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41
which repair is indicated has also not been dened. Seth etal. examined 53 blunt
traumatic carotid injuries over a 10-year period at the University of Maryland. They
suggested a modied grading system that subdivided grades II and III into grade IIa/
IIIa as <70% stenosis and grade IIb/IIIb as >70% stenosis. They utilized this modi-
cation to limit treatment to those with grade IIb or IIIb lesions, progressive pseu-
doaneurysm growth, and continued neurologic events despite appropriate medical
therapy. They utilized stent-assisted coil embolization which is a combination of
uncovered stents with coiling of the pseudoaneurysms via the interstices of the
stent. Three patients suffered transient complications (two weakness and one amau-
rosis) related to the procedures but all recovered without decits. One patient was
found to have an asymptomatic occlusion of his stent and was shown to be noncom-
pliant with the prescribed antiplatelet therapy. The overall complication rate in this
paper was 6.4% [3]. While this complication rate is consistent with other series of
endovascular treatments, it did not improve overall outcomes compared with other
studies.
While exact indications and thresholds for endovascular treatment remain
unclear, it is also unclear as to what is the best technique for endovascular treatment,
and most data in regard to technique come from small case series. Some of the tech-
niques which have been utilized include embolization of the carotid with detachable
balloons, coil, or glue embolization with balloon test occlusion, as well as uncov-
ered stents with and without coil embolization of the pseudoaneurysms, and cov-
ered stent grafts. The former embolization techniques are often reserved for
intracranial injuries due to the tortuosity of the carotid as it traverses the skull base
making stenting difcult [15].
Stenting of the artery maintains normal anatomic/antegrade ow while also act-
ing as a lter by trapping thrombus within a pseudoaneurysm via the interstices of
the stent. Endothelial cell growth into the interstices also helps decrease ow into a
pseudoaneurysm. Due to the mobility of the neck, exible self-expanding uncov-
ered stents have historically been chosen in comparison to stiffer balloon expand-
able or covered stents. Additionally, large pseudoaneurysms can be coiled through
the interstices of uncovered stents which can prevent the coils from non-target
embolization into the distal cerebral circulation. Furthermore, uncovered stents
allow for improved laminar ow through the true lumen of the artery, decreasing
turbulent ow into the dissection plane or pseudoaneurysm thereby theoretically
decreasing the risk of embolization [5]. Overall, outcomes related to stenting have
been favorable. Edwards etal. treated 18 patients with stents and followed 14 of
these patients for a 30-month mean follow-up time. They showed no long-term stent
occlusions and concluded that endovascular stenting was safe and effective [16].
Cohen etal. also treated ten patients with stenting without stent-related complica-
tions for a mean follow-up of 28months [17].
Covered stent grafts seem very attractive given that they exclude the false lumen
and pseudoaneurysm altogether, while restoring normal anatomic ow. Currently,
there are no covered stent grafts which are FDA approved for use in the carotid, and
there are no commercially available tapered covered stents which are often neces-
sary when the repair involves both the internal and common carotid arteries. These
3 Endovascular Management ofCervical Vascular Trauma
42
considerations not withstanding several series have shown them to be effective [5].
Assadian etal. showed no complications out to 6 months while Maras etal. showed
a 15% occlusion rate, all of which were asymptomatic and were felt to be due to
“complicated injuries” [18, 19]. While most covered stents have been used for pen-
etrating trauma, there are no glaringly obvious reasons as to why they could not be
considered in the case of pseudoaneurysms in blunt trauma.
Cerebral protection devices have also not been widely described in the trauma
literature. This is likely due to the distal nature in Zone III in many of these injuries
making distal protection devices difcult to place in the petrous portion of the
carotid. Schultz etal. used embolic protection devices (EPD) in ve of seven dissec-
tion patients with good results.
Another major factor to be considered in the use of stents, whether covered or
not, is the use of postoperative antiplatelet medications. While it has become stan-
dard of care that some form of antiplatelet medications be used postoperatively, it is
unclear as to the duration of treatment. Many authors advocate dual antiplatelet
therapy with aspirin and clopidogrel for at least 3 months and some form of anti-
platelet therapy for life. Furthermore, it is imperative to have long-term follow-up
with imaging to evaluate for restenosis due to intimal hyperplasia and atherosclero-
sis in the long term. Duplex ultrasound seems like the obvious choice; however, it
should be noted that there is no well-established velocity criteria for in-stent reste-
nosis after endovascular therapy. CTA is probably a more reliable imaging modality
for the initial short-term follow-up, with Duplex ultrasonography used as an alterna-
tive for long-term follow-up once several stable data points have been established.
While many uncertainties remain and future studies are needed to establish best
practices, endovascular treatment is becoming increasingly utilized for blunt carotid
and vertebral artery injuries. As technology and techniques improve, this minimally
invasive treatment promises to be an important tool in the management of these dif-
cult cases.
3.6 Penetrating Cervical Vascular Injuries
As reported in the 2013 National Trauma Data Bank annual report, penetrating cer-
vical trauma contributed to less than 2% of all reported injuries [20]. These injuries
occur predominately in adults secondary to assault from rearms and stab injuries.
Other less frequent etiologies include falls or motor vehicle accidents. Despite
being infrequent, these injuries are associated with a mortality rate as high as 6%
and the majority of deaths are secondary to ischemic stroke with the remainder due
to exsanguination [21]. Carotid artery injuries account for approximately 20% of all
cervical vascular injuries and are seen predominantly in the common carotid and, to
a lesser degree, in the internal carotid artery [22]. Vertebral artery injuries tend to
have a much lower incidence and, unlike carotid injuries, rarely produce exsangui-
nation, airway collapse, or stroke [23].
Penetrating trauma to the carotid and vertebral arteries can result in similar inju-
ries to those seen in blunt cerebrovascular injuries, such as dissections or
T. Simon and K. Brown
43
pseudoaneurysms, and treatments are likewise similar. However, unlike blunt
trauma, penetrating cervical vascular injuries can also result in arteriovenous stu-
las (AVF), transections, expanding hematomas, and exsanguinating hemorrhage.
Due to the often difcult exposure in this anatomic region, endovascular treatment
is an attractive and often lifesaving therapy.
When discussing penetrating cervical trauma, it is best to start with the zones of
the neck. Zone I extends from the clavicles to the cricoid cartilage; Zone II, from the
cricoid cartilage to the angle of the mandible; and Zone III, from the angle of the
mandible to the base of the skull (see Fig.3.1). The vertebral arteries are not well
represented in this classication system and are best described by location. V1
extends from the origin to the C6 transverse process, V2 extends through the cervi-
cal transverse processes of C6–C2, V3 is the segment between C2 and the skull
Fig. 3.1 Cervical trauma zones of the neck. Zone I extending from the clavicles to the cricoid
cartilage. Zone II extending from the cricoid cartilage to the angle of the mandible. Zone III
extending from the angle of the mandible to the base of the skull
3 Endovascular Management ofCervical Vascular Trauma
44
base, and V4 is an intracranial segment from the skull base to the conuence of the
basilar artery (see Fig.3.2). Direct surgical exposure and repair of injuries to the
vertebral artery, as well as the common carotid artery in Zone I and the distal inter-
nal carotid artery in Zone III, can be extremely difcult and are beyond the intent of
this chapter.
Based on several older studies involving penetrating neck trauma, physical exami-
nation tended to be the best initial guide in determining whether or not further diag-
nostic testing or operative intervention was needed [24–26]. When hard signs of
vascular injury such as active pulsatile bleeding, expanding hematoma, bruit, or
evolving stroke (distal ischemia) are present, quick operative exploration is the stan-
dard rather than delaying surgery for imaging studies. In patients with soft signs of
vascular injury who are stable, data now supports CTA as the imaging modality of
Fig. 3.2 Segments of the vertebral arteries. V1 extending from the origin to the C6 transverse
process. V2 extending through the cervical transverse processes of C6–C2. V3 extending from C2
to the skull base. V4 intracranial segment from skull base to the conuence of the basilar artery
T. Simon and K. Brown
45
choice. It has been shown to have a sensitivity of 90% and a specicity of 100% in
diagnosing arterial injuries caused by penetrating neck trauma. Moreover, CTA can
accurately diagnose associated injures to the spine, aerodigestive tract, chest, or head
which are often present in this patient population [27]. In the recent PROOVIT reg-
istry, DuBose etal. reported that CTA was the most commonly used modality to
identify vascular injury in 39.6% of patients. This was followed by operative explo-
ration and traditional angiography in 29.7% and 11.4% of patients, respectively [28].
While surgical repair still remains the most common management technique in
all zones of the neck for penetrating injuries, there has been an increasing trend over
the years in the application of endovascular techniques [28–30]. This is especially
true for Zones I and III of the neck. However, despite the growing use of endovas-
cular therapy, open surgical treatment of penetrating Zone II injuries to the carotid
artery via a vertical anterior neck incision is still advocated by the majority of sur-
geons [21]. This exposure is neither morbid to the patient nor as technically chal-
lenging to the surgeon.
Generally speaking, if patency is not an issue, the vessel can be embolized with
coils such as in penetrating injuries to the external carotid artery and any of its
branches. When patency is preferable, such as in the case of the internal carotid,
inaccessible penetrating carotid artery injuries can be treated with covered stents.
However, it should be stated that even internal carotid arteries can be ligated or
embolized in lifesaving circumstances such as exsanguination. DuToit etal. reported
their experience in treating 19 penetrating carotid artery injury patients using a vari-
ety of covered stents. Proximal common carotid injuries were seen in 14 patients,
and 5 patients had distal internal carotid injuries as diagnosed by aortic arch and
four-vessel arteriography. Injuries included 10 pseudoaneurysms and 9 traumatic
arteriovenous stulas. They reported 100% technical success with only one early
stroke and one non-stent graft-related procedural death. Mean follow-up of 4 years
was obtained in 14 patients, of which no stent-graft related deaths, stroke, or other
complications were reported. Of note, embolic protection devices were not used
during their interventions [22]. Yevich and colleagues advocate acute endovascular
treatment of gunshot injuries to the face and neck in order to achieve hemodynamic
stability and prevent or minimize neurological sequelae from thromboembolic
events. They report on successful emergency endovascular treatment of two verte-
bral artery transections treated with embolization using coils and liquid embolic
agents, eight external carotid artery branches also occluded with liquid embolic
agents, and one severe dissection of the internal carotid artery treated with stenting.
All except one patient survived these injuries with minor or no residual neurologic
decits [31].
Due to the difcult exposure of the vertebral artery regardless of its anatomic zone,
endovascular treatment is an attractive option here too. In the rare case of exsanguinat-
ing hemorrhage, the practical endovascular intervention is to embolize the artery in
order to stop the bleeding. Several authors have published small series and case reports
of patients with reasonable outcomes. Cohen etal. presented a case report of a patient
with exsanguinating hemorrhage due to a right VA transection from a gunshot wound
to the face. In this case, the patient required additional embolization of the distal VA
3 Endovascular Management ofCervical Vascular Trauma
46
from the contralateral vertebral artery in a retrograde manner in order to attain hemo-
stasis. This case demonstrates the challenging technique of contralateral VA selection
with navigation of a microcatheter through the distal left VA, the vertebrobasilar junc-
tion, and then in a retrograde fashion through the distal right VA to the injury site [32].
In the case of traumatic AVF, the optimal treatment is a little less clear. Herrera etal.
treated 18 vertebral AVF with occlusion/embolization without any signicant neuro-
logic complications when performed with balloon test occlusion [33]. However, Greer
etal. advocated stenting the vertebral artery due to the ability to maintain antegrade
ow after they evaluated four penetrating combat vertebral injuries with pseudoaneu-
rysms treated with a combination of coil embolization and covered stent placement
with no short-term complications [34]. While stenting does offer the ability to main-
tain antegrade ow, this technique may not be possible in the case of hemorrhage or
concomitant injury due to the need for long-term antiplatelet therapy to maintain stent
patency in the carotid or vertebral arteries.
Starnes and Arthurs describe using endovascular techniques as an adjunct to
standard open repair for penetrating Zone I injuries with hard signs that require
immediate operative intervention. For instance, an occlusion balloon from the groin
can provide endoluminal control proximally and allow for a more controlled surgi-
cal exposure as well as potentially avoiding a sternotomy and/or thoracotomy. This
technique additionally allows time to perform an angiogram in order to locate and
subsequently repair the injury [35]. Similarly, endoluminal balloon control of a
Zone III internal carotid artery injury, where surgical exposure and distal control is
complicated by the need for an extensive dissection, styloid resection, or mandible
subluxation to gain exposure, might be best obtained this way [36].
Endovascular procedures are best done in an angiography suite with full opera-
tive capabilities or an operating room with xed imaging or high-quality portable
imaging with a vascular operating table. Furthermore, the vascular surgeon, inter-
ventional radiologist, or interventional neuroradiologist must be readily available
and have sufcient experience with multiple endovascular techniques in order to
achieve the best results. Lastly, for emergency endovascular treatment to be suc-
cessful, one must have the appropriate supplies and equipment as well as ancillary
staff who are knowledgeable and well trained. The desire to proceed with endovas-
cular management must also be tempered by the potential need for anticoagulation
and antiplatelet therapy [37, 38]. Of course these patients need to be carefully
selected because stent placement in the carotid or vertebral arteries requires dual
antiplatelet therapy for several months followed by aspirin indenitely.
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© Springer Nature Switzerland AG 2020
T. Hörer et al. (eds.), Endovascular Resuscitation and Trauma Management,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-030-25341-7_4
R. R. Rajani (*) · C. Ramos
Division of Vascular and Endovascular Surgery, Department of Surgery, Emory University
School of Medicine, Atlanta, GA, USA
e-mail: r.rajani@emory.edu; Christopher.r.ramos@emory.edu
4
Endovascular Management ofThoracic
andAbdominal Trauma
RaviR.Rajani andChristopherRamos
4.1 Introduction
Traumatic injury imposes the highest burden on the global population for life
years lost prior to the age of 65 years. Control of hemorrhage is the key to
improving survival, since this is the second leading cause of death following
central nervous system injury [1]. Unlike central nervous system injury, which is
at times irreversible, hemorrhage can be intervened upon through direct mea-
sures such as compression, surgical repair, and more recently endovascular
approaches. Major advances have been made in the rapid control of compressible
hemorrhage through the use of tourniquets for extremity hemorrhage, yet initial
management of non-compressible torso hemorrhage (NCTH) still presents a sig-
nicant challenge.
This chapter outlines the contemporary utilization of endovascular techniques in
the setting of NCTH as an adjunct to surgery for control and denitive repair.
Developed and rened approaches for hemorrhage associated with axillosubclavian
injuries, blunt thoracic aortic injuries, visceral injuries, aortic injuries, and pelvic
injuries will be described.
50
4.2 Initial Evaluation
Patient presentation and vital signs will determine the diagnostic pathway in all
cases. Advanced Trauma Life Support (ATLS) guidelines should be followed during
the initial survey of all trauma patients. If there is concern for a torso injury, a chest
and pelvic X-ray and a focused assessment with sonography for trauma (FAST) will
aid in the initial assessment to evaluate for a vascular injury in hemodynamically
unstable patients and can suggest the localization of the bleeding. On chest X-ray,
apical capping, hemothorax, and a widened mediastinum suggest a vascular injury
that may require intervention or immediate chest tube placement if indicated. A
displaced pelvic fracture may contribute to ongoing blood loss, and this can be sta-
bilized with a pelvic binder. Despite stabilization, pelvic fractures may have ongo-
ing venous and arterial bleeding that may require intervention in unstable patients.
In victims of blunt trauma, the FAST may reveal free uid in the abdomen consis-
tent with hemoperitoneum or hollow organ injury. FAST, CXR, and pelvic X-ray
can suggest the localization of the bleeding or other causes of circulatory distress
and guide one to the correct body cavity in the correct order [2].
In patients in extremis or with unstable vital signs, the initial evaluation of a
trauma patient is typically performed using a multidisciplinary approach, and
actions are performed in parallel. During this evaluation, a common femoral arterial
(CFA) line can be placed under ultrasound guidance if performed in a timely man-
ner. Ultrasound guidance is recommended to ensure that the arterial puncture site is
above the bifurcation of the CFA but below the circumex iliac artery and on the
anterior wall of the artery. Common femoral arterial access can then be used to help
guide resuscitation, but in the event of clinical deterioration, this can be readily
upsized to a larger sheath for additional diagnostic imaging and intervention [3].
4.3 Line Placement Considerations
CFA access should not delay any additional diagnostic or therapeutic interventions
in the trauma bay. Previous algorithms have been proposed for the management of
exsanguinating torso trauma [4]. Patients who arrive to the trauma bay receiving
cardiopulmonary resuscitation (CPR) should undergo a resuscitative thoracotomy
(RT) in the ED, as long as the duration of CPR does not exceed 15min for penetrat-
ing thoracic trauma, 10min for blunt trauma, or 5min for non-torso-penetrating
trauma. Patients in hemorrhagic shock after penetrating or blunt thoracic trauma
will generally require additional emergent interventions based on ATLS guidelines
[4]. In these patients, lifesaving interventions should not be delayed for the place-
ment of an arterial line.
Prior to line placement, the area should be prepared using an antiseptic such as
chlorhexidine or Betadine. Following placement, a sterile occlusive dressing should
be placed, in the event this access will be used for additional imaging/interventions. If
R. R. Rajani and C. Ramos