Management of extra-cranial vertebral artery injuries.

OBJECTIVES: To review the management of vertebral artery injuries, and the impact of pre-operative angiography. MATERIALS AND METHODS: A retrospective review was conducted of all patients with vertebral artery (VA) injuries admitted to Groote Schuur Hospital, Cape Town between January 1987 and December 2002. Patients presenting with uncontrolled active bleeding or haemodynamic instability with a poor response to resuscitation were taken immediately to surgery. Stable patients, including those who stabilised after simple resuscitation, with evidence of a vascular injury (a bruit or a large haematoma) or trans-cervical gunshot wounds, underwent routine aortic arch and selective angiography. RESULTS: One hundred and one patients with vertebral artery injuries were included in the study. Ninety-two patients sustained penetrating injuries (41 gunshot, 51 stab), three were iatrogenic and six due to blunt trauma. Angiography was performed as the primary investigation in 88 patients, while seven patients had angiography following surgery. Thirty-nine vertebral artery occlusions, 11 arteriovenous fistulae, two intimal injuries and 36 false aneurysms were identified. Thirty-three radiological interventions were performed. There were 22 associated vascular injuries in 16 patients, 27 nerve injuries in 25 patients, 11 osseous injuries in nine patients and eight aerodigestive injuries. Seven patients died. CONCLUSIONS: Angiography and intervention is of great benefit in the diagnosis and management of traumatic vertebral artery injuries. Angiography often avoids unnecessary exploration and permits endovascular treatment.

Chylous ascites following abdominal aortic surgery.

Chylous ascites is an extremely rare complication of abdominal aortic surgery. A case with a successful outcome is presented, followed by a review of the 17 published cases. Chylous ascites can result in nutritional imbalance, immunological deficit and respiratory dysfunction. Paracentesis confirms the diagnosis and provides symptomatic relief. Conservative management, beginning with a low-fat diet and medium-chain triglyceride (MCT) supplementation, is recommended, changing to total parenteral nutrition if unsuccessful. Failure of non-operative treatment may necessitate the need for laparotomy and ligation of leaking lymphatics or peritoneovenous shunting.

Closed traumatic forequarter amputation without fracture. A case report.

Closed forequarter amputation (scapulothoracic dissociation) is a rare, easily missed, life-threatening injury. The diagnosis should be suspected in patients with a pulseless, flail limb, supraclavicular haematoma, lateral scapular displacement and clavicular disruption. Early surgery is essential to control haemorrhage and completion of the amputation with attention to closure of the resulting defect is often required. Prognosis for long-term functional recovery is poor, in spite of modern prosthetic aids.