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Stafforini N, Murphy B, Singh N, Quiroga E. Evolving Strategies for the Management of Carotid Artery Injuries due to Penetrating Trauma. Ann Vasc Surg 2024:S0890-5096(24)00609-5. [PMID: 39413996 DOI: 10.1016/j.avsg.2024.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 09/23/2024] [Accepted: 09/30/2024] [Indexed: 10/18/2024]
Affiliation(s)
| | - Blake Murphy
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Elina Quiroga
- Division of Vascular Surgery, University of Washington, Seattle, WA.
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Muñoz CA, Hadad AG, González P, Burgos A, Ordoñez CA, Serna JJ. Carotid artery penetrating trauma: Report of 4 cases and literature revision. Int J Surg Case Rep 2024; 121:109940. [PMID: 38971033 PMCID: PMC11269920 DOI: 10.1016/j.ijscr.2024.109940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE In penetrating neck trauma, carotid artery penetrating trauma is considered one of the most complicated injuries to treat. Active bleeding, large hematomas, and rapid occlusion of the airways make the surgical approach to controlling bleeding and repairing the vessel much more complex, constituting an essential clinical challenge to every surgeon. CASE PRESENTATION We present 4 cases of patients with carotid artery penetrating trauma. Two patients were treated with endovascular therapy, one with surgery, and the fourth one treated conservatively. None of the patients had posterior neurological impairment. CLINICAL DISCUSSION Carotid artery penetrating trauma is uncommon yet is associated with high rates of mortality and neurological impairment. The common carotid artery is the most frequently injured, and gunshot wounds (GSW) are the most frequent trauma mechanism. Angiotomography (CTA) is the first-line exam for diagnosing these injuries. Treatment should be prompt and individualized and may include conservative techniques, endovascular therapy, and traditional surgical repair. CONCLUSION Carotid artery penetrating trauma is an uncommon but complex injury that requires a timely diagnosis and treatment to avoid potentially devastating consequences, particularly in hemodynamically unstable patients. Traditionally, the treatment strategies for these injuries used to be limited to vascular repair or ligation. However, endovascular therapy and conservative management are viable alternatives, which have become more and more useful in selected patients, allowing less invasive approaches with fewer morbidity and acceptable results.
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Affiliation(s)
- Carlos Andres Muñoz
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia.
| | - Adolfo González Hadad
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia.
| | - Paola González
- Departamento de Cirugía General, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Alejandro Burgos
- Departamento de Cirugía General, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Carlos Alberto Ordoñez
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia; Departamento de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - José Julián Serna
- Departamento de Cirugía de Trauma y Emergencias, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia; Departamento de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
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Przeslawski C, Knaggs M, Habib PM, Ghamraoui A, Wahl C, Gerken J. A Penetrating Neck Injury Resulting in the Complete Transection of the Ipsilateral Common Carotid Artery, Delayed Contralateral Pneumothorax, and Occult Esophageal Injury: A Case Report With a Multidisciplinary Approach to Management. Cureus 2024; 16:e56988. [PMID: 38665745 PMCID: PMC11045256 DOI: 10.7759/cureus.56988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
A 29-year-old male presented with a zone one penetrating neck injury resulting in complete transection of the left carotid sheath and its contents. The proximal common carotid artery and internal jugular vein injuries were successfully managed with vessel ligation without adverse neurological sequelae. The patient also developed a contralateral pneumothorax, which was due to an occult through-and-through esophageal injury at the junction of the cervical and thoracic esophagus. The esophageal injury was successfully managed with surgical repair and wide drainage of the neck and right chest.
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Affiliation(s)
| | - Michaela Knaggs
- General Surgery, Beaumont Hospital - Farmington Hills Campus, Farmington Hills, USA
| | - Peter M Habib
- Osteopathic Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, USA
- General Surgery, Beaumont Hospital - Farmington Hills Campus, Farmington Hills, USA
| | - Ahmed Ghamraoui
- Vascular Surgery, Beaumont Hospital - Farmington Hills Campus, Farmington Hills, USA
| | - Caitlin Wahl
- Thoracic Surgery, Beaumont Hospital - Farmington Hills Campus, Farmington Hills, USA
| | - Jeffrey Gerken
- General Surgery, Beaumont Hospital - Farmington Hills Campus, Farmington Hills, USA
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Góes AMDO, Parreira JG, Kleinsorge GHD, Dalio MB, Alves PHF, Gomes FJSDDV, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian guidelines on diagnosis and management of traumatic vascular injuries. J Vasc Bras 2023; 22:e20230042. [PMID: 38021277 PMCID: PMC10647898 DOI: 10.1590/1677-5449.202300422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.
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Affiliation(s)
- Adenauer Marinho de Oliveira Góes
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Centro Universitário do Pará - CESUPA, Faculdade de Medicina, Belém, PA, Brasil.
- Universidade Federal do Pará - UFPA, Faculdade de Medicina, Belém, PA, Brasil.
| | - José Gustavo Parreira
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil.
| | - Gustavo Henrique Dumont Kleinsorge
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Fundação Hospitalar do Estado de Minas Gerais - FHEMIG, Clínica de Cirurgia Vascular, Hospital João XXIII, Belo Horizonte, MG, Brasil.
| | - Marcelo Bellini Dalio
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade de São Paulo - USP, Divisão de Cirurgia Vascular e Endovascular, Hospital das Clínicas, Ribeirão Preto, SP, Brasil.
| | - Pedro Henrique Ferreira Alves
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, III Clínica Cirúrgica, São Paulo, SP, Brasil.
| | - Francisco João Sahagoff de Deus Vieira Gomes
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Sociedade Brasileira de Atendimento Integrado ao Traumatizado - SBAIT, São Paulo, SP, Brasil.
- Universidade do Estado do Rio de Janeiro - UERJ, Faculdade de Ciências Médicas, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
- Polícia Militar do Estado do Rio de Janeiro - PMERJ, Rio de Janeiro, RJ, Brasil.
| | - Walter Junior Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade Federal do Paraná - UFPR, Hospital das Clínicas, Divisão de Angiorradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade de São Paulo - USP, Divisão de Cirurgia Vascular e Endovascular, Hospital das Clínicas, Ribeirão Preto, SP, Brasil.
| | - Julio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular - SBAC, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro - UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Plotkin A, Weaver FA, Owattanapanich N, Byerly S, Schellenberg M, Inaba K, Magee GA. Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries. J Vasc Surg 2023; 78:920-928. [PMID: 37379894 DOI: 10.1016/j.jvs.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.
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Affiliation(s)
- Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Natthida Owattanapanich
- Division of Trauma and Acute Care Surgery, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| | - Saskya Byerly
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Morgan Schellenberg
- Division of Trauma and Acute Care Surgery, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| | - Kenji Inaba
- Division of Trauma and Acute Care Surgery, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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Choi KK, Cho J, Lee MA, Eun SM, Jeon YB. Successful management of a common carotid artery injury using a Pruitt-F3 Carotid Shunt: a case report. JOURNAL OF TRAUMA AND INJURY 2022; 35:S3-S7. [PMID: 39381172 PMCID: PMC11309161 DOI: 10.20408/jti.2021.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 11/05/2022] Open
Abstract
Penetrating neck injuries are a surgical challenge. In particular, penetrating neck injuries associated with carotid artery injuries have a high mortality rate. Overt external hemorrhage is unanimously considered as an indication for surgical exploration. The authors present a case of successful surgical management for a penetrating common carotid artery injury using a Pruitt-F3 Carotid Shunt (LeMaitre Vascular Inc., Burlington, MA, USA) in a 60-year-old male patient who was transferred to the level 1 trauma center due to a metal fragment piercing his neck while working. Active pulsatile bleeding was observed from the 3-cm-long external wound on the anterior neck in zone II. Emergent neck exploration showed near-total transection of the left common carotid artery just below the carotid bifurcation. After a Pruitt-F3 Carotid Shunt was applied to the injured carotid artery as a temporary vascular shunt, artificial graft interposition was performed for the injured common carotid artery. The patient experienced cerebral infarction as a complication caused by ischemia-reperfusion of the common carotid artery but was discharged in a suitable state for rehabilitation therapy.
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Affiliation(s)
- Kang Kook Choi
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jayun Cho
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Min A Lee
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Soo Min Eun
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Yang Bin Jeon
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Ronaldi AE, Polcz JE, Robertson HT, Walker PF, Bozzay JD, Dubose JJ, White PW, Rasmussen TE, White JM. A multi-registry analysis of military and civilian penetrating cervical carotid artery injury. J Trauma Acute Care Surg 2021; 91:S226-S232. [PMID: 34039922 DOI: 10.1097/ta.0000000000003296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Penetrating cervical carotid artery injury is an uncommon but high-stake scenario associated with stroke and death. The objective of this study was to characterize and compare penetrating carotid injury in the military and civilian setting, as well as provide considerations for management. METHODS Cohorts with penetrating cervical carotid artery injury from the Department of Defense Trauma Registry (2002-2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012-2018) were analyzed. A least absolute shrinkage and selection operator multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality. RESULTS There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo nonoperative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds, 2.1; p < 0.001) and internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds, -0.21 per point; p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds, 0.05 per point; p = 0.005). CONCLUSION The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke. LEVEL OF EVIDENCE Retrospective cohort analysis, level III.
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Affiliation(s)
- Alley E Ronaldi
- From the Department of Surgery (A.E.R., J.E.P., P.F.W., J.D.B., P.W.W., T.E.R., J.M.W.), Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Surgical Critical Care Initiative, Bethesda (H.T.R.); and R Adams Cowley Shock Trauma Center (J.J.D.), University of Maryland Medical System, Baltimore, Maryland
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