Case Report
Indirect surgical management of a penetrating vertebral artery injury
Vascular 2014, Vol. 22(6) 468–470 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114529278 vas.sagepub.com
Sinisˇa Pejkic´1, Nikola Ilic´1,2, Marko Dragasˇ1,2, Andreja Dimic´1, Igor Koncˇar1,2, Slobodan Cvetkovic´1,2 and Lazar Davidovic´1,2
Abstract Introduction: Vertebral artery injury caused by penetrating neck trauma is a rare occurrence. Direct surgical repair is difficult due to anatomy and exposure. Proximal and distal ligation or/and embolization represent the most common management in cases which require intervention. Case report: A young man accidentally stabbed in the neck was admitted to the emergency department with active arterial bleeding from the wound. Immediate surgical exploration revealed an isolated injury of the left vertebral artery intraosseous segment. Lesion was managed by proximal segment ligature and distal Fogarty catheter balloon-tamponade. Postoperative angiography excluded the need for further interventions. Balloon-catheter was successfully extracted after 72 hours and patient discharged neurologically intact on postoperative day 7. Fourteen months later, there are no signs of vascular or neurologic complications. Conclusion: Balloon-tamponade is a valuable technical adjunct in either temporizing or definitive management of surgically inaccessible vascular trauma.
Keywords Vertebral artery injury, penetrating neck trauma, ligature, therapeutic embolization, balloon-tamponade
Introduction Vertebral artery (VA) is among the least frequently injured major arteries, owing to its deep and protected location. For the same reasons, direct surgical repair is fraught with difficulties and may prove technically impossible. Ligation or/and embolization is the suggested management in the majority of cases which require intervention.1–3
Case report A 26-year-old man got knife stabbed in the neck in a street fight. On admission to emergency department, an isolated deep stab wound in the zone II of the left posterolateral cervical region was noticeable. Gauze sponges used for wound tamponade were bloodsoaked and ongoing arterial hemorrhage was apparent. Patient’s vital signs were stable and he showed no neurologic deficit (Glascow Coma Scale score 15/15) or signs of aerodigestive tract injuries. After the basic physical examination and volume resuscitation in the
trauma resuscitation area, the patient was immediately taken to the operating room for surgical exploration of the actively bleeding penetrating neck wound. An endotracheal tube was placed, and formal left-sided neck exploration through standard ante-sternocleidomastoid incision was performed, while digital pressure was applied to minimize the blood loss from the traumatic wound. The apex of the stab wound trajectory was found to reach just short of the carotid sheath and major anterior vascular structures were intact. Next, direct assessment of the stab wound revealed persistent arterial bleeding coming from the depths of the bony tunnel of the transverse processes of the C3–C4. Based on clinical presentation and intraoperative findings, 1 Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia 2 Faculty of Medicine, University of Belgrade, Serbia
Corresponding author: Nikola Ilic´, Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Koste Todorovic´a Street 8, 11000 Belgrade, Serbia. Email: [email protected]
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Figure 1. Schematic representation of the VA anatomic divisions, the location of the stab wound and the management of the VAI. Anatomically, the VA is divided into four segments (1) pars praevertebralis (V1), from its origin as the first branch of the subclavian artery until it enters the foramen transversarium of C6; (2) pars transversaria (V2), ascending in the osseous tunnel from C6 to C2 in front of the cervical nerve roots and surrounded by venous and sympathetic plexus; (3) pars atlantica (V3), from C2 to the atlantooccipital membrane through the foramen magnum and (4) pars intracranialis (V4), from the base of the skull to the basilar artery, which then joins the circle of Willis.
injury to the left VA intraosseous segment (V2) was diagnosed (Figure 1). In view of the lesion’s inaccessible location and lack of experience with direct V2 segment exposure, we proceeded with transverse supraclavicular approach to the left subclavian artery and ligation of the VA at its origin. Significant but incomplete cessation of the hemorrhage ensued, mandating additional measures for control of back bleeding. Attempts at blind clipping of the vessel proved futile, leaving tamponade as the only remaining option. Initially used Foley catheter was inadequate to seal the bleeding point, but a more delicate No. 4 Fogarty embolectomy catheter effectively achieved local hemostasis. The catheter’s free end was brought out through the stab wound and suture-fixed to the skin. On further operative exploration, cervical esophagus was found to be intact. Wounds were irrigated, suction-drained and closed in multiple layers, except for the stab wound, which was only loosely approximated. Estimated intraoperative blood loss was 1700 ml. Control conventional arch aortography was done on postoperative day
Figure 2. Postoperative arch aortogram, demonstrating complete exclusion of the left VA with contralateral vessel patent and somewhat hypoplastic.
0, after patient’s stabilization and awakening from anesthesia. It documented complete exclusion of the left VA, without contrast extravasation or other signs of residual vascular injuries (Figure 2). It also demonstrated the patency of a rather hypoplastic contralateral VA, in the presence of otherwise typical arterial anatomy. No further endovascular or open surgical interventions were deemed necessary. Balloon-catheter was extracted uneventfully after 72 hours of observation in the intensive care unit. Patient was discharged in good condition and neurologically intact on postoperative day 7. Fourteen months later, there are no clinical and duplex-ultrasound signs of central neurologic or local vascular complications.
Discussion Vertebral artery injuries (VAIs) fortunately are rare, since direct control of the V2–4 segments can be extremely challenging. In 1853, Maisonneuve successfully ligated the VA for a stab wound.4 In 1893, Matas4 published the first literature review of 42 VAIs, reporting 80% mortality.4 Radner5 reported angiography of the VA in 1947. With liberal use of arteriography, VAIs are being diagnosed more often.1,2 The management of VAIs has been revolutionized by the advances in endovascular surgery.6 Prior to these advances, surgery for VAIs carried a mortality risk of 50%.7
Downloaded from vas.sagepub.com at University of British Columbia Library on July 11, 2015
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Several treatment options are available for VAIs.8 For stable asymptomatic injuries detected by diagnostic imaging, expectant management, anticoagulation therapy, embolization or stenting is appropriate.9,10 Endovascular treatment may fulfill diverse roles: in acute phase or in chronic post-injury setting; as an isolated modality or a part of a ‘‘hybrid’’ management; prior to operative exploration or after surgical ‘‘damage control.’’9–11 For actively bleeding patient, immediate operative exploration is indicated.1,9 If exposure of the injured segment is uncomplicated, proximal and distal ligation is performed.1,9,10 Most vascular surgeons, however, are unfamiliar with the approaches to V2–V4. Rather than undergoing a difficult and potentially morbid dissection, the patient may be better served by proximal ligation of the V1 segment; wound tamponade and proceeding to postoperative embolization of the distal VA if needed.1,9 Gauze sponges, bone wax or oxidized cellulose can be used to compress the injured VA. An alternative is a balloon-catheter tamponade.12,13 It may be a temporizing ‘‘bridge’’ to definitive intervention, or prove sufficient adjunct in itself to arrest the back bleeding. The optimum timing of catheter removal is unclear, although 48–72 hours appears to be a safe period.13,14 Regardless of the treatment modality, it is advisable that patients with VAIs are monitored for late neurological sequelae and complications such as vertebral arteriovenous fistula and false aneurysm.9
Conclusion VAIs are being identified more frequently in both blunt and penetrating trauma, because of widespread use of diagnostic imaging. Knowledge of the surgical anatomy of this vessel and awareness of the available treatment modalities are important for successful outcome. Most VAIs can be safely treated nonoperatively or with angiographic embolization. The ongoing sophistication of endovascular techniques and devices and growing experience with their usage will further optimize this form of treatment both in acute trauma and in latepresenting arteriovenous fistulas and false aneurysms. Surgical intervention should be reserved for patients with severe active bleeding or when angiographic embolization fails. Balloon-tamponade is a valuable tool in a surgeon’s armamentarium for emergency preoperative or intraoperative management of surgically inaccessible vascular trauma, including penetrating injury of the VA. Successful management of VAIs with minimal mortality and morbidity may be expected
with a multidisciplinary approach and by adhering to selective treatment guidelines as outlined above.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Jeffery P, Immelman E and Beningfield S. A review of the management of vertebral artery injury. Eur J Vasc Endovasc Surg 1995; 10: 391–393. 2. Golueke P, Sclafani S, Phillips T, et al. Vertebral artery injury – diagnosis and management. J Trauma 1987; 27: 856–865. 3. Reid JD and Weigelt JA. Forty-three cases of vertebral artery trauma. J Trauma 1988; 28: 1007–1012. 4. Matas R. Traumatisms and traumatic aneurisms of the vertebral artery and their surgical treatment with the report of a cured case. Ann Surg 1893; 18: 477–521. 5. Radner S. Intracranial angiography via the vertebral artery: preliminary report of a new technique. Acta Radiol 1947; 28: 838–842. 6. Binkley M and Wylie EJ. A new technique for obliteration of cerebrovascular arteriovenous fistulae. Arch Surg 1973; 106: 524–527. 7. Fogelman MJ and Stewart RD. Penetrating wounds of the neck. Am J Surg 1956; 91: 581–596. 8. Yee HF, Olcott EW, Knudson M, et al. Extraluminal, transluminal, and observational treatment for vertebral artery injuries. J Trauma 1995; 39: 480–486. 9. Demetriades D, Salim A, Brown C, et al. Neck injuries. Curr Probl Surg 2007; 44: 13–85. 10. Mwipatayi BP, Jeffery P, Beningfield SJ, et al. Management of extra-cranial vertebral artery injuries. Eur J Vasc Endovasc Surg 2004; 27: 157–162. 11. Starnes BW and Arthurs ZM. Endovascular management of vascular trauma. Perspect Vasc Surg Endovasc Ther 2006; 18: 114–129. 12. Pearce CW, McCool E and Schmidt FE. Control of bleeding from cardiovascular wounds: balloon catheter tamponade. Ann Surg 1966; 163: 257–259. 13. Ball CG, Wyrzykowski AD, Nicholas JM, et al. A decade’s experience with balloon catheter tamponade for the emergency control of hemorrhage. J Trauma 2011; 70: 330–333. 14. Meier DE, Brink BE and Fry WJ. Vertebral artery trauma: acute recognition and treatment. Arch Surg 1981; 116: 236–239.
Downloaded from vas.sagepub.com at University of British Columbia Library on July 11, 2015
Indirect surgical management of a penetrating vertebral artery injury
Vascular 2014, Vol. 22(6) 468–470 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114529278 vas.sagepub.com
Sinisˇa Pejkic´1, Nikola Ilic´1,2, Marko Dragasˇ1,2, Andreja Dimic´1, Igor Koncˇar1,2, Slobodan Cvetkovic´1,2 and Lazar Davidovic´1,2
Abstract Introduction: Vertebral artery injury caused by penetrating neck trauma is a rare occurrence. Direct surgical repair is difficult due to anatomy and exposure. Proximal and distal ligation or/and embolization represent the most common management in cases which require intervention. Case report: A young man accidentally stabbed in the neck was admitted to the emergency department with active arterial bleeding from the wound. Immediate surgical exploration revealed an isolated injury of the left vertebral artery intraosseous segment. Lesion was managed by proximal segment ligature and distal Fogarty catheter balloon-tamponade. Postoperative angiography excluded the need for further interventions. Balloon-catheter was successfully extracted after 72 hours and patient discharged neurologically intact on postoperative day 7. Fourteen months later, there are no signs of vascular or neurologic complications. Conclusion: Balloon-tamponade is a valuable technical adjunct in either temporizing or definitive management of surgically inaccessible vascular trauma.
Keywords Vertebral artery injury, penetrating neck trauma, ligature, therapeutic embolization, balloon-tamponade
Introduction Vertebral artery (VA) is among the least frequently injured major arteries, owing to its deep and protected location. For the same reasons, direct surgical repair is fraught with difficulties and may prove technically impossible. Ligation or/and embolization is the suggested management in the majority of cases which require intervention.1–3
Case report A 26-year-old man got knife stabbed in the neck in a street fight. On admission to emergency department, an isolated deep stab wound in the zone II of the left posterolateral cervical region was noticeable. Gauze sponges used for wound tamponade were bloodsoaked and ongoing arterial hemorrhage was apparent. Patient’s vital signs were stable and he showed no neurologic deficit (Glascow Coma Scale score 15/15) or signs of aerodigestive tract injuries. After the basic physical examination and volume resuscitation in the
trauma resuscitation area, the patient was immediately taken to the operating room for surgical exploration of the actively bleeding penetrating neck wound. An endotracheal tube was placed, and formal left-sided neck exploration through standard ante-sternocleidomastoid incision was performed, while digital pressure was applied to minimize the blood loss from the traumatic wound. The apex of the stab wound trajectory was found to reach just short of the carotid sheath and major anterior vascular structures were intact. Next, direct assessment of the stab wound revealed persistent arterial bleeding coming from the depths of the bony tunnel of the transverse processes of the C3–C4. Based on clinical presentation and intraoperative findings, 1 Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia 2 Faculty of Medicine, University of Belgrade, Serbia
Corresponding author: Nikola Ilic´, Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Koste Todorovic´a Street 8, 11000 Belgrade, Serbia. Email: [email protected]
Downloaded from vas.sagepub.com at University of British Columbia Library on July 11, 2015
Pejkic´ et al.
469
Figure 1. Schematic representation of the VA anatomic divisions, the location of the stab wound and the management of the VAI. Anatomically, the VA is divided into four segments (1) pars praevertebralis (V1), from its origin as the first branch of the subclavian artery until it enters the foramen transversarium of C6; (2) pars transversaria (V2), ascending in the osseous tunnel from C6 to C2 in front of the cervical nerve roots and surrounded by venous and sympathetic plexus; (3) pars atlantica (V3), from C2 to the atlantooccipital membrane through the foramen magnum and (4) pars intracranialis (V4), from the base of the skull to the basilar artery, which then joins the circle of Willis.
injury to the left VA intraosseous segment (V2) was diagnosed (Figure 1). In view of the lesion’s inaccessible location and lack of experience with direct V2 segment exposure, we proceeded with transverse supraclavicular approach to the left subclavian artery and ligation of the VA at its origin. Significant but incomplete cessation of the hemorrhage ensued, mandating additional measures for control of back bleeding. Attempts at blind clipping of the vessel proved futile, leaving tamponade as the only remaining option. Initially used Foley catheter was inadequate to seal the bleeding point, but a more delicate No. 4 Fogarty embolectomy catheter effectively achieved local hemostasis. The catheter’s free end was brought out through the stab wound and suture-fixed to the skin. On further operative exploration, cervical esophagus was found to be intact. Wounds were irrigated, suction-drained and closed in multiple layers, except for the stab wound, which was only loosely approximated. Estimated intraoperative blood loss was 1700 ml. Control conventional arch aortography was done on postoperative day
Figure 2. Postoperative arch aortogram, demonstrating complete exclusion of the left VA with contralateral vessel patent and somewhat hypoplastic.
0, after patient’s stabilization and awakening from anesthesia. It documented complete exclusion of the left VA, without contrast extravasation or other signs of residual vascular injuries (Figure 2). It also demonstrated the patency of a rather hypoplastic contralateral VA, in the presence of otherwise typical arterial anatomy. No further endovascular or open surgical interventions were deemed necessary. Balloon-catheter was extracted uneventfully after 72 hours of observation in the intensive care unit. Patient was discharged in good condition and neurologically intact on postoperative day 7. Fourteen months later, there are no clinical and duplex-ultrasound signs of central neurologic or local vascular complications.
Discussion Vertebral artery injuries (VAIs) fortunately are rare, since direct control of the V2–4 segments can be extremely challenging. In 1853, Maisonneuve successfully ligated the VA for a stab wound.4 In 1893, Matas4 published the first literature review of 42 VAIs, reporting 80% mortality.4 Radner5 reported angiography of the VA in 1947. With liberal use of arteriography, VAIs are being diagnosed more often.1,2 The management of VAIs has been revolutionized by the advances in endovascular surgery.6 Prior to these advances, surgery for VAIs carried a mortality risk of 50%.7
Downloaded from vas.sagepub.com at University of British Columbia Library on July 11, 2015
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Vascular 22(6)
Several treatment options are available for VAIs.8 For stable asymptomatic injuries detected by diagnostic imaging, expectant management, anticoagulation therapy, embolization or stenting is appropriate.9,10 Endovascular treatment may fulfill diverse roles: in acute phase or in chronic post-injury setting; as an isolated modality or a part of a ‘‘hybrid’’ management; prior to operative exploration or after surgical ‘‘damage control.’’9–11 For actively bleeding patient, immediate operative exploration is indicated.1,9 If exposure of the injured segment is uncomplicated, proximal and distal ligation is performed.1,9,10 Most vascular surgeons, however, are unfamiliar with the approaches to V2–V4. Rather than undergoing a difficult and potentially morbid dissection, the patient may be better served by proximal ligation of the V1 segment; wound tamponade and proceeding to postoperative embolization of the distal VA if needed.1,9 Gauze sponges, bone wax or oxidized cellulose can be used to compress the injured VA. An alternative is a balloon-catheter tamponade.12,13 It may be a temporizing ‘‘bridge’’ to definitive intervention, or prove sufficient adjunct in itself to arrest the back bleeding. The optimum timing of catheter removal is unclear, although 48–72 hours appears to be a safe period.13,14 Regardless of the treatment modality, it is advisable that patients with VAIs are monitored for late neurological sequelae and complications such as vertebral arteriovenous fistula and false aneurysm.9
Conclusion VAIs are being identified more frequently in both blunt and penetrating trauma, because of widespread use of diagnostic imaging. Knowledge of the surgical anatomy of this vessel and awareness of the available treatment modalities are important for successful outcome. Most VAIs can be safely treated nonoperatively or with angiographic embolization. The ongoing sophistication of endovascular techniques and devices and growing experience with their usage will further optimize this form of treatment both in acute trauma and in latepresenting arteriovenous fistulas and false aneurysms. Surgical intervention should be reserved for patients with severe active bleeding or when angiographic embolization fails. Balloon-tamponade is a valuable tool in a surgeon’s armamentarium for emergency preoperative or intraoperative management of surgically inaccessible vascular trauma, including penetrating injury of the VA. Successful management of VAIs with minimal mortality and morbidity may be expected
with a multidisciplinary approach and by adhering to selective treatment guidelines as outlined above.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Jeffery P, Immelman E and Beningfield S. A review of the management of vertebral artery injury. Eur J Vasc Endovasc Surg 1995; 10: 391–393. 2. Golueke P, Sclafani S, Phillips T, et al. Vertebral artery injury – diagnosis and management. J Trauma 1987; 27: 856–865. 3. Reid JD and Weigelt JA. Forty-three cases of vertebral artery trauma. J Trauma 1988; 28: 1007–1012. 4. Matas R. Traumatisms and traumatic aneurisms of the vertebral artery and their surgical treatment with the report of a cured case. Ann Surg 1893; 18: 477–521. 5. Radner S. Intracranial angiography via the vertebral artery: preliminary report of a new technique. Acta Radiol 1947; 28: 838–842. 6. Binkley M and Wylie EJ. A new technique for obliteration of cerebrovascular arteriovenous fistulae. Arch Surg 1973; 106: 524–527. 7. Fogelman MJ and Stewart RD. Penetrating wounds of the neck. Am J Surg 1956; 91: 581–596. 8. Yee HF, Olcott EW, Knudson M, et al. Extraluminal, transluminal, and observational treatment for vertebral artery injuries. J Trauma 1995; 39: 480–486. 9. Demetriades D, Salim A, Brown C, et al. Neck injuries. Curr Probl Surg 2007; 44: 13–85. 10. Mwipatayi BP, Jeffery P, Beningfield SJ, et al. Management of extra-cranial vertebral artery injuries. Eur J Vasc Endovasc Surg 2004; 27: 157–162. 11. Starnes BW and Arthurs ZM. Endovascular management of vascular trauma. Perspect Vasc Surg Endovasc Ther 2006; 18: 114–129. 12. Pearce CW, McCool E and Schmidt FE. Control of bleeding from cardiovascular wounds: balloon catheter tamponade. Ann Surg 1966; 163: 257–259. 13. Ball CG, Wyrzykowski AD, Nicholas JM, et al. A decade’s experience with balloon catheter tamponade for the emergency control of hemorrhage. J Trauma 2011; 70: 330–333. 14. Meier DE, Brink BE and Fry WJ. Vertebral artery trauma: acute recognition and treatment. Arch Surg 1981; 116: 236–239.
Downloaded from vas.sagepub.com at University of British Columbia Library on July 11, 2015
