Editing Vascular trauma (section)

= Chest: =

* Major vascular injury generally requires operation
* Ascending/transverse aorta and innominate artery left CCA: median sternotomy
* Descending aorta and left subclavian: left anterolateral thoracotomy
* Aortic - Blunt trauma can cause aortic isthmus injury, although 80% die at scene. Can see patients with contained injuries (intramural haematoma or false aneurysm) in hospital. Decrease risk of rupture by prompt control of HR and BP. Definitive repair can be deferred up to 24 hours to allow resus and stabilisation, unless they also have a head injury requiring higher BP, in which case it should be repaired immediately.
** Thoracic endovascular aortic repair (TEVAR) is preferred for blunt aortic injury - now recommended whenever anatomically possible. Need to land in healthy aorta with at least 20mm of neck proximal and distal to the aortic injury. This can lead to coverage of left subclavian. Patients with absent right vertebral artery or prior left internal mammary artery cardiac bypass should have early revascularisation. If problems with TEVAR occur, it's usually within the first 3 months. 
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** Most grade 1 injuries heal spontaneously - serial imaging (around day 3), impulse control
** Grade 2: likely safe to observe. Some people group them with grade 1 injury. 
** Grade 3: perhaps feasible to manage non-operatively, but this is dangerous, and needs to carefully considered. Most would repair them, but can be delayed while other injuries are managed and the patient is stabilised. 
** Grade 4: proceed immediately for repair
* Axillosubclavian:
** Open exposure is difficult and time-consuming
** CTA will be very helpful - even if the patient is unstable - try to get the patient through the scanner
** Endovascular has lower morbidity and mortality when feasible - but is often used in more stable patients with less severe injuries. Brachial access is often the quickest way to get across it (can be percutaneous, but in practice a brachial cutdown is often preferred). Covered self-expanding stents or balloon-expandable stents can be used, and 10-20% oversizing is recommended. Note very high risk for stent thrombosis.
* Tracheoinnominate artery fistula
** Caused by pressure of tracheostomy cuff against overlying crossing innominate artery
** Presentation
*** Suspect in any patient with new bleeding from tracheostomy, especially if it was placed >3 days ago
*** Quite commonly has herald bleed followed by catastrophic bleed - needs urgent evaluation
*** Bronchoscopy is diagnostic (look for lesion on anterior trachea wall adjacent to pulsation of artery) - CTA rarely gives answer
** Maneuvers:
*** Ready OT
*** Over-inflate tracheostomy balloon
*** If ineffective, try digital compression of innominate against manubrium (Utley maneuver) after placing a finger into pre-tracheal plane, usually through tracheostomy after orotracheal intubation
*** Reasonable to attempt endovascular repair if facilities available, with close post-op follow-up and lifelong antibiotics (stent-graft placement across the lesion via femoral approach, although carotid approach can also be used)