antiplatelet therapy; therefore, a prudent protocol includes heparin therapy and

transition to warfarin if an absolute contraindication to systemic anticoagulation does not

exist. If full anticoagulation is not able to be completed, antiplatelet therapy should be
initiated. These lesions all require follow-up imaging with either CTA or catheter-based
angiography anywhere from 1 to 3 months post-injury. Edwards et al. found that at 3 months,
one can expect 72 % of grade I injuries to be com- pletely healed . Grade II injuries are fairly
evenly distributed: 33 % are improved, 33 % are stable, and 33 % progress. Grade III injuries
tend to either remain unchanged or enlarge but rarely resolve. These lesions typically have a
low risk of rupture but can be a source of distal embolic events or thrombosis, and as such,
con- tinued anticoagulation is recommended.

Treatment of Penetrating Injuries and Grade V Blunt Injuries

The management of grade V blunt injuries (complete transaction) and penetrating
injuries is a much more complex decision tree. In essence, they may be treated as
synonymous injuries. Penetrating injuries in zone II should be opera- tively explored and
repaired surgically. This can be accomplished via a cervical incision. The external jugular
and facial veins may be ligated with little concern. Injuries to the internal jugular vein may be
primarily repaired but can be ligated in emergency conditions if necessary. Whenever
surgical intervention is undertaken, at least one leg must be prepped to allow for vein
harvesting for patch or interposition conduit harvesting. Saphenous vein patch can be used to
repair partial injuries and should be harvested from the groin rather than the ankle.
Alternatively, some have used bovine pericardium if no vein is pres- ent, but this carries
increased risk of infection in a contaminated field. Injuries due to iatrogenic cannulation or
from stab wounds can often be repaired primarily; ballistic injuries most often require
segmental resection and interposition grafting. The saphenous vein offers a good size match
for the internal carotid in these cases and in some cases for the distal common carotid. If size
mismatch is an issue, some have proposed the use of the superficial femoral artery with
interposition polytetrafluoroethylene (PTFE) grafting in the superficial femoral artery (SFA)
harvest location. This allows for autologous reconstruction in the contaminated field and
prosthetic reconstruction in the clean harvest bed. The patient should always be fully
heparinized prior to any clamping of the carotid system; temporary shunts can be used at the
discretion of the operative surgeon. Simple ligation of the carotid artery has significant
consequences and results in nearly 45 % mortality. Because of this, it should be reserved only
for those injuries at the base of the skull that are not amenable to reconstruction or when
complete transection with thrombosis is already present without resulting neurologic incident.
Penetrating carotid artery injuries in zone I and III present a much more complex
problem. Proximal and distal control can be a significant issue or require much more
morbidity with jaw dislocation, mandibulotomy, median sternotomy, or trapdoor incisions.
Because of this, endovascular techniques have increased in popularity for control of these
injuries. These techniques have the added benefit of being able to be completed under local
anesthesia, allowing for continuous neurologic monitoring. Multiple groups have shown low-
risk profiles with the use of covered stents for the treatment of hemodynamically sig- nificant
dissection, pseudoaneurysms, partial transections, and other injuries to the carotid ves- sels in
these zones.

Treatment of Blunt Injuries

As with blunt carotid injuries, the mainstay of blunt vertebral injuries is systemic
anticoagulation, unless complete transection with extravasation is noted. Studies from the
past decade have shown a reduced neurologic incident rate from 20 to 35 % with no
anticoagulation to 0–14 % with heparin therapy. Again, as with carotid blunt injury, if
systemic anticoagulation cannot be administered, antiplatelet therapy should be given.

Treatment of Penetrating Injuries and Blunt Transection Injuries

Because of the difficult surgical access to the vertebral vessel, endovascular
techniques have become a first approach to the treatment of penetrating and blunt transection
injuries. Selective angiography and crossing of the lesion can allow for proximal and distal
coil embolization in most patients. Even in cases of complete transection, crossing of this
lesion can be successful, allowing endovasculartreatment. Upto 50% of the time, selective
angiography will reveal that the vessel has already thrombosed, and thus no further therapy is
needed. There have been rare reports of covered stent graft placement in the vertebral system,
but this is not routinely performed.
If endovascular techniques are not available or do not succeed in controlling the
bleeding, open operative ligation can be com- pleted with an expected stroke rate of 3–5 %.
The most straightforward approach involves isolation of the V1 segment of the vertebral
artery and ligation at this point, with packing of the wound to assist in retrograde and
collateral back bleeding. This portion of the vertebral artery can be obtained through the same
exposure as the carotid artery. The sternocleidomastoid muscle attachments to the sternum
and clavicle are taken down, the scalene fat pad is mobilized, and the anterior scalene muscle
is divided with care not to injure the phrenic nerve. At this point, the subclavian artery and
origin of the vertebral artery can be dissected and ligated to control bleeding.