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Injury to the visceral portion of the abdominal aorta may involve the celiac artery, the superior mesenteric artery (SMA), or one of the renal arteries (RA). Injuries to any of these arteries are uncommon. Ligation rather than repair is used frequently for the celiac artery, and survival for all those with open approaches approximates 40% to 60% when penetrating wounds cause greater than 85% of injuries (Table 13-1).1,2 The other and least important visceral vessel is the inferior mesenteric artery arising from the infrarenal abdominal aorta.
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Major mesenteric vascular injuries (perforation, transection, and thrombosis from contact with missile) are most commonly caused by penetrating wounds. In contrast, proximal intimal tears with or without an associated thrombosis are occasionally seen after deceleration trauma in motor vehicle crashes. Diagnosis is carried out at operation after penetrating wounds. However, intimal tears of the SMA without thrombosis will only be detected if duplex ultrasonography, traditional abdominal aortography, or computed tomographic (CT) aortography is performed. Operative management of a penetrating injury to either the celiac axis or the proximal SMA is difficult because of the following issues: (1) retroperitoneal location; (2) proximity of the two vessels; (3) overlying celiac ganglia and lymphatics (celiac artery) and pancreas (SMA); (4) associated injuries in the upper abdomen to the visceral abdominal aorta, superior mesenteric vein, pancreas, and gastrointestinal tract; and (5) the fact that a proximal injury to the SMA should never be ligated without restoring flow to the midgut. Endovascular management is particularly helpful in patients with intimal tears, late diagnosis of an injury, or complications of an open repair.
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Renal vascular injuries are as uncommon as those to the SMA. The incidence of blunt injuries (intimal tear with or without thrombosis) is, however, recognized to be significantly higher in the modern era with the routine use of contrast-enhanced CT in hemodynamically stable patients. The principles of operative management of a penetrating injury to a renal artery are as follows: (1) always palpate for the presence of a normal contralateral kidney before deciding on repair of a through-and-through injury or a transection; (2) ligation of a solitary renal artery will result in loss of the kidney; (3) repair of a single renal artery ...