9/4/2012

VascularTrauma:
AbdominalInjury
W.DarrinClouse,MDFACS
SVSComprehensiveReviewCourse
Chicago,IL September8,2012

NothingtoDisclose

AbdominalVascularInjury

Neck

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AbdominalVascularInjury
Abdominal Arterial Injury

2.0%

2.3%

2.9%
6.0%

EffectsofBodyArmor

AbdominalVascularInjury

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AbdominalVascularInjury
Grady 2001
Davis, et al. Am Surg 2001; 67: 565-71

LAC 2000
Asensio, et al. Am J Surg 2000; 180:528-34

AbdominalVascularInjury
1525%ofVascularInjury
Spectrumofpresentation
Usuallyassociatedwithmultitraumaand
multiplevascularinjuries
7590%Penetrating
Highincidenceofshockonpresentation
HIGHmorbidityandmortality
FactorsassociatedwithM&Mrelatetoshock,
coagulopathy,organischemia,MSOF,numberof
vascularinjuriesandmoreproximalinjuries

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AbdominalVascularInjury

AbdominalVascularInjury

AbdominalVascularInjury

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AbdominalVascularInjury
ZoneI:
Explorationmandatory
Supramesocolic Exposure:LMVR
+/ lesseromental adjunctview
+/ thoracicaorticcontrol
Inframesocolic Exposure:
StandardInframesocolic +/ SCAo
+/ RMVR

ZoneII:
SelectiveExploration
Exposure:Inframesocolic +/ MVR

ZoneIII:
SelectiveExploration
Exposure:Inframesocolic +/cecal and/or
leftcolonmobilization

AbdominalVascularInjury:
ExposuresbasedonRPattachments

AbdominalVascularInjury:
TransomentalSCAorticControl

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AbdominalVascularInjury:
InframesocolicExposure

AbdominalVascularInjury:
InframesocolicExposure

AbdominalVascularInjury:
LeftMedialVisceralRotation

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AbdominalVascularInjury:
LeftMedialVisceralRotation

Aorta
Renal A.
Celiac

SMA

AbdominalVascularInjury:
RightMedialVisceralRotation

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AbdominalVascularInjury:
RightMedialVisceralRotation

AbdominalVascularInjury:
LesserOmentalAdjunctExposures

AbdominalVascularInjury:
LesserOmentalAdjunctExposures

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AbdominalVascularInjury:
CentralZoneI:AortoCaval/Branches

Timeisprecious
Limitedchanceforrepair
Mostdieduringrepair
Oneshotatdoingitright

AbdominalVascularInjury:
CentralZoneI:AortoCaval/Branches

CommonErrors!

Noproximalcontrol

Inadequatemobilization

sneakinguponit

Inadequateinjurydefinition

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AbdominalVascularInjury:
GeneralRules!

ExposureandControl
(mayneedthechestorSCAo=prepwidely)

BalloonsandSpongesticksareuseful

Customizevesselcontroloncedefined

Packing,damagecontrol,2nd lookOKgoal

VeinRepairisconsideredifSTABLE!
(thisincludeshypothermia,acidosis,coagulopathy!!)

Dontforgettoconsiderfasciotomies

Observeforcompartmentsyndrome

AbdominalVascularInjury:
RepairOptions

InitialShuntand
DamageControl

Ligation

LateralPrimaryRepair

Transposition

VeinGraftorPatch
(GSV,FV,IJ,panel,
pantaloon)

ProstheticGraft

AbdominalVascularInjury:
RepairOptions

InitialShuntand
DamageControl

Ligation

LateralPrimaryRepair

Transposition

VeinGraftorPatch
(GSV,FV,IJ,panel,
pantaloon)

ProstheticGraft

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AbdominalVascularInjury:
RepairOptions

InitialShuntand
DamageControl

Ligation

LateralPrimaryRepair

Transposition

VeinGraftorPatch
(GSV,FV,IJ,panel,
pantaloon)

ProstheticGraft

AbdominalVascularInjury:
RepairOptions

InitialShuntand
DamageControl

Ligation

LateralPrimaryRepair

Transposition

VeinGraftorPatch
(GSV,FV,IJ,panel,
pantaloon)

ProstheticGraft

AbdominalVascularInjury:
RepairOptions

InitialShuntand
DamageControl

Ligation

LateralPrimaryRepair

Transposition

VeinGraftor
Patch(GSV,FV,IJ,
panel,pantaloon)

ProstheticGraft

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AbdominalVascularInjury:
RepairOptions

InitialShuntand
DamageControl

Ligation

LateralPrimaryRepair

Transposition

VeinGraftor
Patch(GSV,FV,IJ,
panel,pantaloon)

ProstheticGraft

AbdominalVascularInjury:
ContaminatedFieldAlternatives

InternalJugularVein

FemoralVein

Hypogastric artery

Translocated SFAwith
prostheticgraftreplacement

Extraanatomicbypass

AbdominalVascularInjury:
ContaminatedFieldReconstruction

Shunt(arteryandveiniffeasible)

Resect/Repairhollowviscus andpackaway

Washout

Reconstruct

Cover(RP,Omentum)

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RenalArteryInjuries
Timeisoftheessence!
Confirmfunctioningcontralateral
kidney
Mostinjuriesleadtonephrectomy
Centralcontrolofrenalvessels
controversial
Allsinglekidneysandbilateral
injuriesshouldhaveattempted
repair
Ifischemicrenalmasslikelyviable
considerrepairbaseduponpatient
conditionandotherinjuries
EndovascularSolutions?!

InjuryoftheInferiorVenaCava
IVCmaybedividedintofivesections:uniquechallenges

Thebifurcation(CIAdivisiondescribed)
Infrarenal(alotoflumbarcollaterals!)
Perirenal(enlargesandrequiresKocher)
Subhepatic(Aboveplusthecaudate)
Retrohepatic(TotalHepaticIsovs.Atriocavalshunt)

Oftenpresentasstablehematomasinretroperitoneum
Question theneedforexplorationifitappearsstable
Associatedrebleedingaftertamponadeisashighas40%

InjuryoftheInferiorVenaCava
TechnicalAspects
Exposure
Prepare
SpongeSticks
Hydrogrip Clamps
VesselLoops
Fascial Pledgets
LargerNeedles
Autologouspatching
Graftvs.multiplerepairs
Intraluminalrepair
Shouldnotnarrow>40%,particularly
perirenal andhigher
Ligationofinfrarenal/bifurcationarea
maybenecessaryincomplexinjuries
Aliveisbetterthandead

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InjuryofthePortalVein
Multipleinjuries,coagulopathyusual
DamageControlShunt?
Primaryrepair
Interpositiongrafting
Ligationanoption:~50%mortality
DONOTdividepancreas
DONOTperformportosystemic shunts
Anotheroption:SMVtodistalsplenicvein
transpositionorbypass
RepairmandatedwithHAinjury
Massivefluidsequestration(compartment
syndrome)

EndovascularOptions
DeepPelvicBleeding(Embolization)
SolidOrganBleeding(Hepaticand
SplenicEmbolization)
SelectBluntAbdominalAortoiliac
Injuries
RenalArteryInjuries
DelayedPresentationMinorInjuries
MoreElective(AVF,PSA,LIF,
stenosis)

AbdominalAorticInjury

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AbdominalVascularInjury
1. A 55 year-old man is stabbed in the back on the left. He
presents with a BP of 80/45 and P134. His Focused
Abdominal Ultrasound for Trauma shows clear fluid in the
left colic gutter. What is the most appropriate next step in
management?
A. CT scan of the chest, abdomen and pelvis.
B. ICU resuscitation with crystalloid and PRBC.
C. Abdominal Exploration
D. Aortography and possible selective arteriography

AbdominalVascularInjury
1. A 55 year-old man is stabbed in the back on the left. He
presents with a BP of 80/45 and P134. His Focused
Abdominal Ultrasound for Trauma shows clear fluid in the
left colic gutter. What is the most appropriate next step in
management?
A. CT scan of the chest, abdomen and pelvis.
B. ICU resuscitation with crystalloid and PRBC.
C. Abdominal Exploration
D. Aortography and possible selective arteriography

AbdominalVascularInjury
2. On exploration a large left zone II hematoma is expanding
what is the most appropriate next operative step?
A. Pack and leave the abdomen open
B. Initial inframesocolic left renal artery and veincontrol
followed by left colic medialization and hematoma
exploration
C. Aortic control from the lesser sac
D. Right medial visceral rotation including Kocher

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AbdominalVascularInjury
2. On exploration a large left zone II hematoma is expanding
what is the most appropriate next operative step?
A. Pack and leave the abdomen open
B. Initial inframesocolic left renal artery and vein
control followed by left colic medialization and
hematoma exploration
C. Aortic control from the lesser sac
D. Right medial visceral rotation including Kocher

AbdominalVascularInjury
3. A 30 year-old police officer is shot in the left abdomen and taken to the
operating room due to persistent hypotension. On exploration a midline
zone I large hematoma at the base of the transverse mesocolon is found
along with several small bowel injuries. The bowel is dusky. The
hematoma is not rapidly expanding. He is responding to resuscitation. All
of the following may be appropriate next steps except:
A. Watch the hematoma. If it does not expand then resect the
small bowel injuries and leave the abdomen open.
B. Supraceliac aortic control in anticipation of exploration
C. Adjunctive intra-aortic balloon control of the distal thoracic
aorta with exploration
D. Left medial visceral rotation with attention to supraceliac
control first, then exploration

AbdominalVascularInjury
3. A 30 year-old police officer is shot in the left abdomen and taken to the
operating room due to persistent hypotension. On exploration a midline
zone I large hematoma at the base of the transverse mesocolon is found
along with several small bowel injuries. The bowel is dusky. The
hematoma is not rapidly expanding. He is responding to resuscitation. All
of the following may be appropriate next steps except:
A. Watch the hematoma. If it does not expand then resect the
small bowel injuries and leave the abdomen open
B. Supraceliac aortic control in anticipation of exploration
C. Adjunctive intra-aortic balloon control of the distal thoracic
aorta with exploration
D. Left medial visceral rotation with attention to supraceliac
control first, then exploration

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AbdominalVascularInjury
4. Which of the following is true regarding abdominal vascular
injury?
A. The most commonly injured intra-abdominal vessel
is the celiac axis
B. Injuries always present with minimal physiologic
derangement
C. The need for temporary damage control maneuvers
is infrequent
D. It occurs less frequently than extremity vascular
injury

AbdominalVascularInjury
4. Which of the following is true regarding abdominal vascular
injury?
A. The most commonly injured intra-abdominal vessel
is the celiac axis
B. Injuries always present with minimal physiologic
derangement
C. The need for temporary damage control maneuvers
is infrequent
D. It occurs less frequently than extremity vascular
injury

AbdominalVascularInjury
5. Which of the following is true regarding abdominal vascular
injury?
A. The greater the number of named vessels injured
the higher the mortality
B. Resuscitation in the ER is just as good as in the OR
C. More proximal aortic injuries portend better survival
D. Right medial visceral rotation with Kocher maneuver
is the proper exposure for the supramesocolic cava
and aorta

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AbdominalVascularInjury
5. Which of the following is true regarding abdominal vascular
injury?
A. The greater the number of named vessels injured
the higher the mortality
B. Resuscitation in the ER is just as good as in the OR
C. More proximal aortic injuries portend better survival
D. Right medial visceral rotation with Kocher maneuver
is the proper exposure for the supramesocolic aorta

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