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KEY POINTS

KEY POINTS

  • Patients with gunshot wounds to the abdomen will have injury to a named abdominal vessel 20% to 25% of the time.

  • Abdominal vessel injuries will present with intraperitoneal hemorrhage; a contained mesenteric, retroperitoneal, or portal hematoma; thrombosis; or some combination of these.

  • Options for management of abdominal vessel injuries include nonoperative (intimal flap on computed tomography angiogram), endovascular (hostile abdomen, delayed diagnosis, or failed prior repair), and operative.

  • A midline supramesocolic hematoma is approached with a left-sided medial mobilization maneuver, whereas hemorrhage is approached directly through the lesser sac to the diaphragmatic aorta.

  • The proximal superior mesenteric artery and common and external iliac arteries should always be shunted and never ligated during damage control operations.

  • Ligation of the infrarenal inferior vena cava after a severe injury is more commonly practiced in the modern era and is usually well tolerated in young patients.

  • Endovascular stents or stent grafts are commonly placed to cover intimal defects or restore arterial flow after blunt injury of the renal artery.

  • An end-to-end anastomosis or interposition graft in the common or external iliac artery in the presence of significant enteric or colonic contamination has an increased rate of postoperative infection and subsequent arterial blowout.

  • Survival rates after abdominal arterial injuries are as follows: suprarenal aorta, 8% to 24%; infrarenal aorta, 34% to 58%; superior mesenteric artery, 40% to 61%; and iliac artery, 60% to 80%.

  • Survival rates after abdominal venous injuries are as follows: infrarenal inferior vena cava, 46% to 76%; superior mesenteric vein, 35% to 71%; iliac vein, 74% to 91%; and portal vein, 50%.

INTRODUCTION

Abdominal vessel injuries are among the most lethal injuries encountered by trauma surgeons because the vast majority of these patients arrive at trauma centers in profound hemorrhagic shock.1-4 Patients sustaining abdominal vessel injuries best exemplify the lethal vicious cycle of shock, with secondary hypothermia, acidosis, and a coagulopathy.

The major sites of hemorrhage in patients sustaining blunt or penetrating abdominal trauma are the viscera, the mesentery, and the major abdominal vessels. The term abdominal vascular or vessel injury generally refers to injury to major intraperitoneal or retroperitoneal vessels and is classified into four zones described as follows and in Table 38-1:

  • Zone 1: Midline retroperitoneum

    • Supramesocolic region

    • Inframesocolic region

  • Zone 2: Upper lateral retroperitoneum

  • Zone 3: Pelvic retroperitoneum

  • Zone 4: Porta hepatis/retrohepatic inferior vena cava

TABLE 38-1:Classification of Abdominal Vessel Injury

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