Chapter 72: Chapter 72: Abdominal Vascular Abdominal Vascular

InjuriesInjuries

October 24, 2005October 24, 2005

Abdominal trauma zonesAbdominal trauma zones

Trauma algorithmsTrauma algorithms

Damage control proceduresDamage control procedures

Persistent attempts to reconstruct or Persistent attempts to reconstruct or repair all abdominal injuries may repair all abdominal injuries may result in increased mortalityresult in increased mortality

‘‘damage control’ approachdamage control’ approach– All complex venous injuries are ligatedAll complex venous injuries are ligated– Arterial injuries may be shuntedArterial injuries may be shunted– Any diffuse retroperitoneal or Any diffuse retroperitoneal or

parenchymal bleeding is controlled by parenchymal bleeding is controlled by tight gauze packingtight gauze packing

Abdominal compartment Abdominal compartment syndromesyndrome

Normal pressure resting supine is near zeroNormal pressure resting supine is near zero Elevation of pressure above 25 to 30 cm of water may Elevation of pressure above 25 to 30 cm of water may

cause severe organ dysfunctioncause severe organ dysfunction Abdominal compartment syndrome characterized byAbdominal compartment syndrome characterized by

– Tense abdomenTense abdomen– Tachycardia with or without hypotensionTachycardia with or without hypotension– Respiratory dysfunction with high peak inspiratory pressuresRespiratory dysfunction with high peak inspiratory pressures– OliguriaOliguria

Risk factorsRisk factors– Massive blood transfusionsMassive blood transfusions– Prolonged hypotensionProlonged hypotension– HypothermiaHypothermia– Aortic cross clampingAortic cross clamping– Damage control proceduresDamage control procedures– Tight closure of abdominal wallTight closure of abdominal wall

Abdominal compartment Abdominal compartment syndromesyndrome

High risk patients can be followed with High risk patients can be followed with clinical exam and serial bladder pressure clinical exam and serial bladder pressure measurementsmeasurements

Pressures greater than 30 indicate need Pressures greater than 30 indicate need for surgical decompression of abdomenfor surgical decompression of abdomen

Temporary abdominal wall closure can be Temporary abdominal wall closure can be performed with large dialysis bag or performed with large dialysis bag or synthetic meshsynthetic mesh

When bowel edema improves several days When bowel edema improves several days later the abdomen can be closedlater the abdomen can be closed

Abdominal aortic injuriesAbdominal aortic injuries

Blunt injury is rare 0.04% of all blunt Blunt injury is rare 0.04% of all blunt trauma admissionstrauma admissions– Intimal dissections and thrombosis most Intimal dissections and thrombosis most

common lesionscommon lesions Penetrating trauma more likelyPenetrating trauma more likely

– 2.7% of gunshot wounds to abdomen2.7% of gunshot wounds to abdomen– 1.5% of knife wounds to abdomen1.5% of knife wounds to abdomen– 21% of all abdominal vascular injuries, second 21% of all abdominal vascular injuries, second

most commonly injured vascular structuremost commonly injured vascular structure

Abdominal aortic injuriesAbdominal aortic injuries

Operative exposure Operative exposure by medial visceral by medial visceral rotationrotation

Celiac artery injuriesCeliac artery injuries

Rare, 302 cases of vascular injury, the Rare, 302 cases of vascular injury, the celiac artery was involved in 3.3% of casesceliac artery was involved in 3.3% of cases

Operative exposure through lesser sac or Operative exposure through lesser sac or medial visceral rotation, this does not medial visceral rotation, this does not need to include the left kidneyneed to include the left kidney

Ligation is tolerated well secondary to rich Ligation is tolerated well secondary to rich collateral blood supplycollateral blood supply

Mortality ranges from 38 to 75%, probably Mortality ranges from 38 to 75%, probably secondary other concominant injuriessecondary other concominant injuries

SMA injuriesSMA injuries

Zone 1 aortic origin Zone 1 aortic origin to inferior to inferior pancreaticoduodenpancreaticoduodenal arteryal artery

Zone 2 to the Zone 2 to the middle colic arterymiddle colic artery

Zone 3 distal to Zone 3 distal to middle colic arterymiddle colic artery

Zone 4 segmental Zone 4 segmental intestinal branchesintestinal branches

Ligation of SMA in Ligation of SMA in zones 1 and 2 zones 1 and 2 results in severe results in severe ischemia of small ischemia of small bowel and right bowel and right coloncolon

Ligation of SMA in Ligation of SMA in zones 3 and 4 may zones 3 and 4 may result in localized result in localized ischemiaischemia

SMA injuriesSMA injuries

Penetrating injuries are the most Penetrating injuries are the most common mechanism of injurycommon mechanism of injury

SMA injuries diagnosed in 0.09% of SMA injuries diagnosed in 0.09% of trauma admissions and account for trauma admissions and account for 10% of all abdominal vascular 10% of all abdominal vascular injuries, Asensio Am J Surg.injuries, Asensio Am J Surg.

Blunt trauma responsible for 10 to Blunt trauma responsible for 10 to 20% of these injuries20% of these injuries

SMA injuriesSMA injuries

Any hematoma injury involving bowel ischemia Any hematoma injury involving bowel ischemia should be exploredshould be explored

Author does not explore stable hematomas if the Author does not explore stable hematomas if the bowel is not compromised, they are followed post-bowel is not compromised, they are followed post-operatively by angiography or doppler ultrasoundoperatively by angiography or doppler ultrasound

Sharp partial transections can be managed by Sharp partial transections can be managed by lateral arteriorrhaphy in 40% of caseslateral arteriorrhaphy in 40% of cases

Mobilization of SMA made difficult by surrounding Mobilization of SMA made difficult by surrounding dense neuroganglionic tissue and multiple dense neuroganglionic tissue and multiple branches, thus end to end anastomosis rarely branches, thus end to end anastomosis rarely possiblepossible

Ligation of SMA below middle colic artery associated Ligation of SMA below middle colic artery associated with moderate risk of bowel ischemiawith moderate risk of bowel ischemia

SMA injuriesSMA injuries Ligation of SMA proximally only in Ligation of SMA proximally only in

the presence of necrotic bowel, the presence of necrotic bowel, otherwise may result in short bowel otherwise may result in short bowel syndromesyndrome

In critical ill patients with In critical ill patients with hypothermia, acidosis, and hypothermia, acidosis, and coagulopathy a damage control coagulopathy a damage control procedure with a temporary procedure with a temporary endoluminal shunt may be endoluminal shunt may be performedperformed

Later reconstruction may be Later reconstruction may be performed with saphenous vein or performed with saphenous vein or PTFE from the aorta, if there is any PTFE from the aorta, if there is any associated pancreatic injury all associated pancreatic injury all attempts should be made to keep attempts should be made to keep the anastomosis away from the the anastomosis away from the pancreas and should be protected pancreas and should be protected by omentum and soft tissueby omentum and soft tissue

Some authors mandate a second Some authors mandate a second look operation in 24 hours, others look operation in 24 hours, others look for persistent metabolic look for persistent metabolic acidosis despite adequate fluid acidosis despite adequate fluid hydrationhydration

SMA injuriesSMA injuries

Reported mortality with SMA injuries Reported mortality with SMA injuries varies from 33 to 68% in multiple varies from 33 to 68% in multiple seriesseries

This is difficult to assess as patient This is difficult to assess as patient typically have multiple other typically have multiple other associated injuriesassociated injuries

IMA injuriesIMA injuries

Rare and almost always due to Rare and almost always due to penetrating traumas, 1% of all penetrating traumas, 1% of all abdominal vascular injuriesabdominal vascular injuries

Ligation is well tolerated with no Ligation is well tolerated with no cases of colorectal ischemia have cases of colorectal ischemia have been reported in traumabeen reported in trauma

Iliac vascular injuriesIliac vascular injuries Low reported incidence from WW2, Korean war Low reported incidence from WW2, Korean war

and Vietnam war, 1.7 to 2.6%and Vietnam war, 1.7 to 2.6% Urban trauma centers report 10% of all Urban trauma centers report 10% of all

abdominal vascular injuries for both arteries and abdominal vascular injuries for both arteries and veinsveins

26% have combined injures26% have combined injures Penetrating trauma involves common iliac vesselsPenetrating trauma involves common iliac vessels Blunt usually involves branches of internal iliac Blunt usually involves branches of internal iliac

arteryartery– Also pelvic fractures can directly tear iliac vessels or Also pelvic fractures can directly tear iliac vessels or

result in stretching of the vessel resulting in intimal tear result in stretching of the vessel resulting in intimal tear and subsequent thrombosisand subsequent thrombosis

Iliac vascular injuriesIliac vascular injuries Blunt trauma explore ifBlunt trauma explore if

– Intraperitoneal leakIntraperitoneal leak– Expanding hematomaExpanding hematoma– Absent or dimished femoral pulseAbsent or dimished femoral pulse

Penetrating trauma should be exploredPenetrating trauma should be explored Ureter should be identified and protectedUreter should be identified and protected Avoid iatrogenic injuries to underlying veinAvoid iatrogenic injuries to underlying vein Isolation and control of internal iliac artery Isolation and control of internal iliac artery

important even proximal and distal control is important even proximal and distal control is presentpresent

If exposure is difficult an additional transverse If exposure is difficult an additional transverse lower abdominal incision or longitudinal groin lower abdominal incision or longitudinal groin incision can be madeincision can be made

Iliac vascular injuriesIliac vascular injuries Small arterial injuries can be repaired with 4-0 and Small arterial injuries can be repaired with 4-0 and

5-0 sutures5-0 sutures Venous or PTFE patch can be used to avoid Venous or PTFE patch can be used to avoid

stenosisstenosis With most gunshot wounds and blunt trauma, With most gunshot wounds and blunt trauma,

reconstruction by an end to end anastomosis can reconstruction by an end to end anastomosis can be undertaken size 6 to 8mmbe undertaken size 6 to 8mm– Balloon tipped catheter should be passed proximally and Balloon tipped catheter should be passed proximally and

distally to remove clotsdistally to remove clots– Author recommends local heparin, role for systemic Author recommends local heparin, role for systemic

heparin?heparin? Author suggests no significant role for Author suggests no significant role for

extraanatomic bypasses in traumaextraanatomic bypasses in trauma Burch (Trauma 1990) suggests that enteric Burch (Trauma 1990) suggests that enteric

spillage is not a contraindication to prosthetic graftspillage is not a contraindication to prosthetic graft

Iliac vascular injuriesIliac vascular injuries Ligation of the common or external iliacs a bad Ligation of the common or external iliacs a bad

choicechoice– Instead a temporary intraluminal shunt should be usedInstead a temporary intraluminal shunt should be used

Author believe transection of the right common Author believe transection of the right common iliac artery to gain better access to the iliac veins is iliac artery to gain better access to the iliac veins is “extreme and should rarely be considered.”“extreme and should rarely be considered.”– Instead careful mobilization and retraction of the artery Instead careful mobilization and retraction of the artery

should be performedshould be performed– Ligation and division of the internal iliac artery may also Ligation and division of the internal iliac artery may also

be helpfulbe helpful Ligation of an iliac vein is preferable to a repair Ligation of an iliac vein is preferable to a repair

that causes stenosis that can lead to thrombosis that causes stenosis that can lead to thrombosis and pulmonary embolismand pulmonary embolism– Role of filters in narrowed iliac veins yet to be determinedRole of filters in narrowed iliac veins yet to be determined– Patient tend to develop transient leg ischemiaPatient tend to develop transient leg ischemia

Iliac vascular injuriesIliac vascular injuries

Many patients develop compartment Many patients develop compartment syndrome of their extremities and require syndrome of their extremities and require fasciotomiesfasciotomies– Role of prophylactic fasciotomies controversialRole of prophylactic fasciotomies controversial– If fasciotomy is not performed, close clincal If fasciotomy is not performed, close clincal

examination and pressure measurements are examination and pressure measurements are warrantedwarranted

Mannitol may be useful to reduce effects Mannitol may be useful to reduce effects of reperfusion injury and inhibiting the of reperfusion injury and inhibiting the development of compartment syndromedevelopment of compartment syndrome

Renovascular injuriesRenovascular injuries 16% of all abdominal vascular injuries16% of all abdominal vascular injuries Left renal artery 1.3 to 1.6 times more likely Left renal artery 1.3 to 1.6 times more likely

to be injured than right renal artery, thought to be injured than right renal artery, thought to be due to its course underneath IVCto be due to its course underneath IVC

50% of cases of blunt arterial injury result in 50% of cases of blunt arterial injury result in intimal tears and subsequent arterial intimal tears and subsequent arterial thrombosisthrombosis

12% of cases involve avulsion12% of cases involve avulsion 9 to 14% of cases involve both arteries9 to 14% of cases involve both arteries When possible abdominal CT scan a very When possible abdominal CT scan a very

good diagnostic toolgood diagnostic tool

Renovascular injuriesRenovascular injuries For penetrating injuries generally reconstruction or For penetrating injuries generally reconstruction or

nephrectomy is performed depending on extent of injurynephrectomy is performed depending on extent of injury All zone 2 hematomas secondary to penetrating injury All zone 2 hematomas secondary to penetrating injury

should be exploredshould be explored Blunt trauma is very time dependentBlunt trauma is very time dependent

– Renal function severly affected after three hours of total Renal function severly affected after three hours of total ischemia and six hours after partial ischemiaischemia and six hours after partial ischemia

– More aggressive approaches to those with bilateral injuries or More aggressive approaches to those with bilateral injuries or those with injuries to a solitary kidney, some authors have those with injuries to a solitary kidney, some authors have attempted revascularization up to 20 hours after initial injuryattempted revascularization up to 20 hours after initial injury

Cumulative success of revascularization is 28% with Cumulative success of revascularization is 28% with subsequent hypertension developing in 12 to 58% of subsequent hypertension developing in 12 to 58% of patientspatients

32 to 40% of patient managed non-operatively develop 32 to 40% of patient managed non-operatively develop renovascular hypertensionrenovascular hypertension

Renovascular injuriesRenovascular injuries

Ligation of the left renal vein well Ligation of the left renal vein well tolerated near IVC because of tolerated near IVC because of drainage through left gonadal vein, drainage through left gonadal vein, left adrenal vein and lumbar veinsleft adrenal vein and lumbar veins

Ligation of the right renal vein should Ligation of the right renal vein should be followed by nephrectomybe followed by nephrectomy

Endovascular techniques useful to Endovascular techniques useful to treat selected cases of intimal tears, treat selected cases of intimal tears, false aneurysms, and AV fistulasfalse aneurysms, and AV fistulas

IVC injuriesIVC injuries Most commonly injured abdominal vessel Most commonly injured abdominal vessel

accounting for 25% of all injuriesaccounting for 25% of all injuries– Blunt trauma account for 10% of these injuries and Blunt trauma account for 10% of these injuries and

typically retrohepatictypically retrohepatic– With penetrating injuries also 18% of patients have With penetrating injuries also 18% of patients have

associated aortic injuryassociated aortic injury All hematomas secondary to penetrating trauma All hematomas secondary to penetrating trauma

should be explored, except for stable retrohepatic should be explored, except for stable retrohepatic hematomashematomas– Infrarenal/juxtarenal IVC best exposed by medial rotation Infrarenal/juxtarenal IVC best exposed by medial rotation

of the right colon, hepatic flexure of colon, and duodenumof the right colon, hepatic flexure of colon, and duodenum– Exposure of retrohepatic IVC by dividing ligaments, Exposure of retrohepatic IVC by dividing ligaments,

extending incision to include right subcostalextending incision to include right subcostal– Median sternotomy if atriocaval shunt is plannedMedian sternotomy if atriocaval shunt is planned

IVC injuriesIVC injuries Hepatic vascular Hepatic vascular

isolationisolation– Cross clamping Cross clamping

infradiagphragmatic infradiagphragmatic aorta, suprahepatic IVC, aorta, suprahepatic IVC, infrahepatic IVC above infrahepatic IVC above renals, and portal triadrenals, and portal triad

– Failure to clamp aorta Failure to clamp aorta first may result in severe first may result in severe hypotension and then hypotension and then cardiac arrest due to cardiac arrest due to reduced venous returnreduced venous return

Atriocaval shuntAtriocaval shunt– Typically with poor Typically with poor

results but some case results but some case reports describe some reports describe some successessuccesses

IVC injuriesIVC injuries Liver can be divided along gallbladder IVC plane to provide Liver can be divided along gallbladder IVC plane to provide

direct exposuredirect exposure Most IVC injuries repaired with 3-0/4-0 proleneMost IVC injuries repaired with 3-0/4-0 prolene Cava can be rotated to expose posterior injuriesCava can be rotated to expose posterior injuries With anterior and posterior injuries, the posterior injury can With anterior and posterior injuries, the posterior injury can

be repaired through the anterior injury (can also be be repaired through the anterior injury (can also be lenghtened)lenghtened)

Ligation can be considered above the renal veins in very Ligation can be considered above the renal veins in very unstable patients or those with significant stenosis after unstable patients or those with significant stenosis after repairrepair– Post-op patient should have lower extremities wrapped in firm Post-op patient should have lower extremities wrapped in firm

elastic bandages and elevated, edema usually subsides in elastic bandages and elevated, edema usually subsides in several weeksseveral weeks

– Patients may develop compartment syndrome and require Patients may develop compartment syndrome and require fasciotomiesfasciotomies

IVC injuriesIVC injuries

MortalityMortality– Half of patients with IVC injuries die before Half of patients with IVC injuries die before

reaching the hospitalreaching the hospital– Those reaching the hospital have reported Those reaching the hospital have reported

survival rates of 20 to 57%survival rates of 20 to 57%– Kuene (Am Surg, 1999) reported an overall Kuene (Am Surg, 1999) reported an overall

mortality of 52%, the mortality decreased to mortality of 52%, the mortality decreased to 35% if the patient reached the operating 35% if the patient reached the operating roomroom Associated higher mortality with suprarenal Associated higher mortality with suprarenal

injuriesinjuries

Portal vein system injuriesPortal vein system injuries

Injury is very rare, about 1% of those Injury is very rare, about 1% of those patients undergoing laparotomy for patients undergoing laparotomy for traumatrauma

About 5% of abdominal vascular injuriesAbout 5% of abdominal vascular injuries SMV injuries about 11% and splenic vein SMV injuries about 11% and splenic vein

about 4% of abdominal vascular injuriesabout 4% of abdominal vascular injuries Majority of portal vein injuries secondary Majority of portal vein injuries secondary

to penetrating trauma 90%to penetrating trauma 90% Associated vascular injuries reported to Associated vascular injuries reported to

be high, 70 to 90% due to anatomybe high, 70 to 90% due to anatomy

Portal vein system injuriesPortal vein system injuries Blunt trauma usually Blunt trauma usually

involves SMV and direct involves SMV and direct blow to abdomen or blow to abdomen or deceleration forcesdeceleration forces– Results in thrombosis of Results in thrombosis of

vessels and sometimes vessels and sometimes avulsion and bleedingavulsion and bleeding

– With isolated thrombosis, With isolated thrombosis, diagnosis made on CT diagnosis made on CT scanscan

Stapled division of the Stapled division of the pancreatic neck should be pancreatic neck should be considered earlyconsidered early

Suprapancreatic portal Suprapancreatic portal vein exposure by medial vein exposure by medial rotation of right colon and rotation of right colon and hepatic flexure and a hepatic flexure and a Kocher maneuverKocher maneuver

Portal vein system injuriesPortal vein system injuries Portal vein injuries should be repaired with lateral Portal vein injuries should be repaired with lateral

venorrhaphyvenorrhaphy– Complex reconstructions often fail and only undertaken if Complex reconstructions often fail and only undertaken if

hepatic artery is outhepatic artery is out– Ligation of both hepatic artery and portal vein is not compatible Ligation of both hepatic artery and portal vein is not compatible

with life, in this case reconstruction of the portal vein should be with life, in this case reconstruction of the portal vein should be undertaken with saphenous veinundertaken with saphenous vein

– Ligation of the portal vein with an open hepatic artery survival Ligation of the portal vein with an open hepatic artery survival ranges from 55 to 85%ranges from 55 to 85%

Patients with ligated SMV or portal veins will need further Patients with ligated SMV or portal veins will need further attentionattention– Bowel will become massively edematous resulting in abdominal Bowel will become massively edematous resulting in abdominal

compartment syndrome, thus the abdomen should not be closedcompartment syndrome, thus the abdomen should not be closed– Can develop patch bowel wall necrosis and a re-look operation Can develop patch bowel wall necrosis and a re-look operation

should be performed in 48 to 72 hoursshould be performed in 48 to 72 hours– Patients require massive fluid replacementPatients require massive fluid replacement– Long term evidence is limited but survivors do not develop portal Long term evidence is limited but survivors do not develop portal

hypertensionhypertension

Portal vein system injuriesPortal vein system injuries

Mortality is high and ranges between Mortality is high and ranges between 50% to 72%50% to 72%

AdvancesAdvances

Introduction of the policy of scoop and Introduction of the policy of scoop and run in addition to early surgical control run in addition to early surgical control of bleeding is now standard of careof bleeding is now standard of care

Concept of damage controlConcept of damage control Recognition of abdominal compartment Recognition of abdominal compartment

syndrome and use of temporary syndrome and use of temporary prostheticprosthetic

Endovascular techniques to specific Endovascular techniques to specific vascular occlusions, av fistulas and vascular occlusions, av fistulas and false aneurysmsfalse aneurysms