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Vascular Trauma: Abdominal


Abdominal vascular injuries are the most common cause of death after penetrating abdominal trauma. Accurate diagnosis, rapid surgical exposure and control, and the definitive management of these injuries may challenge the skills and judgment of even the most experienced surgeons. These can be made even more complex by any associated intraabdominal injuries. Rapid transportation to a trauma center, early recognition of the injuries, early surgical intervention, excellent knowledge of the anatomy, and good surgical judgment are critical for optimizing patient survival.

Surgical Anatomy

For vascular trauma purposes, the abdomen is conventionally divided into the intraperitoneal and retroperitoneal areas. The retroperitoneum is further divided into four distinct zones ( Fig. 182.1 ):

  • Zone 1, which includes the midline retroperitoneum extending from the aortic hiatus to the sacral promontory. This zone is subdivided into the supramesocolic and inframesocolic areas. The supramesocolic area contains the suprarenal aorta and its major branches (celiac axis, superior mesenteric artery [SMA], and renal arteries), the supramesocolic inferior vena cava (IVC) with its major branches, and the superior mesenteric vein (SMV). The inframesocolic area contains the infrarenal aorta and IVC.

  • Zone 2 (left and right), which includes the kidneys, paracolic gutter, and renal vessels.

  • Zone 3, which includes the pelvic retroperitoneum and contains the iliac vessels.

  • Zone 4, which includes the perihepatic area containing the retrohepatic IVC and hepatic veins.

Figure 182.1, Retroperitoneal Vascular Zones.

Epidemiology

Penetrating trauma is responsible for most abdominal vascular injuries and accounts for approximately 90% of cases in urban trauma centers. Low-velocity missiles cause direct injury to the vessel. High-velocity missiles and blast can also cause injury by means of a shock wave and transient cavitation. These injuries may manifest as early or late thrombosis, in addition to hemorrhage.

In patients who undergo exploratory laparotomy for injury, the incidence of vascular trauma is 14.3% for gunshot injuries, 10% for stab wounds, and 3% for blunt injuries.

Blunt abdominal trauma may cause vascular injuries by one of three mechanisms:

  • 1.

    Rapid deceleration, as occurs in high-speed vehicular collisions or falls from height; this can cause avulsion or intimal tearing and subsequent thrombosis.

  • 2.

    Direct anteroposterior crushing, from a seat belt or a direct blow to the anterior abdomen.

  • 3.

    Direct laceration of a major vessel by a bone fragment, for example with severe pelvic fractures.

Abdominal arterial and venous injuries occur with the same incidence. In a review of 302 abdominal vascular injuries from our center, the incidence of arterial injuries was 49% and that of venous injuries was 51%. The most commonly injured abdominal vessel was the IVC, accounting for 25% of injuries, followed by the aorta (21%), iliac arteries (20%), iliac veins (17%), SMV (11%), and SMA (10%). Overall, patients with penetrating trauma who sustained a vascular injury had an average of 1.7 vascular injuries per patient.

Clinical Presentation

Many patients with major abdominal vascular injuries die at the scene. Of the patients who are transported to a hospital, approximately 14% lose vital signs en route or on arrival in the emergency department. The clinical presentation depends on the injured vessel, the size and type of injury, the intraperitoneal or retroperitoneal location of injury, the presence of associated injuries, and the time elapsed.

Penetrating injuries to the abdomen associated with hypotension and abdominal distention are highly suggestive of vascular injury. Asymmetric femoral pulses may indicate iliac artery injury. Many patients may be normotensive on admission only to decompensate a few minutes later. Some patients present in a hemodynamically stable condition because of thrombosis of the vessel or containment of the bleeding in the retroperitoneum. In most cases the diagnosis is made intraoperatively.

Diagnostic Evaluation

In most patients with abdominal vascular injuries, no investigations are needed because of the altered hemodynamics and obvious need for immediate laparotomy. For penetrating injuries, hemodynamic instability, peritonitis on examination, or an unevaluable patient mandates immediate laparotomy and any vascular injuries will be diagnosed intraoperatively. Whenever possible, plain radiographs should be obtained ( Fig. 182.2 ) for localizing any bullet fragments. If the patient does not require immediate laparotomy and is to undergo a trial of nonoperative management, CT would be the next diagnostic evaluation and has excellent sensitivity and specificity for vascular injury ( Figs. 182.3 and 182.4 ). For blunt trauma, peritonitis or hemodynamic instability with a positive abdominal FAST (Focused Assessment with Sonography in Trauma) exam requires immediate laparotomy. For unstable patients with negative FAST, a diagnostic peritoneal aspirate is performed to exclude a false negative FAST and other sources of bleeding are sought. This includes the retroperitoneum, ideally imaged using CT ( Fig. 182.5 ). In selected cases, such as asymmetrical femoral pulses following abdominal trauma in the stable patient, catheter angiography may have diagnostic and therapeutic value ( Fig. 182.6 ).

Figure 182.2, The pelvic location of the missile on the abdominal radiograph, combined with hypotension, is highly suggestive of an iliac vascular injury.

Figure 182.3, ( A ) Computed tomography (CT) scan of a traffic accident victim shows a large pelvic hematoma (circle) due to injury of the right common iliac artery. ( B ) CT scan with intravenous administration of contrast material in a high-speed traffic accident patient shows poor uptake of the contrast agent in the right kidney because of occlusion of the renal artery (circle) .

Figure 182.4, Postoperative computed tomography scan of a patient with a gunshot wound shows an abdominal aortic false aneurysm (circle) .

Figure 182.5, Algorithm for the Evaluation of Abdominal Trauma.

Figure 182.6, A 5-year-old child presented with a severe pelvic fracture and absent right femoral pulse. Angiography shows a complete occlusion of the right common iliac artery (arrow) .

Treatment

Prehospital Treatment

The most important factor for the survival of salvageable patients with vascular injuries is rapid transportation to a trauma center, followed by immediate surgical control of the bleeding. Prehospital advanced life support has no place in penetrating trauma, especially in an urban environment. A policy of “scoop and run” is currently the recommended approach. The role of prehospital intravenous fluid administration is controversial; some studies show improved survival with fluid restriction and others show no effect on survival. Experimental work on abdominal aortic injuries has shown that, in the presence of uncontrolled bleeding, aggressive fluid resuscitation increases mortality and the rate and volume of hemorrhage. , However, avoidance of all fluid resuscitation in near-fatal hemorrhage may result in cardiac arrest before bleeding is controlled. It seems that some degree of controlled hypotension is beneficial and prevents massive exsanguination while avoiding the risk of cardiac arrest due to massive blood loss and severe hypotension. , Experimental work suggests that a systolic pressure of 80 to 90 mm Hg is the optimal pressure in the presence of active vascular bleeding.

Emergency Department Treatment

The extent of resuscitation required in the emergency department depends on the clinical condition of the patient. For patients arriving in cardiac arrest, endotracheal intubation and a resuscitative thoracotomy should be performed in the emergency department. A left anterolateral thoracotomy through the fourth to fifth intercostal space is performed, the thoracic aorta is cross-clamped, and the heart is resuscitated. If cardiac activity returns, the operation is completed in the operating room. The survival rate after resuscitative thoracotomy for abdominal vascular injuries is approximately 2%.

An attractive alternative to resuscitative thoracotomy for patients with suspected intraabdominal vascular injury, particularly in the pelvis, is endoluminal aortic occlusion with use of a percutaneous balloon inserted through the femoral artery. , The balloon is inflated in the distal thoracic aorta. The aortic occlusion reduces intraabdominal bleeding and facilitates resuscitation. Experimental work comparing endoluminal balloon aortic occlusion to thoracotomy with aortic clamping in a model of hemorrhagic shock showed that aortic balloon occlusion was associated with increased central perfusion pressures with less physiologic disturbance, and clinical experience with this technique is rapidly increasing.

In all other patients with suspected vascular injuries, large-bore intravenous catheters should be placed in the upper extremities or the central veins of the thoracic inlet. Femoral vein catheters should be avoided in case the victim has an injury to the IVC or the iliac veins. As discussed earlier, the concept of controlled hypotension should be borne in mind, and aggressive fluid resuscitation should be avoided. Except for patients in cardiac arrest or at risk for imminent cardiac arrest, endotracheal intubation should be avoided in the emergency department because rapid sequence induction is often associated with cardiovascular decompensation.

Surgical Treatment

General Principles

All possible steps should be taken to mitigate heat loss and hypothermia. All infused fluids should be prewarmed to 40°–42°C, and the patient’s extremities should be covered with a warming blanket. Rapid infusion devices should be ready, and the blood bank should be notified. After a vascular injury is identified, the aggressive replacement of shed blood with products in a 1:1:1 ratio directed by a massive transfusion protocol has been demonstrated to improve outcomes. The patient’s entire torso, from the neck to the knees, should be prepared and draped. Although the initial incision is a full midline laparotomy, additional thoracotomy or saphenous vein harvesting may become necessary. The surgical team should be ready, and the skin preparation should be performed before induction of anesthesia because it is often associated with rapid hemodynamic decompensation in these patients.

Some surgeons have advocated a preliminary left thoracotomy and aortic cross-clamping to prevent cardiovascular collapse after anesthesia and laparotomy. , The effectiveness of this procedure has been challenged by other authors. We believe that this approach should be considered only for patients at risk of imminent cardiac arrest. A thoracotomy is an additional traumatic insult that may aggravate hypothermia and coagulopathy and has little effect on the control of bleeding from major venous injuries. We advocate an immediate laparotomy, temporary control of bleeding by direct compression, and aortic cross-clamping, if necessary, at the diaphragm. In our experience, this is almost always possible, even in obese patients. To facilitate aortic exposure, division of the left crus of the diaphragm may be necessary. In cases where a retroperitoneal hematoma extends high toward the aortic hiatus, infradiaphragmatic exposure of the aorta is difficult, and a left thoracotomy may be necessary for aortic control.

Endoluminal aortic occlusion, as described before, is promising but still underused. The use of this technique intraoperatively can reduce the need for thoracotomy for proximal vascular control. In addition, it may make the exploration of anatomically difficult upper zone 1 hematomas safer and easier. Training of surgeons in the use of this technique may add a useful tool to the armamentarium available for the management of these complex cases.

Retroperitoneal Hematoma

The management of retroperitoneal hematomas depends on the mechanism of injury. As a general rule, almost all hematomas due to penetrating trauma should be explored, irrespective of size. Underneath a small hematoma, there is often a vascular or hollow viscus perforation. The only exception to this recommendation is a contained zone 4 retrohepatic hematoma. Surgical exploration of the retrohepatic vena cava or the hepatic veins is extremely challenging and in most cases will be detrimental because these contained venous injuries do very well with nonoperative management.

Retroperitoneal hematomas due to blunt trauma rarely require exploration because of the very low incidence of underlying vascular or hollow viscus injuries requiring surgical repair. If the hematoma is in zone 1, it should be explored. However, in patients with zone 2 hematomas, surgical exploration may result in the unnecessary loss of the kidney. Similarly, exploration of a stable zone 3 hematoma due to pelvic fractures may cause severe bleeding that is uncontrollable. Exploration of zone 2 and 3 retroperitoneal hematomas should therefore be limited to patients with expanding, pulsatile, or leaking hematomas. In addition, zone 3 pelvic hematomas associated with an absent ipsilateral femoral pulse should be explored because of the potential for an iliac artery injury. Paraduodenal hematomas also require exploration to exclude an underlying duodenal injury. Finally, hematomas at the root of the mesentery in the presence of ischemic bowel may harbor an injury to the SMA and should be explored. Exploration of these hematomas is technically difficult and potentially dangerous and should not be performed in the absence of ischemic bowel. Unexplored hematomas should be evaluated postoperatively using color-flow Doppler studies (which may be difficult because of bowel gas), CT angiography, or catheter-based angiography. With the advancement of endovascular technology and the availability of hybrid operating rooms with angio-interventional capabilities, there is now the option to perform on-table diagnostic angiography instead of opening a contained retroperitoneal hematoma. Any significant injuries may be managed endovascularly, if amenable, with stenting or embolization. This approach has the additional advantages of keeping the retroperitoneum intact, especially important in the presence of associated hollow viscus injuries.

Once the hematoma is open, in the presence of severe active bleeding, the immediate priority is to control the bleeding by direct compression. After this critical task is achieved, the next step is to identify the bleeding vessel and obtain proximal and distal control. If control is difficult or the patient is severely hypotensive, the abdominal aorta can be compressed digitally or with an aortic compressor at the aortic hiatus. After dissection of the peritoneum over the aorta and, if necessary, division of the left crus of the diaphragm (at the 2-o’clock position to avoid bleeding), the aorta can be cross-clamped. Endoluminal aortic occlusion with a percutaneously placed catheter balloon, as described before, is an attractive but still underused alternative.

The exploration of the area of bleeding or hematoma should proceed systematically. Each anatomic zone requires a different technical maneuver. Zone 1 supramesocolic bleeding or hematoma is the most difficult to approach because of the dense concentration of major vessels (aorta, celiac artery, SMA, renal vessels, IVC), the difficult exposure of many of these vessels, and the difficult proximal control of the infradiaphragmatic aorta. For some injuries, the only safe way to achieve proximal aortic control is through a left thoracotomy or with endoluminal aortic occlusion. The supramesocolic aorta, along with the origins of its major branches, is best exposed by mobilization and medial rotation of the viscera in the left upper abdomen. The first step of this approach is to divide the peritoneal reflection lateral to the left colon, the splenic flexure of the colon, and the spleen. The fundus of the stomach, spleen, tail of the pancreas, colon, and left kidney are then rotated to the right. This maneuver provides exposure of the aorta, origin of the celiac axis, SMA, and left renal vessels ( Fig. 182.7 ). Some surgeons prefer not to include the left kidney in the medial rotation. However, for injuries involving the posterior wall of the aorta, inclusion of the left kidney in the visceral rotation improves the exposure. In suspected supramesocolic IVC injuries, zone 1 should be explored through a medial rotation of the right colon and hepatic flexure and Kocher mobilization of the duodenum and head of the pancreas ( Fig. 182.8 ). The inframesocolic zone 1 area can be approached by retracting the transverse colon cephalad and displacing the small bowel to the right. The peritoneum over the aorta and IVC is then incised, and the vessels are exposed. An alternative approach is medial rotation of the right or left colon.

Figure 182.7, Left medial visceral rotation provides good exposure of the supramesocolic aorta and the origin of the celiac axis, superior mesenteric artery (SMA), and left renal vessels. IMA , inferior mesenteric artery; IVC , inferior vena cava.

Figure 182.8, Medial visceral rotation of the right colon and hepatic flexure and Kocherization of the duodenum and pancreas provide excellent exposure of the inferior vena cava and the origins of the renal veins.

Zone 2 bleeding or hematoma is explored by mobilization and medial rotation of the right colon, duodenum, and head of the pancreas on the right side or the left colon on the left side. The source of bleeding in zone 2 is the renal vessels or the kidneys.

Zone 3 vessels are explored by dissection of the paracolic peritoneum and medial rotation of the right or left colon. In some cases, direct dissection of the peritoneum over the vessels can provide the necessary exposure.

The reconstruction of major vessels with synthetic grafts in the presence of intestinal spillage poses significant risks for graft infection. Copious irrigation before graft placement, use of autologous graft material whenever possible, and omental wrapping or soft tissue coverage for polytetrafluoroethylene (PTFE) grafts will reduce the risk of infection.

Damage Control Procedures

Many patients with major abdominal vascular injuries require massive blood transfusions, are hypotensive, and become severely hypothermic, acidotic, and coagulopathic intraoperatively. Persistent attempts to definitively reconstruct the injury are ill advised and will result in increased mortality. These patients should undergo early damage control and definitive reconstruction at a later stage when their physiology improves. Earlier reports recommended that damage control procedures be considered in patients in extremis who had exhausted their physiologic reserves and were in danger of irreversible shock and death. However, to be effective, damage control should not be a procedure of last resort but should be considered at a much earlier stage, before the patient becomes severely hypotensive and coagulopathic. This concept is even more important in patients with major comorbidities, such as older age or chronic medical problems, and in suboptimal environments, such as small community hospitals or combat zones.

With the damage control approach, all complex venous injuries are ligated, arterial injuries are shunted, and any diffuse retroperitoneal or parenchymal bleeding is controlled by tight gauze packing. If commercially produced vascular shunts are not available, temporary intraluminal shunts can be constructed from sterile intravenous or nasogastric tubing. The shunt is secured with proximal and distal ligatures ( Fig. 182.9 ). The abdomen is then closed temporarily with a prosthetic material or vacuum dressing techniques and the patient is transferred to the intensive care unit (ICU) for further resuscitation. The abdomen should never be closed primarily because of the very high incidence of abdominal compartment syndrome. The patient is returned to the operating room after resuscitation and stabilization for definitive vascular repair and abdominal wall closure.

Figure 182.9, Temporary arterial shunt for damage control in a hemodynamically unstable patient with a gunshot wound and complete transection of the iliac artery.

Endovascular Techniques

Endovascular techniques have revolutionized the management of blunt thoracic aorta and other arterial injuries. Hybrid operating rooms with angiographic radiology capabilities provide an opportunity to improve the management of abdominal vascular injuries by either temporary control of life-threatening bleeding or definitive care with angioembolization or stenting. In the appropriate cases the combination of endovascular adjuncts and open surgery may be lifesaving.

The role of endovascular techniques in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is usually limited. However, the use of endoluminal balloons for temporary proximal aortic control can be a useful adjunct during open surgery. In addition, endovascular techniques may be the best therapeutic intervention in most cases with delayed vascular complications such as aneurysms, arteriovenous fistulae, and arterial occlusions.

Abdominal Compartment Syndrome

The normal intraabdominal pressure in the resting supine position is near zero. Elevation of the intraabdominal pressure greater than 12 mm Hg constitutes a diagnosis of intraabdominal hypertension. A pressure that exceeds 20 mm Hg in addition to organ dysfunction results in abdominal compartment syndrome. Abdominal compartment syndrome is characterized by a tense abdomen, tachycardia with or without hypotension, respiratory dysfunction with high peak inspiratory and plateau pressures in mechanically ventilated patients, and oliguria. However, significant organ dysfunction may begin long before classic abdominal compartment syndrome is manifested.

All patients with severe abdominal trauma, especially vascular trauma, are at risk for development of abdominal compartment syndrome. Major risk factors include massive blood transfusions, prolonged hypotension, hypothermia, aortic cross-clamping, damage control procedures, and closure of the abdominal wall. After severe trauma, the abdomen should never be closed under tension. Similarly, after damage control procedures, the abdominal wall fascia should not be closed because progressive postoperative bowel edema will frequently result in abdominal compartment syndrome.

The diagnosis of abdominal compartment syndrome is based on clinical examination and intraabdominal pressure measurements. All high-risk patients and those in whom abdominal compartment syndrome is suspected clinically should be monitored closely with serial intraabdominal pressure measurements. The intraabdominal pressure can be measured reliably through the bladder catheter. The catheter is used to empty the bladder. Approximately 20 mL of sterile saline is injected back into the bladder to allow pressure transduction without the false elevation in pressure expected from bladder wall tension in a full bladder. The pressure is then measured through the catheter by either a simple water column or a commercial pressure transduction device. Definitive management requires surgical decompression. In general, pressures higher than 20 to 30 mm Hg are considered strong indicators for surgical decompression of the abdomen. If organ dysfunction is present, the pressure threshold may be lower. The abdomen can be opened in the operating room or even in the ICU if necessary. Temporary abdominal wall closure can be achieved with the use of a commercially available vacuum closure device, or a sterile X-ray cassette cover, laparotomy sponges, closed suction drains, and sticky drapes can be used to accomplish temporary coverage. When the bowel edema improves, usually within 2 to 3 days, the patient is returned to the operating room for definitive abdominal wall closure.

Specific Vascular Injuries

Abdominal Aorta Injuries

Anatomy

The aorta descends into the retroperitoneum between the two crura of the diaphragm at the T12–L1 level and bifurcates into the common iliac arteries at the L4–L5 level, which approximately corresponds to the level of the umbilicus. The first branches of the abdominal aorta are the phrenic arteries that originate from its anterolateral surface. Immediately below is the celiac trunk that originates from the anterior surface of the aorta, and 1 to 2 cm below that is the SMA, followed by the renal arteries 1 to 1.5 cm below the origin of the SMA and finally, the inferior mesenteric artery (IMA), 2 to 5 cm above the bifurcation.

Mechanism of Injury

Blunt injury to the abdominal aorta is extremely rare, diagnosed in 0.04% of all blunt trauma admissions. Fractures of the thoracolumbar spine and seat belt injuries are associated with an increased risk of abdominal aortic injuries. , Intimal dissection and thrombosis are the most common lesions in patients reaching the hospital alive. False aneurysms occur less frequently. Patients with free ruptures die at the scene and rarely receive medical care. , In a review of 28 cases with blunt abdominal aortic injuries, intimal tears or large intimal flaps were the most common lesion (60%), followed by free rupture (30%) and pseudoaneurysm (10%).

Penetrating injuries are by far the most common cause of abdominal aortic injuries. In a review of 1218 patients with abdominal gunshot injuries from our center, there were 33 abdominal aortic injuries (2.7%). In 529 knife wounds to the abdomen, the aorta was injured in 1.5%. The infrarenal aorta is injured in 50% of patients, the supraceliac aorta in 25%, and the aorta between the celiac trunk and the renal arteries in 25% of patients.

Clinical Presentation

The clinical presentation depends on the mechanism of injury (blunt or penetrating), type of aortic injury, presence of free intraperitoneal bleeding or retroperitoneal hematoma, associated injuries, and time elapsed since the injury. In blunt trauma, two-thirds of patients have acute symptoms of bleeding or visceral or lower extremity ischemia. The diagnosis is made during the initial hospitalization by means of CT or angiography or at laparotomy. In one-third of cases the diagnosis is made many months or even years after the injury.

The clinical presentation of penetrating aortic injuries is usually dramatic. Many victims die at the scene. Of those who are treated, approximately 28% have an unrecordable blood pressure, and approximately 21% require a resuscitative thoracotomy. In approximately 18% of cases the bleeding is temporarily contained in the retroperitoneum and the patients are normotensive on admission. On rare occasions the injury is missed at operation only to manifest at a later date as a false aneurysm or arteriovenous fistula (see Fig. 182.4 ).

Management

Almost all patients with penetrating aortic injuries require open repair. In blunt trauma the management depends on the location and type of the injury. Many patients with small intimal tears can safely be managed nonoperatively. More severe blunt injuries with free rupture or large intimal flaps require open or endovascular repair. In a National Trauma Data Bank analysis of 436 patients with blunt abdominal aortic injuries, 394 patients (90%) were managed nonoperatively and 29 (7%) underwent endovascular repair, with only 13 patients (3%) undergoing open aortic repair or extra-anatomic bypass.

Endovascular treatment

Endovascular management has a definitive role in selected cases of infrarenal aortic injury. Patients with limited infrarenal aortic dissection, large intimal flaps, false aneurysms, or aortocaval fistulae have been treated successfully with angiographically placed stents. ,

Surgical treatment

The surgical exposure of the vascular structures in zone 1 is achieved by medial visceral rotation, as described in the section on retroperitoneal hematoma. For high supramesocolic injuries, a left thoracotomy may be necessary for cross-clamping of the aorta. Approximately 93% of patients with penetrating trauma have other associated intraabdominal injuries, the most common being injuries to the small bowel (45%), colon (30%), and liver (28%). Before any definitive management that requires a prosthetic graft, all enteric spillage should be controlled and the peritoneum should be washed out. Lateral aortorrhaphy is possible in most cases. More complex repairs with prosthetic grafts may be necessary. Many authors do not consider the presence of enteric spillage a contraindication to the use of prosthetic material.

Mortality

The prognosis of abdominal aortic injuries after blunt trauma is significantly better than that of injuries due to penetrating trauma. The reported overall mortality in blunt trauma is approximately 30%.

The mortality after penetrating trauma in two large series with 146 patients was 67%. , In another series of 57 patients with gunshot wounds, the mortality rate was 85%. Suprarenal aortic injuries have a significantly worse outcome than infrarenal injuries. The mortality in patients undergoing emergency center resuscitative thoracotomy is almost 100%. , The prognosis of penetrating abdominal aortic injuries is significantly better than that of injuries to the thoracic aorta, most likely owing to the retroperitoneal containment of bleeding in abdominal injuries. In a comparison of 67 abdominal aortic injuries with 26 thoracic aortic injuries, the mortality rates were 76% and 92%, respectively.

Celiac Artery Injuries

Anatomy

The celiac artery originates from the anterior wall of the abdominal aorta, immediately below the aortic hiatus, at the level of T12–L1. The main trunk is 1 to 1.5 cm long, and at the upper border of the pancreas it has three branches (the tripod of Haller): the common hepatic artery, left gastric artery, and splenic artery. Because of the extensive fibrous, ganglionic, and lymphatic tissues that surround the trunk, surgical dissection may be tedious.

Mechanism of Injury

Injuries to the celiac artery are rare and almost always due to penetrating trauma. In a review of 302 abdominal vascular injuries, the celiac artery was involved in 10 cases (3.3%).

Surgical Treatment

The surgical exposure can be achieved either by direct dissection over the upper abdominal aorta through the lesser sac or by medial rotation of the upper abdominal viscera, as described previously. The rotation does not need to include the left kidney. The celiac artery can be ligated without ischemic sequelae to the stomach, liver, or spleen because of the rich collateral circulation of these organs. The left gastric and splenic arteries may also be ligated with impunity. Ligation of the common hepatic artery is usually well tolerated because of adequate supply from the portal vein and the gastroduodenal artery.

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