Management of Penetrating Trauma to the Major Abdominal Vessels
Penetrating abdominal vascular injuries result in significant mortality. In the pre-hospital phase of care, “scoop and run” is the optimal strategy while on-scene interventions are restricted only to basic airway maneuvers. Early in-hospital diagnosis and operative interventions are prerequisites for survival in vascular trauma. Hypotension and peritonitis following penetrating abdominal trauma mandate immediate access to the operating room with vascular surgery capabilities. Patients presenting in extremis should be managed with a resuscitative thoracotomy in the emergency department. The majority of abdominal vascular injuries surviving to the operating room are subjected to damage control intervention. In hemodynamically stable patients, diagnostic modality of choice is computed tomography angiography and endovascular interventions are evolving.
KeywordsAbdominal vascular injury Penetrating trauma Management abdominal vessels
Abdominal vascular injuries are associated with a significant on-scene mortality rate both in civilian and in combat settings. Historic study by DeBakey and colleagues reported that only 2 % of all arterial injuries to the abdominal vessels to arrive to field hospitals in World War II . Similarly, Rich and colleagues documented only 2.9 % of combat-related abdominal vascular lesions per 1000 vascular injuries admitted to field hospitals during the Vietnam conflict . Along the advancements of tactical combat casualty care, more severely injured military casualties survive to support hospitals with vascular injuries. Thus, Clouse and colleagues observed an incidence of 6.8 % abdominal vascular lesions arriving to combat care hospitals in the Iraq conflict . Likewise, in a study by Fox and co-authors, vascular torso injuries are admitted in increasing frequency in contemporary military conflicts .
In civilian settings, the recent multi-institutional investigation by DuBose and colleagues reported 7.8 % vascular injuries to the intra-abdominal vessels admitted to 13 US trauma facilities [5••]. The increasing incidence of vascular injuries arriving to medical care in the USA can be associated with truncated on-scene times, evolving prehospital management, and hemostatic resuscitation .
The overall in-hospital mortality of patients with abdominal vascular trauma ranges between 45 and 54 % [7, 8]. Factors related to detrimental outcomes are the mechanism of injury, number of vessels injured, higher injury severity score, lower systolic blood pressure (SBP) on arrival, hypothermia, advanced age, and increased requirement of blood component transfusion [7, 8].
General Principles of Management
In abdominal vascular injury, early diagnosis and interventions are prerequisites for patient survival. In the prehospital phase of care, the best strategy is to “scoop and run.” On-scene interventions should be restricted only to basic airway maneuvers. Insertion of an intra-venous (IV) line is best attempted during transportation with similar success rates as compared to on-scene venous access . Shorter prehospital times have resulted in more patients with abdominal vascular injuries reaching the hospital in extremis, thus increasing the overall in-hospital mortality following abdominal vascular trauma [10•].
Damage control resuscitation (DCR) throughout the preoperative phase of care is the emerging strategy for hypotensive patients sustaining penetrating trauma to the torso . Nevertheless, the recent Cochrane analysis found no evidence for or against the use of early or smaller-volume IV fluid replacement in uncontrolled hemorrhage [11•]. However, the landmark study by Bickell and colleagues showed improved survival in delaying resuscitation in torso vascular injuries until arrival to the operating room . Similarly, Cotton and co-authors noted survival benefit in patients requiring emergent trauma laparotomy subjected to DCR .
The optimal primary management follows Advanced Trauma Life Support (ATLS) principles. After definitive airway is secured and an adequate tissue perfusion is restored, mild hypotension is preferred until definitive treatment. IV access is accomplished via two large-bore peripheral IVs (16 gauge or larger) preferably in the upper extremities. Many trauma centers utilize large-bore double-lumen IV sheaths inserted into internal jugular or subclavian vein for access. It is of paramount importance to obtain vascular access that feeds into the superior vena cava (SVC) tributaries because abdominal vascular injury may include the inferior vena cava (IVC) that can preclude adequate vascular containment of infused volumes. Balanced volume replacement is provided early with blood products. Tranexamic acid should be given as early as possible in bleeding patients [14, 15•]. Per the CRASH-2 study, in patients that receive tranexamic acid within the initial 3 h after the injury, risk of death due to bleeding was significantly lower; however, treatment later than 3 h may not be effective and may even be harmful . The blood bank is notified immediately of the massive blood component requirement for 1:1:1 transfusion protocol [16•]. It has been noted, however, that fresh frozen plasma (FFP) administration in massive transfusion setting should be delayed until the first 6 units of red cell units are administered. In a study by Inaba et al., the authors noted that patients who did not require massive transfusion protocol (MTP) but received FFP too early suffered significantly more complications .
Hypotension following penetrating abdominal injury mandates immediate access to the operating room (OR) and an exploratory laparotomy incision from xiphoid to symphysis as the gold standard. When an immediate laparotomy is mandatory, a trauma OR with experienced staff should be readily available. Basic laparotomy and vascular trays should be available, and a table-mounted self-retaining retractor system provides optimal exposure. In sophisticated trauma facilities, autologous blood recovery and thoracic autotransfusion systems are frequently utilized.
Resuscitative laparotomy in the ED is controversial, and results are very poor. In a study by Mattox and colleagues, only 22 % of patients subjected to resuscitative ED laparotomy reached the OR and mortality was 100 % .
The most commonly injured arteries in the abdomen are iliac vessels, followed by renal arteries and abdominal aorta; however, penetrating injuries accounted only 36.5 % of the injuries per the PROOVIT registry [5••]. Asensio and colleagues observed that aortic injuries were most commonly followed by iliac arteries, superior mesenteric artery (SMA), renal arteries, splenic artery, celiac trunk, hepatic artery, and inferior mesenteric artery with penetrating mechanism contributing to 88 % of injuries . The most frequently major abdominal veins injured in descending order are IVC, iliac veins, renal veins, superior mesenteric vein (SMV), portal vein, hepatic veins, retrohepatic vena cava, splenic vein, and inferior mesenteric vein (IMV) .
Zone I, supramesocolic region: suprarenal aorta, celiac axis, proximal superior mesenteric artery (SMA), superior mesenteric vein (SMV), renal artery
Zone I, inframesocolic region: infrarenal aorta, inferior mesenteric artery (IMA), and infrahepatic inferior vena cava (IVC)
Zone II: renal artery and vein
Zone III: common, internal, and external iliac arteries and veins
Zone IV: retrohepatic vena cava, portal vein, and hepatic artery
Supramesocolic Zone I
A hematoma or hemorrhage in the supramesocolic zone I is due to an injury of the abdominal aorta, celiac axis, SMA, or SMV. Injuries to the suprarenal aorta are associated with a mortality rate over 90 % . Nevertheless, if the abdominal aortic injury is contained in the retroperitoneal space, the patient may survive to the hospital. The best approach for the suprarenal aorta is a left medial visceral rotation popularized by DeBakey and Mattox . The left colon is mobilized at the line of Toldt, the splenic flexure is taken down, and the spleen along with pancreatic tail is rotated to the midline exposing the abdominal aorta with its branches in the retroperitoneal space. Proximal control of the aorta at the hiatus of the diaphragm can be achieved by pressure with a sponge stick, a compression device, or by digital control. Aortic cross-clamping to the lowest segment of the thoracic aorta is the next step after dividing some left crural muscle fibers.
Injuries of the celiac axis are rare. In a study from Los Angeles County General Hospital, 13 patients reached the hospital with celiac axis injury during 132-month period and 92 % of those patients had sustained a penetrating trauma. The survival rate was 38 %, 80 % of the surviving patients were treated with ligation . The ligation of celiac axis is well tolerated due to extensive collateral circulation; however, ischemia of the gallbladder may occur requiring cholecystectomy when hemodynamic stability is ensured . For the limited injuries, primary repair is recommended and ligation should be reserved for more destructive injuries. Complex repairs with an end-to-end anastomosis, autologous interposition graft, or synthetic graft repairs are not recommended as the morbidity with celiac axis ligation is low .
The SMA requires more extensive approach to prevent detrimental bowel ischemia. Fullen described four anatomical zones of SMA to unify the management . Zone I is beneath the pancreas, zone is II between the pancreaticoduodenal complex and middle colic branches of the artery, zone III is beyond the middle colic branches, and zone IV is at the level of enteric branches. The more proximal the location of injury, the higher the mortality, ranging from 76.5 % for the zone I and 23.1 % for the zone IV injuries, respectively . Exposure of zone I and zone II injuries may require transection of the pancreatic neck after the proximal control of the aorta is achieved by supraceliac aortic cross-clamping. When accessed through the left medial visceral rotation, the repair is feasible without dividing the pancreas. Zone III and zone IV injuries can be achieved by reflecting the transverse colon in a cranial direction accessing the SMA at the mesenteric root distal to the transverse mesocolon. SMA injuries need to be repaired primarily, reimplanted to the aorta, or managed with an interposition graft. In the damage control setting, temporary shunting is the best option.
Inframesocolic Zone I
Associated intra-abdominal injuries are often present, with small bowel and liver injuries being the most frequent . In the pediatric population, IVC injuries are reported as the most common venous injuries [40•].
There are two approaches for renovascular injuries—medial or lateral approach—with the latter being faster. For the lateral approach, the injured kidney is approached by entering the retroperitoneum laterally at the line of Toldt and mobilizing the colon. Gerota’s fascia is opened with sharp and blunt dissection, and the kidney is mobilized to midline followed by digital control or clamping of the hilum.
For the compromised patient with two kidneys, nephrectomy is best implemented if a renal arterial injury is found and the contralateral kidney is confirmed by palpation of the contralateral retroperitoneal compartment. If the patient is stable, renal arterial injury can be managed with a lateral arteriorraphy or with end-to-end anastomosis. Graft repair is rarely described in the trauma setting, and every minute of warm ischemia associated with hemodynamic compromise is detrimental to the renal unit. Each additional minute of warm ischemia time is found to increase the risk of renal failure in non-trauma settings and therefore makes complex arterial repairs questionable . Mortality due to renal artery injury is about 36.4 % .
Renal vein injuries are best managed with primary lateral repair if possible. The left renal vein can be ligated safely between IVC and the left gonadal vein if the left gonadal and adrenal veins are intact, however, nephrectomy should be performed if a left renal arterial injury is also present. Ligation of the right renal vein mandates nephrectomy. Mortality after renal vein injury is reported to be 44 % .
Injuries to the iliac veins can be managed by lateral venorrhaphy or ligation.
Retrohepatic IVC and hepatic vein insults are some of the most devastating abdominal vascular injuries with mortality rate beyond 90 % . Exploration of contained retrohepatic hematoma should be avoided if at all possible; however, decompressed hematomas with massive bleeding require exploration and intervention. The first best option is perihepatic packing. If packing does not work, hepatic isolation with subdiaphragmatic aortic cross-clamping followed by clamping of the suprarenal and suprahepatic IVC in addition to a Pringle maneuver is the next possible maneuver. The last option is atriocaval shunting with very few successful case reports in the literature [34, 42, 43, 44].
Hematoma in the portal triad is associated with injured hepatic artery or portal vein. Before entering the hematoma, the Pringle maneuver should be applied. In the damage control setting, the hepatic artery can be ligated; however, the portal vein has to be intact. Cholecystectomy should be performed if the hepatic artery is ligated.
Mortality in portal vein injury is about 70 % . Access to the portal vein is obtained by right medial visceral rotation followed by the Kocher maneuver. Stapled pancreatic division may be required if the injured part of the portal vein is located behind the pancreatic neck. Iatrogenic injuries to the hepatic artery or common bile duct should be avoided during the exposure. The first option for injured portal vein is lateral repair if at all feasible and hemodynamics are favorable. In an exsanguinating patient, early ligation may be preferable. The survival rate is somewhat higher if the decision to ligate is done very early. However, intact hepatic artery is required if ligation of portal vein is performed . The abdomen should be left open to avoid abdominal compartment syndrome, and a massive resuscitation may be required due to splanchnic bed fluid sequestration following portal vein ligation.
Abdominal vessel injuries are becoming more common as the prehospital care has advanced. Management of these injuries mandates familiarity with the anatomy and quick repair by the surgeon. The vessels are mostly retroperitoneal and are divided into four zones. These zones assist in diagnosis of the vessel injured and the proposed repair of the injury. Suture repair, patch, or end-end anastomosis is the variety of options in the hemodynamically stable patient for the majority of vascular injuries. Ligation of the injured vessel may be necessary in the hemodynamically unstable patient; however, vascular shunts should be considered in those vessels that cannot be ligated with impunity.
Compliance with Ethical Standards
Conflict of Interest
Drs. Peep Talving, Lydia Lam, and Sten Saar declare no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any authors.
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