CHAPTERXXVII
Wounds of the GreatVessels of the Abdomen (75 Casualties)
Hugh F. Swingle, M. D., and Dominic S. Condie, M. D.
Therewere 75 wounds of one or more of the major vessels of the abdomenincluded in the 3,154 abdominalinjuries treated by the 2d Auxiliary Surgical Group during 1944 and 1945 (table89).1 These injuries (table 90) consisted of:
1. Injuries to the major veins, including the vena cava;the common, internal, and external iliac veins; and the portal vein (53 cases).
2. Injuries to major arteries, including the common,internal, and external iliac arteries (13 cases).
3.Injuries to some combination of these arteries and veins (9 cases).
TABLE 89.- Essential data in 75 wounds of major vessels of abdomen
Type of injury | Cases | Frequency | Deaths | Case fatality rate | |
| In 3,154 abdominal injuries | In 75 vascular injuries | ||||
|
| Percent | Percent |
|
|
Vascular only | 8 | 0.25 | 10.7 | 5 | 62.5 |
Vascular and visceral | 67 | 2.13 | 89.3 | 50 | 74.6 |
| 75 | 2.38 | 100.0 | 55 | 73.3 |
Of the 75 casualties, 55 (73.3 percent)died, and no soldier with an injury to the abdominal aorta survived long enoughto undergo surgery in a field hospital.
INJURIESTO THE MAJOR VEINS
Injuries of the majorveins of the abdomen (table 90) occurredalone in 45 cases,in combination with injuries of the blood supply of various viscera in 8 cases, and in combination with injuries of the majorarteries of the abdomen in 9 cases.
1Injuries to the bloodsupply of special viscera, such as the colon, spleen, and kidney, are discussedunder the heading of the viscus involved and are excluded from this discussionunless they complicated wounds of the major blood vessels of the abdomen. As a matter of convenience, combined injuries of the arteries and veinsare discussed under the headingof arterial injuries. Because of the wide distribution of injuries and operations and the smallnumbers in each category, it is necessary to describe many cases in allcategories individually.
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TABLE 90.-Influence of type of injury oncase fatality rates of 75 wounds of major vessels of abdomen
Injury | Cases | Deaths | Case fatality rate |
Veins only | 45 | 33 | 73.3 |
| Single vein | 38 | 27 | 71.1 |
| Two or more veins | 7 | 6 | 85.7 |
Vein and visceral blood supply | 8 | 8 | 100.0 |
Arteries only | 13 | 8 | 61.5 |
Artery and vein | 9 | 6 | 66.7 |
| 75 | 55 | 73.3 |
Vena caval injuries.-The vena cava was injured 33 times(table 91), more frequently than any other single vessel. In the 22 cases inwhich the injury was univisceral, there were 17 deaths. Nine followed ligation,which was employed in twelve of the univisceral injuries, and four followedsuture, which was employed in six cases in the same category. In one fatal case,the vena cava was clamped tangentially, as a temporary measure, and in the threeother univisceral fatalities hemorrhage proved uncontrollable.
The were 10 deaths in the 11injuries associated with injuries of other major abdominal vessels or of thevisceral blood supply.
TABLE 91.-Essential data in 33 injuries ofvena cava
Type of injury and therapy | Cases | Deaths | Case fatality rate |
Vena cava: |
|
|
|
| Without other injuries | 22 | 17 | 77.3 |
| With other vascular injuries | 4 | 3 | 75.0 |
| With visceral and other vascular injuries | 7 | 7 | 100.0 |
| 33 | 27 | 81.8 |
Therapy (all vena caval injuries): |
|
|
|
| Ligation | 16 | 13 | 81.2 |
| Suture | 8 | 5 | 62.5 |
| Tangential clamping | 1 | 1 | 100.0 |
Spontaneous thrombosis | 1 | 1 | 100.0 |
Uncontrollable hemorrhage | 7 | 7 | 100.0 |
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Univisceralinjuries of other major veins.-In the 16 univisceral vascular injuries in which veins otherthan the vena cava were implicated, the distribution of cases, procedures, anddeaths was as follows:
Sixinjuries of the common iliac vein were treated by ligation in five cases and bypacking in one case, with four deaths.
Fiveinjuries of the external iliac vein were treated by ligation, with two deaths.
Twoinjuries of the internal iliac vein were treated by ligation, with one death.Another, similar injury was treated by packing and ended fatally. In thelast-mentioned case, the injury was described as involving the"pelvic" vein, but the record left no doubt that the vessel injuredwas the internal iliac vein.
Two injuries of the portalvein were both fatal. Packing was employed in one case, and in the other hemorrhage wasuncontrollable by any measures.
Multiple venous injuries.-In the 7 casesin which 2 or more of the major veins of the abdomen were injured (table 90),the distribution of the cases, procedures, and (6) deaths was as follows:
Theinferior vena cava and the common iliac vein were involved in three cases. Onepatient, treated by suture, survived. One died after venous ligation, and inthe third case hemorrhage was uncontrollable.
The inferior vena cava, bothcommon iliac veins, and the right internal iliac vein were injured in one case.Death followed ligation.
The leftcommon iliac vein and the left internal iliac vein were wounded in one case, andthe same veins on the right side were wounded in another. Death followed venousligation in both.
Theright internal and external iliac veins were wounded in one case, in which deathfollowed ligation.
Combinedinjuries of the major abdominal veins and the visceral blood supply.-All eight cases in which venousinjuries were combined with injuries of the blood supply of major abdominalviscera ended fatally (table 90):
The inferior vena cava, thehepatic artery, and the portal vein were wounded in one case, in which death wascaused by uncontrollable hemorrhage.
The inferior vena cava and the hepaticartery were injured in one case. The artery was ligated, and the vena cavaunderwent spontaneous thrombosis.
The inferior vena cava and the superiormesenteric artery were injured in one case. The vena cava was ligated and the artery sutured.
Theinferior vena cava and the right gastric artery and vein were injured in onecase. The gastric artery and vein were ligated, but the patient died ofuncontrollable hemorrhage from the vena cava.
The inferior vena cava andthe right renal pedicle were injured in three cases. Nephrectomy was done in two cases, once combined with suture, and oncewith ligation, of the vena cava. In the third case, hemorrhage from both sources proved uncontrollable.
The portal vein and the hepatic artery were injured in onecase, in which packing was employed.
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INJURIES TO THE MAJOR ARTERIES
Arterial injuries.-In the13 cases in which major arteries of the abdomen were injured withoutcomplicating injuries of other vessels (table 92), the distribution of cases,procedures, and deaths was as follows:
Six wounds of the external iliac artery were treated bysuture in one case, with survival, and by ligation in five cases, with fourdeaths.
Three wounds of the internal iliac artery were treated byligation, with two deaths.
Four injuries of the common iliac artery were treated bysuture in two cases, with survival in both, and by ligation in two cases, withdeath in both.
Combined arterial and venous injuries.-There were 6 deathsin the 9 combined arterial and venous injuries (table 93). In one instance, aclamp was applied to the internal iliac artery and vein and left in situ becausethe
TABLE 92.- Essential data in 13injuries of major abdominal arteries
Injuries and therapy | Cases | Deaths | Case fatality rate |
Vessel injured: |
|
|
|
| External iliac | 6 | 4 | 66.7 |
| Internal iliac | 3 | 2 | 66.7 |
| Common iliac | 4 | 2 | 50.0 |
| 13 | 8 | 61.5 |
Therapy: |
|
|
|
| Ligation | 10 | 8 | 80.0 |
| Suture | 3 | 0 | 0 |
TABLE 93.-Essential data in 9combined injuries of major arteries and veins of abdomen
Vessel injured and therapy | Cases | Deaths | Case fatality rate |
External iliac artery and vein | 2 | 1 | 50.0 |
Internal iliac artery and vein | 6 | 4 | 66.7 |
Common iliac artery and vein | 1 | 1 | 100.0 |
| 9 | 6 | 66.7 |
| Therapy: |
|
|
|
| Ligation | 8 | 5 | 62.5 |
| Clamp | 1 | 1 | 100.0 |
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patient was moribund; he died before a more definitive procedure could be accomplished. Both the vein and the artery were ligated in the other eight cases. Three patients survived, one with a wound of the external iliac artery and vein and two with wounds of the internal iliac artery and vein.
POSTOPERATIVE VASCULAR INSUFFICIENCY
Postoperativevascular insufficiency occurred in 9 patients in this series who survived injuryand operation long enough to present it. The veins were affected in 4 cases, thearteries in 3, and both arteries and veins in 2, as follows:
Two patients with injuries of the inferior vena cavapresented swelling of the lower extremity. In one instance, the vein had beenligated. The other patient, who later died of massive pulmonary embolism, hadundergone suture of the vein. Twoother patients with similar injuries presented distention of the veins of thelower extremities. In one instance, the vena cava had been ligated; in the other, it hadbeen sutured, and it was thought that thrombosis had probably occurredsubsequently at the site of injury and repair.
In oneinjury of the external iliac artery, gangrene followed ligation of the arteryand elective ligation of the vein. The leg was demarcating at the midcalf whenthe patient died on the third day after operation of anuria combined with anoverlooked retroperitoneal injury of the cecum. In another injury of the external iliac artery treated by ligation,amputation was necessary at the left midthigh on the seventh day afteroperation because of gangrene resulting from arterial insufficiency andclostridial myositis.
In oneinjury of the common iliac artery, the artery was ligated, and electiveligation of the vein was also done. Amputation was later necessary through thethigh on the affected side, and the patient eventually died of clostridialinfection in the stump.
In one case in which wounds of the left external andinternal iliac veins and the left internal iliac artery were treated by ligation,the affected leg became mottled and cold 12 hours after operation. The patientdied 40 hours after operation, in shock from severe peritonitis. Amputation ofthe extremity would probably have been necessary if he had lived.
In one case in which the left common iliac artery and vein were injured,both vessels were ligated. Gangrene ensued, and amputation of the extremitythrough the thigh was necessary on the fourth postoperative day.
Conditionsin forward hospitals did not permit intensive efforts at combatingpostoperative vascular insufficiency in the lower extremities. Environmentaltemperature control was not feasible. No anticoagulant drugs were available. The only practical prophylacticmeasure was control of the patient's position, and the optimum posture wasusually contraindicated by the presence of severe intraperitoneal injuries. Afew sympathectomies were done on patients with injuries of the femoral artery,but this procedure was not employed in any intra-abdominal vascular injury.
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FACTORSOF MORTALITY
Sincethe frequency of injury to any abdominal viscus is directly proportional tothe space which it occupies (p. 92), it would seem that injury tocorresponding major arteries and veins would occur with approximately the samefrequency because the vessels are of approximately the same size. In this series of 75 injuries of major abdominal blood vessels, thisgeneralization did nothold. Fifty-three injuries involved one or more veins, while only twenty-twoinvolved either arteries alone or arteries and veins. These figures requireinterpretation. The considerable discrepancy is probably nota disparity of incidence butrather a disparity in lethality. It arises from the fact that fewer patients with arterial injuriesreached field hospitals to undergo treatment. This reasoning is supported by the fact that this series, although itincludes 33 lesions of the vena cava, includes no lesion of the abdominal aorta, sinceno patient with an injury of that vessel survived to undergo surgery. Evenwhen the damage to the veins was severe, many patients were brought to thehospital alive, apparently because a point was reached in the hemorrhagicprocess at which the intra-abdominal tension was sufficiently high, and thevenous pressure had become sufficiently low, to prevent complete exsanguinationand death. This physiologic process apparently occurred much less often inarterial injuries, with the result that fewer patients in this category werereceived in forward hospitals.
The case fatality rate forall arterial injuries was 63.6 percent (14 of 22cases), as compared to a rate of 75.8percent (47 of 62cases) for all injuries of the veins. The lower case fatality rate in arterial injuries must be attributed tounusual circumstances which permitted the patients to reach field hospitalsalive. No precise data are available, but it seems reasonable to assume that inthese cases the injuries were slight to minimal, the blood loss before operationwas not excessive, and bleeding could be controlled promptly after the abdomenwas opened.
Only 6of the 33 patients with injuries of the vena cava (table 91) survived long enough after operation to be evacuated from the fieldhospital. Three had been treated by suture and three by ligation, the procedurein each instance being performed below the renal veins. No patient survived when the injury was above the renalvessels.
The case fatality rate ininjuries of the great vessels apparently rested on much the same basis asinjuries of other viscera. Half of the deaths in the 54fatalities in which the causeof death could be determined resulted from shock and hemorrhage. Twelve wereattributed to anuria, four to pulmonary embolism, three each to pneumonia andto pulmonary edema, two each to peritonitis and to clostridial myositis, andone to retroperitoneal suppuration.
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One factor of great importance in the outcome was the stage of shock. In very severe shock, the blood pressure and pulse were not usually obtainable, and in several other cases the blood pressure and pulse were not recorded when the patient was first seen in the field hospital. The classification into degrees of shock was therefore made on the clinical findings. The case fatality rate (table 94) was directly proportional to the degree of shock on the patients' admission. The numbers of cases in some categories are too small to be sig?nificant statistically, but the results are in full accord with clinical impressions
Degree of shock | Cases | Deaths | Case fatality rate |
None | 4 | 2 | 50.0 |
Mild | 2 | 1 | 50.0 |
Moderate | 16 | 10 | 62.5 |
Severe | 8 | 6 | 75.0 |
Very severe | 39 | 33 | 84.6 |
| 69 | 52 | 75.4 |
1In6 cases, 3 of which were fatal, the degree of shock was not recorded.
The case fatality rate inthese 75 vascular injuries also depended upon a number of other considerations,including the presence or absence of associated visceral injuries and the numberof viscera involved (table 95). There is one discrepancy-that the rate was higher when noabdominal viscera were involved than when one organ was injured. With this exception, there was a gradual rise in the rate as the numberof abdominal organs injured increased. When the multiplicity factor for all abdominal injuries (p. 107)is studied in relation to the multiplicity factor in these 75cases, it becomes clear that the injury to the greatvessels was the most important cause of the consistently high case fatality ratein this group of cases.
Injuries to the great vesselsof the abdomen carried the highest case fatality rate of any category ofinjuries in this series of 3,154 abdominal wounds. No problemso challenged the technical skill of the surgeon as the control of severeintra-abdominal hemorrhage with sufficient rapidity to give the patient a chanceof survival.
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Organs injured | Cases | Deaths | Case fatality rate |
Major vessels only | 8 | 5 | 62.5 |
Major vessels and 1 viscus | 22 | 12 | 54.5 |
Major vessels and 2 viscera | 21 | 17 | 81.0 |
Major vessels and 3 viscera | 13 | 11 | 84.6 |
Major vessels and 4 viscera | 1 | 1 | 100.0 |
Major vessels and 5 viscera | 2 | 2 | 100.0 |
| 67 | 48 | 71.6 |
1In 8 cases, 7 of whichwere fatal, no data are available concerning the number of viscera injured.
