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Carotid, Jugular andVertebral Blood

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Vessel Injuries

DirkLe Roux, MartinVeller, andIanGrant

• Trauma to the neck is dangerous and has a high mortality and morbidity.

• Penetrating neck injuries remains challenging, as there are a number of important structures in a small volume. Injury to any of these structures is not always initially apparent.

• The cervical blood vessels are involved in 25% of patients with head or neck trauma, and carotid artery injury constitutes 5–10% of all arterial injuries. The reported mortality for carotid injuries ranges from 10% to 31% with permanent neurological decit ranging from 16% to 60% and remains high despite advances in diagnosis and treatment.

• The management of penetrating neck trauma has undergone considerable development in recent years. In the 1980s, a policy of routine exploration was slowly replaced by a policy of selective exploration. More recently, treatment strategies have been rened by the introduction of accurate diagnostic modalities in the stable patient (mostly rapid multi-slice CT scanning) and the use of endovascular therapies.

Caveat

Severe vascular injury after neck trauma can be present even in the absence of clinical signs. Liberal Duplex Doppler or angiography after penetrating trauma when cervical vessel injuries cannot be ruled out is indicated. Associated injuries of the cervical spine, airway and digestive tract must always be considered.

Always stabilise the neck of patients in all types of severe

cervical trauma until the entire spectrum of injuries is known.

If the patient is stable, CT angiography should always be

performed in penetrating injuries to zones I and III.

D. Le Roux (*) · M. Veller · I. Grant Division of Vascular Surgery, Wits Donald Gordon Hospital, University of the Witwatersrand Medical School, Johannesburg, South Africa e-mail: leroux@vascare.co.za; acv@icon.co.za

Duplex Doppler or CT angiography should be performed (if available) in order to select between conservative, endovascular and surgical management.

The surgical anatomy of the superior mediastinum and neck is shown in Fig.35.1, demonstrating the proximity of the vessels and nerves around the aero-digestive tract (Fig.35.1).

The neck contains many vital structures located in a small volume:

• The important anterior structures of the neck lie deep in

the platysma, and as a result, only injuries that have pen-

etrated through this muscle are clinically signicant.

• As a result of the aero-digestive tract’s position in the

midline and its close relationship to the major blood ves-

sels in the neck injuries, that cross the midline usually

cause a greater degree of damage.

• The sternocleidomastoid muscle divides the posterior and

anterior triangles of the neck. Within the anterior triangle

lie the aero-digestive tract and the major blood vessels

supplying the brain and face, while the posterior triangle

contains the brachial plexus and blood vessels to the

upper limbs.

• The area of the neck posterior to the cervical vertebral

body and the scalene muscles is composed mainly of

muscle, bone and other nonvital structures. The spinal

cord is encased in the cervical spine which can usually

only be penetrated by gunshots. The vertebral arteries

may be injured by a gunshot or stab and could potentially

require intervention.

• The neck is divided into three zones using anatomic land-

marks (Fig.35.2). The management of injuries in these

zones varies due to the vital structures that each zone con-

tains and the manner in which access can be gained.

• There has recently been some work to support a ‘non-

zonal’ approach. It is important to remember that an

external injury in a specic zone is not limited to an injury

in that zone and may extend to an adjacent zone.

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298

Sternocleidmastoid Muscle

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Fig. 35.1 The surgical anatomy of the superior mediastinum and neck indicating the proximity of the vessels and nerves around the aero-digestive tract

Brachial

plexus

D. Le Roux et al.

Scalenus anterior m.

Ver tebral a.

Recurrent

laryngeal n.

agus n.

Common carotid a.

– Zone I is the area between the clavicle/suprasternal

notch and the cricoid cartilage, encompassing the thoracic outlet structures (Fig.35.2a). The proximal common carotid arteries, internal jugular veins, vertebral arteries and veins and the subclavian arteries and veins and the trachea, oesophagus, thoracic duct and thymus are located here (Fig.35.2b).

– Zone II is the area between the cricoid cartilage and

the angle of the mandible. It contains the internal and external carotid arteries; jugular veins; pharynx; larynx; oesophagus; cranial, sympathetic and recurrent laryngeal nerve; spinal cord; trachea, thyroid and parathyroid glands.

– Zone III is the area that lies between the angle of the

mandible and the base of the skull. It contains the distal extracranial internal carotid and vertebral arteries, the uppermost segments of the jugular veins and cranial nerves IX to XII.

• Tight fascial compartments of neck structures may limit external haemorrhage from vascular injuries, but it may increase the risk of airway compromise by an expanding haematoma.

Esophagus

Phrenic n.

Thoracic duct

Subcla

Subclavian v.

Trachea

Zone III

Zone II

Cricoid

Zone I

Zone III

Jugular

vein

Fig. 35.2 (a) Zones of the neck, projected onto the cervical spine. (b) Zones of the neck and vascular structures

Comman carotid artery

Zone II

Zone I

35 Carotid, Jugular andVertebral Blood Vessel Injuries

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35.1 Pathophysiology

Wounding instruments have specic characteristics that affect surgical ndings. Two factors in the mechanism of injury or kinematics in penetrating neck trauma determine the extent of damage to the tissue:

• Weapon characteristics:

– Tissue injury results from either a direct impact by the

penetrating projectile or tissue displacement from temporary cavitation caused by high-velocity projectiles.

– Stab wounds typically have a 10% higher rate of nega-

tive exploration than injuries from projectiles.

– Secondary missiles (created as the projectile breaks

apart or liberates bony fragments) in gunshots frequently add to the injury severity. The trajectory may change and a lot of kinetic energy is transferred to the tissues

• Location of injury and human tissues involved:

– Wound sites and, if present, the wounding agent

(retained bullet or stabbing implement) provide an indication of the likely injury complex.

– Implied wound tract, particularly if it crosses the mid-

line, is of particular importance.

Penetrating injuries may cause partial or complete tran-

section with thrombosis of the vessel or pseudoaneurysm. Pseudoaneurysm may have an acute or delayed onset with progressive enlargement causing compression of the surrounding structures. An arteriovenous stula may develop if there is adjacent perforation of an artery and vein and is often accompanied by a pseudoaneurysm. Intimal injury can be caused by a high-velocity missile shock wave. The vessel is macroscopically intact with minimal bruising, but on opening the vessel, there is an intimal tear with or without a superimposed thrombosis.

The potential neurological consequences of vascular inju-

ries are caused by hypoperfusion (caused by transected or thrombosed vessels) or embolisation from intimal injuries, pseudoaneurysm or AV stulae.

35.2 Clinical Signs

Rapidly expanding cervical haematoma, absent carotid pulse, a bruit or thrill and external bleeding are hard signs indicative of vascular injury. Soft signs which may indicate a vascular injury and warrant further investigation include active or previous bleeding from wounds of the neck or the pharynx, a supercial temporal artery pulse decit, ipsilateral Horner’s sign, IX–XII cranial nerve dysfunction and a widened mediastinum. Neurological decit may be present but obscured due to concomitant head injury, shock or the

use of alcohol or drugs. Cavitation caused by the shockwave of gunshot wounds can cause a blunt injury to the nearby carotid and vertebral arteries. These injuries could initially be asymptomatic in 50% of patients, but 43–58% of these will eventually develop neurological signs. Physical exam is most reliable for arterial injuries but less sensitive to venous and aero-digestive tract injuries. The presence of distal pulses does not rule out an arterial injury. Be aware of concomitant injury to nearby structures. Signs of laryngeal injury include respiratory distress, stridor, subcutaneous air, haemoptysis, odynophagia and anterior neck pain. Dysphagia, bloody saliva, subcutaneous air and haematemesis are all features suggestive of oesophageal injury. Neurological fallout will vary depending on the affected segment.

35.3 Management

35.3.1 The Stable Patient: Diagnostics—CT Scan or Equivalent

• Patients with active bleeding and a compromised airway

require immediate exploration. Occasionally, such bleeding can be controlled with the insertion of a Foley catheter, using the inated balloon as a method to tamponade active bleeding. This technique can convert an extremely dangerous setting to a semi-elective one.

• Haemodynamically stable patients with a patent airway

who have the following signs should undergo further appropriate investigations:

– In gunshot injuries:

Proximity of wounds or expected wound tracts to vessels. Evidence of crossing the midline. Bleeding that has been controlled by a Foley catheter or similar manoeuvre.

– In stab wounds:

Wound penetrating platysma and with bleeding that has been controlled by a Foley catheter or similar manoeuvre.

• The diagnostic modalities used are:

– Multislice contrast CT and CTA have replaced arteri-

ography in recent years, as it not only demonstrates vascular anatomy well but also gives substantial additional information about other structures in particular those of the aero-digestive tract. A review by Woo and colleagues reports that the use of CTA is associated with less operative exploration, less negative explorations and reduced use of invasive studies, such as conventional angiography. Physical examination ndings supplemented by CTA should have a prominent role in the selective management of penetrating neck injuries.

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Fig. 35.3 CTA has replaced angiography as the initial study of choice in the vascular evaluation of a neck injury (here in a patient with a fragmented gunshot neck). Arrows indicate bullet fragments and injury tract with external carotid injury

D. Le Roux et al.

sels and evaluation for possible endovascular treatment. Certain centres that have in-house angiographers may perform angiography for injuries in zone I and zone III despite hypotension or haemorrhage. Angiography remains the criterion standard for dening arterial anatomy and injury complexes, with an accuracy close to 100% (arteriography demonstrates a low yield in asymptomatic patients). Arteriography is usually performed using a digital subtraction angiography (DSA) technique that reduces the amount of contrast required and yields a superior computermanipulated image for evaluation. Angiography is more invasive than other imaging modalities but lends the opportunity for endovascular intervention. The decision-making regarding open or endovascular approach is usually made based on other diagnostic imaging, typically CTA.

– MR angiography may be valuable in carotid artery and

vertebral artery dissection but only in a stable patient, as monitoring of the vital signs is difcult during the investigation and MRA is a time-consuming investigation.

– Cervical anteroposterior and lateral radiography with

bullet markers is used to evaluate for vertebral bony injury; retained foreign bodies; and foreign body deformity, location, size and number. These radiographs can also give additional valuable information like retropharyngeal or mediastinal air which are indicative of aero-digestive tract injuries.

CTA has replaced angiography as the initial study of choice in the vascular evaluation of a neck injury (Fig.35.3).

– Duplex Doppler examination is useful for investigat-

ing zone II vascular injuries. Duplex scanning, however, has its limitations in zones I and III due to anatomical constraints. Duplex Doppler is not as readily available at all times and requires an experienced operator.

– A CT scan of the brain should be obtained to investi-

gate patients with associated head trauma, bone injuries of the spine and skull and those with neurological decits. A CT scan of the brain is a good predictor of outcome: Patients who have an infarct on initial CT on admission have a high mortality with a worse chance of neurological recovery compared to those patients who have a normal CT on admission.

– Arch angiography remains a good alternative if CTA

is not available for the diagnosis of cervicomediastinal (zone I) and zone III vascular injuries. It gives information regarding suspected injuries to other ves-

35.3.2 The Unstable Patient: Operative Approach

35.3.2.1 Management intheEmergency

Department

Advanced Trauma Life Support (ATLS) guidelines should be followed for severe cervical vascular injuries. Thus, airways with cervical spine control and respiration have rst priority, followed by control of bleeding. Control of bleeding is best achieved by manual compression or the application of a Foley catheter (see later) applied directly to the bleeding site. Blind application of haemostatic clamps should not be attempted because of the risk of injuries to blood vessels as well as to other vital structures. Do not remove impaled objects until the patient is in a controlled environment and you are ready to control the bleeding.

The concept of hypotensive resuscitation should be adhered to as hyper- or even normotension may increase bleeding and also induce the progression of dissection, while severe hypotension will increase the risk for thrombosis and decreased cerebral perfusion.

Balloon compressing

35 Carotid, Jugular andVertebral Blood Vessel Injuries

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Sucking neck wounds can be covered by an occlusive dressing to avoid air embolism. Also, turn the patient to a left lateral position and tilt the bed head down.

Intubation should be performed in such a manner as to avoid coughing and an increase in blood pressure, which might dislodge thrombus and thus cause haemorrhage or embolisation. Take care not to ex the patient’s neck at the intubation because of the risk of associated cervical vertebral fractures or dislocations. Only use bag-mask ventilation if absolutely necessary because you may force additional air into the soft tissues and distort the anatomy further. The intubation might also be difcult because a haematoma might cause compression of the trachea. Emergency tracheotomy or cricothyroidotomy is then the only alternative, but it may also be complicated by the deranged anatomy and risk of bleeding. The risk of profuse and uncontrolled haemorrhage is greatest if the haematoma is located in the anterior triangle of the neck because the tamponade will be lost when the pretracheal fascia is incised. By using liberal intubation early on and under controlled conditions, loss of airway can be avoided. Consider awake bre optic intubation if available and always be fully prepared for a surgical airway. Prepare two suction units and have alternative airways like laryngeal mask devices ready.

Place IV lines on the opposite side to the injuries as there may be a subclavian vessel injury. Blood tests need to be individualised per patient. Commonly needed tests are prothrombin time (PT), partial thromboplastin time (PTT), urea and electrolytes, haemoglobin and a crossmatch to order blood.

35.3.2.2 After Initial Resuscitation: What Now?

1. Injuries in zone II not penetrating the platysma need no

further examination.

2. Immediate operation is indicated for unstable patients

with active bleeding not responsive to resuscitation or with a rapidly expanding haematoma or airway obstruction, irrespective of the anatomical zone.

3. All others require further diagnostic evaluation to deter-

mine whether critical structures have been injured. CT angiography is most commonly used and is nowadays available in most trauma centres. If CTA, angiography and high-quality duplex ultrasound are not available, injuries in zone II need to be surgically explored.

a safe alternative; however, the patient needs to be followed on an inpatient basis for a couple of days to monitor for the appearance of neurological symptoms. We employ Duplex Doppler examination repeatedly. Anticoagulation therapy and antiplatelet therapy are routinely initiated.

Management of signicant carotid artery injury existing with major neurological decit and coma is controversial. Some suggest only observation and palliation, especially in patients with CT-veried cerebral infarction, because of the poor prognosis. We advocate repair and are aware of the risk of converting an ischaemic infarct into a haemorrhagic infarct. This strategy however requires extensive experience in carotid surgery and/or endovascular intervention. Most patients with carotid artery injuries are best managed by primary arterial repair, regardless of neurological status. We consider neurological decit only a contraindication to surgical repair in case of a deeply comatose patient with a dense neurological decit, arterial occlusion and a large infarct on cerebral CT scan; these patients have poor outcomes regardless of the treatment. All other patients with associated neurological decits would benet from arterial repair with improved mortality and nal neurological status.

When the carotid artery is occluded and there are no neurological symptoms, we recommend observation and anticoagulation with heparin and antiplatelet therapy followed by 3–6 months of an oral anticoagulant and antiplatelet irrespective of the type of trauma to prevent progression of thrombus or embolisation.

In the unstable patient, a Foley catheter (extraluminally) or a Fogarty catheter (intraluminally) can be utilised to tamponade bleeding temporarily while waiting to move the patient to the operating theatre (Fig.35.4). As a generalised dictum, a liberal sternotomy and clamping of the proximal neck vessels in the upper mediastinum is a safe method to gain proximal vessel control.

Foley’s catheter

We recommend repair in all patients with penetrating carotid injuries when there is still evidence of prograde ow and the patient has no major neurological symptoms.

For minor injuries to the carotid artery, including those with small but adherent intimal aps, defects or pseudoaneurysms <5mm in size, repair is recommended in symptomatic patients. If the patient is asymptomatic and there is no ongoing active bleeding, a conservative approach has proven to be

subclavian artery

Fig. 35.4 In the unstable patient, a Foley catheter (extraluminally) or a Fogarty catheter (intraluminally) can be utilised to tamponade bleeding temporarily while waiting to move the patient to the operating theatre

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Standard incision

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South African experience from large series suggests that all penetrations beyond the platysma should at least be evaluated if not explored due to the high morbidity and mortality associated with missed injuries, not only of the vital arteries but also of the aero-digestive tract (Fig.35.8).

35.4 Operative Technique

Remember that vascular control may be problematic in zone I (proximal control) and zone III (distal control). This consequently leads to higher mortality rates in patients with vascular injuries in these neck zones.

The general principles of management are as follows:

1. In order to have good exposure, be sure to have the patient

in a supine position with a bolster between the scapulae, the neck extended and the head rotated to the contralateral side. The patient must be draped to allow access from the base of the skull to the xiphisternum.

2. Zone II injuries are explored by the standard incision

overlying the anterior border of the sternocleidomastoid muscle. Figure35.5 shows the steps of standard exposure of the common carotid bifurcation.

3. Zone I injuries usually require a median sternotomy

unless endovascular or similar control of vascular structures can be achieved.

4. Various techniques have been described to improve expo-

sure of the distal internal carotid artery in zone III injuries by dislocating the jaw and detaching the sternocleidomastoid muscle from its insertion on the mastoid process and resecting the styloid process. We use endovascular

Mastoid process

anr. border

Laryngeal

cartilage

Alternate

incision

Fig. 35.5 Standard approach to the common carotid bifurcation

2cm

of SCM muscle

techniques like over-the-wire Fogarty balloons in conjunction with open surgery.

5. We only make use of intraluminal shunts during complicated repairs of the internal carotid artery.

6. The external carotid artery can be safely ligated if the internal carotid artery is patent.

7. Internal carotid artery ligation is only allowed when the distal vessel is thrombosed with no back bleeding following extraction of thrombus.

8. Minor venous injuries can be managed by lateral suture repair, but complex venous repair is not indicated as there is a high occlusion rate, and it increases the magnitude of the operative procedure. Ligation of a single internal jugular vein can be performed without signicant sequelae.

9. Protect the vascular repair in the presence of associated injuries to the trachea and oesophagus by soft tissue interposition (sternocleidomastoid muscle).

An incision anterior and parallel to the anterior border of the sternocleidomastoid muscle is recommended. The incision can be extended dorsal to the ear and down to the sternal notch. As previously stated, preparations need to have been made to allow elongation of the incision into a median sternotomy in order to obtain proximal control of the neck vessels.

A transverse or collar-type incision can be performed for suspected injuries traversing the cervical region, providing exposure to both sides and obviating the need for bilateral neck incisions.

The specic injuries described below must be conrmed and treated during neck exploration. Note that multiple structures are frequently injured from penetrating neck injury because of the numerous vital structures that are contained in a small area.

Carotid artery injuries are the most common, with an incidence of approximately 9%. They also pose one of the most immediate life-threatening situations. The objective of surgery is to arrest haemorrhage yet maintain cerebral blood ow and preserve neurological function. Arteriorrhaphy, vein patch or interposition repair with autogenous reversed saphenous vein graft can be performed to repair the injury. Arterial repair is shown to have lower morbidity and mortality rates than ligation. The presence of neurological decits, coma and shock, especially preoperatively, are poor prognostic signs but are not absolute contraindications for carotid artery repair. Carotid ligation is advocated in patients who are comatose with no evidence of anterograde ow in the internal carotid artery. Ligation can also be an option when uncontrollable haemorrhage is present and temporary shunt placement is technically difcult.

Jugular vein injury repair is contingent on the condition of the patient. The repair can be performed by simple lateral closure, resection and reanastomosis or saphenous vein graft

35 Carotid, Jugular andVertebral Blood Vessel Injuries

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reconstruction, particularly the internal jugular. Repairing at least one side is very important if both internal jugular veins are injured. The external jugular vein can be ligated without any adverse effects.

35.5 Technical Tips

35.5.1 Surgical Exposure oftheCarotid Arteries

After the skin has been incised, subcutaneous fat and the platysma are divided. The sternocleidomastoid muscle is retracted laterally, and a dissection plane anterior to the muscle is identied. The next structure overlying the carotid medially is the facial vein and its conuence to the internal jugular vein (Fig.35.6). This is suture-ligated and divided and is usually a very good landmark because it is located just above the carotid bifurcation (beware—the hypoglossal nerve may be adherent to the posterior surface of this vein). Dividing this vein allows posterior retraction of the internal jugular vein and exposure of the common carotid and its bifurcation. When preparing the carotid arteries, care must be taken to avoid manipulation of the vessel to avoid the risk of embolisation to the brain. Vessel loops are applied, and the most cranial clamp is applied rst to avoid embolisation when the more proximal parts are clamped. Important struc-

tures to protect are the hypoglossal and vagus nerves. The former usually crosses over the internal carotid artery 2–3cm cranial to the bifurcation and is best exposed after cranial retraction of the digastric muscle. The vagus nerve runs parallel, posterior and between the common carotid artery and jugular vein. The sympathetic trunk runs posterior to the carotid sheath. The ansa cervicalis, often located obliquely over the carotid bifurcation, may be divided to facilitate exposure. We use local heparinised saline solution and not general heparinisation. We routinely leave a 15 French soft silicone suction drain in the wound, taking care to place it away from the arterial repair.

35.5.2 Vertebral Artery Injuries

The incidence of vertebral artery injury is low with the reported incidence of penetrating neck trauma ranging from 1% to 7%. Gunshot wounds are the most common mechanism of injury.

The majority of patients with vertebral artery injuries have associated injuries of the cervical spine, spinal cord and other vascular structures in the neck or the aero-digestive tract. Helical CT angiography has a high sensitivity and specicity for detecting vertebral arterial injury and is being used increasingly in penetrating neck trauma.

Angiographic embolisation is the treatment of choice in the majority of patients with vertebral artery injuries, as access to the vertebral artery may be difcult and timeconsuming (Fig.35.7). Operative management is only indicated for severe active bleeding or when embolisation has

Internal

jugular

vein

Fig. 35.6 The next structure overlying the carotid medially is the facial vein and its conuence to the internal jugular vein

rtebral

artery

injuries

Facial vein

Fig. 35.7 Exposure of the vertebral artery in its canal may be difcult and time-consuming

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D. Le Roux et al.

failed. Ligation, use of wax, careful cauterisation and even packing of the area can be done to control the bleeding. Haemodynamically stable patients with a thrombosed vertebral artery do not need any intervention.

35.5.3 Postoperative Procedure

Vascular injuries are managed postoperatively to ensure haemorrhage is stopped and blood supply and drainage to affected organs is adequate. Continually, monitor the neurological status of the patient. Follow-up angiographic and Doppler ultrasound studies can be performed to evaluate suspected complications with the repaired vessels. We routinely start these patients on antiplatelet therapy (aspirin) postoperatively. Thromboprophylaxis with low molecular weight heparin should be given until the patient is fully mobilised (Fig.35.8).

Stable patient

- No hard signs of vascular injury

- No airway compromise

- Haemodynamically stable

- Not penetrating platysma

Monitoring

- Serial examinations

- Close monitoring

- Further investigations if any worrisome symptoms arise

Stable with possibility of injury

- Active or previous bleeding

- Superficial temporal artery deficit

- Ipsilateral Horner’s sign

- Cranial nerve IX - XII dysfunction

- Widened mediastinum

- Gunshot: crossing midline, proximity to vessels, controlled bleeding

- Stab: penetrating platysma with controlled bleeding

Diagnostic investigations

- Duplex Doppler for zone II injuries, but if not available: Consider surgical exploration

- Multi slice contrast CT and CTA

- CT Brain

- Arch angiography: zone I and III

- MRI valuable in a stable patient

- Cervical AP and Lateral radiographs

- Contrast swallow and endoscopy

Important Points

• The neck contains a vast amount of vital structures in a

small space.

• This region illustrates the importance of the stepwise

“ABCDE” approach used in ATLS resuscitation. It con-

tains the aero-digestive tract and cervical spine (A). The

respiratory system is in close proximity (B). It involves

the major blood vessels (C) supplying the brain (D). It is

important to fully expose the neck anteriorly and posteri-

orly to assess the extent of the injuries (E).

• The unstable patient should be explored immediately

while the stable patient allows for further

investigation.

• The physical exam is more sensitive to arterial injury

so venous and aero-digestive injuries can easily be

missed.

• Early airway control is essential as this may be lost at any

stage.

Unstable patient

- Rapidly expanding haematoma

- Absent carotid pulse

- Bruit or thrill

- External bleeding

Emergency management

- ATLS guidelines: ABCDE

- Intubate early, protect C Spine

- Control bleeding by compression Foley’s catheter

- Hypotensive resuscitation

- Prepare for emergency surgery

Immediate surgical exploration

Adherent intimal flaps,

pseudoaneurysm < 5mm

Symptomatic

Immediate

surgical

exploration

Asymptomatic

Conservative management

- Follow up as inpatient

- Serial examinations, Dupplex Doppler scans

- Anticoagulation and antiplatelet therapy

Fig. 35.8 Diagnosis and management of penetrating neck injuries

Intimal flaps,

pseudoaneurysm

> 5mm

Aero - digestive

tract injury

Immediate surgical exploration

Significant carotid

injury with major

neurological deficit

Deeply

comatosed,

arterial occlusion and large

infarct on CT

Palliative care

Carotid

occlusion

but no

neurological

failout

Observation, oral

anticoagulation and

antiplatelet treatment

3 - 6 months

35 Carotid, Jugular andVertebral Blood Vessel Injuries

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• Proper positioning of the patient allows for adequate exposure of the structures in this region.

• The use of endovascular techniques to gain proximal and distal control has introduced very useful adjuncts in operating in this eld—the so-called hybrid approach.

• Endovascular techniques are also useful in the denitive treatment of injuries to the vessels—both in accessible and inaccessible regions.