Abdominal Vascular Trauma Research Articles

Intra-abdominal vascular injuries after blunt abdominal trauma

Vascular injuries and hemorrhaging are serious potential complications in the management of patients with blunt abdominal trauma. The treatment depends on the extent and localization and can range from surveillance to endovascular treatment up to open surgery. The keys to success include the focused assessment with sonography for trauma (FAST) management and timely decision making. Abdominal vascular trauma continues to be adifficult problem and open and endovascular techniques continue to evolve in order to address this complex disease process.

Endovascular Balloon Occlusion of the Inferior Vena Cava in Trauma: A Single-Center Case Series.

Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries-4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open-endovascular operative techniques in abdominal vascular trauma.

Damage control in abdominal vascular trauma.

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries.

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma.

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa

BackgroundThe optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death.MethodsProspective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications.ResultsOne-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35–60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications (p = 0.074).ConclusionSurgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

Intraabdominal Vascular Injuries in Blunt Trauma: Spectrum of Presentation, Severity and Management Options

Purpose of Review Blunt abdominal vascular injury is rare, hard to diagnose and there is little consensus as to what constitutes best management. This review was undertaken to assess how blunt abdominal vascular trauma management has changed over last few years and what new therapies have been reported.

Abdominal vascular trauma.

Abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. However, when it does occur, it can be quite lethal, with mortality ranging from 20% to 60%. Increased early mortality has been associated with shock, acidosis, hypothermia, coagulopathy, free intraperitoneal bleeding and advanced American Association for the Surgery of Trauma Organ Injury Scale grade. These patients often arrive at medical centers in extremis and require rapid surgical control of bleeding and aggressive resuscitation including massive transfusion protocols. The most important factor in survival is surgical control of hemorrhage and restoration of appropriate perfusion to the abdominal contents and lower extremities. These surgical approaches and the techniques of definitive vascular repair can be quite challenging, particularly to the inexperienced surgeon. This review hopes to describe the most common abdominal vascular injuries, their presentation, outcomes, and surgical techniques to control and repair such injuries.

Abdominal vascular trauma in 760 severely injured patients

The relevance of abdominal vascular injuries in polytraumatic patients within a large collective has not yet been thoroughly analyzed. This study aimed at assessing the prevalence of traumatic injuries in relation to outcome and currently established treatment options. 51,425 patients from the Trauma Registry of the German Society of Trauma Surgery (TR DGU) (1993-2009) were analyzed retrospectively. All patients who had an Injury Severity Score (ISS) of ≥16, were directly admitted to a trauma center and subsequently received treatment for at least threedays, were ≥16years old, and had an abdominal injury (AISabdomen ≥2) were included. Patients with abdominal trauma (AISabdomen ≥2) were compared with patients with additional vascular trauma (AISvascular 2-5). 10,530 (20.5%) of the 51,425 patients had documented abdominal injury. 760 (7.2%) of the patients with abdominal injury additionally showed abdominal vascular injury (AISabdomen ≥2, AISvascular 2-5) and were analyzed based on the classification of the American Association for the Surgery of Trauma (AAST) organ severity score (AAST vascular injury grade: II, 2.4%; III, 2.7%; IV, 1.8%; V, 0.2%. Patients with high-grade abdominal vascular injury (grades IV and V) showed a significant increase in mortality (IV, 44.6%; V, 60%) and consequently a decrease in the need for surgical intervention (IV, 67.4%; V, 64%). The results presented here show the prevalence and outcome of abdominal vascular injuries in a large collective within the TR DGU for the first time. Based on the current literature and these findings, a treatment algorithm has been developed.

The Double Jeopardy of Blunt Thoracoabdominal Trauma

To examine the specific injuries, need for operative intervention, and clinical outcomes of patients with blunt thoracoabdominal trauma. Trauma registry and medical record review. Level I trauma center in Los Angeles, California. All patients with thoracoabdominal injuries from January 1996 to December 2010. Injuries, incidence and type of operative intervention, clinical outcomes, and risk factors for mortality. Blunt thoracoabdominal injury occurred in 1661 patients. Overall, 474 (28.5%) required laparotomy, 31 (1.9%) required thoracotomy (excluding resuscitative thoracotomy), and 1146 (69.0%) required no thoracic or abdominal operation. Overall incidence of intraabdominal solid organ injury was 59.7% and hollow viscus injury, 6.0%. Blunt cardiac trauma occurred in 6.3%; major thoracic vessel injury, in 4.6%; and diaphragmatic trauma, in 6.0%. The majority of solid organ injuries were managed nonoperatively (liver, 83.9%; spleen, 68.3%; and kidney, 91.2%). Excluding patients with severe head trauma, mortality ranged from 4.5% with nonoperative management to 18.1% and 66.7% in those requiring laparotomy and dual cavitary exploration, respectively. Age 55 years or older, Injury Severity Score of 25 or more, Glasgow Coma Scale score of 8 or less, initial hypotension, massive transfusion, and liver, cardiac, or abdominal vascular trauma were all independent risk factors for mortality. Most patients with blunt thoracoabdominal trauma are managed nonoperatively. The need for non-resuscitative thoracotomy or combined thoracoabdominal operation is rare. The abdomen contains the overwhelming majority of injuries requiring operative intervention and should be the initial cavity of exploration in the patient requiring emergent surgery without directive radiologic data.

Trauma vascular abdominal: tipo de lesiones vasculares hospital de Kennedy 2002-2007

Introducción: las lesiones vasculares abdominales son difíciles y desafiantes. Ejemplifican el círculo vicioso letal de choque, acidosis, hipotermia, coagulopatía y arritmias cardíacas. El objetivo del estudio es describir la fre­cuencia y las características epidemiológicas de los casos manejados en el Hospital Occidente de Kennedy en los últimos cinco años. Materialesy métodos: se evaluaron 150 historias clínicas de pacientes atendidos entre enero 2002 y diciembre 2007 con diagnóstico principal de trauma vascular abdominal. Se excluyeron aquellas sin ade­ cuado registro de las variables a estudio. Resultados: los hombres fueron más afectados (85,3%) y el promedio de edad 28.9 años. El principal método para identificar la lesión fue abdomen agudo (112 casos, 74,6%). Como mecanismo más común de trauma se observó el abierto, por proyectil de arma de fuego (80 casos, 53,3%). Las lesiones más frecuentes corresponden a grado m (86), la visceral asociada fue de intestino delgado (28, 18,6%). En todos se realizó laparotomía y en 22 (15%) toracotomía. Como reparación más utilizada se hizo sutura pri­ maria (104, 69,3%). La principal complicación fue sepsis (14, 9,3%). La mortalidad fue de 64 casos (42,6%). Las lesiones más asociadas con mortalidad ocurrieron en aorta, cava infrarrenal y retrohepática, porta y vasos mesentéricos e ilíacos. La muerte en seis pacientes se debió a sepsis de origen abdominal. Recuperación clínica: 86 sobrevivieron; de veinte con abdomen abierto diez (6,6%) tuvieron evolución favorable y después se les realizó eventrorrafia con malla; 46 se recuperaron en el posoperatorio inmediato con salida temprana (tipos I-m. A los restantes se manejaron las complicaciones con amputación en cuatro casos, además de fístula intestinal y anti­ bióticos en heridas infectadas. Conclusiones: el adecuado abordaje y control de las lesiones vasculares permiten manejarlas con procedimientos simples como la sutura lateral. Las tres lesiones vasculares mayores con alta tasa de mortalidad son en aorta, cava y porta. Se debe considerar para el pronóstico la isquemia, mecanismo de lesión, alteraciones asociadas, enfermedad vascular crónica y presentación clínica.

Effect of damage control surgery on major abdominal vascular trauma

BackgroundIn 1982, we reported our experience with abdominal vascular trauma, highlighting the critical role of hypothermia, acidosis, and coagulopathy. Damage control surgery was subsequently introduced to address this “lethal triad.” The purpose of the present study was to evaluate the outcomes from our most recent 6-year experience compared with a cohort from 30 years ago. MethodsPatients with major abdominal vascular injuries were examined, and the most recent 6-year period was compared with archived data from a similar 6-year period three decades ago. ResultsThe number of patients with major abdominal vascular injuries decreased from 123 patients in 1975 to 1980 to 64 patients in 2004 to 2009. The mean initial pH decreased from 7.21 to 6.96 (1975 to 1980 versus 2004 to 2009) for patients with overt coagulopathy. Despite increasingly protracted acidosis, mortality attributable to refractory coagulopathy decreased from 46% to 19% (1975 to 1980 versus 2004 to 2009, chi-square = 4.36, P = 0.04). No significant difference was found in mortality from exsanguinating injuries (43% versus 62%, 1975 to 1980 versus 2004 to 2009, chi-square = 1.96, P = 0.16). The prehospital transport times were unchanged (22 versus 20 min, 1975 to 1980 versus 2004 to 2009). Despite the administration of additional clotting factors and the advent of damage control surgery, the overall mortality remained largely unchanged (37% versus 33%, 1975 to 1980 versus 2004 to 2009, chi-square = 0.385, P = 0.53). ConclusionsThe adoption of damage control surgery, including the implementation of a massive transfusion protocol, was associated with a reduction in mortality for abdominal vascular injuries due to coagulopathy; however, patients have continued to die of exsanguination.

The Impact of Damage Control on Major Abdominal Vascular Trauma

The Impact of Damage Control on Major Abdominal Vascular Trauma

Bullet embolization to the external iliac artery after gunshot injury to the abdominal aorta: a case report

IntroductionAbdominal vascular trauma is fairly common in modern civilian life and is a highly lethal injury. However, if the projectile is small enough, if its energy is diminished when passing through the tissue and if the arterial system is elastic enough, the entry wound into the artery may close without exsanguination and therefore may not be fatal. A projectile captured may even travel downstream until it is arrested by the smaller distal vasculature. The occurrence of this phenomenon is rare and was first described by Trimble in 1968.Case presentationHere we present a case of a 29-year-old Albanian man who, due to a gunshot injury to the back, suffered fracture of his twelfth thoracic and first lumbar vertebra, injury to the posterior wall of his abdominal aorta and then bullet embolism to his left external iliac artery. It is interesting that the signs of distal ischemia developed several hours after the exploratory surgery, raising the possibility that the bullet migrated in the interim or that there was a failure to recognize it during the exploratory surgery.ConclusionIn all cases where there is a gunshot injury to the abdomen or chest without an exit wound and with no projectile in the area, there should be a high index of suspicion for possible bullet embolism, particularly in the presence of the distal ischemia.

Splenic Vein Turndown Repair in Superior Mesenteric Vein Trauma: A Reasonable Alternative

To determine previous experience and results of autologous splenic vein graft repairs in traumatic superior mesenteric vein (SMV) avulsions. Systemic review was conducted for SMV trauma and methods of repair between 1897 and 2010. Articles were further analyzed for use of the splenic vein as an alternative conduit and were included in this study. Of the 56 articles identified during our search, 4 included use of the splenic vein as an autologous vein graft. A total of 5 cases using the splenic vein turndown repair were identified in addition to our case. Of the 6 patients, 4 survived. Only one other case exists regarding the successful use of the splenic vein turndown technique in blunt abdominal trauma. There is little information regarding the feasibility and success of this technique in traumatic SMV disruption. Future studies are required to assess its role in abdominal vascular trauma.

Factors Associated with Mortality in Patients with Penetrating Abdominal Vascular Trauma

Objective. Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries. Methods. Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality. Results. Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 ± 3.6 min, while TT was 31.8 ± 7.1 min. For ED parameters, initial BP was 94.8 ± 6.4 mm Hg and initial heart rate was 109 ± 7 beats per minute. Mean operative EBL for all patients was 3518 ± 433 ml. The mean BD for all patients was −12.9 ± 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD ( P < 0.0001), BP ( P = 0.0062) and EBL ( P = 0.0002). MANOVA revealed that only base deficit ( P < 0.0001) had an independent effect on mortality. Conclusions. In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.

Diagnosis and management of thoracic and abdominal vascular injuries

Thoracic and abdominal vascular injuries present a formidable challenge to the most experienced surgeon. As prehospital care improves, more patients with these injuries are reaching the hospital alive. Thus, the trauma surgeon must be prepared to deal with them rapidly and precisely. Hemodynamically unstable patients should be transferred directly to the operating room. In stable patients with penetrating thoracic wounds, chest X-ray and arteriography are typically employed to exclude vascular injury. Patients sustaining blunt chest trauma can be screened effectively with CT scanning. Incisions are chosen based on the injured vessel. Hemorrhagic shock is the usual presentation for abdominal vascular trauma. A high index of suspicion is critical in diagnosing occult injuries. This presentation reviews the etiology, diagnosis, and treatment of major thoracic and abdominal vascular injuries.

155 vascular injuries: a retrospective study in Kuwait, 1992-2000.

To audit the management of vascular trauma in Kuwait, 1992-2000. Retrospective open study. Vascular surgery unit, teaching hospital, Kuwait. 155 patients with vascular injuries, most of which (n = 118) involved the extremities. 21 had neck injuries, 10 abdominal, and 6 chest. Revascularisation usually using the long saphenous vein in addition to direct repair or end-to-end anastomosis. Morbidity (amputation) and mortality. Four lower limb grafts failed, two of which (2/69, 3%) required amputation. Overall, four patients died (3%), one of pulmonary embolism and 3 of severe injuries to major abdominal vessels. 3/10 patients with abdominal vascular trauma died. Mean (SD) follow up period was 4.4 (2) years. Civilian violence has increased in Kuwait. Vascular trauma to abdominal vessels is associated with high mortality. Autogenous saphenous vein forms an excellent conduit for revascularisation.

Results with Abdominal Vascular Trauma in the Modern Era

This is a report of a 10-year experience (1989-1998) with 300 consecutive patients found to have an injury to a named abdominal vessel at the time of an exploratory laparotomy for trauma. An abdominal gunshot wound was the mechanism of injury in 78 per cent of patients, and injury to more than one named abdominal vessel was present in 42 per cent. The abdominal aorta, inferior vena cava, and external iliac artery and vein were the most commonly injured vessels. When management for the five most commonly injured arteries was grouped, exsanguination before attempts at repair occurred in 11 to 15 per cent of patients and the mean survival in the remainder was 46 per cent. When management for the five most commonly injured veins was grouped, exsanguination before attempts at repair occurred in 5 per cent of patients and the mean survival in the remainder was 64 per cent. A number of administrative and medical changes in the management of patients with abdominal trauma occurred from 1992 through 1994. Despite significantly increased Injury Severity Scores for patients treated from 1993 through 1998 as compared with those treated from 1989 through 1992 survival rates for patients with injuries to the abdominal aorta and inferior vena cava were unchanged. Survival rates for injuries to the external iliac artery and vein increased significantly. The local changes in management should be considered for prospective studies in other urban trauma centers.

Blunt thoracic and abdominal vascular trauma and organ injury caused by road traffic accident.

To analyse the relationship between vascular trauma and associated injuries to intra-thoracic and abdominal organs caused by traffic accidents. Design retrospective study in a university hospital. We investigated 458 consecutive patients who were admitted with blunt thoracic and/or abdominal trauma caused by road traffic accidents between 1986 and 1999. Vascular trauma was encountered in 54 patients (12%). The injured vessels were located in the abdomen in 45 patients and in the chest in nine patients. Mesenteric vessels were the most frequently injured vessels (33/45) in the abdomen, while the aorta and major vessels were most frequently injured (9/9) in the chest. Injury to the large/small intestine was often associated with mesenteric vessel injury (26/27). In the 190 patients with blunt abdominal organ injury, the frequency of mesenteric vessel injury was also highest, regardless of the injured organ. Vascular reconstruction was necessary only in one of 51 patients who underwent operation. Our results demonstrate that the mesenteric vessels are susceptible to blunt thoracic and abdominal trauma in road traffic accidents. Vascular reconstruction may be indicated for selected patients as long as the injuries to hollow organs are assessed carefully because of their strong association with vascular injury.