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Abdominal vascular injury

Author: Megan Brenner, MD, MS, RPVI, FACS
Section Editors: Eileen M Bulger, MD, FACS, John F Eidt, MD, Joseph L Mills, Sr, MD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature rev iew current through: Apr 2020. | This topic last updated: Mar 20, 2020.

INTRODUCTION

Some of the most challenging and complex injuries involve trauma to vascular structures of the abdomen,
retroperitoneum, and pelvis. The hallmarks of vascular injury and its sequelae include difficulty obtaining
immediate proximal control and adequate exposure, repairing injury in the face of contamination, managing
the consequences of ischemia to critical end organs, and providing long-term surveillance to follow-up for
patency.

The general principles for identifying and managing abdominal vascular injury are reviewed here. The initial
management of the patient with blunt or penetrating abdominal injury that might result in vascular injury is
reviewed separately. (See "Initial evaluation and management of blunt abdominal trauma in adults" and
"Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and
management of abdominal gunshot wounds in adults".)

MECHANISM OF INJURY

The approach to the patient differs in many respects depending upon the mechanism of injury (ie, blunt
versus penetrating). Blunt abdominal trauma can result in diffuse arterial injury while injuries related to
penetrating mechanisms occur along the trajectory of the projectile(s). But whereas a knife will only cause
direct tissue injury to the location(s) through which it has traveled, gunshot wounds can also cause a
significant blast effect in the surrounding tissues.

Blunt injury to the abdominal aorta is much less common compared with blunt injury to the thoracic aorta,
occurring in <0.1 percent of blunt injury patients [1]. Blunt injuries to the aorta may arise from compression
between a seat belt and the spinal column (ie, seat belt aorta), which may be associated with other
compression injuries (ie, seat belt syndrome) such as vertebral (Chance) fracture, solid organ (kidney,
spleen), intestinal or pancreatic injuries, and abdominal wall injury (rectus abdominis rupture, abdominal
wall disruption) [2].

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Injury to the duodenum or pancreas can be also result in injuries to the superior mesenteric artery, superior
mesenteric vein, inferior vena cava, or portal vein, particularly in the setting of penetrating trauma. Blunt
mechanisms can result in intimal injuries to these vessels but rarely result in full-thickness injury or
transection.

Penetrating injuries to the solid organs (ie, spleen, liver, and kidneys) can significantly destroy the major
arterial supply and venous drainage. Blunt forces cause vascular injuries usually by stretching of the arteries
causing intimal tears, with larger tears at risk for thrombosis and/or embolization downstream to the end
organ. However, this is rare, occurring more commonly with the renal arteries. The vasculature within solid
organs can be significantly disrupted by either mechanism, producing significant lacerations,
pseudoaneurysms, or arteriovenous (AV) fistulas.

Pelvic fracture can be associated with iliac vessel injury with potential bleeding from branches of the internal
iliac arteries and veins. However, bleeding causing hemodynamic instability in the setting of pelvic fracture is
most commonly due to hemorrhage from the pelvic venous plexus. Transpelvic gunshot wounds can cause
partial- or full-thickness injuries to the aortoiliac vessels depending upon the trajectory and blast effect.
Contamination from associated rectal injuries complicates repair options.

CLINICAL FEATURES AND DIAGNOSIS

Initial findings — The clinical features associated with abdominal vascular injury are generally nonspecific
and can include abdominal distention/pain, back/flank pain, signs of end-organ ischemia (eg, abdominal
pain), or signs of ongoing blood loss (eg, hypotension, tachycardia, diaphoresis).

Abdominal distention related to blood loss into the abdominal cavity (ie, hemoperitoneum) from vascular
injury is usually associated with hemodynamic instability. Findings of flank bruising (Grey-Turner sign) or
scrotal ecchymosis are also nonspecific but may indicate retroperitoneal bleeding. If retroperitoneal injury is
associated with violation of the retroperitoneum such as with penetrating injury, significant hemorrhage will
freely enter into the peritoneal cavity, rapidly leading to shock. Blunt injuries often remain contained in the
retroperitoneum, but free anterior rupture can also occur. (See "Overview of the diagnosis and initial
management of traumatic retroperitoneal injury".)

Minor intimal injury or low-grade solid organ parenchymal injury is not appreciated on clinical examination,
but a high degree of suspicion based on mechanism of injury and physical exam may provide clues to its
presence. As examples, splenic or hepatic injury may be suspected, depending on the side impacted in
motor vehicle accident, and diminished or absent femoral pulses or scrotal hematoma can suggest bleeding
from the pelvis. Such findings warrant further investigation.

A diagnosis of abdominal vascular injury is typically heralded by finding free fluid on focused assessment
with sonography for trauma (FAST) in the emergency department. However, injuries limited to the
retroperitoneum have no or only a small amount of free blood in the intraperitoneal cavity. Significant
retroperitoneal venous injuries, such those involving the retrohepatic inferior vena cava, can be subtle, with
patients presenting initially with no signs or only with transient hypotension that is responsive to

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resuscitation. Such patients are at high risk for sudden cardiovascular collapse.

In hemodynamically unstable patients, the type and location of abdominal vascular injury is definitively
determined in the operating room in the context of damage control surgery. For hemodynamically stable
patients, advanced vascular imaging is usually needed to confirm suspected vascular injury. (See
'Abdominal/retroperitoneal exploration' below and 'Advanced vascular imaging' below.)

Delayed presentations — The incidence and timing of delayed presentations are unknown, as these are
overall rare. Subtle injury to the abdominal aorta can be asymptomatic and found incidentally on admission
imaging. Traumatic intimal tears can manifest as intimal flaps, which can be complicated by
thromboembolism and distal ischemia to extremities. (See 'Hemodynamically stable' below and "Embolism
to the lower extremities".)

Unless an injury to the superior mesenteric artery has caused complete occlusion, mesenteric ischemia
does not typically present acutely. Delayed presentations may be related to thrombosis or progression of a
dissection. (See "Overview of intestinal ischemia in adults" and "Acute mesenteric arterial occlusion" and
"Mesenteric venous thrombosis in adults".)

Advanced vascular imaging — Suspected abdominal vascular injury in a hemodynamically stable patient
requires advanced vascular imaging. It is not uncommon to need more than one imaging modality to
diagnose abdominal vascular injury. The choice depends upon the patient's clinical condition, physical
examination findings, and availability.

Computed tomographic (CT) angiography with intravascular contrast is widely available and the most
sensitive initial study to evaluate for abdominal vascular injury in the hemodynamically stable patient [3]. CT
angiography relies on contrast extravasation to demonstrate active bleeding. Thus, abdominal vascular injury
cannot be reliably ruled out without the use of contrast. CT angiography has a very low risk for renal toxicity
and should generally not be withheld if there is a significant risk of detecting abdominal vascular injury [4].
Surveillance of vascular injuries can be safely performed using repeat CT angiography within 24 to 72 hours.
If iodinated contrast cannot be safely administered (eg, severe allergy, renal dysfunction) and noncontrast CT
is performed, vascular injury may be suspected if hematoma is seen in the area of concern.

It is important to remember that patients with potentially significant vascular injury who appear
hemodynamically stable and who are taken for CT angiography are at high risk for rapid hemodynamic
decompensation. A decision to proceed to the CT scanner depends upon resources, time, and distance
required to travel to the scanner. At the very least, placing a common femoral arterial catheter for more
sensitive hemodynamic monitoring prior to leaving the resuscitation suite is wise. An additional benefit to this
practice is the ability to rapidly upsize the arterial catheter for resuscitative endovascular balloon occlusion of
the aorta (REBOA). In institutions where REBOA is part of clinical practice, the catheter may be inserted prior
to CT, allowing for rapid balloon inflation in the event of hemodynamic collapse. (See 'Role of REBOA' below.)

Conventional catheter-based aortography, which has been used for decades to identify vascular injury, has
certain advantages over CT angiography. Aortography is a dynamic study permitting direct visualization of flow
through the vessels in real time, particularly in areas of injury causing potential stenosis. In comparison, CT

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