Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly

Vascular Trauma

Trauma is a leading cause of death and disability in young adults in developed countries with the high impact on future patient quality of life and productivity. The traumatic injury of the vessels is one of the most dangerous types of injury, requiring a fast and reliable diagnosis and, in vast majority of cases, immediate surgical treatment. In this chapter, the authors describe various types of vascular injuries according to injury types and locations. The prehospital care algorithms in patients with vascular trauma are proposed with the emphasis on bleeding control techniques and transportation technique to the nearest hospital. In the next subsection, the various peripheral vascular injuries of specific body areas are described. The truncal vessel trauma is discussed in the next subsection, focusing on fast diagnosis and decision on surgery. In the last subsection, a problem of iatrogenic vascular injury is described due to a rapid increase of minimally invasive techniques in which a vascular injury, as a complication of therapy, may occur

Foreign Intravascular Object Embolization and Migration: Bullets, Catheters, Wires, Stents, Filters, and More

Foreign intravascular object embolization (FIOE) is an important, yet underreported occurrence that has been described in a variety of settings, from penetrating trauma to intravascular procedures. In this chapter, the authors will review the most common types of FIOEs, including bullet or “projectile” embolism (BPE), followed by intravascular catheter or wire embolization (ICWE), and conclude with intravascular noncatheter object (e.g., coil, gelatin, stent, and venous filter) migration (INCOM). In addition to detailed topic-based summaries, tables highlighting selected references and case scenarios are also presented to provide the reader with a resource for future research in this clinical area

Vertebral artery injuries associated with cervical spine injuries: a review of the literature

Journal ArticleObjective: To determine the incidence of vertebral artery injuries (VAIs) in association with cervical spine trauma and investigate the optimum diagnostic and treatment protocols. Summary of Background Data: VAIs may result from cervical spine trauma and have the potential to cause cerebral, brainstem, and even spinal cord ischemia. Screening and treatment for traumatic VAI are very controversial, with conflicting recommendations within the trauma and spine literature. Methods: A literature review was performed to identify publications pertaining to VAIs associated with cervical spine trauma. These publications were evaluated to determine the incidence, radiographic evaluation, and treatment options of VAIs. Results: Approximately 0.5% of all trauma patients will have a VAI, and 70% of all traumatic VAIs will have an associated cervical spine fracture. Cervical spine translation injuries and transverse foramen fractures are most commonly cited as having a significant association with VAIs. The incidence of neurologic deficits secondary to VAI ranges from 0% to 24% in published series that incorporate a screening protocol for asymptomatic patients. Catheter angiography has been the gold standard for the diagnosis of VAIs; however, new 16-slice computed tomography angiography seems to have sensitivity and specificity close to that of catheter angiography. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments. Although some authors have advocated antithrombotic therapy for most asymptomatic VAIs, there is a lack of class I evidence to support any strong guidelines for treatment. Conclusions: VAIs can occur in association with cervical spine trauma and have the potential for neurological ischemic events. Screening for and treatment of asymptomatic VAIs may be considered, but it is unclear based on the current literature whether these strategies improve outcomes

Wses Position Paper On Vascular Emergency Surgery

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).1

State of the art: noninvasive imaging and management of neurovascular trauma

Neurotrauma represents a significant public health problem, accounting for a significant proportion of the morbidity and mortality associated with all traumatic injuries. Both blunt and penetrating injuries to cervicocerebral vessels are significant and are likely more common than previously recognized. Imaging of such injuries is an important component in the evaluation of individuals presenting with such potential injuries, made all the more important since many of the vascular injuries are clinically silent. Management of injuries, particularly those caused by blunt trauma, is constantly evolving. This article addresses the current state of imaging and treatment of such injuries

Endovascular Treatments of Traumatic Carotid and Vertebral Vascular Injuries

Objective：The purpose of this report is to determine the safety and efficacy of endovascular therapy in the management of craniocervical vascular injuries. Methods : Fifteen patients with traumatic carotid and vertebral lesions were treated using therapeutic endovascular methods. In 13 patients with blunt trauma, five patients had a carotid-cavernous fistula, 8 had a dissecting pseudoaneurysm or arterial dissection. One of two penetrating patients had complete transection of the vertebral artery, and the other had an internal carotid artery-internal jugular vein fistula with two pseudoaneurysms. Endovascular therapy was accomplished by implanting the balloons, porous or polytetrafluoroethylene covered stent, and/or embolic materials including coils or glue. Results : All fistulas and pseudoaneurysms were successfully embolized with coils, glue, or stents. Most of all parent arteries except two patients were preserved. Sacrifice of the parent artery was inevitable in cases of thrombus formation due to coil migration into the parent artery and the existing transaction of the parent artery. No additional surgical procedures for vascular lesions were required. There were no delayed neurological or vascular complications. Additionally, no lesions recurred during follow-up periods (mean 26.9 months). Conclusion : From the author's experiences, the endovascular therapy using stents, balloons, and coils is both feasible and safe in treatment of the traumatic vascular injuries. Long-term follow-up review of these repairs will be requisite to provide a full evaluation of the safety and efficacy of these devices.ope

Spontaneous carotid artery dissection-associated medial changes in a selected autopsy population

Spontaneous carotid artery dissection (SCAD) is a major cause of stroke in young adults, yet its pathogenesis remains unclear. Hereditary connective tissue diseases, hormonal influences, sympathomimetic drugs or upper respiratory tract infections may predispose to dissection. Mechanical stress or minimal trauma may also act as a trigger. Various lesions of the arterial wall have been described in association with SCAD, but no prospective autopsy study to evaluate the presence of these lesions in normal controls was found. We performed a histologic evaluation of the carotid bifurcation and the aortic arch in an autopsy series to establish a baseline anatomy of the bifurcation and to determine whether similar lesions could be observed. In seven of 54 (12.96%) selected cases we observed isolated changes closely resembling those described for medionecrosis, fibromuscular dysplasia, mucoid degeneration and elastinolysis; and in one case, prior carotid artery dissection and coiling with a patent false lumen. Generally, vascular microanatomy in the carotid bifurcation can be highly variable. Lesions similar to those associated with spontaneous dissection are present in controls and appear non-specific for spontaneous dissection. They can be explained as reactive changes of smooth muscle cells (SMC) and the vascular wall in response to various stressors. Recent advances in vascular physiology are discussed to illustrate the concept of SMC phenotypic modulation. Forensic pathology can provide a large control population for extensive vascular analyses and further the understanding of normal and pathological vascular wall changes to help elucidate spontaneous arterial dissection.Spontane Carotisdissektionen (SCAD) sind einer der Hauptgründe für Schlaganfälle im jungen Erwachsenenalter, und doch ist über den Pathomechanismus dieser Erkrankung wenig bekannt. Erbliche Bindegewebserkrankungen, Hormoneinflüsse, sympathomimetische Drogen und virale Infektionen der oberen Atemwege können die Entstehung einer spontanen Dissektion begünstigen, ebenso wie mechanische Belastung oder minimale Traumata. Zahlreiche vaskuläre Läsionen werden im Zusammenhang mit SCAD beschrieben, jedoch gibt es bis heute keine prospektive Studie, die das Vorhandensein derartiger Veränderungen am Gesunden evaluiert. Wir haben eine histologische Untersuchung der Karotisbifurkation und des Aortenbogens anhand einer Kontrollpopulation aus dem Sektionsgut des Zentrums der Rechtsmedizin durchgeführt, um die normale Anatomie der Bifurkation zu beschreiben und festzustellen, ob Läsionen ähnlich der für spontane Dissektion beschriebenen auffindbar sind. In 7 von 54 Fällen (12,96%) wurden isolierte Läsionen oder Veränderungen gefunden, die wie Medionekrose, Fibromuskuläre Dysplasie, Mukoide Mediadegeneration oder Elastinolyse imponieren. In einem Fall fand sich sogar eine ältere Dissektion mit durchgängigem falschen Lumen und Invagination der dissezierten Media. Im allgemeinen ist die Histoanatomie der Karotisbifurkation hoch variabel. Läsionen ähnlich derer bei spontaner Dissektion finden sich in der Kontrollpopulation und sind wahrscheinlich unspezifisch für spontane Dissektion. Sie können als reaktive Veränderungen der Gefäßmuskelzellen und Gefäßwand auf diverse Stressfaktoren und äußere Einflüsse erklärt werden. Aktuelle Erkenntnisse aus der Gefäßphysiologie werden vorgestellt, um den Vorgang der Phänotyp-Modulation von Gefäßmuskelzellen zu illustrieren. Die Bedeutung der forensischen Medizin als Quelle für Kontrollfälle soll unterstrichen werden. Umfangreiche Analysen können so durchgeführt werden und das Verständnis über normale und pathologische Gefäßwände verbessern, um die Hintergründe der spontanen Dissektion besser begreifen zu können