战时颈总动脉损伤的处理与转归。
Management and outcomes of wartime cervical carotid artery injury.
机构信息
From the Department of Surgery, Uniformed Services University of the Health Sciences; and Walter Reed National Military Medical Center, Bethesda, Maryland.
出版信息
J Trauma Acute Care Surg. 2020 Aug;89(2S Suppl 2):S225-S230. doi: 10.1097/TA.0000000000002755.
BACKGROUND
Cervical carotid artery injuries entail high morbidity and mortality and are technically challenging to repair. This retrospective study describes the management and outcomes of cervical carotid injuries sustained during the recent wars in Iraq and Afghanistan.
METHODS
The Department of Defense Trauma Registry was queried to identify US military personnel who sustained battle-related cervical carotid injury between January 2002 and December 2015. Retrospective chart reviews of the military Electronic Health Record were performed on patients identified. Demographics, injury characteristics, surgical management, and outcomes were reviewed. Statistical analysis was performed to identify associations between injury and management factors, as well as stroke and mortality.
RESULTS
In total, 67 patients (100% male; age, 25 ± 7 years) were identified with cervical carotid artery injuries. Fifty-six patients (84%) sustained a common carotid artery (CCA) or internal carotid artery (ICA) injury, and 11 patients (16%) had an isolated external carotid artery (ECA) injury. The anatomic distribution of injury was as follows: CCA, 26 (38.8%); ICA, 24 (35.8%); CCA and ICA 2 (3%); ICA and ECA 3 (4.5%); and CCA, ICA, and ECA 1 (1.5%). Of the 56 CCA or ICA injuries, 39 underwent vascular repair, 9 (16%) were managed with ligation, 1 was treated with a temporary vascular shunt but succumbed to injuries before vascular repair, and 7 (13%) were treated nonoperatively. Seven (23%) of 30 ICA injuries were ligated compared with 2 (7.7%) of 26 injuries isolated to the CCA (p = 0.02). Compared with repair, ligation of the CCA/ICA was associated with a higher rate of stroke (89% vs. 33%, p = 0.003) and increased mortality without statistical significance (22% vs. 10%, p = 0.3). Every patient who underwent ICA ligation had a stroke (7/7). There was no difference in Injury Severity Score between the ligation and repair groups (23.8 ± 10.6 vs. 24.7 ± 13.4, p = 0.9). At a mean follow-up of 34.5 months, 10 of 17 stroke survivors had permanent neurologic deficits.
CONCLUSION
In modern combat, penetrating injuries involving the cervical carotid arteries are relatively infrequent. In this experience, isolated ICA injuries were three times more likely to be ligated than those involving the CCA. As a surgical maneuver, ICA ligation resulted in stroke in all cases.
LEVEL OF EVIDENCE
Retrospective cohort analysis, level III.
背景
颈总动脉损伤的发病率和死亡率都很高，修复技术也具有挑战性。本回顾性研究描述了最近在伊拉克和阿富汗战争中发生的与战斗相关的颈总动脉损伤的处理和结果。
方法
检索国防部创伤登记处，以确定 2002 年 1 月至 2015 年 12 月期间发生的与战斗相关的颈总动脉损伤的美国军人。对确定的患者进行了对军事电子健康记录的回顾性图表审查。对患者的人口统计学、损伤特征、手术管理和结果进行了回顾。对损伤和管理因素以及中风和死亡率之间的关联进行了统计学分析。
结果
总共确定了 67 名（100%为男性；年龄 25 ± 7 岁）患有颈总动脉损伤的患者。56 名患者（84%）发生颈总动脉（CCA）或颈内动脉（ICA）损伤，11 名患者（16%）发生颈外动脉（ECA）孤立性损伤。损伤的解剖分布如下：CCA，26 例（38.8%）；ICA，24 例（35.8%）；CCA 和 ICA，2 例（3%）；ICA 和 ECA，3 例（4.5%）；CCA、ICA 和 ECA，1 例（1.5%）。在 56 例 CCA 或 ICA 损伤中，39 例行血管修复，9 例（16%）行结扎，1 例行临时血管分流术，但在血管修复前死于损伤，7 例（13%）非手术治疗。30 例 ICA 损伤中有 7 例（23%）结扎，而 26 例仅累及 CCA 的损伤中有 2 例（7.7%）结扎（p = 0.02）。与修复相比，CCA/ICA 的结扎与更高的中风发生率（89%比 33%，p = 0.003）和统计学上无显著差异的死亡率（22%比 10%，p = 0.3）相关。接受 ICA 结扎的每位患者均发生中风（7/7）。结扎组和修复组的损伤严重程度评分无差异（23.8 ± 10.6 比 24.7 ± 13.4，p = 0.9）。在平均 34.5 个月的随访中，17 例中风幸存者中有 10 例存在永久性神经功能缺损。
结论
在现代战争中，涉及颈总动脉的穿透性损伤相对较少。在本研究中，ICA 损伤比 CCA 损伤更有可能被结扎。作为一种手术操作，ICA 结扎会导致所有病例中风。
证据水平
回顾性队列分析，III 级。
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