Vascular Trauma

The Old, The New and The Unusual

Outline/Objectives
Carotid

Popliteal

Abdominal Aortic and Iliac

Thoracic Aortic
Carotid Trauma
A rare but serious problem in vascular
trauma

Incidence of 0.08% to 0.86% of blunt
trauma admissions

Routine screening of high-risk patients can
reveal an incidence of up to 2%

Actually represents a spectrum of injury

Minor intimal tear to acute occlusion

RISK: evolution of dissection,
pseudoaneurysm , thrombosis

Potentially, a devastating event

Mortality rates of 20 to 40%

Permanent, severe neurologic morbidity of up to
50% in survivors

Often presents 24 or more hours following injury

Mechanism of Injury
Classic stretch

Direct trauma

At the end of the day, what matters is the
degree of carotid injury and neurologic status

Presentation
Arterial hemorrhage from nose/mouth/neck

Cervical bruit or expanding hematoma

Focal neuro deficit (TIA, Horners, etc)

Neuro deficit not compatible with CT findings



High energy mechanism with: Le Forte II or III

Basilar skull fracture involving the carotid canal

CHI with DAI and GCS < or = 8

Clothesline injury or near hanging

Cervical vertebral body fx, subluxation or
ligamentous injury at any level, C1 to C3 fx

Diagnostic Imaging

US: Not useful for vertebral injury, misses at
least 20% of carotid injuries

CTA: 16 or 32 slice CTA is the study of choice

Angio: Often difficult, always expensive,
sometimes morbidstill the gold standard?

Grading the Injury
Grade I: Less than 25% luminal narrowing
from wall irregularity of dissection

Grade II: More than 25% lumen compromise
from dissection or intramural hematoma,
thrombus or intimal flap

Grade III: Pseudoaneurysm

GradingMore

Grade IV: Occlusion


Grade V: Transection with free extravasation

Therapy
No Level I evidence, because there are no
prospective, randomized trials

All recommendations are based on
observational studies and expert opinion

If there is profound neurologic compromise,
no therapy has been shown to be of benefit

Any Meaningful Literature?
Western Trauma Association Critical Decisions
in Trauma: Screening for and Treatment of
Blunt Cerebrovascular Injuries

Biffl, et al

J Trauma, Dec 2009

Whats More
Blunt Cerebrovascular Injury Practice
Management Guidelines: the Eastern
Association for the Surgery of Trauma

Bromberg et al

J Trauma, Feb 2010

Therapy:
The consequences of BCI are so significant,
treatment is warranted in all patients without
overwhelming contraindications

For grade I and II injuries, initial heparinization
with long term antiplatelet therapy is
indicated

For Grade I and II:
Follow up angiography at 7 to 10 days post
injury (or in the face of worsening symptoms)
is indicated

Length of antiplatelet therapy is controversial,
but probably should not be less than 90 days

Follow up imaging is important, leading to a
change in therapy in 50% of patients

More Therapy
Grade III injuries: angiography and possible
percutaneous intervention

Grade IV: Rarely is intervention indicated

Grade V: Immediate surgical intervention if
accessible; most require an endovascular
approach

PEARLS
1) Carotid injuries are potentially devastating
and easily missed

2) Find it by thinking to look for it

3) US isnt a good way of looking

4) Treat it when you do find it


Popliteal Artery Trauma
HOW MANY times did you see this?

Wait, you were what?

Maybe I should check one of these

So, now what do I do about it?
Am Surg 1997 Mar;63(3):228-31

Blunt popliteal artery trauma: a challenging
injury.

Harrell, DJ et al

Frequency
Incidence of popliteal artery injuries with
fractures about the knee was 3 per cent

16 per cent of patients with posterior knee
dislocations had vascular injuries

Amputations were required in 14 of the 38
injured limbs (36%). None of these patients
had a pulse or Doppler signal on admission

Frequency

Most common with posterior dislocations
(more force needed to produce the injury)


Fractures of the distal femur or tibial plateau
may cause arterial contusion, with intimal
disruption and thrombosis
- note that the worst error to make is to
underestimate the need to promptly treat
these injuries;
- there are anecdotal reports of patients
who ended up with AKA (from vascular injury)
who were reported to have diminished but
"dopplerable pulses
Popliteal Injury: Activities
Water skiing

Snow skiing

Longboarding

Parasailing

MVA

Horseback riding
Why is Shear an Issue?
I think, therefore I.
Examine the pulses

Obtain an ABI

Consider duplex US

Order an angio???
So, Now What?

Watchful waiting

Open bypass with contralateral GSV

Percutaneous stenting
PEARLS
Pulses count (in the ER and later)

If there is significant femur/knee trauma,
suspect popliteal injury

ABIs are your friend


Blunt Aortic & Iliac Trauma

It happened how?

Why should I care?

What do I do about it?
JVS 2012 Sep;56(3):656-60.

Associated injuries, management, and
outcomes of blunt abdominal aortic injury

De Mestral, C; Dueck, AD et al
All patients age 16 years with ISS 16 from
blunt trauma, treated at US level 1 or 2
trauma centers, 2007 to 2009.

436 patients from 180 centers

84% of patients were injured in an MVA.
394 patients (90%) managed nonoperatively; 42
(10%) underwent repair

42 repaired: 29 (69%) had endovascular repair, 11
patients were done open, two had extra-
anatomic bypass

Median time to repair was 1 day

Overall mortality was 29%
Patients with MAI are at low risk: observe with
serial physical exams and US

Injuries associated with bleeding, malperfusion,
or thromboembolism require intervention, most
often endovascular

For observed patients, long-term surveillance is
required; document complete resolution as even
MAI can progress

PEARLS
Sohow did it happen?


Why should I care?


What do I do about it?




Thoracic Aorta


Things just arent what they used to be
Open Thoracic Repair
Complications of thoracotomy!

of heparin

paralysis rates of 2-20%

emergent OR in the face of polytrauma
New Approaches.

Treat them like an aortic dissection


Endovascular operation once clinically
opportune
Bad Drive Home

60 yo male professional

Restrained driver of a small SUV

Hits an ice patch at highway speed

Transported
Arrives in the ER

Initial resuscitation

Arrests!

Resuscitated, once again
Multiple rib fractures, bilaterally

CHI with LOC and intracranial bleed

Extensive bilateral pulmonary contusions

Various bumps, lumps and fractures


Hes just arrested

Has significant intracranial injury

Significant thoracic cage and pulmonary injury

Who wants to do a thoracotomy right now?
To the unit he goes.
IV betablockers

IV cleviprex

Keep MABP ~ 60

Keep Pulse <60
4 days later

Hes still alive

In fact, getting better

Neurosurgery twitching less
To the OR.


Almost two weeks post injury.
Three months later
Seen in the office

Initial follow up CTA of chest looks great

Still with mild discomfort from his chest wall

Walked in, walked out and walked back to his
car to return to work.