Advertisement

Penetrating Cervical Vascular Injuries

  • Matt Strickland
  • Erik Roedel
  • Kenji InabaEmail author
Trauma to the Neck (W Biffl, Section Editor)
  • 3 Downloads
Part of the following topical collections:
  1. Topical Collection on Trauma to the Neck

Abstract

Purpose of Review

This article reviews penetrating cervical vascular injuries, with a focus on the initial control, diagnostic workup, and operative or endovascular management. The review highlights the change in management approach from one based on anatomical zones of the neck to the contemporary approach of using physical exam and computed tomographic angiography to guide decision making.

Recent Findings

The approach to penetrating neck injuries has evolved over the past 40 years with a resultant decrease in the rate of non-therapeutic operations, driven primarily by improvements in imaging technology. The role of endovascular techniques is now established for vertebral artery injuries and continues to evolve for non-emergent carotid injuries.

Summary

Penetrating cervical injuries pose a significant risk to life and triage of patients to the operating room or further imaging by computed tomographic angiography (CTA) must occur promptly based on the physical examination. In the operating room, the management of complex venous injuries consists of simple ligation. Vertebral injuries can be temporized with packing or bone wax and then managed with percutaneous endovascular interventions. Carotid injuries may generally be managed with arteriorrhaphy, primary repair, or reconstruction with venous or PTFE graft. In damage control situations, shunting is preferred.

Keywords

Neck trauma Vascular trauma Hemorrhage control Temporary vascular shunt No zone approach 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Nason R, Assuras G, Gray P, Lipschitz J, Burns C. Penetrating neck injuries: analysis of experience from a Canadian trauma Centre. Can J Surg. 2001;44(2):122–6.PubMedPubMedCentralGoogle Scholar
  2. 2.
    • Low GM, Inaba K, Chouliaras K, Branco B, Lam L, Benjamin E, et al. The use of the anatomic “zones” of the neck in the assessment of penetrating neck injury. 2014;80(10):970. A study looking critically at traditional neck zones which cast doubt on the validity of using external markings of injury to predict which underlying structures were injured. Google Scholar
  3. 3.
    •• Inaba K, Branco BC, Menaker J, Alea T, Crane S, DuBose JJ, et al. Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg. 2012;72(3):576 The AAST multi-center trial that most significantly established MDCTA’s superiority as the radiographic method to evaluate penetrating neck injuries. The authors showed this tool to be very sensitive and specific for vascular and aerodigestive structures.CrossRefGoogle Scholar
  4. 4.
    • Ibraheem K, Khan M, Rhee P, Azim A, O’Keeffe T, Tang A, et al. “No zone” approach in penetrating neck trauma reduces unnecessary computed tomography angiography and negative explorations. J Surg Res. 2018;221:113–20 A large, retrospective review of penetrating neck injuries was used to show that the “no zone” approach can decrease rates of negative exploration and that physical exam, not location, should be the principal input to guide management.CrossRefGoogle Scholar
  5. 5.
    Bell BR, Osborn T, Dierks EJ, Potter BE, Long WB. Management of penetrating neck injuries: a new paradigm for civilian trauma. J Oral Maxillofac Surg. 2007;65(4):691–705.CrossRefGoogle Scholar
  6. 6.
    Markey J, Hines J, Nance F. Penetrating neck wounds: a review of 218 cases. Am Surg. 1975;41(2):77–83.PubMedGoogle Scholar
  7. 7.
    Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma. 1979;19(6):391–7.CrossRefGoogle Scholar
  8. 8.
    Tisherman SA, Bokhari F, Collier B, Cumming J, Ebert J, Holevar M, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008;64(5):1392–405.CrossRefGoogle Scholar
  9. 9.
    Biffl W, Moore E, Rehse D, Offner P, Franciose R, Burch J. Selective management of penetrating neck trauma based on cervical level of injury 1997;174(6):678.Google Scholar
  10. 10.
    • Prichayudh S, Choadrachata-anun J, Pak-art R, Sriussadaporn S, Kritayakirana K, et al. Selective management of penetrating neck injuries using “no zone” approach. Inj. 2015;46(9):1720 A large series of penetrating neck injuries managed with a “no zone” approach. The authors showed that the there was a low rate of negative exploration and no missed injuries with this updated approach.CrossRefGoogle Scholar
  11. 11.
    Joos E, Inaba K. Neck operations for trauma: general principles. In: Demetriades D, Inaba K, Velmahos G, editors. Atlas of Surgical Techniques in Trauma. Cambridge: 2013. pp. 47–52.Google Scholar
  12. 12.
    Warriner Z, Lam L, Matsushima K, Benjamin E, Strumwasser A, Demetriades D, et al. Initial evaluation of the efficacy and safety of in-hospital expandable hemostatic minisponge use in penetrating trauma. J Trauma Acute Care Surg. 2018;Publish Ahead of Print:1.Google Scholar
  13. 13.
    Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, et al. Western trauma association critical decisions in trauma. J Trauma Acute Care Surg. 2013;75(6):936–40.CrossRefGoogle Scholar
  14. 14.
    Shiroff A, Gale SC, Martin ND, Marchalik D, Petrov D, Ahmed HM, et al. Penetrating neck trauma: a review of management strategies and discussion of the “No Zone” approach. 2013;79(1):23.Google Scholar
  15. 15.
    Núñez DB, Torres-León M, Munera F. Vascular injuries of the neck and thoracic inlet: helical CT-angiographic correlation. Radiographics. 2004;24(4):1087–98.CrossRefGoogle Scholar
  16. 16.
    Munera F, Soto JA, Palacio DM, Castañeda J, Morales C, Sanabria A, et al. Penetrating neck injuries: helical CT angiography for initial evaluation. Radiology. 2002;224(2):366–72.CrossRefGoogle Scholar
  17. 17.
    Mazolewski P, Curry J, Browder T, Fildes J. Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries. J Trauma. 2001;51(2):315.Google Scholar
  18. 18.
    Gracias V, Reilly P, Philpott J, Klein W, Lee S, Singer M, et al. Computed tomography in the evaluation of penetrating neck trauma: a preliminary study 2001;136(11):1231.Google Scholar
  19. 19.
    E, Schroeder JW, Ptak T, Corey AS, Ahmed O, Biffl WL, et al. ACR Appropriateness Criteria® penetrating neck injury. J Am Coll Radiol. 2017;14(11S):S500.Google Scholar
  20. 20.
    Inaba K, Munera F, McKenney M, Rivas L, de Moya M, Bahouth H, et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. J Trauma. 2006;61(1):144–9.CrossRefGoogle Scholar
  21. 21.
    Munera F, Cohn S, Rivas LA. Penetrating injuries of the neck: use of helical computed tomographic angiography 2005;58(2):413.Google Scholar
  22. 22.
    Steenburg SD, Sliker CW, Shanmuganathan K, Siegel EL. Imaging evaluation of penetrating neck injuries. Radiographics. 2010;30(4):869–86.CrossRefGoogle Scholar
  23. 23.
    Múnera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000;216(2):356–62.CrossRefGoogle Scholar
  24. 24.
    Jarvik J, Philips G, Schwab C, Schwartz J, Grossman R. Penetrating neck trauma: sensitivity of clinical examination and cost-effectiveness of angiography 1995;16(4):647.Google Scholar
  25. 25.
    Rivers S, Patel Y, Lany H, Veith F. Limited role of arteriography in penetrating neck trauma 1988;8(2):112.Google Scholar
  26. 26.
    Al-Ameri H, Thomas ML, Yoon A, Mayeda GS, Burstein S, Kloner RA, et al. Complication rate of diagnostic carotid angiography performed by interventional cardiologists. Catheter Cardiovasc Interv. 2009;73(5):661–5.CrossRefGoogle Scholar
  27. 27.
    Ginzburg E, Montalvo B, LeBlang S, Nunez D, Martin L. The use of duplex ultrasonography in penetrating neck trauma 1996;131(7):691.Google Scholar
  28. 28.
    Fry W, Dort J, Smith R, Sayers D, Morabito D. Duplex scanning replaces arteriography and operative exploration in the diagnosis of potential cervical vascular injury 1994;168(6):693.Google Scholar
  29. 29.
    Montalvo B, LeBlang S, Nuñez D, Ginzburg E, Klose K, Becerra J, et al. Color Doppler sonography in penetrating injuries of the neck 1996;17(5):943.Google Scholar
  30. 30.
    Demetriades D, Theodorou D, Cornwell E, Weaver F, Yellin A, Velmahos G, et al. Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow Doppler imaging. 1995;130(9):971.Google Scholar
  31. 31.
    Yaquinto J, Harms S, Siemers P, Flamig D, Griffey R, Foreman M. Arterial injury from penetrating trauma: evaluation with single-acquisition fat-suppressed MR imaging. Am J Roentgenol. 1992;158(3):631–3.CrossRefGoogle Scholar
  32. 32.
    Friedman D, Flanders A, Thomas C, Millar W. Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences. Am J Roentgenol. 1995;164(2):443–7.CrossRefGoogle Scholar
  33. 33.
    Zarrinkoob L, Ambarki K, Wåhlin A, Birgander R, Eklund A, Malm J. Blood flow distribution in cerebral arteries. J Cereb Blood Flow Metab. 2014;35(4):648–54.CrossRefGoogle Scholar
  34. 34.
    Kwon E, Grabo D, Velmahos G. Carotid artery and internal jugular vein injuries. In: Demetriades D, Inaba K, Velmahos G, editors. Atlas of surgical techniques in trauma. Cambridge: 2013. pp. 53–68.Google Scholar
  35. 35.
    Demetriades D, Nash N. Vertebral artery injuries. In: Demetriades D, Inaba K, Velmahos G, editors. Atlas of surgical techniques in trauma. Cambridge: 2013. pp. 88–93.Google Scholar
  36. 36.
    Feliciano D, Vercruysse G. Management of specific injuries - neck. In: Mattos K, Moore E, Feliciano D, editors. Trauma. 8th Ediction: 2017. pp. 414–429.Google Scholar
  37. 37.
    Apffelstaedt J, Müller R. Results of mandatory exploration for penetrating neck trauma. 1994;18(6):917.Google Scholar
  38. 38.
    Gonzalez RP, Falimirski M, Holevar MR, Turk B. Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. 2003;54(1):61.Google Scholar
  39. 39.
    Inaba K, Munera F, McKenney MG, Rivas L, Marecos E, de Moya M, et al. The nonoperative management of penetrating internal jugular vein injury. J Vasc Surg. 2006;43(1):77–80.CrossRefGoogle Scholar
  40. 40.
    McGovern P, Swan K. Management of bilateral internal jugular venous injuries. Elsevier Ltd 1985;16(4):259.Google Scholar
  41. 41.
    Sakata K, Endo Y, Kimura F, Yamamoto I. Effects of bilateral jugular vein ligation on local cerebral blood flow 1999;9(3):207.Google Scholar
  42. 42.
    Moore O, Frazell E. Simultaneous bilateral neck dissection: experience with 151 patients. Am J Surg. 1964;107(4):565–8.CrossRefGoogle Scholar
  43. 43.
    Liekweg WG, Greenfield LJ. Management of penetrating carotid arterial injury. Ann Surg. 1978;188(5):587–92.CrossRefGoogle Scholar
  44. 44.
    Demetriades D, Skalkides J, Sofianos C, Melissas J, Franklin J. Carotid artery injuries: experience with 124 cases. J Trauma. 1989;29(1):91–4.CrossRefGoogle Scholar
  45. 45.
    Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, et al. Multicenter evaluation of temporary intravascular shunt use in vascular trauma. J Trauma Acute Care Surg. 2016;80(3):359–65.CrossRefGoogle Scholar
  46. 46.
    Almazedi B, Lyall H, Bhatnagar P, Kessel D, McPherson S, Patel JV, et al. Endovascular management of extra-cranial supra-aortic vascular injuries. Cardiovasc Intervent Radiol. 2014;37(1):55–68.CrossRefGoogle Scholar
  47. 47.
    Herrera DA, Vargas SA, Dublin AB. Endovascular treatment of penetrating traumatic injuries of the extracranial carotid artery. J Vasc Interv Radiol. 2011;22(1):28–33.CrossRefGoogle Scholar
  48. 48.
    • DuBose J, Recinos G, Teixeira PG, Inaba K, Demetriades D. Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience. J Trauma. 2008;65(6):1561 A systematic review of endovascular stenting for carotid injuries demonstrating that, as of 2008, the reported experience was mainly for blunt injuries. Stents were generally deployed safely and successfully with no stent-related mortalities reported.CrossRefGoogle Scholar
  49. 49.
    Lam Y-Y, Tsui H-F, Wong H-L, Chow Y-Y. Management approach of penetrating vertebral artery injury with concomitant cervical nerve root injury in regional hospital: report of two cases. J Orthop Traumatol Rehabil. 2018;25:5–10.Google Scholar
  50. 50.
    Uchikawa H, Kai Y, Ohmori Y, Kuratsu J-I. Strategy for endovascular coil embolization of a penetrating vertebral artery injury. Surg Neurol Int. 2015;6(1):117.CrossRefGoogle Scholar
  51. 51.
    Mwipatayi B, Jeffery P, Beningfield S, Motale P, Tunnicliffe J, Navsaria P. Management of extra-cranial vertebral artery injuries. Eur J Vasc Endovasc Surg. 2004;27(2):157–62.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Trauma and Surgical Critical Care, LAC+USC Medical CenterUniversity of Southern CaliforniaLos AngelesUSA

Personalised recommendations