Traumatic vascular injuries in the neck; principles of management Joel Arudchelvam SLSVS carotid.pptx

Traumatic vascular injuries in the neck; principles of management Joel Arudchelvam

1. Traumatic vascular injuries in the neck; principles of management Joel Arudchelvam MBBS (Col), MD (Sur), MRCS ( Eng ), FCSSL(Hon) Consultant Vascular and Transplant Surgeon

2. Neck vascular injuries Neck Vascular Injuries (NVI) occur in 4.4 % of the civilian injuries Carotid artery injuries present in 80% Carotid injuries (CI) result in a mortality rate of 22 % to 33 % Stroke rate - 9.1 % - 23%  Males - 9 (90 %), Mean age - 46.9 years (18 - 75 ) * J Arudchelvam, Teaching Hospital Anuradhapura (unpublished) ++Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad . 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.

3. Neck vascular injuries - Causes Cut /Stab -41.7% Road traffic accidents -16.7% Iatrogenic - 15.0% Industrial injury - 8.3% Impalement - 8.3% *Penetrating Carotid Injuries, A Single Surgeon Experience . J Arudchelvam, C Gurusinghe , AGAVJ Abeysinghe , N L Mohotti , N Gowcikan , N Harivallavan , R Cassim , M Wijeyaratne . Colombo : s.n., 2022. Sri Lanka Surgical Congress 2022.

4. Anatomy and neck zones Zone 3 Internal carotid Zone 2 Distal common carotid Carotid bifurcation Internal and external carotid Zone 1 Common carotid Subclavian

5. Anatomy and neck zones Zone - II ( 63.6 .%). N Gowcikan , Joel Arudchelvam, et.al; Neck Vascular Injuries, A Single Unit Experience, University Vascular and Transplantation Surgical Unit, NHSL

6. Management - Factors to consider Stability of the patient Zone of injury Presence of vascular injuries Associated aero-digestive system injury Neurological status

7. Preoperative imaging Stable patients Can undergo imaging – to assess vascular or aero-digestive tract injury Unstable patients Should go to the operation theatre immediately

8. “ Changing concepts” Early period (1950 s) - Platysma muscle Mandatory exploration in patients with the  platysma muscle penetration (*) Later (1970 s)- Haemodynamic stability and the neck zones Zone 2 - Mandatory exploration irrespective of the haemodynamic stability Zone 1 / zone 3 - Imaging if the patients are haemodynamically stable (**). *Penetrating wounds of the neck. Fogelman MJ, Stewart RD. 1956, Am J Surg , Vol. 91, p. 581e93. ** Carotid vertebral trauma. Monson DO, Saletta JD, Freeark RJ. 1969, J Trauma, Vol. 9, p. 987e99

9. Current concept Haemodynamic stability Presence of aero-digestive injuries.  Neurological status / imaging appearance

10. Open surgery Incision along the anterior border of the sternocleidomastoid For proximal carotid vessel (Zone 1) - sternotomy For distal control (Zone 3) - mandibulotomy Proximal and distal control – Endo-vascular balloon occlusion

11. Open surgery - Options Repair Direct arterial repair (lateral arteriorrhaphy) Interposition graft repair Patch repair End to end repair Ligation *Penetrating carotid injuries: a single surgeon's experience. Joel Arudchelvam, C M Gurusinghe , AG AVJ Abeysinghe , M R N Cassim , M Wijeyaratne , N Gowcikan , N Harivallavan , N LMohotti .  Supplement S1 ISSN 1391-491X, 2022, The Sri Lanka Journal of Surgery, Vol. 40, p. 33 Our experience * Sidewall laceration and contusion (80%) Direct repair (80%) Interposition graft (20%)

12. Side wall injury

13. Interposition graft repair

14. Indications for ligation Persistent hypotension / unstable patient Severe  soft tissue injury to the neck

15. Ligation Vs Repair Ligation is associated with Higher stroke rate - 56% vs 10% Higher mortality - 50% vs 17% Repair should be done whenever possible provided

16. Endovascular options False aneurysm Intimal flaps and luminal narrowing To achieve proximal and distal control - zone 1 and 3 injuries

17. Neurological status and carotid repair Old believe Repair of carotid arteries was contraindicated in the presence of a neurological deficit ( believed to convert an ischaemic stroke into a haemorrhagic stroke) Recent studies Majority die due to cerebral edema due to ischemia than haemorrhagic transformation

18. Neurological status and carotid repair Revascularization even after prolonged neurological deficit improve after revascularization Due to the resolution of cerebral oedema R evascularization even in the presence of a neurological deficit is advised Provided there is no evidence of massive infarction on CT

19. Outcomes Survival - 72.7 % (8/11) Causes of mortality - Effects of massive bleeding Recovered without neurological deficit - 6 (54.5 %) Right upper limb weakness - 1 (9.1%) Hoarseness of voice - 1 (9.1%) *N Gowcikan , Joel Arudchelvam, et.al; Neck Vascular Injuries, A Single Unit Experience, University Vascular and Transplantation Surgical Unit, NHSL

20. Summary Neck vascular injuries occur in 4.4% of vascular injuries in the local setting Repair of the carotid artery is done in stable patients even in the presence of neurological status Repair is associated with Reduced stroke rate Reduced mortality

21. Thank You