Trauma to the proximal superior mesenteric artery: A case report and review of the literature William A. B o u r l a n d , MD, John F. Kispert, M D , G o r d o n L. H y d e , M D , and Andris K a z m e r s , M D , Lexington, Ky. Visceral arterial injuries account for a small but important portion of major abdominal vascular trauma. A case of proximal superior mesenteric artery trauma is presented. The advantages and drawbacks of the surgical approaches to these injuries are discussed. On the basis of a review of the literature describing the management of these injuries, ligation of the proximal superior mesenteric artery for trauma cannot be recommended. Prompt surgical intervention with revascularization offers the best chance for the survival of these critically injured patients. (J VAsc SURG 1992;15:669-74.)
Mesenteric arterial injuries account for a small but important portion o f penetrating civilian vascular injuries, constituting 12% o f cases in a large series. 1 Abdominal arterial injuries in general and mesenteric arterial injuries in particular are conspicuous in their absence f r o m reports o f military vascular trauma. 2-4 Because lovcer-velocity gunshot wounds and stabbings are more c o m m o n , and access to care is more rapid in nonmilitary trauma, major intraabdominal vascular injuries are an important problem for the civilian surgeon. M a n a g e m e n t o f trauma to the proximal superior mesenteric artery (SMA) presents unique surgical challenges. Difficulties with exposure and control o f hemorrhage:, the lethality o f intestinal ischemia, and the c o m m o n presence o f associated injuries account for the high mortality rates associated with proximal SMA injuries. Successful m a n a g e m e n t o f a patient with a penetrating injury to the proximal SMA is described, and the literature related to these unusual injuries is reviewed. CASE R E P O R T A 24-year-old man sustained a self-inflicted .25 caliber handgun wound to the midabdomen. On presentation at a local hospital, he was hypotensive with a distended abdomen and was taken to the operating room. A laparotomy revealed a laceration of the left lobe of the liver, From the Vascular Surgery Section, Division of General Surgery, Departmenl: of Surgery, University of Kentucky, Lexington. Reprint requests: Andris Kazmers, MD, University of Kentucky Chandler Medical Center C-218, 800 Rose St., Lexington, KY 40536-0084. 24/4/33302
perforation of the midtransverse colon, multiple perforations of the third portion of the duodenum, and a large posterior midline hematoma at the root of the small bowel mesentery. Segmental resection of the transverse colon, colostomy, and mucous fistula were performed. The duodenal injuries were primarily repaired. The patient received 11 units of packed red cells and 6 units of fresh frozen plasma during the procedure. Because the retroperitoned hematoma had remained unchanged and the patient was hemodynamically stable, he was transferred after these initial procedures to the University of Kentucky Medical Center for further treatment. On arrival at the hospital the patient was alert with a pulse rate of 98 beats/min and blood pressure of 150/90 mm Hg. The abdomen was moderately distended and diffusely tender, with a bullet entrance wound just above and to the left of the umbilicus. The colostomy and mucous fistula appeared pink and viable. The hematocrit level was 25%. The serum amylase value was normal. Arteriography demonstrated injury to the SMA between its origin and the middle colic artery, which communicated with a pseudoaneurysm 4 cm in diameter (Fig. 1). The patient was transferred from the angiography suite to the operating room. At reoperation, arterial bleeding from the root of the mesentery was encountered. This was controlled initially by direct digital pressure followed by exposure and crossclamping of the supraceliac aorta (Figs. 2 and 3). The proximal SMA was exposed through the left side of the root of the small bowel mesentery, reflecting the inferior border of the pancreas superiorly. A near-complete transection of the SMA was evident at the level of the exit of the middle colic artery from beneath the uninjured pancreas. The damaged proximal and distal ends of the SMA were ligated. The aorta was then undamped. At this point the entire small bowel, except for the proximal 35 cm of jejunum, appeared ischemic. No arterial Doppler flow signals were present distal to the proximal jejunum. 669
670 Bourland et al.
J~ournal of VASCULAR SURGER#
~ce/iac ) 0
Fig. 1. Preoperative angiogram demonstrates SMA pseudoaneurysm. Fig. 3. Operative approach to SMA repair.
side of the colon, which appeared pink and viable. Suture exclusion of the pylorus, duodenostomy, gastrostomy, and jejunostomy were performed. Because of edema of the viscera and abdominal wall, primary dosure of the laparotomy incision without excessive tension was not possible. Therefore the abdomen was closed With polyglycolic acid mesh. The patient was maintained on total parenteral nutrition for 13 days followed by jejunal robe feedings. He did not have diarrhea. Three days later the pyloric exclusion suture was removed endoscopically, and an oral diet was well tolerated. Postoperative angiography confirmed patency of the iliomesenteric bypass graft on postoperative day 17 (Fig. 5). After closure of the abdominal wound by skin grafting, the patient was discharged on a regular diet on the thirty-ninth day after injury. Graft patency was confirmed 3 months after injury by duplex ultrasonography, which revealed normal fasting SMA flow velocity and the expected postprandial augmentation of diastolic SMA flow velocity.
Fig. 2. Operative approach to SMA repair. A reversed saphenous vein was used to bypass from the right common iliac artery to the midportion of the SMA in an end-to-side fashion (Fig. 4). The total ischemia time of the small bowel was approximately 6 hours. Arterial pulses were restored to the entire small bowel and remaining right
DISCUSSION Blunt or penetrating trauma to the proximal SMA is unusual. The rarity o f such injuries in modern military experience can be attributed to the lethality o f high-velocity wounding agents and inaccessibility to immediate surgical treatment.24 Although uncommon, SMA injuries are more prevalent in civilian vascular trauma in which lower-velocity handguns or stabbings are the c o m m o n agents, and access to definitive care is more rapid) Superior mesenteric artery injuries may present
Volume 15 Number 4 April 1992
Trauma to proximal superior mesenteric artery
671
Fig. 4. Illustration of iliomesenteric reconstruction with saphenous vein graft.
=Lv
iL,
MNJJ
I U
.%gI-HMK-~U
-
W
Fig. 5. Postoperative angiogram confirms graft patency.
with hemorrhage, intestinal ischemia, or arteriovenous fist-tfla.~'6 Gradual occlusion of the SMA is compatible with survival in the canine because of development of collateral circulation. 7 Likewise in humans it is recognized that chronic atherosclerotic
occlusion of the SMA may be tolerated because of collateral flow development. Collateral circulation is not sufficient to prevent bowel ischemia after acute SMA occlusion in patients with previously normal mesenteric circulation. Extrapolation from the effects
672
lournal of VASCULAK SURGERY
Bourland et al.
.~XUS
Fig. 6. Surgical anatomy pertinent to repairs of S/VIAinjuries. of gradual SMA occlusion to the situation of acute ligation in the hypotensive, usually young, trauma victim is not appropriate. Shirkey et al.8 are credited with the first successful repair of penetrating SMA transection. Although repair of such injuries is preferred, SMA ligation has been advocated. 912 It has been suggested that injuries to the SMA origin can be treated by ligation, whereas those distal to the inferior edge of the pancreas require reconstmctionY ° Others believe that injuries proximal to the jejunal branches always necessitate repair, n Although Fullen et a1.13reported SMA ligation in patients, these in fact represented ligation of segmental jejunal, ileal, or colic branchesl Such minor ligations may be tolerated because of collateral flow through arcuate branches, assuming SMA trunk flow is preserved) 4 Even if intestinal necrosis results from such branch ligation, bowel resection compatible with survival is possible. Courcy et al.~s reported that ligation of both SMA and superior mesenteric vein resulted in extensive intestinal ischemia. Graham et al.16 reported only one ligation in a large series of SMA injuries, and that patient died. Kashuk et al)7
also attempted proximal SMA ligation, but the patient died of gut infarction. The approach to the SMA from the left side of the root of the small bowel mesentery was used in the case reported herein (Figs. 2, 3, and 6). Advantages of this approach are its direcmess, ease, and the ability to deal with concomitant mesenteric venous injuries. Disadvantages include difficulty in exposure of the proximal SMA. "Medial visceral rotation" (Fig. 7) affords wide exposure of the proximal visceral and supraceliac segments of the abdominal aorta, s Drawbacks are the time required and the limited access provided to both distal visceral arteries and superior mesenteric v e n o u s i n j u r i e s . 5,11,16,18 A third approach to the SMA (Fig. 8) uses an extensive Kocher maneuver. 19 Superior mesenteric artery injuries should be reconstructed. In the patient with a limited injury involving a portion of the artery wall, lateral arteriorrhaphy may be possible. Because of the multitude of short SMA side branches, sufficient mobilization for primary repair of an SMA transection may not be feasible or may result in failure of the reconstruction. n'16 Associated duodenal, pancreatic, or colonic
Volume 15 Number 4 April 1992
Trauma to proximal superior mesenteric artery
673
mesetgterlc A.
Fig. 7. Exposure by left medial visceral rotation.
mesentenb ~/ me'¢entonc A.
Fig. 8. Exposure by extensive Kocher maneuver (right medial visceral rotation).
injuries may preclude safe local reconstruction in the area of the proximal SMA. Such considerations led to extraanatomic reconstruction with autogenous tissue in our patient, with proximal and distal anastomoses at sites as far from the pancreas and duodenum as possible, bdthough prosthetic grafts have been employed in the face of enteric contamination, autogenous grafts are recommended. 2°'21To expedite repair in patient~; known to have SMA injury, exposure of the saphenous vein before laparotomy could be
considered in the unusual event that the patient's condition permits. Use of temporizing shunts cannot be recommended because of the difficulties in placement related to the anatomy of the SMA, the delay in definitive SMA repair, and the lack of proved efficacy for patients with visceral arterial injury. Injury to the superior mesenteric vein occurs in 50% of patients with proximal SMA injury and is the most frequent concomitant abdominal vascular i n j u r y . 5,9,16-18 Superior mesenteric vein repair rather
674
Journalof VASCULAR 5LIRGERY
Bourland et al.
than ligation is strongly recommended for combined injuries. 1~ Superior mesenteric artery-superior mesenteric vein arteriovenous fistula may protect patients from intraperitoneal hemorrhage. 6,~6 Repair of such fistulas is indicated to avoid complications of portal hypertension. As prehospital trauma care and patient transport improve, it is hkely that more patients with blunt and penetrating SMA injury will reach trauma centers alive. 1,22"24 Prompt control of hemorrhage followed by SMA revascularization offers the best chance of survival. A review of the literature indicates that such arterial repair is preferred over truncal SMA ligation in the patient with SMA injury.
11.
12. 13.
14. 15.
16. 17.
REFERENCES 1. Mattox KL, Feliciano DV, Burch J, Beall AC Jr, Jordan GL Jr, DeBakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698-707. 2. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War !I: an analysis of 2,471 cases. Ann Surg 1946;123:534-79. 3. Hughes CW. Arterial repair during the Korean War. Ann Surg 1958;147;555-61. 4. Rich NM, Bangh JH, Hughes CW. Acute arterial injuries in Vietnam: 1000 cases. J Trauma 1970;10:359-69. 5. Accola KD, Feliciano DV, Mattox KL, Burch JM, Beall AC Jr, Jordan GL Jr. Management of injuries to the superior mesenteric artery. J Trauma 1986;26:313-9. 6. WoodM, Nykamp PW. Traumatic arteriovenous fistulaof the superior mesenteric vessels. J Trauma 1980;20:378-82. 7. BlalockA, Levy SE. Gradual complete occlusion of the celiac axis, the superior and inferior mesenteric arteries,with survival of animals: the effects of ischemia on blood pressure. Surgery 1939;5:175-8. 8. Shirkey AL, Quast DC, Jordan GL Jr. Superior mesenteric artery division and intestinal function. J Trauma 1967;7:7-24. 9. FelicianoDV, Burch JM, Graham JM. Vascularinjuries of the chest and abdomen. In: Rutherford RB, ed, VascularSurgery. 3rd ed. Philadelphia: WB Sannders, 1989:598. 10. Feliciano DV, Burch JM, Graham JM. Abdominal vascular
18.
I9.
20.
21.
22.
23.
24.
injury. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. 1st ed. Norwalk: Appleton & Lange, 1988:524. Lucas AE, Richardson JD, Flint LM, Polk HC Jr. Traumatic injury of the proximal superior mesenteric artery. Ann Surg 1981;193:30-4. Well PH. Management of retroperitoneal trauma. Curr Probl Surg 1983;20:540-620. Fullen WD, Hunt J, Altemeier WA. The clinicalspectrum of penetrating injury to the superior mesenteric arterial circulation. J Trauma 1972;12:656-64. Noer RJ, ManningJE. Acomparative study ofsmall intestinal circulation. Tram West Surg Assoc 1942;51:272-91. Courcy PA, Bromaan S, Oster-Granite M, Soderstrom CA, Siegel JH, Cowley RA. Superior mesenteric artery and vein injuries from blunt abdominal trauma. J Trauma 1984;24: 843-5. Graham JM, Mattox KL, BeallAC, DeBakeyME. Injuries to the visceral arteries. Surgery 1978;84:835-9. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma: a unified approach. J Traum~ 1982;22:672-9. " Ekbom GA, Towne JB, Majewski IT, Woods JH. Intraabdominal vascular trauma: a need for prompt operation. I Trauma 1981;21:1040-4. Bonnichon P, Rossat-Mignod JC, Corlieu P, Aaron C, Yandza T, Chapuis Y. Surgical approach to the superior mesenteric artery by the Kocher maneuver: anatomy study and clinical applications. Ann Vasc Surg 1987;1:505-8. Lan JM, Mattox KL, Beall AC, DeBakey ME. Use of substitute conduits in traumatic vascular injury. J Trauma 1977;17:54I-6. Ogburn N, Pories WI. Reconstruction of the mesenteric and coeliac arteries. In: DeWeese J, ed. Vascular surgery, vol 17. Rob & Smith's operative surgery. 4th ed. London: Butterworths, 1985:158-9, Yaw PB, van Beek AL, Glover JL. Successful repair of a gunshot wound to the first part of the superior mesenteric artery. J Trauma 1974;14:885-7. Pezzella AT, Grif~n WO Jr, Ernst CB. Superior mesenteric artery injury following blunt abdominal trauma: case report with successfulprimary repair. J Trauma 1978;18:472-4. Sirinek KR, Levine BA. Traumatic injury to the proximal superior mesenteric vessels. Surgery 1985;98:831-5.
Submitted June 18, 1991; accepted Aug. 16, 1991.
Mesenteric arterial injuries account for a small but important portion o f penetrating civilian vascular injuries, constituting 12% o f cases in a large series. 1 Abdominal arterial injuries in general and mesenteric arterial injuries in particular are conspicuous in their absence f r o m reports o f military vascular trauma. 2-4 Because lovcer-velocity gunshot wounds and stabbings are more c o m m o n , and access to care is more rapid in nonmilitary trauma, major intraabdominal vascular injuries are an important problem for the civilian surgeon. M a n a g e m e n t o f trauma to the proximal superior mesenteric artery (SMA) presents unique surgical challenges. Difficulties with exposure and control o f hemorrhage:, the lethality o f intestinal ischemia, and the c o m m o n presence o f associated injuries account for the high mortality rates associated with proximal SMA injuries. Successful m a n a g e m e n t o f a patient with a penetrating injury to the proximal SMA is described, and the literature related to these unusual injuries is reviewed. CASE R E P O R T A 24-year-old man sustained a self-inflicted .25 caliber handgun wound to the midabdomen. On presentation at a local hospital, he was hypotensive with a distended abdomen and was taken to the operating room. A laparotomy revealed a laceration of the left lobe of the liver, From the Vascular Surgery Section, Division of General Surgery, Departmenl: of Surgery, University of Kentucky, Lexington. Reprint requests: Andris Kazmers, MD, University of Kentucky Chandler Medical Center C-218, 800 Rose St., Lexington, KY 40536-0084. 24/4/33302
perforation of the midtransverse colon, multiple perforations of the third portion of the duodenum, and a large posterior midline hematoma at the root of the small bowel mesentery. Segmental resection of the transverse colon, colostomy, and mucous fistula were performed. The duodenal injuries were primarily repaired. The patient received 11 units of packed red cells and 6 units of fresh frozen plasma during the procedure. Because the retroperitoned hematoma had remained unchanged and the patient was hemodynamically stable, he was transferred after these initial procedures to the University of Kentucky Medical Center for further treatment. On arrival at the hospital the patient was alert with a pulse rate of 98 beats/min and blood pressure of 150/90 mm Hg. The abdomen was moderately distended and diffusely tender, with a bullet entrance wound just above and to the left of the umbilicus. The colostomy and mucous fistula appeared pink and viable. The hematocrit level was 25%. The serum amylase value was normal. Arteriography demonstrated injury to the SMA between its origin and the middle colic artery, which communicated with a pseudoaneurysm 4 cm in diameter (Fig. 1). The patient was transferred from the angiography suite to the operating room. At reoperation, arterial bleeding from the root of the mesentery was encountered. This was controlled initially by direct digital pressure followed by exposure and crossclamping of the supraceliac aorta (Figs. 2 and 3). The proximal SMA was exposed through the left side of the root of the small bowel mesentery, reflecting the inferior border of the pancreas superiorly. A near-complete transection of the SMA was evident at the level of the exit of the middle colic artery from beneath the uninjured pancreas. The damaged proximal and distal ends of the SMA were ligated. The aorta was then undamped. At this point the entire small bowel, except for the proximal 35 cm of jejunum, appeared ischemic. No arterial Doppler flow signals were present distal to the proximal jejunum. 669
670 Bourland et al.
J~ournal of VASCULAR SURGER#
~ce/iac ) 0
Fig. 1. Preoperative angiogram demonstrates SMA pseudoaneurysm. Fig. 3. Operative approach to SMA repair.
side of the colon, which appeared pink and viable. Suture exclusion of the pylorus, duodenostomy, gastrostomy, and jejunostomy were performed. Because of edema of the viscera and abdominal wall, primary dosure of the laparotomy incision without excessive tension was not possible. Therefore the abdomen was closed With polyglycolic acid mesh. The patient was maintained on total parenteral nutrition for 13 days followed by jejunal robe feedings. He did not have diarrhea. Three days later the pyloric exclusion suture was removed endoscopically, and an oral diet was well tolerated. Postoperative angiography confirmed patency of the iliomesenteric bypass graft on postoperative day 17 (Fig. 5). After closure of the abdominal wound by skin grafting, the patient was discharged on a regular diet on the thirty-ninth day after injury. Graft patency was confirmed 3 months after injury by duplex ultrasonography, which revealed normal fasting SMA flow velocity and the expected postprandial augmentation of diastolic SMA flow velocity.
Fig. 2. Operative approach to SMA repair. A reversed saphenous vein was used to bypass from the right common iliac artery to the midportion of the SMA in an end-to-side fashion (Fig. 4). The total ischemia time of the small bowel was approximately 6 hours. Arterial pulses were restored to the entire small bowel and remaining right
DISCUSSION Blunt or penetrating trauma to the proximal SMA is unusual. The rarity o f such injuries in modern military experience can be attributed to the lethality o f high-velocity wounding agents and inaccessibility to immediate surgical treatment.24 Although uncommon, SMA injuries are more prevalent in civilian vascular trauma in which lower-velocity handguns or stabbings are the c o m m o n agents, and access to definitive care is more rapid) Superior mesenteric artery injuries may present
Volume 15 Number 4 April 1992
Trauma to proximal superior mesenteric artery
671
Fig. 4. Illustration of iliomesenteric reconstruction with saphenous vein graft.
=Lv
iL,
MNJJ
I U
.%gI-HMK-~U
-
W
Fig. 5. Postoperative angiogram confirms graft patency.
with hemorrhage, intestinal ischemia, or arteriovenous fist-tfla.~'6 Gradual occlusion of the SMA is compatible with survival in the canine because of development of collateral circulation. 7 Likewise in humans it is recognized that chronic atherosclerotic
occlusion of the SMA may be tolerated because of collateral flow development. Collateral circulation is not sufficient to prevent bowel ischemia after acute SMA occlusion in patients with previously normal mesenteric circulation. Extrapolation from the effects
672
lournal of VASCULAK SURGERY
Bourland et al.
.~XUS
Fig. 6. Surgical anatomy pertinent to repairs of S/VIAinjuries. of gradual SMA occlusion to the situation of acute ligation in the hypotensive, usually young, trauma victim is not appropriate. Shirkey et al.8 are credited with the first successful repair of penetrating SMA transection. Although repair of such injuries is preferred, SMA ligation has been advocated. 912 It has been suggested that injuries to the SMA origin can be treated by ligation, whereas those distal to the inferior edge of the pancreas require reconstmctionY ° Others believe that injuries proximal to the jejunal branches always necessitate repair, n Although Fullen et a1.13reported SMA ligation in patients, these in fact represented ligation of segmental jejunal, ileal, or colic branchesl Such minor ligations may be tolerated because of collateral flow through arcuate branches, assuming SMA trunk flow is preserved) 4 Even if intestinal necrosis results from such branch ligation, bowel resection compatible with survival is possible. Courcy et al.~s reported that ligation of both SMA and superior mesenteric vein resulted in extensive intestinal ischemia. Graham et al.16 reported only one ligation in a large series of SMA injuries, and that patient died. Kashuk et al)7
also attempted proximal SMA ligation, but the patient died of gut infarction. The approach to the SMA from the left side of the root of the small bowel mesentery was used in the case reported herein (Figs. 2, 3, and 6). Advantages of this approach are its direcmess, ease, and the ability to deal with concomitant mesenteric venous injuries. Disadvantages include difficulty in exposure of the proximal SMA. "Medial visceral rotation" (Fig. 7) affords wide exposure of the proximal visceral and supraceliac segments of the abdominal aorta, s Drawbacks are the time required and the limited access provided to both distal visceral arteries and superior mesenteric v e n o u s i n j u r i e s . 5,11,16,18 A third approach to the SMA (Fig. 8) uses an extensive Kocher maneuver. 19 Superior mesenteric artery injuries should be reconstructed. In the patient with a limited injury involving a portion of the artery wall, lateral arteriorrhaphy may be possible. Because of the multitude of short SMA side branches, sufficient mobilization for primary repair of an SMA transection may not be feasible or may result in failure of the reconstruction. n'16 Associated duodenal, pancreatic, or colonic
Volume 15 Number 4 April 1992
Trauma to proximal superior mesenteric artery
673
mesetgterlc A.
Fig. 7. Exposure by left medial visceral rotation.
mesentenb ~/ me'¢entonc A.
Fig. 8. Exposure by extensive Kocher maneuver (right medial visceral rotation).
injuries may preclude safe local reconstruction in the area of the proximal SMA. Such considerations led to extraanatomic reconstruction with autogenous tissue in our patient, with proximal and distal anastomoses at sites as far from the pancreas and duodenum as possible, bdthough prosthetic grafts have been employed in the face of enteric contamination, autogenous grafts are recommended. 2°'21To expedite repair in patient~; known to have SMA injury, exposure of the saphenous vein before laparotomy could be
considered in the unusual event that the patient's condition permits. Use of temporizing shunts cannot be recommended because of the difficulties in placement related to the anatomy of the SMA, the delay in definitive SMA repair, and the lack of proved efficacy for patients with visceral arterial injury. Injury to the superior mesenteric vein occurs in 50% of patients with proximal SMA injury and is the most frequent concomitant abdominal vascular i n j u r y . 5,9,16-18 Superior mesenteric vein repair rather
674
Journalof VASCULAR 5LIRGERY
Bourland et al.
than ligation is strongly recommended for combined injuries. 1~ Superior mesenteric artery-superior mesenteric vein arteriovenous fistula may protect patients from intraperitoneal hemorrhage. 6,~6 Repair of such fistulas is indicated to avoid complications of portal hypertension. As prehospital trauma care and patient transport improve, it is hkely that more patients with blunt and penetrating SMA injury will reach trauma centers alive. 1,22"24 Prompt control of hemorrhage followed by SMA revascularization offers the best chance of survival. A review of the literature indicates that such arterial repair is preferred over truncal SMA ligation in the patient with SMA injury.
11.
12. 13.
14. 15.
16. 17.
REFERENCES 1. Mattox KL, Feliciano DV, Burch J, Beall AC Jr, Jordan GL Jr, DeBakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698-707. 2. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War !I: an analysis of 2,471 cases. Ann Surg 1946;123:534-79. 3. Hughes CW. Arterial repair during the Korean War. Ann Surg 1958;147;555-61. 4. Rich NM, Bangh JH, Hughes CW. Acute arterial injuries in Vietnam: 1000 cases. J Trauma 1970;10:359-69. 5. Accola KD, Feliciano DV, Mattox KL, Burch JM, Beall AC Jr, Jordan GL Jr. Management of injuries to the superior mesenteric artery. J Trauma 1986;26:313-9. 6. WoodM, Nykamp PW. Traumatic arteriovenous fistulaof the superior mesenteric vessels. J Trauma 1980;20:378-82. 7. BlalockA, Levy SE. Gradual complete occlusion of the celiac axis, the superior and inferior mesenteric arteries,with survival of animals: the effects of ischemia on blood pressure. Surgery 1939;5:175-8. 8. Shirkey AL, Quast DC, Jordan GL Jr. Superior mesenteric artery division and intestinal function. J Trauma 1967;7:7-24. 9. FelicianoDV, Burch JM, Graham JM. Vascularinjuries of the chest and abdomen. In: Rutherford RB, ed, VascularSurgery. 3rd ed. Philadelphia: WB Sannders, 1989:598. 10. Feliciano DV, Burch JM, Graham JM. Abdominal vascular
18.
I9.
20.
21.
22.
23.
24.
injury. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. 1st ed. Norwalk: Appleton & Lange, 1988:524. Lucas AE, Richardson JD, Flint LM, Polk HC Jr. Traumatic injury of the proximal superior mesenteric artery. Ann Surg 1981;193:30-4. Well PH. Management of retroperitoneal trauma. Curr Probl Surg 1983;20:540-620. Fullen WD, Hunt J, Altemeier WA. The clinicalspectrum of penetrating injury to the superior mesenteric arterial circulation. J Trauma 1972;12:656-64. Noer RJ, ManningJE. Acomparative study ofsmall intestinal circulation. Tram West Surg Assoc 1942;51:272-91. Courcy PA, Bromaan S, Oster-Granite M, Soderstrom CA, Siegel JH, Cowley RA. Superior mesenteric artery and vein injuries from blunt abdominal trauma. J Trauma 1984;24: 843-5. Graham JM, Mattox KL, BeallAC, DeBakeyME. Injuries to the visceral arteries. Surgery 1978;84:835-9. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma: a unified approach. J Traum~ 1982;22:672-9. " Ekbom GA, Towne JB, Majewski IT, Woods JH. Intraabdominal vascular trauma: a need for prompt operation. I Trauma 1981;21:1040-4. Bonnichon P, Rossat-Mignod JC, Corlieu P, Aaron C, Yandza T, Chapuis Y. Surgical approach to the superior mesenteric artery by the Kocher maneuver: anatomy study and clinical applications. Ann Vasc Surg 1987;1:505-8. Lan JM, Mattox KL, Beall AC, DeBakey ME. Use of substitute conduits in traumatic vascular injury. J Trauma 1977;17:54I-6. Ogburn N, Pories WI. Reconstruction of the mesenteric and coeliac arteries. In: DeWeese J, ed. Vascular surgery, vol 17. Rob & Smith's operative surgery. 4th ed. London: Butterworths, 1985:158-9, Yaw PB, van Beek AL, Glover JL. Successful repair of a gunshot wound to the first part of the superior mesenteric artery. J Trauma 1974;14:885-7. Pezzella AT, Grif~n WO Jr, Ernst CB. Superior mesenteric artery injury following blunt abdominal trauma: case report with successfulprimary repair. J Trauma 1978;18:472-4. Sirinek KR, Levine BA. Traumatic injury to the proximal superior mesenteric vessels. Surgery 1985;98:831-5.
Submitted June 18, 1991; accepted Aug. 16, 1991.
