Carotid & Vertebral Artery Injuries Chapter 70. Controversies Pros and cons of duplex versus angiography versus newer modalities Selective versus mandatory.

Carotid & Vertebral Artery Carotid & Vertebral Artery InjuriesInjuries

Chapter 70Chapter 70

ControversiesControversies

Pros and cons of duplex versus Pros and cons of duplex versus angiography versus newer modalitiesangiography versus newer modalities

Selective versus mandatory exploration for Selective versus mandatory exploration for penetrating Zone II injuriespenetrating Zone II injuries

Treatment of patients with comaTreatment of patients with coma

Blunt carotid injuryBlunt carotid injury

Penetrating Carotid Artery TraumaPenetrating Carotid Artery Trauma

EpidemiologyEpidemiology– Young, healthy, intoxicated malesYoung, healthy, intoxicated males– Stab wounds & low velocity missilesStab wounds & low velocity missiles

6% of penetrating neck injuries6% of penetrating neck injuries

22% of all cervical vascular injuries22% of all cervical vascular injuries

– CCA>ICACCA>ICA– Iatrogenic trauma during central line Iatrogenic trauma during central line

placementplacement

Evaluation of Patients with Evaluation of Patients with Penetrating TraumaPenetrating Trauma

Hard signs of vascular injuryHard signs of vascular injury– 8-25% of patients with penetrating neck injury8-25% of patients with penetrating neck injury

ShockShockActive bleedingActive bleedingExpanding hematomaExpanding hematoma

– Require expeditious operative explorationRequire expeditious operative exploration

Soft signs of vascular injurySoft signs of vascular injury– Majority of patientsMajority of patients

History of pulsatile bleedingHistory of pulsatile bleedingSmall, stable hematomaSmall, stable hematomaCranial nerve injuryCranial nerve injuryUnexplained neurologic deficitUnexplained neurologic deficit““Proximity” injury without other signsProximity” injury without other signs

Penetrating Neck TraumaPenetrating Neck TraumaInjuries not penetrating the platysma are Injuries not penetrating the platysma are superficial and require no further workupsuperficial and require no further workup

Zone IIIZone III– Angle of mandible to base of skullAngle of mandible to base of skull

Exposure of this area difficultExposure of this area difficultPharynx; distal carotid and vertebral Pharynx; distal carotid and vertebral arteries; parotid gland; cranial nervesarteries; parotid gland; cranial nerves

Zone IIZone II– Cricoid to angle of mandibleCricoid to angle of mandible

Usually clinically apparent injuriesUsually clinically apparent injuriesCartoid and vertebral arteries; jugular vein, Cartoid and vertebral arteries; jugular vein, larynx; esophagus; trachea; vagus; larynx; esophagus; trachea; vagus; recurrent nerverecurrent nerve

Zone IZone I– Thoracic inlet (sternal notch to cricoid)Thoracic inlet (sternal notch to cricoid)

Injuries to this area have highest mortalityInjuries to this area have highest mortalityProximal carotid, subclavian, vertebral Proximal carotid, subclavian, vertebral arteries; upper lung; esophagus; trachea; arteries; upper lung; esophagus; trachea; CNSCNS

Initial ManagementInitial ManagementAirwayAirway– Endotracheal intubation for any difficulty with Endotracheal intubation for any difficulty with

oxygenation, ventilation, or depressed sensoriumoxygenation, ventilation, or depressed sensorium– Obvious tracheal injury can be treated with ETT into Obvious tracheal injury can be treated with ETT into

the woundthe wound

Bleeding controlled with direct pressureBleeding controlled with direct pressureCXR and lateral C-spine filmsCXR and lateral C-spine filmsMajor vascular injury in Zone II usually clinically Major vascular injury in Zone II usually clinically apparent with significant hematoma or frank apparent with significant hematoma or frank external hemorrhageexternal hemorrhage– Approached by immediate surgical explorationApproached by immediate surgical exploration

Due to difficulties of vascular exposure in Zone I Due to difficulties of vascular exposure in Zone I and III, angiography is needed prior to surgical and III, angiography is needed prior to surgical exploration unless extremely unstableexploration unless extremely unstable

Physical exam normalPhysical exam normal– No hypotension, active bleeding, unequal UE pulses, No hypotension, active bleeding, unequal UE pulses,

expanding neck hematoma, motor function expanding neck hematoma, motor function abnormalities, clavicular fracture, SQ air, stridor, nor abnormalities, clavicular fracture, SQ air, stridor, nor voice abnormalitiesvoice abnormalities

Proposed algorithm for Zone I injuryProposed algorithm for Zone I injury

CONTROVERSY:CONTROVERSY:Optimal approach for patients with Zone II injuriesOptimal approach for patients with Zone II injuriesMANDATORYMANDATORY– Low rate of complications Low rate of complications

with exploration (2.2% and with exploration (2.2% and 0%)0%)

– Potentially devastating Potentially devastating effect of delay in diagnosis effect of delay in diagnosis of aerodigestive injuriesof aerodigestive injuries

– Unreliability of physical Unreliability of physical signs for predicting cervical signs for predicting cervical vascular injuryvascular injury

SELECTIVESELECTIVE– High rate of negative High rate of negative

exploration (40-60%)exploration (40-60%)– Low incidence of Low incidence of

devastating complications devastating complications of delaying therapyof delaying therapy

• Current data shows similar outcome for both approaches

• Selective management include various combinations of physical examination, triple endoscopy, angiography, esophagography, CT scanning, duplex

Zone II Injury Selective WorkupZone II Injury Selective WorkupDemetriades et al, Demetriades et al, Br J SurgBr J Surg ’93 ’93– 176 stable patients undergoing arteriography176 stable patients undergoing arteriography

19% with vascular injury, 8% requiring intervention (all were 19% with vascular injury, 8% requiring intervention (all were symptomatic)symptomatic)Low yield for arteriography in asymptomatic patientsLow yield for arteriography in asymptomatic patients

Fry et al, Fry et al, Am J SurgAm J Surg ’94 ’94– 100 stable patients evaluated100 stable patients evaluated

15 underwent DUS then arteriography15 underwent DUS then arteriography– 1 arterial injury found on DUS confirmed on arteriography1 arterial injury found on DUS confirmed on arteriography

Remaining 85 had arteriography only when DUS abnormalRemaining 85 had arteriography only when DUS abnormal– 7 arterial injuries found on DUS confirmed7 arterial injuries found on DUS confirmed– 2 venous injuries2 venous injuries– Remaining 76 patients with normal DUS were stableRemaining 76 patients with normal DUS were stable

Frykberg et al, Frykberg et al, J Vasc SurgJ Vasc Surg ’00 ’00– 145 prospective injuries studied145 prospective injuries studied

91 patients with isolated Zone II injuries observed without sequelae91 patients with isolated Zone II injuries observed without sequelae23 patients underwent arteriography with 3 injuries23 patients underwent arteriography with 3 injuriesMissed injury rate 0.9%Missed injury rate 0.9%

CT-A for Neck InjuryCT-A for Neck InjuryGonzalez, et al. J Trauma ‘03Gonzalez, et al. J Trauma ‘03– 42 prospective patients with Zone II underwent CT + esophagography, 42 prospective patients with Zone II underwent CT + esophagography,

then explorationthen exploration4 esophageal injuries (2/4 on CT, 2/4 on esoph)4 esophageal injuries (2/4 on CT, 2/4 on esoph)7 IJ injuries (4/7 on CT)7 IJ injuries (4/7 on CT)

Gracias, et al. Arch Surg ‘01Gracias, et al. Arch Surg ‘01– 23 patients with penetrating neck injuries underwent CT initially23 patients with penetrating neck injuries underwent CT initially

13 patients no injury (4 discharged from ED)13 patients no injury (4 discharged from ED)10 patients had angiography, 2 required endoscopy due to proximity10 patients had angiography, 2 required endoscopy due to proximity

Mazolewski, et al. J Trauma ‘01Mazolewski, et al. J Trauma ‘01– 14 prospective patients with Zone II injuries underwent CT, then 14 prospective patients with Zone II injuries underwent CT, then

mandatory explorationmandatory exploration4 scans deemed high probability, 3 had surgical injury4 scans deemed high probability, 3 had surgical injuryNo missed injuriesNo missed injuries

Munera, et al. Radiology ‘02Munera, et al. Radiology ‘02– 175 patients with penetrating neck injuries175 patients with penetrating neck injuries

Injuries idenitified in 27 patients (15.6%), observation in 146Injuries idenitified in 27 patients (15.6%), observation in 146Sensitivity 90%, specificity 100%, PPV 100%, NPV 98%Sensitivity 90%, specificity 100%, PPV 100%, NPV 98%One missed injury of pseudoaneurysm at common carotid originOne missed injury of pseudoaneurysm at common carotid origin

Surgical ManagementSurgical ManagementAll significant penetrating carotid artery lesions should be All significant penetrating carotid artery lesions should be repaired when technically feasiblerepaired when technically feasible– Primary repairPrimary repair– Patch angioplastyPatch angioplasty– Internal-to-external carotid artery transpositionInternal-to-external carotid artery transposition– Interposition graftInterposition graft

Controversy surrounds carotid injuries to patients with Controversy surrounds carotid injuries to patients with comacoma– Initial anecdotal reports of conversion of ischemic infarcts to Initial anecdotal reports of conversion of ischemic infarcts to

hemorrhagic infarctshemorrhagic infarcts– Recent evidence that most deficits remain unchanged or Recent evidence that most deficits remain unchanged or

improveimprove– Collected seriesCollected series

28 comatose patients treated with ligation (61% mortality, 14% good 28 comatose patients treated with ligation (61% mortality, 14% good outcome)outcome)42 comatose patients repaired (26% mortality, 50% good outcome)42 comatose patients repaired (26% mortality, 50% good outcome)

Minor carotid injury (intimal defect or small Minor carotid injury (intimal defect or small pseudoaneurysm)pseudoaneurysm)– Nonoperative management in neurologically intact patients safeNonoperative management in neurologically intact patients safe

Outcomes/Future DirectionsOutcomes/Future Directions

Mortality 17%Mortality 17%

Stroke rate 28%Stroke rate 28%– Higher if coma or shock present (50% & 41%)Higher if coma or shock present (50% & 41%)

Endovascular case reports for Zone I and Endovascular case reports for Zone I and III injuriesIII injuries

Blunt Carotid Artery TraumaBlunt Carotid Artery Trauma

Accounts for 3-10% of carotid injuryAccounts for 3-10% of carotid injury4 mechanisms4 mechanisms– Cervical hyperextension-rotation (most common)Cervical hyperextension-rotation (most common)– Direct blow to the neckDirect blow to the neck– Intraoral traumaIntraoral trauma– Basilar skull fractureBasilar skull fracture

Injuries results in dissection, thrombosis, Injuries results in dissection, thrombosis, pseudoaneurysm formation, carotid-cavernous pseudoaneurysm formation, carotid-cavernous sinus fistula, complete disruptionsinus fistula, complete disruptionDistal ICA>CCA (90%:10%)Distal ICA>CCA (90%:10%)

Diagnostic EvaluationDiagnostic Evaluation

Diagnosis of blunt carotid injuries increased due Diagnosis of blunt carotid injuries increased due to heightened awareness and more aggressive to heightened awareness and more aggressive screeningscreening– Fabian et al, Fabian et al, Ann SurgAnn Surg ’96 ’96

96 cases reported up to 1980, 75 cases in 80s, 309 cases 96 cases reported up to 1980, 75 cases in 80s, 309 cases from ’90-’95from ’90-’95

Optimal screening modality not establishedOptimal screening modality not established– 4 vessel cerebral angiograms not cost-effective4 vessel cerebral angiograms not cost-effective– DUS has difficulty with high ICA lesionsDUS has difficulty with high ICA lesions– CT-A (Berne et al, CT-A (Berne et al, J TraumaJ Trauma ’04) recently thought to ’04) recently thought to

be best screening testbe best screening test

Grading SystemGrading System

Grade I: mild injuryGrade I: mild injury– Most (66%) heal even without treatmentMost (66%) heal even without treatment

Grade II: dissection or hematoma with Grade II: dissection or hematoma with luminal stenosisluminal stenosis

Grade III: pseudoaneurysmGrade III: pseudoaneurysm

Grade IV: carotid occlusionGrade IV: carotid occlusion

Grade V: transectionGrade V: transection– Usually lethal and not amendable to treatmentUsually lethal and not amendable to treatment

Treatment/OutcomesTreatment/Outcomes

Carotid-cavernous sinus fistulaeCarotid-cavernous sinus fistulae– Balloon occlusion techniquesBalloon occlusion techniques

Dissection, thrombosis, pseudoaneurysm have Dissection, thrombosis, pseudoaneurysm have varied approachesvaried approaches– Recent literature supports nonsurgical management Recent literature supports nonsurgical management

for dissections and thrombosisfor dissections and thrombosisSystemic heparinization followed by 3-6 mo coumadinSystemic heparinization followed by 3-6 mo coumadin

– Pseudoaneurysms should be surgically repairedPseudoaneurysms should be surgically repaired

Prognosis is generally poorPrognosis is generally poor– Mortality rates 5-43%Mortality rates 5-43%– Good neurological outcomes in only 20-63% of Good neurological outcomes in only 20-63% of

survivorssurvivors

Vertebral Artery TraumaVertebral Artery TraumaExceedingly rareExceedingly rare– 2 largest series have 43 and 47 patients2 largest series have 43 and 47 patients

Clinical presentation and outcomes related to associated Clinical presentation and outcomes related to associated injuriesinjuries– 70-80% of patients with vertebral artery injury have no evidence 70-80% of patients with vertebral artery injury have no evidence

of arterial trauma on examof arterial trauma on exam– Usually diagnosed on angiography or CT-A for neurologic Usually diagnosed on angiography or CT-A for neurologic

deficitsdeficits

Most injuries (AV fistulae and pseudoaneurysms) can be Most injuries (AV fistulae and pseudoaneurysms) can be managed with proximal and distal artery occlusionmanaged with proximal and distal artery occlusion– Surgical ligation versus endovascular coilingSurgical ligation versus endovascular coiling– Vertebral occlusion can be observedVertebral occlusion can be observed

Occasionally some risk of rebleedingOccasionally some risk of rebleeding

– Arterial repair reserved for rare circumstance when preoperative Arterial repair reserved for rare circumstance when preoperative arteriography suggest inadequate collateral circulationarteriography suggest inadequate collateral circulation

Major Venous TraumaMajor Venous Trauma

Operative exposure for venous injuries should Operative exposure for venous injuries should follow adjacent arteries/arterial injuriesfollow adjacent arteries/arterial injuriesSevere injuries to innominate, IJ, subclavian Severe injuries to innominate, IJ, subclavian veins can be ligatedveins can be ligated– Definite treatment option for unstable patients or Definite treatment option for unstable patients or

those with significant other injuriesthose with significant other injuries– Lateral venorrhaphy can be attempted if >50% Lateral venorrhaphy can be attempted if >50%

luminal sizeluminal size

SVC or bilateral innominate/IJ injuries can be SVC or bilateral innominate/IJ injuries can be considered for repair to prevent SVC syndrome considered for repair to prevent SVC syndrome or acute cerebral edemaor acute cerebral edema

SummarySummaryHard signs of vascular injury mandate operative Hard signs of vascular injury mandate operative explorationexplorationGood results can be obtained with mandatory Good results can be obtained with mandatory exploration, routine arteriography or DUS or CT-A, or exploration, routine arteriography or DUS or CT-A, or physical examination alone in properly selected patientsphysical examination alone in properly selected patients– Adopted approach should be based on experience, volume, Adopted approach should be based on experience, volume,

local diagnostic capabilities, and personnel resourceslocal diagnostic capabilities, and personnel resources

All significant penetrating carotid artery lesions should be All significant penetrating carotid artery lesions should be repaired when technically feasiblerepaired when technically feasibleDiagnosis of blunt carotid injury requires high index of Diagnosis of blunt carotid injury requires high index of suspicion, but optimal screening tool remains suspicion, but optimal screening tool remains controversialcontroversialNonsurgical treatment and anticoagulation is the Nonsurgical treatment and anticoagulation is the mainstay of treatment for most blunt carotid injuriesmainstay of treatment for most blunt carotid injuriesVertebral artery injuries are rare and treated by exclusion Vertebral artery injuries are rare and treated by exclusion of the injured artery from the posterior circulationof the injured artery from the posterior circulation