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Management of penetrating carotid artery trauma at Hospital João XXIII. A comparison between arterial ligation and reconstruction
(Portuguese PDF version)

Daniel Mendes Pinto,¹ Leonardo Ghizoni Bez,¹ Ricardo Costa-Val,¹ Sérgio Figueiredo Campos Christo,¹ Eduardo Vergara Miguel²

1. Vascular Surgeon, Hospital João XXIII, Fundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG, Brazil.
2. Chiel of the Division of Vascular Surgery, Hospital João XXIII, Fundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG, Brazil.

Correspondence:
Daniel Mendes Pinto
Rua Padre Rolim, 383/904
CEP 30130-090 - Belo Horizonte, MG
Brazil
E-mail: dmpnet@terra.com.br

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ABSTRACT

Objective: To compare penetrating carotid trauma results in patients treated with arterial reconstruction or ligation.

Methods: Retrospective analysis of internal and common carotid trauma victims from February 1999 to May 2003, according to treatment and evolution of neurologic deficits.

Results: There were 28 penetrating carotid injuries (27 men, median age 22.2 years), submitted to 23 arterial reconstructions; two developed hemiplegia but no deaths were reported. Carotid ligation was made in five patients, with one death; two presented with definitive neurologic deficit. Arterial ligation was a statistically significant variable to neurologic deficit (P < 0.05). Two patients with previous neurologic deficit were treated with arterial reconstruction and discharged from hospital without symptoms. Eighteen cases had common carotid injuries (two patients developed neurologic deficit following arterial reconstruction) and 10 had internal carotid injuries (two patients developed neurologic deficits following ligation, one death reported).

Conclusion: Complications are less in arterial reconstruction of penetrating carotid trauma, including patients with or without previous neurologic deficit. Morbidity is greater in internal carotid lesions cases.

Key-words: carotid artery injuries, reconstructive surgical procedures, ligation.
Palavras-chave: lesões das artérias carótidas, procedimentos cirúrgicos reconstrutivos, ligadura.

J Vasc Br 2004;3(3):247-52

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Penetrating injuries to carotid artery are sometimes difficult to approach. Issues such as the relation between their management with arterial ligation and what procedure to follow in patients with neurologic deficit are still controversial.^1,2 The literature has been reporting series on isolated cases, and current information on how to treat injuries are usually based on literature review studies.^1-4 Hospital João XXIII is a trauma center in the metropolitan region of Belo Horizonte. Since 1998, the hospital counts on a service of vascular trauma records, which provided the data for our study.

In this article we assess penetrating common and internal carotid injuries managed in the Hospital in the periods from 1999 to 2003. The neurological complications associated with type of treatment and recommendations for arterial ligation were focused.

METHODS

Records of patients presented with penetrating injuries to common and internal carotid arteries, who entered the Vascular Trauma Division from February 1999 to May 2003, were analyzed. Among 825 cases found, 28 were selected to enter the study.

The patients' hemodynamic status was assessed through data on admission; hypovolemic shock was defined in systolic arterial pressure < 90 mmHg. Data on patients neurological status were registered according to the Glasgow coma scale (score of 8 or less is consistent with the definition of coma - the worst possible score is 3), and also by observing the presence of motor deficits (hemiplegia or hemiparesis) on admission and after surgical management. All patients presented Zone II injuries (the region above the cricoid cartilage and below the angle of the mandible) and underwent exploratory cervicotomy. The Hospital does not count on devices for arteriography, thus it was not carried out.

Vascular Doppler ultrasonography of the cervical zone was performed in three patients, depending on the availability of a vascular surgeon at the moment.

We tried to set a statistical significance relationship between neurologic deficits and the following variables: type of surgical procedure (arterial reconstruction or ligation), presence of hypovolemic shock, and neurological changes before surgery.

Comparison of differences in the frequency of events was accomplished with the chi-square and Fisher's exact tests, and statistical significance was established at P < 0.05.

RESULTS

In the period from February 1999 to May 2003, 28 records of penetrating injuries to carotid artery in 27 men and women, mean age 22.2 years (11 to 59 years) were entered. Eight penetrating injuries (29%) were caused by knife and 20 (71%) by gunshot.

Table 1 outlines treatments and complications. Eighteen patients had common carotid artery injuries, 16 were managed with arterial reconstruction and two with carotid arterial ligation. Two patients submitted to reconstruction had hemiplegia, and a cranial tomography diagnosed it was resultant from an ischemic stroke. In these patients, neurologic deficit remained until discharge from hospital. No deaths were reported in this group.

Table 1 - Injuries site, management and complications

Injuries site and management	Complications
Common carotid artery - 18 cases
16 arterial reconstruction	2 (13%) neurologic deficits /death
2 ligation	0 neurologic deficits /death
Internal carotid artery - 10 cases
7 arterial reconstructions	0 neurologic deficits /death
3 ligations	3 (100%) neurologic deficits /death
All injuries - 28 casos
23 reconstructions	2 (9%) neurologic deficits /death
5 ligations	3 (60%) neurologic deficits /death

Ten patients had internal carotid artery injuries; arterial ligation was performed in three: two presented with neurologic deficit, and the other had an early death. Those who underwent arterial reconstruction (seven) did not present neurologic deficit nor died.

Among all patients managed with arterial reconstruction, 9% presented permanent neurologic deficit (two cases in 23). In the group managed with carotid ligation, two cases presented motor degeneration or ischemic stroke and one patient died, accounting for 60% of complications. Development of neurologic deficit/death was higher in the group of patients with arterial ligation (P = 0.027) (Table 2), however, when death is excluded from the analysis, the statistical difference disappears (P = 0.09).

Table 2 - Evolution of 28 patients with penetrating carotid trauma

Evolution	Arterial reconstruction	Ligation
Permanent neurologic deficit at hospital discharge	2	2
Death	0	1
No neurologic deficit at hospital discharge	21	2
Total	23	5

Hypovolemic shock on admission (systolic arterial pressure < 90 mmHg) did not show to contribute to the development of neurologic deficit (P = 0.64) (Table 3).

Table 3 - Neurological development related to shock and neurological alteration on admission in 28 carotid artery injuries

	Development of neurologic deficit/death	No development of neurologic deficit/death	Total
Shock	2	10	12
No shock	3	13	16
Total	5	23	28
With neurological alteration on admission	1	2	3
Without neurological alteration on admission	4	21	25
Total	5	23	28

Three patients were already undergoing neurological alterations on admission at the emergency room (Table 3). All of them had contralateral motor deficit and reduction of level of consciousness (one Glasgow coma scale score 7, two Glasgow coma scale score 12). In patient score 7, the cranial tomography showed hypoperfusion in the brain hemisphere irrigated by the injured carotid; in the other two patients, cranial tomography was normal in one, and the other was not submitted to this examination. In both cases with Glasgow score 12, patients underwent arterial reconstruction and had an improvement in the neurological status. Both were discharged from hospital with no motor deficit.

Ligation was performed in the patient with hemiplegia on admission (distal injury in internal carotid artery - patient 5, Table 4, Glasgow score 7), and there was deterioration of the neurological status resultant from an ischemia in a brain hemisphere.

Among the 25 patients without neurological alterations on admission, three developed a permanent deficit (two after reconstruction, one after ligation) and one died due to intense bleeding of the internal carotid artery (patient 4, Table 4). The presence of neurological alteration on admission was not a statistically significant factor for development of permanent deficit/death (P = 0.45).

Table 4 - Causes for ligation of carotid arteries and post-operative evolution

Patient	Causes
1	Internal carotid artery thrombosis diagnosed with Doppler sonography, motor deficit installed, hemiplegia persisted after ligation.
2	Common carotid artery thrombosis diagnosed with Doppler sonography, no previous neurologic deficit, no development of neurological alterations
3	Cervical trauma with serious hemorrhage of the common carotid artery, no development of neurologic deficit after ligation.
4	Cervical trauma with serious hemorrhage of the internal carotid artery, extensive ischemic stroke, death.
5	Distal lesion in internal carotid artery, no conditions for reconstruction via cervicotomy, persistent hemiplegia and extensive cerebral hemisphere ischemia.

Five carotid artery ligations were performed, three in internal carotid arteries and two in common carotid arteries. The reason for surgical procedures were arterial thrombosis, massive bleeding and technical difficulties in the reconstruction, as shown in Table 4.

In the 23 cases of carotid artery reconstruction, the use of saphenous vein grafts predominated followed by reconstruction with polytetrafluorethylene (PTFE) interposition grafts (see Table 5). The two cases of reconstruction which had neurologic deficit were resultant from common carotid artery lesion; one was managed with saphenous vein interposition and the other with primary suture.

Table 5 - Type of reconstruction in 23 penetrating carotid injuries

	n	%
Saphenous vein interposition	9	39%
Interposition of PTFE prosthesis	8	35%
Primary suture	3	13%
Dissection and T-T anastomosis	2	9%
PTFE Patch	1	4%
Total	23	100%

DISCUSSION

The penetrating carotid artery trauma management has some controversial issues, such as the restoration of arterial flow in patients with neurologic deficits or with complete occlusion of the internal carotid artery. Another challenging question is if revascularization should be performed in patients with complete carotid transection and without neurological symptoms. Most of review articles suggest management with arterial reconstruction.^1,2

The first cases reported of penetrating injuries in the cervical zone were managed with ligation. David Fleming, in 1893, performed the first successful ligation of a common carotid artery injury caused by a sword cut. The patient survived and made an uninterrupted recovery without neurological damage.⁷

Cohen⁸ and Bradley⁹ analyzed patients submitted to arterial reconstruction during an acute phase of ischemia. They concluded that the cerebral blood flow restoration leads to hemorrhagic stroke, suggesting that the management of traumatic injuries should be performed with ligation. The transformation of an ischemic stroke into an hemorrhagic stroke is a matter of concern and it is significant in the trauma, as observations on endarterectomy procedures in acute strokes suggested.

Ledgerwood has called the attention to the fact that patients with neurological degeneration resultant from cerebral vascularization had cerebral edema.¹⁰ Since then, several publications have stressed the employment of arterial reconstruction in the management of carotid trauma, highlighting that the cerebral edema was more important than the hemorrhagic transformation.^1-4,¹¹ Besides, even if during the reconstruction procedures embolization and transitory cerebral ischemia may happen, its use is preferable than the ligation, as the rate of complications following ligation is higher.^2,3,^12,13 Data found in our study do not match the literature, as reconstruction procedures may present neurologic deficit cases, but in a lower rate than ligation.

The endovascular management of patients with penetrating traumatic injuries is described by some authors, but its employment in the acute phase of the trauma is still controversial.¹⁴

Percutanous management is specially used to approach the complications of the penetrating trauma, such as pseudoanuerysm or fistualae.¹⁵ Patients were not submitted to arteriography because the Hospital does not offer haemodynamic monitoring or angioradiology services in the surgical unit.

Five ligation procedures were performed in patients with internal carotid artery thrombosis (diagnosed with Doppler-sonography), volumous bleeding and technical difficulty for reconstruction. Three patients underwent cervical Doppler; and two were diagnosed with internal carotid artery thrombosis. Today, Doppler sonography of cervical vessels and angiographic computed tomography have been used to study stable patients, with no diagnostic damage,^16,17 and these are the procedure followed at Hospital João XXIII. Several authors say that, even in completely obstructed carotid arteries of asymptomatic patients (with no neurologic deficit), arterial restoration should be carried out, due to a smaller rate of subsequent complications,²,^18-21 especially in internal carotid artery injuries. In our series, all ligations made in internal carotid arteries underwent complications (two neurologic deficits, one death); and in the overall picture (internal and common carotid artery injuries), the incidence of complications was smaller in the group submitted to arteries reconstruction.

Discussion about arterial revascularization or ligation procedures is also undertaken concerning patients with trauma and neurologic deficit. There are many reasons for conscience level to be reduced in a patient with trauma: hypovolemia, alcoohol or drug levels, sedatives used in intubation and administered by the pre-hospital care personnel, besides the cerebral ischemia caused by carotid injury. Most of times it is not possible to evaluate the importance of these factors in the patients' management. Among the three patients who presented with neurological alterations on admission, two were submitted to reconstruction and showed improvement (both with reduced conscience level and motor deficit contralateral to the cervical lesion), and were asymptomatic on discharge from hospital. In the other, who underwent ligation, hemiplegia persisted.

In two cases, patients had serious hemodynamic deterioration. Arterial ligation was made because of volumous cervical bleeding, acting as a damage control. Ligation is recommended in these cases, and can be made in other great vessels.²²

When bleeding from distal stump is difficult to control, such as in lesions of the high internal carotid, or when there are no ideal conditions for safe control of the distal stump, especially if it is thrombosed (with risk of embolization during manipulation), ligation becomes an important option.²,²² One patient of the present study underwent this situation (case 5 - Table 4) and remained with severe cerebral ischemia.

CONCLUSION

Data from this study have shown that carotid arteries reconstruction should be experimented for penetrating injuries, both in asymptomatic and with neurologic deficit patients, as it presents a smaller incidence rate of complications and the possibility of neurological symptoms improvement. Despite the small number of cases, which prevents us from making strong causality relations, injuries in the internal carotid should be reconstructed, due to the high incidence of complications related to the ligation. The arterial ligation is a good option in situations where the distal stump of internal carotid artery is difficult to control and when there is volumous bleeding; many times in patients with multiple penetrating traumas, where damage control in the cervical region should be made.

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