Trauma: Abdominal/Pelvic Vascular Trauma

Abdominal/Pelvic Vascular Injury

AAST Abdominal Vascular Injury Scale

Retroperitoneal Hematoma Management

  • Zone I (Central): Mandatory Exploration
    • *Between Kidneys from Diaphragm to IVC Bifurcation
    • Associated with Pancreaticoduodenal & Major Vascular Injury
  • Zone II (Lateral):
    • Penetrating: Selective Exploration
    • Blunt: Open Only if Expanding, Pulsatile or with Active Hemorrhage
    • *First Step: Palpate Contralateral Kidney to Assess Size & Determine Need for Heroic Measures to Save Ipsilateral Kidney
  • Zone III (Pelvis):
    • Penetrating: Mandatory Exploration
    • Blunt: Open Only if Expanding, Pulsatile or with Active Hemorrhage

Retroperitoneal Zones

Aorta Injury

  • Small: Lateral Aortorrhaphy with Permanent Suture
    • Connect Multiple Wounds if Close to Each Other
  • Large or Significant Narrowing: Patch Angioplasty
    • Consider Interposition Graft if Infrarenal

IVC Injury

  • Retrohepatic IVC Injury
  • Infrahepatic IVC Injury
    • Stable:
      • < 50% Diameter: Primary Repair (Venorrhaphy)
      • > 50% Diameter: Patch (Saphenous Vein or Synthetic)
    • Unstable: Infrarenal Ligation
      • Monitor for Compartment Syndrome
    • Considerations:
      • Apply Pressure to Stop Bleeding
        • Do Not Clamp (Will Tear Easily)
      • Posterior Wall Injury: Cut Through Anterior Wall to Access
      • May Require Right Common Iliac Division to Visualize Distal IVC or Bifurcation
        • Primary Repair Artery Later

Arterial Branch Injuries

Celiac Axis

  • Simple: Arteriorrhaphy
  • Complex: Ligate (Good Collaterals)
    • Gallbladder Has Poor Collaterals – Cholecystectomy Indicated

Common Hepatic Artery

Renal Artery

  • Small: Lateral Arteriorrhaphy
  • Large: Interposition Graft (Saphenous or PTFE)
  • Damage Control: Nephrectomy
    • Only if Contralateral Kidney Palpated as Normal

Superior Mesenteric Artery

  • Fullen Classification
    • Zone I – Proximal to First Branch (Inferior Pancreaticoduodenal)
    • Zone II – Distal to First Branch
    • Zone III – Distal to Middle Colic
    • Zone IV – Segmental Branches
  • Proximal (Zone I/II):
    • Stable: Primary Repair vs Bypass Graft to Distal Infrarenal Aorta
      • Cover Graft with Retroperitoneal Fat or Omentum to Prevent Aortoenteric Fistula
    • Unstable: Primary Repair vs Ligation
      • Consider Intraluminal Shunt in Damage Control to Avoid Ligation
      • Collaterals Often Inadequate for Ligation if Unstable
    • Distal (Zone III/IV): Primary Repair vs Ligation
      • Ligation Poorly Tolerated Since Distal to Collaterals

Inferior Mesenteric Artery

  • < 50% Diameter: Primary Repair
  • > 50% Diameter: Ligate

Iliac Arteries

  • Common or External Iliac: Repair
    • Options:
      • Lateral Arteriorrhaphy
      • Grafting
      • Replace with Mobilized Ipsilateral Internal Iliac
      • Transposition to Contralateral Iliacs if at Bifurcation
    • Consider Extra-Anatomic Bypass if Significant Contamination Present
  • Internal Iliac: Can Ligate Both with Impunity

Abdominal Vasculature

Celiac Artery 1

Celiac Artery 1

SMA 1

IMA 1

Venous Injuries

Other Venous Injury

  • Can Ligate Any Vein Distal to Renals If Necessary

Superior Mesenteric Vein

  • Repair vs Ligation

Portal Vein Injury

Renal Veins

  • Left Renal Vein
    • Good Collaterals (Adrenal/Gonadal)
    • Tx: Lateral Venorrhaphy
      • If Unable or Damage Control: Ligate Near IVC
  • Right Renal Vein
    • Shorter Than Left, Poor Collaterals
    • Tx: Lateral Venorrhaphy
      • If Forced to Ligate Preform Nephrectomy Also

References

  1. Gray H. Anatomy of the Human Body (1918). Public Domain.