Double trouble! penetrating injury to the internal carotid artery and internal jugular vein repaired with non-reversed saphenous vein interposition graft: A case report

Abstract

IntroductionVascular injury occurs in 6–20 % of penetrating neck trauma and is associated with high rates of morbidity and mortality. Stroke secondary to carotid dissection and/or thromboembolism can have devastating consequences and arterial reconstruction to maintain cerebral perfusion is preferrable to ligation. We describe the management of a single stab injury to Zone III of the neck causing a combined arterial-venous injury. Case detailsA 32-year-old man on Rivaroxaban for an unprovoked pulmonary embolism presented in Class III haemorrhagic shock with a single stab wound to the apex of the anterior triangle of the neck. He was alert and neurologically intact on arrival with hard signs of vascular injury. CT-Angiography identified a large pseudoaneurysm of the ICA, sternocleidomastoid haematoma and an arteriovenous fistula. After initial deliberation about a temporising endovascular approach, the patient was taken to theatre for neck exploration. The transected internal jugular vein was ligated and the internal carotid artery was repaired with a non-reversed interposition saphenous vein graft. The patient had a perioperative stroke in watershed territory, likely secondary to hypotension and vasospasm, but was discharged two weeks post-operatively with no deficits. DiscussionThis rare injury requires an individualised approach and both open and endovascular techniques can be considered. As the carotid was transected, we feared a wire passed antegrade across the defect may become extraluminal, and opted for open repair. Considering this patient's young age, underlying prothrombotic tendency and the contaminated operating field, we decided autologous vein would be preferable to a synthetic conduit for reconstruction.