Carotid artery injuries, Joel Arudchelvam, SLSC 2022, Carotid artery injuries
Causes
Hard signs of vascular injury
Associated signs
Anatomy and neck zones
Management
Factors to consider
Preoperative imaging
Management – changing concepts
Vascular surgical intervention
Open surgery
2. Carotid artery injury
Carotid artery injury (CAI) occur in 4.9% to 6% following penetrating
neck injuries and in 1% to 2.6% following blunt neck injury
Penetrating carotid injuries (PCI) result in a mortality rate of 22% to 33%
PCI - about 23% stroke
Management of carotid artery trauma. Lee TS, Ducic Y, Gordin E, Stroman D. 3, 2014, Craniomaxillofacial trauma & reconstruction, Vol. 7, pp. 175–
189
Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad. 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.
3. Penetrating carotid artery injury
Causes
Road traffic accidents
Industrial injury
Stab
Iatrogenic
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. Penetrating carotid artery injury
PCI involve common and internal carotid arteries
at similar rates
Internal jugular venous injuries associated in
about 26%
Management of carotid artery trauma. Lee TS, Ducic Y, Gordin E, Stroman D. 3, 2014, Craniomaxillofacial trauma & reconstruction, Vol. 7, pp. 175–189
Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad. 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.
5. Hard signs of vascular injury
Active haemorrhage
Expanding hematoma
Hypotension not responding to fluid resuscitation
Thrill or bruit
Neurological deficit (PCI- about 23% stroke)
Associated signs
Horner's syndrome (due to associated sympathetic
chain injury)
Features of injury to the last four cranial nerves
8. Anatomy and neck zones
Zone 1
Proximal common carotid
Subclavian arteries
Zone 2
Distal common carotid
Division of the carotid
Internal and external carotid
arteries.
Zone 3
Internal carotid arteries.
9. Management
Factors to consider
Stability of the patient
Signs of vascular injury
Zone of injury
Neurological status
Associated aero-
digestive system injury
10. Preoperative imaging
Stable patients
Can undergo imaging – to
assess vascular or aero-
digestive tract injury
Unstable patients
Should go to the operation
theatre immediately
11. Management
“Changing concepts”
Early period (1950 s) - mandatory exploration in whom
the platysma muscle was penetrated (8)
Later (1970 s)- haemodynamic stability and the neck
zones
Zone 2 should undergo mandatory exploration
irrespective of the haemodynamic stability
Zone 1 / zone 3 needs further imaging if the patients are
haemodynamically stable (9).
8. Penetrating wounds of the neck. Fogelman MJ, Stewart RD. 1956, Am J Surg, Vol. 91, p. 581e93.
9. Carotid vertebral trauma. Monson DO, Saletta JD, Freeark RJ. 1969, J Trauma, Vol. 9, p. 987e99
14. Open surgery
Position
Supine, sand bag in
between the scapula
Neck slightly extended,
chin tilted upwards,
turned to the
contralateral side
15. Open surgery
Skin preparation
Neck, upper chest (to
expose the upper chest in
zone 1 injury for proximal
control)
Mandibular area (for
mandibulotomy in zone 3
injury)
16. 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 – can
use endo-vascular balloon
occlusion
17. Open surgery
Options
Repair
Direct arterial repair (lateral
arteriorrhaphy)
Patch repair (venous and
synthetic)
End to end repair
Interposition graft repair (venous
or synthetic graft)
Ligation
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.
Our experience
Sidewall laceration and
contusion (80%)
Direct repair (80%)
Interposition graft (20%)
18. Indications for ligation
Persistent hypotension
Fixed dilated pupils
Signs of irreversible ischemic changes on the
computed tomography
Internal carotid artery injury close to the base of the
skull
Severe soft tissue injury to the neck
Absent back bleeding during the surgery
19. Management
Ligation is associated with
Higher stroke rate - 56% vs 10% (13)
Higher mortality - 50% vs 17% (2)
compared to the repair group
Repair should be done whenever possible provided
No contraindications for repair
Haemodynamically stable patient
20. Endovascular
Endovascular options
False aneurysm
Intimal flaps
Luminal narrowing
To achieve proximal and distal control - zone 1 and 3
injuries
21. 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 showed that the majority died due to
cerebral edema due to ischemia than haemorrhagic
transformation
22. Neurological status and carotid repair
In addition studies showed that revascularization
after prolonged neurological deficit and infarctions
improve after revascularization
Probably due to the resolution of cerebral oedema
Therefore revascularization even in the presence of a
neurological deficit is advised
23. Summary
Repair is associated with
Reduced stroke rate
Reduced mortality
Ligation of carotid artery is associated with
Increased stroke rate
Increased mortality
Even in the presence of neurological status provided
the patient is stable and there are no contraindications