Aorta Injury

• Small (< 50% Diameter): Lateral Aortorrhaphy (Primary Repair)
  • Use Permanent Suture (3-0 or 4-0 Polypropylene)
  • May Connect Multiple Injuries into a Single Wound if Close to Each Other
• Large (> 50% Diameter): Patch Angioplasty with PTFE Graft
  • May Consider Interposition Graft if Infrarenal
• Damage Control: Shunt with a Chest Tube

Celiac Axis

• Simple: Lateral Arteriorrhaphy (Primary Repair)
• Complex: Ligate (Good Collaterals)
  • Gallbladder Has Poor Collaterals and Concurrent Cholecystectomy Should Be Performed if Ligating the Hepatic Artery – High Risk for Hepatic Abscess

Renal Artery

• Small (< 50% Diameter): Lateral Arteriorrhaphy (Primary Repair)
• Large (> 50% Diameter): Patch Angioplasty vs Interposition Graft (Saphenous Vein or PTFE)
• Damage Control: Ligation with Nephrectomy
  • First Palpate the Contralateral Kidney to Confirm Normal in Deciding the Need for Heroic Measures at Saving the Injured Kidney

Superior Mesenteric Artery (SMA)

• Fullen Classification
  • Zone I – Proximal to the First Branch (Inferior Pancreaticoduodenal Artery)
  • Zone II – Between the First Branch and Middle Colic Artery
  • Zone III – Distal to the Middle Colic Artery
  • Zone IV – Segmental Branches
• Zone I/II (Proximal to the Middle Colic):
  • Stable: Primary Repair vs Bypass Graft (Saphenous Vein or PTFE)
    • Bypass Grafts Should Be Made to the Distal Infrarenal Aorta (Away from the Pancreas and Potential Leak)
    • Cover Grafts with Retroperitoneal Fat or Omentum to Prevent Aortoenteric Fistula
  • Damage Control: Shunt vs Ligation
  • Theoretically the Collaterals are Adequate to Perfuse the Midgut if SMA is Ligated Proximally
• Zone III/IV (Distal to the Middle Colic): Primary Repair vs Ligation
  • Stable: Primary Repair
  • Damage Control: Ligation
  • Ligation of the Distal SMA is Poorly Tolerated and May Require Extensive Bowel Resection as it is Distal to the Collaterals

Inferior Mesenteric Artery (IMA)

• Small (< 50% Diameter): Lateral Arteriorrhaphy (Primary Repair)
• Large (> 50% Diameter): Ligate

Iliac Artery (Common/CIA or External/EIA)

• Small (< 50% Diameter): Lateral Arteriorrhaphy (Primary Repair)
• Large (> 50% Diameter): Patch Angioplasty vs Interposition Graft (Saphenous Vein or PTFE)
  • Additional Options:
    • Replace with Mobilized Ipsilateral Internal Iliac Artery
    • Transposition to the Contralateral Iliac Artery if Injury is at the Bifurcation
  • May Consider Extra-Anatomic Bypass if Significant Contamination is Present

Internal Iliac Artery (IIA)

• Can Ligate Both Internal Iliac Arteries with Near Impunity

The Use of Endovascular Repair for Abdominal Vascular Injury is Evolving but May Be Considered for Select Injuries