eMedicine Specialties > Trauma > Abdominal Trauma

Abdominal Vascular Injuries: Treatment

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

Treatment

Medical Therapy

Initial resuscitation of a patient with abdominal vascular injuries depends on his or her condition at arrival to the ED. Insert multiple large-bore catheters into the upper extremities, or, if necessary, obtain central venous access for rapid infusion of warm isotonic fluid. Because a possibility of intra-abdominal venous injury exists, lower extremity venous access is not recommended.

In the agonal patient with a distended abdomen suggesting major intraperitoneal bleeding, ED thoracotomy with cross clamping of the descending aorta may be necessary. This is usually associated with a poor prognosis and low survival rates.

Perform blood replacement during resuscitation with type-specific blood if time permits receiving this blood in the ED. If time does not permit, use O-negative blood (or O-positive blood for males), which should be immediately available in the ED. Start efforts to limit hypothermia as soon as the patient arrives. Ensure that prewarmed fluids, high-flow blood warmers, and prewarmed blankets are available.

Preoperative Details

• Place the patient on a warming blanket, and make every effort to reduce heat loss.
• Drape the patient to expose chest and both thighs in the event that a thoracotomy or vein harvest is required.
• Perform a generous midline incision from the xiphoid to well below the umbilicus, which can be extended to the pubis if needed to improve exposure.
• Aggressively administer blood replacement therapy.
• A radial arterial line may be helpful for monitoring blood pressure and arterial blood gases.

Intraoperative Details

Enter the peritoneal cavity through a midline incision. Quickly evacuate blood and clots and perform 4-quadrant packing. After initial stabilization, systematically remove the packing and evaluate the injuries. Injuries to major abdominal vessels can be grouped into the following 5 regions:

• Midline supramesocolic hemorrhage or hematoma (superior to the transverse mesocolon)
  
  
  • This problem is usually from an injury to the suprarenal aorta, celiac axis, proximal superior mesenteric artery, or proximal renal artery.
  • Use aortic compression to obtain proximal aortic control at the hiatus.
  • Once aortic control is achieved, gain direct access to the vessels through retroperitoneal mobilization and medial rotation of all left-sided abdominal viscera (Mattox maneuver) or an extensive Kocher maneuver on the right side.
  • An injured celiac axis may be safely ligated in critical situations.
  • Access to the superior mesenteric artery and vein may require transection of the pancreas. Primary repair of this major vessel is usually the first choice; however, ligation, particularly of the venous structures, may be a better option. Significant venous congestion can compromise viability of the bowel.
     
• Midline inframesocolic hemorrhage or hematoma
  
  
  • This problem results from infrarenal aortic or IVC injury.
  • Obtain exposure by incising the posterior peritoneum in the midline after evisceration of the small bowel and cephalic retraction of the transverse mesocolon, or divide the white line of Toldt adjacent to the cecum and extend cephalad through the hepatic flexure followed by medial rotation of the right colon and small bowel (Cattel-Braasch maneuver).
  • Place an aortic clamp just below the left renal vein and apply a distal clamp near the aortic bifurcation. The injury is primarily repaired.
  • If the aorta is intact, suspect injury to the IVC and obtain access to the infrahepatic IVC by mobilizing the right colon and duodenum.
  • Preferably, repair anterior injuries in transverse fashion. Posterior injuries can be repaired from inside the IVC. Both approaches require proximal and distal control of the vessel.
  • Apply a Satinsky clamp or Judd Alyce clamp to the injury.
  • Large IVC defects may be repaired by using a patch from the peritoneum.
  • In patients with multiple injuries and exsanguinating hemorrhage, ligate the infrarenal IVC.
     
• Lateral perirenal hematoma or hemorrhage
  
  
  • This problem suggests injury to the renal vessels or kidneys.
  • Exploration after blunt trauma is not necessary in patients with a negative result on abdominal CT scan, preoperative intravenous pyelogram, or arteriogram, or if the hematoma is not expanding.
  • Penetrating injury usually indicates a necessity for exploration.
  • Obtain vascular control of the ipsilateral renal artery.
  • Expose the kidney and clamp the renal vessels if active bleeding from the kidney or an overlying retroperitoneum is present.
  • Only 30-40% of kidneys with arterial injuries can be salvaged. Before performing a nephrectomy, assess the viability of the contralateral kidney.
     
• Lateral pelvic hematoma or hemorrhage
  
  
  • This problem indicates injury to the iliac artery, iliac vein, or both.
  • Obtain vascular control at the aortic bifurcation proximally and close to the inguinal ligament distally.
  • If an injury to the right common iliac vein is present, it may require a division of the overlying right common iliac artery.
  • For best visualization of the internal iliac artery, elevate the common and external iliac arteries on vascular tapes.
  • Repair injuries to the common or external iliac arteries.
  • Treat injuries to the iliac veins with lateral venography or ligation.
  • Once initial control of the hemorrhage is completed and gross contamination is controlled, terminate the procedure and transfer the patient to the recovery room for further resuscitation. Measurement of abdominal compartment pressure may be needed.
     
• Hepatoduodenal ligament hematoma
  
  
  • This problem indicates injury to the portal vein, hepatic artery, or both.
  • Obtain vascular control by clamping the porta hepatis with vascular clamps proximal and distal to the injury (double Pringle maneuver).
  • Portal vein ligation may be required to expeditiously manage portal vein injuries if the patient is exsanguinating, although primary repair may be attempted.
  • Hepatic artery injuries are generally managed by ligation. If portal vein inflow is compromised, the liver should be assessed for ischemia, and restoration of hepatic arterial inflow or resectional debridement of the ischemic section should be undertaken or staged.

Postoperative Details

Patients may require aggressive resuscitation involving the correction of acidosis, active rewarming, and massive blood transfusion (>10 U of blood within 24 h).

Fresh frozen plasma, platelets, cryoprecipitate, or recombinant factor VIIa (rFVIIa) may be required on an individual basis to correct coagulopathy induced by massive transfusion.

A planned reoperation 24-48 hours after the initial procedure is done to complete a damage control sequence.

Complications

Early

• Ongoing bleeding
• Coagulopathy
• Abdominal compartment syndrome

Late

• Intra-abdominal infections
• Wound dehiscence
• Acute respiratory distress syndrome (ARDS)
• Pneumonia

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