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Trauma > Abdominal Trauma
Abdominal Vascular Injuries
Article Last Updated: Apr 13, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Timothy H Pohlman, MD, FACS, Professor, Section of Trauma and Critical Care, Department of Surgery, Indiana University School of Medicine; Director, Surgical Critical Care, Consulting Staff, Methodist Hospital, Clarian Health Partners Inc
Timothy H Pohlman is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Society of University Surgeons, and Surgical Infection Society
Coauthor(s):
H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc;
Aleksander R Komar, MD, Fellow, Section of Trauma and Critical Care, SUNY Stony Brook;
Richard Fogler, MD, DS, FACS, Chair, Program Director, Department of Surgery, Division of Surgical Oncology, Brookdale University Hospital and Medical Center
Editors: Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
abdominal hemorrhage, abdominal trauma, internal injury, internal injuries, gunshot wound, gun shot wound, GSW, stab wound, penetrating wound, motor vehicle accident, MVA, blunt trauma, blunt force trauma, midline supramesocolic hemorrhage, midline supramesocolic hematoma, midline inframesocolic hemorrhage, midline inframesocolic hematoma, lateral perirenal hemorrhage, lateral perirenal hematoma, lateral pelvic hemorrhage, lateral pelvic hematoma
The incidence of abdominal vascular injuries in 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 striking difference between combat vascular trauma and noncombat vascular trauma can be attributed to low-energy missiles from civilian handguns and short prehospital transit times in urban settings, thereby making it more likely that a civilian with penetrating abdominal vascular injury will survive long enough to reach surgical care.
Problem
Injuries to major abdominal vessels are uncommon but highly lethal vascular crises. Predictably, exsanguinating hemorrhage is the most important cause of early death. Intra-abdominal vascular injuries are associated with extremely rapid rates of blood loss and pose challenges of exposure during celiotomy, given the posterior position, except for the portal vein and the hepatic artery, of the major abdominal vascular structures. Essential to the successful management of these injuries is a thorough knowledge of the complex anatomy of intra-abdominal vascular structures and a familiarity with the techniques of proximal and distal control combined with selected application of primary repair, bypass, and/or ligation.
Once exposure and proximal and distal control have been obtained, all abdominal vascular injuries should be graded using the American Association for the Surgery of Trauma-Organ Injury Scale for vascular injuries (AAST-OIS) (see Table).
American Association for the Surgery of Trauma-Organ Injury Scale for Vascular Injuries OIS
Grade*
| Artery Injured | Vein Injured | | II | Hepatic
Splenic
Gastric
Gastroduodenal
Inferior mesenteric
Primary named vessels of the SMA
| Splenic
Inferior mesenteric
| | III | Renal
Iliac
Hypogastric
| Superior mesenteric
Renal
Iliac
Hypogastric
Vena cava (infrarenal)
| | IV | Superior mesenteric (trunk)
Celiac axis
Aorta (infrarenal)
| Vena cava (infrahepatic) | | V | Aorta (suprarenal) | Vena cava (suprahepatic)
Vena cava (retrohepatic)
Portal
Hepatic (extrahepatic)
|
* Grade I injury includes the following: No named superior mesenteric artery or superior mesenteric vein branches. Nonnamed inferior mesenteric artery or inferior mesenteric vein branches. Phrenic artery/vein. Lumbar artery/vein. Gonadal artery/vein. Ovarian artery/vein. Other nonnamed small arterial or venous structures requiring ligation.
Frequency
The incidence of abdominal vessel injury in patients with blunt trauma is estimated at approximately 5-10%. A similar incidence of 10.3% is reported in patients with penetrating stab wounds to the abdomen. Patients with gunshot wounds (GSWs) to the abdomen will have major vessel injury in 20-25% of cases.
Pathophysiology
In blunt trauma, rapid deceleration during a motor vehicle accident (MVA) results in an avulsion of the small branches of major vessels (eg, mesenteric tear). Another mechanism of injury is related to a direct crush or blow to the major vessels, resulting in an intimal tear with thrombosis or vessel rupture and hemorrhage.
Penetrating injuries directly disrupt the vessel wall or create intimal flaps secondary to the blast effect. Because of the anatomical position of the major vascular structures in the abdomen, injuries to these vessels have a high probability of association with other major injuries in the abdomen, particularly to the small bowel. Hemorrhagic shock from intra-abdominal hemorrhage often leads to metabolic acidosis accompanied by coagulopathy and hypothermia, the so-called lethal triad of trauma. Metabolic acidosis in trauma patients is the result of lactate overproduction, most often from decreased oxygen delivery as a result of hypovolemic shock. Acidosis adds to the overall lethality of preexisting injury primarily by depression of myocardial contractility and by impairment of coagulation. Furthermore, hypothermia (below 34°C) inhibits platelet function and slows coagulation factor activation. This self-perpetuating cycle is responsible for 80% of deaths in patients with major vascular injury and must be rapidly corrected to prevent a dismal outcome.
Clinical
Clinical data obtained from emergency medical services (EMS) can be crucial and may be the only patient information available. In inner city hospitals, GSWs and stab wounds predominate. Mechanism of injury, vital signs at the scene of the accident, and transit time are essential. The amount of intravenous fluid the patient received in the field and during transport should also be elicited from EMS. Penetrating trauma to the chest below the nipple line should also be considered as penetrating trauma to the abdomen.
Blunt trauma Hemodynamically stable patients who have peritoneal signs or positive CT findings require exploration. Hemodynamically unstable patients with positive results, including pericardial effusion, on focused abdominal ultrasound for trauma (FAST) examination or diagnostic peritoneal lavage (DPL) require surgery. Penetrating trauma Evaluate stable patients with posterior wounds and most patients with anterior stab wounds with triple-contrast CT scanning (eg, oral, intravenous, rectal), diagnostic laparoscopy to exclude peritoneal penetration, and/or FAST examination to exclude hemoperitoneum. GSWs to the abdomen require celiotomy for evaluation and treatment, although some trauma surgeons prefer selective nonoperative evaluation of abdominal GSWs in stable patients. Hemodynamically unstable patients should be transported immediately to the operating room (OR) if the airway is secure and ventilation is adequate, preferably within 5 minutes of arrival to the emergency department (ED).
The following anatomical locations should be distinguished:
- Midline supramesocolic hemorrhage or hematoma (superior to the transverse mesocolon) is usually caused by injury to the suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery.
- Midline inframesocolic hemorrhage or hematoma results from infrarenal aorta or inferior vena cava (IVC) injury.
- Lateral perirenal hematoma or hemorrhage suggests injury to the renal vessels or kidneys.
- Lateral pelvic hematoma or hemorrhage indicates injury to the iliac artery, iliac vein, or both.
- Hepatoduodenal ligament hematoma or hemorrhage indicates portal vein and/or hepatic artery injury.
Patients without recorded vital signs at the scene of injury and blunt trauma victims without vital signs at the time of arrival to the ED rarely survive after resuscitation, with or without ED thoracotomy.
Imaging Studies
- Hemodynamically stable patients with blunt trauma and suspected abdominal vascular injuries may benefit from abdominal CT scanning, which helps localize a hematoma and evaluate solid organ injuries.
- Stable patients with stab wounds may undergo laparoscopy to confirm peritoneal penetration. If time permits, also perform chest and pelvic radiography to exclude bleeding into the chest and pelvic fracture.
- Hemodynamically unstable patients with penetrating trauma should be transported immediately to the OR; no imaging studies are necessary. The assessment of hemodynamically unstable patients with blunt trauma to the abdomen may include FAST examination or DPL to confirm hemoperitoneum as well as portable chest radiography only if expeditious transport to the OR is not to be interrupted.
Diagnostic Procedures
- In penetrating trauma, perform an abdominal exploration on most patients with a GSW to the abdomen.
- Angiography with or without embolization may be considered in stable patients, particularly in patients with blunt trauma.
Medical therapy
Initial resuscitation of a patient with abdominal vascular injuries depends on his or her condition at arrival to the ED. Insert multiple large-bore catheters into the upper extremities, or, if necessary, obtain central venous access for rapid infusion of warm isotonic fluid. Because a possibility of intra-abdominal venous injury exists, lower extremity venous access is not recommended. In the agonal patient with a distended abdomen suggesting major intraperitoneal bleeding, ED thoracotomy with cross clamping of the descending aorta may be necessary. This is usually associated with a poor prognosis and low survival rates. Perform blood replacement during resuscitation with type-specific blood if time permits receiving this blood in the ED. If time does not permit, use O-negative blood (or O-positive blood for males), which should be immediately available in the ED. Start efforts to limit hypothermia as soon as the patient arrives. Ensure that prewarmed fluids, high-flow blood warmers, and prewarmed blankets are available.
Preoperative details
- Place the patient on a warming blanket, and make every effort to reduce heat loss.
- Drape 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 the xiphoid to well below the umbilicus, which can be extended to the pubis if needed to improve exposure.
- Aggressively administer blood replacement therapy.
- A radial arterial line may be helpful for monitoring blood pressure and arterial blood gases.
Intraoperative details
Enter the peritoneal cavity through a midline incision. Quickly evacuate blood and clots and perform 4-quadrant packing. After initial stabilization, systematically remove the packing and evaluate the injuries. Injuries to major abdominal vessels can be grouped into the following 5 regions: - Midline supramesocolic hemorrhage or hematoma (superior to the transverse mesocolon)
- This problem is usually from an injury to the suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery.
- Use aortic compression to obtain proximal aortic control at the hiatus.
- Once aortic control is achieved, gain direct access to the vessels through retroperitoneal mobilization and medial rotation of all left-sided abdominal viscera (Mattox maneuver) or an extensive Kocher maneuver on the right side.
- An injured celiac axis may be safely ligated in critical situations.
- Access to the superior mesenteric artery and vein may require transection of the pancreas. Primary repair of this major vessel is usually the first choice; however, ligation, particularly of the venous structures, may be a better option. Significant venous congestion can compromise viability of the bowel.
- Midline inframesocolic hemorrhage or hematoma
- This problem results from infrarenal aortic or IVC injury.
- Obtain exposure by incising the posterior peritoneum in the midline after evisceration of the small bowel and cephalic retraction of the transverse mesocolon, or divide the white line of Toldt adjacent to the cecum and extend cephalad through the hepatic flexure followed by medial rotation of the right colon and small bowel (Cattel-Braasch maneuver).
- Place an aortic clamp just below the left renal vein and apply a distal clamp near the aortic bifurcation. The injury is primarily repaired.
- If the aorta is intact, suspect injury to the IVC and obtain access to the infrahepatic IVC by mobilizing the right colon and duodenum.
- Preferably, repair anterior injuries in transverse fashion. Posterior injuries can be repaired from inside the IVC. Both approaches require proximal and distal control of the vessel.
- Apply a Satinsky clamp or Judd Alyce clamp to the injury.
- Large IVC defects may be repaired by using a patch from the peritoneum.
- In patients with multiple injuries and exsanguinating hemorrhage, ligate the infrarenal IVC.
- Lateral perirenal hematoma or hemorrhage
- This problem suggests injury to the renal vessels or kidneys.
- Exploration after blunt trauma is not necessary in patients with a negative result on abdominal CT scan, preoperative intravenous pyelogram, or arteriogram, or if the hematoma is not expanding.
- Penetrating injury usually indicates a necessity for exploration.
- Obtain vascular control of the ipsilateral renal artery.
- Expose the kidney and clamp the renal vessels if active bleeding from the kidney or an overlying retroperitoneum is present.
- Only 30-40% of kidneys with arterial injuries can be salvaged. Before performing a nephrectomy, assess the viability of the contralateral kidney.
- Lateral pelvic hematoma or hemorrhage
- This problem indicates injury to the iliac artery, iliac vein, or both.
- Obtain vascular control at the aortic bifurcation proximally and close to the inguinal ligament distally.
- If an injury to the right common iliac vein is present, it may require a division of the overlying right common iliac artery.
- For best visualization of the internal iliac artery, elevate the common and external iliac arteries on vascular tapes.
- Repair injuries to the common or external iliac arteries.
- Treat injuries to the iliac veins with lateral venography or ligation.
- Once initial control of the hemorrhage is completed and gross contamination is controlled, terminate the procedure and transfer the patient to the recovery room for further resuscitation. Measurement of abdominal compartment pressure may be needed.
- Hepatoduodenal ligament hematoma
- This problem indicates injury to the portal vein, hepatic artery, or both.
- Obtain vascular control by clamping the porta hepatis with vascular clamps proximal and distal to the injury (double Pringle maneuver).
- Portal vein ligation may be required to expeditiously manage portal vein injuries if the patient is exsanguinating, although primary repair may be attempted.
- Hepatic artery injuries are generally managed by ligation. If portal vein inflow is compromised, the liver should be assessed for ischemia, and restoration of hepatic arterial inflow or resectional debridement of the ischemic section should be undertaken or staged.
Postoperative details
Patients may require aggressive resuscitation involving the correction of acidosis, active rewarming, and massive blood transfusion (>10 U of blood within 24 h).
Fresh frozen plasma, platelets, cryoprecipitate, or recombinant factor VIIa (rFVIIa) may be required on an individual basis to correct coagulopathy induced by massive transfusion.
A planned reoperation 24-48 hours after the initial procedure is done to complete a damage control sequence.
Early
- Ongoing bleeding
- Coagulopathy
- Abdominal compartment syndrome
Late
- Intra-abdominal infections
- Wound dehiscence
- Acute respiratory distress syndrome (ARDS)
- Pneumonia
Mortality
- Suprarenal aorta (60%)
- Superior mesenteric artery (40-80%)
- Superior mesenteric vein (20%)
- Combined injury to the suprarenal aorta and IVC (100%)
- Infrarenal abdominal aorta (50%)
- Infrarenal vena cava (30%)
- Renal artery (15%)
- Iliac artery (40%)
- Iliac vein (30%)
| Media file 1:
Abdominal vascular injuries. Tangential gunshot injury to the inferior vena cava repaired by means of lateral venography (arrow). |
 |  View Full Size Image | |
Media type: Photo
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Abdominal Vascular Injuries excerpt Article Last Updated: Apr 13, 2007
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