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Zone 1 Vascular Injury
Patients who are in profound shock or who are exsanguinating
from the neck wound should go directly to the operating
room for haemorrhage control. It may be possible to
achieve temporary control by inserting a urinary (Foley)
catheter into the wound track and inflating the balloon
within the track. Gentle traction may help with this
manoeuver.
Vascular control of vessels in Zone 1 can be difficult.
Which operative approach is used will depend on the
site of vascular injury and this may not be clear from
the site of the stab or gunshot wound. If immediately
available, angiography is very useful in determining
the site of the injury and hence planning the surgical
approach.
 
This angiogram shows a patient who was stabbed in Zone
1 of the left neck, and shows an injury to the first
part of the left subclavian artery. Proximal control
of this injury requires entry into the thoracic cavity.
Angiography may also be used to achieve proximal control
of such injuries. Fogarty balloon catheters or angioplasty
balloons can be placed either proximal to or across
the site of an injury to achieve control. During subsequent
operation, the balloon may be felt by the surgeon, and
location of the injured vessel in the surrounding haematoma
is made easier. The patient below has an subclavian
arterio-venous fistula due to a Zone 1 stab injury.
An angioplasty balloon was placed across the site of
the injury and the patient transferred to the operating
room for definitive repair.
 
Patients who are not exsanguinating should have a careful
physical examination. If there is no expanding haematoma,
and no distal vascular deficit, patients may be observed
in a critical care area. The brachial plexus is closely
related to the vascular structures in the root of the
neck, and neurological deficits may be a marker for
a vascular injury. Potential vascular injuries should
be investigated with angiography.
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