eMedicine Specialties > Trauma > Abdominal Trauma

Abdominal Vascular Injuries

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, Consulting Staff, Methodist Hospital, Clarian Health Partners Inc
Coauthor(s): H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc; Aleksander R Komar, MD, Fellow, Section of Trauma and Critical Care, SUNY Stony Brook; Richard Fogler, MD, DS, FACS, Chair, Program Director, Department of Surgery, Division of Surgical Oncology, Brookdale University Hospital and Medical Center
Contributor Information and Disclosures

Updated: Apr 13, 2007

Introduction

The incidence of abdominal vascular injuries in military conflicts is surprisingly low, generally less than 5% of all vascular injuries. In contrast, approximately 30% of all vascular injuries observed in civilians occur in the abdomen. This striking difference between combat vascular trauma and noncombat vascular trauma can be attributed to low-energy missiles from civilian handguns and short prehospital transit times in urban settings, thereby making it more likely that a civilian with penetrating abdominal vascular injury will survive long enough to reach surgical care.

Problem

Injuries to major abdominal vessels are uncommon but highly lethal vascular crises. Predictably, exsanguinating hemorrhage is the most important cause of early death. Intra-abdominal vascular injuries are associated with extremely rapid rates of blood loss and pose challenges of exposure during celiotomy, given the posterior position, except for the portal vein and the hepatic artery, of the major abdominal vascular structures.

Essential to the successful management of these injuries is a thorough knowledge of the complex anatomy of intra-abdominal vascular structures and a familiarity with the techniques of proximal and distal control combined with selected application of primary repair, bypass, and/or ligation. 
 
Once exposure and proximal and distal control have been obtained, all abdominal vascular injuries should be graded using the American Association for the Surgery of Trauma-Organ Injury Scale for vascular injuries (AAST-OIS) (see Table).
 
American Association for the Surgery of Trauma-Organ Injury Scale for Vascular Injuries 

Open table in new window

* 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.

Frequency

The incidence of abdominal vessel injury in patients with blunt trauma is estimated at approximately 5-10%. A similar incidence of 10.3% is reported in patients with penetrating stab wounds to the abdomen. Patients with gunshot wounds (GSWs) to the abdomen will have major vessel injury in 20-25% of cases.

Pathophysiology

In blunt trauma, rapid deceleration during a motor vehicle accident (MVA) results in an avulsion of the small branches of major vessels (eg, mesenteric tear). Another mechanism of injury is related to a direct crush or blow to the major vessels, resulting in an intimal tear with thrombosis or vessel rupture and hemorrhage.

Penetrating injuries directly disrupt the vessel wall or create intimal flaps secondary to the blast effect. Because of the anatomical position of the major vascular structures in the abdomen, injuries to these vessels have a high probability of association with other major injuries in the abdomen, particularly to the small bowel.

Hemorrhagic shock from intra-abdominal hemorrhage often leads to metabolic acidosis accompanied by coagulopathy and hypothermia, the so-called lethal triad of trauma. Metabolic acidosis in trauma patients is the result of lactate overproduction, most often from decreased oxygen delivery as a result of hypovolemic shock. Acidosis adds to the overall lethality of preexisting injury primarily by depression of myocardial contractility and by impairment of coagulation. Furthermore, hypothermia (below 34°C) inhibits platelet function and slows coagulation factor activation. This self-perpetuating cycle is responsible for 80% of deaths in patients with major vascular injury and must be rapidly corrected to prevent a dismal outcome.

Presentation

Clinical data obtained from emergency medical services (EMS) can be crucial and may be the only patient information available. In inner city hospitals, GSWs and stab wounds predominate. Mechanism of injury, vital signs at the scene of the accident, and transit time are essential. The amount of intravenous fluid the patient received in the field and during transport should also be elicited from EMS. Penetrating trauma to the chest below the nipple line should also be considered as penetrating trauma to the abdomen.

Indications

Blunt trauma

Hemodynamically stable patients who have peritoneal signs or positive CT findings require exploration. Hemodynamically unstable patients with positive results, including pericardial effusion, on focused abdominal ultrasound for trauma (FAST) examination or diagnostic peritoneal lavage (DPL) require surgery.  

Penetrating trauma

Evaluate stable patients with posterior wounds and most patients with anterior stab wounds with triple-contrast CT scanning (eg, oral, intravenous, rectal), diagnostic laparoscopy to exclude peritoneal penetration, and/or FAST examination to exclude hemoperitoneum. GSWs to the abdomen require celiotomy for evaluation and treatment, although some trauma surgeons prefer selective nonoperative evaluation of abdominal GSWs in stable patients. Hemodynamically unstable patients should be transported immediately to the operating room (OR) if the airway is secure and ventilation is adequate, preferably within 5 minutes of arrival to the emergency department (ED).

Relevant Anatomy

The following anatomical locations should be distinguished:

• Midline supramesocolic hemorrhage or hematoma (superior to the transverse mesocolon) is usually caused by injury to the suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery.
• Midline inframesocolic hemorrhage or hematoma results from infrarenal aorta or inferior vena cava (IVC) injury.
• Lateral perirenal hematoma or hemorrhage suggests injury to the renal vessels or kidneys.
• Lateral pelvic hematoma or hemorrhage indicates injury to the iliac artery, iliac vein, or both.
• Hepatoduodenal ligament hematoma or hemorrhage indicates portal vein and/or hepatic artery injury.

Contraindications

Patients without recorded vital signs at the scene of injury and blunt trauma victims without vital signs at the time of arrival to the ED rarely survive after resuscitation, with or without ED thoracotomy.

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