Traumatic Vascular Disruption in the Thoracocervical Region: Surgical Outcome and Predictors of Survival

Abstract

Traumatic vascular injury in the thoracocervical region is associated with significant morbidity and mortality. The goal of this study was to examine surgical outcome of these injuries and to establish predictors of survival. The medical records of all patients sustaining traumatic injury to the carotid, vertebral, subclavian, and proximal axillary vessels and undergoing operative repair were retrospectively reviewed. Sixteen patients (11 men, 5 women, mean age 31.1 ±16.6) during a four-year period underwent emergent surgical repair for traumatic vascular disruption. There were 6 lesions of the carotid, 7 of the subclavian, and 2 of the proximal axillary vessels and 1 vertebral artery injury. Sixty- two percent of the patients were hemodynamically unstable on admission. In these patients the diagnosis was established by clinical examination. Hemodynamically stable patients with a high index of suspicion for vascular injury underwent urgent arteriog raphy to confirm the diagnosis and assist in the operative approach. Surgical procedures included lateral arteriorrhaphy (2), end-to-end anastomoses (2), synthetic interposition grafts (3), and autogenous vein graft (2). Seven patients underwent emergent ligation of the subclavian, carotid, or vertebral artery. Despite 3 of 16 patients presenting in either unresponsive shock or with severe head trauma, overall mortality was 25%. Nonsurvivors had significantly higher injury severity scores than survivors (36.3 ±13.1 vs 19.8 ±7.9, P < 0.05). Length of time from trauma scene to hospital was a significant predictor of survival (33.4 ± 13.3 vs 50.8 ±6.5 minutes) as was the presence of associated organ system injury (2.8 ±0.9 organ systems vs 4.3 ±0.9, P < 0.05) in survivors and nonsur vivors, respectively. No neurologic compromise or limb ischemia was noted in the group undergoing arterial ligation. Among similarly injured vessels, the type of surgical repair did not influence patient survival. The outcome of surgical repair of a traumatic lesion of the thoracocervical vessels depends upon the rapid recognition of the injury, time delay to the trauma unit, and the magnitude of associated injury.