1. Carotid & Vertebral Artery Injuries
Chapter 70

2. Controversies
Pros and cons of duplex versus angiography versus newer modalities
Selective versus mandatory exploration for penetrating Zone II injuries
Treatment of patients with coma
Blunt carotid injury

3. Penetrating Carotid Artery Trauma
Epidemiology
Young, healthy, intoxicated males
Stab wounds & low velocity missiles
6% of penetrating neck injuries
22% of all cervical vascular injuries
CCA>ICA
Iatrogenic trauma during central line placement

4. Evaluation of Patients with Penetrating Trauma
Hard signs of vascular injury
8-25% of patients with penetrating neck injury
Shock
Active bleeding
Expanding hematoma
Require expeditious operative exploration
Soft signs of vascular injury
Majority of patients
History of pulsatile bleeding
Small, stable hematoma
Cranial nerve injury
Unexplained neurologic deficit
“Proximity” injury without other signs

5. Penetrating Neck Trauma
Injuries not penetrating the platysma are superficial and require no further workup
Zone III
Angle of mandible to base of skull
Exposure of this area difficult
Pharynx; distal carotid and vertebral arteries; parotid gland; cranial nerves
Zone II
Cricoid to angle of mandible
Usually clinically apparent injuries
Cartoid and vertebral arteries; jugular vein, larynx; esophagus; trachea; vagus; recurrent nerve
Zone I
Thoracic inlet (sternal notch to cricoid)
Injuries to this area have highest mortality
Proximal carotid, subclavian, vertebral arteries; upper lung; esophagus; trachea; CNS

6. Initial Management Airway Bleeding controlled with direct pressure
Endotracheal intubation for any difficulty with oxygenation, ventilation, or depressed sensorium
Obvious tracheal injury can be treated with ETT into the wound
Bleeding controlled with direct pressure
CXR and lateral C-spine films
Major vascular injury in Zone II usually clinically apparent with significant hematoma or frank external hemorrhage
Approached by immediate surgical exploration
Due to difficulties of vascular exposure in Zone I and III, angiography is needed prior to surgical exploration unless extremely unstable

7. Physical exam normal
No hypotension, active bleeding, unequal UE pulses, expanding neck hematoma, motor function abnormalities, clavicular fracture, SQ air, stridor, nor voice abnormalities

8. Proposed algorithm for Zone I injury

9. CONTROVERSY: Optimal approach for patients with Zone II injuries
MANDATORY
Low rate of complications with exploration (2.2% and 0%)
Potentially devastating effect of delay in diagnosis of aerodigestive injuries
Unreliability of physical signs for predicting cervical vascular injury
SELECTIVE
High rate of negative exploration (40-60%)
Low incidence of devastating complications of 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

10. Zone II Injury Selective Workup
Demetriades et al, Br J Surg ’93
176 stable patients undergoing arteriography
19% with vascular injury, 8% requiring intervention (all were symptomatic)
Low yield for arteriography in asymptomatic patients
Fry et al, Am J Surg ’94
100 stable patients evaluated
15 underwent DUS then arteriography
1 arterial injury found on DUS confirmed on arteriography
Remaining 85 had arteriography only when DUS abnormal
7 arterial injuries found on DUS confirmed
2 venous injuries
Remaining 76 patients with normal DUS were stable
Frykberg et al, J Vasc Surg ’00
145 prospective injuries studied
91 patients with isolated Zone II injuries observed without sequelae
23 patients underwent arteriography with 3 injuries
Missed injury rate 0.9%

11. CT-A for Neck Injury Gonzalez, et al. J Trauma ‘03
42 prospective patients with Zone II underwent CT + esophagography, then exploration
4 esophageal injuries (2/4 on CT, 2/4 on esoph)
7 IJ injuries (4/7 on CT)
Gracias, et al. Arch Surg ‘01
23 patients with penetrating neck injuries underwent CT initially
13 patients no injury (4 discharged from ED)
10 patients had angiography, 2 required endoscopy due to proximity
Mazolewski, et al. J Trauma ‘01
14 prospective patients with Zone II injuries underwent CT, then mandatory exploration
4 scans deemed high probability, 3 had surgical injury
No missed injuries
Munera, et al. Radiology ‘02
175 patients with penetrating neck injuries
Injuries idenitified in 27 patients (15.6%), observation in 146
Sensitivity 90%, specificity 100%, PPV 100%, NPV 98%
One missed injury of pseudoaneurysm at common carotid origin

12. Surgical Management
All significant penetrating carotid artery lesions should be repaired when technically feasible
Primary repair
Patch angioplasty
Internal-to-external carotid artery transposition
Interposition graft
Controversy surrounds carotid injuries to patients with coma
Initial anecdotal reports of conversion of ischemic infarcts to hemorrhagic infarcts
Recent evidence that most deficits remain unchanged or improve
Collected series
28 comatose patients treated with ligation (61% mortality, 14% good outcome)
42 comatose patients repaired (26% mortality, 50% good outcome)
Minor carotid injury (intimal defect or small pseudoaneurysm)
Nonoperative management in neurologically intact patients safe

13. Outcomes/Future Directions
Mortality 17%
Stroke rate 28%
Higher if coma or shock present (50% & 41%)
Endovascular case reports for Zone I and III injuries

14. Blunt Carotid Artery Trauma
Accounts for 3-10% of carotid injury
4 mechanisms
Cervical hyperextension-rotation (most common)
Direct blow to the neck
Intraoral trauma
Basilar skull fracture
Injuries results in dissection, thrombosis, pseudoaneurysm formation, carotid-cavernous sinus fistula, complete disruption
Distal ICA>CCA (90%:10%)

17. Diagnostic Evaluation
Diagnosis of blunt carotid injuries increased due to heightened awareness and more aggressive screening
Fabian et al, Ann Surg ’96
96 cases reported up to 1980, 75 cases in 80s, 309 cases from ’90-’95
Optimal screening modality not established
4 vessel cerebral angiograms not cost-effective
DUS has difficulty with high ICA lesions
CT-A (Berne et al, J Trauma ’04) recently thought to be best screening test

18. Grading System Grade I: mild injury
Most (66%) heal even without treatment
Grade II: dissection or hematoma with luminal stenosis
Grade III: pseudoaneurysm
Grade IV: carotid occlusion
Grade V: transection
Usually lethal and not amendable to treatment

19. Treatment/Outcomes Carotid-cavernous sinus fistulae
Balloon occlusion techniques
Dissection, thrombosis, pseudoaneurysm have varied approaches
Recent literature supports nonsurgical management for dissections and thrombosis
Systemic heparinization followed by 3-6 mo coumadin
Pseudoaneurysms should be surgically repaired
Prognosis is generally poor
Mortality rates 5-43%
Good neurological outcomes in only 20-63% of survivors

20. Vertebral Artery Trauma
Exceedingly rare
2 largest series have 43 and 47 patients
Clinical presentation and outcomes related to associated injuries
70-80% of patients with vertebral artery injury have no evidence of arterial trauma on exam
Usually diagnosed on angiography or CT-A for neurologic deficits
Most injuries (AV fistulae and pseudoaneurysms) can be managed with proximal and distal artery occlusion
Surgical ligation versus endovascular coiling
Vertebral occlusion can be observed
Occasionally some risk of rebleeding
Arterial repair reserved for rare circumstance when preoperative arteriography suggest inadequate collateral circulation

21. Major Venous Trauma
Operative exposure for venous injuries should follow adjacent arteries/arterial injuries
Severe injuries to innominate, IJ, subclavian veins can be ligated
Definite treatment option for unstable patients or those with significant other injuries
Lateral venorrhaphy can be attempted if >50% luminal size
SVC or bilateral innominate/IJ injuries can be considered for repair to prevent SVC syndrome or acute cerebral edema

22. Summary Hard signs of vascular injury mandate operative exploration
Good results can be obtained with mandatory exploration, routine arteriography or DUS or CT-A, or physical examination alone in properly selected patients
Adopted approach should be based on experience, volume, local diagnostic capabilities, and personnel resources
All significant penetrating carotid artery lesions should be repaired when technically feasible
Diagnosis of blunt carotid injury requires high index of suspicion, but optimal screening tool remains controversial
Nonsurgical treatment and anticoagulation is the mainstay of treatment for most blunt carotid injuries
Vertebral artery injuries are rare and treated by exclusion of the injured artery from the posterior circulation