Major blood vessels are in proximity to other vital structures in the neck and base of skull. Infections and tumors of the head and neck can invade vascular structures. Vascular injuries can lead to massive hemorrhage, cerebral ischemia, or stroke. Emergency and definitive management can be challenging.
Key learning points
At the end of this article, the reader will:
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Understand the risk factors for vascular injury.
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Be able to identify and classify vascular injuries.
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Know the options for emergency management of vascular injuries.
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Know the options for definitive management of vascular injuries.
Introduction
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Major blood vessels are in proximity to other vital structures in the neck and base of skull.
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Infections and tumors of the head and neck can invade vascular structures.
- •
Vascular injuries can lead to massive hemorrhage.
- •
Vascular injuries can lead to cerebral ischemia or stroke.
- •
Emergency and definitive management can be challenging.
Intraoperative injury to the carotid artery can rapidly lead to exsanguinating hemorrhage. Depending on the location of the injury, vascular control may be straightforward or extremely challenging. Exposure of the carotid artery at the base of the neck or the base of the skull may require a coordinated effort between 2 or 3 surgical subspecialty services. Potential for neurologic injury (ie, stroke) may affect management strategies. Endovascular approaches, if available and feasible, have revolutionized the management of these situations. Open procedures, however, may be necessary or preferable in some circumstances. This article focuses on the open surgical approaches for control of hemorrhage intraoperatively and postoperatively. Open operative management of the carotid blowout is discussed briefly with more in-depth discussion in other articles.
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Tumor in close proximity to carotid artery
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Previous radiation
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Presence of infection
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Previous operations
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Level of surgeon’s experience
Intraoperative injury to major vascular structures can be avoided with appropriate preoperative evaluation of the patient and meticulous operative technique. Tumors near vital structures may be amenable to neoadjuvant therapy to shrink the tumor and facilitate the resection. This potential benefit should be weighed against the downside of the tissue changes caused by radiation, however. Previous operations and infections may also add fibrosis that makes the dissection more difficult.
Introduction
- •
Major blood vessels are in proximity to other vital structures in the neck and base of skull.
- •
Infections and tumors of the head and neck can invade vascular structures.
- •
Vascular injuries can lead to massive hemorrhage.
- •
Vascular injuries can lead to cerebral ischemia or stroke.
- •
Emergency and definitive management can be challenging.
Intraoperative injury to the carotid artery can rapidly lead to exsanguinating hemorrhage. Depending on the location of the injury, vascular control may be straightforward or extremely challenging. Exposure of the carotid artery at the base of the neck or the base of the skull may require a coordinated effort between 2 or 3 surgical subspecialty services. Potential for neurologic injury (ie, stroke) may affect management strategies. Endovascular approaches, if available and feasible, have revolutionized the management of these situations. Open procedures, however, may be necessary or preferable in some circumstances. This article focuses on the open surgical approaches for control of hemorrhage intraoperatively and postoperatively. Open operative management of the carotid blowout is discussed briefly with more in-depth discussion in other articles.
- •
Tumor in close proximity to carotid artery
- •
Previous radiation
- •
Presence of infection
- •
Previous operations
- •
Level of surgeon’s experience
Intraoperative injury to major vascular structures can be avoided with appropriate preoperative evaluation of the patient and meticulous operative technique. Tumors near vital structures may be amenable to neoadjuvant therapy to shrink the tumor and facilitate the resection. This potential benefit should be weighed against the downside of the tissue changes caused by radiation, however. Previous operations and infections may also add fibrosis that makes the dissection more difficult.
Initial resuscitation from vascular injury
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Airway management
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Breathing
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Circulation
The management of a life-threatening situation is initially focused on airway, breathing, and circulation. If a patient does not already have an endotracheal tube or surgical airway in place, the airway should be secured in most of these situations. Once airway access is assured, the adequacy of ventilation should be assessed. Bleeding from the oral cavity can enter the airway via the larynx. Bleeding from the neck can enter the airway via a surgical stoma. Significant amounts of blood in the lungs can cause severe hypoxemia. The airway should be aggressively suctioned. Fiberoptic bronchoscopy may be needed to adequately clear the airway.
Management of circulatory compromise from hemorrhage involves simultaneous fluid resuscitation and procedures to achieve hemostasis.
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Adequate venous access
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Activate massive transfusion protocol
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Transfuse packed red blood cells
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Hemostatic resuscitation
Fluid resuscitation from intraoperative or postoperative hemorrhage should follow the principles of resuscitation from traumatic hemorrhagic shock. Venous access needs to be obtained with at least 2 large-bore catheters. The blood bank should be alerted because there may be a need for large amounts of blood products quickly. Many hospitals have established transfusion protocols in preparation for vascular emergencies. If a patient is hypotensive, that patient has most likely lost at least 30% to 40% of blood volume. Blood products should be administered as soon as possible, using O-negative blood if necessary. If a patient is hypotensive, the goal of fluid resuscitation should be to prevent cardiac arrest but not necessarily to achieve normotension unless cerebral blood flow may be comprised at this time. This permissive hypotension may decrease hemorrhage temporarily but may, in some cases, increase the risk of stroke.
Once bleeding has been controlled, restoring adequate vital organ perfusion as rapidly as possible should be the priority. Recent trauma literature suggests that a hemostatic resuscitation approach, in which fresh frozen plasma and platelets are transfused along with the red cells to prevent dilutional coagulopathy, may be beneficial. The optimal ratio for these products is not clear. All fluids should be warmed during infusion to help prevent hypothermia. The antifibrinolytic agent, tranexamic acid, may also decrease blood loss.
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Vascular surgery principles
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Obtain proximal vascular control
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Obtain distal vascular control
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Restore flow as soon as possible
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Consider temporary vascular shunt to restore cerebral perfusion
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Assess the injury location and severity
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Options for definitive management
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Ligation
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Repair
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Bypass
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Zones of the neck (trauma perspective)
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Zone I: sternal notch to cricoid
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Zone II: cricoid to angle of mandible
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Zone III: above the angle of the mandible
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