Introduction

Carotid artery injuries have the potential of creating serious morbidities and mortalities. Their potential of creating mortality and morbidity can develop between minutes and hours. The most important part of these injuries which have very serious outcomes is their having necessity for emergent surgical intervention.

Carotid artery injuries reveal as a specific and relatively small group of vascular trauma. Hemorrhage from vessels of this diameter and flow (10 % of cardiac output) has predominantly a fatal end or shows severe neurological sequelae. Cut and stab wounds represent the majority of carotid injuries, often associated with venous damage(₁).

Central Neurologic deficit resulting primarily or secondarily from surgery is a major concern in patients with extracranial arteriel trauma, injury to the brachiocephalic, carotid, or vertebral arteries. Associated combined stroke and mortality rates vary between %5-%50(₂,₃,₄).

This study reviews a recent 8 year experience with 18 penetrating carotid artery injuries and focuses on the surgical managemet of the injuries and the neurological outcome of these injuries.

Patients And Methods

Patients who have come to the emergency room of our hospital between March 1998 and February 2005 at ?zmir Ataturk Training and Research Hospital (Department Of Cardiovascular Surgery) and taken to emergent surgical operation were included retrospectively in the study. Injuries were classified according to anatomic location (artery injury), zone of penetration, mechanism of injury, pathologic findings (complete transection, partial transaction, false aneurysm, arteriovenouse fistula), and patency versus occlusion of the injured vessel. Heamodynamic instability at admission (systolic blood pressure≤70 mm Hg), airway compromise (intrinsic laryngotracheal injury or extrinsic compression requiring intubation or tracheostomy), mediastinal hematoma, and associated injuries were recorded as present or absent.

All unstable patients were resuscitated along Advanced Trauma Life Support guidelines. Patients with active uncontrolled bleeding and/or haemodynamic instability with little or no response to resuscitation were taken to surgery immediately. Stable patients as well as those who stabilized after simple resuscitation and had evidence of a vascular injury (bruit, large haematoma), proximity lesions and transcervical gunshot wounds underwent routine aortic arch and four vessel neck angiography. The Glasgow Coma Score (GCS), preoperative systolic blood pressure (SBP) and gross focal neurological signs of central origin of each patient were recorded prior to surgical intervention. All of the patients were evaluated by Neurologist preoperative and post operative period. Computerized axial tomography (CAT) scan of the brain was performed in stable patients who had been in coma for more than four hours duration and/or who had focal neurological signs. Injuries to the Common carotid artery (CCA) and internal carotid artery (ICA) detected at emergency exploration were repaired-even in the presence of coma and /or neurological deficit. Similarly, injuries to the CCA and ICA discovered with angiography without the disruption of distal flow were repaired. Carotids arterial Doppler ultrasonography was applied to 5 patients whose conditions were stable and to 7 of the patients' angiography of selective arcus aorta and its branches was applied (Figure 1).

Figure 1

Figure 1

Conventional neck and computerized thorax tomography was performed to patients who had only mediastinal hematoma. While the patients were under general anesthesia, from the medial side longitudinal incision of sternocleidomastoid muscle, extra cranial carotid artery was reached.

Results

15 (%82.5) of the patients were male and 3(%16.5) of they were female and the age range was 16-54 (Average age: 29.7 years) (Table I).

Figure 2

Table 1

Mortality occurred in one of patients during the 25th postoperative day as a result of multiple organ injury and sepsis (etiologic agent was founded pseudomonas aeruginosa in the blood sample) and another patient has been transferred to neurology and physical treatment clinics as a result of right hemiplegia during the 5th postoperative day. The common carotid artery was the most commonly injured vessel. Have been summarized injuries arteries in the table II.

Figure 3

Table 2: Neurologic Results were detected after early postoperative period.

Injury to the brachiocephalic artery was associated with the highest mortality but the lowest stroke rate, whereas internal carotid artery injury resulted in death or stroke in a high proportion of patients. Similar mortality and stroke rates were encountered for both stab and gunshot wounds. Patients with complete arterial transection fared poorer than did those with partial transection. Common carotid –jugular fistulae were described in 2 patients.

Six of patients were taken to the surgery room as a result of abnormal general condition and hypovolemic preschock and in only 1 of them gott shunt was used as a result of small systolic pressure's being under 50 mmHg(%5.5). Stroke occurred in 3 (%16.5) patients. Stroke was occurred in 2 patients in zone III (%11), and 1 patient (%5.5) in zone I (Table4). Airway compromise was present in 3 patients (%16.5). Mortality was marginally higher in these patients than in those with an intact airway.

One or more additional structures were injured in 9 patients (%49.5). Four of our patients also had Vena jugularis internal injury and primer repair was applied to these four patients. Hemothorax or pneumothorax (n=2), peripheral nerve injury (n=2), upper aerodigestive tract injury (n=3) injury to other arteries (n=3), and injury to the thoracic duct (n=1). The only associated injury that negatively influenced outcome was injury to the upper aero digestive tract.

Preoperative angiography was performed in 7 of the 12 who were hemodynamically stable at admission. All but 6 of 18 patients who were hemodynamiccally unstable at admission could be resuscitated sufficiently that Neurologic evaluation could be performed. Neurologic deficits were all apparent immediately postoperatively. Arteries repaired (11, primary repair; 4, expanded polytetrafluoroethylene (ePTFE) 2 Vena saphena magna) and one patient end to end anastomosis.

Of 9 surviving patients with defined preoperative neurologic deficit undergoing repair, 7 improved, with return to normal neurologic function in 5 patients. Only 2 patients with preoperative neurologic deficit survived ligation, and neither demonstrated improvement in neurologic status. (Table 2 and 3).

Figure 4

Table 3: Neurologic Results were folow up end of the 3.months.

Mean cross-clamping period was 8 minutes (4-18 min.). Haemovac drainage system was used in all cases. It was observed that two of our patients had arteriovenous fistula and interestingly there was no external bleeding symptom and also hematoma was on minimum level. They were taken to surgery as a result of hearing a murmur during physical examination and osculation. Average reaching to the hospital time was 45 min (20-120 min.).

Discussion

As carotid artery injuries can create very serious mortality and morbidity, these injuries should be intervened immediately and should be followed seriously during the postoperative period. Although arterial Doppler ultrasonography can provide useful information in these kinds of injuries standard method is conventional angiography of aorta and its branches (₅). However, patients who do not have a stable condition, who have hematoma and serious bleeding should be immediately taken into surgery (₆). As these patients who have been immediately taken into surgery are from the young group, arterial wholeness, which will be provided without losing time during the surgery, will give satisfying results. Besides, it is useful pointing out the importance of duration of time between the injury and operation time. We think that the less the duration of this period is the more the results will be better.

When the vascular injuries at the neck area are as a result of cutter equipments, injury along the cut line could take place; at the injuries with high energy guns the injuries could take place with the blast effect. In the blunt vascular injuries not having surface occurrence of the injury makes examination and treatment harder. In these kinds of blunt traumas, it should be considered that there could be a probability of having neck and spinal injuries (₇).

In cervical injuries, it will be helpful to investigate the neck area in three parts. Manson and all have made this discrimination: Zone 1; Base of the neck that is 1 cm above and under of Clavicle and thoracic area. Zone 2; Area that is between 1 cm above Clavicle and mandibular angle. Zone 3; Area between base of the skull and mandibular angle (₈).

At the injuries that are round the neck area, routine surgical exploration is performed in some medical centers and some surgeons prefer elective surgery with arteriography. According to our view, the most appropriate method is applying surgical exploration without further investigation for cases that have active bleeding and applying elective surgery after further investigation for cases that have stable condition.

Sekharan and colleagues indicate that only physical examination is adequate for diagnosis and surgical planning for injuries around zone 2 (₆). However, in some of our patients all of our physical examination findings, except some unimportant hematoma, were normal. Preoperative angiography can be performed to eliminate the need for operation and to determine the lesion that could not be identified with clinic examination. Liu et al described a case who was 20 year old male and victim of internal carotid artery injury induced by motorcycle accident, initially presented with a clear consciousness and had normal computed tomography (CT) of brain (₉). Two days after injury, the patient suffered from left hemiplegia and coma. And then right internal carotid artery injured was founded.

Montalvo and colleagues have obtained diagnostic results with colored doppler ultrasonography that are identical to angiography; the results are especially identical at carotid artery injuries at zone 2(₅). They also indicate that ultrasonography has advantages in terms of coast and hospitalization period and being non invasive. We think that conventional angiography is more useful as standard diagnostic method. Because it is very important to clearly indicate at mediastinal zone which artery causes patients vascular pathology. Munera and colleagues indicated that diagnosis of carotid and vertebral artery injuries can be obtained with high sensitivity using helical computerized tomography and they also indicated that compared to angiography this method is faster, cheaper and non invasive (₁₀).

When vascular injury is suspected in patients having healthy general condition, these patients can be taken under elective surgery after routine examinations and arterial and venous Doppler ultrasonography, on the other hand patients whose general condition is not good and who have active bleeding and/or big hematoma, arterial-venous fistula should be taken to surgery immediately (₁₁). Arterial reconstruction provides the best outcome for all penetrating carotid artery injuries except nonocclusive limited intimal injuries that require only observation(₁₂).

Certain arterial injuries such as small intimal defects, small pseudoaneurysms, minör dissection with intact distal flow; and high carotid-jugular fistulas can be treated with conservation, endovascular stenting and/or arteriographic embolization(₁₃,₁₄). We were not include this study that performed endovascular,and /or arteriographic embolization. We focused surgical prosedure in the carotid artery injuries.

The safety of modern shunts with carotid endarterectomy surgery is well established.however, the role of shunting in penetrating carotid trauma remains controversial. Some authors have found that shunting probably does not influence outcome(₁₅,₁₆). We used shunts only one patients who were systolic arteriel pressure under 50 mmhg.

As the gunfire injury may not proceed linearly all of the organs having injury probability should be investigated. We think that procedure should be completed as quickly as possible and it will be helpful to apply the primer fixation of the artery.

The number of postoperative surgical and neurological complications was moderate. Most patients with stab or gunshot wounds to the common or internal carotid artery in cervical zone II (sternal notch to angle of mandible) are symptomatic with external or intraoral hemorrhage, a rapidly expanding hematoma, evidence of a carotid-jugular arteriovenous fistula at an obvious site, or loss of the carotid pulse with a neurologic deficit. Immediate airway control and arterial repair are indicated in such patients. Other patients present with stab or gunshot wounds with proximity only to the carotid sheath, a stable hematoma, unknown level of a carotid-jugular arteriovenous fistula, or loss of the carotid pulse without a neurologic deficit. Diagnostic options in this latter group include duplex ultrasound, color duplex imaging, and standard arteriography, while the role of CT or MRI angiography in evaluating patients with penetrating cervical wounds is unclear at this time. Certain arterial injuries discovered on diagnostic tests are currently managed with observation, endovascular stenting (for intimal or wall irregularities), and arteriographic embolization (for small pseudoaneurysms or high carotid-jugular fistulas). Patients with penetrating cervical wounds, preoperative neurologic deficits, and immediate transport to the trauma center should have repair rather than other surgical technical of the injured carotid artery.

Correspondence to

Doç. Dr. Ufuk YETKIN 1379 Sok. No: 9,Burç Apt. D: 13 35220, Alsancak – IZMIR / TURKEY Tel: +90 505 3124906 Fax: +90 232 2434848 e-mail: ufuk_yetkin@yahoo.fr