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35 • South Africa 395
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presented in hypovolemic shock, Nair et al. showed that
ligation is an acceptable form of treatment in the presence
of hemodynamic instability.
16
TRANSMEDIASTINAL OR TRANSABDOMINAL
TORSO INJURIES
Most patients with intrathoracic or intraabdominal aortic
injury usually die before they reach the hospital. Where possible, endovascular stenting has become the treatment of
choice. With trans-torso gunshot wounds, there is a much
higher incidence of associated injuries (e.g., the esophagus).
Blunt thoracic aortic dissection is generally diagnosed
based on the CT scan rather than on angiography; the
causes are like those in other countries. The treatment is
generally regarded as similar, as well, and endovascular
stenting as the treatment of choice.
CARDIAC INJURIES
Most penetrating cardiac injuries do not survive to reach the
hospital; however, of those that do, most have a good out-
17,18
come.
Most South African residents will have completed
several emergency room thoracotomies (ERTs) with both
anterolateral and sternotomy approaches before completion
of their residencies. The repair techniques are similar to those
practiced elsewhere. An interesting challenge is the patient
who presents with a second stab wound to the heart, having
had a previous injury repaired on another occasion. A different approach is often required, especially if there has been a
previous sternotomy with repair or closure performed using
steel wires!
Strategies to Sustain and to Train
the Next Generation of Trauma
Surgeons
Medical training in South Africa is normally 5 to 6 years,
followed by a 2-year internship period and a further year
doing compulsory community medical service, usually in a
rural or community hospital. This is performed before any
approved specialty training program.
General surgical training (which includes at least 3
to 6 months of specic critical care training) consists of a
5-year training period similar to that in many Western countries, and it is possible to do a further 2-year subspecialty
fellowship in vascular surgery or trauma surgery, including
trauma critical care, and completion of the relevant fellowship, resulting in an independent subspecialist qualication.
As part of their general surgical training, most general
surgical trainees will spend at least 1 year out of their 5 years
dealing primarily with trauma cases from within a dedicated trauma center. Acute care surgery as practiced in the
United States does not exist in South Africa, as all acute surgery cases are dealt with by the same trainees and surgeons
who would deal with the general surgery and trauma emergencies, in addition to their time spent in dedicated burns,
trauma, or intensive care settings. Many specialist centers,
especially those associated with an academic institution, will
have a separate emergency vascular service. The volume of
both acute care surgical cases and trauma cases that require
operative intervention is high enough that surgical skills are
retained. However, the lack of supervision at some level II
Centers means that surgical decision-making skills are
sometimes absent. The success of the DSTC course in a highvolume environment may reect this.
Both trauma and emergency medicine are young specialties with an enthusiastic following, and those going into
trauma as a career will practice critical care as well. Nonetheless, most vascular trauma will continue to be dealt with
by general surgeons as part of their greater practice, and at
least in South Africa, most of such procedures, especially
outside of the major academic and private centers, will be
open in nature, rather than endovascular.
References
1. Plani F. Vascular trauma. In: Nicol A, Steyn E, eds. Oxford Handbook
of Trauma for Southern Africa. 3rd ed. Oxford: Oxford University Press;
2010:258–272.
2. Veller MG, Pillai J. Vascular injuries. In: Adeloye A, Adekunle OO,
Awojobi A, eds. Davey’s Companion to Surgery in Africa. 3rd ed. Uruwa:
Acecool Medical Publishers Nigeria; 2009:33–40.
3. Degiannis E, Levy RD, Soanos C, Florizoone MG, Saadia R. Arte-
rial gunshot injuries of the extremities: a South African experience.
J Trauma. 1995;39(3):570–575.
4. Franklin J, Hatzitheophilou C, Pantanowitz D. Vascular trauma. In:
Pantanowitz D, ed. Modern Surgery in Africa: the Baragwanath Experi-
ence. Johannesburg: Southern Book Publishers; 1988.
5. Bowley DM, Degiannis E, Goosen J, Boffard KD. Penetrating vas-
cular trauma in Johannesburg, South Africa. Surg Clin North Am.
2002;82(1):221–235.
6. Boffard KD, ed. Manual of Denitive Surgical Trauma Care (DSTC). 5th
ed. Boca Raton: CRC Press; 2019.
7. Brenner M, Bulger EM, Perina DG, etal. Joint statement from the Amer-
ican College of Surgeons Committee on Trauma (ACS COT) and the
American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta
(REBOA). Trauma Surg Acute Care Open. 2018;13(3(1)):e000154.
https://doi.org/10.1136/tsaco-2017-000154.
8. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for
life threatening haemorrhage in penetrating neck trauma. World Jour-
nal of Surg. 2008;32(12):2716–2723.
9. MacFarlane C, Boffard KD, Saadia R, Wilkinson AE. Emergency room
arteriography: a useful technique in the assessment of peripheral vascular injuries. J Roy Col Surg Edin. 1989;34(6):310–313.
10. Boffard KD, Goosen J, Plani F, Degiannis E, Potgieter H. The use of
low dosage x-ray (Lodox/Statscan) in major trauma: comparison
between low dose x-ray and conventional x-ray techniques. J Trauma.
2006;60(6):1175–1178.
11. Veller MG, Le Roux D. Carotid, jugular and vertebral blood vessel inju-
ries. In: Velmahos GC, Degiannis E, Doll D, eds. Penetrating Trauma.
2nd ed. Heidelberg: Springer; 2016:229–238.
12. Demetriades D, Stewart M. Penetrating injuries of the neck. Ann R Coll
Surg Engl. 1985;67(2):71–74.
13. Robbs JV, Baker LW, Human RR, Vawda IS, Duncan H, Rajaruthnam P.
Cervico-mediastinal arterial injuries. Arch Surg. 1981;116(5):663–668.
14. Du Toit DF. Penetrating trauma to the subclavian vessels. In: Velmahos
GC, Degiannis E, Doll D, eds. Penetrating Trauma. 2nd ed. Heidelberg:
Springer; 2016:229–238.
15. Robbs J, Baker LW. Subclavian and axillary artery injury. S Afr Med J.
1977;19(51(8)):227–231.
16. Nair R, Robbs JV, Muckart DJ. Management of penetrating cervico-
mediastinal venous trauma. Eur J Vasc Endovasc Surg. 2000;19(1):
65–69.
17. Robbs J, Baker LW. Cardiovascular trauma. Curr Probl Surg.
1984;21(4):1–87.
18. Degiannis E, Loogna P, Doll D, Bonanno F, Bowley DM, Smith MD. Pen-
etrating cardiac injuries: recent experience in South Africa. World J
Surg. 2006;30(7):1258–1264.
36
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Colombia: Don’t Dread the
Popliteal and Axillary Fossa
CARLOS A. ORDOÑEZ and MICHAEL W. PARRA
According to the World Health Organization, traumatic
injuries worldwide are responsible for over 5 million
deaths annually.1 As an integral part of this epidemic,
Latin America has one of the highest homicide rates.2
The region has just 8% of the world’s population, but
accounts for 33% of the total number of murders with a
bafing rate of 21.5 per 100,000 inhabitants compared
to the average of 7 per 100,000 inhabitants worldwide.2
Interpersonal violence among young people is the leading
cause of death in countries like Colombia, which unfortunately nds itself among the top 50 most violent countries
on earth. Adding insult to injury, most of this violence
resides among the poor, whose access to adequate health
care is scarce to none.
Trauma centers from Cali, Colombia, have vast experience in penetrating and blunt vascular trauma and
in a published retrospective cohort study, a total of 175
patients with popliteal artery injuries were reviewed. Of
these injuries, the most frequent arterial procedure was
interposition grafting in 116 (66.3%) patients; vein grafts
were used in 105 and synthetic grafts in 11. Direct anastomosis was performed in 34 (19.4%) patients. Popliteal
venous injuries were reported in 102 patients (58.3%)
and 46 (26.3%) required ligation of the vessel, venorrhaphy in 38 (21.7%), direct anastomosis in 7 (4%), and
interposition grafting with vein grafts in 2 (1.1%). Finally,
only 4 (1.5%) patients required amputation and the overall mortality was 9.6% (n = 19).4 As a result of this vast
operative experience, we have developed a couple of useful
surgical pearls.
3
Don’t Dread the Fossa: The
Posterior Popliteal Artery Approach
A 23-year-old male victim arrives at our level I trauma
center hemodynamically stable with a gunshot wound
to the right knee area (Fig. 36.1) with associated pain,
swelling, and decreased distal pulses on palpation. Plain
x-rays reveal no associated extremity fracture and the
patient’s vital signs remain stable. A computed tomography (CT) angiogram of the extremity is done which
reveals a mid-popliteal artery injury without contrast
extravasation and without reconstitution of distal flow.
It is our belief that a preoperative CT angiogram of the
involved extremity is paramount to determine the exact
location and extent of injury in hemodynamically stable
patients. Cases in which patients present with hemodynamically unstable and/or active arterial bleeding should
be taken immediately to the operating room where an ontable traditional angiogram can be performed. Once the
popliteal artery injury has been clearly identified, then it
is our recommendation that the ideal surgical approach
396
for open surgical repair is via the posterior approach
because:
1. Of the ease of repair of any portion of the popliteal
artery
2. It avoids muscle splitting incisions
3. It requires minimal dissection to identify and achieve
proximal and distal control of the vessel
The posterior approach originally described by Dr. Rudolph
Matas in 1921 for the management of traumatic arteriovenous aneurysms of the popliteal vessels entailed a vertical
incision via the fossa.5 Dr. Shumacker in 1946, following
his vast experience managing hundreds of American combat casualties from World War II, described in detail several nonvertical incisions to the popliteal fossa that avoided
the often seen heavy scars and joint contractures with the
Matas incision.6 Currently, the posterior approach requires
that the trauma/vascular and/or general surgeon perform
prophylactic and/or therapeutic four compartment fasciotomies to the lower leg and harvest the greater saphenous vein from the contralateral leg prior to positioning
the patient in the prone position.7 It is our recommendation that fasciotomies be performed in all cases of popliteal
artery injuries because the morbidity of the incisions are
signicantly less than the potential morbidity of a missed or
delayed extremity compartment syndrome. Upon completion, a negative pressure dressing is placed on the recently
created fasciotomy wounds and a proximal longitudinal
incision over the contralateral groin/thigh area is done to
harvest a considerable segment of the proximal greater
saphenous vein (minimum of 5 cm). Then the patient is
ipped and positioned in the prone position with appropriate padding and airway protection. The injured limb is
then re-prepped and draped. The popliteal fossa skin incision is preformed vertically in an “S” like fashion with the
purpose of avoiding postoperative scar retraction that could
potentially limit the range of motion of the involved knee
(Fig. 36.2). After performing the skin incision, the rest of the
subcutaneous dissection should be directed midline and the
popliteal vascular/nervous bundle is located very shallow
to the skin incision (Fig. 36.3). The complete extent of the
popliteal artery can be exposed with ease and both proximal
and distal vessel control can be achieved similarly without
the need to split any muscles (Fig. 36.4). At this point, the
surgical repair of the popliteal artery depends more on the
extent of the injury and can include anything from simple
direct repair to patching with autologous or synthetic material to segmental replacement similarly with autologous or
synthetic material (Fig. 36.5). We usually end up performing a reverse saphenous interposition graft for most injuries
with prior formal Fogarty (3 Fr) catheter embolectomies of
both proximal and distal ends (Fig. 36.6). We also routinely
systemically heparinize our patients and locally infuse
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Fig. 36.4 Popliteal artery is exposed.
Fig. 36.1 (A) Entry wound. (B) Exit wound.
Fig. 36.2 The popliteal fossa skin incision is preformed vertically in an
“S” like fashion.
Fig. 36.5 Closer view of the popliteal artery injury.
Fig. 36.3 After performing the skin incision, the rest of the subcutane-
ous dissection should be directed midline.
Fig. 36.6 Fogarty catheter embolectomy of the popliteal artery.
heparinized ush prior to completing our graft anastomosis (Fig. 36.7). Upon completion, an on-table angiography
is recommended to verify adequate distal ow. If there is an
associated popliteal vein injury, we recommend primary
vessel suture repair in most cases. If primary vein repair is
not feasible, then the vein can be ligated. Vein interposition
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Fig. 36.8 Closed incision.
Fig. 36.7 (A, B) Interposition vein graft.
grafts to x the popliteal vein notoriously fail and are so not
indicated. Finally, the incision is closed by layers (Fig. 36.8).
Patient is transferred postoperatively to a monitored nursing oor where serial vascular checks can be performed.
Fasciotomy wounds are closed or reapproximated as soon as
possible and physical therapy initiated early in the recovery
and carried out as an outpatient.
The popliteal artery anteromedial approach with associated fasciotomies is the most widely used technique in the
world by vascular and trauma surgeons alike, and is the
most cited and described technique in the medical literature
that addresses the management of these injuries. Originally
described by Dr. Szilagyi in 1959, it requires a medial incision over the thigh and leg and requires extensive muscle
splitting dissection to reach the vessel for both proximal
and distal control.8 This dissection is time consuming and
tedious, and the vessel distally is deeper and harder to access
and control.9 Regarding long-term outcomes, the literature
does not report any signicant difference regarding patency
and subsequent amputation rates.10 But we, the authors,
have been able to demonstrate a signicant reduction (more
than 50%) in total operative time. It is our belief and practice that all surgeons who are currently involved in the care
of trauma patients should “embrace the fossa” and include
the posterior approach as a key component to their armamentarium when confronting a patient with a potential
popliteal vessel injury.
Don’t Dread the Fossa: The Axillary
Artery Approach
A 27-year-old male patient arrives at our level I trauma
center hemodynamically unstable, pale, and diaphoretic
with a blood pressure of 90/60 mm Hg, a heart rate of 115
bpm and a gunshot wound to the right shoulder. The institution’s massive transfusion protocol is activated and the
patient undergoes rapid sequence intubation by anesthesia staff. On secondary survey, a gunshot wound is seen at
the level of the right infraclavicular area with the anterior
axillary line. Active arterial bleeding ensued profusely from
the gunshot wound orice, which was managed initially
by the application of direct pressure. Patient responds well
to our initial resuscitation efforts in the trauma bay and
is taken immediately to the CT suite for a CT chest with
right upper extremity run-off. A proximal right axillary
artery injury with active extravasation is identied and
the patient is taken immediately to the operating room for
surgical repair.11 The traditional surgical incision is one
that starts at the infraclavicular area and extends over the
delto-pectoral fossa and ends, if needed, over the medial
aspect of the upper arm. This incision requires usually the
transection of both the pectoralis major and minor muscle
bundles to expose and achieve proximal vascular control.12
This approach is time consuming, technically difcult, and
morbid for the patient.13 Because of this, and considering
the experiences obtained in elective cases of axillary lymph
node dissections for breast cancer, we have adapted a similar technique to better deal with these complex trauma
cases. The patient is placed in the supine position with the
injured upper extremity hand alongside the patient’s forehead (modied military salute pose) (Fig. 36.9). The incision is drawn along the axilla fossa in a slightly inverted
“S” fashion. The purpose of the shape of the incision is to
avoid subsequent scar retraction which may compromise
36 • Colombia: Don’t Dread the Popliteal and Axillary Fossa 399
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Fig. 36.11 Ligated axillary vein and resected ends of the axillary artery.
Fig. 36.9 Patient placed in modified military salute pose. The incision is
drawn along the axilla fossa in a slightly inverted “S” fashion.
Fig. 36.10 Incision site showing axillary artery and bullet hole.
the long-term mobility and range of motion of the shoulder. Both proximal and distal vascular control of the axillary artery can be performed quickly and safely through
this incision, without the need of transecting any mayor
muscle groups (Fig. 36.10). The proximal dissection of
the artery can be extended all the way to the ipsilateral
rib cage and control can be obtained of the vessel as it
emerges from the chest. At this point the surgical repair
Fig. 36.12 Interposition synthetic graft.
of the axillary artery depends more on the extent of the
injury and can include anything from simple direct repair
to patching with autologous or synthetic material to segmental replacement similarly with autologous or synthetic
material (Figs. 36.11 and 36.12). We usually end up performing a reverse saphenous interposition graft for most
injuries with prior formal Fogarty (3-Fr) catheter embolectomies of both proximal and distal ends. We strongly recommend performing the proximal anastomosis rst when
an interposition graft option has been decided, prior to any
proximal manipulation or embolectomy of the vessel, to
avoid the risk of losing the proximal end of the native vessel due to its potential to retract back into the chest. We
also routinely systemically heparinize our patients and
locally infuse heparinized ush prior to completing our
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Fig. 36.13 Closed incision.
distal graft anastomosis. Upon completion, an on-table
angiography is recommended to verify adequate distal
ow. If there is an associated axillary vein injury, we recommend primary vessel suture repair in most cases. If primary vein repair is not feasible, then the vein can be ligated
(see Fig. 36.11). Vein interposition grafts to x the axillary
vein notoriously fail and so are not indicated. Finally, the
incision is closed by layers (Fig. 36.13). The need for fasciotomies of the upper extremity is considered in a caseby-case scenario, always defaulting towards performing
them if there is any question of possible ensuing compartment syndrome or hypertension. The patient is transferred
postoperatively to a monitored nursing oor where serial
vascular checks can be performed. Fasciotomy wounds are
closed or reapproximated as soon as possible and physical/occupational therapy initiated early in the recovery
and carried out as an outpatient. Once again, it is our
belief and practice that all surgeons who are currently
involved in the care of trauma patients should “embrace
the fossa” and include the axillary fossa approach as a key
component to their armamentarium when confronting a
patient with a potential axillary vessel injury. We want to
emphasize that the original Matas operation performed
more than 100 years ago (1888) has stood the test of time
and we, the authors, have adapted its modied version by
Elkin and applied it not only to manage complex traumatic
injuries of the popliteal vessels, but also to those complex
injuries of the upper extremity: the Cali Approach to the
Axillary Vessels.
14,15
References
1. World Health Organization. Injuries and violence: the facts 2014.
WHO. World Health Organization; 2015. https://www.who.int/
violence_injury_prevention/media/news/2015/Injury_violence_
facts_2014/en.
2. Muggah R, Aguirre Tobón K. Citizen Security in Latin America: Facts
and Figures. 2017. https://igarape.org.br/wp-content/uploads/2018/
04/Citizen-Security-in-Latin-America-Facts-and-Figures.pdf.
3. Instituto Nacional de Medicina Legal y Ciencias Forenses. Forensis
2017: Datos para la Vida. Colombia. 2018;19(1). https://www.medicina-
legal.gov.co/documents/20143/262076/Forensis+2017+Interactivo.
pdf/0a09fedb-f5e8-11f8-71ed-2d3b475e9b82.
4. Garcia AF, Sanchez AI, Millan M, et al. Limb amputation among
patients with surgically treated popliteal artery injury: analysis of 15
years of experience in an urban trauma center in Cali. Colombia. Eur J
Trauma Emerg Surg. 2012;38:281–293.
5. Matas R. Military Surgery of the Vascular System. Philadelphia: WB
Saunders; 1921.
6. Shumacker Jr. HB. Incisions in surgery of aneur ysms: with special ref-
erence to explorations in antecubital and popliteal fossae. Ann Surg.
1946;124:586–598.
7. Hamza N, Marath A, Al-Fakhry MR. The management of aneurysms
and arterio-venous stulae of the popliteal artery arising from war
trauma. Emphasis on sigmoid operative approach. J Cardiovasc Surg
(Torino). 1990;31(4):457–461.
8. Szilagyi DE, Whitcomb JG, Smith RF. Anteromedial approach to
the popliteal artery for femoropopliteal artery grafting. Arch Surg.
1959;78:647.
9. Sciarretta JD, Macedo FI, Otero CA, Figueroa JN, Pizano LR, Namias
N. Management of traumatic popliteal vascular injuries in a level I
trauma center: a 6-year experience. Int J Surg. 2015;18:136–141.
10. Fairhurst PG, Wyss TR, Weiss S, Becker D, Schmidli J, Makaloski V.
Popliteal vessel trauma: surgical approaches and the vessel-rst strategy. Knee. 2018;25(5):849–855.
11. Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Vascular injuries
of the axilla. Ann Surg. 1982;195:232–238.
12. Padegimas EM, Ramsey ML, Austin M, et al. Evaluation and man-
agement of axillary artery injury: the orthopaedic and vascular surgeon’s perspective. Orthopedics. 2017;40(4):223–229.
13. Mazzini FN, Vu T, Prichayudh S, etal. Operative exposure and manage-
ment of axillary vessel injuries. Eur J Trauma Emerg Surg. 2011;37(5):451.
14. Elkin DC. Traumatic aneurysm; Matas operation - 57 years after. Surg
Gynecol Obstet. 1946;82:1–12.
15. Matas R. Traumatic aneurysm of the left brachial artery—incision
and partial excision of sac: recover y. Phil Med News. 1888;53:462–466.
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Brazil
ROSSI MURILO and RINA PORTA
Introduction
For the purposes of this chapter, vascular trauma is considered in the following anatomic distributions, each of which
has differing diagnostic and management considerations:
(1) cervical or carotid, (2) axillo-subclavian, (3) thoracic, (4)
abdominal, and (5) extremity domains. Whereas the majority of vascular injury is managed via an open operative
approach, the use of endovascular techniques is common in
the metropolitan centers throughout the country. In these
instances, stent grafts are often used to treat or “seal” vascular disruption in anatomically-challenging-to-reach vessels
such as those in the thorax and thoracic outlet. In Brazil,
challenges exist as to the “best training paradigms” to prepare trauma and vascular surgeons. However, a number of
Brazilian medical centers and emergency medical systems,
working alongside the efforts of professional societies such
as the Brazilian Trauma Society (Sociedade Brasileira de
Atendimento Integrado ao Politraumatizado, SBAIT), have
emphasized the importance of trauma care in the country.
Epidemiology
Currently, urban violence, automobile crashes, and workrelated accidents are responsible for most injuries in Brazil;
a notable amount of those injuries are to major vascular
structures.
saving interventions and early resuscitation strategies have
been established in many of the larger emergency rooms in
Brazil. Additionally, a full understanding of the epidemiology
of vascular trauma is hampered by the lack of standardized
data retrieval and archiving mechanisms or databases.
According to Brazil’s Institute of Geography and Statistics, just over 210 million people live in Brazil. Increasing
levels of violence and trauma within certain urban areas
and regional locations in Brazil (Table 37.1) were the norm
until the most recent decade (2010–19). This trend has
lessened recently as rates of violent crime, including homicide, have plateaued or declined in proportion to population
growth. Currently, the overall homicide rate uctuates at
around 30 per 100,000 people.
The growth in homicide over these three and a half
decades was largely due to death from rearms, whereas
deaths from other means remained relatively constant. In
the early 1980s, there was an “arms race” associated with
an increase in social tension, caused by a massive growth
in urban population (following population transition from
rural areas), although the 2003 Disarmament Statute
helped to limit rearm availability.
We have two types of health care systems in Brazil:
public (Sistema Único de Saúde, SUS) and private (health
and private plans). About 90% of the Brazilian popula tion
1–3
Concomitant with this experience, better life-
1–3
1–3
rely on the public health system that is maintained by the
government. The health system is composed of facilities of varying complexity: basic health units and Emergency Care Units, secondary hospitals, tertiary hos pitals
and University Hospitals, where some tertiary and university hospitals correspond and function as trauma
centers (Fig. 37.1). Systematized, standardized clinical
responses to polytraumatized patients began in the public (University) hospitals in the 1980s, with the introduction and expansion of Advanced Trauma Life Support
in Brazil. In the last decade, some private hospitals have
started to implement trauma care systems based around
teams of trauma surgeons. Prehospital emergency care is
performed by the Emergency Medical Care Service (Serviço de Atendimento Móvel de Urgência, SAMU), which
is structured with basic care units composed of technicians and nurses and advanced units composed of doctors
and nurses. An emergency medical response (ambulância)
is obtained by telephoning 192. However, in some cities
such as São Paulo, Rio de Janeiro, and Curitiba, in addition to the SAMU response, prehospital trauma care is performed by physicians and nurses in conjunction with the
rescue team of the Fire Department (Corpo de Bombeiros),
activated by dialing 193.
URBAN SETTING
The severity of vascular trauma varies, with injuries stemming from military- or combat-related munitions generally
cause more extensive damage.
ally have little experience of managing severe injury caused
by military munitions and explosive devices, although
the sporadic use of military-type weapons in the urban
setting is a regrettable but new reality that is not unique
to Brazil. Although uncommon, vascular trauma resulting
from weapons such as the AR-15, AK-47, M16, and even
grenades occurs on a sporadic basis in some areas of Brazil
(Fig. 37.2), though the proportion of such injuries was seen
to decline in a series from the Hospital Municipal Souza
Aguiar (1995–2000). This observation was made during
a time when the homicide rate was increasing, suggesting
that high-velocity munitions remained a signicant cause
of trauma including lethal injury. In an encouraging and
more-recent trend, the rate of violence and the number of
high-velocity gunshot wounds currently tended to in the
state has plummeted.
1–3
4,5
Brazilian surgeons gener-
RURAL SETTING
Between 1% and 4% of injuries in the more remote areas
of Brazil have a vascular component. Lower extremity traumas usually result from automobile crashes, whereas upper
extremity injuries typically occur as result of factory or
401
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Table 37.1 Ranking of States by Homicide Rates (per 100,000): Brazil 2000–16.
2000 2010 2016
State
Alagoas 25.6 11th 66.8 1st 55.9 3rd
Espirito Santo 46.8 3rd 50.1 2nd 32.5 16th
Pará 13.0 21st 45.9 3rd 50.9 4th
Pernambuco 54.0 1st 38.8 4th 47.6 6th
Amapá 32.5 9th 38.7 5th 49.6 5th
Paraíba 15.1 20th 38.6 6th 33.1 13th
Bahia 9.4 23rd 37.7 7th 46.5 7th
Rondônia 33.8 8th 34.6 8th 32.8 14th
Paraná 18.5 16th 34.4 9th 25.9 20th
Distrito Federal 37.5 7th 34.2 10th 22.1 22nd
Sergipe 23.3 12th 33.3 11th 64.0 1st
Mato Grosso 39.8 5th 31.7 12th 35.5 11th
Amazonas 19.8 14th 30.6 13th 29.4 18th
Ceará 16.5 17th 29.7 14th 39.8 9th
Goiás 20.2 13th 29.4 15th 43.8 8th
Roraima 39.5 6th 27.3 16th 19.8 25th
Rio de Janeiro 51.0 2nd 26.2 17th 37.6 10th
Mato Grosso do Sul 31.0 10th 25.8 18th 22.7 21st
Ri Grande do Norte 9.0 24th 22.9 19th 56.9 2nd
Tocantins 15.5 19th 22.5 20th 27.1 19th
Maranhão 6.1 27th 22.5 21st 33.7 12th
Acre 19.4 15th 19.6 22nd 29.8 17th
Rio Grande do Sul 16.3 18th 19.3 23rd 31.2 16th
Minas Gerais 11.5 22th 18.1 24th 20.7 24th
São Paulo 12.2 4th 13.9 25th 11.0 27th
Piauí 8.2 25th 13.7 26th 21.9 23rd
Santa Catarina 7.9 26th 12.9 27th 15.0 26th
Sistema de Informação sobre Mortalidade (SIM)/Secretária de Vigilância em Saúde (SVS)/Ministério da Saúde (MS); Araujo et al. (2006), Waiselfisz (2018), and
Rossi et al. (2013).
Rate Position Rate Position Rate Position
Fig. 37.1 State Institute of Cardiology Aloísio de Castro (IECAC) in Rio
de Janeiro, which is the primary medical center of the authors of this
international perspective.
industrial accidents, agricultural mishaps, or domestic disputes (i.e., knife or glass lacerations). In the case of domestic disputes where knife and lacerations from glass are more
common, upper extremity vascular injury is often conned
to the radial artery (34% of cases) or the ulnar artery (36%
of cases), either of which frequently can be managed by
ligation instead of repair or reconstruction.
Fig. 37.2 Right external iliac (vein and artery) following a high-velocity
gunshot wound (wounding by AK-47).
AUTOMOBILE CRASHES
Brazil has one of the highest numbers of trauma deaths due
to trafc, exceeded only by India, China, the United States,
37 • Brazil 403
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and Russia. Between 1980 and 2011, almost one million
people died due to trafc accidents in the country; between
2000 and 2010, the number of fatalities increased from
28,995 to 42,844, a 32.3% increase. Males accounted for
82.3% of this total and the highest rates were observed in the
Midwest and South regions, with rates of 29.0 and 25.4 deaths
per 100,000 inhabitants. Motorcyclists accounted for 76.9%
of all deaths. The trend of motorcycle fatalities has also been
found in Great Britain, with an annual increase of 4.6% in
hospitalizations of road accidents. In Brazil, a 2008 study from
Campinas, State of São Paulo, recorded a signicant increase
in fatal trafc accidents with motorcyclists accounting for
49.3% of deaths in trafc.
6
Evaluation and Diagnosis of
Vascular Injury in Brazil
There is wide disparity in the resources available to trauma patients in the more remote and smaller towns of
Brazil and the resources available to patients in the larger
urban medical centers. In the metropolitan areas of Brazil,
the routine triage, evaluation, and diagnosis of vascular injury is similar to that in other developed countries
of the world. A detailed summary of the discrepancy of
resources between public and private medical centers in
Brazil is beyond the scope of this review. As such, this
report focuses on the diagnosis and management of vascular injury in Rio de Janeiro, which has a population of
more than 7.5 million people and is the second largest city
in Brazil. In this setting, the prehospital evaluation of the
trauma victim is divided into four phases, all conducted by
the Fire Department (emergency physicians):
1. Rapid assessment: Completed in a matter of minutes, this
phase aims to diagnose and treat conditions that are lifethreatening and to evaluate whether a patient is critical.
2. Critical intervention and transportation: Transportation to
the one of seven trauma referral centers in Rio de Janeiro
should occur immediately after stabilization procedures
are completed.
3. Nonessential procedures: These are deferred until after the
patient is transported to a trauma referral center.
4. Detailed examination: This examination is to diagnose
injuries that were not observed during the rapid assessment. For critical patients, this phase must be performed
during transportation; whereas, for stable patients, it
can be performed on the scene in less than 5 minutes.
and any lifesaving maneuvers are performed, the patient
is usually transferred to one of three locations: radiology
for additional imaging, the intensive care unit for monitoring and resuscitation, or the operating room for resuscitation and repair. In most cases of significant vascular
trauma, patients are transferred from the resuscitation
room to the operating room where additional imaging
and repair can be performed as needed while resuscitation is ongoing.
Vascular Injury Patterns and
Treatment Strategies
A retrospective study from the Municipal Hospital Souza
Aguiar (one of the largest emergency centers in Latin
America) between 1998 and 2008 reported 1478 vascular
injuries in 1236 patients. Like other regions of the world,
ndings from this study revealed that vascular trauma in
Brazil occurs most commonly in men (73% of the cohort)
under 40 years of age (69% of the cohort). The main
mechanism of vascular injury in this study was gunshot
wound (73%) with low-velocity injuries being more common
than high-velocity wounds (83% and 17%, respectively).
The most common anatomic location of vascular injury
was the lower extremities followed by the upper extremities (54% and 33%, respectively). Approximately 5% of the
vascular injuries were in the cervical region with a similarly
small percentage in the abdomen (5%) and the thorax (3%).
Surgical management of vascular injury in this retrospective series consisted of primary anastomosis (39%), graft
reconstruction (21%), ligation (16%), and suture repair
(12%). Primary amputation was reported in only 1.5%
of the cases of extremity vascular trauma. The main conduit used as a vascular substitute was autologous vein,
with synthetic grafts used in only 5% of the reconstructions. When an autologous conduit was used, great saphenous vein was used in 90% of cases (Fig. 37.3), with arm
cephalic vein used in few instances (1.3%). Unsurprisingly
(and like other regions of the world), patients with vascular
Referral trauma centers in the city of Rio de Janeiro,
Belo Horizonte, and São Paulo use modern resuscitation
rooms, which are accessible to prehospital emergency
vehicle(s) and providers with ample space for a multidisciplinary team to quickly triage and perform a range of
diagnostic and resuscitative maneuvers. These resuscitation rooms are equipped with radiography and ultrasound
equipment to perform diagnostic imaging and assist with
vascular access, as well as operative equipment to facilitate resuscitation (i.e., transfusion), fracture stabilization, and immediate lifesaving interventions. Depending
on the injury, as soon as the initial survey is complete
Fig. 37.3 Saphenous vein interposition graft for arterial reconstitution.
404 SECTION 5 • Global Perspectives on Vascular Trauma
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and nonvascular trauma (i.e., polytrauma) had the highest rates of mortality in the review, especially patients with
vascular trauma and concomitant cranial and/or thoracic
7
injury.
ENDOVASCULAR FACILITIES
Sufce it to say that, as in other areas of the world, endovascular technologies (i.e., balloons, stents, and stent grafts)
have played increasingly important roles in managing
some patterns of vascular trauma, especially in the larger
and better-equipped tertiary trauma centers in Brazil
(Fig. 37.4). In general, endovascular stent graft manage-
ment of vascular trauma is reserved for central vascular injuries of the aorta and its proximal branch vessels,
such as the subclavian, intrathoracic carotid, and even
occasionally a mesenteric vascular injury.
these therapies, the development of a single physical
location (i.e., resuscitation with angiography, percutaneous techniques, and operative repair) where percutaneous therapies, operative interventions, cross-sectional
imaging, and initial critical care can all be delivered is
extremely attractive. This concept of hybrid surgery and
resuscitation has been used in the main trauma centers
in our country. The vascular surgeon on duty is part of
the emergency surgical team and works together with
the trauma team to control bleeding and treat vascular
injury. Severely injured patients are taken to the operating room and placed in a surgical radioscopy table. There
are standard angiography equipment, diagnostic marker
ush catheters, and guide wires for most vascular interventions. Equipment specic to aortic interventions,
including large diameter sheaths, super-stiff guidewires,
and varying sizes and types of aortic endografts are available. In this way, hybrid procedures are performed in some
University Hospitals.
8–10
To deliver
SPECIFIC CONSIDERATIONS
Carotid Injuries
Lesions of the common and internal carotid artery may
cause thrombosis and/or hemorrhage, especially when the
wound is lateral or in the intimal lesion, which may go unnoticed and cause future problems (i.e., pseudoaneurysm). Our
experience is that an open repair and reconstruction is the
best option, even in patients with neurologic symptoms. A
neurological assessment of the patient before and after the
operation is essential to outline the best therapeutic course
and to assess its outcome. For injuries to the external carotid
artery and its branches, endovascular embolization has been
useful with good results for these authors.
Subclavian Injuries
Like others, the authors recognize that there is a signicant difference in the surgical approach to the three distinct segments of the subclavian artery. The intrathoracic
segment of the subclavian artery is typically approached
using a high anterolateral thoracotomy with or without
a separate supraclavicular exposure of the more distal
artery. Because of the challenges associated with exposing
and controlling the intrathoracic subclavian artery, the
authors have found this injury location particularly well
suited for endovascular treatment using a covered stent.
The more distal subclavian artery segments behind and
distal to the rst rib can be exposed with a supraclavicular
incision often combined with an infraclavicular approach
of the axillary artery. The authors have found endovascular repair of the more distal subclavian and even proximal
axillary artery favorable in some cases (Fig. 37.5).
Cardiac Injuries
Cardiac trauma has high mortality. It can cause exsanguination, varying degrees of mediastinal and pleural
Fig. 37.4 (A) Computed tomographic angiography showing blunt injury of the thoracic aorta (pseudoaneurysm) caused by an automobile accident.
(B) Digital subtraction angiogram of thoracic endovascular aortic repair stent-graft. Note variant aortic arch branching anatomy (origin of left common
carotid artery from brachiocephalic artery).
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