury and maintained its length and diameter. If the ing ligation of the infrarenal IVC is swelling of the lower
edges of the injured site are jagged or their viability in ques- extremities, potentially severe enough to cause compart-
tion, they should be débrided with Potts scissors to ensure ment syndrome. Historically, prophylactic fasciotomy has
integrity of any subsequent suture line. Closing longitudi- been recommended for patients undergoing ligation of the
nal tears transversely minimizes vessel narrowing. How- cava.9 However, recent guidelines focus more on clinical
ever, this maneuver is not advisable with long linear injuries vigilance rather than prophylactic fasciotomy.19,36,44 If the
which either need to be fixed with patch angioplasty or IVC is ligated, one must closely monitor lower extremities
by placement of an interposition graft. Vessel repair is compartment and have a low threshold to measure com-
done with fine monofilament suture (4-0, 5-0, or 6-0 partment pressures and perform fasciotomy.
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 233

Reconstructive Techniques
If the patient has sound hemodynamic and physiologic
measures, more complex repairs of the vena cava can
­
be considered. Though some degree of narrowing can
be expected or tolerated following primary venorrhaphy,
attempts to primarily close injuries of more than 50% cir-
cumference are likely to cause too much luminal compro-
mise, clot formation, and even thrombosis.
The optimal reconstructive technique will depend on the
extent of venous injury. Those that involve both the anterior
and posterior wall of the cava are relatively common and
require comprehensive mobilization of the vessel and side
branches (e.g., lumbar veins) in order to gently rotate and
visualize the back wall. When possible, the knots of mono-
filament repair sutures (e.g., Proline sutures) should be
extraluminal to avoid them becoming a nidus for thrombus
formation. In the cephalad position, the cava is more fixed,
tethered by the renal and hepatic veins and liver parenchyma.
If there is an injury to the front and back walls of the cava
Graft
in these locations, the anterior venotomy can be extended to
allow repair of the posterior laceration from inside the lumen
Cannula
(Fig. 19.3B). In this instance the monofilament knots may be
left intraluminal as a matter of expediency.
Transected vessels may be amenable to an end-to-end
anastomosis, although it is rare that a patient with this
injury pattern would be stable enough to tolerate more than IVC
ligation. End-to-end anastomosis is difficult in this location
due to tethering of the cava from visceral and lumbar tribu-
taries making it difficult to mobilize the vessel for a tension-
free anastomosis. This is especially true when segments of Fig. 19.4 Spiral vein graft used for inferior vena cava (IVC) repair.
the vessel wall have been lost or need to be débrided.
When primary repair of the vein is not possible, other
options include an interposition graft, patch angioplasty, which the clot from a thrombosed venous shunt cannot be
and placement of an endovascular stent graft. The vena removed, the patient is then essentially left with a function-
cava’s larger caliber is such that standard saphenous vein ally ligated venous injury.
interposition graft will not provide adequate luminal size. Patch angioplasty is a reasonable option when injury to
If time permits and the expertise exists, the saphenous vein the cava results in loss of part of the vessel wall or when
can be harvested, opened along its length to create a long primary repair will cause more than 30% to 50% luminal
panel that can then be sewn over a chest tube to create a narrowing. Patches may be constructed from autologous
spiral vein graft (Fig. 19.4). The internal jugular or deep vein, polytetrafluoroethylene (PTFE), or bovine pericar-
femoral veins are larger-caliber options that may be consid- dium.49 Each option has advantages and disadvantages and
ered as options for an interposition caval reconstruction. A patient physiology and local circumstances will influence
downside of using autologous vein for this type of recon- the choice. Autologous vein has the lowest infection rate
struction is the time and expertise required to harvest and and is usually available, but it does take additional time to
prepare the vein graft, requisites that may not be present harvest and prepare and this method leaves the patient with
in resource-limited environments or with unstable patients. vein harvest incisions. PTFE is generally available but has
Delayed reconstruction of the transected vena cava can slightly higher rates of infection, especially if there are con-
also be an option.45,46 If the patient has severely compro- cerns of contamination in the field. Bovine pericardium is a
mised physiology mandating a damage control approach, biologic material, and has a slightly higher rate of infection
the vena cava can be shunted with a thoracostomy tube as a compared to autologous vein, but it is a good “off the shelf ”
way to quickly maintain flow for a short period of time. Once option if it is stocked in the operating room.
the patient has been resuscitated, a “second look” operation Endovascular options are appealing in situations when it
can be performed, typically within 12 to 36 hours, where is difficult to access and control a vessel such as the proxi-
the temporary shunt can be removed and a more formal mal portions of the IVC. If radiographic evidence of this
vascular repair performed. Though temporary vascular injury pattern is present prior to laparotomy, endovascu-
shunts are most often being used in instances of arterial lar balloons may be placed prior to making the incision to
injury, reports of their effectiveness in the management of prevent further hemorrhage. Increasingly, reports in the
venous injuries exist, including experience which confirms literature detail the use of intravenous stents to seal or
acceptable patency when used in a damage control situa- repair injuries to the cava. Long-term outcomes are lacking
tion.47,48 Even if the venous shunt occludes with thrombus, and stent grafts can be thrombogenic in low-flow vessels, a
the clot can almost always be cleared (i.e., thrombectomy) property which could increase the risk of venous thrombo-
at the time of the shunt removal. In the rare instance in embolism (VTE). However, initial reports on the use of stent
234 SECTION 4 • The Management of Vascular Trauma

grafts for caval injuries are promising and an endovascular the portal vein, the ascending colon and hepatic flexure are
approach may be the best option to manage these hard-­ mobilized and reflected from right to left at least to the mid-
to-reach injury patterns that are associated with a persis- line or even further into the left side of the abdominal cavity.
tently high mortality rate.39,40,50 A wide Kocher maneuver is next performed with leftward
reflection of the duodenum and head of the pancreas which
allows near complete exposure of the portal vein and asso-
THE PORTAL VEIN
ciated structures. The common bile duct may be isolated
Injury to the portal vein is uncommon, documented in one and retracted leftward as well, to provide additional access
series at 0.1% of all injuries over 20 years.13 Morbidity and to the anterior surface of the vein. Division of the pancre-
mortality associated with portal vein injury is high, attrib- atic neck may be necessary to access more distal portions
utable to the frequency of significant associated injuries of the portal vein. A Pringle maneuver, in which an atrau-
including those in the region of the portal triad.5 In a mul- matic clamp, vessel loop, umbilical tape, or manual pressure
ticenter review of 99 portal triad injuries, survival was only is used to occlude the portal structures, is often needed to
20% if more than one portal structure was damaged. Of control hemorrhage while the portal structures are being
patients with portal triad injuries who died in the operating mobilized.13
room, 85% had at least one portal vein injury.51
The portal vein is formed from the confluence of the Bleeding Control
splenic vein and the SMV behind the neck of the pancreas In the circumstance of massive hemorrhage, proximal con-
(Fig. 19.5). Contained within the hepatoduodenal liga- trol will consist of supraceliac aortic control with a clamp or
ment, the closely associated hepatic artery and bile ducts performance of zone 1 REBOA. This may be the only way to
are frequently injured at the same time. The average diam- reasonably control in-flow; both splenic flow from the celiac
eter of the portal vein is 2 cm and despite a high flow rate, axis and superior mesenteric flow. In less dire circumstances,
approaching 1 L/min, pressures within the vessel are low at the Pringle maneuver is generally the most useful method of
approximately 10 mm Hg or less.5 controlling hemorrhage from suprapancreatic portal vein
injuries. However, the Pringle maneuver often obscures dis-
Exposure and Mobilization section and exposure of the injured portal vein. Even in the
The portal vein is best approached through a midline lapa- setting of more limited injuries, the occlusive tape or clamp
rotomy and from the right side of the abdomen. To expose placed around the porta hepatis prevents v ­ isualization of

Portal vein

Liver Gastric vein

Splenic vein

Spleen

Duodenum
IMV
Pancreas

SMV

Ascending
colon Descending
colon

Fig. 19.5 Anatomy of the portal vein in

situ. IMV, Inferior mesenteric vein; SMV,
superior mesenteric vein.
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 235

the venous injury site. Indiscriminate clamping of the porta The excessive mortality associated with portal vein
hepatis and portal vein should be avoided to prevent injury l­igation is likely attributable to unintentional “under-­
to delicate structures in the region.4,14,52 Proximal and distal resuscitation.” Resuscitation of patients with this injury
control of the portal vein is obtained with the assistance of pattern should adhere to the 1:1:1 strategy during the
direct compression while dissecting the vein free from the acute phase of care. However, this population of patients
hepatic artery and bile duct. Working back from the effec- is likely to continue to have a significant requirement for
tive application of manual pressure with one’s fingers or crystalloid and colloid infusion even after the bleeding has
hand can be accomplished with gentle application of small been controlled. Many reports of high mortality following
sponge sticks or lower profile Kittner dissecting sponges. portal vein ligation were made prior to the understanding of
Once the injury is visualized, it can be gently grasped with intraabdominal hypertension and compartment syndrome
Judd-Allis clamps and mobilized to allow suture closure or and the benefits of temporary abdominal closure. Contem-
passage of vascular control tapes. porary, blood-component based resuscitation along with
Endovascular options are limited in controlling hemorrhage temporary abdominal closure strategies are likely to improve
from a portal vein injury. A Fogarty balloon catheter may be outcomes of patients who require portal vein ligation.
introduced at the site of portal vein injury to occlude the vessel Delayed complications specific to portal vein ligation are
and its inflow/outflow.34 Access from more distal sites, such as common. Low mesenteric flow combined with shock may
femoral access, is not practical for portal vein injuries. lead to venous thrombosis, bowel ischemia, and necro-
sis.16 The degree of bowel infarction may vary from patchy
Repair of Portal Venous Injuries necrosis of small segments of bowel to near total small
Repair of the portal vein follows the principles outlined for bowel infarction. Additionally, portal vein thrombosis and
the vena cava and other large venous injuries. After the portal hypertension may occur as sequelae in this setting.
edges of the injured vein have been débrided, the surgeon The complications of portal vein ligation are sobering but
must decide if a primary repair is possible. Simple repairs unavoidable when ligation is the only option to control
should be performed using 5-0 or 6-0 monofilament suture, bleeding and provide immediate patient survival.
often in an interrupted fashion. If the portal vein has been
divided, an end-to-end anastomosis may be accomplished if THE SUPERIOR MESENTERIC VEIN
there is minimal tension between the two ends. Behind the
pancreas, small medial tributaries entering the portal vein It is uncommon to manage a patient with an SMV injury as
may be ligated and divided to achieve additional length. they account for less than 1.0% of all trauma admissions.15
Additionally, if it has not already been done to achieve con- When present, mesenteric vein injuries most likely occur
trol, partial division of the pancreas and ligation of small from penetrating mechanisms. However, blunt trauma can
medial tributaries may provide further mobilization to make result in a high degree of shear force exerted on the mobile
an anastomosis possible. Placement of a reverse saphenous mesentery, which can cause tearing or avulsion of the mes-
vein interposition graft is possible if a large segment of the enteric vein. Due to its anatomic association with the SMA,
portal vein has been injured; however, few patients with this the two vessels are often injured in tandem. Found to the
significant an injury are stable enough to permit this kind patient’s right of the mesenteric artery, the vein provides
of reconstruction. In cases in which repair is not feasible, outflow for the jejunum, ileum, appendix, and the colon to
the only alternative is ligation. the mid-transverse segment. Portions of the pancreas and
duodenum are also dependent on the SMV for outflow.
Portal Vein Ligation Due to the central location of the SMV, associated inju-
Patients with portal venous injuries usually sustain massive ries are common. In a study focusing on 51 patients with
blood loss, have associated injuries, and present in a state of SMV injuries, the average number of additional injuries was
extremis which precludes an extensive venous repair. From a 3.5.16 As with all the major abdominal veins, mortality is
review of 18 patients with portal vein injuries between 1958 high with reported rates varying between 50% and 71%,
and 1980, only 13% survived when ligation was used as a depending on the number of associated vascular and solid
last-ditch salvage option.13,53 However, when the portal vein organ injuries.3
was ligated earlier in the course of operative management
(i.e., before cardiovascular collapse), the rate of survival Exposure and Mobilization
improved to 80%.53,54 Because of the detrimental effects asso- Although relatively more accessible than the portal vein, the
ciated with abrupt occlusion of splanchnic outflow, portal proximal portions of the SMV may require division of the
vein ligation is less well tolerated than ligation of the vena pancreas for successful access. Adjacent to the SMA and
cava and carries a survival rate ranging from 10% to 85%.5,51 the other major visceral and vascular structures, exposure of
If portal vein ligation is required, the anesthesia team must the vein is complicated when other injuries are present in the
be made aware as up to 50% of a patient’s blood volume may region. The SMV is quite accessible in its distal portion com-
be sequestered in the splanchnic circulation.5 Ligation of pared to the other major abdominal veins and is approached
the portal vein results in decreased venous return with sub- operatively in the same manner as the SMA (Fig. 19.6). A
sequent splanchnic hypertension and systemic hypoperfu- direct approach at the base of the mesentery may be appro-
sion.55 Aggressive fluid administration, both intraoperatively priate if the injury occurs several centimeters distal to the
and in the ICU, is required. Patients develop massive visceral inferior border of the pancreas. Medial visceral rotation may
swelling due to the portal venous congestion; therefore, the be necessary to access the root of the mesentery. If very prox-
abdomen should be left open to prevent abdominal hyperten- imal control of the SMV is required, then the operative expo-
sion and compartment syndrome. sure mirrors that used for the portal vein with mobilization
236 SECTION 4 • The Management of Vascular Trauma

Celiac
Hepatic trunk
proper a. Splenic a.
Portal v.
Splenic v.

Bile duct
Spleen
Duodenum

Right kidney

Left kidney
Pancreas
IMV

Descending
colon

Ascending SMV
colon Aorta
SMA
IVC

IMA

Fig. 19.6 Superior mesenteric vein in situ. a, Artery, IMA, inferior mesenteric artery; IMV, inferior mesenteric vein; IVC, inferior vena cava; SMA, superior
mesenteric artery; SMV, superior mesenteric vein; v, vein.

of the right colon and performance of a Kocher maneuver to i­ ndicate that patients requiring ligation of the SMV will likely
provide access. As mentioned, the body of the pancreas may tolerate the procedure and may fare as well as those having
need to be divided to gain proximal control of the SMV.4,16 venous repair. The possibility of splanchnic hypertension and
bowel ischemia exist with ligation, as they do with ligation of
Bleeding Control and Repair the portal vein. Those surviving SMV ligation should undergo
A distal SMV injury that is out in the mesentery of the temporary abdominal closure and second look operations
bowel may be first controlled with manual compression and to evaluate viability of the intestines prior to definitive clo-
then ligated. Dissection of the injury at this level can allow sure. Whether it be the SMV, the portal vein, or the IVC, liga-
placement of small vessel loops, clamps, or clips to obtain tion should not necessarily be viewed as a last-ditch option.
control. In contrast, and as noted previously, the more prox- In many scenarios of abdominal venous injury, early and
imal SMV injury will require pancreatic division to access. controlled ligation – in communication with the anesthesia
Bleeding is more significant with more proximal SMV team – is preferable to prolonged attempts at repair that can
injuries and poor exposure of the vessel can lead to blind be associated with large volume blood loss and irrecoverable
placement of suture ligatures, incomplete hemostasis, and shock. Judgment and composure are required to recognize
iatrogenic injury to neighboring structures. In these cases, the need for early ligation and to accomplish it quickly, prior
bleeding can be temporarily controlled by occlusion of the to massive blood loss and futile attempts at repair.
distal SMV and a Pringle maneuver, though back-bleeding Temporary shunts should be considered for portal and supe-
from the splenic vein may still complicate the field to some rior mesenteric venous injuries in the setting of an unstable
extent. These maneuvers may be adequate to slow hemor- patient whose injury anatomy is amenable to shunting. The
rhage and allow mobilization of the proximal SMV. Primary relative low flow in the venous compared to the arterial system
repair of the SMV may be accomplished with interrupted may result in a higher rate of thrombosis with venous shunts.
5-0 or 6-0 monofilament suture. In cases where significant However, this approach may provide options for reconstruc-
tissue loss precludes primary repair, a saphenous vein inter- tion during a second-look laparotomy. In many regards, if
position graft may be required. shunt thrombosis does occur, it will result in a situation similar
to ligation of the vein.
Ligation of the Superior Mesenteric Vein
Patients who require SMV ligation fare better than those
requiring portal vein ligation. Various studies describe a 15% Endovascular Options
to 33% mortality associated with SMV ligation, as opposed
to 36% to 43% mortality in the repair group.13,56 Asensio Endovascular techniques are now more commonly used to
et al. found no difference in mortality in 84 patients with manage vascular injury and a new generation of trauma sur-
SMV injury, 53 of whom underwent ligation.57 These reports geons are familiar and facile with these less invasive options.
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 237

Although definitive data regarding the effectiveness of for hepatic vein inflow by fenestrating the graft prior to
endovascular balloon occlusion or stent grafts for major ­placement has even been performed.47 Concerns exist that
venous injury is lacking, their practical utility is clear in stent grafts may be thrombogenic during the early/immedi-
many cases. An increasing number of reports, primarily ate phases after deployment, especially in a low-flow venous
case reports and small single-center series, now show that system.39 As such, and in cases in which the patient’s injury
catheter-based techniques are useful to temporize and, in pattern allows it, the use of anticoagulation to prevent
some cases, definitively treat these complex injuries. thrombus formation should be considered, although this
Although both interventional radiology and vascular is controversial and should be considered on a case by case
and endovascular surgery are available in most trauma basis.47,58
centers, several variables should be considered before a
trauma surgeon opts for this management strategy. First, ALTERNATIVE MANAGEMENT OPTIONS
practitioners who are skilled in these techniques must be
readily available. In many centers, trauma surgeons are Temporary Venous Shunts: The use of temporary pros-
able to perform endovascular interventions. However, if thetic shunts in the management of venous injuries is
this is not an option, the patient's hemodynamic status may increasing. Military operations in Iraq and Afghanistan ini-
preclude waiting for the vascular surgery or interventional tially raised the profile of temporary shunts used for dam-
radiology specialist to arrive. Additionally, a hybrid opera- age control vascular surgery, though the vast majority of
tive suite should be available to accommodate the multiple this evidence is from extremity injuries. A 2009 review of
demands of resuscitation, open operative exploration, and 64 extremity arterial injuries in US troops demonstrated
fluoroscopic imaging needed for the endovascular methods. 38% with concomitant venous injuries. These authors note
An extensive inventory of guidewires, catheters, and grafts that several of the patients in their study cohort underwent
of various sizes is also required, although recent efforts have venous shunting and subsequent restoration of venous
been made to refine a more manageable, trauma-­specific continuity.45 Though carotid shunts, such as the Javid or
endovascular inventory.58 Argyle shunt, are the most widely used for arterial shunt-
Catheter-based options offer the greatest potential for ing, the larger luminal size of the major abdominal veins
vena cava injuries which often occur in anatomic locations renders a small caliber chest tube a better match. The use of
that are difficult to access. The anatomy of the portal and venous shunts for abdominal trauma may facilitate damage
superior mesenteric veins precludes conventional endovas- control surgery via improved hemorrhage control and by
cular treatments although use of balloons and stents intro- allowing time for patient resuscitation, operative planning,
duced into the vessels at the time of open operation can be or, potentially, transfer to a higher level of care.
used in select cases. Whereas the patency rates of temporary arterial shunts
Occlusion Balloons: The use of endovascular occlusion bal- are encouraging, reports of temporary venous shunting
loons to control bleeding is one of the most appealing appli- remain largely limited to small series and limited objec-
cations of endovascular technology. As means to maintain tive data exists on patency rates in these cases. Rasmussen
central aortic pressure and perfusion, REBOA may be indi- et al. note in a 2006 review that four venous injuries were
cated for patients who are in extremis or who have uncon- shunted in combat troops and all remained patent.44 As
trolled or unidentified intraabdominal hemorrhage. Balloon dwell times for shunts in theater are limited by transport
occlusion techniques can also be used in the venous system policy, however, it remains unclear how damage control
to control/isolate areas of laceration or avulsion. As an venous shunts would fare over longer time periods, in light
example, in the setting of an IVC injury, an occlusive balloon of lower flow rates and pressures. From a practical stand-
can be introduced into the venous system via femoral vein point, if hemorrhage is controlled but the patient’s physio-
access to control inflow into the injured segment. In some logic status mandates damage control surgery, a temporary
instances, a second balloon can be placed through a tran- prosthetic shunt is a reasonable alternative to ligation. The
sjugular approach (i.e., from above) to isolate the injury and shunt should be secured with ligatures at both the proximal
facilitate management more completely. Depending on oper- and distal end to prevent dislodgment during transport and
ative circumstances, an endovascular or Foley balloon can be subsequent ICU care. Definitive operative choices may then
inserted directly through the venous injury to control bleed- be made during a second look, when the patient’s status
ing while proximal and distal control are obtained. As with accommodates potential reconstruction. Venous shunts are
proximal control obtained with a vascular clamp, occluding an acceptable choice when damage control is required, but
the vena cava with a balloon results in loss of right heart fill- surgeons must remain mindful that patency times are not
ing and potentially lethal hypotension.38 In cases in which a well-defined.
caval injury is identified or occlusion of the vena cava can be Atriocaval Shunt: First described by Schrock in 1968,
anticipated, large bore vascular access in the upper extremi- this shunt functionally bypasses the site of a retrohepatic
ties or internal jugular veins should be secured. caval injury. A large diameter chest tube is introduced via
Stent Grafts: Endovascular covered stents (i.e., stent grafts) an incision in the right atrial appendage. With the tube
can provide an effective approach for managing select ret- outflow protruding from the right atrium and clamped, fen-
rohepatic and suprahepatic IVC injuries. Multiple reports estrations in the tube are positioned in the intrapericardial
describe the use of stent grafts in conjunction with lapa- IVC and below the site of injury, usually the infrarenal cava
rotomy to manage IVC injuries.39,40,50,59,60 If the patient is (Fig. 19.7). Vessel loops or Rommel tourniquets are used
stable enough to undergo immediate endovascular access, to secure the vessel around the tube.41,42,62 Unfortunately,
direct stent repair may be a superior option for retrohe- survival following the atriocaval shunt is poor. Burch et al.
patic and suprahepatic IVC lacerations.61 Accommodations had only 6 of 31 patients survive with the shunt; all were
238 SECTION 4 • The Management of Vascular Trauma

and repaired, bloodlessly, on a back table. Potentially, a sec-

ond team may address remaining vascular or other visceral
injuries in vivo. The transplant option is extremely rare and
Right atrium feasible in only extraordinary circumstances, in part due to
lack of organ availability and the presence of other injuries
that occurred at the time of the hepatic/caval trauma.63

Chest tube
Pitfalls and Points
n Ligation of the infrarenal IVC is well-tolerated and the
preferred management strategy for patients in extremis.
Suprahepatic IVC ligation, however, is uniformly lethal.
n Endovascular options may be superior to address injuries
Damaged IVC to the retrohepatic IVC.
Rommel tourniquet n Portal vein and SMV ligation is a reasonable bail-out
option when catastrophic bleeding is present.
n Division of the head of the pancreas should not be
delayed when improved portal vein exposure is needed.
n Ligation of the IVC, portal vein, or SMV requires second-
look laparotomy to ensure viability of bowel.
n Both the atriocaval shunt and resuscitative thoracotomy
have extremely poor outcomes and are to be avoided.
REBOA should be considered for aortic occlusion for
patients in extremis.

POSTOPERATIVE CARE AND COMPLICATIONS

Patients who survive large intraabdominal venous trauma
Fig. 19.7 Atriocaval shunt. IVC, Inferior vena cava. are prone to develop a few early and late complications
unique to these injury patterns. Stenosis and/or thrombo-
sis at the venous repair sites may occur after primary repair
gunshot wounds to the retroperitoneal IVC.62 Advances in or other types of venous reconstruction (e.g., patch angio-
endovascular technology will likely make atriocaval shunts plasty or interposition graft). Varying degrees of lower
obsolete. extremity swelling, which can improve or be self-limited
Venovenous Bypass, Circulatory Arrest, and Trans- over time, occur in nearly all instances of IVC ligation.
plantation: The profound hemorrhage from major Vigilance for the development of lower extremity compart-
abdominal vein injuries, combined with a young, oth- ment syndrome resulting from acute venous hypertension
erwise healthy trauma patient, may place the trauma must be maintained in these situations and in rare cases
surgeon in the position of attempting truly heroic mea- fasciotomies performed. Splanchnic hypertension with
sures. Falling into the camp of uncommon measures for portal and superior mesenteric venous narrowing or liga-
hemorrhage control, venovenous bypass or circulatory tion may also occur.32,36
arrest have intermittently been described in case reports Long-term outcomes following IVC repair are generally
with marginal success. To entertain these options, a favorable. However, concern remains regarding the possibil-
trauma center must have personnel experienced in plac- ity of complications, primarily thrombosis, and the potential
ing patients on bypass, experience managing a pump, and for embolism. Though there are isolated reports of sudden
cannula availability.35 Cannula placement includes open death from pulmonary embolism in patients having under-
approaches via the right atrium or left pulmonary artery gone IVC ligation, the literature is scarce regarding venous
(beneficial in preventing right heart overload and tricuspid thromboembolism following repair. Postoperative screen-
regurgitation), or percutaneous placement in the femoral, ing with duplex ultrasonography is warranted to monitor
subclavian, or internal jugular veins.23,32 Once on bypass, the cava following repair, especially in patients with lower
repair in a fairly bloodless field may commence. Hypother- extremity edema or other symptoms. In symptomatic or
mic circulatory arrest is appealing for the potential tissue high-risk patients, consideration may be given to a caval
protective effects of profound hypothermia. Practically filter or extended oral anticoagulation.36 Finally, in some
speaking, achieving venovenous bypass or circulatory instances of blunt caval injury, late development of throm-
arrest is logistically difficult in the unplanned case for a bosis and Budd-Chiari syndrome have been observed.22
patient in extremis.
There are reports of liver explantation or transplantation
for severe IVC injuries combined with profound hepatic dis- Conclusion
ruption. Isolated reports of liver explantation with back-table
repair and autotransplantation exist, with poor survival. If Despite advances in prehospital care, resuscitation, and inten-
total hepatic isolation can be achieved, the liver is explanted sive care, and the development of endovascular techniques,
 19 • Inferior Vena Cava, Portal, and Mesenteric Venous Systems 239

the mortality associated with intraabdominal large-vein 21. Netto FA, Tien H, Hamilton P, et al. Diagnosis and outcome of
injuries has changed little over the last several decades.9,13,36 blunt caval injuries in the modern trauma center. J Trauma.
2006;61(5):1053–1057.
In a trend that likely reflects more effective prehospital care 22. Cole K, Shadis R, Sullivan Jr TR. Retrohepatic hematoma caus-
and operating on more severely injured patients, the mortal- ing caval compression after blunt abdominal trauma. J Surg Educ.
ity associated with these injuries may have even increased 2009;66(1):48–50.
compared to series reported in the 1980s and 1990s.9 More 23. Marino IR, di Francesco F, Doria C, Gruttadauria S, Lauro A, Scott VL.
effective, blood component-based resuscitation and an A new technique for successful management of a complete suprahe-
patic caval transection. J Am Coll Surg. 2008;206(1):190–194.
emphasis on permissive hypotension will like prove especially 24. Graham M, Mattox KL, Beall Jr AC, De Bakey ME. Injuries to the
beneficial in the management of these low pressure venous visceral arteries. Surgery. 1978;84(6):835–839.
injuries. Abdominal venous injuries must be evaluated on a 25. Lucas AE, Richardson JD, Flint LM, Polk Jr HC. Traumatic injury of
case-by-case basis, as no one algorithm is adequate to guide the proximal superior mesenteric artery. J Trauma. 1981;193(1):
30–34.
all the steps in managing these cases. One will be well served 26. Tibbits EM, Hoareau GL, Simon MA, et al. Location is everything: the
by the principles of adequate operative exposure, intentional hemodynamic effects of REBOA in zone 1 versus zone 3 of the aorta.
vascular control, and implementation of damage control or J Trauma Acute Care Surg. 2018;85(1):101–107.
repair techniques while limiting time in the operating room. 27. Lallemand MS, Moe DM, McClellan JM, et al. Resuscitative endovascu-
lar balloon occlusion of the aorta for major abdominal venous injury
in a porcine hemorrhagic shock model. J Trauma Acute Care Surg.
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4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg. 37. Yilmaz TH, Ndofor BC, Smith MD, Degiannis E. A heuristic approach
1989;209(6):698–707. and heretic view on the technical issues and pitfalls in the manage-
12. Huerta S, Bui TD, Nguyen TH, Banimahd FN, Porral D, Dolich MO. ment of penetrating abdominal injuries. Scand J Trauma Resusc Emerg
Predictors of mortality and management of patients with traumatic Med. 2010;18(40):1–7.
inferior vena cava injuries. Am Surg. 2006;72(4):290–296. 38. Angeles AP, Agarwal N, Lynd Jr C. Repair of a juxtahepatic inferior
13. Fraga GP, Bansal V, Fortlage D, Coimbra R. A 20-year experience with vena cava injury using a simple endovascular technique. J Trauma.
portal and superior mesenteric injuries: has anything changed? Eur J 2004;56(4):918–921.
Vasc Endovasc Surg. 2009;37:87–91. 39. Castelli P, Caronno R, Piffaretti G, Tozzi M. Emergency endovascular
14. Asensio JA, Petrone P, Garcia-Nunez L, Healy M, Martin M, Kuncir E. repair for traumatic injury of the inferior vena cava. Eur J Cardiothorac
Superior venous mesenteric injuries: to ligate or to repair remains the Surg. 2005;28:906–908.
question. J Trauma. 2007;62(3):668–675. 40. Erzurum VZ, Shoup M, Borge M, Kalman PG, Rodriguez H, Silver GM.
15. Petersen SR, Sheldon GF, Lim Jr RC. Management of portal vein Inferior vena cava endograft to control surgically inaccessible hemor-
­injuries. J Trauma. 1979;19(8):616–620. rhage. J Vasc Surg. 2003;38:1437–1439.
16. Asensio JA, Berne JD, Chahwan S, et al. Traumatic injury to the supe- 41. Clark JJ, Steinemann S, Lau JM. Use of an atriocaval shunt in a trauma
rior mesenteric artery. Am J Surg. 1999;178:235–239. patient: first reported case in Hawai’i. Hawaii Med J. 2010;69:47–48.
17. Asensio JA, Chahwan S, Hanpeter D, et al. Operative manage- 42. Rosenthal D, Wellons ED, Shuler FW, Levitt AB, Henderson VJ. Retro-
ment and outcome of 302 abdominal vascular injuries. Am J Surg. hepatic vena cava and hepatic vein injuries: a simplified experimental
2000;180:528–534. method of treatment by balloon shunt. J Trauma. 2004;56(2):450–452.
18. Broering DC, Al-Shurafa HA, Mueller L, Pothmann W, Nierhaus A, 43. Votanopoulos KI, Welsh FJ, Mattox KL. Suprarenal inferior vena cava
Rogiers X. Total vascular isolation and in situ cold perfusion for man- ligation: a rare survivor. J Trauma. 2009;67(6):E179–E180.
agement of severe liver trauma. J Trauma. 2002;53(3):564–567. 44. Matsumoto S, Jung K, Smith A, Coimbra R. Management of infe-
19. Feliciano DV, Moore EE, Biffl WL. Western Trauma Association critical rior vena cava injury: repair or ligation? A propensity score match-
decisions in trauma: management of abdominal vascular trauma. J ing analysis using the National Trauma Data Bank. J Am Coll Surg.
Trauma Acute Care Surg. 2015;79(6):1079–1088. 2018;226(5):752–759.
20. Tsai R, Raptis C, Schuerer DJ, Mellnick VM. CT appearance of 45. Droz NM, Bini JK, Jafree KA, Matsuura JH. Staged reconstruction of
traumatic inferior vena cava injury. Am J Roentgenol. 2016;207: the inferior vena cava after gunshot injury. J Vasc Surg Cases Innov
705–711. Tech. 2017;3(3):136–138.
240 SECTION 4 • The Management of Vascular Trauma

46. Tulip HH, Smith SV, Valentine RJ. Delayed reconstruction of the 55. Sabat J, Hsu CH, Chu Q, Tan TW. The mortality for surgical repair is
superior mesenteric vein with autogenous femoral vein. J Vasc Surg. similar to ligation in patients with traumatic portal vein injury. J Vasc
2012;55:1773–1774. Surg Venous Lymphat Disord. 2018:1–6.
47. Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith 56. Donahue T, Strauch G. Ligation as definitive management of injury to
DL. The use of temporary vascular shunts as a damage control the superior mesenteric vein. J Trauma. 1988;28(4):541–543.
adjunct in the management of wartime vascular injury. J Trauma. 57. Asensio JA, Britt LD, Borzotta A, et al. Multiinstitutional experience
2006;61:8–15. with the management of superior mesenteric artery injuries. J Am
48. Gifford SM, Aidinian G, Clouse WD, et al. Effect of temporary shunting Coll Surg. 2001;193(4):354–365.
on extremity vascular injury: an outcome analysis from the Global War 58. Sam 2nd AD, Frusha JD, McNeil JW, Olinde AJ. Repair of blunt trau-
on Terror vascular injury initiative. J Vasc Surg. 2009;50(3):549–555. matic inferior vena cava laceration with commercially available endo-
49. Mansukhani NA, Havelka GE, Helenowskin IB, Rodriguez HE, Hoel grafts. J Vasc Surg. 2006;43(4):841–843.
AW, Eskandari MK. The enduring patency of primary inferior vena 59. Hommes M, Kazemier G, van Dijk L, et al. Complex liver trauma with
cava repair. Surgery. 2017;161:1414–1422. bilhemia treated with perihepatic packing and endovascular stent in
50. Watarida S, Nishi T, Furukawa A, et al. Fenestrated stent-graft for the vena cava. J Trauma. 2009;67(2):E51–E53.
traumatic juxtahepatic inferior vena cava injury. J Endovasc Ther. 60. Denton JD, Moore EE, Coldwell DM. Multimodality treatment for grade
2002;9:134–137. V hepatic injuries: perihepatic packing, arterial embolization and
51. Jurkovich GJ, Hoyt DB, Moore FA, et al. Portal triad injuries. J Trauma. venous stenting. J Trauma. 1997;42(5):964–968.
1995;39(3):426–434. 61. de Naeyer G, Degrieck I. Emergent infrahepatic vena cava stenting for
52. Emmiler M, Kocogullari CU, Yilmaz S, Cekirdekci A. Repair of the life-threatening perforation. J Vasc Surg. 2005;41(3):552–554.
inferior vena cava with autogenous peritoneo-fascial patch graft 62. Burch JM, Feliciano DV, Mattox KL. The atriocaval shunt. Facts and
following abdominal trauma: a case report. Vasc Endovascular Surg. fiction. Ann Surg. 1988;207(5):555–568.
2008;42(3):272–275. 63. Boggi U, Vistoli F, Del Chiaro M, et al. Extracorporeal repair and liver
53. Stone HH, Fabian TC, Turkleson ML. Wounds of the portal venous sys- autotransplantation after total avulsion of hepatic veins and retrohe-
tem. World J Surg. 1982;6(3):335–340. patic inferior vena cava injury secondary to blunt abdominal trauma.
54. English WP, Johnson MB, Borman KR, Turner Jr WW. Mesenteric J Trauma. 2006;60(2):405–406.
ischemia: an unusual presentation of traumatic intrahepatic arterio-
portal fistula. Am Surg. 2001;67(9):865–867.
 20 Neck and Thoracic Outlet
GREGORY A. MAGEE and FRED A. WEAVER

Introduction symptoms, but posterior cerebral symptoms such as ataxia,

dizziness, vomiting, facial and body analgesia, or visual
Perhaps no other anatomic region contains so many vital field deficits mandate evaluation of their cerebral vascula-
structures in such a compact space as the neck and thoracic ture. Complaints of headache, neck, ear, face, or periorbital
outlet. Injuries in this region can result in hemorrhage, pain may indicate intramural hemorrhage or dissection.6
stroke, upper and/or lower extremity paralysis, loss of air- Because of the frequent association of blunt cerebrovascu-
way, and digestive tract injury. Consequently, the clinician lar injuries (BCVI) with closed head injury, many patients
must adopt a thorough approach and maintain a high have a decreased Glasgow Coma Scale (GCS) on arrival,
index of suspicion when caring for patients with injuries in which makes physical examination–directed diagnosis a
this area. The spectrum of vascular trauma in the cervical challenge. Patients with BCVI may also arrive at the emer-
region ranges from exsanguinating hemorrhage to subtle gency department (ED) with no neurological deficit and
imaging findings with a seemingly innocuous examination then develop a delayed neurologic deficit 10 to 72 hours
that can lead to delayed hemispheric stroke. The variation later.7 Penetrating subclavian artery injuries are particu-
in presentation and potentially devastating nature of neck larly lethal due to severe noncompressible hemorrhage with
and thoracic outlet injuries has led to an increased aware- over half who survive to the hospital requiring resuscitative
ness and screening for patients with penetrating wounds thoracotomy.8–12 More than a third of those who survive
and those at risk for blunt vascular injury. also have associated brachial plexus injuries, which cause
The surgical management of carotid artery injuries dates significant postoperative morbidity.13,14
back to 1552, when Ambroise Paré reported the success- Physical examination is extremely important in the
ful management of a common carotid artery and jugular evaluation of penetrating injuries, including the number,
vein injury by ligation.1 The patient developed aphasia and location, and possible trajectory of wounds. Hard signs of
hemiplegia but survived. Fleming later reported a favorable vascular injury are pulsatile hemorrhage, expanding hema-
outcome after ligating an injured common carotid artery, toma, absent distal pulses, and palpable thrill, all of which
and this became the standard surgical management until mandate exploration. Soft signs include peripheral nerve
the Korean War.2 In his review of the management of arte- deficit, significant hemorrhage at the scene, nonexpand-
rial injuries during World War II, DeBakey found that arte- ing hematoma, and decreased distal pulse, which should
rial repair was associated with higher mortality rates, and be evaluated by computed tomography angiography (CTA)
based on this report, the US military abandoned arterial or other imaging modality. Minor vascular injuries do not
repair.3 Frank Spencer is credited with bringing back arte- always require repair and can be followed by serial physi-
rial injury repair during the Korean War with improved cal examination with or without duplex ultrasound, an
results, including injuries to the carotid.4 Subsequently, approach that has 95% sensitivity for detecting injuries that
these reconstructive techniques were applied to civilian require repair.14–22
carotid and subclavian artery injuries. More recently, endo- Because most blunt cerebrovascular injuries are clinically
vascular techniques have been applied to selected injuries occult, screening CTA of the neck should be performed on
of the neck and thoracic outlet vessels.5 patients with risk factors such as: (1) head and neck trauma
associated with severe neck hyperextension and rotation
or hyperflexion; (2) a Lefort II or III fracture; (3) a basilar
Indications skull fracture involving the carotid canal; (4) a closed head
injury consistent with diffuse axonal injury presenting with
Patients with neck/thoracic outlet vessel injury frequently GCS score less than 6; (5) a cervical vertebral body or trans-
have concomitant injuries. The use of advanced trauma verse foramen fracture, subluxation, or ligamentous injury
life support protocol is crucial to recognize and treat life- at any level or any fracture of C1–C3; or (6) a seat-belt or
threatening injuries first and then thoroughly evaluate for other clothesline-type injury with significant cervical pain,
other possible injuries. The secondary survey of the patient swelling, or altered mental status.7,23
should include a neurologic examination, auscultation Definitive repair of penetrating carotid injuries in patients
for bruits, and assessment of carotid and upper extremity with a neurologic deficit has been controversial. In the
pulses, and blood pressure in both arms. Pressure differ- 1970s, Cohen and Bradley raised the concern that repair
entials or decreased pulses may suggest a thoracic outlet of a carotid injury in a patient with a neurologic deficit may
injury. lead to intracranial hemorrhage.24 However, subsequent
Patients with carotid injuries may present with contra- studies found that regardless of the initial neurologic defi-
lateral extremity deficit, aphasia, or Horner's syndrome. cit, mortality and final neurologic status was improved if
Vertebral artery injuries rarely present with neurological carotid repair was performed.25–27 A comprehensive review

241
242 SECTION 4 • The Management of Vascular Trauma

of the US military’s experience with cervical carotid injury

during the wars in Afghanistan and Iraq showed that com- Preoperative Preparation
mon and internal carotid artery repair resulted in lower
rates of stroke and death when compared to ligation.28 The preoperative preparation of patients with a docu-
Relative contraindications to repair include surgically mented neck and thoracic outlet vascular injury depends
inaccessible lesions, a delay of more than 3 to 4 hours from on the presence of active bleeding and the suspected loca-
establishment of coma, large areas of cerebral infarct on tion or zone of injury. Patients who have hard signs of
admission CT, and absence of retrograde back-bleeding vascular injury should go directly to the operating room
from the distal arterial segment after operative exposure (OR) for exploration, vascular control, and repair. Rapid
and open thrombectomy.29 establishment of an oral or nasotracheal airway is critical.
Nonoperative management of neurologically intact Patients with soft signs of vascular injury require expedi-
patients with penetrating injuries is occasionally war- tious diagnostic imaging and, in select circumstances,
ranted. For patients with a carotid or vertebral artery require formal catheter-based diagnostic angiography. This
occlusion and normal neurologic examination, observa- approach is especially applicable for patients with zone
tion and anticoagulation with heparin is an acceptable I and III injuries in which surgical access to the vessels in
approach. Likewise, minimal arterial injuries, defined as question is difficult. Duplex ultrasonography can provide
non–flow-limiting intimal flaps and pseudoaneurysms less a rapid, accurate, and noninvasive assessment of zone II
than 5 mm in size, can be safely observed, based on series neck and thoracic outlet vasculature; however, it is often
with follow-up extending to 10 years.30,31 These injuries not available in the ED, whereas CTA has become the diag-
should be evaluated by repeat CTA or duplex prior to dis- nostic evaluation of choice.41–43 CTA findings are accurate
charge to confirm they have not progressed. The current and may be used as the basis for operative planning.19,44,45
grading system for BCVI is: grade I, intimal injury with Recently published recommendations specify that a 16-slice
less than 25% luminal narrowing; grade II, dissection or higher CTA is required for assessment of a possible blunt
or hematoma with more than 25% luminal narrowing; vascular injury.7,37 However, subsequent studies have docu-
grade III, pseudoaneurysm; grade IV, occlusion; and grade mented a sensitivity of 29% to 64%, and 51% to 54% with
V, vessel transection. 16-slice and 64-slice scanners, respectively.46–48 Depending
BCVI are almost always managed nonoperatively based on on the mechanism, location, and type of injury, endovascu-
Fabian’s finding that antithrombotic therapy improved sur- lar intervention at the time of diagnostic angiography may
vival (P < .02) and neurologic outcome (P < .01) in patients be an appropriate and definitive treatment.
with this injury pattern, a result that has been confirmed
in several subsequent reports.32–35 Antithrombotic therapy
consists of either therapeutic anticoagulation with heparin Pitfalls and Danger Points
followed by warfarin, or antiplatelet therapy with aspirin or
aspirin plus clopidogrel. A recent Cochrane meta-analysis n CTA: For stable patients without hard signs of vascu-
of antiplatelet therapy versus anticoagulation therapy for lar injury, it is advisable that a CTA be performed before
carotid dissection showed no differences in stroke rate or operative intervention in order to demonstrate the extent
hemorrhagic complications between the two treatment and the zone of the injury. This information guides the
regimens.36 However, dual antiplatelet therapy may be pre- surgical field(s) and exposure(s) required for proximal
ferred due to its safety and cost profile.7 A follow-up CTA is and distal vascular control.
recommended 7 to 10 days after injury because over 60% n Blunt cerebrovascular injuries (BCVI): Most of these
of injuries will change in grade or severity during this time injuries should be managed by antithrombotic therapy
interval. Grade I and II BCVI can often develop into grade with either heparin followed by warfarin or by antiplatelet
III pseudoaneurysms. Additionally, imaging 3 to 6 months therapy. Dual antiplatelet therapy may be preferable due to
after the injury is warranted in these cases to exclude the a better safety and cost profile.7 Failure to screen for these
development of an enlarging pseudoaneurysm over time. injuries and failure to treat with antithrombotic therapy
Current recommendations are that patients with grade increase the risk of stroke and long-term morbidity.
I–IV BCVI should be treated with antithrombotic therapy. n Exit and entry wounds: Although a penetrating
Grade V injuries are frequently associated with nonvas- wound may be in a surgically accessible zone or segment
cular injuries and may require operative intervention as a of a neck or thoracic outlet, the trajectory of the pen-
life-saving maneuver. These injuries should be surgically etrating object should be considered when preparing the
repaired, if possible, but in many instances they are surgi- operative field. The surgeon must anticipate the need for
cally inaccessible and require ligation or embolization.7,37,38 more proximal or distal exposure depending on the tra-
The natural history of BCVI is that 90% of stenotic lesions jectory and the course of the penetrating object.
will resolve and that 67% of occluded vessels will recanalize n Neurologic deficit: Careful neurologic examination
with antithrombotic therapy only.39 Blunt vertebral artery of patients with a suspected or known cerebrovascular
injuries tend to occur at junctions between fixed and mobile injury is essential. Documentation of neurologic status
segments with the V2 segment most commonly affected in before an intervention is critical to anticipating and rec-
adults, and the V3 and upper V2 segments more commonly ognizing new neurologic changes postoperatively.
affected in children. Approximately one-third of patients n Associated aerodigestive injuries: Surgical exposure
have bilateral injuries.40 The need for operative intervention of a cervical wound includes careful inspection for injury
or endovascular repair is rare for both blunt and penetrat- to the trachea and or esophagus before proceeding with for-
ing vertebral artery injuries. mal carotid artery repair. If present, one should protect the
 20 • Neck and Thoracic Outlet 243

arterial repair by interposing muscle between the arterial

repair and aerodigestive tract injury and place at least one
drain near the injury before closing the wound. Vascular
reconstruction in a contaminated field is best performed with
an autologous conduit to avoid prosthetic graft infection.
n Brachial plexus injury: The brachial plexus is fre-
quently injured in the setting of thoracic outlet injuries.
Consequently, a preoperative neurologic examination
of the affected extremity is important to establish the
degree of neurologic compromise. This allows for detec-
tion of evolving neurologic deficits postoperatively due
to operative trauma or to the development of an upper
extremity compartment syndrome.
n Proximal vascular control: Essential to successful
repair and minimization of blood loss is proximal control
of the artery before exposure of the injury. This is particu-
larly important for proximal subclavian injuries and zone
I carotid injuries, where a median sternotomy, proximal III
endovascular balloon occlusion, or a third–fourth inter-
space left thoracotomy (in the case of a left subclavian
artery injury) may be required. The proximal left subclavian
artery is difficult to control through a median sternotomy.
II
n Venous injuries: Venous injuries are frequently asso-
ciated with cervical arterial injuries. Ligation usually
causes minimal morbidity; however, the more proximal I
the injury, the greater the likelihood that the venous
injury requires operative repair. In the setting of bilateral Fig. 20.1 Carotid zones of the neck. Zone I extends from the sternal
internal jugular vein injuries, repair of one is necessary notch to the cricoid cartilage. Zone II extends from the cricoid cartilage
to prevent intracranial venous hypertension. to the angle of the mandible. Zone III extends from the angle of the
n Cranial and phrenic nerves: The anatomic proxim- mandible to the base of the skull.
ity of these nerves to the vasculature of the neck and
thoracic outlet place them at risk during exposure and
repair of vascular trauma in this region. Identification (Fig. 20.1). Zone I spans from the clavicle to the cricoid car-
and preservation of nerve structures are important to tilage, zone II from the cricoid cartilage to the angle of the
minimize short- and long-term morbidity. mandible, and zone III from the angle of the mandible to
n Internal carotid repairs: Thrombosis of the internal the skull base.50 The zone II carotid artery travels within the
carotid artery due to either a blunt or penetrating injury carotid sheath, which also contains the vagus nerve and
may extend intracranially. Gentle passage of a thrombec- internal jugular vein. The common carotid divides into the
tomy catheter from the cervical carotid may be necessary internal and external within zone II, in most instances one
to evacuate distal thrombus. However, it is important to to two fingerbreadths below the angle of the mandible. An
allow “back-bleeding” pressure to remove most of the awareness of carotid bifurcation anatomy is important in
thrombus and not pass the thrombectomy catheter too preoperative planning, particularly for those injuries at the
far up the carotid artery (e.g., into the cavernous portion junction of zones II and III.
of the carotid). In the absence of back-bleeding, repair The operative field for repair of a carotid injury requires
and reperfusion of the distal internal carotid should not preparation of the neck and chest as well as a thigh for pos-
be performed and the artery may be ligated. In patients sible great saphenous vein harvest. For patients with a zone
for whom back-bleeding is restored, intraoperative angi- I carotid or innominate artery injury, median sternotomy
ography should be used to document complete evacua- is required for proximal control (Fig. 20.2). Alternatively,
tion of distal thrombus before repair and reperfusion. endovascular balloon occlusion can be used to establish
n Avoidance of hypotension and hypoxia: For patients proximal control. After proximal control via median ster-
with a neurologic deficit secondary to cortical brain notomy, extension of the incision along the anterior bor-
injury, maintenance of normal blood pressure and der of the ipsilateral sternocleidomastoid provides excellent
avoidance of hypoxemia are essential to prevent second- exposure of the cervical carotid (Fig. 20.3). Opening of the
ary brain injury. carotid sheath and retraction of the internal jugular vein
laterally exposes the facial vein, usually located near the
carotid bifurcation. The facial vein should be ligated and
Operative Strategy and Technique divided allowing for lateral retraction of the internal jugular
vein and exposure of the cervical carotid artery. Care should
be taken to identify and protect the vagus nerve within the
CAROTID
carotid sheath. Cephalad dissection along the medial edge
In 1969, Monson described three zones of the neck for guid- of the internal jugular vein exposes the proximal inter-
ance in diagnosis and treatment of carotid artery trauma49 nal carotid artery. Dissection along the lateral border of
244 SECTION 4 • The Management of Vascular Trauma

Fig. 20.2 (A) Photograph of a zone 1 gunshot wound. (B) Operative

photograph following resection of injured segment of innominate
artery from gunshot wound. (C) Operative photograph of innominate
artery repair with expanded polytetrafluoroethylene (ePTFE) interposi-
tion graft. (Operative photos courtesy Gregory A. Magee, University of
Southern California.)

the internal carotid exposes the hypoglossal nerve, which helpful.51 Dividing the stylohyoid muscles and ligament as
traverses across the superficial surface of the internal and well as the styloid process allows exposure of the internal
external carotid arteries. Identification of the hypoglossal carotid distally to where it enters the skull base. Alternative
nerve can be facilitated by following the ansa cervicalis to its techniques such as mandibular subluxation and osteotomy
junction with the hypoglossal trunk. impart little additional advantage and are associated with
More distal exposure of the internal carotid artery at greater morbidity.
the junction of zones II and III may require division of It is advisable to obtain proximal control prior to exposing
the occipital artery and mobilization of the posterior belly the injury to prevent substantial blood loss. After the injured
of the digastric muscle by release of its posterior fascial segment is exposed, a 2- or 3-Fr Fogarty balloon thrombectomy
investment. Care should be taken to identify and preserve catheter should be passed gently both proximally and distally to
the glossopharyngeal and spinal accessory nerves, which remove thrombus. It is important to use an appropriately small
typically lie posterior and superior to the posterior belly of thrombectomy catheter and to not overinflate the balloon in
the digastric muscle and are at risk during zone III expo- the internal carotid artery in order to avoid arterial spasm,
sure. Anterior displacement of the mandible with fixation dissection, or intimal injury that can lead to thrombosis, and
by intraoral wires may provide additional exposure, but this perforation. Both proximal and distal arterial lumens should be
maneuver requires preoperative planning with placement flushed with heparinized saline solution (e.g., 2000 units hep-
of a nasotracheal airway. In practice this maneuver is rarely arin/1 L saline); and systemic heparin, if not contraindicated,
 20 • Neck and Thoracic Outlet 245

If necessary, an autogenous repair with a vein graft is

recommended, particularly in the presence of aerodigestive
tract injuries. However, in the absence of a contaminated
field prosthetic grafts are a better size match for the common
carotid and have excellent patency (Fig. 20.5). For proxi-
mal internal carotid injuries, transposition of the external
carotid to internal carotid provides another option when
autogenous conduit is not available (Fig. 20.6). Zone III
internal carotid artery injuries may extend to the skull base,
thereby precluding direct operative repair. In this situation,
depending on the type of injury, nonoperative management
or an endovascular approach may be the better option. In
selected circumstances, ligation may be necessary, but this
is associated with a high incidence of stroke.52 Completed
vascular repairs should be tension free and covered by via-
ble soft tissue. Intraoperative completion arteriography or
duplex scanning is helpful to document technical perfec-
tion of the repair and patency of distal arterial segments.53
Fig. 20.7 depicts a successful endovascular treatment of an
internal carotid artery pseudoaneurysm caused by a gun-
A shot wound to zones II and III of the neck.
Endovascular management permits repair of injuries
that are difficult or impossible to surgically expose (e.g., dis-
tal zone III injuries). Endovascular treatment is particularly
useful for treatment of flow-limiting dissections and size-
B able pseudoaneurysms. Vascular access can be achieved
with a femoral approach followed by placement of a 70- to
80-cm sheath into the proximal common carotid artery.
Covered stents may be useful to quickly cover a pseudoan-
eurysm, but they are more likely to cause thrombosis than
uncovered stents so they should be used cautiously and
treated postoperatively with dual antiplatelet therapy for 3
months. Endovascular management is certain to expand as
hybrid operating rooms become more widely available and
surgeons become more adept at endovascular treatment
Fig. 20.3 Operative photograph of a left zone I common carotid artery modalities. The outcome of internal carotid artery ligation
repair performed with a reversed greater saphenous vein interposition or embolization for high zone III injuries is acceptable in
graft (A). Note the position of the left common carotid origin posterior patients who remain neurologically intact with preligation
to the innominate artery (B) on the aortic arch. In this approach, which provocative temporary balloon occlusion testing.
was through a median sternotomy extended proximally in continuity
with a left longitudinal cervical incision, the left subclavian artery origin
VERTEBRAL
is not visible. (Operative photo courtesy Todd E. Rasmussen, the Uni-
formed Services University.) The vertebral artery arises as the first branch of the subcla-
vian, usually at the C6–C7 level. In up to 6% of individu-
als, the left vertebral artery arises directly from the aortic
should be administered to decrease the risk of thrombosis and arch between the origins of the left common carotid and
clot propagation. Intraluminal temporary vascular shunts left subclavian arteries.54 The vertebral artery is divided
(such as the Sundt or Argyl) establish antegrade arterial flow into four anatomic segments (Fig. 20.8). V1 spans from the
to the internal carotid artery and may be beneficial in select origin until entry into the C6 transverse foramen. The V2
circumstances where other life-threatening injuries require segment extends from entry into the C6 transverse fora-
immediate attention and the operative surgeon has experience men until exit from the transverse process of C2. V3 is the
with their use. Proximal common carotid injuries, however, extracranial segment between the transverse process of C2
can be repaired without the use of a shunt in most instances. and the base of the skull. V4 describes the intracranial seg-
The type of repair is dictated by the extent of injury. Pri- ment, beginning at the entrance to the foramen magnum
mary repair or patch angioplasty is possible if the injury is and terminating at its junction with the contralateral ver-
a simple, small laceration as might occur with a stab wound tebral artery forming the basilar artery. The redundant
(Fig. 20.4). For more extensive injuries, it is important to nature of the posterior circulation reduces the likelihood of
identify and débride the injured arterial segment back to adverse neurologic consequences should the smaller, non-
normal artery. Repair of more extensive injuries will require dominant vertebral artery need to be ligated.55,56 Unilateral
an end-to-end anastomosis, an interposition graft or, when hypoplasia of the vertebral artery occurs in approximately
adjacent soft injury is extensive, a bypass graft (i.e., routed 10% of individuals and can be identified on preoperative CT
away from the extensive soft tissue injury). or catheter-based angiography.40
246 SECTION 4 • The Management of Vascular Trauma

Fig. 20.4 (A and B) Through and through injury to the common carotid artery from an ice pick managed by primary repair. (Operative photos courtesy
Damon Clark, University of Southern California.)

Management of a vertebral artery injury depends upon

which anatomic segment is injured, and on the condition
of the contralateral vertebral artery. Vertebral arteries are
more difficult to surgically access than the carotid, making
surgical repair challenging. Consequently, for most pene-
trating or blunt injuries, regardless of the segment injured,
ligation, embolization, or nonoperative management is
appropriate. It is important to determine, if possible, which
of the vertebral arteries is the larger or dominant vessel.
If it is determined that the injured artery is the dominant
or only vertebral artery, an effort should be made to main-
tain antegrade flow. When there is significant hemorrhage
from a vertebral artery it should be surgically explored and
ligated or embolized, accepting the risk of a possible poste-
rior circulation stroke.
For the rare injury requiring open repair, exposure of
the V1 segment of the vertebral artery is via a medial
transverse supraclavicular incision over the two heads
of the sternocleidomastoid. Dividing the heads or split-
ting the two heads longitudinally exposes the carotid
sheath. Opening the sheath, retracting the carotid medi-
ally, retracting the vagus nerve and internal jugular vein
laterally, and dividing the vertebral vein allows direct
access to the vertebral artery and proximal subclavian
artery.
Exposure of the V2–V4 segment is rarely necessary
and challenging as the V2 segment courses through the
Fig. 20.5 Interposition expanded polytetrafluoroethylene (ePTFE) bony transverse foramina. Through the same exposure
repair of right common carotid injury. (Operative photo courtesy Todd E.
Rasmussen, the Uniformed Services University.)
discussed for the V1 segment, the longus coli muscle is
encountered in the deep posterior aspect of the neck. Once
 20 • Neck and Thoracic Outlet 247

Fig. 20.6 Illustration of external

carotid–internal carotid transposition.
(A) Proximal ICA injury is depicted.
(B) Transposition is accomplished
by proximal mobilization of ECA
with transposition and end-to-end
anastomosis of the proximal ECA
and ICA distal to the injury. ECA,
External carotid artery; ICA, internal
A B carotid artery.

10.32*mm

Fig. 20.7 (A) Angiogram of right inter-

nal carotid artery pseudoaneurysm
due to a shotgun blast to zones II and
III. The arrow points to the pseudoan-
51.69*mm eurysm. (B) Completion angiogram fol-
lowing endovascular treatment with a
bare-metal stent and coiling (arrow) of
A B the pseudoaneurysm.

this muscle is swept off of the underlying bony structure, medial to the anterior scalene muscle, contains the most
the anterior tubercle of the transverse process and the important branches, including the vertebral artery, the
vertebral bodies are visualized. A bone rongeur may be internal mammary artery, and the thyrocervical trunk. The
used to remove the anterior rim of the vertebral foramen second segment of the subclavian artery is posterior to the
to expose the vertebral artery. Moderate to severe bleed- anterior scalene, and the short third segment extends from
ing may occur during this part of the dissection due to the lateral border of the anterior scalene muscle to the lat-
the venous plexus of the bony canal. Care should be taken eral edge of the first rib, where it becomes the axillary artery.
not to injure the cervical nerve roots, which lie directly The phrenic nerve lies either directly on or medial to the
posterior to the artery. A posterior auricular approach is anterior scalene muscle and can be injured during exposure
required to expose the V3 segment of the artery, and the of the first and second segments of the artery. The artery
V4 segment can only be exposed with a craniotomy. Expo- anatomically is posterior to the subclavian vein, the verte-
sure of V3 and V4 segments is best done with the assis- bral vein, the anterior scalene muscle, and the thoracic duct
tance of a neurosurgeon. on the left.55
Penetrating subclavian injuries are commonly associated
with hemodynamic instability, which requires immediate
SUBCLAVIAN
surgical exploration. For injuries that are bleeding, tempo-
The left subclavian artery arises as the third and final great rizing measures including resuscitative thoracotomy in the
vessel from the aortic arch. The right subclavian artery ED may be necessary. Rapid control has also been achieved
arises from the innominate artery. The subclavian artery by inserting a Foley catheter in the wound tract and inflat-
extends from its origin to the lateral border of the first rib ing the balloon.9 Patients who are hemodynamically nor-
and is divided into three segments based on the relationship mal require CTA for delineation of the penetrating wound
of the anterior scalene muscle (Fig. 20.9). The first portion, and of the extent of vessel injury.
248 SECTION 4 • The Management of Vascular Trauma

the right subclavian artery, a median sternotomy is nec-

essary to achieve proximal control. The sternotomy inci-
sion may be combined with a supraclavicular extension
V4 to allow full exposure of the right subclavian artery. On
the left, proximal control requires a third or fourth space
anterolateral thoracotomy due to the left subclavian's ori-
V3
gin from the more posterior distal arch. Following proxi-
mal control, a supraclavicular incision can be made for
exposure. If the capability is present, proximal control of
either subclavian artery can also be achieved by endovas-
cular balloon occlusion at the time of diagnostic angiog-
raphy or operation.
If the vessel injury is localized to the second or third
V2 segments of the subclavian artery on the left or right,
a supraclavicular incision may be all that is needed to
access and repair the injury. Injuries associated with cer-
vical or supraclavicular swelling, mediastinal widening,
or intrathoracic bleeding may still require intrathoracic
proximal control. Distal control may be obtained bilater-
ally by exposure of the axillary artery through an infra-
clavicular incision.9
V1
For simple stab wounds, primary repair may be pos-
sible, but in most cases an interposition graft is necessary
for reconstruction. Prosthetic graft with 8-mm diameter
is recommended. Saphenous vein should be reserved for
Fig. 20.8 Anatomic segments of the vertebral artery. V1 is from the sub- cases of severe contamination due to the poor size match
clavian origin to the entry into the C6 transverse foramen. V2 is from the between saphenous vein and the subclavian artery. When
C6 transverse foramen to the exit from the bony canal at the transverse extensive repair is required or if the patient is physiologi-
process of C2. V3 is the extracranial segment between the transverse cally compromised, ligation can be performed as a damage
process of C2 and the base of the skull. V4 is the intracranial segment, control maneuver. In cases in which the subclavian artery
terminating at its junction with the contralateral vertebral artery. must be ligated, the robust collateral network of the shoul-
der and supraclavicular fossa often provides enough perfu-
sion to maintain a viable, if not relatively ischemic, arm and
hand. Concomitant venous injuries are common and lateral
Anterior scalene repair is preferable to ligation, when possible. More complex
muscle repairs are not necessary because subclavian vein ligation
is usually well tolerated, although it can be associated with
arm swelling. More proximal venous injuries involving the
Vertebral artery brachiocephalic veins or the superior vena cava should be
repaired when possible.
Endovascular repair of subclavian artery injuries has been
performed in stable patients with success rates over 93%.57–60
Endovascular therapy can be utilized as definitive treatment
or as a means to stabilize the patient and to provide a bridge
to definitive therapy. It is estimated that approximately 50%
of penetrating subclavian artery injuries are amenable to
endovascular treatment.58,61,62 The procedure is performed in
conjunction with a diagnostic arteriogram via femoral access
III II I and long sheaths or via an ipsilateral retrograde brachial
artery approach. Once the guidewire traverses the injured
Fig. 20.9 Anatomic segments of the subclavian artery. Segment I segment, a covered stent can be delivered and deployed. If
extends from the subclavian origin to medial border of the anterior sca- coverage of the vertebral artery is necessary, a patent nor-
lene muscle. Segment II is posterior to the anterior scalene muscle. Seg- mal or dominant ­contralateral vertebral artery should be
ment III extends from the lateral edge of the anterior scalene muscle to documented by catheter-based angiography or CTA.63
the lateral edge of the first rib.

The anatomic location of the injury on the subclavian Postoperative Care, Complications,
artery dictates which operative exposure will best facilitate and Outcomes
vascular control and repair. For all operative repairs of
subclavian injuries, the neck and chest should be included Patients who undergo operative or endovascular repair
in the operative field. For injuries of the first segment of should be monitored postoperatively in the intensive care
 20 • Neck and Thoracic Outlet 249

unit (ICU) for vascular or neurologic changes. Cerebral

edema, and on rare occasions hemorrhagic conversion of
an infarct, may be preceded by headache and a deterioration
in neurologic status.64 Intracranial hypertension resulting
from cerebral injury is associated with hemodynamic insta-
bility, particularly bradycardia and hypertension. Continu-
ous infusion of intravenous calcium channel blockers may
be used to lower blood pressure in patients who are hyper-
tensive. With injury to extracranial cerebral vessels with or
without clinical neurologic change, the injured brain may
be sensitive to hypotension and prone to secondary brain
injury. As such, strict maintenance of a normal mean arte-
rial pressure (70–90 mm Hg) and avoidance of hypoxemia
are crucial to limiting extension of any neurologic damage
in the ischemic penumbra.65
For vascular injuries in the cervical region, postoperative
coagulopathy and soft tissue swelling may lead to airway Fig. 20.10 Completed closure of right common carotid artery repair
compromise. To protect the airway, endotracheal intuba- over a closed suction drain. (Operative photo courtesy Todd E. Rasmus-
tion should be maintained until the neck hematoma and sen, the Uniformed Services University.)
edema have subsided. For zone I carotid and proximal sub-
clavian injuries, monitoring of chest tube and wound drain
output as well as daily chest x-rays are required to promptly The development of a postoperative lateralizing neuro-
detect unexpected bleeding. Chest CT may also be helpful in logic deficit after carotid reconstruction is an ominous devel-
identifying occult postoperative bleeding. Refractory hypo- opment. In most patients, this is due to either progressive
tension and falling hemoglobin should prompt a return to cerebral edema or occlusion of the arterial repair. Cerebral
the operating room for wound exploration and hemorrhage edema should be managed by monitoring of intracranial
control. pressure, measures to limit brain swelling, and craniectomy
Patients who have undergone axillary or subclavian if refractory. If an occluded arterial repair is documented,
artery repairs run the risk of upper extremity reperfusion the decision for carotid exploration and repair depends
injury and subsequent compartment syndrome. Although upon the degree of neurologic deficit, the head CT scan find-
this phenomenon is less common in the upper than in the ings, and the hemodynamic stability of the patient. For sta-
lower extremity, patients should be monitored closely in the ble patients with minimal to no evidence of cerebral injury
postoperative period for increased forearm or hand pain and on brain CT, a rapid return to the OR for thrombectomy
for the development of neurologic deficits in the forearm or and repair is indicated. As was the case with the primary
hand. In patients who develop such symptoms, evaluation repair, gentle passage of a thrombectomy catheter distally
of compartment pressures and/or performance of a fore- with the reestablishment of back-bleeding is required before
arm fasciotomy is indicated. proceeding with formal repair and reperfusion. Intraopera-
Nearly all cases of open operative repair of vascular tive angiography is helpful to document complete evacua-
trauma in the thoracic outlet or cervical region should be tion thrombus and evaluate for stenoses or other causes of
closed over a closed suction drain (e.g., flat Jackson-Pratt early graft failure. For patients with a large cerebral injury
or similar closed suction drain) (Fig. 20.10). This practice shown on head CT, nonoperative management is probably
allows control and management of missed or inadvertent the best course of action, as the prognosis is poor regardless
injuries to the esophagus, or the thoracic duct should the of whether or not flow can be established in through the
operative exposure have been of the left thoracic outlet. injured carotid artery segment.
Generally, there should be minimal if any output from these Penetrating carotid artery trauma is associated with
drains. However, should there be persistent drainage, the an all-cause mortality of 60%, with a mortality due spe-
fluid can be checked for elevated triglycerides and the pres- cifically to the carotid injury of 20% to 42%.71,72 Worse
ence of chylomicrons either of which would confirm an outcomes are associated with hypotension or coma on
injury to the thoracic duct.66 arrival at the ED. Internal carotid artery injuries have a
In the absence of contraindications, postoperative anti- higher stroke rate than common carotid injuries because
platelet therapy should be administered in the form of antegrade internal carotid artery flow can be maintained
aspirin if vein or prosthetic graft was used for arterial via retrograde flow from the external carotid.73 Operative
reconstruction. Typically, antiplatelet therapy is contin-
­ management of patients with a neurologic deficit leads to
ued for a minimum of 30 days. Patients undergoing stent stabilization or improvement in the neurologic deficit in up
placement should be placed on dual antiplatelet therapy for to 92% of patients.28 Worse operative outcomes are associ-
a minimum of 30 days and up to 6 months after the inter- ated with a gunshot wound versus a stab wound and with
vention. This has been recommended in patients undergo- more complex operative repairs. Endovascular therapy has
ing stenting for atherosclerotic carotid disease67 and has been focused on the management of carotid and vertebral
been confirmed to be of benefit in the trauma literature as pseudoaneurysms that are surgically inaccessible. Multiple
well.68–70 Repeat imaging using CTA or duplex ultrasound studies evaluating the use of stents to treat cerebrovascular
of the stent is recommended during follow-up to evaluate injuries have shown high technical success with low stroke
for restenosis.67 and mortality rates.53,68,69,74
250 SECTION 4 • The Management of Vascular Trauma

The value of intensive screening and treatment for clini- 9. Demetriades D, Chahwan S, Gomez H, et al. Penetrating injuries
cally occult blunt carotid and vertebral artery injuries can- to the subclavian and axillary vessels. J Am Coll Surg. 1999;188(3):
290–295.
not be overemphasized. If one can detect and then treat 10. Bricker DL, Noon GP, Beall Jr AC, DeBakey ME. Vascular injuries of the
BCVI with antiplatelet and or anticoagulation therapy, the thoracic outlet. J Trauma. 1970;10(1):1–15.
incidence of adverse neurologic events can be reduced. In a 11. Lin PH, Koffron AJ, Guske PJ, et al. Penetrating injuries of the subcla-
retrospective review of 147 patients with BCVI, the stroke vian artery. Am J Surg. 2003;185(6):580–584.
12. Graham JM, Feliciano DV, Mattox KL, Beall Jr AC, DeBakey ME.
rate was 25.8% for untreated patients versus 3.9% for those Management of subclavian vascular injuries. J Trauma. 1980;20(7):
receiving any mode of antiplatelet or anticoagulation ther- 537–544.
apy.75 Blunt carotid trauma tends to have a higher stroke 13. Hyre CE, Cikrit DF, Lalka SG, Sawchuk AP, Dalsing MC. Aggressive
rate correlated with an increasing grade or severity of management of vascular injuries of the thoracic outlet. J Vasc Surg.
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of injury.6 15. Sekharan J, Dennis JW, Veldenz HC, Miranda F, Frykberg ER. Con-
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carotid trauma.76 At discharge, 78% of penetrating carotid arteriography in patients with penetrating zone II neck wounds. Arch
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The mortality rate for subclavian artery injury is approx- 18. Demetriades D, Theodorou D, Cornwell 3rd E, et al. Penetrating
imately 34% for those who survive to the hospital, and injuries of the neck in patients in stable condition. Physical exami-
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is associated with early failure rates of approximately 5%.58 19. Inaba K, Munera F, McKenney M, et al. Prospective evaluation
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 Upper Extremity and Junctional
21 Zone Injuries
MATTHEW VUONCINO, JOSEPH M. WHITE, and W. DARRIN CLOUSE

available studies, and several general comments pertaining

Epidemiology of Upper Extremity to the characterization of upper extremity vascular injury
Vascular Injury and subsequent outcomes can be made.
Upper extremity vascular trauma is less common than
Reports from civilian and military settings have shown the that in the lower extremity, in both military and civil-
distribution and outcomes of major vascular injuries going ian environments. Historically, upper extremity vascular
as far back as the Civil War (Table 21.1).1–24 Although some injury accounts for approximately 30% of all vascular inju-
publications comment on and provide details related to vas- ries.4,9,16 In several of the most recent civilian series, as well
cular injury in the upper extremity, it is often difficult to dis- as in the Balad Vascular Registry (BVR) and Department
cern specific epidemiology and outcomes of upper extremity of Defense Trauma Registry (DoDTR), upper extremity
vascular injuries. An exception to this would be the contem- arterial injury constitutes 30% to 40% of extremity arte-
porary epidemiologic characterization of the wars in Iraq rial trauma. Penetrating mechanisms of injury are more
and Afghanistan.1,23,24 Following implementation of a mod- common than blunt mechanisms, especially in the military
ern trauma system registry, detailed analysis of vascular setting. However, in civilian series, blunt mechanisms are
injury is now feasible. As a consequence, patterns concern- associated with a higher morbidity and mortality compared
ing upper extremity vascular injury can be observed across to penetrating injury. This is mostly attributable to the

Table 21.1 Select Civilian and Military Series Reporting Upper Extremity Arterial Injuries.
Injured Artery Distribution

Penetrating: Number of Injured

Series Setting Year Blunt Arteries (UE:LE) Subclavian Axillary Brachial Radial Ulnar
Graham et al. Civilian 1955–78 93%:8% 93 93 NR NR NR
Mattox et al. Civilian 1958–88 NR 859 : 4901c 168 143 446 261
Hardin et al. Civilian 1967–79 84%:16% 100 NR 21 43 36
Fitridge et al. Civilian 1969–91 55%:45% 114 16 12 62 24
Graham et al. Civilian 1970–80 95%:5% 85b 9 51 13 NR
Humphrey et al. Civilian 1970–90 59%:41%c 115 : 56 3 9 30 36 37
Pasch et al. Civilian 1979–84 100%:0%a 48 : 91 NR 15 33 NR
Costa et al. Civilian 1981–87 0%:100% 15 15 NR NR NR
Shaw et al. Civilian 1983–92 78%:12% 43 15 28 NR
Lin et al. Civilian 1991–2001 100%:0% 54 54 NR NR NR
Demetriades et al. Civilian 1993–97 100%:0% 79b 59 NR NR
Brown et al. Civilian 1992–98 70%:30% 64 6 13 26 5 6
Menakruru at al. Civilian 1996–2002 16%:84%a 67 : 63 6 4 38 11 8
Zellweger et al. Civilian 1999–2002 97%:3% 124 NR NR 124 NR
Shanmugam et al. Civilian 2000–02 55%:44% 27 0 2 13 7 5
Dragas et al. Civilian/Military 1992–2006 77%:23% 189 3 41 104 40
Peck et al. Civilian 2004–06 88%:3%a 40 : 150 NR 4 25 11
DeBakey et al. Military WWII NR 864 : 1607 21 74 601 99 69
Hughes Military KW NR 112 : 192 3 20 89 NR
Rich et al. Military 1965–68 95%:1.1%a 350 : 650 8 59 283 NR
Clouse et al. Military 2004–05 85%:15% 43 10 25 23
Clouse et al. Military 2004–06 94%:6%a 76 : 225 11 42 23
a
Data combines upper and lower extremity artery injury data.
b
Data combines upper extremity artery and venous injury data.
c
Data combines all cardiovascular injuries.
d
Data is for upper extremity artery injury only.
AVAG/P, Autologous vein or artery graft or patch angioplasty; KW, Korean war; LE, lower extremity; NR, not reported; UE, upper extremity.

252
 21 • Upper Extremity and Junctional Zone Injuries 253

effects of concomitant injuries. Interestingly, recent epide- Addressing Complex Upper

miologic data has demonstrated a transition with respect
to the most commonly injured vessels in the upper extrem- Extremity Vascular Injury
ity. Previously, the brachial artery was reported as the ves-
sel with the most significant incidence of trauma; however, GENERAL CONSIDERATIONS
distal or forearm vessels are now the most common injury Unpredictable arterial injury patterns require that surgeons
identified. The next most commonly injured are the brachial be able to apply a diverse armamentarium of techniques.
vessels, whereas the axillary and subclavian arteries in the Efficient application requires foresight of potential intraop-
junctional zone are the least frequently injured vessels of erative and postoperative issues during the diagnostic and
the upper extremity. With respect to types of repair, pri- assessments stage. Failure to correctly prepare can prolong
mary, patch angioplasty, and autologous vein interposition operative time and result in suboptimal outcomes. Intra-
grafting are the most common techniques used to manage venous access should be obtained in another uninjured
vascular injuries in the arm. extremity, and central venous access may be helpful. As
The incidence of amputation associated with upper detailed in previous chapters of this text, attention to resus-
extremity arterial injury ranges from 1% to 28% with citation must be diligent.
more recent reports demonstrating a rate of approxi- Orthopedic and soft-tissue injuries often occur in tan-
mately 10%. It has been suggested that in modern military dem with upper extremity vascular injuries. This is espe-
settings, the rate of early limb loss with upper extremity cially germane in combat scenarios given the frequency of
vascular injury may be more pronounced than in the high-energy weaponry and improvised explosive devices.
lower extremity.1,2 Multimechanistic etiology with blast, When faced with arterial injury in conjunction with bone
penetration, and burn are common. This, along with the and/or nerve injuries, several concepts should be reviewed.
smaller surface area and soft tissue structure of the arm, Orthopedic long bong injuries should be brought to length
may lead to difficulties with revascularization and soft tis- with temporary fixation before definitive vascular repair.
sue coverage. Mortality associated with upper extremity In most instances, when vascular and orthopedic injuries
vascular trauma is rare but not negligible, ranging from occur together, wound concerns require external fixation of
0% to 34% and mostly attributable to concomitant head the fracture with permanent internal fixation kept as an
and torso injuries. option, if needed, once other aspects of injury are optimized.

Operative Repair Technique Associated Injuries Outcomes

Series Limb Series

Primary AVAG/P Prosthetic Ligation Nerve Bone Vein Loss Mortality
33 8 17 0 18 (19%) 17 (18%) 38 (40%) NR 12 (13%)
NR NR NR NR NR NR NR NR NR
69 19 0 19 46 (46%) 6 (6%) 14 (14%) 2 (2%) NR
39 45 1 14 47 (41%) 35 (30%) NR 9 (7%) 3 (2%)
20 13 18 0 23 (35%) NR 20 (30%) 1 (1%) 2 (3%)b
126c 40c 15c 47c 63 (29%)c 70 (32%)c NR 26 (11.4%)c 10 (4.8%)c
14 34 0 0 38%d NR 62 (45%)a 1 (0.7%)a 0a
NR NR NR NR 8 (53%) 12 (80%) NR 2 (13%) 1 (7%)
NR NR NR NR 13 (30%) 3 (6%) NR 3 (10%) NR
38 10 3 3 17 (31%) NR 23 (44%) NR 39%
19 18 22 0 26 (32%) NR 20 (25%) NR 27 (34%)b
27 32 6 6 12 (19%) 8 (13%) 20 (31%) 4 (5%) 2 (3%)
103a 32a 4a NR 16 (10%)a 90 (60%)a 13 (9%)a 9 (6%) 12 (8%)
47 73 2 2 77 (62%) 17 (14%) 12 (10%) NR NR
5 12 2 6 6 (22%) 10 (37%) 10 (37%) 1 (3%) 0
57 99 2 6 91 (55%) 45 (27%) 62 (37%) 10 (6%) 4 (2.4)%
4 25 2 9 NR NR 15 (38%) 4 (3%)a 2 (1.5%)a
81a 40a 14a 1639a NR NR NR 214 (24%)d NR
77 20 0 15 NR NR 192 (63%)a 13%a NR
464a 462a 4a 15a 424 (42%)a 285 (29%)a 377 (38%)a 19 (2%)d 17 (1.7%)a
7 26 2 1 38 (88%) 10 (23%) 5 (11%) 4 (9.3%) NR
15a 47a 1a 13a NR NR NR 7 (8.5%)a 14 (4.3%)a
254 SECTION 4 • The Management of Vascular Trauma

Temporary vascular shunts should be considered as a way had a survival advantage as compared with application of
to quickly restore perfusion to the extremity before place- the tourniquet in the emergency department (ED) after the
ment of external fixation devices. This strategy or sequence patient had developed shock (90% vs. 10%; P < .001).25,26 A
allows for expedited perfusion to the extremity, a more small percentage (1.7%) of patients experienced nerve palsy
thoughtful and well-done fixation, and an easier platform at the application level, but no amputations resulted from
for definitive arterial and/or venous reconstruction. tourniquet use.
Débridement of devitalized tissue should be performed In another study by the Israeli Defense Forces, the use of
and, in some scenarios, primary amputation should be con- combat tourniquets was evaluated over 4 years. In all, 110
sidered. In our experience, routing of vascular bypass grafts tourniquets were applied for extremity injury, of which 34
through deep anatomic planes is possible in the majority of were used to treat upper limb trauma. In that study, 94% of
cases. In instances where cavitary soft-tissue defects exist, upper limb injuries were controlled by tourniquet, as com-
extraanatomic routes may be needed and deep intermus- pared to only 74% of lower extremity injuries.27 Neurologic
cular or subcutaneous planes can be used depending on complications developed in seven limbs and four of these
which path provides the best route for protecting the graft. involved nerve palsies of the upper extremity. Injuries distal
Consideration must be given to primary repair of con- to the axillary artery are most amenable to control by tour-
comitant nerve injuries versus tagging the nerve ends for niquet. Designs include windlass tourniquets, such as the
delayed neurorrhaphy once the wound has been stabilized. Combat Application Tourniquet (CAT) and the Special Oper-
As described in the following sections of this chapter, repair ations Forces Tactical Tourniquet (SOFTT), both of which
of venous injury may improve limb outcomes and should be are commonly issued to combat troops. The Emergency and
entertained particularly with axillosubclavian injuries and Military Tourniquet (EMT) has a pneumatic compression
in the absence of other life-threatening injuries. We give design. One study of volunteers who self-applied the CAT,
serious consideration to reconstruction of at least one vein SOFTT, or EMT found each design to consistently interrupt
in the upper arm when brachial, cephalic, and basilic veins distal perfusion as assessed by Doppler.28
have been disrupted (Fig. 21.1). The brachial or basilic veins Historically, there had been apprehension about the use
are favored for reconstruction because they lie within the of tourniquets in the prehospital setting. However, more
exposure field required to manage the arterial injury and recent studies, largely propelled from modern combat expe-
are more easily covered with tissue. rience in Iraq and Afghanistan, have shown tourniquets
to be an important means of preventing extremity hemor-
rhage death.29,30 It is difficult to generalize this data to set-
tings outside of military systems which, through extensive
TOURNIQUETS IN UPPER EXTREMITY VASCULAR
training efforts and rapid medical transport, have created
INJURY circumstances that lend themselves to successful tourni-
The use of tourniquets in the modern civilian trauma set- quet use.31 Thus, although it may be premature for wide-
ting has not been systematically endorsed, but the effective- spread use of tourniquets in the civilian setting, some upper
ness of tourniquets has been demonstrated in the combat extremity vascular injuries would surely benefit from their
environment. Early application of tourniquets in Operation use as long as they are removed as soon as possible.
Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) has
proven effective and life-saving in patients with extremity
injuries. In 2009, Kragh et al. reported that application of a Considerations for Management of Upper
tourniquet in the absence of shock in a prehospital setting Extremity Vascular Trauma
1. Tourniquets for hemorrhage control, temporary shunts
for early restoration of perfusion, and low threshold
B
for fasciotomy when facing delayed repair or complex
upper extremity injuries.
2. Prepare and drape the patient to allow for appropriate
proximal and distal control of the injury, as well as har-
vesting of autologous conduit such as saphenous vein.
3. Exposure in the upper extremity junctional zone is dif-
ficult. Be prepared for sternotomy and thoracotomy.
4. Long bong fractures should be brought to length before
vascular repair. (Consider immediate vascular shunt
placement followed by placement of fixation devices.)
D C 5. Liberal use of interposition grafting and patching
A
avoids arterial narrowing that often results from pri-
Fig. 21.1 View from the patient's head. A high-energy gunshot injury mary repair.
to the left inner arm resulted in a “blowout” injury at the bullet exit site. 6. Prosthetic conduit is an acceptable option in upper
A greater saphenous vein (GSV) brachial artery to radial artery bypass extremity junctional zone injuries where size match is
was performed to address the brachial artery injury, and a GSV interpo- important and where infectious complications are less
sition graft was used to repair the basilic vein injury. Fasciotomy was common than in the groin.
performed. Arrows indicate cavitation injury, brachioradial GSV bypass, 7. Repair of venous injury may improve limb outcomes
basilic vein interposition, and median nerve. (A) Cavitation injury. (B) and should be entertained, particularly in the proximal
Brachioradial GSV bypass. (C) Basilic vein. (D) Median nerve. upper extremity or junctional zone.
 21 • Upper Extremity and Junctional Zone Injuries 255

8. Endovascular repair of upper extremity vascular injury

is now possible with reasonably good early results, par-
ticularly in proximal or central injuries.
9. Liberal use of Duplex ultrasound as a means to sur-
veille the repair is recommended.
10. Elevation of the extremity, early rehabilitation, and
antithrombotic therapy are important in the postop-
erative care after revascularization for upper extremity
trauma.

TEMPORARY VASCULAR SHUNTS IN UPPER

EXTREMITY VASCULAR INJURY
Traditionally, the operative strategy for extremity vascular
injury was guided by the dictum “life over limb.” In the wars
in Afghanistan and Iraq, experience with damage control
resuscitation and damage control surgery have shown that
in many instances of mangled extremity it is possible to save
both life and limb. An understanding of damage control Fig. 21.2 Brachial artery temporary vascular shunt used to maintain
adjuncts such as temporary vascular shunts and a methodi- distal perfusion while orthopedic fixation was performed to bring the
cal evaluation of complex extremity injuries can assist in humerus to length.
minimizing morbidity and mortality while attempting to
maximize functional outcomes in these scenarios.
Temporary shunts can allow for rapid restoration of dis-
tal arm perfusion when immediate vascular reconstruction Table 21.2 Mangled Extremity Severity Score (MESS).
is not possible (Fig. 21.2).32–40 Delays in vascular repair may Variable Injury Assessment Points
result from a need for fixation of an associated fracture, Skeletal Low energy (stab; simple fracture; civilian 1
débridement of a soft tissue wound, or even harvesting and GSW)
preparing vein conduit. Vascular injury repair may also Medium energy (open or multiple 2
need to be postponed while more serious, life-threatening fractures, dislocation)
injuries are managed. Finally, if there is not time or the High energy (close-range shotgun or 3
clinical expertise at the initial operation, delayed repair of military GSW; crush injury)
the injury may be necessary. In any of these cases, and as Very high energy (above + gross 4
discussed in a dedicated chapter of this textbook, placement contamination; soft-tissue avulsion)
of a temporary vascular shunt may be indicated as a means Limb ischemia Pulse reduced or absent but perfusion 1a
to restore perfusion and buy time until formal repair can be intact
accomplished. Pulseless; paresthesias; diminished 2a
capillary refill
Cool; paralyzed; insensate; numb 3a
MANGLED EXTREMITY SCORES IN UPPER Shock SBP always >90 mm Hg 0
EXTREMITY VASCULAR TRAUMA Transient hypotension 1
A mangled extremity is defined as an injury involving soft Persistent hypotension 2
tissue, bone, nerve, and vasculature. Determining which Age (years) <30 0
patients and mangled upper extremities will benefit from 30–50 1
aggressive attempts at limb salvage and which would be bet- >50 2
ter served with primary amputation is challenging. Exhaus-
tive efforts at limb salvage in severely injured patients may
a
Score doubled for ischemia time >6 hours.
GSW, Gunshot wound; SBP, systolic blood pressure.
result in misdirection of care, whereas premature extremity Adapted from Johansen, et al. Objective criteria accurately predict
amputation may preclude optimal functional outcome. amputation following lower extremity trauma. J Trauma. 1990;30:568–572,
Scoring systems have been developed to take into consider- discussion 72–73.
ation concomitant injuries, as well as the degree and nature
of the bony, soft tissue, the nerve features, and the vessel
features of extremity injury. These systems are designed to and Limb Salvage Index (LSI), has been evaluated and each
assist in decision-making during the early phases of man- system’s ability to predict limb-salvage and functional out-
gled limb management and to provide a mechanism to do come assessed.42–44 Only the MESI was proposed to evaluate
comparative retrospective studies of extremity injury.41,42 mangled upper extremities, but the MESS has also been ret-
These systems could theoretically discern between those rospectively applied to upper extremity injuries.41,45–47
extremities in which salvage will be successful and those The most robust validation studies of mangled extrem-
in which up-front amputation is most appropriate. The use ity scores focused on the lower extremity, and caution is
of scoring systems, such as the Mangled Extremity Severity advised in applying the MESS to upper extremity inju-
Score (MESS) (Table 21.2), Mangled Extremity Syndrome ries.42,47 However, the simplicity of determining the MESS
Index (MESI) (Table 21.3), Predictive Salvage Index (PSI), (evaluation of four clinical variables—skeletal/soft-tissue
256 SECTION 4 • The Management of Vascular Trauma

Table 21.3 Mangled Extremity Syndrome Index (MESI).

MESS scores less than 4. However, graduated reductions
in amputation-free survival were observed in patients with
Variable Injury Assessment Points a MESS of 5 to 7 (relative risk [RR] 3.5; 95% confidence
Injury severity 0–25 1 interval [CI] 0.97–12.4; P = .06) and a MESS of 8 to 12
score 25–50 2 (RR 16.4; 95% CI 3.79–70.98; P < .001).
>50 3 Collectively, we believe that mangled extremity scores
Integument Guillotine 1 serve as objective reminders of subjective clinical experi-
Crush/burn 2
ence. They provide cues to the nuances leading to either limb
salvage, or limb loss in severely injured extremities, and pro-
Avulsion/degloving 3
vide general guidelines. However, their clear and unques-
Nerve Contusion 1
tioned use as indicators of whether an upper extremity
Transection 2 should be primarily amputated remains to be proven, and
Avulsion 3 the expertise and opinion of the evaluating surgical team
Vascular Artery transection 1 remains most essential in the approach to management.
Artery thrombosed 2
Artery avulsed 3
Venous injury 1
Surgical Management for Upper
Bone Simple fracture 1
Segmental fracture 2 Extremity Vascular Injury
Segmental-comminuted fracture 3
Although hemorrhage and ischemia are the key determi-
Segmental-comminuted with bone 4
loss <6 cm nants indicating the need for intervention and repair, a
Segmental fracture intra-extra 5
deeper understanding of the presentation and diagnostic
articular nuances of the different upper extremity arteries is nec-
Segmental fracture intra-extra articu- 6 essary. This knowledge allows one to optimize decisions,
lar with bone loss >6 cm including in situations where nonoperative management
Bone loss >6 cm Add 1 may be appropriate. Unstable patients should be taken to
Lag time 1 point for every hour >6 hours the operating room. Those with normal vital signs and no
Age 40–50 1
signs of bleeding may undergo further diagnostic imaging
to better inform their treatment. Chest x-ray can reveal a
50–60 2
fractured rib(s) or clavicle(s) and hemopneumothoraces,
60–70 3
and provide information about the mediastinum. Bilat-
Preexisting disease 1 eral arm pressures using continuous wave-Doppler (i.e.,
Shock Systolic blood pressure <90 2 measurement of an injured extremity index) functions
as an extension of the physical examination that allows
diagnosis of arterial injury. In a hemodynamically stable
patient, CT angiography (CTA) offers the opportunity
injury, limb ischemia, shock, and age) has resulted in its to determine the location and nature of upper extrem-
use in assessing upper extremities for viability. Slauterbeck ity injury and define concomitant non-vascular injuries,
et al. reported on 43 upper extremity injuries, and found all thereby optimizing operative planning. Duplex ultrasound
9 arms with a MESS of greater than or equal to 7 were pri- can be helpful in diagnosis beyond the subclavian artery.
marily amputated, whereas a score of less than 7 resulted in Contrast arteriography is useful, particularly when cath-
successful limb salvage.46 Durham et al. also evaluated the eter-based endovascular repair (e.g., stent-graft repair) is
application of limb-salvage scores for both upper and lower considered.
mangled extremities and concluded MESS and MESI both
decently predicted upper limb salvage (MESI Sn = 100%,
Sp = 67%, PPV = 90%, NPV = 100%; MESS Sn = 78%, SUBCLAVIAN ARTERY
Sp = 100%, PPV = 100%, NPV = 60%).45 Interestingly,
the authors concluded that these scores did not accurately Subclavian Artery Injuries
predict functional outcome, emphasizing that limb viability The relatively short extent of the subclavian vessels, along
and limb function are related but not the same. with their surrounding bony structures and musculature,
The application of MESS to combat-related upper extrem- makes injuries to these proximal upper extremity vessels rare.
ity injury has been published from experiences during the Although injury to the subclavian artery is more common
wars in Iraq and Afghanistan. In a combination of 17 upper in penetrating trauma, reports from military and civilian
and 43 lower extremity injuries, Rush and colleagues sug- centers show the prevalence of subclavian artery injuries to
gested a MESS of 7 or greater predicted limb loss.48 In a pro- range from 1% to 10%. Subclavian vascular injury should
pensity-adjusted, multivariate analysis of 64 shunted versus be considered when the bony structures of the thoracic out-
61 matched, non-shunted arterial extremity injuries with let, such as the first rib or the clavicle are fractured. Sub-
nearly 2-year follow-up, Gifford confirmed the fidelity of the clavian artery injury may not present with critical ischemia
MESS.49 This case-control study included 35 upper extrem- given the ample collateral circulation around the shoulder.
ity injuries and 90 lower extremity injuries. No difference Absence of a distal pulse in an upper extremity, reduction in
in amputation-free survival was seen in extremities with the injured extremity index (less than 0.9), or the presence
 21 • Upper Extremity and Junctional Zone Injuries 257

of hemodynamic collapse with apparent mechanism should relationship to the anterior scalene and the branches provide
be considered highly suspicious for occult subclavian artery collateral pathways around the shoulder (Fig. 21.4). The first
injury. In fact, many patients with a subclavian artery portion is proximal to the muscle and its branches include
injury will present in shock. Hemopneumothorax is com- the vertebral artery, the thyrocervical trunk, and the inter-
mon. Other signs can include supraclavicular and low cer- nal thoracic artery. The phrenic and vagus nerves cross ante-
vical swelling or tracheal compression from a hematoma. rior to the artery, and the internal jugular and subclavian
Concomitant injuries to the cervical or thoracic spine may vein join anterior to the nerves. On the left, the thoracic duct
be present, and brachial plexus injuries along with associ- courses across the proximal subclavian artery and drains
ated venous injury will commonly be present. Meticulous into the junction of the left internal jugular and left subcla-
assessment for these injuries should be performed as soon vian vein. The mid portion of the subclavian artery is poste-
as the patient's status permits. rior to the anterior scalene, abuts the brachial plexus trunks
located posteriorly and superiorly to the artery, and gives off
the dorsalscapular branch. The third portion is located lat-
Anatomy of the Junctional Zone and Subclavian eral to the anterior scalene and remains in close proximity to
Artery the brachial plexus as the cords form from the trunks. These
The junctional zone of the upper extremity is composed cords are intimately associated with the third part of the sub-
of the thoracic aperture and shoulder. The articulations clavian artery, which does not have side branches.
between the first rib, the sternum, and spinal column create
the bony boundaries of the thoracic outlet. The clavicle con-
nects to the manubrium anterior to the first rib, and these Operative Management of Junctional Zone and
anatomic relationships make direct access to the vascula- Subclavian Artery
ture, including the subclavian vessels and their branches, The proximal portion of the right subclavian artery can be
challenging. The musculature surrounding the thoracic exposed via a median sternotomy. Further exposure may
outlet can be best visualized as an inverted cone with the require a supraclavicular extension of the incision, with
anterior and posterior scalenes attaching to the first and or without resection of the clavicular head. The origin of
second ribs, respectively, the sternothyroid; the sternohy- the left subclavian artery is in a more posterior location
oid attaching to the sternum; and the sternocleidomastoid on the aortic arch and must be exposed through a high,
attaching to the medial clavicle and sternum. Although the left anterolateral thoracotomy (Fig. 21.5). The mid to
complexity of the anatomy in this area creates a protective distal left subclavian artery may be controllable through
cage for the underlying vessels and nerves, obtaining proxi- a median sternotomy with a supraclavicular or cervical
mal control in rushed situations can easily result in inad- extension or via “trapdoor” thoracotomy. When the goal
vertent damage to critical structures. is to expose the mid-portion of the artery, a combined
The major arterial structure of the thoracic outlet is the supraclavicular and infraclavicular (two-incision) tech-
subclavian artery (Fig. 21.3). The right subclavian originates nique has been described, but in the authors' experience
from the innominate artery posterior to the costoclavicular a single-incision approach with subperiosteal clavicular
joint, and the left subclavian artery originates from the aor- resection (with or without simultaneous reconstruction of
tic arch at roughly the level of the 4th left interspace. The the clavicle) seems most expeditious and flexible. A distal
subclavian artery is divided into three sections based on the left subclavian and proximal axillary vessel injury can be

Vagus nerve
Brachial plexus

Phrenic nerve
Subclavian vein
Anterior scalene
Subclavian artery muscle

A
B

Fig. 21.3 (A) Anterior view of the thoracic outlets. (B) Angiogram of the left subclavian artery with branches. (Adapted from Gregory RT, et al. The
mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma. 1985;25(12):1147–1150.)
258 SECTION 4 • The Management of Vascular Trauma

exposed by a separate supraclavicular incision. Alterna-

tively, the clavicle can be resected in a subperiosteal fash-
Right axillary artery ion to expose the subclavian vessels. The distal subclavian
artery and proximal axillary artery is potentially treatable
from a two-incision approach, but injury management
may require a lateral clavicular resection, again with or
without bony replacement.
Dissection in the area of the subclavian artery and vein
should be performed with care given the abundance of
adjacent nerve structures (Fig. 21.6). In addition to the
Level of brachial plexus and vagus, the phrenic nerve sits on the
tourniquet anterior scalene muscle and should be identified and pre-
served. The abundance of collaterals around the shoulder
and neck may allow for ligation of the subclavian artery in
emergency situations with modest upper extremity isch-
emia. Temporary shunting, however, may be considered
and, in the authors' opinions, provides a better alternative
Fig. 21.4 Angiogram demonstrating collateral circulation in the shoul- to ligation. Tension-free repair of the subclavian artery can-
der. The important collateral vessels are the thoracoacromial, the lat- not be overemphasized as the vessel is relatively thin, non-
eral thoracic, the subscapular, and the anterior and posterior humeral muscular, and delicate. Because of this, primary repair and
circumflex arteries. patch angioplasty is challenging. If these are entertained,

Supraclavicular
incision
Infraclavicular
incision

Median
sternotomy

Fig. 21.5 Surgical exposure of the junctional zone

vessels can be obtained by supraclavicular and
Left anterolateral infraclavicular incisions, by left anterolateral thora-
thoracotomy cotomy, and by median sternotomy.
 21 • Upper Extremity and Junctional Zone Injuries 259

A B
B

Junction innominate artery bifurcation

Vagus nerve
Internal jugular
Phrenic nerve

Subclavian artery primary repair with pledgets

Fig. 21.6 (A) A gunshot wound sustained to the left sternoclavicular region is shown. (B) A view from the patient's head. A supraclavicular incision was
performed, and a subclavian artery and vein injury were identified. A subclavian artery greater saphenous vein (GSV) interposition graft was performed,
as well as a subclavian vein to internal jugular GSV bypass. (C) The complexity of the anatomy in the area of the subclavian artery and vein necessitates
meticulous dissection during operative exposure.

use of pledgets is recommended. Prosthetic material can (just below the breast in a female patient, along the lower
be used as an interposition graft for larger, more proximal contour of the pectoralis major muscle in a male patient).
great vessel and upper extremity reconstructions. Autolo- Divide the pectoralis fascia and muscle fibers at the 4th
gous conduit such as saphenous vein, paneled saphenous intercostal space, then the intercostal muscles. Enter the
vein, internal jugular vein, or even femoral vein can be used 4th intercostal space at the cranial aspect of the 5th rib and
depending on size and length considerations. The choice is incise the parietal pleura. At this point, place a rib spreader
dependent on patient condition and associated soft-tissue retractor (i.e., Fianchetto rib retractor). Retract superiorly
injury. In more extensive injuries, ligation and revascular- below the left lung caudally and visualize the aortic arch,
ization using bypass with inflow based more proximally, then divide the mediastinal pleura overlying the arch and
such as from the ascending aorta, the innominate artery, or descending thoracic aorta. Identify the proximal origin of
the carotid systems, may be options. the left subclavian artery. Of note, avoid injury to the left
vagus and recurrent laryngeal nerves at this location.
Operative Technique Achieve proximal control of the left subclavian artery.
In order to accomplish proximal surgical control of the left The supraclavicular approach to the subclavian pro-
subclavian, an anterolateral thoracotomy is completed. vides exposure to the mid and distal portions of the artery.
Position the patient supine and place shoulder roll. Create a The surgeon should consider that this approach is more
transverse, curvilinear incision over the left 5th rib from the ­time-consuming and subjects critical nerve structures to
lateral border of the sternum to the anterior axillary line risk. Position the patient supine and place shoulder roll.
260 SECTION 4 • The Management of Vascular Trauma

Create a transverse, supraclavicular incision approximately and lateral thoracic artery. The third part contains three
one fingerbreadth cranial to the clavicle with the medial branches, the subscapular branch, the anterior humeral cir-
extent originating at the medial aspect of the clavicular cumflex, and the posterior humeral c­ ircumflex arteries. The
head of the sternocleidomastoid muscle. Divide the clavicu- axillary artery is bordered medially by the axillary vein and
lar head of the sternocleidomastoid and expose the scalene posteriorly by the cords of the brachial plexus. Moving dis-
fat pad. Identify and protect the phrenic nerve which is tally, the cords of the brachial plexus surround the axillary
located at the anterior aspect of the anterior scalene mus- artery, and ultimately these form the named nerves of the
cle. Mobilize the scalene fat pad cephalolaterally. Complete arm at the level of the distal axillary and proximal brachial
a phrenic neurolysis to increase nerve mobility and facili- artery.
tate division of the anterior scalene muscle. Divide (resect
if required) the anterior scalene muscle and identify the Operative Management of Axillary Artery Injuries
underlying subclavian artery. Circumferentially, isolate the The skin of the ipsilateral neck, chest, and supraclavicu-
subclavian artery and achieve proximal and/or distal con- lar fossa should be prepared and draped into the sterile
trol. The thyrocervical trunk can be ligated if required. field in order to allow for proximal control. Generally, the
The trapdoor thoracotomy provides excellent exposure arm, hand and fingers should also be prepped as part of the
to the left subclavian artery and is another option that sur- operative field to allow thorough intraoperative assessment
geons should be familiar with. Perform an anterolateral of distal perfusion, and in some cases performance of fasci-
thoracotomy as previously described. Next, control the otomy. The authors advocate for achieving proximal control
proximal subclavian artery. Ligate the internal mammary/ proximal to any hematoma, which, depending on the loca-
thoracic vessels and perform a supraclavicular approach as tion of axillary artery injury and the size of the hematoma,
previously described. Then complete a vertical incision over may be at the subclavian artery which is controlled through
the sternum to connect the medial borders of the anterolat- a supraclavicular incision.
eral thoracotomy and supraclavicular incisions. Divide the To expose the axillary artery an infraclavicular incision is
exposed sternum via median sternotomy. made two fingerbreadths below and parallel to the clavicle
(see Fig. 21.7A). In the case of proximal injuries, one may
choose both supra- and infraclavicular incisions allowing
AXILLARY ARTERY for more completed control of the subclavian and axillary
arteries. Clamps should be applied with care and precision
Axillary Artery Injuries in these locations, given the proximity of the artery to the
Axillary artery injuries are more common than subclavian axillary vein and brachial plexus (Fig. 21.7B). A primary
artery injuries because the artery is longer and outside of end-to-end repair of the axillary artery can be performed,
the protective structures of the thoracic outlet. Similar to with ligation and division of side branches to enable mobili-
subclavian vessels, penetrating trauma is the most common zation of the artery and provision of a tension-free anasto-
form of axillary artery injury. In contrast to isolated sub- mosis. However, most axillary artery injuries require a more
clavian artery injuries—in which patients often present in extensive repair in the form of interposition graft recon-
shock—isolated injuries to the axillary artery rarely pres- struction. As is the case with subclavian artery, the use of
ent with hemodynamic collapse. More common hallmarks an autologous vein as an interposition or paneled graft is a
include absent distal pulse or reduced injured extremity reasonable option, particularly in the setting of a significant
index (less than 0.9), pulsatile bleeding, and/or an expand- soft-tissue injury. Prosthetic grafts such as Dacron or ePTFE
ing hematoma. The substantial collateral network often are often favored because they are readily available (i.e., off
precludes the development of critical ischemia, and an the shelf) and they come in uniform sizes that better match
­axillary artery injury may not be readily recognized with- the diameter of the artery. Although the collateral circula-
out the aid of the continuous-wave Doppler and measure- tion of the upper extremity may allow for ligation of an iso-
ment of the injured extremity index. As with other forms of lated axillary artery injury with few adverse consequences,
vascular trauma, arteriography is a useful diagnostic tool in most injuries are associated with soft-tissue trauma which
many situations, including those in which an endovascular disrupts these collaterals making repair of the main artery
therapy is considered.7 However, with good physical exami- a must. Temporary intravascular shunting is a good alter-
nation, use of continuous-wave Doppler and other nonin- native to ligation of the artery and allows limb perfusion,
vasive imaging modalities, most axillary artery injuries can patient stabilization, and deferred definitive repair.
be diagnosed without arteriography. Anterior dislocation of
the humeral head or fractures of the humerus can result in Operative Technique
axillary artery injury, as well as injury to the nearby nerves The patient should be positioned supine and with a small
of the brachial plexus and the axillary vein. roll placed transversely under his or her shoulders to pro-
vide gentle extension of the neck. An infraclavicular inci-
Axillary Artery Anatomy sion is created 1 to 2 cm below the clavicle, beginning at
The axillary artery is the continuation of the subclavian the mid-clavicle extending laterally. The clavipectoral fascia
artery and extends from the lateral border of the first rib. It is next divided and the fibers of the clavicular head of the
becomes the brachial artery at the lateral border of the teres pectoralis major are completely separated or divided for the
major muscle. The three parts of the artery are defined by the length of the incision. The subclavian vein, often covered
relationship to the anteriorly located pectoralis minor. The by a soft fatty wad of tissue is encountered and should be
first part has only one branch, the ­superior thoracic artery. mobilized/retracted caudally. This often requires ligation
The second part contains two branches, the thoracoacromial and division of branches emptying into the main axillary
 21 • Upper Extremity and Junctional Zone Injuries 261

Infraclavicular
incision

C5

C6
Subclavian Brachial
C7
artery plexus
Lateral C8
A cord
T1
Axillary artery

Musculocutaneous
nerve
Median nerve

Anterior circumflex artery

Radial nerve

Pectoralis minor muscle B

(cut)

Fig. 21.7 (A) An infraclavicular incision made two fingerbreadths below and parallel to the clavicle can expose the proximal axillary artery. Surgical
anatomy of the axillary artery and six branches with the three parts defined by the relationship to the anteriorly located pectoralis minor. (B) The cords
of the brachial plexus are located posteriorly to the proximal axillary artery, but surround the distal axillary artery. This close relationship explains the
high incidence of nerve injuries with axillary artery trauma.

vein. Once the vein is mobilized, one can feel and the expose Most brachial artery injuries can be diagnosed with phys-
the axillary artery. Frequently, the pectoralis minor muscle ical examination, use of the continuous-wave Doppler, and
may be lifted and retracted laterally and or medially, or it measurement of an injured extremity index (normal index
may be divided to facilitate complete exposure of the axil- greater than 0.90). Other findings, such as a supracondylar
lary artery. The incision can be extended laterally onto the fracture or elbow dislocation, increase the likelihood of a
upper, medial arm as required. brachial artery injury.50 Use of the brachial artery for vas-
cular access, either for hemodynamic monitoring or endo-
vascular procedures, can lead to iatrogenic brachial artery
BRACHIAL ARTERY injury (i.e., thrombosis or pseudoaneurysm). As with the
other extremity vascular injuries, a thorough sensorimotor
Brachial Artery Injuries examination should be performed and documented before
Patients with brachial artery injury, especially those with any operative intervention.
injuries sustained from a penetrating mechanism, will typi-
cally present with hard signs of vascular injury. In some Brachial Artery Anatomy
instances, however, critical ischemia may not develop The brachial artery is the continuation of the axillary artery
because of the robust collateral network around the elbow. and extends from the inferior border of the teres major mus-
The degree of ischemia resulting from a brachial artery cle to its bifurcation in the antecubital fossa (Fig. 21.8). The
injury will depend on whether or not the injury occurred brachial artery resides medial to the humerus and is in close
proximal or distal to the origin of the deep brachial artery anatomic proximity to the median, ulnar, and radial nerves.
and the degree of muscle and soft-tissue damage associated The radial nerve courses away via the triangular interval
with the injury. The second factor relates to interruption of with the profunda brachii artery. The ulnar nerve courses
the deep brachial artery (collateral) network that makes sig- posterior to the brachial artery, then toward the posterior
nificant ischemia more likely in cases of injury with larger medial humeral epicondyle in the ulnar groove. As the bra-
soft-tissue defects. chial artery approaches the elbow joint, the median nerve
262 SECTION 4 • The Management of Vascular Trauma

Brachial
plexus

Subclavian artery
Brachiocephalic vein
Cephalic vein

Aortic arch
Axillary artery

Subclavian vein
Brachial artery Axillary vein

Brachial vein
Humerus

Teres major muscle

Basilic vein

Antecubital fossa

Radial artery Median cubital vein

Ulnar artery

Fig. 21.8 The brachial artery is the continuation of the axillary artery and extends from the inferior border of the teres major muscle to its bifurcation in
the antecubital fossa. Important anatomic relationships include three main artery branches, three associated veins, three associated nerves, and three
associated muscles.

travels from lateral to medial by crossing anterior to the examination, including Doppler interrogation. To access
artery. Following its exit from the axilla, the brachial artery the proximal brachial artery, a longitudinal incision is made
is fairly superficial, and is the most commonly injured vessel on the medial side of the upper arm in the palpable groove
in the upper extremity. The three branches of the brachial between the biceps and the triceps. With retraction of the
artery are (from proximal to distal) the profunda brachii pectoralis muscles, exposure as high as the distal axillary
artery, the superior ulnar collateral artery, and the inferior artery is possible. The close proximity of the basilic vein and
ulnar collateral artery. The profunda brachii artery passes the median and ulnar nerves to the artery requires care-
posteriorly with the radial nerve and runs between the ful dissection without excessive retraction. The basilic vein
medial and lateral heads of the triceps. The branches of the should be preserved if possible, and ligating its tributaries
profunda brachii form important collateral networks with will allow it to be more completely mobilized and retracted.
the axillary artery proximally and the forearm vessels dis- Distally, the bicipital aponeurosis can be retracted or divided
tally. Distal branches form the superior radial collateral net- to expose the brachial artery (Fig. 21.9). The position of the
work, along with branches from the proximal radial artery. median nerve in relationship to the brachial artery changes
The superior and inferior ulnar arteries accompany the as the nerve extends peripherally. The nerve courses from a
ulnar nerve medially and also provide a collateral network proximal, lateral position to a distal, medial position, with
around the elbow. respect to the brachial artery.
Brachial artery injuries resulting from low-energy stab-
Operative Management of Brachial Artery Injuries bing mechanisms may be repaired primarily if the artery
If the vessel is bleeding, proximal control should be obtained is not devitalized. As expected, this type of repair is rarely
by compression of the brachial artery against the humerus. used for injuries resulting from high-energy blunt or pen-
Bleeding may have ceased due to vessel contraction and etrating mechanisms. Instances in which the artery is more
local thrombosis. As with other upper extremity vascular heavily damaged or transected require use of a vein patch
injuries, the ipsilateral neck and chest should be widely or more commonly an autogenous vein interposition graft
prepped and draped in case more proximal exposure is (see Fig. 21.1). Spatulation of the ends of the anastomosis
required. The wrist, hand, and fingers should be prepped is a good idea to avoid narrowing and, in some instances,
into the operative field so that they are freely accessible for an interrupted suture technique can be useful given the
 21 • Upper Extremity and Junctional Zone Injuries 263

trauma. The most common mechanism, as with the more

proximal vessels of the upper extremity, is penetrating
Biceps brachii injury. Hypothenar eminence hammer syndrome is a rare
muscle manifestation of repeated blunt trauma to the distal ulnar
artery which results in aneurysmal dilation, thrombosis,
Brachialis muscle and/or distal embolization. Hematoma within the fore-
arm can expand and result in compartment syndrome and
Brachioradialis ultimately what is referred to as a Volkmann flexure con-
muscle tracture. Signs of a tense hematoma within the forearm
Brachial
Pronator artery associated with decrements in sensory or motor function
teres muscle with or without an obvious perfusion abnormality should
Median prompt consideration of a fasciotomy.
nerve
Radial and Ulnar Artery Anatomy
After the brachial artery crosses the antecubital fossa, it
bifurcates into the radial and ulnar arteries (Fig. 21.10).
Whereas the radial is the more direct continuation of the
brachial artery, the ulnar artery is typically the larger of
the two. The ulnar artery gives off two branches, the ante-
rior and posterior ulnar recurrent arteries, which form the
Fig. 21.9 Surgical exposure of the brachial artery is obtained rapidly by distal components of the collateral circulation around the
a longitudinal incision along the artery’s course with an extension as elbow. The other branch of the ulnar artery—the com-
an S curve either across the axilla proximally or across the antecubital mon interosseous artery—passes posterolateral toward the
fossa distally. The median nerve and basilic vein are in close proximity interosseous membrane, where it bifurcates into the ante-
to the artery. rior and posterior interosseous arteries that run on oppos-
ing sides of the membrane. The superficial palmar arch is
most commonly the terminal segment of the ulnar artery.
In the forearm, the ulnar artery is positioned next to the
relatively small size of the brachial artery and its tendency ulnar nerve. The radial artery contains only one branch in
to spasm. Injuries to the brachial distal to the origin of the the proximal portion, the radial recurrent artery, which is
profunda brachii will be associated with a variable degree responsible for collateral circulation around the elbow. In
of ischemia depending on the amount of damage to the the forearm, the radial artery is positioned next to the radial
collateral circulation. Use of a temporary vascular shunt is nerve and most commonly forms the deep palmar arch of
recommended when reconstruction of the brachial artery the hand.
is not feasible due to the patient’s adverse physiology, or in
situations in which the surgeon is not familiar or comfort-
able with (or does not have the time) performing a formal Operative Management of Radial and Ulnar Artery
arterial reconstruction. Injuries
Typically, bleeding from the forearm can be controlled
Operative Technique with direct pressure, but a tourniquet can be used if
An incision overlying the medial bicipital groove facilitates needed. In the operating room, the proximal portion of
good exposure of the brachial artery. Proximal or tourni- the arm, the hand, and fingers should be prepped and
quet control can be accomplished based on the location of draped in a circumferential manner to allow for full oper-
the injury. The surgeon should identify and expose the bra- ative exposure, assessment, and control of the radial and
chial artery after entering the brachial sheath while identi- ulnar arteries. An S-shaped incision over the antecubital
fying and protecting the median nerve. Direct exposure of fossa allows for proximal extension and exposure of both
the injured vessel is often appropriate in the arm. Ligation the radial and ulnar arteries. Identifying the brachial
of the brachial artery distal to profunda brachii may be tol- artery as described previously and tracing it distally may
erated if the collateral networks are intact and distal perfu- aid in identifying the ulnar and radial arteries. The radial
sion can be confirmed with a Doppler. Of note, the brachial artery follows the medial border of the brachioradialis
artery is relatively elastic and redundant and one should muscle, and the medial groove of this muscle can be used
flex and extend the arm while setting up an interposition as a landmark to make an incision in the mid forearm
graft to estimate optimal length and to avoid kinking of the (Fig. 21.11). In the distal portion of the wrist, the radial
conduit. High bifurcation of the brachial artery in the upper artery can be exposed by a longitudinal incision slightly
third of the arm is a common variant to standard anatomy. lateral to the artery.
The ulnar artery courses deep to the pronator teres,
slightly beyond the bifurcation and remains deep to the
RADIAL AND ULNAR ARTERIES flexor muscles of the proximal forearm before emerging
into a more superficial position at the midpoint of the
Radial and Ulnar Artery Injuries forearm, which can make proximal exposure difficult. To
Vascular injuries in the forearm artery injury are common expose the ulnar artery, a longitudinal incision is made
among the clinical series or reports on extremity ­vascular on the medial side of the arm about four fingerbreadths
264 SECTION 4 • The Management of Vascular Trauma

Posterior branch of distal to the medial epicondyle. The artery can be identified
profunda brachii artery between the flexor carpi ulnaris and the flexor digitorum
superficialis (see Fig. 21.11). In the wrist, the ulnar artery
Superior ulnar can be exposed through a longitudinal incision on the
Radial collateral branch collateral artery
of profunda brachii artery radial side of the flexor carpi ulnaris muscle in order to
Inferior ulnar
Radial nerve collateral artery
avoid the ulnar nerve, which lies lateral to the ulnar artery.
Radial recurrent artery Typically, the management of forearm artery injury
Anterior ulnar
recurrent artery is dependent on whether or not there is a satisfactory
Deep br. of radial nerve
Superficial br. Posterior ulnar
­continuous-wave Doppler signal at the wrist and/or in the
of radial nerve recurrent artery hand. Because of the redundant nature of perfusion to the
Interosseous Common hand, if there is an arterial signal in the palmar arch with
recurrent artery interosseous artery the injured vessel occluded, then ligation of the injured
Volar Dorsal vessel is a reasonable maneuver. If the hand is completely
interosseous artery interosseous artery ischemic (i.e., no arterial Doppler signal distal to the fore-
Median nerve
Anterior arm injury), then one of the two arteries (radial or ulnar)
interosseous nerve should be repaired. Primary repair of a simple laceration
Radial artery Ulnar nerve using fine, monofilament suture is reasonable if the injury
has not resulted in the loss of arterial length. If an end-to-
Ulnar artery
end repair is attempted, the two ends of the vessel should be
spatulated to increase the area of the anastomosis (i.e., pre-
vent narrowing). Often because of loss of arterial length, or
because of the elastic nature of the ulnar and radial arter-
ies, an interposition vein graft is needed to restore perfusion
to the distal arm and hand. For reconstruction at the wrist
it is helpful to have a hand surgeon or someone familiar
with microvascular repair present during the operation.
Interposition repair of forearm arterial injury typically
requires a smaller portion of saphenous vein or another
Fig. 21.10 The radial and ulnar arteries have close relationships with type of arterial conduit.51
the radial nerve and ulnar nerve in the forearm.

Superficial radial
nerve

Brachioradialis
muscle
Ulnar nerve
Flexor digitorum Radial artery
Ulnar artery
superficialis muscle
Flexor digitorum Flexor carpi
profundus muscle ulnaris muscle

A B

Fig. 21.11 (A) The ulnar artery can be exposed through a longitudinal incision made on the medial arm about four fingerbreadths distal to the medial
epicondyle. The artery can be identified between the flexor carpi ulnaris and flexor digitorum superficialis. (B) The medial groove can be used as a land-
mark to expose the radial artery, which follows the medial border of the brachioradialis muscle.
 21 • Upper Extremity and Junctional Zone Injuries 265

the upper arm and axilla may reduce venous hyperten-

Operative Technique sion and its sequelae. Efforts to maintain venous outflow of
Proximal control of the forearm vessels may require expo- the arm are most appropriate in the setting of a penetrat-
sure of the distal brachial artery bifurcation. The patient is ing wound that has disrupted what is otherwise a gener-
positioned supine with the arm abducted 60 to 90 degrees ous venous collateral circulation.52,53 Extremity venous
and supported on an arm-board. One should expose the repair gained popularity during the Vietnam War with Rich
brachial bifurcation at the antecubital fossa through an reporting successful repair of 124 (33%) of 377 injuries.
S-shaped incision across the antecubital crease while at the Lateral suture was the most common form of reconstruc-
same time identifying and protecting the basilic vein and tion (n = 106) followed by end-to-end anastomosis (n = 10),
medial antebrachial cutaneous nerve. One can then divide and vein interposition (n = 5) and patch (n = 3).54 Rich and
the bicipital aponeurosis to expose the brachial artery colleagues noted a low rate of thromboembolic complica-
which can be exposed distally to identify its bifurcation and tions, suggested that venous repair may play a role in limb
the proximal portions of the radial and ulnar arteries. salvage, and posited that failed venous repair often recana-
Generally, longitudinal incisions in the axis of the fore- lizes with a good result.54
arm are used to approach the mid and distal segments of In a more-recent military series, Quan et al. reviewed
the radial and ulnar arteries. For the radial artery, the plane 82 patients with 103 venous injuries sustained in the Iraq
of the incision extends from the midpoint of the antecubital War.55 The majority of patients (63%) in that series were
fossa to the styloid process of the radius, corresponding to treated with ligation with no observed difference in postop-
the groove on the medial edge of the brachioradialis muscle. erative thromboembolic complications between the ligated
The extent of incision is based on the specific injury pattern and repaired groups. In 2009, Gifford and colleagues iden-
and the section of the artery requiring exposure. One can tified venous repair as protective against amputation (RR =
divide the antebrachial fascia and in the proximal and mid- 0.2; 95% CI [0.04–0.99], P = .05) in their evaluation of 135
portions of the forearm, the radial artery will be deep to injuries, 35 of which were to the upper extremity.49 These
the medial fibers of the brachioradialis muscle and can be studies and personal experiences have led these authors to
exposed in the groove between this muscle and the prona- recommend selective ligation of extremity venous injury
tor teres. In the distal forearm, the radial artery lies deep to (i.e., ligate some but not all).
the fascia, between the tendons of the brachioradialis and Few civilian experiences have reported on upper extrem-
flexor carpi radialis muscles. In the middle third of the fore- ity venous repair. Meyers et al. reported 34 patients with
arm, one should identify and protect the superficial radial venous injury (26 lower and 8 upper extremity) showing
nerve which lies closely adjacent to the radial artery. At an early patency rate of 61% for all repairs; 40% for inter-
the wrist, a longitudinal incision is created directly over the position vein graft repairs. This report did not detail the dif-
radial artery just proximal to the styloid process. The radial ferences between upper and lower extremity outcomes.56
artery lies directly underneath the antebrachial fascia. Nypaver and colleagues reviewed longer-term follow-up
The proximal ulnar artery is relatively deep and can be (mean 49 months; range 6–108 months) for 32 patients
challenging to expose. To accomplish this, a longitudinal who had venous reconstruction, and found long-term
incision is created four fingerbreadths distal to the medial patency to be 90% as determined by Duplex ultrasound.57
epicondyle of the humerus extending on the plane from the However, only six upper extremity vein reconstructions
medial epicondyle to the pisiform. One should then divide (one axillary, five brachial) were performed in this series and
the antecubital fascai to expose the ulnar artery between 60% of the brachial vein repairs eventually occluded.
the flexor carpi ulnaris and the flexor digitorum superfici-
alis muscles. In the middle of the forearm, the artery lies
deep to the flexor carpi ulnaris muscle. Of note, the ulnar
nerve accompanies the artery near the border of the upper, Endovascular Management of
middle-third of the forearm and should be identified and Upper Extremity Vascular Injuries
protected. In the wrist, the ulnar artery can be exposed
through a longitudinal incision on the radial side of the As endovascular technologies have been developed for the
flexor carpi ulnaris in order to avoid the ulnar nerve, which treatment of cardiovascular disease conditions, their use
will be lateral to the artery at this level. At the wrist, a lon- in the diagnosis and management of trauma has become
gitudinal incision is created over the ulnar artery just lat- more common.58 Several descriptions of endovascular
eral to the flexor carpi ulnaris muscle. The ulnar artery lies therapies in the Iraq and Afghanistan Wars can be found in
directly underneath the antebrachial fascia. the literature, including Rasmussen and colleagues’ initial
report on the development and implementation of endovas-
cular capability at a level III facility in Iraq.59 During this
Upper Extremity Venous Injury period, 150 catheter-based procedures were performed, 12
of which included angiographic evaluation of the upper
Most upper extremity venous injuries can be ligated. Liga- extremity vasculature with two patients undergoing cov-
tion is indicated for the smaller and more distal veins of the ered stent placement for axillosubclavian artery injury.
forearm and most venous injuries between the elbow and Catheter-based techniques may offer advantages for
the axilla. Ligation is particularly indicated when the sur- proximal upper extremity and junctional zone injuries in
geon is in a resource-limited or austere condition and when the acute setting, as well as for the less-urgent sequelae of
other life-threatening injuries takes priority. If the patient’s vascular trauma such as arteriovenous fistula and pseu-
condition permits, repair of larger more proximal veins of doaneurysm (Fig. 21.12). Endovascular approaches for the
266 SECTION 4 • The Management of Vascular Trauma

Fig. 21.12 (A) A 21-year-old (with

multiple injuries caused by an
improvised explosive device, includ-
ing bilateral lower extremity long
bone fractures) underwent “clam-
shell” thoracotomy for bilateral hilar
injuries and subsequent laparotomy
with multiple enteric injuries. A large
6-cm pseudoaneurysm of the axil-
lary brachial junction was identified
on CT angiogram postoperatively.
(B) A retrograde left brachial artery
endovascular approach allowed for
A B deployment of covered stents.

Fig. 21.13 (A) A 30-year-old woman

sustained a high-impact blunt injury
to her right shoulder with a clavicle
fracture. Active extravasation was
seen from the subclavian artery. (B)
Covered stent endovascular repair
was performed from a femoral
A B access approach.

axillary region may help avoid the morbidity associated with ­ anagement with a stent graft or open operative repair.
m
emergent open operations in a hematoma near or around Endovascular control and repair of axillosubclavian injury
the brachial plexus. The use of covered stents in the subcla- may require antegrade femoral access, retrograde brachial
vian and axillary artery positions is evolving into a favored access, or both. Passing the wire under fluoroscopic guid-
alternative for the management of blunt and ­penetrating ance across the vessel disruption from either the antegrade
injury to these vessels (Fig. 21.13).60,61 Endovascular con- femoral or retrograde brachial approach may be challeng-
trol and repair of junctional and upper extremity injuries ing. The shorter distance from the access site to the injury
can even be considered in the presence of hard signs of makes a retrograde brachial approach preferable in many
vascular injury. As hybrid operating rooms (i.e., open and situations. Directional catheters and balloon centering and
endovascular capabilities) become more commonplace, guidance are other techniques to achieve wire access across
starting with catheter-based techniques and converting to the injured vessel.
an open operation as needed is favored by many surgeons Self-expanding and balloon-expandable covered stents
and trauma teams. are effective in managing select innominate and axil-
When the patient is stable and there are soft signs of vas- losubclavian injuries. In contrast, bare metal stents are
cular injury, CTA or Duplex allow for confirmation of an more commonly used for the treatment of intimal flaps or
injury and more organized planning for endovascular treat- dissections. A multicenter trial evaluating the use of the
ment. When there are hard signs of injury, the patient may self-expanding Wallgraft Endoprothesis (Boston Scientific;
be taken directly for angiography and endovascular therapy Natick, MA) for the treatment of 62 iliac, femoral or sub-
without preliminary imaging. Rapid control of the proxi- clavian arterial injuries showed that self-expanding stents
mal brachial and axillosubclavian arteries can be achieved achieved injury exclusion 94% of the time, including in
with endovascular balloon occlusion, with ­ follow-on 90% of subclavian artery injuries.62 Freedom from bypass
 21 • Upper Extremity and Junctional Zone Injuries 267

was achieved in 100% of injured subclavian arteries. There e­ ndovascular intervention for brachial artery transection
was no procedure-related mortality in that experience and have been published, although the long-term results of this
the most common complication involved eventual stenosis approach are unknown.76
or occlusion. Although data support endovascular manage-
ment of extremity arterial injury, most of the procedures in
this series were for iatrogenic injury (78%) and extrapola-
tion of these results should be done with caution. Nonoperative Management in
Du Toit and colleagues reported 57 patients with pene- Upper Extremity Injury
trating subclavian artery injury who underwent stent-graft
treatment over a 10-year period.63 The most common injury Nonocclusive arterial injuries including pseudoaneu-
was pseudoaneurysm (74%) followed by arteriovenous fis- rysm, intimal flap, and non–flow-limiting stenosis may be
tulas (21%) and occlusion (5%). None of the patients under- ­managed nonoperatively.77,78 Anticoagulants or antiplate-
going endovascular treatment required conversion to open let therapy should be considered in the management of a
repair and the catheter-based approach was successful in all contained flap or with dissection-type injuries. These inju-
cases as confirmed by angiography. One patient in this series ries must be monitored closely in the early phases of nonop-
died due to other injuries, and three (5%) ­developed early, erative care and treated with prompt endovascular or open
non–limb-threatening stent-graft occlusion. ­ Follow-up intervention if ischemic symptoms develop. Follow-up at
data was available for 16 patients at a mean of 61 months regular intervals is advisable for these injuries and should
showing that five had claudication and roughly half had include surveillance with noninvasive techniques such as
in-stent stenosis that was treated with balloon angioplasty. Duplex ultrasound.
Three asymptomatic patients in the f­ollow-up cohort
had asymptomatic stent occlusion that did not require­
intervention. Postoperative Care
There are also case reports of the use of endografts in
the setting of upper extremity arterial trauma.64–71 Her- MONITORING
shberger et al. reviewed 195 studies published between
1995 and 2007 showing that endovascular treatment of Patients require close monitoring after treatment of the
supradiaphragmatic arterial injury was successful in 96% injured limb and its circulation. The decision to admit the
of cases.72 When all reports reviewing endovascular treat- patient to the intensive care unit or to an intermediate
ment of innominate (n = 7), subclavian (n = 91), and care ward is institution-specific and depends on blood
axillary (n = 12) artery injuries were assessed, technical loss and the need for resuscitation, rewarming, and cor-
success was achieved in 86%, 97%, and 100% of cases, rection of physiology. Continuous-wave Doppler helps
respectively. Procedural morbidity ranged between 0 and assess the adequacy of any vascular repair before return
12% depending on the anatomic location of the injury. Rare of a palpable pulse, although the mere presence of an
complications associated with endovascular repair of upper arterial signal does not mean that the reconstruction is
extremity vascular injury include access-site pseudoaneu- patent. Other measures of perfusion include tempera-
rysm, arm claudication, and stent fracture and thrombosis. ture, the presence or absence of sensorimotor function,
Although short-term durability of endovascular repair and capillary refill. Duplex can also be used to assess
has been suggested to be equivalent to operative repair, the patency of any vascular repair and in some cases identify
durability of either approach is not well-defined.60,61,63,73–75 a technical defect that can require early reintervention.
Despite concerns related to the durability of endovascular For some injuries, the patient may also need monitor-
repairs, results are encouraging with patency rates that ing for the development of extremity compartment syn-
appear to be acceptable with few reports of open surgery drome.
to revascularize after a failed upper extremity stent-graft
placement. The possibility of infection is a legitimate con- WOUND CARE
cern, but there is no suggestion that the use of covered
stents in trauma patients poses undue risk. The authors are Negative pressure dressings (e.g., vacuum-assisted closure
not aware of stent graft–related infectious complications [VAC] dressing) can be beneficial for controlling wounds in
in the admittedly low number of grafts placed in Iraq and which skin closure is not feasible. Negative pressure wound
Afghanistan. It is likely that case selection plays a role in lim- therapy promotes wound granulation, but vascular repairs
iting infectious complications associated with endovascu- should be covered with viable soft tissue or muscle to prevent
lar repair and that upper extremity/junctional injuries are contact between the vacuum dressing sponge and the vessel
prone to fewer infections than injuries in other body regions. in order to prevent desiccation and disruption of the vessel
The younger age of the trauma population makes attain- or anastomosis.79,80 Similarly, whereas wound closure over a
ing meaningful follow-up of these procedures difficult vascular repair can be delayed, soft-tissue coverage of the ves-
and thus the data on patency and the effect of antiplatelet sels must be completed as soon as possible, whether through
therapy for these interventions is limited. However, the use delayed primary closure, skin graft, or muscle flap (Fig. 21.14).
of endovascular stents as a first option does not preclude
subsequent catheter-based procedures to assist patency REHABILITATION
or future open repair if needed. As endovascular capabili-
ties improve, their application in the management of more Physical and occupational therapy should be started as
distal upper extremity injuries seems likely. Reports of soon as possible after upper extremity injury to prevent
268 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 21.14 (A) Wound vacuum-assisted closure (VAC) placement after a forearm fasciotomy was performed. (B) Maintenance of domain allowed for a
delayed primary closure to be performed. Full closure was achieved post injury day 6.

muscular contractures and atrophy. Checking for sen- particularly in patients who have endured prolonged isch-
sorimotor deficits is a requisite for therapy that is aimed emia or transport times and in those who require sizable
at regaining, or learning to compensate for, lost func- fluid resuscitation. The earliest symptom of compartment
tion. The timing of rehabilitation (e.g., range of motion, syndrome is increasing pain. As the syndrome progresses,
weight-bearing) should be coordinated among the vari- findings on physical examination will be pronounced and
ous specialists involved in the care of patients with include tense compartments, pain on passive extension,
upper extremity vascular trauma. The intricate and progressive loss of sensation, and weakness. Loss of a distal
complex tasks of the hand and arm make rehabilita- pulse is a late finding.
tion of upper more challenging than that of the lower Direct pressure measurement of the compartments can
extremity. help confirm the diagnosis, with normal compartment
pressures ranging from 0 to 9 mm Hg. Although debatable,
a compartment pressure over 30 mm Hg is considered ele-
vated and warrants prompt fasciotomy. Some use the pres-
Complications After Upper sure difference between the diastolic blood pressure and
Extremity Vascular Injury the compartment pressure as a marker for compartment
syndrome. When this difference in pressure is 30 mm Hg
Complications after upper extremity arterial injury and or less, compartment syndrome is suggested. However, the
repair include reperfusion injury, thrombosis, anastomotic finding of normal pressure does not preclude the presence
hemorrhage, infection, and pseudoaneurysm. The risk of of compartment syndrome or its development at a future
complication varies according to the type and severity time point, and prophylactic fasciotomy should be consid-
of injury, but has not been well-defined in the literature. ered. This is important if prolonged transport to definitive
In the authors' experience with 45 war-injured patients, care is anticipated. In austere environments such as mili-
the rate of early complications after repair included infec- tary combat, where compartment pressure measurements
tion (5%), thrombosis (9%), anastomotic hemorrhage are not easily performed, the threshold to perform a prophy-
(2%), and early amputation (9%).2 A high index of sus- lactic fasciotomy is much lower than in an urban civilian
picion with repeat clinical evaluations and use of Duplex setting. Indications for fasciotomy are shown in Box 21.1.
ultrasound and/or CTA is recommended to enable early Furthermore, in one study from Iraq and Afghanistan of
­diagnosis of postoperative complications and mitigation air-evacuated patients with extremity injuries, the need
of their effects. for fasciotomy revision predicted mortality and tissue loss,
whereas delayed fasciotomy predicted mortality, tissue loss,
and amputation.81
COMPARTMENT SYNDROME
Kim et al. reviewed 139 patients with brachial artery
Although less commonly observed in the upper extremity injury and found that 29 patients (21%) were diagnosed
compared with the lower extremity, compartment syndrome with upper extremity compartment syndrome. Multiple
may affect the forearm or, less frequently, the upper arm arterial injuries, total intraoperative blood loss, and open
(triceps/deltoid). The diagnosis should always be considered fractures were found to be significant independent risk fac-
in any patient with blunt or penetrating extremity trauma, tors for the development of compartment syndrome in this
 21 • Upper Extremity and Junctional Zone Injuries 269

Box 21.1 Indications for Fasciotomy in the

Combat Setting

• >4- to 6-hour evacuation delay to revascularization

• Combined arterial and venous injuries
• Crush injuries A
• High–kinetic energy mechanism
• Vascular repair
• Arterial or venous ligation
• Comatose, closed head injury, or epidural analgesia
• Tense compartments
• Prophylactic
B
Adapted from Starnes BW, et al. Extremity vascular injuries on the battle-
field: tips for surgeons deploying to war. J Trauma. 2006;60:432–442. Fig. 21.15 (A) Fasciotomy of the upper extremity should begin medi-
ally in the arm and become sinusoidal from medial to lateral at the
antecubital fossa, incorporating the bicipital aponeurosis. Extension
must be sufficiently lateral to open the fascia over the extensor wad.
series (odds ratio 1.12, 5.79, and 2.68, respectively).82 In Gentle incision back to the volar fascia will help to also release this
a follow-up study, Kim et al. developed a prognostic score aspect. (B) Extensor counterincision is rarely necessary.
for compartment syndrome after upper extremity vascular
injury based on the three aforementioned variables (1 point
for every 100 mL of intraoperative blood loss, 6 points for
the presence of multiple arterial injuries, 3 points for the In a retrospective study, Hardin et al. reviewed 99
presence of open fracture).83 A score of less than 2.5 had upper extremity arterial injuries involving 21 axillary,
97% sensitivity and 37% specificity for development of 43 brachial, 12 radial, 13 ulnar, and 10 combined radial
compartment syndrome, whereas a score of 20 had 97% and ulnar vessels.8 Ultimately, only five patients required
specificity and 38% sensitivity. Although this scoring sys- amputation. Return of function occurred in half of these
tem may offer an adjunct to the clinical decision making of patients, whereas half were left with permanent functional
whether or not to perform a fasciotomy of the upper extrem- impairment. Axillary artery injury was associated with
ity after arterial injury, it is important to keep in mind this the highest rate of neurological impairment, attributed to
score has not been prospectively validated. its proximity to the brachial plexus and a higher burden of
The skin and fascial incisions for upper extremity fasci- distal ischemia. Shotgun and gunshot injuries were more
otomy extend from the lower medial aspect of the upper often associated with long-term disability, whereas lacera-
arm, becoming sinusoidal from medial to lateral at the tions, stab wounds, and blunt injuries were associated with
antecubital fossa, incorporating the bicipital aponeurosis better recovery.
(Fig. 21.15). The incision extends sufficiently lateral to open Brown et al. performed a review of patients who under-
the forearm fascia over the extensor wad. The incision then went operative management of upper extremity arterial
curves back to the volar aspect to release the fascia with or injury.19 The limb-salvage rate was 94%, and follow-up after
without carpal tunnel release depending on the extent of injury was 6.3 months. Patients who sustained blunt injury
injury. were more likely to have disability than patients with a pen-
etrating injury. Those with concomitant orthopedic trauma
were as likely to have functional recovery as those without
such injury. The importance of associated nerve damage
Outcomes after Treatment of was highlighted and patients who had a concomitant nerve
Upper Extremity Vascular Injury injury, whether combined with an orthopedic injury or not,
were less likely to regain function. Patients who had delayed
Outcomes after treatment of upper extremity arterial inju- nerve repair were more likely to have severe disability or
ries are presented in Table 21.1. In general, the more distal delayed amputation. The authors found that patients with
the injury the lower the chance that it will be fatal or lead injuries deemed severe enough to require fasciotomy did not
to limb loss. Outcomes after upper extremity injury have gain functional recovery and were left with the most severe
evolved beyond measurements of mortality alone, largely disability. It seems clear that whereas restoration of arterial
because advancements in prehospital and early resusci- perfusion and stabilization of bony injuries is often feasible,
tative care mean that injury to an upper extremity artery the ability to treat the functional sequelae of nerve and soft-
rarely leads to death. Moreover, limb salvage in and of itself tissue damage determines the outcome in many cases.
is a poor indicator of successful treatment, as many limbs Dubose et al. performed a review of 32 reports describ-
may be painful or dysfunctional, even though they are ing the endovascular management of axillosubclavian
via­ble after revascularization.84,85 These limitations may injuries.86 The most common mechanism of injury was
lead to delayed amputation, rehabilitation. Function-related penetrating (56.3%), followed by iatrogenic catheter based
out­come after upper extremity injury and vascular recon- (22%), blunt (21%), and open surgical injury (1%). The
struction may be a more relevant and modern measure of most common injury lesions treated in the review were
success. pseudoaneurysm (48%), arteriovenous (17%), ­perforation
270 SECTION 4 • The Management of Vascular Trauma

(14%), and occlusion (10%). Five of 160 (3%) injuries rare. In the future, endovascular techniques are likely to play
treated with an endovascular approach had acute stent a larger role in the management of this injury pattern and a
­failure, 4 ­requiring conversion to open repair; however, 97% greater emphasis will be placed on improving functional limb
of patients in the analysis underwent successful stent-graft salvage as a benchmark of meaningful recovery.
repair. Procedure-related complications included access
site complications (2%), embolic events (1%), and mortal- References
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272 SECTION 4 • The Management of Vascular Trauma

78. Stain SC, Yellin AE, Weaver FA, Pentecost MJ. Selective management 84. Hancock HM, Stannard A, Burkhardt GE, et al. Hemorrhagic shock
of nonocclusive arterial injuries. Arch Surg. 1989;124:1136–1140, worsens neuromuscular recovery in a porcine model of hind limb
discussion 40–41. vascular injury and ischemia-reperfusion. J Vasc Surg. 2011;53:
79. Labler L, Rancan M, Mica L, Härter L, Mihic-Probst D, Keel M. Vac- 1052–1062, discussion 62.
uum-assisted closure therapy increases local interleukin-8 and vas- 85. Burkhardt GE, Gifford SM, Propper B, et al. The impact of ischemic
cular endothelial growth factor levels in traumatic wounds. J Trauma. intervals on neuromuscular recovery in a porcine (Sus scrofa) survival
2009;66:749–757. model of extremity vascular injury. J Vasc Surg. 2011;53:165–173.
80. Jacobs S, Simhaee DA, Marsano A, Fomovsky GM, Niedt G, Wu JK. 86. DuBose JJ, Rajani R, Arthurs ZA, et al. Endovascular management of
Efficacy and mechanisms of vacuum-assisted closure (VAC) therapy axillo-subclavian arterial injury: a review of published experience.
in promoting wound healing: a rodent model. J Plast Reconstr Aesthet Injury. 2012;43:1785–1792.
Surg. 2009;62:1331–1338. 87. Waller CJ, Cogbill TH, Kallies KJ, et al. Contemporary manage-
81. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciot- ment of subclavian and axillary artery injuries: A Western Trauma
omy revision and delayed compartment release in combat patients. J Association multicenter review. J Trauma Acute Care Surg. 2017;83:
Trauma. 2008;64:S153–S161, discussion S61–62. 1023–1031.
82. Kim JY, Buck 2nd DW, Forte AJ, et al. Risk factors for compartment 88. Branco BC, Boutrous ML, DuBose JJ, et al. Outcome comparison
syndrome in traumatic brachial artery injuries: an institutional expe- between open and endovascular management of axillosubclavian
rience in 139 patients. J Trauma. 2009;67:1339–1344. arterial injuries. J Vasc Surg. 2016;63:702–709.
83. Kim JY, Schierle CF, Subramanian VS, et al. A prognostic model for 89. Matsagkas M, Kouvelos G, Peroulis M, Xanthopoulos D, Bouris V,
the risk of development of upper extremity compartment syndrome Arnaoutoglou E. Endovascular repair of blunt axillo-subclavian
in the setting of brachial artery injury. Ann Plast Surg. 2009;62: arterial injuries as the first line treatment. Injury. 2016;47:1051–
22–27. 1056.
 Lower Extremity Vascular
22 Trauma
DAVID S. KAUVAR and BRANDON W. PROPPER

Introduction and Scope injury) are not specifically reported in the literature but
presumably occur more frequently than injury at multiple
In this chapter we present the workup and surgical man- levels.
agement of vascular trauma to the lower extremities span-
ning from the common femoral vessels in the groin to the MECHANISM OF INJURY
tibial vasculature at the ankle. The term “vascular injury”
is used primarily to denote injury to a named artery of the Most reports of lower extremity vascular injuries have about
leg. Venous injuries will be considered separately from arte- equal proportions of blunt and penetrating injuries. In civil-
rial injuries and both in the context of concomitant arterial ian trauma, blunt arterial injuries are more frequently seen
trauma and as isolated injuries. The topics of hemostasis, at or below the knee in the popliteal and tibial segments
vascular damage control, endovascular therapies, and the than above the knee in the femoral segment. Common
implications of multiple tissue injuries (mangled extrem- superficial and deep femoral arterial injuries are more likely
ity), though topically relevant to lower extremity vascular to be caused by penetrating mechanisms.6,9 Blunt mecha-
trauma, are discussed in detail elsewhere in this textbook nisms in civilian trauma produce higher rates of fracture
and are not covered in significant depth here. We intend for and significant soft tissue and nerve injuries than penetrat-
this chapter to serve as a resource for the civilian or mili- ing ones.10 Correspondingly, these injuries tend to be associ-
tary practitioner of trauma surgery in the decision-making ated with greater limb injury severity and have poorer limb
process of planning for and executing open surgical lower outcomes.6,8,11,12 In modern military trauma, recent reports
extremity revascularization procedures. of lower extremity vascular injury consist of almost three-
quarters of injuries produced via explosions.13–15 These
injuries are particularly devastating, resulting in extensive
Injury Characteristics tissue destruction and rates of limb salvage correspondingly
lower than those seen in civilian lower extremity vascular
trauma.7,14–16 In limbs sustaining combat-related below-
LEVEL OF INJURY
knee explosive trauma with fracture and arterial injury, the
The lower extremity is the most frequent site of arterial delayed amputation rate following initial limb salvage has
injury in both civilian and military trauma.1–5 The femoral been reported at almost 80%.17
arteries in general and the superficial femoral artery (SFA) Table 22.1 presents selected civilian and military arterial
specifically have the highest consistently reported rates of injury data since 2000.
injury, with the remainder divided between the popliteal
and tibial arteries. The distribution of tibial artery injuries ARTERIAL PATHOLOGY
is not consistently reported in the literature and injuries to
the anterior tibial, posterior tibial, and peroneal arteries The nature of the injury to a lower extremity artery has
are variably consolidated or reported individually, making implications for the workup and treatment that will be dis-
it difficult to compare injury location data across studies. cussed later in the chapter. Arterial occlusion is reported
In general, however, the reported combined rate of overall in up to a third of cases, while transection is seen in 25%
tibial artery injury is similar to that of combined femoral to 45% of lower extremities. Other arterial injury types
injuries. Multiple arterial injuries in a single lower extrem- explicitly reported in the civilian literature include: lacera-
ity are likely to have resulted from a devastating degree of tion (partial transection), intimal injury, and pseudoaneu-
traumatic energy transfer—either trans-extremity pene- rysm.1,8–10 The reported pathologies represent the majority
trating trauma or near or complete traumatic amputations of the variety of traumatic injuries that can affect the arter-
from high impact blunt and shear forces. Such patterns of ies of the lower extremity. There are two basic categories of
vascular injury are reported most commonly at the tibial these pathologies: occlusive and disruptive. These patho-
level and are present in 6% to 20% of cases.6,7 Concomitant logic categories align with clinical presentations that will be
injury to multiple lower extremity artery levels is reported discussed later in this chapter.
in civilian trauma patients in 10% to 20% of cases.6,8 This Occlusive injuries can disrupt flow completely or par-
finding is more common with more complex injury pat- tially and are the result of thrombosis, intimal dissection,
terns, such as those produced by severe blunt trauma and mural hematoma, or entrapment/kinking. Thrombosis
crush injuries. Multiple injuries at the same arterial level or of an injured artery is caused by intimal damage that pre-
within the same artery (for example, multiple tibial artery cipitates platelet activation and initiation of the clotting
injuries or concomitant above- and below-knee popliteal mechanisms. Focal dissection and mural hematoma result
273
274 SECTION 4 • The Management of Vascular Trauma

Table 22.1 Civilian and Military Arterial Injury Data

Time Blunt/ Concomitant
Author Frame Source CFA SFA PFA Popliteal Tibial Blast Vein Injury Notes
Civilian Alarhayem 2012–15 NTDB 11% 37% NR 30% 24% 46% 25%
et al.
DuBose et al. 2013–14 PROOVIT 40% 26% 34% 47% NR 14 centers
Liang et al. 2004–14 Trauma Center 13% 17% NR 33% 36% 46% 11%
(USA)
Franz et al. 2005–10 Trauma Center 5.30% 32% 5.30% 21% 36% 44% 31%
(USA)
Topal et al. 2002–09 Trauma Center 47% 19% 34% 12% 42%
(Turkey)
Military Sisli et al. 2011–13 Syrian Conflict 41% 33% 27% 47% 41%
(Turkey)
Perkins et al. 2003–12 JTTR-Iraq/ 31% 5.40% 22% 42% 71% 43%
Afghanistan
(USA)
Stannard 2003–08 JTTR-Iraq/ 42% 16% 42% 76% NR Immediate
et al. Afghanistan amputations
(UK) included
Clouse et al. 2004–06 Field Hospital 5.70% 34% 7.60% 25% 28% 55% NR
Registry
CFA, Common femoral artery; JTTR, Joint Theater Trauma Registry; NTDB, National Trauma Data Bank; PFA, deep (profunda) femoral artery; PROOVIT,
Prospective Observational Vascular Injury Treatment registry; SFA, superficial femoral artery.

in direct luminal diameter compromise and can also serve as

a nidus for thrombosis. Lower extremity arterial entrapment
within, or kinking of a vessel around, a fracture can also
cause an occlusive injury. Depending on the degree of ves-
sel wall trauma in the area of the bony injury, the occlusion
may resolve with surgical freeing of the entrapped artery or
fracture reduction without the necessity for vascular recon-
struction. This highlights the importance of early reduc-
tion of displaced fractures and reassessment of the vascular
status of the limb prior to committing to an operative plan.
Regardless of the underlying pathology, complete or partial
occlusive lower extremity arterial injuries present with vary-
ing degrees of clinical ischemia distal to the arterial injury.
Complete and partial arterial transections, punctures,
and pseudoaneurysms comprise the pathologies producing
disruptive arterial injuries.10 These pathologies all involve
varying degrees of direct luminal disruption resulting in
the potential for blood to escape the vessel. Arterial wall Fig. 22.1 Bilateral military lower extremity injuries resulting from an
disruption usually results from direct trauma to the vessel improvised explosive device. Multiple arterial injuries are clearly pres-
whether by a projectile, blade, or fragment of bone. Iatro- ent and the limbs may or may not be salvageable.
genic femoral artery injuries such as those resulting from
percutaneous access typically result in disruptive inju-
ries that may be initially occult. These injuries manifest ischemia seem to predict limb loss regardless of mechanism.
as pseudoaneurysms or arteriovenous fistulas and can be Due to the complex nature of occlusive injuries and the
a challenge to diagnose and treat. Bleeding from named varying degree of thrombosis that can be involved, recon-
arterial disruptive injuries can be significant, and even life- struction of these injuries can be challenging.
threatening. These injuries present clinically with signs of Military lower extremity injuries usually result from
hemorrhage and usually demand prompt identification and high-energy explosions and deserve special mention due to
hemorrhage control. Traumatic arteriovenous fistula may their unique nature. Explosions produce extensive damage
also be present if a major artery and vein sustain disruptive to multiple limb tissues due to primary (blast overpressure),
injuries in proximity to each other. Though not explicitly secondary (fragment), and tertiary (blunt) blast trauma.
reported, it stands to reason that occlusive arterial injuries The high-energy and complex nature of the military explo-
to the lower extremities are more likely to result from blunt sion mechanism of injury can produce any of the arterial
mechanisms, whereas transections (both partial and com- pathologies listed previously alone or in combination. Com-
plete) are more likely to arise from penetrating trauma. The plex segmental arterial destruction, sometimes at multiple
degree of traumatic tissue disruption and the degree of limb levels, is a common finding (Fig. 22.1).
 22 • Lower Extremity Vascular Trauma 275

Patient and Limb Outcomes

The major outcomes of interest for lower extremity vascular
injuries are mortality and delayed amputation. In general,
limb salvage is the primary goal of the surgical manage-
ment of vascular injuries to the leg. Vascular reconstruction
to salvage a limb should not take priority over interventions
to preserve life in the multiply injured patient. The surgeon
planning to perform a vascular reconstruction in a trau-
matically injured leg must understand the limb injury in
the context of the entire complex of traumatic injuries and
physiologic status of the patient in order to most effectively
plan the intervention and ensure the potential for the best
possible outcome for the limb and the patient. Both pre- and
intraoperative communication with the entire team caring
for the patient is vital to this understanding. Trauma and
orthopedic surgeons and anesthesiologists can provide sig-
nificant insight that is vital to planning a vascular recon- Fig. 22.2 Massive, high-energy military lower extremity trauma. This
struction in the context of the patient’s overall condition injury was caused by an improvised explosive device and primary
and potential for limb salvage. amputation was performed.

MORTALITY
multiple tibial arteries are injured, in which case the ampu-
In the injured patient, hemorrhage causes of about one-third tation rate can exceed 10%.6,8,12,31 At any arterial level, limbs
of deaths.18–20 Deaths resulting from hemorrhaging isolated injured via blunt mechanism are at higher risk of second-
lower extremity vascular injuries, however, are very uncom- ary amputation than are those having sustained penetrat-
mon, even in the presence of a named arterial or venous ing trauma, likely due to the preponderance of associated
injury.12,21 Because of this, mortality is infrequently reported tissue injuries produced by blunt trauma.6,8,12,26,28,31–33 The
as an outcome in clinical series of vascular injuries to the mangled extremity severity score (MESS) was developed
lower extremity and specific risk factors are not defined. The as a clinical tool to predict amputation in civilian extrem-
recent, military inspired adoption of tourniquets as primary ity trauma,34,35 and higher MESS has been associated with
hemostatic measures in the civilian prehospital arena may amputation in single-center reports.6,8 A consistently pre-
serve to diminish mortality associated with vascular injuries dictive MESS cutoff score has been elusive, however, and
to the leg further.22–25 In isolated leg vascular injuries, as the the efficacy of the scoring system itself has been called
level of vascular injury becomes more proximal, the mor- into question.36 Published registry data also suggests that a
tality rate increases, ranging from around 1% with tibial delay of greater than 60 minutes from the time of injury to
injuries to almost 8% at the common femoral level. Because the time of an operation for revascularization is associated
hemorrhage is the likely cause of mortality from a vascular with amputation in civilian trauma,32 though this is not
injury to the lower extremity, it stands to reason that disrup- a consistent finding in single-center reports.6,8 Prolonged
tive injuries (primarily resulting from penetrating mecha- ischemia of greater than 6 hours, however, is a consistent
nisms) produce most of these fatalities.12,21 predictor of delayed amputation in military and civilian
vascular trauma.7,13,26
The secondary amputation rate encountered following
AMPUTATION
military lower extremity vascular injury is strongly related
Limb salvage should be the primary goal of vascular inter- to the mechanism of limb injury. The high-energy blast
vention on the lower extremity in the setting of limb trauma trauma that results in the large majority of modern military
as long as the attempt does not threaten the patient’s life. vascular injuries is associated with much higher amputa-
In military lower extremity vascular injury, primary ampu- tion rates than gunshot wounds, which comprise most
tation (defined as amputation without an attempt at limb of the remaining injuries.7,15,17,37 As with civilian lower
salvage) is predominantly performed in cases of massive tis- extremity vascular trauma, popliteal artery injuries carry
sue injury as a damage-control maneuver13 (Fig. 22.2). In especially high amputation rates.37,38 Secondary amputa-
civilian trauma, secondary amputation (defined as ampu- tion following military injuries is associated with the sever-
tation following an attempt at limb salvage) is the most ity of concomitant limb tissue injuries, especially in cases
commonly reported outcome measure in clinical series of where there has been significant tissue destruction.13,17
lower extremity vascular injuries. Injury to the popliteal Various aspects of the presenting physiology of the patient
artery consistently produces the highest amputation rates, and characteristics of the limb injury complex have been
with the common femoral injury producing the lowest.26 studied as potential risk factors for secondary amputation
Overall, amputation following blunt injury to the popliteal in published civilian and military series’ including all lower
artery is performed in up to 35% of patients; however, sec- extremity arterial levels.
ondary amputation after attempted reconstruction has an Table 22.2 presents a review of studies of civilian lower
incidence of around 10%.12,27–30 Tibial artery injuries gen- extremity vascular injury and associated risk factors for
erally produce low rates of secondary amputation, unless secondary amputation.
276 SECTION 4 • The Management of Vascular Trauma

Table 22.2 Studies of Civilian Lower Extremity Vascular Injury and Associated Risk Factors for Secondary Amputation
Multiple Injury
Time Blunt/ Pulse Nerve Popliteal Arterial Soft Tissue Severity
Author Frame Source Blast Hypotension Deficit Injury Fracture Injury Injuries Destruction MESS Score
Civilian Alarhayem 2012–15 NTDB X O X X X X
et al.
Liang et al. 2004–14 Trauma Center X O X O X X X X
(USA)
Topal et al. 2002–09 Trauma Center O X X X O X X X
(Turkey)
Perkins 1984–2008 Metaanalysis X O O X O X X O O
et al.
Kauvar 2002–06 NTDB X O O O X X X O O O
et al.
Military Sisli et al. 2011–13 Syrian Conflict X O X X O X
(Turkey)
Perkins 2003–12 JTTR-Iraq/ X X X X X X X X
et al. Afghanistan
(USA)
Thomas 2004–12 JTTR Iraq/ X X X X O X X
et al. Afghanistan
(USA)
Blank, not studied; X, found to be a risk factor; O, not found to be a risk factor; .JTTR, Joint Theater Trauma Registry; MESS; mangled extremity severity score; NTDB,
National Trauma Data Bank.

meticulous vascular surgical technique is the best way to

LIMB COMPLICATIONS prevent stenosis or thrombosis of a vascular reconstruction.
Complications other than amputation are infrequently Using the best available conduit (preferably single-segment
reported in both the civilian and military vascular trauma saphenous vein), constructing spatulated anastomoses free
literature. Limb complications may not develop during the of tension and torsion, and avoiding kinking or twisting of
initial inpatient stay and may be underreported, especially the graft are all aspects of technique which minimize the
in data from civilian centers where loss to follow-up rates chance for a graft stenosis or thrombosis.
are notoriously high. Complications of the reconstruc- Breakdown of the anastomosis or of the graft itself (typi-
tion itself include thrombosis, stenosis, and anastomotic cally at the site of a saphenous tributary) occurs with about
or graft breakdown which can present as pseudoaneu- half the frequency of graft thrombosis and presents with
rysm, blowout, and arteriovenous fistula. Saphenous vein potentially catastrophic hemorrhage.40 Like graft steno-
is the conduit of choice for the repair of lower extremity sis, these complications take time to develop and are likely
vascular injuries, but even with the use of this conduit, underreported from civilian centers. In military reports
early (within 30 days) graft thrombosis is reported in 10% with longer clinical follow-up periods, graft breakdown is
or more of civilian lower extremity vascular reconstruc- seen at a rate of approximately 6%, about twice that seen in
tions. The thrombosis risk is related to the location of the civilian trauma.40–43 There is an association between anas-
distal target (and thus the robustness of the outflow) of tomotic dehiscence and acute or chronic vascular graft
the graft; grafts to the tibial vessels perform much more infections in nontrauma reconstructions which likely holds
poorly than those with more proximal targets.39,40 Early in the trauma setting as well. Accordingly, any anastomotic
thrombosis of a vascular reconstruction should be taken as dehiscence or graft breakdown not directly attributable to
a sign that there is a problem either with the reconstruc- a technical error should be investigated and treated with a
tion itself or with the outflow, and investigation (typically high index of suspicion for infection.
re-exploration, thrombectomy, and angiography) should Limb wound infection following vascular reconstruc-
be performed. If necessary, the reconstruction may require tion in high-energy military blast trauma is another slowly
revision or replacement to maximize the chance for limb developing complication and is reported in up to 30% of
salvage. Despite these maneuvers, early graft failure is asso- cases. Wound infections following civilian lower extrem-
ciated with a high limb loss rate.37,39 Graft or anastomotic ity vascular injury are reported in about 10% of cases and
stenosis is a late-developing complication that is essentially are probably related to the magnitude of tissue injury and
unreported in the civilian literature. It is generally thought contamination rather than the vascular injury or its treat-
that stenosis is less common in vascular trauma reconstruc- ment. In addition to infection, desiccation of a vascular
tions than in those performed for chronic occlusive disease reconstruction can also lead to breakdown and potentially
because of the relative absence of atherosclerosis in the significant hemorrhage. In addition to employing the best
typically young, healthy trauma patient. There is no good possible aseptic surgical technique, coverage of all exposed
quality evidence to support this supposition, however, nor vascular graft tissue, including complete coverage of all
is there any indication that duplex ultrasound surveillance anastomoses with healthy musculocutaneous tissue, is the
of vein grafts placed for vascular trauma may facilitate key to preventing desiccation and minimizing the chance of
early identification of graft-threatening stenosis. The use of infection.
 22 • Lower Extremity Vascular Trauma 277

significant hemorrhage. The decision to ligate or reconstruct

FUNCTIONAL OUTCOMES AND QUALITY OF LIFE such injuries, whether they occur in isolation or concomi-
Patient-level outcomes such as extremity performance and tant with arterial injury, remains controversial. Disrupted
quality of life following lower extremity vascular injury single tibial veins can be safely ligated; however, ligation of
have been largely unreported, in part due to the noted dif- a major (femoropopliteal) lower extremity vein in the set-
ficulty in attaining mid- and long-term clinical follow-up of ting of limb trauma carries the theoretical risk of precipi-
these patients. A discussion of the functional implications tating venous hypertension leading to distal tissue edema
of posttraumatic amputation is beyond the scope of this and potentially compartment syndrome. However, venous
chapter, but even following salvage of a severely injured surgical repair in the trauma setting is technically demand-
extremity, there may be significant disability and quality of ing, time consuming, and is believed to have generally poor
life issues for both military and civilian patients.44–46 Much patency in the low flow venous system.50 Both lateral venor-
of the disability and dissatisfaction reported by patients fol- rhaphy and venous interposition graft reconstructions are
lowing extremity vascular injury is due to the pain and loss unfavorable given that they disrupt endothelial continuity
of physical performance caused by musculoskeletal and and narrow the flow lumen, risking thrombosis. Early (7-
nerve damage and not significantly attributable to vascu- to 30-day) patency rates for lower extremity venous recon-
lar insufficiency. Blunt mechanism and limb injury severity structions performed for trauma are between 60% and 70%
predict poor results on functional independence and qual- in reports, and it is likely that this represents an overestima-
ity of life scales in the few studies that have examined these tion of venous patency because occlusions may be clinically
variables over the long-term in populations of patients fol- silent.52,54 If these are attempted, they have the best chance
lowing leg vascular injuries.13,33,47 for success if there is undisturbed distal venous inflow (i.e.,
Functional outcomes specific to the vascular injury in minimal distal soft tissue disruption) and preserved proxi-
lower extremity trauma remain unstudied for the most part. mal venous outflow. Major lower extremity venous ligation
Applying the dogma of chronic vascular insufficiency in the is well accepted in cases in which the time needed to surgi-
setting of posttrauma outcomes, it would be expected that cally reconstruct the vein injury is not available due to the
failure of a femoropopliteal reconstruction would result in patient’s tenuous physiologic status or when the severity of
exertional ischemia and intermittent claudication, whereas the overall injury complex makes the venous injury a low
failure of a more distal reconstruction would result in isch- priority.
emic rest pain or in tissue loss. The pathophysiology of Even with decades of retrospective data from clinical
atherosclerotic vascular insufficiency and that of vascu- studies, there is no consensus in the literature regard-
lar trauma differ significantly, however, as do the patient ing the appropriate surgical management of major lower
populations. Without long-term follow-up data on trauma extremity venous injuries. The theoretical physiologi-
patients to support the application of chronic disease prin- cal risks of major venous injuries are acknowledged, and
ciples to the outcomes of vascular reconstruction for inju- symptomatic leg edema is reported, but very few studies
ries, we can only guess as to the nature and strength of any published in the past decade describe an association with
association between the two disease processes. As we move venous ligation and limb loss. Secondary amputation rates
towards examining the true functional outcomes in chronic of approximately 5% to 10% following ligation of injured
lower extremity vascular insufficiency, we should make an femoropopliteal veins are reported in recent studies that
effort to study these outcomes in the trauma population include concomitant arterial injuries, with much lower
as well.48,49 rates following ligation of isolated venous injuries.50,52,53,55
Ligation of a major lower extremity vein injury is also
thought to predispose the patient to the development of
venous thromboembolism (VTE). The VTE rate does appear
Concomitant and Isolated to be high in cases of lower extremity venous injury, rang-
Vein Injury ing from 30% to 50% in studies.50,51,56 However, the devel-
opment of VTE does not appear to be associated with the
Major lower extremity venous injuries are reported in com- surgical management of major lower extremity venous
bination with arterial injury in a quarter to a half of cases injuries. In fact, lower VTE rates have been reported with
of military and civilian limb trauma. Concomitant vein ligation than repair in some studies.50,54
injuries are most frequently seen accompanying SFA injury Table 22.3 presents a brief review of published studies of
(approximately 40%–60%), and are less common with com- lower extremity venous injury outcomes.
mon femoral and popliteal (10%–25%) and tibial (10%) Given the lack of consensus in the literature, our typi-
artery injuries.12,50 Isolated lower extremity major venous cal practice is to avoid routinely performing complex lower
injury is infrequently described and is likely underreported extremity venous reconstructions for trauma. Operative
as most attention is focused on the management and out- treatment is rarely required for isolated venous injuries in
comes of arterial injuries. The reports that do exist of lower hemodynamically stable patients and bleeding from larger
extremity venous injuries have concomitant arterial injury veins may be surgically controlled with direct suture or liga-
rates of 15% to 40%.51–54 Concomitant vein injury in the tion with or without formal inflow and outflow control. We
setting of a lower extremity arterial injury is a marker of a generally reserve inline venous reconstruction for cases in
more severe limb injury complex and an indicator of poor which outflow compromise is demonstrated by early arterial
limb salvage prognosis. or shunt thrombosis, poor quality arterial signals following
Major lower extremity venous injuries consist of ves- reconstruction (after fasciotomy and confirmatory angio-
sel transections and lacerations that can present with gram), or overt evidence of compromised venous outflow
278 SECTION 4 • The Management of Vascular Trauma

Table 22.3 Studies of Lower Extremity Venous Injury Table 22.4 Hemorrhagic and Ischemic Signs of
Extremity Arterial Injury
Author Year Cases Major Findings
Parry et al. 2003 86 treated femo- No difference in amputa- Hemorrhagic Signs Ischemic Signs
ropopliteal vein tion rate between Active hemorrhage (especially Diminished or absent distal
injuries ligation and repair pulsatile) from a limb wound pulse
No difference in patency History of large volume of limb Ankle-brachial index <1.0
between venorrhaphy, hemorrhage
interposition with Systemic hypotension not Cool limb distal to suspected
autologous vein or PTFE accounted for by other injuries injury
Kurtoglu 2007 63 ligated 89% postoperative edema Pulsatile mass in proximity to Pallor distal to suspected injury
et al. iliofemoral and 59% DVT <5 days suspected area of injury
popliteal vein
injuries 15 of 25 with follow-up Palpable thrill in proximity to Impaired motor or sensory func-
CEAP C2 or C3 suspected area of injury tion distal to suspected injury
Quan et al. 2008 82 combat venous No difference in VTE, Hematoma (especially expanding)
injuries phlegmasia, or fasci- or limb circumference
otomy rate between discrepancy
ligation and repair
22% vein repair
thrombosis include absence of distal pulse, active pulsatile bleeding,
Manley 2017 94 isolated venous No difference in amputa- palpable thrill or audible bruit, and expanding hematoma.
et al. injuries tion rate between Soft signs suggest an arterial injury and include diminished
ligation and repair
distal pulses, reported history of significant bleeding, neu-
VTE more common with
repair
rologic deficit, and proximity of a wound to a named ves-
sel. These signs were developed primarily for the evaluation
Matsumoto 2019 2120 NTDB Ligation a weak indepen-
et al. venous injuries dent predictor of ampu- of patients with penetrating limb trauma and are intended
(includes tibial) tation and fasciotomy to drive the decision of whether to take a patient directly
to the operating room for surgical exploration (in the pres-
CEAP, Clinical impact, Etiology, Anatomy and Pathophysiology (classifica-
tion); DVT, deep vein thrombosis; NTDB, National Trauma Data Bank; PTFE, ence of hard signs) or to pursue vascular-specific imaging
polytetrafluoroethylene; VTE, venous thromboembolism. (with soft signs). The data validating hard and soft signs of
vascular injury is now over 30 years old and was produced
long before the adoption of routine CT angiography (CTA)
with early massive venous bleeding or tissue edema. The imaging for nearly all trauma patients. Given this and that
most common lower extremity locations to require venous the vast majority of trauma occurs via a blunt mechanism,
reconstruction are the popliteal segment (especially above the traditionally applied distinction between hard and soft
the knee) and the femoral confluence. Significant loss of presenting extremity signs is not particularly useful in the
antegrade venous drainage at either of these levels gener- modern trauma workup.
ally produces significant distal venous congestion. A more relevant and modern distinction can be made
Venous reconstructions usually require distal thrombec- between hemorrhagic and ischemic presenting signs of
tomy. It can be difficult to pass an embolectomy catheter dis- extremity vascular injury. These are better suited to guide
tally, and we therefore favor Esmarch thrombectomy from the initial workup and management plan for an extremity
the foot to the surgical site to deliver any thrombus and con- with suspicion of a vascular injury and broaden the scope
firm patent venous inflow. Inline venous reconstructions of initial suspicion for an injury to prevent missed injuries
can consist of simple suture repair, lateral venorrhaphy, (Table 22.4). These signs are operationally relevant in that
or short interposition grafts. Long venous bypasses do not they not only suggest the presence of a vascular injury, but
have good patency when performed in the elective setting, also inform the initial management of an injured extremity.
and we do not recommend them for use in the setting of Hemorrhagic signs tend to result from penetrating trauma
acute trauma. Autologous conduits are preferred, but large- and typically represent localized vascular injury. The pres-
diameter expanded polytetrafluoroethylene (ePTFE) grafts ence of a hemorrhagic sign may be evidence of a poten-
have been reported to have similar short-term patency.52 tially life-threatening major arterial injury requiring urgent
intervention. Such injuries may require urgent temporary
hemostasis measures such as the application and mainte-
Presentation, Diagnosis, and nance of direct manual pressure, placement of a tourniquet
or, potentially, placement of an infrarenal occlusion balloon,
Workup especially if they are accompanied by systemic hypotension
and/or shock. In these cases, urgent temporary bedside
The characteristics of an extremity injury’s early presenta- hemostasis should be followed by a rapid clinical evaluation
tion are key factors in determining the urgency of the clini- of the anatomy of the injury including an assessment of
cal workup and the nature of necessary initial interventions. the most feasible locations to achieve vascular inflow and
The traditional workup for lower extremity vascular injuries outflow control. Many urgent hemostasis measures alter or
has been based on the presence or absence of hard and soft cease flow to and through the zone of injury, making vas-
signs of vascular injury. Hard signs are reported to provide cular-specific imaging problematic for identifying the anat-
definitive evidence for the presence of an arterial injury and omy of a vascular injury. Urgent operative exploration with
 22 • Lower Extremity Vascular Trauma 279

expeditious vascular control is indicated when such mea- Table 22.5 Operative Planning Considerations for
sures make quality vascular imaging impossible. However, Extremity Vascular Injury
if the patient can be stabilized and extremity hemorrhage
Sequencing 1. Consideration of temporary shunting
controlled without disrupting overall limb arterial flow, we
recommend preprocedural vascular imaging evaluation to 2. Temporary fracture reduction
identify at least the extent of the vascular lesion and the 3. Vascular reconstruction
inflow and outflow vessels for operative planning in limbs 4. Fasciotomy
with hemorrhagic signs. Good quality CTA imaging is read- Technique Equipment availability and limitations
ily and rapidly available in most trauma departments and (radiolucent table)
provides a wealth of vascular and associated tissue infor- Inflow and outflow Incision placement
mation, making it our first choice for the imaging of limbs exposures Clamp requirements
with suspicion of lower extremity vascular injury.57,58 Conduit choice Surgical prep and drape
Limbs presenting with ischemic signs tend to have sus- Wound category
tained blunt injury and their vascular pathology can be Tissue coverage Local flap
expected to be more extensive than that seen in limbs with Negative pressure dressing
hemorrhagic signs. One would also expect there to be a
greater degree of associated bony and soft tissue injury in
the face of ischemic signs. Bony injury can often be help- tamponade at the injury site. In cases with active hemor-
ful in localizing the level of vascular injury in blunt limb rhage (hemorrhagic signs), a proximally placed tourniquet
trauma. An unstable knee dislocation suggests an injury to or direct manual pressure should be applied for temporary
the popliteal segment directly behind the knee, whereas a hemorrhage control and proximal vascular exposure and
tibial plateau fracture will may be associated with an injury control performed remotely. Once proximal exposure and
to the distal popliteal artery or tibioperoneal trunk. These control are achieved, the focus should then turn to distal
injuries can therefore be more complex to reconstruct than vascular exposure. We favor distal exposure in an area that
hemorrhagic injuries, but because of the absence of life- is outside of the zone of tissue injury if feasible. This is of
threatening hemorrhage, the clinician has more time to particular value in cases with hemorrhagic presentations,
investigate their anatomy and plan reconstruction. Inter- as active bleeding can be remotely controlled and the injury
vention planning for limbs presenting with ischemic signs more fully assessed. Once both proximal and distal circum-
benefits significantly from CTA imaging for the reasons ferential vascular control are achieved, direct exposure of
mentioned previously. Ischemic vascular injuries tend to the zone of injury can commence.
require longer and more complex reconstructions occur- The vascular injury itself should be circumferentially dis-
ring in the context of significant nonvascular tissue injuries sected and fully explored. Mechanism of injury is a signifi-
that may require concomitant, prior, or subsequent surgical cant consideration as extended ballistic tissue effects may not
repair. In such cases, the additional information provided by be fully appreciated in the local exposure and more extensive
a good quality CTA is invaluable for multidisciplinary surgi- dissection may be required to fully evaluate the vascular
cal planning. In ischemic extremity vascular injuries, it is injury in high-energy injuries. The evaluation should note
important to determine a reasonable estimate of the length the overall appearance of the vessel and degree of exter-
of time the limb has been ischemic because this may influ- nal mural disruption. The injured vessel should be opened
ence the operative sequencing and the use of damage con- (typically longitudinally) to evaluate the type and degree
trol techniques such as shunting (discussed in Chapter 23) of intimal injury with care taken in penetrating injuries to
as well as defining the potential risk for reperfusion injury examine for the presence of disruption of the deep wall of
and the need for fasciotomy. the vessel. Primary luminal repair for noniatrogenic inju-
In any limb with hemorrhagic or ischemic signs of vascu- ries is not the best option for reconstruction in most cases.
lar injury, whether guided by preprocedural imaging or not, It is often tempting to “tack down” a seemingly focal intimal
one should go to the operating room with a basic plan for injury, but this can lead to short- or long-term failure.
the revascularization. This plan should be communicated Direct exploration offers the opportunity to select appro-
to the entire multidisciplinary trauma care team and at a priate sites for inflow and outflow that will fully exclude the
minimum should include the items presented in Table 22.5. injury. In general, shorter reconstructions are preferred due
to their better patency. The inflow source should be inline
and free of proximal obstruction and the outflow should
Technical Aspects of Vascular be inline to a patent named vessel. Once these are estab-
Reconstruction lished, the quality of proximal pressure and backbleeding
should be assessed. If either is poor or absent, an attempt
at balloon-catheter thrombectomy should be made. If no
GENERAL CONSIDERATIONS
thrombus is returned and inflow or outflow remain com-
The initial procedure in the surgical management of lower promised, further direct exposure and exploration may be
extremity vascular trauma is achieving proximal vascular needed, especially in cases of inadequate inflow. An on-table
control. In a limb without active hemorrhage (ischemic angiogram may be considered to evaluate for a more proxi-
signs), vascular exposure for proximal control should occur mal vascular lesion. A lack of backbleeding in the absence
in an area that is generally free from tissue injury to ensure of thrombus does not necessarily denote the absence of
that the inflow source can be assessed fully through a stan- adequate outflow, especially in cases of severe injury with
dard vascular approach and to avoid potential disruption of long ischemic times or large amounts of hemorrhage. To
280 SECTION 4 • The Management of Vascular Trauma

evaluate for outflow patency in the circumstance, distal conduit in lower extremity trauma. Traditionally, the con-
limb compression should elicit some degree of backbleeding tralateral leg has been preferred; however, in cases where
and is a reassuring finding. no ipsilateral venous injury is present, the use of ipsilat-
In cases of severe (usually blunt) limb trauma with large eral vein is reasonable and does not appear to be associated
degrees of tissue disruption, we generally recommend place- with a higher complication rate than the use of contralat-
ment of a temporary vascular shunt when anatomically eral vein.39,59 One advantage of harvesting contralateral
feasible, even for relatively short planned ischemic times. saphenous vein is that if multiple surgeons are available, it
Temporary shunting of a lower extremity arterial injury can often be harvested simultaneously with arterial expo-
provides two benefits: it facilitates evaluation of the expected sure and preparation. If a conduit of greater diameter is
result of vascular reconstruction—presence of a reasonable required, the internal jugular vein can be used. This ves-
distal Doppler signal confirms adequate inflow and out- sel lacks length, however, and saphenous vein is preferred
flow—and it allows for perfusion during vein harvest and/ and nearly always suitable for lower extremity reconstruc-
or orthopedic manipulation. Once an arterial shunt is in tions. We generally avoid using femoral vein in the setting
place, the distal limb should be examined. In the presence of of major lower extremity injury.
concomitant venous injury, we consider leaving our arterial In lower extremity trauma, tunneling is most often per-
shunt in place for 15 to 20 minutes while vein is harvested. formed from above to below the knee. For femoral artery
Shunt thrombosis or development of a water hammer Dop- injuries, an interposition can usually be performed directly
pler signal in the shunt should prompt consideration of out- within the exposure site and short tibial to tibial artery
flow obstruction or poor venous return requiring venous bypasses are rare. A wide variety of tunnelers are available,
reconstruction. Arterial shunting will also precipitate but our preference is to use a device employing a cylindri-
venous outflow in the zone of injury and can be used to iden- cal tube that remains in place during graft tunneling and
tify veins requiring ligation or reconstruction to preserve is removed over the graft, protecting it from twisting and
limb outflow. Specific shunts are discussed in detail else- trauma. If a tunneler is not available, a long vascular clamp
where in Chapter 23, but in lower extremity trauma, each can be used to pull the graft through the tunnel, but this
device offers different advantages. Thin tube shunts (Argyle) risks graft injury. It is critical that above-to-below-the-knee
are easy to place and secure and can be placed entirely inside tunnels are made in the plane between the femoral and tib-
the artery. They are generally short, and extension into nor- ial condyles to prevent graft kinking. Blunt finger dissection
mal vascular tissue is required both proximally and distally, should be used proximally and distally to guide the tunnel
potentially crossing branches placing them at risk of throm- into the appropriate plane.
bosis. Longer flexible shunts with bulb tips (Sundt) require Twisting of the conduit can result in early graft failure.
securing close to the injury and therefore do not have long We recommend two techniques for avoiding this. Creation
purchase lengths; however, they can bridge long distances, of a single, continuous longitudinal mark on the vein graft
and do not typically cross branch points, which may allow is a common practice and is advisable. There has been some
for greater limb manipulation while they are in place. recent debate about the potential for alcohol containing
Once shunts are in place, a multidisciplinary discussion marker ink to cause vein damage, but we believe that the
should occur if bony injuries are present. It is generally pref- benefits of marking outweigh the likely small risk of this.
erable to have the orthopedic team return the limb to length The marking should be made with the vein graft pressur-
so that an accurate distance to be bridged by the vascular ized and should be placed along the vein such that it can
reconstruction can be determined. If both the proximal and be visualized for both the proximal and distal anastomosis.
distal arterial segments will be easily accessed following Care should be taken to remember that distal rotational
fixation, it is reasonable to proceed with temporary or per- graft orientation might not be the same as proximal. The
manent orthopedic manipulation with the shunt in place. second recommendation is to allow arterial pressurization
It has been our experience, however, that fixation spanning of the graft following the proximal anastomosis, which will
the knee joint often impairs exposure of the popliteal seg- generally untwist it prior to orienting for the distal anas-
ments, which are almost always more accessible with the tomosis. Care should be taken to not hold the graft during
leg bent and a bump placed under the distal thigh. In these pressurization as it can prevent untwisting. Pulsatile arte-
cases, we favor performing the proximal anastomosis, then rial flow should be clearly visualized through the graft or a
bringing the leg to length and measuring conduit distance. problem with inflow or the graft itself should be suspected.
In reconstructions spanning the knee, we recommended The most important aspect of graft length measurement
an additional centimeter of redundancy in the vein graft is harvesting adequate vein for creation of a conduit. Fol-
to allow for flexion without anastomotic tension. The distal lowing harvest, the vein graft will shorten until it is pressur-
reconstruction is performed, followed by temporary or per- ized; therefore, length measurements should be performed
manent orthopedic fixation. Regardless of the sequencing with the vein in situ. An external measurement with suture
of the orthopedic and vascular limb procedures, it is criti- can be used to determine the needed graft length—this
cal to assess the physical status and patency of the vascular measurement will be longer than the distance spanning
reconstruction following limb elongation and fixation. the proximal and distal anastomoses and will usually
ensure that adequate vein is harvested. Measurements
should account for the likely necessary excision of proxi-
CONDUIT, TUNNELING, TWISTING, AND
mal and distal graft ends and for distance lost to spatula-
MEASURING tion. The GSV can generally be spatulated and/or dilated to
An autogenous conduit of greater saphenous vein (GSV) is accommodate the diameter necessary for any needed lower
the typical and most versatile choice for use as an arterial extremity bypass procedure.
 22 • Lower Extremity Vascular Trauma 281

TECHNIQUES FOR ANASTOMOSIS

If the patient cannot be systemically anticoagulated with
Aorta
heparin, local administration of heparin (10–100 units/mL)
by direct vascular injection through the anastomotic arteri-
otomy is advisable to prevent vessel thrombosis during clamp-
ing. When interposition or bypass grafting is required, we Common iliac artery

recommend large spatulated anastomoses on both the proxi-

mal and distal ends. For most vessels, 2 cm of spatulation will External iliac artery
be adequate to ensure effective flow through the graft. The
native vascular tissue used for the anastomosis should be free
of injury and we recommend avoiding complete arterial tran-
section leaving a bridge of arterial wall posteriorly if possible.
This prevents vessel retraction and is most important when Reflected
peritoneal cavity
performing an interposition graft. With an intact posterior
strip of arterial wall remaining, the proximal and distal anas-
tomoses can be measured and completed. Then the remain-
ing tissue bridge can be lysed if desired (this maneuver is most
useful for brachial artery reconstruction, but is also helpful
for SFA interpositions). Standard running sutures of mono-
filament polypropylene are almost always most appropriate, Fig. 22.3 Extraperitoneal approach to iliac vessels for control of junc-
and care should be taken to avoid narrowing at the heel and tional groin hemorrhage.
the toe of the anastomosis. The “parachute” technique is
often required to adequately visualize the initial heel and toe
sutures placed for popliteal anastomoses, as these typically lie
deep within the surgical bed. This technique consists of place-
ment of the first few sutures without pulling the stitch taut
such that both the arteriotomy and graft can be easily seen.
Once sufficient sutures have been placed so that the remain-
ing sutures will comprise the midportion of the anastomosis,
the sutures can be pulled taut and the graft brought in to
meet the arteriotomy. Just prior to completing the distal anas- Right
tomosis, the graft should be forward bled and backbleeding Ext. iliac a. common iliac a.
permitted to flush the reconstruction of all air and debris. In Deep iliac Int. iliac a.
the absence of atherosclerotic disease, once the reconstruc- Superf. iliac Superior
tion is complete and flow is permitted through the graft, a circumflex a. gluteal a.
palpable pulse should be present in the distal outflow vessel. Superf. Inf. gluteal a.
In some cases, this may not be the case until fasciotomies are epigastric a. Common
Ascend. branch lat. femoral a.
performed. If a pulse is not present, on-table angiography can Obturator a.
circumflex a.
be performed to confirm restoration of distal flow, as signifi- Transverse branch lat. Medial circumflex
cant vasospasm can occur in otherwise healthy vessels. circumflex femoral a. femoral a.
Lat. circumflex
femoral a.
INJURIES TO NAMED VESSELS Superf.
Descend. branch lat. femoral a.
Common Femoral Artery circumflex femoral a.
Injury to the common femoral artery (CFA) is most fre- Perforating branches
Deep femoral a.
quently caused by penetrating inguinal trauma but blunt deep femoral a.
injuries have been reported. Proximal exposure for vascular
control may require a retroperitoneal approach (Fig. 22.3),
which is especially helpful in hemorrhagic cases in which
direct pressure is being applied to the femoral artery or a
proximal thigh tourniquet is in place. The inguinal incision
should be made longitudinally and the inguinal ligament Descend.
genicular a.
identified and cleared overlying the inguinal canal. The ves-
sels lie just beneath the ligament and, if proximal extension
is necessary, fibers of the inguinal ligament can be divided
to facilitate proximal tissue retraction to access the distal Lat. sup. genicular a.
external iliac artery. Care should be taken here to avoid
injury to a circumflex iliac vein coursing over the distal iliac
artery. This vein can be ligated and divided if necessary. A
schematic representation of the anatomy of the arteries of
the pelvis, groin, and thigh is presented in Fig. 22.4. Fig. 22.4 Surgical anatomy of femoral vessels.
282 SECTION 4 • The Management of Vascular Trauma

bifurcation injuries. In femoral bifurcation reconstructions

we prefer performing an end-to-end anastomosis from the
CFA (or distal external iliac artery) to the PFA first. This
allows for the best visualization of the deeply positioned
PFA reconstruction. Following this, a separate bypass can
be done from the PFA bypass (end-to-side) to the SFA (end-
to-end). If suitable autologous conduit is not available for
this reconstruction, an 8-mm prosthetic graft can be used
for the PFA bypass and a 6- or 8-mm for the SFA.
Superficial Femoral Artery
Treatment of an SFA injury in a patient with otherwise
healthy vessels is usually straightforward. For most of its
course through the thigh, the SFA can be simply exposed
via a longitudinal incision with anterior mobilization of the
overlying sartorius muscle. The most frequently-made expo-
sure error is to make the incision too far posteriorly, overlying
the adductor longus or magnus muscle. Keeping the incision
at the level of the femur can help to avoid this. It is generally
unwise to attempt extensive mobilization and primary end-
to-end anastomosis of the SFA. Short distance end-to-end
interposition grafting with GSV is ideal for most SFA inju-
ries. For more extensive SFA injuries, a formal bypass may
be necessary. In the setting of otherwise healthy vessels, we
recommend choosing the most distal portion of uninjured
Fig. 22.5 Stab wound to the common femoral artery (A). The superfi- artery to serve as the inflow vessel. The distal target for SFA
cial (B) and deep (C) femoral arteries are also circumferentially dissected reconstruction should be the most proximal uninjured por-
and controlled. The stab wound on the anterior surface of the common tion of uninjured vessel with inline flow to the foot.
femoral artery (arrow) was accompanied by a smaller, posterior, full-
thickness injury. Isolated Profunda Femoris Injuries
In contrast to the CFA and SFA, the PFA is a thin-walled ves-
sel with a variable branching pattern. Isolated injuries to the
Once the CFA is controlled and circumferentially dis- PFA typically result from penetrating trauma and can mani-
sected, longitudinal arteriotomy and luminal exploration fest with overt external hemorrhage or thigh hematoma, or
are performed. Small defects may be repaired using patch as occult arteriovenous fistula or pseudoaneurysm seen on
angioplasty with autologous vein or a bioprosthetic patch CT imaging (Fig. 22.6). Occult distal PFA injuries may present
(Fig. 22.5). This is most suitable in cases of iatrogenic CFA in a delayed fashion and can be diagnosed with duplex ultra-
injury from percutaneous access attempts. Due to the short sound. Isolated proximal PFA injuries can be reconstructed
length of the vessel, patch repair is typically not sufficient via standard techniques, most frequently interposition graft-
to reconstruct a CFA injured via a high-energy mechanism. ing (Fig. 22.7). Open surgical exposure and reconstruction
For contaminated wounds, autogenous CFA reconstruction become challenging as the profunda and its branches course
is preferred. GSV is the conduit of choice but if it is too small, deeper in the thigh (see Fig. 22.4). For these distal injuries,
the internal or external jugular vein can offer a larger diam- we favor endovascular intervention with embolization via
eter conduit. However, this is rarely necessary over time a an antegrade approach from contralateral CFA access. We
GSV placed in the CFA position will dilate to accommodate recommend mechanical coil embolization over chemical
the CFA diameter. foam or gel treatment as it preserves distal collateral perfu-
The CFA is a short vessel, and as a result, inguinal vas- sion and effectively depressurizes the area of injury.
cular injuries often involve the superficial and/or deep
(profunda) femoral arteries (SFA and PFA). Even in cases in Popliteal Artery
which the SFA or PFA are not directly involved, these vessels For practical purposes the popliteal artery has three seg-
may require exploration to rule out injury and achieve dis- ments: above, behind, and below the knee. Penetrating
tal vascular control. It is usually easiest to dissect the femo- injury can impact any popliteal segment, whereas blunt
ral bifurcation from proximal (at the inguinal ligament) to trauma typically results in behind- or below-knee popli-
distal. The caliber change from the CFA to the SFA is eas- teal injury. A schematic representation of the anatomy
ily visible and is a good landmark for the location of the of the popliteal artery is presented in Fig. 22.8. The true
deeply positioned PFA origin. A Potts vessel loop around the injury area is challenging to identify on imaging as injury
PFA trunk is often helpful to control this vessel and, when to the popliteal artery in the proximal or middle segment
tightened, can serve to stabilize the femoral bifurcation to often results in dissection flaps that can extent distally. In
facilitate reconstruction. If the PFA trunk is too short for cases of popliteal vascular injury, preoperative CTA imag-
vessel loop control, a profunda clamp can be used to con- ing offers a wealth of information regarding distal collateral
trol the trunk and first 1 to 2 branches. Individual control flow, the extent and level of bony injuries, and evidence of
of PFA branches is not typically necessary to treat femoral pseudoaneurysm, arteriovenous fistula, or extravasation in
 22 • Lower Extremity Vascular Trauma 283

Descend. branch Femoral a.

lat. circumflex
Descend.
femoral a.
genicular a.
Popliteal a. Articular branches
descend. genicular a.

Superior medial
Superior lat. genicular a.
genicular a.

Inf. lat. genicular a.

Ant. tibial Inf. medial

recurrent a. genicular a.

Ant. tibial a. Post. tibial a.

Fig. 22.8 Surgical anatomy of popliteal vessels including bony

landmarks.

the surgically inaccessible behind-knee segment (Fig. 22.9).

Fig. 22.6 CT angiogram of an acute left profunda femoris artery pseu- On imaging, the popliteal artery from (just proximal to) the
doaneurysm (arrow, top panel). An arteriovenous fistula is also present, top to (just distal to) the bottom of the patella is surgically
evidenced by layering arterial phase contrast within the femoral vein inaccessible from the medial approach without complete
(arrow, bottom panel). lysis of the medial knee ligaments (essentially a disarticula-
tion). This maneuver is highly morbid and is rarely neces-
sary except in cases of severe ongoing popliteal hemorrhage
following proximal and distal anatomic vascular control.
Most injuries to the behind the knee popliteal segment can
be treated with planned exclusion from arterial flow after
reconstruction from above to below the knee.
Proximal popliteal exposure can be obtained as the SFA
exits the adductor canal or slightly higher or lower as needed.
This area provides generally predictable anatomy and a rela-
tively superficial vessel location. Distal popliteal exposure is
somewhat more challenging, requiring a longitudinal inci-
sion 1 to 2 fingerbreadths medial to the medial border of the
tibia, blunt posterior mobilization of the medial head of the
gastrocnemius, and opening of the deep posterior compart-
ment by dividing the attachments of the proximal soleus
muscle to the tibia. Fig. 22.10 depicts above- and below-knee
approaches. The tibial nerve is sizable in this location and is
a good palpable landmark for the popliteal vasculature. This
exposure can be extended distally to the origin of the anterior
tibial artery (ATA; running laterally away from the surgeon)
and further to expose the tibioperoneal trunk (TPT) and pos-
terior tibial artery (PTA). This is important as blunt popliteal
injuries can cause significant intimal disruption that may
extend distally. Ligation and division of the anterior tibial
vein facilitates exposure of the TPT. We recommend initial
preservation of this vein, with division if bypass to the TPT is
required. Even in thin patients, the popliteal artery lies fairly
deep in the wound in standard popliteal exposures. Deep cer-
ebellar or Henley retractors can be seated on one side against
Fig. 22.7 Delayed presentation of a pseudoaneurysm of the profunda the femur or tibia and facilitate mobilization of the overlying
femoris artery following military blast fragment injury to the right soft tissues. Potts vessel loops can be used for arterial con-
inguinal region. The pseudoaneurysm orifice (forceps, upper right trol and, when tightened, will serve to bring the artery more
panel) was resected and excluded with a saphenous interposition graft superficially, facilitating an easier anastomosis and avoiding
(bottom panel). large metal clamps impinging on the small operative field.
284 SECTION 4 • The Management of Vascular Trauma

Rectus femoris
Vastus medialis
Adductor longus
Sartorius
Saphenous nerve
Venae comitantes
Popliteal artery
Popliteal vein

Sartorius
Gracilis
Soleus
(partially divided)
Popliteal artery
Anterior tibial artery
Gastrocnemius Popliteal vein
Posterior tibial artery
Peroneal artery

Fig. 22.10 Above- and below-knee exposure of the popliteal artery.

there is concern for injury to the TPT, we recommend expo-

sure of the PTA for use as a distal target for reconstruction.
The anatomic location of the PTA allows for creation of a
relatively straight tunnel and reconstruction. A bypass to the
PTA can fill the ATA and PTA through retrograde TPT flow.
Fig. 22.9 CT angiogram of a blunt injury to the left popliteal area with
arterial injury and arteriovenous fistula. Top panel: the popliteal artery Tibial Arteries
(arrow) has arterial contrast opacification, as does the adjacent popli- Injuries to the tibial arteries are encountered in the set-
teal vein. There is a large pseudoaneurysm with hematoma in the pop- ting of severe lower extremity injury, especially in the pres-
liteal fossa. Bottom panel: the popliteal artery (wide arrow) abruptly ence of complex open tibial fractures (Gustillo IIIB/C).60 A
occludes just above the knee joint. The popliteal vein (anterior) and detailed physical examination is required in these cases and
pseudoaneurysm (posterior) also fill with arterial phase contrast. preoperative CTA imaging can provide a good assessment
of the uninjured arterial supply to the foot. If CTA cannot
provide the requisite detail, then conventional angiogra-
Reconstructions limited to the above- or below-knee pop- phy can be helpful. Traditional dogma is that a single pat-
liteal segments for trauma are rare. An above-to-below-knee ent vessel to the foot (with a palpable pedal pulse and/or an
bypass is most commonly performed. Proximally, both end- ankle-brachial index of 1.0 or greater) is adequate for limb
to-end and end-to-side anastomoses are reasonable. If large salvage. If motor and sensory function is intact and there is
geniculate vessels are identified proximally, we favor and an at least one vessel to the foot, operative reconstruction may
end-to-side proximal anastomosis with ligation of the pop- not offer an acute limb salvage benefit, especially in the face
liteal artery distal to them to preserve collateral flow. The of significant bony and soft tissue injury that may influ-
above-to-below-knee tunnel must be created between the ence the decision to amputate.31,40 Single tibial artery inju-
femoral and tibial condyles and typically results in a bypass ries presenting with hemorrhage may generally be safely
length that is shorter than expected, but some redundancy treated with ligation. We recommend temporary occlusion
should be retained in the graft to accommodate knee flexion. and assessment of distal perfusion (possibly with angiogra-
Distal popliteal anastomoses can also be performed end-to- phy) prior to formal surgical ligation.
side or end-to-end. In the end-to-side configuration, we favor In severely injured lower extremities with complex injury
ligation of the native popliteal proximal to the anastomosis patterns, the number of patent runoff vessels does seem to
to prevent continued pressurization of the excluded popliteal correlate inversely with the risk of amputation, but given
segment. Tibial plateau fractures are high-energy injuries the wide anatomic distribution of the tibial vasculature,
and those with any degree of posterior displacement should this likely represents the severity of the vascular injury
prompt concern for distal popliteal and/or TPT injury. If as a surrogate for the magnitude of limb tissue injury31,60
 22 • Lower Extremity Vascular Trauma 285

(Fig. 22.11). In these cases, the operative focus should be on is not undertaken in vain. Of critical importance is the fact
restoration of inline tibial flow to the foot via a single vessel. that there must be adequate perfused tissue at the conclusion
This usually involves a bypass, often using the below-knee of the vascular reconstruction to completely cover the graft.
popliteal artery for inflow. When planning vascular recon-
struction with a tibial target in severe limb trauma, the even- FASCIOTOMY
tual perfusion result must be considered carefully. These are
often cases of high-energy, transtibial trauma with a zone Following major lower extremity arterial reconstruction for
of severe bony and soft tissue injury between the inflow and trauma, a four-compartment calf fasciotomy should be con-
outflow vessels. Revascularization of a single tibial vessel sidered and typically performed to prevent the development
and restoring flow to the foot may not result in satisfactory of compartment syndrome with limb reperfusion. The rare
perfusion to these injured tissues to support eventual limb exceptions to this are in cases with extremely short ischemic
salvage.31 These cases require careful consideration and dis- (including operative) times of 2 hours or less or in cases
cussion between the vascular, orthopedic, and reconstructive where the acute reconstruction was performed in the setting
surgical teams to ensure that early vascular reconstruction of underlying chronic arterial occlusive disease in which col-
lateral circulation is present during ischemia. We generally
perform fasciotomy in cases of trauma regardless of these
situations, however, unless the clinical status of the limb can
be frequently and closely monitored following revasculariza-
tion. This is a very rare situation in the trauma setting.
The calf fasciotomy can be performed early during the
surgical procedure or following revascularization. Early fas-
ciotomy allows for more accurate assessment of flow dur-
ing and immediately following reperfusion with shunting
or reconstruction, but can often lead to additional blood
loss during the procedure. The below-knee arterial expo-
sures give a “head start” on decompressing the anterior
compartment (ATA) and deep posterior compartment (TPT
and PTA), but it is critical to decompress the entire length
of each of the four calf compartments. The most frequently
missed compartment is the lateral, so care should be taken
to properly identify the intermuscular septum laterally and
divide both the anterior and lateral compartments’ invest-
ing fascia completely (Fig. 22.12).
Fig. 22.11 Gustillo grade IIIC tibial fracture with massive soft tissue dis- If a fasciotomy is performed and the surgeon feels that
ruption and transection of all tibial arteries. Due to the severity of the the patient is at low risk for developing compartment syn-
soft and bony tissue injuries, the limb was deemed not salvageable. drome in the perioperative period, the fascia can be kept

Anterior tibial a.
Saphenous nerve
and v.
Great saphenous v. Tibia
Lateral incision

Medial incision

Peroneal n.

Fibula

Tibial n.

Posterior tibial a.
and v.

Fibular a.
and v.

Small Fig. 22.12 Surgical exposure for two-incision, four-

saphenous v. compartment lower extremity fasciotomy.
286 SECTION 4 • The Management of Vascular Trauma

open and the overlying skin incisions closed with staples 18. Kauvar DS, Wade CE. The epidemiology and modern management of
if skin flaps can be mobilized. This technique preserves the traumatic hemorrhage: US and international perspectives. Crit Care.
2005;9:S1–S9.
option for rapid decompression via bedside staple removal 19. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma
if it becomes necessary and avoids the potential morbid- outcome: an overview of epidemiology, clinical presentations, and
ity of open wounds postoperatively. For the majority of therapeutic considerations. J Trauma—Inj Infect Crit Care. 2006;60(6
limbs, a full compartment release should be completed and Suppl:S3–S11.)
20. Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Holcomb JB.
the superficial and fascial layers left open. We favor using Trends in 1029 trauma deaths at a level 1 trauma center: impact of a
negative pressure therapy dressings over the skin and sub- bleeding control bundle of care. Injury. 2017;48:5–12.
cutaneous tissues to temporarily dress the wound. We use 21. Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated
interlaced vessel loops in a “Jacobs ladder” configuration civilian penetrating extremity injury. J Trauma. 2005;59:217–222.
to pull the skin edges together. This technique minimizes 22. Kauvar DS, Miller D, Walters TJ. Tourniquet use is not associated with
limb loss following military lower extremity arterial trauma. J Trauma
the extent of open wound but accommodates edema of the Acute Care Surg. 2018;85:495–499.
underlying tissues and prevents skin retraction facilitating 23. Smith AA, Ochoa JE, Wong S, et al. Pre-hospital tourniquet use in
early primary closure. penetrating extremity trauma: decreased blood tranfusions and limb
complications. J Trauma Acute Care Surg. 2019;86:43–51.
24. Teixeira PG, Brown CV, Emigh B, et al. Civilian prehospital tourniquet
References use is associated with improved survival in patients with peripheral
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treatment (PROOVIT) registry: multicenter data on modern vascular late: major limb trauma without a pre-hospital tourniquet has
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10. Usman R, Jamil M, Anwer MF. Evaluation, surgical management and amputation: preliminary results of the mangled extremity severity
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11. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin ria accurately predict amputation following lower extremity trauma.
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13. Perkins ZB, Yet B, Glasgow S, Marsh W, Tai NRM, Rasmussen TE. rial injury. J Trauma Acute Care Surg. 2019;87:S172–187.
Long-term patient-centered outcomes of lower extremity vascular 38. Dua A, Patel B, Kragh JF, Holcomb JB, Fox CJ. Long-term follow-up and
trauma. J Trauma Acute Care Surg. 2018;85:S104–S111. amputation-free survival in 497 casualties with combat-related vas-
14. Stannard A, Brown K, Benson C, Clasper J, Midwinter M, Tai NR. Out- cular injuries and damage-control resuscitation. J Trauma Acute Care
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J Surg. 2011;98:228–234. 39. Klocker J, Bertoldi A, Benda B, Pellegrini L, Gorny O, Fraedrich G. Out-
15. Sharrock AE, Remick KN, Midwinter MJ, Rickard RF. Combat vas- come after interposition of vein grafts for arterial repair of extremity
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ury.2018;50:125–130. 40. Fortuna G, DuBose JJ, Mendelsberg R, et al. Contemporary outcomes
16. Dua A, Patel B, Desai SS, et al. Comparison of military and civilian of lower extremity vascular repairs extending below the knee: a multi-
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17. Gwinn DE, Tintle SM, Kumar AR, Andersen RC, Keeling JJ. Blast- 41. Peck MA, Clouse WD, Cox MW, et al. The complete management of
induced lower extremity fractures with arterial injury: prevalence extremity vascular injury in a local population: a wartime report from
and risk factors for amputation after initial limb-preserving treat- the 332nd Expeditionary Medical Group/Air Force Theater Hospital,
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42. Fox CJ, Perkins JG, Kragh JF, Singh NN, Patel B, Ficke JR. Popliteal 52. Parry NG, Feliciano DV, Burke RM, et al. Management and short-term
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pursuit to save life and limb. J Trauma. 2010;69:S123–34. Surg. 2003;186:631–635.
43. Ratnayake A, Samarasinghe B, Bala M. Outcomes of popliteal vascu- 53. Matsumoto S, Jung K, Smith A, Coimbra R. Outcomes comparison
lar injuries at Sri Lankan war-front military hospital: case series of 44 between ligation and repair after major lower extremity venous injury.
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Trauma Amputation/Limb Salvage (METALS) study: outcomes of The effect of vein repair on the risk of venous thromboembolic events:
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45. Bernhoff K, Björck M, Larsson J, Jangland E. Patient experiences of 55. Dua A, Desai SS, Ali F, Yang K, Lee C. Popliteal vein repair may not
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48. Kauvar DS, Osborne CL. Identifying content gaps in health status mea- 58. Wallin D, Yaghoubian A, Rosing D, Walot I, Chauvapun J, de Virgilio
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49. Osborne CL, Kauvar DS. A content analysis of peripheral arterial trauma experience. Ann Vasc Surg. 2011;25:620–623.
disease patient-reported outcome measures using the International 59. Reddy NP, Rowe VL. Is it really mandatory to harvest the contra-
Classification of Functioning, Disability and Health. Disabil Rehabil. lateral saphenous vein for use in repair of traumatic injuries? Vasc
2019;41:456–464. Endovascular Surg. 2018;52(7):548–549. https://doi.org/10.1177/
50. Manley NR, Magnotti LJ, Fabian TC, Croce MA, Sharpe JP. Impact of 1538574418781124.
venorrhaphy and vein ligation in isolated lower-extremity venous 60. Stranix JT, Lee ZH, Jacoby A, et al. Not all Gustilo type IIIB fractures
injuries on venous thromboembolism and edema. J Trauma Acute Care are created equal: arterial injury impacts limb salvage outcomes. Plast
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51. Kurtoglu M, Yanar H, Taviloglu K, Sivrikoz E, Plevin R, Aksoy M. Serious
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 23 Surgical Damage Control and
Temporary Vascular Shunts
DANIEL J. SCOTT and SHAUN M. GIFFORD

Introduction a temporary means of perfusion that would promote col-

lateral formation as the tube slowly occluded. In 1932,
Since the turn of the century, there have been major changes in Blakemore and Lord introduced use of a new composite
the management of the severely injured patient. Perhaps alloy called Vitallium (composed of cobalt, chromium, and
most notable is the adoption of damage control or staged molybdenum). Initially, the Vitallium tube was internally
procedures. Stone and colleagues provided the landmark lined with vein graft but was soon followed by a two-tube
description of a staged operation in 1983.1 With intent method with interposed vein, again as a sutureless tech-
to limit the physiologic burden on an already threatened nique (Fig. 23.1). Despite theoretical advantages and wide-
patient, they demonstrated a survival advantage in a series spread dissemination in World War II, the use of such tubes
of 17 patients. Later coined by Rotondo et al. as “dam- was limited by logistics and prolonged medical evacuation
age control surgery,” this concept of limiting the “bloody times of the wounded to surgical facilities.7–9
vicious cycle” of hypothermia, acidosis, and coagulopathy Experimental use of intravascular shunts as a means
has been embraced in nearly every major trauma center of temporary restoration of blood flow has roots to both
with reproducible results.2–4 One of the tenets of staged the French-Algerian war (1954–62) and the Soviet war
laparotomy as described by Stone and colleagues was the in Afghanistan (1981–85).10,11 Both accounts described
attention to control and repair of blood vessel injuries. the use of temporary shunts to maintain blood flow to
Hemorrhage (and subsequently, hemorrhagic shock) is per- allow time for either onward transport, or to “administer
haps the most significant factor contributing to the triad of antishock therapy.” Among the first modern descriptions
coagulopathic bleeding. Incidentally, the management of of temporary shunts is that from Eger et al., who in 1971
injured blood vessels in a severely injured patient is often used a temporary vascular shunt prior to orthopedic fixa-
arduous, technically demanding, and time-consuming, all tion. This practice ultimately demonstrated a decreased fre-
of which can force vessel ligation out of desperation. This quency of extremity amputation in the setting of complex
chapter provides a review of a technique that offers a viable popliteal artery injury.10,12
alternative to ligation and adheres to the mantra of damage
control, namely the use of temporary intravascular shunts.
Temporary shunts have many benefits in the multip­ly Modern Use of Intravascular
injured patient. Not only do they allow for reperfusion Shunts
and/or venous decompression across the injured vessel, but
they also afford time to transport a patient to a higher level MILITARY AND COMBAT EXPERIENCE
of care or to manage concomitant life-threatening injuries.
In this context, “extra time” means that flow is restored Despite advances in civilian damage control, use of tempo­
across the injured artery and/or vein through the shunt rary vascular shunts in trauma had been limited to a few
while resuscitation, orthopedic fixation, cranial decompres- case series prior to the events of September 11, 2001.13–20
sion or other lifesaving procedures are performed. In addi- One bittersweet effect of war is the renaissance of surgi-
tion to gaining time to treat the patient, temporary shunts cal experience, technology, and technique. In a report
also limit the ischemic insult that results from vascular liga- from Operation Iraqi Freedom, Rasmussen et al. described
tion, which can also negatively impact the physiology of the a 1-year experience of 126 extremity vascular injuries,
patient. in which 30 temporary vascular shunts were utilized in
the management of vascular injury. In this report, shunts
were used as a damage control adjunct to either facilitate
Historical Use of Intravascular casualty evacuation, or to allow perfusion while other life-
Shunts threatening injuries were managed. In this series, 57% of
patients had patent shunts on arrival to a higher level of
The concept of an implantable prosthetic conduit has a care (typically <2 hours after initial surgery). The authors
long history, with first descriptions in World War I by Tuffier noted that patency of the shunts hours after placement
and Makins.5,6 These paraffin-lined silver tubes were pro- was higher (86%) when they had been used in larger, more
posed for the perceived advantages of sutureless technique proximal vessel injuries.21 The favorable experience with
and initially meant for permanent placement. The general the use of vascular shunts in this initial report was cor-
goal was not long-term patency of the conduit, but rather roborated by subsequent series provided by other combat

288
 23 • Surgical Damage Control and Temporary Vascular Shunts 289

Vein

Vitallium

Silk Tie
Artery
Vein

Vitallium Artery

Fig. 23.1 Illustration of the experimental and clinical application of the Vitallium tube techniques used by Blakemore and Lord.

surgical teams.22–24 Fig. 23.2 details a case example in 94% and a secondary amputation rate of 3.5%. In distinc-
which a mid-subclavian artery injury was initially treated tion, shunts were used primarily in the extremities but were
at a forward surgical location with the insertion of an intra- also successfully implemented in aortic, iliac, and visceral
luminal shunt and subsequently repaired with interposi- ­vessels.26 Table 23.1 details both the military and civilian
tion graft at a higher level of care. experience with peripheral vascular shunting in the setting
Gifford and colleagues provided one of the only studies of trauma.21–25,27
to characterize longer-term extremity outcomes following
the use of temporary vascular shunts. In their study, the
authors used case-controlled methodology to show that Indications
the use of temporary shunts had no adverse outcome in the
years following vascular repair and likely extended the win- Damage control, that is, physiologic instability or presence
dow for limb salvage, especially in the most severely injured of higher operative priorities precluding definitive recon-
extremities.25 struction of the vascular injury, is the primary indication
for the use of a temporary shunt. The rapid placement of a
shunt is useful to reduce the time to reperfusion (i.e., oxy-
CIVILIAN TRAUMA EXPERIENCE
gen delivery) beyond the disrupted vessel when there are
Following the normalization of vascular shunts in war- other higher-priority management steps required. With the
time trauma, civilian trauma centers have embraced and shunt in place, stabilization of associated fractures or perfor-
published a favorable experience as well. In 2008, a large mance of a laparotomy, craniotomy, or thoracotomy can be
10-year review of the civilian experience from Dr. Feliciano’s completed with the extremity or other end-organ perfused
group at Grady Memorial, Subramanian et al. confirmed instead of having continued and compounding ischemic
the utility of shunts in certain patterns of vascular injury. injury. Finally, expedited placement of a shunt may be useful
This study demonstrated a 95% patency rate and an overall if a surgeon desires to curtail the intervention due to lack of
survival rate of 88% following major vascular injury. In this training in or comfort with performing the vascular recon-
series of 101 vascular shunts, the authors documented a struction. Placement of a shunt in the setting of p ­ rolonged
secondary amputation rate of 18%. The safety profile and ischemia provides end-organ perfusion and may allow the
total body implementation was reinforced in a subsequent infusion of medications designed to limit thrombosis or isch-
multicenter review of 213 injuries over a 9-year period. emia-reperfusion injury (e.g., heparin or mannitol). Use of
Dr. Inaba et al. demonstrated a favorable patency rate of a temporary shunt in an axial vessel of a severely mangled
290 SECTION 4 • The Management of Vascular Trauma

Fig. 23.2 (A) The distal aspect of a Javid shunt inserted into the right
axillary artery is shown in this image. The proximal aspect of the shunt
had been placed in the proximal most right subclavian artery and
routed in an extra-anatomic fashion above the clavicle, underneath the
pectoralis major muscle, and out of the zone of injury, which was the
mid-right subclavian artery. (B) A wider image of the same case show-
ing the proximal aspect of the exposure which was median sternot-
omy. The proximal Javid shunt has been removed and is secured with
a hemostatic clamp in the upper portion of the photograph. The proxi-
mal anastomosis of a 6-mm expanded polytetrafluo­roethylene (ePTFE)
graft has been created to the origin of the right subclavian artery with
the graft routed in an anatomic fashion in preparation for the distal
anastomosis to the right axillary artery. (C) A completion image fol-
lowing successful reconstruction using 6-mm ePTFE from the proximal
most right subclavian artery to the right axillary artery. The subclavian
artery injury in this case was over sewn just proximal to the clavicle.
A (Courtesy Rasmussen, TE.)

upon early reports of successful use of vascular shunting

in theater, the Department of Defense Joint Trauma System
created a clinical practice guideline for extremity vascular
injury that provided guidance on the use of vascular shunts.29
In its guidance to deploying surgeons, shunts should be
considered for all extremity vascular injuries including
proximal venous injuries.
Most situations of vascular injury afford the option of
shunt placement, making rare contraindications for their use.
Control of hemorrhage requires exposure where the decision
to ligate or place a shunt can be made. Clearly, the patient
B would need to be in a stable enough condition to allow explo-
ration of the vascular injury to commence with anticipated
blood loss during that operation. With adequate exposure of
the vascular injury, placing and securing a shunt can be done
in the same amount of time as is needed to ligate both ends
of a damaged blood vessel. Access to adequate shunt material
(see subsequent section) is needed to successfully temporize
the injury. In the extremity with multiple injuries and the
possibility for vascular disruption in multiple segments, the
surgeon must ensure re-establishment of flow does not lead
to worsening hemorrhage. The tenant of damage control vas-
cular surgery is the control of hemorrhage, with limitation
of ischemic insult being a close second. Placement of a shunt
to establish flow leading to continued hemorrhage from the
limb would not be prudent. Additionally, reports demonstrate
few ill effects from placement of shunts.30 Theoretically, fur-
ther damage to the uninjured vessel after shunt placement,
embolization of the shunt, occlusion, and/or dislodgment of
the shunt could occur. These are of limited likelihood and one
could argue that ligation leads to a worse outcome. Ligation
after shunt placement is always a consideration; however, the
C reverse is unlikely to be an option due to distal thrombosis
and loss of outflow.

extremity allows for the limb to be stabilized, débrided, and Shunt Materials
reassessed at a second-look operation if needed. This strategy
allows for a more organized mobilization of requisite surgical Many hollow tubular devices have been described to function
disciplines to assess the limb at a scheduled time after the as temporary vascular shunts including large bore angio-
initial operation has been performed. The indications for the catheters, sterile intravenous tubing, endotracheal tubes,
use of temporary shunts are provided in Box 23.1.12,28 Based feeding tubes, and small caliber chest tubes. Although these
 23 • Surgical Damage Control and Temporary Vascular Shunts 291

Table 23.1 Combat Versus Civilian Use of Temporary Vascular Shunts21–24,26,27

Average Early (<30 days)
Shunt Shunt Type and Shunt Secondary Shunt-Related
Review Year Location Number % Patencya Time Amputationsb Complicationsc
Rasmussen 2004–05 30 arterial Javid 16 Arterial Proximal 86%
et al. (combat) 4 venous Argyle 12 Distal 12% <2 h 2 0
Sundt 2 Venous Proximal 100%
Taller et al. 2006–07 14 arterial Javid NL Arterial Proximal 100%
(combat) 9 venous Argyle NL Venous 89% ~5h 0 0
Unknown NL
Chambers et al. 2004–05 18 arterial Javid NL Arterial Proximal 86%
(combat) Distal 50% ~ 1.5 h 3 (1) 0
11 venous Sundt NL Venous 82%
Borut et al. 2003–07 42 arterial Argyle NL NL NL
(combat) Sundt NL NL 4 (0) NL
8 venous Javid NL
12-Fr feeding NL
tube
Subramanian 1997– 72 arterial Argyle 61 Arterial 91%
et al. 2007 Chest tube 16 23.5 h 10 (1) 0
(civilian)
29 venous Pruitt-Inahara 20
5-Fr feeding 1 Venous 100%
tube
16-ga. 1
Angiocath
Inaba et al. 2005–13 202 Argyle 173 Arterial Extremity 95%
(civilian) arterial Chest tube 16 <24 h 7 (0) 0
11 venous Pruitt-Inahara 20 Trunk 99%
Nasogastric/ 4 Venous 100%
feeding
tube
a
Proximal = brachial artery and proximal in upper extremity or popliteal artery and proximal in lower extremity
b
Parentheses = secondary amputations attributable to shunt thrombosis
c
Shunt-related complications = shunt displacement, bleeding, or thromboembolism
d, Day; Fr, French; ga, gauge; h, hour; NL, not listed.

improvised “shunts” may provide temporary flow, they are

Box 23.1 Indications for Temporary Vascular not designed for this purpose and are predisposed to caus-
Shunts ing vessel injury and/or thrombosis due to a number of
physical characteristics. Currently, there are no Food and
Damage control surgery for patients in extremis
Drug Administration–approved shunts for trauma and
Complex skeletal injury requiring fixation (e.g., Gustilo IIIc) surgeons must rely on off-label use of devices designed for
Temporary restoration of flow during vein harvest use for carotid endarterectomy and other cardiovascular
Management of other injuries operations. Examples include the Javid (Bard PV, Tempe,
Multiple vascular injuries AZ), Argyle (Cardinal Health, Dublin, OH), Sundt (Integra,
Prolonged ischemia (>6 hours) Plainsboro, NJ), and Pruitt-Inahara (LeMaitre Vascular,
Re-plantation of avulsed limbs Burlington, MA) shunts. There are no studies that have
Temporary flow for delayed re-evaluation in mangled extremity or compared the effectiveness of these shunts to one another
prior to limb replantation in the setting of trauma and any one or more may be used
Need for perfusion during complex vascular reconstruction for vascular trauma even at the same institution.27 Never-
Truncal vascular control theless, extrapolation from translational hemodynamic and
Complex repair of zone III neck injuries hydrodynamic studies of commonly used shunts seems to
favor larger diameter, in-line (shorter) shunts as they tend to
Adapted from Eger M, Golcman L, Goldstein A. The use of a temporary
shunt in the management of arterial vascular injuries. Surg Gynecol Obstet.
produce higher flow rates and distal perfusion pressures.31
1971;132(1):67–70; Abou Ali AN, Salem KM, Alarcon LH, et al. Vascular shunts Aufiero et al. also recommends the use of tapered shunts
in civilian trauma. Front Surg. 2017;4(July):2–7. when smaller diameter shunts (<12 Fr) are required.32
292 SECTION 4 • The Management of Vascular Trauma

Several physical characteristics must be weighed when Insertion Technique

selecting the type of shunt to use and a list of features of
commonly used devices is provided in Table 23.2. In-line Inserting a vascular shunt, although seemingly straight-
shunts are shorter and useful when operative space is lim- forward, has the potential to cause injury if tissues are
ited and the gap in or injury to the vessel is short. In-line not respected. Suggested sequential steps are outlined in
shunts lie inside of the injured vessel and once in place
are not likely to become entangled with wound dressing
material, surgical retractors, orthopedic fixator devices, or
monitor wires which often surround the injured extremity
(Figs. 23.3 and 23.4). Looped shunts are longer with a sig-
nificant portion outside of the vessel and therefore more
prone to becoming entangled. However, looped shunts are
more effective at bridging longer injuries or segments of
missing vessel and this design may be preferable when the
vascular injury crosses a joint or unstable fracture prone
to significant motion. In these instances, the longer, looped
shunt allows for motion across this defect with a lower like-
lihood of the device being dislodged. Finally, looped shunts
allow visualization of arterial or venous flow and are readily
assessed by continuous wave Doppler (Fig. 23.5).
Some shunts, such as the Bard Brener and Pruitt F3, have
a designed side-port that provides the opportunity for addi-
tional management considerations. Invasive monitoring of
blood pressure via tubing attached to the port can be uti-
lized to support ongoing resuscitation efforts. Blood draws
for point-of-care testing can be obtained if no other access
is available or if arterial blood is needed. In addition, the
port can be used for infusion of drugs or for use in diagnos- Fig. 23.3 12-Fr Argyle shunt within a left external iliac artery injury just
tic angiography of distal structures. A unique design, the above the inguinal ligament. This shunt is truly in the “in-line” con-
Pruitt F3 shunt has a side-arm port that may prove useful. figuration placed within the short segment arterial defect and out of
Secured by proximal and distal balloons, placement of the the way of retractors, packs, or other operative apparatus. This shunt,
Pruitt F3 may be made easier and avoids the need for exces- which is seen secured with silk ties, was patent approximately 6 hours
sive proximal and distal vessel dissection (Fig. 23.6). after placement. (Courtesy Rasmussen, TE.)

Table 23.2 Shunt Types

Manufacturer Type Features Composition Sizes
Bard Straight ± bevel tip; ± side holes; Polyvinyl chloride (± latex Diameter: 9 Fr (balloon),
± balloon tip balloon) 10 Fr, 12 Fr, 14 Fr, 16 Fr
Javid Tapered ± loop Length: 13 cm
Brener Tapered w/ side arm
Burbank Tapered; depth
markings
Cardinal Argyle ± loop; kit with all 4 Polyvinyl chloride Diameter: 8 Fr, 10 Fr, 12 Fr,
sizes 14 Fr
Length: 11 in (loop), 6 in
(straight)
Integra Sundt ± loop; steel Silicone elastomer Diameter: 3 × 4 mm,
reinforcement ± non-­ 3 × 5 mm, 4 × 5 mm
reinforced segment; Length: 30 cm (loop), 10 cm
cone-shaped ends (straight)
LeMaitre Pruitt F3 ± T-port; color coding; Polyurethane (latex balloon) Diameter: 8 Fr, 9 Fr, 10 Fr,
depth marks; balloon 12 Fr, 14 Fr
with safety sheath; kit Length: 31 cm (outlying),
with 4 sizes 15 cm (inlying), 13 cm
(inlying)
cm, Centimeter; Fr, French; in, inch; mm, millimeter.
Data from manufacturer websites:
www.bard.pv.com/_vascular/product.php=37.
www.kendall-ltp.com/Kendall-LTP/pageBuilder.aspx?topicID=67419&breadcrumbs=81035:0,67418:0.
integalive.com/Neurosurgeon/Neurosurgeon-Product-Detail.asp.
www.lemaitre.com/medical_shunts.asp.
 23 • Surgical Damage Control and Temporary Vascular Shunts 293

B
A

Fig. 23.4 12-Fr Argyle shunt within a left proximal superficial femoral Fig. 23.6 Modern (carotid) shunt types. (A) Looped (Sundt) shunt.
artery injury just distal to the origin of the left profunda femorus artery. (B) In-line (Sundt) shunt. (C) Looped Pruitt-Inahara shunt.
Difficult to observe in this photograph, deep to the arterial shunt is a
shunt in the proximal superficial femoral vein. Also observed in this
image is the left greater saphenous vein which was exposed and used as vessel may be subjected to balloon-catheter thrombectomy.
interposition conduit for reconstruction of this injury pattern. Although Several passes with the thromboembolectomy catheter can
the arterial shunt in this case was patent 5 hours after placement, the be performed until no additional clot is retrieved and good
venous shunt had thrombosed. Both artery and vein were successfully fore and back bleeding is achieved. Instillation of a heparin-
reconstructed in this case after shunt removal. (Courtesy Rasmussen, TE.) ized saline solution into the proximal and distal ends of the
injured vessel (i.e., local heparinization) should be considered
followed by re-clamping of the vessel. The vessel ends should
be inspected, carefully trimmed to healthy or normal appear-
ing segments (securing the shunt to questionable vessel wall
may lead to inadvertent disruption and hemorrhage). It is not
uncommon for vasospasm to be present. To ease insertion
and decrease risk of injury, gentle dilation of the vessel may
be necessary.
Following selection of a size-matched shunt, the distal/
smaller end (if tapered) is gently inserted into the distal ves­
sel, allowed to back-bleed to clear any platelet aggregates
or bubbles, and is secured with thick (size 0) silk tie. It is
important to avoid the tendency to over-tighten the
suture as this may cause unintended narrowing and even
occlusion of the shunt. The proximal end of the shunt is
then inserted, and also secured with a silk tie or similar
material. Handheld Doppler evaluation is next performed
to confirm patency and marking of distal arterial signals as
able, thus facilitating future/serial Doppler examinations.
If the shunt traverses a noninjured joint, splinting of
the joint is performed to avoid dislodgement. Ideally, the
wound should be stapled closed and soft-tissue coverage
of the shunted vessel secured. If left open, wound-vacuum
Fig. 23.5 Looped (30 cm) Sundt shunt placed to bridge a defect in the dressings should not be applied directly to the vessel. The
right superficial femoral artery. Although difficult to observe anatomic need for fasciotomy should be considered (see later) and
context, this injury is exposed through an above-knee popliteal artery time of shunt placement marked on both the patient and
exposure. Note that this shunt is able to be elevated out of the wound on the chart.
and has ample length should the arterial injury or defect be over a
long length or an unstable fracture prone to movement. (Courtesy
REMOVAL TECHNIQUE
­Rasmussen, TE.)
After patient transport and/or completion of other dam-
Fig. 23.7. The injured blood vessel should be carefully dis- age control procedures, the surgical team should prepare
sected to allow vascular clamp application. This step may be to remove the shunt and perform a more definitive vascular
circumvented by endovascular balloon occlusion if proximal reconstruction. Exposure of the shunted vessel is carried
control is likely to be lengthy or technically c­hallenging (i.e., out in a similar fashion as to when the device was placed.
proximal subclavian injuries). Once controlled and opened, the Additional exposure of the proximal and distal vessel may
294 SECTION 4 • The Management of Vascular Trauma

Fig. 23.7 Sequential steps in placement of a temporary vascular shunt (TVS). (A) Proximal and distal control of the artery. (B) Clean transection of the
artery in an uninjured area and systematic Fogarty catheter thrombectomy. (C) Placement of a TVS with a diameter close to that of the artery, inserted
to a depth of 15 to 20 mm. (D) Water-tight fixation of the shunt with two heavy-gauge ligatures. (From Hornez E, Boddaert G, Ngabou UD, et al. Temporary
vascular shunt for damage control of extremity vascular injury: a toolbox for trauma surgeons. J Vasc Surg. 2015;152:363–368.)
 23 • Surgical Damage Control and Temporary Vascular Shunts 295

be needed for adequate placement of clamps and allow for of the vascular injury. Shunts are more amenable to, and
placement of an interposition graft to noninjured segments perform better in larger vessels. Interruption of blood flow
of the vessel. The shunt is then clamped in the center and in large, more proximal locations has a greater impact on
removed from the proximal and distal portions of the inter- the limb or end organ as the vessel is more commonly the
rupted vessel allowing for fore- and back-bleeding prior to main channel on which inflow or outflow depends. As such,
application of appropriately positioned clamps. Repeat bal- continued tourniquet application or ligation of large, proxi-
loon-catheter thrombectomy and instillation of heparinized mal vascular injuries has more severe consequences which
saline solution is recommended in most cases to confirm can be mitigated by restoring flow with a shunt. Temporary
and optimize inflow and outflow following shunt removal. shunts are also technically easier to place in large vessels
Systemic heparinization may not be possible depending on which have high flow rates and better patency.
the status of the patient and concomitant injuries. If not, In contrast, small vessels located in the distal extremity
instillation of a heparinized saline solution into the proxi- or the torso vasculature are often part of a redundant cir-
mal and distal ends of the injured vessel (i.e., local heparin- culation and are thus less significant. It is also more chal-
ization) should be performed followed by re-clamping. lenging to place a shunt in a small vessel which carries less
Inspection of the proximal and distal end of the artery flow and is more prone to thrombosis.21 Examples include
where the shunt was secured is important to confirm the forearm, where both the ulnar and radial arteries sup-
healthy, uninjured vessel wall. In most cases, the ves- ply the hand, and the leg, where a redundant tibial circula-
sel should be trimmed/débrided to avoid degeneration of tion perfuses the foot. Injury to one of these arteries does
the injured or ischemic segment of the artery or vein that not typically threaten limb and ligation may be the favored
was used to secure the shunt. Appropriate conduit should maneuver. Although placement of shunts in small vessels
be prepared with great saphenous vein being the optimal should be the exception, there are patients with multiple
choice in most situations. Adequate length is important, distal artery injuries, or those with incomplete collateral
and one should err on the side of caution in the event that perfusion which will benefit from temporary restoration of
the bypass segment needs to be longer than the shunted flow using this technique.
segment. After the shunt is removed and these preparatory As with all forms of vascular trauma, real time assess-
steps are taken, the vascular reconstruction should be com- ment of distal perfusion prior to making a reperfusion deci-
pleted with meticulous attention to technical detail (e.g., sion is required. Surgeons Lavenson, Rich, and Strandness
spatulated ends, monofilament suture, and fore- and back- were among the first to report the usefulness of continu-
bleeding and flushing prior to restoring flow). ous wave Doppler in determining distal perfusion and limb
viability in the setting of vascular trauma.33 The presence
or absence of an audible Doppler signal distal to the injury
Dwell Time provides important information as one decides whether to
ligate, shunt, or reconstruct any vascular injury. Continu-
There is no exact answer as to how long a temporary vascu- ous wave Doppler can also be repeated over the course of
lar shunt can remain in place, and given the wide range of the management scenario and used to confirm the flow
scenarios in which they may be applied, optimal dwell time through the shunt or vascular reconstruction.
is at the discretion of the damage control team. Because
shunt-related complications, such as thrombus formation, ANTICOAGULATION
with or without distal embolization or occlusion, increase
with time, the device should be removed as soon as possi- Full-dose anticoagulation is often not needed to maintain
ble; typically, as soon as circumstances allow for definitive patency of temporary vascular shunts and should be used
vascular reconstruction. Although clinical reports docu- with caution in the setting of severe injury. Although sys-
ment shunts remaining patent for up to 52 hours, these are temic anticoagulation is appealing from the standpoint of
extreme cases and more common scenarios have shunts in maintaining shunt patency, one must consider the risk of
place between 2 and 5 hours. Typically, shunts temporize causing bleeding complications from other sites of injury
the vascular injury and maintain distal flow during the (e.g., brain, pelvic, or solid organ). Even slow bleeding from
time it takes to stabilize an extremity fracture, perform a soft tissue wounds, bone fractures, or fasciotomy incisions
higher-priority operation or optimize a patient’s physiology can become problematic with the use of full anticoagu­
before attempting definitive vascular reconstruction. Dwell lation.
times of 2 to 5 hours are also common among recent mili- Translational studies and clinical reports on the topic
tary reports as the time needed to transport a casualty to a show that full-dose anticoagulation is not needed for shunts
higher level or echelon of care. Some civilian series report to remain patent during the early, damage control phase of
dwell times that reflect a “resuscitation time” or that are care. Dawson and colleagues demonstrated in a porcine
required to normalize patient physiology in the damage model that the Argyle shunt stayed patent for 24 hours
control setting (averages of 24 hours).16 without full anticoagulation, a finding that was confirmed
by Gifford et al. who used the Sundt device.34,35 Clinical
Special Considerations series from military and civilian settings also show that vas-
cular shunts are effective without systemic doses of hepa-
rin. These reports acknowledge the selective use of full-dose
ANATOMIC LOCATION (VESSEL SIZE)
heparin in rare cases when the injury is isolated or associ-
An important consideration regarding whether or not to ated with a complicating factor such as initial shunt throm-
place a temporary shunt relates to the anatomic location bosis or a heavy burden of clot in the outflow circulation.
296 SECTION 4 • The Management of Vascular Trauma

It is the authors’ recommendation that systemic antico­ In this approach, the early use of vascular shunts to restore
agulation not be a routine part of temporary vascular perfusion serves as an initial step in determining whether or
shunt use. Instead, we recommend use of heparinized saline not to press on with attempted limb salvage.
infused onto and into the vessels in question (i.e., regional Temporary shunts can reduce the warm ischemic time
use of heparin) during shunt placement. Doses of systemic that negatively affects peripheral nerves, neuromuscular
anticoagulation should be reserved for select cases in which junctions, and skeletal muscle. Preserving these functional
there are no concomitant injuries and/or cases in which the units improves quality limb salvage (i.e., an extremity that
shunt remains in place for longer periods of time. is more functional). Studies have confirmed this relation­
ship between ischemic time and nerve and muscle damage
and in recent years, limb salvage research has focused on
VENOUS SHUNTING
the principles of achieving quality, and not just statistical
Attendant with the success of arterial shunts is the ques-
tion of the value of this technique for isolated or con-
comitant venous injuries. The majority of experience with
shunting of venous injuries is from wartime reports in Severe extremity
which combined artery and vein injuries were more com- injury
mon. Preservation of venous outflow has practical benefits,
including reduced venous hypertension and blood loss from
distal wounds, including fasciotomy incisions. Preservation
Operation
of venous outflow may also help maintain arterial patency exploration
and thus improve limb or end-organ perfusion.
Like arterial shunts, placement of these devices in venous
injuries is straightforward. Although flow rates are lower
than those in arterial shunts, the patency of venous shunts, Vascular injury?
especially those placed in larger more proximal veins, is
comparable.21–23 The use of shunts in extremity vein inju-
ries has been reported by military and civilian authors,
including Parry and colleagues from Atlanta who described
18 cases in which orthopedic fixation and/or damage con- Yes No
trol surgery was facilitated with this approach. All venous
shunts in the series from Atlanta were patent upon re-
exploration at a mean dwell time of 22 hours.36 Wartime
experience with vascular shunts was predominately in the Debridement/
Simple Complex
Fixation as indicated
management of arterial injuries. However, most of the war-
time reports included subsets of patients in whom venous
shunting was useful and effective in the management of
their injuries. Primary repair
Shunt placement
(Consider shunt)

ROLE IN LIMB SALVAGE

The decision to attempt to salvage a severely injured limb Debridement/
Delayed
versus perform an amputation is often difficult. Arguably reevaluation - limb
Fixation as indicated
the most immediate and influential factor in limb preserva- viable?
tion is the perfusion status of the extremity. Timely resto-
ration of blood flow is a critical principle upon which limb
viability and functionality rests. Contemporary analysis of Yes No
data from the National Trauma Data Bank by Alarhayem
et al. demonstrated that the previously held 6-hour isch-
emic threshold may be shorter than previously supposed.
In their analysis of over 4400 patients with lower extrem- Debridement/
Amputation
ity arterial injury, amputation rates were significantly lower Fixation
when repair occurred within 60 minutes (6%), compared to
repair within 1- to 3-hour (11.7%) or 3- to 6-hour windows
(13.4%).37
Revascularization
To evaluate the effect of shunt use on limb salvage, Glass (consider fasciotomy)
et al. performed a review of 101 cases of lower extremity
injury and found that limb salvage was greatly influenced
by ischemic time.38 When ischemic time was longer than 6 Fig. 23.8 Limb salvage algorithm implementing temporary vascu-
hours, limb salvage rates decreased from 87% to 61% and in lar shunts. (Adapted from Glass GE, Pearse MF, Nanchahal J. Improving
this report, the use of vascular shunts was associated with a lower limb salvage following fractures with vascular injury: a systematic
lower amputation rate (13% vs. 27%). An adapted treat­ review and new management algorithm. J Plast Reconstr Aesthet Surg.
ment algorithm from this report is presented in Fig. 23.8.38 2009;62:571–579.)
 23 • Surgical Damage Control and Temporary Vascular Shunts 297

limb salvage.39,40 As part of this approach to attain ­func­­­­­­­­tional 1–2 hours), penetrating or crush mechanism(s), injury to
limb salvage, the authors recommend using vascular shunts as multiple below-knee or forearm arteries, open-fractures or
one way to limit malperfusion during damage control oper- nerve injuries, and large intraoperative blood loss.44–48
ations and the reconstruction of vascular trauma.
Whereas use of shunts in proximal limb injuries is intui- VASCULAR BRANCH POINTS
tive and more common, this adjunct can also be useful in
restoring flow through certain distal vascular injuries. Of Injuries that are close to, or that involve bifurcation points
particular importance are injuries in which more than one such as the distal common femoral or brachial arteries,
artery of an otherwise redundant circulation (i.e., collat- deserve special consideration in the context of vascular
eral vessels) to an extremity or end organ are interrupted. shunts. In these cases, the most common approach involves
As stated previously, continuous wave Doppler is useful temporarily occluding the branch vessel to stop retrograde
in these situations to determine the status of arterial flow bleeding and placing the shunt in the main channel. As
and whether or not a vascular shunt may be beneficial.21,33 a creative means to restore flow in both lumens, Choudry
Injuries to small, distal vessels that result in the absence et al. described using an improvised shunt fashioned from
of any arterial signal should be considered for shunting a dual lumen 14.5-Fr Mahurkar (Covidien, Mansfield,
regardless of size.41 In our experience, if shunts in small, MA) catheter to restore flow in the superficial and deep
distal vessels thrombose it does not preclude performance femoral arteries in the setting of a common femoral artery
of a thrombectomy and continued pursuit of limb salvage. injury.48 These injuries are rare enough that there is little
Often the thrombosed shunt can be removed, a thrombec- clinical experience to guide attempts to shunt both branch
tomy performed, and vascular reconstruction carried out as point vessels. If a proximal arterial branch point injury is
needed.21 encountered (e.g., the femoral bifurcation), the authors
recommend vessel loop occlusion of the large side branch
(e.g., the deep femoral artery) to stop retrograde bleeding
FASCIOTOMY (PROPHYLACTIC)
and then placement of the shunt into the main axial ves-
The development of extremity compartment syndrome has sel (e.g., the superficial femoral artery). Other means such
negative implications for limb salvage. When diagnosed, as a large clip, a Rummel tourniquet, or even a ligature
extremity compartment syndrome requires immediate per- can be used to occlude the branch vessel which can then
formance of a fasciotomy to relieve elevated pressures and be reconstructed at a later time when the wound is explored
restore normal perfusion to affected tissue beds. However, and the shunt removed. Although there is room for creativity
recognizing the onset of compartment syndrome is chal- in these situations, the surgeon must be mindful of dam-
lenging, especially in patients who are being transported age control principles and keep whatever option chosen
through multiple levels of care, often at different medical as quick as possible.
facilities. As such, prophylactic fasciotomy is acknowledged
as a common practice when vascular shunts are used. TRUNCAL VASCULAR INJURIES
Although a difficult topic to study with prospective method-
ology, at least one retrospective report from the US military Temporary vascular shunts also have shown utility as an
has shown a four-fold increase in mortality associated with alternative to ligation for the management of visceral vas-
delayed or missed diagnosis of compartment syndrome.42 cular injuries. Torso vascular injuries may be associated
Patients requiring temporary shunt placement often with genitourinary or gastrointestinal contamination, large
have the greatest number of risk factors for the develop- blood loss (with hemodynamic instability and coagulopa-
ment of extremity compartment syndrome, including isch- thy), and challenging operative exposures. Although these
emia, underlying muscle, and possibly bone contusion and situations tend to force a surgeon to ligate bleeding “out of
they frequently require large volume resuscitation. These desperation,” restoration of flow with a vascular shunt may
factors explain the high rate of prophylactic fasciotomy be a better option that will mitigate end-organ damage and
reported in military and civilian series (ranging from 60% adverse physiology.49
to 100%).21,25,27 The association between shunt use and Mesenteric arterial injuries are rare and associated with
compartment syndrome is so strong that when considering high mortality rates. Like other anatomic locations, the
patients with combined vascular and orthopedic injuries, immediate decision point in managing an arterial injury in
the lack of a temporary vascular shunt has been shown to the mesentery is whether to ligate, shunt, or repair. Reports
be associated with an increase in the development of com- of intraluminal shunting of the mesenteric vessels (e.g., the
partment syndrome.43 superior mesenteric artery [SMA]) are few, but do include
For these reasons, the military’s practice recommends translational research and clinical experience.50 Subrama-
performing prophylactic fasciotomy in cases of extrem- nian and colleagues describe two patients with shunts that
ity vascular injury regardless of shunt use, especially in were placed in the SMA. Although both shunts thrombosed,
patients to be cared for by different providers throughout only one patient expired (after care was withdrawn).27 Reilly
different echelons of care.42 For cases in which the need for et al. described the successful use of an SMA shunt during
prophylactic fasciotomy is in question, one can consider damage control surgery for penetrating injury to the abdo-
the following as more objective measures to tip the scale in men. Despite a dwell time of nearly 36 hours, the shunt
favor of performing the procedure: severe extremity injury remained patent with demonstrable viability of both the
(Abbreviated Injury Score 3 or higher, or Mangled Extremity small and large bowel upon re-exploration.51 Shunting of
Severity Score 5 or higher), combined arterial and venous SMA injuries is recommended in the damage control setting
injury, prolonged ischemia or tourniquet time (more than as an alternative to reconstruction and is particularly
298 SECTION 4 • The Management of Vascular Trauma

r­ elevant for injuries within Fullen’s anatomic zones I and 9. Debakey ME, Simeone FA. Battle injuries of the arteries in World War
II (i.e., origin of the artery at the aorta to the middle colic II: an analysis of 2,471 cases. Ann Surg. 1946;123(4):534–579.
10. Rich NM, Spencer FC. Vascular Trauma. Philadelphia WB Saunders;
branch). 1978.
Injuries to the major visceral venous structures, includ- 11. Brusov PG, Nikolenko VK. Experience of treating gunshot wounds
ing the superior mesenteric and portal vein, are also highly of large vessels in Afghanistan. World J Surg. 2005;29(suppl 1):
lethal. In a retrospective study of 51 patients with supe- 25–29. https://doi.org/10.1007/s00268-004-2081-z.
12. Eger M, Golcman L, Goldstein A, Hirsch M. The use of a temporary
rior mesenteric venous injuries, Asensio et al. reported a shunt in the management of arterial vascular injuries. Surg Gynecol
survival rate of 55% and noted that mortality worsened Obs. 1971;132(1):67–70.
with each additional vascular injury. The authors found a 13. Hossny A. Blunt popliteal artery injury with complete lower limb
survival benefit in primary repair of superior mesenteric ischemia: is routine use of temporary intraluminal arterial shunt
venous injuries although they advocated rapid ligation in justified? J Vasc Surg. 2004;40(1):61–66. https://doi.org/10.1016/j.
jvs.2004.03.003.
the unstable patient with multiple other life-threatening 14. Sriussadaporn S, Pak-art R. Temporary intravascular shunt in com-
injuries. Expectedly, ligation resulted in bowel edema and plex extremity vascular injuries. J Trauma. 2002;52(6):1129–1133.
venous engorgement with splanchnic hypertension syn- 15. Reber PU, Patel AG, Sapio NLD, Ris HB, Beck M, Kniemeyer HW.
drome and bowel necrosis.52 Additional reports of por- Selective use of temporary intravascular shunts in coincident vascu-
lar and orthopedic upper and lower limb trauma. J Trauma—Inj Infect
tal vein injuries also recommend repair when possible, Crit Care. 1999;47(1):72–76. https://doi.org/10.1097/00005373-
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use of intraluminal arterial shunts without systemic anticoagulation.
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Conclusion 17. Husain AK, Khandeparkar JM, Tendolkar AG, Magotra RA, Parulkar
GB. Temporary intravascular shunts for peripheral vascular trauma. J
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19. Nichols JG, Svoboda JA, Parks SN. Use of temporary intralu-
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more critical examination of the ischemic threshold of the shunts: resolution of a management dilemma in complex vascular
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21. Rasmussen TE, Clouse WD, Jenkins DH, Peck M, Eliason JL, Smith
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8. Blakemore A, Lord J. A nonsuture method of blood vessel anastomosis. 29. Rasmussen TE, Stockinger Z, Antevil J, et al. Clinical Practice Guideline
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30. Gifford CSM, Aidinian G, Darrin CW, et al. Effect of temporary 43. Wlodarczyk JR, Thomas AS, Schroll R, et al. To shunt or not to shunt
shunting on extremity vascular injury : an outcome analysis from the in combined orthopedic and vascular extremity trauma. J Trauma
Global War on Terror vascular injury initiative. YMVA. 2007;50(3): Acute Care Surg. 2018;85(6):1038–1042. https://doi.org/10.1097/
549–556. https://doi.org/10.1016/j.jvs.2009.03.051. TA.0000000000002065.
31. Grossi EA, Giangola G, Parish MA, Baumann FG, Riles TS, Spen- 44. Branco BC, Inaba K, Barmparas G, et al. Incidence and predictors for
cer FC. Differences in carotid shunt flow rates and implications for the need for fasciotomy after extremity trauma: a 10-year review in
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32. Aufiero TX, Thiele BL, Rossi JA, Miller CA, Neumyer MM. Hemo- 45. Gonzalez RP, Scott W, Wright A, Phelan H, Rodning CB. Anatomic
dynamic performance of carotid artery shunts. Am J Surg. location of penetrating lower-extremity trauma predicts compart-
1989;158(2):95–99, discussion 100. ment syndrome development. Am J Surg. 2009;197(3):371–375.
33. Lavenson GS, Rich NM, Strandness DE. Ultrasonic flow detector value https://doi.org/10.1016/j.amjsurg.2008.11.013.
in combat vascular injuries. Arch Surg. 1971;103(5):644–647. 46. Morin RJ, Swan KG, Tan V. Acute forearm compartment syndrome
34. Dawson DL, Putnam AT, Light JT, et al. Temporary arterial shunts secondary to local arterial injury after penetrating trauma. J Trauma.
to maintain limb perfusion after arterial injury: an animal study. J 2009;66(4):989–993. https://doi.org/10.1097/TA.0b013e31818c10e3.
Trauma. 1999;47(1):64–71. 47. Kim JYS, Buck DW, Forte AJ, et al. Risk factors for compartment
35. Gifford SM, Eliason JL, Clouse WD, et al. Early versus delayed res- syndrome in traumatic brachial artery injuries: an institutional
toration of flow with temporary vascular shunt reduces circulat- experience in 139 patients. J Trauma. 2009;67(6):1339–1344.
ing markers of injury in a porcine model. J Trauma. 2009;67(2): https://doi.org/10.1097/TA.0b013e318197b999.
259–265. https://doi.org/10.1097/TA.0b013e3181a5e99b. 48. Choudry R, Schmieder F, Blebea J, Goldberg A. Temporary femoral
36. Parry NG, Feliciano DV, Burke RM, et al. Management and short-term artery bifurcation shunting following penetrating trauma. J Vasc Surg.
patency of lower extremity venous injuries with various repairs. Am J 2009;49(3):779–781. https://doi.org/10.1016/j.jvs.2008.11.041.
Surg. 2003;186(6):631–635. 49. Ball CG, Feliciano DV. Damage control techniques for common
37. Alarhayem AQ, Cohn SM, Cantu-Nunez O, Eastridge BJ, Rasmus- and external iliac artery injuries: have temporary intravascu-
sen TE. Impact of time to repair on outcomes in patients with lower lar shunts replaced the need for ligation? J Trauma. 2010;68(5):
extremity arterial injuries. J Vasc Surg. 2019;69(5):1519–1523. 1117–1120. https://doi.org/10.1097/TA.0b013e3181d865c0.
https://doi.org/10.1016/j.jvs.2018.07.075. 50. Ding W, Ji W, Wu X, Li N, Li J. Prolonged indwelling time of tempo-
38. Glass GE, Pearse MF, Nanchahal J. Improving lower limb salvage rary vascular shunts is associated with increased endothelial injury
following fractures with vascular injury: a systematic review in the porcine mesenteric artery. J Trauma. 2011;70(6):1464–1470.
and new management algorithm. J Plast Reconstr Aesthet Surg. https://doi.org/10.1097/TA.0b013e31820c9b4e.
2009;62(5):571–579. https://doi.org/10.1016/j.bjps.2008.11.117. 51. Reilly PM, Rotondo MF, Carpenter JP, Sherr SA, Schwab CW. Tem-
39. Burkhardt GE, Gifford SM, Propper B, et al. The impact of ischemic porary vascular continuity during damage control: intraluminal
intervals on neuromuscular recovery in a porcine (Sus scrofa) sur- shunting for proximal superior mesenteric artery injury. J Trauma.
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Surg [and] Int Soc Cardiovasc Surgery, North Am Chapter. 2011;53(1): 52. Asensio JA, Petrone P, Garcia-Nuñez L, Healy M, Martin M, Kuncir E.
165–173. https://doi.org/10.1016/j.jvs.2010.07.012. Superior mesenteric venous injuries: to ligate or to repair remains the
40. Scott DJ, Arthurs ZM, Stannard A, Monroe HM, Clouse WD, Rasmus- question. J Trauma. 2007;62(3):668–675, discussion 675. https://
sen TE. Patient-based outcomes and quality of life after salvageable doi.org/10.1097/01.ta.0000210434.56274.7f.
wartime extremity vascular injury. J Vasc Surg. 2014;59(1):173–179. 53. Mattox KL, Espada R, Beall AR. Traumatic injury to the portal vein.
41. Burkhardt GE, Cox M, Clouse WD, et al. Outcomes of selective tibial Ann Surg. 1975;181(5):519–522.
artery repair following combat-related extremity injury. J Vasc Surg. 54. Graham JM, Mattox KL, Beall AC. Portal venous system injuries. J
2010;52(1):91–96. Trauma. 1978;18(6):419–422.
42. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciot- 55. Fraga GP, Bansal V, Fortlage D, Coimbra R. A 20-year experience
omy revision and delayed compartment release in combat patients. with portal and superior mesenteric venous injuries: has anything
J Trauma. 2008;64(2 Suppl):S153–S161, discussion S161–S162. changed? Eur J Vasc Endovasc Surg. 2009;37(1):87–91. https://doi.
https://doi.org/10.1097/TA.0b013e3181607750. org/10.1016/j.ejvs.2008.09.018.
 24 Considerations for Conduit
Repair of Vascular Injury
NITEN SINGH and REBECCA JOY UR

Introduction c­ omplicate repair. The limiting factor in trauma is the fact

that many individuals have concomitant orthopedic, soft-
In 1949, Jean Kunlin performed the first saphenous vein tissue, or abdominal injuries that need to be addressed in
bypass in the lower extremity of a patient suffering from addition to the vascular injury. Furthermore, although
ischemia.1 The work was not the result of chance alone as his vascular repair is usually feasible, it is the ability to place
predecessors in vascular surgery had been working on per- the repair conduit through a contaminated wound or soft-
fecting the technique of arterial surgery. Individuals such tissue deficit that often limits success. Specifically, the need
as Alexis Carrel developed the technique of a meticulous to assure adequate soft-tissue coverage to protect the con-
anastomosis, as well as experimenting with venous inter- duit from contamination and disruption often determines
position grafts and the use of allografts, and Jay McClean ultimate success or failure.
discovered heparin, which was utilized in Kunlin's success- As documented throughout this text, the approach to
ful procedure.2 In the same manner, our current treatment vascular trauma is generally straightforward. Approaches
of vascular trauma is based on lessons learned in the civil- to the injured vessel include primary repair or restoration
ian sector as well as from military experiences. For example, of perfusion using an interposition or bypass graft. The
in World War II (WW II), the majority of vascular injuries technique of patch angioplasty is also a useful approach in
were treated with ligation, leading to an amputation rate select injuries that are less severe. Finally, ligation may be
of 49%. During WW II, vein grafts were employed in a very used as a damage control approach in some cases. When
small number of patients (40), resulting in an amputation considering whether to reconstruct or ligate an arterial
rate of 58%.3,4 At that time, ligation of vascular injuries was injury, one should consider the patient's physiologic condi-
felt to be necessary due to the long transport time required tion and other coexisting injuries. Also, one must consider
for wounded service personnel. With decreased transport the degree of ischemia likely to result from vessel ligation.
times and knowledge of these past experiences, Rich and If the artery is minimally disrupted, it may be able to be
colleagues successfully implemented arterial repair in the débrided, mobilized, and repaired primarily.
majority of patients in the Vietnam War and subsequently In the situation where the artery cannot be repaired pri-
reported an amputation rate of 13%. In that experience, marily, or cannot be safely ligated there is the need for an
nearly all interposition grafts were reversed great saphe- interposition or longer bypass graft. As detailed in Chap-
nous vein, and that form of reconstruction was used in ter 23, temporary vascular shunts are useful as a bridge
46% of the cases.5 In the civilian setting in the 1960s and to interposition or bypass grafting when ligation is not an
1970s, the abandonment of ligation as treatment for vas- option. When considering interposition or bypass graft-
cular trauma led to amputation rates that ranged from ing, one must address the same technical factors that are
2% to 10%.6 It is these advances, both in the civilian and important in elective vascular reconstruction as follows: (1)
the military settings, that have led to the current standard inflow vessel, (2) outflow vessel, and (3) conduit. Although
of repairing vascular injury—in those that will tolerate the vascular injury itself may be straightforward, the
repair—with interposition or bypass grafting as needed. patient is often not straightforward and may have suffered
multiple injuries. The overall injury severity and any hemo-
dynamic instability will impact the choice of conduit and
Identification of the Optimal the outcome of the procedure (Fig. 24.1). The ease of avail-
Vascular Conduit ability and necessary length of conduit are also factors to
be considered when pursuing this form of reconstruction.
The search for the optimal vascular conduit, in both elec- It would be nice to imagine that one solution applies to both
tive and emergency situations, has been a source of debate military and civilian scenarios, but the settings (and the
and the source of many research projects. The ideal vascu- nature of the wounds) are most often different. This chapter
lar conduit should be durable, able to be incorporated by the will describe the options for selection of the vascular con-
host or recipient, resistant to infection, and readily available. duit to be used for repair of vascular injury.
In numerous studies of elective peripheral vascular bypass,
autologous vein has proven superior to prosthetic modali-
ties in the lower extremities, whereas prosthetic grafts are Types of Conduit
generally better suited for the larger caliber central arter-
ies. Unlike elective situations, trauma cases differ in the The use of a conduit in vascular trauma is, in principle, the
sense that patients are generally younger and have healthy same as its use for atherosclerotic occlusive or aneurysmal
vessels free of atherosclerotic occlusive disease that can disease. Vascular conduits can be considered in the following
300
 24 • Considerations for Conduit Repair of Vascular Injury 301

incision, skip incisions, or a newer minimally invasive tech-

nique. The single incision is the most expedient and most
commonly described technique for greater saphenous vein
harvest. However, this is associated with wound infection
and dehiscence in 17% to 44% of patients.9,10 In an effort
to decrease wound complications, attempts have been made
to harvest this vein with multiple, shorter incisions and
intervening “skin bridges.” Although this technique may
take additional time and familiarity with the approach, it
has been shown to decrease wound complications (9.6%)
in at least one large series.11 The least invasive technique
for saphenous vein harvesting is the newer endoscopic
approach. With this technique, the vein is harvested with
electrocautery through several percutaneous incisions.
Although risk of wound infection is decreased with the
endoscopic technique, this does carry the added risk of
thermal injury to the vein. Although it is desirable to reduce
wound morbidity associated with saphenous vein harvest,
Fig. 24.1 Massive soft-tissue destruction from an improvised explosive it seems that as the method becomes less invasive, the time
device blast. needed for the procedure increases, as does the need for
expertise with the endoscopic procedure. Because of this,
the less-invasive approaches to saphenous vein harvest are
not practical in most centers for cases of vascular trauma.
categories: (1) autologous vein and artery (i.e., autografts), Although rarely used, arterial conduits may provide a bet-
(2) prosthetics, and (3) biologics. Vascular trauma has a ter size match for the injured vessel and they do not require
rate of wound contamination that is proportional to the lysis of valves. Arterial conduits may also have improved
mechanism of injury and degree of soft-tissue injury. The handling characteristics, better compliance match, and even
degree of contamination can be minor such as with a single superior patency. The use of autologous arterial conduit is
stab wound or a laceration with a piece of glass, or it can feasible and efficacious, but remains limited in the setting of
be major such as with an open femur fracture with soft-tis-­ trauma due to the paucity of harvest sites, their challenging
sue wound. More than a decade of war in Afghanistan and anatomic locations, and the lack of redundancy or length.
Iraq has laid bare the complexities associated with vascu- The internal mammary (internal thoracic) artery is the most
lar trauma in highly contaminated wounds resulting from commonly used arterial conduit. However, due to its con-
improvised explosive devices (IEDs).7 Traditional teach- fined location, access is only feasible through a median ster-
ing has emphasized the use of autologous vein grafts for notomy. The gastroepiploic artery has also been used with
vascular repair in the setting of contamination. However, favorable patency in coronary artery bypass surgery when
due to the complexities of different trauma scenarios such the internal mammary artery and the saphenous vein are
as bilateral lower extremity injury, this conduit (e.g., the not available.12 The most commonly explanted autologous
great saphenous vein) may not be feasible or appropriate. artery is the radial artery, which ranges from 2 to 4 mm. The
If autologous vein is not available, vascular hemorrhage internal iliac artery can be used, but this is infrequent except
can be controlled by ligation, the use of temporary vascular in select cases of pediatric injury. Klonaris et al. described the
shunts, or reconstruction using a commercially available benefits of using the internal iliac artery for repair of infected
prosthetic or biologic conduit.8 femoral artery pseudoaneurysm resulting from trauma from
repeated access during illicit drug use. This report describes
the use of internal iliac artery for reconstruction in 9 (5
AUTOLOGOUS CONDUIT
patch, 4 interposition graft) of 12 patients. At a mean of 19
The gold-standard conduit is autologous tissue and most months after repair, Klonaris et al. reported no complica-
commonly a vein. In rare cases, one may choose to use an tions or instances of limb loss.13 Finally, the external carotid
arterial conduit for vascular reconstruction. Because the artery can serve as an autologous conduit in repair of proxi-
venous system has multiple, redundant outflow tracts there mal internal carotid artery injuries. In these cases, the exter-
are several choices for vein harvest. The lower extremity has nal carotid can be transposed onto the mid or distal internal
the longest and most commonly used options, including the carotid in situations where the proximal portion is injured.
greater and lesser saphenous veins, the femoral vein, and Other arteries such as the deep inferior epigastric may be
dorsal foot vein. The cephalic and basilic veins of the upper used as a microvascular graft to replace a damaged arterial
extremity can be used independently or as a longer single- segment, but these smaller arteries are not typically a consid-
segment graft. In the neck, the anterior, exterior, and inter- eration in trauma.14
nal jugular veins are options for vascular conduit. The veins
of the neck are most commonly used as adjuncts for carotid PROSTHETIC CONDUITS
artery repair because of their proximity.
Use of autologous vein requires adhering to the tenants Since the first prosthetic graft made of woven nylon, a
of safe and effective dissection and procurement. In general, variety of grafts have been developed, including collagen-
superficial veins may be harvested using a single continuous impregnated, woven nylon (Hemashield Dacron, Maquet
302 SECTION 4 • The Management of Vascular Trauma

Germany), heparin-bonded Dacron, expanded polytetraflu- in trauma has been espoused by some who purport that
oroethylene (ePTFE), heparin-bonded ePTFE (PROPATEN, short segments or lengths of prosthetics are durable and
Gore Medical, Flagstaff, AZ), hooded PTFE (Distaflo, Bard react more favorably than vein in contaminated fields.
PV, Tempe, AZ), ring reinforced ePTFE, and even multilayer– Figure 24.2 shows a through and through carotid artery
hybrid grafts consisting of both woven nylon and ePTFE injury repaired with a short segment PTFE interposition
(Triplex, Vascutek Terumo, Scotland, UK and FUSION graft. Some of these studies also point to preservation of the
Maquet Cardiovascular, Wayne, NJ). Biosynthetic vessels autologous vein for future revascularization as an advan-
(Omniflow II, LaMaitre Vascular, Burlington, MA) consist- tage of using prosthetic conduits as the initial option.
ing of a woven ovine collagen overlying polyester have been
used with some success in infected fields but is unavailable BIOLOGIC CONDUITS
for sale in the United States.15
For large vessels such as the aorta and iliac arteries, pros- The most modern construct of the vascular conduit is the
thetic grafts have been used with great success. However, biologic graft. These may be allografts, xenografts, or those
higher rates of thrombosis remain a disadvantage of pros- created (i.e., grown) using modern regenerative medicine
thetic grafts in smaller vessels regardless of conduit compo- technologies. Allografts include cryopreserved vein, cryo-
sition. In the classic studies of Bergen and Veith, comparing preserved artery, and preserved treated human umbilical
vein to ePTFE for reconstruction of age-related disease, vein (HUV). Dardik began work on HUV as a conduit s­ tarting
short-term (2-year) patency was comparable between the in the 1970s.18 At 37 to 40 weeks of gestation, the HUV
conduits. When longer-term patency rates of these studies (2- to 3-mm diameter) is of similar caliber to that of small
were reported, saphenous vein was found to be superior.16,17 arteries and contains moderate amounts of collagen and
Prosthetic grafts are used today for elective bypass proce- elastin to provide elasticity. In a qualitative analysis of the
dures, but mainly in the femoral and above-knee location. microstructure of HUVs, Li et al. showed that the collagen
Adjuncts such as heparin bonding of the luminal surface to elastin ratio in these vessels is similar to an artery of the
of the ePTFE have been used with modest or mixed results same caliber. Studies by Li and colleagues also demonstrated
in attempts to improve patency. The use of prosthetic grafts that HUV had comparable morphologic and microstructural
indices as similar-size arteries. These authors concluded
that because of the similarities, HUV may be a substitute
for small-caliber arteries such as coronary, brachial, radial,
and tibial.19 In a review of 211 femoral-to-popliteal bypass
operations (using the second-generation glutaraldehyde-
stabilized HUV grafts), Neufang et al. reported the primary,
primary-assisted, secondary patency, and limb salvage after
5 years as 54%, 63%, 76%, and 92%, respectively (with no
difference between above-knee and below-knee grafts).20
Cryopreserved saphenous vein allografts, also referred
to as cadaveric saphenous vein, have been utilized as an
alternative conduit. Early results with this conduit demon-
strated poor patency. Walker et al. studied 35 patients who
underwent lower extremity bypass grafts for symptomatic
ischemia. The primary patency was 67% at 1 month,
28% at 12 months, and 14% at 18 months.21 In an effort
to improve patency, Buckley et al. prospectively enrolled
patients for femoral-to-below-knee popliteal artery bypass
using an anticoagulation protocol. Twenty-four patients
with ischemic lower limbs underwent bypass with cryopre-
served vein and were treated with aspirin, low-dose hepa-
rin, low-molecular-weight dextran 40, dipyridamole, and
warfarin. The limb salvage rate in this study was 88% at
6 months and 80% at 24 months.22 Although this report
demonstrated improved patency, it enrolled a small num-
ber, and patients required high levels of anticoagulation to
obtain the results, an option oftentimes not available to a
multiply injured trauma patient.
Cryopreserved, cadaveric arterial allografts have been
developed as an alternative to cryopreserved vein. Cryopre-
served artery is derived from the descending thoracic and
intrarenal aorta, as well as the iliac and femoral arteries of
human cadavers. Due to the variety of diameters, one can
find an appropriately sized cryopreserved allograft for any
vessel in the body. Cryopreserved allografts are commonly
Fig. 24.2 PTFE interposition graft repair of right common carotid artery. used for in-line arterial reconstruction in the treatment of
(Image courtesy of Todd Rasmussen, Mayo Clinic.) prosthetic graft infections or contaminated wounds such
 24 • Considerations for Conduit Repair of Vascular Injury 303

as a mycotic aneurysm or aortoenteric fistula. Although setting of resistant or recurrent infection and that it may
cryopreserved arterial allografts have been anecdotally have applicability in trauma.23
reported in the repair of vascular trauma with contami- Animal-derived conduits (xenografts) include bovine
nated wounds, there are no large series. Reports on the use carotid artery (Artegraft, North Brunswick, NJ), bovine
of this conduit in infected abdominal and extremity vascu- pericardium, bovine jugular vein (Contegra, Contegra,
lar beds suggest that it would be a safe consideration in the Medtronic, Santa Rosa, CA) as well as a porcine pulmonic
xenograft. The use of bovine carotid as a hemodialysis graft
was initially reported by Chinitz.24 The patency of bovine
carotid has been compared to ePTFE in hemodialysis grafts
by Kennealey. Although there was no difference in second-
ary patency, primary and assisted-primary patency were
higher with bovine carotid than with ePTFE (60% ver-
sus 10% and 60% versus 21% at 1 year, respectively).25
Although bovine carotid has not been studied in vascular
trauma, experience in lower extremity bypass demonstrates
good results for patency in bypasses to the above- and below-
knee position as well as in tibial vessels with patency of 87%
at one year.26 Similarly, bovine jugular vein plays a role in
reconstruction of the right ventricular outflow tract in con-
genital heart surgery.27 Although its use in trauma remains
to be defined, this conduit is available in diameters from 12
to 22 mm and would appear to be an appropriate size match
for torso vascular structures.28
The human acellular vessel (HAV) (Humacyte, Inc.,
Durham, North Carolina) is a new bioengineered blood ves-
sel or conduit consisting of decellularized (non-antigenic)
extracellular matrix originating from arterial smooth mus-
Fig. 24.3 Human acellular vessel (HAV) being sewn to left common cle cells (Figs 24.3 and 24.4).29 This product is manufac-
femoral artery. (Image courtesy of Todd Rasmussen, Mayo Clinic.) tured using regenerative medicine techniques and results

Fig. 24.4 Human acellular vessel as a new bioengineered autogenous conduit. (Image courtesy of Todd E. Rasmussen, Mayo Clinic, and created by Sofia
Echelmeyer, Uniformed Services University, Bethesda, Maryland.)
304 SECTION 4 • The Management of Vascular Trauma

in an “off-the-shelf ” conduit of uniform caliber that can be Table 24.1 Various Sizes of Arteries Affected by Trauma.
implanted as a patch or as an interposition or bypass graft.
Because the conduit is a non-antigenic biologic, evidence Artery Normal Diameter (mm)
suggests that overtime it becomes populated by endothelial Common carotid 10
cells from the recipient patient.30 The HAV is not yet cleared Innominate 12–14
by the US Food and Drug Administration (FDA), but piv- Subclavian 10
otal clinical trials designed to assess the safety, efficacy, and Axillary 8–10
durability of the conduit for dialysis access, peripheral arte- Radial 4–6
rial disease, and vascular trauma are underway in the US
Thoracic aorta 20–25
and Europe.31 The US Military Health System research pro-
Abdominal aorta 15–20
gram has supported the development and clinical study of
the HAV in the hopes that this conduit may provide an off- Common iliac 10–14
the-shelf option that is well incorporated and resistant to External iliac 8–10
infection for use in the setting of wartime vascular injury.32 Internal iliac 8–10
Common femoral 8–10
Superficial femoral 6–8
Decision Making in the Choice of Profunda femoral 6–8
Conduit Popliteal 6–8

LOCATION AND NATURE OF THE INJURY

The anatomic location of the vascular injury plays an Extremity Vessels
important role in consideration of conduit. If the environ- Blunt arterial extremity injury classically leads to disrup-
ment in which conduit will be used is relatively innocu- tion of the intima and flow-limiting defects. The difficulty
ous, such as a low-velocity penetrating wound, the injury with blunt trauma is confirming the diagnosis and specific
may be amenable to anatomic or in situ interposition graft location of vascular injury. As discussed in other chapters
reconstruction. In contrast, if the injury is more extensive, of this textbook, this scenario is often delineated with imag-
is heavily contaminated, or is associated with soft-tissue ing such as duplex, contrast computed tomography (CT), or
injury, there may not be viable soft tissue to cover an in situ conventional arteriography. Penetrating injuries may lead
graft. These more severe cases may preclude anatomic or in to vessel transection or intimal injury due to direct or indi-
situ reconstruction and instead require positioning or rout- rect contusion (i.e., concussive effect). Partial transection of
ing of a bypass conduit in an alternative or extra-anatomic the vessel may prevent retraction and vasoconstriction and
location. Understanding the size of the injured vessel and may lead to more bleeding from the injury. In contrast, com-
the extent of contamination and soft-tissue injury allow plete transection of the elastic arteries in the upper extremi-
one to make a judgment about the best type of conduit. ties often results in vessel retraction, vasoconstriction, and
Table 24.1 provides a summary of approximate sizes of ves- a relative degree of hemostasis. In the upper extremity, the
sels that may be affected in the setting of severe injury. axillary and brachial arteries are frequently injured by pen-
etrating mechanisms, and in the lower extremity, the super-
Thoracic and Abdominal Injuries ficial femoral and popliteal arteries are most affected (see
The thoracic aorta and its branches are protected by the Fig. 24.5).37,38 The smaller infrageniculate vessels can also
bone and muscular structures of the thorax. Blunt injuries be injured. However, if in isolation, these injuries are associ-
that carry enough force to disrupt these vessels often result ated with lower rates of mortality and morbidity than the
in death. In the civilian setting, blunt aortic injury (BAI) is larger, more-proximal vessels. If multiple tibial vessels are
often manifested as a transection of the proximal descend- injured in the same extremity, the degree of ischemia and
ing aorta at or immediately distal to the ligamentum arte- even the propensity for limb loss are likely to be worse.39
riosum. In this scenario a patient will survive based on the
integrity of the periadventitial tissue in the mediastinum. IDEAL CONDUIT FOR VASCULAR TRAUMA
Although this situation is not stable in the long term, a
contained BAI may allow the patient to be transported to The ideal characteristics of conduit include ease of procure-
a trauma center and treated with an open interposition ment, durability, resistance to infection, ability to incorpo-
graft or an endovascular stent graft. Penetrating injury to rate with surrounding tissues, and appropriate diameter for
the thoracic aorta is often lethal due to the numerous vital the vessel being reconstructed. There is a general consen-
structures in the anatomic vicinity. Even low velocity pen- sus that until biologic conduits, such as the HAV, become
etrating injuries (i.e., stab wounds) may be lethal in this more commonplace, autologous vein is the favored conduit
location.33,34 Blunt injury to the abdominal aorta is infre- option. However, given the varied mechanisms of trauma
quent and accounts for 5% of aortic injuries.35 The majority and the different sizes of injured vessels, one will need to be
of abdominal aortic trauma involves the infrarenal segment familiar with more than just saphenous vein for vascular
but its branches may also be injured. Penetrating injuries to conduit. Table 24.2 lists several commonly used conduits,
the abdominal aorta and its branches are often complicated each with real or perceived advantages and disadvantages.
by injuries to solid or hollow viscus organs leading to bleed- As noted, the choice of conduit depends on the anatomic
ing and or enteric contamination.36 region of injury. Since the Vietnam War—and especially
 24 • Considerations for Conduit Repair of Vascular Injury 305

Fig. 24.5 Repair of a combined arterial and venous wound of the left lower extremity. (A) Preoperative image of left leg with combined femoral
artery and vein injury. (B) Exposure of left femoral artery and vein injuries with shunts in place. (C) Completed repair of combined femoral artery and vein
injuries with saphenous vein interposition grafts. (Image courtesy of Todd Rasmussen, Mayo Clinic.)

Table 24.2 Conduit Class: Common Conduits in Trauma.

Resistance to
Conduit Type Accessibility Durability Infection Size Matched Miscellaneous Issues
Autologous vein Easily accessible if there is Extremely good Good if there is Excellent for the Can lead to pseudoaneurysm
(e.g., GSV) not polytrauma (i.e., bilat- adequate tissue upper and lower or blowout if not properly
eral IED injury to the lower coverage extremities covered
extremities)
Prosthetic “Off the shelf” Not the same Good; antibiotic Excellent size for all Can lead to pseudoaneurysm
as GSV but impregnation injuries or thrombosis if placed in
adequate available contaminated field
Cryopreserved Accessible if cold storage Very good Numerous reports Very good for a Requires freezer and time
allograft available for intraabdominal variety of sizes to thaw; not available in
replacement with ­austere or military settings
good success
GSV, Greater saphenous vein; IED, improvised explosive device.

during the wars in Afghanistan and Iraq—the percentage can result in an autologous vein conduit with a caliber that
of cervical and extremity vascular injuries has increased.40 is twice that of the original saphenous vein diameter.42 A
Larger-diameter torso vascular injuries often require recon- 2018 retrospective review of this technique demonstrated
struction with appropriately sized, off-the-shelf, ePTFE or an 85% 1-year patency in repairs of multiple traumatically
Dacron. These conduits are favored in the torso because of injured vessels.43
their ready availability and their uniform and larger diam- Because of the constraints involved with autologous
eters. For smaller torso vessels, or in cases of enteric con- repair of torso vascular injuries, particularly with regard
tamination, one may consider autologous vein as conduit. to the larger-caliber vessels, repair has traditionally been
In these cases, depending on the extent of injury, one may performed using prosthetic of collagen impregnated, woven
use the deep femoral or the great saphenous vein. nylon, or ePTFE. Woven nylon grafts have the disadvantage
The aorta is most commonly repaired primarily or with of stretching up to 40% over the lifetime of the graft. As
a prosthetic conduit for reasons already mentioned. The such, the diameter of the woven nylon graft should be rela-
aorta may also be reconstructed with a bifurcated graft tively undersized compared to the diameter of the native
comprised of the deep femoral veins sewn side-to-side for artery being repaired. ePTFE grafts are relatively porous
5 cm to create a large common channel that approximates and are prone to leaching serous fluid through the graft
the diameter of the aorta. This neoaorta procedure is material. This phenomenon, also referred to as “sweating,”
almost exclusively used in the elective or the semi-elective can lead to formation of seromas in the graft tract. In an
setting following removal of an infected prosthetic aortic effort to mitigate each of these disadvantages, a multilay-
graft and should rarely be used as the primary procedure for ered woven nylon and ePTFE graft is available. The new
trauma.41 Reconstruction of the iliac artery may be accom- Triplex prosthetic conduit (Vascutek Terumo, Renfresw-
plished with prosthetic or with saphenous or femoral vein shire, Scotland) consists of three layers. The inner layer is a
depending on the setting. One strategy to construct a larger standard uncoated Dacron graft (DuPont, Wilmington, DE),
caliber conduit using saphenous vein is referred to as a and the outer is a standard ePTFE graft. These two layers are
“panel graft.” In this case, a long length of the great saphe- fused together by a central layer of self-sealing elastomeric
nous is opened longitudinally and divided into two approxi- membrane.44
mately equal segments or “panels.” The panels are then Adjunctive maneuvers such as presoaking a woven
sewn side-to-side and closed over a small or midsized chest nylon graft with rifampin (60 mg/mL) can be performed
tube. Variations of the panel graft exist, and the strategy as a measure to deliver antibiotic to the field of injury and
306 SECTION 4 • The Management of Vascular Trauma

to reduce the risk of graft infection. Similarly, ePTFE grafts Rockwell et al. described use of epigastric artery and dorsal
can be treated to decrease infections when placed in a con- hand vein transposition for thumb reimplantation following
taminated field. Fischer et al describes a method by which traumatic amputation.54 The dorsal hand or foot veins are
minocycline and rifampin are bound to ePTFE graft using of good caliber but harvesting them will leave a significant
a unique methylacrylate technology to promote controlled scar and there is potential for injury to the extensor tendons
antibiotic elution and to reduce infection risk.45 In vitro, of the hand or fibrotic scar formation resulting in decreased
the antibiotic-bound ePTFE grafts sustained gradual local function of the hand. In the case of hypothenar hammer
release of the antibiotics that provided resistance from syndrome, trauma to the hypothenar eminence of the palm
infection by Staphylococcus aureus and Staphylococcus epider- causes injury to the ulnar artery often with formation of
mis for up to 2 weeks. An additional in-vitro study of silver a symptomatic aneurysm. Traditional vein graft repair of
impregnated Dacron demonstrated increased resistance to a thrombosed ulnar artery using reversed saphenous vein
infection with MRSA and Escherichia coli in dogs without has been reported.55 However, Temming et al. proposed that
increasing biomarkers of a local inflammatory response.46 an arterial autograft would be superior conduit (i.e., bet-
The available and best-suited conduit for the repair of ter size, durability) compared to vein graft in this scenario.
upper and lower extremity arterial injury is the greater This group subsequently reported three successful cases of
saphenous vein. It is generally recommended that this ulnar artery reconstruction using the descending branch of
autologous conduit be harvested from the leg contralat- the lateral circumflex femoral artery. In this novel report,
eral to any injury to decrease the risk of venous conges- patency of the reconstruction was confirmed by duplex
tion resulting from trauma. This is especially important if ultrasound at periods as long as 28 months after repair.56
the injured lower extremity has concomitant arterial and
venous injuries (see Fig. 24.5). In McCready's series of
patients with extremity trauma, it was found that 43 of 49 Conduit in Austere and Military
patients with femoral and popliteal artery injuries recon- Settings
structed with saphenous vein experienced an excellent
outcome 33 months after the event.47 Similar outcomes AUTOLOGOUS CONDUITS
have been reported in other series, although lack of follow-
up with this subset of the population means longer-term Conduit other than greater saphenous vein is often not
results are less well characterized.48,49 Late thrombosis of available or feasible in military or civilian scenarios of dam-
saphenous vein grafts does not necessarily mean catastro- age control surgery. In this context, one must consider the
phe. In Rich's Vietnam experience, 24 of 34 patients who patient's overall injury pattern and injury severity (i.e.,
experienced vein graft thrombosis required no operative polytrauma) when considering harvest of autologous con-
intervention because of adequate collateral circulation. duit and vascular reconstruction. The benefits of autolo-
It is likely that other associated extremities injuries (e.g., gous conduit include its familiarity and demonstrated
bone, nerve) limited use of the limb and the degree to which effectiveness in scenarios of elective revascularization for
mild to moderate ischemia resulting from graft thrombosis chronic limb ischemia. Additionally, retrospective studies
would result in symptoms such as claudication.50 have shown the effectiveness of vein as a conduit in extrem-
If saphenous vein is not available as conduit, the upper ity trauma. Nonetheless, one notable drawback of greater
extremity veins such as the cephalic and basilic can be used. saphenous vein is the time and expertise required to harvest
The basilic vein has been described for use in bypass and and prepare the conduit. Keen reviewed the experience with
exclusion of a popliteal artery aneurysm. The basilic vein autologous vein repair in extremity injury (n=134) in a
can be harvested from the arm while simultaneous expo- busy trauma setting and estimated that it required 10 min-
sure of the lower extremity artery is performed by another utes to harvest and prepare the conduit. To many, including
surgical team. Tal et al. described basilic vein grafts used the authors of this text, the finding of 10 minutes is a low
to bypass and exclude popliteal artery aneurysm in five estimate. In most experiences, harvesting and preparing
patients with good results up to 3 years after the repair.51 the saphenous vein requires at least 30 minutes and longer
In another small series from Parmar et al., basilic vein if difficulties are encountered with a dual or duplicate sys-
was employed as the replacement for infected prosthetic tem, or if one includes wound closure in the time estimate.
grafts in the iliac and femoral arterial regions. The basilic Keen and colleagues reported no vein graft infections in
vein provided appropriate size match and was used for in their population and attributed this success to liberal use of
situ replacement.52 Although arm vein performs favorably rotational muscle flaps and routing the autologous grafts in
with respect to patency and limb salvage when compared an extra-anatomic manner, out of the contaminated sites
to synthetic conduit, it does require more frequent second- of injury.57
ary interventions to maintain patency. In a series of 37 arm The observations of success-related routing grafts out of
vein bypasses, Varcoe et al. reported a 30-day primary and or around the zone of injury and contamination (i.e., extra-
secondary patency of 89% and 95%, respectively, with 95% anatomic) should be understood by military surgeons. Sev-
limb salvage.53 eral studies have demonstrated that vein grafts are prone
If one is to reconstruct arterial injuries in the distal to undergoing transmural necrosis or anastomotic disrup-
extremities (e.g., forearm, leg), the conduit must be of tion when they are placed in a contaminated field without
smaller caliber. Autologous artery or vein is still preferred in viable soft-tissue coverage. In this setting, the conduit can
these challenging situations. To obtain an appropriate size degrade or break down because of bacterial contaminated
match, the distal greater saphenous vein at the ankle or the with or without desiccation of the main body of the graft
lesser saphenous vein provides relatively familiar options. or at the anastomotic sites. In general, it is uncommon to
 24 • Considerations for Conduit Repair of Vascular Injury 307

or possibly amputated, there is often no saphenous vein to

use as conduit for vascular repair. These complex scenar-
ios have required military surgeons to innovate either by
using temporary vascular shunts for long periods of time
(i.e., “extreme shunting”) or by using ePTFE as a first (but
likely temporary) interposition graft material. One series
described using ePTFE first as a damage control option,
even in the setting of severe contamination and poor tissue
coverage, with the plan to remove the prosthetic graft for a
longer-term solution in the days following the initial opera-
tion (Fig. 24.7).59 In this setting, the patient and ePTFE graft
are monitored closely for graft disruption and the prosthetic
is removed and a more viable reconstruction performed
within 5 to 10 days (Fig. 24.8). Revising the vascular repair,
at even this modest time interval, often allows for procure-
ment of an alternative vein conduit or rerouting of a revised
reconstruction through an extra-anatomic location.58
In the civilian setting, prosthetic grafts such as ePTFE
Fig. 24.6 Short-length interposition saphenous graft in the brachial have been used more commonly with satisfactory results.59
artery. In the treatment of chronic limb ischemia, ePTFE grafts
have been reported, in some studies, to have similar patency
as saphenous vein, and Feliciano et al. reported 5-year
require a long segment of vein for reconstruction of vascu- patency of approximately 70% for arterial injuries man-
lar trauma (Fig. 24.6). In up to 40% of military extremity aged with ePTFE.60,61 In contrast, this same group reported
vascular injuries, the patient has a concomitant orthope- poor results with the use of ePTFE for repair of extremity
dic fracture. In these scenarios, exposing and controlling veins with all reconstructions having thrombosed during
the vascular injury with or without the use of a vascular follow-up. In the military experience, prosthetic grafts too
shunt is accomplished first. Then the contralateral saphe- often fail to incorporate with surrounding soft-tissue cov-
nous vein is harvested while the fracture is reduced and erage. In some cases, this is because of primary soft tissue
stabilized. After the orthopedic injury is stabilized, the vas- injury or bacterial or fungal contamination, and in others it
cular injury is re-exposed, any temporary vascular shunt is may simply be due to a noninfected seroma surrounding the
removed, and the injury is reconstructed with the harvested ePTFE graft. Even if the original cause is not infectious, the
vein (i.e., graft, patch angioplasty). If the greater saphenous presence of a seroma and nonincorporated graft in a poly-
vein is not available, the lesser saphenous, the cephalic, or trauma patient is prone to become infected and evolve to an
the basilic veins should be considered. Most commonly, cir- anastomotic disruption. As such, ePTFE has been discour-
cumstances such as patient positioning, other injuries, or aged in the recent wartime experience, and closely moni-
indwelling intravenous lines exclude exposure and procure- tored in scenarios when it has been used because of the lack
ment of these alternative vein conduits. of autologous vein. As described, ePTFE can be removed or
revised in an elective or more controlled setting (i.e., staged
removal) if needed in the weeks and months following the
PROSTHETIC CONDUITS
initial injury.62,63
Prosthetic conduits such as Dacron and ePTFE have been
employed in civilian trauma for a number of years and offer
a wide range of sizes. However, most studies examining the Future Considerations
use of prosthetic grafts in trauma have been in the civilian
setting where the level of soft-tissue injury and contamina- BIOENGINEERED BLOOD VESSELS
tion are less than in the military setting. Rich's experience
from Vietnam demonstrated that the majority of prosthetic The limitations associated with the currently available
grafts used for reconstruction of vascular trauma were autologous conduits have led to numerous efforts to create
associated with complications, either infection or throm- artificial blood vessels. Teebken outlined the desired char-
bosis. These observations have been corroborated during acteristics of an artificial blood vessel as follows: (1) com-
the wars in Afghanistan and Iraq, and the use of prosthetic pliance, (2) lack of thrombogenicity, and (3) resistance to
graft material to reconstruct wartime vascular injury is infection.64 Indeed, these traits and the availability of a wide
generally discouraged. Clouse et al. reviewed 301 arterial range of uniform, off-the-shelf sizes would be ideal for elec-
injuries in Iraq and found that 3% were repaired using pros- tive and trauma situations. Kakisis and colleagues reviewed
thetic grafts, whereas 57% were managed with autogenous the literature on the creation of artificial blood vessels and
vein repair.58 identified the three basic elements required for construc-
The severity of extremity injury during the wars in tion of a blood vessel as follows: (1) a structural scaffold, (2)
Afghanistan and Iraq, including those described by the cells, and (3) a nurturing environment.65 Most scaffolds are
Dismounted Complex Blast Injury Task Force, presented a created from a collagen matrix, and in 1986 Weinberg cre-
particular challenge related to use of autologous vein. Spe- ated the first in vitro vessel based on this matrix.66 The inner
cifically, in cases where both lower extremities are mangled surface of the graft was seeded with bovine endothelial
308 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 24.7 Operative photos of penetrating right common carotid artery injury repaired using an 8-mm ePTFE interposition graft. (A) The patient's head
is turned to the left, and the jugular vein is to the anatomic right of the interposition graft. At the top aspect of the photo, the intact right facial vein
can be observed crossing the more distal common carotid and carotid bifurcation. The small, hand-held, Bookwalter retractor is at the base of the neck
at the sternoclavicular junction. (B) The wound is closed over a closed suction drain. The second drain at the top of this photo is of a negative pressure
wound therapy device placed over the débrided entrance wound. ePTFE was chosen as a conduit in this instance because of its ready, “off-the-shelf”
availability and its excellent size match. Of note, in this case there was minimal soft-tissue injury and no esophageal (i.e., enteric) trauma. (Image courtesy
of Todd Rasmussen, Mayo Clinic.)

cells, and Dacron mesh was embedded into the wall. In the risk of infection due to the prolonged duration of cul-
models created without the mesh, the burst strength was ture, and the need to investigate the use of new biopoly-
very low compared to those with mesh. mers (as opposed to using the preexisting scaffolds).65 A
Scaffold-free techniques use free sheets of cells which more comprehensive discussion of tissue-engineered arter-
then assemble into multilayer constructs. These layered ies is beyond the scope of this chapter, but it is likely that
sheets are then wrapped into a cylindrical shape to achieve advances in this field will lead to the development of artifi-
a multiply layered vessel. New techniques with three- cial blood vessels as technology advances.
dimensional printing have also shown promise in develop- In one of the most innovative, and now clinically prom-
ment of tissue-engineered vascular grafts with the ability ising efforts to date, a group of scientists, engineers, and
to produce a predefined, computer-generated structure con- clinicians with Humacyte (Durham, North Carolina) have
sisting of multiple layers of different cell types. Cells used to devised a method to grow human vessels in vitro using
create these constructs vary from embryonic stem cells with human vascular smooth muscle cells that are cultured on a
full differentiation potential to progenitor cells with limited biodegradable scaffold. These newly grown vessels are then
differentiation ability.67,68 rendered acellular by a decellula rization process that gen-
One of the issues that influences the strength of engi- tly removes antigenic material, preserving the extracellular
neered vessels is the orientation of the smooth muscle cells matrix proteins and mechanical integrity of the conduit,
on the scaffold. Numerous techniques, including the appli- resulting in a human acellular vessel or HAV.70 The HAV is
cation of pulsatile flow and magnetic fields, have been used an off-the-shelf conduit of uniform caliber that can be used
to reorient the smooth muscle cells in a favorable, circum- as a patch, or as an interposition or bypass conduit. Because
ferential axis. Edelman identified that, although artificial the HAV is a non-antigenic biologic, evidence suggests that,
blood vessels may not have the ideal properties of native over time, it becomes populated by endothelial cells from the
vessels, the implanted vessels should ideally grow or incor- recipient patient.29 The HAV is not yet FDA-cleared, but suc-
porate to the local environment if they are composed of cessful use of this conduit for arteriovenous access has been
viable tissue.69 Kakisis identified constraining factors in the reported in phase I/II clinical studies.71 In 2020, Gutowski et
use and development of artificial vessels as the long period al. reported the results of a first-in-human, phase II trial of
of preparation required to produce bioengineered products, the HAV as a bypass conduit (above-knee, femoral popliteal
 24 • Considerations for Conduit Repair of Vascular Injury 309

A B

Fig. 24.8 Operative photo of a mangled right upper extremity and axilla resulting from an explosive mechanism. Limb salvage was pursued despite a
brachial artery injury and massive soft-tissue damage because the median and radial nerves were visualized intact and there was no injury to the wrist
or hand. The right forearm wound is a fasciotomy incision. (A) The brachial artery has been reconstructed with a 6-mm ePTFE graft as a damage control
maneuver. This graft was placed at the initial operation with the expectation that it would be temporary and replaced by an autologous vein graft dur-
ing subsequent operations if the attempt at limb salvage was continued. (B) This photograph was taken 2 weeks later, after the soft-tissue wound had
been stabilized over the course of four operations. The ePTFE graft has been replaced with an autologous reversed greater saphenous vein interposition
graft. In this image, a right latissimus dorsi rotational flap had been accomplished to fill in the soft-tissue defect and to cover the autologous vascular
reconstruction. (C) This shows the injury at the completion of the operation with the right extremity wound controlled using an extensive negative
pressure wound therapy mechanism. (Image courtesy of Todd Rasmussen, Mayo Clinic.)

position), in patients with chronic limb ischemia from The grafts must then be shipped at this temperature and
peripheral arterial disease. The Gutowski study showed the require approximately 30 to 40 minutes to thaw before use,
HAV to be safe, have acceptable patency, and a low rate of limiting significantly their applicability for trauma (mili-
infection. Histologic examination of biopsies of the HAV tary and civilian).72–75 An analysis by Cullen found that the
revealed vascular remodeling and repopulation of the con- patency of cryopreserved conduits performed for ischemic
duit by host cells.31 The US military has supported the devel- disease correlated with the warm ischemia time of the host
opment and clinical study of the HAV in the hopes that it from which the graft was harvested. This gives hope that
may provide an off-the-shelf conduit that becomes incorpo- perhaps future advances in the understanding of these con-
rated and resistant to infection the setting of wartime vas- duits will lead to improved patency.76
cular injury.32

IMPROVEMENTS IN STORAGE AND HARVEST Conclusion

It is worth noting that the development of new and effica- When conduit is required for the management of vascular
cious preservation techniques for human vascular allografts trauma, several options are available. When it is accessible
would also be useful for vascular trauma. Although vascu- and of good quality, autologous saphenous vein is preferred
lar allografts have many advantages, they currently require for extremity vascular injury. Because of its “off-the-shelf ”
procurement, cryopreservation and storage at −135°C. availability and range of size, prosthetic conduit, such as
310 SECTION 4 • The Management of Vascular Trauma

Dacron and ePTFE, is preferable for torso and cervical inju- 19. Li WC, Shang HM, Wang PJ, et al. Qualitative analysis if the micro-
ries. The selection of a conduit is at the surgeon’s discretion structure of human umbilical vein for assessing feasibility as vessel
substitute. Ann Vasc Surg. 2008;22:417–424.
and there are scenarios in which autologous saphenous vein 20. Neufang A, Espinola-Klien C, Dorweiler B, Messow CM, Schmiedt W,
should be used to repair torso and cervical vascular injuries Vahl CF. Femoropopliteal prosthetic bypass with glutaraldehyde stabi-
and synthetic used to repair extremity vascular trauma. The lized human umbilical vein (HUV). J Vasc Surg. 2007;46:280–288.
ability to route the conduit out of the zone of injury is impor- 21. Walker PJ, Mitchell RS, McFadden PM, James DR, Mehigan JT. Early
experience with cryopreserved saphenous vein allografts as a conduit
tant in scenarios in which there is extensive contamination for complex limb salvage procedures. J Vasc Surg. 1993;18:561–568,
and a paucity of soft-tissue coverage. Wartime experience discussion 568–569.
has shown that synthetic conduit can be used as an initial, 22. Buckley C, Abernathy S, Lee S, et al. Suggested treatment protocol
damage control strategy to restore perfusion even in heav- for improving patency of femoral-infrapopliteal cryopreserved saphe-
ily contaminated fields. In these situations, the prosthetic nous vein allograft. J Vasc Surg. 2000;23:731–738.
23. Vardaian AJ, Chau A, Quinones-Baldrich W, Lawrence PF. Arterial
functions as a temporary conduit that is observed closely allograft allows in-line reconstruction of prosthetic graft infection
for a short period of time after which a staged revision is with low recurrence and mortality. Am Surg. 2009;75:1000–1003.
performed in a more controlled setting. Off-the-shelf autog- 24. Chintz JL, Tokoyama T, Bower R, Swartz C. Self-sealing prosthesis
enous conduits are being grown using innovative regenera- for arteriovenous fistula in man. Trans Am Soc Artif Intern Organs.
1972;18:452–457.
tive medicine techniques with several having demonstrated 25. Kennealey PT, Elias N, Hertl M, et al. A prospective, randomized
promise in translational and clinical studies. comparison of bovine carotid artery and expanded polytetrafluo-
roethylene for permanent hemodialysis vascular access. J Vasc Surg.
2011;53:1640–1648.
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18. Dardik H. A 30-year odyssey with the umbilical vein graft. J Am Coll third generation of ascending aorta Dacron graft: preliminary experi-
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 24 • Considerations for Conduit Repair of Vascular Injury 311

45. Fischer PE, Fabian TC, deRiik WG, et al. Prosthetic vascular conduit in 60. Feliciano DV, Mattox KL, Graham JM, Bitondo CG. Five-year experi-
contaminated fields: a new technology to decrease ePTFE infections. ence with PTFE grafts in vascular wounds. J Trauma. 1985;25:71–82.
Am Surg. 2008;74:524–528, discussion 528–529. 61. Avgerinos ED, Sachdev U, Naddag A, et al. Autologous alternative
46. Jeanmonod P, Laschke MW, Gola N, et al. Silver acetate coating veins may not provide better outcomes than prosthetic conduits for
promotes early vascularization of Dacron vascular grafts with- below-knee bypass when great saphenous vein is unavailable. J Vasc
out inducing host tissue inflammation. Journal of Vascular Surgery. Surg. 2015;62(Aug):385–391.
2013;58(Dec):1637–1643. 62. Cheek RC, Cole FH, Smith HF. Comparison of Dacron and aortic
47. McCready RA, Logan NM, Daugherty ME, Mattingly SS, Crocker C, autografts in wounds contaminated with fecal matter. Ann Surg.
Hyde GL. Long-term results with autogenous tissue repair of trau- 1974;40:439–442.
matic extremity vascular injuries. Arch Surg. 1987;206:804–808. 63. Knott LH, Crawford FA, Grogan JB. Comparison of autogenous vein,
48. Lau JM, Mattox KL, Beall AC, DeBakey ME. Use of substitute conduits Dacron, and Gore-tex in infected wounds. J Surg Res. 1978;24:288–293.
in traumatic vascular injury. Am J Surg. 1984;148:229–233. 64. Teebken OE, Haverich A. Tissue engineering of small diameter vascu-
49. Shah DM, Leather RP, Corson JD, Karmody AM. Polytetrafluoroethyl- lar grafts. Eur J Vasc Endovasc Surg. 2002;23:475–485.
ene grafts in the rapid reconstruction of acute contaminated periph- 65. Kakisis JD, Liapis CD, Breuer C, Sumpio BE. Artificial blood vessels: the
eral vascular injuries. Am J Surg. 1981;142:695–698. Holy Grail of peripheral vascular surgery. J Vasc Surg. 2005;41:349–354.
50. Rich NM, Baugh JH, Hughes CW. Significance of complications associ- 66. Weinberg CB, Bell E. A blood vessel model constructed from collagen
ated with vascular repairs in Vietnam. Arch Surg. 1970;100:646–651. and cultured vascular cell. Science. 1986;231:397–400.
51. Tal R, Rabinovich Y, Zelmanovich L, Wolf YG. Preferential use of 67. Askari F, Solouk A, Shafieian M, Seifalian AM. Stem cells for tissue
basilic vein for surgical repair of popliteal aneurysms via the posterior engineered vascular bypass grafts. Artificial Cells Nanomedicine and
approach. J Vasc Surg. 2010;51:1043–1045. Biotechnology. 2017;45(5):999–1010.
52. Parmar CD, Kumar S, Torella F. Autologous basilic vein for in situ 68. Hoch E, Tovar GE, Borchers K. Bioprinting of artificial blood vessels:
replacement of infected prosthetic vascular grafts: initial experience. current approaches towards a demanding goal. Eur J Cardiothorac
J Vasc Surg17. 2009:158–160. Surg. 2014;46(5):767–778.
53. Varcoe RL, Chee W, Subramaniam P, Roach DM, Benveniste GL, 69. Edelman ER. Vascular tissue engineering: designer arteries. Circ Res.
Fitridge RA. Arm vein as a last autologous option for infraingui- 1999;85:1115–1117.
nal bypass surgery: is it worth the effort. Eur J Vasc Endovasc Surg. 70. Dahl SL, Koh J, Prabhakar V, Niklason LE. Decellularized native and
2007;33:737–741. engineered arterial scaffolds for transplantation. Cell Transplant.
54. Rockwell WB, Haidenberg J, Foreman KB. Thumb reimplantation 2003;12:659–666.
using arterial conduit and dorsal vein transposition. Plast Reconstr 71. Lawson JH, Glickman MH, Ilzecki M, et al. Bioengineered human acel-
Surg. 2008;122:840–843. lular vessels for dialysis access in patients with end-stage renal dis-
55. Marques E. Ulnar artery thrombosis: hypothenar hammer syndrome. ease: two phase 2 single-arm trials. Lancet. 2016;387:2026–2034.
J Amer Coll Surg. 2008;206:188–189. 72. Fahner PJ, Idu MM, van Gulik TM, Legemate DA. Systematic review of
56. Temming JF, van Ulchelen JH, Tellier MA. Hypothenar hammer syn- preservation methods and clinical outcome of infrainguinal vascular
drome: distal ulnar artery resection with autologous descending allografts. J Vasc Surg. 2006;44:518–524.
branch of the lateral circumflex femoral artery. Tech Hand Up Extrem 73. Martinez PG, Rodriguez M, Serrano N, Serrano N, Bellón JM, Buján J.
Surg. 2011;15:24–27. Patency and structural changes in cryopreserved arterial grafts used
57. Keen RR, Meyer JP, Eldrup-Jorgensen J, et al. Autogenous vein graft as vessel substitutes in the rat. J Surg Res. 2005;124:297–304.
repair of injured extremity arteries: early and late results with 134 74. Byrom MJ, Bannon PG, White GH, Ng MK. Animal models for
consecutive patients. J Vasc Surg. 1991;13:664–668. the assessment of novel vascular conduits. J Vasc Surg. 2010;52:
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 25 Management of Pediatric
Vascular Injury
MATTHEW A. GOLDSHORE and JEREMY W. CANNON

Introduction for extracorporeal membrane oxygenation (ECMO) or car-

diopulmonary bypass, umbilical artery catheter placement,
In the United States, injuries account for approximately arterial line placement, arterial puncture for blood gas anal-
10,000 childhood fatalities every year.1 Unintentional ysis, and complications from routine venipuncture. Vascu-
injury results in one in four pediatric medical visits, and the lar complication rates from these procedures vary from 2%
direct cost of these injuries is estimated to be over $50 bil- to 45% depending on patient age, the type of procedure, size
lion annually.2,3 of catheter, and proceduralist experience. Unfortunately, as
Vascular injuries represent a small proportion of this noted above, the true demographics of iatrogenic vascular
disease burden (0.6%–1%), and the incidence of noniatro- injuries remains unknown due to underreporting and lack
genic pediatric vascular injury rates may be decreasing due of multi-institutional observational research.
principally to public health initiatives centered on motor Noniatrogenic vascular injuries are more common than
vehicle safety. However, unsafe handling and storage of fire- iatrogenic in children age 7 and above, and of these inju-
arms remain an important risk factor for penetrating vas- ries, approximately 75% result from a penetrating mecha-
cular trauma in young children,4,5 and combat operations nism. Since 2010, there have been nearly 16,000 injuries
represent an increasingly recognized cause of both blunt and 2711 deaths from gunshot wounds in children aged
and penetrating pediatric vascular trauma. Iatrogenic between 0 and 19 in the United States.5 Firearms are the
injury represents another important cause of pediatric vas- second leading cause of trauma-related deaths in the pedi-
cular compromise, and the incidence of these injuries has atric population, and among those who survive, 50% suffer
increased with widespread use of catheter-based proce- long-term disability. Analysis of the National Trauma Data
dures, especially in tertiary pediatric hospitals. Bank revealed that firearm-associated vascular injury was
Although the overall incidence of pediatric vascular injury the most lethal mechanism, and whereas injuries associated
is relatively small, children with vascular injury require with motor vehicle crashes have decreased, the incidence of
significantly more surgical and procedural interventions, firearm injury in 2007–12 was unchanged compared with
have longer hospitalizations, and have a higher mortality 2002–06.4
than those without vascular compromise.4,6–8 Furthermore, Modern warfare commonly occurs in proximity to civil-
despite advances in trauma care, the mortality rate of chil- ian populations leading to injuries in host-nation children.
dren who have sustained vascular injury has not improved In contrast to civilian vascular injuries, combat injuries
over the past decade7,9–11 ranging from 3% to 23%. tend to result from high-velocity weapons or from explo-
Significant variability exists in the initial evaluation, sions. These mechanisms cause significant disruption of
diagnostic work-up, therapeutic approach, and follow-up
of children with vascular injuries for a number of reasons
(Box 25.1). In an effort to minimize this variability in the Box 25.1 Sources of Variable Recommendations
future, this chapter begins with a brief overview of the epi- in the Approach to Pediatric Vascular Injuries
demiology of both iatrogenic and noniatrogenic vascular
trauma as well as anatomic and physiologic considerations Low incidence of pediatric vascular injury
unique to children. We examine diagnostic modalities and - Evidence largely single-center case series
therapeutic approaches available to the pediatric vascular - No prospective studies
surgery team as well as outline specific injury patterns in Wide range of specialties involved in management
the head/neck, torso, and upper and lower extremities. We - Surgical specialties:
- Pediatric Surgery
conclude with a discussion of postinjury surveillance and - Vascular Surgery
future directions for the field of pediatric vascular surgery. - Plastic Surgery
Key points of emphasis in the diagnosis and management - Orthopaedic Surgery
of pediatric vascular trauma are summarized in Table 25.1. - Interventional radiology
- Interventional cardiology
Limited long-term outcome data
Epidemiology - Outcomes for operative vs. nonoperative management unclear
- Success of endovascular options uncertain
Approximately half of all vascular injuries in children are Limited translatability from adult experience
iatrogenic with most of these injuries occurring in neonatal - Smaller diameter vessels
- Increased vasomotor tone
and school-age children.12 Causes of these iatrogenic vascu- - Lower circulating blood volume
lar injuries include diagnostic catheterization, cannulation

312
 25 • Management of Pediatric Vascular Injury 313

Table 25.1 Key Management Principles of Pediatric

Diagnosis and Evaluation
Vascular Injuries as Compared with Adult Vascular
Injuries. Diagnosis of pediatric vascular injuries requires a high
index of suspicion and a careful physical examination as the
Etiology Most commonly from iatrogenic injuries
presentation of vascular occlusion may be more nuanced
Anatomy/Physiology Small-caliber vessels more prone to vasospasm
compared with adults. A thorough vascular examina-
Diagnosis If pulses are diminished without hard signs of tion in patients with potential vascular injury includes an
vascular injury, resuscitate, rewarm, and then
re-assess ­assessment of potential sites of injury for both hard and
Normal IEI/ABI in children 2 years and younger soft signs of vascular injury, skin color, capillary refill, and a
is 0.88 thorough assessment of both central and peripheral pulses.
Normal IEI/ABI in children over 2 years is 1 Before performing invasive vascular procedures, establishing
CTA is a reliable diagnostic tool for large vessels a preprocedure baseline pulse examination is essential for
Operative Use interrupted, nonabsorbable monofilament subsequent detection of subtle blood flow compromise. In the
management suture multiply injured child, hemorrhagic shock alone may cause
Spatulate the anastomosis extremity hypoperfusion in the absence of vascular injury.
From Cannon JW, Villamaria CY, Peck MA. Pediatric vascular injury. In: With resuscitation and rewarming, vasospasm will tend to
Rasmussen TE, Tai NRM, eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia, resolve, whereas a major vascular injury will not improve.
PA: Elsevier; 2016, permission pending. In the setting of penetrating trauma, hard signs of vas-
ABI, Ankle-brachial index; CTA, computed tomography angiography; IEI,
injured extremity index. cular injury include pulsatile hemorrhage, an expanding
hematoma, obvious distal ischemia, or findings of a bruit
or thrill on auscultation of the site of injury. In more subtle
cases with a potential injury, measurement of the injury
extremely index (IEI) using continuous-wave Doppler is a
surrounding tissue, making repair more complex. In a reliable, noninvasive means of initially assessing for pedi-
series of 155 pediatric patients with vascular injuries rep- atric arterial injury. Accurate and precise IEI relies on mea-
resenting 3.5% of pediatric admissions, 96% were caused surement with appropriately sized blood pressure cuffs. The
by a penetrating mechanism, and 66% involved extremity cuff should easily encircle the circumference of the arm
vessels13 (Fig. 25.1). and should cover 75% of the extremity length. A continu-
ous-wave Doppler probe is used to determine the pressure at
which the arterial signal occludes with cuff inflation. The
Anatomic and Physiologic calculation is taken from the branchial artery in an unin-
Considerations jured extremity. If both arms are uninjured, the higher of
the two occlusion pressures is used as the denominator of
Numerous anatomic factors contribute to iatrogenic vas- the ratio equation. For lower extremity injury, an appro-
cular injuries in children. Pediatric vascular access involves priately sized cuff is positioned just proximal to the ankle
cannulation of small vessels in remarkably compact ana- and Doppler occlusion pressures are measured at both the
tomic spaces with relatively large catheters. Ultrasound dorsalis pedis and posterior tibial arteries. The highest value
studies have shown that as many as 12% of femoral vessels is used as the numerator to calculate the IEI ratio. If an
in children from birth to 9 years old are either partially or injured upper extremity is being assessed, the cuff is placed
completely overlapping.14 Thus, landmark-based attempts distal to the injury and the occlusion pressure measured
at venous access in the groin can easily result in inadvertent at the wrist, taking the higher value of the radial or ulnar
arterial puncture. The use of inappropriately sized arterial artery occlusion pressure. An abnormally low IEI (less than
catheters also predisposes the child to vasospasm, increas- 0.9 in children over 2 and less than 0.88 in children 2 and
ing the risk of limb ischemia.15 under) indicates a potential vascular injury that warrants
Physiologic factors in children who undergo invasive further assessment.16
vascular procedures often promote arterial occlusion. Com- In a child with clinical concern for vascular injury
promised cardiac output, polycythemia, and low intravas- who does not respond appropriately to resuscitation,
cular volume secondary to hemorrhage can all contribute localizing and confirmatory studies should be pursued.
to thrombosis. Furthermore, severe persistent vasospasm In children, duplex ultrasound is extremely safe, can con-
(lasting hours) and spontaneous arterial thrombosis both firm vascular occlusion and is able to localize the site of
suggest pediatric vessels are hyperreactive as compared injury as well as diagnose the presence of an AV fistula
with the adult vasculature. or pseudoaneurysm. Sonography can also differentiate
A wide array of injuries can lead to complete vascu- acute occlusion and vasospasm. Limitations of ultra-
lar occlusion including intimal flaps, arterial dissec- sound include limited utility for small vessels, and a steep
tions, and avulsion injury. The inciting traumatic event learning curve for optimal image acquisition. Moreover,
may cause luminal obstruction and/or local vasospasm sedation may be necessary for complete sonographic
with resultant thrombosis. Limb hypoperfusion can also examination in a young child.
occur as a result of traumatic arteriovenous (AV) fistu- Computed tomography angiography (CTA) is being
lae, pseudoaneurysm, or complete vascular transection used more often in children for the diagnosis of vascular
following venous or arterial puncture. Traumatic AV injury and has been shown to be more reliable for truncal
fistulae can also result in high-output cardiac failure in and great vessel trauma than for injuries of the peripheral
children. vasculature17 (Fig. 25.2). If the diagnosis remains unclear
314 SECTION 4 • The Management of Vascular Trauma

Head/neck/face
15 (9)

Upper extremity
46 (29)

Thoracic
12 (7)

Lower extremity
60 (37)

Abdomen/pelvis
28 (17)
Fig. 25.1 Distribution of 185 pediatric vascu-
lar injuries in 155 patients managed during
Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF). Numbers are n (%).
(From Cannon JW, Villamaria CY, Peck MA. Pedi-
atric vascular injury. In: Rasmussen TE, Tai NRM,
eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia,
PA: Elsevier; 2016.)

Therapeutic Approach
Historically, short of exsanguinating hemorrhage follow-
ing major arterial disruption, pediatric vascular injury
was managed with systemic anticoagulation. However,
poor long-term results from this medical management
approach are now more widely recognized, including
early tissue loss and long-term limb length disparity.6,15
Historic concerns of a high negative exploration rate due
to vasospasm and seemingly poor postoperative results in
A B
children less than 2 years old15 have been assuaged with
improved diagnostic imaging and more experience with
Fig. 25.2 Computed tomography angiography can be used to evalu- operative exploration across all age groups.11,18–20 Further-
ate for vascular injuries in large vessels including the carotid artery more, mounting evidence of the negative consequences
(A, black arrow) and the subclavian artery (B, white arrow). Contrast of even relatively short warm ischemia times compels
should be injected contralateral to the suspected injury. In very small early intervention to optimize long-term functional out-
children, a hand injection may be necessary. In both instances, the comes.10,21,22
injuries resulted from a tiny metal fragment (B, black arrowhead). The
carotid pseudoaneurysm (A) was managed with open exploration
OPEN SURGICAL EXPLORATION AND REPAIR OF
and repair with an interposition graft, whereas the subclavian artery
injury was repaired with a vein patch angioplasty. (A, From Cannon JW,
EXTREMITY VASCULAR INJURIES
Peck MA. Vascular injuries in the young. Perspect Vasc Surg Endovasc Ther. Pediatric vascular injuries can be managed with the full
2011;23:100–110; B, courtesy Jerry Pratt.) (From Cannon JW, Villamaria CY, range of accepted vascular repair and reconstruction
Peck MA. Pediatric vascular injury. In: Rasmussen TE, Tai NRM, eds. Rich’s ­techniques including primary repair, vein patch angioplasty,
Vascular Trauma. 3rd ed. Philadelphia, PA: Elsevier; 2016.) and interposition grafting using reversed greater saphe-
nous vein (GSV) or other autologous vessels. Minimal inju-
ries such as clean transections or a simple laceration can be
reconstructed primarily or with a vein patch, respectively.
despite noninvasive testing, conventional angiography can These techniques have been used exclusively in multiple ­case
be useful to identify the site of injury or to differentiate reports and several case series. These repair techniques are
vascular injury from vasospasm. In the setting of hemody- acceptable for low-velocity penetrating injuries, as well as in
namic compromise or if invasive and noninvasive tests are certain blunt injuries, as they minimize size mismatch and
inconclusive, surgical exploration is indicated. luminal growth issues at the repair site.11,23,24
 25 • Management of Pediatric Vascular Injury 315

For more complex injuries in the setting of tissue loss, ­ ediatric v

p ­ ascular trauma because of concerns over infec-
interposition grafting is required (Fig. 25.3). Management tion, patency, and relative stenosis over time due to lack of
in these situations includes débridement of the injured conduit growth.
artery back to healthy tissue and reconstruction with an Long-term follow-up of extremity and other arterial
interposition graft. Concomitant orthopedic injury, soft reconstructions has historically been extremely poor.10,15,29
tissue defects, and injuries to adjacent nerves and veins Despite reports of vein bypasses for renal artery reconstruc-
often accompany these severe injuries.25 GSV is gener- tion as having a high rate of aneurysmal degeneration, no
ally the preferred conduit as it is the most size-appropri- such reports exist for the peripheral vasculature.27,28
ate and easily available arterial replacement.19,26–28 As in Injured deep veins of the proximal extremities – including
adults with extremity injuries, the ipsilateral GSV should the femoral, popliteal, and axillary veins – should undergo
be avoided to avoid compromise of venous outflow of the repair or reconstruction whenever possible. Vein repair is
injured extremity.27 Lesser saphenous and upper extremity particularly important for alleviating limb edema, improv-
veins may be used provided they are size-appropriate. Syn- ing patency of concomitant arterial repairs and improved
thetic conduits are generally avoided in the management of functional outcomes. Primary repair, lateral venorrhaphy,

A B

C D

Fig. 25.3 (A) Penetrating wound to the right thigh of a 5-year-old girl.
(B and C) The right foot had a weakly palpable pulse. There was a Doppler
signal, but the injured extremity index was diminished at 0.35. The right
foot and great toe manifested a noticeable pallor when compared with
the uninjured left extremity. (D) The wound was hemostatic, so hepa-
rin (75 units/kg) was bolused in the emergency department. The right
leg was explored, and the injured superficial femoral artery (SFA) was
exposed. The injured segment was 4 cm distal to the takeoff of the deep
femoral artery. (E) (Arrows) A reversed greater saphenous vein interpo-
sition graft was used to replace the injured segment of the SFA. Inter-
rupted 6.0 monofilament expanded polytetrafluoroethylene sutures
were used for both the proximal and distal anastomosis. (From Cannon
JW, Villamaria CY, Peck MA. Pediatric vascular injury. In: Rasmussen TE, Tai
E NRM, eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia, PA: Elsevier; 2016.)
316 SECTION 4 • The Management of Vascular Trauma

non–reversed vein interposition and synthetic interposition abdominal organ injuries and major abdominal venous
bypasses have all been described. Early patency of all types injuries, and they carry a high mortality.24,36 Like cerebro-
of vein reconstruction is excellent.26 vascular and thoracic injury, management is dictated by the
hemodynamic stability of the child and the severity of asso-
ciated injuries. Methods of repair include aortic replace-
CERVICAL AND TORSO VASCULAR INJURIES
ment with synthetic graft, use of the greater saphenous
Special discussion is warranted for management of penetrat- vein or hypogastric artery for other arterial injuries, and lat-
ing trauma to the great vessels. Similar to other large vessel eral venorrhaphy, ligation, or, in some instances, panel graft
injury, primary repair, patch angioplasty, and ­interposition reconstruction of the inferior vena cava or iliac veins.37
grafting with autologous vein are acceptable methods of
repair. Ligation of the distal internal carotid artery may be PEDIATRIC VASCULAR ANASTOMOTIC
required when injuries are too distal for operative repair. Dis-
tal extracranial (zone III) carotid pseudoaneurysm may be TECHNIQUE
excluded with a percutaneously placed endovascular stent Numerous classic studies have supported the recommenda-
graft for injuries that extend up to the base of the skull. All tion of performing an interrupted suture technique for arte-
proximal carotid artery (zone I) injuries may be reached rial anastomoses in growing vessels.38–40 There are now more
through a median sternotomy with extension of the incision recent animal models that have compared various repair
to the traumatized side of the neck. Although operative inter- methods and materials. Titanium clips, running dissolvable
vention is appropriate for these zone I injuries, endovascular suture, and interrupted permanent suture anastomoses have
stenting may be possible although outcomes in pediatric been evaluated to determine the optimal anastomotic tech-
patients are unknown. Interestingly, in infants cannulated for nique. In these studies, a running-type anastomosis using
ECMO with subsequent ligation of the right common carotid, permanent suture was shown to impede vessel growth and is
there is detectable blood flow to the right middle cerebral more commonly associated with stricture.26,40,41
artery within 15 minutes.30 However, longer-term cognitive To date, different anastomotic techniques have not been
and overt neurologic deficits may result.31,32 Further study of directly compared in pediatric patients, however. Although
the long-term implications of unilateral compromise to cere- a running-type anastomosis with absorbable suture may
bral perfusion is necessary to discern the implications of liga- be considered, absorbable suture is more thrombogenic
tion as a therapeutic option for penetrating carotid injuries. than a permanent monofilament suture. Thus, an inter-
In contrast to penetrating cerebrovascular injuries, blunt rupted technique using permanent suture (e.g., Prolene)
injuries rarely benefit from surgical intervention as medical will both minimize the risk of thrombosis while also per-
management with systemic anticoagulation or antiplatelet mitting future vessel growth26,28,42,43 (see Fig. 25.3). Finally,
therapy has been met with a low rate of stroke or bleeding.33 for interposition grafts, both the conduit and native vessel
Although there is no screening recommendation for blunt should be spatulated to create a functionally enlarged com-
cerebrovascular injuries (BCVI) in children, adaptation of munication that permits vessel growth without narrowing
adult screening protocols have exposed the incidence of BCVI (Fig. 25.4).
in children who present to the trauma bay with neurological
compromise. Given the importance of stroke prevention in
these children, widespread implementation of BCVI screen-
ing programs is paramount to prevent long-term disability.34
Access to the innominate and proximal right subclavian
arteries generally require median sternotomy to achieve
proximal control in the setting of penetrating injury. Supra-
clavicular incisions are required for more distal subclavian
artery injuries bilaterally. The left subclavian is accessed via
a high left anterior-lateral thoracotomy; however, combina-
tion incisions (i.e., trap door) may be necessary to improve
exposure to complex left-sided injuries.
Most cases of pediatric thoracic aortic injuries are man-
aged with open repair – often in a delayed fashion – using
an interposition graft. Delayed repair with early initiation
of β-blocker therapy has been shown to be a survival benefit Fig. 25.4 On-table angiogram in a 13-year-old who fell off her bicycle
to patients.35 Disruption of aortic flow is treated with the and suffered a blunt injury to her right superficial femoral artery (SFA)
clamp-and-sew technique utilizing a synthetic interposi- and vein (SFV). The SFV was able to be repaired primarily. The SFA was
tion graft. Although complete thoracic aortic transection is transected and completely occluded requiring reconstruction with
rarely survivable, for children who reach the hospital alive, reversed saphenous vein from the contralateral leg. The anastomoses
survival is estimated at 80% with very low rates of paraple- were performed with interrupted 6-0 Prolene sutures. (A) (Arrow) The
gia. Most deaths in these patients who survive to the hospi- initial completion angiogram demonstrated a significant stenosis at
tal are a result of concomitant head trauma or associated the distal anastomosis. (B) (Arrow) The anastomosis was revised with
cervical, abdominal, or extremity hemorrhage. more extensive spatulation of the vein graft resulting in a widely patent
The distribution of abdominal vascular injury is often distal anastomosis on repeat imaging. The patient subsequently had a
divided into aortic, renal, visceral, and iliac injuries. These full recovery with normal perfusion to her foot. (Images courtesy Venkat
vascular injuries are often associated with concomitant Kalapatapu, MD.)
 25 • Management of Pediatric Vascular Injury 317

containing solutions to prolong vessel patency in children

ENDOVASCULAR OPTIONS with indwelling arterial catheters.49–51 Both topical 2% lido-
The use of endovascular techniques as a minimally inva- caine and papaverine have also been described as intraop-
sive operative approach to pediatric vascular injuries has erative adjuncts to mitigate vasospasm; however, their use
recently gained some momentum. Although data support- has not been systematically studied in children.52
ing endovascular therapy in acute pediatric vascular trauma The use of temporary vascular shunts has gained increased
are mostly limited to case reports,29,44,45 more recent obser- attention as an important adjunct in patients undergoing
vational research supports an increased use of endovascular damage control surgery. Their use has been shown to reduce
technique in pediatric vascular arterial trauma, especially in overall ischemic time and can serve as a bridge to definitive
children with severe blunt injuries.9 Based on these limited repair.53 The reduction in ischemia time may result in lower
reports, it appears that children who underwent endovascu- rates of compartment syndrome, nerve injury, and muscle
lar treatment had comparable outcomes to those who under- loss, which may improve the overall quality of limb salvage
went open surgical intervention; however, the authors note and in turn prevent later amputations resulting from poor
significant differences in demographic characteristics among limb function.53–56 Both military and civilian experience indi-
children offered endovascular procedures including older cate that proximal extremity arterial shunts remain patent
age, higher prevalence of thoracic injury, and higher injury in 85% to 95% of cases; however, more distal shunts have
severity score (ISS). Limitations to the broader application of poor patency and likely do not improve limb salvage. Given
endovascular therapies in pediatric vascular trauma include these experiences, a similar approach should be considered in
the size ranges of available stents and grafts and the inability pediatric patients in the setting of severe hemorrhagic shock
of endovascular implants to grow with the child. These limi- or devastating associated injuries requiring complex recon-
tations highlight the need for further endovascular innova- struction. Balloon catheter thrombectomy should be per-
tion to enable more routine use in pediatric patients. formed both before placement and after removal of a shunt.
Heparinized saline should be liberally infused locally. Finally,
an appropriately sized device should be selected to balance
ADJUNCTS TO MANAGEMENT: between maintained patency and preventing an unwanted
ANTICOAGULATION, PAPAVERINE, arterial dissection (Fig. 25.5).
THROMBOLYSIS, AND SHUNTS
Although the use of heparin as a stand-alone therapy for Special Situations
most vascular injuries has fallen out of favor because of sub-
optimal outcomes, its systemic or regional use is essential, ECMO
particularly in the setting of extremity trauma with vascu-
lar reconstruction.46 Intraoperatively, heparinized saline ECMO cannulation is associated with pediatric vascular
should be infused both proximally and distally once the injury; however, even without direct vascular injury, the
injury has been isolated and any thrombus extracted.47 A relative occlusion of the carotid artery has been implicated
bolus of therapeutic heparin should also be strongly con- in both cognitive and motor neurologic deficits.31,32 Such
sidered intraoperatively to improve postoperative patency of evidence, comparable to the long-term limb length discrep-
the vascular reconstruction. Continuation of heparin ther- ancies previous described, has led some centers to perform
apy may have a role following repair of small arteries and carotid artery reconstruction after decannulation. This
when vasospasm is present. Low-dose aspirin should also approach has resulted in increased carotid arterial patency
be considered postoperatively following arterial reconstruc- as well as favorable neurologic outcomes compared with
tion to mitigate platelet aggregation at the anastomosis. controls.57
There is a very limited role for thrombolytic therapy in
arterial trauma because concurrent injuries often contra-
indicate their use. The greatest utility may be when there is
a delay in diagnosis following blunt or iatrogenic injury to
the distal lower extremity tibial arteries, although in these
situations, thrombectomy is usually adequate. Catheter
directed intraarterial administration at the proximal extent
of the occlusion is the preferred methodology. Tissue plas-
minogen activator is currently the only available agent at
a dose of 0.25 to 1.5 mg/h. Fibrinogen levels are trended
to ensure lysis of the thrombus with discontinuation of the
infusion once systemic fibrinogen levels decrease, suggest-
ing clot dissolution. Heparin infusion is used post-throm-
bolysis to prevent clot propagation. Follow-up angiography
is then performed through the existing catheter to identify
residual luminal defects that need additional management,
such as angioplasty and surgical reconstruction.
Given the incidence of vasospasm in the injury pediatric Fig. 25.5 Options for temporary vascular shunts in pediatric trauma.
vessel, pharmacomanipulation is often employed to prevent Top, 8-Fr Argyle straight shunt. Bottom, modified 14-Ga angiocatheter
occlusion.48 Multiple studies support the use of papaverine (approximately 6 Fr).
318 SECTION 4 • The Management of Vascular Trauma

SUPRACONDYLAR HUMERUS FRACTURES AND Postinjury Surveillance and

BRACHIAL ARTERY INJURIES
Outcomes
Supracondylar humerus fractures are associated with
vascular injury in up to 20% of fractures with significant Little is known of the outcomes of pediatric vascular inju-
displacement.58 Angulation and displacement of the proxi- ries. As noted previously, the mortality rate in these patients
mal fragment puts the brachial artery, as well as both the is high at approximately 10%.7,10,11
median and radial nerve, at risk. Vascular injury typically Regarding limb-specific outcomes, in one case series of
results from either stretch leading to intimal disruption or iatrogenic vascular injury, successful restoration of a pal-
from vascular impingement. Because of the rich network of pable pulse after surgical intervention was achieved in 10
collateral vessels around the pediatric elbow, the hand may of 14 patients (71%, age 6 months to 9 years) with acute
appear pink, even with absent distal pulses. If urgent closed femoral ischemia.15 In another retrospective series of noni-
or open reduction of the fracture does not improve distal atrogenic trauma, 11 of 58 children (19%) with distal vas-
perfusion (Doppler signal or palpable pulse present), sur- cular injury has subsequent limb-loss and an additional 2
gical exploration is indicated.59 In cases of vessel impinge- children were diagnosed with limb length discrepancy dur-
ment, release of the vessel may re-establish normal distal ing longer-term follow-up.11 A 2019 case series from a large
flow. Otherwise, arteriotomy with embolectomy should be pediatric level 1 trauma center indicated superior extremity
the initial maneuver if an injury is identified. If the vessel outcomes in 23 patients with a restoration of in-line flow
is severely injured with intimal disruption, reconstruction as compared with 3 patients who did not undergo vascular
with reversed GSV should be performed. intervention. In this series, there were no deaths at 30 days
Like supracondylar fractures, posterior elbow disloca- and no secondary amputations over a 43-month follow-up
tions can also result in vascular injury. Management strate- period.29
gies include reduction of the dislocation and evaluation of
distal perfusion. Evidence of continued malperfusion after
fracture reduction warrants surgical exploration. Future Directions
The vast majority of the recommendations included in this
COMPARTMENT SYNDROME AND FASCIOTOMY
review are based on evidence from case series and expert
Prophylactic lower extremity four-compartment fasciot- opinion. Although there has been recent increased atten-
omy is indicated in the setting of prolonged arterial isch- tion to pediatric vascular trauma, the existing evidence
emia, combined arterial and venous injuries, and vascular remains limited due to small sample sizes, only short-term
injury with hemorrhagic shock. Similarly, therapeutic four- follow-up, and lack of uniform approaches to management.
compartment fasciotomy should be performed immedi- Given the small numbers of pediatric vascular trauma
ately upon the diagnosis of compartment syndrome. These cases at any one institution, to move beyond this low level
principles are well-established in the adult literature and of evidence, multiinstitutional collaboration is imperative.
can also be applied to pediatric patients.28 Similarly, upper Future collaborative efforts to systematically evaluate the
extremity fasciotomy should also be performed for the indi- short- and long-term outcomes of neonatal and pediatric
cations outlined (Fig. 25.6). Though there is little research vascular injuries should be high priority, as these injuries
on post-fasciotomy outcomes, these interventions likely have the greatest associated costs in terms of disability. Ded-
improve incidence of ischemic limb salvage. icated adult vascular injury registries such as the American
Association for the Surgery of Trauma (AAST) PROspec-
tive Observational Vascular Injury Treatment (PROOVIT)
registry demonstrate the value of multicenter collaboration
to better understand the demographics of vascular injury
and to identify optimal treatment approaches.60 A similar
registry with long-term outcomes should be developed for
pediatric vascular trauma as well.
Importantly, survey of providers caring for children with
vascular injury has exposed the relative discomfort of most
vascular surgeons in the care of pediatric vascular dis-
ease.61 Given the complex nature of these injuries and their
infrequent occurrence, after control of life-threatening
hemorrhage, further management should be centralized in
tertiary referral centers with pediatric specialists in general/
vascular surgery, plastic/reconstructive surgery, orthopedic
surgery, and interventional radiology.62

Conclusions
Fig. 25.6 Upper extremity fasciotomy in a 2-year-old girl following a Pediatric vascular injuries result from iatrogenic compli-
crush injury to the left arm. cations, penetrating injuries, and blunt trauma. Although
 25 • Management of Pediatric Vascular Injury 319

historical approaches to these injuries have emphasized 16. Katz S, Globerman A, Avitzour M, Dolfin T. The ankle-brachial index in
nonoperative management, modern experience indicates normal neonates and infants is significantly lower than in older chil-
dren and adults. J Pediatr Surg. 1997;32(2):269–271.
that both open operative repair and select endovascular 17. Patel RP, Hernanz-Schulman M, Hilmes MA, Yu C, Ray J, Kan JH. Pedi-
intervention is both feasible and safe in children. Results atric chest CT after trauma: impact on surgical and clinical manage-
from vascular trauma management in combat suggests ment. Pediatr Radiol. 2010;40(7):1246–1253.
that a comprehensive approach, including damage con- 18. Arshad A, McCarthy MJ. Management of limb ischaemia in the neo-
nate and infant. Eur J Vasc Endovasc Surg. 2009;38(1):61–65.
trol resuscitation with selective shunting, use of interposi- 19. Chen LE, Seaber AV, Urbaniak JR. Microvascular anastomoses in grow-
tion graft for reconstruction with interrupted sutures, use ing vessels: a long-term evaluation of nonabsorbable suture materials.
of perioperative regional and systemic anticoagulation J Reconstr Microsurg. 1993;9(03):183–189.
and liberal use of fasciotomy result in good short-term 20. Tshifularo N, Moore SW. Surgical intervention in vascular trauma in
outcomes. Future directions should focus on multiinstitu- children. Pediatr Surg Int. 2012;28(4):375–378.
21. Alarhayem AQ, Cohn SM, Cantu-Nunez O, Eastridge BJ, Rasmussen TE.
tional collaboration with long-term follow-up to optimize Impact of time to repair on outcomes in patients with lower extremity
study sample size and to determine the benefit of various arterial injuries. J Vasc Surg. 2019;69(5):1519–1523.
management options in this vulnerable and poorly studied 22. Wahlgren CM, Kragsterman B. Management and outcome of
­population. pediatric vascular injuries. J Trauma Acute Care Surg. 2015;79(4):
563–567.
23. Aspalter M, Domenig CM, Haumer M, Kitzmüller E, Kretschmer G,
Hölzenbein TJ. Management of iatrogenic common femoral artery
Disclaimer injuries in pediatric patients using primary vein patch angioplasty.
J Pediatr Surg. 2008;42(11):1898–1902.
The opinions expressed in this document are solely those 24. Fayiga YJ, Valentine RJ, Myers SI, Chervu A, Rossi PJ, Clagett GP.
Blunt pediatric vascular trauma: analysis of forty-one consecutive
of the authors and do not represent an endorsement by or patients undergoing operative intervention. J Vasc Surg. 1994;20(3):
the views of the United States Air Force, the Department of 419–425.
Defense, or the United States ­Government. 25. Peck MA, Clouse WD, Cox MW, et al. The complete management
of extremity vascular injury in a local population: a wartime
report from the 332nd Expeditionary Medical Group/Air Force
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 26 Soft-Tissue and Skeletal Wound
Management in the Setting of
Vascular Injury
SHEHAN HETTIARATCHY and JON CLASPER

Introduction 35 combined orthopedic and vascular injuries, 14 (40%)

involved the femoral vessels, 9 (26%) compromised the
Extremity injuries involving significant trauma to bone, popliteal vessels, and 8 (23%) involved the brachial artery.6
soft tissue, and major vessels are relatively uncommon out- Upper limb injury complexes were often related to gunshot
side of the wartime setting. This constellation of injuries wounds compared to lower limb injuries. In Brown's series
may also be referred to as the mangled extremity. Much (reporting experience from the British military), 11 injuries
of the difficulty encountered in managing patients with a (30.5% of all cases) involved the upper limb, with 7 involv-
mangled extremity is due to the fact that few surgeons gain ing the brachial artery, and 4 involving the radial and/or
much experience in dealing with this challenging injury ulnar arteries.
pattern. In order to meet this challenge, such injuries are The orthopedic injury most commonly associated with a
best dealt with by a multidisciplinary team that combines vascular injury is dislocation of the knee, particularly when
the subject-matter expertise of vascular, plastic, and ortho- the dislocation is posterior in nature. The orthopedic injury
pedic specialists.1 The purpose of this chapter is to consider is of relatively low priority in the initial management of
the nature of the extravascular component of severe limb the patient as the knee will usually be easy to reduce and,
trauma, the priorities in reconstruction, and the sequenc- in some cases, may have been reduced before the vascular
ing of interventions in order to furnish the vascular sur- injury is appreciated. In general, the majority of these will
geon with the key imperatives of soft-tissue and skeletal be closed injuries. In a literature review totaling 245 knee
management as understood by their orthopedic and plastic dislocations with a 32% incidence of vascular injuries, time
surgical colleagues. to revascularization was the most important factor in deter-
mining outcome. The authors described a salvage rate of
89% when this was carried out in less than 8 hours, com-
Epidemiological Factors pared to an amputation rate of 86% when the delay was
greater than 8 hours.7 A prospective report, undertaken as
The likelihood of fracture-associated extremity vascular part of a multicenter study depicting the outcome of severe
trauma depends on the nature of the associated orthopedic lower limb injuries described 18 patients, of whom 4 (22%)
injury, with an overall incidence estimated to be less than required amputation (a figure that is relatively consistent in
1%.2 However, certain orthopedic injury patterns, such as the literature). Despite successful salvage, patients still had
posterior knee dislocation, mandate a higher index of sus- a moderate to high level of disability 2 years after the injury;
picion. Young et al.3 found an incidence of 9% of vascular the knees were stiffer and weaker; and only two were stable
injuries in a series of 661 civilian open tibial shaft fractures. in all directions.8
These had an amputation rate of 38% compared to a rate
of 5% in open fractures without vascular injuries. Vascular
injuries may also be more commonly associated with frac- Grading of Open Fractures
tures in the high-energy ballistic and blast environments of
military trauma. From a database of 679 patients with mili- Open fractures represent a heterogeneous group of injuries,
tary extremity trauma, Brown et al. identified 34 patients but the relationship between extent of tissue damage and
and 37 limbs with vascular injury.4 In only nine of these likelihood of limb salvage and functional recovery has been
limbs was the vascular trauma not associated with a cor- recognized for decades. As such, a formal system for grad-
responding fracture. The authors of this study noted that ing the severity of open fractures was introduced by Gustilo
outcome was worse in patients with combined orthopedic and Anderson in 1976 (Table 26.1).9 This remains a uni-
and vascular injury, and this was attributed to the unfa- versally accepted classification of the wound associated
vorable soft-tissue sequelae of energy transfers sufficiently with an open fracture, relating especially well to the risk of
large to cause bone fracture. This finding is also consistent infection. For Gustilo type I fractures, an infection rate of
with examples of high-energy extremity wounds reported 1% or less can be expected, and for type II fractures, a rate
in the civilian literature.5 In an Israeli report of 35 casual- of approximately 3% has been reported.10 Since the original
ties, both military and civilian, Romanoff revealed that of description, it has been recognized that those with type III

321
322 SECTION 4 • The Management of Vascular Trauma

Table 26.1 Gustilo-Anderson Classification of Open

older, less-mobile population may have lower expectations.
Tibial Fractures. Expectation management forms a key part of the duty
of the multidisciplinary team in cases of limb salvage or
Type I An open fracture with a wound less than 1 cm long and
clean
amputation, with regular and consistent counseling of the
patient and their relatives in order to allow realistic but posi-
Type II An open fracture with a laceration more than 1 cm long
without extensive soft-tissue damage, flaps, or avulsions tive interpretations of recovery potential.
Type III An open segmental fracture, an open fracture with exten-
Studies have reported the long-term outcomes and
sive soft-tissue damage, or a traumatic amputation quality of life in limb-salvage patients with open tibial
shaft fractures and severe soft-tissue loss compared to
amputees.12 Limb-salvage patients took longer to achieve
full weight-bearing status, were less willing or able to
fractures are a large and heterogeneous group, and, to work, and had a significant loss in range of movement at
reflect this, a modification to the original grading was made the ankle. Fairhurst et al. demonstrated that early ampu-
with subdivision of type III fractures as follows: tees had higher functional scores, fewer operations, and
returned to work and sporting activities within 6 months.
n Type IIIA—Adequate soft-tissue cover of the bone despite They concluded that early amputation was better when
extensive laceration confronted with a borderline salvageable tibial injury.13
n Type IIIB—Extensive soft-tissue loss, with periosteal However, reports from a prospective multicenter trial of
stripping and exposed bone. Usually associated with 556 patients (the Lower Extremity Assessment Project
massive contamination [LEAP]), reported no difference in functional outcomes
n Type IIIC—Open fracture with vascular injury that between patients who either underwent limb-salvage sur-
needs repair gery or early amputation at 2-year and 7-year follow-up
points.14 The level of amputation was a further predic-
For type IIIA fractures, an infection rate of 17% has been tor of outcome. Further analysis of the difference in cost
reported, and for type IIIB, 26%. However, lower infection analysis of limb salvage, and amputation has shown that
rates are achievable. Wordsworth et al. reported a 1.6% the latter is significantly more expensive if the ongoing
infection rate in a series of 65 patients with IIIB open tib- maintenance and replacement costs of the prostheses are
ias.11 Type IIIC fractures have a variable infection rate, included.
depending on the soft-tissue injury and the time to revascu- Several scoring systems have been developed to help
larization. A proportion of IIIC injuries require amputation guide the decision as to whether or not to amputate after
due to lack of reconstructive options, and late infection is severe lower limb trauma, and they have been designed
of less relevance as an outcome measure in this group. A to augment subjective clinical impression with objective
series of 661 open tibial shaft fractures showed an amputa- assessment based on specific criteria. In their retrospective
tion rate of 38% for IIIC injuries compared to a of rate 5% in review of 58 severely injured limbs, Bonanni et al. showed
IIIB injuries.3 The relative rarity of these injuries, combined low sensitivities of Mangled Extremity Severity Score
with their heterogeneous nature, means that meaningful (MESS) (22%), limb-salvage index (61%), and predictive
comparison of outcomes (either between different papers salvage index (33%).15 The LEAP study assessed MESS,
or even between patients reported in the same paper) is dif- predictive salvage index, limb-salvage index, nerve injury;
ficult, if not impossible. ischemia/soft tissue contamination; skeletal; shock; age
(NISSA); and Hannover Fracture Scale (HFS)-97. The
authors reported a high specificity but much lower sen-
Salvage Versus Amputation sitivities for the scores than those reported by the devel-
oping authors. The performance decreased further when
In essence only the following three decisions are available immediate amputations were excluded.14 A further study
to the surgeon managing an extremity injury where limb from the same group suggested that lower limb extrem-
ischemia is present: perform primary amputation, defer pri- ity scores do not predict short- or longer-term functional
mary amputation to a later date, or attempt surgical inter- outcome. Overall, scoring systems have not proven to be
vention with a view to limb salvage. The latter may involve useful for prospective clinical decision making and are not
a lengthy or complex revascularization procedure, defini- widely used for this purpose—the final decision to salvage
tive fracture fixation, and soft-tissue coverage extending to a limb must be tailored to the patient, their injury, and
microvascular tissue transfer. There are inherent risks of their future functional goals.16
attempted limb salvage as the procedures may be costly in
terms of patient reserve and risk of mortality, need for mul-
tiple operative procedures, and prolonged rehabilitation. Strategies in Managing
“Successful limb salvage” is a subjective phrase: outcomes the Severely Injured Limb
can be variably defined according to patient factors such as
pain, function, return to work, and satisfaction. Expecta- SEQUENCING OF INTERVENTIONS
tion of recovery varies according to the individual. Younger
patients tend to have higher levels of preinjury activity, and Considerable debate has centered on the sequencing of
rehabilitation will be concordantly longer in order to ensure operative steps in the management of the mangled extrem-
recovery to previous functional capability. In contrast, the ity. The following elements of treatment are necessary for
 26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 323

most limbs that exhibit an open fracture associated with Ireland.22 These formed the basis for UK Department of
major vascular injury: Health guidance issued by the UK's National Institute for
Clinical Excellence (NICE, Box 26.1).1 This suggests that the
n The extent of soft-tissue damage, vascular compromise, sequence of shunt, skeletally stabilize, and then perform
and skeletal instability must be systematically assessed. vascular repair is usually best. It should be remembered
n The wound should be débrided so that all unviable tissue that the skeletal stabilization may not be definitive so care
is removed. must be taken of the vascular repair if further orthopedic
n Vascular repair/reconstruction should be performed. procedures are performed.
n Skeletal stabilization must be performed.
n Mitigation of complications—such as infection or com- MAJOR LIMB AMPUTATION FOR TRAUMA
partment syndrome—must be undertaken proactively.
Amputations undertaken for the acutely injured and unsal-
Determining the optimal sequence of reperfusion versus vageable extremity offer a set of challenges that differ from
stabilization of the limb may be difficult because the follow- those regularly encountered by vascular surgeons managing
ing two competing imperatives have to be reconciled: the patients with unreconstructible peripheral vascular disease. In
period of warm ischemia must be as limited as possible (and particular, patients with limbs that have been rendered unsal-
should never extend beyond 6 hours from time of injury), vageable by blast have very specific requirements. In such
yet skeletal stability must be achieved in a timely fashion circumstances, guidelines developed by UK Defence Medical
without compromising any vascular repair. Deciding on the Services may prove helpful (and are applicable to the patient
best sequence has attracted much debate since the 1980s. with non–blast-mangled extremity) as set out in Box 26.2.
A metaanalysis of the data concluded that amputation In assessing the viability of the distal soft-tissue envelope
rates are not affected by the sequencing of revasculariza- (which will define the level of amputation), medial and lat-
tion, whether undertaken before or after fracture stabiliza- eral longitudinal incisions along fasciotomy lines should
tion.17 The authors acknowledged the retrospective nature be used to extend the wounds in order to allow adequate
of the cohort studies analyzed, and outcomes other than exposure if the preexisting wounds do not afford this assess-
amputation were not considered in their review. ment. At initial débridement, all viable tissue should be pre-
McHenry, in 2002, retrospectively studied a cohort of served even if bone length appears excessive or if excess soft
27 limbs with orthovascular injury secondary to gunshot tissue is present. This is to avoid compromising definitive
wounds and concluded that revascularization (whether closure, particularly if further skin or soft-tissue necrosis
definitive or via a shunt) should be carried out before skeletal occurs. Definitive flaps should not be performed at the ini-
stabilization, on the basis of a nonsignificant trend toward tial débridement. This may result in the excision of viable
higher fasciotomy rates in five cases where stabilization was tissue, which could be required for definitive wound closure,
prioritized.18 The cohort included brachial, femoral, and particularly if further excision is required or if nonstandard
popliteal injuries; but the authors did not include patients flaps are necessary. Definitive flaps are created at the time of
with crural vessel injury. Furthermore, 13 of the 14 inter- wound closure, usually 2 to 5 days later.
nal fixations were carried out in the group that had initial Essentially, a trauma amputation should be considered
revascularization, suggesting possible selection bias. Initial an extension of débridement, rather than a definitive pro-
revascularization followed by skeletal fixation was not asso- cedure in its own right. By adopting this attitude, the limb is
ciated with damage of the vascular repair, contradicting an removed as part of the débridement of nonviable tissue, the
often-quoted rationale that orthopedic manipulation and tissues are excised at the most distal point possible, and the
fracture fixation in the setting of a freshly repaired vessel temptation to fashion formal flaps is avoided.
carries a major risk of disruption.
The debate around sequencing has been blunted by the
development of temporary vascular shunting as a means of Box 26.1 Vascular Injury
ensuring early restoration of flow and facilitation of a win-
dow of opportunity for orthopedic intervention. Extensive 1. Use hard signs (lack of palpable pulse, continued blood loss, or
experience with the use of vascular shunts during the wars expanding hematoma) to diagnose vascular injury.
in Afghanistan and Iraq includes clinical data suggesting that 2. Do not rely on capillary return or Doppler signal to exclude
vascular injury.
this damage control adjunct extends the window of limb sal- 3. Perform immediate surgical exploration if hard signs of
vage in the most severely injured extremities.19,20 Translational vascular injury persist after any necessary restoration of limb
large animal data, also stemming from investigation during the alignment and joint reduction.
wars, has shown improved extremity neuromuscular recovery 4. In patients with a devascularized limb following long bone
and function with shorter ischemic times (less than 3 hours).21 fracture, use a vascular shunt as the first surgical interven-
Whichever strategy is chosen, it is worth reiterating that these tion before skeletal stabilization and definitive vascular
injuries are infrequently seen and often require individualized reconstruction.
solutions. Some cases merit early stabilization, others shunt- 5. Do not delay revascularization for angiography in people with
ing, and some early definitive vascular repair. complex fractures.
In the United Kingdom, the sequencing debate has been 6. For humeral supracondylar fractures in children (under
16 years) without a palpable radial pulse but with a well-
largely settled by national evidenced-based guidance. Pro- perfused hand, consider observation rather than immediate
tocols were developed jointly by the British Orthopaedic vascular intervention.
Association and The Vascular Society of Great Britain and
324 SECTION 4 • The Management of Vascular Trauma

bony contour, joint function, and axial stability according

Box 26.2 UK Defence Medical Services to the usual “look/feel/move” paradigm.
Guidelines Concerning Trauma Amputation A full neurovascular examination should be performed,
although a depressed level of consciousness will not per-
1. The examination findings, together with the indications to mit a full assessment of motor and sensory functions. The
amputate the limb, should be documented. peripheral nerves of the extremity should be examined
2. Existing limb salvage scores should NOT be used to deter-
(Table 26.2). In the foot, these are saphenous nerve (instep)
mine the need for amputation.
3. Whenever possible, the decision to amputate a limb should medial and lateral plantar nerves (sole), sural nerve (outer
be confirmed by a second surgeon. border), superficial peroneal nerve (dorsum), and deep
4. All wounds should be photographed. peroneal nerve (first web-space dorsum). In the hand, these
5. Radiographs should be obtained before amputation. are the median nerve (index finger), the ulnar nerve (little
6. Neurological dysfunction (particularly numbness of the sole finger), and the superficial branch of the radial nerve (first
of the foot) should NOT be part of the criteria used to decide web space).
amputation. Motor examination may be limited by pain from the
7. The site of amputation should be at the lowest level possible. injury or mechanical disruption of the muscles being
8. Guillotine amputations should not be performed. tested. In the lower extremity, the tibial nerve (ankle plantar
9. There should be no fashioning of flaps at initial débridement.
flexion) and deep branch of the peroneal nerve (ankle dorsi-
10. Bone should be cut at the most distal soft-tissue levels.
11. Amputation should not be carried out at the level of any flexion) are examined. In the upper extremity, the following
fracture unless this is the appropriate skin/soft-tissue level. nerves should be tested: the median nerve (thumb abduc-
12. No part of the wound is to be closed at initial surgery. tion); the ulnar nerve (finger abduction); the radial nerve
13. No attempt is to be made to prevent skin retraction. (elbow/wrist/finger at metacarpophalangeal joint exten-
14. Through-knee amputation is acceptable if appropriate. sion); and the musculocutaneous nerve (elbow flexion).
Detailed examination of the individual muscle groups may
also be performed.
ASSESSMENT OF THE INJURED EXTREMITY The vascular examination should be performed before
and after any reduction of fractures or joint dislocations.
The patient with a severely injured or mangled extremity Hard signs of vascular injury can be difficult to elicit in a
should be managed within trauma protocols based around severely distorted limb and pulse oximetry can be a useful
Advanced Trauma Life Support guidelines or their equiva- adjunct. Absence of an arterial waveform or different wave-
lent. The limb injury, no matter how severe, should not form from a contralateral uninjured limb should be taken as
detract from or delay any lifesaving interventions that need a suggestion of vascular injury.23 Compartment syndrome
to be undertaken to ensure that major hemorrhage is con- should be actively excluded. The wounds are then inspected
trolled and that the airway is secured. Bleeding from the via careful removal of overlying dressings. At this stage,
limb should be controlled: direct pressure applied through only visual inspection may be possible, so the assessment
sterile dressings, combined with elevation, is appropriate. If will not be as informative as the exploration or definitive
unsuccessful, the application of a tourniquet is indicated. assessment performed in the operating theater. The location
Ideally this should be a pneumatic tourniquet but a mili- and size of the wounds should be documented. Tire marks
tary-style combat application mechanical tourniquet with or abrasions on the skin may seem innocuous but may be
a windlass mechanism will suffice. the result of a shearing force and hence important indica-
Each tissue type, skin, muscle, and nerve should be con- tors of degloving. The exposure of any fractures or joints
sidered and assessed separately. The zone of injury (i.e., the should be documented.
part of the limb that has received the energy transference Large, loose particles of gross contamination should be
from the wounding mechanism) should be determined. removed, but formal irrigation of wounds within the emer-
This zone can vary in size depending on how the injury gency department (ED) is not required as this is best under-
was induced, but, irrespective of size, all tissues within the taken in the operating theater. ED irrigation risks flushing
injury zone will have been affected to a lesser or greater contaminants deeper into the wound, worsening of patient
extent. Certain tissues, such as skin, are more robust and hypothermia, and delaying definitive surgery. Similarly,
can tolerate a degree of injury, whereas others (fat, muscle) there is no indication for wound exploration in the ED as
are more likely to suffer irreparable damage. this can be achieved in a far more comprehensive and con-
For extremities, it is important to determine whether a trolled fashion in the operating room. Once the soft-tissues
degloving component is present. This is when the skin has have been assessed, the wounds should be photographed
been sheared off the deep fascia, leading to thrombosis or and then dressed with a saline-moistened gauze covered by
avulsion of the skin perforating vessels and subsequent an occlusive dressing. The limb should then be splinted as
skin death. Degloving occurs in traction or shearing inju- close to the anatomical position as is possible.
ries and is often observed if a limb has been run over by a All patients should receive tetanus prophylaxis if there is
vehicle. Degloving also occurs in blast injuries, where the doubt about native immunity. A stat dose of antibiotics should
blast mechanism strips the skin away from the underlying be administered intravenously (e.g., Co-amoxiclav 1.2 g or
tissues. Detecting the presence of a degloving injury can be cefuroxime 1.5 g). (If the patient has a documented penicillin
difficult but should always be considered given a suspicious allergy, clindamycin 600 mg IV can be used instead.)
mechanism of injury. Soft-tissue appraisal should occur in If there is doubt about vascular integrity (e.g., if pulses
conjunction with the orthopedic assessment. This should are not restored following an early attempt at traction and
include an assessment of limb-length discrepancy, abnormal splinting), further investigation may be merited as discussed
 26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 325

Table 26.2 Functional Motor and Sensory Assessment of the Extremities.

Nerves Motor Sensory Significance
UPPER LIMB
Musculocutaneous nerve Elbow flexion Radial border Injury in axilla/upper arm; risk of axillary/brachial artery injury
of forearm
Median nerve Wrist flexion, abduction of thumb. Thumb Consider flexor compartment syndrome.
(Thumb can be brought out at
90 degrees from palm.)
Ulnar nerve Abduction of fingers Little finger May also have ulnar artery injury
Radial nerve Extension of elbow, wrist, and First web Consider extensor compartment syndrome.
fingers at metacarpophalangeal
joints
LOWER LIMB
Saphenous nerve (terminal Medial border Thigh injury or anterior thigh compartment syndrome.
branch of femoral nerve) of foot Femoral artery/vein may be injured.
Tibial nerve (sensory medial Plantar flexion of the foot Sole of foot Posterior compartment of leg injury or compartment
and lateral plantar nerves) syndrome. Posterior tibial artery may also be injured.
Sural nerve (branch of common Lateral border Popliteal fossa injury
peroneal nerve) of foot
Common peroneal nerve Ankle eversion (lateral Indicates injury before division into deep and superficial
compartment) branches (sensory loss in both superficial and deep branches).
Lateral compartment injury or compartment syndrome
Superficial branch peroneal Dorsum of Lateral compartment injury or compartment syndrome
nerve foot
Deep branch peroneal nerve Dorsiflexion of the foot First web Anterior compartment injury or compartment syndrome.
space Anterior tibial artery may also be injured.

in Chapter 8. However, it should be appreciated that routine scrub brush. This is termed a “social clean” and does not
preoperative angiography is not indicated in single-level involve scrubbing the wound itself. A pneumatic tourni-
injuries. In this scenario, the vascular injury is invariably quet should be placed on the proximal limb if the wound
at the same level as the soft-tissue and bony injuries. Glass permits. The decision to inflate will be influenced by the
et al. found that angiography had no impact on limb-sal- degree of control of hemorrhage at the start, with further
vage rates, regardless of the time interval to revasculariza- appraisal of the hemorrhage once surgical exploration of
tion (intervals less than 6 hours: 85% and 90% limb-salvage the wound has begun. The bloodless field afforded by a
rates with and without angiography, respectively; intervals tourniquet allows easier identification of important struc-
greater than 6 hours: 61% and 67% limb-salvage rates with tures, but the aggregate tourniquet time must be moni-
and without angiography, respectively).24 We advocate judi- tored carefully with the goal of minimizing the ischemic
cious use of angiography and only in the scenario of multi- insult to vulnerable tissues. The limb should be prepped
level soft-tissue or skeletal injury where the site of vascular and draped in the standard fashion.
injury is not clear. This approach is also advocated by the 2. Reestablishment of circulation via a shunt and reassessment
various UK national organizations. The first step is to rapidly identify the injured vascular
Much of the debate regarding the value of routine angi- axis, to apply local control measures, and then to judi-
ography in patients with open fractures has been made ciously shunt arterial and venous structures. The selec-
nugatory by the ubiquity of multidetector computed tomog- tion and use of temporary vascular shunts as damage
raphy (CT). CT angiography (CTA), performed as part of the control adjuncts in this setting are reviewed in detail in
CT series assessing other aspects of the limb injury (e.g., Chapter 23. Once perfusion has been reestablished with
the positions of bony fragments) or other injuries to other temporary vascular shunt(s), further assessment of
bodily areas (head, axial skeleton, torso), may be utilized to options for limb salvage should be made by swift exami-
avoid the need for formal digital subtraction angiography. nation of the wounded tissues. This may involve the use
However, if CTA has not been performed but angiography of a “trial of débridement” using a combination of lim-
is still indicated, an on-table study may be the most expedi- ited débridement and surgical exposure of deeper tissues
tious way of obtaining the necessary information. lying within and bordering on the injury zone to gain
more information on the extent of disruption and the
likelihood of functional recovery.
INITIAL SURGICAL MANAGEMENT
3. Surgical débridement of injured tissues
The first steps in the surgical management of the poly trau- Definitive débridement should be systematic and
matized extremity are as follows: meticulous but should not be so radical as to resect
frankly uninjured and uncontaminated tissue border-
1. Pre-scrubbing of the limb ing the wound. Where the degree of functional recovery
While the patient is in the anesthetic room, the limb may hinge on preservation of tissue volume, an overly
should be prescrubbed with a soap solution and a surgic­al aggressive approach is not correct.
326 SECTION 4 • The Management of Vascular Trauma

The normal sequence is to work superficial-to-deep

and peripheral-to-central. Where there has been sig-
nificant anatomical disruption, it can be prudent to
identify the main neurovascular structures first to
avoid inadvertent injury during débridement. The
skin edge of the traumatic wound should be excised.
The wounds usually need to be extended to allow
access to all damaged tissues. In the lower limb, exten-
sions are performed along fasciotomy lines to limit the
additional damage of débridement. All overtly devi-
talized and contaminated tissue should be débrided.
The layers and tissues should be worked through sys-
tematically. Assessing the viability of different tissues
can be difficult and requires experience. For skin, the
best assessment is bleeding from a cut edge. Fat can
appear discolored if devascularized. Muscle is assessed
by the “four Cs”: contractility (muscle twitches when Fig. 26.1 Multiplanar degloving of a lower limb following being run
lightly gripped with forceps); consistency (does not over by a truck. Looking into the popliteal fossa, the posterior aspect of
tear when gently handled); color (red-pink color; not a the leg is visible. The vessels were intact, but the severity of the bony
dusky purple); and capacity to bleed. However, studies and soft-tissue injury were not compatible with salvage.
have shown even using these signs is not an accurate
way of confirming viability and there is a risk of over-
débridement.25 Bone may be difficult to assess, but a
combination of intact periosteum and bleeding from if vascularity is poor. Once the soft-tissue and bony
the bone ends suggests viability. All nerves should be débridement has been completed, the wound should be
preserved. Note that absence of bleeding is unreliable irrigated and washed with low-pressure saline lavage
as a marker of unviability if the patient is hypoten- of between 3 and 6 L depending on wound size. There is
sive or hypothermic or if a tourniquet is being used. no evidence to support the use of additional antimicro-
If there is a suggestion that tissue may be viable but bial agents.26 Hydrogen peroxide does not confer any
underperfused, it should be left for subsequent review benefit but acts solely to damage tissues. It should not
when perfusion has been optimized. be used.
As discussed previously, degloving injury occurs when At any stage in this process of concurrent débride-
tissue, particularly skin, is sheared away from its under- ment and wound assessment, it may become apparent
lying structures. This leads to damage of the perforat- that tissue loss is catastrophic and that there is no rea-
ing vessels and subsequent tissue death, although this sonable hope of limb salvage. Depending on the nature
may only manifest itself after 3 to 5 days. Making an and the degree of injury, as well as the experience of the
assessment of the viability of degloved tissue is difficult, operator, this position may be reached within minutes
and incisions close to an area of degloving may lead to of surgical exposure and débridement, or it may become
further compromise of perfusion and may precipitate apparent only after a more thorough and prolonged
the death of tissue that may have otherwise survived. assessment of deeper structures within the wound. In
Degloved skin is more fragile than normal skin, must be these circumstances, the decision to amputate a limb
handled delicately, is intolerant of tension when used to depends on multiple factors, but patient physiology is a
close wounds, and should be used with caution when consistent variable. In the polytraumatized and critically
fashioning amputation flaps. ill individual, there is nothing to be gained from delaying
Multiplanar degloving occurs when muscles and limb ablation. However, where physiology permits—and
neurovascular structures are sheared in different tissue unless the situation demands urgent separation of the
planes (Fig. 26.1). This signifies a more severe injury limb from the body—a decision concerning amputation
and a poorer chance of limb salvage. The main issue should be explored with the patient and consent obtained
with degloving is that the extent of the soft-tissue defect as appropriate. It is often wise to defer amputation until
may not be apparent immediately and it may take up to a a later second-look opportunity, 24 to 48 hours after the
week for all non-viable tissue to declare. This means that initial surgery, in order to counsel the patient and to set
reconstruction may need to be delayed until it is clear expectations accordingly.
what has survived and what has not. 4. Stabilization of the fracture site
Once the soft-tissue débridement has been completed, Operative stabilization eliminates fracture move-
bony débridement is begun. The bone ends should ment, protects the vascular repair, and reduces the
be delivered and again assessed for viability and con- risk of infection.9 In one of the earliest reports, Rich
tamination. All grit and debris should be removed by et al. reviewed the results of open fractures that
scrubbing, by bone excision, or with a burr. Any loose required a vascular repair during the war in Viet-
bony fragments that do not have soft-tissue attachment nam, and reported that 50% of all intramedullary
should be removed. Larger fragments, particularly if (IM) nails required removal for complications directly
they comprise the articular surface of a joint may be related to the implant.27 The most common complica-
preserved, although they risk becoming sequestra tion was infection, and the authors concluded that,
 26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 327

in the military environment, external splints with the 6. Coverage of repair with soft tissue
use of transfixion pins was a safer option for the sta- The vascular repair will be threatened if the extent
bilization of fractures associated with vascular injury. of injury means that soft-tissue cover is not possible.
In his 1979 series, Romanoff reported on patients of Negative pressure wound therapy (NPWT) dressings are
whom the majority had internal fixation with screws commonly used to seal open fractures associated with
or plates.6 Internal fixation was associated with a a soft-tissue defect, but they may contribute to anasto-
lower rate of amputation (30%) than external fixation motic breakdown if they are placed directly in contact
(45.3%), but the authors acknowledged that this was with exposed vessels. If NPWT is used in this scenario,
likely to be related to injury factors rather than the cho- a double sheet of silicone dressing should be placed over
sen technique. However, the authors concluded that the vessels for protection. The pressure should be kept
infection rates were directly influenced by the method low (50 mm Hg) to prevent compromise of perfusion.
of fixation, with higher rates associated with internal Ideally, viable soft tissue must be placed over the repair
fixation (45% versus 27.2%). and, if this is not possible through local apposition, local
Plate fixation of open fractures of the lower limb fell flaps must be mobilized (Fig. 26.2). Sartorius, if avail-
out of favor in the 1980s. Bach and Hansen reported able, is a good option for covering the common femoral
a prospective trial of plate versus external fixator for vessels. Other types of flap coverage are discussed later
severe open tibial fractures in 1989. Of 26 fractures in this chapter.
treated by plate fixation, 9 (35%) developed wound 7. Performance of fasciotomies
infections and 5 (19%) developed chronic osteomy- Fasciotomies of the calf should be two-incision fasci-
elitis. Of the 30 fractures treated by external fixation, otomies (to enable full access to all four compartments).
4 (13%) developed wound infections and only 1 (3%) The most critical aspect of performing calf fasciotomies
developed chronic osteomyelitis. At final follow-up, is accurate placement of the incisions. Medially, there
all tibial fractures had healed, but the conclusion of are three perforating vessels that arise from the poste-
the authors was that plate fixation had little role in rior tibial vessels at 5, 10, and 15 cm above the medial
the stabilization of severe open tibial fractures.28 Most joint line of the ankle and reach the skin 1.5 to 2 cm
contemporary sources agree that plate stabilization of posterior to the medial subcutaneous border of the
open femoral fractures is rarely indicated and that IM tibia. These perforators are important in open fractures
nails have been more commonly used. A 2006 review because they provide the blood supply for the distally
has also concluded that IM nailing is the treatment of based local fasciocutaneous flaps that can be used to
choice, although the authors admit that there are few cover open fractures. Preservation is assured by mak-
prospective studies of open femoral fracture.29 IM nails ing the medial incision 1.5 cm posterior to the medial
were associated with a deep infection rate of 3.3%, subcutaneous border of the tibia. This distance should
compared with 13.3% with definitive external fixation; be measured and marked before making the incision.
the latter was also associated with a malunion rate of By following this method, all potential reconstructive
23.3% and a reoperation rate of 17% (outcomes poorer options are preserved. If there has been extensive vas-
than reported with traction). cular disruption and these perforators are no longer
Despite the apparent superiority of IM nailing for intact, the placing of the incision is less critical, but it
internal fixation, it should be noted that few of the is important not to expose the subcutaneous border of
patients included in these studies had sustained a the tibia. The lateral incision is placed 2 cm lateral to
vascular injury. In such cases, where timely limb the lateral subcutaneous border of the tibia. The ante-
reperfusion is a prerequisite to successful outcome, rior compartment is opened, and the intermuscular
the advantage of definitive IM fixation is often out- septum between it and the lateral/peroneal compart-
weighed by the expediency of external fixation. The ment is identified and released. When extending the
latter facilitates concurrent activity such as vein har- incision, proximally care should be taken to protect the
vest, and requires less specialist equipment and, argu- common peroneal nerve.
ably, less technical expertise. Furthermore, external
fixators can be used to span a disrupted joint and to RECONSTRUCTION
maintain stability of fractures involving the articular
surfaces. In effect, external fixation can be effectively Orthopedic interventions should be planned and then exe-
used as a damage control technique before definitive cuted at the same time as definitive soft-tissue reconstruc-
vascular repair and, from there, IM fixation and soft- tion. When it is not possible to approximate soft tissue over
tissue cover. Complications such as pin-site infection the defect, appropriate reconstructive options must be con-
must be guarded against through rigorous care of sidered. It should be remembered that adequate and timely
the fixator–skin interface and minimization of delay débridement must be performed before reconstruction: it is
to definitive IM fixation in order to prevent long-term the quality of this initial débridement that sets the founda-
infective sequela. tion for success.
5. Definitive vascular repair with autologous graft
Definitive vascular repair establishing adequate perfu- Timing of Reconstruction
sion to the mangled extremity is a key tenet of manage- There has been much emphasis on the timing of bony and
ment. The use of autologous vein (e.g., great saphenous) soft-tissue reconstruction. The argument is the sooner the
as a vascular conduit is preferred in nearly all cases of skeleton is stabilized and the soft-tissue defect closed, the
mangled extremity. lower the risk of infection.
328 SECTION 4 • The Management of Vascular Trauma

Fig. 26.2 (A) A reversed vein

graft to manage a brachial artery
defect following a high-energy
gunshot wound to the antecu-
bital fossa. There are few local
cover options for the graft. (B) A
proximally based adipofascial flap
A B raised from the forearm and cov-
ering the vessel.

The “fix and flap” approach consists of near simultane- often required. Where possible, and in low-energy transfer
ous skeletal fixation and soft-tissue coverage with a flap. wounds, a local flap may be possible assuming the local vas-
This technique is predicated on the evidence that early cular supply (as mediated by perforating vessels) is robust.
wound closure decreases the risk of deep infection.30 Godina Formal intraarterial angiography, obtained post-vascular
et al.'s 1986 series of 532 patients treated with microsurgi- reconstruction, may help in this determination. There is
cal reconstruction for extremity trauma revealed a postop- much debate about what type of flaps should be used, e.g.,
erative infection rate of 1.5% for patients treated within muscle flaps versus fasciocutaneous flaps. There is little
72 hours of injury, compared to 17.5% in those who clinical evidence to argue the superiority of one flap over
received delayed operations.31 Byrd and Spicer (1985) also another; the choice will come down the defect, the patient,
found that reconstructions performed within 5 days had a and the surgeon.
lower incidence of osteomyelitis (5%) than those covered
later (40%).32 Delay leads to technical difficulty (the tissues Flap Reconstruction
are more friable and planes often fibrosed) and is associated For lower limb trauma, the choice of local flaps, that is, flaps
with higher flap failure rate and predisposition to long-term raised from tissue bordering the defect, is contingent on the
infection.32,33 Furthermore, extremity fractures covered by site of the injury:
free flaps—fully transposed blocks of vascularized tissue
that are grafted onto a local vascular axis in order to remain n Upper-third tibia/knee
viable—heal faster when the flap is performed within The upper third of the tibia can be covered using a gas-
15 days.34 Achieving early fix and flap may be difficult if trocnemius muscle flap. The medial and/or lateral heads
the patient is unstable secondary to their polytrauma or are mobilized and pedicled on their supplying vessel, the
if institutional factors make timely work-up very difficult. sural artery. The muscle can be completely detached and
Naique et al. reported a deep infection rate of 8.5% for an can be used to cover defects as high as the suprapatel-
average coverage time of 6.8 days, which suggests that a lar region. The flap relies on the sural artery being intact
threshold of 7 days to fix and flap is a clinically appropriate and extensive vascular disruption around the knee may
time frame.33 preclude this option. Alternately, a proximally based
The current UK standard is to attempt coverage within saphenous artery fasciocutaneous flap can be utilized for
72 hours. However, it should be noted that in the litera- upper-third defects. This vessel, a branch of the descend-
ture series with the lowest bone infection rate, 25% of the ing genicular artery, should be intact unless the vascular
patients had coverage after 7 days.11 injury is midthigh.
n Middle-third tibia
Choice and Type of Reconstruction Distal fasciocutaneous flaps based on the medial per-
The nature of the tissue defect is the principal factor that forators from the posterior tibial artery are best suited to
determines the choice of reconstructive technique. Bare cover defects here. The perforators tend to arise 5, 10,
bone and joint tissue do not tend to granulate so split skin and 15 cm above the medial joint line of the ankle. A
grafts will not work. Where there are large complex defects vascular injury to the posterior tibial vessels or a medial
with substantial loss of volume or where the tissues over- fasciotomy incision placed too posteriorly may compro-
lying bone are thin (as is the case with the tibia), a flap is mise these perforators and preclude use.
 26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 329

n Distal-third tibia/ankle taken as a thin flap (or thinned after being raised) to
Few local fasciocutaneous flap options are available provide a low-profile solution to tissue defects around
for use in this zone. A fasciocutaneous flap based on the foot and ankle. Other commonly used fasciocuta-
the posterior tibial perforators may be raised and then neous free flaps include the radial forearm (for smaller
rotated through 180 degrees around the axis of the defects), the scapular flaps, and the parascapular flaps
perforator to bring the flap into the defect ("propellor" (raised around vessels close to the axilla). The latter are
flap). Such flaps have a tenuous venous drainage and commonly used around the ankle but can be bulky due
a concordantly higher complication rate. Other local to the thickness of the dermis (Fig. 26.4).
options include a flap based on the sural neurovascu- n Muscle flaps
lar bundle that allows tissue from the posterior aspect The latissimus dorsi (LD) flap is used when a large
of the calf to be pedicled in a reversed fashion to cover area of cover (up to 20 cm × 40 cm) is required because
defects around the ankle. Such flaps tend to have a it is based on the largest muscle in the body. It has a long
higher complication rate with partial flap loss, though pedicle (6 to 16 cm; average 9 cm) and can be quick to
Parrett et al. suggest that the evidence is skewed by raise. LD flaps are raised with the patient in the lateral
comorbidity and that sural flaps are reliable in fit, position, which requires an intraoperative change in
healthy patients.35 patient position, and are associated with postoperative
shoulder dysfunction. The latter may retard rehabilita-
Free Flaps tion, the ability to transfer from wheelchair to bed, and/
Distal defects are frequently treated with free tissue transfer or the proper use of crutches. Alternative flaps include
flaps due to the lack of local flap options. Free flaps can be serratus anterior muscle flap and gracilis muscle flap
used when the defect is too large for local flaps or when local (the latter suitable for long, narrow defects).
vascular compromise precludes the use of a local flap. After
the free flap is raised, its native blood supply is disconnected Commonly Used Flaps for Upper Limb Wounds
and the flap is moved to the distal leg, with reanastomosis of Options include radial forearm flaps for smaller defects or
the flap vascular pedicle to local vessels using microsurgical ALT flaps for larger defects. Local flaps include reversed
technique. Free tissue transfer relies on the presence of pat- radial forearm, posterior interosseous artery, and lateral
ent vessels outside of the injury zone in order to secure both arm flaps. All of these can be pedicled on their supplying
flap perfusion and venous outflow. Vessel segments chosen vessels to cover various defects from the elbow downward.
as targets for flap inflow should not have been traumatized As with lower limb local flaps, a vascular injury and repair
in the injury. Normally vessels proximal to any injury are will compromise the choice of vessel used, and a formal
used, though it is possible to use vessels distal to the injury if angiogram is often required to confirm the local options.
they are of good quality. Vein loops can be used if the length Where necessary, the upper limb can be moved to the
of the free flap pedicle is too short to reach good native ves- area of a potential flap raised from the groin or abdomen,
sels but a better option might be to select a free flap with a a maneuver not permissible for the lower limb. Such flaps
long pedicle. A less-optimal solution is to perform an end-to- can be raised and left connected to the native blood supply
side anastomosis on the vein graft used to restore perfusion and from there grafted onto the limb defect. After 3 weeks,
after vascular injury, though this risks compromising both the blood supply of the flap integrates with that of the
the limb and flap perfusion. Free tissue transfer in the face
of vascular reconstruction always requires careful evalua-
tion of the best inflow/outflow vessel option.
When free flap extremity surgery is being considered, the
patient must be physiologically stable and able to withstand
fluid shifts/circulatory changes. Late amputation should be
considered if it is anticipated that the patient will be unable
to tolerate the process of free tissue transfer in a timely
fashion. However, late coverage of open fractures, despite
having a higher risk of infection, may still be a reasonable
option in polytraumatized patients due to the potential of
overall better functional outcome.
Commonly Used Flaps for Lower Limb Wounds
n Fasciocutaneous flaps
The anterolateral thigh (ALT) flap (Fig. 26.3) is a very
popular flap for lower limb reconstruction for several
reasons. It is based on an area of skin and fascia on the
anterolateral aspect of the thigh supplied by perfora-
tors of the descending branch of the lateral circumflex
femoral artery. This provides a very large flap (15 cm
× 35 cm) with a long pedicle (up to 12 cm) providing Fig. 26.3 An anterolateral thigh flap with a block of vascularized mus-
a coverage solution for most defects of the lower limb. cle (chimeric flap) to cover a lower limb open fracture. There is experi-
The ALT flap can be raised from the contralateral leg mental evidence that the muscle may be beneficial for faster fracture
without any intraoperative repositioning and can be union.
330 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 26.4 (A) Anterolateral thigh flap being raised on the right thigh. (B) Flap raised to show the feeding vessel, perforators from the descending branch
of the lateral circumflex femoral artery.

upper limb; and the connection to the donor site is surgi- 15 (52%) underwent primary amputation, 13 of which
cally divided to leave an island of torso tissue covering the were damage control procedures in critically ill patients. In
upper limb defect. No microsurgical vascular anastomosis is the remaining two patients (both of whom had experienced
required, and there is no need to formally evaluate or utilize a time interval from point of injury to surgery of greater
the axial vessels of the upper limb, unlike free-flap or local than 6 hours), the injured limbs were deemed anatomically
fasciocutaneous techniques. unsalvageable. Fourteen limbs had vascular repairs under-
taken, with a much higher incidence of postoperative com-
plications in patients with an associated fracture.
Outcomes of Limb Salvage
Saddawi-Konnefka and colleagues reviewed 28 observa- Summary
tional studies concerning the treatment of tibial fractures
and observed that the most common complications after The management of a devascularized extremity with a
limb salvage were the following: osteomyelitis (17.9%) and significant bone and soft-tissue injury is challenging. The
fracture nonunion (15.5%) with secondary (late) amputa- complexity of these cases requires a team approach in order
tion in 7.9%.36 The authors were able to compare the sec- to ensure that unfeasible options are rejected and that the
ondary amputation rate between those without vascular optimal route to maximal functional recovery is selected.
injuries (5.1%) and those with vascular injury (28.7%). It can be appreciated that there are numerous reconstruc-
Taking the groups together, 63.5% of salvage patients tive options and that the eventual choice will depend on
returned to work, compared to 73% of amputees. the patient, the nature of the defect, and the surgical pref-
In 1997, Lin et al. reported on 36 lower extremity revas- erence. Finally, it should be remembered that amputation
cularizations performed on 34 patients. After the revas- of the mangled extremity may be the best reconstructive
cularization, seven (19.4%) patients with IIIC fractures option for the patient in some cases.
underwent secondary amputation within 1 week. At the
2-year follow-up, the overall secondary amputation rate had References
risen to 25% (9 of 36). Of 29 salvaged limbs among their 1. National Institute for Health and Care Excellence. Fractures (Com-
27 patients, 23 limbs (79.3%) required secondary coverage plex): Assessment and Management. London: Nice; 2016. https://
procedures that included 12 free flap transfers (41.4%). All www.nice.org.uk/guidance/ng37/resources/fractures-complex-
assessment-and-management-pdf-1837397402053.
27 patients required further surgery to improve functional 2. Miranda F, Dennis J, Veldenz H, Dovgan PS, Frykberg ER. Confirma-
outcome.37 tion of the safety and accuracy of the physical examination in the
Outcome seems to improve when temporary vascular evaluation of knee dislocations for injury of the popliteal artery: a
shunts are used,24 although the protective nature of shunt- prospective study. J Trauma. 2002;52:247–252.
3. Young K, Aquilina A, Chesser TJS, et al. Open tibial fractures in major
ing may be of far less benefit in more-distal and higher- trauma centres: a national prospective cohort study of current prac-
grade fractures such as Gustilo IIIC injuries.5 tice. Injury. 2019;50:497–502.
Wartime injuries are typically characterized by high- 4. Brown K, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC.
energy transfer, gross contamination, and delay in defini- Complications of extremity vascular injuries in conflict. J Trauma.
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5. Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E,
and devascularized limbs, 29 had an associated fracture and Feliciano DV. A decade’s experience with temporary vascular shunts
6 did not.4 Of the patients who had an associated fracture, at a Level 1 trauma centre. J Trauma. 2008;65:316–326.
 26 • Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 331

6. Romanoff H, Goldberger S. Combined severe vascular and skeletal 22. https://www.boa.ac.uk/standards-guidance/boasts/trauma-boasts.

trauma. J Cardiovasc Surg. 1979;20:493–498. html
7. Green N, Allen B. Vascular injuries associated with dislocation of the 23. Kwasnicki R, Din A, Hettiaratchy S. The use of pulse oximetry to diagnose
knee. J Bone Joint Surg Am. 1977;59-A:236–239. limb ischaemia. J Plast Reconstr Aesthet Surg. 2018;71:1816–1834.
8. Patterson B, Agel J, Swiontkowski M, Mackenzie EJ, Bosse MJ. Knee 24. Glass G, Pearse M, Nanchahal J. Improving lower limb salvage follow-
dislocations with vascular injury: outcomes in the Lower Extrem- ing fractures with vascular injury: a systematic review and manage-
ity Assessment Project (LEAP) study LEAP Study Group. J Trauma. ment algorithm. J Plast Reconstr Aesthet Surg. 2009;62:571–579.
2007;63:855–858. 25. Sassoon A, Riehl J, Rich A, et al. Muscle viability revisited: Are we
9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of removing normal muscle? A critical evaluation of dogmatic debride-
one thousand and twenty-five open fractures of long bones. J Bone ment. J Orthop Trauma. 2016;30:17–21.
Joint Surg Am. 1976;58-A:453–458. 26. Anglen JO. Comparison of soap and antibiotic solutions for irrigation
10. Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on of lower-limb open fractures: an experimental study. J Orthop Trauma.
the management of open fractures of the tibial shaft. Clin Orthop. 2005;19:591–596.
1998;350:18–25. 27. Rich NM, Metz CW, Hutton JE, Baugh JH, Hughes CW. Internal versus
11. Wordsworth M, Lawton G, Nathwani D, et al. Improving the care of external fixation of fractures with concomitant vascular injuries in
patients with severe open fractures of the tibia: the effect of the intro- Vietnam. J Trauma. 1971;11:463–473.
duction of major trauma networks and national guidelines. Bone Joint 28. Bach AW, Hansen ST. Plates versus external fixation in severe open
J. 2016;98:420–424. tibial shaft fractures. Clin Orthop. 1989;241:89–94.
12. Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial 29. Giannoudis PV, Papakostidis C, Roberts C. A review of the manage-
fractures with severe soft-tissue loss. Limb salvage compared with below- ment of open fractures of the femur and tibia. J Bone Joint Surg Br.
the-knee amputation. J Bone Joint Surg Am. 1993;75:1431–1441. 2006;88-B:281–289.
13. Fairhurst MJ. The function of below-knee amputee versus the 30. Gopal S, Majumdar S, Batchelor A, Knight SL, De Boer P, Smith RM.
patient with salvaged grade III tibial fracture. Clin Orthop Relat Res. Fix and flap: the radical orthopaedic and plastic treatment of severe
1994;301:227–232. open fractures of the tibia. J Bone Joint Surg Br. 2000;82:959–966.
14. MacKenzie EJ, Bosse MJ, Pollak A, et al. Long-term persistence of 31. Godina M. Early microsurgical reconstruction of complex trauma of
disability following severe lower-limb trauma. J Bone Joint Surg Am. the extremities. Plast Reconstr Surg. 1986;78:285–292.
2005;87-A:1801–1809. 32. Byrd HS, Spicer TE, Cierney 3rd G. Management of open tibial frac-
15. Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of tures. Plast Reconstr Surg. 1985;76:719–730.
mangled lower extremities. J Trauma. 1993;34:99–104. 33. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial
16. Fochtmann A, Binder H, Rettl G, et al. Third degree open fractures fractures: the need for combined orthopaedic and plastic surgical treat-
and traumatic sub-/total amputations of the upper extremity: out- ment in specialist centres. J Bone Joint Surg Br. 2006;88:351–357.
come and relevance of the mangled extremity severity score. Orthop 34. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ.
Traumatol Surg Res. 2016;102:785–790. Microvascular soft-tissue transplantation for reconstruction of acute
17. Fowler J, MacIntyre N, Rehman S, Gaughan JP, Leslie S. The impor- open tibial fractures: timing of coverage and long-term functional
tance of surgical sequence in the treatment of lower extremity results. Plast Reconstr Surg. 1992;98:478–487.
injuries with concomitant vascular injury: a meta-analysis. Injury. 35. Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE, Orgill DP.
2009;40:72–76. Risk analysis for the reverse sural fasciocutaneous flap in distal leg
18. McHenry T, Holcomb J, Aoki N, Lindsey RW. Fractures with major reconstruction. Plast Reconstr Surg. 2009;123:1499–1504.
vascular injuries from gunshot wounds: implications of surgical 36. Saddawi-Konnefka D, Kim H, Chung K. A systematic review of
sequence. J Trauma. 2002;53:717–721. outcomes and complications of reconstruction and amputation
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adjunct in the management of wartime vascular injury. J Trauma. 37. Lin C, Wei F, Levin S, Su JI, Yeh WL. The functional outcomes of
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21. Hancock HM, Stannard A, Burkhardt GE, et al. Hemorrhagic shock Howard PW, Makin GS. Lower limb fractures with associated vascular
worsens neuromuscular recovery in a porcine model of hind limb injury. J Bone Joint Surg Br. 1990;72:116–120.
vascular injury and ischemia/reperfusion. J Vasc Surg. 2011;53 Nanchahal J, Nayagam S, Khan U, et al. Standards for the Management of
(4):1052–1062. Open Fractures of the Lower Limb. London: RSM Press Ltd; 2009.
 27 Vascular Surgery in the Austere
Environment
DAVID M. NOTT

Introduction vascular repairs). The aim of this chapter is to review the

management of the patient with vascular and associated
Vascular surgery is normally conducted in a highly tech- injuries from the perspective of marked resource constraint and
nical environment with a full complement of specialized to highlight areas of differences and commonality with
equipment including noninvasive ultrasound technol- trauma surgery as it is practiced in replete, developed-world
ogy, state-of-the-art computed tomography (CT), modern settings.
fluoroscopy, specialized instruments for open surgery, and
postoperative intensive care units and wards staffed with
experienced vascular nurses and junior doctors. Perform- Fundamentals
ing vascular surgery in an austere environment is the
antithesis to this. Faced with major vascular injury, the Fig. 27.1 demonstrates much of the basic equipment that
surgeon will find few tasks more demanding of his or her should be taken on austere missions in which extensive
wisdom, especially with regard to decision making. The pri- injury management is anticipated: a handheld Doppler
mary principles are always control of life-threatening hem- machine, magnifying loops, an operating headlight with
orrhage and prevention of end-organ ischemia. However, batteries, 20 or so umbilical vein catheters (size 4 and size 6),
time, resources, and the patient's physiology are pressing and four boxes of 5-0 Prolene. Most nongovernmental orga-
factors that require constant consideration. The diagnosis nization (NGO) operating theaters are well provisioned, but
and management of arterial and venous injury are per- lighting is usually a limitation, and the instruments tend to
formed by careful clinical examination supplemented with be fairly large and cumbersome.
a continuous-wave Doppler probe. In the austere setting, In general, clinical evidence of an arterial injury is mani-
there are rarely other, more elaborate diagnostic modali- fested in one of the following four ways: external bleeding,
ties. Correct clinical decisions are paramount with limited end-organ or extremity ischemia, pulsatile hematoma, or
equipment, inexperienced intensive care staff, and a limited internal bleeding accompanied by signs of shock. Patients
means to transfer patients to a higher level of care. present very early, early, late, or very late. Those who pres-
It is vitally important to begin the task with the right ent late are a self-selected group, often hemodynamically
mindset and to approach all vascular injuries in damage normal but with mummified limbs (if in hot, dry climates).
control mode. Blood loss alone will have altered the patient's In this scenario, there is no role for revascularization; and
physiology, and the overriding necessities are to stop bleed- amputation is the necessary option (Fig. 27.2).
ing, to reestablish blood flow using shunts combined with Sometimes the patient may not understand the conse-
fasciotomy or to ligate, and, if necessary, to perform ampu- quences of an arterial injury, therefore, making the rational
tation. One must also be prepared to make quick decisions. argument for the amputation in order to save the patient's
This is not the environment in which to spend a long time
performing extensive and difficult vascular reconstructions.
In general, one should not entertain the idea of performing
a complex vascular anastomosis at the first operation. If the
decision is to shunt the injured vessel, one must make sure
all the bleeding has stopped and bring the patient back the
following day for a more definitive operation. That strategy
will allow time for the patient to warm up, will allow for
adequate resuscitation to take place, and will allow time to
source blood donors if blood is still required.
The single surgeon working in a relief or humanitarian
aid scenario requires a multiplicity of skills. Apart from
knowledge pertaining to vascular anatomy and surgical
techniques, including extraanatomic bypass, it is also nec-
essary to be able to perform nerve and tendon repairs, to
undertake orthopedic trauma management (reduction
of fractures, external fixation), and to be able to perform
elements of plastic surgery (which entails knowledge of
the blood supply to muscles and skin necessary to cover Fig. 27.1 Important tools for the austere vascular surgeon.
332
 27 • Vascular Surgery in the Austere Environment 333

Fig. 27.2 A 14-year-old girl who fell off a tree while picking mangos in Fig. 27.4 This patient had absent distal Doppler pulses due to a gun-
Chad and presented to the hospital 2 weeks later. shot wound to the leg and refused treatment on religious grounds.

Soft signs of vascular injury consist of a stable hematoma,

diminished distal pulses, injury in the proximity of a major
vessel, or neurological deficit. The most common arterial
injury associated with hard signs is either a partial lacera-
tion or a complete vessel transection. In general, complete
transection leads to retraction and thrombosis of the proxi-
mal and distal ends of the vessel with subsequent ischemia.
In contrast, partial laceration causes persistent bleeding or
pseudoaneurysm formation. In the austere environment,
only those patients with hard signs undergo treatment. The
diagnostic equipment is generally not available to accu-
rately diagnose vascular injury presenting only with soft
signs. Repeat examinations or serial clinical monitoring
and pressure measurements (i.e., injured extremity index
[IEI]) with the handheld Doppler will often reveal a trend in
patients who initially present with soft signs and then go on
Fig. 27.3 Discussions pertinent to the level of amputation. to develop hard signs.1

life can be extremely challenging. The patient in Fig. 27.3

Neck Injuries
did not appreciate that his leg was beyond salvage. When CAROTID INJURIES
he did agree to an amputation 4 days later, he consented
only to a below-knee amputation (though the whole of the In austere environments, the only indication for surgery
below-knee compartment was necrotic). It took another in the neck is penetrating trauma with hard signs. Blunt
week of intense discussion before the patient agreed to the carotid injuries resulting in intimal disruption with
definitive procedure, and by that time sepsis was present. In subsequent dissection or thrombosis may present with cata­
these instances, even if the patient understands that a limb strophic neurological symptoms that develop some time
is not viable, culture and religion sometimes decree that a after the injury was sustained. Such patients do not normally
person must die with his/her body in toto or intact. In such present to the surgeon. In cases of penetrating trauma, the
difficult circumstances, the surgeon must rely on his or her method of exposure and treatment of injuries to the vas-
understanding and empathy for the patient's personal and cular structures of the neck is determined in large part by
religious beliefs. The patient in South Sudan (Fig. 27.4) was the precise location of the injury and the anatomy of blood
otherwise very fit and well, but he chose to return to his vil- vessels and surrounding structures. The neck has been
lage with a wooden splint and died 2 weeks later. classically divided into three zones (Fig. 27.5). Zone I is from
The decision to operate on vascular trauma is based on below the cricoid cartridge to the superior border of the
hard and soft signs of injury. Hard signs of vascular injury clavicle; zone II lies between the cricoid cartilage and the
include the absence of distal pulses, active external hemor- angle of the jaw; zone III extends above the angle of the jaw
rhage, signs of ischemia, expanding or pulsatile hematoma, to the base of the skull. Hard signs include external or intra-
and a bruit or thrill (in the case of an arteriovenous fistula). oral bleeding, an expanding (arterial) or stable (venous)
334 SECTION 4 • The Management of Vascular Trauma

external-to-internal carotid artery transposition is a good

option when treating proximal internal carotid artery (ICA)
injuries in children.10 Injuries involving the jugular veins
can be ligated with impunity, and this is the preferred option
over reconstruction in the austere setting.11
There has been debate about the use of a cervical collar
in penetrating neck injuries. In the author's opinion, most
patients with penetrating neck injuries will not survive if
they have cervical spine trauma because they are already tet-
raplegic or have associated major head injury. Those with no
III neurological signs rarely have a spinal injury, so using a collar
ne
Zo
may potentially obstruct the airway and mask other injuries.12
The patient with a hard sign or signs of cervical vascular
trauma should be taken urgently to the operating theater
II
ne because rapid expansion of a hematoma may occur, result-
Zo
ing in deviation of the trachea and elevation of the floor of
the mouth. In this circumstance, one must be prepared to
perform an emergency tracheostomy or cricothyroidotomy
I
ne if the anesthetist is having any difficulty with intubation.
Zo
One must also be sure to prepare the neck and chest, in case
of the requirement for proximal control, and to prepare the
proximal thigh for vein harvesting (Fig. 27.6). If needed,
suction drains can easily be made by creating a vacuum in a
50-mL syringe and then using plungers from 20-mL syringes
to maintain the plunger in the suction position (Fig. 27.7).
Preoperatively, it is very important to assess the neu-
rological status of the patient using the Glasgow Coma
Scale (GCS). An adverse outcome is more likely to occur in
Fig. 27.5 Zones of the neck. (Redrawn from Bagheri et al. Penetrating a patient with a GCS of less than 8, and in this situation,
neck injuries. Oral Maxillofacial Surg Clin N Am. 2008;20:393–414.) the ICA should be ligated if it is found to be the cause of
the bleeding. In this scenario, no attempt at carotid repair
should be made, even if there is antegrade flow, due to the
hematoma, stridor and air bubbling from the wound, and a risks of causing propagation of thrombus and, on resto-
palpable thrill or audible bruit. In the absence of hard signs, ration of perfusion, converting an ischemic infarct into a
assessment of the neck is by careful clinical examination, hemorrhagic one.13,14 Those not in coma or with only a mild
which must be repeated serially. Without clinical signs of a neurological deficit should be considered for carotid repair
vascular- or aerodigestive injury (such as pain on swallow- using a vein patch or reversed vein. Because only 35% of
ing, subcutaneous emphysema, or soft tissue air on a lateral patients have an intact circle of Willis, there is a risk of sig-
neck radiograph), nonoperative management should be fol- nificant neurological insult if the ICA is ligated.15
lowed.2–4 If facilities for a barium/Gastrografin swallow are Carotid–jugular fistulae are rare. In 1994, during this
available, that should be performed. author's mission to Sarajevo, a 13-year-old girl with a frag-
Nonoperative management does not equate with conser- ment wound to the neck presented for care. The penetrating
vative management, and these patients should be regularly wound had become swollen and there was a readily palpable
reviewed. Any change in status may mean a change in the thrill over the enlarged neck mass. Unlike arteriovenous fis-
management plan is needed. There has been considerable tulae in the limbs, carotid–jugular fistulae are particularly
debate in the literature regarding whether it is mandatory prone to complications such as intractable high-output
to explore any wound in the neck that has penetrated the cardiac failure, atrial fibrillation, and embolization.16 In the
platysma. This author's policy is to not explore the neck in case of the 13-year-old girl, the common carotid artery was
the absence of hard signs.5–7 clamped, and perfusion of the internal carotid relied on flow
If it is bleeding from the external carotid artery or its from the external carotid. Having isolated the fistula, both
branches, ligation is the preferred option. An injury to the the internal jugular vein and the common carotid artery
common carotid artery below the bulb, if deemed unre- were repaired with 5-0 Prolene.
constructible, can be managed with ligation. In these chal- It is recognized that internal carotid artery stump pres-
lenging cases, one must accept that perfusion of the brain sures are highly variable, but, on the whole, the ICA back
on the injured side will occur via retrograde flow from the pressure may be augmented by 10 to 15 mm Hg if the exter-
posterior circulation and the contralateral side. Other inju- nal carotid artery is maintained in continuity. If this can be
ries of the bulb and internal carotid artery can be recon- maintained, it may augment internal carotid artery stump
structed with a vein patch and segmental defects managed pressures to the degree that repair of some carotid injuries
with an interposition vein graft. In all cases, the long saphe- may not be necessary.17 Although some surgeons advocate
nous vein should be harvested from the groin because there using a shunt in isolated common carotid artery injuries,
are reports of carotid patch disruption if the vein is taken this author has not used one in this situation, and there are
from the ankle.8,9 Resection of the internal carotid with no studies to support its role in this setting.18
 27 • Vascular Surgery in the Austere Environment 335

Fig. 27.6 Tetraplegic patient

with a low-velocity gunshot
wound to the side of the face,
causing external carotid artery
and internal jugular vein dis-
ruption. Both the artery and
B C the vein were ligated.

esophagus. Repair of local damage to the esophagus may

be undertaken with a two-layered 3-0 absorbable suture,
using the sternomastoid muscle to buttress the suture line
and to reduce the risk of leakage. This muscle takes its blood
supply from the occipital artery and the superior thyroid
artery branches of the thyrocervical trunk and thus can
be mobilized from the clavicle by dividing the sternal and
clavicular heads. Tracheal injuries can be repaired primar-
ily with an absorbable suture and similarly buttressed with
the sternomastoid muscle. If the tracheal defect is large, it
should be converted into a tracheostomy.19

OPERATIVE MANAGEMENT OF ZONE III INJURIES

Various techniques for gaining access to the inherently
difficult-to-expose distal internal carotid artery have been
reported. However, methods involving subluxation of the
temporomandibular joint and vertical ramus osteotomy are
often not achievable in the austere environment.20,21 A use-
ful technique is to divide the digastric muscle and to par-
tially sublux the mandibular condyle. This is accomplished
Fig. 27.7 Syringe suction bottle. by forceful opening of the mouth, kept open by careful
positioning of a self-retaining retractor with swabs over the
molars and a Langenbeck retractor placed under the angle
of the jaw to lift it forward.22 This was the technique used in
ASSOCIATED NECK INJURIES
one such case that is depicted in Fig. 27.8.
In the setting of penetrating neck wounds with a vascu- One may be faced with significant bleeding from a Zone III
lar component, one should always look for injuries to the injury of the internal carotid artery, where the techniques
esophagus and the laryngotrachea. If preoperative radi- described previously may not be possible. In that case, the
ology is not possible, one can ask the anesthetist to pass only option would be ligation of the internal carotid or
a nasogastric tube to allow easier identification of the proximal ligation and packing of the area for several days to
336 SECTION 4 • The Management of Vascular Trauma

postoperative care. In some circumstances, appropriate facil-

ities are available, and in these cases a median sternotomy is
the best option. Indeed, if the necessary equipment is avail-
able, this exposure is not difficult to perform and provides an
excellent working view of zone I vascular structures.
However, without the benefit of either good x-rays or a CT
scan then the difficult decision based on clinical parameters
needs to be undertaken. If the decision has been made to
explore for a zone I injury in such austere settings, then I
would suggest a clamshell maneuver with wide retraction
to allow access into the vessels in the root of the neck. The
gateway to the arch is division of the brachiocephalic vein,
allowing exposure of the arch and its branches. Again,
based on experience alone, it is more preferable to ligate ves-
sels from the arch including the innominate artery rather
than to try and perform a complicated vascular reconstruc-
A tion. There are obvious downsides in ligation such as distal
ischemia, but is often quite surprising how collateralization
around the shoulder allows for improvement. Consideration
also must be made for fasciotomy of the forearm if this is
performed. There is also the risk of stroke caused by ligation
of the carotid arteries which must, of course, be tempered
by the postoperative facilities available, which in an austere
environment may be extremely limited.

Upper Limb Vascular Injuries

SUBCLAVIAN AND AXILLARY VESSEL
The subclavian artery is divided into three parts. Bleeding
from the third part as it passes beyond the first rib can be
one of the most challenging operations in difficult environ-
B ments. A supraclavicular incision with division of the cla-
vicular head of the sternomastoid allows exposure of the
Fig. 27.8 Zone III injury of the carotid (A), with the defect repaired internal jugular vein which is the first landmark. Lateral
using a vein patch (B). to this is the scalenus fat pad which is retracted laterally to
expose the scalenus anterior muscle and the phrenic nerve,
which passes from lateral to medial. Division of the scalenus
anterior muscle allows for exposure of the first and second
allow thrombosis of the distal part, accepting the inevitable part of the subclavian artery. Excision of the clavicle, which
40% stroke risk. Proximal ligation and closure of the wound (contrary to opinion) does not destabilize the shoulder (pro-
leaving pressure from a Foley catheter balloon to further vided the muscles attached to it are reconstituted23,24) allows
compress the area may be another option as this obviates for excellent exposure of the subclavian, proximal carotid,
the necessity for reopening the wound. and axillary arteries, but is rarely needed. Instead, injuries
under the clavicle involving the subclavian axillary can be
dealt with by dividing the clavicle at its midpoint using a
OPERATIVE MANAGEMENT OF ZONE I INJURIES
Gigli saw and retraction using orthopedic hooks.
Penetrating injuries either from fragmentation or gunshot Because of the difficulty in successful subclavian artery
wound into zone I of the neck are often very difficult to deal reconstruction, I would always ligate the vessel. In most
with. Most cases in austere environments are either in extre- cases, upper limb circulation is maintained via the rich col-
mis or dead on arrival. Resuscitation fluids may be in short lateral circulation around the shoulder girdle (Fig. 27.10).25
supply. However, if the patient is cerebrating and maintains Because of the close anatomical relationship of the
a systolic blood pressure, a decision based on resources neurovascular structures, the brachial plexus is injured
available must be taken into account before embarking on in about one-third of patients with subclavian or axillary
surgery. vascular trauma. In this situation it is necessary to per-
The classic teaching for zone I injuries of the neck is that form a nerve repair, primarily by dissecting the nerve and
proximal control of the innominate, the subclavian, and the suturing the epineural layer with 5-0 Prolene during the
carotid arteries should be enabled via a median sternotomy, first exploration.26 Access to the axillary artery is achieved
followed by cervical extension into either side of the neck by using an infraclavicular incision made from the delto-
(Fig. 27.9). In the austere environment, this approach has to pectoral groove to the lateral two-thirds of the clavicle.
be tempered with the available resources for preoperative and This exposure requires splitting the fibers of the pectoralis
 27 • Vascular Surgery in the Austere Environment 337

Fig. 27.9 (A–C) Pulsatile swelling in zone

I and zone II of the neck due to a gunshot
wound with median sternotomy to gain
B C proximal control of the carotid artery.

A B

Fig. 27.10 (A) Gunshot to zone I of the neck. (B) Removal of the clavicle and ligation of the subclavian artery.

major muscle and dividing the pectoralis minor muscle as and retracted inferomedially. The underlying pectoralis
it attaches to the coracoid process. Straightforward and minor muscle is then divided near its insertion on the cor-
quick to perform, this is the method of choice in nearly all acoid process and is retracted. This allows exposure of the
cases of penetrating arm injuries to gain proximal control whole of the axillary artery up to the lower border of the
before isolating the damaged vessels (Fig. 27.11). Further teres major.
exposure of the axillary artery can be performed very rap- Because the axillary vessels are usually soft, lateral repair
idly by dividing the origins of the pectoralis major and pec- will narrow the vessel and better results are obtained if a
toralis minor muscles (Fig. 27.12). Pectoralis major can vein patch or an interposition graft using autologous
be divided about 2 cm from its attachment to the humerus long saphenous vein is employed. However, if repair is not
338 SECTION 4 • The Management of Vascular Trauma

Fig. 27.11 (A and B) Exposure of

the infraclavicular axillary artery
for proximal control. A B

Fig. 27.12 Complete exposure of the axillary artery.

possible, the extensive collateral circulation around the

axillary artery means that ligation is an option (with an
acceptance of a risk of ischemic sequelae of 25% to 30%). Fig. 27.13 Arteriogram performed 2 weeks after a gunshot wound to
Primary ligation of a vein in the upper limb is usually well the axillary artery causing thrombosis.
tolerated because of lower hydrostatic pressure within the
superior vena cava associated with erect posture, smaller
minute volume blood flow, and extensive collaterals (Figs.
27.13 and 27.14).27 A fasciotomy is always performed half of cases, and therefore flow should be reestablished
when managing extremity vascular trauma in the austere (particularly if the injury lies in the proximal vessel above
domain. The forearm contains the following three compart- the origin of the profunda brachii).28 Direct suture repair
ments: the volar compartment, dorsal compartment, and should never be performed in the brachial artery because
mobile wad containing the brachioradialis; the extensor of the potential to narrow the vessel. Instead, short-section
carpi radialis brevis; and the extensor carpi radialis lon- resection and primary end-to-end anastomosis, vein patch
gus. The carpal tunnel should be opened or released during angioplasty, or application of reversed saphenous vein
upper extremity fasciotomy in most cases. interposition graft is preferable. The use of shunts is often
warranted. Though thrombosis may occur, limb-threaten-
ing sequelae are not always apparent. This author has had
BRACHIAL AND FOREARM VESSELS
two cases, both transferred from field hospitals deep in hos-
In contrast to the axillosubclavian arterial segment, liga- tile territory, where the non–vascular-trained surgeon had
tion of the brachial artery results in amputation in nearly elected to place shunts into the brachial artery. Both cases
 27 • Vascular Surgery in the Austere Environment 339

Fig. 27.14 This child had a gunshot wound to the axilla and necessi-
tated the ligation of the axillary artery just above the border with teres
major muscle; no vascular sequelae followed. Fig. 27.15 Slings made out of surgical gloves and shunts form naso-
gastric tubes.

had a long transfer time of 4 to 5 days. When explored, the

shunts were occluded although the arms and were well kept long during harvesting, this portal can also be used to
perfused with good radial and ulnar Doppler signals. The reintroduce the catheter into the vein lumen and then into
shunts were removed and the brachial artery ligated in the proximal artery for administration of heparin flush.
each patient, with no troublesome consequences. One pos- The proximal anastomosis can be completed around the
sibility is that slow occlusion over a period of days may have catheter before its removal, and the long side tributary can
allowed collaterals to open with no loss of end perfusion. be ligated. In Fig. 27.16, there were no slings available or
It is this author's preference to place a temporary vascu- arterial clamps and the umbilical catheter acted as means
lar shunt when managing an extremity with a combined of occluding the arterial flow, held in place by a pair of
orthopedic and vascular injury. This strategy is employed forceps.
to reduce the warm ischemic time before application of an Single vessel injury in the forearm need not be repaired
external fixator. Any sort of sterile plastic tubing can be but can be ligated. However, repair is mandatory if either
used, and different sizes of nasogastric tube or intravenous the radial or ulnar artery was previously ligated as is so
fluid sets will suffice to ensure diameter match is consistent common in machete wounds (Fig. 27.17). When both radial
with the vessel concerned. For upper extremity injuries, and ulnar arteries are injured, the ulnar artery should be
slings can be manufactured or improvised using a wrist- repaired as it is usually the dominant vessel.
band in a surgical glove (Fig. 27.15). When fashioning a
shunt, one should ensure that it is slightly smaller than the
artery and should cut carefully so that it is unlikely to dam- Abdominal Vascular Injuries
age the intima. The shunt should be secured in the intravas-
cular position with a double silk suture tied on the outside On opening the abdomen for exsanguinating abdominal
of the vessel. Having shunted the vessel (and following vascular trauma, the surgeon must perform the following
application of the external fixator) the long saphenous vein three tasks: (1) identify the zone of bleeding, (2) obtain
can be harvested and prepared as a reversed vein interposi- proximal and distal control, and (3) achieve hemostasis
tion graft. The vascular shunt may then be removed and the with or without restoration of critical flow. From a trauma
vein interposed and grafted. point of view, the abdomen is divided into three zones
Umbilical vein catheters are a vital piece of equipment (Fig. 27.18). In general, hematomas due to blunt injury in
in the austere setting and have many uses. Placed via the zones II and III are not disturbed. All hematomas in zone I
lumen of the vein graft and then into the distal artery, this are explored, as are expanding hematomas in zones II and
type of catheter serves to stent open the anastomosis while III. Zone I can be divided into supramesocolic and inframe-
suturing it with individual 5-0 Prolene. This maneuver socolic areas by the transverse mesocolon. Proximal control
reduces the risk of narrowing the anastomosis and may can be very challenging, but knowledge of techniques such
also reduce the number of sutures. After the anastomo- as the Cattell-Braasch maneuver29 for inferior vena cava
sis is complete, heparinized saline (5000 U/500 mL) can (IVC) injury and the left-sided medial visceral rotation (Mat-
be injected down the catheter to reduce the risk of distal tox maneuver) for supramesocolic aortic injury is manda-
thrombosis. The catheter can then be withdrawn and tory if the patient is to have a chance of survival.
attention paid to the proximal anastomosis. By ensuring Successful application of surgical technique is not the
that one of the side-tributary stumps of the vein graft is sole determinant of outcome. Most patients with significant
340 SECTION 4 • The Management of Vascular Trauma

A B

C D

Fig. 27.16 (A–D) A series of photographs showing the insertion of a shunt before external fixator and the author's method of protecting the anastomo-
sis, as well as the final definitive result.

II II

III

Fig. 27.17 A machete wound to the forearm.

intraabdominal hemorrhage require a massive transfusion

and postoperative ventilation. Even then, the chance of
avoiding a fatal outcome is low.30,31 If there is a cumulative
blood loss of 6 L or more, mortality can approach 100%.32
This is the context for the difficult nature of decisions fac-
ing surgeons working in a resource-limited environment. Fig. 27.18 Zones of the abdomen.
 27 • Vascular Surgery in the Austere Environment 341

A B

Fig. 27.19 (A and B) Left visceral rotation in order to obtain exposure of the supramesocolic aorta.

A B C

Fig. 27.20 (A–C) Through-and-through gunshot wound with injury to the inferior vena cava approached by performing the Cattell-Braasch maneuver.

Knowing that massive intraabdominal bleeding is likely to wall of the third part of the duodenum, and the vena cava,
end up in patient mortality, the surgeon may be faced with resulting in a large zone I hematoma. The Cattell-Braasch
the decision of whether to initiate treatment or, instead, maneuver was performed in this scenario to gain proximal
to triage the patient to an “expectant” category. Resources and distal control of the IVC. Hemostasis was secured with
that are expended in trying to save a potentially futile situ- swabs (sponges)-on-sticks, applied proximal and distal to the
ation may be wasted, but one may face significant pressure venous injury, which was eventually repaired with a lateral
to attempt salvage from the patient's family members and running 3-0 Prolene suture. In more difficult circumstances,
from the attending hospital staff. In these difficult scenarios, ligation of the IVC would have been a justifiable option.
it is best to try to save the life but also to set clear limits and
recognize nonsalvageable situations in order to stop care
and conserve resources. Resuscitative Thoracotomy
In Fig. 27.19, the patient suffered a fragment injury from
a rocket-propelled grenade to the abdomen. In this case, Some field hospitals that I have worked in are on the front-
a left anterolateral thoracic incision was made in order to line. This means that patients are presented via a scoop and
apply an aortic clamp before opening the abdomen. A left run policy to the emergency department, sometimes min-
medial visceral rotation (Mattox maneuver) was performed, utes after being wounded by a bullet or fragment, which in
and clamps were applied to the supraceliac aorta in an turn means that patients who would have died on the battle-
attempt to control the hemorrhage. Although aortic con- field are now surviving and being presented to the trauma
trol was achieved, the liver was badly macerated, and the team. Exsanguinating hemorrhage often results in patients
patient succumbed to hemorrhage and shock. being brought in extremis, having “bled out” because of
In Fig. 27.20, the Cattell-Braasch maneuver is demon- their injuries and requiring external cardiac massage.
strated exposing the IVC, which was bleeding consequent Immediate decisions in these circumstances must be made.
to a gunshot wound. More often than not hemorrhage from These decisions are sometimes very difficult, emotions run
the vena cava is partly constrained by retroperitoneal tissues, high, and the rule of the gun takes president over the rule of
reducing the opportunity for immediate exsanguination. In the law and occasionally one is forced to operate. However,
the illustrated case, the injury track included the anterior a clear understanding of the outcome must be at the fore-
and posterior walls of the stomach, the anterior and posterior front of the operating surgeon’s mind.
342 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 27.21 (A and B) A one-shot arteriogram.

If a patient having cardiopulmonary resuscitation (CPR) examined not once but over a period of time using a com-
due to a single penetrating wound to the heart causing a bination of physical examination and noninvasive pressure
pericardial tamponade is to have a chance of survival, measurements using a handheld Doppler. Continuous-
a resuscitative thoracotomy must be performed within wave Doppler alone and in conjunction with measurement
10 minutes. Wounds that cause blood on the floor from a of pressure ratios (i.e., IEI or ankle-brachial pressure index
penetrating injury to the limbs have a chance of survival [ABPI]) have a sensitivity and specificity of greater than
if the resuscitative thoracotomy is performed within 5 min- 95%.33,34 Specifically, an IEI or ABPI of 0.9 or greater is
utes of CPR. Those who have a blunt injury having CPR will normal and suggests that no further diagnostic studies or
not survive. interventions are needed. An IEI or ABPI of less than 0.9
A resuscitative thoracotomy requires a left anterolateral is an indication for arteriography, if the facilities are avail-
thoracotomy, opening up of the pericardial sac to confirm able, or for operative exploration.35
whether the heart is full or empty, a clamp on the distal If available, contrast arteriography is also useful in the
thoracic aorta, and a large central line in the subclavian or setting of a reduced IEI in patients with multiple candidate
internal jugular for resuscitation fluids. If a patient has lost sites of injury along the vascular axis (i.e., penetrating
so much blood that they require CPR, it means that they have wounds at multiple levels of the extremity). This can be per-
most likely lost around 4 L of blood. That means that to even formed in the operating theater using local anesthetic and
begin the resuscitation eight units of blood are required. a cut-down on the common femoral artery. Once the artery
In my opinion, a further eight units are then required for is exposed, an umbilical vein catheter can be introduced via
the procedure and following that, a further eight units are limited arteriotomy. Modern day micropuncture catheters
required over the next few hours. This amounts to around (4 or 5 Fr) are also useful for this maneuver and may obviate
24 units of blood per patient who requires a resuscitative the need for an open operative exposure. Once the catheter
thoracotomy. Unless the blood bank is well-stocked, it is is positioned in the common femoral artery, an x-ray plate is
usually futile to begin resuscitating a patient who presents wrapped in a sterile drape and positioned beneath the area
with exsanguinating to hemorrhage in the austere environ- of interest on the injured lower extremity before injection of
ment as most blood banks contain 2 to 4 units of blood. 20 mL of contrast (usually 50% Hypaque) down the cath-
eter. Exposure should be timed to occur as the surgeon is
administering the last 2 mL of contrast (Fig. 27.21).36
Lower Limb Vascular Injuries In general, ligation above the trifurcation of the tibial
arteries should be avoided in order to reduce the likelihood
The diagnosis of extremity vascular trauma, including the of severe limb ischemia and amputation. Ligation of the
utility and effectiveness of continuous-wave Doppler and common femoral artery increases the risk of amputation
other imaging modalities, is detailed in Chapters 7 and 8. by 50% and the risk of limb loss associated with popliteal
To review, patients with hard signs of vascular injury man- artery ligation is 75%. As such, the proximal and midlevel
date immediate operative intervention, whereas patients lower extremity axial arteries should be repaired if at all
without hard signs but with suspicious injury patterns possible.29 The redundant nature of tibial artery circulation
should be monitored with an especially high index of to the leg and foot means that uninterrupted flow through
suspicion. Lower extremity injury patterns known to be one of the three vessels is all that is required to maintain
associated with vascular trauma include displaced medial limb viability and salvage. In other words, it is generally
tibial plateau fractures, distal femoral shaft fractures, and acceptable to ligate or leave unrepaired two of the three
gunshot wounds in proximity to lower limb neurovascu- tibial vessels as long as one remaining vessel is uninjured
lar structures. In these instances, the patient should be throughout its length.
 27 • Vascular Surgery in the Austere Environment 343

A B C

Fig. 27.22 A gunshot injury to the groin. (A) Initial extraperitoneal exposure of the external iliac artery to gain proximal control. (B) Arterial and venous
shunting to maintain perfusion, followed by fasciotomy. (C) Twelve hours later, the definitive procedure was performed using the long saphenous vein
from the other leg to repair the femoral artery and femoral vein.

Once the lower extremity vascular injury has been iden- should be reassessed. In all cases, but especially those in an
tified, proximal and distal control should be achieved. Oper- austere setting, the surgeon should consider whether it is
ating in virgin territory and staying out of the hematoma is necessary to complete the definitive operation during that
the preferred technique in most cases. For common femoral setting or to defer reconstruction until the patient is physi-
artery injuries, this requires either division of the inguinal ologically improved. Having the shunt in place also allows
ligament or an extraperitoneal approach to the external one to assess whether vascular reconstruction is even nec-
iliac artery to gain proximal control (Fig. 27.22). Below the essary as the shunt can be temporarily occluded and distal
hematoma, the vessels are isolated and clamped. In rou- limb perfusion can be assessed with the continuous-wave
tine developed-world practice, Fogarty catheters are used Doppler. In some instances in which collateral circulation
to ensure good inflow and backflow and to remove throm- has been preserved, there may be an arterial signal in the
bus. If Fogarty catheters are not available and if thrombus leg or foot distal to the manually occluded shunt. In these
seems to be present (manifested by poor inflow), the clamp cases, it may be that arterial repair can be delayed for a
is applied more proximally in an area of good pulsation and period of time or even indefinitely. Ligating the axial artery
a small arteriotomy is made below this level. An umbilical and leaving the leg and foot relatively ischemic but viable
catheter may then be inserted and the thrombus washed may be the appropriate damage control maneuver in some
out by attaching the spigotted end to a syringe and infusing cases in the austere setting. In these instances, the leg and
copious amounts of heparinized saline until one is confi- foot can be monitored with repeat IEI measurements and
dent that the artery is clear of thrombus. This action can assessment for clinical signs of ischemia. Revascularization
be performed on the distal outflow vessel as well. It is very can then be performed at an interval period of time if isch-
important to close the small arteriotomy carefully so as not emia worsens, although this may be deferred for weeks or
to cause any intimal injury. This author has used this tech- longer if collateral circulation is significant.
nique on several occasions to be confident in securing opti- This author has frequently left a shunt in place for
mal inflow and backflow from the distal vessel. 24 hours and brought the patient back to the operating the-
Once the vascular injury site has been controlled and the ater the following day. Vascular shunts have been used for
bleeding stopped, it is important to take stock of the situa- many years to maintain perfusion of injured limbs during
tion. Questions that may be particularly relevant in an aus- transfer to other facilities and have been known to remain
tere setting include: How much blood has been lost? How patent for up to 54 hours.37–40 Temporary shunts permit
long ago did the injury occur? What resources (i.e., surgi- time for a fuller appreciation and surgical treatment of the
cal tools, blood bank) are available? What is the physiol- injury, allowing for the complete débridement of nonviable
ogy of the patient? In the austere setting, the surgeon may soft tissue before committing to definitive vascular proce-
not have access to sophisticated blood-serum analysis but dure. Shunting also allows for the proper consideration of
can assume that the patient who has lost 1 L or more of definitive soft-tissue coverage options, using muscle or a fas-
blood from an arterial injury is physiologically unwell. In ciocutaneous flap to cover the vascular reconstruction. In
these situations, this author makes liberal use of damage this way, one may avoid the situation in which a perfectly
control vascular techniques, including use of a temporary good vascular repair has been performed only for the recon-
vascular shunt to preserve blood flow and to limit extrem- struction to span a soft-tissue defect that has no support or
ity ischemia time. In cases of combined arterial and venous possibility of soft-tissue coverage.
trauma, one may use a shunt in both the artery and the The long saphenous vein from the extremity contra-
vein because maintenance of venous outflow may contrib- lateral to the injury is the preferred conduit for definitive
ute to arterial patency. Shunting the vein first also reduces vascular repair. Although the saphenous vein from the
venous bleeding once arterial flow has been reestablished. injured extremity can be used, if there is a concomitant
Following control of the vascular injury and placement venous injury in the limb, that saphenous vein may provide
of a temporary vascular shunt or shunts, the situation an element of venous return making its harvest ill-advised.
344 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 27.23 (A and B) Consider primary amputation as the procedure of choice in a resource-limited environment.

Major veins of the lower limb should be repaired with the

FUTILITY OF TREATMENT
same care as arterial injuries. The femoropopliteal vein When dealing with extremity vascular trauma in the aus-
is usually repaired first to allow for venous return before tere environment, it is not always easy to make the right
repairing any artery injury. Ligation of major veins in the decision in regard to limb salvage. Significant risk of mor-
lower limbs (external iliac, common femoral, superficial tality and morbidity follows a failed attempt at limb salvage.
femoral) results in significant edema in 50% of patients There are at least five scoring systems available to assist
compared with 7% after repair.27 There may also be an one in making the decision as to whether to amputate the
argument for the necessity of popliteal vein reconstruction extremity or to perform a limb-saving procedure.43 However,
to prevent limb loss.41 However, this should be considered in reports suggest that these scoring systems are not reliable44;
the context of the physiology of the patient and operative and, moreover, there are no scoring systems that relate to
time required. If deemed inappropriate, ligation of lower the austere environment.
extremity venous injury may have to be performed as a mat- In the author's opinion, limb salvage in the austere envi-
ter of damage control. ronment should be considered only if the following five con-
The absolute indications for fasciotomy include pro- ditions are met:
longed ischemia time, combined arteriovenous injury, com-
plex injuries (including bone and soft tissue), and crush 1. There was less than 6 hours' time from point of injury.
injury. However, in the austere environment, prophylactic 2. There was less than 30% soft-tissue loss.
fasciotomy should be routine because time scales cannot 3. Bone shaft is in continuity. If fractured, the ends are fixed
be assumed and preoperative information (i.e., injury tim- in continuity with external fixation.
ing, circumstances) is frequently misleading. Furthermore, 4. Major nerve damage is easily repairable (i.e., less than 2
it is unlikely, in the resource-limited environment, that the to 3 cm segmental loss).
surgeon will be able to closely monitor and reassess the 5. Vascular reconstruction is able to be covered with viable
patient in whom there is a concern for the development of and available soft tissue.
compartment syndrome. Ideally, the fasciotomy should be
performed before the orthopedic and vascular procedures. In the author's experience, if these conditions are not
There are some who doubt whether routine fasciotomy is present and the surgeon is in a significantly resource-lim-
necessary, citing the risk of infection and long-term conse- ited environment, primary amputation is the procedure of
quences. However, routine fasciotomy is this author's stan- choice (Fig. 27.23).
dard practice, especially in the austere setting.42
In summary, in the setting of a mangled extremity in
which there is a fracture and a major vascular injury, this Soft-Tissue Injury
author's preferred order of management is as follows: (1)
exploration and control (proximal and distal) of the injury, The management of the soft-tissue defect associated with
(2) performance of fasciotomy, (3) placement of a tempo- vascular trauma is important to consider. Misdirected
rary vascular shunt, (4) débridement of soft-tissue wounds, attempts to preserve local tissue for vascular coverage can
(5) external fixation of the fracture, and (6) harvest of long lead to inadequate débridement, wound sepsis, and more
saphenous vein and definitive vascular repair after the extensive secondary débridement resulting in further expo-
patient is physiologically improved. The vascular recon- sure of the repaired vessel at the base of a necrotic and
struction should then be covered by muscle and the wounds contaminated wound. The common sequel in this unfortu-
dressed with fluffed-up gauze held in place by a light crepe nate situation is delayed and often life-threatening hemor-
bandage. The wounds should not be touched by anyone rhage from an exposed and disrupted vascular anastomosis,
other than the surgeon, and, after 5 days, the patient should necessitating emergency ligation. This is a disaster and
be returned to the operating theater, the dressings removed, leads to outcomes no better than those observed more than
and the wound closed by delayed primary closure or split 60 years ago during the World War II. If the initial vascular
skin graft. operation is not performed properly, the problem is merely
 27 • Vascular Surgery in the Austere Environment 345

passed from one surgeon, as he or she leaves the mission, muscle flaps that this author considers most useful for the
to the incoming clinician who has to pick up these pieces vascular surgeon to learn.
while wondering whether the patient would have done bet-
ter with ligation and a primary amputation.
Therefore it is incumbent on the surgeon who intends VASCULARIZED COMPOSITE MUSCLE FLAPS FOR
to practice in the austere environment to learn the tech- COVERAGE OF VASCULAR RECONSTRUCTION
niques that will enable graft coverage, including the
raising of muscle flaps followed by a split skin graft. The Brachioradialis Flap
technique of fasciocutaneous grafts is also important for Fig. 27.24 depicts a gunshot wound to the distal brachial
surgeons in these challenging situations to understand. artery whereby both the distal brachial and radial and the
There are many opportunities to learn such techniques ulnar arteries were significantly damaged. A long saphe-
through attending various flap courses, watching and assist- nous vein graft was performed to the brachial and radial
ing plastic surgical colleagues, and reading the extensive artery and covered by the brachioradialis muscle after pre-
literature that is available.45,46 Box 27.1 summarizes the serving its blood supply from the distal radial artery. The
patient subsequently underwent a split skin graft with an
excellent result.
Box 27.1 Muscle and Fasciocutaneous Flaps Rectus Abdominus Flap
Neck, supraclavicular fossa, axilla, and upper arm This is an excellent flap based on the inferior epigastric
Sternocleidomastoid artery and is used to cover large soft-tissue defect over the
Pectoralis major groin when there is insufficient sartorius muscle to permit
Latissimus dorsi coverage of exposed vessels. An incision is made in the groin
Antecubital fossa to proximal forearm crease 3 cm above the inguinal ligament, and the rectus
Flexor digitorum
muscle is harvested up to the interdigitations with the cos-
Brachioradialis
Radial forearm flap
tal cartilage. It is mobilized off of the posterior rectus sheath
Forearm fasciocutaneous flap after ligation of the superior epigastric artery and is swung
Chest down over the groin defect (Fig. 27.25).
Pectoralis major
Omentum
Soleus and Gastrocnemius Muscle Flaps
Rectus abdominus Soleus muscle provides a very useful flap to cover distal leg
Latissimus dorsi wounds. The soleus muscle has two pedicles from the pos-
Groin to upper thigh terior tibial and peroneal arteries, which supply the muscle
Groin flap from both the proximal and distal sites. The muscle can
Rectus femoris
survive on either pedicle and can therefore be mobilized
Rectus abdominus
Tensor fascia lata
proximally or distally. The medial or lateral gastrocnemius
Sartorius muscle is also useful to mobilize to cover more proximal leg
Popliteal fossa to ankle wounds (Fig. 27.26).
Medial and lateral gastrocnemius
Cross-leg flap
Fasciocutaneous Flaps
Soleus In Fig. 27.27, a lateral malleolar flap is used to cover a
Vastus lateralis defect in the forefoot. Fig. 27.28 demonstrates a fasciocu-
Lateral malleolar flap taneous saphenous artery flap used to cover the tibia. The
Sural artery flap anterior border of the flap includes the long saphenous vein

A B

Fig. 27.24 (A and B) Brachioradialis flap.

346 SECTION 4 • The Management of Vascular Trauma

A B

C D

Fig. 27.25 Rectus abdominis flap. (A) Infected groin with ligation of the femoral vessels. The sartorius was destroyed. (B) Mobilization of the rectus
abdominis muscle. (C) The tunnel was created. (D) Coverage of the wound with the muscle.

Cross-Leg Flap
This is a very versatile fasciocutaneous flap, receiving its
blood supply from perforating branches, mainly the pos-
terior tibial artery. A 4-year-old boy was injured during
a barrel bomb attack in Syria. He had lost all the blood
vessels to his foot. Of course, the easiest solution would
have been to perform a primary below knee amputation.
However, a decision is made to use the long saphenous
vein of the non-injured leg and perform a tibioperoneal to
posterior tibial bypass (Fig. 27.31A). This was successful.
He also had an injury to his ankle which required exter-
nal fixation (Fig. 27.31B). After 24 hours, he was brought
back to the operating theatre where the distal anastomosis
was covered after harvesting a flap from the non-injured
leg based on perforating vessels. The flap was sutured to
the skin of the injured leg such that the vein graft was
covered (Fig. 27.31C). Both limbs were immobilized for
Fig. 27.26 Soleus muscle flap. 3 weeks to allow the flap to acquire a blood supply from
the donor leg. The flap was then cut and the legs separated
and the external fixator removed, and the boy was walking
to preserve the saphenous artery. Fig. 27.29 shows a groin after 6 weeks.
flap based on the superficial circumflex iliac artery covering
a distal ulnar artery anastomosis with significant tissue loss. Radial Forearm Flap
A sural artery flap used to cover a calcaneal defect can be The radial forearm flap, a fasciocutaneous free flap based
very useful to cover the posterior tibial artery (Fig. 27.30). on the radial artery with drainage from the cephalic vein,
 27 • Vascular Surgery in the Austere Environment 347

A B

Fig. 27.27 (A) Lateral malleolar flap. (B) Lateral malleolar flap after 5 days.

Fig. 27.29 Groin flap used to cover ulna artery anastomosis.

Forequarter Amputation
Sometimes it is necessary to perform difficult amputa-
tions (Fig. 27.33), and it is always worth carrying a USB
stick containing the steps required to perform these taxing
procedures. One does not want to be caught out and to be
required to receive instructions via a text message!47

Working in Austere Environments

B
This chapter has focused particularly on vascular surgery,
but, as can be seen, this specialty overlaps general, ortho-
Fig. 27.28 (A and B) Saphenous fasciocutaneous flap. pedic, and plastic surgery. For the surgeon to be able to
do the best for his or her patients in the austere environ-
ment requires a degree of proficiency in all of these areas.
It is true that in austere environments a vascular surgeon
can be mobilized to cover posterior defects and any part of must, by necessity, become the type of general surgeon seen
the forearm or distal upper limb (Fig. 27.32). The size of the before the rise of superspecialization. In these challeng-
radial artery lends itself to perhaps the only flap that can be ing environments, one's hand is also likely to be turned to
harvested and used as a free flap in the austere environment urology, neurosurgery, pediatric surgery, and obstetrics and
as it is possible to anastomose the radial artery to any artery gynecology, among other medical disciplines. To train or
using loops and therefore does not require a microscope. to prepare for these challenging but extremely rewarding
348 SECTION 4 • The Management of Vascular Trauma

A B

Fig. 27.30 Sural artery flap in a child with skin loss over the calcaneum.

Fig. 27.31 (A) Tibioperoneal to posterior tibial artery reversed long

saphenous vein grafting for blast injury in a 4-year-old child. (B) Exter-
B nal fixation. (C) Cross-leg flap.
 27 • Vascular Surgery in the Austere Environment 349

C B

Fig. 27.32 (A–C) A radial artery flap.

A B C

Fig. 27.33 (A–C) Forequarter amputation.

situations, one must commit to learning the skills and the just expert surgical skill and technique. Accomplishing aus-
knowledge required, including observing and working with tere missions, whether during wartime situations or Third
colleagues, attending courses, and participating with an World medical missions, requires coping with stress associ-
experienced group during such austere missions. ated with being away from home in a country with differ-
One such course which the author directs is called the ent cultures and different religious beliefs. In these settings,
Surgical Training for the Austere Environment. It is a 5-day one's team frequently consists of known partners and/or
course which takes a surgeon through all the specialties friends but also of expats from all over the world who have
that are required before going on a mission. The course runs their own cultures. Because of this, one must be prepared to
twice a year in London. Due to its expense, the author set adapt and to become part of a unit that is both insular and
up the David Nott Foundation which offers scholarships to yet diverse.
any surgeon in the world to attend this course. The scholar- There is no doubt that it is getting more dangerous to
ships pay for travel, food, accommodation, and course fees. work abroad in conflict zones and that security cannot be
Each course for the past 4 years has had 14 scholarships guaranteed even when working for the established and well-
awarded. Those interested are requested to apply via www. known agencies such as the International Committee of the
Davidnottfoundation.com. Red Cross (ICRC) and Medecins sans Frontieres (MSF). A
Successfully completing an austere medical or surgical recent symposium in London entitled “Health Care in Dan-
mission requires mental and physical resiliency and not ger” highlighted the problems faced by health workers.48
350 SECTION 4 • The Management of Vascular Trauma

It is paramount that one obeys all of the security rules of 8. Bove T, Van den Brande P. Is the use of ankle saphenous vein for carotid
the organization that one deploys with. Although one's artery patch closure justified? Acta Chir Belg. 1995;95:275–277.
9. O’Hara PJ, Hertzer NR, Krajewski LP, Beven EG. Saphenous vein patch
freedom of movement might be significantly limited during rupture after carotid endarterectomy. J Vasc Surg. 1992;15:504–509.
an austere surgical mission, such precaution is often neces- 10. Galante JM, London JA, Pevec WC. External-internal carotid artery
sary not only for personal safety but also for the safety and transposition for repair of multiple pseudoaneurysms from penetrat-
success of the larger project. ing injury in a pediatric patient. J Pediatr Surg. 2009;44:E27–E30.
11. Hill SJ, Thomas JM, Nott DM. Reconstruction of the iliofemoral venous
On coming home from a deployment or a mission, it is circulation using internal jugular vein autograft. Ann R Coll Surg Engl.
important to attend available debriefing sessions. These 1997;79:460–461.
sessions improve resiliency, draw a line under one's period 12. Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the les-
away, and help one complete the mission. If one immedi- sons from conflict: pre-hospital cervical spine stabilisation following
ately returns to a normal work and family schedule without ballistic neck trauma. Injury. 2009;40:1342–1345.
13. Wood J, Fabian TC, Mangiante EC. Penetrating neck injuries. Recom-
a period of time to decompress, it may be difficult to adapt. mendations for selective management. J Trauma. 1989;29:602–605.
It is not uncommon for surgeons who have been on medi- 14. Teehan EP, Padberg FT, Thompson PN, et al. Carotid arterial trauma:
cal or surgical missions to have feelings of guilt relating to assessment with the Glasgow Coma Scale (GCS) as a guide to surgical
the native people cared for and left behind. If not addressed management. Cardiovasc Surg. 1997;5:196–200.
15. He J, Liu H, Hunag B, et al. Investigation of morphology and anatomic
properly and professionally, these recollections and senti- variations, of circle of Willis and measurement of diameter of cere-
ments can percolate into and even overwhelm one's work bral arteries by 3D-TOF angiography. Sheng Wu Yi Xue Gong Cheng Xue
and home life. If one has spent time in a particularly dan- Za Zhi. 2007;24:39–44.
gerous situation, it does take time to get over this, and it is 16. Kakkar S, Angelini P, Leachman R, Cooley DA. Successful closure of
important to keep in contact with others who have been on post-traumatic carotid-jugular arteriovenous fistula complicated by
congestive heart failure and cerebrovascular insufficiency. Cardiovasc
the mission to share experiences and improve resiliency. It Dis. 1979;6:457–462.
is normal for one to feel elated on return from an austere 17. Connolly JE, Kwaan JHM, Stemmer EA. Improved results with carotid
mission, only for a more reflective mood and even sadness endarterectomy. Ann Surgery. 1977;186:334–340.
to follow. However, intentional steps to debrief, decompress, 18. Bagheri SC, Khan A, Bell RB. Penetrating neck injuries. Oral Maxil-
lofacial Surg Clin N Am. 2008;20:393–414.
and improve resiliency are generally effective. 19. Losken A, Rozycki GS, Feliciano DV. The use of the sternocleidomas-
The beauty of an austere mission lies in one's challenging toid muscle flap in combined injuries to the esophagus and carotid
but extremely rewarding role as a physician and surgeon. artery or trachea. J Trauma. 2000;49:815–817.
In these settings, one's job is to perform the operations and 20. Dossa C, Shepard AD, Wolford DG, Reddy DJ, Ernst CB. Distal internal
look after the patients on the ward while being mindful that carotid exposure: a simplified technique for temporary mandibular
subluxation. J Vasc Surg. 1990;12:319–325.
many surgeons who have passed through the mission, as 21. Larsen PE, Smead WL. Vertical ramus osteotomy for improved expo-
well as the local staff, have been in that setting over a long sure of the distal internal carotid artery: a new technique. J Vasc Surg.
period of time. It is likely that these and others associated 1992;15:226–231.
with the mission have seen it all. As always, the surgeon 22. Coll DP, Lerardi R, Mermer RW, Matsumoto T, Kerstein MD. Exposure
of the distal internal carotid artery: a simplified approach. J Am Coll
should treat the team with humility, understanding that his Surg. 1998;186:92–95.
or her role is only for a finite period of time whereas many 23. Abbott LC, Lucas DB. The function of the clavicle: its surgical signifi-
of those working in the mission will have to endure the cance. Ann Surg. 1954;140:583–597.
stresses of the situation for much longer periods of time. As 24. Maylivahanan N, Mellor I, Malawar MM. Claviculectomy for bone
always, one should avoid engaging in the politics of the situ- tumors. Indian J Orthop. 2006;40:115–118.
25. Mohiuddin C, Kirton OC, Lukose D, Gallagher J. Ligation of the sub-
ation, should never diminish the value of a team member, clavian artery after blunt trauma presenting as massive hemothorax.
and should leave the frustrations one has at home. Medical J Trauma. 2008;64:1126–1130.
and surgical missions in the austere environment are truly 26. Demetriades D, Chahwan S, Gomez H, et al. Penetrating injuries to the
in a different place and time. One should engage the mis- subclavian and axillary vessels. J Am Coll Surg. 1999;188:290–295.
sion, enjoy it, and give it his or her best shot! 27. Agarwal N, Shah PM, Clauss RH, Reynolds BM, Stahl WM. Experience
with 115 civilian venous injuries. J Trauma. 1982;22:827–832.
28. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War
References II. Ann Surg. 1946;123:534–536.
1. Dennis JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS. Vali- 29. Cattell RB, Braasch JW. A technique for exposure of the third and
dation of nonoperative management of occult vascular injuries and fourth portions of the duodenum. Surg Gynecol Obstet. 1960;111:
accuracy of physical examination alone in penetrating extremity 378–379.
trauma: 5- to 10-year follow-up. J Trauma. 1998;44:243–253. 30. Asensio JA, Chahwan S, Hanpeter D, et al. Operative manage-
2. Sofianos C, Degiannis E, Van den Aardweg MS, Levy RD, Naidu M, ment and outcome of 302 abdominal vascular injuries. Am J Surg.
Saadia R. Selective surgical management of zone II gunshot injuries 2000;180:528–534.
of the neck: a prospective study. Surgery. 1996;120:785–788. 31. Stannard AK, Brown C, Benson J, Clasper J, Midwinter M, Tai NR. Out-
3. Demetriades D, Charalambides D, Lakhoo M. Physical examination come after vascular trauma in a deployed military trauma system. Br J
and selective conservative management in patients with penetrating Surg. 2011;98:228–234.
injuries of the neck. Br J Surg. 1993;80:1534–1536. 32. Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control:
4. Atteberry LR, Dennis JW, Menawat SS, Frykberg ER. Physical exami- an approach for improved survival in exsanguinating penetrating
nation alone is safe and accurate for evaluation of vascular injuries in abdominal injury. J Trauma. 1993;35:375–382.
penetrating zone II neck trauma. J Am Coll Surg. 1994;179:657–662. 33. Lynch K, Johansen K. Can Doppler pressure measurement replace
5. Bishara RA, Pasch AR, Douglas DD, Schuler JJ, Lim LT, Flanigan DP. “exclusion” arteriography in the diagnosis of occult extremity
The necessity of mandatory exploration of penetrating zone II neck trauma? Ann Surg. 1991;214:737–741.
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6. Meyer JP, Barret JA, Schuler JJ, Flanigan DP. Mandatory vs selec- rent Vascular Surgical Diagnosis and Treatment. Norwalk, CT: Appleton
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592–597. 35. Levy BA, Zlowodzki MP, Graves M, Cole PA. Screening for extrem-
7. Apfelstaedt JP, Muller R. Results of mandatory exploration for pen- ity arterial injury with the arterial pressure index. Am J Emerg Med.
etrating neck trauma. World J Surg. 1994;18:917–920. 2005;23:689–695.
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36. O’Gorman RB, Feliciano DV. Arteriography performed in the emer- 42. Abouezzi Z, Nassoura Z, Ivatury RR, Porter JM, Stahl WM. A criti-
gency center. Am J Surg. 1986;152:323–325. cal reappraisal of indications for fasciotomy after extremity vascular
37. Eger M, Goldman L, Goldstein A, Hirsch M. The use of a temporary trauma. Arch Surg. 1998;133:547–551.
shunt in the management of arterial vascular injuries. Surg Gynaecol 43. Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ, LEAP
Obstet. 1971;132:67–70. Study Group. Ability of lower-extremity injury severity scores to
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The use of temporary vascular shunts as a damage control, adjunct in 2008;90:1738–1743.
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39. Ding W, Wu X, Li J. Temporary intravascular shunts used as a damage the clinical utility of the lower-extremity injury-severity scores. J Bone
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 SECTION 5
G­lo­bal P­er­sp­ectives on
Vascular Trauma

352
 28 Australia and New Zealand
IAN D. CIVIL

Region-Specific Epidemiology land. In general, it is not well systematized, although the

state of Victoria in Australia has run an effective statewide
Australia and New Zealand have a combined population trauma system since the early 2000s and has been able to
of approximately 30 million people (approximately the demonstrate both a significant reduction in mortality and
population of Texas) spread over a very large land mass of an improved functional outcome for survivors.10,11 The
nearly 8 million square kilometers (roughly the size of the American College of Surgeons (ACS) verification system has
continental United States). In Australia and New Zealand, been adopted by the Royal Australasian College of Surgeons
ownership and use of firearms and, in particular, handguns (RACS), and some hospitals and regions have embraced this
is limited by strict laws. With large farming areas in both process improvement strategy in systems for the delivery of
countries, firearms are present but at a much lower per cap- care. In general, however, trauma care is provided by a range
ita rate than in the United States (26.3 guns per 100 people of hospitals whose size and capability vary widely. In the
in New Zealand; 14.5 guns per 100 people in Australia; large metropolitan centers of Australia and New Zealand,
120.5 guns per 100 people in the United States).1 Addition- there exist hospitals that match to a greater or lesser degree
ally, the incidence of a mass shooting events in Australia the trauma care capabilities of an ACS level I trauma center.
and New Zealand has been very low but these do occur spo- In the regional and provincial areas, base hospitals usually
radically.2 have the capabilities of an ACS level III center. In more rural
As in most countries, despite being illegal, the carrying and remote areas, trauma capabilities are limited. In the rural
of knives is harder to police. Among most cultural groups areas, most trauma patients are taken to the nearest regional
in Australia and New Zealand, interpersonal violence most hospital, which is the only real option. In the cities and urban
commonly involves blunt mechanisms rather than stab- areas, there is usually some form of geographic boundary
bings or shootings.3 As a result the vast majority (over used to define the receiving medical center. Only in Victoria
90%) of trauma in both Australia and New Zealand is of a has a really effective destination policy been developed that is
blunt mechanism with penetrating mechanisms being the highly efficient in ensuring major trauma patients are taken
cause in less than 10% of trauma patients.4 Most vascular to one of only two adult or one pediatric (level I) centers.
trauma that occurs in the community is therefore to lower
extremity vessels in association with fractures and disloca-
tions (Fig. 28.1), to the thoracic aorta in association with Surgical Training and Certification
deceleration injury (Fig. 28.2), and to the cervical vessels
in association with blunt trauma (Fig. 28.3). Penetrating The RACS is the only training oversight body for surgeons in
trauma occurs with the usual distribution of injury from Australia and New Zealand, and the College trains in nine
accidental injuries such as arms lacerated when placed surgical disciplines including vascular surgery. Prior to 1997,
though windows and, less commonly, from interpersonal vascular surgery was integral to general surgical training
violence with firearms. Given the increasing rate of endo- with further expertise being available in post-fellowship posi-
vascular procedures performed by a range of providers and tions, but lately there has been a separate training program
in areas such as in intensive care units (ICUs), a significant that has graduated up to 10 vascular surgeons per year. There
proportion of penetrating vascular trauma in Australia and is no separate training program in trauma surgery, and addi-
New Zealand arises from iatrogenic mechanisms (e.g., dam- tional expertise in this area, beyond what might be obtained
age to the femoral, the subclavian, and the carotid vessels).5 in general, orthopedic, neurosurgical, or vascular surgical
Long-established institutional registries such as the Auck- training, is only available in post-fellowship programs either
land City Hospital Trauma Registry established in 1994, and within Australia and New Zealand or overseas. Thus, it is
other cumulative reports, indicate an incidence of vascular possible to be deemed by the registering authorities as a certi-
injury comprising approximately 1.5% of trauma admis- fied general surgeon or a certified vascular surgeon, but not a
sions.6–8 In this extensive trauma experience, roughly 75% certified trauma surgeon as this specialty is not one of those
of vascular injuries have occurred due to blunt mechanisms recognized by the regulatory entities. Overall, in New Zealand
and 25% from penetrating mechanisms. Since the 1990s, and Australia there is approximately 1 surgeon for every
there have been no major changes in the etiology of vascu- 6000 people. However, with respect to the specific specialties
lar trauma, although the absolute numbers have increased likely to manage vascular trauma, there is 1 general surgeon
gradually in line with population growth.9 for every 16,000 persons and 1 vascular surgeon for every
145,000 (RACS surgical workforce projections 2025).12

Region-Specific Systems of Care Access to Care

There is considerable variation in the systems of care under In Australia and New Zealand there are private health-care
which trauma care is provided in Australia and New Zea- systems, but most trauma and acute care is managed within
353
354 SECTION 5 • Global Perspectives on Vascular Trauma

Fig. 28.3 Common carotid traumatic dissection secondary to blunt

trauma.

the hospital are managed in the public or national health-

care program.

Fig. 28.1 Dislocated knee associated with distal ischemia. Prehospital Care
Prehospital care in New Zealand is provided by a single
prehospital provider in each geographic area. One pro-
vider, the Order of St John, is responsible for over 90% of
all prehospital care in New Zealand. There is a single emer-
gency telephone number, and three mirrored call centers
manage all emergency ambulance calls. Although tasked
by these call centers, air ambulances are not part of the
road provider system, but, like it, they are funded largely
by the government for noninjury work. For patients suffer-
ing injury, funding is mainly by the Accident Compensa-
tion Corporation as well as by sponsorship and charitable
donations. In Australia, each state and territory has its own
ambulance system and integrated air ambulances.
Advanced Trauma Life Support (ATLS) was introduced
into Australia and New Zealand in 1988 (referred to as
Early Management of Severe Trauma), and it has been
mandatory for all surgical trainees since 1994. Since 1997,
the Definitive Surgical Trauma Care (DSTC) course has
been run in Australia and, since 2003, in New Zealand,
and there are currently four courses in Australia and one in
Fig. 28.2 Computed tomography (CT) showing blunt thoracic aortic New Zealand each year. DTSC is strongly recommended by
rupture. the General Surgeons' associations for trainees who began
training in 2012. In 2017, the ACS ASSET course was run
in Sydney and there are plans for annual provision of this
the public or national health-care system. This system vascular anatomic exposure course to be run using locally
affords a baseline of routine and emergency care for all trained instructors together with internationally qualified
citizens of Australia and New Zealand. Personal, private, or faculty.
government-supported insurance allows patients to access
the private system for semi-acute and elective needs, and in
New Zealand a universal no-fault accident insurance (Acci-
dent Compensation Corporation) allows private care of Region-Specific Considerations for
injuries after the first 10 days postinjury (unless the patient Diagnosis
is still an inpatient in a public health-care facility, which is
then obligated to continue providing care). Almost all epi- As most vascular trauma is the result of a blunt mecha-
sodes of trauma significant enough to warrant admission to nism, evidence-based contemporary diagnostic strategies
 28 • Australia and New Zealand 355

are in place. Clinical examination, the ankle-brachial practice has been associated with excellent results, and, in
index (ABI) Doppler, and the computed tomography angi- a population that is somewhat easier to follow than some
ography (CTA) are commonly used as diagnostic modalities regions of the world, endovascular repair in Australia and
for lower extremity vascular trauma. Chest radiography – New Zealand has been associated with few mid- and long-
followed by contrast-enhanced CTA of the chest, abdo- term problems.14
men, and pelvis – is the common approach for injuries In the setting of penetrating trauma to the limb or a
significant enough to risk blunt aortic injury. As in many severely mangled extremity (including traumatic ampu-
parts of the world, blunt cervical vascular injury has tation), Australia and New Zealand have recognized
been underappreciated with rates of approximately 0.2% the importance and utility of modern tourniquets. Led
of trauma admissions.13 With greater use of a screening by recent military experience and study, tourniquets
protocol and much more liberal use of CTA concurrent have been deemed important in civilian circumstances,
with CT imaging of the head and C-spine, the diagnosed and all ambulances used for acute response to trauma
incidence of cervical vascular injury is now closer to 1%. in New Zealand are equipped with two combat action
Penetrating vascular trauma is often associated with hard tourniquets (CAT). Since initiation of this policy, there
signs of vascular injury, such as hemorrhage or profound have been numerous anecdotal experiences of tourni-
ischemia. As has been well outlined in this textbook, in the quet application controlling extremity hemorrhage and
absence of hard signs, further evaluation using CTA or allowing the injured patient to be quickly stabilized. In
duplex ultrasound is typical in most centers in Australia these cases, hemorrhage has been controlled at or close
and New Zealand. to the scene of injury with the tourniquet, and initiation
of resuscitation, transport to the hospital, and even oper-
ative repair have been conducted in controlled circum-
stances (Fig. 28.5).
Region-Specific Treatment Penetrating neck injuries are uncommon, and tradi­
Strategies tionally those in zone II (between the cricothyroid cartilage
and the angle of the mandible), having penetrated the
With a large focus on blunt thoracic aortic injury, Aus- platysma, underwent operative exploration. More recently,
tralian and New Zealand surgeons have been quick to in the era of sensitive and specific contrast CTA, a recogni­
embrace endovascular technology for the repair of these tion has developed that in the absence of hard signs,
injuries. Since approximately 2005, the vast majority of the likelihood of vascular or visceral injury is low. This
blunt aortic injuries in both countries have been repaired evolution has led to a modern practice in Australia and
with endovascular stent grafts, nearly all of which have New Zealand of selective exploration, in which many
been placed by certified vascular surgeons (Fig. 28.4). This penetrating neck wounds are now imaged with CTA and
observed.15 Because of the low incidence of penetrating
trauma, as well as what are generally longer transport
times in most parts of Australia and New Zealand, the need
for resuscitative thoracotomy is extremely rare. However,
this potentially lifesaving maneuver is still taught to
general surgical trainees as part of the DSTC course, and,
occasionally, there are reports of its successful application
in Australasia.

Fig. 28.4 Aortogram showing placement of a thoracic aortic stent Fig. 28.5 A combat-action tourniquet applied to a patient with a
graft. laceration of the brachial artery.
356 SECTION 5 • Global Perspectives on Vascular Trauma

Strategies to Sustain and Train individual and institutional practices to assist in training
the future generation of trauma specialists.
the Next Generation of Trauma
Surgeons References
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reports/RPT_RACS_Workforce-Projection-to-2025_FIN.pdf ?rev=f9
treatment of blunt aortic and other patterns amenable to 982c1cce9b46b1bc59774a739ab730. Accessed 9 July 2019.
this less-invasive approach. 13. Beliaev AM, Barber P, Marshall RJ, Civil I. Denver screening protocol
Because of the challenges associated with low volumes for blunt cerebrovascular injury reduces the use of multidetector com-
of vascular trauma, surgical graduates from either vascu- puted tomography angiography. Aust NZ J Surg. 2014;84:429–432.
lar surgery or general surgery with an interest in trauma 14. Khashram M, He Q, Oh T, et al. Late radiological and clinical outcomes
of traumatic thoracic aortic injury managed with thoracic endovas-
are encouraged to work for a period overseas in a region cular aortic repair. World J Surg. 2016;40:1763–1770.
with a high incidence of penetrating trauma and to bring 15. Insull P, Adams D, Segar A, Ng A, Civil I. Is exploration mandatory in
this experience back to Australia and New Zealand to their penetrating zone 2 neck injuries? Aust NZ J Surg. 2007;77:261–264.
 29 Sri Lanka
AMILA SANJIVA RATNAYAKE, SANJEEWA H. MUNASINGHE, and
SUJEEWA P.B. THALGASPITIYA

Introduction by popliteal artery (6). Four out of six limbs (66.6%) with
popliteal arterial injuries had to be amputated, in contrast
In 2009 Sri Lanka emerged from a civil war which was mainly to only 2 out of 17 (11.7%) limbs in the superficial femoral
fought in the Northern and Eastern parts of the country and artery group.2
spanned 26 years. During this war, soldiers (and to a lesser
degree civilians) in the conflict zones sustained injuries due
to high-velocity gunshots, artillery, mortars, rocket-propelled Epidemiology of Wartime Injury
grenades, and antipersonnel mines (APMs). Furthermore,
people living in villages bordering the conflict zone, Colombo COMBAT-RELATED GEOGRAPHY, TERRAIN,
(and the city’s suburbs), and other parts of the country were AND WEATHER
subjected to suicide bomb attacks.
Surgeons and vascular services faced a multitude of The conflict zone comprised heterogeneous vegetation
challenges managing these patients. They had to manage types: semiarid flat land with tropical thorn forests, dry
combatants who had sustained penetrating vascular inju- evergreen jungles, and bush-type vegetation.3 Occasion-
ries, traumatic amputations of the limbs, and civilians with ally, heavy fighting erupted in coastal areas where there
blast injuries. This was in addition to the normal burden was minimal cover, which took a heavy toll on both sides
of civilian injuries due to road traffic accidents, stabs, and due to concentrated artillery fire. In the urban and subur-
low-velocity gunshot injuries. ban terrains where close-range fighting occurred, injuries
Ten years after the war, the epidemiology of vascular sustained were predominantly due to small arms fire. In the
injuries has changed and new challenges have arisen. With last phase of war, a unique strategy used by the LTTE cadre
the improvement of road infrastructure and the resul- was to build 10-meter-high earth bunds-cum-ditches; the
tant increase of movement of people within the country, bunds were saturated with improvised antipersonnel mines
road traffic accidents have increased.1 An influx of weap- (iAPMs) causing multiple deaths and limb losses (Fig. 29.2).
ons and gunmen (who were formerly Liberation Tigers of Furthermore, the areas concerned were afflicted with
Tamil Eelam (LTTE) cadres) to the South has resulted in a seasonal North-Eastern monsoon rain from December to
rise in gunshot wounds occurring amongst members of February.4 Therefore, the terrain became water-logged, thus
drug cartels and the criminal underworld. The advent of making casualty evacuation extremely challenging. This in
endovascular procedures (246 endovascular laser abla- turn led to delay in admissions to role 3 military base hos-
tions; 19 angiographies, and 66 angioplasties in 2018 at pitals (MBHs). At other times, the scorching sun caused
the Teaching Hospital Anuradhapura [THA]), and subse- heatstroke to the combatants, particularly during the mass
quent increase in the numbers and complexity of such pro- withdrawal of the 3rd Eelam war.
cedures, has given rise to access site pseudoaneurysms.a A
unique type of injury sustained by the civilians of the dry
zones of Sri Lanka is the trap gun injury. The trap gun is a WAR TACTICS AND WEAPONS
locally made, illegal muzzle-loading firearm with a victim- During the 26 years of protracted war in Sri Lanka, there
activated trigger mechanism used by farmers to protect their were four main phases, with intervening periods of lesser
crops from wild animals and by poachers to obtain meat. activity and intensity, especially during ceasefire. During
The most common wild animal targeted is the wild boar, the active phases, forces engaged in conventional war with
hence the trip wire is adjusted to about 70 to 90 cm above a defined front line. They used high-velocity rifles (AK-47
the ground. As the gun cannot discriminate humans from and T-56), rocket-propelled grenades, 60-, 81-, and 120-
animals, an unsuspecting victim who activates the trigger mm mortars, and heavy artillery including 122-, 130-,
mechanism sustains injuries mainly in the vicinity of the and 152-mm howitzers. “No man’s land” was seeded with
thigh and knee, leading to superficial femoral and popliteal iAPMs with the aim of maiming rather than killing sol-
artery injuries (Fig. 29.1). In a study done at THA in 2007, diers. Unique to tiger guerrillas were improvised devises
there were 58 patients with trap gun injuries. Twenty-eight connecting multiple blast components together to inflict
victims sustained vascular injuries and the commonest ves- severe injuries on a number of victims at a given time. In
sel injured was the superficial femoral artery (17), followed addition, claymore mines were used; these fire steel balls
in a 60-degree arc, inflicting heavy damage to dismounted
Two documented access site pseudoaneurysms: personal communication
a troops.5
with Arudchelvam JD, MD, and Marasinghe A, MD, via email on 19th of APMs inflicted heavy tolls on infantry troops, which
April 2019. resulted in a large number of amputations and there

357
358 SECTION 5 • Global Perspectives on Vascular Trauma

A B

Fig. 29.1 (A) Trap gun, which is an improvised homemade devise. (B) Multiple pellet injuries in and around the knee of a victim. (Courtesy Dr. A.P. Nellihela)

vention was adopted by 133 signatories under the auspices

of the United Nations.8

DEMOGRAPHICS
In the last phase of the civil war, an incidence of vascular
injuries of 2.2% was reported in 5821 security personnel
injured between December 2008 and June 2009. High-
velocity rifle bullets (65/128) and natural and preformed
explosive fragments (52/128) were responsible for combined
arterial and venous injuries in 58 patients, arterial injuries
in 53, isolated major venous injuries in 11, and nonaxial
vessel injuries in 4. Injury types included 73 transections,
24 lacerations, 13 thromboses, 4 through-and-through
injuries, and 1 case of arterial spasm. Reconstruction with
interposition vein graft (IPVG) was the commonest mode of
repair (80/128) (Fig. 29.3).9

Fig. 29.2 Earth bund-cum-ditch—a unique tactic used in the last

phase of war in Sri Lanka. System of care
are around 6000 post-war amputees in the Sri Lankan Due to the intensity and nature of the protracted war,
Army. Most of these APMs were locally manufactured and compounded by the limitations of human and physi-
referred as “Jony mines” and intended to be triggered by the cal infrastructure, it was apparent that the Sri Lanka
victim stepping on it. The shock from the explosion drives Medical Corps alone could not manage the continuum of
dirt, clothing, metal, and plastic fragments into the soft tis- combat casualty care from the point of injury to rehabili-
sues with the ballistic effect causing blood vessels to throm- tation at tertiary care centers. The solution was to create
bose extensively beyond the visible injury zone. This in turn a uniquely hybrid approach by integrating military and
leads to ischemic and contaminated musculofascial layers civilian health systems coordinated at the highest level
at a high risk of infection and sepsis. Most of these victims in order to achieve a common goal. Resuscitation, stabi-
ended up with below-knee amputations and post-conflict lization, and transport out of the battle front was carried
rehabilitation of these amputees is a challenging task in out by field surgeons who were well-versed in managing
a resource-poor setting. Furthermore, the indiscriminate war casualties, whereas the brunt of definitive care was
nature of these mines caused civilian and animal injuries borne by civilian surgeons and health-care personnel in
during the war and post-war period.6 multiple tertiary care centers. A few Health Ministry Gen-
In a single-surgeon experience spanning a period of 26 eral Hospitals, located at the border of the conflict zone,
months commencing from June 1st, 1990, there were 191 were converted to centers dedicated to the management
victims of APM injuries. In this cohort, 153 (80%) were of battle trauma and these were provided with the nec-
victims of direct injuries to lower limbs (due to stepping on essary material and human resources. Ministry of Health
an APM) and 24 (12.6%) had shrapnel injury in multiple consultants, doctors, and nurses volunteered to work at
body regions by being close to the explosion. Ten (5.2%) had army base hospitals to cater for the number of casualties
injuries sustained while handling APMs and four victim’s threatening to overburden the military medical system.
data was not adequate for analysis. Of the 191, 113 (73%) This integrated military–civilian hybrid system of care
underwent below-knee amputation.7 was proven to be effective in Israel, where rapid dissemina-
In September 1997, with the clear aim of ending the suf- tion of knowledge gained during war was applied to civil-
fering caused by APMs, the Antipersonnel Mine Ban Con- ian trauma care.10
 29 • Sri Lanka 359

45

40

35
Other
30 Ligation
Number of vessels

Iry repair
25
IPVG
20

15

10

0
Axillary artery
Axillary vein

Brachial artery
Brachial vein

Forearm artery
Forearm vein

Illiac

Femoral artery
Femoral vein

Popliteal artery
Popliteal vein

Tibioperoneal artery
Tibioperoneal vein

Profunda femoris artery

Profunda femoris vein
Fig. 29.3 Anatomical distribution and types of
repair of 128 combatants who sustained military
vascular trauma. IPVG, Interposition vein graft; Iry,
primary.

MEDICAL
equipped with two operating theaters (Fig. 29.4C), a three-
The first line of care was sited in close proximity to the front bed intensive care unit, and an 80-bed ward.
line for provision of basic casualty care immediately after Complex vascular injuries that required combined
injury (Fig. 29.4A). This primary care included arrest of ­orthopedic and reconstructive services were transferred to
bleeding, establishment of intravenous access, pain relief, Colombo Army Hospital (CAH) and the National Hospital
and fracture immobilization. A variety of tourniquet types of Sri Lanka (NHSL), situated 199 km from Anuradhapura
were used to manage severely mangled extremities, from (equivalent to 5–6 hours of travelling time by road). All
a piece of twined cloth to improvised military tourniquets injured combatants ultimately ended up in CAH and Ragama
consisting of a belt and a buckle. Rehabilitation Hospital where they underwent rehabilitation.
The second line of care consisted of advance dressing sta-
tions (ADS) (Fig. 29.4B), main dressing stations (MDS), and
field hospitals. ADS facilities were sited equidistant from three ADMINISTRATIVE STRUCTURE
forward regimental aid points, around 400 to 5000 m behind When personnel were transferred from the point of injury
the front line. Typical ADS manning included a single medi- to tertiary care hospitals, their specific field medical card,
cal officer, two nurses, and three nurse assistants who were detailing injuries and management, accompanied them.
equipped and trained to handle emergency combat resusci- Details from these and the constant feedback received from
tation, including intubation, chest-drain insertion, arrest of medical field commanders (who visited the front line on a
bleeding, and infusion of intravenous fluids. A single MDS weekly basis) helped to identify shortcomings and formulate
facility was sited behind three ADSs, and had capability to treatment guidelines. Improvement was further facilitated
stabilize and airlift casualties to definitive care facilities. MDSs by the visit of the Director of Medical Services to the battle
were manned by one senior medical officer, four nurses, six front who, along with the consultants, proved instrumental
nurse assistants, and other supportive care personnel. Staff in improving logistics and upgrading the system of care.
at the MDS had the capacity to transfuse uncrossmatched
group O blood and to perform basic lifesaving surgical proce-
dures such as tracheotomies, emergency amputations, and Considerations for Diagnosis
wound exploration to achieve hemostasis.
The third line of care were MBHs and general hos- Like any other austere situations, diagnosis was primarily
pitals capable of delivering definitive surgical care via based on clinical skills learned at medical schools (hard and
specialized services that included vascular, orthopedic, soft signs of vascular injury) and sharpened by teaching from
oral-maxillofacial, neurosurgical, and intensive care unit senior colleagues and consultants at formal and informal
facilities. In 2008–09, the MBH in Anuradhapura, situated encounters. The management of pulsatile arterial bleeding
180 km away from the conflict zone, was converted to a cen- was straightforward as the challenge was to staunch bleed-
ter for definitive extremity vascular care. General surgeons ing and save life. More challenging was to manage patients
trained in vascular surgery were deployed to this ­hospital presenting with ischemia but no signs of overt bleeding,
to minimize the delay in revascularization. The MBH was particularly when the number of casualties delivered at any
360 SECTION 5 • Global Perspectives on Vascular Trauma

A B

Fig. 29.4 (A) Field care under austere condition. (B) Performing a limb fasciotomy at a main dressing station (MDS) with improvised proximal tourni-
quet in situ. (C) Operation Theater at Military Base Hospital Anuradhapura. (B, Courtesy Col. Kalana Wijewardane, MD.)

given time to role 1 and 2 MBHs stretched the capacity of from Operation Iraqi Freedom (OIF) and Operation Endur-
health care personnel. Medical attendants missed pulseless ing Freedom (OEF) demonstrating the efficacy of early use
limbs which were only detected at a later stage in the line of combat application tourniquets (CATs), training and for-
of care. Although clinical and Doppler assessment of each mation of guidelines in their use, and shortened evacuation
injured limb was performed at the base hospital (to record the timelines to minimize ischemia times.12–15
injured extremity index and so confirm and measure severity In the Sri Lankan theatres of war, where terrain, tempo,
of ischemia), this practice was not strictly adhered to at ADS and weather meant that evacuation times were prolonged
and MDS. Duplex and CT angiogram facilities were not avail- (5.5 hours; range 2.5–16.3) the liberal application of tour-
able at the base hospitals during the war, but they were avail- niquets was discouraged, with the exception of limbs so
able at CAH. X-rays were done at the MBH to detect fractures severely traumatized that amputation was likely. Applica-
and retained foreign bodies. tion of direct pressure and gauze packing, sometimes with
Limbs with full-blown ischemia detected too late to be sal- overlay sutures, was used to control bleeding, especially in
vaged had to be amputated. Other injuries which had trau- through-and-through wounds caused by bullets or small
matic arteriovenous fistulae and pseudoaneurysms were fragments, which helped to preserve collateral circulation,
managed at CAH both by open and endovascular methods. thus preserving both life and limb (Fig. 29.5A).16 Further-
more, where this did not control hemorrhage within the
Treatment strategies ADS/MDS setting, exploration and vessel ligation at ADS/
MDS were conducted. The overall efficacy of these prac-
tices is difficult to ascertain due to lack of reliable data on
HEMORRHAGE CONTROL
killed in action (KIA) and post mortem findings. Though
According to Brian Eastridge’s analysis of 4596 combat the practice of blind application of hemostats was clearly
deaths, hemorrhage is the most common cause of ­potentially discouraged, there was a single case recorded as present-
preventable death in the combat setting11 with experience ing to MBH where multiple hemostats had been hastily and
 29 • Sri Lanka 361

indiscriminately applied in the presence of catastrophic large soft tissue defect not amenable to simple gauze pack-
bleeding (Fig. 29.5B). ing where exploration and ligation of vessels at the earli-
Three patterns of bleeding limb wound were therefore est possible stage was required; and severely mangled limbs
identified: through-and-through injuries where packing likely to require amputation16 managed with improvised
and/or overlay suture could be employed; wounds with a tourniquets at the point of injury (Fig. 29.5C).

A B

Fig. 29.5 (A) Gauze packing in a through-and-through wound profile to achieve successful bleeding control. (B) Blind application of hemostatic clamps.
(C) Application of improvised tourniquets to arrest bleeding.
362 SECTION 5 • Global Perspectives on Vascular Trauma

MITIGATING ISCHEMIC INSULT (PROPHYLACTIC DEFINITIVE VASCULAR RECONSTRUCTION

FASCIOTOMY AND TEMPORARY INTRALUMINAL
Standard vascular reconstruction technique was employed
SHUNTING) where initially proximal and distal control of injured
The second challenge of vascular trauma is limb isch- vessels were achieved with rubber loops. Adequate débride-
emia and irrecoverable muscle necrosis resulting in limb ment of vessel ends, Fogarty embolectomy and local hep-
loss. Usually, this is diagnosed clinically, with presence arinized saline flushing were performed prior to reverse
of the classic “6 P” features (pallor, paralysis, paresthe- saphenous vein graft (RSVG) (Fig. 29.7). RSVG was neces-
sia, pain, pulselessness, poikilothermia) prompting the sary due to the extent of damage seen with ballistic injury
attending surgeons to employ four-quadrant fasciotomy and the degree of débridement required: the resulting gap
and ­temporary intraluminal shunting as soon as pos- could not be approximated without replacement conduit.
sible. The validity of the classical 6-hour cut-off time to RSVG was often harvested from the contralateral limb,
reperfusion has been scrutinized17–20 and the authors are employing a technique to prepare the vein in situ using a
currently investigating the impact of time as a variable in heparinized saline infusion via a 24-gauge cannula. The
clinical decision-making concerning vascular reconstruc- proximal anastomosis was performed first and graft per-
tion versus amputation. Ischemia was a common finding fused to gauge the correct length prior to completion of the
in our series of vascular injuries (89/128) with 21 cases distal anastomosis in order to prevent kinking of the graft.
undergoing four-quadrant fasciotomy at the field (MDS Systemic u­ nfractionated heparin (1000 U/h) was infused
setting) and 43 at MBH. Fasciotomy was found to facili- for 48 hours, unless contraindicated due to concomitant
tate assessment of viability (by electrical stimulation of torso or craniocerebral trauma.
muscles, color, and consistency) to aid decision-making as Vascular repair was done as the primary step ahead of soft
to whether to proceed with revascularization or not and, tissue débridement to minimize ischemic time. Muscle viabil-
when conducted for prophylactic reasons, to be an impor- ity was assessed using the time-tested criteria of contractility,
tant part of the response to war-time casualty treatment capillary bleeding, consistency, and color and erred towards
characterized by fragmentation of care, austerity, and conservatism, with any doubtful cases taken back to theater
unpredictable transfer times. Similarly, temporary intra- after 24 to 48 hours for reassessment. Soft tissue wounds
luminal shunting, using intravenous infusion giving–set were managed with serial wound lavage and débridement till
tubing, was employed to “buy time” on 14 patients where the wound bed was healthy for definitive closure. The major-
either multiple patient demand or the need to address ity of vascular repairs were primarily covered with soft tis-
other injuries demanded this damage-control technique sues using rotational flaps and wounds were dressed in bulky
(Fig. 29.6).9 gauze, cotton, and crepe bandage. Negative pressure wound
therapy was not available for consideration at the MBH.21
Most of the fasciotomy wounds were managed with serial
RESUSCITATION STRATEGY wound lavage and once the edema subsided, they were cov-
O positive packed blood was transfused (total 78 units at ered with split-thickness skin graft.
MDS and 160 units at MBH, respectively) as resuscita-
tion fluid in severely (class III or IV shock) compromised
patients. During this time, component therapy (damage MANAGING INFECTIONS
control resuscitation) was not practiced at either MDS or Thorough débridement, serial lavage, and antibiotics were
MBH.9 the cornerstones of successful prevention or minimization

Fig. 29.6 Sterile plastic infusion tube used as an improvised temporary Fig. 29.7 Interposition vein graft (IPVG), the commonest mode of
intraluminal shunt. repair in ballistic vascular trauma.
 29 • Sri Lanka 363

of infections. The commonest complication at immediate trauma centers in strategic locations to sustain the ability
setting was soft tissue infection with Pseudomonas spp. fol- to manage patients with vascular injury.
lowed by gram-positive organisms. Antibiotic cover (amoxy-
cillin and clavulanate or cephalosporin and gentamicin)
were used in the majority of cases.
MILITARY-RELATED STRATEGIES
After the war, the military medical community established
the Sri Lanka College of Military Medicine (SLCOMM)
CONCOMITANT INJURIES which started collaborative endeavors with international
In the midst of time restraints and multiple casualty set- institutes such as the Uniformed Services University of the
tings, critically injured patients with concomitant venous Health Sciences in Bethesda, USA. The College’s planned
injuries (58/128) were more often managed with ligation development of an MSc in military medicine and launch
(43/58) instead of repair (15/58). In the latter instances, of programs such as the Advanced Surgical Skill for Expo-
lateral suture (13/15) or complex venous repair tech- sure in Trauma [ASSET] and Tactical Combat Casualty
niques (2/15) was used successfully.22 Patients with com- Course [C4] will invigorate interest among junior doctors in
bined arterial and venous injury needed higher volumes military medicine as a viable career with opportunities to
of blood transfusion than those with arterial injury alone maintain high professional standards.b
and, when seen with concomitant skeletal trauma, resulted With the advent of lightened responsibilities at home,
in a greater chance of amputation.22 Associated popli- Sri Lankan army has participated in multiple UN missions
teal vein injuries were usually ligated (3 repairs out of a which have provided valuable experience in field medical
total of 28 associated venous injuries in 39 documented care to members of the Medical Corps. For instance, the
popliteal artery injuries).23 Management of fractures (40 SRIMED level 2 hospital was established to provide medi-
reported out of the 128, 31 had most severe comminuted cal care for UN forces, workers, and civilians in South
fractures) was secondary to immediate vascular priori- Sudan.c Recent deployment of military medical core in
ties and skeletal stability was often addressed with plas- support of the Nepal earthquake, and in national flood
ter of Paris until external fixation could be undertaken disaster management, justifies the necessity of main-
at CAH or at other regional tertiary care centers where taining a well-equipped and prepared military medical
orthopedic facilities were available. Concomitant fractures core during peacetime; close-knit teams which are easily
(a surrogate marker of soft tissue and collateral circulation deployable are especially suited to support domestic emer-
injuries23) carried a poor prognosis for the limb, especially gency situations such as Easter Sunday massacre in 2019.
in the context of popliteal vascular injury. Anastomotic The Kotelawala Defense University (named after the 3rd
dehiscence was observed in a handful of cases where Prime Minister of Sri Lanka) recruits cadets drawn from
insufficient skeletal stabilization led to vascular disrup- the three Armed Forces and trains them with the aim of
tion. Nerve injuries (19/128) were tagged to be repaired producing professionals competent in both military and
later at the tertiary care centers where reconstructive ser- medical duties. Over the last 5 years, the medical school
vices were available.9 has produced 159 military medical officers with 211 cadet
officers ready to join them during the next 5 years.d
COMPLICATIONS
GENERAL STRATEGIES
Postoperative thrombosis (10), anastomotic dehiscence (5),
secondary amputation (5), and death (4) were observed in Several strategies to improve the standards of trauma
this cohort of 128 patients.9 care have been implemented. Medical schools have intro-
duced trauma and vascular modules to the undergradu-
ate ­curriculum. The Post Graduate Institute of Medicine
Sustaining and Training the Next has a dedicated program to train surgeons in vascular and
transplant surgery and introduced programs to train sur-
Generation geons in general surgery with a special interest in trauma or
vascular surgery.24 The College of Surgeons of Sri Lanka
CHALLENGES commenced a National Trauma Management Course
Sustaining surgical readiness for the management of war (NTMC) in 2009 and an Advanced Trauma Life Support
casualties proved challenging in the post-war period due (ATLS) course in 2017 for medical graduates, as well as a
to the reduced number of trauma-related admissions to dedicated course for nurses, aiming to enhance the quality
army hospitals, reduced opportunities for recruitment of of trauma care in the country.25
surgeons (in peacetime where patriotic recruitment driv-
ers are less evident), and because the harsh, hierarchical
nature of remote deployments, often separated from fam-
ily, are unattractive to newly graduated state sector medi- b
Personal communication with Brig. DTN Munasinghe, MD, verbal com-
cal professionals. Furthermore, the peacetime requirement munication on 23 March 2019 and CDR Tamara J Worlton, MD, email
to divert funds away from the military sector toward other communication on 12 October 2018.
development projects has had an impact, as has the limited c
Personal communication with Col. Saveen Semage, MD, email communi-
number of vascular and trauma surgeons working within cation on 4 March 2019.
Sri Lanka to sustain this capability. There remains a need to d
Personal communication with Dr RN Ellawala, MS, FRCS. email commu-
train more surgeons and establish dedicated vascular and nication on 25 April 2019.
364 SECTION 5 • Global Perspectives on Vascular Trauma

Conclusion 11. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–
2011): implications for the future of combat casualty care. J Trauma
Acute Care Surg. 2012;73(6):S431–S437.
The civil war in Sri Lanka produced a large case-load 12. Kragh Jr JF, Swan KG, Smith DC, Mabry RL, Blackbourne LH. Histori-
of war-injured that required the development of a sys- cal review of emergency tourniquet use to stop bleeding. Am J Surg.
2012;203(2):242–252.
tem that combined both military and civilian elements, 13. Kragh Jr JF, Littrel ML, Jones JA, et al. Battle casualty survival with
where austere conditions necessitated improvised tech- emergency tourniquet use to stop limb bleeding. J Emerg Med.
niques to sustain life and limb in the forward areas, fol- 2011;41(6):590–597.
lowed by damage control surgery in more sophisticated 14. Shackelford SA, Butler FK, Kragh JF, et al. Optimizing the use of limb
settings. A decade of peace and changes in injury epi- tourniquets in tactical combat casualty care: TCCC Guidelines Change
14-02. J Spec Oper Med Peer Rev J SOF Med Prof. 2015;15(1):17–31.
demiology has meant that new strategies have had to be 15. Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour
exploited in order to maintain the military and civilian policy on the morbidity and mortality of combat casualties. JAMA
surgical skill base. Surg. 2016;151(1):15–24.
16. Ratnayake AS, Worlton TJ. Bleeding control in combat fields with
extreme transfer time. J R Army Med Corps. 2020;166(3):203.
https://doi.org/10.1136/jramc-2018-001120.
17. Burkhardt GE, Gifford SM, Propper B, et al. The impact of ischemic
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Ceylon Med J. 1995;40(4):141–145. lessons learnt from venous injuries at Sri Lankan combat theatres.
8. Ratnayake AS. 1997 Anti-Personnel Mine Ban Convention – Fact- J R Army Med Corps. 2017;163(2):135–139. https://doi.org/10.1136/
sheet. International Committee of the Red Cross. https://www.icrc. jramc-2016-000649.
org/en/document/1997-convention-prohibition-anti-personnel- 23. Ratnayake A, Samarasinghe B, Bala M. Outcomes of popliteal vascu-
mines-and-their-destruction. Accessed 28 April 2019. lar injuries at Sri Lankan war-front military hospital: case series of
9. Ratnayake A, Samarasinghe B, Halpage K, Bala M. Penetrating 44 cases. Injury. 2014;45(5):879–884. https://doi.org/10.1016/j.
peripheral vascular injury management in a Sri Lankan military hos- injury.2014.01.003.
pital. Eur J Trauma Emerg Surg. 2013;39(2):123–129. 24. Thalgaspitiya SPB. PGIM Monthly Research Meeting Scale Develop-
10. Kashuk JL, Peleg K, Glassberg E, Givon A, Radomislensky I, Kluger Y. ment | University of Colombo, Sri Lanka. https://cmb.ac.lk/event/pgim-
Potential benefits of an integrated military/civilian trauma system: monthly-research-meeting-scale-development. Accessed 28 April 2019.
experiences from two major regional conflicts. Scand J Trauma Resusc 25. Thalgaspitiya SPB. The College of Surgeons of Sri Lanka. https://
Emerg Med. 2017;25(1):17. www.surgeons.lk/. Accessed 28 April 2019.
 30 Vascular Trauma in Finland
PIRKKA VIKATMAA

Introduction Alcohol and drug consumption play a role in traumatic

deaths both in traffic accidents and violence. Alcohol con-
Europe covers a land area of 10 million km2 and has a sumption increased steadily until 2007 and has declined by
population of 750 million people in 45 independent coun- 20% since then, but is still high at greater than 10 L/year/
tries with a significant variability in the standard of living, capita (expressed in terms of 100% ethanol) in the over
culture, religion, ethnics, and politics. Despite a history of 15-year-old population. The drug statistics are less reliable,
wars, the continent has seen long periods of peace and a but the frequency of “tested during lifetime” answers is
gradual increase in wealth and stability. The European small at less than 5% in the 15- to 69-year-old age group for
Union (EU) has 27 member countries after Brexit in 2020 all drugs except cannabis, which has tested at 24% accord-
and has, during its existence, functioned as a significant ing to a 2018 national survey.3 Finland has the fourth high-
organ for peace, increased equality, and improved standard- est death rate by unintentional injury in the EU, almost
ization in many areas of society, including health care and twice the European average and higher than in the other
education. The Nordic countries form a relatively uniform Nordic countries (stat.fi).
area concerning politics and public health-care funding. In 2016, 186 firearm deaths were recorded, a 50%
They have small populations in a geographically large area decline from 1990, when 366 firearm deaths were seen.
(except for Denmark), standardized education systems, and Ninety percent of these were suicidal, 7% were homicides,
good availability of modern technologies. and 3% were accidental. In comparison with the rest of
Europe, the number of firearms in Finland is high—1.5
million or 0.27/inhabitant (1.2/inhabitant in the United
Finland as a Northern European States)—and almost all firearms are registered, mostly for
recreational hunting. A high registration rate overestimates
Example in Trauma and Trauma the number of firearms in international comparisons. The
Care highest per capita firearm density is seen in rural areas with
strong hunting traditions, e.g., 1.6 guns/inhabitant in the
Finland, a country with 5.5 million inhabitants and an area Åland island, Kumlinge, where seabird hunting is common,
similar to Germany (357 000 km2 and 83 million inhabit- but only 0.1 guns/inhabitant in the capital, Helsinki. Since
ants), is divided into five university hospital districts, with 1950, 13 mass murders (i.e., more than two victims) have
an increasingly active trend to centralize the health-care taken place, killing 58 persons and injuring 200. These
system. Major trauma is treated exclusively in publicly include three school shootings (1989, 2007, and 2008)
funded hospitals and all citizens are covered by national with 22 deaths.
insurance. The largest trauma center, Helsinki University Most homicides and serious penetrating vascular trauma
Hospital Trauma unit, covers most of Southern Finland are typically caused by stabbing. The causes of death have
with a catchment area of little short of 2 million inhabit- been registered in Finland since 1754 and the year 2017
ants and a transportation range of 200 km. Although most recorded the lowest homicide incidence since 1782, with
medical emergency transfer is taken care of by ground 1.11 victims/100,000 inhabitants. Despite positive changes
transportation, helicopter emergency medical services in society and a decline in many risk factors, stabbings still
(HEMS) are available in all parts of the country, including, happen, usually in private apartments, between middle-
most importantly, in the difficult-to-reach archipelago and aged, unemployed, alcohol-addicted men who are known
sparsely populated northern areas. to each other. Both the victim and the stabber typically
Similar to many countries with an aging population, have 1 to 3 mg/mL of alcohol in their blood (findikaattori.
trauma is the fourth leading cause of death in Finland, fi/en). Assaults against police officers are rare. In the Hel-
after cardiovascular diseases, tumors, and dementia. In sinki region with roughly 1 million inhabitants, 22 officers
2017, 4% of all deaths were due to trauma. A decrease have been killed, including all causes, in the 103 years since
in fatal traffic accidents, but a recent increase in deaths independence. In the 21st century, two officers have been
from falls of the elderly has occurred. In females, the killed in Finland. The police fired 122 times between 2003
incidence of traumatic deaths has been stable at around and 2013 and seven persons were killed in these incidents4,5
30/100,000 inhabitants since 1970, whereas the inci- (poliisi.fi/en).
dence has declined in men from 85/100,000 in 1970 to The exact incidence of vascular trauma in Finland is
55/100,000 inhabitants in 2017 (Statistics Finland, stat. unknown because of the distribution of victims to different
fi). Rural areas with longer distances, more socioeconomic hospitals and the lack of a dedicated registry that includes
problems, and a higher proportion of home and leisure- all vascular-trauma victims. Validated trauma registries
time injuries suffer from a higher incidence of prehospital do not include all these patients as an injury severity score
deaths due to trauma.1,2 (ISS) of greater than 15 is required.6 The national hospital

365
366 SECTION 5 • Global Perspectives on Vascular Trauma

discharge registry, based on ICD-10 coding, gives rough manda­­­­tory common general surgical period was shortened,
estimates, but not more detailed information and, although and a 5-year specialty-specific, target-oriented training
validated for other vascular diseases,7 their reliability in program was introduced. From the beginning, endovascu-
detecting vascular trauma has not been evaluated. Finnvasc, lar treatment has been a part of the training of vascular
glob­ally among the first vascular registries with national surgeons. It is currently increasing in volume, as hybrid
coverage, was founded in 1989, but was reduced to regional operation theatres are used primarily by vascular surgeons.
registries due to data privacy issues. It is currently regain- Despite typical problems (as to who takes care of which
ing national coverage. The national vascular registry will, patients and performs which procedures), significant turf
as regards vascular injury, still suffer from the fact that wars have been avoided and today the collaboration between
vascular trauma is treated by many different hospitals and angioradiologists and vascular surgeons is mostly nonprob-
surgeons do not systematically report all incidents to the lematic. This is due to the absence of strong economic incen-
registry. In the second largest hospital, Tampere University tives to guide patient flow and because public hospitals treat
Hospital, 143 noniatrogenic vascular trauma patients were all patients in their respective regions. Furthermore, there
treated between 2006 and 2010, giving an incidence of is no competing angiology specialty and neither neuro nor
5.8/100,000 inhabitants. Of these patients, 58% (n = 85) cardiac interventionalists perform peripheral interventions.
sustained injuries to the upper arm. Penetrating mecha- Trauma surgery has traditionally been practiced by
nism was more common in men than women (83% vs 17%). trauma-oriented orthopedic surgeons, with nonskeletal
Sixty-five percent of the vascular injuries were treated with trauma managed by general and visceral surgeons (with
open surgery, 11% by endovascular means, and 24% with- the support of plastic, vascular, and cardiothoracic sur-
out vascular intervention. Two (12%) of the lower limb vas- geons when appropriate). Embolizations are performed by
cular injuries led to amputation. The 30-day mortality was angioradiologists and increasingly also by vascular sur-
zero, but this did not include prehospital deaths.8 geons. Acute care medicine is a new and growing specialty,
Iatrogenic vascular injuries are today by far the most com- yet to define its role in trauma care.
mon type of vascular trauma, obviously caused by the huge
increase in cardiac, neurovascular, and vascular interven-
tions. In Sweden, 1/6000 knee prosthesis operations lead to Vascular and Endovascular Trauma
a popliteal artery injury (32 injuries in 24 years), whereas
a total of 888 iatrogenic vascular injuries were registered
Surgery Training, Availability, and
during the same time period, mostly from endovascular pro- Challenges
cedures.9 The proportion of iatrogenic injuries amongst all
injuries increased progressively from 57% in 1987–93 to Due to the generally small numbers of trauma patients in
79% in 2002–05.10 any given health system, specific trauma-oriented training
programs are essential. The Finnish Trauma Association
(traumasurgery.fi), founded in 2000, has taken an active
Vascular and Trauma Surgery role and introduced several formal training opportunities
since 2008. Currently, the Definitive Surgical Trauma Care
Finland became independent in 1917 and the early years (DSTC), European Trauma Course (ETC) and Advanced
of trauma surgery were profiled by military surgery due to Surgical Skills for exposure in Trauma (ASSET) are almost
unrest both in the region and internationally. The founding mandatory for young surgeons and acute care specialists
father of Red Cross Finland, a prominent military surgeon who wish to focus on trauma. Many have spent time abroad
who served in seven major conflicts from the Russo-Japa- in dedicated trauma centers, and simulation training of
nese War to the Second World War, was Richard Faltin trauma teams is routine in many hospitals.
(1867–1952). In his honor, the Finnish Surgical Society One of the limiting issues in modern trauma care is the
still annually acknowledges prominent national and inter- availability of 24/7 endovascular skills. All five univer-
national surgeons with a Faltin prize and lecture (including sity hospitals can provide this with their on-call systems,
Norman M. Rich in 2013). From the early days of surgical though not necessarily residential in-hospital availability.
training in Finland, doctors have realized the importance of Most smaller hospitals have angiology suites and c-arms in
international collaboration and many vascular and trauma the theatres, but round-the-clock expertise is not as readily
surgeons have earned their expertise in the international available and depends on committed individuals. In 2001,
scene. Helsinki University Hospital (HUS) built the first hybrid the-
Vascular surgery became an independent specialty in Fin- atre in Finland—one of the first in Europe. It took 10 years
land in 1997 when it officially separated from cardiothoracic for the vascular surgeons to properly learn to utilize this
surgery, and a national training program was defined with tool. Up to 2010, less than 100 hybrid operations were per-
3 years general surgical training in all surgical specialties, formed annually, but in 2019 vascular surgeons performed
followed by 3 years of vascular surgical training. In Sweden, 386 hybrid procedures (excluding diagnostic or comple­
vascular surgery evolved from general surgery, became a tion angiographies and procedures performed primarily by
branch specialty in 2006, and a monospecialty in 2015. angioradiologists). These were undertaken in two hybrid
Irrespective of the different backgrounds, vascular surgery suites with minimal friction, supported by angioradiologists
in the Nordic countries today may be considered similarly: —clearly fulfilling the criteria for modern 24/7 endovascu-
an independent specialty performing both open and endo- lar trauma care capacity (Fig. 30.1). Trauma teams regu-
vascular surgery. In Finland in 2020, in order to better larly train in simulation activities and hybrid theatre teams
adapt to the needs of highly specialized modern surgery, the train in endovascular ruptured aneurysm treatment.11
 30 • Vascular Trauma in Finland 367

450

400

350

300

250

200

150

100

50

0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Fig. 30.1 Hybrid procedures performed by vascular surgeons in Helsinki 2003–19. It took almost 10 years for the vascular surgeons to learn how to use
the hybrid theatre effectively in Helsinki University Hospital. Procedures performed in regular operation theatres with a c-arm are not included. In addi-
tion, diagnostic and completion angiographies and procedures performed primarily by an angioradiologist or cardiologist (transcatheter valves, etc.) are not
included. In 2013–14, the second hybrid theatre was built.

Resuscitative balloon occlusion of the aorta (REBOA) is

a controversial hot topic achieving fast worldwide approval
with increasing experience12 and is described in detail in
Chapter 11. In Finland, REBOA is widely trained for and
occasionally used in trauma but is used routinely in rup-
tured aneurysm surgery (Fig. 30.2). Trauma protocols
in the large hospitals include systematic instructions on
REBOA use and simulation training is used extensively. In-
hospital trauma protocols are changing towards including
an early femoral sheath placement to facilitate REBOA, con-
tinuing to urgent endovascular treatment, when appropri-
ate. REBOA is not used in the prehospital setting, at least
until more positive data is available.13 Hybrid rooms make
combinations of treatments possible in all university hospi-
tals (Fig. 30.3). In Helsinki, the first RAPTOR suite (resus-
citation with angiography, percutaneous techniques, and
operative repair) with a combination of CT, angiography,
and open surgery possibility, is under construction.14,15
The wide array of technical possibilities for the treatment
of severely injured patients16 brings pressure to change the
training of physicians and both prehospital and in-hospital
trauma protocols, as well as health-care systems in general,
with a greater need for centralization.
Hand-in-hand with the increase of endovascular skills,
the risk of decline in open vascular reconstruction skills is
inevitable. On the other hand, training programs are much
more systematic now than they were 20 years ago and, in
a study including blunt trauma laparotomies, only 11/89 Fig. 30.2 Fluroscopic image of REBOA being undertaken as automated
operations needed a more complex skill set.17 Open vascular external cardiac compressions are applied. Resuscitative balloon occlu-
surgery is still readily performed, especially in the lower limb. sion of the aorta (REBOA) is most often initially used blindly but is more
Due to an increase in the elderly population, bypass sur- controlled when screening fluoroscopy is available. Here an automatic
gery is on the rise despite the fact that many more patients resuscitating device is used while the REBOA is positioned in the descend-
are treated with endovascular methods (Fig. 30.4). Major ing thoracic aorta. In order to make vascular puncture easier and safer, it is
open abdominal surgery is performed in large quantity, recommended to stop the resuscitating device for some seconds.
368 SECTION 5 • Global Perspectives on Vascular Trauma

and trauma-oriented surgeons train in transplantation and

cardiothoracic surgery. Vascular surgeons are familiar with
large exposures thanks to a substantial increase in onco-
vascular surgery, where tumor surgery is combined with
vascular reconstructions and justified by improved onco-
logical care. It seems that such interdisciplinary collabora-
tion in the operating theatre is easier today than it was in
the late 20th century.

Summary
Finland and the Nordic countries are stable societies where
noniatrogenic vascular trauma is rare. Trauma systems are
publicly funded, planned, and organized. Economic stability
has made it possible to distribute modern facilities amongst
all parts of the country, but sparsely populated large areas
are a true challenge to the system. The political pendu-
Fig. 30.3 Hybrid Theatre. One or more hybrid theatres with a robotic lum is moving towards a more centralized system, leaving
c-arm are available in the five university hospitals in Finland. Staffing these many smaller hospitals with a diminishing role and mak-
on a full-time basis requires large centers with sufficient round-the-clock- ing longer transportation of even severely injured trauma
activity. A considerable amount of training, including radiation safety, is patients mandatory. Education, training, and international
mandatory. collaboration are essential in maintaining and improving
the numbers of skilled vascular trauma surgeons, who
need to be ready to choose and perform the best open,
endovascular, or hybrid approach according to the situa-
tion. Furthermore, the “optimized trauma surgeon” should
have excellent collaboration and communication skills—a
challenging training task to tackle.

References
1. Raatiniemi L, Liisanantti J, Niemi S, et al. Short-term outcome and dif-
ferences between rural and urban trauma patients treated by mobile
intensive care units in Northern Finland: a retrospective analysis.
Scand J Trauma Resusc Emerg Med. 2015;23:91.
2. Kristiansen T, Søreide K, Ringdal KG, et al. Trauma systems and early
management of severe injuries in Scandinavia: review of the current
state. Injury. 2010;41:444–452.
3. Obstbaum Y. Kannabikseen suhtautumisessa eroja Pohjoismaissa. (In
Finnish) Haaste. 2019;19:12–13.
4. Rikander H. Voimankäyttöselvityshankkeen loppuraportti (In
Finnish, English abstract). Police academy report. 2016:124.
5. Niemi H. Rikollisuustilanne 2017. University of Helsinki, Institute for
criminology and justice politics. Report 29. English summary. Crime
trends in Finland, 2018.
6. Brinck T, Handolin L, Paffrath T, Lefering L. Trauma registry com-
parison: six-year results in trauma care in Southern Finland and
Germany. Eur J Trauma Emerg Surg. 2015;41:509–516.
7. Taha AG, Vikatmaa P, Albäck A, Aho PS, Railo M, Lepäntalo M. Are
adverse events after carotid endarterectomy reported comparable in
different registries? Eur J Vasc Endovasc Surg. 2008;35:280–285.
8. Pöyhönen R, Suominen V, Uurto I, Salenius J. Non-iatrogenic civilian
vascular trauma in a well-defined geographical region in Finland. Eur
J Trauma Emerg Surg. 2015;41:545–549.
9. Bernhoff K, Rudström H, Gedeborg R, Björck M. Popliteal artery
injury during knee replacement: a population-based nationwide
study. Bone Joint J. 2013;95:1645–1649.
10. Rudström H, Bergqvist D, Ogren M, Björck M. Iatrogenic vascular
injuries in Sweden. A nationwide study 1987-2005. Eur J Vasc Endo-
vasc Surg. 2008;35:131–138.
11. Aho P, Vikatmaa L, Niemi-Murola L, Venermo M. Simulation train-
ing streamlines the real-life performance in endovascular repair
of ruptured abdominal aortic aneurysms. J Vasc Surg. 2019;69:
Fig. 30.4 Open exposure of proximal brachial artery. Open surgery is 1758–1765.
still the most common approach to penetrating vascular trauma, as in this 12. Borger van der Burg BLS, van Dongen TT, Morrison JJ, et al. A system-
case where a young construction site worker fell 2 m onto a steel pole atic review and meta-analysis of the use of resuscitative endovascular
which penetrated his right armpit. balloon occlusion of the aorta in the management of major exsangui-
nation. Eur J Trauma Emerg Surg. 2018;44:535–550.
 30 • Vascular Trauma in Finland 369

13. Bulger EM, Perina DG, Qasim Z, et al. Clinical use of resuscitative endo- 15. Kinoshita T, Yamakawa K, Yoshimura J, et al. First clinical experiences
vascular balloon occlusion of the aorta (REBOA) in civilian trauma sys- of concurrent bleeding control and intracranial pressure monitoring
tems in the USA, 2019: a joint statement from the American College of using a hybrid emergency room system in patients with multiple inju-
Surgeons Committee on Trauma, the American College of Emergency ries. World J Emerg Surg. 2018;13:56.
Physicians, the National Association of Emergency Medical Services 16. Faulconer ER, Branco BC, Loja MN, et al. Use of open and endovascu-
Physicians and the National Association of Emergency Medical Techni- lar surgical techniques to manage vascular injuries in the trauma set-
cians. Trauma Surg Acute Care Open. 2019;4(2019):e000376. https:// ting: a review of the American Association for the Surgery of Trauma
doi.org/10.1136/tsaco-2019-000376. eCollection. PROspective Observational Vascular Injury Trial registry. J Trauma
14. Kirkpatrick AW, Vis C, Dubé M, et al. The evolution of a purpose Acute Care Surg. 2018;84:411–417.
designed hybrid trauma operating room from the trauma service 17. Kosola J, Brinck T, Leppäniemi A, Handolin L. Blunt abdominal trauma
perspective: the RAPTOR (Resuscitation with Angiography Percuta- in a European trauma setting: need for complex or non-complex skills
neous Treatments and Operative Resuscitations). Injury. 2014;45: in emergency laparotomy. Scand J Surg. 2020;109(2):89–95. https://
1413–1421. doi.org/10.1177/1457496919828244. Epub 2019 Feb 20.
 31 Sweden
TAL M. HÖRER and CARL MAGNUS WAHLGREN

Introduction units as required, and arranges and controls patient trans-

fers. The majority of severely injured patients in these net-
The management of severe traumatic injury has undergone works are transported by ground ambulance, but a large
major changes over the last 20 years, as Advanced Trauma and increasing proportion are transported by helicopter
Life Support (ATLS), the concept of damage control, mas- to university hospitals. Ground ambulances are generally
sive transfusion protocols, new technological innovations, equipped with basic life-support facilities and ambulance
and improved intensive care have been implemented across nurses. Helicopter transport is available in most regions,
the world.1 Even in the field of vascular trauma, there have but there is no national helicopter service. Some regions of
been developments in hemostatic resuscitation and vascu- the country have physician-operated air and ground ambu-
lar damage control including the use of tourniquets, vas- lance services. There is no dedicated trauma-ambulance
cular shunts, endovascular occlusion balloons, endografts service in Sweden.
(i.e., stent grafts), and embolization to refine operative
techniques.2–5 Computed tomography angiography (CTA)
is regarded as the first line of investigation for all patients The Swedish Trauma and Vascular
with suspected vascular trauma with no immediate indi- Registries
cation for operative intervention.6 This review will provide
insights into current Swedish vascular trauma practice but There is a national Swedish trauma registry since 2011,
also discuss new nationwide trends in treatment modalities SweTrau, that gathers data on all trauma cases. At present
and their implementation. 46 hospitals in Sweden receiving serious trauma are con-
nected to SweTrau. The national Swedish vascular registry,
Swedvasc, has been collecting information on procedures
The Swedish Trauma System since the late 1980s, and all cases of trauma that are car-
ried out by vascular surgeons should be recorded in this
Sweden is the largest and most populated Scandinavian registry. All hospitals and vascular units perform endovas-
country with a total population of 10.2 million (Swedish cular surgery to some extent, but the amount varies accord-
government agency, 2019), and the fifth largest country ing to experience, capabilities, facilities, etc. The Swedvasc
in Europe by area. It has a low population density of 22 annual report of 2018 showed a clear and increasing trend
inhabitants per square kilometer (57/sq. mile) and about in use of endovascular procedures for vascular disease and
85% of the population live in urban areas (about 40% in vascular injury within the country.
the metropolitan areas of Stockholm, Gothenburg, and
Malmö). The country has several hard-to-reach areas,
mountainous, forested, and coastal, and a harsh winter Trauma in Sweden
climate which imposes heavy demands on the prehospital
organization. These facts point out that the conditions for The amount of major trauma in Sweden has been increasing
trauma care differ within the country. There are currently as reported in recent SweTrau annual reports. Blunt injury
7 university hospitals and 57 emergency hospitals in Swe- constitutes more than 90% of all trauma, half of which is
den. The university hospitals (Fig. 31.1) have resources traffic-related, while one-third is due to falls (Fig. 31.2). There
that might meet the criteria for a level-1 or level-2 trauma has also been an increase in the number of firearm injuries in
center, with access to 24/7 general and vascular sur- recent years.7 In the largest Swedish trauma center, the pro-
gery, neuro- and thoracic surgery, and also intensive care portion of penetrating trauma injuries increased from 5.3%
units. There has been an increasing trend towards trauma in 2005 to 12% in 2016, and the proportion of firearm inju-
care centralization in recent years, with severely injured ries among all penetrating trauma injuries increased from
patients being transferred to major university hospitals 16% in 2005 to 36% in 2016.8 Injuries from violence are three
when possible. times more common among men compared to women, but fall
The national trauma system in Sweden is currently accidents are seen in a greater proportion among women. The
being reviewed after a 2015 national trauma investigation trauma distribution relating to age and gender in Sweden is
report stated that it is essential for trauma care in Sweden shown in Fig. 31.3. In summary, the mechanisms of injury
to be structured through the formation of networks (the are dominated by traffic and falls, but there has been a recent
National Board of Health and Welfare, 2015). Such a net- increase in penetrating injuries. Overall injury mortality over
work consists of a trauma center as hub with fully equipped time remains unchanged in Sweden but, looking at different
acute-care and surgical hospitals for trauma management subgroups, there is a decline in mortality among children
as satellites. All emergency activities are centralized at (boys) and working-age groups, but an increase in mortality
one command center (“SOS alarm,” or “112”) that directs among the elderly.8

370
 31 • Sweden 371

Fig. 31.3 Age and gender distribution of trauma injuries in Sweden.

(From The Swedish Trauma Registry—SweTrau 2017, with permission.)

There are many challenges to the optimal management

of a severe injury in a country where trauma has not been
a major issue and where dedicated trauma surgeons are not
at hand. With trauma on the rise, many aspects of train-
ing, education, and centralization are constantly being dis-
cussed in Sweden. Issues concerning who should care for
trauma patients and how trauma teams should be trained
and maintain capacity are important.

Vascular Trauma in Sweden

There are 23 vascular surgery units in the country. All uni-
versity hospitals have endovascular service available 24/7
with vascular surgeons and/or interventional radiologists.
There is also around the clock access to hybrid suites in
many hospitals and, in a few, even to a dedicated hybrid
trauma suite with a trauma surgeon on call. Traditionally,
vascular surgeons have been involved in the management
of severe traumatic injury and for bleeding control, both as
Fig. 31.1 University hospitals in Sweden. Trauma care and vascular general and vascular surgeon. Since 2010, their involve-
trauma treatment are provided in these centers. All university hospitals ment has become ever more important, not only because
have full emergency-surgery capacity 24/7, with vascular, cardiotho- of trends in embolization and other endovascular methods,
racic, and neurosurgery units. but also because of the growing need for more specialized
surgeons. Interventional radiologists are mainly involved
in embolization procedures, although they vary in number
between hospitals in Sweden.
60%
2013
Vascular injuries in Sweden, in particular iatrogenic ones,
appear to be increasing when two time periods, 1955–84
50% 2015
and 1987–2005, are compared.9,10 The annual incidence
40%
2017 of procedures undertaken for the treatment of vascular
injuries increased from 1.2 to 1.6 per 100,000 inhabitants
30% between 1987 and 2005.8,9 Of all vascular injuries, there
were 48% iatrogenic, 29% penetrating, and 23% blunt
20% trauma. More recent data show a larger volume of firearm-
related injuries; 17% of patients had major vascular inju-
10% ries, a proportion that increased over the years.7 The most
commonly injured vascular region is the lower extremity
0% vessels at 26/54 (48%), followed by vessels in the chest
Traffic Fall Stab/shot Blunt object Other and abdomen. The femoral artery was the most commonly
injured vessel (24%), followed by the inferior vena cava
Fig. 31.2 Trauma injuries in Sweden by mechanism. (From The Swed- (9%), visceral vessels (9%), and iliac arteries (9%).7 Vascular
ish Trauma Registry—SweTrau 2017, with permission.) injuries in children are fortunately relatively un­common,
372 SECTION 5 • Global Perspectives on Vascular Trauma

both in Sweden and globally.11,12 A survey of Swedvasc New Developments in Vascular

data on injuries in children undergoing vascular surgery,
between 1987 and 2013, showed that boys (148/222) and Trauma Management: the Concept
blunt trauma were predominant.12 The primary anatomic of Endovascular Resuscitation and
locations of vascular injuries in children were the upper
(60%) and the lower extremities (29%), followed by the Trauma Management (EVTM)
abdomen (7.2%). Repair techniques included interposition
graft, patch, primary repair (lateral suture/direct anasto- Vascular surgery has undergone major changes since
mosis), and bypass. Endovascular techniques were used for 2000, in both Sweden and most other developed coun-
only eight children (3.7%). The outcome at 30-days showed tries. One of the major developments lies in the shift
one above-knee and two below-knee amputations as well as from open to endovascular surgery, with an exponential
one death, but there were no further deaths at 1-year after increase in the number of endovascular interventions.
injury. In general, endovascular techniques are being used For example, currently about 60% of infrarenal aortic
with great caution in children, for obvious reasons related aneurysms are treated by endovascular aortic repair
to age and growth, and open surgery remains the method (EVAR) with an increasing trend over the last few years
of choice wherever possible for many injuries. (Swedvasc annual report, 2019). As endovascular and
The national volume of procedures for aortic trauma has hybrid methods have advanced, with concomitant devel-
been low and constant in recent years (Fig. 31.4). There opments in the use of CTA, ultrasound, and angiography,
were 81 registered procedures between 2010 and 2017: the majority of ruptured aneurysms can now be treated
mean age 55 years (SD 21), 73% men, 30-day and 90-day by endovascular means. Indeed, in some centers, endo-
mortality both 12% (Swedvasc annual report, 2018). vascular treatment predominates.13 On a national level
Endovascular procedures clearly predominated, and the in 2018, 53% of ruptured infrarenal aortic aneurysms
­anatomic locations were mainly in the arch and descending were treated with EVAR (Swedvasc annual report 2019).
thoracic aorta. Several centers in Sweden have been among the leaders

200 Aneurysm
Dissection
Trauma

150
Number of registrations

100

50

2010 2011 2012 2013 2014 2015 2016 2017

Fig. 31.4 The number of registered operations for treatment of aortic aneurysms, dissections, and trauma between 2010 and 2017 (treatment of
infrarenal aorta excluded). (From the Swedish vascular registry—Swedvasc 2018, with permission.)
 31 • Sweden 373

in the endovascular era and paved the way for the use level of ­experience, from residents to senior consultants, aim
of endovascular and hybrid tools in trauma and bleeding to increase knowledge and experience in the management
management.14 Endovascular balloon occlusion of the of vascular trauma. Some of the traditional courses have
aorta during EVAR for ruptured aneurysms was adopted adopted the EVTM concept and parts of EVTM are being
at an early stage in Sweden.13–16 Embolization procedures incorporated in coming courses (i.e., the DSTC course).
for traumatic, gastrointestinal, and obstetric bleeding
have been used not only by interventional radiologists,
but also and increasingly, in some centers solely, by vas- Future Aspects
cular surgeons. Endografts, in relatively small volumes,
for iatrogenic and vascular trauma have been part of Vascular trauma in Sweden is likely to increase in the com-
the treatment algorithm in Sweden for many years, and ing years, and proper training for surgical techniques to
more recently REBOA (resuscitative endovascular bal- control hemorrhage and restore circulation are very impor-
loon occlusion of the aorta) has been used for suitable tant. The early involvement of vascular surgeons in trauma
patients in selected centers. cases and the implementation of the EVTM concept may
The evolution of technology, in conjunction with the improve results. Continuous registry data evaluation with
work of skilled and enthusiastic vascular surgeons, has critical review of traumatic vascular cases using different
laid the foundation for the development of endovascular surgical techniques, will help us to improve the outcomes of
and hybrid (combined open and endo) tools for bleeding challenging vascular injuries.
and resuscitation. Many different but parallel efforts in
this area around the world have now coalesced under the References
name Endovascular Resuscitation and Trauma Manage-
1. Cannon J. Hemorrhagic shock. N Engl J Med. 2018;378:1850–1853.
ment or EVTM.14,16 With Sweden as the global hub, EVTM 2. Kalkwarf KJ, Cotton BA. Resuscitation for hypovolemic shock. Surg
has emerged as a multidisciplinary group of professionals Clin North Am. 2017;97(6):1307–1321.
and an expanding set of technologies applied to the man- 3. Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in
agement of the severely ill and injured patient (http://www. patients with severe traumatic hemorrhage: a practice management
jevtm.com/about/). The EVTM concept is focused on chal- guideline from the Eastern Association for the Surgery of Trauma.
J Trauma Acute Care Surg. 2017;82(3):605–617.
lenging the dogma of “open surgery always” for unstable 4. Inaba K, Siboni S, Resnick S, et al. Tourniquet use for civilian extrem-
or potentially unstable patients. Some of the tools involved ity trauma. J Trauma Acute Care Surg. 2015;79(2):232–237.
are early vascular access, REBOA if needed, embolization, 5. Gruen RL, Brohi K, Schreiber M, et al. Haemorrhage control in
endograft, surgery in a hybrid or semihybrid suite, with an severely injured patients. Lancet. 2012;380(9847):1099–1108.
6. Patterson BO, Holt PJ, Cleanthis M, et al. Imaging vascular trauma. Br
endo-tool adjunct to open surgery available at all times (Top J Surg. 2012;99(4):494–505.
Stent Manual, 2017:16). The extent of implementation of 7. Bäckman PB, Riddez L, Adamsson L, Wahlgren CM. Epidemiology of
these methods varies from hospital to hospital, but they can firearm injuries in a Scandinavian trauma center. Eur J Trauma Emerg
be and are applied in modern centers as well as in austere Surg. 2020;46(3):641–647.
environments.16,17 EVTM is developing as a scientific plat- 8. Bäckström D, Larsen R, Steinvall I, Fredrikson M, Gedeborg R,
Sjöberg F. Deaths caused by injury among people of working age
form in the Journal of Endovascular and Trauma Manage- (18–64) are decreasing, while those among older people (64+) are
ment (JEVTM) (www.jevtm.com) and also for collaboration increasing. Eur J Trauma Emerg Surg. 2018;44(4):589–596.
in endovascular and hybrid procedures for both trauma and 9. Bergqvist D, Helfer M, Jensen N, Tägil M. Trends in civilian vascu-
nontrauma cases. lar trauma during 30 years. A Swedish perspective. Acta Chir Scand.
1987;153(7-8):417–422.
10. Rudström H, Bergqvist D, Ogren M, Björck M. Iatrogenic vascular
injuries in Sweden. A nationwide study 1987–2005. Eur J Vasc Endo-
Education in Vascular Trauma vasc Surg. 2008;35(2):131–138.
11. Kayssi A, Metias M, Langer JC, et al. The spectrum and management
There has been a traditional emphasis on trauma educa- of noniatrogenic vascular trauma in the pediatric population. J Pediatr
Surg. 2018;53(4):771–774.
tion in Sweden, in part to offset and prepare for a relatively 12. Wahlgren CM, Kragsterman B. Management and outcome of pediat-
low volume of severely injured patients. Both theoretical ric vascular injuries. J Trauma Acute Care Surg. 2015;79(4):563–567.
and practical courses in vascular trauma have been avail- 13. Mayer D, Aeschbacher S, Pfammatter T, et al. Complete replacement
able for residents in surgery, but also post-specialization in of open repair for ruptured abdominal aortic aneurysms by endovas-
cular aneurysm repair: a two-center 14-year experience. Ann Surg.
surgery and vascular surgery. Live-tissue training has been 2012;256(5):688–695.
used to teach and maintain vascular exposure skills, as well 14. Hörer TM, Skoog P, Pirouzram A, Nilsson KF, Larzon T. A small case
as for the practice of open and endovascular techniques. series of aortic balloon occlusion in trauma: lessons learned from its
The Swedish Surgical Society’s course in Emergency Vascu- use in ruptured abdominal aortic aneurysms and a brief review. Eur J
lar & Trauma Surgery and the Definitive Surgical Trauma Trauma Emerg Surg. 2016;42(5):585–592.
15. Malina M, Veith F, Ivancev K, Sonesson B. Balloon occlusion of the
Care courses (DSTC; International Association for Trauma aorta during endovascular repair of ruptured abdominal aortic aneu-
Surgery and Intensive Care; IATSIC) have been available for rysm. J Endovasc Ther. 2005;12(5):556–559.
general and vascular surgeons for many years. There is also 16. Hörer T. Resuscitative endovascular balloon occlusion of the aorta
a military version of the DSTC course in Sweden. Wo­rkshops (REBOA) and endovascular resuscitation and trauma management
(EVTM): a paradigm shift regarding hemodynamic instability. Eur J
on the EVTM concept and on REBOA are held several times Trauma Emerg Surg. 2018;44(4):487–489.
a year, attracting great interest and participation in Sweden 17. Reva V, Hörer TM, Samokhalov I, et al. Femoral arterial closure after
and from other countries (http://www.jevtm.com/work- REBOA using the fascia suture technique: first experiences in a mili-
shop/). These courses and workshops including different tary setting. JEVTM. 2018;2(2):7–76.
 32 Russia
IGOR M. SAMOKHVALOV and VIKTOR A. REVA

Historical Background During the SWA, a first-aid kit contained two field dress-
ings and a rubber tourniquet. Combat medics were equipped
Russian surgeons have made significant contributions to with 15 to 20 field dressings, 4 or 5 tourniquets, 2 units
vascular surgery. After Nikolai Pirogov, one of the founders of crystalloid, and a supply of drugs for 3 days. Nowadays,
of military surgery, investigated vascular trauma and pub- elastic bandages, new tactical tourniquets (ZhK-01/02,
lished one of the first atlases on vascular anatomy, many Medplant, Russia), and chitosan-based local hemostatic
Russian surgeons have contributed to the field of vascular agents (Hemoflex, Russia and others) are used for prehos-
trauma: the portocaval anastomosis by Nikolai Ekk (1877), pital hemorrhage control. There was a reduction in tourni-
a lateral arterial suture by Alexander Yassinovsky (1899), quet application for external bleeding from SWA to CO-NC
blood pressure “sounds” of Nikolai Korotkov (1905),1 first from 51% to 32% and then to 22%. This was because for
suturing of the ascending aorta by Yustin Dzhanelidze every second casualty injured in Afghanistan where a tour-
(1913), the first heart-lung machine by Sergey Brukho- niquet was applied, extremity amputation was performed
nenko (1920), the first vascular circular-suturing device because of prolonged tourniquet times.
by Vasilij Gudov (1945), and kapron temporary intravas- For the purpose of achieving skilled casualty tactical
cular shunts (TS) by Colonel Boris Matveev (1959). After evacuation, advanced airmobile medical teams – consist-
WWII, vascular centers and units (Boris Petrovsky, Petr ing of a surgeon, an anesthetist, and an anesthetist-nurse
Kupriyanov, Alexander Shalimov, Victor Savel'ev, Anatoly – were created. Standard anesthesia equipment on board
Pokrovsky, etc.) were established in big cities. Post-WWII high-capacity Mil Mi-8 helicopters equipped with a two-
achievements include the first temporary balloon occlusion stretcher special module was used during evacuation (more
of the internal carotid artery for selective cerebral angiog- than 90% of all evacuations were by air). Average time to
raphy and detachable balloons by Fedor Serbinenko (1969), initial surgery decreased from 4 to 6 hours in the SWA to
and the invention of the stent graft and its first implanta- 2.5 to 4 hours in the CO-NC and 2 to 3 hours in the CO-S.
tion for blunt traumatic aortic pseudoaneurysm by Nikolai Damage control surgery was provided at role 2/2E forward
Volodos (1987). Endovascular surgery in Russia derived medical units in Bagram, Kunduz, Feizabad, and Jelalabad
from vascular surgery and is nowadays a separate specialty deployed in wooden detachable modules (SWA), at Mozdok,
covering all the issues of neuro-, cardiac, and peripheral Vladikavkaz Harrison military hospitals (CO-NC), and at the
interventions. In turn, open vascular surgery has been sig- Khmeimim Air Base hospital primarily deployed in inflat-
nificantly improved during recent armed conflicts. able tents, and since 2018, in sheltered containers (CO-S).
Russian military medics provided care to casualties during To provide optimal care for vascular injuries, one mili-
the Soviet War in Afghanistan (1979–89; SWA), counter- tary vascular surgeon and one blood bank physician have
terrorist operations in the North Caucasus region (1994–96, been included in every surgical team. In SWA, however, a
1999–2002; CO-NC), and lately in Syria (since 2015; CO-S). group of vascular specialists in the Kabul Army Hospital in
Kabul was established in 1985. Vascular surgeons were also
sent to role 3 during the CO-NC.
Epidemiology Role 2 or 3 facilities had access to air transportation infra-
structure, and most of the injured were strategically evacu-
The rate of major vascular injuries has increased from 4.5% ated within a few postoperative days. This was performed
in SWA to 6% in CO-NC to 10% in CO-S, reaching the num- by an anesthetist-based team on board an Ilyushin IL-76
bers reported by other investigators. Extremity artery inju- aircraft equipped with a module for care of the severely
ries prevailed in all conflicts due to “mine war,” accounting wounded. Definitive surgical care was provided at the Kabul
for 80% to 90% of all vascular cases. Carotid artery injuries Army Military Hospital (SWA) and/or in Regional (Rostov-
occurred in less than 5% of cases, with the remaining 5% to on-Don, CO-NC) and Central (Moscow) Military Hospitals or
15% being torso vascular injuries. in the Kirov Military Medical Academy (Saint-Petersburg).

Specific Systems of Care Specific Considerations for

Modern combat casualty care (CCC) algorithms were Diagnosis
first implemented during the CO-S. CCC consists now of
5 sequential stages: prehospital care and tactical evacuation Physical examination, single-shot angiography, and vascu-
(role 1), primary (damage control) surgery and resuscita- lar exposure were previously used for timely diagnosis. Cur-
tion (role 2), definitive in-theater surgery (role 3), strategic rently, extensive imaging capabilities have appeared in more
evacuation, and specialized surgical care (role 4 or 5). forward hospitals. Hand-held Doppler, portable ultrasound
374
 32 • Russia 375

Table 32.1 Modern Classification of Acute Limb Ischemia Related to Vascular Trauma
Level Category Sub-Category Basic Treatment Strategy Alternate Approach
I Compensated (viable) — Repair/Ligation/Conservativea Stent/Stent-graft repair
II Uncompensated (threatened) Early TS/repair
Critical [late] TS/repair + fasciotomy
III Irreversible Early TS + fasciotomy + RRTb NA
Late Amputation
Matched definitions from the Rutherford’s classification of acute limb ischemia are noted in brackets.
a
In case of blunt trauma
b
At specialized trauma centers or at role 3 medical treatment facilities.
NA, Not applicable; RRT, renal replacement therapy; TS, temporary shunt.
Modified from Vadim Kornilov (1971).

and, very recently, formal angiography u sing a mobile

c-arm are liberally used for vascular injury diagnosis. None-
theless, computed tomography is not freely available at role
2E. Modified Kornilov’s classification of acute limb ischemia
(primarily found in 1967 and released in 19712) is now
used for limb evaluation and decision-making concerning
vascular treatment strategy according to new interven-
tional capabilities (Table 32.1).

Specific Treatment Strategies

Injured major artery ligation decreased from 31% in SWA
to 16% in the CO-NC and is now considered an option only
for critically unstable patients. The use of TS increased from
17% in SWA to 25% in CO-NC and to about 40% in CO-S
for common or local damage control (Fig. 32.1). Among
64 shunted patients, 20% of shunts thrombosed within
12 hours, 30% within 12 to 24 hours, and 50% remained Fig. 32.1 A plastic improvised temporary shunt is inserted into the
common femoral artery for intraoperative limb perfusion 7 hours after
patent for more than 24 hours.3 The average rate of shunt blunt occlusive arterial injury (blast mechanism). The patient was admit-
thrombosis was about 40% (less for femoral and more for ted with undetectable blood pressure, underwent REBOA, explorative
popliteal arteries). In addition to improvised TSs (plastic laparotomy, pelvic packing, external fixation of pelvic fractures, and
tubes), the Pruitt F3 carotid shunt is now widely used for marginally threatened limb ischemia was then recognized. Immediate
intraoperative limb perfusion. No patients were strategically temporary shunting, angiography, wide lower leg fasciotomy followed
by autologous vein grafting saved the limb with excellent function.
evacuated with an in-dwelling shunt. Type of arterial repair REBOA, Resuscitative endovascular balloon occlusion of the aorta.
was distributed equally between lateral suture, end-to-end
anastomosis, and autologous vein grafting.
Among vascular injury patients treated in the SWA, 88% using an autologous vein graft. During the CO-S, for the
of patients survived, 33% returned to duty, and 43% of first time in Russian history, endovascular techniques were
patients recovered with either good or satisfactory results. used in a combat zone. The first cases of successful REBOA4
During the CO-NC, the rate of secondary amputations did and fluoroscopy-free upper extremity endovascular revas-
not exceed 4% to 5%. Infectious complications occurred in cularization5 at role 2 confirmed the effectiveness of endo-
12.4% of patients with vascular injuries. Total mortality vascular techniques in austere environments (Fig. 32.2).
amounted to between 7.6% and 9.4% in the CO-NC. More As a result, only exceptionally rare secondary amputations
than half of all vascular patients (57.4%) returned to duty. and mortalities were registered at role 2 and again at role 5.
Significant updates in CCC were achieved during the
CO-S. An advanced resuscitative team provided prehos-
pital blood and plasma transfusion during tactical evacu- Strategies to Sustain and Train
ation (crossmatching was performed en-route); the team
was also equipped with a resuscitative endovascular bal- the Next Generation of Trauma
loon occlusion of the aorta (REBOA) kit (no prehospi- Surgeons
tal usage registered). Open vascular exposure and repair
were performed in most cases according to hemodynamic Military vascular surgeons from the Kirov Military Medi-
status. Severe vascular injury, especially associated with cal Academy, and Central and Regional Military Hospitals
bone fractures, underwent TS followed by a formal repair have been directly involved in the coordination of surgical
376 SECTION 5 • Global Perspectives on Vascular Trauma

Conclusion
Russian military experience demonstrates a gradual reduc-
tion of vascular injury-related mortality from 12% during
the SWA to 7.6% in the CO-NC and further during the ongo-
ing operations. While maintaining the practice of the best
post-WWII achievements, prehospital care improvements,
modern imaging modalities, damage control vascular tech-
niques, and endovascular capabilities have allowed vascu-
lar care to the wounded to be optimized.
Surgical experience gained has allowed for improvements
in medical care for civilian practice. Routine CT angiogra-
phy, REBOA, urgent angioembolization even for unstable
patients, and the first steps in extracorporeal membrane
oxygenation use for trauma are now part of the civilian
trauma system. A newly constructed emergency hybrid
operation room in the Military Medical Academy and first
Fig. 32.2 A vascular team (left) and an orthopedic team (right) have experience with endovascular surgery in a combat zone
simultaneous surgery on both severely injured hands (due to blast injury). encourages us to remember the words of Nikolai Pirogov:
Multiple closed fractures of both hands, a partial amputation of the right “For surgery, a new era would come if it were possible to
forearm, and absent right upper extremity pulses (axillary artery injury) quickly and accurately stop blood circulation in a large
were diagnosed. Using a combination of gentle catheter-wire manipula-
tion and serial radiographs (no c-arm available), the lesion was traversed
artery, without exposing or ligating it.” (1866).
via the brachial artery and access to normal subclavian artery obtained.
A Fluency Stent Graft (6 × 100 mm) was then deployed, followed by a References
completion angiogram, which demonstrated restoration of extremity 1. Samokhvalov IM, Reva VA, Fomin NF, Rasmussen TE. Contributions
perfusion. This is the first case of successful upper extremity endovascular of the surgeon Nikolai Korotkov (1874–1920) to the management
revascularization in an austere environment. of extremity vascular injury. J Trauma Acute Care Surg. 2016;80(2):
341–346.
care during the conflicts, which has significantly improved 2. Samokhvalov IM, Pronchenko AA, Reva VA. International perspec-
tives: Europe. Russia. In: Rasmussen TE, Tai NRM, eds. Rich's Vascular
vascular care outcome. The assignment of vascular sur- Trauma. 3rd ed. Philadelphia: Elsevier; 2016:301–308.
geons to frontline medical facilities has led to a new gen- 3. Samokhvalov IM, Zavrazhnov AA, Kornilov EA. Results of usage of
eration of surgeons skilled in the care of combat vascular temporary prosthetics in cases of combat injuries of extremities. Voen
injury. It turned out, however, that vascular cases were Med Zh. 2006;327:29–33, [Russian].
the most challenging, and the deployment of a vascu- 4. Reva VA, Petrov AN, Samokhvalov IM. First Russian experience with
endovascular balloon occlusion of the aorta in a zone of combat opera-
lar surgeon was absolutely necessary. To educate young tions. Angiol Sosud Khir. 2020;26(2):61–75.
military surgeons, a 3-day S ­MART-course (including 5. Reva VA, Morrison JJ, Samokhvalov IM. Successful fluoroscopy-free
dry lab, live tissue, and cadaver training) was established extremity endovascular revascularization in an austere environment.
in the Kirov Military Medical Academy and extended with J Endovasc Resusc Trauma Management. 2019;3(3):133–138.
endovascular (SMART.REBOA) and advanced vascular
(SMART.ANGIO) modules.
 33 Serbia
LAZAR B. DAVIDOVIC and MIROSLAV MARKOVIC

Introduction eight variables showed that only failed revascularization,

associated nonvascular injuries, and secondary operation
For many centuries a simple ligation was the main treat- significantly increased the amputation rate after arterial
ment option in patients with vascular injury. The first sig- vascular repair.
nificant series of vascular reconstructions applied for the
treatment of vascular injuries was published by Serbian
surgeon Vojislav Soubbotich at the beginning of the 20th Lesson 2: Strategy During
century.1 Namely, during the Balkan wars between 1912 Management of Vascular Trauma
and 1913, 60 false traumatic aneurysms and 17 trau-
matic arteriovenous fistulas were treated by himself and Throughout history, the management of vascular trauma
his coworkers. In about 40% of cases some kind of vascular has included three phases: life-saving, extremity-­saving,
reconstruction was performed; they included 15 end-to- and saving of functional extremity.5 It can be assumed that
end anastomoses, making an exciting surgical step forward the order of these main objectives is still used in the modern
at that time. More than three decades later, in the series of approach to vascular injury, which is why primary bleed-
2471 arterial injuries from the Second World War, DeBakey ing control, rapid transportation of the injured person, ade-
and Simeone reported only 81 repairs, including three end- quate diagnosis, and timely vascular repair are necessary.
to-end anasthomosis.2 Commenting on this, Norman Rich
said: “It is ironic that nearly 40 years passed before similar
successful efforts were achieved during the latter part of the Lesson 3: Primary Bleeding Control
Korean conflict (1952–53).”3
Less than 100 years after Soubbotich’s time, at the end The first step in the successful management of vascular
of the 20th century, the former Yugoslavia experienced civil trauma is to control primary bleeding, which is a life-sav-
war, closely followed by the North Atlantic Treaty Organ- ing procedure. However, if it is not performed adequately,
isation (NATO) bombing of Serbia. Due to these unpleasant primary bleeding control can cause additional damage to
facts, a whole generation of vascular surgeons, including already injured arterial vessels. The method used in the initial
the authors of this chapter, had the opportunity to treat approach to primary hemostasis significantly influences the
a significant number of war-related vascular injuries. In extent of the subsequent vascular reconstruction. However,
addition, a significant number of civil vascular injuries in a crisis, first aid is often driven by only one objective: stop
have been treated in our hospital over the past few decades. the bleeding at all costs. Unfortunately, vascular surgeons
What have we learned? often have to pay the price for these crisis-driven methods of
achieving hemostasis as can be seen in Fig. 33.2.
Lesson 1: War Versus Civil Vascular
Trauma Lesson 4: Vascular Repair or
Primary Amputation?
Common opinion is that the management of vascular inju-
ries inflicted during war is fundamentally different to those The first question that a vascular surgeon has to answer
acquired during peace. However, that is not necessarily the before the treatment of vascular trauma even begins is
case. Besides natural disasters (earthquakes, etc.), traffic, whether there is any point in doing vascular repair. Accord-
industrial, and agricultural trauma, as well as the increas- ing to current guidelines, the indications for primary ampu-
ing frequency of terrorist attacks, and even sport injuries, tation in the case of vascular trauma include: bone fracture
can all be accompanied by severe damage to blood vessels with loss of continuity of more than 6 cm in length; massive
(Fig. 33.1). soft tissue damage and loss; prolonged limb ischemia; severe
The insignificant differences regarding the early out- nerve destruction; major vein obstruction; and exten-
come between war and peacetime vascular injuries was sive calf wounds associated with small vessels injury.5,6
also presented in our study published in 2005.4 That study Even though these indications are quite clear, the decision
compared 273 civil and 140 war-related vascular injuries. regarding primary amputation following vascular trauma
According to univariate analysis, out of 54 included vari- is quite difficult, especially in young patients (Fig. 33.3).
ables, only failed revascularization, associated nonvascular
injuries, secondary operation, explosive injury, war injury,
arterial contusion, popliteal artery injury, and delayed Lesson 5: Diagnosis
treatment significantly increased the amputation rate
after repair of the injured peripheral arteries. However, A minor surface wound can often conceal serious vascu-
multivariate logistic regression analysis of the previous lar injury. How does one recognize and not miss a vascular
377
378 SECTION 5 • Global Perspectives on Vascular Trauma

lesion when the “hard signs” of vascular trauma (external

arterial bleeding, acute limb ischemia, absent distal pulses,
expanding hematoma, false aneurysm, and bruit/thrill over
the area of injury) are not present? We use a simple diag-
nostic algorithm for penetrating wounds of the extremi-
ties.4,7,8 Firstly, digital subtraction angiography (DSA) or
multidetector computed tomography (MDCT) angiography
is indicated in all cases with “soft” signs of vascular trauma
(history of severe bleeding, diminished distal pulses, small
nonexpanding hematoma, injury to anatomically related
nerve, and anatomic proximity of wound to a major ves-
sels).9 In addition, we also perform DSA or MDCT angiogra-
phy in all hemodynamically stable patients with hard signs
of vascular injuries. These procedures are essential in con-
firming or excluding the presence of arterial trauma. Addi-
A
tionally, they show the location, extent, and complexity of
the injury. DSA or MDCT angiography findings can suggest
the surgical approach as well as the type of vascular repair
needed. However, in our experience, lesser vascular lesions
can be omitted on initial MDCT angiogram. Whenever the
initial MDCT finding does not correlate with the clinical pre-
sentation, it should be checked with conventional angiog-
raphy (i.e., DSA) during the observation period. Finally, in
our opinion, only hemodynamically unstable patients with
hard signs of vascular injuries require immediate surgical
exploration without additional diagnosis.4,7,8

Lesson 6: Vascular Repair

In relation to arterial vascular repair, the following are
important: the selection of the repair procedure; the choice
of vascular graft; the treatment of associated venous inju-
ries; the presence of associated or other complex injuries;
and finally, the approach to prolonged limb ischemia.
The simplest methods of injured vessel repair are lateral
suture or end-to-end anastomosis. However, they can be only
performed in cases where the defect between the edges of the
injured vessel is not too long (less than 2 cm). Otherwise, a
graft interposition or bypass procedure is indicated. Autolo-
gous saphenous vein is the material of choice for the repair
of injured peripheral vessels. Prosthetic grafts are a necessity
when the reconstruction of great vessels is indicated.

Lesson 7: Venous Injury

The repair of an injured vein improves the patency of an
already repaired artery, and minimizes swelling of the
extremity and development of compartment syndrome, as
well as long-term chronic venous insufficiency. For these
reasons, the repair of injured iliac, femoral, popliteal, and
subclavian veins in all hemodynamically stable patients is
recommended.4,7 However, large and mid-sized veins should
be repaired with panel or spiral venous grafts, which require
additional preparation time (Fig. 33.4).
B

Fig. 33.1 (A) This serious leg injury was caused by a so-called “slide Lesson 8: Complex Injuries
tackle” during a football match. (B) Besides a tibia fracture, the patient
had a false traumatic aneurysm of the popliteal artery. We managed to Complex injuries should be treated by an experienced inter-
save this patient’s leg but he was not able to play football again. disciplinary team consisting of a vascular surgeon and other
 33 • Serbia 379

B C

Fig. 33.2 (A) Too distant proximal ligation of the injured femoral artery for the purpose of primary bleeding control has contributed to the extent of the
lesion by secondary thrombosis. (B and C) Additional damage to the injured anterior tibial artery in this case was caused by numerous, mostly unneces-
sary, clamps.

specialists.4 A significant number of patients with injured we realized that in cases with contaminated or infected
peripheral vessels have also associated bone fractures. In wounds, as well as in cases with massive skin destruc-
such cases, vascular reconstruction might be compromised tion and soft tissue loss, anatomic reconstruction was sig-
by traction and secondary movement of bone fragments.4,10 nificantly associated with secondary hemorrhage, usually
Therefore, after proximal and distal bleeding has been con- resulting in major amputations.4,10,11 Acknowledging this,
trolled and a shunt inserted, bone fracture fixation should we decided that the anatomic reconstruction of injured
precede vascular repair (Fig. 33.5). arteries should be avoided in the presence of contaminated
At the start of the civil war in the former Yugoslavia, wounds and massive soft tissue damage and loss. In such
we used to perform vascular repairs with standard ana­ cases, extraanatomic procedures provided significantly bet-
tomic vascular reconstructions. During follow-up, however, ter early outcome and limb-saving.
380 SECTION 5 • Global Perspectives on Vascular Trauma

Lesson 9: Late Revascularization

Late (or delayed) attempts at revascularization after periph-
eral vascular trauma can result in many serious disorders:
compartment syndrome; muscle contracture and necrosis;
disabling efferent neuralgia; poor functionality; and, even-
tually, major amputation. Patients with untreated traumatic

Fig. 33.3 (A and B) Angiography shows patent bypass from the

median to distal (retromaleolar) part of the posterior tibial artery. This
was associated with a very complex tibial and fibular fracture with a
long bone defect associated with massive soft tissue loss. Therefore,
B
functional recovery of the extremity was unlikely. A secondary ampu-
tation was performed a few months later, but the authors believe that Fig. 33.4 (A and B) Creation of panel saphenous vein graft for repair of
a primary amputation would have been the better option in this case. mid- or large-sized injured vein.
 33 • Serbia 381

A D

B E

Fig. 33.5 Humeral fracture with complete dislocation (A) caused the injury of the axillar artery (B). Step 1: Bleeding control and temporary shunt inser-
tion (C). Step 2: Bone fracture stabilization by external fixation (D). Massive skin and muscular destruction are notable. Step 3: Injured axillar artery is
replaced with saphenous vein graft (E). Control digital subtraction angiography. The arrow points at patent saphenous vein graft (F). Step 4: Reconstruc-
tion of soft tissue defect using vascularized muscular flap (G).
382 SECTION 5 • Global Perspectives on Vascular Trauma

F G

Fig. 33.5 (Continued)

arteriovenous fistulas can develop congestive heart fail-

ure8,12 (Fig. 33.6).
The most threatening sequelae of late revasculariza-
tion can be prevented by the use of a temporary vascular
shunt. Use should be considered in cases of prolonged limb
ischemia, in polytraumatized patients, and in patients with
associated orthopedic injuries. If compartment syndrome
occurs, immediate fasciotomy, releasing all four calf com-
partments, is neccessary.13 Fasciotomy is rarely indicated in
the upper extremity.

Lesson 10: Early Complications

After Vascular Repair
We have found stenosis, thrombosis, and infection to be
the most frequent and severe early complications follow-
ing vascular repair.4,10,11 Anastomotic stenosis is especially
common in cases of small arterial repair (crural arteries,
etc.) and also when reconstruction is performed by an inex-
perienced vascular surgeon. The oblique shape of an ideal
end-to-end anastomosis prevents stenosis and provides bet-
ter early and long-term patency. This technique was origi-
nally described by Alexis Carrel more than a century ago.14
Residual distal thrombosis can compromise an ade-
quately performed proximal reconstruction of the injured
artery. For this reason, exploration of distal arteries using a
Fogarty catheter, before the repair, is mandatory.4,10
In the case of arterial contusion, an abundant resection
of the damaged artery is necessary prior to reconstruction
(Fig. 33.7). Inadequate arterial débridement is a common
cause of arterial thrombosis during the early postoperative
period.4,10
Inadequate débridement of damaged/necrotic tissue and
vascular repair in the presence of contamination, as in
Fig. 33.6 Traumatic fistula between femoral artery and vein initially cases with massive soft tissue damage and loss and primary
not recognized and untreated. Consequently, secondary venous vari- skin closure, increases the incidence of early infection and
ces and swelling of the extremity developed. secondary hemorrhage after vascular trauma treatment.4,8
 33 • Serbia 383

A B

C D

Fig. 33.7 (A) Blunt trauma of the shoulder followed by contusion of the axillar artery. (B) Digital subtraction angiography findings. (C) Intraoperative
findings. (D) Opening of the contused arterial segment showed intimal dissection.

In such circumstances, a new, extraanatomic reconstruc- segment of the subclavian artery18 (Fig. 33.8). Emboli-
tion should be considered; if it is unfeasible, amputation is zation is the ideal procedure in the case of bleeding from
the only remaining and life-saving option. surgically unapproachable midsized and small arteries
(Fig. 33.9). Endovascular repair can also be employed for
the treatment of early and long-term stenosis after open
Lesson 11: Endovascular Repair of repair of an injured artery (Fig. 33.10).
Contraindications to the endovascular repair of pen-
Injured Vessels etrating arterial injuries include hemodynamic instability,
extensive vascular injuries, and injuries without sufficient
Endovascular repair is currently the method of choice in proximal or distal vascular fixation points, as well as arterial
the treatment of blunt thoracic aorta injuries.15 The open transection. In our opinion, this list could be even longer.
repair of the injured intrathoracic segment of the supraaor-
tic brunches requires sternotomy or thoracotomy, partial
clamping of the aortic arch, and even extracorporeal cir- Lesson 12: Pediatric Vascular
culation.16 All these procedures are avoided if endovascular
repair is used.17 However, it requires relatively hemodynam-
Trauma
ically stable patients.
Endovascular procedures are the methods of choice The main characteristics of pediatric vascular trauma are
for the treatment of injured internal carotid and verte- arterial vasospasm, a less well-developed collateral cir-
bral arteries in zone III of the neck, and for the proximal culation, and a smaller total volume of blood with limited
384 SECTION 5 • Global Perspectives on Vascular Trauma

Fig. 33.8 Endovascular repair (stenting) of a false traumatic aneurysm of the subclavian artery.

Fig. 33.9 Combined endovascular treatment of an iatrogenic pseu-

doaneurysm and fistula between the deep femoral artery and vein.
(A) Pseudoaneurysm and arteriovenous fistula. (B) Embolization of the
pseudoaneurysm. (C) Stenting of the deep femoral artery.

C
 33 • Serbia 385

A B

Fig. 33.10 (A) Significant stenosis after open repair of injured popliteal artery (arrow). (B) Control angiography after stenting.

tolerance to hemorrhagic shock in comparison with Lesson 13: Long-Term

adults. Due to this, pediatric vascular injury requires more Complications After Repair of
aggressive and earlier intervention.
Several factors unique to children should be considered Vascular Trauma
during vessel repair. Firstly, the dimensions of the injured
vessels make surgical correction more complex and increase Two of the long-term complications following the open repair
the complication rate. Secondly, circumferential running of injured arteries are true vein graft aneurysms and steno-
suture causes a “purse stringing” effect with further arte- sis (due to neointimal hyperplasia). Endovascular repairs of
rial growth. For this reason, interrupted suture repair that injured arteries can be complicated by early thrombosis and
allows for vessel development is recommended. Also, during distal embolism. The long-term results following endovascu-
repair of injured vessels in children, surgeons should think lar repair of vascular trauma are unknown. Endograft migra-
about the significant risks of growth and development com- tion, fracture, and stenosis caused by neointimal hyperplasia
plications including limb-length disparities, claudication, are potential complications.
and decreased perfusion. There are significant limitations
concerning the use of synthetic conduits or allografts due
to long-term patency concerns. On the other hand, vein Conclusion
graft dilatation should be expected over time (Fig. 33.11).
This is why some authors suggest reinforcement of the vein Endovascular repair has an important role in the treatment
graft with synthetic mesh. Neointimal hyperplasia is poten- of vascular trauma (e.g., blunt trauma of the descending
tially more frequent because of the longer time available for thoracic aorta and the intrathoracic segment of supraaor-
this to develop in children compared with adults. From our tic brunches; hemostasis from surgically unapproachable
perspective, it seems reasonable to use endovascular tech- mid-to-small arteries; or failure after open repair). How-
niques – at least as a bridge – in children with multiple asso- ever, in the majority of cases, open surgery is the method
ciated injuries. of choice.
386 SECTION 5 • Global Perspectives on Vascular Trauma

Fig. 33.11 (A and B) Saphenous vein graft aneurysm developed

12 years after repair of an injured popliteal artery during childhood.

References
1. Soubbotich V. Military experiences of traumatic aneurysms. Lancet.
1913;2:720–721.
2. DeBakey ME, Simeone FA. Battle injures of the arteries in the World
War II. Ann Surg. 1946;123:534–579.
3. Rich N, Clagett P, Salander JM, Piščević S. The Matas/Soubbotich con-
nection. Surgery. 1983;93:17–19.
4. Davidovic L, Cinara I, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil
and war peripheral arterial trauma: review of risk factors associated
with limb loss. Vascular. 2005;13:141–147.
5. Fingerhut A, Lappaniemi A, Androulakis G, et al. The European expe-
rience with vascular injuries. Surg Clin North Am. 2002;82:175–188.
6. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the deci-
sion to amputate or reconstruct after high-energy lower extremity
trauma. J Trauma. 2002;52:641–649.
7. Dragas M, Davidovic L, Kostic D, et al. Upper extremity arterial
injuries: factors influencing treatment outcome. Injury. 2008;40:
815–819.
8. Davidovic LB, Banzic I, Rich N, Dragaš M, Cvetkovic SD, Dimic A. False
traumatic aneurysms and arteriovenous fistulas: retrospective analy-
sis. World J Surg. 2011;35:1378–1386.
9. Feliciano DV, Herskowitz K, O’Gorman RB, et al. Management of vas-
cular injuries in the lower extremities. J Trauma. 1988;28:319.
10. Velinovic M, Davidovic L, Lotina S, et al. Complications of opera-
tive treatment of injuries of peripheral arteries. Cardiovasc Surg.
2000;8:256–264.
11. Davidovic L, Lotina S, Kostic D, et al. Popliteal artery war injuries. Car-
diovasc Surg. 1997;5:37–41.
12. Marković M, Davidović L, Kuzmanović I, Dragas M, Ilić N. Giant post-
traumatic pseudoaneurysm of the peroneal artery with arteriove-
nous fistula and fibular notch. Am Surg. 2009;75:627–629.
13. Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin
North Am. 1983;63:539–565.
A 14. Carrel A. The surgery of blood vessels. John Hopkins Med J. 1907;18:18.
 33 • Serbia 387

15. Riambau V, Böckler D, Brunkwall J, et al. Management of descend- 17. du Toit DF, Strauss DC, Blaszczyk M, de Villiers R, Warren BL. Endo-
ing thoracic aorta diseases. Eur J Vasc Endovasc Surg. 2017;53: vascular treatment of penetrating thoracic outlet arterial injuries.
4–52. Eur J Vasc Endovasc Surg. 2000;19:489–495.
16. Sladojevic M, Markovic M, Ilic N, et al. Open treatment of blunt 18. Shalhub S, Starnes WB, Tran NT. Endovascular treatment of axil-
trauma of supra-aortic brunches. Case series. Ann Vasc Surg. 2016;31: losubclavian arterial transection in patients with blunt traumatic
205–210. injury. J Vasc Surg. 2011;53:1141–1144.
 34 Israel
EITAN HELDENBERG and ELON GLASSBERG

Israeli hospitals, as part of the national health system, mostly airlifted,preferably by the Israeli Air Force (IAF)
offer advanced medical care, which includes vascular combat rescue and evacuation unit (669), manned by
surgery. senior physicians (Fig. 34.3).
As in other developed countries, endovascular treatment Since the early 1990s, a worldwide epidemic of ter-
of peripheral arterial occlusive disease is replacing the “old“ rorist attacks against civilians has been raging. Aimed
surgical approach. For example, endovascular treatment at creating large numbers of victims, inducing fear, and
of aortic aneurysms, both simple and complicated, has causing chaos among nations, most attacks are conducted
become the preferred mode of treatment. Enjoying one of using improvised explosive devices (IEDs) as shown in
the highest life expectancies in the world, the demand for Fig. 34.4.
vascular procedures among the Israeli population is on the Unfortunately, the literature regarding terror-related
rise.1 To meet these demands, specialized vascular units trauma is anecdotal, with a large portion originating from
provide 24/7 immediate vascular treatment in every public Israel and related to the experience gained from treating
hospital in Israel, including trauma victims. the casualties of suicide bombings. In the early years of the
The principal characteristics of vascular trauma surgery 21st century,7–14 Israel experienced a wave of suicide bomb-
in Israel resemble those of other Western countries, with ers targeting buses, semi-confined spaces (restaurants,
both penetrating and blunt mechanisms as causes of vas- cafés, night clubs, etc.) and open spaces (outdoor cafés, bus
cular injuries. The rate of iatrogenic vascular injuries has stops, and open markets) as shown in Fig. 34.5.14
increased over the last decades, with the spread of mini- Unlike the “classic” civilian-related trauma, IED explo-
mally invasive techniques within specialties such as cardi- sions present civilian trauma and vascular surgeons with
ology, vascular and general surgery.2 military (combat) type injuries. Heldenberg et al. described
Located in the Middle East (Fig. 34.1) and having had the Israeli experience with terror-related vascular trauma
to fight for its existence since its establishment in 1948, (TVT) in two studies.15,16 In comparison with non–terror-
Israel has a history of military conflicts. Those military con- related vascular trauma (NVT), a significant difference
flicts, although uncommon, involved high intensity clashes was found in the prevalence of vascular injuries (9.85% in
between the armies of the surrounding Arab states and the TVT casualties versus 1.1% in NVT, P < .01).14 Moreover,
Israeli Defense Forces (IDF). The experience from these con- the prevalence of severely injured patients (injury severity
flicts has been widely reported (both in the field of general score [ISS] 25+) was 3.3 times higher among TVT victims as
trauma, as well as vascular trauma).3 Unfortunately, over compared to NVT victims (51.4% and 15.5%, respectively),
the years Israel has also been confronted with terrorist- probably reflecting the massive tissue damage caused by
related attacks and maintains, generally speaking, a high IEDs.16 This higher ISS is also testament to the importance
state readiness (Fig. 34.2). of expeditious evacuation of patients who otherwise would
Most Israeli physicians are recruited to the IDF during not have survived. As most of the explosions took place in
times of need as reservists. Practicing in civilian hospi- the center of large cities, the proximity to level 1 trauma
tals (the IDF does not operate hospitals, but relies on the centers and the availability of experienced vascular sur-
national health system), these physicians receive addi- geons probably played a crucial role in their survival.16
tional annual military-specific and trauma-related train- In addition to the classic manifestations of blunt, penetrat-
ing by the IDF. Thus, the IDF’s surgeons (during times of ing, and burn injuries, victims of explosion may also suffer
full-scale conflict) are mostly drafted civilians. It is also blast injuries. Projectiles, such as steel balls, nails, screws,
worth mentioning that the IDF provides Advance Trauma and nuts packed around an explosive substance, were also
Life Support (ATLS) training to almost every resident frequently used by terrorists in Israel and caused devastating
in Israel, regardless of whether they are in the reserves. penetrating injuries and increased mortality.7,9,13,14,16–18
These intimate collaborations between the Israeli civilian The severity of the injuries caused by explosions relates
and military medical services allow for the rapid adapta- to the proximity of the casualty to the explosion. The kinetic
tion of combat-related military medical professional les- energy of shrapnel is maximal closer to the center of the
sons in the civilian arena. explosion, thus increasing the risk of vascular injuries19–21
Data from past IDF conflicts demonstrated vascular for individuals in this zone. Peleg has shown that the pat-
injury rates that resemble those reported by the US mili- tern of civilian injuries in terrorist attacks is different from
tary in Afghanistan.4–6 The casualties were treated by those of military injuries, probably due to the difference
forward IDF teams and evacuated to the civilian trauma in the setting, evacuation times, and the lack of protective
centers. Rapid evacuation of the injured victims from the gear worn by civilians. In general, civilians were found to be
scene to the nearest hospital is the most important factor more vulnerable to terrorist-induced injuries and suffered
in those victims’ prognosis. The severely wounded were higher mortality rates.22

388
 34 • Israel 389

Fig. 34.1 Israel and neighboring countries. Fig. 34.3 (A and B) Wounded civilian evacuated by the Israel Air Force
special combat rescue and evacuation unit—unit 669.

Fig. 34.2 The ruins of a bus blown up by a suicide bomber in the mid- Fig. 34.4 Improvised explosive device.
dle of Tel Aviv, October 19, 1994.

The Israeli experience with TVT, such as with civilians The high prevalence of vascular injuries among casual-
injured by IEDs, demonstrates the importance of a thorough ties from terrorist attacks, particularly civilian IED victims,
examination to exclude vascular injuries as part of the initial further demonstrates the importance of establishing and
assessment in terrorist attacks. In a multicasualty incident, maintaining a national vascular surgery–trauma system
when decisions are typically based on clinical judgment, tri- that is ever-ready. Unfortunately, as bombings affect more
age officers should consider the high probability of vascular and more cities around the world, the lessons learned in
injury and maintain a high index of suspicion. Israel since the 2000s are ever more relevant.
390 SECTION 5 • Global Perspectives on Vascular Trauma

8. Kluger Y, Mayo A, Soffer D, Aladgem D, Halperin P. Functions and

principles in the management of bombing mass casualty incidents:
lessons learned at the Tel-Aviv Sourasky Medical Center. Eur J Emerg
Med. 2004;11:329–334.
9. Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A, Israeli Trauma
Group. The special injury pattern in terrorist bombing. J Am Coll Surg.
2004;199:875–879.
10. Almogy G, Belzberg H, Pikarsky AK, Zamir G, Rivkind AI. Suicide
bombing attacks: update and modification to the protocol. Ann Surg.
2004;239:295–303.
11. Kluger Y, Mayo A, Hiss J, et al. Medical consequences of terrorist
bombs containing spherical metal pellets: analysis of a suicide terror-
ism event. Eur J Emerg Med. 2005;12:19–23.
12. Alfici R, Ashkenazi I, Kessel B. Management of victims in a mass casu-
alty incident caused by a terrorist bombing: treatment algorithms
for stable, unstable, and in extremis victims. Mil Med. 2006;171:
1155–1162.
13. Aschkenazy-Steuer G, Shamir M, Rivkind A, et al. Clinical review: the
Israeli experience: conventional terrorism and critical care. Crit Care.
2005;9:490–499.
Fig. 34.5 The Maxim restaurant explosion by a suicide bomber in Haifa, 14. Almogy G, Mintz Y, Zamir G, et al. Suicide bombing attacks. Can exter-
October 4, 2003. nal signs predict internal injuries? Ann Surg. 2006;243:541–546.
15. Heldenberg E, Givon A, Simon D, Bass A, Almogy G, Peleg K. Terror
attacks increase the risk of vascular injuries. J Front Public Health.
2014;2(47). https://doi.org/10.3389/fpubh.2014.00047.
References 16. Heldenberg E, Givon A, Simon D, et al. Civilian casualties of terror-
related explosions: the impact of vascular trauma on treatment and
1. Life expectancy and healthy life expectancy—data by country. The prognosis. J Trauma Acute Care Surg. 2016;81:435–440.
World Health Organization. http://apps.who.int/gho/data/node.main.­ 17. Peleg K, Aharonson-Daniel L, Stein M, et al. Gunshot and explosion
688?lang=en. Retrieved 8 August 2020. injuries: characteristics, outcomes, and implications for care of ter-
2. Martin JM, Long BW. Vascular trauma: epidemiology and natural his- ror-related injuries in Israel. Ann Surg. 2004;239:311–318.
tory. In: Rutherford’s Vascular Surgery. 8th ed. Philadelphia, PA: Else- 18. Ministry of Foreign Affairs. The nature and extent of Palestinian ter-
vier Saunders; 2422–2426. rorism. Israel Ministry of Foreign Affairs, 2006. https://mfa.gov.il/
3. Rich NM. Historical and military aspects of vascular trauma (with MFA/ForeignPolicy/Terrorism/Palestinian/Pages/Palestinian%20
lifetime reflections of Doctor Norman Rich). In: Rich NM, Mattox terrorism%202006.aspx Accessed August 1, 2020.
KL, Hirshberg A, eds. Vascular Trauma. 2nd ed. Philadelphia: Elsevier 19. Champion HR, Holcomb JB, Young LA. Injuries from explosions:
Saunders; 2004:3–7. physics, biophysics, pathology, and required research focus. J Trauma.
4. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, 2009;66:1468–1477.
Rasmussen TE. The epidemiology of vascular injury in the wars in 20. Ramasamy A, Hill AM, Clasper JC. Improvised explosive devices:
Iraq and Afghanistan. Ann Surg. 2011;253:1184–1189. pathophysiology, injury profiles and current medical management. J
5. Nigel T, Rasmussen T. Epidemiology of vascular injury. In: Rasmussen R Army Med Corps. 2009;155:265–272.
T, Nigel T, eds. Rich’s Vascular Trauma. 3rd ed. Philadelphia: Elsevier 21. Kluger Y. Bomb explosions in acts of terrorism—detonation, wound
Saunders; 2015:13–20. ballistics, triage and medical concern. Isr Med Assoc J. 2003;5:
6. Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries 235–240.
in an urban combat setting: experience from the 2006 Lebanon War. 22. Peleg K, Jaffe DH, Israel Trauma Group. Are injuries from terror and
Vascular. 2010;18:1–8. war similar? A comparison study of civilians and soldiers. Ann Surg.
7. Mayo A, Kluger Y. Terrorist bombing. World J Emerg Surg. 2006;1:33. 2010;252:363–369.
https://doi.org/10.1186/1749-7922-1-33.
 35 South Africa
KENNETH BOFFARD

Region-Specific Epidemiology J­ohannesburg area, both the homicide rate and the inci-
dence of penetrating injury has dropped, in some cases by
South Africa is a large country (1,200,000 km2), with a up to 70%. In 2011, the same trauma registry showed 2200
population of about 60 million, of whom half live in the cases overall, of which 900 were penetrating. In the Univer-
urban environment and half live in the rural environment. sity’s private Milpark Academic Trauma Centre, out of 1200
There is inevitably a wide difference in the availability of cases per year, the percentage of gunshots has dropped from
general and specialized medical care as a result. 60% to less than 10%, and penetrating injury to less than
For many years, South Africa has had a background 25% overall. The incidence of gunshot injuries in the Cape
of violence. Some of this can be attributed to the political Town and Durban areas has not shown such a dramatic fall-
and other difficulties of the Apartheid era, but a significant off, but this may be partly due to increased use of firearms
proportion is of criminal and intercommunity origin. The secondary to an increased gang culture and drug culture. It
trauma registry at Johannesburg hospital, which has been is now rare to see any high-energy rifle injuries.
in existence since 1984, reflects that in 1984 of the 1000 A substantial number of vascular injuries seen in the
major trauma resuscitations per annum (injury severity South African context present late, with other compet-
score [ISS] greater than 15), some 300 injuries were pen- ing injuries, and patients are in hypovolemic shock. The
etrating in nature. In the 1980s these were predominantly patients’ outcome may also be compromised by the high
due to stab wounds and usually associated with alcohol. prevalence of HIV.
Around the time of the advent of full democracy in 1994, The common mechanisms of injury in blunt trauma are
there was initially an upsurge in interpersonal violence, similar to other countries and are related to long bone frac-
partly due to the relatively free availability of firearms and tures, direct blows to the neck, and compression injuries.
partly due to some initial instability in the political system Many are industrial related. South Africa has a very high
before the democratic elections. At that time, not only was incidence of pedestrian injuries from motor vehicles, with
there an upsurge in the number of gunshot wounds but a associated pelvic, femoral, and lower limb fractures, many
higher prevalence of wounds from high-energy assault- of which are associated with vascular injury as well.
rifle (AK-47) ammunition was found in both rural and Other injuries seen include strangulation, animal bites
urban environments. By 1994, of the 2000 resuscitations (a different form of penetrating injury, Fig. 35.2), ejection
at Charlotte Maxeke Johannesburg Academic Hospital from motor vehicles, and an association between high cervi-
(CMJAH), 1000 were penetrating, and by 1999, there were cal fractures and fractures involving the foramen transver-
2500 resuscitations of which 2000 were penetrating, the sarium, associated with blunt internal carotid artery injury.
majority of which were gunshots. At the two major univer- In penetrating trauma, currently 50% of vascular inju-
sity teaching hospitals in Johannesburg (Chris Hani Barag- ries are gunshot-wound related and are particularly com-
wanath Academic Hospital [CHBAH] in Soweto and CMJAH mon in the neck and torso, with transmediastinal injury,
in central Johannesburg [Fig. 35.1]), the incidence of pen- transabdominal injury, and injury to the femoral vessels.
etrating trauma was approximately 85% of all trauma vic- The bulk of stab wounds causing vascular injury are to be
tims. Of these, 70% were secondary to gunshot injuries. found in the neck, particularly zone I and zone II (in asso-
Most of the remaining injuries were due to stabbing. ciation with aerodigestive injuries, Fig. 35.3)1–4.
Since 1994, government focus has been on bringing A relatively large number of patients with stab wounds to
primary health care to poorer people, especially in rural the heart survive to reach the hospital and our experience,
areas. The money has had to come from somewhere, and, like similar series from elsewhere, has been that, if they sur-
despite dramatic increases in total budget, famous urban vive to reach hospital alive, they are likely to leave the hos-
hospitals like CHBAH, and Groote Schuur in Cape Town fell pital alive. A separately described subset of injury is that of
into neglect while hundreds and thousands of rural dwell- patients presenting with a repeat stab heart!
ers received some medical attention, many for the first time Finally, South Africa has a significant gold and coal min-
in their lives. The distances to major facilities are, however, ing industry. The deepest mines are found about 50 miles
unchanged, and air transport is limited. (80 kilometers) to the west of Johannesburg in the West
Since 2009 (apart from drug and gang related violence), Wits Goldfield (Tau Tona and Mponeng mine). Active min-
there has been a decline in the homicide rate across the ing takes place at up to 5000 m/17,000 feet (about 3 miles)
country. Stringent firearm laws including a background below ground level. At this depth, the uncooled tempera-
check and a practical certificate of competency prior to ture of the rock can reach 67°C/150°F and the air pressure
licensing, as well as a mandatory jail sentence for posses- can reach more than twice that at sea level. Rock movement
sion of an unlicensed firearm, have seen a significant reduc- is common. The mining industry has an excellent safety
tion in the use of firearms. There has been a slight increase record, but the challenges of the injuries caused include
in the number of stabbings, but overall, particularly in the rock falls causing crush and compartment syndromes, often
391
392 SECTION 5 • Global Perspectives on Vascular Trauma

Fig. 35.3 Penetrating injury to zone 1 of the chest. Knife still in place.
Fig. 35.1 Emergency Medical Services (EMS) helicopter flying past
Charlotte Maxeke Johannesburg Academic Hospital and metropolitan
Johannesburg. complicated by the long periods (up to 2 hours) required to
reach the surface.
Reliable follow-up is often difficult in South Africa and
treating minimal injury conservatively (nonoperatively) is
not always either feasible or possible. There is an associated
shortage of high-care beds, so many injuries that would no
longer be operated on elsewhere are dealt with surgically,
including with the use of endovascular techniques. Long-
term follow-up is difficult in institutions in South Africa,
particularly after trauma, mainly because of socioeco-
nomic factors. It is expected that only approximately one-
third of patients will return to clinic visits within 2 months
of discharge.

Region-Specific Systems of Care

There is approximately 1 physician for 25,000 patients in
the rural areas, and 1 physician per 700 patients in the
urban areas of South Africa. There are approximately 50
registered subspecialist vascular surgeons and 35 regis-
tered subspecialist trauma surgeons for the country, almost
all concentrated in the urban areas, and most in Academic
centers.5 There are some 800 practicing general surgeons
nationwide, mostly in the major centers, and it is they who
bear the brunt of the vascular trauma load.
Currently there are eight medical schools in South Africa,
producing 2000 graduates per annum. Unfortunately, 700
doctors leave the country each year primarily to Canada
and Australia, many of whom have already trained as spe-
cialists, including surgery. Thus, there is a significant short-
fall of medical practitioners in general, and of surgeons,
in particular. Although qualified general surgeons provide
the full range of trauma care in most instances, select cases
requiring subspecialty care or techniques (e.g., endovascu-
lar stent grafts) may be referred to subspecialty vascular or
trauma centers. By its very nature and urgency, a good deal
of trauma is dealt with by general surgeons, or even general
practitioners in regional or district hospitals.
There is a thriving private health sector, which inevitably
spends considerably more of the national health dollar per
Fig. 35.2 (A) Hippopotamus bite to the left side of the neck, with dam- patient than the state sector. In general, private facilities
age to the carotid and jugular vessels. (B) Same patient showing lacera- are better equipped and staffed; and many centers are capa-
tion of the shoulder, and crush injury to the back. ble of advanced surgery (e.g., stereotactic neurosurgery,
 35 • South Africa 393

cardiac and lung transplantation). Diagnostic imaging

is usually far superior and more accessible at these pri-
vate facilities, as is endovascular and minimally invasive
surgery. A substantial proportion of the population (up
to one-third) are covered by private health insurance, by
a gasoline tax if the victim is injured in an automobile
accident, and by a workman’s compensation insurance
scheme. Thus, a significant amount of trauma will be
dealt with by the private sector; and, indeed, the first two
level I trauma centers accredited by the Trauma Society of
South Africa were fully privately funded.
Much rural surgery, both basic surgery and obstetric sur-
gery, is performed by general practitioners. Although there
is a mix of public and private facilities across the country,
the reality is that most trauma, particularly outside the
major city centers, is dealt with in the public sector hospi- Fig. 35.4 Patient with a stab wound of the neck showing the use of the
tals by government-employed doctors or “Medical Officers,” Foley catheter for tamponade.
many of whom are quite junior and lack senior backup,
adequate infrastructure, and may have neither appropriate
training nor adequate supervision. MANAGEMENT OF ACUTE VASCULAR
As with many other developing countries, prehospital
care in the major cities is good in parts, with a combina-
HEMORRHAGE
tion of public and private ambulance services, paramedics, There is emphasis on arresting hemorrhage with con-
linked road and air ambulances, and an integrated system ventional techniques and sometimes with tamponade,
of care. However, in the rural areas, the level of training is using adjuncts such as the Foley catheter.8 This technique
often poor, the vehicles are ill equipped, and the distances has proven useful, especially in stab wounds of zone I of
long, resulting in interhospital transport times of up to the neck, allowing transfer to a more appropriate center
8 hours. Like Australia, many parts of the country are (Fig. 35.4).
served by a rural flying doctor service, though sometimes The surgical tourniquet (perhaps because South Africa
during daylight hours only. does not have the recent combat experience of the Middle
East and Afghanistan) is not in frequent use. The penetrat-
ing wounds are generally low-energy gunshot wounds or
Techniques of Care stab wounds, and almost all can be controlled by direct pres-
sure or using a blood pressure cuff.
There is considerable emphasis on short courses to
upgrade trauma care and the recognition of vascular
injury. The Advanced Trauma Life Support program MANAGEMENT OF ACUTE ISCHEMIA
(ATLS) of the American College of Surgeons has been in Failure to recognize acute ischemia, especially in blunt
place since 1978. In addition to the specialist fellowships injuries, remains a challenge, and limb ablation as a result
such as surgery (usually 5 years), and subspecialty fellow- of delays in both recognition and patient transfer remains
ships such as vascular surgery, and trauma surgery with a real issue. Rehabilitation facilities in the state sector are
trauma critical care (usually 2 years further), the College often rudimentary.
of Medicine of South Africa also offers a 2-year Higher
Surgical Diploma to provide extra preparation and sup-
port for rural general practitioners involved in basic gen-
eral surgery, including life-saving surgery such as damage Region-Specific Considerations for
control surgery. Diagnosis
The Definitive Surgical Trauma Care (DSTC) Course of
the International Association for Trauma Surgery and Many of the same considerations referred to previously in
Intensive Care (IATSIC) has been very popular, with some training and care delivery also apply to diagnostic imaging.
1000 surgeons and surgical medical officers now trained In major urban hospitals, the computer tomography angio-
in advanced emergency surgical life- and limb-saving tech- gram (CTA) is usually the diagnostic method of choice, often
niques, including damage control, vascular shunting, and associated with simplex or duplex Doppler imaging. Mag-
basic vascular repair.6 netic resonance angiography (MRA) is generally available
The technique of resuscitative endovascular balloon as well. Interventional angiography is less readily available.
occlusion of the aorta (REBOA) is in some use, though the The technique of emergency room angiography, although
cost is prohibitive within the state sector. As a result, the well-described, is practiced by very few centers.9
technique still must find a defined place in South Africa, as The use of the low-dose digital x-ray unit (Lodox; www.
to date, it is primarily used in the tertiary hospitals to “buy lodox.com, Fig. 35.5), a South African-developed unit
time” in Obstetrics and Gynecology, and some penetrat- originally created for detection of swallowed diamonds in
ing trauma. The technique is not used in the prehospital the mining industry, is very fast and effective (Fig. 35.6).10
environment.7 The Lodox can produce a high-quality digital whole-body
394 SECTION 5 • Global Perspectives on Vascular Trauma

Fig. 35.5 Photograh of the Lodox unit.

Fig. 35.7 Photograph showing a limb arteriogram performed on

the Lodox.

Commercially available self-expanding stent graft is a logi-

Fig. 35.6 A Lodox whole-body scan showing an impalement injury. cal choice where there is incomplete arterial disruption and
separation, and where the angiographic capabilities and
endovascular grafts are available.
x-ray in as little as 13 seconds, at an ultralow-radiation
dose. Its use has halved total resuscitation times, and at our
center, is installed in the resuscitation unit room itself, so NECK
that all x-rays are complete within 120 seconds of arrival, Management of penetrating wounds of the neck has favored
and no further x-rays are routinely required. selective conservatism in Johannesburg for at least two
Particularly with the use of the Lodox unit, emergency decades, although one incentive for pursuit of a nonopera-
room angiography using a contrast dose of as little as 20 mL tive policy is the heavy trauma load presenting in our hospi-
over the same period allows high-quality limb angiograms tals, together with comparatively limited resources. This is a
(Fig. 35.7). two-edged sword, as the number of operating rooms avail-
However, in the rural areas, even 24-hour general x-rays or able is often outstripped by demands on them, and the origin
hand-held Doppler units are not readily available, and there- of the selective nonoperative policy was that several patients
fore diagnosis is primarily clinical with transfer to the nearest became asymptomatic and recovered while awaiting surgery!
appropriate center. These transfers are frequently associated Of those patients observed with penetrating neck wounds,
with delays and subsequent limb loss. Rehabilitation facilities 6% to 9% had delayed surgery within 24 hours for missed
are few and far between, and, although available at a very injuries, usually esophageal or laryngeal injuries. Duplex
advanced level to the mining and private sector, they are not Doppler is used to follow-up minor carotid injuries, identi-
commonly available to the vast majority of patients. fied angiographically, that are not operated on. It is gener-
ally agreed that surgical intervention should be reserved for
unstable patients with zone I and zone III injuries, patients
with ongoing bleeding, and patients requiring exploration
Region-Specific Treatment for other injuries. With other cases they are treated noninva-
Strategies sively or with endovascular techniques.11,12

The treatment of vascular injuries follows the same tech- CERVICOMEDIASTINAL INJURIES
niques, using the same equipment, as in most Western
countries, including primary repair, vein patching, and Cervicomediastinal venous trauma can be very difficult
interposition grafts using either vein or synthetic graft. to control.13–15 In a series of 49 patients, 45% of whom
 35 • South Africa 395

presented in hypovolemic shock, Nair et al. showed that have a separate emergency vascular service. The volume of
ligation is an acceptable form of treatment in the presence both acute care surgical cases and trauma cases that require
of hemodynamic instability.16 operative intervention is high enough that surgical skills are
retained. However, the lack of supervision at some level II
Centers means that surgical decision-making skills are
TRANSMEDIASTINAL OR TRANSABDOMINAL
sometimes absent. The success of the DSTC course in a high-
TORSO INJURIES volume environment may reflect this.
Most patients with intrathoracic or intraabdominal aortic Both trauma and emergency medicine are young special-
injury usually die before they reach the hospital. Where pos- ties with an enthusiastic following, and those going into
sible, endovascular stenting has become the treatment of trauma as a career will practice critical care as well. None-
choice. With trans-torso gunshot wounds, there is a much theless, most vascular trauma will continue to be dealt with
higher incidence of associated injuries (e.g., the esophagus). by general surgeons as part of their greater practice, and at
Blunt thoracic aortic dissection is generally diagnosed least in South Africa, most of such procedures, especially
based on the CT scan rather than on angiography; the outside of the major academic and private centers, will be
causes are like those in other countries. The treatment is open in nature, rather than endovascular.
generally regarded as similar, as well, and endovascular
stenting as the treatment of choice. References
1. Plani F. Vascular trauma. In: Nicol A, Steyn E, eds. Oxford Handbook
CARDIAC INJURIES of Trauma for Southern Africa. 3rd ed. Oxford: Oxford University Press;
2010:258–272.
Most penetrating cardiac injuries do not survive to reach the 2. Veller MG, Pillai J. Vascular injuries. In: Adeloye A, Adekunle OO,
hospital; however, of those that do, most have a good out- Awojobi A, eds. Davey’s Companion to Surgery in Africa. 3rd ed. Uruwa:
Acecool Medical Publishers Nigeria; 2009:33–40.
come.17,18 Most South African residents will have completed 3. Degiannis E, Levy RD, Sofianos C, Florizoone MG, Saadia R. Arte-
several emergency room thoracotomies (ERTs) with both rial gunshot injuries of the extremities: a South African experience.
anterolateral and sternotomy approaches before completion J Trauma. 1995;39(3):570–575.
of their residencies. The repair techniques are similar to those 4. Franklin J, Hatzitheophilou C, Pantanowitz D. Vascular trauma. In:
Pantanowitz D, ed. Modern Surgery in Africa: the Baragwanath Experi-
practiced elsewhere. An interesting challenge is the patient ence. Johannesburg: Southern Book Publishers; 1988.
who presents with a second stab wound to the heart, having 5. Bowley DM, Degiannis E, Goosen J, Boffard KD. Penetrating vas-
had a previous injury repaired on another occasion. A differ- cular trauma in Johannesburg, South Africa. Surg Clin North Am.
ent approach is often required, especially if there has been a 2002;82(1):221–235.
previous sternotomy with repair or closure performed using 6. Boffard KD, ed. Manual of Definitive Surgical Trauma Care (DSTC). 5th
ed. Boca Raton: CRC Press; 2019.
steel wires! 7. Brenner M, Bulger EM, Perina DG, et al. Joint statement from the Amer-
ican College of Surgeons Committee on Trauma (ACS COT) and the
American College of Emergency Physicians (ACEP) regarding the clin-
Strategies to Sustain and to Train ical use of Resuscitative Endovascular Balloon Occlusion of the Aorta
(REBOA). Trauma Surg Acute Care Open. 2018;13(3(1)):e000154.
the Next Generation of Trauma https://doi.org/10.1136/tsaco-2017-000154.
8. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for
Surgeons life threatening haemorrhage in penetrating neck trauma. World Jour-
nal of Surg. 2008;32(12):2716–2723.
Medical training in South Africa is normally 5 to 6 years, 9. MacFarlane C, Boffard KD, Saadia R, Wilkinson AE. Emergency room
arteriography: a useful technique in the assessment of peripheral vas-
followed by a 2-year internship period and a further year cular injuries. J Roy Col Surg Edin. 1989;34(6):310–313.
doing compulsory community medical service, usually in a 10. Boffard KD, Goosen J, Plani F, Degiannis E, Potgieter H. The use of
rural or community hospital. This is performed before any low dosage x-ray (Lodox/Statscan) in major trauma: comparison
approved specialty training program. between low dose x-ray and conventional x-ray techniques. J Trauma.
2006;60(6):1175–1178.
General surgical training (which includes at least 3 11. Veller MG, Le Roux D. Carotid, jugular and vertebral blood vessel inju-
to 6 months of specific critical care training) consists of a ries. In: Velmahos GC, Degiannis E, Doll D, eds. Penetrating Trauma.
5-year training period similar to that in many Western coun- 2nd ed. Heidelberg: Springer; 2016:229–238.
tries, and it is possible to do a further 2-year subspecialty 12. Demetriades D, Stewart M. Penetrating injuries of the neck. Ann R Coll
fellowship in vascular surgery or trauma surgery, including Surg Engl. 1985;67(2):71–74.
13. Robbs JV, Baker LW, Human RR, Vawda IS, Duncan H, Rajaruthnam P.
trauma critical care, and completion of the relevant fellow- Cervico-mediastinal arterial injuries. Arch Surg. 1981;116(5):663–668.
ship, resulting in an independent subspecialist qualification. 14. Du Toit DF. Penetrating trauma to the subclavian vessels. In: ­Velmahos
As part of their general surgical training, most general GC, Degiannis E, Doll D, eds. Penetrating Trauma. 2nd ed. Heidelberg:
surgical trainees will spend at least 1 year out of their 5 years Springer; 2016:229–238.
15. Robbs J, Baker LW. Subclavian and axillary artery injury. S Afr Med J.
dealing primarily with trauma cases from within a dedi- 1977;19(51(8)):227–231.
cated trauma center. Acute care surgery as practiced in the 16. Nair R, Robbs JV, Muckart DJ. Management of penetrating cervico-
United States does not exist in South Africa, as all acute sur- mediastinal venous trauma. Eur J Vasc Endovasc Surg. 2000;19(1):
gery cases are dealt with by the same trainees and surgeons 65–69.
who would deal with the general surgery and trauma emer- 17. Robbs J, Baker LW. Cardiovascular trauma. Curr Probl Surg.
1984;21(4):1–87.
gencies, in addition to their time spent in dedicated burns, 18. Degiannis E, Loogna P, Doll D, Bonanno F, Bowley DM, Smith MD. Pen-
trauma, or intensive care settings. Many specialist centers, etrating cardiac injuries: recent experience in South Africa. World J
especially those associated with an academic institution, will Surg. 2006;30(7):1258–1264.
 36 Colombia: Don’t Dread the
Popliteal and Axillary Fossa
CARLOS A. ORDOÑEZ and MICHAEL W. PARRA

According to the World Health Organization, traumatic for open surgical repair is via the posterior approach
injuries worldwide are responsible for over 5 million because:
deaths annually.1 As an integral part of this epidemic,
Latin America has one of the highest homicide rates.2 1. Of the ease of repair of any portion of the popliteal
The region has just 8% of the world’s population, but artery
accounts for 33% of the total number of murders with a 2. It avoids muscle splitting incisions
baffling rate of 21.5 per 100,000 inhabitants compared 3. It requires minimal dissection to identify and achieve
to the average of 7 per 100,000 inhabitants worldwide.2 proximal and distal control of the vessel
Interpersonal violence among young people is the leading
cause of death in countries like Colombia, which unfortu- The posterior approach originally described by Dr. Rudolph
nately finds itself among the top 50 most violent countries Matas in 1921 for the management of traumatic arteriove-
on earth. Adding insult to injury, most of this violence nous aneurysms of the popliteal vessels entailed a vertical
resides among the poor, whose access to adequate health incision via the fossa.5 Dr. Shumacker in 1946, following
care is scarce to none.3 his vast experience managing hundreds of American com-
Trauma centers from Cali, Colombia, have vast expe- bat casualties from World War II, described in detail sev-
rience in penetrating and blunt vascular trauma and eral nonvertical incisions to the popliteal fossa that avoided
in a published retrospective cohort study, a total of 175 the often seen heavy scars and joint contractures with the
patients with popliteal artery injuries were reviewed. Of Matas incision.6 Currently, the posterior approach requires
these injuries, the most frequent arterial procedure was that the trauma/vascular and/or general surgeon perform
interposition grafting in 116 (66.3%) patients; vein grafts prophylactic and/or therapeutic four compartment fas-
were used in 105 and synthetic grafts in 11. Direct anas- ciotomies to the lower leg and harvest the greater saphe-
tomosis was performed in 34 (19.4%) patients. Popliteal nous vein from the contralateral leg prior to positioning
venous injuries were reported in 102 patients (58.3%) the patient in the prone position.7 It is our recommenda-
and 46 (26.3%) required ligation of the vessel, venor- tion that fasciotomies be performed in all cases of popliteal
rhaphy in 38 (21.7%), direct anastomosis in 7 (4%), and artery injuries because the morbidity of the incisions are
interposition grafting with vein grafts in 2 (1.1%). Finally, significantly less than the potential morbidity of a missed or
only 4 (1.5%) patients required amputation and the over- delayed extremity compartment syndrome. Upon comple-
all mortality was 9.6% (n = 19).4 As a result of this vast tion, a negative pressure dressing is placed on the recently
operative experience, we have developed a couple of useful created fasciotomy wounds and a proximal longitudinal
surgical pearls. incision over the contralateral groin/thigh area is done to
harvest a considerable segment of the proximal greater
saphenous vein (minimum of 5 cm). Then the patient is
flipped and positioned in the prone position with appro-
Don’t Dread the Fossa: The priate padding and airway protection. The injured limb is
Posterior Popliteal Artery Approach then re-prepped and draped. The popliteal fossa skin inci-
sion is preformed vertically in an “S” like fashion with the
A 23-year-old male victim arrives at our level I trauma purpose of avoiding postoperative scar retraction that could
center hemodynamically stable with a gunshot wound potentially limit the range of motion of the involved knee
to the right knee area (Fig. 36.1) with associated pain, (Fig. 36.2). After performing the skin incision, the rest of the
swelling, and decreased distal pulses on palpation. Plain subcutaneous dissection should be directed midline and the
x-rays reveal no associated extremity fracture and the popliteal vascular/nervous bundle is located very shallow
patient’s vital signs remain stable. A computed tomog- to the skin incision (Fig. 36.3). The complete extent of the
raphy (CT) angiogram of the extremity is done which popliteal artery can be exposed with ease and both proximal
reveals a mid-popliteal artery injury without contrast and distal vessel control can be achieved similarly without
extravasation and without reconstitution of distal flow. the need to split any muscles (Fig. 36.4). At this point, the
It is our belief that a preoperative CT angiogram of the surgical repair of the popliteal artery depends more on the
involved extremity is paramount to determine the exact extent of the injury and can include anything from simple
location and extent of injury in hemodynamically stable direct repair to patching with autologous or synthetic mate-
patients. Cases in which patients present with hemody- rial to segmental replacement similarly with autologous or
namically unstable and/or active arterial bleeding should synthetic material (Fig. 36.5). We usually end up perform-
be taken immediately to the operating room where an on- ing a reverse saphenous interposition graft for most injuries
table traditional angiogram can be performed. Once the with prior formal Fogarty (3 Fr) catheter embolectomies of
popliteal artery injury has been clearly identified, then it both proximal and distal ends (Fig. 36.6). We also routinely
is our recommendation that the ideal surgical approach systemically heparinize our patients and locally infuse
396
 36 • Colombia: Don’t Dread the Popliteal and Axillary Fossa 397

Fig. 36.4 Popliteal artery is exposed.

Fig. 36.1 (A) Entry wound. (B) Exit wound.

Fig. 36.5 Closer view of the popliteal artery injury.

Fig. 36.2 The popliteal fossa skin incision is preformed vertically in an

“S” like fashion.

Fig. 36.6 Fogarty catheter embolectomy of the popliteal artery.

heparinized flush prior to completing our graft anastomo-

sis (Fig. 36.7). Upon completion, an on-table angiography
is recommended to verify adequate distal flow. If there is an
associated popliteal vein injury, we recommend primary
Fig. 36.3 After performing the skin incision, the rest of the subcutane- vessel suture repair in most cases. If primary vein repair is
ous dissection should be directed midline. not feasible, then the vein can be ligated. Vein interposition
398 SECTION 5 • Global Perspectives on Vascular Trauma

Fig. 36.8 Closed incision.

Don’t Dread the Fossa: The Axillary

Artery Approach
A 27-year-old male patient arrives at our level I trauma
center hemodynamically unstable, pale, and diaphoretic
Fig. 36.7 (A, B) Interposition vein graft. with a blood pressure of 90/60 mm Hg, a heart rate of 115
bpm and a gunshot wound to the right shoulder. The insti-
tution’s massive transfusion protocol is activated and the
patient undergoes rapid sequence intubation by anesthe-
grafts to fix the popliteal vein notoriously fail and are so not sia staff. On secondary survey, a gunshot wound is seen at
indicated. Finally, the incision is closed by layers (Fig. 36.8). the level of the right infraclavicular area with the anterior
Patient is transferred postoperatively to a monitored nurs- axillary line. Active arterial bleeding ensued profusely from
ing floor where serial vascular checks can be performed. the gunshot wound orifice, which was managed initially
Fasciotomy wounds are closed or reapproximated as soon as by the application of direct pressure. Patient responds well
possible and physical therapy initiated early in the recovery to our initial resuscitation efforts in the trauma bay and
and carried out as an outpatient. is taken immediately to the CT suite for a CT chest with
The popliteal artery anteromedial approach with associ- right upper extremity run-off. A proximal right axillary
ated fasciotomies is the most widely used technique in the artery injury with active extravasation is identified and
world by vascular and trauma surgeons alike, and is the the patient is taken immediately to the operating room for
most cited and described technique in the medical literature surgical repair.11 The traditional surgical incision is one
that addresses the management of these injuries. Originally that starts at the infraclavicular area and extends over the
described by Dr. Szilagyi in 1959, it requires a medial inci- delto-pectoral fossa and ends, if needed, over the medial
sion over the thigh and leg and requires extensive muscle aspect of the upper arm. This incision requires usually the
splitting dissection to reach the vessel for both proximal transection of both the pectoralis major and minor muscle
and distal control.8 This dissection is time consuming and bundles to expose and achieve proximal vascular control.12
tedious, and the vessel distally is deeper and harder to access This approach is time consuming, technically difficult, and
and control.9 Regarding long-term outcomes, the literature morbid for the patient.13 Because of this, and considering
does not report any significant difference regarding patency the experiences obtained in elective cases of axillary lymph
and subsequent amputation rates.10 But we, the authors, node dissections for breast cancer, we have adapted a simi-
have been able to demonstrate a significant reduction (more lar technique to better deal with these complex trauma
than 50%) in total operative time. It is our belief and prac- cases. The patient is placed in the supine position with the
tice that all surgeons who are currently involved in the care injured upper extremity hand alongside the patient’s fore-
of trauma patients should “embrace the fossa” and include head (modified military salute pose) (Fig. 36.9). The inci-
the posterior approach as a key component to their arma- sion is drawn along the axilla fossa in a slightly inverted
mentarium when confronting a patient with a potential “S” fashion. The purpose of the shape of the incision is to
popliteal vessel injury. avoid subsequent scar retraction which may compromise
 36 • Colombia: Don’t Dread the Popliteal and Axillary Fossa 399

Fig. 36.11 Ligated axillary vein and resected ends of the axillary artery.

Fig. 36.9 Patient placed in modified military salute pose. The incision is
drawn along the axilla fossa in a slightly inverted “S” fashion.

Fig. 36.12 Interposition synthetic graft.

of the axillary artery depends more on the extent of the

injury and can include anything from simple direct repair
to patching with autologous or synthetic material to seg-
mental replacement similarly with autologous or synthetic
material (Figs. 36.11 and 36.12). We usually end up per-
Fig. 36.10 Incision site showing axillary artery and bullet hole. forming a reverse saphenous interposition graft for most
injuries with prior formal Fogarty (3-Fr) catheter embolec-
the long-term mobility and range of motion of the shoul- tomies of both proximal and distal ends. We strongly rec-
der. Both proximal and distal vascular control of the axil- ommend performing the proximal anastomosis first when
lary artery can be performed quickly and safely through an interposition graft option has been decided, prior to any
this incision, without the need of transecting any mayor proximal manipulation or embolectomy of the vessel, to
muscle groups (Fig. 36.10). The proximal dissection of avoid the risk of losing the proximal end of the native ves-
the artery can be extended all the way to the ipsilateral sel due to its potential to retract back into the chest. We
rib cage and control can be obtained of the vessel as it also routinely systemically heparinize our patients and
emerges from the chest. At this point the surgical repair locally infuse heparinized flush prior to completing our
400 SECTION 5 • Global Perspectives on Vascular Trauma

belief and practice that all surgeons who are currently

involved in the care of trauma patients should “embrace
the fossa” and include the axillary fossa approach as a key
component to their armamentarium when confronting a
patient with a potential axillary vessel injury. We want to
emphasize that the original Matas operation performed
more than 100 years ago (1888) has stood the test of time
and we, the authors, have adapted its modified version by
Elkin and applied it not only to manage complex traumatic
injuries of the popliteal vessels, but also to those complex
injuries of the upper extremity: the Cali Approach to the
Axillary Vessels.14,15

References
1. World Health Organization. Injuries and violence: the facts 2014.
WHO. World Health Organization; 2015. https://www.who.int/
violence_injury_prevention/media/news/2015/Injury_violence_
facts_2014/en.
2. Muggah R, Aguirre Tobón K. Citizen Security in Latin America: Facts
and Figures. 2017. https://igarape.org.br/wp-content/uploads/2018/
04/Citizen-Security-in-Latin-America-Facts-and-Figures.pdf.
3. Instituto Nacional de Medicina Legal y Ciencias Forenses. Forensis
2017: Datos para la Vida. Colombia. 2018;19(1). https://www.medicina-
legal.gov.co/documents/20143/262076/Forensis+2017+Interactivo.
pdf/0a09fedb-f5e8-11f8-71ed-2d3b475e9b82.
4. Garcia AF, Sanchez AI, Millan M, et al. Limb amputation among
patients with surgically treated popliteal artery injury: analysis of 15
years of experience in an urban trauma center in Cali. Colombia. Eur J
Trauma Emerg Surg. 2012;38:281–293.
5. Matas R. Military Surgery of the Vascular System. Philadelphia: WB
Saunders; 1921.
6. Shumacker Jr. HB. Incisions in surgery of aneurysms: with special ref-
erence to explorations in antecubital and popliteal fossae. Ann Surg.
Fig. 36.13 Closed incision. 1946;124:586–598.
7. Hamza N, Marath A, Al-Fakhry MR. The management of aneurysms
and arterio-venous fistulae of the popliteal artery arising from war
trauma. Emphasis on sigmoid operative approach. J Cardiovasc Surg
(Torino). 1990;31(4):457–461.
distal graft anastomosis. Upon completion, an on-table 8. Szilagyi DE, Whitcomb JG, Smith RF. Anteromedial approach to
angiography is recommended to verify adequate distal the popliteal artery for femoropopliteal artery grafting. Arch Surg.
flow. If there is an associated axillary vein injury, we rec- 1959;78:647.
ommend primary vessel suture repair in most cases. If pri- 9. Sciarretta JD, Macedo FI, Otero CA, Figueroa JN, Pizano LR, Namias
mary vein repair is not feasible, then the vein can be ligated N. Management of traumatic popliteal vascular injuries in a level I
trauma center: a 6-year experience. Int J Surg. 2015;18:136–141.
(see Fig. 36.11). Vein interposition grafts to fix the axillary 10. Fairhurst PG, Wyss TR, Weiss S, Becker D, Schmidli J, Makaloski V.
vein notoriously fail and so are not indicated. Finally, the Popliteal vessel trauma: surgical approaches and the vessel-first strat-
incision is closed by layers (Fig. 36.13). The need for fas- egy. Knee. 2018;25(5):849–855.
ciotomies of the upper extremity is considered in a case- 11. Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Vascular injuries
of the axilla. Ann Surg. 1982;195:232–238.
by-case scenario, always defaulting towards performing 12. Padegimas EM, Ramsey ML, Austin M, et al. Evaluation and man-
them if there is any question of possible ensuing compart- agement of axillary artery injury: the orthopaedic and vascular sur-
ment syndrome or hypertension. The patient is transferred geon’s perspective. Orthopedics. 2017;40(4):223–229.
postoperatively to a monitored nursing floor where serial 13. Mazzini FN, Vu T, Prichayudh S, et al. Operative exposure and manage-
vascular checks can be performed. Fasciotomy wounds are ment of axillary vessel injuries. Eur J Trauma Emerg Surg. 2011;37(5):451.
14. Elkin DC. Traumatic aneurysm; Matas operation - 57 years after. Surg
closed or reapproximated as soon as possible and physi- Gynecol Obstet. 1946;82:1–12.
cal/occupational therapy initiated early in the recovery 15. Matas R. Traumatic aneurysm of the left brachial artery—incision
and carried out as an outpatient. Once again, it is our and partial excision of sac: recovery. Phil Med News. 1888;53:462–466.
 37 Brazil
ROSSI MURILO and RINA PORTA

Introduction rely on the public health system that is maintained by the

government. The health system is composed of facili­
For the purposes of this chapter, vascular trauma is consid- ties of varying complexity: basic health units and Emer­
ered in the following anatomic distributions, each of which gency Care Units, secondary hospitals, tertiary hos­pitals
has differing diagnostic and management considerations: and University Hospitals, where some tertiary and uni­
(1) cervical or carotid, (2) axillo-subclavian, (3) thoracic, (4) versity hospitals correspond and function as trauma
abdominal, and (5) extremity domains. Whereas the major- centers (Fig. 37.1). Systematized, standardized clinical
ity of vascular injury is managed via an open operative responses to polytraumatized patients began in the pub­
approach, the use of endovascular techniques is common in lic (University) hospitals in the 1980s, with the introduc­
the metropolitan centers throughout the country. In these tion and expansion of Advanced Trauma Life Support
instances, stent grafts are often used to treat or “seal” vascu- in Brazil. In the last decade, some private hospitals have
lar disruption in anatomically-challenging-to-reach vessels started to implement trauma care systems based around
such as those in the thorax and thoracic outlet. In Brazil, teams of trauma surgeons. Prehospital emergency care is
challenges exist as to the “best training paradigms” to pre- performed by the Emergency Medical Care Service (Ser­
pare trauma and vascular surgeons. However, a number of viço de Atendimento Móvel de Urgência, SAMU), which
Brazilian medical centers and emergency medical systems, is structured with basic care units composed of techni­
working alongside the efforts of professional societies such cians and nurses and advanced units composed of doctors
as the Brazilian Trauma Society (Sociedade Brasileira de and nurses. An emergency medical response (ambulância)
Atendimento Integrado ao Politraumatizado, SBAIT), have is obtained by telephoning 192. However, in some cities
emphasized the importance of trauma care in the country. such as São Paulo, Rio de Janeiro, and Curitiba, in addi­
tion to the SAMU response, prehospital trauma care is per­
formed by physicians and nurses in conjunction with the
Epidemiology rescue team of the Fire Department (Corpo de Bombeiros),
activated by dialing 193.
Currently, urban violence, automobile crashes, and work-
related accidents are responsible for most injuries in Brazil;
a notable amount of those injuries are to major vascular URBAN SETTING
structures.1–3 Concomitant with this experience, better life- The severity of vascular trauma varies, with injuries stem-
saving interventions and early resuscitation strategies have ming from military- or combat-related munitions generally
been established in many of the larger emergency rooms in cause more extensive damage.4,5 Brazilian surgeons gener-
Brazil. Additionally, a full understanding of the epidemiology ally have little experience of managing severe injury caused
of vascular trauma is hampered by the lack of standardized by military munitions and explosive devices, although
data retrieval and archiving mechanisms or databases.1–3 the sporadic use of military-type weapons in the urban
According to Brazil’s Institute of Geography and Statis- ­setting is a regrettable but new reality that is not unique
tics, just over 210 million people live in Brazil. Increasing to B­ razil. Although uncommon, vascular trauma resulting
levels of violence and trauma within certain urban areas from weapons such as the AR-15, AK-47, M16, and even
and regional locations in Brazil (Table 37.1) were the norm ­grenades occurs on a sporadic basis in some areas of ­Brazil
until the most recent decade (2010–19). This trend has (Fig. 37.2), though the proportion of such injuries was seen
lessened recently as rates of violent crime, including homi- to decline in a series from the Hospital Municipal Souza
cide, have plateaued or declined in proportion to population Aguiar (1995–2000). This observation was made during
growth. Currently, the overall homicide rate fluctuates at a time when the homicide rate was increasing, suggesting
around 30 per 100,000 people.1–3 that high-velocity munitions remained a significant cause
The growth in homicide over these three and a half of trauma including lethal injury. In an encouraging and
decades was largely due to death from firearms, whereas more-recent trend, the rate of violence and the number of
deaths from other means remained relatively constant. In high-velocity gunshot wounds currently tended to in the
the early 1980s, there was an “arms race” associated with state has plummeted.1–3
an increase in social tension, caused by a massive growth
in urban population (following population transition from
rural areas), although the 2003 Disarmament Statute RURAL SETTING
helped to limit firearm availability. Between 1% and 4% of injuries in the more remote areas
We have two types of health care systems in Brazil: of Brazil have a vascular component. Lower extremity trau-
public (Sistema Único de Saúde, SUS) and private (health mas usually result from automobile crashes, whereas upper
and private plans). About 90% of the Brazilian popula­tion extremity injuries typically occur as result of factory or
401
402 SECTION 5 • Global Perspectives on Vascular Trauma

Table 37.1 Ranking of States by Homicide Rates (per 100,000): Brazil 2000–16.
2000 2010 2016
State Rate Position Rate Position Rate Position
Alagoas 25.6 11th 66.8 1st 55.9 3rd
Espirito Santo 46.8 3rd 50.1 2nd 32.5 16th
Pará 13.0 21st 45.9 3rd 50.9 4th
Pernambuco 54.0 1st 38.8 4th 47.6 6th
Amapá 32.5 9th 38.7 5th 49.6 5th
Paraíba 15.1 20th 38.6 6th 33.1 13th
Bahia 9.4 23rd 37.7 7th 46.5 7th
Rondônia 33.8 8th 34.6 8th 32.8 14th
Paraná 18.5 16th 34.4 9th 25.9 20th
Distrito Federal 37.5 7th 34.2 10th 22.1 22nd
Sergipe 23.3 12th 33.3 11th 64.0 1st
Mato Grosso 39.8 5th 31.7 12th 35.5 11th
Amazonas 19.8 14th 30.6 13th 29.4 18th
Ceará 16.5 17th 29.7 14th 39.8 9th
Goiás 20.2 13th 29.4 15th 43.8 8th
Roraima 39.5 6th 27.3 16th 19.8 25th
Rio de Janeiro 51.0 2nd 26.2 17th 37.6 10th
Mato Grosso do Sul 31.0 10th 25.8 18th 22.7 21st
Ri Grande do Norte 9.0 24th 22.9 19th 56.9 2nd
Tocantins 15.5 19th 22.5 20th 27.1 19th
Maranhão 6.1 27th 22.5 21st 33.7 12th
Acre 19.4 15th 19.6 22nd 29.8 17th
Rio Grande do Sul 16.3 18th 19.3 23rd 31.2 16th
Minas Gerais 11.5 22th 18.1 24th 20.7 24th
São Paulo 12.2 4th 13.9 25th 11.0 27th
Piauí 8.2 25th 13.7 26th 21.9 23rd
Santa Catarina 7.9 26th 12.9 27th 15.0 26th
Sistema de Informação sobre Mortalidade (SIM)/Secretária de Vigilância em Saúde (SVS)/Ministério da Saúde (MS); Araujo et al. (2006), Waiselfisz (2018), and
Rossi et al. (2013).

Fig. 37.1 State Institute of Cardiology Aloísio de Castro (IECAC) in Rio

de Janeiro, which is the primary medical center of the authors of this
international perspective.

industrial accidents, agricultural mishaps, or domestic dis- Fig. 37.2 Right external iliac (vein and artery) following a high-velocity
putes (i.e., knife or glass lacerations). In the case of domes- gunshot wound (wounding by AK-47).
tic disputes where knife and lacerations from glass are more
common, upper extremity vascular injury is often confined AUTOMOBILE CRASHES
to the radial artery (34% of cases) or the ulnar artery (36%
of cases), either of which frequently can be managed by Brazil has one of the highest numbers of trauma deaths due
ligation instead of repair or reconstruction. to traffic, exceeded only by India, China, the United States,
 37 • Brazil 403

and Russia. Between 1980 and 2011, almost one million and any lifesaving maneuvers are performed, the patient
people died due to traffic accidents in the country; between is usually transferred to one of three locations: radiology
2000 and 2010, the number of fatalities increased from for additional imaging, the intensive care unit for moni-
28,995 to 42,844, a 32.3% increase. Males accounted for toring and resuscitation, or the operating room for resus-
82.3% of this total and the highest rates were observed in the citation and repair. In most cases of significant vascular
Midwest and South regions, with rates of 29.0 and 25.4 deaths trauma, patients are transferred from the resuscitation
per 100,000 inhabitants. Motorcyclists accounted for 76.9% room to the operating room where additional imaging
of all deaths. The trend of motorcycle fatalities has also been and repair can be performed as needed while resuscita-
found in Great B ­ ritain, with an annual increase of 4.6% in tion is ongoing.
hospitalizations of road accidents. In Brazil, a 2008 study from
Campinas, State of São Paulo, recorded a significant increase
in fatal traffic accidents with motorcyclists accounting for
49.3% of deaths in traffic.6 Vascular Injury Patterns and
Treatment Strategies
A retrospective study from the Municipal Hospital Souza
Evaluation and Diagnosis of Aguiar (one of the largest emergency centers in Latin
Vascular Injury in Brazil America) between 1998 and 2008 reported 1478 vascular
injuries in 1236 patients. Like other regions of the world,
There is wide disparity in the resources available to tra- findings from this study revealed that vascular trauma in
uma patients in the more remote and smaller towns of Brazil occurs most commonly in men (73% of the cohort)
Brazil and the resources available to patients in the larger under 40 years of age (69% of the cohort). The main
urban medical centers. In the metropolitan areas of Brazil, mechanism of vascular injury in this study was gunshot
the routine triage, evaluation, and diagnosis of vascu- wound (73%) with low-velocity injuries being more common
lar injury is similar to that in other developed countries than high-velocity wounds (83% and 17%, respectively).
of the world. A detailed summary of the discrepancy of The most common anatomic location of vascular injury
resources between public and private medical centers in was the lower extremities followed by the upper extremi-
Brazil is beyond the scope of this review. As such, this ties (54% and 33%, respectively). Approximately 5% of the
report focuses on the diagnosis and management of vas- vascular injuries were in the cervical region with a similarly
cular injury in Rio de Janeiro, which has a population of small percentage in the abdomen (5%) and the thorax (3%).
more than 7.5 million people and is the second largest city Surgical management of vascular injury in this retrospec-
in Brazil. In this setting, the prehospital evaluation of the tive series consisted of primary anastomosis (39%), graft
trauma victim is divided into four phases, all conducted by reconstruction (21%), ligation (16%), and suture repair
the Fire Department (emergency physicians): (12%). Primary amputation was reported in only 1.5%
of the cases of extremity vascular trauma. The main con-
1. Rapid assessment: Completed in a matter of minutes, this duit used as a vascular substitute was autologous vein,
phase aims to diagnose and treat conditions that are life- with synthetic grafts used in only 5% of the reconstruc-
threatening and to evaluate whether a patient is critical. tions. When an autologous conduit was used, great saphe-
2. Critical intervention and transportation: Transportation to nous vein was used in 90% of cases (Fig. 37.3), with arm
the one of seven trauma referral centers in Rio de Janeiro cephalic vein used in few instances (1.3%). Unsurprisingly
should occur immediately after stabilization procedures (and like other regions of the world), patients with vascular
are completed.
3. Nonessential procedures: These are deferred until after the
patient is transported to a trauma referral center.
4. Detailed examination: This examination is to diagnose
injuries that were not observed during the rapid assess-
ment. For critical patients, this phase must be performed
during transportation; whereas, for stable patients, it
can be performed on the scene in less than 5 minutes.

Referral trauma centers in the city of Rio de Janeiro,

Belo Horizonte, and São Paulo use modern resuscitation
rooms, which are accessible to prehospital emergency
vehicle(s) and providers with ample space for a multidis-
ciplinary team to quickly triage and perform a range of
diagnostic and resuscitative maneuvers. These resuscita-
tion rooms are equipped with radiography and ultrasound
equipment to perform diagnostic imaging and assist with
vascular access, as well as operative equipment to facili-
tate resuscitation (i.e., transfusion), fracture stabiliza-
tion, and immediate lifesaving interventions. Depending
on the injury, as soon as the initial survey is complete Fig. 37.3 Saphenous vein interposition graft for arterial reconstitution.
404 SECTION 5 • Global Perspectives on Vascular Trauma

and nonvascular trauma (i.e., polytrauma) had the high­ SPECIFIC CONSIDERATIONS
est rates of mortality in the review, especially patients with
vascular trauma and concomitant cranial and/or thoracic Carotid Injuries
injury.7 Lesions of the common and internal carotid artery may
cause thrombosis and/or hemorrhage, especially when the
wound is lateral or in the intimal lesion, which may go unno-
ENDOVASCULAR FACILITIES ticed and cause future problems (i.e., pseudoaneurysm). Our
Suffice it to say that, as in other areas of the world, endovas- experience is that an open repair and reconstruction is the
cular technologies (i.e., balloons, stents, and stent grafts) best option, even in patients with neurologic symptoms. A
have played increasingly important roles in managing neurological assessment of the patient before and after the
some patterns of vascular trauma, especially in the larger operation is essential to outline the best therapeutic course
and better-equipped tertiary trauma centers in Brazil and to assess its outcome. For injuries to the external carotid
(Fig. 37.4). In general, endovascular stent graft manage­ artery and its branches, endovascular embolization has been
ment of vascular trauma is reserved for central vascu­ useful with good results for these authors.
lar injuries of the aorta and its proximal branch vessels,
such as the subclavian, intrathoracic carotid, and even Subclavian Injuries
occasionally a mesenteric vascular injury.8–10 To deliver Like others, the authors recognize that there is a signifi-
these therapies, the development of a single physical cant difference in the surgical approach to the three dis-
location (i.e., resuscitation with angiography, percuta­ tinct segments of the subclavian artery. The intrathoracic
neous techniques, and operative repair) where percuta­ segment of the subclavian artery is typically approached
neous therapies, operative interventions, cross-sectional using a high anterolateral thoracotomy with or without
imaging, and initial critical care can all be delivered is a separate supraclavicular exposure of the more distal
extremely attractive. This concept of hybrid surgery and artery. Because of the challenges associated with exposing
resuscitation has been used in the main trauma centers and controlling the intrathoracic subclavian artery, the
in our country. The vascular surgeon on duty is part of authors have found this injury location particularly well
the emergency surgical team and works together with suited for endovascular treatment using a covered stent.
the trauma team to control bleeding and treat vascular The more distal subclavian artery segments behind and
injury. Severely injured patients are taken to the operat­ distal to the first rib can be exposed with a supraclavicular
ing room and placed in a surgical radioscopy table. There incision often combined with an infraclavicular approach
are standard angiography equipment, diagnostic marker of the axillary artery. The authors have found endovascu-
flush catheters, and guide wires for most vascular inter­ lar repair of the more distal subclavian and even proximal
ventions. Equipment specific to aortic interventions, axillary artery favorable in some cases (Fig. 37.5).
including large diameter sheaths, super-stiff guidewires,
and varying sizes and types of ­aortic endografts are avail­ Cardiac Injuries
able. In this way, hybrid procedures are performed in some Cardiac trauma has high mortality. It can cause exsan­
University Hospitals. guination, varying degrees of mediastinal and pleural

Fig. 37.4 (A) Computed tomographic angiography showing blunt injury of the thoracic aorta (pseudoaneurysm) caused by an automobile accident.
(B) Digital subtraction angiogram of thoracic endovascular aortic repair stent-graft. Note variant aortic arch branching anatomy (origin of left common
carotid artery from brachiocephalic artery).
 37 • Brazil 405

Fig. 37.5 Motorcycle polytrauma with multiple fractures of right upper limb, right brachial plexus injury, right subclavian artery (SCA) injury, and right
pulmonary contusion. (A) Digital subtraction angiography reveals filling defect in SCA. The defect was crossed with Viabahn 9- × 100-mm stent (B) with
satisfactory restitution of flow (C).

hemorrhage, and cardiac tamponade. The classic pre­ or with the use of temporary vascular shunts. If shunts are
sentation of the Beck triad (jugular turgidity, choking of used, they are removed and vascular repair is performed after
heart sounds, and hypotension) occurs in less than 40% the fracture fixation has been completed. Another impor­
of cases11 (Fig. 37.6). tant consideration is adequate soft-tissue coverage of the
vascular repair. If tissue destruction is such that this can­
Thoracic Vascular Trauma not be accomplished with the vascular graft routed in the
Given the prevalence of automobile crashes in Brazil, experi­ normal or in-situ position, the authors favor extraanatomic
ence with blunt thoracic aortic injuries is considerable. Like bypass to reduce the risk of infection and disruption. Dif­
other developed regions of the world, diagnosis of this injury ficulties in acquiring suitable prosthetics and rehabilita­
is now almost solely based on contrast-enhanced CT imag­ tion for amputees in Brazil emphasize the need for surgical
ing and/or magnetic resonance imaging (MRI). Contrast teams to maximize efforts at limb salvage in patients with
angiography is typically reserved for use during stent graft extremity vascular injury.17,18
repair of blunt aortic injury, which is now the approach of
choice for the majority of these types of injuries12,13 given
the low mortality rates (less than 5%) associated with tho­ Training the Next Generation of
racic endovascular aortic repair (TEVAR) and the much
higher rates observed with surgical repair of blunt thoracic
Trauma Surgeons
aortic injury (10% to 35%).2,3 As is the case in other parts
of the world, the challenge is to make this treatment more Learning from our own experience and mindful of military
widely available in rural as well as metropolitan areas. practice and reports from around the world, there are two
clinical settings by which trauma-training opportunities
Abdominal Vascular Trauma can be exploited in Brazil.8–10 The first setting is within aca­
The authors prefer an open approach (i.e., laparotomy) to demic university hospitals that are associated with medical
abdominal aortic injuries (blunt or penetrating). Because schools and which received trauma patients. The second
of the propensity for large resuscitation and damage to hol- concerns a larger collection of hospitals, mostly public, that
low viscus or solid organs, principles of damage control lap- have a long history with and experience of caring for trauma
arotomy are espoused by the authors, focusing on patient victims, but which do not offer opportunities for formal aca­
physiology and resuscitation while controlling hemorrhage demic study within the field of trauma surgery. To become
and contamination, while also planning to return to the a general surgeon in Brazil, the doctor must always per­
operating room at a later time for more definitive repair.14–16 form a minimum of 2 years of general surgery residency—
one can then be certified as a general surgeon and practice
Extremity Vascular Trauma acute care surgery. A further 2 to 3 years specialization (e.g.,
Such injuries often require a multidisciplinary approach in Vascular Surgery) is required to develop specialist skills.
that includes vascular, trauma, and orthopedic surgeons. Some residency programs supplement the initial 2 years of
Like other anatomic areas of vascular injury, the priorities general surgical training with advanced general surgery for
in the extremities are to control hemorrhage and to restore an additional 2 years. Specialist surgeons in Brazil have two
perfusion. However, unlike other anatomic areas, fracture titles: general surgeon and another title that reflects their
reduction and stabilization must be considered alongside specialty.
vascular repair, which is often necessary. Following hemor­ In Brazil, annually there are 55 vacancies for medical
rhage control, fracture reduction and alignment is usually residency programs in trauma surgery, distributed across
accomplished. The authors typically proceed with reestab­ 9 states. These residency programs consist of 2 years of gen­
lishing perfusion to the limb prior to skeletal fixation. This eral surgery plus 1 year of training in trauma. This pro­g ram
can be accomplished with a formal vascular reconstruction is still deficient with respect to accumulation of trauma
406 SECTION 5 • Global Perspectives on Vascular Trauma

In conclusion, it is the authors’ viewpoint that the

future of vascular surgery, specifically vascular trauma, is
very promising in Brazil. It is a good sign for the country
and region that the overall indices of urban violence are
decreasing and that the number of established and capable
trauma centers is increasing. Challenges remain as to the
“best training paradigms” for trauma and vascular surgery;
however, with the emergence of improved methods of dam­
age control and resuscitation and with the rapid acceptance
of catheter-based, endovascular techniques to treat some
forms of vascular injury, patients with this challenging
injury pattern stand to have improved outcomes.19–21

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64(2):500–505.
16. Ho XN, Wee IJ, Syn N, Harrison M, Wilson L, Choong AM. The
Fig. 37.6 High-velocity projectile heart injury with repair of heart on endovascular repair of blunt traumatic thoracic aortic injury in Asia: a
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 Index
Note: Page numbers followed by “f  ” refer to illustrations; page numbers followed by “t ” refer to tables; page numbers followed by “b” refer to boxes.

Aerodigestive injuries, in carotid/vertebral Antyllus, 13

A injuries, 242–243 Aortic clamping, thoracic, 4, 5f, 6f
Afghanistan Aortic injuries, 216–218
Abdomen, zones of, 339, 340f military vascular surgery in, during Gulf investigations on, 217
Abdominal aorta, injury to War, 20 treatment of, 217–218, 218f
blunt, 304 vascular injury rates, 388 Aortic stenting, 208
penetrating, 304 Air-bag, inflation of, blunt thoracic injury and, 3 Aortocaval fistulas, abdominal vascular injuries
Abdominal aortic trauma, 212 Air leaks, as lung injury complication, 27 and, 214
anatomy in, 213, 213f Alcohol and drug consumption, 365 Aortogram, of thoracic aortic stent-graft
aortic injuries in, 216–218 Alliance for Physician Certification and placement, 355f
follow-up for, 218 Advancement (APCA), 98 Aortography
investigations on, 217 Allografts, 302 in blunt thoracic aortic injury, 201
treatment of, 217–218, 218f Alpha (α) Angle, 76 of traumatic false aneurysm, 200f
in central retroperitoneal area (zone I), 213 American Association for the Surgery of Trauma Aortorrhaphy, 19
clinical presentation of, 213–214 (AAST), 318 APMs. See Antipersonnel mines (APMs)
complications of, 222 organ injury scale for abdominal vascular Archigenes, 12
endovascular balloon occlusion, 224–225 injury, 226, 227t Argyle shunt, 292f, 292t, 293f
endovascular treatment of, 222–225 American College of Surgeons (ACS), Arrhythmias, blunt cardiac injury and, 9
embolization in, 222–223
verification system for systems of Arterial access, for REBOA, 128–129, 129f
solid organs and pelvic trauma, 223
care, 353 Arterial conduits, 301
iliac artery in, injuries to, 220–221, 221b
American College of Surgeons Committee on Arterial fistulas, abdominal vascular injuries
investigations in, 214
Trauma (ACS COT) and, 214
mechanism of injury in, 212–213
Resources for the Optimal Care of the Injured Arterial injury, 332, 333f
in pelvic retroperitoneum (zone III), 213
Patient, 36 Arterial occlusion, 273
surgical management of, 221–222
Verification Review Committee, 36 angiographic findings in, 92t
surgical techniques for, 214–216
AMPLTZER Vascular Plugs (AVPs), 116 ultrasound findings in, 98t
in upper lateral retroperitoneum (zone II),
Amputation, 333f Arterial repair
213
visceral arteries in, injuries to, 218–220 in complex upper extremity vascular trauma, nonsuture method of, during World War II,
celiac artery and branches, 218 254 18, 18f
endovascular treatment for, 220 forequarter, 347 performed by Halowell, 14f
inferior mesenteric artery, 219 versus salvage, 322 Arterial stenosis
mortality in, 220 Analgesia, for lung injuries, 24 angiographic findings in, 92t
renal artery, 219–220 Anastomosis ultrasound findings in, 98t
superior mesenteric artery, 218–219 of artery, first end-to-end, 15, 15f Arterial suture, techniques for, 16
Abdominal hemorrhage, 62–63 techniques, 281 Arterial trauma, ligation for, 12
Abdominal injuries, vascular conduit for, 304 Anastomotic stenosis, 382 Arterial wall disruption, 274
Abdominal vascular injuries, 83 Anatomy. See Surgical anatomy Arteriogram
in austere environment, surgery for, 339– Angiography, 91–97, 92t in lower limb vascular injuries, 342f
341, 340f, 341f complications of, 97 in upper limb vascular injuries, 338f
clearing trauma patients from, 87b in iliac artery injuries, 221 Arteriography
organ injury scale for, 227t indications for, 91–93 in axillary artery injury, 260
Abdominal vascular trauma, 405 on-table, 96 trauma, technical sophistication of, 94
ABI. See Ankle-brachial index (ABI) operative strategy in, 94–96, 94f, 95f Arteriovenous fistula
Access to care, in Australia and New Zealand, operative technique in, 96–97, 96f, 97f angiographic findings in, 92t
353–354 pitfalls and danger points of, 94 ultrasound findings in, 98t
Acidosis, coagulopathy in, 71 portable, for vascular injury, 88 Artificial blood vessels, 307–308
ACS COT. See American College of Surgeons postoperative care in, 97 Artificial Kidney Initiation in Kidney Injury
Committee on Trauma (ACS COT) preparation for, 93 (AKIKI) trial, 160
Acute ischemia, management of, 393 transcatheter, 91–93 Ascending aortic arch, penetrating wound
Acute respiratory distress syndrome (ARDS), Animal-derived conduits (xenografts), 303 of, 19
161 Ankle-brachial index (ABI), 87 Association for the Surgery of Trauma (AAST),
Acute traumatic coagulopathy (ATC), 65–66, Anterolateral thigh (ALT) flap, 329, 329f 117
65f, 66f Anterolateral thoracotomy, 3 ATLS. See Advanced Trauma Life Support (ATLS)
Adenosine, administration of, 11 bilateral, 4 ATOM. See Advanced Trauma Operative
Advance dressing stations (ADS), 359 and pericardiotomy, 9–10 Management (ATOM)
Advanced Surgical Skills for Exposures in left, 4, 5f Atriocaval shunt, 237–238, 238f
Trauma (ASSET), 49–50, 50f, 50t, 366 Anticoagulation, in temporary vascular shunts, Auckland City Hospital Trauma Registry, 353
Advanced Trauma Life Support (ATLS), 71, 354, 295–296 Austere environment
370, 388, 393 Antipersonnel mines (APMs), 357–358 vascular surgery in, 332
guidelines for patient assessment for vascular Antiplatelet therapy, dual, for blunt carotid/ working in, 347–350
injury, 86 vertebral injuries, 242 Australia, vascular trauma in
injured extremity assessment guidelines, 324 Antithrombotic therapy access to care in, 353–354
Advanced Trauma Operative Management for cervical arterial injuries, 242 considerations for diagnosis of, 354–355
(ATOM), 49 postoperative, 249 epidemiology in, 353

407
408 Index

Australia, vascular trauma in (continued) complications in, 207t, 208f Cardiac injuries, 404, 406f
prehospital care in, 354 versus open repair, 208t penetrating, 395
strategies for sustaining and training of epidemiology of, 199–200, 199f Cardiac rhythm, restoration of, for great vessel
trauma surgeons in, 356 history of, 199 injuries, 11
surgical training and certification in, 353 initial management of, 202 Cardiac tamponade, 7
systems of care in, 353 natural history of, 200 “Cardio-Stable” induction strategies, 74–75
treatment strategies in, 355, 355f nonoperative management of, 209 Cardiovascular management, 75–76
Autologous conduit, 301 open surgical repair of, 204–205, 205f C-arm fluoroscopy system, 96
in austere and military settings, 306–307, 307f versus endovascular aortic repair, 208t Carotid artery, external, bleeding from, ligation
Autologous graft, definitive vascular repair with, region-specific treatment strategies of, 355 for, 334
327 screening of, 200–202, 201f Carotid artery injuries, 241
Autologous vein site of, 200, 201f operative strategy and technique for,
conduit, 305t TEE in, 202, 202t 243–245, 245f
use of, 307 type of, 200, 201f penetrating right common, ePTFE
Automated partial aortic flow control, 138–142 Blunt thoracic aortic rupture, computed interposition graft in, 308f
limitations, 141 tomography of, 354f repair of, 241
regional perfusion optimization, 138–141, Blunt trauma, 391 Carotid artery trauma, penetrating, 249
139f, 140f, 141t in abdominal vascular injuries, 212 Carotid injuries, 404
Automobile crashes, 393 carotid traumatic dissection secondary to, in austere environment, vascular surgery for,
in Brazil, 402–403 354f 333–334, 334f, 335f
Axillary artery to great vessels Carotid-jugular fistulae, 334
anatomy of, 260, 261f diagnosis of, 17 Carotid traumatic dissection, secondary to blunt
complete exposure of, 338f etiology of, 14, 14f trauma, 354f
Axillary artery approach, 398–400, 399f incidence of, 13 Carrel, Alexis, 300
Axillary artery injuries, 260–261 presentation of, 14–15, 16f Catastrophic hemorrhage, control, 72–73
operative management of, 260 to heart Catheter angiography
operative technique of, 260–261 diagnosis of, 9 in iliac artery injuries, 221
tourniquet in, 254–255 incidence of, 7 for vascular injury, 89
presentation of, 7 Cattell-Braasch maneuver, 341, 341f
in iliac artery injuries, 220 Ceiling-mounted system, 109, 109f
to lungs Celiac artery, injuries to, 218
B etiology of, 23 Celsus, 12
incidence of, 23 Cerebral edema, management of, 249
Balloon and sheath removal, for REBOA, 131 thoracic CTA for, 102 Cerebral ischemia, 21
Balloon catheter thrombectomy, 317 Bony pelvis, stabilization of, 223 Cervical and torso vascular injuries, 316
Balloon deflation, for REBOA, 130–131 Boris Matveev, Colonel, 374 Cervical collar, for penetrating neck injuries, 334
Balloon-expanding stents, 116–117 Boyden, Allen M., 18 Cervical vascular injury, 122–123
Balloon inflation, for REBOA, 130 Brachial artery, anatomy of, 261–262, 262f Cervicomediastinal injuries, 394–395
Balloon occlusion, for hemorrhage control, Brachial artery injuries, 261–263, 318 CFA. See Common femoral artery (CFA)
230, 237 operative management of, 262–263, Chest radiograph, anteroposterior, in mediastinal
Basic Endovascular Skills for Trauma (BEST), 51 263f vascular injury, 83
Basilic vein, as conduit, 306 operative technique of, 263 Chest vascular injuries, clearing trauma patients
BCVI. See Blunt cerebrovascular injuries (BCVI) Brachial plexus injury, 241, 243 from, 87b
Bec de corbin, 13, 13f Brachioradialis flap, 345, 345f Chest x-ray
Beck’s triad of hypotension, 7 Brazil, vascular trauma in, 401 for lung injuries, 24
Biologic conduits automobile crashes, 402–403 for penetrating injuries, 4–5
allografts, 302 endovascular facilities, 404 in screening of blunt thoracic aortic injury,
xenografts, 302 epidemiology of, 401–403 201, 201f
Bleeding evaluation and diagnosis, 403 CIN. See Contrast-induced nephropathy (CIN)
control of homicide rates, 401, 402t Circulatory arrest, vein injuries and, 238
in inferior vena cava injuries, 230–232, 231f patterns and treatment strategies, 403–405 Civilian and military arterial injury, 273, 274t
in portal vein injuries, 234–235 rural setting, 401–402 Civilian lower extremity vascular injury, 275,
in superior mesenteric vein injuries, 236 training next generation of trauma surgeons, 276t
embolization in, 222–223 405–406 Civilian vascular injury, 26–29
limb wound, 361 urban setting, 401 Clamp-and-sew technique, 204, 205f
Blood pressure, in thoracic aortic injuries, Brener shunt, 292t Clamping, cross, 25
202–203 Brukhonenko, Sergey, 374 Clinical practice guideline (CPG), in systemizing
Blood transfusion, 78 BTAI. See Blunt thoracic aortic injury (BTAI) vascular-injury care, 39
Blunt abdominal vascular injury, 212–213 Burbank shunt, 292t Clinical trials
Blunt aortic injury (BAI), 304 designs, 168
Blunt cerebrovascular injuries (BCVI), 122t, 316 methodological and practical challenges,
Blunt injury, 212–213 167–168
thoracic aortic, 199 C Closed incision site, 400f
Blunt thoracic aortic dissection, 395 Coagulation, optimization of, 76–77
Blunt thoracic aortic injury (BTAI), 199 Cadaver-based training, in vascular exposures, 46 Coagulopathy
aortography in, 201 Calcium, 67 pathophysiology of, 71–72
chest x-ray in, 201, 201f Calf fasciotomy, 285 acidosis, 71
clamp-and-sew technique in, 204, 205f Cardiac arrest, 152 endothelial dysfunction, 71–72
classification of, with treatment guidelines, Cardiac box, 3 hemodilution, 71
202f Cardiac compression, with sternal closure, 21 hypothermia, 71
CT scan in, 201, 202f Cardiac failure, after repair of injury and, 12 tissue trauma, 71
definitive management of, 203–209, 204t Cardiac, great vessel, and pulmonary injuries, 1 in trauma, 65, 65f
timing of, 203, 203f advanced trauma life support in, 3–5 Coil embolization, in control of bleeding, 223
diagnosis of, 200–202, 202t evaluation and management of, in emergency Coils, 115–116
endograft design for, advances in, 207–208 center, 3–5 College of Medicine of South Africa, 2-year
endovascular aortic repair for, 205–207, 206f mechanism of, 3 Higher Surgical Diploma, 393
 Index 409

Colombia Cryopreserved allograft conduit, 305t Doppler ultrasound, adjunctive measures, 87

vascular trauma in, 396 Cryopreserved arterial allografts, 302–303 DSA. See Digital subtraction angiography (DSA)
axillary artery approach, 398–400, 399f Cryopreserved artery, 302–303 DSTC. See Definitive Surgical Trauma Care (DSTC)
posterior popliteal artery approach, Cryopreserved saphenous vein allografts, 302 DSTC course, 395
396–398, 397f, 398f CT. See Computed tomography (CT) DSTS. See Definitive Surgical Trauma Skills
Colombo Army Hospital (CAH), 359 CTA. See Computed tomography angiography (DSTS)
COMBAT randomized controlled trials, 74 (CTA) Duplex color flow imaging, 87
Combat-action tourniquet, 355, 355f CVSA. See Comprehensive vascular skills Duplex ultrasound scanning (DUS), 98
Combat casualty care (CCC), 374 assessment (CVSA) DVT. See Deep venous thrombosis (DVT)
trauma systems in, 36–37 Dzhanelidze, Yustin, 374
Combat medics, 374
Combat-related geography, terrain, and weather, D
357, 358f
Combat troops, vascular trauma in, 25–26
E
Damage control, considerations for conduit
Common carotid artery, blunt tear of, repair of, 21
repair of vascular injury, 300 Eastern Association for the Surgery of Trauma
Common femoral artery (CFA), 281–282, 281f,
Damage control resuscitation (DCR) (EAST), 117
282f
for thoracic trauma, 4 Ebers’ papyrus, 12
Compartment pressure, normal, 268
for vascular trauma, 70 EBVS. See European Board of Vascular Surgery
Compartment syndrome
axillary or subclavian artery repair and, 249 definitions, 70 (EBVS)
and fasciotomy, 318, 318f emergency department reception, 72–77 ECMO. See Extracorporeal membrane
upper extremity vascular injury and, future development of, 78–79 oxygenation (ECMO)
268–269, 269b, 269f Damage control surgery (DCS), 70 Education in vascular trauma, Sweden, 373
vascular injury and, 89–90, 89f Data collection, in systemizing vascular-injury EFAST. See Extended FAST examination (EFAST)
Complex injuries, 378–379, 381f care, 38–39, 39b Egyptians, ancient methods of hemostasis by, 12
Comprehensive vascular skills assessment DCR. See Damage control resuscitation (DCR) Ekk, Nikolai, 374
(CVSA), 48 DCS. See Damage control surgery (DCS) Elbow dislocation, brachial artery injury and, 261
Computed tomography (CT), 101–105, 102f DeBakey, vascular injury burden in WWII, 25 Elective peripheral vascular bypass, studies of, 300
for blunt thoracic aortic injury, 201, 202f, Debranching and reimplantation of arch- Ellis, 14
202t branches, 208, 209f Embolization agents, 114–116
for blunt thoracic aortic rupture, 354f Debridement, in complex upper extremity permanent, 115–116
for caval injury, 228 vascular trauma, 254 coils, 115–116
complications of, 105 Deceleration plugs, 116
historical background of, 91 injury, 3 thrombin, 115
indications for, 102–103, 102f, 103f severe, in abdominal vascular injuries, 212–213 temporary, 114–115
pitfalls and danger points of, 104 Decision making, in choice of vascular conduit, for trauma, 115t
postexamination care in, 105 304–306 Embolization, control of bleeding by, 222–223
preparation, 103 Deep cerebellar, 283 complications in, 224
strategy for, 104 Deep venous thrombosis (DVT), duplex scanning Emergency center thoracotomy, 3–5
technique for, 104–105 for, 98 Emergency department (ED)
Computed tomography angiography (CTA), Definitive Surgical Trauma Care (DSTC), 48, management, 75–77
354–355, 370, 396 366, 393 reception, 72–77
of carotid and vertebral injuries, 241 Definitive Surgical Trauma Skills (DSTS), 48–49 Emergency vascular service, 111–113
in iliac artery injuries, 221 Definitive vascular reconstruction, 362 clinical need, 111, 112f, 112t
of neck and thoracic outlet vascular trauma, Degloving component, in injured extremity, 324 practical implementation, 111–112
241 Degloving injury, 326–327 training issues, 112
pediatric vascular injury, 313–314, 314f Diagnosis of vascular injury, 82 Empyema, 27
performance of, 242–243 clearing trauma patients from presence of, Endograft design, advances in, 207–208, 209f
three-dimensional, 105 87–88, 87b Endothelial dysfunction, 71–72
two-dimensional, 105 compartment syndrome and, 89–90, 89f Endovascular aortic repair (EVAR), 372–373
Computed tomography arteriography, 17 definitive diagnosis of, 88–89 for thoracic aortic injuries, 205–207, 206f
Concomitant injuries, 363 catheter angiography in, 89 complications in, 207t, 208f
Concomitant vein injury, 277–278 multidetector CT angiography in, 89 versus open repair, 208t
Cone-beam computed tomography (CBCT), 110 portable angiography in, 88 Endovascular balloon occlusion, 224–225
Continuous RRT (CRRT), 158 surgical exploration in, 88, 88f Endovascular grafts, 235
Continuous veno-venous hemodiafiltration hard signs of, 86b for hemorrhage control, 230
(CVVHDF), 158–159 mechanism, setting, and patterns of, 82 Endovascular hemorrhage control, principles
Continuous veno-venous hemo-dialysis pattern of recognition in, 82–86 of, 114
(CVVHD), 158–159 abdominal, 83 Endovascular repair of injured vessels, 383,
Continuous veno-venous hemofiltration (CVVH), head and neck, 82–83, 84f, 85f 384f, 385f
158–159 high-risk, 86 Endovascular resuscitation, 154–156
Continuous-wave Doppler, 313 lower extremity, 85–86 clinical decision-making in, 149
Contrast arteriography, in lower limb vascular thoracic, 83, 85f rationale for, 147–149
injuries, 342, 342f upper extremity, 84, 86f Endovascular Resuscitation and Trauma
Contrast-induced nephropathy (CIN), 93 penetrating, 82 Management (EVTM), 51, 372–373
Counter-terrorist operations in the North physical examination of, 86–87, 86b Endovascular Skills for Trauma and Resuscitative
Caucasus region (CO-NC), 374 soft signs of, 86b Surgery (ESTARS), 51
CPG. See Clinical Practice Guideline (CPG) Digital subtraction angiography (DSA), 96, 378 Endovascular suites
Cranial nerves, 243 Direct anastomosis, 396 imaging capability, 110–111, 110f, 111f
CRASH-2 study, 67 Disability, assessment of, 74 organizational issues, 109–110
Crew resource management (CRM), 46 Dislocation, elbow, brachial artery injury and, 261 principle, 108
Cross-clamping, of hilum of lung, 25 Distal extracranial (zone III) carotid room design, 108–109, 109f
Cross-leg flap, 346, 348f pseudoaneurysm, 316 Endovascular surgery, 45
Crossover left innominate vein, 21 Distal ischemia, dislocated knee associated with, Endovascular techniques, in vascular surgery,
Crush injuries, in abdominal vascular injuries, 354f 236–238
212–213 Distal popliteal exposure, 283 Endovascular therapy, 248–249
410 Index

Endovascular variable aortic control (EVAC), compartment syndrome in, 89 Halsted, 14

138–142 machete wound to, 338–339, 340f Hand-held Doppler, 374–375
Epidemiology, definition of, 23 Forearm artery injury, 263 Hard signs, of vascular injury, 86b, 333
EPTFE. See Expanded polytetrafluoroethylene Fracture-associated extremity vascular trauma, Head vascular injuries, 82–83, 84f
(ePTFE) 321 clearing trauma patients from, 87b
Ethics, of resuscitation, 77–78 Fractures “Health Care in Danger,” symposium entitled, 350
Ethnicity, vascular trauma and, 28–29 blunt thoracic aortic injury and, 83 Heart, injured, 5–13
Etomidate, 75 of humerus, axillary artery injury and, 260 diagnosis of, 7–9
European Board of Vascular Surgery (EBVS), 48 open, 321–322, 322t history of, 5
European Trauma Course (ETC), 366 stabilization of site, 326–327 incidence of, 5–7
European Vascular Masterclass (EVM), 50–51 supracondylar, brachial artery injury and, 261 major complications in, 12
EVM. See European Vascular Masterclass (EVM) Free flaps, 329 nonoperative management of, 9
EVTM. See Endovascular resuscitation and Fullen’s classification, of superior mesenteric operative management of, in emergency
trauma management (EVTM) artery injury, 219t department and operating room, 9–12
Expanded polytetrafluoroethylene (ePTFE), 246f, Functional motor assessment, of extremities, cardiopulmonary bypass, acute need for,
278, 302, 307, 308f 325t 11, 12f, 12t
Exsanguination, 25 Functional sensory assessment, of extremities, cardiorrhaphy, treatment in operating
Extended FAST examination (EFAST), 23–24, 98 325t room after, 11–12
External carotid artery, 301 hemorrhage from the heart, control of,
External carotid-internal carotid transposition, 10–11, 10t
247f G incisions in, 9
Extraanatomical bypass, 222 pericardiotomy, 9–10
Extracorporeal life support (ECLS), 161 suturing techniques, 11
Galen, 12–13
Extracorporeal membrane oxygenation (ECMO), presentation of, 7
Gas exchange, 73–74, 73t
161–162, 317 blunt trauma, 7
Gastric artery, left, injuries to, 218
Extremity compartment syndrome, 297 penetrating trauma, 7
Gastrocnemius muscle flaps, 345
Extremity hemorrhage, 56–58 survival, 12, 13t
Gastroepiploic artery, 301
practicalities, 58, 58b Helicopter emergency medical services (HEMS),
principles, 56–58, 57f Gelfoam, 114–115
in control of bleeding, 223 365
Extremity injuries, 321 Helicopter transport, 370
assessment of, 324–325, 325t General surgical training, 395
Geriatric trauma, 29–30 Heliodorus, 12
incidence of, 26 Hematoma, retroperitoneal, in major vein injury,
Extremity vascular injuries Glasgow Coma Scale (GCS), 334
Goyanes, 16 227
among local national populations, 26 Hemodilution, coagulopathy in, 71
lower. See Lower extremity vascular injuries Graduate medical education, in vascular trauma,
42–44 Hemodynamic collapse, axillary artery injury
repair of, 314–316, 315f and, 257
upper. See Upper extremity vascular injury Graft or anastomotic stenosis, 276
Grafts Hemopneumothorax, subclavian artery injury
Extremity vascular trauma, 123, 405 and, 257
Extremity vessels, vascular conduit for, 304 autologous, definitive vascular repair with,
327 Hemorrhage, 114
endovascular, 230, 237 active, angiographic findings in, 92t
ePTFE, 302, 307, 308f acute vascular
F interposition. See Interposition graft management of, 393, 393f
panel, 305 external, finger control of, 17
Faltin, Richard, 366 spiral vein, for inferior vena cava repair, 233, initial control of, 12–14
Fasciocutaneous flaps, 345–346, 345b, 347f 233f life-threatening, 86
for lower limb wounds, 329 stent, 237 Hemorrhage control, 360–361, 361f
Fasciotomy, 285–286, 285f Greater saphenous vein (GSV), 280, 314 Hemorrhage-induced traumatic cardiac arrest
absolute indications for, 344 as conduit, 306 (HiTCA), 152–154, 154f, 155f
compartment syndrome and, 318, 318f Great vessels, injuries to, 13–22 Hemostasis, Egyptians and, 12
indications for, in combat setting, 268, 269b definition/classification of, 13, 13t Hemothorax, 23
performance of, for extremity injuries, 327 diagnosis of, 17 Henley retractors, 283
prophylactic etiology of, 14 Heparin, 300, 317
ligation of vena cava and, 232 extravascular management of, 17, 17f Heparinized saline, 317
temporary vascular shunt and, 297 history of, 13 Hepatic artery, injury to, 218
of upper extremity, 268, 269f incidence of, 13–14 High-energy extremity wounds, 321
Finland, vascular trauma in, 365 major complications of, 21–22 High-velocity projectile, in abdominal vascular
northern European example in trauma and operative management of, in emergency injuries, 212
trauma care, 365–366 department and operating room, 17–21 High-volume hemofiltration (HVHF), 160–161
surgery training, availability, and challenges, presentation of, 14–17 Hilar twist, 25
366–368, 367f survival in, 22, 22t Hollow tubular devices, as temporary vascular
vascular and trauma surgery, 366 Groin flap, 347f shunts, 290–291
Firearm deaths, 365 Groins, 59 Homicides, 365
Firearms, 312 GSV. See Greater saphenous vein (GSV) Hounsfield units (HU), 104
Fix and flap reconstruction, 328 Gudov, Vasilij, 374 Human acellular vessel (HAV), 303–304, 303f,
Fixed imaging units, 96–97, 97f Gulf War, military vascular surgery during, 20 308–309
Flap reconstruction, 328–329 Gunshot wound Human umbilical vein (HUV), as conduit, 302
Flat panel detectors (FPD), 110 in abdominal vascular injuries, 212 Humeral head, anterior dislocation of, axillary
Fleming, 13–14 Cattell-Braasch maneuver for, 341f artery injury and, 260
Floor-mounted system, 108–109, 109f Gustilo-Anderson classification, of open tibial Humerus, fracture of, axillary artery injury and,
Focal dissection, 273 fractures, 322t 260
Focused assessment with sonography for trauma Hunter, John, 13
(FAST), 98 Hunter, William, 13
Fogarty catheter embolectomy, 397f Hybrid theatre, 367, 368f
Fogarty catheters, 343 H Hybrid trauma operating room (HTOR), 108
Forearm Hypotension
amputation, 347, 349f Haire, 13 avoidance of, 243
compartments of, 338–339 Hallowell, in early vascular surgery, 14, 14f permissive, 65
 Index 411

Hypothenar eminence hammer syndrome, 263 Interposition graft, 222 Ligated axillary vein, 399f
Hypothermia, 64–65 ePTFE, 308f Ligation
coagulopathy in, 71 saphenous, in brachial artery, 307f for carotid artery injury, 334
Hypoxia, avoidance of, 243 Interposition or bypass grafting, technical factors for inferior vena cava injuries, 232
of, 300 for initial control of hemorrhage, 12
Interposition synthetic graft, 399f portal vein, 235
Interposition vein graft, 398f of superior mesenteric vein, 236
I Intracardiac lesions, delayed diagnosis of, 12 for vascular trauma, 300
Intravascular shunts Limb
Iatrogenic femoral artery injuries, 274 historical use of, 288 amputation, 323, 324b
Iatrogenic injury, 312 modern use of, 288–289, 290f, 291t loss of, associated with upper extremity
Iatrogenic vascular injuries, 366 civilian trauma experience, 289 arterial injury, 253
Iatrogenic vascular injury, 30–31 military and combat experience, 288–289 pre-scrubbing of, 325–327
IATSIC. See International Association for Intravascular ultrasound (IVUS), 101, 101f Limb complications, 276
the Surgery of Trauma and Surgical Iodoxinol, 93 Limb salvage, 275, 322
Intensive Care (IATSIC) Ionizing radiation, attendant risk in, 94 in austere environment, 344
IEDs. See Improvised explosive devices (IEDs) Iraq, military vascular surgery in, during Gulf outcomes of, 330
Iliac artery, injury to, 220–221, 221b War, 20 role of temporary vascular shunt in,
Iliac vessel, injury to, 212 Ischemia 296–297, 296f
Imaging, for vascular trauma, 91 acute, management of, 393 Limb Salvage Index (LSI), 255
historical background of, 91 in brachial artery injury, 261 Limb-threatening arterial, occlusive injuries
modalities in, 91–105 Isolated profunda femoris injuries, 282, 283f with, 86
Implantable prosthetic conduit, 288 Isolated vein injury, 277–278 Limb trauma, component of, 321
Improvised explosive devices (IEDs), 301, 388, Israeli Air Force (IAF), 388 Limb wound infection, 276
389f Israeli Defense Forces (IDF), 388 Liver injury, 119
massive soft-tissue destruction from, 301f Israel, vascular trauma in, 388 Lobectomy, 26
Inadequate arterial débridement, 382 IVUS. See Intravascular ultrasound (IVUS) Long venous bypasses, 278
Incisions Looped shunts, 291–292, 293f
for great vessel injuries, 18–19, 18f, 19f Low-dose aspirin, 317
for lung injuries, 24–25 Lower extremity
Inferior mesenteric artery, injuries to, 219 J crush injuries of, 85–86
Inferior vena cava (IVC), injuries to, 226 mangled, 307
bleeding control in, 230–232, 231f Javid shunt, 290f, 292t Lower Extremity Assessment Project (LEAP), 322
complication of, 227 Jerome of Brunswick, 13 Lower extremity vascular injuries, 85–86
considerations for repair of, 232 Joint Theater Trauma Registry (JTTR), 25 characteristics, 273–275
exposure and mobilization of, 229–230, 230f Joint Theater Trauma System (JTTS), arterial pathology, 273–274, 274f
ligation in, 232 organization of, 37–38 level of injury, 273
management options for, 237–238 Joint Trauma System (JTS), 36 mechanism of injury, 273
operative management of, 228–236 “Jony mines”, 358 clearing trauma patients from, 87b
pitfalls and points, 238 JTS. See Joint Trauma System (JTS) concomitant and isolated vein injury,
postoperative care, and complications in, 238 JTTS. See Joint Theater Trauma System (JTTS) 277–278
preoperative preparation for, 227–228 Judd-Allis clamps, in vein injuries, 231, 231f diagnosis of, 278–279
reconstructive techniques for, 231f, Junctional hemorrhage hemorrhagic and ischemic signs, 278–279,
233–234, 233f complex/novel options, 60–61, 60f 278t
surgical anatomy in, 229, 229f hemostatic dressings, 59–60, 60b operative planning considerations, 279t
vascular repair of, 21 practicalities in management, 58–59 patient and limb outcomes, 275–277
Inflow occlusion, for control of hemorrhage, principles, 58 amputation, 275
10–11 Junctional vascular trauma, 123 functional outcomes and quality of life, 277
Infraclavicular axillary artery, exposure of, for Junctional zone, of upper extremity limb complications, 276
proximal control, 338f anatomy of, 257 mortality, 275
Infrarenal inferior vena cava, 228–234, 229f injury to, operative management of, 257– presentation of, 278–279
Injuries to named vessels, 281–285 259, 258f, 259f technical aspects of vascular reconstruction,
common femoral artery, 281–282, 281f, 282f 279–286
isolated profunda femoris injuries, 282, 283f conduit, tunneling, twisting, and
popliteal artery, 282–284, 283f, 284f
superficial femoral artery, 282
K measuring, 280
fasciotomy, 285–286, 285f
tibial arteries, 284–285, 285f general considerations, 279–280
Injury extremely index (IEI), 313 Ketamine, 75
Knee, dislocation of, 85, 321 injuries to named vessels, 281–285
Injury severity score (ISS), 65, 365–366 techniques for anastomosis, 281
In-line shunts, 291–292, 292f, 293f associated with distal ischemia, 354f
Korean Conflict, vascular surgery during, 19–20 workup, 278–279
Innominate artery Lower extremity venous injury, 277, 278t
blunt tear of, repair of, 20–21, 20f Kunlin, Jean, 300
Kussmaul’s sign, 7 Lower limb
penetrating wound of, repair of, 19–20 compartment syndrome, after vascular
Institute of Cardiology Aloísio de Castro (IECAC), trauma, 222
401, 402f vascular injuries, in austere environment,
Intercollegiate Surgical Curriculum Programme L surgery for, 342–344, 342f, 343f
(ISCP), 44 wounds, commonly used flaps for, 329
Internal carotid repairs, 243 Laceration, direct, in abdominal vascular LSI. See Limb Salvage Index (LSI)
Internal iliac artery, 301 injuries, 212–213 Lungs, injuries to, 22–26
Internal iliac pseudoaneurysms, 214 Lateral malleolar flap, 347f classification of, 22, 22t
Internal mammary (internal thoracic) artery, Late revascularization, 380–382, 382f complications to, 27
301 Latissimus dorsi (LD) flap, 329 diagnosis of, 23–24
International Association for the Surgery of LEAP. See Lower Extremity Assessment Project etiology of, 23
Trauma and Surgical Intensive Care (LEAP) history of, 22
(IATSIC), 48 Lethal triad, 64 incidence of, 22–23
Interpersonal violence, 353, 396 Liberation Tigers of Tamil Elam (LTTE), 357 nonoperative management of, 24
412 Index

Lungs, injuries to (continued) Murphy, J.B., 15 Open exposure of proximal brachial artery,
operative management of, in emergency Muscle flaps, 345b 367–368, 368f
department and operative room, 24–26 for lower limb wounds, 329 Open fractures, grading of, 321, 322t
indications for, 24, 24b, 25f vascularized composite, for coverage of Open surgical exploration, 314–316, 315f
proximal vascular control in, 25, 25b vascular reconstruction, 345–347 Open surgical repair, of blunt thoracic aortic
presentation of, 23 Myocardial ischemia, 7 injury, 204–205, 205f
survival of, 27, 27t versus endovascular aortic, 208t
thoracic damage control in, 26–28, 27b Open surgical subxyphoid pericardial window, 8
LY30, 77, 78f Open tibial fractures, 322t
N Open tibial shaft fractures, limb salvage patients
with, 322
National Hospital of Sri Lanka (NHSL), 359 Operation Iraqi Freedom (OIF), 288–289
M National Trauma Data Bank (NTDB), 26, 312 Operative hemorrhage control, 108
NCTH. See Noncompressible torso hemorrhage Optimal vascular conduit, problem identification
Machete wound, to forearm, 340f (NCTH) of, 300, 301f
Magnetic resonance angiography (MRA), Neck Order of St John, 354
101–102, 393 direct trauma to, 83 Organ injury scale, for abdominal vascular
Magnetic resonance imaging (MRI), 101–102 penetrating trauma of, 394 injury, 227t
Main dressing stations (MDS), 359, 360f zones of, 243, 333–334, 334f Orthopedic fractures, grading of, 322t
Major hemorrhage packs, 74 Neck injuries Orthopedic injury, 321
Major hemorrhage protocols (MHP), 74 in austere environment, vascular surgery for, Ownership, in systemizing vascular-injury care,
Major trauma centers (MTCs), 34 333–336 38
Mangled extremity associated, 335 Oxygen delivery, 76
definition of, 255–256 zone I, 336, 337f
lower, 307 zone III, 335–336, 336f
management of, 344 penetrating, 355
Mangled Extremity Severity Score (MESS), 255, Neck outlet, vascular trauma to, 241 P
256t, 275 complications of, 248–250
Mangled Extremity Syndrome Index (MESI), indications of, 241–242, 243f, 247f Packed red blood cells (pRBC), 67
255, 256t operative strategy and technique for, 243–248 PAMPER, 74
Massive, high-energy military lower extremity outcomes of, 248–250 “Panel graft”, 305
trauma, 275, 275f pitfalls and danger points in, 242–243 Parachute metaphor, 166
Mass shooting, 353 postoperative care for, 248–250 Paraplegia, 204
Matas, Rudolph, 396–398 preoperative preparation for, 242 Paré, Ambroise, 12
Mattox maneuver, 341, 341f Neck vascular injuries, 59, 82–83, 85f Partial REBOA (P-REBOA), 133
Maxillofacial hemorrhage, 63–64, 64f Negative pressure therapy, for upper extremity Patch angioplasty, technique of, 300
Maximal amplitude (MA), 76–77 vascular injury, 267 Patient and limb outcomes, lower extremity
MBHs. See Military base hospitals (MBHs) Negative pressure wound therapy (NPWT) vascular injuries, 275–277
McClean, Jay, 300 dressings, 327 amputation, 275
MDCT. See Multidetector computed tomography Nelson, Horatio, 13 functional outcomes and quality of life, 277
(MDCT) Nephropathy, contrast-induced, 93 limb complications, 276
MDCTA. See Multidetector computed Neurological deficit, great vessel injuries and, 22 mortality, 275
tomographic angiography (MDCTA) Neurologic deficit Pediatric vascular anastomotic technique, 315f,
MDS. See Main dressing stations (MDS) in carotid/vertebral injuries, 243 316, 316f
Mean arterial pressure (MAP), 75 postoperative lateralizing, after carotid Pediatric vascular injury, 312
Mechanism of injury, 82 reconstruction, 249 anatomic and physiologic considerations, 313
in abdominal aortic trauma, 212–213 New Injury Severity Score (NISS), 56, 57f computed tomography angiography, 313,
of cardiac, great vessel, and pulmonary New Zealand, vascular trauma in 314f
injuries, 3 access to care in, 353–354 diagnosis and evaluation of, 313–314
upper extremity vascular injury, 252–253 considerations for diagnosis of, 354–355 diagnosis and management of, 312b, 313t
Medial visceral rotation, 214 epidemiology in, 353 epidemiology of, 312–313, 314f
exposing inferior vena cava, 230f prehospital care in, 354 future directions, 318
left-sided, 215f, 216f strategies for sustaining and training of postinjury surveillance and outcomes, 318
right-sided, 217f trauma surgeons in, 356 special situations, 317–318
Median sternotomy, 3, 10, 18, 18f surgical training and certification in, 353 brachial artery injuries, 318
for zone I neck injuries, 336 systems of care in, 353 compartment syndrome and fasciotomy,
Mesenteric arterial injuries, 297–298 treatment strategies in, 355, 355f 318, 318f
Mesenteric venous systems, 226 Next generation of trauma surgeons, 405–406 extracorporeal membrane oxygenation
Mesenteric vessels, intraluminal shunting of, N-methyl-D-aspartate (NMDA), 75 (ECMO), 317
297–298 “No man’s land”, 357 supracondylar humerus fractures, 318
MESS. See Mangled Extremity Severity Score (MESS) Noncompressible torso hemorrhage (NCTH), 108 therapeutic approach, 314–317
Military base hospitals (MBHs), 359–361 Noniatrogenic vascular injuries, 312 anticoagulation, papaverine, thrombolysis,
Military conflict, vascular trauma and, 25–26 Non-terror-related vascular trauma (NVT), 388 and shunts, 317, 317f
Military lower extremity injuries, 274, 274f Novel hybrid resuscitation, 66 cervical and torso vascular injuries, 316
Minimal aortic injury (MAI), 209 NTDB. See National Trauma Data Bank (NTDB) endovascular options, 317
Mitigating ischemic insult, 362 open surgical exploration, 314–316, 315f
Modern ECLS, 163 pediatric vascular anastomotic technique,
MTCs. See Major trauma centers (MTCs) 315f, 316, 316f
Multidetector computed tomographic
O repair of extremity vascular injuries,
angiography (MDCTA), for vascular 314–316, 315f
injury, 89 Obesity, vascular trauma and, 28–29 Pediatric vascular trauma, 29, 383–385,
Multidetector computed tomography (MDCT), Occlusion balloons, for hemorrhage control, 386f
101, 110, 378 230, 237 Pelvic bleeding, 120–122
Multiplanar degloving, 326–327, 326f Occlusive injuries, 273 Pelvic hemorrhage, 63, 63b
Multiple arterial injuries, 273 OIF. See Operation Iraqi Freedom (OIF) Pelvic packing, 214
Mural hematoma, 273 On-table angiography, 398–400 Pelvic trauma, endovascular treatment of, 223
 Index 413

Penetrating injury, 212 Pseudoaneurysm, 91 problems with, 137–138, 138t

to inferior vena cava, 228 abdominal vascular injuries and, 214 strategy to address limitations of, 137–138
neck injuries, 355 angiographic findings in, 92t technical aspects of
Penetrating trauma, 391, 392f ultrasound findings in, 98t step-by-step placement, 128–131, 128b
in abdominal vascular injuries, 212 Pulmonary artery, intrapericardial clamping tools and materials, 127–128, 127f, 128f
in axillary artery injury, 260 of, 25 treatment, 131–132, 131f, 132f
to great vessels Pulmonary contusion, supportive care after, 24 Resuscitative thoracotomy (RT), 341–342
diagnosis of, 17 Pulmonary pseudocyst, 27 for vein injury, 228
etiology of, 14 Pulmonotomy, 25–26, 26f Retrohepatic cava, injury to, 228
incidence of, 13 Pulse examination of, at wrist and foot, 86–87 Retrohepatic inferior vena cava, 228, 229f
presentation of, 14, 14f, 15f, 16f Retroperitoneal hematoma, in major vein injury,
to heart 228
diagnosis of, 7–9 Revascularization, for severely injured limb, 323
incidence of, 5–7
Q Reverse saphenous vein graft (RSVG), 362,
presentation of, 7 362f
in iliac artery injuries, 220 Quality improvement (QI), trauma, 35 Right common carotid artery repair, 249f
to lungs Ringer’ s lactate, for thoracic trauma, 4
etiology of, 23 Rotational thromboelastometry (ROTEM), 76
incidence of, 22 R Royal Australasian College of Surgeons (RACS),
of neck, 394 353
region-specific epidemiology of, 353 RSVG. See Reverse saphenous vein graft (RSVG)
Radial artery, anatomy of, 263, 264f
Pericardiocentesis, 7 R-Time, 76
Radial artery flap, 349f
Permanent embolization agents, 115–116 Rufus of Ephesus, 12–13
Radial artery injuries, 263–265
coils, 115–116 Rural populations, vascular trauma in, 28
operative management of, 263–264, 264f
plugs, 116 Rural setting, in Brazil, 401–402
operative technique of, 265
thrombin, 115 Russia, vascular trauma in, 374
Radial forearm flap, 346–347, 349f
Permissive hypotension, 65 epidemiology of, 374
Radiation, exposure to, from diagnostic CT scans,
Phrenic nerves, 243 historical background, 374
104
Physical examination, in penetrating injuries, next generation of trauma surgeons, 375–
RAPTOR suite, 367
241 376
REBOA. See Resuscitative endovascular balloon
Pirogov, Nikolai, 374 specific considerations for diagnosis, 374–
occlusion of the aorta (REBOA)
Plate fixation, of open fractures, 327 375, 375t
Plugs, 116 Reconstruction
fix and flap, 328 specific systems of care, 374
Pneumonectomy, 26 specific treatment strategies, 375, 375f, 376f
Pneumothorax, 23 flap, 328–329
open, 23 in soft tissue and skeletal wound
tension, 23 management, 327–330
Point-of-care ultrasound (POCUS), 99 choice and type of, 328 S
Poly traumatized extremity, surgical Rectus abdominus flap, 345, 346f
management of, 325–327 Referral trauma centers, 403 SAAP. See Selective aortic arch perfusion (SAAP)
Polyvinyl alcohol (PVA), 115 Regional perfusion optimization (REPO), Saphenous fasciocutaneous flap, 347f
Popliteal artery, 282–284, 283f, 284f 138–141, 139f, 140f, 141t Saphenous vein
Popliteal artery injury, 397f Regional trauma system, 34 bypass, 300
Popliteal fossa skin incision, 397f Renal artery, injuries to, 219–220 in vascular repair, 343–344
Portal vein, injury to, 234–235, 234f Renal injury, 119–120 Saphenous vein graft aneurysm, 386f
bleeding control in, 234–235 Renal replacement therapy (RRT), 158 Scaffold free techniques, 308
exposure and mobilization of, 234 Reperfusion injury, upper extremity, axillary or Selective aortic arch perfusion (SAAP)
ligation in, 235 subclavian artery repair and, 249 advantages, 152
repair of, 235 Residual distal thrombosis, 382 description of, 144, 145f, 146f
Positioning of balloon, for REBOA, 129–130, Resources for the Optimal Care of the Injured in endovascular resuscitation, 154–156
130f, 130t Patient, 36 laboratory animal studies, 152–154
Posterior popliteal artery approach, 396–398, Responsibilities, in systemizing vascular-injury in hemorrhage-induced traumatic cardiac
397f, 398f care, 38 arrest, 153–154, 154f, 155f
Potts vessel loops, 283 Resuscitation in ventricular fibrillation cardiac arrest,
Poverty, vascular trauma and, 29 ethics of, 77–78 152–153, 153f
Predictive Salvage Index (PSI), 255 thoracic aortic occlusion, history of, 126 limitations, 152
Prehospital care, for vascular injury, in Australia Resuscitation strategies, 65–66 rationale for
and New Zealand, 354 acute traumatic coagulopathy, 65–66, 65f, cardiac arrest survival, 144–145
Prehospital management, of vascular injury, 55 66f limitations, 146–147
bleeding, 56–64 choice of fluid, 66–67 standard resuscitation, 146–147
replacing lost volume, 64–67 novel hybrid resuscitation, 66 sequential interventions, 149–152, 150f
Primary bleeding control, 377, 379f pharmacological adjuncts, 67 catheter perfusion support, 151
Prophylactic fasciotomy practical application, 66 with oxygenated autologous blood, 151
in austere environment, 344 transport destination, 67 with oxygenated exogenous oxygen carrier,
ligation of vena cava and, 232 Resuscitation strategy, 362 149–151
PROspective Observational Vascular Injury Resuscitative endovascular balloon occlusion of transition from, 151
Treatment (PROOVIT) registry, 212, 318 the aorta (REBOA), 39–40, 51, 61, 137, Self-expanding stents, 117
Prosthetic conduits, 301–302, 302f, 305t, 307 367, 367f, 393 Serbia, vascular trauma in, 377
in austere and military settings, 307, 308f, clinical outcomes, 127 Serbinenko, Fedor, 374
309f complications of Severely injured limb
triplex, 305 arterial access complications, 133–134, 133f strategies in managing of, 322–330
Proximal carotid artery injuries, 316 placement-related complications, 134, 134f major limb amputation for trauma, 323, 324b
Proximal popliteal exposure, 283 reperfusion complications, 134–135 sequencing of interventions, 322–323
Proximal vascular control, minimization of blood extended applications of, 133 Shock packs, 74
loss and, 243 history of, 126 Shock, subclavian artery injury and, 257
Pruitt F3 shunt, 292, 292t, 293f physiologic limitations, 126–127 Shumacker, 396–398
414 Index

Shunts treatment strategies, 360–363 trauma in Sweden, 370–371, 371f

Argyle, 292f, 292t, 293f complications, 363 Swedish trauma and vascular registries, 370
atriocaval, 237–238, 238f concomitant injuries, 363 Swedish trauma system, 371f
Brener, 292t definitive vascular reconstruction, 362 Syringe suction bottle, 335f
Burbank, 292t hemorrhage control, 360–361, 361f Systems of care
Javid, 290f, 292t managing infections, 362–363 in Australia and New Zealand, 353
Pruitt F3, 291–292, 292t, 293f mitigating ischemic insult, 362 in South Africa, 392–393
straight, 292t resuscitation strategy, 362 in vascular injury management, 34
Sundt, 292t, 293f Stabilization of bony pelvis, 223 clinical practice guidelines in, 39
temporary vascular. See Temporary vascular Stab wounds, in abdominal vascular injuries, community outreach, 40
shunts 212 data collection and comparison in, 38–39,
temporary venous, 237 Stapled wedge resection, 25 39b
SIC. See Societé International de Chirugie (SIC) Stenosis, arterial key components of, 34–35
Simulation-based training, for vascular trauma, angiographic findings in, 92t ownership and responsibilities in, 38
47–48 ultrasound findings in, 98t point of injury therapy, 40
Skin staplers, disposable, 10 Stents-grafts, 116–117, 237 REBOA, 39–40
Slings, for upper extremity injuries, 339, 339f balloon-expanding stents, 116–117 tracking of new technology in, 39
Societé International de Chirugie (SIC), 48 self-expanding stents, 117 trauma center function in, 35–36
Soft signs, of vascular injury, 86b, 333–334 Sternotomy, limited, for zone I neck injuries, 336 whole blood, 40
Soft-tissue and skeletal wound management Straight shunt, 292t
assessment of injured extremity, 324–325, Stryker Pressure Monitor™, 89–90, 89f
325t Styptics, in initial control of hemorrhage, 12
epidemiological factors of, 321 Subclavian artery
T
grading of open fractures, 321–322, 322t anatomy of, 257, 257f
initial surgical management in, 325–327 blunt thoracic aortic injury in, 200f, 207, Teaching Hospital Anuradhapura (THA), 357
reconstruction in, 327–330 208f Team-based training, for vascular trauma,
salvage versus amputation, 322 blunt trauma to, 14 46–47
in setting of vascular injury, 321 injuries to, 256–257 Technology, new, in systemizing vascular-injury
strategies in managing severely injured limb, endovascular repair of, 248 care, 39
322–330 operative management of, 257–259, 258f, Teflon pledgets, 10
Soft tissue, coverage of repair with, 327, 328f 259f Temporary embolization agents, 114–115
Soft-tissue injury, in austere environment, repair of, 249 Temporary shunting, vascular, for severely
vascular surgery for, 344–347, 345b operative strategy and technique for, injured limb, 323
Soleus muscle flaps, 345, 346f 247–248, 248f Temporary vascular shunts, 288, 317, 317f, 339
Solid organ injury, management of, 117–120, surgical treatment of, 247 anatomic location in, 295
118t Subclavian injuries, 404, 405f dwell time of, 295
liver, 119 Subclavian vessels, right and left, 21 indications of, 289–290, 291b
postintervention, 120 Sundt shunt, 292t, 293f insertion technique of, 292–295, 294f
renal, 119–120 Superficial femoral artery (SFA), 273, 282 materials for, 290–292, 292f, 293f
splenic injury, 117–119 Superior mesenteric artery (SMA), injury to, for multiply-injured patient, 288
Solid organs, trauma in, endovascular treatment 218–219, 219f for reestablishment of circulation, 325
of, 223, 224f Fullen’s classification of, 219t removal technique of, 293–295
Soubbotich, Vojislav, 377 Superior mesenteric vein, injuries to, 235–236 special considerations in, 295–298
South Africa, vascular trauma in, 391 bleeding control in, 236 types of, 292t, 293f
considerations for diagnosis of, 393–394, exposure and mobilization of, 235–236, 236f in upper extremity vascular injury, 255, 255f
394f ligation in, 236 vascular branch points in, 297
epidemiology of, 391–392, 392f repair of, 236 Temporary venous shunts, 237
strategies for sustaining and training of Superior vena cava, injuries to, vascular repair Terror-related vascular trauma (TVT), 388–389
trauma surgeons in, 395 of, 21 TEVAR. See Thoracic endovascular aortic repair
systems of care in, 392–393 Supracondylar fracture, brachial artery injury (TEVAR)
treatment strategies for, 394–395 and, 261 Thoracic aorta, penetrating injury to, 304
Soviet War in Afghanistan (SWA), 374–375 Supracondylar humerus fractures, 318 Thoracic aortic injury, blunt, 199
Specialty advisory committees (SACs), 44 Suprahepatic inferior vena cava, 229, 229f Thoracic aortic occlusion, history of,
Spiral vein graft, for inferior vena cava repair, Suprarenal inferior vena cava, 229, 229f resuscitation, 126
233, 233f Surgical anatomy, in inferior vena cava injuries, Thoracic aortic stent-grafts, aortogram of, 355f
Splenic angioembolization (SAE), 117 229, 229f Thoracic endovascular aortic repair (TEVAR), 94
Splenic artery, injuries to, 218 Surgical Council on Resident Education (SCORE), Thoracic hemorrhage, 62
Splenic injury, 117–119 42–43 Thoracic injuries, vascular conduit for, 304
Sri Lanka College of Military Medicine Surgical damage control, 288 Thoracic outlet, vascular trauma to, 241
(SLCOMM), 363 Surgical débridement, of injured tissues, 325–326 complications of, 248–250
Sri Lanka Medical Corps, 358 Surgical innovation indications of, 241–242, 243f, 247f
Sri Lanka, vascular injuries in, 357 complex interventions, 166–167 operative strategy and technique for, 243–
considerations for diagnosis, 359–360 stages of, 167, 167t 248
epidemiology of wartime injury, 357–358 Surgical techniques, for abdominal aortic outcomes of, 248–250
combat-related geography, terrain, and trauma, 214–216 pitfalls and danger points in, 242–243
weather, 357, 358f Surgical treatment, facilitating, 77 postoperative care for, 248–250
demographics, 358, 359f Suture pneumonorrhaphy, 25 preoperative preparation for, 242
war tactics and weapons, 357–358 Suture repair, 10 Thoracic spine, fracture of, 83
sustaining and training the next generation, factors for, 4 Thoracic vascular injuries, 83, 85f
363–364 Sweden, vascular trauma in, 370–372 Thoracic vascular trauma, 405
challenges, 363 education in vascular trauma, 373 Thoracotomy (RT), 61
general strategies, 363 endovascular resuscitation and trauma Thoracotomy, resuscitative, for vein injury, 228
military-related strategies, 363 management (EVTM), 372–373 3-D resuscitation, 72
system of care, 358–359 new developments, 372–373 Thrombin, 115
administrative structure, 359 Swedish trauma system, 370, 371f Thromboelastography (TEG), 76, 77f
medical, 359, 360f trauma and vascular registries, 370 Thrombophilia, 99
 Index 415

Thrombosis, after vascular trauma, 222 endovascular procedures, 100 in civilian experience, 20–21
Tibial artery injuries, 273, 284–285, 285f guide real-time certain vascular, 100 early vascular surgery in, 14–17
Tibial fractures, open, 322t indications for, 98–99, 99f during Gulf War, 20
Tibial plateau fracture, 85–86 pediatric vascular injury, 313 initial control of hemorrhage in, 12–14
Tibioperoneal trunk (TPT), 283 pitfalls and danger points of, 99–100 during Korean Conflict, 19–20
Tissue trauma, coagulopathy in, 71 preparation for, 99 in Vietnam, 19–20, 20t
Tissue-type plasminogen activator (tPA), 71 as screening tool, 100 during World War I, 17
Torso hemorrhage, noncompressible, 61–63 strategy for, 100 during World War II, 17–18
abdominal hemorrhage, 62–63 technique for, 100–101 pediatric. See Pediatric vascular injury
advanced prehospital services, 61 transthoracic, 8, 8f soft signs of, 333–334
pelvic hemorrhage, 63, 63b Umbilical vein catheters, 339 soft-tissue and skeletal wound management
thoracic hemorrhage, 62 Upper extremity vascular injury, 84, 86f in setting of, 321
treatment, 62 axillary artery injuries, 260–261 systems of care in, 34
Torso vascular injuries, 297 brachial artery injuries, 261–263 clinical practice guidelines in, 39
Total hepatic vascular exclusion, for hemorrhage compartment syndrome and, 268–269, combat casualty care in, 36–37
control, 232 269b, 269f data collection and comparison in, 38–39,
Tourniquets (TQs), 56, 72–73 complex, general considerations in 39b
combat-action, 355, 355f addressing, 253–256, 254f ownership and responsibilities in, 38
development of, 13 complications after, 268–269 tracking of new technology in, 39
in upper extremity vascular injury, approach endovascular management of, 265–267, temporary shunts for, 290–292
to, 254–255 266f upper extremity
TPT. See Tibioperoneal trunk (TPT) epidemiology of, 252–253 axillary artery injuries, 260–261
Tranexamic acid (TXA), 4 mangled extremity scores in, application of, brachial artery injuries, 261–263
Transabdominal torso injuries, 395 255–256, 256t compartment syndrome and, 268–269,
Transcatheter angiography, 91–93 monitoring for, 267 269b, 269f
Transesophageal echocardiography (TEE), 101 nonoperative management of, 267 complex, general considerations in
for blunt thoracic aortic injury, 202, 202t operative strategy for, 255 addressing, 253–256, 254f
Transfusion, of blood products, 66 operative technique for, 259–260 complications after, 268–269
Transmediastinal torso injuries, 395 outcomes after, 253t, 269–270 endovascular management of, 265–267,
Transplantation, vein injuries and, 238 postoperative care for, 267–268 266f
Transthoracic echocardiography, cardiac radial artery injuries, 263–265 epidemiology of, 252–253, 253t
tamponade and, 8, 8f, 8t rehabilitation in, 267–268 mangled extremity scores in, application of,
Trapdoor thoracotomy, 260 subclavian artery injuries, 256–257 255–256, 256t
Trauma tourniquets in, approach to, 254–255 monitoring for, 267
implications for, 156 ulnar artery injuries, 263–265 nonoperative management of, 267
limb amputation for, 323, 324b wound care in, 267, 268f operative strategy for, 255
surgery, 108 Upper extremity venous injury, optimal outcomes after, 253t, 269–270
in Sweden, 370–371, 371f management of, 265 postoperative care for, 267–268
Trauma center, function of, 35–36 Upper limb injury complexes, 321 radial artery injuries, 263–265
Trauma-induced ARDS, 162–163 Upper limb vascular injuries, in austere rehabilitation in, 267–268
Trauma-induced coagulopathy (TIC), 71–72 environment, surgery for, 336–339, subclavian artery injuries, 256–257
Trauma quality improvement, 35 337f, 338f, 339f tourniquets in, approach to, 254–255
Trauma service, 36 brachial and forearm vessels, 338–339 ulnar artery injuries, 263–265
Trauma surgery, 366 subclavian and axillary vessel, 336–338, wound care in, 267, 268f
Trauma systems 337f, 338f, 339f Vascular injury
in combat casualty care, 36–37 Upper limb wounds, commonly used flaps for, in neck, 59
key components of, 34–35 329–330 prehospital management of, 55
organization of Joint Theater Trauma System, Urban populations, vascular trauma in, 27–28 bleeding, 56–64
37–38, 37t, 38t Urban setting, in Brazil, 401 replacing lost volume, 64–67
overview of, 34 Vascular reconstruction, 275, 379
Traumatic arteriovenous (AV) fistulae, 274, 313 Vascular repair, for great vessel injuries, 19–21
Traumatic false aneurysm, 200, 200f Vascular repair or primary amputation,
abdominal vascular injuries and, 214
V 377–378, 380f
Trauma units (TUs), 34 Vascular surgery, 156
“Trial of debridement”, 325 Vascular and trauma surgery, in Finland, 366 in austere environment, 332
Triplex prosthetic conduit, 305 Vascular conduit for abdominal vascular injuries, 339–341,
Tris-acryl gelatin (TAGM), 115 in austere and military settings, 306–307 340f, 341f
Troponin, cardiac, 9 considerations for, in repair of vascular equipment for, 332, 332f
Truncal vascular injuries, temporary vascular injury, 300 forearm amputation, 347, 349f
shunts for, 297–298 decision making in choice of, 304–306 fundamentals of, 332–333, 332f, 333f
TU. See Trauma units (TUs) ideal, for vascular trauma, 304–306, 305f, futility of, 344, 344f
Tube thoracostomy, for lung injuries, 24 305t for lower limb injuries, 342–344, 342f, 343f
location and nature of injury, 304, 305t for neck injuries, 333–336
future considerations of, 307–309 resuscitative thoracotomy, 341–342
artificial blood vessels, 307–308 for soft-tissue injury, 344–347, 345b
U improvements in storage, 309 for upper limb injuries, 336–339, 337f,
problem identification of, 300, 301f 338f, 339f
UK Defence Medical Services, guidelines types of, 300–304 vascularized composite muscle flaps for
concerning trauma amputation, 324b allografts, 302 coverage of vascular reconstruction,
Ulnar artery autologous, 301 345–347
anatomy of, 263, 264f prosthetic, 301–302 early, 14–17, 14t
injuries to, 263–265 xenografts, 303 Vascular surgical training, and certification,
operative management of, 263, 264f Vascular injuries, 273, 312 353
Ultrasound, 97–101 diagnostic tests for, 92t Vascular trauma
complications of, 101 hard signs of, 333 in Brazil, 401
as diagnostic tool, 100 legacy, 11 automobile crashes, 402–403
416 Index

Vascular trauma (continued) considerations for diagnosis of, 393–394, via Gulf War 1991 to Afghanistan and Iraq,
endovascular facilities, 404 394f military vascular surgery in, 20
epidemiology of, 401–403 epidemiology of, 391–392, 392f Vietnam Vascular Registry, 19, 20t
evaluation and diagnosis, 403 strategies for sustaining and training of Violent injury, in urban populations, 27
homicide rates, 401, 402t trauma surgeons in, 395 Visceral arteries, injuries to, 218–220
patterns and treatment strategies, systems of care in, 392–393 celiac artery and branches, 218
403–405 treatment strategies for, 394–395 endovascular treatment for, 220
rural setting, 401–402 training paradigms for, 42 inferior mesenteric artery, 219
training next generation of trauma Advanced Surgical Skills for Exposures in mortality in, 220
surgeons, 405–406 Trauma, 49–50, 50f, 50t renal artery, 219–220
urban setting, 401 Advanced Trauma Operative Management, superior mesenteric artery, 218–219
in Colombia, 396 49 Visceral rotation, medial, 214, 215f, 216f
axillary artery approach, 398–400, 399f, Basic Endovascular Skills for Trauma, 51 Visceral vessel injuries, 212
400f Definitive Surgical Trauma Care course, 48 Vitallium tube techniques, 288
posterior popliteal artery approach, Definitive Surgical Trauma Skills, 48–49 experimental and clinical application of, 289f
396–398, 397f, 398f Endovascular Resuscitation and Trauma Volodos, Nikolai, 374
endovascular to extracorporeal systems for, Management Workshop, 51 Volume resuscitation, 74
158 Endovascular Skills for Trauma and von Esmarch, Freidrich, 13
combining techniques, 163–164 Resuscitative Surgery, 51 VTE. See Venous thromboembolism (VTE)
lung support, advances in, 161–163, 162f, European Vascular Masterclass, 50–51
163f in general surgery, residency, 43–44, 43t
renal support, advances in, 158–161 in graduate medical education, 42–44 W
epidemiology of, 23, 24b, 24t simulation-based training for, 47–48
among local national populations, 26 team-based training for, 46–47 War tactics and weapons, 357–358
categorization of, 24–31 tools, 45–46 Wartime injuries, 330, 357–358
in civilian society, 26–29 in vascular surgery, residency, 44–45 War versus civil vascular trauma, 377, 378f
in combat troops, 25–26 ways forward for, 45–51 World War I experience, vascular surgery and,
extremes of age, 29–30 Vascular trauma in Sweden, 371–372, 372f 17
in iatrogenic vascular injury, 30–31 Vein graft, for arterial defect, 17f World War II
lifestyle and socioeconomic factors and, Venous iatrogenic injury, 31 arterial repair, nonsuture method of, during,
28–29 Venous injury, 273, 378, 380f 18, 18f
and military conflict, 25–26 neck/thoracic outlet arterial injuries experience, vascular surgery and, 17–18
principles of, 23 associated with, 243 interposition grafts and, 300
ideal conduit for, 304–306, 305f, 305t Venous repair, considerations for, 232 Wound infections, 276
in Israel, 388 Venous shunting, 296
management of, 21 Venous thromboembolism (VTE), 277
region-specific considerations for diagnosis of, Venous thrombosis, ultrasound findings in, 98t
354–355 Venovenous bypass, 238
X
in Serbia, 377 Ventilator-associated pneumonia, 27
complex injuries, 378–379, 381f Ventricular fibrillation cardiac arrest, 152–153, Xenografts, 303
diagnosis, 377–378 153f
early complications, 382–383, 383f Verification Review Committee (VRC), ACS COT, 36
endovascular repair of injured vessels, 383, Vertebral artery, 245–247 Y
384f, 385f anatomic segments of, 248f
late revascularization, 380–382, 382f injuries to, 241 Yassinovsky, Alexander, 374
long-term complications, 385 management of, 246
pediatric vascular trauma, 383–385, 386f natural history of, 242
primary amputation, 377, 380f operative strategy and technique for, Z
primary bleeding control, 377, 379f 245–247, 248f
strategy during management of, 377 Vessel injury, single, in forearm, 339 Zone I injuries, of neck, operative management
vascular repair, 377–378, 380f Veteran’s Administration (VA) study, 46 of, 336, 337f
venous injury, 378, 380f Vietnam Zone II injuries, of vascular injuries, 213
war versus civil vascular trauma, 377, 378f experience in, vascular surgery in, 19–20, Zone III injuries, of neck, operative management
in South Africa, 391 20t of, 335–336, 336f
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2019v1.0