Challenges in acute care surgery: penetrating vertebral artery injury in ‘extremis’ patient

Given a suspected VA injury in zone 2 in a patient in critical hemodynamic state, and not having immediate angioembolization, we decided to maintain temporary hemostatic control with a Foley balloon and extended the anterior sternocleidomastoid incision to a right supraclavicular approach (figure 2)...

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Bibliographic Details
Published in:	Trauma surgery & acute care open Vol. 6; no. 1; p. e000684
Main Authors:	Ramos Perkis, Juan Pablo, Goyenechea Miralles, Francisco, Rodriguez Galvan, Huascar, Benítez Pérez, Julio, Ottolino, Pablo
Format:	Journal Article
Language:	English
Published:	England BMJ Publishing Group Ltd 05-04-2021 BMJ Publishing Group LTD BMJ Publishing Group
Subjects:	Challenges in Trauma and Acute Care Surgery Embolization Ethics Injuries neck injuries Trauma vascular system injuries Veins & arteries vertebral artery vertebral artery neck injuries vascular system injuries
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Summary:	Given a suspected VA injury in zone 2 in a patient in critical hemodynamic state, and not having immediate angioembolization, we decided to maintain temporary hemostatic control with a Foley balloon and extended the anterior sternocleidomastoid incision to a right supraclavicular approach (figure 2). The main mechanism of trauma in the civil environment is by firearm with zone 2 being the most affected.1 2 In patients with hemodynamic stability, CT angiography is the best tool for diagnosis and management decisions.2 Endovascular angioembolization is the most frequently used treatment modality with the use of stents as a less common option.2 3 When the patient arrives with hemodynamic instability, as in the case presented, the diagnosis should be intraoperative after the evaluation of other vascular and aerodigestive lesions.1 In a damage control context, options such as ligation or packing with gauze are described for a lesion in zone 2.4 Control of this lesion is made difficult by its intraosseous route, therefore, use of clips or ligation in the proximal zone (zone 1) and the use of bone wax could be other hemostatic options. In centers that have hybrid operating rooms available, a joint approach can be performed to explore aerodigestive lesions and perform endovascular treatment in anatomic areas that are difficult to access. 1 3 4 Among the complications or sequelae of this injury, we find pseudoaneurysms, arterial-venous fistulas and infarcts in the cerebellar or medullary territory (Wallenberg syndrome), the latter being associated with a high mortality rate.5 6 Ethics statements Patient consent for publication Not required.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	2397-5776 2397-5776
DOI:	10.1136/tsaco-2021-000684