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40 Operative Management ofDelayed Complications ofPulmonary andPleural Injury
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341
sule start to form, and in this phase evacuation via VATS is
usually successful. Thrombolysis has been shown to be
effective, however, outcomes following surgery are superior, and hence, thrombolysis may be reserved for patients
not t for surgery. Once progressed beyond the brinopurulent phase, thoracotomy may be necessary. Open window
thoracostomy is an alternative in selected cases.
40.2.3 Fibrothorax
40.2.3.1 Background
Fibrothorax is dened as pleural space brosis, where there
is extensive dense brosis of the visceral pleura leading to
fusion of the visceral and parietal pleura, which ultimately
leads to contracture of the involved hemithorax and lung
entrapment. Though being one of the most feared complications, this is fortunately relatively rare and can be a sequela
from RHTX or empyema.
40.2.3.2 Investigations
The characteristic ndings on CT are diffuse, smooth pleural
thickening (hence the term ‘pleural peel’) and the associated
signicant volume loss of the ipsilateral hemothorax.
40.2.4.3 Management
Given the rarity of chylothorax, management remains controversial. In general, a trial of nonoperative management
may be offered in the form of nil by mouth and parenteral
nutrition. Medium-chain triglycerides may be considered
orally but should be abandoned if chyle output increases.
Octreotide has been used as an adjunct. The optimal duration
of an expectant approach is unknown; however, in the face of
persistent high output (>1500 mL/24 h) for more than 2
weeks, especially if the patient is losing ground nutritionally
or immunologically, intervention should be considered.
Once the leak is located with lymphangiography, this can be
approached via coil embolization or operatively via thoracoscopy or thoracotomy. Intra-operative localisation can be
aided by administering cream to the patient prior to the operation, making direct ligation possible. Mass ligation of the
thoracic duct at the level of the diaphragm can address both
right- and left-sided leaks. Helpful adjuncts include complete decortication to allow full lung expansion, postoperative ventilation for 24h, and nil by mouth for up to seven
days after surgery.
40.2.5 Recurrent Pneumothorax
40.2.3.3 Management
Patients may present with chronic respiratory symptoms.
Treatment is decortication via thoracotomy. This constitutes
major surgery and the decision to operate is made on a caseby- case basis.
40.2.4 Chylothorax
40.2.4.1 Background
Chylothorax, rst described by Bartolet in 1633, is an accumulation of chyle within the pleural cavity and in the setting
of penetrating thoracic trauma is most commonly associated
with disruption of the thoracic duct. It is usually a result of
penetrating injury to the thoracic inlet or transmediastinal
injuries, with a known association with thoracic aortic and
oesophageal injuries. This is a rare complication; a large
series from a major centre in South Africa recorded only
eight such cases over a 13-year period.
40.2.4.2 Investigations
Chylothorax generally declares itself by drainage of characteristic milky uid from the pleural cavity, and uid triglyceride concentration >110mg/dL is virtually diagnostic. The
presence of chylomicrons also supports the diagnosis.
Lymphangiography can be used to locate the precise area of
the injury and assist with operative planning.
40.2.5.1 Background
Recurrent pneumothorax (RPTX) following chest tube
removal is a well-recognised complication. It is a phenomenon associated with poor removal technique which may
necessitate a new chest tube and this is associated with
increased morbidity, septic complications and increased
length of hospital stay. The ideal timing of chest tube removal
in relation to the respiratory cycle remains highly controversial and there is both theoretical and physiological support
for removing the chest tube during either the end-inspiratory
or end-expiratory phase of the respiratory cycle. Removing
the chest tube at the end inspiratory phase ensures that the
lung is fully expanded and that the parietal and visceral
pleura are closely opposed. Removal during the endexpiratory phase, however, minimises the pressure difference between the intrapleural space and the atmosphere and
theoretically reduces the risk of inadvertent airow into the
pleural cavity. Despite the paucity of literature on the topic,
two major studies from South Africa and the United States
respectively have consistently demonstrated the development of RPTX is unrelated to the respiratory cycle and that
the actual removal technique is the most important component. It is also possible that RPTX may occur due to premature chest tube removal when there is still some unnoticed air
leak. If this scenario is suspected, it may be prudent to clamp
the chest tube and repeat CXR after 6–8h. The chest tube is
removed if there is no evidence of pneumothorax.
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G. V. Oosthuizen et al.
40.2.5.2 Investigations
Evidence of recurrent pneumothorax on CXR following
removal of chest tube.
40.2.5.3 Management
The technique of removal must ensure that the chest tube is
removed with a single motion and that the wound is swiftly
closed and sealed either with the application of an occlusive
dressing or with a suture technique. If RPTX does occur, a
repeat chest tube is generally only required if the patient
becomes symptomatic. The majority will settle without
re-intervention.
40.3 Pulmonary Complications
40.3.1 Pneumonia
40.3.1.1 Background
Nosocomial pneumonia is by far the most common complication of thoracic trauma and the incidence is as high as 30%
in mechanically ventilated patients. Established risk factors
for the development of nosocomial pneumonia include
increasing age, aspiration, and prolonged duration of
mechanical ventilation. Ventilator-associated pneumonia
(VAP) is a specic type of nosocomial pneumonia and is
dened as pneumonia arising 48h after commencement of
mechanical ventilation.
40.3.1.2 Investigations
Diagnosis is difcult and is supported by clinical evidence of
sepsis, radiological features of new pulmonary inltrates,
and bacterial cultures from endotracheal aspirate or bronchial lavage samples.
40.3.1.3 Management
Early aggressive treatment with appropriate antibiotics and
associated supportive measures is paramount. In nonmechanically ventilated patients, the importance of aggressive early mobilisation and chest physiotherapy as
preventative measures cannot be overemphasised. There is
no current evidence to support the use of prophylactic antibiotics in mechanically ventilated patients to prevent VAP.
40.3.2 Acute Respiratory Distress Syndrome
(ARDS)
40.3.2.1 Background
ARDS is commonly encountered in surgical critical care and
is associated with mortality of up to 50%. It has been postulated to be a result of an uncontrolled inammatory response
to either direct or indirect respiratory insult leading to diffuse
alveolar damage. The Berlin consensus denition denes
ARDS as the following: Timing: Within 1week of a known
clinical insult or new/worsening respiratory symptoms.
Radiological: Bilateral opacities not fully explained by effusions. Lobar/lung collapse or nodules. Origin of oedema:
Respiratory failure not fully explained by cardiac failure or
uid overload. Objective assessment (e.g. echocardiography) is needed to exclude hydrostatic oedema if no risk factors are present. Oxygenation: mild: 26.6 kPa < PaO2/
FIO2< 39.9kPa with PEEP or CPAP 5cmH2O moderate:
13.3 kPa < PaO2/FIO2 ≤ 26.6 kPa with PEEP or CPAP
5 cmH2O. Severe: PaO2/FIO2 ≤ 13.3 kPa with PEEP
5cmH2O.The pathophysiological changes are well recognised and characterised by three overlapping clinical phases.
The initial exudative phase results in severe hypoxaemia and
reduces compliance largely from the exudation of proteinrich uid. Following the initial response, the proliferative
phase is characterised by bro-proliferation and microvascular thrombosis which eventually progresses to the chronic
brotic phase with widespread brosis of the lung
parenchyma.
40.3.2.2 Investigation
ARDS remains a clinical diagnosis, supported by radiological changes that are in concordance with the clinical
situation.
40.3.2.3 Management
The principle of management is largely supportive, with various mechanical ventilation strategies that have been known
to improve outcomes. Low tidal volumes (6 mL/kg) and a
plateau pressure <30 cmH2O, born out by the landmark
ARMA study have been shown to improve survival. Prone
ventilation has also been associated with lower mortality.
Other measures such as high-frequency oscillatory ventilation and extracorporeal membrane oxygenation have yet to
be proven to have a signicant impact on outcome.
40.3.3 Retained Missiles
40.3.3.1 Background
Retained missiles in the lung parenchyma especially in
the form of a bullet (or fragments) are not uncommon but
the indication for removal is dependent on risk assessment. Many authors would opt to leave an asymptomatic/
uncomplicated retained missile alone and consider
removal only if there is pain, the missile is adjacent to a
blood vessel, very supercial, or causes any complication.
Most tend to be asymptomatic but can lead to a range of
complications including empyema, bronchopleural stula, and erosion into major pulmonary vascular
structures.
40 Operative Management ofDelayed Complications ofPulmonary andPleural Injury
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40.3.3.2 Investigations
CT is the investigation of choice, dictated by the patient’s
clinical presentation. Although most retained missiles will be
identied in the acute setting, studies from World War II survivors have reported delayed presentation of complications
as late as 50years.
40.3.3.3 Management
Most of the contemporary management strategies are based
on wartime experience dating back to World War II.Historical
military experience of early removal was associated with a
mortality rate of approximately 1% and increases to over 7%
with delayed removal. It is recommended that a delay of
4weeks may allow parenchymal inammation to settle and
thus allow for easier removal. Tractotomy or lobectomy may
be required.
40.3.4 Persistent Air Leak
40.3.4.1 Background
Persistent air leak (PAL) is said to be present when an air
leak persists beyond 5–7days, although the precise denition remains unclear. Conceptually, this is thought of as stulous communication between the pleural space and either
the main bronchial tree (central) or the alveoli (peripheral).
Major PAL is uncommon in the setting of penetrating trauma
but every trauma surgeon should have a sound management
approach. PAL is especially challenging in ventilated
patients, where concurrent pneumonia and respiratory failure may co-exist.
40.3.4.2 Investigations
The diagnosis is usually obvious clinically with the appearance of persistent bubbling in the underwater seal collection
system connected to a chest tube. The Cerfolio classication
is a commonly used system that categorises the severity
based on the degree of air leak and the respiratory phase in
which it occurs. The most severe form of PAL is a continuous air leak which occurs during both inspiration and expiration. The most common type of leak is one that occurs during
expiration, and these usually improve to occur only during
forced expiration as the stula heals. CXR is a useful
adjunct—a fully expanded lung in the presence of PAL is
usually a good indicator that the stula will heal without
intervention, while a persistently collapsed lung, especially
in the presence of difculty oxygenating the patient, would
generally warrant intervention. Bronchoscopy may be a useful adjunct to identify and dene a bronchial injury as well as
to clear the airways of mucus and blood and hence allow
improved oxygenation.
40.3.4.3 Management
Most air leaks will improve with time. Some degree of air
leak is not uncommon after major lung resection. In the presence of a fully expanded lung on CXR and no difculty with
oxygenation, nonoperative management can continue.
Intervention is usually required if the leak persists beyond
7days, or earlier if there is difculty oxygenating the patient.
If PAL occurs in the context of a major penetrating injury, a
second chest tube may be placed if the lung is not expanding.
If the lung is expanded, however, the original chest tube may
be placed on continuous low-level suction. In ventilated
patients, low-pressure and low-volume lung protective ventilation strategies are important. There are three major factors
to consider when evaluating an air leak: volume, duration,
and trend of the leak. A smaller air leak that is improving
daily is more likely to resolve spontaneously, while a larger
air leak that has been present for longer without any improvement has a low likelihood of resolution. Surgical management can be challenging and includes VATS with parenchymal
stapling or mechanical pleurodesis, with thoracotomy if
VATS is not feasible. Additional approaches include autologous blood pleurodesis, bronchoscopic insertion of endobronchial valves, and other anecdotal interventions.
40.3.5 Necrotising Lung Infection
40.3.5.1 Background
Necrotising lung infection (NLI) is an uncommon clinical
syndrome that overlaps with complications from necrotising
pneumonia, pulmonary abscess and pulmonary gangrene.
The common central pathology is infected, de-vascularized
lung tissue.
40.3.5.2 Investigations
Patients are usually in intensive care with severe sepsis and
CT may demonstrate a range of ndings including reduced
parenchymal enhancement (from liquefaction), consolidation, and air/uid cavity.
40.3.5.3 Management
The principle of early antibiotics and intervention directed at
source control is paramount. Percutaneous intervention for
drainage comes with the risk of developing a bronchopleural
stula. Formal surgical resection may be required for source
control.
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G. V. Oosthuizen et al.
Important Points
Pleural complications
Retained
hemothorax
Empyema • The mainstay of treatment is evacuation of
Fibrothorax • Decision to operate is guided by the degree of
Chylothorax • Low output chyle stula may be successfully
Recurrent
pneumothorax
Pulmonary complications
Pneumonia • Aggressive early mobilization and chest
ARDS • Management is largely supportive with
Retained
missiles
Persistent air
leak
Necrotizing lung
infection
• Repeat chest tube is usually successful if
pleural contents is liquid
• Otherwise, VATS or thoracotomy may be
indicated
• Intrapleural lytic therapy may be benecial in
poor surgical candidates
pleural pus and antibiotic therapy
• Early empyema may be treated by chest tube
while later stages (brinopurulent and
organizing stages) usually necessitate
operative intervention (VATS or thoracotomy)
respiratory incapacity
treated nonoperatively
• High output stula will usually require
intervention—coil embolization or ligation
via VATS/thoracotomy
• Careful attention to timing and technique of
chest tube removal is critical
physiotherapy are paramount in preventing
this complication
• Guided antimicrobial therapy remains the
mainstay of treatment
various available mechanical ventilation
strategies
• Asymptomatic, uncomplicated missiles may
be left alone
• Consideration for missile removal is
warranted in a small number of specic
indications
• Large air leaks and those persisting beyond
7days warrant intervention
• Management strategies include additional
chest drain insertion, negative drain suction,
ventilation strategies, bronchoscopy, and
operative intervention
• Early antibiotics and surgical source control
(resection) are paramount
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Penetrating Injuries totheMediastinal
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Vessels
AgnetaGeldenhuys
41.1 Introduction
Injury to the great vessels of the mediastinum accounts for
approximately 10% of cardiovascular injuries. On the other
hand, more than 90% of injuries to the great mediastinal vessels are a result of penetrating trauma. These are challenging
injuries to manage, and most are fatal prior to arrival at the
hospital. Those who do reach the medical system in time are
mostly haemodynamically unstable and must be dealt with
immediately and denitively. A small percentage are physiologically stable enough to allow a limited window of opportunity for workups or investigations and often need
emergency room surgery.
41
41.2 Management Strategy
Survivors of penetrating injuries to the great vessels of the
mediastinum are self-selected potentially salvageable
cohorts with a 60% incidence of haemodynamic instability
and 50% associated mortality. Haemodynamic management
and resuscitation by Advanced Trauma Life Support (ATLS)
guidelines should happen simultaneously with assessment.
Physiologically stable patients can be appropriately investigated but constantly monitored for the development of instability, which might need prompt surgical treatment
(Fig. 41.1). Computed tomography (CT) angiogram is the
most appropriate form of imaging for accurate injury localization if physiological status allows (Figs.41.2 and 41.3).
The haemodynamically unstable group will require immediate surgical treatment with the aim of correcting appropriate
physiological ow through the damaged vessel rather than
damage control as in the usual trauma setting in view of the
critical supply by these large mediastinal vessels to the cerebral, pulmonary and systemic circulation.
A. Geldenhuys (*)
Department of Cardiothoracic Surgery, Netcare Milpark Hospital,
Johannesburg, South Africa
Fig. 41.1 Chest X-ray demonstrating a large mediastinal haematoma
as typically seen in a penetrating injury of the large mediastinal
vessels
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_41
347
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Fig. 41.2 CT angiogram conrming a large mediastinal haematoma
A. Geldenhuys
position, bearing in mind that a hypovolemic patient can
rapidly decompensate when changed from the supine to
decubitus position requiring adequate and ongoing uid
resuscitation prior to and during turning as well as rapid
surgical entry into the thorax. It is often benecial to have
the theatre sister prepared with all surgical instruments
and scrubbed prior to turning the patient.
• The smaller undiagnosed and undrained pneumothoraces
of penetrating injuries can be converted into tension pneu-
mothoraces by adhesive sterile surgical drapes. These
may require urgent chest tube drainage or needle decom-
pression if clinical monitoring shows haemodynamics to
worsen soon after these drapes were applied. Have a low
index of suspicion for these sudden changes, and monitor
the patients constantly and very carefully.
• Always have internal debrillator pads available for inter-
nal cardiac debrillation in these unstable patients.
Whenever previous sternotomy or thoracotomy scars are
present in trauma patients, add external adhesive debril-
lator pads prior to sterile draping as entry into the thorax
can be more cumbersome due to adhesions of previous
surgery, and access to the heart for internal debrillator
pad usage may therefore be limited or delayed.
• Once the mediastinal vessel injury is denitively man-
aged, always consider injuries to adjacent mediastinal
structures like the trachea, bronchia or oesophagus.
• Endovascular management of some of these large vessel
injuries (e.g. the descending thoracic aorta) is an evolving
science in unstable trauma patients but should denitely
be considered should such expertise be available in the
treating hospital.
Fig. 41.3 CT angiogram (with reconstruction) demonstrating a penetrating injury to the innominate artery
A few practical guidelines for dealing with these patients
follow:
• Always ensure universal protective gear when treating
these injuries as a stable situation could at any time
change into a spurting arterial bleed once successful uid
resuscitation becomes effective.
• If at all possible, install cell-saving measurements with
autotransfusion in view of the massive possible blood loss
encountered, thereby preventing massive bank blood
transfusions.
• Keep these patients warm with adequate uid resuscitation and constant effective communication with the
anaesthetic team in order to avoid the deadly triad of
hypothermia, lactic acidosis and coagulopathy.
• Many of these injuries need to be managed via a posterolateral thoracotomy with the patient in lateral decubitus
41.3 Incisions andExposure
These injuries are mainly managed via median sternotomy,
anterolateral thoracotomy or posterolateral thoracotomy.
The details of these techniques are described in Chaps. 39
and 42.
41.4 Management ofSpecic Injuries
41.4.1 Injuries totheAscending Aorta
Bleeding from penetrating trauma to the ascending aorta
results in pericardial tamponade due to the fact that it is anatomically situated inside the pericardial sac. Emergency
median sternotomy should be performed and the sternal
retractor opened. A tense pericardium due to tamponade can
be difcult to grab for pericardiotomy. Use a scalpel blade to
make a small incision, and then quickly open the pericardium vertically in the midline with scissors, and create lat-
41 Penetrating Injuries totheMediastinal Vessels
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349
eral perpendicular extensions at the inferior, diaphragmatic
part of the pericardial incision. This should give the pericardiotomy the shape of an inverted “T” which usually provides
the best exposure. Manually evacuate the pericardial content
causing the tamponade, and assess cardiac contraction and
rhythm status. If asystole or ventricular brillation is present,
internal cardiac massage should be maintained until a perfusing rhythm and adequate cardiac lling volume can be
established. Communicate closely with the anaesthetic team
with appropriate administration of resuscitation drugs like
Adrenalin throughout. Internal debrillation paddles can be
used to debrillate a non-perfusing ventricular rhythm but
should be avoided in asystole. Find the bleeding laceration
on the ascending aorta, and control it with digital compression or a side-biting clamp (Satinsky or large Wiley “J”
clamp). Once temporary haemostasis is achieved in this
manner, use limited (but well-spent) time with attention to
exposure and planning the repair. Pericardial retraction
sutures improve access to the ascending aorta. Negotiate
mentally whether repair underneath a digitally compressing
nger or a carefully applied side-biting clamp will be most
effectively performed. If a side-biting clamp is used, ensure
adequate residual patency of the underlying aorta for proper
ejection of the heart to perfuse the head and neck vessels.
Consider the type of injury or defect and appropriate repairing strategy using 3.0 or 4.0 monolament nonabsorbable
sutures. If a small pinpoint penetrating hole is encountered, a
pledgeted “U” suture (autologous pericardial or Teon felt
pledget) is most effective for repair. In a larger defect (but
where the edges can be approximated), a lateral aortorrhaphy
will sufce using direct suturing with a double layer of rst
a horizontal mattress suture technique, ensuring that the
endothelium is caught with every suture in order to traverse
the full-thickness aortic wall and especially the strong adventitial layer with the suturing needle. This technique should
ensure a full thickness of 2–3mm of the aortic wall in the
rst layer, which is then followed with a second layer of
over-and-over suturing while ensuring that the bites of the
second layer are just fractionally more supercial than the
rst layer in order to avoid creating new suture holes. A
larger defect where edges cannot be approximated should be
repaired with the use of an autologous pericardial patch or
prosthetic material (e.g. Dacron or Gore-Tex). The pericardium can easily be harvested from the pericardiotomy site
and should be used untreated (kept moist in a saline-soaked
Ratex swab after harvesting) with the smooth aspect of the
pericardium applied to the internal aspect of the aorta. While
sutures are tied on the aorta, it is ideal that the systolic blood
pressure should be carefully lowered. A skilled anaesthetist
may be able to perform this formidable task in an unstable
trauma patient, but the easiest way is usually to manipulate
the head-up bed position for a few seconds prior to tying a
suture in order to achieve temporary but very reversible mild
hypotension. Complete cross-clamping of the ascending
aorta should be avoided if at all possible in view of the disastrous complication of cardiac distension with irreversible
distension injury to the left ventricle. Should aortic crossclamping be necessary, it should be accompanied by inow
occlusion of the superior vena cava (SVC) and inferior vena
cava (IVC) prior to the aortic cross-clamp in order to empty
the heart and prevent over-distension injury. These are formidable manoeuvres that could have very serious side effects
and should not be performed without careful consideration
and should only be performed in inexperienced hands. It
serves no purpose to have a repaired ascending aorta but an
irreversibly injured myocardium.
Whenever an anterior injury to the ascending aorta is
encountered, the posterior surface should always be checked
in view of a possible through-and-through injury. A posterior
injury is far more challenging to repair but could be managed
with careful mobilization of the distal ascending aorta.
Carefully divide the tissue between the aorta and pulmonary
artery with diathermy on low settings (staying on the aortic
aspect of this tissue and avoiding injury to the thin-walled
pulmonary artery). Pass a Curly-Semb vascular clamp behind
the aorta in the transverse sinus, and pull a wet umbilical
tape through the transverse sinus looped around the distal
aorta (Figs.41.4 and 41.5). Give this to the assistant to use as
a handle to pull the aorta away from the superior vena cava.
The same could be performed more proximally on the aorta,
Fig. 41.4 Curly-Semb vascular clamp passed behind the ascending
aorta in the transverse sinus
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A. Geldenhuys
Fig. 41.5 Umbilical tape looped around the ascending aorta in order to
aid retraction
and in this manner, reasonable retraction with exposure of
the posterior surface can be achieved. Be careful to narrow
the aortic lumen too aggressively as cardiac output will be
compromised, and constant communication with the anaesthetic team is imperative. The same principles for repair
apply. In cases where adequate exposure of the posterior aortic surface cannot be achieved, a cardiopulmonary bypass
will be required in order to maintain circulating volume and
create a bloodless eld. The posterior surface of the aorta can
be packed well with Ratex swabs and tamponade bleeding in
this manner until cardiopulmonary bypass equipment can be
organized.
41.4.2 Injuries totheAortic Arch
Stable patients with contained injuries of the aortic arch are
far safer repaired using cardiopulmonary bypass with the
introduction of deep hypothermic cardiac arrest, a bloodless
eld and physiological cerebral protection. Unfortunately in
the acute trauma setting, these adjuncts are rarely available.
The same principles apply in the methods of repair as for the
ascending aorta, but most importantly, the chances of a successful repair are greatly enhanced by optimal exposure.
Extend the median sternotomy cervically. The thymus tissue
can be wiped aside from the midline with an abdominal
swab, but the venous drainage of the thymus needs to be
carefully ligated from the innominate vein with preferably a
Fig. 41.6 A looped innominate (or brachiocephalic) vein being pointed
at by a surgical diathermy
Ligaclip. These unimpressive thymic veins are small and
shut down in hypovolemic trauma patients but open up with
reperfusion and adequate resuscitation and have been the
reason for many relook sternotomies due to bleeding after an
initial successful operation. The innominate vein can be
looped with a vascular tape and pulled in a cephalic direction
in order to expose the aortic arch better (Fig. 41.6), or if
exposure is still inadequate, it can be double ligated, divided
and retracted. Most importantly, the aortic arch is anatomically situated outside the pericardium, and in the presence of
an anterior mediastinal haematoma, tissue dissection can
lead to a false dissection plane within the aortic wall (between
adventitia and media) resulting in an iatrogenic dissection
injury. Approach to the aortic arch should be initiated from
within the pericardial sac with accurate differentiation
between haematoma and adventitia. Be prepared to manage
inow occlusion of the superior and inferior vena cava and
ascending aorta with a short-term cross-clamping. It is far
safer to loop the ascending aorta and both cavae in anticipation of inow occlusion than to manage it amidst exsanguinating circumstances. Looping of the ascending aorta with
an umbilical tape can be performed as described above. For
looping of the superior vena cava (SVC), the soft tissue
41 Penetrating Injuries totheMediastinal Vessels
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Fig. 41.7 A looped SVC (with wet umbilical tape) was prepared to be
clamper for inow occlusion
medial to the SVC (between the SVC and the aorta) must be
lifted with forceps and incised with scissors. An
O’Shaughnessy or Lahey forceps is passed behind the SVC
from lateral to medial (taking careful consideration of the
fact that the right pulmonary artery branch is just deep to that
and the azygos vein enters the SVC from posterior) and used
to pull a wet umbilical tape through to loop it (Fig.41.7). For
looping of the inferior vena cava (IVC), a long pair of scissors is used to develop the area between the right inferior
pulmonary vein and the IVC.A Curly-Semb vascular clamp
is passed from medial to lateral and used to circumnavigate
the IVC by pulling a loop of umbilical tape through. The
principles of repair are the same for the ascending aorta.
41.4.3 Injuries totheBranches
oftheAorticArch
It is imperative that the surgeon treating injuries to the
branches of the aortic arch knows and understands the possible anatomic anomalies to be encountered. A bovine arch
(where both the innominate and left common carotid arteries
have a common origin from the aortic arch) can be encountered in 5–30% of cases depending on the treated population.
This may complicate repair, but a clear anatomic understanding should result in accurate correction of the injury.
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Approach to the branches of the aortic arch is enabled via
a longitudinal cervical extension of the median sternotomy
or supraclavicular extension to the right for the innominate
artery injury or to the left for the left common carotid injury.
Division of the strap muscles of the neck from its insertion
point into the sternum gives improved exposure to the carotid
sheath. Carefully dissect the arch vessels free, and avoid the
area of injury until proximal and distal control is achieved.
The proximal right subclavian artery (SCA) should be
approached with extra care as the vagus nerve with recurrent
laryngeal branch hooks around the proximal 1.5–3cm of the
right SCA after the bifurcation of the innominate artery.
Digital pressure control of active bleeding is essential until
proximal and distal control is achieved. Contained injuries at
the base of the innominate or left common carotid arteries
(where it originates from the arch) are managed by far superiorly with cardiopulmonary bypass and deep hypothermic
cardiac arrest or contralateral axillary artery cannulation for
cerebral perfusion above a primary end-to-end anastomosis.
If these adjuncts are not readily available and life- threatening
bleeding is at hand, primary repair should be performed with
Satinsky or Wiley “J” vascular clamps of the arch and distal
control. No temporary shunts are needed in these vessels as
adequate cerebral crossover ow usually exists in younger
trauma patients and can be more time-consuming to achieve
in the acute situation and unnecessary in the controlled situation where cardiopulmonary bypass could be obtained.
Small partial tears can be directly oversewn, but larger
injuries require the bypass exclusion technique as described
by Johnston etal.: a technique that does not require cardiopulmonary bypass, systemic anticoagulation or hypothermia. A Dacron tube graft is used to perform a bypass graft
from the ascending aorta to the distal portion of the injured
vessel while avoiding the injured area at rst until adequate
bypass grafting is completed. Using a partially occluding
side-biting vascular clamp on an area of the ascending aorta
away from the origin of the innominate artery and thereafter, isolate a distal portion of the innominate artery with
both proximal and distal clamps (ensuring the distal clamp
is proximal to the bifurcation of the innominate artery—this
ensures perfusion of the right carotid artery from the collateral ow to the right subclavian artery). Divide the artery
and perform an end-to-end anastomosis of the distal segment of the divided artery to the distal portion of the Dacron
graft. Before tying the nal knots on the suture line, this
graft should be de-aired by releasing the proximal clamp
and distal clamps one after the other. If possible, the right
SCA and right carotid arteries should be separately clamped.
First, release the proximal clamp on the innominate artery to
de-air this section of the graft and reclamp. Then release the
right SCA clamp as backow from the RCA completes the
de- airing process, while cerebral air emboli are avoided by
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