Abdominal vascular trauma

Proper hepatic artery transection followed by blunt abdominal trauma: A case report and review of literature

Abdominal vascular injuries, especially in the celiac trunk, are uncommon in blunt trauma, yet their life-threatening nature necessitates rapid surgical interventions to control possible massive bleedings. Damage control surgery principles may aid management. It is crucial to thoroughly assess all trauma patients, even in instances of initial normal physical examinations.

Iatrogenic Vascular Injuries in Resource-Limited Setting: A 4-Year Experience Monocentric Retrospective Study

Background

Iatrogenic vascular injuries (IVIs) due to diagnostic and therapeutic interventions are known but rare or probably under-reported. We present our four-year findings on patients with IVIs after catheterization or surgery who underwent vascular surgical repairs in a resource-limited setting.

Methods

A retrospective case series study between Jun 2018 and Sep 2022 of 35 patients diagnosed with IVIs and treated surgically at our hospital was included. The data on IVIs including patient characteristics, causes and type of injury, treatment, and outcomes were collected and analyzed.

Results

The mean age was 37.12± 17.0 years, and most patients (65.7%) were male. Of the 35 IVIs, 21 were caused by percutaneous procedures, while 14 occurred intraoperatively and affected various arteries and veins. The main injured vessels were the femoral artery (20%) and direct blood vessel puncture made by non-qualified specialists (42.9%) during dialysis cannulation was the main cause. The intraoperative IVI affected the inferior vena cava in three patients, the aorta in two patients, the external iliac artery in four, the tibial and popliteal arteries in four, and the internal carotid artery in one. The following types of repairs were recorded: direct suture of the vessel with or without endarterectomy (71.4%), synthetic patch placement (25.7%), ligation (8.6%), bypass or interposition graft (14.3%), and thromboembolectomy (5.7%). Vascular repair was successful in 32 (91.4%) patients while three patients (8.6%) were expired. Complications occurred in 7 (20%) patients, of which superficial wound infections were the common complication (11.6%) and were treated with proper antibiotic therapy.

Conclusion

Prompt identification of IVIs, as well as proper triage for future treatment, can enhance patient outcomes. Our data showed that non-qualified specialists seem to be responsible for the majority of IVIs. For that, we emphasize the importance of performing vascular procedures by a qualified specialist with adequate training.

Coeliac artery avulsion secondary to high velocity blunt abdominal trauma: a case report

Coeliac artery (CA) injuries are an extremely rare subset of blunt abdominal trauma with a reported incidence of only 0.01%. Patterns of CA injury include intimal tear, dissection, thrombosis and pseudoaneurysm, with the most rare being complete CA avulsion. These complex injuries pose a treatment challenge due to rapid blood loss and anatomical difficultly in achieving proximal and multiple points of distal vascular control. To our knowledge, this case of CA avulsion from blunt polytrauma is only the 7th case reported in the literature. To assist in management, we report a case of blunt traumatic CA avulsion managed successfully with open ligation following endovascular balloon occlusion of the juxta-coeliac aorta for haemorrhage control.

Abdominal Wall Evisceration Coupled With Iliac Vascular Injury After Blunt Trauma

Abdominal evisceration after blunt trauma is uncommon and rarely survivable when coupled with a concomitant iliac vascular injury. Blunt abdominal injury is rarely a cause of abdominal evisceration but may, on occasion, present in patients affected by a unique or high-energy traumatic injury. In these instances, major vascular injury is exceedingly rare but is associated with a high mortality rate. Damage to important vessels that may present more subtly, such as iliac arterial injury, can still be lethal and are important to evaluate in the trauma workup for blunt evisceration. We report the case of a 20-year-old woman who survived an abdominal wall and vascular injury in a motor vehicle accident. Management of this unusual association is discussed.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review

Background

Ruptured middle colic artery aneurysm is extremely uncommon. Diagnosis can be challenging, as symptomatology can be attributed to more common abdominal pathologies. Due to the rarity of this condition, only case reports are available to inform management.

Case Presentation

We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully.

Conclusion

A middle colic artery aneurysm can be challenging to diagnose and treat. Management options include endovascular techniques, open surgery, or a combination approach. Intra-aortic balloon placement for emergency vascular control is a novel approach that could avoid hemorrhage when intra-abdominal vascular access is challenging.

Liver Trauma: Until When We Have to Delay Surgery? A Review

Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic “wait and see” attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver.

H12‐(ADP)‐liposomes for hemorrhagic shock in thrombocytopenia: Mesenteric artery injury model in rabbits

Background

Objective

Methods

Results

Conclusion

A through-and-through abdominal gunshot wound without intra-abdominal damage: A case report

Abdominal gunshot trauma is the third leading cause of death and is responsible for more than 90% of deaths among people ages 15 to 24 years old. It can cause multi-system organ damage, shock, and infection. We present a case of a through-and-through abdominal bullet wound where laparotomy exploration has found nothing as damage inside the abdomen.

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.

Avoiding Misdiagnosis of Abdominal Vascular Catastrophes

Abdominal vascular emergencies are an uncommon entity in emergency medicine, but when they present, they are often catastrophic. These time-sensitive and life-threatening diagnoses are often hidden in nonspecific complaints such as nausea, vomiting, or flank pain, so the emergency physician must remain diligent and consider these in the differential diagnoses. The following is an overview of the more common of these abdominal vascular emergencies, in the hope that they help the Emergency Physician avoid the misdiagnosis and subsequent vascular catastrophe that would follow.

Blunt Mesenteric Vascular Injuries: Endovascular Management and Midterm Outcomes

INTRODUCTION

Visceral artery injuries are rare but lethal entities that pose significant management challenges in a patient who presents with blunt trauma. There is a paucity of specific guidelines both in the trauma and vascular literature regarding the management of blunt intra-abdominal vascular injuries. The midterm outcomes of two cases of blunt traumatic visceral artery injuries managed successfully with endovascular interventions are presented.

REPORT

An 18 year old male victim of a motor vehicle accident was found to have infrarenal aortic, coeliac artery (CA), and superior mesenteric artery (SMA) injuries. The second patient was a 15 year old male who presented with traumatic occlusion of the CA after an all terrain vehicle collision. Both patients had other associated abdominal and bony injuries. All vascular injuries were addressed endovascularly, which was followed by repair of other associated injuries. In the first case, a self expanding non-covered nitinol stent was used in the injured but tortuous CA; for repair of the SMA, a covered balloon expandable stent was used. In the second patient, a balloon expandable non-covered stent was used to repair the CA occlusion. In both cases, the 12 month post-operative follow up showed that all stents were patent and the patients were asymptomatic.

DISCUSSION

Endovascular repair of the mesenteric arteries following traumatic injury can be achieved safely, with good midterm outcomes. More data are needed to define the indications for and long term safety and patency of stents used in traumatic visceral artery injuries.

Role of Emergent Nephrectomy for Grade V Blunt Renal Injuries

Case series

Patients: Male, 18-year-old • Female, 21-year-old

Final Diagnosis: Grade V renal laceration

Symptoms: Abdominal pain • flank pain

Medication: —

Clinical Procedure: Nephrectomy

Specialty: Surgery

CT of Penetrating Abdominopelvic Trauma

Penetrating abdominopelvic trauma usually results from abdominal cavity violation from a firearm injury or a stab wound and is a leading cause of morbidity and mortality from traumatic injuries. Penetrating trauma can have subtle or complex imaging findings, posing a diagnostic challenge for radiologists. Contrast-enhanced CT is the modality of choice for evaluating penetrating injuries, with good sensitivity and specificity for solid-organ and hollow viscus injuries. Familiarity with the projectile kinetics of penetrating injuries is an important skill set for radiologists and aids in the diagnosis of both overt and subtle injuries. CT trajectography is a useful tool in CT interpretation that allows the identification of subtle injuries from the transfer of kinetic injury from the projectile to surrounding tissue. In CT trajectography, after the entry and exit wounds are delineated, the two points can be connected by placing cross-cursors and swiveling the cut planes obliquely in orthogonal planes to obtain a double-oblique orientation to visualize the wound track in profile. The path of the projectile and its ensuing damage is not always straight, and the imaging characteristics of free fluid of different attenuation in the abdomen (including hemoperitoneum) can support the diagnosis of visceral and vascular injuries. In addition, CT is increasingly used for evaluation of patients after damage control surgery and helps guide the management of injuries that were overlooked at surgery. An invited commentary by Paes and Munera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

High Mortality and Venous Thromboembolism Risk Following Major Penetrating Abdominal Venous Injuries

BACKGROUND

Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality.

METHODS

The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality.

RESULTS

Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001).

CONCLUSION

Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

Retrohepatic IVC injury: A new treatment approach with arterial stent graft

Traumatic injuries to the inferior vena cava (IVC) are rare and among the most dreadful injuries encountered in evaluation of both penetrating and blunt traumatic settings. Clinical outcome of IVC injury is multifactorial with injuries being classically managed surgically. In this report, we present a case of 52 years old male patient with successfully treated blunt retrohepatic IVC injury utilizing arterial stent graft and anticoagulation regime without short-term complications. Evidence based standardized approach for endovascular management of IVC injury is not yet available. We hope that our report can contribute to worldwide procedure and postprocedural anticoagulation standardization.

A Gardening Session Turns Into a Life Threatening Aortic Transection

INTRODUCTION

Penetrating injuries to the sub-diaphragmatic aorta are challenging, with high mortality rates. Most penetrating aortic trauma results from gunshots or stab wounds. This case reports a successful aortic bypass, following partial aortic transection caused by an accidental fall on a utility knife.

REPORT

A healthy 82 year old woman was admitted to the emergency department following penetrating abdominal trauma following an accidental fall on an 18 cm long utility knife. On admission, the patient was haemodynamically stable, with no neurological deficit. Computed tomography angiography revealed multiple abdominal injuries to the stomach, duodenum, L4-L5 left vertebrae, and infrarenal abdominal aorta. The patient underwent urgent midline laparotomy, followed by successful aortic repair using a 14 mm polyester graft. The gastric and duodenal lesions were repaired with an omental patch. The post-operative course was uneventful.

DISCUSSION

Penetrating abdominal trauma with visceral lesions and aortic transection are high risk injuries, albeit rarely described in the literature. A low threshold for imaging, and multidisciplinary management by vascular and visceral surgeons are essential for timely recognition and successful intervention.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Acute postoperative delayed hemorrhage following anterior colporrhaphy and cystoscopy: A case report and a review of the literature

The development of a retroperitoneal hematoma is a rare complication in gynecologic surgery. The literature on the condition is largely in the form of case reports describing its occurrence in relation to vaginal procedures. We report the case of a 40-year-old woman who had acute delayed-onset postoperative hemorrhage and retroperitoneal hematoma formation following an uncomplicated anterior colporrhaphy. She re-presented to the hospital several hours after discharge, with severe pain and vaginal bleeding. On imaging, she was found to have a large pelvic hematoma that was displacing the uterus, with extraperitoneal free fluid and active contrast extravasation. She underwent resuscitation and successful coil embolization of a small branch of the right uterine artery. This case report adds to the body of literature on the occurrence of retroperitoneal hematoma in vaginal surgery and underscores the importance of maintaining a high index of suspicion in individuals presenting with signs or symptoms suggestive of this diagnosis.

Liver trauma: WSES 2020 guidelines

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.

Hematomas in Tiger Territory

A 26-year-old man presented with gunshot wound to the epigastrium. At surgery, he was hemodynamically stable and had a tense hematoma with thrill in zone 2 (right side) and porta triad. After liver injury was controlled, he underwent percutaneous stenting of a renal artery-vena cava fistula and the hepatic artery injury was followed. Historically, penetrating injury to zone 2 has mandated operative exploration. However, with the advent of endovascular options, in stable patients, catheter-based options offer a reasonable alternative with less risk of blood loss and possible nephrectomy. Renal artery stenting has been advocated for renal artery cava fistulas. The role of timing, hybrid operating suites, and traditional operative exposure will vary based on presentation and institutional capabilities.