Surgical Treatment of Penetrating Carotid Artery Injury
Article information
Abstract
Penetrating carotid artery injury (PCAI) is a life-threatening condition that requires prompt diagnosis and intervention. Surgical treatment is often necessary to control bleeding, prevent complications, and restore blood flow to the brain. The choice of surgical technique depends on the severity of the injury, the patient’s overall condition, and the surgeon’s expertise. Common surgical approaches for PCAI include arterial repair, ligation, and bypass grafting. The choice of surgical approach should be based on a careful assessment of the patient’s condition and the extent of the arterial damage. Preoperative planning and intraoperative monitoring are essential to minimize complications and optimize patient outcomes. In recent years, endovascular techniques, such as angioplasty and stenting, have been increasingly used in the management of PCAI. These techniques may be considered in selected cases, especially when the injury is located in the distal carotid artery or when the patient is at high risk for surgical complications. However, the long-term durability of endovascular interventions for PCAI remains uncertain, and surgical repair may still be preferred in many cases. The choice of surgical technique should be tailored to the individual patient’s needs, and careful preoperative planning, intraoperative monitoring, and postoperative care are essential for optimizing patient outcomes.
Introduction
Penetrating carotid artery injury (PCAI) results in high rates of morbidity, where mortality may reach 50%, and the incidence of persistent neurological deficit is reportedly 80% [1,2]. In US civilian trauma, PCAI is primarily caused by gunshot wounds and stab wounds, and patients often sustain fatal injuries [3]. In addition, patients with neurological deficit develop more severe symptoms and have worse outcomes [2–4]. The high morbidity and mortality associated with PCAI is accompanied by controversy about the benefits that can be gained when treating vascular damage and ligation. Observations following surgical management of PCAI vary, with some researchers reporting improved neurological function after treatment, and other researchers observing little difference when compared with ligation [5,6]. These reports increase uncertainty in the diagnosis and treatment of PCAI [5,7–9].
Generally, hemodynamically unstable patients will likely require operative exploration, whereas hemodynamically stable patients can undergo further radiological assessment and have several options for management. Surgical treatment can be very challenging, especially in an environment accompanied by injuries in Zones 1 and 3 of the neck where surgical exposure is difficult. Other surgical techniques include temporary shunting, which is attempted, especially when the patient is unstable [6,9]. However, in the case of shunting, a retrospective US study of PCAI (N = 4,723) from 2007–2018 using a large national database suggested a higher incidence of stroke and hence a higher prognosis and mortality than the typical repair [10].
This current review specifically will describe the diagnosis and operational management of penetrating carotid injuries. In some cases, the damaged artery may be ligated, effectively closing it off. This may be necessary when the injury is extensive or if the patient’s condition is critical. However, ligation can lead to significant ischemia and neurological complications if the collateral blood supply is inadequate.
1. Diagnosis
The classification of carotid injury is based anatomically on the 3 cervical zones as described by Monson et al in 1969 [11]: (1) Zone I is below the sternal notch and is intrathoracic; (2) Zone II is between the sternal notch and the angle of the mandible; and (3) Zone III is above the angle of the mandible, and carotid injury at this location is rare and unlikely to be present because there are no physical signs.
In hemodynamically stable patients, penetrating carotid injury within Zone II will typically proceed to operative management relative to the other zones, in part because of access and exposure. On the other hand, penetrating carotid injury within Zones I and III are more likely to undergo endovascular intervention [7,12]. In the patient with a penetrating cervical wound and proximity to the carotid artery (usually the wound would extend through Zone II), a stable hematoma, unknown level of a carotid-jugular arteriovenous fistula, loss of the carotid pulse without a neurologic deficit or proximity to the vertebral artery, diagnostic tests are indicated.
To allow for a precise evaluation of carotid artery injury, computed tomography (CT) arteriography is used with an intravenous injection of contrast followed by a helical CT (Figure 1). Of the diagnostic techniques, CT angiography is the most accurate [13,14], but, CT should only be considered when the patient is hemodynamically stable. If the patient’s condition is unstable, or hemodynamically unstable, emergency surgical management should be considered first. In the event of an airway problem accompanied by carotid artery injury, it is important to take a closer look for the presence or absence of hard signs and respond quickly (Table 1).
Carotid artery injury diagnosed with angio-CT 3D reconstruction.
Active bleeding in the right common carotid artery bifurcation (red arrow).
Hard Signs of Neck Injury
Manual compression of the common carotid artery, at the base of the neck or directly over the penetrating wound, may temporarily control bleeding from the injured carotid artery into the airway before emergency tracheal intubation is performed. To control hemorrhage, occasionally, the direct application of a finger, insertion of a balloon catheter into an intraoral defect, or gauze packing of the oral cavity may be necessary. In such cases an emergency cricothyroidotomy is required. Rapid expansion of a cervical hematoma may occur and result in deviation of the trachea, and elevation of the floor of the mouth. After moving the patient rapidly to the operating room, an emergency nasotracheal intubation over a fiberoptic bronchoscopy should be performed when the size of the sublingual hematoma precludes orotracheal intubation. In the event of failure of nasotracheal intubation an emergency cricothyroidotomy should follow.
2. Operative management
In the case of patients who visit the Emergency Room due to a penetrating wound to the carotid artery, direct compression is immediately performed to control surgical hemorrhage. In addition, a massive transfusion protocol is performed (according to institution guidelines), and preparations are made to move the patient to the operation room. The initial surgical approach is made according to the investigation site. When the hematoma of the enclosure site is extended, the general access route, and the anterior edge of the sternocleidomastoid muscle is often difficult to identify due to its ambiguous boundaries. In addition, when there is severe damage to surrounding structures, it is difficult to identify “common land marks” such as facial veins. As a guide for the initial incision, Serna et al recommended an imaginary line between the earlobe crease and the sternum notch [15]. Proximal and distal control should be immediately implemented if carotid artery injury is identified. In the case of common carotid artery injury, if the origin is damaged, a median sternotomy may be required for proximal control. If the damage occurs in the external carotid artery, you can exercise proximal control by dissection of the bifurcation of the common carotid artery. In the case of internal carotid artery injury, a surgical approach is possible, but only for the extracranial portion. Proximal control of internal carotid artery damage can be relatively easily accessed through the common or proximal internal carotid artery (Figure 2). However, distal control can be technically difficult and anterior manual displacement may be required for better visibility. This method, in most patients, can expose about 2 cm more of the distal blood vessel. If it is difficult to perform distal control, the insertion of the balloon catheter can be performed by inserting a foley catheter into the wound. An alternative is placing a Fogarty catheter into the injured vessel and achieving distal control by advancing the catheter beyond the injury site and inflating the balloon [5,16]. Following hemorrhagic control, the surgeon should choose an appropriate surgical approach for the injury. The injury site in the wall of the carotid artery is treated with minimal debridement of frayed intima or contused wall, and a transverse arteriography is performed with interrupted 6-0 polypropylene sutures. When the defect is near the bifurcation of the common carotid artery, a vein or thin walled polytetrafluorethylene (PTFE) patch angioplasty is performed using a continuous 6-0 polypropylene suture. A large segmental injury in the common carotid artery is treated with resection and insertion of an interposition saphenous vein or PTFE graft [17]. PTEF in this injury site has reliable longevity [18]. However, a segmental resection of the internal carotid artery is best treated with an interposition saphenous vein graft because of improved patency in this location [17]. Although ligation of the blood vessels is recommended as definitive surgical therapy if the patient presents with a poor overall prognosis, no distal reflux bleeding from injured blood vessels, or external carotid artery damage associated with hemodynamic instability. Otherwise, primary repair of the blood vessels is recommended. In general, it is better to attempt repair for carotid artery injury [7]. In particular, vascular reconstruction should be actively considered for a single penetrating wound. Suturing the injured artery directly is typically preferred for smaller injuries and the artery can be repaired without significant loss of blood flow. Additionally, injuries to the common carotid and internal carotid arteries necessitate separate incisions, extend surgical time, and should be managed using synthetic materials like Gore-Tex or PTFE interposition grafts or autologous tissue grafts. In contrast, autologous reverse saphenous vein grafts require an additional incision, prolong surgical time, and are incompatible with damage control surgery principles. For injuries that present with difficult surgical access (like distal internal carotid injuries) and where hemorrhage control requires Foley or Fogarty catheter balloon placement, the immediate transfer of the patient to a hybrid or angiography suite for endovascular stent placement is necessary. After conducting damage control surgery, surgical field hemostasis should be carefully verified. In cases of ongoing nonsurgical bleeding (due to persistence of coagulopathy), the wound should be packed and a negative pressure dressing should be placed. The patient should then be transferred to the Intensive Care Unit (ICU) to continue with rewarming, correction of coagulopathy, and damage control resuscitation. Close neurological monitoring should be performed in the ICU and a 24-hour follow-up CTA of the head and neck should be performed to evaluate arterial blood flow and secondary tissue injury. The techniques that can be used when implementing the damage control surgery of the carotid artery injury include ligation and temporary shunting (Figure 3). The indications for carotid artery ligation should be limited to: (1) a very severe patient condition; (2) a severe brain injury unrelated to carotid artery injury (e.g., direct brain trauma); (3) an ischemic lesion in the injured artery area diagnosed by computed tomography; (4) an internal carotid artery near the skull base when anastomosis is not feasible; and (5) extensive distal internal carotid thrombosis [9]. In such cases, recovery of brain function cannot be expected. Therefore, life-saving surgery should be the primary goal even at the risk of serious complications. Time-consuming reconstruction surgery can be fatal. In addition, if other damage associated with the carotid artery injury involvement are judged to be more critical, the operation time should be reduced to a minimum through ligation or temporary shunting. Injury of the carotid artery can cause a stroke by itself or can occur following surgery (like ligation or temporary shunting). The overall incidence of a stroke occurring in carotid artery injuries varies from 6.2% to 8.5% [3,10]. It has been reported that penetrating extracranial arterial trauma patients who underwent admission showed higher mortality than the group that underwent repair [19]. In addition, carotid artery repair was not associated with less instances of postoperative stroke, but was associated with lower in-hospital mortality compared with ligation. The additional revascularization after ligation remains controversial, and many surgeons prefer attempts at revascularization even for those patients presenting with severe neurological deficits. It has been reported that as many as 80% of patients will experience neurological improvement and even 33% of patients may see a return to normal neurological function [7,20,21]. Furthermore, if brain function is lost and brain death occurs, active treatment can create opportunities for organ donation.
Example of proximal control and distal control using rubber bands in a typical carotid artery injury.
Example of temporary shunting in an internal carotid artery transection.
Conclusion
Penetrating carotid artery injuries are highly dangerous and often result in severe morbidity and mortality. Treatment is complex and controversial due to the high risk involved. Diagnosis of carotid artery injuries are typically through physical examination, imaging (CT angiography), and assessment of vital signs.
Immediate surgical intervention for carotid artery injury is often required to control bleeding and prevent further complications. Surgical techniques may include ligation, repair, or shunting. In severe cases (very unstable vital signs or if there is a serious co-damage or if the neurological damage has already progressed and the patient is unconscious), the damaged artery may be ligated, effectively closing it off. This can lead to significant ischemia and neurological complications. Otherwise, when possible, the injured artery is repaired using various surgical techniques. This may involve suturing, patching, or grafting. Temporary shunting may be used in certain cases to maintain blood flow while the artery is repaired.
Despite advancements in surgical techniques, penetrating carotid artery injuries remain associated with high rates of mortality and neurological deficit. The choice of treatment depends on various factors including the severity of the injury, the patient’s overall condition, and the surgeon’s expertise. Early diagnosis and prompt surgical intervention are crucial for improving outcomes.
The take home message is that carotid artery injury has a good prognosis. It should be repaired where possible, and in the case of a single penetrating phase, vessel reconstruction should be actively considered. If the patient is in a coma at the time of arrival at hospital or has poor vital signs with additional damage, common carotid artery or internal carotid artery ligation or shunting may be attempted, but in this case, the risk/occurrence of stroke should be considered. It is necessary to apply the principle of damage control (with respect to the patient’s vital signs) during carotid artery injury surgery.
Notes
Conflicts of Interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Ethical Statement
This review did not involve any human or animal experiments.
Data Availability
All relevant data are included in this manuscript.