Abdominal Vascular Injuries Treatment & Management

Updated: Oct 06, 2016
  • Author: Stephen A Tonks, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Treatment

Approach Considerations

Essential to the successful management of these injuries is a thorough knowledge of intra-abdominal vascular anatomy and a familiarity with the techniques of proximal and distal control combined with selective application of primary repair, bypass, or ligation as indicated.

In the treatment of ruptured abdominal aortic aneurysm, Kimball et al conducted a retrospective study comparing standard primary abdominal closure with the initial use of the open abdomen using the vacuum-pack technique followed by delayed abdominal closure. [13] The investigators identified 3 ischemia-reperfusion criteria that predicted mortality and which were also useful as surrogate clinical markers for abdominal compartment syndrome: preoperative hypotension, estimated blood loss of 6 L or greater, or intraoperative resuscitation with 12 L or more.

Patients who had at least 1 of the 3 ischemia-reperfusion criteria had higher in-hospital mortality (43% vs 10%). [13] Of those who had at least 1 criterion, the initial 24-hour mortality as well as the 30-day mortality was higher in those in the primarily closed abdomen group relative to those in the 47% open abdomen group.

In a hypothermic traumatic shock swine model, Ding et al demonstrated that temporary intravascular shunts may improve survival in superior mesenteric artery (SMA) injuries compared with repair by primary vascular anastomosis. [14] Relative to pigs in the primary vascular anastomosis group, the animals treated with temporary shunting required less resuscitation fluid, retained higher superior mesenteric artery flow rates, normalized lactate levels faster, suffered less severe intestine histopathology, and had greater early survival. [14]

Although the investigators caution that further research is needed, they believe that in the setting of superior mesenteric artery transection, temporary intravascular shunts show promise for better management of damage control surgery than primary vascular anastomosis.

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Initial Resuscitation

Initial resuscitation of a patient with abdominal vascular injuries depends on his or her condition at arrival in the emergency department (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. Massive transfusion by protocol may be required for patients presenting with a shock index of greater than 0.9 or those that fail to respond to initial crystalloid resuscitation. [15, 16]

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. 

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive alternative to resuscitative thoracotomy that seems to show promise for the patient in extremis. [17]   After femoral artery access is obtained, the balloon catheter is advanced and inflated to achieve proximal occlusion of the aorta. 

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. Centers that potentially receive patients with these types of injuries should have in place massive transfusion protocols that direct administration of blood components (red blood cells, fresh frozen plasma, platelets) in a fixed ratio (eg, 1:1:1) or by point-of-care coagulation testing with viscoelastic technology. Start efforts to limit hypothermia as soon as the patient arrives. Ensure that prewarmed fluids, high-flow blood warmers, and prewarmed blankets are available.

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Surgical Care

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.

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 5 regions, as follows.

Midline supramesocolic hemorrhage or hematoma

Midline supramesocolic hemorrhage or hematoma (superior to the transverse mesocolon) is usually from an injury to the suprarenal aorta, celiac axis, proximal SMA, 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-side abdominal viscera (the Mattox maneuver) or an extensive Kocher maneuver on the right side. An injured celiac axis may be safely ligated in critical situations.

Mattox Maneuver Motion Graphic Simulation. By Matthew Bacchetta, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors. https://www.columbiadoctors.org/

Access to the SMA and the superior mesenteric vein (SMV) 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

Midline inframesocolic hemorrhage or hematoma results from infrarenal aortic or inferior vena cava (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, then rotate the right colon and small bowel medially (the Cattel-Braasch maneuver). Place an aortic clamp just below the left renal vein, and apply a distal clamp near the aortic bifurcation. Repair the injury primarily.

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 a 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 autologous vein, synthetic, or peritoneal patch. Ligation of the suprarenal IVC will lead to renal failure and should be avoided.  However, in patients with multiple injuries and exsanguinating hemorrhage, ligation of the infrarenal IVC may be indicated.  

Lateral perirenal hematoma or hemorrhage

Lateral perirenal hematoma or hemorrhage suggests injury to the renal vessels or kidneys. Exploration after blunt trauma is not necessary in patients with a negative result on abdominal computed tomography (CT) scanning, preoperative intravenous pyelography (IVP), or arteriography 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 expanding retroperitoneal hematoma 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

Lateral pelvic hematoma or hemorrhage suggests injury to the iliac artery, the 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 venorrhaphy 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

Hepatoduodenal ligament hematoma suggests injury to the portal vein, the hepatic artery, or both. Obtain vascular control by clamping the porta hepatis with vascular clamps proximal and distal to the injury (the double-Pringle maneuver).

Portal vein ligation may be required to manage portal vein injuries expeditiously if the patient is exsanguinating, though 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 measures

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 prothrombin complex concentrate may be required on an individual basis to correct coagulopathy induced by massive transfusion. In addition, aminocaproic acid or tranexamic acid may be given as inhibitors of trauma-associated hyperfibrinolysis if used early. A planned reoperation 24-48 hours after the initial procedure is done to complete a damage control sequence.

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