CLINICAL PRACTICE
GUIDELINES:
PENETRATING NECK
TRAUMA
Samuel A. Tisherman,
MD
Faran Bokhari, MD
Bryan Collier, DO
James Ebert, MD
Michele Holevar, MD
John Cumming, MD
Stanley Kurek, DO
Stuart Leon, MD
Peter Rhee, MD
View the guideline
View the evidentiary tables
Correspondence:
Samuel A. Tisherman, MD
Department of Critical Care Medicine
638 Scaife Hall
3550 Terrace
Street
Pittsburgh,
PA 15261
Phone: 412-647-9914
Fax: 412-802-3308
E-mail: tishermansa@upmc.edu
STATEMENT OF THE PROBLEM
Penetrating wounds
of the neck are common in the civilian trauma population. Risk of significant
injury to vital structures in the neck is dependent upon the penetrating
object. For gunshot wounds, approximately 50% (higher with high velocity
weapons) of victims have significant injuries, whereas this risk may be only
10-20% with stab wounds.
The management of
injuries to the neck that penetrate the platysma is dependent upon the anatomic
level of injury. The neck has been decided into threes zones. Zone I, including
the thoracic inlet, up to the level of the cricothyroid membrane, is treated as
an upper thoracic injury. Zone III, above the angle of the mandible, is treated
as a head injury. Zone II, between Zones I and III, is the area of controversy.
Because of the density of vital structures in this zone, multiple injuries are
common (1) and can affect length of
stay (2). Mortality, particularly for
major vascular injuries may reach 50% (3). Delayed complications such
as pseudoaneurysms or arterio-venous fistulae can affect long-term outcomes (4). Appropriate and timely
management of these injuries is critical. For the patients with hard signs of
significant injury, including active hemorrhage, expanding hematoma, bruit,
pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory
distress, or hemiparesis, operative management is indicated. Controversy arises
over management of the patient without significant symptoms. Our management of
these patients has been evolving from an era of mandatory exploration, which
led to many non-therapeutic explorations, to an era of more selective
management based on clinical experience and new imaging capabilities. Is this
justified? What are the specific roles of physical examination and imaging in
decision-making? Improved imaging modalities, such as high resolution computed
tomography (CT) or specially-performed CT with angiography, might further
improve management of these patients. In addition, some injuries to neck
structures may not require operative intervention.
Goals of the Guideline
This guideline is
designed to answer the following questions regarding the management of
penetrating injuries to Zone II of the neck that penetrate the platysma:
1)
Is operative management mandatory or is selective non-operative
management appropriate?
2)
Is physical examination adequate to rule out injuries to vascular
structures or the aerodigestive tract?
3)
Can duplex ultrasonography (US) or CT angiography rule out an
arterial injury in patients with no hard signs of vascular injury on physical
examination, thereby making arteriography unnecessary?
4)
How should specific vascular injuries be managed?
5)
Are both contrast studies (barium or gastrograffin swallow) and
esophagoscopy needed to safely rule out esophageal injury?
6)
Is there a need for immobilization of the cervical spine?
II. PROCESS
The
process utilized by this committee was developed by the Practice Management
Guidelines Committee of the Eastern Association for the Surgery of Trauma
(www.east.org). The committee agreed upon the questions to be considered.
Literature for review included the following terms: human, trauma patients,
penetrating, and neck; specific structures were also searched (larynx, trachea,
esophagus, carotid artery, and jugular vein). Medline and EMBASE were searched
from 1966 to 2006.
Articles
were distributed among committee members for formal review. Each article was
entered into a review data sheet that summarized the main conclusions of the
study and identified any deficiencies in the study. Furthermore, reviewers
classified each reference by the methodology established by the Agency for
Health Care Policy and Research of the U.S. Department of Health and Human
Services as follows: Class I: prospective, randomized, double-blinded study;
Class II: prospective, randomized, non-blinded trial; Class III: retrospective
series, meta-analysis.
An
evidentiary table (Table) was constructed using the 145 references that were
identified: Class I, 2 references; Class II, 26 references; and Class III, 105
references. Twelve of the references could not be classified. Recommendations
were made on the basis of the studies included in this table. Level 1
recommendations, usually based on class I data, were meant to be convincingly
justifiable on scientific evidence alone. Level 2 recommendations, usually
supported by class I and II data, were to be reasonably justifiable by
available scientific evidence and strongly supported by expert opinion. Level 3
recommendations, usually based on Class II and III data, were to be made when
adequate scientific evidence is lacking, but the recommendation is widely
supported by available data and expert opinion.
III. Recommendations
A.
Selective workup – operation vs selective non-operative
management
Recommendations
Level 1:
Selective operative management and mandatory
exploration of penetrating injuries to Zone II of the neck are equally
justified and safe.
Level 2:
No recommendations.
Level 3:
No recommendations.
Scientific foundation
Nonoperative
management of penetrating neck wounds was common in the early 20th
century. Based on a review of civilian experience, Fogelman and Stewart (5) recognized in 1956 that
mandatory exploration led to less mortality than a strategy of observation. A
significant number of seemingly asymptomatic patients with penetrating neck
injuries actually have injuries (6). In addition, negative neck
explorations have little morbidity, though the financial cost is noteworthy; in
1981, Merion et al (7) estimated the cost of a
negative exploration at $1,930. Although an exploration under local anesthesia
is appealing in terms of limiting recovery time and costs, Almskog et al (8) found that neck explorations
under local anesthesia, compared to general anesthesia, resulted in more
hematomas and missed injuries. Consequently, mandatory exploration under
general anesthesia for injuries that penetrate the platysma seemed reasonable
in the 70s and 80s (9). Some small studies even
later recommend mandatory exploration (10). Slowly, uncontrolled
studies began to suggest that patients without clear signs of vascular or
visceral injury could be observed (11-29),
though observation for up to 48 hours may be necessary (30), depending upon use of
ancillary tests. Evidence of chest injury does not seem to be an indication for
neck exploration (31). Most experience with
selective exploration strategies has been in major trauma centers. Some have
specifically recommended that a well-staffed teaching hospital with a trauma
service and immediate availability of radiologic and endoscopic evaluations is
needed (32). Even in community hospitals
with experienced surgeons, however, selective management may be safe (33). The need for ancillary
studies during observation remains unclear.
Saletta et al (34) reviewed 240 patients at
Cook County Hospital who underwent mandatory neck exploration. Sixty three
percent had negative explorations and had minimal morbidity. Thirteen of the 90
patients who had positive explorations did not have any clinical signs of the
injury. Elerding et al (35) reviewed 75 patients who had
undergone mandatory explorations, of which 56% were negative. In this series,
however, all patients who had injuries had positive physical exams. Bishara et
al (36) similarly reported a 53%
rate of negative explorations with mandatory explorations. Twenty-three percent
of injuries were not suspected clinically, especially venous and
pharyngoesophageal injuries.
In
the early 1970s, data suggesting the safety of a selective approach began to
emerge. Sheely et al (37) reported improved outcomes
of patients with penetrating injuries to the neck over a 22 year period with a
move toward early operation for patients with obvious vascular or visceral
injury and careful observation based on lack of clinical suspicion of injury,
recognizing greater awareness of potential esophageal injuries. Ayuyao et al (38) studied 134 patients who had
undergone mandatory explorations. Sixty eight percent were negative. Because of
this high rate of negative explorations, they managed the next 109 patients
selectively. Sixty-nine of these patients were successfully observed without
operations.
Jurkovich et al (39) compared the results of
mandatory exploration (the preference of the attending surgeon) in 47 patients
with a selective approach in 53 patients utilizing 43 angiograms and 14
endoscopies. In the mandatory exploration group, there were 25 negative
explorations. Twelve injuries were found but only 5 patients benefited from the
studies. Noyes et al (40) examined the accuracy of a
selective management strategy. Arteriography and laryngoscopy/bronchoscopy were
100% accurate, whereas esophagograms were 90% accurate and esophagoscopy was
86% accurate.
Meyer
et al (41) questioned this new approach
of selective exploration for penetrating neck injuries. In a series of 113
patients, they obtained arteriograms, laryngotracheoscopy, esophagoscopy and
esophagography in each patient prior to a mandatory exploration. Forty-eight
injuries were identified in 35 explorations. Of concern was the fact that 5
patients had 6 major injuries that were not identified by the preoperative
testing. Thus they believed that a mandatory exploration approach was
indicated.
In
a series of 128 asymptomatic patients who were observed by Biffl et al (42) primarily based on physical
examination, only 1 patient had a missed injury (from an ice pick). Only 15% of
these patients required adjuvant tests. Sriussadaporn et al (43) also successfully observed
17 asymptomatic patients. Only 2 of 40 patients who underwent exploration did
not need the operation, though they appeared to have deep wounds. In
asymptomatic patients, Nason et al (44) found that 67% underwent negative
explorations. All Zone II vascular injuries were symptomatic.
Narrod
and Moore (45, 46)
reviewed their 10-year experience with penetrating neck trauma. In the first 6
years, mandatory exploration led to a 56% rate of negative explorations. In the
next 4 years, a selective management strategy was employed. Forty-one of 48
patients who underwent exploration had significant injuries (46), whereas 29 asymptomatic
patients were observed without any missed injuries. Few ancillary studies were
performed in this group.
In
a large, retrospective study from Johannesburg, South Africa, Velmahos et al (47) compared results with
patients who underwent immediate surgical exploration vs constant monitoring.
In the exploration group, 3% of the explorations were unnecessary; mortality
was 4.2%. In the monitoring group, 9% had missed injuries; mortality was 4%.
Criteria for observation vs exploration were not clear making the
interpretation of the 9% missed injury rate difficult.
The only
randomized trial comparing mandatory neck exploration with a selective approach
based on physical examination and radiographs was performed by Golueke et al (48) in 160 patients. There was
no difference in hospital stay, morbidity or mortality.
Management of
transcervical gunshot wounds deserves separate consideration because of the
high likelihood of major injury (49). Hirshberg et al (50) explored 41 patients with
transcervical gunshot wounds. Twenty-eight had more than one zone of the neck
involved. Although 7 patients did not have major injuries, 34 patients had 52
major injuries to cervical structures mainly involving vessels and the upper
airway. Sixteen presented with life-threatening problems. They recommended
mandatory exploration. In contrast, Demetriades et al (51) found that a selective
approach based upon physical examination, angiography, esophagoscopy and esophagography was safe.
Management of neck
wounds in the military setting may be different than that in the civilian
world. Prgomet et al (52) found that injuries that did
not penetrate the platysma did not cause significant injuries. Forty-nine of 84
patients who underwent immediate exploration had injuries to vital structures.
They also found that it was safe to close the wound primarily if it was seen
within 6 hours of injury. In their experience, even extensive laryngotracheal
injuries could be repaired safely (53).
There
is little data on selective management of penetrating neck injuries in
children. Small studies (54, 55)
suggest that a selective management strategy is safe.
B. Diagnosis of arterial injury
Recommendations
Level 1:
No recommendations.
Level 2:
CT angiography or duplex
ultrasonography can be used in lieu of arteriography to rule out an arterial
injury in penetrating injuries to Zone II of the neck.
Level 3:
CT of the neck (even without CT
angiography) can be used to rule out a significant vascular injury if it
demonstrates that the trajectory of the penetrating object is remote from vital
structures. With injuries in proximity to vascular structures, minor vascular
injuries such as intimal flaps may be missed.
Scientific Foundation
In
the era of mandatory neck exploration for penetrating trauma, there seemed to
be little need for angiography, though some (9) suggested that the angiogram
could assist in operative planning and thereby minimize morbidity, or rule out
the need for exploration (56, 57).
Physical examination, however, seemed unreliable for ruling out arterial injury
(58). Delayed pseudoaneuryms and
neurologic events have been described in originally asymptomatic patients, prompting
some to advocate angiography in all such patients (59). A negative arteriogram in a
stable patient can rule out an arterial injury (60). North et al (61) reviewed the records of 139
stable patients with penetrating neck trauma. Patients who had at least soft
signs of vascular injury (absent pulse, bruit, hematoma, or altered neurologic
status) had a 30% incidence of vascular injury by angiography, whereas only 2
of 78 asymptomatic patients had injuries (one minor and one that did not affect
management). Gunshot wounds were more likely than stab wounds to cause vascular
injury. Similarly, Hartling et al (62) found that 43 patients with
stab wounds to the neck and minimal symptoms had no significant injuries by
angiography. Even in the 18 patients with physical findings consistent with a
vascular injury, only 2 had significant injuries. Rivers et al (63) similarly questioned the
value of angiography. Of 63 angiograms in 61 patients, only 6 were abnormal.
Three were thought to be spurious on subsequent review, two were clinically
insignificant, and one required surgery. No significant arterial injuries were
identified by arteriography in the absence of suggestive physical findings. No
major arterial injuries were discovered during exploration that were missed
preoperatively. Angiograms did not alter the course of management.
In
contrast, Sclafani et al (64) found that 10 of 26 patients
who had positive angiograms for penetrating vascular injury to the neck had
undergone the angiogram solely because of proximity. Physical examination had a
sensitivity of 61% and specificity of 80%. They also found no differences in their
results based upon mechanism of injury. They suggested that proximity should
not be abandoned as an indication for angiography in these patients.
Menawat
et al (65) performed angiography for
proximity or soft signs of vascular injury. Fifteen injuries were found on 45
angiograms. Forty-two patients without any signs of injury were successfully
observed without angiography or operation. Overall, only 1 patient had a
significant injury that was not predicted by physical examination.
In contrast,
Nemzek et al (66)
found that proximity, based on the addition of plain films or CT of the neck
showing prevertebral soft-tissue swelling, missile fragmentation, or missiles
adjacent to major vessels can be useful but are nonspecific radiographic signs.
To
examine the cost effectiveness of angiography, Jarvik et al (67) studied 111 patients with
penetrating neck trauma. Forty five of the 48 patients with vascular injuries
had abnormal clinical findings. Management in the other 3 patients was not
altered by the angiogram. They calculated the cost of screening angiography in
asymptomatic patients to be approximately $3.08 million per central nervous system
event.
Demetriades
et al (68) prospectively compared
physical examination and duplex US imaging to angiography in 82 stable patients
with penetrating neck injuries. Only 11 patients had vascular injuries by
angiography and only 2 of these needed to be repaired. The serious injuries
were detected or suspected on physical examination, but 6 lesions that did not
require treatment were missed (sensitivity 100% for serious injuries, but 45%
for all injuries). By duplex US
imaging, 10 of 11 injuries, including all serious ones, were identified, for an
overall sensitivity of 91% (100% for clinically important lesions) and
specificity of 99%. Further studies by Demetriades et al (69) included 223 patients. Of
the 160 asymptomatic patients, 11 had injuries that did not require treatment.
Overall, duplex US was 92% sensitive (100% for findings that required an
operation) and 100% specific for defining an injury. Bynoe et al (70) similarly found that duplex
US was 95% sensitive and 99% specific for vascular injuries after both neck and
extremity trauma. The only missed injuries were 2 shotgun pellet injuries that
did not need repair.
In a prospective, double-blind
study, Montalvo et al (71)
found that US identified all 10 significant injuries in 52 patients with
penetrating neck trauma. Duplex US did not identify reversible carotid
narrowing in one patient and did not visualize 2 vertebral arteries. Another
report by the same group (72) found in 55 patients that
duplex US had 100% sensitivity and 85% specificity.
Corr et al (73) reported that duplex US picked up 2 intimal flaps that were not
identified on angiography.
Helical CT angiography is the newest
technology to be tested for identifying vascular injuries from penetrating neck
trauma. Because it might also be useful for identifying or ruling out other
injuries, e.g., aerodigestive tract injury, this modality is particularly
intriguing as a “one stop shop” to evaluate asymptomatic patients for selective
operative management. The speed and resolution of this modality continues to
improve. Gracias et al (74) have already recommended
that if a CT demonstrates trajectories that are remote from vital structures,
the need for additional invasive studies can be eliminated.
Munera et al (75)
prospectively studied 60 patients, who had 10 vascular injuries. There was one
missed injury by CT angiography because the study actually did not include the
entire neck. They later (76) suggested that patients with
bruits or thrill at admission may be better treated by undergoing conventional
angiography because of the potential for endovascular therapy. Helical
CT angiography is limited by artifact due to
metal, which may obscure arterial segments; therefore, these patients should
undergo conventional angiography.
In the setting of
a mandatory exploration protocol, Mazolewski et al (77) found that CT angiography,
compared to operative findings, was 100% sensitive and 91% specific in 14
patients.
C. Diagnosis
of esophageal injury
Recommendations
Level 1:
No recommendations.
Level 2:
Either contrast esophagography or
esophagoscopy can be used to rule out an esophageal perforation that requires
operative repair. Diagnostic workup should be expeditious because morbidity increases
if repair is delayed by more than 24 hours.
Level 3:
No recommendations.
Scientific foundation
The
problem with penetrating injuries to the esophagus is that there are frequently
no findings on physical examination. Esophagography can miss the injury (78). This is of grave concern
since late referral and management can lead to significant morbidity and
mortality (79-81).
Early diagnosis and management, often with primary repair, leads to good
outcomes (82-84).
Even gunshot wounds can be closed primarily (85); more complex repairs may
lead to strictures (86). Location of the injury can
affect outcome as injuries above the arytenoid cartilages can be managed
without intervention, whereas more inferior injuries require neck drainage to
prevent a deep tissue infection (87). Madiba et al (88) also found that patients
with small injuries and contained perforation on contrast studies could be
observed without operation unless there was another indication for exploration.
All 26 patients with injuries had odynophagia. Of 17 patients managed
non-operatively, only 1 developed local sepsis. Six patients had associated
tracheal injuries. In addition, patients with tracheal injuries have worse
outcomes if they have concomitant esophageal injuries (89, 90).
Weigelt
et al (91) utilized a strategy of
esophagography followed by rigid esophagoscopy if the esophagogram were
equivocal to identify esophageal injuries in patients who had no or minimal
symptoms after penetrating neck trauma. All 10 injuries in 118 patients were
identified. Wood et al (92) found that esophagography
alone was 100% sensitive and 96% specific in 225 patients. Ngakane et al (93) reviewed 109 patients with
penetrating neck trauma. All patients with gunshot wounds underwent
esophagography, while patients with stab wounds were only studied if they had
pain with swallowing. Twenty-nine studies were performed and 4 injuries were
identified. All were observed without intervention. Repeat contrast studies
demonstrated resolution of the injury.
In 23 patients
with esophageal injuries, Armstrong et al (86) found that esophagography
only identified 62% of the injuries whereas rigid esophagoscopy detected all
injuries. Srinivasan
et al (94)
found
reasonable accuracy with flexible endoscopy. In 55 patients, flexible
endoscopy identified the only 2 injuries, but suggested an injury in 4
patients, resulting in 4 negative explorations, for an overall sensitivity of
100% and specificity of 92%.
D. Value of the physical exam
Recommendations
Level 1:
No recommendations.
Level 2:
No recommendations.
Level 3:
1) Careful physical examination,
including auscultation of the carotid arteries, is >95% sensitive for
detecting arterial injuries that require repair. Given the potential morbidity
of missed injuries, imaging is still recommended.
2) Physical examination is
inadequate to rule out injuries to the aerodigestive tract.
Scientific
foundation
Early
reports suggested that the physical examination is unreliable to rule out a
vascular injury. McCormick and Burch (95) found physical examination
of neck and extremity injuries yielded a 20% false negative rate and a 42%
false positive rate. Metzdorff and Lowe (96) found an overall 80%
accuracy of physical examination. Apffelstaedt et al (97) found that clinical signs
were absent in 30% of patients with positive neck explorations and in 58% of
patients with negative neck explorations, support their approach of mandatory
exploration.
More recently,
Demetriades et al (98) studied 335 patients with
penetrating neck injuries. Sixty patients underwent exploration for positive
physical examination findings or a positive workup, whereas 269 asymptomatic
patients were observed. Only 2 of the latter patients later required elective
procedures. In a subsequent paper, this group demonstrated that physical
examination did not miss any major vascular or esophageal injuries that
required intervention; though minor injuries were identified by angiography (1
of 8 required intervention) and esophagography. Using a selective approach
based upon careful and repeated physical examinations, Gerst et al (99) observed 58 asymptomatic
patients without sequelae. Of the 52 patients who underwent prompt exploration
based upon physical examination, 17% did not have significant injuries. Beitsch
et al (100) similarly found that only 1
of 71 asymptomatic patients had a vascular injury detected by angiography.
Thus, in this patient population physical examination ruled out 99% of vascular
injuries and the yield for angiography was 1.4%. Atteberry et al (101) found that if patients did
not have physical examination findings of arterial injury (active bleeding,
expanding hematoma or hematoma larger than 10 cm, a bruit or thrill, or a neurologic
deficit) no vascular injuries were present based on angiography, duplex
ultrasound, or clinical follow-up. They observed patients for at least 23
hours.
Conversely,
Sekharan et al (102) found that only 2 of 30
patients who underwent exploration for hard signs of vascular injury did not
have a significant injury. Twenty-three of 114 asymptomatic patients underwent
angiography for proximity or involvement of another zone. Only one of these
patients needed an operation. All 91 other patients with negative physical
examinations were safely observed without imaging. Azuaje et al (103) found that 68% of patients
with positive physical examination had a positive angiogram. Of the 89 patients
with negative physical examinations, only 3 had positive angiograms, but none
needed operations. Overall, physical examinations had sensitivity of 93% and a
negative predictive value of 97%. Both sensitivity and negative predictive
value for injuries requiring operation were 100%.
Subcutaneous
emphysema or crepitance are physical findings suggestive of aerodigestive tract
injuries that may require operative intervention. Goudy et al (104)
reviewed the cases of 19 patients with emphysema or crepitance. Twenty-one
percent had dysphagia, 63% had stridor or hoarseness. Most underwent direct
laryngoscopy and esophagoscopy. Patients without demonstrable injuries or small
tears were successfully observed without exploration.
The
best study, though small, that attempted to determine if imaging adds to
physical examination in the evaluation of patients with penetrating neck
injuries was that by Gonzalez et al (105).
Forty-two patients who did not have obvious need for operation at admission
underwent soft tissue dynamic CT of the neck and esophagography before
mandatory exploration. All tracheal and carotid injuries were identified by
physical examination. Two of 4 esophageal injuries (both from stab wounds) were
missed by both CT and esophagography. CT was better than physical examination
for identifying venous injuries, but most of these did not require
intervention.
E. Management of specific vascular
injuries
Recommendations
Level 1:
No recommendations.
Level 2:
1) Except for minimal intimal
irregularities or small pseudoaneurysms without neurologic deficits,
penetrating injuries to the internal carotid artery should be repaired, even
when severe neurologic deficits are present.
2) Angiographic approaches to the
vertebral artery are preferred to operative approaches for patients with
bleeding from vertebral artery injuries.
3) Ligation of the jugular vein is
appropriate for complex injuries or unstable patients.
Level 3:
No recommendations.
Scientific foundation
Carotid artery injuries. The issues that arise regarding carotid
artery injuries involve the questions of reconstruction, ligation or leaving
the vessel occluded, vs non-operative management. In addition, operative
strategies may include extending the incision beyond the neck via median
sternotomy or anterior thoracotomy to obtain adequate vascular control (106). Weaver et al (107) reviewed the results of
reconstruction vs ligation vs non-operative management in 80 patients with
penetrating carotid artery injuries. Arterial reconstruction provided the best
outcome compared to ligation, except for non-occlusive minimal intimal injuries
that required only observation. The main issue appeared to be ischemia.
Concerns for hemorrhagic transformation of the ischemic brain in patients with
pre-operative neurologic deficits (12) with reperfusion were
unwarranted. Khoury et al (108) reviewed their experience
with penetrating neck trauma in Beirut. Better outcomes were associated with
early arterial repair, though hemodynamics also affected outcome.
Rao
et al (109) advocated a selective
approach to potential carotid artery injuries in stable patients. They
recommended angiography for all injuries to zones I or III. For Zone II
injuries, angiography was performed based on proximity. The carotid artery was
ligated in 3 patients without neurologic deficits. All other carotid artery
injuries were successfully repaired, some with polytetrafluoroethylene (PTFE).
Kuehne
et al (110) examined the impact of a
management algorithm for penetrating carotid artery injuries. Prior to
implementation of the protocol, management was based on surgeon preference. Of
36 patients, 6 deteriorated, 6 improved, and 24 had no change after repair,
ligation, or non-operative management. The new algorithm included routine
angiography for stable patients and reconstruction of injured vessels, unless
the vessel was already occluded or the injury was minimal. Except for 1 patient
who died prior to carotid artery repair, all patients either stayed the same or
improved with this management strategy.
Mittal
et al (111)
proposed a grading scale for carotid artery injuries. In their series, all
patients with internal carotid artery injuries were managed with interposition
grafts. Common carotid artery injuries were treated either with primary repair
or interposition grafts depending upon severity.
Advances
in endovascular therapy may significantly change our strategies for management
of vascular injuries. Diaz-Daza et al (112)
demonstrated good results with embolization and/or stents in 8 patients with 17
vascular injuries of the head and neck resulting in pseudoaneurysms, fistulae,
or hemorrhage.
Vertebrals. Studies of vertebral artery injuries have not compared
management strategies. They have focused mainly on the potential benefits of
radiologic embolization (113, 114).
Golueke et al (115) suggested that occlusion of
the vessel was rarely an issue as long as the posterior inferior cerebellar
artery was intact. If intervention was needed, proximal and distal, if
possible, embolization simplified management. Complex pseudoaneurysms and
arteriovenous fistulae can be managed with this approach (116). Even when surgical
approaches were incomplete or unsuccessful, embolization could still be
successful (117). Yee et al (118) and Demetriades et al (119) similarly found embolization
to be successful. Surgical approaches were recommended for severe hemorrhage.
Non-operative management was appropriate for minimal injuries.
In
43 patients with vertebral artery injuries, Reid and Weigelt (120) reported no issues of
neurologic sequelae secondary to vertebral-basilar ischemia after proximal and
distal control was attained operatively. Minor injuries were successfully
observed.
Venous. If arterial injuries are managed non-operatively, or by
radiologic embolization, there is a possibility of missing a significant venous
injury. Sclafani and Sclafani (121) reported on successful
angiographic embolization of penetrating vascular injuries to the face and
neck. Even though 18% of the injuries involved arteriovenous fistulae, no
clinically significant venous injuries were missed by angiography.
