The anterior operative approach to the cervical vertebral artery.

BACKGROUND: Vertebral arterial trauma continues to be a perplexing diagnostic and therapeutic challenge. Operative management is often required despite improved radiologic interventions for these injuries. Accounts of the operative approaches to anterior cervical vertebral artery injuries have been limited. STUDY DESIGN: We reviewed our experience with anterior cervical vertebral arterial trauma in 53 consecutive patients requiring operative management during a 14-year period. In seven patients, the vertebral arterial injury was identified at urgent surgical intervention either for an expanded cervical hematoma or active bleeding. The remaining injuries were identified by arteriographic investigation of penetrating cervical trauma. The injuries were equally distributed between the three anatomic zones of the anterior cervical vertebral artery. The general features of the operative approaches that were used to manage these injuries were the emphasis of the study. RESULTS: The anterior approaches to patients with vertical arterial trauma were effective in controlling injuries in all cases. Proximal and distal ligation of the artery adjacent to the injury site was accomplished in 95 percent of the patients. Associated major cervical injuries in 43 percent of the patients (carotid artery, eight patients; pharyngoesophageal, six patients; and neurologic, nine patients) contributed to the postoperative morbidity rate and the overall mortality rate of 10 percent. CONCLUSIONS: The surgeon approaching vertebral arterial trauma should have a clear appreciation of the deep anterior cervical anatomy to expedite the operative management and avoid unnecessary complications related to a misdirected surgical dissection. The descriptions of the operative techniques used in this clinical experience can aid the surgeon in managing patients with vertebral vascular trauma.

Albumin adsorption and retention on C18-alkyl-derivatized polyurethane vascular grafts.

The short-term albumin affinity and thrombo-resistance of a polyether polyurethane vascular graft have been improved. The method is based on the C18 alkylation of the polymer. Thrombus formation by a planimetric technique and albumin retention on wire-reinforced polyurethane tubes, both C18 alkylated and untreated, were measured in short-term (4-h) exposure at femoral arterial sites in the dog. 125I-Albumin was preabsorbed on tubes and then exposed to blood for successive 2-h periods. Albumin uptake on alkylated tubes prior to blood exposure and retention following 2 h of blood exposure were significantly greater than on controls. Following a fast desorption phase in blood, the remaining albumin was more slowly desorbed from alkylated than from control tubes. Reincubation with albumin and blood reexposure produced a similar tendency, suggesting blood conditioning does not reduce the albumin affinity-enhancing property of C18 alkylation in the short term. Blood-preconditioning experiments suggested endogenous albumin has a high affinity for the C18-alkylated surface. Scanning electron microscopic examination showed thrombus and platelet densities were higher on control than on alkylated surfaces. These results suggest in vivo albumin affinity is increased for C18-alkylated polyurethane, which may be linked to decreased thrombus formation on these surfaces.

Mandibular subluxation for high carotid exposure.

Twenty-four patients with internal carotid artery lesions extending above the second cervical vertebra underwent mandibular subluxation for additional exposure. The original technique of bilateral arch bar wiring requiring 90 minutes for application has evolved into a circummandibular/transnasal wiring technique requiring approximately 10 minutes. Subluxation of the mandibular condyle 10 to 15 mm anteriorly results in displacement of the mandibular ramus 20 to 30 mm anteriorly. This technique provides a marked increase in exposure of the internal carotid artery up to the base of the skull by transforming a triangular operating field into a rectangular field. The technique is quick, easy to perform, and not associated with objective or subjective temporomandibular joint dysfunction.

Vertebral artery trauma: acute recognition and treatment.

Vertebral artery injury is uncommon and may be initially unrecognized. Sequelae of vertebral artery injury include arteriovenous fistulae and pseudoaneurysms that may appear months after injury. The incidence of the sequelae is unknown. Cervical angiography used in the routine evaluation of a patient with penetrating neck trauma readily demonstrates vertebral artery injuries. This series of 13 cases demonstrates the low morbidity associated with the treatment of isolated vertebral artery injuries. A technique for proximal and distal ligation of the vertebral artery is presented. Its use is recommended in the treatment of any patient with vertebral artery injury who has a normal contralateral vertebral artery and no demonstrable extracranial branches from the vertebral artery to the spinal cord.

Vascular trauma.

The word "spasm" has been purposefully omitted as it is essentially a nonentity in vascular trauma. The surgeon's ability to repair and salvage extremities has increased greatly in the last 30 years. Problem areas still exist, especially in those patients with carotid trauma and neurologic deficit and patients with massive trauma to the extremities with involvement of bone, arteries, veins, nerves, and soft tissue. There is a place and a time for primary amputation, but its role in trauma surgery has definitely decreased and should continue to do so, as long as in so doing we do not jeopardize the life of the patient.