VASCULAR TRAUMA (BLUNT)

Classically, vascular injury mechanisms are divided into penetrating or blunt.

Following blunt trauma, tissue injury is produced by local compression, rapid deceleration,
and the resulting shear forces. In penetrating trauma, the injury is produced by crushing and
separation of tissues along the path of the penetrating object along with the resulting
concussive shockwave. Understanding the biomechanics of specific injuries is important in
determining the potential for vascular injury and the subsequent hemodynamic consequences
of these injuries. Injury severity is proportional to the amount of kinetic energy (KE)
transferred to the tissues, which is a function of the mass (M) and velocity (V); KE =( M ×
V2)/2. This relationship is valid for both blunt and penetrating injury mechanisms. Small
changes in velocity alter the kinetic energy transfer more significantly than do changes in
mass. This is critical when evaluating high- and low-velocity gunshot wounds and their corre-
sponding injury potential.
This chapter focuses on vascular trauma and the decision processes associated with
the workup and treatment of these injuries, both open and endovascular. Vascular injuries
resulting from blunt, penetrating, and iatrogenic sources are considered in the following
pages. Injuries are grouped in a “head-to-toe”-type organization, similar to that encountered
during a trauma sur- vey. The major sections include:
1. Head and Neck Vascular Injuries
2. Thoracic Vascular Injuries
3. Abdominal and Pelvic Vascular Injuries
4. Peripheral (Extremity) Vascular Injuries
We present a general overview to the evalua- tion and workup of each of these
regions, fol- lowed by a vessel-specific review of the current treatment options and
recommendations.

Head and Neck Injuries

Cervical vascular injuries are notoriously difficult to evaluate and manage as a result
of the complex anatomy and confined narrow anatomical space of the neck. The initial
evaluation of these injuries can often be obscured by associated injuries in the head, neck,
and chest. In addition, signs of cerebral ischemia or focal neurologic deficit may not be
obviously present on initial evaluation due to patient condition, sedation, or the need for
mechanical ventilation. Advances in noninvasive imaging (primarily computed tomography)
have revolutionized the
evaluation of stable patients with cervical vascular injuries. Injuries to the distal
internal carotid, proximal common carotid, subclavian, and vertebral arteries are now
amenable to endovascular adjuncts to arrest hemorrhage, stabilize dissections, or exclude
pseudoaneurysms. Following penetrating cervical trauma, cervical blood vessels are the most
commonly injured structures in the neck, accounting for a 7–27 % stroke rate and a 7–50 %
mortality rate. Eighty percent of deaths in this population are stroke related.

Blunt Injury
The overall incidence of blunt cerebrovascular injury (BCVI) has been universally reported as
less than 1 % of all admissions for blunt trauma, but this relatively small population of
patients has stroke rates ranging from 25 to 58 % and mortality rates of 31–59 %. The