J. A. Asensio1, P. J. Dabestani1, C. A. Fernandez1, T. Becker1, R. Bertellotti1, D. Cornell1, T. Kraner1, A. B. Olsen1, D. K. Agrawal1, J. A. Asensio1 1Creighton University Medical Center,Trauma Surgery And Surgical Critical Care,Omaha, NE, USA
Introduction:
Penetrating vertebral artery injuries (VAI) are rare. Their clinical presentation range from asymptomatic to exsanguination. Given their rarity, complex anatomy and difficult surgical exposure, few Trauma Surgeons or Trauma Centers have significant experience with these injuries. The objectives of this study are to review their incidence, clinical presentation, radiologic identification, management – both angiographic and operative, incidence of aneurysms, pseudoaneurysms, arteriovenous fistulas, and outcomes, as well as to review operative approaches for their surgical management.
Methods:
A literature search was conducted on MEDLINE Complete-PubMed. From 1893-2018 all series describing management and outcomes of penetrating VAI's were selected. PRISMA guidelines were employed. Original series and case reports yielded a total 181 studies. They were winnowed to 72 studies, including series and case reports, which form the basis of this collective review. Operative procedures and outcomes were recorded, along with methods of diagnostic imaging, angiographic, and operative management.
Results:
There were a total of 462 patients with penetrating VAI's. Incidence of vertebral artery injury military population – 0.2%, civilian population – 3.1%. More complete data was available from 13 collected VAI specific series and 37 case reports for a total of 362 patients. Mechanism of injury data was available for 341 patients (94.2%): GSW’s – 178 patients (52.2%), SW’s – 131 (43.2%), miscellaneous mechanisms of injury – 32 (9.4%). Anatomic site of injury data was available for 177 (49%) patients: 92 (52%) left, 84 (47.5%) right, and bilateral – 1 (0.5%). Anatomic segment of injury data was available for 206 patients (57%): 28 (13.6%) V-1, 126 (61.2%) V-2, and 52 (25.2%) V-3. Treatment data was available for 212 patients: Operative management – 89 (38.7%), angiography and angioembolization – 67 (29.1%), combined – 16 (7%) and observation – 58 (25.2%). Stenting and repair were less frequently employed – 10 (4.3%). Incidence of aneurysms/pseudoaneurysms – 61 (16.9%), AVF – 67 (21.6%). Calculated mortality VAI specific series – 15.1%, individual case report group –10.5%.
Conclusion:
The majority of VAI's injuries are asymptomatic upon presentation but may present with exsanguinating hemorrhage. CTA is the first line imaging modality to establish diagnosis, if hemodynamically stable. Gunshot wounds account for the majority of these injuries. Most frequently injured segment is V-2. Operative interventions were required in 38.7% and includes: ligation, clipping and packing. Angiography and angioembolization are diagnostic and therapeutic and was required in 29.1%. Trauma surgeons must be adept to surgically expose this vessel, control hemorrhage, prevent exsanguination, and address associated injuries.