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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
Injuries with Blood Loss: Rupture, Perforation,
Laceration, Transection (Grade V)
Transmural arterial injury causes leakage of blood into either the surrounding
structures leading to an expanding hematoma in the soft tissues or into
preformed cavities. Both situations can be associated with critical,
uncontrollable blood loss and can develop quickly into a life-threatening
situation. Open surgery may become necessary in cases with extensive tissue
damage and may allow for control of the blood loss in some locations such as
common carotid artery (CCA) and proximal internal carotid artery (ICA).
Endovascular techniques are more efficient in bleedings arising from the
vertebral or internal maxillary arteries and are considered treatment of choice
for most of these lesions. If blood leaks into large voluminous spaces, such as
the mediastinum, oropharynx, or upper gastrointestinal tract, critical loss can
develop very quickly, leading to shock and possible death. Therefore, rapid
identification of the bleeding source and immediate occlusion of the bleeding
site can become lifesaving measure. Especially, injuries of the IMA (Fig.
21.2) are frequently associated with massive bleedings that are difficult to
control with packing alone and usually require multiple
transfusions.
31–33,52,67–69
In this context, it needs to be clarified that the term
pseudoaneurysm is sometimes used for ruptures of the IMA or
sphenopalatine artery.
29,69
The aneurysm-like appearance is largely caused by
a highly unstable hematoma, only supported by nasal or intraoral packing and
extremely fragile. Any aggressive manipulation with catheters or guidewires
or even the deployment of coils can lead to rerupture. Similarly, transmural
injuries of the vertebral or carotid arteries are prone to additional injury or
rerupture during intravascular manipulation with tools or occlusive devices if
only temporarily occluded by clot.24 Further, it should be noted that also
injuries to small arteries could cause enlarging hematomas of significant size
and critical blood loss (Fig. 21.3). For all vessels difficult to reach by surgery,
EVT is nowadays the method of choice, employing detachable balloons
(currently not available in the United States) or vascular plug devices70 in
larger vessels such as ICA or VA. Embolic liquids such as Onyx or NBCA
are preferably used in smaller arteries (e.g., ECA branches). Depending on
location and flow conditions, combining liquids with coils as matrix is useful
to prevent distal migration (Figs. 21.4 and 21.5).24 Newer occlusion devices
such as the microvascular plug system (MVP) or UNO (Reverse Medical,
Irvine, California), resheatable microcatheter-based occlusion systems, may
be of use as well.
ENDOVASCULAR TREATMENT
Endovascular management of acute arterial injuries is continuously
evolving49 and employs standard techniques used for treating nontraumatic
vascular disorders in the head and neck region. Transfemoral approach with
coaxial systems using 5-Fr or 6-Fr guiding catheters and microcatheter–
guidewire combination is preferred. In cases with difficult access anatomy,
triaxial systems can be used (e.g., 6-Fr Envoy, DePuy Orthopaedics, Inc.,
Warsaw, Indiana; 0.38 DAC, Concentric Medical, Fremont, California;
Excelsior SL-10 microcatheter, Stryker Corporation, Kalamazoo, Michigan).
In some cases, ultrasound- or road map–guided direct puncture of the lesion
can facilitate access (e.g., scalp lesions).44 Pressured flushing systems,
standard in neurovascular procedures to prevent clot formation and distal
thromboembolism, are advisable when embolizing ECA branches. The author
regularly uses 1,000 International Units heparin in 1 L saline for flushing of
guiding catheters. This can be crucial because additional heparinization is
often contraindicated in patients with acute bleedings or suspected additional
internal injuries. Although the choice of microcatheters depends mostly on
the user’s preference, it should be kept in mind that it can become necessary
to combine deployment of coils with the injection of liquids (e.g., Echelon;
Covidien, Plymouth, Minnesota). Carotid artery or VA stenting is generally a
straightforward procedure especially in younger patients. The use of
protection devices may not be necessary as the risk of dislodging plaque
material from the bifurcation usually does not exist.
TIPS AND TRICKS
• Selective injections (ICA, ECA, VA >> CCA, SA) provide more
accurate information than global injection when looking for vessel
injuries.
• Check for vessel stumps or abrupt occlusions in cases with blood loss
and negative angiogram (extravasation can be invisible due to
packing).
• Secure temporary (clot) occluded arteries with additional coils, plugs,
liquids, etc.
• Checking for backflow through extracranial/intracranial collaterals
after proximal/antegrade occlusion is mandatory.
• Avoid heparinization if possible, but flush meticulously guide catheter
and microcatheter to avoid thromboembolism.
• Have a large balloon occlusion catheter (e.g., Cello; Covidien,
Plymouth, Minnesota) ready to prevent massive blood loss while
gaining time to prepare microcatheters and embolic agents (coils,
liquids).
• Gentle guidewire manipulation in injured arteries is mandatory to
avoid rerupture (e.g., use double-angle tip Headliner [Terumo
Medical Corporation, Somerset, New Jersey] or in general loop
techniques).
• Be cautious with coils in ruptured arteries or PAs: Most PAs do not
have a firm wall and can be easily perforated with guidewires or coils;
underpacking may be sufficient and is advised. Consider first the
front door–back door technique if possible.
• Glue (NBCA [Trufill])/Onyx: Both agents may be used depending on
the operator’s comfort level. Glue occlusion is fast and permanent
due to immediate tissue reaction (e.g., 30% NBCA–Ethiodol mixture
for IMA rupture) and high thrombogenicity. Use concentration
greater than 50% for high-flow AVFs; the polymerization would be
faster.
• Glue (NBCA [Trufill])/Onyx: Seal the rupture site proximally and
distally by withdrawing the catheter during injection (trapping). Avoid
proximal occlusion only.
• Glue (NBCA [Trufill])/Onyx: Advance guiding catheter into ECA
before removing a microcatheter after injection into IMA.
• Glue (NBCA [Trufill])/Onyx: Be well familiar with so-called
dangerous anastomoses.
• Glue (NBCA [Trufill])/Onyx: Position the microcatheter close enough
to target to avoid proximal occlusion or backflow.
• Glue (NBCA [Trufill])/Onyx: If possible and not too time consuming,
block anastomoses with coils (e.g., occipital artery–VA) before
injecting.
• Glue (NBCA [Trufill])/Onyx: Use flow control when injecting liquids
into AVFs. Superficial veins in face or scalp can be manually
compressed using a hemostat clamp.
• Circle of Willis approach: Be prepared to perform retrograde approach
to a bleeding site through the circle of Willis if antegrade route is
blocked, too difficult, or time consuming.
• Consider removing packings or deflating balloons for repeat
angiogram if initial run is negative and there is strong clinical
suspicion.
• Consider removing packings postembolization in angiography suite
before sending patient to ICU.
• Use low-molecular-weight or antiplatelet (ASA/Plavix) in minor
(grade I) injuries to prevent thromboembolism and stroke.
CONCLUSION
The endovascular management of traumatic vascular injuries in the head and
neck is technically not more demanding than that of other vascular lesions.
However, the scenarios and settings can be fast-paced and dramatic and thus
may represent a particular challenge for the inexperienced interventionalist.
REFERENCES
1. Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid and vertebral arterial
injuries. World J Surg. 2001;25(8):1036–1043.
2. Biffl WL, Moore EE. Identifying the asymptomatic patient with blunt
carotid arterial injury. J Trauma. 1999;47(6):1163–1164.
3. Biffl WL, Moore EE, Mestek M. Patients with blunt carotid and
vertebral artery injuries. J Trauma. 1999;47(2):438–439.
4. Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid arterial injuries:
implications of a new grading scale. J Trauma. 1999;47(5):845–853.
5. DiCocco JM, Fabian TC, Emmett KP, et al. Optimal outcomes for
patients with blunt cerebrovascular injury (BCVI): tailoring treatment to
the lesion. J Am Coll Surg. 2011;212(4):549–557; discussion 557–559.