Diagnosis and management of penetrating thoracic vascular injury

Although penetrating vascular injuries only account for a small portion of thoracic trauma, they are challenging and can be lethal. Thus, it is imperative that the trauma surgeon understands how to diagnose and manage them. An abnormal pulse exam, an expanding hematoma, or active external hemorrhage are clear signs of a vascular injury. Imaging studies, such as CT angiography, provide valuable information in the hemodynamically normal patient. The patient who is hemodynamically compromised or hypotensive or both requires emergent exploration. The choice of incision is dependent on the anticipated vascular injury. In general, the incision should be versatile while providing optimal exposure. For a proximal carotid or subclavian injury, we favor a sternotomy with cervical or periclavicular extension, respectively, for proximal control on both sides of the thorax. Options for addressing arterial injuries include ligation, primary repair, patch angioplasty, and interposition grafting. Attempts should be made to repair all arterial injuries. However, most venous injuries, with the exception of caval injuries, can be ligated. Endovascular approaches may become more common in the future as the technology and experience progress. Damage control surgery and damage control resuscitation are important adjuncts to the management of these patients. Intravascular shunts are an option in the damage control setting. Complications after vascular repair include bleeding, thrombosis, and conduit infection. Bleeding should prompt immediate operative exploration. Other complications related to thoracic vascular trauma include concomitant pulmonary injuries. Lung-protective ventilator strategies and minimization of intravenous fluids can limit further iatrogenic injury.