Injuries to the abdominal vascular system: how much does aggressive resuscitation and prelaparotomy thoracotomy really help?

The records of 154 patients with 254 abdominal vascular injuries seen over 5 years (1980 to 1985) were reviewed. The overall mortality rate (MR) was 46%. This included 100% (5/5) for blunt injuries, 49% (59/119) for gunshot wounds, and 23% (7/30) for stab wounds. The most common venous injuries and the MRs were: inferior vena cava, 59% (33/56) and iliac veins, 65% (10/16). The most common arterial injuries and the MRs were: aorta, 68% (15/22), iliac artery, 57% (12/21), and superior mesenteric artery, 67% (8/12). Of 84 patients who presented to the emergency department (ED) with a blood pressure (BP) less than 70 mm Hg, 60 (71%) died, and of 64 patients with four or more associated injuries, 41 (64%) died. Failure to reduce the duration of shock, amount of bleeding, or severity of hypotension before surgery is highly lethal. Of the 42 patients who had shock for more than 30 minutes, 38 (90%) died. Of the 93 patients who received more than 10 U of blood in the ED and operating room (OR) 60 (64%) died. Of the 60 patients presenting to the OR with a systolic BP less than 70 mm Hg, 52 (87%) died. Prelaparotomy cross-clamping of the thoracic aorta for persistent shock is controversial. However, of the 26 patients with this procedure, 12 responded with a sustained increase in systolic BP greater than 90 with five (42%) survivors. Of the 14 no responders, none survived. Of 17 patients with persistent shock without a prelaparotomy thoracotomy, only one (6%) survived. In the high-risk group (admission systolic BP less than 70 mm Hg and four or more associated injuries), if shock was kept to less than 30 minutes and bleeding to 10 U of blood or less, the MR was reduced from 92% (24/26) to 0% (0/12). In patients presenting to the OR with a BP less than 70, a prelaparotomy cross-clamping of the aorta should be considered. In those patients not responding, prolonged surgical efforts are futile.