Penetrating carotid injuries-A wartime experience Victor A. Jebara, MD, Georges S. Tabet, MD, Ramzi Ashoush, MD, Michel Ghossain, MD, Joseph Harb, MD, Michele Portoghese, MD, Miguel Sousa Uva, MD, and Bechir Saade, MD, Beirut, Lebanon Thirty-nine patients with penetrating carotid injuries were treated between 1975 and 1987. All were', war victims. On admission 27 (69%) had no neurologic deficit (group I), 8 (20.5%) had a mild neurologic deficit (group II), and 4 (10.5%) had a severe deficit (group III). Repair was undertaken in 38 of 39 (97.5%) patients, and carotid ligation was performed in 1 case (2.5%). Associated injuries were found in 25 (65%) patients. All patients survived. At the time of discharge all group I and II patients had a normal neurologic examination. One patient in group III recovered completely, vchereas two had significant improvement. One patient remained unchanged. We conclude that repair should be attempted in all patients with carotid injuries who are seen early ( < 120 minutes) after the accident. (J VAse SVRG 1991;14:117-20.)
Penetrating injuries to the neck involving the carotid artery continue to present a challenging problem. Although vascular repair is universally accepted to treat patients with carotid injuries and no neurologic deficit:, controversy continues as to the whether or not repair should be undertaken when neurologic problems exist. The purpose of this report is to evaluate the method of management and the results of treatment in 39 patients who sustained penetrating injuries to the carotid arteries. PATIENTS AND METHODS Between 1975 and 1987 39 patients with penetrating injuries to the carotid arteries were treated at the H6tel-Dieu de France in Beirut, Lebanon. Thirty-one were men, and eight were women. Ages ranged from 17 to 58 years (mean, 26 years). All were war victims. Carotid injuries were caused by gunshot wounds in 23 cases (59%) and by shrapnel in 16 cases
(41%). Excluded from this study were patients with brain trauma, spinal cord injuries, bilateral carotid injuries, isolated external carotid artery wounds, and periphFrom the Department of Thoracic and CardiovascularSurgery, H6tel Dieu de France, UniversityHospital, Beirut, Lebanon. Drs. Portoghese and Uva currently at the following address: H6pital Broussais, Dfipartement de Chirurgie Cardiovasculaire, 96 rue Didot, 75014 Paris, France. Reprint requests: Victor Jebara, MD, H6pital Broussais,D~partement de Chirurgie Cardio-vasculaire,96 rue Didot, 75014 Paris, France. 24/4/27973
eral nerve injuries in the neck. Patients who arrived "lifeless" (cardiac arrest or nonpalpable pulses and no blood pressure) at the emergency department were also excluded. The war in Lebanon is an urban war, and our hospital is approximately I km from the battlefront. Because of this particular location most casualties reached the emergency department within 15 minutes of injury. On arrival rapid control of airway was undertaken. Bleeding was controlled by manual compression, and shock was reversed by rapid administration of Ringer's solution until isogroup blood was available. Broad-spectrum antibiotics were routinely administered to all war casualties who arrived at the emergency department. An expeditious history and a physical examination were done in every patient to rule out associated injuries. In this series shock (blood pressure < 80 m m Hg) was present in 14 patients (35%) on admission. All patients with gunshot wounds to the neck were explored surgically. There were 21 injuries to the left side and 19 injuries to the right side. As shown in Fig. 1 the zone of the neck the most frequently involved was zone II (79%), which lies between the cricoid cartilage and the angle of the mandible. Thorough neurologic evaluation was performed before operation in every patient with suspected carotid injury. Patients were graded neurologically and classified into three groups (Table I). Twelve patients (28%) were admitted with some degree of neurologic deficit. Among the four patients in group III all were admitted with severe total profound 117
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118 Jebara et al.
Table I. Neurologic classification of patients on admission
ZONE OF THE NECK INJURY
Classification
ZONE I
n = 6 pts
'
ZONE II
n =31 pts
~~//'~,
J
Group III
No neurologic deficit Mild neurologic deficit (monoparesis, hemiparesis, hemiparesthesia, monoparestesia, transient neurologic symptoms.) Severe neurologic deficit (hemiplegia, aphasia,
27 (69.2%) 8 (20.5%)
4 (10.3%)
and/or coma)
" ~. ~ . ZONE Ill
Group I Group 11
No. patients (%)
£k')f
C-.?f
n-.---~ /
n = 2 pts
Fig. 1. Zones ofthe neck. contralateral hemiplegia, and three were comatose on admission. Preoperative angiograms were obtained in eight patients whose conditions were stable (20%). Indications for this examination are as follows: (1) neck wound in zone I or zone III; (2) suspicion of arteriovenous fistula; (3) suspicion of vertebral or subclavian artery injuries; (4) possible bilateral carotid injuries. Four-vessel studies were obtained by use of conventional selective biplane angiographies. The delay to obtain this examination ranged from 25 to 50 minutes (mean, 31 + 9 minutes). Patients were transferred to the operating room with no delay, and the time lapse between admission to the emergency department and arrival in the operating room ranged from 12 to 90 minutes (mean, 23 + 12 minutes). Surgical exposure. In 35 patients (90%) a long incision along the anterior border of the sternocleidomastoid muscle was sufficient to treat the vascular injury. However, in three cases (7.6%) a median sternotomy was required, and in one case (2.5%) subluxation of the mandible was necessary. Proximal control was always obtained before dissecting the hematoma. Anatomic lesion. The common carotid artery was injured in 28 cases (72%), and the internal carotid artery (ICA) was injured in 11 cases (28%). In seven cases (18%) an associated injury to the external carotid artery was present. The most common type of injury was tangential incomplete transection, 20 cases (51%). Complete transection or avaalsion of the vessel was noted in 15 cases (39%). Parietal contusion (blast) was found in two cases
(5%), and in another two cases (5%) an arteriovenous fistula was noted. In three (7.6%) patients no backflow was present through the distal end of the carotid artery at surgery. Two of the four patients in group III had absent backflow through the distal end, one had a very distal lesion in zone III, and one had avulsion of the carotid bifurcation. Surgical technique. General balanced anesthesia was used in all cases. Vascular repair was possible in 38 patients (97.5%). Table II shows the details of these repairs. Lateral arteriorrhaphy was performed in seven cases (18%), all injuries caused by low velocity missiles (shrapnel). Resection of an arterial segment and end-to-end anastomosis was possible in 14 cases (36%). In 13 cases (33.3%) saphenous vein graft interposition was required for carotid revascularization. Finally in four patients (10.2%) transposition of the proximal external carotid artery was used to revascularize the distal ICA. Ligation of the ICA was performed in one patient (2.5%) in whom the arterial injury was at the base of the skull. In this patient, although subluxation of the mandible was undertaken, vascular repair was not possible. Heparin (1 mg/kg) was used in 30 patients in whom no threatening associated lesions were present. In all patients in situ heparinized diluted solutions were instilled. No intralurninal shunts were used during the repair. In three patients backflow was absent because of the presence of thrombus in the distal carotid artery. Thrombectomy was performed by use of a small Fogarty catheter in two cases and by simply retracting the thrombus in one case. In all cases an excellent backflow was restored, and repair was undertaken. Associated injuries. On completion of the repair thorough exploration of the neck was performed to locate and repair associated injuries. Associated
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Penetrating carotid injuries 119
Table III. Associated injuries
Table II. Details of vascular repair Technique Lateral arteriorrhaphy Resection and end-to-end anastomosis Vein graft interposition Transposition of the proximal ECA to the distal ICA Total
No. cases (%)
Type of injury
No. patients (%)
7 (18%) 14 (36%) ~3 (33.3%) 4 (2.5%)
Jugular vein Esophagus Trachea Lungs Thyroid
21 (54%) 7 ( 18% ) 10 (25%) 8 (20%) 11 (28%)
38 (97.5%)
ECA, External carotid artery; ICA, internal carotid artery.
injuries were noted in 25 patients (65%) and are listed in Table III. In eight patients (20.5%) injuries to the lungs were present and required chest tube insertion in the emergency department. Wide debridement of all so:Pctissues was undertaken. Suction drains were placed before the wound was closed. RESULTS
All patients survived. All group I patients in whom no neurologic deficit existed before operation had an uneventful recow:ry. In group II 7/8 (87.5%) patients had no neurologic manifestations after operation. In one patient who had suffered monoparesis of his contralateral upper limb before operation, transient monoparesis of the same limb recurred i hour after the repair and regressed completely 2 to 3 hours later. Results of the neurologic examination on discharge were normal. In group III patients vascular repair was done in three cases. One patient in a coma, with profound hemiplegia and aphasia before operation had a complete recovery after the operation. In the two other patients with coma and hemiplegia, partial recovery occurred: both were awake with a normal intellect. However, relative weakness of the upper limb persisted in one, and hemiparesis persisted in the other. In the fourth patient in whom carotid ligation was performed aphasia and profound hemiplegia, which existed before operation, persisted at the time of discharge. In the three parients with distal occlusion of the carotid artery in whom embotectomy was performed complete recovery occurred in two cases (one in group II and one in group III), and partial recovery occurred in one case (group III), B-mode Doppler ultrasound studies were obtained in all patients before discharge and showed normal patency in the 38 patients in whom repair was undertaken. All patients were seen between 6 and 12 months after the repair. No new neurologic events were
noted, and B-mode Doppler studies showed normal patency in all the patients in whom repair was undertaken. DISCUSSION
Carotid injuries during wartime are rare; among 1082 arterial injuries treated during the same time period only 51 (4.796) carotid injuries were observed. This may be due to the fact that the high-velocity missiles constantly used inflict substantial damage to the adjacent structures in the head neck and upper chest leading to immediate death. 1,2 Neck injuries caused by gunshot wounds should always be explored. 3-~5 Immediate control of the airway is of prime importance because of (1) expanding cervical or intraoral hematomas, (2) intratracheal bleeding, and (3) neurologic deficit. 7"8 Shock when present should be actively corrected while the patient is rapidly being assessed and prepared for transfer to the operating room. In patients whose condition is stable preoperative angiograms may provide valuable information in zone I and zone III injuries (Fig. 1). s'6'8-n Patients whose condition is unstable and patients with central neurologic deficit are additionally harmed by prolonged ischemic time and additional blood loss. The management of a patient with no preoperative neurologic deficit is well defined? -14 When technically feasible the injured vessel should be primarily repaired as soon as possible. The only exception is the patient in whom there is a complete obstruction of blood flow in the distal segment of the vessel at the time of surgery. Although Snyder et al.s reported that restoration of flow may cause embolization, others advocate gentle extraction of the clot using a small Fogarty catheter or by simply retracting the fresh thrombus from the vessel. 8"~s'16 We have used this technique in three patients in whom satisfactory results were obtained. Controversy continues as to the method of choice to treat patients with carotid injuries and neurologic deficit. Brown et al.,7 Ledgerwood et al.,17 and Robbs et al.~8 reported neurologic recovery in several comatose patients after
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120 Jebara et al.
repair; therefore carotid ligation cannot be uniformly recommended for all comatose patients. Moreover, excellent results have been reported after revascularization in patients with mild neurologic deficits. 713 In our series all eight patients with a mild neurologic deficit in w h o m repair was accomplished had a normal neurologic examination on discharge. In one comatose patient who was revascularized 70 minutes after the accident total recovery was obtained. Significant improvement was obtained in the two other patients who were admitted with severe deficit and who were revascularized. In the only patient in w h o m ligation was necessary for technical considerations, the preoperative neurologic deficit remained unchanged. The type of the arterial repair depends on the nature of the arterial injury. Although arteriorrhaphy is the most common technique in civilian practice, 5'7"8 in this series arteriorrhaphy was used in only 18% of the cases. This is due to the fact that high-velocity missiles cause extensive wall contusions and burns requiring adequate debridement of both arterial edges before repair. In spite of the fact that the use of polytetrafluoroethylene had been advocated by several knowledgeable students of the subject, 6-8 autologous saphenous veins were the only grafts used in this series, and we continue to believe that they constitute the graft of choice in these situations. The need for an intraluminal shunt during arterial repair constitutes another area of controversy. N o intraluminal shunts were used in our series. Anticoagulation is indicated when no serious associated injuries exist; otherwise diluted heparin solutions can be injected locally. The time lapse between injury and the repair is important. In our series because of factors described early, time lapse between injury and repair was short and ranged from 50 to 150 minutes. In group II and III patients the delay was always less than 90 minutes. In conclusion, arterial repair is always recommended in patients with carotid injuries. Patients with no or mild neurologic deficit will have more favorable results than patients with severe neurologic deficit. Prograde flow if present should always be maintained, and when feasible occluded arteries should be carefully opened. Arterial ligation is
indicated when repair is impossible or when the patient has a severe concomitant cerebral injury. We thank Drs. J. N. Fabiani and C. Acar w h o reviewed this paper. We are also indebted to Mrs. Patricia Retaggi for preparation of this manuscript. REFERENCES 1. Jebara VA, Saade B. Penetrating wounds to the heart: a wartime experience. Ann Thorac Surg 1989;47:250-3. 2. Jebara VA, Saade B. Causalgia: a wartime experience- report of 20 treated cases. J Trauma 1987;27:519-24. 3. Obeid FN, Haddad GS, Horst HN, et al. A critical reappraisal of a mandatory exploration policy of penetrating wounds of the neck. Surg Gynecol Obstet 1985;160:517-21. 4. Richardson JD, Vitale GC, Flint LM. Penetrating arterial trauma: analysis of missed vascular injuries. Arch Surg 1987;122:678-82. 5. Snyder WH, Thai ER, Perry MO. Peripheral and abdominal vascular injuries. In: Rutherford RB, ed. Vascular surgery. 2nd ed. Philadelphia: WB Saunders, 1984:460-500. 6. Thai ER. Injury to the neck. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma, Connecticut: Appleton and Lange, 1988:301-313. 7. Brown MF, Graham JIM, Feliciano DV, et al. Carotid artery injuries. Am J Surg 1982;144:748-53. 8. Pearce WH, Whitehill TA. Carotid and vertebral arterial injuries. Surg Clin North Am 1988;68:705-23. 9. Fry RE, Fry WJ. Extracranial carotid artery injuries. Surgery 1980;88:581-6. 10. Fry WJ, Fry RE. Management of carotid artery injury. In: Bergan JL Yao JST, eds.: Vascular surgical emergencies. Orlando: Grune & Stratton, 1987:153-62. 11. Liekweg WG, Greenfield LJ. Management of penetrating carotid arterial injury. Am Surg 1978;188:587-92. 12. Rubio PA, Ruel JG, Beall AC, et al. Acute carotid artery injury: 25 years' experience. J Trauma 1974;14:967-73. 13. Unger SW, Tucker WS, Mrdeza MA, et al. Carotid arterial trauma. Surgery 1980;87:477-87. 14. Karlin RM, Marks C. Extracranial carotid artery injury: current surgical management. Am J Surg 1983;27:225-7. 15. Thompson JE, Austin DJ, Patman RD. Endarterectomy of the totally occluded carotid artery for stroke. Arch Surg 1967;95:791-801. 16. Meyer FB, Piepgras DG, Sandok BA, et aL Emergency carotid endarterectomy in patients with acute carotid occlusion and profound neurologic deficits. Ann Surg 1986;203:82-9. 17. Ledgerwood AM, Mullins RJ, Lucas CE. Primary repair versus ligation for carotid artery injuries. Arch Surg 1980; 115:488-93. 18. Robbs JV, Human RR, Rajaruthnam P, et al. Neurologic deficit and injuries involving the neck arteries. Br J Surg 1983;70:220-2.
Submitted Sept. 26, 1990; accepted Jan. 15, 1991.