Penetrating Carotid Artery: Uncommon Complex and Lethal Injuries

Eur J Trauma Emerg Surg (2011) 37:429–437 DOI 10.1007/s00068-011-0132-3 REVIEW ARTICLE Penetrating carotid artery: 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 neck 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 vein 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 arteries 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 gunshot wound 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- internal carotid artery 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 fascia that incorporating knowledge derived from military experiences encompasses the platysma, and the deep cervical fascia that (see Table 1). encompasses the sternocleidomastoid muscle; the pretra- cheal fascia attaches to the thyroid 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 carotid sheath 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 clavicle to the cricoid cartilage, 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 sternoclavicular joint. 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 thyroid cartilage, 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 jugular vein, and vagus nerve 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.

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