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Vascular injury may be present in up to 3% to 20% of cases of blunt and penetrating craniocervical injury.1 There are three major mechanisms of vascular trauma in the neck, penetrating, blunt, and strangulating. Blunt carotid and vertebral injuries (BCVI) are infrequent and are 1% to 3% of all injuries, but the mortality is much higher than penetrating neck injuries. BCVI has a mortality of 23% to 28%, and over 50% of survivors have permanent neurologic sequelae.2 Penetrating neck injuries comprise 1% of trauma registry cases but likely much less than 0.5% of all adult trauma; however, mortality is as high as 10%. The most common injuries are aerodigestive tract injuries (10%), but internal jugular (IJ) vein (9%) and carotid artery (6.6%) trauma is also frequent. Management of penetrating vascular trauma in the region of the neck requires a detailed understanding of both anatomy and surgical treatment options which we review in this chapter.


Historically, penetrating injuries to the neck are divided into three zones dictating management (Figure 43-1)3,4:

  • Zone I, originally located below the clavicles,3 later revised as below the cricoid membrane,4 includes the innominate vessels, the origin of the common carotid (CC) artery, the subclavian vessels and the vertebral artery, the brachial plexus, the trachea, the esophagus, the apex of the lung, and the thoracic duct and injuries are generally managed as thoracic injuries.

  • Zone II, between the cricoid cartilage and the angle of the mandible, includes the carotid and vertebral arteries, the IJ veins, trachea, and the esophagus. Management of these injuries has been most controversial and has evolved over the decades as will be discussed later.

  • Zone III, extending from the angle of the mandible to the base of the skull, includes the distal carotid and vertebral arteries and the pharynx, and injuries to this zone are most difficult to access and are mostly managed with endovascular techniques.


Saletta zones of the neck.

The right carotid arises from the brachiocephalic trunk, roughly at the sternoclavicular joint, while the left carotid arises from the arch of the aorta. Each CC then travels cephalad lateral to the trachea and esophagus within the carotid sheath and along the IJ veins and vagus nerves. The CC bifurcates around the superior border of the thyroid cartilage at the level of C4, giving rise to the internal carotid (IC), which continues cephalad within the carotid sheath and enters the skull, and the external carotid (EC), which exits the carotid sheath and supplies the thyroid, larynx, pharynx, face, and scalp. The IJ veins begin their course at the base of the skull at the jugular foramen and travel inferiorly in the carotid sheath lateral to the IC then the CC to join the subclavian vein ...

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