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Certain injuries to the aorta, vena cava, and long segments of peripheral vessels preclude lateral arteriorrhaphy or primary end-to-end anastomosis. In such cases some type of vascular prosthesis is required. The choice of a suitable vascular prosthesis in potentially contaminated wounds is open to

With the increased nationwide incidence of major vascular injuries, the need for interposition grafting has become quite common in major trauma centers. Despite extensive experience with such injuries, the choice of a substitute conduit remains controversial. Recent studies have demonstrated the potential of expanded polytetrafluoroethylene (PTFE) as a replacement graft for small arteries and veins. The surgical services at the Ben Taub General Hospital began to use PTFE grafts in traumatic vascular wounds approximately 2 years ago. Eight axillary arteries and 12 brachial arteries have had interposition grafting with PTFE prostheses. Eleven patients have required PTFE interposition grafts in repair of traumatized common, superficial, and profunda femoris arteries and common femoral veins; eight patients had reconstruction in the popliteal artery or vein. Three patients had renal artery revascularization procedures following blunt abdominal trauma, three patient had segmental replacement of the superior mesenteric artery following gunshot wounds, and one carotid artery, one iliac vein, and two axillary veins were grafted with PTFE. All patients with segmental repair of axillary, brachial, femoral, and popliteal vessels have maintained good distal pulses and viable extremities. No grafts have thrombosed, nor become infected, in spite of soft-tissue injury encountered at time or repair. In situations requiring interposition graft placement for reestablishment of distal flow in small arteries and veins, PTFE grafts appear to be an acceptable prosthesis.

From 1978 through 1984, 22 patients with 20 penetrating and two blunt injuries to the proximal superior mesenteric artery were treated. Patients presented with exsanguinating hemorrhage (19), midline hematomas (two), or 'black bowel' (one). Two other patients developed 'black bowel' during operation. Direct cutdown through the mesentery was the approach in 11 patients, and three survived; a Mattox maneuver was used in ten patients, and five survived. Complex bypass or grafting procedures were performed in nine patients, and two survived. Ten of 15 deaths were secondary to hemorrhagic shock; two of five late deaths were related to problems with the vascular repair in patients with multiple injuries. Interposition grafting near a major pancreatic injury may lead to catastrophic postoperative problems. Bypass grafts from the distal aorta should have retroperitoneal tissue coverage of the suture line.

Six hundred thirty-two cases of penetrating wounds of the neck were analyzed in this study in order to re-evaluate our current concepts in the management of these injuries. There were 35 deaths in this series, an overall mortality rate of 5.5%. However, in the last 10 years there were only 13 deaths among 407 patients, a 3.2% mortality rate. Early exploration was performed in 507 patients, and 125 patients were observed. Explorations revealed a total of 625 separate injuries. In 142 explorations, no injury was found. There was no mortality or significant morbidity in these patients with negative explorations. Patients who presented with obvious vascular or visceral injury were immediately explored. Those wounds without obvious injury were either explored or observed, depending on the index of clinical suspicion based on awareness of the innocuous presentation and difficulty in diagnosing esophageal injuries. The mortality rate is a function of multiple factors. Its decrease over the past 25 years is related to many improvements in our health care system. Our own decrease in mortality rate can be attributed in part to decreased transportation time resulting in less blood loss. A greater awareness of esophageal injuries was another factor. No conclusions are possible as to the feasibility of conservative management based upon the mortality rates alone; however, on examination of our experiences with penetrating wounds of the neck, it appears that a significant number of patients when carefully selected by trained personnel can be safely managed with observation.

Penetrating injuries of the thoracic and abdominal aorta are controlled and repaired successfully with increasing frequency. Penetration of the suprarenal abdominal aorta has been associated with a high mortality rate because of difficult exposure and associated injuries. Between January 1969 and July 1973, 28 patients have undergone operative treatment for traumatic injury to the suprarenal aorta and other associated thoraco-abdominal injuries with 10 long-term survivors. Eight survivors sustained their injuries during the last 3 years, when a medial mobilization of the viscera was the preferred approach. Dacron prosthetic material was employed in seven patients, and in two there was ligation of the celiac axis. With satisfactory exposure, control of exsanguinating hemorrhage, and utilization of available vascular reconstructive techniques, successful management of this relatively inaccessible intra-abdominal lesion can be accomplished in an increasing number of patients.