Blunt Arterial Injuries Associated with Multiple Trauma

Original articles

Blunt Arterial Injuries Associated with Multiple Trauma Richard E. Welling, MD, Timothy E. Kremchek, MD, Ranjit K. Rath, MD, John M. Tew, Jr., MD, John K. Johnson, MD, Cincinnati, Ohio and Greenville, South Carolina

In this retrospective study, we reviewed the records of 62 patients who were treated at a tertiary care community teaching hospital between 1977 and 1987 for major arterial injury caused by blunt trauma. Nearly half (45%, 28/62) of the injuries were to the thoracic aorta, 24% (15/62) were to arteries of the head and neck, 21% (13/62) were to the arteries of the extremities, and 10% (6162) were to abdominal arteries. Twenty-eight thoracic aortic transections were repaired, 25 with Dacron grafts and three by primary repalr. One patient developed an adventitial hematoma in the thoracic aorta, which was evacuated. Two patients required nephrectomies secondary to renal artery injury. Ten patients with internal carotid artery dissection were successfully treated with anticoagulationtherapy. Eight (13%) of the 62 patients dled: four from exsanguination, one from cardiac tamponade, one from renal failure, one from pulmonary emboli, and one from cerebral infarction secondary to intracerebral edema. Such injuries are amenable to treatment, with patlent and end-organ viability, if recognlzed and treated promptly by the trauma surgeon. (Ann Vasc Surg 1989; 3:34!+350) KEY WORDS: Trauma; arteries; arterial injury.

In treating the multiple trauma patient, arterial injury assumes a high priority and requires prompt recognition and treatment by the trauma surgeon. This report documents our experience with blunt arterial injuries in 62 multiple trauma patients. Our purpose was to determine the relative frequencies of various types of arterial injury secondary to blunt trauma, to evaluate the technical result of treat-

From the Department of Surgery, Good Samaritan Hospital, University of Cincinnati Medical Center, Cincinnati, Ohio, and the Department of Neurosurgery, Greenville Memorial Hospital, Greenville, South Carolina. Reprint requests: Richard E. Welling, MD, West 7 Annex, Good Samaritan Hospital, 321 7 Clifton Avenue, Cincinnati, Ohio 45220-2489.

ment, and to examine the timing of the arterial repair as it relates to end-organ viability.

PATIENTS AND METHODS From 1977 to 1987, 62 patients were treated at a large community teaching hospital for major arterial injury as a component of multiple trauma. Nearly half (45%) of the injuries involved the thoracic aorta, 24% involved the arteries of the head and neck, 21% involved arteries of the extremities distal to the inguinal ligament or axilla, and 10% involved abdominal arteries. The patients ranged in age from 14 to 69 years, with a mean of 31 years. There were 45 men and 16 women. No patient sustained more than one significant arterial injury.

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Flg. 1. Arteriogram reveals completely torn thoracic aorta distal to subclavian artery, manifested by false aneurysm. Injury was sustained In motor vehicle accldent.

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Fig. 2. Arteriogram taken one month after injury because of respiratory problems and decreased blood pressure. Aortogram shows false aneurysm, which was repaired with Dacron graft.

patients had clean lacerations that permitted primary repair without tension on the aorta. Gott shunts were used in 13 patients and vented We observed four types of arterial injuries in the multiple trauma patient: 1) injuries to the thoracic cannulas were used in seven patients. Intravenous aorta and its branches; 2) injuries to the arteries of heparin (5000 U) was administered to each of these the lower extremities associated with knee disloca- patients. Another patient required venoarterial bytion or pelvic and long bone fractures; 3) renal pass. Shunts were not used in five patients because artery contusion associated with pancreatic of extensive hematoma in the arch and the descendtransection; and 4) torque hyperextension stretch ing aorta. The other two patients had localized lacerations and repair proceeded rapidly without injuries to the internal carotid artery (ICA). shunting. Five patients with thoracic aortic injuries had peripheral neurologic defects postoperatively; Injuries of the intrathoraclc aorta and major branches shunts were used in four of these patients. Three of All 28 thoracic aortic injuries resulted from motor the deficits partially resolved. Three patients had vehicle accidents. None of the patients were wear- mild renal failure with increased BUN and creatiing seat belts at the time of injury. In all but one of nine levels, postoperatively. A shunt was used in these patients, the laceration was in the region of one of these patients. In each case, renal function the isthmus of the aorta (Figs. 1, 2). Twenty-five resumed during the hospital stay. Two of the 28 patients died in the immediate patients were treated with woven Dacron interposition grafts. These patients had total aortic transec- postoperative period: one from cardiac tamponade tions or extensive contusions of the wall necessitat- and the other from uncontrollable bleeding at the ing debridement and resection. The other three proximal shunt site. Two other hospital deaths

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Fig. 3. (a) Anterior/posterior view, (b) lateral view. Popliteal artery occlusion secondary to thrombosis after anterior knee dislocation.

resulted from renal failure and from multiple pulmonary emboli. There were three subclavian artery injuries. One was associated with a fracture of the first rib. This arterial defect was not recognized until the development of forearm claudication three months after the injury. Treatment consisted of placement of an interposition Dacron graft. The other two patients sustained lacerations of the distal subclavian artery in motor vehicle accidents. These patients were also treated with placement of end-to-end interposition grafts. Three patients sustained arterial injuries of the upper extremity. One had an anterior dislocation of the elbow with transection of the brachial artery, which was corrected with a reversed saphenous vein interposition graft and fasciotomy . Another brachial artery injury, associated with a supracondylar fracture, was treated with cephalic vein patch and fasciotomy. An axillary artery injury associated with a fractured humerus and a brachial plexus injury was repaired with reversed vein graft. Long-term disability resulted from the associated brachial plexus injury. Lower extremity arterial injuries distal to the inguinal ligament

Four patients had injuries to the arteries of the lower extremity associated with femur fracture.

Two superficial femoral artery injuries were repaired with end-to-end anastomoses. One patient with a proximal popliteal artery injury was treated with an interposition saphenous vein graft. The fourth patient required resection of the common femoral artery and placement of an interposition vein graft. Three patients had popliteal artery injuries associated with knee dislocation. Two anterior knee dislocations resulted from relatively minor injuries: one patient was “clipped” while playing football, and the other patient stepped into a hole. Both patients had popliteal artery thrombosis (Fig. 3), which required excision of the arterial segments and placement of interposition saphenous vein grafts. A third patient required above knee amputation after a crush injury because of associated soft tissue destruction and peroneal nerve transection (Fig. 4). Injuries of the abdominal arteries

Six patients had abdominal artery injuries. Five were injured in motor vehicle accidents and one was hit by a car. Four had injuries to the iliac artery associated with pelvic fracture. One of these four patients died from an open exsanguinating injury to the left common iliac artery. Two patients had pelvic hematomas. One iliac artery was repaired immediately despite a hematoma because of ipsilat-

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era1 limb nonviability. The fourth patient had iliac artery repair four days after injury. Two patients sustained renal artery injuries and required nephrectomies. The ischemic time was more than 24 hours in both of these cases. These patients also had transections of the body of the pancreas, and both died from exsanguinating hemorrhage of the renal artery. Arterial lnjurles of the head and neck

Fifteen patients had injuries to the arteries of the head and neck. There were two vertebral artery injuries. One was treated expectantly (Fig. 5 ) , the other ligated. There were no immediate neurologic deficits as a result of these treatments, but both patients were lost to long-term follow-up. Thirteen patients had injuries to the ICA. Ten patients with traumatic dissection of the ICA were successfully treated with sodium heparin followed by warfarin for six weeks. Repeat arteriogram confirmed patency. One patient had ICA ligation with Fig. 4. Stretch injury causing thrombosis of popliteal no subsequent neurologic deficit. Another patient artery after knee dislocation.

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Fig. 5. (a) Left posterior oblique view, (b) right posterior oblique view. Left vertebral artery injury sustained in motor vehicle accident. Arterlograms show vertebral artery thrombosis (arrows). Repair was not attempted because collateral circulation was satisfactory.

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had segmental excision and interposition vein graft for a false aneurysm three months after initial injury. The last patient had extracranial to intracranial bypass following ICA ligation but died from cerebral infarction secondary to intracerebral edema.

DISCUSSION Vascular injury adds another dimension to the care of the multiple trauma patient. The trauma surgeon must assess the extent of vascular injuries as quickly and accurately as possible because unrecognized injuries can result in a neurologic deficit, loss of an extremity, or death. Arteriography is usually necessary to diagnose injuries of the ICA, intraabdominal arteries, (i.e., renal, iliac) or the thoracic aorta but may not be necessary for obvious injuries to peripheral arteries of the extremities.

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tion, including those that are reduced prior to hospital evaluation. If arteriography reveals an intimal injury without distal ischemia, the artery should be surgically repaired to prevent subsequent thrombosis. If possible, joints and fractures should be stabilized before arterial repair is attempted. An arterial shunt can minimize the consequences of delay in an ischemic limb [1,2]. We also recommend intraoperative arteriography or ultrasonography after arterial reconstruction to assess the technical result. Injuries of the abdomlnai arteries

Recognition of occlusive intraabdominal vascular injury in the multiple trauma patient is often delayed. Two of our patients sustained subintimal renal artery dissection and subsequent in situ thrombosis. In both cases, diagnosis was delayed more than 24 hours and nephrectomy was required. The normal kidney without collateral blood supply can tolerate approximately 45 minutes of normoinjuries of the lntrathoraclc aorta and major branches thermic ischemia [3,4]. Since early diagnosis of Radiographic evidence of a widened mediasti- blunt renal artery injury is difficult, fewer than 10% num, a pleural cap, tracheal displacement, or an of renal artery reconstructions for occlusive injury absent aortic knob should alert the trauma surgeon are successful [5]. Nevertheless, revascularization to the possibility of a torn thoracic aorta and should should be attempted if the kidney is potentially prompt immediate diagnostic arteriography. Diag- viable. Traumatic occlusion of the common or external nostic aortography is recommended for patients who will require prolonged reconstructive orthope- iliac artery is frequently associated with pelvic dic or neurosurgical operative procedures. Thoracic fracture and a large retroperitoneal pelvic heaortography should only be delayed if the patient matoma. In our experience, these pelvic hematohas associated abdominal injury and is hemodynam- mas are the result of bleeding from veins or muscular arterial branches and often require embolization ically unstable. Clearly, a transected aorta can be managed either for control of bleeding. If the traumatic occlusion of with or without a shunt or cannula. A shunt or the common or external iliac artery results in an cannula is beneficial in perfusing the kidney and ischemic lower extremity, an extraanatomic bypass decompressing the ascending aorta. Since heparin- graft may be necessary to revascularize the ischeized shunts can be difficult to insert, we administer mic extremity and to avoid decompressing the pelsodium heparin (< 5000 U) systemically. If heparin vic hematoma. is contraindicated, we do not employ a shunt. A large hematoma at the aortic tear may also preclude Arterial injuries of the head and neck shunt placement. The importance of the shunt in the prevention of Death or serious neurologic disability occurs in paraplegia is uncertain. With or without a shunt, the up to 85% of patients with ICA injury [6,7]. Arterial risk of paraplegia appears to be high if the ischemic injuries of the head and neck may result from period exceeds one hour. In our series, shunts were rotation and hyperextension of the cervical spine, employed in four of the five patients with postoper- which stretches the ICA over the transverse proative neurologic deficits. Four of the patients also cesses of the C1, C2, and C3 vertebral bodies. ICA had ischemia times of more than one hour. injury should also be suspected in all patients with mandibular fracture or intraoral trauma [8,9]. Patients with severe injury to the mandibular ramus Lower extremity arterial injuries distal to the Inguinal or tonsillar fossa are candidates for duplex scanligament ning. Patients should be scrutinized for transient cereFracture of a long bone or dislocation of a major joint should alert the trauma surgeon to the possi- bral ischemia, Horner’s syndrome, carotodynia or bility of an associated vascular injury. Arteriogra- carotid tenderness upon palpation, amaurosis phy is indicated for any documented knee disloca- fugax, neck hematoma, or carotid bruit [8,10]. De-

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pending upon the nature of the injury and the extent of collateral circulation, signs and symptoms of cerebral dysfunction may or may not be apparent. Fewer than 10% of patients experience symptoms within one hour of injury, and up to 70% may be asymptomatic for 24 hours or more [6,8,11,12]. Arteriography of these lesions is essential to delineate the extent of the injury and to determine the appropriate treatment. The pathologic lesion may be intraluminal arterial stretching or obstruction, pseudoaneurysm, or carotid cavernous fistula [S]. Initial treatment should consist of intravenous heparin, which may produce spontaneous resolution and symptomatic improvement. Surgical intervention is appropriate when anticoagulation is contraindicated by associated injuries. Reconstruction of the ICA is also appropriate when a patient continues to experience neurologic symptoms after six weeks of anticoagulation therapy, and arteriography reveals an injury below the level of the atlas. Lesions located above this level are difficult to treat by direct surgical repair and may require the use of a balloon catheter for arterial occlusion or obliteration of an arteriovenous fistula or aneurysm. Ligation of the ICA is another therapeutic option. It is imperative to maintain adequate cerebral perfusion pressure during any of these procedures; we selectively employ shunts in these patients on the basis of intraoperative EEG readings.

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