Case Study
European Journal of Trauma and Emergency Surgery
Seat Belt Syndrome and Aortoiliac Lesion: Case Report and Review of the Literature Newton R. Aerts, Eduardo Lichtenfels, Nilon Erling Jr.1
Abstract Blunt vascular trauma represents 7–9% of the vascular lesions in civilians. There are few reports associating blunt trauma with aortoiliac lesion to the trauma associated with the use of seat belts. We report a case of aortic bifurcation disruption and bilateral iliac artery thrombosis directly related to seat belt use and not associated with pelvic fractures. Arterial revascularization was accomplished through an aortoiliac bypass with spiraled saphenous vein interposition graft and perfusion was restored to both limbs. However, the patient died 5 days after due to respiratory distress syndrome. A high index of suspicion and early diagnosis are essential for patient survival and limb salvage. Key Words Seat belt Æ Trauma Æ Aortoiliac Eur J Trauma Emerg Surg 2007;33:198–200 DOI 10.1007/s00068-006-5134-1
Introduction The great majority of vascular injuries are a result of penetrating traumas (78%) [1–3]. Blunt trauma secondary to motor vehicle or industrial accidents accounts for 7–9% of vascular lesions in civilians. The number of deaths in motor vehicle accidents decreased from 70 to 33% by the use of seat belts [4–9]. The rate of fatal and critical injuries decreased 45 and 50%, respectively [10]. With the widespread use of seat belt devices, a new pattern of trauma with the varying degree of vascular injury has been recognized, termed the seat belt syndrome [5, 8, 9, 11]. Aortoiliac injury directly related to the trauma
1
associated with seat belt use is rare. Only few reports in the literature described this pattern of lesion [9, 12–15]. Case Report A 74-year-old female was the backseat passenger in a high-speed motor vehicle crash. The patient was admitted 2 h later in the Trauma Center unconscious. Physical examination revealed heart rate 115 beats/ min, blood pressure 70/45 mmHg, respiratory rate 26 breaths/min, temperature 36.4°C and Glasgow Coma Scale (GCS) scoring 8. The abdomen was distended with a 5-cm wide ecchymotic band extending transversely across the abdomen from one anterior superior iliac spine to the other (Figure 1). She had abdominal tenderness with evidence of peritoneal irritation. The lower limbs were pulseless and cold. She also presented signs of thoracic trauma (chest wall contusion) over her left breast (Figure 1). Thorax radiography suggested left lung contusion, with an abbreviated injury scale (AIS) score of 3. The patient revised trauma score (RTS) on admission was 4,502. Prompt laparotomy evidenced the complete disruption of the lower abdominal muscles, intestinal transection with mesenteric disruption and complete transection of the aortic bifurcation with contained hematoma and iliac arteries thrombosis (AIS score 4). The head and neck AIS score was 3. The injury severity score (ISS) of the patient was 34. After thrombectomy, arterial revascularization was accomplished through an aortoiliac bypass with spiraled saphenous vein graft with bilateral branches of approximately 4 cm. The patient had bilateral femoral pulses recovered, and underwent bilateral fasciotomy 6 h later due to bilateral compartmental syndrome. However, the pa-
Department of Vascular Surgery, Santa Casa de Porto Alegre and Hospital Municipal de Pronto-socorro, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Brazil.
Received: October 23, 2005; revision accepted: March 26, 2006; Published Online: February 10, 2007
198
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Aerts NR, et al. Seat Belt Syndrome and Aortoiliac Lesion
Figure 1. Seat belt sign.
tient died 5 days after due to severe acute respiratory distress syndrome and associated pulmonary sepsis. The sequential organ failure assessment (SOFA) score was 12 in the third postoperative day and increased to 16 in the fifth day. Discussion The seat belt syndrome, described initially by Garret and Braunstein in 1962 [11, 16], includes abdominal wall contusion, fracture or displacement of the lumbar spine and abdominal aortic lesion [6, 17–19]. The mechanisms proposed as a cause of the syndrome are the compression of the abdominal wall and viscera among the belt and the lumbar column, the sudden intraluminal pressure increase and the rate of deceleration between free and relatively fixed segments of the aorta, resulting in intimal flaps and disruptions [15, 17, 20, 21]. Atherosclerosis may be associated with aortic intimal disruption due to weakening of the intima in addition to loss of elasticity and compliance [17, 20, 21]. The associated aortoiliac trauma is rare due to the fact that iliac arteries are protected by the pelvis and retroperitoneal position [17, 22–24]. Among aortic blunt trauma, the thoracic location is much more frequent (95%) than the abdominal (0.05–0.08%) [9, 15, 25]. Common iliac artery blunt trauma has been described associated with multiple pelvic fractures, not directly related to the injury caused by the seat belt. Previous reports describe arterial aortoiliac injuries caused by motorcycle crashes, falls [22] and crush traumas [26, 27]. Nitecki and Gupta demonstrated that common iliac artery lesions are truly entities associated with the seat belt trauma, being more prevalent than it is diagnosed now [12, 13].
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
The advanced age and aortoiliac atherosclerosis of this patient corroborates the idea of an increased risk of intimal rupture in arteries with decreased elasticity [13, 28]. Prompt diagnosis and early treatment are essential for a successful outcome, lowering the high amputation rates and mortality. There is a related exsanguination prevalence of 11–15% and a mean survival rate of 46% [3]. Several times the signs of ischemia of the lower limbs are not present (19%), being necessary a high index of suspicion for the diagnosis [15]. The extremity should be examined regarding to the temperature, color, expanding hematomas, bruits, pulses and neurological deficits. The most frequent finding is the absent or decreased pulse (52–96%) [15, 16, 23, 29, 30]. The seat belt sign, a lower abdominal contusion strip like a burn, is present in approximately 12% of the cases, associated with a high risk of intestinal lesions [29]. The prevalence of the seat belt sign is 47% in patients with abdominal aorta injury [15]. In spite of being the gold standard method for diagnosis, preoperative arteriography is contraindicated in the hemodynamically unstable patient with multiorganic injury. In the stable patient, however, arteriography should not be delayed because it will guide the diagnosis and treatment [15, 16, 23, 30–33]. Duplex Doppler ultrasonography, because of its fast and easy access, is useful in the diagnosis of penetrating and nonpenetrating vascular injuries [13]. The surgical treatment of this condition depends on the lesion type and the patient’s general state. Ligation of the iliac arteries, without revascularization, results in a lower limb amputation rate of 50% [13], being an alternative when there is irreversible ischemia of the extremity. Direct arterial repair is a good option when the lesions of the common iliac artery are smaller than 2 cm [23, 34]. When the lesion is more extensive or direct repair is impracticable, the correction with graft interposition is mandatory. Synthetic grafts are ideal for aortoiliac and aortobifemoral repairs, because of their easy manipulation and faster placement. When there is intestinal disruption and grossly peritoneal contamination, the use of prosthetic grafts is generally contraindicated [13, 23, 28]. In these cases, we should use autogenous grafts or artery ligation with extra-anatomical revascularization procedures [35]. The problem of size discrepancy between saphenous vein and aortoiliac arteries can be managed with the spiraled saphenous graft technique. In the case reported, the bypass graft with spiraled saphenous vein was the procedure of choice due to extensive peritoneal contamination and prohibitive risk of vascular prosthesis infection, as well
199
Aerts NR, et al. Seat Belt Syndrome and Aortoiliac Lesion
as the associated traumas hindering an extra-anatomical revascularization procedure. In conclusion, aortoiliac injury due to seat belt trauma is an uncommon lesion rarely recognized. The seat belt sign, when present, should address the investigation for associated multisystemic, specially vascular, trauma. The prompt diagnosis and early repair of those lesions are essential to avoid continuous bleeding and death, as well as to decrease the amputation rates. The treatment choice should be based on the patient’s general conditions and type of arterial injury. The spiraled saphenous vein graft is a good alternative to aortoiliac reconstruction with adverse local conditions. References 1.
Feliciano DV, Bitondo CG, Mattox KL, et al. A one year experience with 456 vascular and cardiac injuries. Ann Surg 1984;199:717. 2. Perry MO. The Management of Acute Vascular Injuries. Williams and Wilkins, Baltimore, 1981. 3. Davis TP, Feliciano DV, Rozycki GS, et al. Results with abdominal vascular trauma in the modern era. Am Surg 2001;67(6), 565–70. 4. Trunkey DD. A plea for surgical leadership. J Trauma 1985;25:461. 5. Asbun HJ, Irana H, Roe EJ, et al. Intra-abdominal and seat belt injury. J Trauma 1990;30:159. 6. Dajee H, Richardson IW, Iype MO. Seat belt aorta: acute dissection and thrombosis of the abdominal aorta. Surgery 1979;85:263. 7. Denis R, Allard M, Atlas H, et al. Changing trends with abdominal injury in seat belt wearers. J Trauma 1983;23:1007. 8. Dreghorn CR. The effect of seat belt legislation on a district general hospital. Injury 1985;16:415. 9. Kruger K, Landwehr P, Kristen F, et al. Unusual pseudoanerysm of an axillofemoral bypass caused by seat belt trauma: case report. J Trauma 1999;46:189–191. 10. Passman C, McGwin G Jr, Taylor AJ, et al. Seat belt use before and after motor vehicle trauma. J Trauma 2001;51:105–109. 11. Garret JW, Braunstein PW. The seat belt syndrome. J Trauma 1962;2:220. 12. Nitecki S, Karmeli R, Ben-Arieh Y, et al. Seat belt injury to the common iliac artery: report of two cases and review of the literature. J Trauma 1992;33:935. 13. Gupta N, Auer A, Troop B. Seat belt-related injury to the common iliac artery: case report and review of the literature. 1998;45:419–21. 14. Tsai FC, Wang CC, Fang JF, et al. Isolated common iliac arter, occlusion secondary to atherosclerotic plaque rupture from blunt abdominal trauma: case report and review of the literature. J Trauma 1997;42:133–6. 15. Roth SM, Wheeler JR, Gregory RT, et al. (1997) Blunt injury of the abdominal aorta: a review. 42:748–55. 16. Muñiz AE, Haynes JH. Delayed abdominal aortic rupture in a child with a seat-belt sign and review of the literature. J Trauma 2004;56:194–7. 17. Matolo NM, Danto LA, Wolfman EF. Traumatic aneurysm of the abdominal aorta: report of two cases and review of the literature. Arch Surg 1974;198:867.
200
18. 19. 20. 21. 22. 23. 24. 25.
26. 27. 28.
29.
30. 31.
32.
33. 34.
35.
MacLeod JH, Nickolson DM. Seat belt trauma to the abdomen. Can J Surg 1969;12:202. Witte CL. Mesentery and bowel injury from automotive seat belts. Ann Surg 1968;167:486. Thal ER, Perry MO, Crighton J. Traumatic abdominal aortic occlusion. South Med J 1971;64:653. Warrian RK, Shoenut JP, Iannicello CM, et al. Seat belt injury to the abdominal aorta. J Trauma 1988;28:1505. Buscaglia LC, Matolo N, MacBeth A. Common iliac artery injury from blunt trauma: case report. J Trauma 1989;29:697. Blackley PF, Duggan E, Wood RFM. Vascular trauma. Br J Surg 1987;74:1077. Ekbom GA, Towne JB, Majewski JT, et al. Intra-abdominal vascular trauma: a need prompt operation. J Trauma 1981;21:1040. Qureshi A, Roberts N, Nicholson A, et al. Three-dimensional reconstruction by spiral computed tomography to locate aortic tear following blunt abdominal trauma. Eur J Vasc Endovasc Surg 1997;14:316–7. Thomford NR, Curtiss P, Marable S. Injuries of the iliac and femoral artery associated with blunt skeletal trauma. J Trauma 1969;9:126. Jafari N, Shapiro RA, Evans RH, et al. Traumatic occlusive intimal flaps. Ill Med J 1977;152:105. Naude GP, Back M, Perry MO, et al. Blunt disruption of the abdominal aorta: report of a case and review of the literature. J Vasc Surg 1997;25:931–5. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg 1997;63:885–8. Gelberman RH, Menon J, Fronek A. The peripheral pulse following arterial injury. J Trauma 1980;20:948. McDonald E, Goodman P, Winestock D. Clinical indications for arteriography in extremity trauma: a review of 114 cases. Radiology 1975;116:45. Smith PL, Lim WN, Ferris EJ, et al. Emergency arteriography in extremety trauma: assesment of indications. Am J Radiol 1981;137:803. Hemreck AS, Sifers TM, Reckling FW, et al. Traumatic vascular injuries. Am J Surg 1974;128:813. Bongard F. Thoracic and Abdominal Vascular Trauma. In: Rutherford RB, eds. Vascular Surgery. 4 edition WB Saunders, Philadelphia 1995, pp 686–704. Robbs JV, Backer LW. Cardiovascular trauma. Curr Probl Surg 1984;21:20–87.
Address for Correspondence Newton R. Aerts, MD, PhD Department of Vascular Surgery Santa Casa de Porto Alegre and Hospital Municipal de Pronto-socorro Fundação Faculdade Federal de Ciências Médicas de Porto Alegre Rua. Prof. Annes Dlas 285 Porto Alegre RioGrande do Sul Brazil Phone (+55/51) 3214-8080, Fax -8585 e-mail: [email protected]
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
European Journal of Trauma and Emergency Surgery
Seat Belt Syndrome and Aortoiliac Lesion: Case Report and Review of the Literature Newton R. Aerts, Eduardo Lichtenfels, Nilon Erling Jr.1
Abstract Blunt vascular trauma represents 7–9% of the vascular lesions in civilians. There are few reports associating blunt trauma with aortoiliac lesion to the trauma associated with the use of seat belts. We report a case of aortic bifurcation disruption and bilateral iliac artery thrombosis directly related to seat belt use and not associated with pelvic fractures. Arterial revascularization was accomplished through an aortoiliac bypass with spiraled saphenous vein interposition graft and perfusion was restored to both limbs. However, the patient died 5 days after due to respiratory distress syndrome. A high index of suspicion and early diagnosis are essential for patient survival and limb salvage. Key Words Seat belt Æ Trauma Æ Aortoiliac Eur J Trauma Emerg Surg 2007;33:198–200 DOI 10.1007/s00068-006-5134-1
Introduction The great majority of vascular injuries are a result of penetrating traumas (78%) [1–3]. Blunt trauma secondary to motor vehicle or industrial accidents accounts for 7–9% of vascular lesions in civilians. The number of deaths in motor vehicle accidents decreased from 70 to 33% by the use of seat belts [4–9]. The rate of fatal and critical injuries decreased 45 and 50%, respectively [10]. With the widespread use of seat belt devices, a new pattern of trauma with the varying degree of vascular injury has been recognized, termed the seat belt syndrome [5, 8, 9, 11]. Aortoiliac injury directly related to the trauma
1
associated with seat belt use is rare. Only few reports in the literature described this pattern of lesion [9, 12–15]. Case Report A 74-year-old female was the backseat passenger in a high-speed motor vehicle crash. The patient was admitted 2 h later in the Trauma Center unconscious. Physical examination revealed heart rate 115 beats/ min, blood pressure 70/45 mmHg, respiratory rate 26 breaths/min, temperature 36.4°C and Glasgow Coma Scale (GCS) scoring 8. The abdomen was distended with a 5-cm wide ecchymotic band extending transversely across the abdomen from one anterior superior iliac spine to the other (Figure 1). She had abdominal tenderness with evidence of peritoneal irritation. The lower limbs were pulseless and cold. She also presented signs of thoracic trauma (chest wall contusion) over her left breast (Figure 1). Thorax radiography suggested left lung contusion, with an abbreviated injury scale (AIS) score of 3. The patient revised trauma score (RTS) on admission was 4,502. Prompt laparotomy evidenced the complete disruption of the lower abdominal muscles, intestinal transection with mesenteric disruption and complete transection of the aortic bifurcation with contained hematoma and iliac arteries thrombosis (AIS score 4). The head and neck AIS score was 3. The injury severity score (ISS) of the patient was 34. After thrombectomy, arterial revascularization was accomplished through an aortoiliac bypass with spiraled saphenous vein graft with bilateral branches of approximately 4 cm. The patient had bilateral femoral pulses recovered, and underwent bilateral fasciotomy 6 h later due to bilateral compartmental syndrome. However, the pa-
Department of Vascular Surgery, Santa Casa de Porto Alegre and Hospital Municipal de Pronto-socorro, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Brazil.
Received: October 23, 2005; revision accepted: March 26, 2006; Published Online: February 10, 2007
198
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
Aerts NR, et al. Seat Belt Syndrome and Aortoiliac Lesion
Figure 1. Seat belt sign.
tient died 5 days after due to severe acute respiratory distress syndrome and associated pulmonary sepsis. The sequential organ failure assessment (SOFA) score was 12 in the third postoperative day and increased to 16 in the fifth day. Discussion The seat belt syndrome, described initially by Garret and Braunstein in 1962 [11, 16], includes abdominal wall contusion, fracture or displacement of the lumbar spine and abdominal aortic lesion [6, 17–19]. The mechanisms proposed as a cause of the syndrome are the compression of the abdominal wall and viscera among the belt and the lumbar column, the sudden intraluminal pressure increase and the rate of deceleration between free and relatively fixed segments of the aorta, resulting in intimal flaps and disruptions [15, 17, 20, 21]. Atherosclerosis may be associated with aortic intimal disruption due to weakening of the intima in addition to loss of elasticity and compliance [17, 20, 21]. The associated aortoiliac trauma is rare due to the fact that iliac arteries are protected by the pelvis and retroperitoneal position [17, 22–24]. Among aortic blunt trauma, the thoracic location is much more frequent (95%) than the abdominal (0.05–0.08%) [9, 15, 25]. Common iliac artery blunt trauma has been described associated with multiple pelvic fractures, not directly related to the injury caused by the seat belt. Previous reports describe arterial aortoiliac injuries caused by motorcycle crashes, falls [22] and crush traumas [26, 27]. Nitecki and Gupta demonstrated that common iliac artery lesions are truly entities associated with the seat belt trauma, being more prevalent than it is diagnosed now [12, 13].
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
The advanced age and aortoiliac atherosclerosis of this patient corroborates the idea of an increased risk of intimal rupture in arteries with decreased elasticity [13, 28]. Prompt diagnosis and early treatment are essential for a successful outcome, lowering the high amputation rates and mortality. There is a related exsanguination prevalence of 11–15% and a mean survival rate of 46% [3]. Several times the signs of ischemia of the lower limbs are not present (19%), being necessary a high index of suspicion for the diagnosis [15]. The extremity should be examined regarding to the temperature, color, expanding hematomas, bruits, pulses and neurological deficits. The most frequent finding is the absent or decreased pulse (52–96%) [15, 16, 23, 29, 30]. The seat belt sign, a lower abdominal contusion strip like a burn, is present in approximately 12% of the cases, associated with a high risk of intestinal lesions [29]. The prevalence of the seat belt sign is 47% in patients with abdominal aorta injury [15]. In spite of being the gold standard method for diagnosis, preoperative arteriography is contraindicated in the hemodynamically unstable patient with multiorganic injury. In the stable patient, however, arteriography should not be delayed because it will guide the diagnosis and treatment [15, 16, 23, 30–33]. Duplex Doppler ultrasonography, because of its fast and easy access, is useful in the diagnosis of penetrating and nonpenetrating vascular injuries [13]. The surgical treatment of this condition depends on the lesion type and the patient’s general state. Ligation of the iliac arteries, without revascularization, results in a lower limb amputation rate of 50% [13], being an alternative when there is irreversible ischemia of the extremity. Direct arterial repair is a good option when the lesions of the common iliac artery are smaller than 2 cm [23, 34]. When the lesion is more extensive or direct repair is impracticable, the correction with graft interposition is mandatory. Synthetic grafts are ideal for aortoiliac and aortobifemoral repairs, because of their easy manipulation and faster placement. When there is intestinal disruption and grossly peritoneal contamination, the use of prosthetic grafts is generally contraindicated [13, 23, 28]. In these cases, we should use autogenous grafts or artery ligation with extra-anatomical revascularization procedures [35]. The problem of size discrepancy between saphenous vein and aortoiliac arteries can be managed with the spiraled saphenous graft technique. In the case reported, the bypass graft with spiraled saphenous vein was the procedure of choice due to extensive peritoneal contamination and prohibitive risk of vascular prosthesis infection, as well
199
Aerts NR, et al. Seat Belt Syndrome and Aortoiliac Lesion
as the associated traumas hindering an extra-anatomical revascularization procedure. In conclusion, aortoiliac injury due to seat belt trauma is an uncommon lesion rarely recognized. The seat belt sign, when present, should address the investigation for associated multisystemic, specially vascular, trauma. The prompt diagnosis and early repair of those lesions are essential to avoid continuous bleeding and death, as well as to decrease the amputation rates. The treatment choice should be based on the patient’s general conditions and type of arterial injury. The spiraled saphenous vein graft is a good alternative to aortoiliac reconstruction with adverse local conditions. References 1.
Feliciano DV, Bitondo CG, Mattox KL, et al. A one year experience with 456 vascular and cardiac injuries. Ann Surg 1984;199:717. 2. Perry MO. The Management of Acute Vascular Injuries. Williams and Wilkins, Baltimore, 1981. 3. Davis TP, Feliciano DV, Rozycki GS, et al. Results with abdominal vascular trauma in the modern era. Am Surg 2001;67(6), 565–70. 4. Trunkey DD. A plea for surgical leadership. J Trauma 1985;25:461. 5. Asbun HJ, Irana H, Roe EJ, et al. Intra-abdominal and seat belt injury. J Trauma 1990;30:159. 6. Dajee H, Richardson IW, Iype MO. Seat belt aorta: acute dissection and thrombosis of the abdominal aorta. Surgery 1979;85:263. 7. Denis R, Allard M, Atlas H, et al. Changing trends with abdominal injury in seat belt wearers. J Trauma 1983;23:1007. 8. Dreghorn CR. The effect of seat belt legislation on a district general hospital. Injury 1985;16:415. 9. Kruger K, Landwehr P, Kristen F, et al. Unusual pseudoanerysm of an axillofemoral bypass caused by seat belt trauma: case report. J Trauma 1999;46:189–191. 10. Passman C, McGwin G Jr, Taylor AJ, et al. Seat belt use before and after motor vehicle trauma. J Trauma 2001;51:105–109. 11. Garret JW, Braunstein PW. The seat belt syndrome. J Trauma 1962;2:220. 12. Nitecki S, Karmeli R, Ben-Arieh Y, et al. Seat belt injury to the common iliac artery: report of two cases and review of the literature. J Trauma 1992;33:935. 13. Gupta N, Auer A, Troop B. Seat belt-related injury to the common iliac artery: case report and review of the literature. 1998;45:419–21. 14. Tsai FC, Wang CC, Fang JF, et al. Isolated common iliac arter, occlusion secondary to atherosclerotic plaque rupture from blunt abdominal trauma: case report and review of the literature. J Trauma 1997;42:133–6. 15. Roth SM, Wheeler JR, Gregory RT, et al. (1997) Blunt injury of the abdominal aorta: a review. 42:748–55. 16. Muñiz AE, Haynes JH. Delayed abdominal aortic rupture in a child with a seat-belt sign and review of the literature. J Trauma 2004;56:194–7. 17. Matolo NM, Danto LA, Wolfman EF. Traumatic aneurysm of the abdominal aorta: report of two cases and review of the literature. Arch Surg 1974;198:867.
200
18. 19. 20. 21. 22. 23. 24. 25.
26. 27. 28.
29.
30. 31.
32.
33. 34.
35.
MacLeod JH, Nickolson DM. Seat belt trauma to the abdomen. Can J Surg 1969;12:202. Witte CL. Mesentery and bowel injury from automotive seat belts. Ann Surg 1968;167:486. Thal ER, Perry MO, Crighton J. Traumatic abdominal aortic occlusion. South Med J 1971;64:653. Warrian RK, Shoenut JP, Iannicello CM, et al. Seat belt injury to the abdominal aorta. J Trauma 1988;28:1505. Buscaglia LC, Matolo N, MacBeth A. Common iliac artery injury from blunt trauma: case report. J Trauma 1989;29:697. Blackley PF, Duggan E, Wood RFM. Vascular trauma. Br J Surg 1987;74:1077. Ekbom GA, Towne JB, Majewski JT, et al. Intra-abdominal vascular trauma: a need prompt operation. J Trauma 1981;21:1040. Qureshi A, Roberts N, Nicholson A, et al. Three-dimensional reconstruction by spiral computed tomography to locate aortic tear following blunt abdominal trauma. Eur J Vasc Endovasc Surg 1997;14:316–7. Thomford NR, Curtiss P, Marable S. Injuries of the iliac and femoral artery associated with blunt skeletal trauma. J Trauma 1969;9:126. Jafari N, Shapiro RA, Evans RH, et al. Traumatic occlusive intimal flaps. Ill Med J 1977;152:105. Naude GP, Back M, Perry MO, et al. Blunt disruption of the abdominal aorta: report of a case and review of the literature. J Vasc Surg 1997;25:931–5. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg 1997;63:885–8. Gelberman RH, Menon J, Fronek A. The peripheral pulse following arterial injury. J Trauma 1980;20:948. McDonald E, Goodman P, Winestock D. Clinical indications for arteriography in extremity trauma: a review of 114 cases. Radiology 1975;116:45. Smith PL, Lim WN, Ferris EJ, et al. Emergency arteriography in extremety trauma: assesment of indications. Am J Radiol 1981;137:803. Hemreck AS, Sifers TM, Reckling FW, et al. Traumatic vascular injuries. Am J Surg 1974;128:813. Bongard F. Thoracic and Abdominal Vascular Trauma. In: Rutherford RB, eds. Vascular Surgery. 4 edition WB Saunders, Philadelphia 1995, pp 686–704. Robbs JV, Backer LW. Cardiovascular trauma. Curr Probl Surg 1984;21:20–87.
Address for Correspondence Newton R. Aerts, MD, PhD Department of Vascular Surgery Santa Casa de Porto Alegre and Hospital Municipal de Pronto-socorro Fundação Faculdade Federal de Ciências Médicas de Porto Alegre Rua. Prof. Annes Dlas 285 Porto Alegre RioGrande do Sul Brazil Phone (+55/51) 3214-8080, Fax -8585 e-mail: [email protected]
Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL
