A systematic review of penetrating extracranial vertebral artery injuries

A systematic review of penetrating extracranial vertebral artery injuries Juan A. Asensio, MD, FACS, FCCM, FRCS (England), FISS, KM, Parinaz J. Dabestani, MA, Florian A. Wenzl, Stephanie S. Miljkovic, MS, John J. Kessler II, BS, Carlos A. Fernandez, MD, FACS, Tyson Becker, MD, David Cornell, MD, FACS, Margaret Siu, MD, Charles Voigt, MD, and Devendra K. Agrawal, PhD, Omaha, Neb

ABSTRACT Background: Penetrating vertebral artery injuries (VAIs) are rare. Because of their rarity, complex anatomy, and difficult surgical exposures, few surgeons and trauma centers have developed significant experience with their management. The objectives of this study were to review their incidence, clinical presentation, radiologic identification, management, complications, and outcomes and to provide a review of anatomic exposures and surgical techniques for their management. Methods: A literature search on MEDLINE Complete-PubMed, Cochrane, Ovid, and Embase for the period of 1893 to 2018 was conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Our literature search yielded a total of 181 potentially eligible articles with 71 confirmed articles, consisting of 21 penetrating neck injury series, 13 VAI-specific series, and 37 case reports. Operative procedures and outcomes were recorded along with methods of angiographic imaging and operative management. All articles were reviewed by at least two independent authors, and data were analyzed collectively. Results: There were a total of 462 patients with penetrating VAIs. The incidence of VAI in the civilian population was 3.1% vs 0.3% in the military population. More complete data were available from 13 collected VAI-specific series and 37 case reports for a total of 362 patients. Mechanism of injury data were available for 341 patients (94.2%). There were gunshot wounds (178 patients [49.2%]), stab wounds (131 [73.6%]), and miscellaneous mechanisms of injury (32 [8.8%]). Anatomic site of injury data were available for 177 (49%) patients: 92 (25.4%) left, 84 (23.2%) right, and 1 (0.3%) bilateral. Anatomic segment of injury data were available for 204 patients (56.4%): 28 (7.7%) V1, 125 (34.5%) V2, and 51 (14.1%) V3. Treatment data were available for 212 patients. Computed tomography angiography was the most common imaging modality (163 patients [77%]). Injuries were addressed by operative management (94 [44.3%]), angiography and angioembolization (72 [34%]), combined approaches (11 [5.2%]), and observation (58 [27.4%]). Stenting and repair were less frequently employed (10 [4.7%]). The incidence of aneurysms or pseudoaneurysms was 18.5% (67); the incidence of arteriovenous fistula was 16.9% (61). The calculated mortality in VAI-specific series was 15.1%; in the individual case report group, it was 10.5%. Conclusions: The majority of VAIs present without neurologic symptoms, although some may present with exsanguinating hemorrhage. Computed tomography angiography should be considered first line to establish diagnosis. Gunshot wounds account for most injuries. The most frequently injured segment is V2. Surgical ligation is the most common intervention, followed by angioembolization, both of which constitute important management approaches. (J Vasc Surg 2019;-:1-9.) Keywords: Vertebral Angioembolization

artery;

Penetrating

operative

Penetrating vertebral artery injuries (VAIs) are rare, are difficult to diagnose, and pose a challenge to surgeons,

From the Department of Surgery, Creighton University School of Medicine. Author conflict of interest: none. Presented as a medical student oral presentation at the Fourteenth Annual Academic Surgical Congress, Association of Academic Surgeons/Society of University Surgeons, Houston, Tex, February 5-7, 2019. Correspondence: Juan A. Asensio, MD, FACS, FCCM, FRCS (England), FISS, KM, Professor of Surgery and Vice Chairman, Department of Surgery, Creighton University School of Medicine, Creighton University Medical Center, 601 N 30th St, Ste 3701, Omaha, NE 68131-2137 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.10.084

management;

Outcomes;

Radiographic

identification;

given their complex anatomy and difficult surgical exposure.1 Because of the rarity of these injuries, few surgeons and trauma centers have developed a significant experience with their management.1 Matas,2 in 1893, described 53 patients collected from the literature, divided as follows: endocranial aneurysms, 11; extracranial cerebral aneurysms, 20; and wounds or lesions of the vertebral artery, 22 patients. In his review, Matas2 credits Samson for his original 1824 description of the first case of a gunshot wound to the vertebral artery in a patient who died and Maisonneuve for his 1853 description of the first successful ligation of a vertebral artery in the neck, also secondary to a gunshot wound in a patient who survived. The wartime incidence of these injuries is low, with Makins3 reporting only three VAIs during World War I. No VAIs were reported during 1

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World War II4 or the Korean War.5 Rich et al,6 however, in 1975, reported on the overall complications of 558 patients with 296 false aneurysms and 262 arteriovenous fistulas (AVFs) from the vascular injuries identified in the Vietnam Vascular Registry. Eight of these cases were specific to the vertebral artery; two pseudoaneurysms and six AVFs of the vertebral artery (1.4% total) occurred as late sequelae. Greer et al,7 in 2013, reported 11 VAIs from the recent Iraq and Afghanistan conflicts. Hence, the objectives of this study were to review the incidence, clinical presentation, radiologic identification, angiographic and operative management, complications, and outcomes for these rare and complex vascular injuries and to provide a targeted review of anatomic exposures and surgical techniques required for their management to familiarize surgeons with limited experience with the management of these injuries.

METHODS Search strategy. A literature search was performed through MEDLINE Complete-PubMed, Cochrane, Ovid, and Embase. Key search phrases included “vertebral artery injuries,” “vertebral artery trauma,” “penetrating vertebral artery injuries,” “penetrating vertebral artery trauma,” “penetrating neck trauma,” “penetrating vertebral artery traumatic aneurysms,” and “vertebral artery arteriovenous fistulas” with specifiers of English language and adult population. Additional queries were performed using the key phrases “penetrating vertebral artery injuries,” “military-related penetrating neck injuries,” “combat-related penetrating neck trauma,” and “military-related vertebral artery injuries.” This collective review strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Fig).8 Study selection and inclusion and exclusion criteria. Because of the rarity of penetrating VAIs and a lack of level I evidence, all articles published were considered. A thorough search of the literature from 1893 to 2018 initially yielded 181 articles for review. Inclusion criteria were patients aged $18 years; articles in the English language; and articles reporting reliable information on diagnosis, imaging, management, and outcomes of penetrating VAIs. Exclusion criteria omitted articles reporting blunt or iatrogenic VAIs, pediatric patients, articles lacking reliable information on patient outcomes, and duplicate articles. Three suitable articles were selected through examination of bibliographies of the eligible articles. Seventy-one articles met our requirements and were thus included in this review (Fig). Of these 71 articles, there were 21 penetrating neck injury (PNI) series reporting significant numbers of VAIs, 13 VAI-specific series, and 37 individual case reports. In total, 462 patients with penetrating VAIs were described. The studies were reviewed thoroughly by at

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Fig. Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram.

Table I. Wartime incidence of extracranial penetrating vertebral artery injuries (VAIs) Conflict

Total artery injuries

1919

World War I

1202

3

DeBakey4 1946

World War II

2471

e

304

e

1000

e

Author 3

Makins

Year

Hughes5

1958

Korea

Rich9

1970

Vietnam

7

Greer Total

2013 Iraq and Afghanistan

VAIs

365

11

5342

14 (0.3%)

least two independent authors, and all data were collectively analyzed. Data extraction. Data extracted included clinical presentation, diagnostic imaging, angiographic or surgical treatment, complications, and outcomes.

RESULTS Incidence. The incidence of penetrating VAIs remains difficult to calculate, given the rarity of these injuries and the paucity of data available in the literature. To determine the incidence of these injuries in the military arenas of warfare, we reviewed series beginning with World War I up to the current conflicts in Iraq and Afghanistan (Operation Iraqi Freedom and Operation Enduring Freedom) totaling 5342 reported acute arterial injuries. Makins,3 in 1919, described three patients from World War I. No VAIs were reported by DeBakey and Simeone4 from World War II, Hughes5 from the Korean conflict, or Rich et al9 from the Vietnam conflict, most likely because of the lack of battlefield-ready imaging techniques or the presence of other exsanguinating vascular injuries. This is certainly a limitation to the calculation of the battlefield incidence. Greer et al,7 in 2013, described 11 patients from the Iraq and Afghanistan conflicts for a total of 14 acute VAIs, with an approximated calculated incidence of 0.3%, confirming that these injuries are indeed rare entities during wartime (Table I). Interestingly, Rich et al,6 in 1975, reported on the

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overall complications of 558 patients diagnosed with false aneurysms (296 [53%]) and AVFs (262 [47%]) from the total number of vascular injuries recorded in the Vietnam Vascular Registry. From these two groups, they identified eight VAIs with complications; two (0.3%) developed false aneurysms and six had AVFs (1.07%). However, these were late sequelae of unidentified VAIs. To calculate the incidence of these injuries in the civilian population, we also reviewed large series reporting numbers of VAIs from PNIs as well as all available VAI-specific series and case reports. A total of 3226 PNI patients were identified, in whom there were 946 vascular injuries (29%) of named cervical vessels. There were a total of 100 VAIs reported in these collected series for a calculated incidence of 3.1% (Table II). Recently, significant emphasis devoted to identification and treatment of blunt VAI has diagnosed these injuries with a greater frequency than previously reported. Many of these injuries have been identified by computed tomography angiography (CTA) or formal arteriography and are for the most part primarily managed nonoperatively with anticoagulation or interventional radiology techniques.30-36 Herein, however, we chose to concentrate our efforts on penetrating extracranial VAIs. Mechanism of injury. To determine mechanism of injury and other relevant data, we reviewed the 100 patients with VAIs collected from the PNI series, with only 29 (29%) reporting their mechanism of injury, the majority of which were gunshot wounds (26 [26%]), followed by stab wounds (2 [2%]) and shrapnel injury (1 [1%]). Because most of the PNI series did not provide adequate data to meet our inclusion criteria, further analysis of these series was deemed noncontributory. A review of the VAI-specific series identified 324 patients; 303 (93.5%) reported mechanism of injury, the majority of which were gunshot wounds (Table III). A review of 37 individual case report series collected 38 patients (one case report described two patients), all of whom had data reporting their mechanism of injury (Table III). To determine the most common anatomic site (laterality) of VAI, right vs left, we reviewed the 13 VAI-specific series along with 38 patients in the case report group (Tables IV and V), collecting a total of 362 VAIs. Eight case series and one case report failed to specify anatomic site of injury. Information was available for 177 patients (49%), separated into 84 (47.5%) right and 92 (52%) left VAIs with a slight predominance of left-sided injuries. One (0.5%) injury was bilateral. The anatomic site of injury for 185 patients (51%) was not specified (Table III). Presentation. Penetrating VAIs are often asymptomatic. Many are diagnosed during the workup of PNIs. Most of the symptoms are attributable to PNI, such as hemorrhage (usually from associated carotid or jugular venous injuries and rarely from VAI), airway compromise,

or symptoms associated with tracheal injuries and dysphagia or odynophagia associated with cervical esophageal injuries. In general, neurologic symptoms are attributable to associated carotid artery injuries caused by transection with occlusion or intimal flaps, which may be manifested with hemiplegia. In our review of the literature, two patients with penetrating VAIs presented with neurologic symptoms. One presented with bilateral VAI occlusions and the “locked-in syndrome,” in which the patient maintained consciousness but had complete paralysis. One presented with the Wallenberg syndrome, which is a lateral medullary lesion resulting in lack of pain and temperature sensation contralaterally and ipsilateral cranial nerve dysfunction also leading to dysphagia; symptoms similar to Horner syndrome may occur as well. Anatomic segment of injury. The vertebral artery is divided into four segments, three being extracranial (V1-V3). To ascertain the distribution of injuries stratified to extracranial segments, the VAI-specific series provided data for 166 (51.2%) of 324 patients (Table III). The individual case report group provided data on the anatomic segment of injury for all 38 patients (Table III). The most frequently injured segment for both groups was V2. Diagnosis and management. In the past, patients sustaining PNIs presenting as hemodynamically stable were studied with conventional angiography to diagnose carotid injuries and VAIs. With the advent of CTA, the role of conventional angiography has diminished significantly. CTA has thus become the primary diagnostic modality for VAIs and has the advantage of being noninvasive. Recently, significant emphasis on the identification and treatment of blunt VAIs has led to an increase in the detection of such injuries. This also holds true for penetrating injuries. Many of these injuries are identified incidentally during the evaluation of PNIs by CTA and rarely with formal arteriography; for the most part, they are primarily managed with endovascular surgical interventions or adjunct interventional radiology techniques plus anticoagulation.30-36 Herein, however, we chose to concentrate our efforts on penetrating extracranial VAIs. Data detailing diagnosis and management were reported for only 55 (55%) of the 100 patients with VAIs in the PNI series (Table IV). Combining the VAI-specific series and individual case reports validates that the majority of these injuries, 163 (77%) of 212 from both groups, required angiography for diagnosis and were considered hemodynamically stable to undergo this procedure (Table V). In addition, 85 (48.9%) of the 174 patients in the VAI-specific series and 7 (18.4%) in the individual case report group were transported immediately to the operating room for definitive surgical intervention (Table V). Combining both groups, 92 (43.4%) of the

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Table II. Penetrating neck injury (PNI) series specifically reporting vertebral artery injuries (VAIs) Year Total a

1956-2015a

No. of PNIs

No. of vascular injuries

No. of VAIs

3226

946 (29.3%)

100 (3.1%)

Study type 4 prospective, 17 retrospective

References 9-29

Table III. Vertebral artery injury (VAI)-specific series: Mechanism of injury, anatomic site of injury, and anatomic segment of injury Mechanism of injury

No. of patients VAI-specific series Total

SW

Misc.

a

162 (53.4)

113 (37.2)

38c

16 (42.1)

18 (47.4)

4d (10.5)

178 (49.2)

131 (73.6)

32 (8.8)

324

Individual case reports

GSW

Anatomic site of injury

362

b

28 (9.2)

Left

Right

68 (48.6) 24 (63) 92 (25.4)

Anatomic segment of injury

Bilateral

V1

V2

72 (51.4)

e

24 (14.5)

101 (60.8)

41 (24.7)

12 (31.5)

1 (2.6)

4 (10.5)

24 (63.2)

10 (26.3)

84 (23.2)

1 (0.3)

125 (34.5)

51 (14.1)

28 (7.7)

V3

GSW, Gunshot wound; Misc., miscellaneous; SW, stab wound. Values are reported as number (%). a References 3,7,37-47 b There were 11 puncture wounds,3 1 gored by ox,3 13 shrapnel wounds,10,37,47 1 shotgun wound,39 and 2 lacerations.41 c References 48-84. d Tack from air compressor,61 shrapnel,67 electric screwdriver,75 and wooden projectile.80

Table IV. Penetrating neck injury (PNI) series reporting vertebral artery injuries (VAIs): Diagnosis and management No. of PNIs

Year 1969a

Total a b c

24

No. of VAIs 3

Diagnostic angiography

Surgery-ligation

Embolization

Stent and repair

Observation

Deaths

e

e

2

1

3

e

b

1981-2000

1143

32

19

22

4

e

7

6

2003-2015c

367

20

19

e

5

e

15

e

1969-2015

1534

55

25 (45.5%)

9 (16.4%)

0 (0%)

22 (40%)

8 (14.5%)

39 (70.9%)

Reference 13. References 14-18,24. References 25,27-29.

Table V. Vertebral artery injury (VAI)-specific series and individual case reports: Diagnosis and management Year

No. of Diagnostic Surgery and Embolization only Observation patients angiography Surgery-ligation embolizationa

Stent and repair

VAI-specific series 1946-2013b

174

132 (75.9)

85 (48.9)

11 (6.3)

50 (28.7)

51 (29.3)

6 (3.4)

1887-2017c

38

31 (81.6)

9 (23.7)

e

22 (57.9)

7 (18.4)

4 (10.5)

212

163

94 (44.3)

11 (5.2)

Individual case reports Total

72 (34)

58 (27.4)

10 (4.7)

Values are reported as number (%). a Preoperative or postoperative embolization. b References 10,37-39,41-45,47. c References 48-84.

212 patients required immediate surgical intervention because of active hemorrhage or hemodynamic instability from the VAI or other associated vascular injuries, most likely carotid and jugular injuries (Table V). All patients requiring surgical intervention had hemorrhage control by ligation of the injured vertebral artery with sutures or clips or a combination of both. Bone wax was also used as an adjunct to pack the intervertebral canal after ligation of the injured vertebral artery.

A minority of patients required surgery plus preoperative or postoperative angioembolization in the combined VAI-specific series and case report group. Embolization as a means of hemorrhage control or treatment was performed less frequently compared with surgical interventions in 34% of the patients (Table V). As techniques of interventional radiology developed, angioembolization became more common over time. In these two groups, 27.4% of the patients were observed. Stenting was less

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Table VI. Vertebral artery injury (VAI)-specific series and individual case reports: Incidence of aneurysms or pseudoaneurysms and arteriovenous fistulas (AVFs) No. of studies

Year

No. of patients

No. of aneurysms or pseudoaneurysms

No. of AVFs

8

1893-2013

219

61 (27.9%)

e

37

1946-2015

38

6 (15.6%)

e

9

1946-2013

236

e

51 (21.6%)

37

1964-2015

38

e

10 (26.3%)

Aneurysms or pseudoaneurysms VAI-specific series Individual case reports AVFs VAI-specific series Individual case reports

frequently employed; 4.7% of these patients underwent this procedure (Table V). One patient underwent primary repair and required a stent postoperatively. Complications. One of the frequent complications experienced by patients sustaining penetrating extracranial VAIs is the development of post-traumatic aneurysm or pseudoaneurysm. In the review of VAI-specific series, eight series reported data of 219 patients describing this complication. There were 61 (27.9%) patients with posttraumatic pseudoaneurysms or aneurysms among these patients and 6 (15.8%) in the case report group. Similarly, injury to the vertebral artery is well known to have a high incidence of associated AVFs, given its accompanying vertebral vein or paired veins and a rich surrounding venous plexus. The VAI-specific series revealed 51 (21.6%) AVFs from nine series with 236 patients. In the case report series, 10 (26.3%) patients developed AVFs (Table VI). For the most part, all were managed with angiography, with angioembolization, and occasionally surgically. Associated injuries. Associated injuries were also reviewed in the VAI-specific series. The most frequently associated artery injuries included the carotid (20 [6.2%]) and subclavian (6 [2%]) arteries. The most frequently associated vein injury was the internal jugular vein (13 [4%]). Spinal cord injury was present in 21 (6.4%) of the patients. Incidentally, there were two (0.6%) thoracic duct injuries. Examination of complications for the VAI-specific series and the case report group revealed a Wallenberg syndrome secondary to occlusion of the right posterior inferior cerebellar artery.51 Another patient presented with the locked-in syndrome due to bilateral occlusion of both vertebral arteries resulting in basilar artery occlusion and brainstem infarction.52 One patient presented with a hypoplastic left vertebral artery and transection of the right vertebral artery. Embolization was performed, and the patient was discharged 6 days postoperatively with no complications; however, because of his homelessness, follow-up was not available.82

DISCUSSION Monson et al,13 in 1969, classified PNIs into three different anatomic zones. The vertebral artery is divided into three extracranial segments within these zones, with a fourth segment located intracranially. The vertebral artery is the first and largest branch off the subclavian artery. Zone I is most proximal and contains the first segment, V1. In addition to V1, many vital structures are contained in this zone; injuries here therefore incur the highest mortality. Zone II contains the second segment of the vertebral artery, V2, which enters through the transverse foramen of C6 coursing upward toward C2. Patients with injuries in this zone may present with clinical symptoms attributed to associated injuries, such as hemorrhage, airway compromise, dysphagia, and neurologic symptoms such as hemiplegia from associated carotid injuries. In our study, V2 was the most frequently injured segment, followed by V3 and V1. Zone III contains the last extracranial portion of the vertebral artery, V3. Most distal from the vertebral artery origin is the fourth segment, V4, which pierces the dura and is completely intracranial. Data were available detailing management of 55 VAI patients in the PNI series; 25 (45.5%) required immediate surgical intervention with ligation, whereas 85 (48.9%) in the VAI-specific series required immediate surgical intervention. Thus, knowledge of anatomy blood flow in this vessel is useful to the surgeon as many of these injuries are ligated or angioembolized. Similarly, the extensive venous plexus and single or paired vertebral veins account for the high incidence of AVFs, 21.6% in this review. The management of penetrating VAIs has spanned different eras. The evolution began approximately in the 1960s, continuing into the 1970s, when the knowledge acquired during the Korean War allowed the nascent field of vascular surgery to emerge; the Vietnam War experiences produced great advancements. During the 1970s to the early 2000s, open vascular surgery was established and evolved into a separate surgical subspecialty. Currently, endovascular techniques have added a

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new dimension to a well-established field, decreasing the number of open vascular procedures while addressing both vascular injuries and disease with minimally invasive techniques. These advancements have been successfully extrapolated to the management of penetrating VAIs. In our studies, surgical ligation was employed in 44.3% of the patients, followed by embolization in 34% of patients. Combined surgical approaches including ligation and embolization accounted for 5.2%. Operative approaches to the extracranial vertebral artery segments are complex as this is a difficult vessel to access surgically. However, it behooves the surgeon to be cognizant that this may not be rapidly or readily obtained in injuries to zone I or when there are combined carotid injuries and VAIs in zone II. To expose V1 requires a supraclavicular incision and exposure of the subclavian artery to visualize the vertebral artery. For hemodynamically unstable patients, median sternotomy with combined supraclavicular extension and possible clavicular excision must always be considered. Exposure of V2, the most frequently injured segment, requires the classic neck incision along the anterior border of the sternocleidomastoid muscle. The entire carotid sheath is then opened. Any associated carotid artery injuries may now be controlled with atraumatic vascular clamps. Vessel loops are equally suitable and effective in obtaining vascular control. V2 requires the Henry approach. In the classic Henry approachdthe posterior approachdthe carotid sheath and its contents including the carotid artery and jugular vein are retracted medially along with the trachea and esophagus to expose the two prevertebral muscles, the longus colli and longus capitis, which lie anterior to the osseous vertebral canal. This approach requires transection of Charpy partitions, which are the ligamentous attachments anchoring the tracheoesophageal complex. They are found in the tracheoesophageal groove. In the modified Henry approachdthe anterior approachdthe carotid sheath vessels are retracted laterally while the tracheoesophageal complex is retracted medially. Periosteal elevators are used to strip prevertebral muscles along with their tendinous insertions to the cervical spine to expose the anterior aspect of the canal. The intervertebral canal is then opened by use of rongeurs to unroof the canal. It is helpful to insert right-angled clamps before using the rongeurs. The unroofing of the canal should not extend too far laterally to avoid damage to the anterior rami of the cervical nerves. Once unroofed, the artery is then identified, isolated, ligated, or clipped. As in the patient described by Bertellotti et al,84 the most difficult exposure of all of the extracranial vertebral artery segments is that of V3. This segment lies in the posterior triangle of the neck. Positioning the patient is the same as for exposure of V1 and V2. The incision is

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then curved posterior to the ear, 2 to 3 cm below the mastoid process, curving cephalad to a point 1 to 2 cm above the mastoid process. It requires detachment of the origin of the sternocleidomastoid and identification of cranial nerve XI. The previously transected sternocleidomastoid muscle is then mobilized and folded caudally to identify the splenius capitis muscle, which is lateral and may be retracted, as well as the longissimus capitis muscle, which is then transected. Endovascular techniques have become a new and superb addition to the surgical armamentarium; thus, the use of these techniques as surgical adjuncts has allowed the control of retrograde blood flow both proximally and distally. In our review of the data, we identified four patients in the individual case report group in whom this combined approach was successful to control bleeding from the V2 segment. Two patients had proximal and distal control; the other two patients had adjunct endovascular approaches to control bleeding from an associated AVF and a pseudoaneurysm, respectively.59,65,71,83 In our study, 27.9% of the patients in the VAI-specific series and 15.6% of the patients in the individual case reports had aneurysms or pseudoaneurysms. The incidence of AVFs in our series was 21.6% in the VAI-specific series and 26.3% in the individual case reports. The calculated mortality in VAI-specific series was 15.1%; in the individual case report group, the mortality was 10.5%. For patients presenting with hemorrhage in centers where hybrid operating rooms are available and in anticipation of surgical exploration, balloon control of the proximal subclavian is a potential adjunct. Similarly, a balloon can be placed in the distal vertebral artery. It may be of help in control of hemorrhage in anticipation of a complex vascular exposure. These techniques require the skillful interventions of vascular surgeons with excellent endovascular skills. This collective review has a number of limitations, namely, those inherent in all reviews of retrospective data; for instance, many of the large PNI series had missing data on the VAIs reported and especially on their operative management. Although VAI-specific series provided better data, case reports are usually prone to publication bias. Similarly, most of the reviewed series provided little information on long-term outcomes, and there was also a paucity of data in the case series with regard to the operative and endovascular procedures or the use of stents. Finally, for all series reviewed, there was no statistical analysis. Unfortunately, a collective review of these data is not suitable for a properly structured meta-analysis.

CONCLUSIONS Extracranial penetrating VAIs are rare. Their presentation covers the entire spectrum from hemodynamic stability to exsanguination. The majority of these injuries are due to gunshot wounds. The most frequently injured segment is V2. With the advent of angiography and

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angioembolization, a whole new dimension has been added to the diagnosis and surgical management of these injuries. A significant number of these patients will, however, require immediate lifesaving surgical intervention. AVFs are common; therefore, in patients requiring surgical interventions, meticulous control of all arterial and venous branches is of utmost importance. Surgeons must be trained to expose this vessel to control hemorrhage, to prevent exsanguination, and to address associated injuries. It is our hope that our detailed review of the operative techniques will familiarize surgeons with the anatomy and surgical approaches for the management of these injuries.

AUTHOR CONTRIBUTIONS Conception and design: JA, PD Analysis and interpretation: JA, PD, FW, SM, JK, DC, CV, DA Data collection: PD, FW, SM, JK, CF, TB, DC, MS, CV Writing the article: JA, PD, DA Critical revision of the article: JA, PD, FW, SM, JK, CF, TB, DC, MS, CV Final approval of the article: JA, PD, FW, SM, JK, CF, TB, DC, MS, CV, DA Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: JA

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Submitted May 17, 2019; accepted Oct 19, 2019.