Blunt Abdominal Aorta, Celiac Artery, and Superior Mesenteric Artery Injuries Treated Endovascularly

Abstract

Abdominal aortic branch injury involving celiac artery and superior mesenteric artery (SMA) after blunt trauma are especially rare and carry very high mortality rates. Although the true incidence of visceral vascular injury is unknown, the incidence of blunt celiac injuries is estimated to be 5 to 10 per cent of all injuries to this vessel,1 where SMA injuries were reported in 0.09 per cent of all admissions to trauma centers.2 Limited cases of celiac trunk and SMA dissection in blunt trauma patients are reported in literature. Blunt abdominal aortic and visceral vascular injuries have been traditionally managed by open surgical repair; however, in recent years, endovascular repairs of these injuries have been increasingly reported. Herein, we report a case of an 18-year-old male patient involved in a high-speed motor vehicle collision (MVC) who sustained, among other traumatic injuries, a triple vessel injury involving the distal abdominal aorta, celiac trunk, and SMA, which were successfully managed with an endovascular approach. An 18-year-old male with past medical history of depression, anxiety, and polysubstance abuse was a restrained passenger in a high-speed MVC. The patient had a Glasgow Coma Score of 15 on presentation and was hemodynamically normal. A “seat belt sign” was identified on secondary survey. Awhole-body CT scan was performed, which showed free fluid in the abdomen without solid organ injury, a retroperitoneal hematoma, and infrarenal abdominal aortic injury with dissection and active extravasation. He was also found to have a three-column fracture of the third lumbar vertebral body with bony retropulsion into the spinal canal. The abdominal aortic laceration was at the level of the comminuted L3 vertebral body fracture, with extravasation and extensive retroperitoneal hemorrhage. In addition, there was focal narrowing of the celiac trunk at the origin with no evidence of flow compromise beyond it, and both superior and inferior mesenteric arteries were patent. The patient was taken emergently to the operating room. Initially, an aortogram was performed confirming a distal infrarenal aortic injury. A 30-mm Endurant aortic cuff graft was placed with sealing of aortic injury and resolution of extravasation (Fig. 1). This was followed by the planned laparotomy which revealed multiple mesenteric tears in the small bowel mesentery with devascularization of approximately 20 cm of jejunum requiring resection. The remainder of the small bowel was pink and viable, and the SMA was confirmed to have a palpable pulse. On postoperative day 6 from his initial surgery, the patient demonstrated a markedly elevated liver function test and a slight elevation of international normalization ratio of 1.41. A repeat CT angiogram of the abdomen and pelvis was performed that showed evidence of hypoperfused liver and severe narrowing of the origins of celiac trunk and SMA (Fig. 2). The