Wounds of common carotid arteries

WOUNDS REPORT

OF COMMON OF SEVENTEEN

CAROTID

CASES FROM

ARTERIES

WORLD

WAR

II

LAWRENCE M. SHEFTS, M.D.*

KNOWLES B. LAWRENCE, M.D.,* Brookline, Massachusetts

San Antonio, Texas

AND JOHN R. MCDANIEL, M.D.* St. Joseph, Missouri

I

and base hospitaIs during WorId War I a death rate of 16.4 per cent is recorded. The incidence of cerebra1 compIications was 29.6 per cent with a fata outcome in 55.3 per cent of such compIicated cases. As in Makins’ series the initia1 handIing of the majority of these 128 carotid wounds was conservative, Iigation and other surgery being performed chieffy for the various compIications. It is impossibIe to judge from these pubhcations how many other patients with undtbrided neck and carotid wounds died of primary or secondary hemorrhage, sepsis or other causes. OnIy twenty-five carotid artery wounds among the American forces were reported by the U. S. Army MedicaI Department for WorId War I.~ The mortaIity rate for this group was 44 per cent but no further particuIars were given. In reviewing a series of 661 instances of major arteria1 wounds treated surgicaIIy in certain forward army hospitaIs of the Mediterranean and European theaters during WorId War II by teams of the Second AuxiIiary SurgicaI Group, seventeen cases of wounds to a common carotid artery were encountered. These patients were treated as earIy as possibIe after wounding; the surgicaI faciIities were good and the after-care generaIIy adequate. It is interesting, therefore, to anaIyze these cases and, in particuIar, to compare the fataIity rate with those pertaining to such wounds in the first worId war. No instance of a wound of interna carotid artery aIone or of both common carotids were found in this series. There was, in addition, one

T is we11 known that sudden interruption of bIood Aow through a common carotid artery wiI1 Iead to cerebra1 ischemia and eventua1 death or hemipIegia in a high percentage of cases. ,Common carotid Iigation in peace time, incIuding eIective cases, appears to carry a mortaIity rate of 20 to 50 per cent.’ War wounds of this artery might be expected to resuIt in an even higher mortaIity. The most significant reports avaiIabIe on this subject are those of British surgeons based on their experience in WorId War I. Makins in his monograph2 states that he never saw a successfu1 case of primary Iigation of the common carotid artery in four years service as consuItant to lines-of-communication hospitaIs. He observed that in virtuaIIy a11 cases of carotid wounds reaching forward hospitaIs aIive the externa1 wounds were very smaI1 and the injury to the artery was “minor, IateraI or through-and through.” Most of the eighty-five patients in Makins’ persona series were treated conservativeIy or had deIayed surgery for secondary hemorrhage, aneurysm or fistula, infection or a foreign body. Ten of the eighty-five manifested we11 estabIished arteria1 aneurysms and forty-eight had arteriovenous aneurysms or IistuIas. The reIativeIy Iow mortaIity rate of 15.2 per cent for his series represented, of course, onIy a portion of the tota mortahty of those with carotid wounds. In the genera1 report of the British medica services3 covering 128 wounds of the carotid arteries treated in both forward * Formerly

members of The Second Auxiliary 29

SurgicaI Group, United States Army.

-

19

21

25

29

19

Age

36 hr. 8 hr.

2,!

I& hr.

,.~

2% hr.

8 hr.

fled:rate

NO

ihock

-

-_

comminuted.

Conscious, quad. riplegia and right facial pals,

no

no

Conscious; hemiplegia

Conscious; hemiplegia Unconscious

no

no

Conscious: hemiplegia

Conscious; hemiplegia

no

Conscious; hemiplegia

Conscious; right Homer’s syndrome paralysis. right diaphragm; no hemiplegia Conscious; no hemiplegia

Preoperative Examination

compound, carotid

_......

L=g

Tim,

*F.C.C.-Fracture t C.C.-Common

NO.

CaSe

.-..-

F.C.C.,* maniIIa and mandible F.C.C.. thyroid cartilage; penetrating wounds of arm and shoulder Contused sop&or and median cords of brachial plexus and phrenic nerve

Penetrating wounds of face

0

of

thoracic

Perforation trachea

Sucking wound

0

Transected right phrenic and recurrent Iaryngeal nerve; con tused sympathe tic chain Contusion of five and sixth cervical nerves

Associated Injuries

C.C.t

sev-

vein

C.C.

CC.

severed

lacer.

lacer-

lacerorigin

Left CC. thrombosed and lefl internal iugulal vein lacerated

Left C.C. Iacerated Left CC. lacerated at bifurcation

Right ated

Right ated

C.C.

C.C. near

ternal jugular

Right ated

-

OF

VC!SS‘Zl

Ooerative

THE

TABLE

1

Ligation ternal vein

left injugular

NOW

None

Tracheotomy

Tracheotomy

of

None

None

Left hemiplegia; lethargy

None

Right hemiplegia; left facial paralysis None

NO”‘?

Signs

-

Recoveries Ce1&d

ARTERIES

Closure sucking wound Tracheotomy

ligation of CC. external and internal carotid arteries

C.

C.

C.

None

Ieft

right

right

CC.

right

None

None

C.C.

1Ligation

Ligation C.

Ligation C.

Ligation,

1Ligation C.

of C.C., external and interna carotid and vertebral ar teries left ,Quadruple ligation

1Ligation

NO",2

Other

Procedures

CAROTID

Ligation of artery; elective ligation ofinternal jugular vein

T

Left CC. lacerated, near aorta I and connected bv fistula to in-

Left C.C. lacerated at bifurcation

Right ered

Type and Degret of Vessel Injury

INJURIES

4

3

6

7

7

D=Y IEvacLl ated

&utopsy showed thrombosed left C.C. artery

. -

mmediate postoperative hemiplegia *lo hemiokia on 18th postoperative day *emiDlenia and leth&g;impr”v ing at time of evacuation Iriginal operation was trache“torn”: C.C. ligationfor hemorrhage on 18th postoperative dny . . . . . .

.eft-sided headache p”stoperativcly

Go had hemiparalysis of vocal cords

Comment and Follow-up

-r day

Post “per atiw

I’

-

0

0

0

0

0

0

0

>eath s

-

IZncephalomalncia

IZncephalomaIacia

IZncephaloma. lncia

CiiUSC

Lag

NO.

456 hr.

..

24 hr.

335 hr.

24

18

9% hr.

24

hr.

6%

Ihe

CaSe

-

_-

vere

-

Se-

NO

NO

Se-

hock

-

INo hemiplegia

-

( hitusion cervical thetics

of left sympa-

wounds of knee, thoracic wall and face

I‘metrating

0

hemiplegia

ILeft

I ‘enetrating wound of thora, ofcer, I ‘erforation vial esophagus; contusion of left phrenic nerve

I ‘enetrating wound of thigh

no

_-

Associated Injuries

’Conscious no hemiplegia

hemiplegia

,Conscious;

IYo hemipIegia

Preoperative Examination

-

perforated

Left C.C. intimn bulged through laceration in muscularis; left subclavian vein lacerated at junction with in terna jugular vein Left internal carotid artery thrombosed and left external carotid arterv

Right CC. Iacerated iust before bifurcation: internal jugular vein severed

Left CC. lacerated near origin iight C.C. lacerated “ear origin; rieht interal ~“~“Iar vein and 1eIt vertebral *rtery transected Left CC lacerated

CC.

Type and Degret of Vessel Injury

-

Lert external rotid artery ligated

ca-

“ Blakemore cuff” anastomosis using saphenous vein: internal j1,gular vein ligated Inversion of aneu. rysm and suture of muscularis. ligation of veins

Tracheotomy

NO”+2

Tracheotomy

Debride“lent

Ligation

of CC.

Tracheotomy

None

0

Procedures

Ligation of CC. and removal of damaged segment Ligation of C.C.

Operative

TABLE I-(Conti~ed)

.

_

.. ...

Cerebral Signs

-

Recoveries

done

I

-

13

-

Day I zvacw ated

i

.

I

jemicomatose postoperatively; partial recovery from hemiplegia by fourth poqtoperative day Yo interruption of blood flow at any time

jemiconmtosc postoperatively

1Had hrmiplegia postoperatively

,..._..........

Comment and Follow-up

-

-

9

19

day

3

-

;amr

2

Day

3.kive

IPost-

-

0

0

Dent}

no

nu-

Encephalomalacia; thrombosis of internal carotid artery extending into cerebral vessels

topsy Encephaloma. lacin

‘Cerebral death;”

Encephalomala& Died before operation of hemorrhage from left vertebral artery into pleural cavity

Cause

32

American

Jourd

0f

surgeryLawrence

case of Iaceration of treated by Iigation technicaIly possible. mediastina1 infection

et aI.-Wounds

the innominate artery since suture was not The patient died of and encephaIomoIacia.

CLINICAL

DATA

TabIe I presents the pertinent cIinica1 data avaiIabIe to us in the cases of common carotid wounds. These patients were young, the average age being twenty-two years. This probabIy was a factor in their favor since the cerebra1 circuIation seems capabIe of greater adaptation in youth. The time lag from wounding to surgery was recorded in thirteen cases. In one of these a smaI1 wound of the common carotid was not identified unti1 the eighteenth post-wound day when sudden hemorrhage from the wound occurred. Excluding this case the average time Iag for the others was I I .6 hours, approximateIy the same time Iag as for the abdomina1 wounds in the Group’s experience and probabIy the minimum possibIe under the prevaIent tactica conditions. UndoubtedIy by that time some irreversibIe changes due to bIood deprivation had occurred in the cerebra1 tissue of three of these patients. This must aIways remain a Iimiting factor in prognosis no matter how technicaIIy satisfactory the surgica1 procedures for restoration of arteria1 continuity may seem. Some notation of the preoperative neuroIogic status was found in the forward hospita1 records in fourteen of the seventeen cases. (TabIe II.) II NEUROLOGIC STATUS TO OUTCOME IN FORWARD HOSPITALS (14 CASES RECORDED) Neurologic Signs Present No Neurologic Signs . 3 Survivals. 6 Deaths.. AI1 died of encephato3 survived, asympmaIacia tomatic I survived with cerebral signs Deaths. 5 4 died (encephaIomaIacia) I died of hemorrhage (before Iigation) RELATION

TABLE OF PREOPERATIVE

Of these fourteen patients, eIeven were conscious and had no hemipIegia or gross

of Carotid

Arteries

JULY, 1948

signs of cerebra1 ischemia prior to surgery; one was unconscious, one manifested a quadripIegia and one a hemipIegia. These Iast three patients a11 died and showed encephaIomaIacia at autopsy. The common carotid was Iigated in ten of the eIeven patients who presented no neuroIogic signs OnIy five of those repreoperativeIy. covered without objective signs of cerebra1 damage; four died with encephaIomaIacia and one had hemipIegia and lethargy, improving at the time of evacuation to another hospita1. The one remaining patient with no cerebra1 signs preoperativeIy died of hemorrhage from a severed verterbra1 artery before carotid Iigation couId be undertaken. Study of the type and magnitude of the arteria1 wound in reIation to the recovery of the patient was not very informative. For example severa patients with perforation or Iaceration of an artery requiring ligation when exposed during wound dCbridement, went on to compIete recovery whereas in two patients without an actua1 wound of the arteria1 waI1, occIusion by thrombosis resulted in encephaIomaIacia and death. It seems IikeIy that the extent and spread of thrombosis in the arterial tree and the quaIity of the pre-existing coIIatera1 circuIation to a hemisphere are the two most potent factors in prognosis for common carotid wounds aIthough both are quite unpredictabIe cIinicaIIy. RESULTS

OF

SURGICAL

TREATMENT

The common carotid artery was Iigated in tweIve of the seventeen patients. As shown in TabIe III six of these patients survived without any cerebra1 manifestations. Two others deveIoped hemipIegia but showed improvement at the time of evacuation. Thus, 66 per cent of the tweIve ligated patients survived reIativeIy sudden interruption of the common carotid bIood ffow on one side. One of the five unIigated patients was treated by primary anastomosis of the Iacerated artery, using the BIakemore nonsuture method.4 In this patient the time

VOL. LXXVI,

Lawrence

No. I

et aI.-Wounds

Iag from wounding to operation was onIy four and one-half hours but he was hemipIegic preoperativeIy. This condition persisted and he died with encephaIomaIacia on the nineteenth postoperative day. A second patient had onIy a tracheotomy and TABLE III RESULTS OF SURGICAL TREATMENT OF COMMON CAROTID WOUNDS (17 CASES)

Surgical

Procedure

Ligation (I2 cases). Anastomosis Suture of incomplete Iaceration. No surgery Thrombosis. . Hemorrhage, ._ Vertebra1 artery hemorrhage

Lived

Lived with Cerebra1 Signs

6

Died

2

4 I

. I

2 1 -__

__-_

7

TotaIs..

--2

8

died shortIy thereafter due to hemorrhage from a coincidenta wound of a vertebra1 artery before carotid Iigation couId be undertaken. In a third case the Iaceration invoIved onIy the outer Iayer of the carotid waI1 resuIting in a smaI1 aneurysm. The blood ffow was not interrupted and, of course, the patient did weI1. In two patients the common carotid became compIetely thrombosed, a Iesion which either deveIoped after operation or was unappreciated at that time. The cerebra1 invoIvement was fata in both cases. The series included one instance of acute A-V fistuIa, i.e., between the common carotid and interna juguIar vein. This was treated by quadrupIe Iigation two and one-half hours after wounding with resuItant recovery. The overa mortaIity of the seventeen patients with common carotid artery wounds during their forward hospita1 stays was 47. per cent. COMMENT

The mortaIity common carotid

rate for wounds of the artery in our smaI1 series

of Carotid

Arteries

American

~~~~~~~

of surgery33

of seventeen cases was 47 per cent. This was the case notwithstanding various advances in the care of the wounded in WorId War II, such as improved evacuation, exceIIent forward surgica1 hospita1 faciIities and the genera1 use of pIasma, bIood, suIfonamides and penicillin. It is impossibIe to compare these figures, of course, with the much Iower mortaIity rates reported by the British for WorId War I for the folIowing reason: EIeven of our seventeen patients received earIy emergency ligation of the artery, whereas in most of the cases in the British series the surgery, in&ding Iigation was deIayed and was performed onIy for estabIished aneurysms or arteriovenous fistuIas, for secondary hemorrhage or incidenta to surgery for infection or a foreign body. AIthough certain of our surgica1 teams were equipped to do BIakemore-non-suture anastomoses during the Iatter part of the European campaign, in onIy one of the cases of carotid injury reported was this actuaIIy performed. No other types of anastomoses were attempted, usually because too great a Iength of the vesse1 had been destroyed or the patient’s condition wouId not permit a proIonged operative procedure. Heparin was not avaiIabIe. It is worthy of re-emphasis that six patients with no hemipIegia or other significant cerebral symptoms preoperatively developed these compIications after Iigation. Serious hemorrhage constituted a positive indication for exposure of the carotid artery and its Iigation in several of our patients. In others, however, d&bridement of the neck wound was done as a routine procedure. The reactivation of hemorrhage as the carotid wound was exposed was not aIways anticipated and couId be controIIed onIy by immediate Iigation. No patient was treated conservativeIy by intention. The one patient in whom the arteria1 wound had plugged itseIf initiaIIy and the artery was not Iigated unti1 the eighteenth post-wound day for secondary hemorrhage, recovered without cerebra1 compIications, perhaps because

34

American

Journal

ofsurgery Lawrence

et aI.-Wounds

the coIIatera1 circmation had improved in the interva1. It wouId seem, therefore, that immediate Iigation of a common carotid artery is highly hazardous and is to be avoided whenever possibIe. SeveraI writers2’3s5 have argued for conservatism in the initia1 treatment of suspected or known wounds of major arteries if the bIeeding appears to have stopped, in the hope that sufficient bIood might continue to pass through the Iumen of the damaged vesse1 unti1 adequate coIIateraI circmation deveIoped. The appIication of this principIe was credited with considerabIe success in wounds of the common carotid (as we11 as other major arteries) during WorId War 1~7~ aIthough it is impossibIe to ascertain from these reports the extent of Ioss of Iife and Iimb consequent on the omission of ditbridement. It is bareIy possibIe that severa of the patients in our series (Cases IV, XII and XIV for exampIe) might have survived if handIed conservativeIy with Iigation onIy as required by compIications. One gathers, however, that most of the wounds in this series were more severe than the non-fata cases described in the British series aIone. UndoubtedIy, a higher percentage of the seriousIy wounded survived to reach forward and base hospitals in World War II than in the first worId war due to improvements in resuscitation and transport. These factors make comparisons dificuIt. OccasionaIIy a perforating wound of the neck, due to a buIIet or other high veIocity missiIe in which the danger of infection is much reduced, may prove suitable for conservative management. The handIing of suspected carotid wounds shouId be individuahzed with this possibihty in view. If hemipIegia or other cerebral signs are present preoperativeIy however, there probabIy is no point in conservative handhng. What IittIe chance of recovery remains to such a patient may be enhanced by making sure he has no further hemorrhage orgepsis factor to contend with. Despite the apparent attractiveness of

of Carotid

Arteries

JULY, 1948

conservative handring, we favor earIy debridement of neck wounds as a general policy because of the threat of serious infection and its compIications, in&ding uncontroIIabIe secondary hemorrhage, if such debridement is omitted. Although impossibIe to prove by available statistics, we think this radica1 poIicy wil1 save more lives if generaIIy foIIowed than wouId conservative management. One shouId, of course, constantIy bear in mind the possibiIity of injury to a carotid in any wound of the neck and be aIert for such teIItaIe puIsating signs as massive hemorrhage, hematoma and cerebra1 signs. Once such a lesion is suspected the patient should be operated upon as soon as possibIe by a team technicaIIy equipped to perform an anastomosis or other bIood vesse1 surgery as indicated. A good suppIy of bIood should be running into a vein. Heparin shouId be avaiIabIe f&r injection into the arteriaI Iumen and postoperative heparinization shouId be instituted if anastomosis is accompIished. RESTORATION

OF ARTERIAL

CONTINUITY

End-to-end arteria1 suture7 has Iong been recognized as a theoreticaIIy idea1 method for restoration of continuity in an interrupted major artery. This did not become a practica1 reaIity, however, unti1 Murray8 demonstrated the efficacy of heparin in the prevention of intravascmar cIotting, particularly at the suture Iine. Suture anastomosis of major arteries in experimenta1 animaIs and in eIective arteria1 surgery are quite different matters from the performance of similar operations in war wounds. It was our observation in World War II that Ioss of substance of an artery, as was frequently the case in such wounds, made it virtuaIIy impossible to approximate the ends for suturing. These patients often were in a critica condition despite resuscitative measures and were poor candidates for tedious operative procedures. Forward operating teams Iacked the time and faciIities when other casuaIties were pouring in for the painstaking

VOL. LXXVI.

No. I

Lawrence

et aI.-Wounds

dissection and meticuIous suturing necessary in a successfu1 suture anastomosis. In the particuIar case of the wounded common carotid artery it is obvious that the time factor is vitaI. Suture anastomosis of this artery requires compIete interruption of blood ffow through it by arteria1 cIamps or temporary ligature until the necessary mobilization of the arteria1 segments has been completed and the suture anastomosis performed, a matter of an hour or more in the most skiIIfu1 hands. This deprivation of bIood suppIy may be quite sufficient to cause irreparable and fata cerebra1 damage to a patient whose brain was stiI1 receiving a minimum necessary blood ffow through a damaged but not compIeteIy occluded vessel unti1 surgery was begun. The same limitations appIy ,to venous grafts for these were found to be diffrcuIt and too time-consuming whenever attempted during the war.9 SuccessfuI restoration of bIood ffow through a wounded carotid artery might then depend on some form of cannuIization or intubation which couId be accomplished in only a few minutes’ time and with minima1 mobiIizations of the vesseI ends. Tuffier’ performed many such cannuIizations of wounded major arteries of extremities during WorId War I, using siIver or glass tubes. The procedure usuaIIy was unsuccessfu1 because the tubes and adjacent vesse1 segments became occIuded by thrombosis in a short time. Murray and James” in 1940 reported a series of successfu1 arteria1 intubations with gIass cannuIas in dogs. They were able to prevent thrombosis and maintain circuIation for indefinite periods by adequate administration of heparin. They suggested IogicaIIy that such cannulization be empIoyed in arteria1 wounds during the current war as a temporary measure to maintain some blood flow to a part unti1 adequate coIIatera1 circulation had deveIoped or axial suture or vein graft couId be performed’ with greater chance of success. Blakemore, Lord and Stefko in I9424

of Carotid

Arteries

American ~~~~~~~ of surgery35

added the further refinement of a VitaIIium tube or tubes Iined with a segment of vein. They attributed their high percentage of successfu1 anastomoses in dogs, even without the aid of heparin, to avoidance of bacterial infection and of damage to the exposed intima of either the artery or the vein segment by their method of non-suture anastomosis. As indicated in the report of DeBakey and Sirnone,” the BIakemore anastomosis method proved too technicaIIy diffrcuIt and time-consuming in actua1 practice for wide appIication. In a smaI1 group of wounded major arteries anastomosed in this way there was onIy 50 per cent Iimb saIvage, no improvement over initia1 ligation in larger groups of simiIar cases. MustardI of the RoyaI Canadian Army MedicaI Corps has reported somewhat promising resuIts for immediate restoration of arteria1 continuity in actuaI war wounds. He adapted the method of temporary cannuIization pIus heparinization, as advocated by Murry and’Janes, to fifteen instances of war wounds of major periphera1 arteries. AIthough the percentage of Iimb salvage was Iow due in part to the time Iag between wounding and surgery and to infection, he found it possible to maintain the cannuIas patent and unthrombosed when heparinization was adequate. There was one common carotid wound in this group. AIthough the cannula was Ieft in place onIy eight hours and Iigation of the artery was done at that time, the patient recovered without cerebra1 diffrcuIties. In Mustard’s cases the wounds. were debrided as soon as possibIe after wounding. ImmediateIy on exposure of the wound in the artery he removed a11 accessibIe cIot and perfused the dista1 arteria1 tree with a soIution of heparin in physioIogic saIine. He then inserted a gIass or pIastic tube of suitable Iength and caIiber into the vesse1 ends to budge the defect or damaged segment and secured it with encircIing Iigatures. LocaI and genera1 heparinization was then instituted. Such an anastomosis was temporary, of course, for after severa

36

* mrrican Journal of Surgery

Lawrence

et al.-Wounds

days the vesseI ends wouId be cut through by the encircIing Iigatures. Before such an accident was caIcuIated to occur Mustard re-expIored the wound and performed an anastomosis by suture or vein graft, reinserted a new tube or, if the coIIatera1 circuIation seemed adequate, simply Iigated the vesseI. A temporary intubation anastomosis of this type may permit sufhcient bIood ffow to nourish the parts unti1 an adequate coIIatera1 circulation has deveIoped. Technica1 advantages of this procedure as an emergency measure over suture anastomosis or non-suture anastomosis of the BIakemore type are that it shouId require much Iess time, Iess technica ski11 and Iess mobiIization of the arteria1 segments with possibIe injury to coIIatera1 vesseIs, factors which have contributed to the disappointing resuIts of initia1 forma1 anastomosis for acute arteria1 injuries. Mustard demonstrated the feasibihty of carrying out this pIan of treatment, incIuding heparinization, in British forward miIitary hospitaIs. Two technica deveIopments which may prove usefu1 adjuncts to Mustard’s method of handIing major arteria1 wounds have been reported in recent months. These may be of particuIar vaIue in common carotid wounds. Jenkins13 has demonstrated the vaIue of wrapping pads of geIatin sponge reinforced by cuffs of fascia about injured or cannuIated major arteries to strengthen the IocaI segments and to inhibit secondary hemorrhage. It seems IikeIy that such a reinforcement couId be appIied quickIy about a cannuIated carotid artery. The other deveIopment reported by HufnageI’* is the successfu1 “permanent” intubation anastomosis of the thoracic aorta in dogs with highly polished tubes of a pIastic Iucite. For some unexplained reasons thrombosis did not take pIace in these tubes or in the adjacent arteria1 segments aIthough systemic anticoaguIants were not used. After experimentation HufnageI found that an especiaIIy braided DeknateI Iigature for tying the Iucite tube into the arteria1 ends avoided the

of Carotid

Arteries

JULY. 1948

usua1 necrosis of the arteria1 waI1 at this point and resuItant rupture of the anastomosis. A fibrous union deveIoped and the intubations became in effect permanent. This method might we11 be successfu1 in war wounds of the common carotid artery. These observations on war wounds involving the common carotid artery have an obvious bearing on peacetime wounds or injuries to this structure. Differences in the situation of the injured civiIian from that of the wounded soIdier such as the usua1 singIe wound of the civilian, the decreased IiabiIity to serious wound infection, the shorter time lag before definitive care and the abiIity to hold the patient at one point without necessary evacuation are a11 in favor of the injured civilian. Except for the singIe factor that the FiviIian may be oIder than the soIdier these advantages should resuIt in a Iower mortality rate for those with peacetime injuries. It is suggested, therefore, that arbitrary Iigation of the common carotid artery, often made necessary by circumstances in war casuaIties, be avoided whenever possibIe in peacetime injuries and that anastomoses of either the temporary or permanent type plus immediate heparinization be attempted more generaIIy. SUMMARY

A series of seventeen wounds invoIving the common carotid artery is reported from experiences in certain forward army hospitais during WorId War II. The artery was Iigated in tweIve patients and eight of these survived, with cerebra1 signs (transient hemipIegia) in 0nIy two cases. Of the five unIigated patients four died, two from arteria1 occIusion by thrombosis, one due to coincidenta hemorrhage from a severed vetebral artery and one foIIowing arteria1 anastomosis (BIakemore method). The overa mortaIity rate for this series was 47 Der cent.

Vol. I.XXVI,

No. ,

Lawrence

et al.- -Wounds

The authors prefer early dkbridement and direct attack on the arterial wound to conservative management of suspected common carotid wounds. Immediate ligation of this artery is highIy hazardous, however, and should be avoided whenever possible. Recent improvements in surgica1 methods for restoring bIood vessel continuity and the circuIation distaIly, notabIy by cannulization, may reduce the mortaIity rate somewhat and should be empIoyed. The unavoidabIe time lag before surgery under combat conditions and inherent inadequacies in cerebral coIIatera1 circuIation shown by many individuak, however, probabIy wiI1 maintain this rate at a reIativeIy high Ievel. REFERENCES

I. DECOSTA, JOHN C. Modern Surgery. 8th ed., p. 55 I. Philadelphia, Igrg. W. B. Saunders Co. 2. MAKINS, GEORGE H. On Gun Shot Injuries to the Blood Vessels. Baltimore igig. William Wood & co. 3. MACPHERSON, W. G. ET AL. History of the Great War: Medical Services. Surgery of the War. Vol. 2, p. 170. London, 1922. H. M. Stationery Offrce.

of Carotid 4.

6.

6.

7. 8. g.

Arteries

Amrrican ~~~~~~~~~ ,>fsurgery37

A. I I., Lonn, J. W. and STEFKO, P. I.. Restoration of blood Ilow in damaged arteries. Ann. Surg., 117: 481, 1943. \IASON-BROWN. J. J. A oIea for conservatism in the primary surgery of wounds of main arteries of the limbs. Proceedings of the Congress of Central Mediterranean Force Surgeons. Rome, Italy, February 1945. AledicaI Department of the United States Army in the WorId War. Vol. II. Washington, D. C., 1927. Government Printing Office. CARREL, A.2 MURRAY, D. W. G. Heparin in thrombosis and embolism. Brit. J. Surg., 27: 567-587, 1940. DEBAKEY, M. D. and SIMEONE, F. A. Battle injuries of the arteries in world war II. Ann. Surg., RLAKEMOKE,

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