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Abdominal vascular injury

Definition
Abdominal vascular injury refers to any trauma to the major blood vessels in the abdomen, which can lead to potential life-threatening hemorrhage.
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Pathophysiology
Abdominal vascular injury typically results from trauma or iatrogenic causes, such as surgical procedures. The injury can lead to disruption of the vessel wall, resulting in bleeding and potential organ ischemia due to loss of blood supply.
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Epidemiology
The prevalence of abdominal vascular injury is particularly high in trauma patients, especially in instances of motor vehicle accidents, falls from height, or interpersonal violence.
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Disease course
The clinical manifestations of abdominal vascular injury can be acute or delayed. Acute symptoms include hypotension and abdominal pain, which can be indicative of ongoing bleeding. Delayed symptoms may include anemia due to chronic blood loss or an abdominal bruit, which can suggest the presence of a vascular injury.
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Prognosis and risk of recurrence
The mortality and morbidity rates associated with this injury are high due to the potential for life-threatening hemorrhage.
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Key sources
The following summarized guidelines for the evaluation and management of abdominal vascular injury are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/WTA/PTS 2023), the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023; 2019), the American Heart Association (AHA/ACC 2022), the World Society of Emergency Surgery (WSES/AAST 2020), the World Society of Emergency Surgery (WSES 2020; 2017), the Society of Interventional Radiology (SIR 2020), and the Eastern Association for the Surgery of Trauma (EAST 2012; 2011).
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Guidelines

1.Diagnostic investigations

FAST ultrasound
As per EAST 2011 guidelines:
Avoid relying on FAST results to exclude intraperitoneal bleeding in the presence of a pelvic fracture.
D
Rely on FAST results in patients with unstable vital signs and pelvic fracture to decide on laparotomy to control bleeding.
A
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  • Angiography

2.Medical management

Nonoperative management: as per ACC 2022 guidelines, initiate anti-impulse therapy, if clinically tolerated, and obtain repeat imaging within 24-48 hours of the initial imaging to reduce the risk of injury progression in patients with grade 1-2 blunt traumatic abdominal aortic injury without malperfusion.
B

3.Therapeutic procedures

Pelvic packing: as per ABC-T 2023 guidelines, perform temporary extraperitoneal packing when bleeding is ongoing and/or when angioembolization cannot be achieved promptly. Consider combining extraperitoneal packing with open abdominal surgery when necessary.
B

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  • Angioembolization

  • REBOA

4.Perioperative care

Perioperative prophylactic antibiotics: administer a single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage in all patients with penetrating abdominal trauma.
A
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5.Surgical interventions

Damage-control surgery
As per WSES 2017 guidelines:
Perform resuscitative thoracotomy with aortic cross-clamping to achieve temporary control of hemorrhage in patients with pelvic trauma and exsanguinating hemorrhage.
A
Consider performing REBOA as an alternative to aortic cross-clamping.
C

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  • Definitive repair

6.Specific circumstances

Pediatric patients
Consider performing emergency department thoracotomy in pediatric patients presenting pulseless to the emergency department following a penetrating abdominopelvic injury with signs of life.
C
Avoid performing emergency department thoracotomy in pediatric patients presenting pulseless to the emergency department following a penetrating abdominopelvic injury without signs of life.
D

7.Follow-up and surveillance

Serial imaging assessment
Consider obtaining surveillance imaging at intervals appropriate for the repair approach and location in patients with blunt traumatic aortic injury undergone aortic repair.
C
Consider obtaining surveillance CT at 1 month, 6 months, and 12 months after the diagnosis and, if stable, at appropriate intervals thereafter (depending on the type and extent of the injury) in patients with blunt traumatic aortic injury not undergone repair.
C