Penetrating trauma in the endovascular era

Roberto Chiesa

By Roberto Chiesa

The dawn of modern vascular traumatology dates back to World War II and is associated with two important aspects: the use of powerful weapons and the shortening in evacuation time. The introduction of high energy firearms in modern warfare has led to a more frequent deep vascular involvement, with important bleeding or ischaemic consequences. Similarly the widespread adoption of explosives caused an increased number of limb-lesions characterised by extensive soft tissue/bone disruption (the so called “Shrapnel wound”), often needing primary emergent amputation.

Another lesson coming from war surgery was that, in case of war trauma,
the time lapse between wounding and treatment is crucial for limb salvage. As an example, during World War II, the mean evacuation time was 10 hours with an amputation rate of 50%. In the Vietnam War the introduction of immediate evacuation by helicopter reduced the amputation rate to 10%.

The same concepts hold true in the civilian setting, but with the difference of availability of endovascular techniques. The lower and upper limbs are the most common site for penetrating lesions in civilian series and account for more than 60% of cases. In the lower limbs, the role of classic surgery is important as it allows to deal with associated bone fractures and to perform immediate decompression surgery when needed.

Similarly, lesions to the upper limbs are often associated to nerve lesions, which requires prompt concomitant repair. Another issue in cases of penetrating trauma to upper limbs is the frequent presence of arterial thrombosis, specifically to the brachial artery, where mechanical thrombectomy is mandatory. Moreover, involvement of the upper limbs in work-related penetrating trauma is often localised in the forearms with transection of the wrist arteries, thus requiring microsurgical reconstruction.

Although the progress in surgical techniques, major series of penetrating trauma of the limbs still report a grim prognosis, and
amputation, in our personal experience, remains as high as 30%. Endovascular treatment has a specific role in the correction of bleeding from small vessels, typically with embolisation of small muscular arterial branches. 

Neck wounds, due to gunshot or stabbing, are the second most common injury site in civilian series. Even in this situation, the mainstay of treatment is surgical exploration with direct repair of the damaged vessel, avoiding blind extraction of eventual foreign bodies.
Modern endovascular techniques have a role in specific situations such as those where immediate control of bleeding with open surgery cannot be accomplished rapidly (typically in the case of lesions limited to the intrathoracic segment of the supra-aortic vessels). 

Aortic penetrating lesions are, in our personal experience, a rare but catastrophic entity. These lesions represent an extreme event that is almost invariably fatal before any treatment can be even attempted and with characteristics that are often unsuitable for endovascular repair. The reason for this is that, due to the characteristics of the injury mechanism itself, the nearby organs are invariably extensively involved with important concomitant bleeding.

Due to the complexity of the topic,
a modern approach to penetrating trauma can only be multidisciplinary, with strict cooperation between different specialists. An aggressive and early open surgical treatment is of mandatory importance, as it allows treating the vascular injury and, at the same time, resolving associated nerve and bone lesions.

Repair of the vascular lesion with direct suture of the vessel wall is often the only reconstruction needed. When extensive damage is present and bypassing is required, the use of autologous vein grafts is advisable as these lesions are invariably grossly contaminated.

Although the progress of vascular surgery, penetrating vascular trauma still entails high morbidity and mortality, and direct amputation often remains the only possible option. Endovascular treatment, although extremely valuable in specific situations, has yet a limited role in this setting and sometimes can be used as a bridging option to a more definitive surgical correction.

Roberto Chiesa is professor of vascular surgery and director, Unit of Vascular Surgery, San Raffaele Hospital, Milan, Italy.