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Eur J Trauma Emerg Surg (2011) 37:429–437 DOI 10.1007/s00068-011-0132-3

REVIEW ARTICLE

Penetrating carotid : uncommon complex and lethal injuries

J. A. Asensio • T. Vu • F. N. Mazzini • F. Herrerias • G. D. Pust • J. Sciarretta • J. Chandler • J. M. Verde • P. Menendez • J. M. Sanchez • P. Petrone • C. Marini

Received: 16 June 2011 / Accepted: 19 June 2011 / Published online: 15 July 2011 Ó Springer-Verlag 2011

Abstract Carotid arterial injuries are the most difficult or occasionally via surgical cricothyroidotomy. Establish- and certainly the most immediately life-threatening injuries ing a surgical airway can be a difficult procedure given the found in penetrating trauma. Their propensity to bleed distortion of anatomic landmarks caused by hemorrhage. It actively and potentially occludes the airway and makes is also fraught with danger, as the incision may release the surgical intervention very challenging. Their potential for contained hematoma, resulting in torrential bleeding that causing fatal neurological outcomes demands that trauma can obscure the operative site and place the patient at risk surgeons exercise excellent judgment in the approach to for aspiration. These injuries incur high morbidity and their definitive management. The purpose of this article is mortality. Their neurologic sequelae can be devastating. to review the diagnosis and management of these injuries. Fortunately they are not common.

Keywords Vascular Á Trauma Historical perspective

Introduction The first documented case of the treatment of a cervical vascular injury is attributed to the French surgeon Ambrose Carotid arterial injuries are the most difficult and certainly Pare (1510–1590) [1], who was able to ligate the lacerated the most immediate life-threatening injuries found in carotid artery and a jugular of a wounded soldier. The penetrating neck trauma. Their propensity to bleed actively patient’s survival was complicated by the development of a and potentially occlude the airway makes surgical inter- profound neurological defect consisting of aphasia and left- vention very challenging. Their potential to cause fatal sided hemiplegia. In 1803, Fleming ligated the lacerated neurological outcomes demands that trauma surgeons common carotid artery of a sailor with a successful out- exercise excellent judgment in the approach to their come. In 1811 [1], Abernathy ligated the lacerated left definitive management (see Fig. 1). Frequently, the rapid- common and internal carotid in a patient that had ity with which these injuries bleed causes early airway been gored by a bull. This patient developed profound occlusion from the extensive hemorrhage contained within hemiplegia and subsequently died from this injury. During the fascial planes of the neck, often necessitating the World War I, Makins reported 128 patients among whom immediate achievement of an airway either by intubation 30% underwent carotid artery ligation with subsequent neurological deficits. These complications prompted a conservative approach to the treatment of the acutely J. A. Asensio (&) Á T. Vu Á F. N. Mazzini Á F. Herrerias Á G. D. Pust Á J. Sciarretta Á J. Chandler Á J. M. Verde Á injured carotid arteries, reserving operative intervention for P. Menendez Á J. M. Sanchez Á P. Petrone Á C. Marini complications. During World War II, Lawrence reported Division of Trauma Surgery and Surgical Critical Care, only two attempts at repair of a carotid artery injury, while Dewitt-Daughtry Family Department of Surgery, University only four repairs were reported from the Korean conflict by of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL 33136-1018, USA Hughes. Both Cohen and Rich reported 50 carotid artery e-mail: [email protected] injuries from the Vietnam conflict, giving an incidence of 123 430 J. A. Asensio et al.

and neck trauma, and that carotid artery injuries account for 5–10% of all arterial injuries. In 1970, Rich reported an incidence of 5% in his hallmark series of 1,000 arterial injuries reported from Vietnam. Penetrating mechanisms of injury are responsible for the vast majority of carotid artery injuries. Gunshot wounds, rarely shotgun wounds, and occasionally lacerations by jagged and cutting objects such as glass often produce these injuries.

Anatomy

The anatomy of the neck is unique. In no other part of the Fig. 1 High-velocity impacted in the common body are there so many vital structures located within such carotid artery below the bifurcation tight confines; nor is there any other area of the body that includes representative structures of so many different 5%. Thirty-eight were common injuries and 12 were systems—the cardiovascular, respiratory, digestive, endo- injuries. It was not until the 1970s crine, and central nervous systems. All neck structures are that significant civilian series emerged in the literature, invested by two fascial layers: the superficial that incorporating knowledge derived from military experiences encompasses the platysma, and the that (see Table 1). encompasses the sternocleidomastoid muscle; the pretra- cheal fascia attaches to the and cricoid cartilages and blends with the pericardium in the thoracic cavity. The Incidence and mechanism of injury prevertebral fascia encompasses the prevertebral muscles and blends with the axillary sheath, which houses the Carotid artery injuries are estimated to be present in 6–13% subclavian vessels. The is formed by all [1–3] of all penetrating injuries to the neck. Asensio [1] has three components of the deep cervical fascia. Such tight reported an incidence of 11–13% carotid arterial injuries fascial compartmentalization of the neck structures limits for all penetrating neck injuries. According to Demetriades external bleeding from vascular injuries, thus minimizing [2, 3], carotid artery injuries are present in 6% of all the chance of exsanguination [1]. penetrating injuries to the neck and account for 22% of all The neck is divided into three anatomic zones; zone I cervical vascular injuries. Weaver [4] estimates that cer- extends from the to the , zone II vical vessels are involved in 25% of all penetrating head extends from the cricoid to the angle of the mandible, and

Table 1 Anatomic locations of carotid arterial injuries Authors (year) No. of patients No. of injuries CC IC EC

Cohen et al. (1970) [7]858566190 Bradley (1973) [8]24261772 Rubio et al. (1974) [9]7281611010 Thal et al. (1974) [10]606048120 Liekweg et al. (1978) [17]1819172 0 Ledgerwood et al. (1980) [11]333323100 Unger et al. (1980) [12] 564 564 415 49 0 Brown et al. (1982) [13] 129 143 103 20 20 Demetriades et al. (1989) [14] 124 124 104 10 10 Ditmars et al. (1997) [18] 13 15 0 11 4 Mittal et al. (2000) [19]1818972 Navasaria et al. (2002) [20]3234244 6 Ferguson et al. (2005) [21]6 6 0 3 3 Total 1,160 1,189 870 (73%) 262 (22%) 57 (5%) CC common carotid, IC internal carotid, EC external carotid

123 Penetrating carotid artery 431 zone III extends from the angle of the mandible to the base has been greatly facilitated by the reliability of the avail- of the skull. These zones are used to describe the location able diagnostic tools. Some surgeons believe that physical of injury in the neck. The origin of the common carotid examination is a very safe and reliable mode for detecting arteries differs on the two sides. On the left, the common significant vascular injuries requiring treatment. Demetri- carotid artery originates from the aortic arch, whereas the ades [2, 3], in a prospective study of 335 patients with right common carotid artery arises from the brachioce- penetrating neck injuries, evaluated vascular structures on phalic artery. However, the anatomy in the neck is the the basis of a detailed written protocol and reduced the same. incidence of angiography. Demetriades and Asensio [1–3], The common carotid artery originates in the neck behind in another prospective study consisting of 223 patients who the . Each artery courses obliquely underwent a clinical examination according to a written upward from beneath this joint and terminates at the level protocol, reported that 47 patients did not undergo angio- of the upper border of the , where it graphic evaluation because of life-threatening problems divides into the external and internal carotid arteries. The that required an emergency operation (19 patients) or common carotid artery is the largest artery in the neck. It because they refused angiography (28 patients). The has a widened portion known as the carotid bulb at its remaining 176 patients underwent four-vessel angiography. bifurcation, which is innervated by the nerves of Hering, a Abnormal angiographic findings were identified in 34 of branch of the glossopharyngeal nerve. The carotid bulb these 176 patients (19.3%), but only 14 of the patients contains a specialized sensory organ, known as the carotid (8.0%) required treatment of the vascular lesions. The body, which is a vascular chemoreceptor located at the remaining 20 patients were successfully managed nonop- bifurcation on the posteromedial side. The common carotid eratively. Altogether 160 patients (71.7%) had no clinical artery, internal , and are contained signs suggestive of vascular injury, and none of them within the carotid sheath. There are no branches from the required an operation or any other form of treatment common carotid artery prior to its bifurcation. The external (specificity and NPV were both 100%). Angiography was carotid artery is the smaller of the two terminal branches of performed on 127 of these 160 patients, and another five the common carotid artery, and extends from the upper patients were operated on because of other associated portion of the thyroid cartilage to the angle of the mandi- injuries requiring surgery. None of the five patients who ble. The internal carotid artery ascends into the skull, underwent neck exploration had vascular injuries. Angi- piercing the skull via the foramen lacerum as it passes into ography revealed 11 vascular injuries (8.3%), none of the carotid canal of the temporal bone from its origin at the which required any type of treatment. This study supports upper border of the thyroid cartilage, and terminating the use of physical examination to exclude patients intracranially by dividing into the anterior and middle requiring four-vessel angiography. . Although angiography remains the gold standard for the At the upper border of zone II, surgeons often encounter evaluation and diagnosis of cervical vascular injury, it the common facial vein, which is often ligated or retracted should be reserved for injuries to zones I and III and for when exposing carotid artery injuries. The hypoglossal confirming injuries detected by color flow Doppler (CFD), nerve crosses anterior to the internal carotid artery at the which has become the technique of choice for the inves- upper borders of zone II of the neck. The marginal man- tigation of zone II injuries. Numerous studies by several dibular branch of the facial nerve is located directly under authors consistently report sensitivities, specificities and the inferior border of the mandible. accuracies of greater than 95% for CFD in establishing the diagnosis of carotid arterial injuries. We currently recommend a thorough and meticulous Diagnosis physical examination for all patients suspected of harbor- ing carotid artery injuries. Those that present with clinical Physical findings serving as reliable indicators of the signs associated with cervical vascular injuries or that are presence of injuries to the vascular structures in the neck hemodynamically unstable should be immediately trans- include pulsatile or expanding hematomas, the absence of a ported to the operating room. Patients that are hemody- , the presence of bruits, and active external hemor- namically stable may be clinically observed or examined rhage. A global neurologic defect associated with aphasia utilizing CFD or angiography. In 1996, Nemzek et al. or hemiplegia likewise signals an underlying vascular suggested that CT angiography (CTA) could replace rou- injury. However, a thorough neurologic examination often tine conventional angiography as a screening test in cannot be performed, as many patients are admitted in trauma. Munera et al. [22], in a study comparing CTA and and are thus unable to cooperate with such an angiography in the diagnosis of penetrating trauma to the examination. Establishing a diagnosis of vascular injury arteries of the neck, demonstrated favorable results for 123 432 J. A. Asensio et al.

CTA with 90% sensitivity, 100% specificity, positive pre- draped separately, should a segment of a saphenous vein be dictive value of 100% and negative predictive value of needed as an autogenous graft for the repair of carotid 98% [23]. Any injuries requiring further definition should injuries. be investigated with angiography. Angiography should be The neck is explored though a standard incision in the reserved for the evaluation of patients who are hemody- anterior border of the sternocleidomastoid muscle extend- namically stable but may be harboring injuries to vascular ing from the angle of the mandible to the sternoclavicular structures in zones I and III [1–3]. junction (see Fig. 2). An extension of the incision towards the origin of the sternocleidomastoid may be made. For injuries located in zone III, additional exposure may be Anatomic location of injury obtained through division of the . Access to the internal carotid artery above the digastric muscle The majority of carotid arterial injuries are confined to the may also be facilitated by anterior subluxation of the common carotid artery. We reviewed 1,160 patients who mandible. Fixation of the subluxed mandible can be incurred 1,189 carotid artery injuries. Among these accomplished using arch bars, or more simply by securing patients, 870 (73%) had common carotid artery injuries, the lower teeth to a wire passed transnasally. This converts 262 (22%) had internal carotid artery injuries, and 57 (5%) the narrow triangular field at the junction of zones II and III had injuries (see Table 1). into a much wider rectangular opening, thus allowing further exposure of the internal carotid artery up to the base of the skull. Further exposure can be obtained by extending Surgical management the skin incisions circumferentially around the lobe of the ear and elevating the lower lobe. This exposure has been In the operating room (OR), the patient is placed supine on described by Dossa et al. [24] (see Fig. 3). the operating table with the head extended and rotated to In the lower aspect at the junction of zones II and I, the the side opposite to the area to be explored. Placing a towel is usually transected to obtain greater roll under the shoulders is very helpful [1]. The face, neck, exposure. If exposure is necessary to deal with the origin of supraclavicular and thoracic areas are included in the the carotid arteries in zone I, a median sternotomy is the operating fields, just in case an extension of the incision incision of choice. This will allow for of the high in the angle of the mandible or a thoracotomy be origin of the carotid arteries off the arch of the and, in necessary for the exposure and the management of zone I the case of the right common carotid artery, off the and III injuries involving the very proximal and very distal brachiocephalic trunk. Rarely, in the presence of an asso- carotid artery. The contralateral groin is prepared and ciated subclavian vessel injury, a clavicular incision can be

Fig. 2 Exposures for zone I and II injuries

123 Penetrating carotid artery 433

Fig. 3 Exposure for zone III injuries

made to expose and control these vessels. When bilateral neck explorations are needed, the incisions on the anterior borders of the sternocleidomastoid muscle may be con- nected by transverse incision, which will allow the trauma surgeon to elevate a flap in a cephalad direction, thus exposing all structures in the midline of the neck. Once exposure has been obtained, the first priority is to secure immediate control of life-threatening hemorrhage. Digital control of the bleeding site is maintained while dissection is carried out to obtain both proximal and distal control of the carotid artery and its branches. Rapid but meticulous dissection of the carotid sheath with meticulous attention paid to the preservation of the structures con- tained in it is of the utmost importance. It is always easier to locate the common carotid artery at the base of the neck. This is facilitated by transection of the omohyoid. This Fig. 4 Kitzmiller clamps, right and left maneuver will provide for rapid proximal vascular control. A45° angled DeBakey vascular clamp should be utilized to Routine techniques for vascular surgical repair should obtain proximal control. Alternatively, a 60° angled De- be employed to deal with carotid arterial injuries. Lateral Bakey or Castaneda clamp (see Fig. 4) can also be used. arteriorrhaphy for injuries amenable to primary repair These same clamps can be used to obtain proximal control should be employed. However, injuries that have caused of the internal carotid artery and also the external carotid significant destruction to the wall of the carotid vessels artery. Total control of these three vessels is very impor- should be excised and debrided meticulously with Potts tant. Right or left Kitzmiller clamps are optimal to obtain scissors. If there are jagged edges of the intima present, very high proximal control of the internal carotid artery they should be meticulously elevated utilizing either a (see Fig. 5)[1, 2]. Penfield or a Freer dissector, and the feathered edges 123 434 J. A. Asensio et al.

Fig. 6 Argyle shunts

Fig. 5 Castaneda clamps should be tacked down with monofilament sutures of 6-0, 7-0 or 8-0 polypropylene. The presence of backflow from the proximal carotid artery should be observed. The pres- ence of excellent backflow signifies adequate cross-cere- bral perfusion via the circle of Willis. The trauma surgeon must be cognizant of the fact that an intact circle of Willis is present in only 20% of the population. Some surgeons prefer to measure stump pressures as an objective indicator for when to utilize shunts. If a stump pressure is measured, Fig. 7 Pruitt–Inahara shunts a pressure of 40–50 mmHg is stated to be a safe pressure, indicating that no shunt needs to be used. However, our group is a proponent of utilizing carotid artery shunts for any complex internal carotid or common carotid artery injury that would require extensive reconstruction with either an autogenous or prosthetic graft; or if the patient is or has experienced any period of hypotension [1–3] (see Figs. 6, 7, 8). The passage of Fogarty catheters into a proximal injury of the internal carotid artery to re-establish flow is a decision that needs to be made by the attending trauma surgeon with full knowledge that this is one particular area where the creation of an iatrogenic injury with such catheter can have devastating circumstances. Although some authors prefer not to systemically heparinize patients with carotid artery injuries, serious consideration must be given by the attending trauma surgeon to the Fig. 8 Argyle shunt placed in the left carotid artery prior to bypass utilization of heparin as a very valuable adjunct when with nonreversed autogenous saphenous vein graft completing these repairs. We prefer to utilize 5,000 units of heparin systemically in the presence of any carotid primary end-to-end anastomosis of the vessel can be car- artery injury [1, 2]. ried out if the vessel is not under tension. It is best to use an Common carotid artery injuries can be primarily interposition graft if any degree of tension is present. It is repaired if they are tangential injuries. Occasionally, a preferable to utilize an autogenous saphenous vein graft for 123 Penetrating carotid artery 435 the repair of all carotid artery injuries, but, if such conduit is not available for common carotid artery injuries, PTFE may be utilized. For internal carotid artery injuries, every effort should be made to secure an autogenous saphenous vein (see Figs. 9, 10, 11, 12, 13, 14). When a carotid artery injury repair is completed, the proximal clamps should be released first so that any debris or clots is flushed out prior to the completion of the anastomosis. The distal clamp is then replaced and the proximal clamp is released to flush out any debris or clot. The external carotid artery is then released, and the proximal clamp is again released so that if there is any debris or clots it may preferentially flush into the external carotid artery. After this done, if a shunt has been placed it is then removed, and the anastomosis is completed by placing the last sutures. It is extremely Fig. 11 Autogenous nonreversed saphenous vein graft that was used important to always use systemic heparinization when a to repair a common carotid at its origin, approximately 3 cm from the shunt has been placed. We generally utilize 6-0 poly- aortic arch. The patient required a median sternotomy as the injury proplylene sutures [1]. was intrathoracic Asensio [1, 2] has recently reviewed several series describing the management of carotid arterial injuries. A

Fig. 9 Nonreversed autogenous saphenous vein graft that was used to repair a common carotid below the bifurcation Fig. 12 Gunshot wound to the intrathoracic left common carotid artery. Proximal and distal control are shown. The artery is being debrided with Pott’s scissors

total of 433 patients who incurred 456 injuries were examined. Three hundred ninety-two (86%) of these patients underwent primary repair and 64 (14%) of these patients underwent ligation. Every conceivable attempt must be made to repair carotid artery injuries, as outcomes are much better with primary repair. Ligation for carotid artery injuries should be reserved for injuries where hemorrhage is life-threatening and cannot be controlled by any other means. Ligation should also be employed for distal thrombosed or nonreconstructible internal carotid artery injuries, or for patients who have fixed and Fig. 10 Polytetrafluoroethylene (PTFE) graft that was used to repair profound neurological deficits prior to exploration (see a common carotid Table 2). 123 436 J. A. Asensio et al.

Outcomes and mortality

Numerous reports by Liekweg [17] and Greenfield [17], Fry [15], Ledgerwood [11] and Weaver [4] confirm that outcomes are much improved if primary repair of the carotid can be carried out. Unger [12] analyzed 722 patients who sustained carotid artery injuries. Of the 186 patients presenting with severe neurological deficit, 34% improved when they underwent primary repair, in contrast to only 14% of those that underwent ligation or were not treated surgically. We reviewed 1,647 patients who had sustained carotid artery injuries. Mortality in all of these reviewed series ranged from 0 to 33%. The aver- age mortality rate for carotid artery injuries is 15% (see Table 3). Fig. 13 After mobilization, repair is achieved by end-to-end primary anastomosis Morbidity

Short-term complications from carotid arterial repairs include acute thrombosis, distal embolization, propagation of cerebral infarction, hemorrhage wound hematomas, wound infections, and nerve injury to either the hypo- glossal or marginal mandibular nerve. The most devastat- ing complication is massive cerebral infarction leading to cerebral death and/or a permanent vegetative state.

Conclusions

Carotid artery injuries are uncommon but extremely chal- lenging. Their repair requires excellent and meticulous surgical techniques to avoid devastating consequences. Fig. 14 Repair completed approximately 2 cm from the arch of the They incur high morbidity and mortality [1–19]. Every aorta. Doppler probe was used to detect triphasic flow signal conceivable attempt must be made to repair these injuries,

Table 2 Operative Author No. of cases under No. of injuries Repaired Ligated management of carotid arterial operative repair injuries Cohen (1970) [7]8585787 Bradley (1973) [8]2222202 Rubio (1974) [9]72816912 Liekweg (1978) [17]1819154 Ledgerwood (1980) [11]36 36 315 Fry (1980) [15]54544212 Brown (1982) 13] 125 139 115 24 Richardson (1988) [16]39 39372 Ditmars (1997) [18]3 5 2 3 Mittal (2000) [19]1818162 Navsaria (2002) [20]3234286 Ferguson (2005) [21]6 6 3 3 Total 492 519 441 (85%) 78 (15%)

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Table 3 Mortality rates of carotid artery injuries 4. Weaver FA, Yellin AE, Wagner WH, Brooks SH, Weaver AA, Milford MA. The role of arterial reconstruction in penetrating Authors (year) No. of Mortality carotid injuries. Arch Surg. 1988;123:1106–11. cases rates (%) 5. Kuehne JP, Weaver FA, Papanicolaou G, Yellin AE. Penetrating trauma of the internal carotid artery. Arch Surg. 1996;131:942–8. Cohen et al. (1970) [7] 85 15.0 6. Kuma SR, Weaver FA, Yellin AE Cervical vascular injuries. Bradley (1973) [8] 24 33.0 Carotid and jugular venous injuries. In: Asensio JA, Demetriades Rubio et al. (1974) [9] 72 23.4 D, Feliciano DV, Hoyt DV, eds. Vascular trauma: complex and challenging injuries (Surgical clinics of North America), vol. 81, Thal et al. (1974) [10] 60 8.3 no. 6, part 1. Philadelphia: W.B. Saunders Co., 2002;1331–44. Liekweg and Greenfield (1978) [17] 233 10.0 7. Cohen CA, Brief D, et al. Carotid artery injuries. An analysis of Ledgerwood et al. (1980) [11] 36 16.0 eighty-five cases. Am J Surg. 1970;120(2):210–4. Fry and Fry (1980) [15] 54 10.0 8. Bradley EL 3rd. Management of penetrating carotid injuries: an a alternative approach. J Trauma. 1973;13(3):248–55. Unger et al. (1980) [12] 722 21.0 9. Rubio PA, Reul GJ Jr, et al. Acute carotid artery injury: 25 years’ Brown et al. (1982) [13] 129 20.9 experience. J Trauma. 1974;14(11):967–73. Richardson et al. (1989) [16] 45 6.6 10. Thal ER, Snyder WH 3rd, et al. Management of carotid artery injuries. Surgery. 1974;76(6):955–62. Demetriades et al. (1989) [14] 124 22.0 11. Ledgerwood AM, Mullins RJ, et al. Primary repair vs ligation for Ditmars et al. (1997) [18]130 carotid artery injuries. Arch Surg. 1980;115(4):488–93. Mittal et al. (2000) [19] 18 16.6 12. Unger SW, Tucker WS Jr, et al. Carotid arterial trauma. Surgery. Navasaria et al. (2002) [20] 32 6.3 1980;87(5):477–87. 13. Demetriades D, Skalkides J, et al. Carotid artery injuries: expe- Total 1,647 Avg. calculated rience with 124 cases. J Trauma. 1989;29(1):91–4. mortality 15% 14. Brown MF, Feliciano DV, et al. Carotid injuries. Am J Surg. a Defined for only 513 cases 1982;144:748. 15. Fry RE, Fry WJ. Extracranial carotid artery injuries. Surgery. 1980;88:581. 16. Richardson JD, Simpson C, et al. Management of carotid artery as outcomes are much better with primary repair versus trauma. Surgery. 1988;104(4):673–80. ligation. 17. Liekweg WC Jr, Greenfield LJ. Management of penetrating arterial injury. Ann Surg. 1978;188:587. Conflict of interest None. 18. Ditmars ML, Klein SR, Bongard FS. Diagnosis and management of zone III carotid injuries. Injury. 1997;28(8):515–20. 19. Mittal VK, Paulson TJ, Colaiuta E, Habib FA, Penney DG, Daly B, Young SC. Carotid artery injuries and their management. J Cardiovasc Surg (Torino). 2000;41(3):423–31. References 20. Navsaria P, Omoshoro-Jones J, Nicol A. An analysis of 32 sur- gically managed penetrating carotid artery injuries. Eur J Vasc 1. Asensio JA, Valenziano CP, Falcone RE, Grosh JD. Management Endovasc Surg. 2002;24(4):349–55. of penetrating neck injuries. The controversy surrounding Zone II 21. Ferguson E, Dennis JW, Vu JH, Frykberg ER. Redefining the role injuries. In: Asensio JA, Weigelt JA, eds. Surgical clinics of of arterial imaging in the management of penetrating zone 3 neck North America, contemporary problems in trauma surgery, vol. injuries. Vascular. 2005;13(3):158–63. 71, no. 2. Philadelphia: W.B. Saunders Co., 1991;267–96. 22. Nemzek WR, Hecht ST, Donald PJ, McFall RA, Poirier VC. 2. Demetriades D, Asensio JA, Velmahos G, Thal E. Complex Prediction of major vascular injury in patients with gunshot penetrating neck injuries. In: Asensio JA, Demetriades D, Berne wounds to the neck. Am J Neuroradiol. 1996;17:161–7. TV, eds. Surgical clinics of North America. complex and chal- 23. Munera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of lenging problems in trauma surgery, vol. 76, no. 4. Philadelphia: arterial injuries caused by penetrating trauma to the neck: com- W.B. Saunders Co., 1996;685–724. parison of helical CT angiography and conventional angiography. 3. Demetriades D, Theodorou D, Comwell EE, Beme TV, Asensio Radiology. 2000;216:356–62. JA, Belzberg H, Velmahos G, Weaver F, Yellin A. Evaluation of 24. Dossa C, Shepard AD, Wolford OG, et al. Distal internal carotid penetrating injuries of the neck: a propective study of 223 exposure. A simplified technique for temporary mandibular patients. World J Surg. 1995;21:41–48. subluxation. J Vasc Surg. 1990;12:319.

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