Carotid artery injuries, Joel Arudchelvam, SLSC 2022, Carotid artery injuries Causes Hard signs of vascular injury Associated signs Anatomy and neck zones Management Factors to consider Preoperative imaging Management – changing concepts Vascular surgical intervention Open surgery

1. Joel Arudchelvam
MBBS (Col), MD (Sur), MRCS (Eng), FCSSL(Hon)
Consultant Vascular and Transplant Surgeon

2. Carotid artery injury
 Carotid artery injury (CAI) occur in 4.9% to 6% following penetrating
neck injuries and in 1% to 2.6% following blunt neck injury
 Penetrating carotid injuries (PCI) result in a mortality rate of 22% to 33%
 PCI - about 23% stroke
Management of carotid artery trauma. Lee TS, Ducic Y, Gordin E, Stroman D. 3, 2014, Craniomaxillofacial trauma & reconstruction, Vol. 7, pp. 175–
189
Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad. 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.

3. Penetrating carotid artery injury
Causes
 Road traffic accidents
 Industrial injury
 Stab
 Iatrogenic
Penetrating Carotid Injuries, A Single Surgeon Experience . J Arudchelvam, C
Gurusinghe, AGAVJ Abeysinghe, N L Mohotti, N Gowcikan, N Harivallavan, R
Cassim, M Wijeyaratne. Colombo : s.n., 2022. Sri Lanka Surgical Congress 2022.

4. Penetrating carotid artery injury
 PCI involve common and internal carotid arteries
at similar rates
 Internal jugular venous injuries associated in
about 26%
Management of carotid artery trauma. Lee TS, Ducic Y, Gordin E, Stroman D. 3, 2014, Craniomaxillofacial trauma & reconstruction, Vol. 7, pp. 175–189
Carotid artery trauma: A review of contemporary trauma center experiences. Ramadan, Fuad. 1995, Journal of Vascular Surgery, Vol. 1, pp. 46-56.

5. Hard signs of vascular injury
 Active haemorrhage
 Expanding hematoma
 Hypotension not responding to fluid resuscitation
 Thrill or bruit
 Neurological deficit (PCI- about 23% stroke)
 Associated signs
 Horner's syndrome (due to associated sympathetic
chain injury)
 Features of injury to the last four cranial nerves

6. Anatomy and neck zones

7. Zone II injury

8. Anatomy and neck zones
 Zone 1
 Proximal common carotid
 Subclavian arteries
 Zone 2
 Distal common carotid
 Division of the carotid
 Internal and external carotid
arteries.
 Zone 3
 Internal carotid arteries.

9. Management
 Factors to consider
 Stability of the patient
 Signs of vascular injury
 Zone of injury
 Neurological status
 Associated aero-
digestive system injury

10. Preoperative imaging
 Stable patients
 Can undergo imaging – to
assess vascular or aero-
digestive tract injury
 Unstable patients
 Should go to the operation
theatre immediately

11. Management
“Changing concepts”
 Early period (1950 s) - mandatory exploration in whom
the platysma muscle was penetrated (8)
 Later (1970 s)- haemodynamic stability and the neck
zones
 Zone 2 should undergo mandatory exploration
irrespective of the haemodynamic stability
 Zone 1 / zone 3 needs further imaging if the patients are
haemodynamically stable (9).
8. Penetrating wounds of the neck. Fogelman MJ, Stewart RD. 1956, Am J Surg, Vol. 91, p. 581e93.
9. Carotid vertebral trauma. Monson DO, Saletta JD, Freeark RJ. 1969, J Trauma, Vol. 9, p. 987e99

12. Management – changing
concepts
 Current
 Haemodynamic stability
 Presence of aero-digestive
injuries.

13. Vascular surgical intervention
Options
Open
Endovascular

14. Open surgery
 Position
 Supine, sand bag in
between the scapula
 Neck slightly extended,
chin tilted upwards,
turned to the
contralateral side

15. Open surgery
 Skin preparation
 Neck, upper chest (to
expose the upper chest in
zone 1 injury for proximal
control)
 Mandibular area (for
mandibulotomy in zone 3
injury)

16. Open surgery
 Incision along the anterior
border of the
sternocleidomastoid
 For proximal carotid vessel
(Zone 1) - sternotomy
 For distal control (Zone 3) -
mandibulotomy
 Proximal and distal control – can
use endo-vascular balloon
occlusion

17. Open surgery
 Options
 Repair
 Direct arterial repair (lateral
arteriorrhaphy)
 Patch repair (venous and
synthetic)
 End to end repair
 Interposition graft repair (venous
or synthetic graft)
 Ligation
Penetrating Carotid Injuries, A Single Surgeon Experience . J Arudchelvam, C Gurusinghe, AGAVJ Abeysinghe, N L Mohotti, N
Gowcikan, N Harivallavan, R Cassim, M Wijeyaratne. Colombo : s.n., 2022. Sri Lanka Surgical Congress 2022.
Our experience
Sidewall laceration and
contusion (80%)
Direct repair (80%)
Interposition graft (20%)

18. Indications for ligation
 Persistent hypotension
 Fixed dilated pupils
 Signs of irreversible ischemic changes on the
computed tomography
 Internal carotid artery injury close to the base of the
skull
 Severe soft tissue injury to the neck
 Absent back bleeding during the surgery

19. Management
 Ligation is associated with
 Higher stroke rate - 56% vs 10% (13)
 Higher mortality - 50% vs 17% (2)
 compared to the repair group
 Repair should be done whenever possible provided
 No contraindications for repair
 Haemodynamically stable patient

20. Endovascular
 Endovascular options
 False aneurysm
 Intimal flaps
 Luminal narrowing
 To achieve proximal and distal control - zone 1 and 3
injuries

21. Neurological status and carotid repair
 Old believe
 Repair of carotid arteries was contraindicated in the
presence of a neurological deficit ( believed to convert
an ischaemic stroke into a haemorrhagic stroke)
 Recent studies showed that the majority died due to
cerebral edema due to ischemia than haemorrhagic
transformation

22. Neurological status and carotid repair
 In addition studies showed that revascularization
after prolonged neurological deficit and infarctions
improve after revascularization
 Probably due to the resolution of cerebral oedema
 Therefore revascularization even in the presence of a
neurological deficit is advised

23. Summary
 Repair is associated with
 Reduced stroke rate
 Reduced mortality
 Ligation of carotid artery is associated with
 Increased stroke rate
 Increased mortality
 Even in the presence of neurological status provided
the patient is stable and there are no contraindications