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Abdominal Vascular Injuries Workup

  • Author: Timothy H Pohlman, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 20, 2015
 

Approach Considerations

Stable patients with stab wounds may undergo laparoscopy to confirm peritoneal penetration. If time permits, also perform chest and pelvic radiography to exclude bleeding into the chest and pelvic fracture.

Hemodynamically unstable patients with penetrating trauma should be transported immediately to the operating room (OR); no imaging studies are necessary.

Hemodynamically stable patients with blunt trauma and suspected abdominal vascular injuries may benefit from abdominal computed tomography (CT) scanning, which helps localize a hematoma and evaluate solid organ injuries.[6, 7, 8, 9, 10]

A retrospective study by Benjamin et al suggested that negative CT finding for an asymptomatic patient after blunt abdominal trauma is sufficient to exclude major intra-abdominal injury.[11, 12]

The assessment of hemodynamically unstable patients with blunt trauma to the abdomen may include focused assessment with sonography for trauma (FAST) or diagnostic peritoneal lavage (DPL) to confirm hemoperitoneum as well as portable chest radiography only if expeditious transport to the OR is not to be interrupted.

In penetrating trauma, perform an abdominal exploration on most patients with a GSW to the abdomen.

Angiography with or without embolization may be considered in stable patients, particularly in patients with blunt trauma.

Also see Focused Assessment with Sonography in Trauma (FAST).

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Grading

Once exposure and proximal and distal control have been obtained, all abdominal vascular injuries should be graded according to the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) for vascular injuries (see the table below).

Table 1. American Association for the Surgery of Trauma Organ Injury Scale for Vascular Injuries (Open Table in a new window)

OIS



Grade*



Artery Injured Vein Injured
II Hepatic



Splenic



Gastric



Gastroduodenal



Inferior mesenteric



Primary named vessels of superior mesenteric



Splenic



Inferior mesenteric



III Renal



Iliac



Hypogastric



Superior mesenteric



Renal



Iliac



Hypogastric



Vena cava (infrarenal)



IV Superior mesenteric (trunk)



Celiac axis



Aorta (infrarenal)



Vena cava (infrahepatic)
V Aorta (suprarenal) Vena cava (suprahepatic)



Vena cava (retrohepatic)



Portal



Hepatic (extrahepatic)



* Grade I injury includes the following: No named superior mesenteric artery or superior mesenteric vein branches; nonnamed inferior mesenteric artery or inferior mesenteric vein branches; phrenic artery/vein; lumbar artery/vein; gonadal artery/vein; ovarian artery/vein; other nonnamed small arterial or venous structures requiring ligation.
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Contributor Information and Disclosures
Author

Timothy H Pohlman, MD, FACS Professor, Section of Trauma and Critical Care, Department of Surgery, Indiana University School of Medicine; Director, Surgical Critical Care, Methodist Hospital, Indiana University Health Partners, Inc

Timothy H Pohlman, MD, FACS is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Society of University Surgeons, Surgical Infection Society

Disclosure: Nothing to disclose.

Coauthor(s)

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Richard Fogler, MD, DS, FACS Chair, Program Director, Department of Surgery, Division of Surgical Oncology, Brookdale University Hospital and Medical Center

Richard Fogler, MD, DS, FACS is a member of the following medical societies: American College of Surgeons, American Society of Abdominal Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas

Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Aleksander R Komar, MD, to the development and writing of the source article.

References
  1. Fabian TC. Abdominal trauma including indications for celiotomy. Feliciano DV, Moore EE, Mattox KL, eds. Trauma. 3rd ed. Norwalk, Conn: Appleton and Lange; 1996. 441-59.

  2. Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg. 1984 Apr. 199(4):467-74. [Medline]. [Full Text].

  3. Morris JA Jr, Eddy VA, Rutherford EJ. The trauma celiotomy: the evolving concepts of damage control. Curr Probl Surg. 1996 Aug. 33(8):611-700. [Medline].

  4. Ganter MT, Pittet JF. New insights into acute coagulopathy in trauma patients. Best Pract Res Clin Anaesthesiol. 2010 Mar. 24(1):15-25. [Medline].

  5. Fikry K, Velmahos GC, Bramos A, et al. Successful selective nonoperative management of abdominal gunshot wounds despite low penetrating trauma volumes. Arch Surg. 2011 May. 146(5):528-32. [Medline].

  6. Feliciano DV. Abdominal vascular injury. Feliciano DV, Moore EE, Mattox KL, eds. Trauma. 3rd ed. Norwalk, Conn: Appleton and Lange; 1996. 615-33.

  7. Feliciano DV. Injuries to the great vessels of the abdomen. Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, eds. Scientific American Surgery. New York, NY: Scientific American; 1996, revised 1998.

  8. Vu M, Anderson SW, Shah N, Soto JA, Rhea JT. CT of blunt abdominal and pelvic vascular injury. Emerg Radiol. 2010 Jan. 17(1):21-9. [Medline].

  9. Dayal M, Gamanagatti S, Kumar A. Imaging in renal trauma. World J Radiol. 2013 Aug 28. 5(8):275-84. [Medline]. [Full Text].

  10. Genovese EA, Fonio P, Floridi C, Macchi M, Maccaferri A, Ianora AA, et al. Abdominal vascular emergencies: US and CT assessment. Crit Ultrasound J. 2013 Jul 15. 5 Suppl 1:S10. [Medline]. [Full Text].

  11. Benjamin ER, Siboni S, Haltmeier T, Lofthus A, Inaba K, Demetriades D. Negative Finding From Computed Tomography of the Abdomen After Blunt Trauma. JAMA Surg. 2015 Dec 1. 150 (12):1194-5. [Medline].

  12. Harding A. Blunt Trauma Patients May Be Discharged After Negative Abdomen CT. Reuters Health Information. Available at http://www.medscape.com/viewarticle/851568. September 28, 2015; Accessed: December 21, 2015.

  13. Kimball EJ, Adams DM, Kinikini DV, Mone MC, Alder SC. Delayed abdominal closure in the management of ruptured abdominal aortic aneurysm. Vascular. 2009 Nov-Dec. 17(6):309-15. [Medline].

  14. Ding W, Wu X, Pascual JL, Zhao K, Ji W, Li N, et al. Temporary intravascular shunting improves survival in a hypothermic traumatic shock swine model with superior mesenteric artery injuries. Surgery. 2010 Jan. 147(1):79-88. [Medline].

  15. Vandromme MJ, Griffin RL, Kerby JD, McGwin G Jr, Rue LW 3rd, Weinberg JA. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011 Feb. 70(2):384-8; discussion 388-90. [Medline].

  16. Doll D, Matevossian E, Kayser K, Degiannis E, Hönemann C. [Evisceration of intestines following abdominal stab wounds : Epidemiology and clinical aspects of emergency room management.]. Unfallchirurg. 2013 Jun 12. [Medline].

 
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Abdominal vascular injuries. Tangential gunshot injury to the inferior vena cava repaired by means of lateral venorrhaphy (arrow).
Table 1. American Association for the Surgery of Trauma Organ Injury Scale for Vascular Injuries
OIS



Grade*



Artery Injured Vein Injured
II Hepatic



Splenic



Gastric



Gastroduodenal



Inferior mesenteric



Primary named vessels of superior mesenteric



Splenic



Inferior mesenteric



III Renal



Iliac



Hypogastric



Superior mesenteric



Renal



Iliac



Hypogastric



Vena cava (infrarenal)



IV Superior mesenteric (trunk)



Celiac axis



Aorta (infrarenal)



Vena cava (infrahepatic)
V Aorta (suprarenal) Vena cava (suprahepatic)



Vena cava (retrohepatic)



Portal



Hepatic (extrahepatic)



* Grade I injury includes the following: No named superior mesenteric artery or superior mesenteric vein branches; nonnamed inferior mesenteric artery or inferior mesenteric vein branches; phrenic artery/vein; lumbar artery/vein; gonadal artery/vein; ovarian artery/vein; other nonnamed small arterial or venous structures requiring ligation.
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