Are arteriograms necessary in penetrating zone II neck injuries? Sunil S. Menawat, M D , James W. Dennis, M D , FACS, Lillian M. Laneve, RaN, and Eric R. Frykberg, M D , FACS, Jacksonville, Fla. The evaluation and management of potential arterial injuries in penetrating neck trauma are controversial. Routine surgical exploration or arteriography can be very expensive and time-consuming and can overburden available resources if used in all patients. We reviewed the records of 4035 patients seen in our trauma center during a 20-month period and identified a total of 110 patients (2.7%) with penetrating wounds to zone II of the neck; 50 were from gunshot wounds, 43 from stab wounds, 7 from shotgun injuries, and 10 from lacerations. In 42 (39%) patients there was no arteriogram or surgery based on location of the wounds or lack of any physical findings. None of these patients later had any evidence of an arterial injury. Forty-five patients (40%) had arteriograms based on proximity or a "soW' sign of vascular injury, which included evidence of significant bleeding or a stable hematoma. A total of 15 injuries to major arteries were identified: 3 common carotid, 5 internal carotid, and 7 vertebral. One patient died during initial resuscitation, and four patients went directly to surgery with no preoperative arteriogram for active bleeding and expanding hematoma (n = 1), an expanding hematoma (n = 2), and a large, stable hematoma (n = 1). Only one patient (of the 110) had a significant major arterial injury requiring surgery that was not predicted by physical findings. Nine arterial injuries were treated nonoperatively: six vertebral, two common carotid intimal flaps, and one small distal internal carotid psendoaneurysm (diagnosed late). Three additional minor external carotid artery injuries were observed with no adverse sequelae. Associated neck injuries included 8 to the larynx/trachea, 7 to the esophagus, 11 to the pharynx, and 9 to the spinal cord. Associated injuries caused seven other deaths in this series. These results indicate that clinical evaluation is highly accurate in determining which patients need surgical intervention. Arteriograms have too low a yield(< 1% in this study) of findings that alter treatment to justify routine application in these patients with zone II penetrating injuries. We have embarked on a prospective evaluation of the proper role of arteriography in this setting as a result of these data. (J VASC SURG 1992;16:397-401.)
Manditory surgical exploration of all deep penetrating neck injuries was considered the standard of care for several decades. 13 Recently there have been calls for more selective management of these injuries mostly because of the high rate of negative neck explorations and associated morbidity when all such wounds are explored. Some centers recommend diagnostic arteriography in all neck injuries with no hard signs of vascular trauma to identify patients in need of surgical intervention, whereas others use selective management. 4,~ This is based on the use of From the Department of Surgery, Universityof Florida Health Science Center/lacksonvitle. Presented at the Sixteenth Annual Meeting of the Southern Associationfor Vascular Surgery, St. Thomas, Virgin Islands, lan. 22-25, 1992. Reprint requests: lamesW. Dennis,MD, Departmentof Surgery, Universityof Florida Health ScienceCenter, 653-2 W. Eighth St., Jackson~lle, FL 32209. 24/6/39149
these radiologic techniques when there are no hard signs o f vascular injury but the wound is in proximig¢ to a major vessel or shows soft signs. We embarked on this retrospective review to look at the role of physical examination and arteriography in the discovery of arterial injuries that need surgical repair in penetrating zone II neck trauma. Our institution follows the practice of selective operative management of penetrating injuries in this zone o f the neck, where physical examination is possible. Based on previous studies on minimal arterial inju° ties, we also practice nonoperative management of small intimal defects and segmental narrowings seen on arteriography. 6,7 METHODS During a 20-month period from January 1, 1990, to August 31, 1991, we reviewed the records of 4035 trauma admissions to University Medical Center, a 397
398
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Table I. Vascular injuries found on physical examination Vessel injured Common carotid Internal carotid Vertebral Internal jugular vein
Physical findings Active bleeding/expanding hematoma Expanding hematoma Active bleeding Large hematoma
level I trauma center in Jacksonville, Fla., for penetrating zone II neck injuries. Zone II was defined as above the clavicle and below the angle of the mandible. Only patients who had injuries deep to the platysma were included in the study group. One hundred ten patients (2.7% of total trauma admissions) met this criteria, and their charts were reviewed in detail. The average age of the 110 patients that constituted the study group was 31.1 years, with a range of 15 to 72 years. There were 95 male and 15 female patients. The average Injury Severity Score was 11.5, and the average Glascow Coma Scale score was 13.5 on arrival to the trauma center. If the eight trauma center deaths are excluded, the average Glascow Coma Scale score was 14.2. On arrival to the trauma center all patients were treated according to the Advanced Trauma Life Support protocol, which included airway management and volume resuscitation as needed. All patients with hard signs of vascular trauma (active bleeding, large or expanding hemotoma, distal ischemia, and bruit/thrill) 8 or other associated life-threatening injuries requiring surgery were taken directly to the operating room. The management of the remaining patients was based strictly on physical findings. Patients with wounds in proximity to major vessels or showing soft signs of vascular injury (history of bleeding, small/stable hematoma, or associated nerve injury) were taken immediately for four-vessel arteriography. Those with no physical findings and nonproximity were admitted to the hospital and observed for a minimum of 24 hours. RESULTS
The mechanisms of injury included gunshot wounds in 50 patients (45%), stab wounds in 43 patients (39%), laceration in 10 patients (9%), and shotgun wounds in 7 patients (6%). All injuries were judged to be deep to the platysma. Of the 110 patients, 15 were taken directly to the operating room, four of whom had hard signs of vascular injury. All four were found to have vascular
injuries requiring surgical repair (Table !). Of the other 11 patients (none of whom had hard signs of vascular injury), four had torso injuries and negative neck explorations, four had tracheal/laryngeal injuries, two had pharyngeal injuries, and one had an esophageal injury. Not one of these 11 patients had a vascular injury. Forty-two patients of the 110 patients were determined to have no vascular injury based on lack of any physical findings, and their injury was not considered to be near any major vessels. None of these patients had an entrance wound in the anterior triangle. These patients had no further workup for vascular injury (no arteriogram or surgical exploration) and were observed for at least 24 hours and discharged (when their associated injuries permitted) and followed in the clinic. The average hospital stay in this group is 2 1/2 days, with 30 patients staying in the hospital less than 48 hours. Long-term follow-up was available on 30 (70%) of these 42 patients. No patients in this group later showed signs of vascular injury. The average length of follow-up was 173 clays (range 4 to 565 days). Forty-five patients who had soft signs of vascular injury or in whom the injury was in proximity to a major vessel underwent arteriography to rule out vascular injury. The rate of arteriography was 23/50 of the gunshot wounds, 17/42 of the stab wounds, 4/7 shotgun wounds, and 1/10 for lacerations. Twenty-seven of these 45 test results were negative and eight showed injury to noncritical vessels such as branches of external carotid artery. Ten studies showed involvement of a major vessel in injury (Table II). Six vertebral artery injuries, including three asymptomatic occlusions and three minimal intimal defects, were observed. Two small intimal defects of the common carotid and one of the internal carotid artery were also observed. Only one injury, a small pseudoaneurysm of the internal carotid artery, required surgical repair. This patient's injury was caused by a gunshot wound that resulted in a hematoma in the neck, but review of his records revealed no details regarding its size. The eight patients with noncritical arterial injuries were also treated nonoperatively. None of these patients had any vascular complications from the injuries that required delayed surgery or interventional radiology. These patients were observed a minimum of 24 hours, and longer follow-up was available only on two patients (2 and 5 weeks). Eight patients died during initial resuscitation. One death could be attributed to hemorrhagic shock as a result of two arterial injuries in the neck. Other
Volume 16 Number 3 September 1992
deaths were attributable to associated injuries that included gunshot wounds to the head and the chest. There were two delayed deaths, both a result of multiple-organ system failure from associated injuties. In the surviving patients, associated injuries in the neck were eight to the larynx/trachea, seven to the esophagus, 11 to the pharynx, and nine spinal cord injuries. DISCUSSION
The evaluation of penetrating neck injuries remains controversial. The early experience with this disease was primarily from war injuries and was limited to airway management and wound debridement. The first large civilian series, published 10 years after World War II, reported 100 consecutive cases and made a strong case for mandatory exploration of all deep penetrating neck wounds while describing 86 total injuries in 100 patients. 9 This has been the standard of care for many years.:3 The high rate of negative neck explorations in most institutions and the advent of newer technologies has called for protocols to selectively identify patients in need of surgical intervention. 4,s,:°-:2 Vascular trauma is the most common finding in patients with zone II neck injuries, and different protocols have been suggested to select patients who may need surgical repair. 4,12qs With advances in contrast arteriography, some have recommended this as a routine study in all these patients. 4'5 Although arteriography combined with panendoscopy is considered equal to surgical exploration in the discovery of disease in patients with penetrating neck injury, there is still no consensus on which patients need to be worked up with diagnostic Studies. 16"2° These advances in technology have given the surgeon the ability for nonoperative evaluation of vascular injuries distinctly from visceral injuries. Previously published experience with penetrating extremity injuries noted a less than 1% missed injury rate with evaluation based only on physical findings. The results of physical examination are now used as the sole criterion to determine operative management versus observation in patients with these injuries. 6,2: Because zone II of the neck is also amenable to physical examination, physical evidence of vascular injury should be apparent if it has occurred and may be managed in a similar manner. These studies have also demonstrated that the vast majority of minimal intimal injuries will heal spontaneously without surgical intervention. The sensitivity of hard signs of vascular injury in need of surgical repair is 4/5 (80%), with a specificity
Arteriograms in penetrating zone II neck injuries 399
Table II. Results of arteriography (n = 45) No injury Noncritical vessels External carotid Thyrocervical trunk Costocervical mink Major vessels Common carotid Internal carotid Vertebral
27 8 3 3 2 10 2 2 6
of 101/101 (100%). The missed injury rate based solely on physical findings is 0.9% (1/110). This is nearly identical to the quoted 1% missed injury rate for arteriography.22 The mortality rate was 9% overall with the majority occurring during trauma center resuscitations. This is consistent with other studies with similar injuries. ~4,18 The rate of arterial injuries and visceral injuries is also same as those quoted elsewhere. 9~2°There was a much lower rate of surgical intervention for vascular injuries (4.5%) than in other studies, which is consistent with our policy of nonoperative management of minimal vascular injuries. 21 Based on these data and review of the literature, routine use of arteriography in zone II penetrating neck injuries is probably not justified. 7,i6"2° We recommend that prospective studies be conducted to evaluate better the exact role of arteriography in management of this type of trauma. Because of limited available resources and the high cost of surgical or radiologic intervention, the necessity of these procedures should be examined and established dearly. REFERENCES 1. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391-7. 2. Ashworth C, Williams LF, Byrne JJ. Penetrating wounds of the neck, re-emphasisof the need for prompt exploration. Am J Surg 1971;121:387-91. 3. Mclnnis WD, Cruz AB, Aust JB. Penetrating injuries to fl:e neck: pitfalls in management. Am J Surg 1975;130:416-30. 4. McCormick TM, Burch BH. Routine angiographic evaluation of neck and extremity injuries. J Trauma 1979;19:384-7. 5. Sclafani SJA, Cavaliere G, Atweh N, Duncan AO, Scalea T. The role of angiography in penetrating neck trauma. J Trauma I991;31:557-63. 6. Dennis JW, Frykberg ER, Cmrnp JM, Vines FS, Alexander RH. New perspective on the management of penetrating trauma in proximity to major limb arteries. J Vase Surg 1990;11:85-93. 7. Frykberg ER, Crump JM, Dennis JW, Vines FS, Alexander RH. Nonoperative observation of clinically occult arterial
400
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injuries: a prospective evaluation. Surgery 1991;109:85-96. 8. Faliciano DV. Pitfalls in the management of peripheral vascular injuries. In: Roses DF, ed. Problems in general surgery. Philadelphia: JB Lippincott, 1986:101-13. 9. Fogelman MJ, Stewart RD. Penetrating wounds of the neck. Am J Surg 1956;91:581-96. 10. Stroudt WH, Yarbrough DR III. Penetrating neck wounds. Am J Surg 1980;140:323-6. 11. Elerding SC, Manart FD, Moore EE. A reappraisal of penetrating neck injury management. J Trauma 1980;20: 695 -7. 12. Campbell FC, Robbs JV. Penetrating injuries of the neck: a prospective study of 108 patients. Br J Surg 1980;67:582-6. 13. Massac E Jr, Suryanarayana MS, Leffall LD Jr. Penetrating neck wounds. Am J Surg 1983;145:263-5. 14. Merion RM, Harness JK, Ramsburgh SR, Thompson NW. Selective management of penetrating neck trauma: cost implications. Arch Surg 1981;116:691-6. 15. WoodJ, FabianTC, MangianteEC. Penetratingneckinjuries: recommendations for selective management. J Trauma 1989; 29:602-5. 16. Obeid FN, Haddad GS, Horst HM, Bivins BA. A critical reappraisal of mandatory exploration policy for penetrating wounds of the neck. Surg Gynecol Obstet 1985;160:517-22.
17. Byers PM, Kopelman T, Fine E, et al. Penetrating cervical trauma: is routine angiography indicated? Panam J Trauma 1990;2:1-5. 18. Lundy LJ Jr, Mandal AK, Lou MA, Alexander JL. Experience in selective operations in the management of penetrating wounds of the neck. Surg Gynecol Obstet 1978;147: 845-8. 19. Noyes LD, McSwain NE, Markowitz IP. Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck. Ann Surg 1986;204:21-6. 20. Mansour MA, Moore EE, Moore FA, Whitehill TA. Validating the selective management of penetrating neck wounds. Am I Surg 1991;162:517-21. 21. Frykberg ER, Dennis JW, Bishop K, Laneve L, Alexander Rt-I. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 1991;31:502-11. 22. Sdafani SJA, Cooper R, Shaftan GW, et al. Arterial trauma: diagnostic and therapeutic angiography. Radiology 1986; 161:165-72. Submitted Jan. 27, 1992; accepted May 6, 1992.
DISCUSSION Dr. Mitchell H. Goldman (Knoxville, Term.). The study represents the activities of a very busy trauma center, and I have to commend you on your excellent results in terms of mortality rates. The occurrence of penetrating injury to the neck raises the question of immediate exploration, exploration after selective arteriography, or observation. The conclusions of the study are that arteriograms have "too low a yield, in this case less than 1%, findings that alter treatment to justify routine application in patients with zone II penetrating injuries." I can agree that routine arteriography is not indicated in patients with "hard" findings. I think we all can agree with that, but I am still not sure that I agree totally with the concept that selective arteriography for "soft" signs of vascular injury is not indicated. The abstract left me unconvinced. The article is a little more convincing, but I still am concerned about .the way you arrived with the less than 1%. The figure of less than 1% comes from the fact that only 1 of 110 patients with penetrating wounds had arteriographic findings that led to surgery. In 53 of those patients, however, there was no arteriogram or surgery based on the location of the wound or lack of physical findings. I do not believe those patients should be included in the statistics. Four patients went to immediate surgery. One patient died without evaluation, leaving 45 patients who underwent arteriography, of whom 15 had injuries to major arteries. Therefore 15 of 45, or 33%, had arterial injury. Of those
15 patients, 1, or 7%, had a lesion that required surgery. This is where I got a little bit confused and the article cleared things up for me in that the one patient was a patient who had a pseudoaneurysm. In addition, from my standpoint, in the carotid territory the word is not out on intimal flaps. One could argue as to whether the intimal flaps were indications for surgery. Taking an incidence of say one in 15 or maybe three in 15, depending on whether you would operate on the intirnal flaps, do you still consider this incidence an indication for not doing selective-not routine but selective-arteriography, or would you continue arteriography in patients with zone II trauma and soft findings? Also, how much of an intimal flap do you leave alone in the internal carotid artery or the common carotid artery, because the consequences of being wrong in that situation are potentially more catastrophic than in the extremity? Do you use anticoagnlation in your patients with intimal flaps? Finally, what would you consider the utility of duplex scanning in this situation? We have found it quite helpful in blunt trauma, although we have not used it extensively in penetrating trauma. Dr. Sunil S. Menawat. As to the idea that we really had a 7% discovery of injury, I think we have been kind to arteriography. In my review of these patients, the one patient was seen early and may have had what I would consider hard signs of vascular injury. This was in the early part of the period that we studied, and if that patient were
Volume 16 Number 3 September 1992
Arteriograms in penetrating zone H neck inju~4es 401
seen in our trauma center today he would have gone directly to the operating room. His record was not very clear and the attending physician at that time felt that arteriography was justified and it was done. I think if dais study were done with the index of suspicion we use today, we probably would have discovered this injury without arteriography. As to the question of whether intimal flaps need surgery and how big an intimal flap to leave, other than saying small ones do not and large ones do, I could not really be much more specific than that. However, I would recommend review of our published data on minimal intimal injuries including injuries in neck wounds. Dr. Frykberg had a very nice article recently in Surgery that talks about prospectively following these iNuries and shows that, other than pseudoaneurysms, small intimal flaps have a benign course. That is on what we base our findings. As to the question of duplex scanning, we have begun a prospective study that involves duplex scanning of these injuries and not getting arteriograms. Other than in patients with hard signs, there is some time before a patient has complications of arterial injury in this group, and you do have time to evaluate them with noninvasive studies. As far as selective arteriography, as I said, we are no longer doing that; we do not believe it is justified. Dr. Richard L. McCann (Durham, N.C.). A popular aggressive weapon in our area of the country is the shotgun. Do you alter ),our policy with regard to shotgun injuries of the neck? When we perform arteriography in these patients, very often we find multiple perforations of the common carotid artery. What do you do clinically under these circumstances? Dr. Menawat. We had only seven patients with shotgun injuries, so we were not able to make any specific recommendations, but in this group four of seven patients
underwent a~eriography and three did not. In our view, our recommendation would be that shotgun injuries require arteriography. That is our current recommendation in extremity wounds also. Dr. G o r d o n L. Hyde (Lexington, Ky.). I agree with your plans for a prospective study, because we certainly need some darification, but in the meantime if a family member had a vascular injury to the neck without hard signs, would you perform arteriography and, if so and he had an intimal injury, would you watch it? Dr. Menawat. I do not treat family members any differently. Every patient I treat gets the same care from me and, yes, I would observe it. I think there are means of following these injuries without taking undue risk because I think the course is usually benign. I would use noninvasive studies m follow the injury. Dr. G. Patrick Clagett (Dallas, Texas). Your clinical evaluation plan would seemingly require thorough followup. At Parkland we have difficult3, with that because so many of our patients end up either across the tracks, across the border, or in jail. We cannot follow them, so I would like to know precisely what is your follow-up plan? H o w long do you follow your patients and what percentage do you actually follow? Dr. Menawat. tn this study I do not have exact data on that. The observed group was followed up only to about 1 month, meaning their first clinic visit. I do not have the exact data of how many patients showed up for their appointments. Our follow-up is based on the fact that we are the only hospital in town that sees these patients, and we are quite confident that if they have a problem they do return to our institution. I can give an example in the extremity wounds. We have had as high as 28% to 30% follow-up for greater than 2 to 3 years on these patients because we are the only hospital in town that provided them care.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOURNAL OF VASCULAR SURGERY for 1992 are available to subscribers only. They may be purchased from the publisher at a cost of $65.00 for domestic, $85.55 for Canadian, and $81.00 for international subscribers for Vol. 15 (January to June) and Vol. 16 (July to December). Price includes shipping charges. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Subscription Services, Mosby-Year Book, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA. In the United States call toll flee (800)325-4177, ext. 4351. In Missouri or foreign countries call (314)453-4351l. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNALsubscription.
Manditory surgical exploration of all deep penetrating neck injuries was considered the standard of care for several decades. 13 Recently there have been calls for more selective management of these injuries mostly because of the high rate of negative neck explorations and associated morbidity when all such wounds are explored. Some centers recommend diagnostic arteriography in all neck injuries with no hard signs of vascular trauma to identify patients in need of surgical intervention, whereas others use selective management. 4,~ This is based on the use of From the Department of Surgery, Universityof Florida Health Science Center/lacksonvitle. Presented at the Sixteenth Annual Meeting of the Southern Associationfor Vascular Surgery, St. Thomas, Virgin Islands, lan. 22-25, 1992. Reprint requests: lamesW. Dennis,MD, Departmentof Surgery, Universityof Florida Health ScienceCenter, 653-2 W. Eighth St., Jackson~lle, FL 32209. 24/6/39149
these radiologic techniques when there are no hard signs o f vascular injury but the wound is in proximig¢ to a major vessel or shows soft signs. We embarked on this retrospective review to look at the role of physical examination and arteriography in the discovery of arterial injuries that need surgical repair in penetrating zone II neck trauma. Our institution follows the practice of selective operative management of penetrating injuries in this zone o f the neck, where physical examination is possible. Based on previous studies on minimal arterial inju° ties, we also practice nonoperative management of small intimal defects and segmental narrowings seen on arteriography. 6,7 METHODS During a 20-month period from January 1, 1990, to August 31, 1991, we reviewed the records of 4035 trauma admissions to University Medical Center, a 397
398
lournal of VASCULAR SURGERY
Menawat et al.
Table I. Vascular injuries found on physical examination Vessel injured Common carotid Internal carotid Vertebral Internal jugular vein
Physical findings Active bleeding/expanding hematoma Expanding hematoma Active bleeding Large hematoma
level I trauma center in Jacksonville, Fla., for penetrating zone II neck injuries. Zone II was defined as above the clavicle and below the angle of the mandible. Only patients who had injuries deep to the platysma were included in the study group. One hundred ten patients (2.7% of total trauma admissions) met this criteria, and their charts were reviewed in detail. The average age of the 110 patients that constituted the study group was 31.1 years, with a range of 15 to 72 years. There were 95 male and 15 female patients. The average Injury Severity Score was 11.5, and the average Glascow Coma Scale score was 13.5 on arrival to the trauma center. If the eight trauma center deaths are excluded, the average Glascow Coma Scale score was 14.2. On arrival to the trauma center all patients were treated according to the Advanced Trauma Life Support protocol, which included airway management and volume resuscitation as needed. All patients with hard signs of vascular trauma (active bleeding, large or expanding hemotoma, distal ischemia, and bruit/thrill) 8 or other associated life-threatening injuries requiring surgery were taken directly to the operating room. The management of the remaining patients was based strictly on physical findings. Patients with wounds in proximity to major vessels or showing soft signs of vascular injury (history of bleeding, small/stable hematoma, or associated nerve injury) were taken immediately for four-vessel arteriography. Those with no physical findings and nonproximity were admitted to the hospital and observed for a minimum of 24 hours. RESULTS
The mechanisms of injury included gunshot wounds in 50 patients (45%), stab wounds in 43 patients (39%), laceration in 10 patients (9%), and shotgun wounds in 7 patients (6%). All injuries were judged to be deep to the platysma. Of the 110 patients, 15 were taken directly to the operating room, four of whom had hard signs of vascular injury. All four were found to have vascular
injuries requiring surgical repair (Table !). Of the other 11 patients (none of whom had hard signs of vascular injury), four had torso injuries and negative neck explorations, four had tracheal/laryngeal injuries, two had pharyngeal injuries, and one had an esophageal injury. Not one of these 11 patients had a vascular injury. Forty-two patients of the 110 patients were determined to have no vascular injury based on lack of any physical findings, and their injury was not considered to be near any major vessels. None of these patients had an entrance wound in the anterior triangle. These patients had no further workup for vascular injury (no arteriogram or surgical exploration) and were observed for at least 24 hours and discharged (when their associated injuries permitted) and followed in the clinic. The average hospital stay in this group is 2 1/2 days, with 30 patients staying in the hospital less than 48 hours. Long-term follow-up was available on 30 (70%) of these 42 patients. No patients in this group later showed signs of vascular injury. The average length of follow-up was 173 clays (range 4 to 565 days). Forty-five patients who had soft signs of vascular injury or in whom the injury was in proximity to a major vessel underwent arteriography to rule out vascular injury. The rate of arteriography was 23/50 of the gunshot wounds, 17/42 of the stab wounds, 4/7 shotgun wounds, and 1/10 for lacerations. Twenty-seven of these 45 test results were negative and eight showed injury to noncritical vessels such as branches of external carotid artery. Ten studies showed involvement of a major vessel in injury (Table II). Six vertebral artery injuries, including three asymptomatic occlusions and three minimal intimal defects, were observed. Two small intimal defects of the common carotid and one of the internal carotid artery were also observed. Only one injury, a small pseudoaneurysm of the internal carotid artery, required surgical repair. This patient's injury was caused by a gunshot wound that resulted in a hematoma in the neck, but review of his records revealed no details regarding its size. The eight patients with noncritical arterial injuries were also treated nonoperatively. None of these patients had any vascular complications from the injuries that required delayed surgery or interventional radiology. These patients were observed a minimum of 24 hours, and longer follow-up was available only on two patients (2 and 5 weeks). Eight patients died during initial resuscitation. One death could be attributed to hemorrhagic shock as a result of two arterial injuries in the neck. Other
Volume 16 Number 3 September 1992
deaths were attributable to associated injuries that included gunshot wounds to the head and the chest. There were two delayed deaths, both a result of multiple-organ system failure from associated injuties. In the surviving patients, associated injuries in the neck were eight to the larynx/trachea, seven to the esophagus, 11 to the pharynx, and nine spinal cord injuries. DISCUSSION
The evaluation of penetrating neck injuries remains controversial. The early experience with this disease was primarily from war injuries and was limited to airway management and wound debridement. The first large civilian series, published 10 years after World War II, reported 100 consecutive cases and made a strong case for mandatory exploration of all deep penetrating neck wounds while describing 86 total injuries in 100 patients. 9 This has been the standard of care for many years.:3 The high rate of negative neck explorations in most institutions and the advent of newer technologies has called for protocols to selectively identify patients in need of surgical intervention. 4,s,:°-:2 Vascular trauma is the most common finding in patients with zone II neck injuries, and different protocols have been suggested to select patients who may need surgical repair. 4,12qs With advances in contrast arteriography, some have recommended this as a routine study in all these patients. 4'5 Although arteriography combined with panendoscopy is considered equal to surgical exploration in the discovery of disease in patients with penetrating neck injury, there is still no consensus on which patients need to be worked up with diagnostic Studies. 16"2° These advances in technology have given the surgeon the ability for nonoperative evaluation of vascular injuries distinctly from visceral injuries. Previously published experience with penetrating extremity injuries noted a less than 1% missed injury rate with evaluation based only on physical findings. The results of physical examination are now used as the sole criterion to determine operative management versus observation in patients with these injuries. 6,2: Because zone II of the neck is also amenable to physical examination, physical evidence of vascular injury should be apparent if it has occurred and may be managed in a similar manner. These studies have also demonstrated that the vast majority of minimal intimal injuries will heal spontaneously without surgical intervention. The sensitivity of hard signs of vascular injury in need of surgical repair is 4/5 (80%), with a specificity
Arteriograms in penetrating zone II neck injuries 399
Table II. Results of arteriography (n = 45) No injury Noncritical vessels External carotid Thyrocervical trunk Costocervical mink Major vessels Common carotid Internal carotid Vertebral
27 8 3 3 2 10 2 2 6
of 101/101 (100%). The missed injury rate based solely on physical findings is 0.9% (1/110). This is nearly identical to the quoted 1% missed injury rate for arteriography.22 The mortality rate was 9% overall with the majority occurring during trauma center resuscitations. This is consistent with other studies with similar injuries. ~4,18 The rate of arterial injuries and visceral injuries is also same as those quoted elsewhere. 9~2°There was a much lower rate of surgical intervention for vascular injuries (4.5%) than in other studies, which is consistent with our policy of nonoperative management of minimal vascular injuries. 21 Based on these data and review of the literature, routine use of arteriography in zone II penetrating neck injuries is probably not justified. 7,i6"2° We recommend that prospective studies be conducted to evaluate better the exact role of arteriography in management of this type of trauma. Because of limited available resources and the high cost of surgical or radiologic intervention, the necessity of these procedures should be examined and established dearly. REFERENCES 1. Roon AJ, Christensen N. Evaluation and treatment of penetrating cervical injuries. J Trauma 1979;19:391-7. 2. Ashworth C, Williams LF, Byrne JJ. Penetrating wounds of the neck, re-emphasisof the need for prompt exploration. Am J Surg 1971;121:387-91. 3. Mclnnis WD, Cruz AB, Aust JB. Penetrating injuries to fl:e neck: pitfalls in management. Am J Surg 1975;130:416-30. 4. McCormick TM, Burch BH. Routine angiographic evaluation of neck and extremity injuries. J Trauma 1979;19:384-7. 5. Sclafani SJA, Cavaliere G, Atweh N, Duncan AO, Scalea T. The role of angiography in penetrating neck trauma. J Trauma I991;31:557-63. 6. Dennis JW, Frykberg ER, Cmrnp JM, Vines FS, Alexander RH. New perspective on the management of penetrating trauma in proximity to major limb arteries. J Vase Surg 1990;11:85-93. 7. Frykberg ER, Crump JM, Dennis JW, Vines FS, Alexander RH. Nonoperative observation of clinically occult arterial
400
Journal of VASCULAR SURGERY
M e n a w a t et al.
injuries: a prospective evaluation. Surgery 1991;109:85-96. 8. Faliciano DV. Pitfalls in the management of peripheral vascular injuries. In: Roses DF, ed. Problems in general surgery. Philadelphia: JB Lippincott, 1986:101-13. 9. Fogelman MJ, Stewart RD. Penetrating wounds of the neck. Am J Surg 1956;91:581-96. 10. Stroudt WH, Yarbrough DR III. Penetrating neck wounds. Am J Surg 1980;140:323-6. 11. Elerding SC, Manart FD, Moore EE. A reappraisal of penetrating neck injury management. J Trauma 1980;20: 695 -7. 12. Campbell FC, Robbs JV. Penetrating injuries of the neck: a prospective study of 108 patients. Br J Surg 1980;67:582-6. 13. Massac E Jr, Suryanarayana MS, Leffall LD Jr. Penetrating neck wounds. Am J Surg 1983;145:263-5. 14. Merion RM, Harness JK, Ramsburgh SR, Thompson NW. Selective management of penetrating neck trauma: cost implications. Arch Surg 1981;116:691-6. 15. WoodJ, FabianTC, MangianteEC. Penetratingneckinjuries: recommendations for selective management. J Trauma 1989; 29:602-5. 16. Obeid FN, Haddad GS, Horst HM, Bivins BA. A critical reappraisal of mandatory exploration policy for penetrating wounds of the neck. Surg Gynecol Obstet 1985;160:517-22.
17. Byers PM, Kopelman T, Fine E, et al. Penetrating cervical trauma: is routine angiography indicated? Panam J Trauma 1990;2:1-5. 18. Lundy LJ Jr, Mandal AK, Lou MA, Alexander JL. Experience in selective operations in the management of penetrating wounds of the neck. Surg Gynecol Obstet 1978;147: 845-8. 19. Noyes LD, McSwain NE, Markowitz IP. Panendoscopy with arteriography versus mandatory exploration of penetrating wounds of the neck. Ann Surg 1986;204:21-6. 20. Mansour MA, Moore EE, Moore FA, Whitehill TA. Validating the selective management of penetrating neck wounds. Am I Surg 1991;162:517-21. 21. Frykberg ER, Dennis JW, Bishop K, Laneve L, Alexander Rt-I. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 1991;31:502-11. 22. Sdafani SJA, Cooper R, Shaftan GW, et al. Arterial trauma: diagnostic and therapeutic angiography. Radiology 1986; 161:165-72. Submitted Jan. 27, 1992; accepted May 6, 1992.
DISCUSSION Dr. Mitchell H. Goldman (Knoxville, Term.). The study represents the activities of a very busy trauma center, and I have to commend you on your excellent results in terms of mortality rates. The occurrence of penetrating injury to the neck raises the question of immediate exploration, exploration after selective arteriography, or observation. The conclusions of the study are that arteriograms have "too low a yield, in this case less than 1%, findings that alter treatment to justify routine application in patients with zone II penetrating injuries." I can agree that routine arteriography is not indicated in patients with "hard" findings. I think we all can agree with that, but I am still not sure that I agree totally with the concept that selective arteriography for "soft" signs of vascular injury is not indicated. The abstract left me unconvinced. The article is a little more convincing, but I still am concerned about .the way you arrived with the less than 1%. The figure of less than 1% comes from the fact that only 1 of 110 patients with penetrating wounds had arteriographic findings that led to surgery. In 53 of those patients, however, there was no arteriogram or surgery based on the location of the wound or lack of physical findings. I do not believe those patients should be included in the statistics. Four patients went to immediate surgery. One patient died without evaluation, leaving 45 patients who underwent arteriography, of whom 15 had injuries to major arteries. Therefore 15 of 45, or 33%, had arterial injury. Of those
15 patients, 1, or 7%, had a lesion that required surgery. This is where I got a little bit confused and the article cleared things up for me in that the one patient was a patient who had a pseudoaneurysm. In addition, from my standpoint, in the carotid territory the word is not out on intimal flaps. One could argue as to whether the intimal flaps were indications for surgery. Taking an incidence of say one in 15 or maybe three in 15, depending on whether you would operate on the intirnal flaps, do you still consider this incidence an indication for not doing selective-not routine but selective-arteriography, or would you continue arteriography in patients with zone II trauma and soft findings? Also, how much of an intimal flap do you leave alone in the internal carotid artery or the common carotid artery, because the consequences of being wrong in that situation are potentially more catastrophic than in the extremity? Do you use anticoagnlation in your patients with intimal flaps? Finally, what would you consider the utility of duplex scanning in this situation? We have found it quite helpful in blunt trauma, although we have not used it extensively in penetrating trauma. Dr. Sunil S. Menawat. As to the idea that we really had a 7% discovery of injury, I think we have been kind to arteriography. In my review of these patients, the one patient was seen early and may have had what I would consider hard signs of vascular injury. This was in the early part of the period that we studied, and if that patient were
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Arteriograms in penetrating zone H neck inju~4es 401
seen in our trauma center today he would have gone directly to the operating room. His record was not very clear and the attending physician at that time felt that arteriography was justified and it was done. I think if dais study were done with the index of suspicion we use today, we probably would have discovered this injury without arteriography. As to the question of whether intimal flaps need surgery and how big an intimal flap to leave, other than saying small ones do not and large ones do, I could not really be much more specific than that. However, I would recommend review of our published data on minimal intimal injuries including injuries in neck wounds. Dr. Frykberg had a very nice article recently in Surgery that talks about prospectively following these iNuries and shows that, other than pseudoaneurysms, small intimal flaps have a benign course. That is on what we base our findings. As to the question of duplex scanning, we have begun a prospective study that involves duplex scanning of these injuries and not getting arteriograms. Other than in patients with hard signs, there is some time before a patient has complications of arterial injury in this group, and you do have time to evaluate them with noninvasive studies. As far as selective arteriography, as I said, we are no longer doing that; we do not believe it is justified. Dr. Richard L. McCann (Durham, N.C.). A popular aggressive weapon in our area of the country is the shotgun. Do you alter ),our policy with regard to shotgun injuries of the neck? When we perform arteriography in these patients, very often we find multiple perforations of the common carotid artery. What do you do clinically under these circumstances? Dr. Menawat. We had only seven patients with shotgun injuries, so we were not able to make any specific recommendations, but in this group four of seven patients
underwent a~eriography and three did not. In our view, our recommendation would be that shotgun injuries require arteriography. That is our current recommendation in extremity wounds also. Dr. G o r d o n L. Hyde (Lexington, Ky.). I agree with your plans for a prospective study, because we certainly need some darification, but in the meantime if a family member had a vascular injury to the neck without hard signs, would you perform arteriography and, if so and he had an intimal injury, would you watch it? Dr. Menawat. I do not treat family members any differently. Every patient I treat gets the same care from me and, yes, I would observe it. I think there are means of following these injuries without taking undue risk because I think the course is usually benign. I would use noninvasive studies m follow the injury. Dr. G. Patrick Clagett (Dallas, Texas). Your clinical evaluation plan would seemingly require thorough followup. At Parkland we have difficult3, with that because so many of our patients end up either across the tracks, across the border, or in jail. We cannot follow them, so I would like to know precisely what is your follow-up plan? H o w long do you follow your patients and what percentage do you actually follow? Dr. Menawat. tn this study I do not have exact data on that. The observed group was followed up only to about 1 month, meaning their first clinic visit. I do not have the exact data of how many patients showed up for their appointments. Our follow-up is based on the fact that we are the only hospital in town that sees these patients, and we are quite confident that if they have a problem they do return to our institution. I can give an example in the extremity wounds. We have had as high as 28% to 30% follow-up for greater than 2 to 3 years on these patients because we are the only hospital in town that provided them care.
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