c l i n i c a l
f o l i o s :
d i s c u s s i o n
Carotid Artery Injury
|
|
| ||
|
|
Carotid Artery Injury | ||
|
| ||
|
|
|
Related narrative: Carotid Artery Nailgun Injury The visceral compartment of the neck contains major vascular conduits, the trachea, and the esophagus tightly packed together (see neck anatomy). One quarter of penetrating neck injuries involve vascular structures, most commonly the internal jugular veins. The carotid artery is involved 5-10% of the time. The proximity of the aerodigestive structures accounts for the high incidence of associated injuries with vascular neck trauma. Endoscopy is indicated if such injury is not clinically ruled out. Minor injuries may be observed. Endovascular repair is the procedure of choice for small terminal arterial lacerations and pseudoaneurysm that are not surgically accessible (base of skull or higher). Open surgical repair is still the gold standard for cervical carotid artery injuries. Open repair allows inspection of surrounding structures for associated injury. Injuries to the external carotid artery are often ligated. The external carotid may also be used to bypass a segmental internal carotid defect. An expanding hematoma is an indication for immediate endotracheal intubation to avert tracheal compression and airway compromise. Unstable patients with active bleeding are taken immediately to the operating room. The groin is routinely prepped in the event autogenous vein graft is needed. The neck is conceptually divided into three zones relative to carotid artery injury, as described above. Exposure of zone II injuries is straightforward with incision along the anterior border of the sternocleidomastoid. The neck can be rotated to the contralateral side if cervical spine injury has been ruled out. Injuries in zone III require division of the posterior belly of the digastric muscle, and may require mandibular subluxation for exposure. Injuries in zone I may require a 4 vessel arch angiogram to define injury to vessels within the superior thoracic aperture and plan the surgical approach (see subclavian catheterization). Duplex scanning for carotid injury correlates well with angio findings (90%), but for logistic reasons, angio remains the gold standard diagnostic study for zone I and III injuries. CT angiogram and magnetic resonance angiogram show promise for defining vascular neck injury. Angiogram is usually not indicated for zone II injuries. If active pulsatile hemorrhage is present, angiographic intervention with balloon catheter placement can be used for temporary proximal control. Exposure of zone I injuries often require median sternotomy to safely obtain proximal control. A shunt with heparinization is commonly used during major vascular repair. There has been a shift in approach regarding the treatment of carotid injury with dense hemispheric neurologic defecit. The older literature suggested that surgical intervention was not indicated with major neurologic defects, but recent literature supports attempts at primary repair with thrombectomy, offering some hope of improvement in most cases. Most vascular surgeons would now operate on all occlusive carotid injuries unless the patient is in a deep coma. Rarely, an occlusive internal carotid injury will present without neurologic defect. Such patients may be observed and treated with anticoagulants to prevent propagation of clot. References: 1. Valentine, RJ, in Wind, GG, Valentine, RJ, Anatomic Exposures in Vascular surgery, Williams & Wilkins, 1991, pp. 40, 84-92. 2. Mattox, KL et. al. in Townsend: Sabiston Textbook of Surgery, 16th ed., W. B. Saunders Company 3. Kumar, SR, et. al., Cervical Vascular Injuries, in Surgical Clinics of North America, 81:6, December 2001, W. B. Saunders Company 4. Hoyt, DB, et. al., Anatomic exposures for vascular injuries, in Surgical Clinics of North America, 81:6, December 2001, W. B. Saunders Company.
|
