Abdomnial Vascular Injuries

Sameer Ahmed Mohialdeen,Nawfal Kamel Khiro Salih,Abbas Jaafar Alanbari
Authors Emails are requested on demand or by logging in
Keywords : Aorta,Vena cava, Common iliac, Hemorrhage,Mortality, Penetrating
Medical Journal of Babylon  13:1 , 2016 doi:1812-156X-13-1
Published :15 April 2016

Abstract

This study a review of 64-patients with abdominal vascular injuries from January 2007 to December 2013.Where treated in the emergency department of the cardiothoracic and vascular surgery. Most of them young age 18-50years,average age(32years).Male 46-patients,female 18-patients.Penetrating injuries (45-cases 70.2%),blunt injury (3-cases 4.8%), accidental (16-cases 25%).Penetrating injuries(blast/shell injury 30-cases,gunshot 12-cases, stab wound 3-cases).Zone I (44-cases),zone II(4-cases), zone III (16-cases).According to organ injury scale Grade IV most common(38-patients 59.37%). Aortic artery injury 28-cases. Inferior vena cava(8-cases) combined injury with aorta (20-cases),renal artery(4),splenic artery(2),celiac trunk (6),left common iliac artery (3),external and internal iliac arteries (13). Small bowel injuries (12-cases),large bowel(6),spleen(2),renal(4),liver(8),ureter, bladder (7). Ligation(19-cases 29.68%),direct repair or by graft (49-cases 76.56%).Complication ongoing bleeding 7.81%, respiratory distress 15..62%, wound dehiscence 9.37%. Mortality rate (12) 18.75%, survival rate(52) 81.25%.Coagulopathy, metabolic acidosis, hypothermia,combined vascular injuries ,and associated abdominal organs injuries increase the morbidity and mortality rates. Trauma surgeon should had a back-ground of the abdominal vascular anatomy ,and the methods of the vascular anastomosis. Primary goal control of the bleeding rather than maintenance of the blood flow to the organs.

Introduction

Penetrating abdominal trauma more seen in the war injury today with injuries of the abdominal cavity by a gunshot ,shell injury, or stab wound. The management of penetrating abdominal trauma has greatly changed over the last century. Before World War I, penetrating trauma was treated by expectantly, and was most of them are fatal. Celiotomy became the treatment of choice during World War I ,but mortality remained high. By World War II, early Celiotomy resulted increase in a survival rate close 50% [1]. The 1950s the facility available of faster transport ,knowledge of the fluid ,and antibiotics, which further increased survival rates. By the late 1950s,mandatory Celiotomy was the rule for the management of the patients with abdominal penetrating trauma [1]. In 1960s.Shaftan suggested a new guide line in patient management. Resuscitation protocols reflect the impact of appropriate crystalloid administration, the blood transfusion, and an understanding for physiologic end points of resuscitation. Damage control surgery (abbreviated laparotomy with physiologic resuscitation in the intensive care unit and staged abdominal reconstruction). More recently, the damage control concept has been also involved the resuscitation of severely injured patients with significant hemorrhage. Termed damage control resuscitation or hemostatic resuscitation, this approach arose from the recognition of early coagulopathy of trauma and its importance [2]. Damage control resuscitation principles include early given of massive blood transfusion protocols with fixed blood product ratios, and avoidance of given a large-volume crystalloid fluids, and appropriate use of permissive hypotension. Technologies help us to be less invasive and more rapid and specific diagnostic evaluations. Selective operative management and increasing application of angioembolization have served to further reduce surgical intervention [2]. Injuries to major abdominal vessels are uncommon but highly lethal vascular crises ,these injuries are also among the most difficult and challenging injuries managed by modern-day trauma surgeon. These patients usually arrive at trauma centers in sever shock secondary to massive blood loss that often unrelenting.Patients sustaining abdominal vascular injuries best exemplify that vicious cycle of the cardiac dysrhythmias, coagulopathy, shock, and acidosis [3]. Many of these patients had some state of cardiac arrest and require drastic life saving measures, such as emergency department, thoracotomy, aortic cross clamping and open cardiopulmonary resuscitation to maximize any chance of reaching an operating room alive[4,5,6]. The surgeon was advised to be guided in critical intraoperative decision making by location of the hematoma and specific maneuvers and techniques that are critical in expeditiously managing these complicated problem [7]. The surgeon must immediately perform three tasks during Celiotomy to avert exsanguinating hemorrhage within abdomen[8].Location of the vessels or vessels injured is identified. Surgical exposure of injured vessels is achieved, hemostasis and restoration of the critical blood flow are accomplished. Bleeding arteries or veins can either repaired or ligated; the surgeon s decision is made for the immediate hemostasis compared with risks of ischemia of the organs. Repairs of the vessels in a field contaminated with enteric contents complicated the decisions regarding the optimal replacement conduit. Increasing emphasis in the recent literature is placed on staged approach to the patients with severe intraabdominal injuries. In the initial operation, the goals are control hemorrhage and reestablish critically required reperfusion of the viscera. Surgery is then stopped after packing the abdomen . The patient is transfer to the intensive care unit, where hours may require to reverse coagulopathy,hypothermia,and acidosis before the patient is returned back to the operating room for repair and management of additional injuries [9,10]. Although penetrating injuries more we seen, but the surgeons must be familial with patterns of the blunt trauma, mediated injury to avoid devastating consequences of delayed management [11]. Endovascular solutions appear appropriate and preferred in certain cases of blunt abdominal aortic injury,which,however,may not be applicable due to device limitation in regard to patient anatomy and limited operating room capability. However, endovascular therapy can be pursued with limited fluoroscopy capability and consumable availability providing a solution that is expeditious and effective for select cases of blunt aortic injury [12]. The abdominal blood vessels by location of the retroperitoneal and anatomic proximity to the other organs, seem to be rarely injured alone. Multiple associated injuries are the rule rather than the exception. Stomach,bowels, liver, spleen, and genitourinary injuries, it is estimated that approximately two to four associated intraabdominal injuries occur with abdominal vascular injuries in these cases, consideration must be given to second look operations to assess the bowel viability [13-18]. Anatomical location of the injuries of the abdominal vessels can be estimated to the classification of the abdominal zones,(zone I, zone II Right & Left , zone III). As soon as the surgeon has identified and classified the hemorrhage or hematoma into one of the zones the zone must be approached to obtain vascular control and exposed the injured blood vessels to attempt definitive repair. Each zone requires different and complex maneuvers to expose these vessels. The diagram (1), below shows the classification of the zones.

Materials and methods

This study encompassed 64-cases with abdominal vascular injuries in general, presented from January 2007 to December 2013 to the cardiovascular and thoracic surgical department as well as patients admitted to the emergency room ,beside the patients already in the operating room of the gynecology department, these included in this study.
We respectively reviewed all cases with abdominal vascular injuries 64-cases, 18-cases were females, while 46-cases were are males. The age incidence range from 18-50 years old ,were the average age was  32-year.These patients either referred directly from the battle field or from the primary care unit, and from the same hospital from other department, during the surgery either emergency cesarean section or during emergency hysterectomy and other pelvic surgery.
The mechanism of the trauma mainly penetrating injuries, missile, shrap-nail. Bullet ,stab wounds. Other from road traffic accident(blunt injury).
The site of the injuries mainly abdominal (48)patients, pelvic vascular injuries (16)patients. The presentation mainly shock status,resuscitation done in the emergency room and in the operation room.The type of intervention and investigation was individually done.The percentage of solitary aorta, inferior vena cava, and mixed injuries. All these cases operation done for them with mortality 12-patients,25- patients with morbidity.




Results

The study of the 64-patients were admitted to our hospital and treated in the emergency department and operation done in the theatre of emergency ,other in the gynecological theatre,few of them done in the theatre of the cardiovascular and thoracic theatre. We review retrospectively these cases from January 2007 till December 2013.Those patients the age incidence range from 18 years to 50 years , the mean age was 32-year. The gender incidence as follow 46-patients were male (71.88%), while 18- patients were female (28.12%). Penetrating injuries was the most common causes of the abdominal vascular injury, while the remaining causes due to either blunt or iatrogenic injuries, table(1). These patients are referral cases from other hospital, or directly from battle field from north and the west of Baghdad .The time interval between the accident and reaching our hospital it range from 1-hour to 10-hours. Shock state 60-patients (93.75%), in different level of the shock, were all done for them cross-match, and given the intravenous fluid 0.9% normal saline. Whole blood, platelet, fresh frozen plasma are transfused preoperative, perioperative, and post-operative, 4-16units according to the condition of the patients, while moderate or severe state of the shock. Most of the patients done FAST (Fast Abdominal Sonography Test), Chest X-rays, and six patients done for them Abdominal Computed-Scan (C-T SCAN),those with blunt trauma and stab wound injury. Those patients done for them investigations included blood sugar,blood urea, serum ceratinine,electrolyte K+/Na+, liver function test. Laparotomy done in the emergency theatre, we found the abdominal vascular injuries according to the site as in the table(3).

Discussions

This article discusses anatomic regions within the abdomen where life-threating vascular injuries occur. The pathophysiologic and diagnostic issues involved with each region are reviewed. Techniques are described for optimal exposure of major abdominal arteries and veins. This study done in department of the cardiothoracic and vascular surgery in Al-Kadhimiya Teaching Hospital-Baghdad from January 2007 till December 2013. The age incidence were range from 18 -50 years, the average age was 32-year.Male gender 46-case(71.88%),female gender was 18-case (28.12%) The incidence of the abdominal vascular injuries in the developed country the military conflicts is surprisingly low, generally less than 5% of all vascular injuries. In contrast approximately 30% of all vascular injuries observed in civilians occur in the abdomen. This is different in the third world still the political and terrorist still high, so the military injury so high compared to the civilian conflict striking. So the low-energy missiles from civilian handguns and short prehospital transit in urban settings, thereby making it more likely that a civilian with penetrating abdominal vascular injury will survive long enough to reach surgical care. This study estimated that 60% of cases were from capital Baghdad which is realistic as it is mostly affected by terroristic assaults. Gunshot wounds and blast injuries of the abdomen have continued to increase , as the purchase of handguns in this country still not fully controlled, as well terroristic events and assassinations especially over the latest few years, the resultant increase in incidence and commonness of the abdominal vascular injuries as it has been evident from our result which due to the penetrating injuries 48-cases(75%). Blunt injuries 3-cases (4.8%)this mainly due to Road –Traffic accident(RTA).Penetrating injuries main cause was blast –shell injuries, 30-patients (46.8%),followed by gunshot 12- patients (18…75%),least by stab wound 3-patients (4.6%). The accidental abdominal vascular injuries occur during elective or emergency hysterectomy ,or as complication during cesarean section of multiparas pregnant patients, most of these operation done by the resident young surgeon, so we have this large number of the accident. The 3 ischemic-reperfusion criteria (preoperative hypotension, estimated blood loss of 6-liter or greater, or intraoperative resuscitation with 12-liters or more). Patients who had at least 1 of the 3 ischemic-reperfusion criteria has higher in-hospital mortality(43%)(21) of those who had at least 1 critrion,the initial 24-hour mortality as well as the 30-day mortality was higher in those with a primarily closed abdomen relative to those with a 47% open abdomen [21]. Emergency department, the resuscitation of the patient with abdominal vascular trauma depends on his or her condition at arrival to the hospital. Insert large bore cannula into the upper extremities, or obtain central venous line for rapid infusion of warm isotonic fluid. Because a possibility of intra-abdominal venous injuries exists, should be aware to use lower extremity venous access. Review condition of the patient Fast Abdominal Sonography (FAST), chest X-ray, Computed Tomography (C-T) of the abdomen in blunt abdominal trauma. The patient to expose chest and both thighs in the event that a thoracotomy or vein harvest is required. Perform a generous midline incision from xiphoid to the pubis needed to improve exposure . Arterial line may be helpful for monitoring blood pressure and arterial blood gases. Quickly evacuated blood clots and perform 4-quadrant packing. After initial stabilization, systemic remove the packing and evaluate the injuries. Use aortic compression to obtain proximal clamp of the aorta ,then we do (Mattox maneuver) or an extensive Kocher maneuver. Celiac axis injured was ligated, were was safely .but unfortunately were unable to control the bleeding from suprarenal aorta and suprarenal vena cava. That were the mortality rate high in these injuries 12-petients (18.75%). The injuries infrarenal of both aorta and vena cava,(Cattel-Braasch maneuver) dividing the white line of Toldt adjacent to the cecum. Direct repair of the aorta using 6-0 prolene,one case of the inferior vena cava used peritoneal patch to close the defect. Renal artery damage were we repair with vein graft 3-patients one done by direct repair because small tear. Splenic artery complete laceration we do ligation and splenectomy. Inferior mesenteric artery ligation done. A planned second look operation 24-48 hours after the initial surgery done to complete a damage control sequence. Most of the patients with abdominal vascular injuries were was at zone I major injury to the aorta and vena cava vein either supra-renal or infra-renal either alone or combined, those supra-renal had high mortality rates, because we found difficult to control the bleeding. Zone II,III we have god results either by doing ligation of the internal iliac artery or vein,splenic artery ligation with splenectomy.graft of the common iliac artery done,other by direct repair, urinary bladder sutured using 2/0 vigreal, ureter re-anastomosis with double J ureteric catheter ,small bowel sutured by double layers, large bowel injuries done for these temporal colostomy. These injuries associated with penetrating injuries directly disrupt the vessel wall or create intimal flaps. Because of the anatomical position of the major vascular in the abdomen have high possibility of associated with other organs. The complications of the trauma and the surgery commonly we found the respiratory complication,ARDS (acute respiratory distress syndrome), chest infection , due to inability to cough ,and most of them were was heavy smoker. Ongoing bleeding due to massive blood transfusion, or DIC (disseminated intra vascular coagulation). Abdominal compartment syndrome in one case due to multiple venous ligations. Intra-abdominal infection due to the bowel spillage and those had abdominal dehiscence. Survival rate were 52-patients (81.25%),were the mortality rate 12-patients(18.75%) most of them were was males. A comparative study see in the table (13).Literature data penetrating trauma volumes are increasing around the world. The major causes of high mortality were depend of hypovolemic shock at the time of admission and difficulty in controlling the bleeding at the early time possible by the surgical residents. Multiple arterial and venous injuries increase mortality. Associated abdominal injury of many organs also increase mortality rates.

Conclusions

Trauma more common in our country. The emergency surgeons are occasionally faced with a patients with abdominal vascular injuries. Important surgical issue in the successful management of these injuries a familiar with abdominal anatomy beside the blood vessels s of the abdomen and the techniques of the vascular repair. The decision of the surgical exploration be performed without delay, that the vascular injury be explored rapidly with control of hemorrhage upon entering the abdomen, that efforts be made to reestablished perfusion initially to the structures at the highest risk of anoxic injury using shunt or temporary Cather, and an understanding that it is occasionally necessary to perform while the general condition of a patient is being stabilized, then we proceed with definitive repair. The primary goal in the management of these patients should be first bleeding control rather than maintenance of the blood flow to the organs. The principles of abbreviated laparotomy with planned second look operation should be used in some patients with major abdominal vascular injuries. The decision to reestablish vascular continuity at later time should be balance anticipated functional outcome against potential complications.

References

1-Fabain Tc.Abdominal trauma including indications for Celiotomy In: Feliciano DV, Moore EE, Mattox KL,ed. Trauma 3rd ed.Norwalk.Conn:Appletion and Lange;1996:441-59.
2-Cox EF.Blunt abdominal trauma. A 5-year analysis of 870 patients requiring Celiotomy. Ann surg.Apr 1984; 199(4);467-74.
3-Morris JA, Eddy VA, Rutherford EJ. The trauma Celiotomy: the evoling concepts of damage control. CurrproblSurg Aug 1996; 33(8):611-700.
4-Asensio JA: Exsanguination from penetrating injuries. Trauma Quarterly 6:1–25, 1989.
5-Asensio JA, Hanpeter D, Gomez H, et al: Exsanguination. In Shoemaker W, Greenvik A, Ayres SM, et al (eds): Textbook of Critical Care, ed 4. Philadelphia, W.B. Saunders Co., pp 37–47, 2000.
6-Asensio JA, Ierardi R: Exsanguination. Emergency Care Quarterly 7:59–75, 1991.
7-Asensio JA, Lejarraga M: Abdominal vascular injury. In Demetriades D, Asensio JA (eds): Trauma Handbook Austin, Texas, Landes Biosciences Co., 2000, pp 356–362.
8- Nicholas JM,Rix EP,Easly KA,et al. Changing patterns in management of penetrating abdominal trauma: the more things change, the more they stay the same Trauma. Dec 2003;55(6):1095-1108.
9-Vandroman MJ,Gritten KL,Kerby JD, Mc Gwin, G JR, Rue LW3rd, Weinberg JA.Identifying risk for massive transfusion in the relatively normotensive patient: Utility of the prehospital shock index. J Trauma.2011;70(2):384-8.
10-Gander MT, Pittet JF, New insights into acute coagulopathy in trauma patients. Best Pract Res Clin Anesthesiology. 2010;24(1):15-25.
11-Isenhour JL, Marx J. Advance in abdominal trauma. Emerg Med Clin North Am. Aug 2007;25(3):713-33.
12-Gilani R.Endovascular therapy for overcoming challenges presented with blunt abdominal aortic injury. Vasc Endovascular Surg. 2012;46(4):329-31.
13-Asensio JA, Chahwan S, Hanpeter D, et al: Operative management and outcome of 302 abdominal vascular injuries. AAST-OIS correlates well with mortality. Southwestern Surgical Congress. Am J Surg 180:528–534, 2000.
14-Demetriades D, Theodoru D, Murray J, et al: Mortality and prognostic factor in penetrating injuries of the aorta. J Trauma, 40:761–763, 1996.
15-. Feliciano DV: Abdominal vessels. In Ivatury R, Cayten CG (eds): The Textbook of Penetrating Trauma. Baltimore, Williams and Wilkins, 1996, pp 702–716.
16-Feliciano DV, Bitondo CG, Mattox KL, et al: Civilian trauma in the 1980s. A 1-year experience with 456 vascular and cardiac injuries. Ann Surg 199:717, 1984.
17-Feliciano DV, Burch JM, Graham JM: Abdominal vascular injury. In Mattox KL, Feliciano DV, Moore EE: Trauma, ed 4. New York, McGraw Hill, 1999, pp 783–805 27.
18-Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 209:698, 1989.
19-Moore EE,Cogbill TH, Jurkovich GJ, et al: Organ injury scaling III:Chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 33:337-339,1993.
20-Vu M;Anderson SW; Shah N; Solo JA; Rhea JT. C-T of blunt abdominal and pelvic vascular injury. Emergency Radiol.01-2010;17(1):21-9.
21- Kimball EJ, Adams DM, Kinikini DV, Mone MC, Alder SC. Delayed abdominal closure in the management of ruptured abdominal aortic aneurysm. Vascular. Dec 2009;17(6):309-15.
22-. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II: An analysis of 2471 cases. Ann Surg 123:534, 1946
23- Perry MO, Thal ER, Shires GT: Management of arterial injuries. Ann Surg 173:403–408, 1971.
24- Perdue GD, Smith RB: Intra-abdominal vascular injuries. Surgery 64:562–568, 1968.
25-Buscaglia LC, Blaisdell FW, Lim RC: Penetrating abdominal vascular injuries. Arch Surg 99:764–769, 1969.
26-Drapanas T, Hewitt RL, Weichert RF, et al: Civilian war injuries: A critical appraisal of three decades of treatment. Ann Surg 172:351–360, 1970.
27-Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1000 cases. J Trauma 10:359, 1970.
28-Billy LJ, Amato JJ, Rich NM: Aortic injuries in Vietnam. Surgery 70:385–391, 1971
29-Perry MO, Thal ER, Shires GT: Management of arterial injuries. Ann Surg 173:403–408, 1971.
30-Lim RC, Trunkey DD, Blaisdell FW: Acute abdominal aortic injury. Arch Surg 109:706–711, 1974.
31-Mattox KL, McCollum WB, Jordan GL, et al: Management of upper abdominal vascular trauma. Am J Surg 128:823–828, 1974.
32-Cheek RC, Pope JC, Smith HF, et al: Diagnosis and management of major vascular injuries: A review of 200 operative cases. Am Surg 41:755–760, 1975.
33-Hardy JD, Raju S, Neely WA, et al: Aortic and other arterial injuries. Ann Surg 181:640–653, 1975.
34-Kelly GL, Eisenman B: Civilian vascular injuries. J Trauma 15:507–514, 1975.
35-Mattox KL, McCollum WB, Beall AC, et al: Management of penetrating injuries to the suprarenal aorta. J Trauma 15:808–815, 1975.
36-Buchness MP, LoGerfo FW, Mason GR: Gunshot wounds to the abdominal aorta. Am Surg 42:1–7, 1976.
37-Phillips CV, Jacobsen DC, Brayton DF, et al: Central vessel trauma. Am Surg 45:517–530, 1979.
38-Myles RA, Yellin AE. Traumatic injuries of the abdominal aorta. Am J Surg 138:273–277, 1979.
39-Lassonde J, Laurendau F: Blunt injury to the abdominal aorta. Ann Surg 194:745–748, 1981.
40-Kashuk JL, Moore EE, Millikan JS, et al: Major abdominal vascular trauma: A unified approach. J Trauma 22:672–679, 1982.
41-Sirinek KR, Gaskill HV, Root HD, et al: Truncal vascular injury: Factors influencing survival. J Trauma 23:372–377, 1983.
42-Brinton M, Miller SE, Lim RC, et al: Acute abdominal aortic injuries. J Trauma 22:481–486, 1984.
43-Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 209:698, 1989.
44-Millikan JS, Moore EE: Critical factors in determining mortality from abdominal aortic trauma. SurgGynObstet 160:313–316, 1985.
45-Accola KD, Feliciano DV, Mattox KL, et al: Management of injuries to the suprarenal aorta. Am J Surg 154:613–618, 1987.
46-Collins PS, Golocovsky M, Salander JM, et al: Intra-abdominal vascular injuries secondary to penetrating trauma. J Trauma 8:S165–S170, 1988.
47-Burch JM, Richardson RJ, Martin RR, et al: Penetrating iliac vascular injuries: Recent experiences in 233 consecutive patients. J Trauma 30:1450–1459, 1990.
48-Frame SB, Timberlake GA, Rush DS, et al: Penetrating injuries to the abdominal aorta. Am Surg 56:651–654, 1990.
49-Jackson MR, Olson DW, Beckett WC, et al: Abdominal vascular trauma: A review of 106 injuries. Am Surg 58:622–626, 1992.
50-Lopez-Viego MA, Snyder WH, Valantine RJ, et al: Penetrating abdominal aortic trauma: A report of 129 cases. J VascSurg 16:332–336, 1992.
51-Demetriades D, Theodoru D, Murray J, et al: Mortality and prognostic factor in penetrating injuries of the aorta. J Trauma, 40:761–763, 1996.
52-Richardson JD, Bergamini TM, Spain DA, et al: Operative strategies for management of abdominal aortic gunshot wounds. Surgery 120:667–671, 1996.
53-Asensio JA, Chahwan S, Hanpeter D, et al: Operative management and outcome of 302 abdominal vascular injuries. AAST-OIS correlates well with mortality. Southwestern Surgical Congress. Am J Surg 180:528–534, 2000.
54- Davis TP, Feliciano DV, Rozycki GS, et al: Results with abdominal vascular trauma in the modern era. Am Surg 67:565–571, 2001.


The complete article is available as a PDF File that is freely accessible. The fully formatted HTML version can be viewed as HTML Page.

Medical Journal of Babylon

volume 13 : 1

Share |

Viewing Options

Abstract
Download Abstract File
( 131 KB )

Related literature

Cited By
Google Blog Search
Other Articles by authors

Related articles/pages

On Google
On Google Scholar
On UOBabylon Rep

User Interaction

332  Users accessed this article in 1 year past
Last Access was at
26/06/2017 22:11:32