Approaches to trauma involving the major vessels of the thorax

Lessons Learned From Treating 114 Inferior Vena Cava Injuries at a Limited Resources Environment - A Single Center Experience

BACKGROUND

The inferior vena cava is the most frequently injured vascular structure in penetrating abdominal trauma. We aimed to review inferior vena cava injury cases treated at a limited resources facility and to discuss the surgical management for such injures.

METHODS

This was a retrospective study of patients with inferior vena cava injuries who were treated at a single center between January 2011 and January 2020. Data pertaining to the following were assessed: demographic parameters, hypovolemic shock at admission, the distance that the patient had to be transported to reach the hospital, affected anatomical segment, treatment, concomitant injuries, complications, and mortality. Non-parametric data were analyzed using Fisher's exact, Chi-square, Mann-Whitney, or Kruskal-Wallis test, as applicable. The Student's t-test was used to assess parametric data. Moreover, multiple logistic regression analyses (including data of possible death-related variables) were performed. Statistical significance was set at P <0.05.

RESULTS

Among 114 patients with inferior vena cava injuries, 90.4% were male, and the majority were aged 20-29 years. Penetrating injuries accounted for 98.2% of the injuries, and the infrarenal segment was affected in 52.7% of the patients. Suturing was perfomed in 69.5% and cava ligation in 29.5% of the patients, and 1 patient with retrohepatic vena cava injury was managed non-operatively. The overall mortality was 52.6% with no case of compartment syndrome in the limbs. A total of 7.9% of the patients died during surgery.

CONCLUSION

The inferior vena cava is often injured by penetrating mechanisms, and the most frequently affected segment was the infrarenal segment. A higher probability of death was not associated with injury to a specific anatomical segment. Additionally, cava ligation was not related to an increased probability of compartment syndrome in the leg; therefore, prophylactic fasciotomy was not supported.

State of the Art Imaging Review of Blunt and Penetrating Cardiac Trauma

Traumatic cardiovascular injuries are only second to the central nervous system injuries as a cause of death in young adult population. Multidetector computed tomography is the gold standard diagnostic modality in patients with blunt or penetrating chest trauma and clinical suspicion of cardiac injury. The imaging spectrum of cardiac injuries includes but not limits to pericardial rupture, myocardial contusions, valve rupture, coronary artery injuries, cardiac herniations, and cardiac tamponade. In this review article, we discuss clinical presentation, types, and mechanism of cardiac trauma with emphasis on the imaging findings and illustrations in blunt, penetrating traumatic, and iatrogenic cardiac injuries.

Efficacy and safety of TEVAR with debranching technique for blunt traumatic aortic injury in patients with severe multiple trauma

BACKGROUND

Blunt traumatic aortic injury (BTAI) patients are severely ill, with high mortality and morbidity. As 60% of BTAIs occur in the distal arch, left subclavian artery (LSCA) management is determined without knowing posterior cerebral or left arm circulation in emergent cases. Because we perform thoracic endovascular aortic repair (TEVAR) + debranching technique for thoracic BTAI, we assessed efficacy and safety of debranching TEVAR in BTAI patients.

METHODS

We retrospectively reviewed vital signs on arrival, injury mechanism, characteristics, clinical time-series, concomitant injuries, injury description, operative procedures, and results from patient records. We excluded patients in cardiopulmonary arrest on arrival.

RESULTS

From April 2014 to December 2018, nine of 25 patients admitted with BTAI underwent TEVAR. Median Injury Severity Score was 34 (29-34) and probability of survival was 0.82 (0.16-0.94). Society for Vascular Surgery BTAI injury grade was III or IV in all patients. Three patients underwent simple TEVAR and six underwent debranching TEVAR (LSCA occlusion + left common carotid artery to LSCA bypass). Median operation time was 108 (75-157) min for simple TEVAR and 177 (112-218) min for debranching TEVAR. Concomitant injuries included intracranial hemorrhage (N = 1), intra-abdominal injuries (N = 3), pneumo- or hemothoraxes (N = 4) and pelvic/extremities fractures (N = 7). Only one complication of left-hand claudication occurred postoperatively in a patient with simple TEVAR with LSCA occlusion.

CONCLUSION

Despite debranching TEVAR taking approximately 60 min longer than simple TEVAR, short-term results indicated it to be acceptable for BTAI in multiple trauma patients to avoid LSCA complications unless we fail to stop bleeding first.

Operating on penetrating trauma to the mediastinal vessels

BACKGROUND AND AIMS

Patients with penetrating trauma of the major vessels of the chest are infrequently encountered. This is due to the fact that the majority of these patients die on scene, as well as due to the overall dramatic decline in the incidence of penetrating trauma in the Western world. A certain proportion of survivors are physiologically stable and can be transferred to adequate care. Patients who are physiologically unstable must be dealt with by the surgeons available without delay. Rapid diagnosis and operation can salvage patients who would otherwise be lost, and all general surgeons should be capable of recognizing these injuries and intervening if a trauma and/or cardiothoracic surgeon is not immediately available.

MATERIAL AND METHODS

Technical description of practical emergency surgery approaches to patients bleeding to death from penetrating mediastinal vessel injuries.

RESULTS

The scope of this review familiarizes the "uninitiated" surgeon with the operative management of this rare and lethal type of injuries. Technical aspects are described, and pitfalls as well as tips and tricks of the trade are discussed.

CONCLUSIONS

Patients with penetrating injuries to the mediastinal vessels can be saved by swift and knowing operative management of this rare and lethal type of injuries, even if a trauma and/or cardiothoracic surgeon is not immediately available.

[Surgical accesses to the major mediastinal vessels in thoracic trauma]

Trauma is the most common cause of death in the economically active population and thoracic trauma is directly or indirectly responsible for one quarter of these deaths. Lesions to the large thoracic vessels are associated with immediate or early death in the hospital setting. Patients admitted alive can be classified as stable or unstable. The access route to be elected for management of these veins will depend on this status, as well as on the anatomical particularities of the patient, which may require combined incisions for adequate access. This article provides a review and discussion of lesions to these structures as well as access routes to them.

Overview of Great Vessel Trauma

Traumatic injury to the aorta and the brachiocephalic branches are potentially lethal injuries. Specialized preoperative imaging and medical management can lead to better outcomes in this group of patients. In addition, improved surgical techniques for spinal cord protection have led to decreased morbidity in surgical candidates. TEVAR remains a promising technique; however, long-term data currently are not available.

Anatomic exposures for vascular injuries

The exposure of vascular injuries is contingent on knowledge of anatomy and the limitations and boundaries for proximal and distal control of each artery. In this article, these are conveniently organized into arteries of the neck, of the chest, of the abdomen, and of the extremities. In addition, the interface between the neck and chest, and the chest and the abdomen provide particular challenges because of the need to expose two body regions frequently. The anatomy, the points of proximal and distal control, the details of exposure, and the key maneuvers required to expose particular arteries are reviewed.

Thoracic aortic and thoracic vascular injuries

Patients with thoracic vascular injuries fall into two groups: those who are exsanguinating and require an empiric operation with a high mortality and those with contained injuries that permit preoperative evaluation. The unstable group requires judgment to determine the appropriate empiric position, exposure, and operation. Unlike abdominal trauma, which is addressed by way of a midline incision, there are multiple thoracic incisions that can be used to access thoracic vascular injuries. Thus, the stable group may benefit from preoperative imaging, which then can suggest a patient position, incision, and operative approach. Avoiding overaggressive resuscitation, obtaining appropriate imaging studies, choosing an operative strategy to achieve proximal and distal control, and using adjuncts based on the injury can make the care of these patients a rewarding but challenging activity.

Blunt traumatic rupture of the thoracic aorta: a report of an unusual mechanism of injury

Classic teaching suggests that blunt thoracic aortic rupture (BTAR) results from high-speed deceleration injury mechanisms. Our recent experience with a patient who sustained fatal aortic rupture resulting from a low-speed crushing injury emphasizes the importance of maintaining a high index of suspicion for BTAR, even in patients with "low-risk" injury mechanisms. Several potential pathophysiologic mechanisms of BTAR are discussed.

Heparinless partial cardiopulmonary bypass for the repair of aortic trauma

OBJECTIVE

We hypothesized that partial cardiopulmonary bypass with a heparin-bonded system would be a technically simple, effective adjunct for reducing paraplegia during repair of traumatic aortic rupture. It avoids the risk of heparin, but, unlike left atrial-arterial bypass, it can heat, cool, oxygenate, and rapidly infuse volume if needed.

METHODS

A retrospective review was conducted of patients admitted for aortic trauma from July 1994 to December 1999. Bypass consisted of femoral venous (right atrial) cannulation, a centrifugal pump, and an oxygenator-heater/cooler. Arterial return was to the femoral artery or distal aorta. The entire system was heparin-bonded and no systemic heparin was given.

RESULTS

Heparin-bonded partial bypass was established in 50 patients (mean age 43 +/- 17 years). Crossclamp time was 32 +/- 11 minutes (range 14-70 minutes), mean flow 3.0 +/- 0.8 L/min, and bypass time 64 +/- 43 minutes. During repair, 58% of patients received volume through the system (mean 1.1 +/- 1.9 L). Core temperature rose slightly (35.9 degrees C +/- 0.7 degrees C to 36.3 degrees C +/- 0.8 degrees C). Three of the 15 patients who underwent percutaneous femoral arterial and venous cannulation concomitant with their angiograms had vessel injury, with one limb loss, and this procedure was discontinued. Thirty-five patients underwent percutaneous femoral vein and direct distal aortic cannulation without event. The mortality rate for patients supported by bypass was 10%, and all deaths were due to other injuries. There were no new cases of paraplegia and no worsening of intracranial or pulmonary injuries.

CONCLUSIONS

Heparin-bonded bypass is technically simple to use and avoids the risk of anticoagulation. Paraplegia was avoided. The ability to correct hypothermia, oxygenate, and rapidly infuse volume may simplify management and improve outcomes.

Main pulmonary artery laceration after blunt trauma: accurate preoperative diagnosis

Blunt chest trauma is associated with a variety of lethal injuries, many of which are responsible for prehospital mortality. Major intrathoracic vascular injury accounts for a vast majority of these fatal injuries. Patients surviving after main pulmonary artery injury are rare. We present the case of a patient who sustained a main pulmonary artery laceration as a result of a blunt motor vehicle crash. He was diagnosed accurately by computed tomography and underwent successful repair.

Antero-superior approaches in the practice of thoracic surgery

OBJECTIVE

To review our experience using antero-superior approaches for resection of a heterogeneous group of tumors, both benign and malignant, involving the thoracic inlet and adjacent structures. These included Pancoast type bronchial carcinomas, primary neurogenic tumors, soft-tissue neoplasms, and metastases from a variety of primary sites.

METHODS

Between October 1993 and January 1998 we undertook 22 operations on 21 patients using a variety of antero-superior approaches. The anterior cervical-transsternal approach was used in 11 operations, the Dartevelle technique was used in five cases, the modification described by Nazari in one patient and that described by Grunenwald in five cases.

RESULTS

21 of the 22 operations were considered to be complete resections with negative margins. There were no intraoperative or postoperative deaths. Major complications occurred in five patients; acute respiratory distress syndrome (n = 4), and thrombosis of the arterial graft and acute respiratory distress syndrome (n = 1). Chronic morbidity was observed in 12 patients; prolonged arm pain (n = 1), arm edema (n = 2), motor and sensory deficits (n = 2), phrenic nerve paresis (n = 1), disfigurement and instability of the pectoral girdle (n = 4), and disturbances in shoulder girdle function (n = 2).

CONCLUSIONS

The anterior cervical-transsternal approach we previously described provides adequate exposure for the resection of neurogenic tumors originating in the brachial plexus and sympathetic chain, and for metastatic nodal disease at the base of the neck or in the superior mediastinum. We have found it to be associated with little morbidity, the postoperative stay has been short, and it has proven flexible enough to cope with the changed circumstances found at surgery. For Pancoast type bronchogenic carcinomas and other malignancies with extensive invasion of major structures at the thoracic inlet, we believe the best present option is the clavicle sparing antero-superior technique described by Grunenwald as a modification of the Dartevelle approach. When operating for lung cancer we presently feel that the antero-superior approach should be combined with a posterolateral thoracotomy, to accomplish complete intraoperative staging and undertake anatomical pulmonary resection under optimal conditions.

Trauma pneumonectomy revisited: the role of simultaneously stapled pneumonectomy

OBJECTIVE

The aim of this study was to compare simultaneously stapled pneumonectomy (SSP) with individual ligation (IND) as a method for performing urgent pneumonectomy (Py) for trauma.

METHODS

Twelve patients who required Py were reviewed. SSP was performed in nine cases and IND in three cases. The two groups had statistically similar injury severity scores, presenting systolic blood pressures, and Trauma and Injury Severity Score derived probabilities of survival. An animal model of Py was developed, in which seven animals underwent SSP and seven underwent IND methods. Burst pressures of the pulmonary artery and bronchus were calculated after 14 days.

RESULTS

There were no differences noted in survival rates between SSP (5 (56%)) and IND (1 (33%)), nor in incidence of bronchopleural fistula. The SSP group had a significantly shorter operative time compared with that of IND (88.9 +/- 14.3 minutes vs 213 +/- 57.8 minutes, respectively, p - 0.01). The animal study revealed no difference in burst pressures of the bronchus (SSP = 662.9 +/- 169.9 mm Hg vs. IND = 591.4 +/- 193.2 mm Hg, p = 0.752) or of the pulmonary artery (SSP = 554.3 +/- 195.1 mm Hg vs. IND = 477.7 +/- 247.5 mm Hg, p = 0.529).

CONCLUSION

Survival after pulmonary injuries that require Py depends upon the rapidity of hilar control and of the procedures itself. Simultaneously stapled pneumonectomy is an effective and rapid method of dealing with such rare injuries.

[Traumatic rupture of the aortic isthmus in a patient with severe head injury]

A 32-year-old man sustained a severe head injury in a road traffic accident. On admission, he was in deep coma (6 on the Glasgow coma scale). The aortic knuckle was difficult to identify on a plain chest film. Twenty hours after admission, the aortic knuckle had completely disappeared and the mediastinal shadow had become enlarged. The diagnosis of a ruptured aortic isthmus was confirmed by angiography. Surgical repair of this lesion may be carried out either with simple aortic cross-clamping, or by using cardiopulmonary bypass (CPB). Either technique may worsen other injuries, especially head injury, by initiating severe arterial hypertension or coagulation disturbances. In this patient, the technique chosen was aortic cross-clamping with permanent monitoring of the intracranial and cerebral perfusion pressures. Anaesthesia was obtained with 5 mg.kg-1 of thiopentone, 30 mg.kg-1 x h-1 of sodium gamma hydroxybutyrate and 8 micrograms.kg-1 x h-1 of fentanyl. Surgery lasted for 90 min, with 33 min of aortic clamping. The increase in arterial blood pressure was controlled with 0.25 mg.kg-1 x h-1 of thiopentone and nicardipine which was stopped 8 min before unclamping. The postoperative course was uneventful. Sedation was stopped after 8 days, and the patient regained consciousness two days later. These remained a paraplegia with no sensory deficit, which had totally receded 15 months later. Carrying out this emergency surgery without CPB means that the intracranial pressure must imperatively be monitored during surgery. Any intracranial hypertension should delay the surgery.

Delayed death from aortic root trauma

A 40-year-old man suffered blunt chest trauma, had a myocardial infarct 58 days later, and died unexpectedly 19 days after that. Autopsy showed partial avulsion of a small branch of the right coronary artery with thrombus extending into the right coronary sinus of Valsalva occluding the right coronary artery and causing a myocardial infarct. Death was caused by a thromboembolus arising from the aortic root thrombus and occluding the left main coronary artery. The case is unusual in that the major consequences of the aortic root trauma were delayed, and death resulted from occlusion of both coronary arteries.