Introduction

One of the most serious consequences of penetrating trauma to the neck is catastrophic vascular injury. The mortality rate in such injuries approaches 20%₁₂ besides the significant associated morbidity. These patients are by and large rare but in war torn areas, some patients do manage to reach health care centers and present a really challenging problem. There is a record of Ambrose Pare successfully ligating the carotid artery in 1552 thereby saving the life of the victim of the duel₃ .Two hundred years ago, successful ligation of the carotid artery of a sailor was recorded by Fleming[[[4.]]] This method continued as the primary surgical technique through World War I ₅. Definitive fine suture repair of the injured carotid artery had to await technical refinements during the Korean₆ and Vietnam Wars₇. Unger et al ₈ in 1980 presented an important study of 722 collected cases of carotid arterial trauma and further established the superiority of arterial repair over ligation.

This report details our experience in managing the extra cranial carotid artery injuries at the Department of Cardiovascular and Thoracic Surgery of Sheri Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India. This is the only referral health institute in this valley catering the needs of a population of more than 10 million .These injuries were practically unknown in this part of world but due to unfortunate armed conflict going on since 1990 , the entire scenario has changed here and 37cases have reported to our center in last 26 years.

Materials And Methods

A retrospective review of all patients treated in the Department of Cardiovascular and Thoracic Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India from Jan.1990 and Dec .2007, for penetrating injuries of the neck was performed and the subset of patients with injuries of common or internal carotid arteries was identified. All the data was retrieved from the stored databank of the Medical Records Department.

Excluded from this study were patients with brain trauma, spinal cord injuries, bilateral carotid injuries, isolated external carotid artery wounds or the unfortunate ones who arrived dead to the accident and emergency department.

As per the records, on arrival at the Accident & Emergency Department, the initial resuscitation was conducted along Advanced Trauma Life Support principles₉- the rapid control of airway with inline stabilization of the cervical spine being the first concern. Bleeding was controlled by manual compression, and shock was reversed by rapid administration of Ringer’s lactate until properly grouped and cross matched blood was available. An expeditious examination was done in every case to rule out associated injuries.

The lag between the time of injury and the time of arrival at the Accident and Emergency Department was on the average 20 minutes and most of the injuries had occurred within the perimeter of 6 miles of this hospital. Patients were transferred to the adjoining Emergency Operation Theatre with the least possible delay and the time lapse between the admission to the Accident & Emergency Department and arrival in the Operation Theatre ranged from 6 minutes to 50 minutes (mean 17 minutes). The injured vessel was exposed by a long incision along the anterior border of the sternomastoid. Proximal and distal control was attained and injuries managed as the case demanded.. On completion of the repair thorough exploration of the neck was performed to locate and repair associated injuries. B- Mode Doppler ultrasound studies were performed in all the surviving patients and normal patency was documented in all the patients. 2 patients were lost to follow up after discharge and rest of patients were followed up in Outpatients department for periods up to 18 months after discharge and B- mode Doppler studies repeated at 3 monthly intervals revealed normal vessel patency and clinically also, no neurodeficits were observed.

Results

There were a total of 37 patients, 28 being males and 9 being females, ranging in age from 16 to 68 years (mean age 26 years). 23 patients had right sided injuries and left side was injured in the rest of 14 cases. The mechanism of injury in our patients is shown in Table 1.

Figure 1

Table 1: Mechanism of injury

Thorough neurological evaluation was performed before operation in every patient and patients were graded neurologically and classified into four groups as shown in Table 2:

Figure 2

Table 2 : Presentation, management & outcome of carotid injuries

The anatomic locations of the wounds causing carotid artery injuries were as shown in table 3:

Figure 3

Table 3: Location of wounds

The anatomic location of the injured vessels is depicted in Table 4:

Figure 4

Table 4: Anatomic location of injured vessels

On exploration, it was found that 23 patients had complete transactions and rest of the 14 patients had incomplete transactions of the carotid arteries. The associated injuries detected during exploration are as shown in Table 5.

Figure 5

Table 5: Associated injuries

As is clear from Table 2, out of 37 patients of carotid injuries, 34 (92%) patients survived. In Group 1(without neurodeficit), one patient died as a result of missed esophageal perforation during initial exploration and rest of the patients recovered uneventfully. In Group 2 (mild neurodeficit), all patients survived but neurodeficit showed improvement in 12 (84%) out of 16 patients. In Group 3, (severe neurodeficit but not comatose), all the 5 patients showed improvement in neurodeficit with 3 (60%) showing complete recovery and in rest of the 2 patients, there remained mild disability. In Group 4 (comatose) , out of the 4 patients , two died within 48 hours of injury but another 2 (50%) survived, with one of the patients leaving with mild disability .

Discussion

Penetrating carotid injuries rarely reach a specialized healthcare facility. In 17 years, we received only 37 patients which form only about 1.8 % of vascular injuries treated during the same period .This is primarily due to the fact that the modern firearms inflict substantial damage to the adjacent structures in the head, neck and chest and lead to immediate death₁₀. Besides Kashmir is a hilly sub Himalayan valley with meager peripheral healthcare and patient transport facilities resulting in death of the patient before reaching our department .The patients who managed to reach the hospital were injured within the perimeter of 7 miles from this hospital. In such patients, as have been emphasized in other studies, the immediate control of airway is of prime importance as airway can be compromised with fatal consequences because of expanding cervical intraoral hematoma, neurological deficit like coma and intratracheal bleeding ₁₀.

After control of airway, ensuring adequate breathing is important as due to concomitant injury to lungs, breathing may be hampered₉. We had two patients who had pneumothorax impairing breathing which required emergency tube thoracostomy as a part of resuscitation. Shock when present should be actively corrected and the neurodeficit clearly defined while the patient is being prepared for transfer to operating room.

Due to the fact all the patients reported with deep bleeding wounds, we resorted to urgent surgical exploration in all our cases and managed the carotid injuries as given in the Table2. It is clear from the literature also₁₁ that the patients presenting with hemodynamic instability, serious bleeding or hematoma need immediate transfer to operating room for wound exploration and needful.

In all the patients of carotid injuries who reported with no neurodeficit or deficit but not in coma, vascular continuity was restored. Out of 4 patients who reported with coma , in 3 vascular continuity was restored but in one patient , who had gun shot injury to Zone III , the carotid ligation was resorted to, due to technical difficulty. In literature, in patients of penetrating carotid injuries without coma, the policy of restoration of carotid vascular continuity is clearly defined_{10121314151617}. However in comatose patients, in literature there are workers who found no difference in outcome of patients after carotid ligation or carotid repair₁₄. Various other workers found significant improvement in outcome after restoration of vascular flow in injured carotids₁₈ . Some other workers question the role of revascularization in presence of severe neurodeficits due to possibility of postrevascularisation hemorrhagic infarction₁₉. Some series recommend the vascular repair only if patient has a score of 8 and above on Glasgow Coma Scale ₂₀. Another opinion in literature recommends the carotid repair only if prograde flow is maintained ₁₀. In all of our comatosed patients, prograde flow was present as per the operation notes .Out of our 4 comatosed patients, 2 succumbed within 48 hours of injury and one of them had undergone carotid ligation and the in other one , carotid vessel had been repaired by vein graft. The 3rd patient survived but with severe residual neurodeficit in form of hemiplegia and aphasia and the 4[[[th]]] patient hand only mild hemi paresis after 3 years of follow-up.

The type of repair required to restore vascular continuity depends on the mechanism of injury. In injuries caused by the civilian trauma, arterioraphhy is the most common technique. However in our series, resection of damaged ends of carotid artery with anastomosis was the most common method followed by vein graft interposition as is true of other studies from war zones . This is primarily due to extensive vessel wall contusions and burns caused by high velocity missiles requiring adequate debridement of both arterial edges before repair₁₀.

One of the patients in Group 1 (without neurodeficit) died, as a result of missed esophageal perforation during the exploration of the neck wound. This missed esophageal injury led to mediastinitis, septicemia and ultimately death on 12[[[th]]] postoperative day. This was an absolutely preventable death and the patient should have left the hospital without any deficit. Such complications are mentioned in literature also and give a very strong message that in case of carotid injuries, besides the management of vascular injury, the search for injuries to other structures has to be meticulous after careful mapping of the knife or missile track₁₈ .

Conclusions

All patients of with carotid injuries must be assessed as per the Advanced Trauma Life Support protocols and in patients presenting with significant bleeding, hematoma or hemodynamic instability with no neurodeficits or deficit short of coma, vascular continuity must be restored urgently and care must be taken to identify and manage the injuries to adjoining organs. In comatosed patients, if prograde flow is maintained, than vascular repair must be attempted and ligation must be resorted to only if repair is technically difficult.

Correspondence to

Dr Sajad Ahmad Salati MBBS, MS, MRCS (Glasgow) Assistant Consultant Surgical Specialties, King Fahad Medical City, Riyadh, KSA Email: docsajad@yahoo.co.in Mob: 00966530435652