List Archives

Thu Aug 23 15:25:32 BST 2007

In a message dated 8/23/2007 9:01:11 A.M. Central Daylight Time,  
jparseno at yahoo.com writes:

I don't  think that because of the fact not many people responded that this 
discussion  wasn't interesting.  It is deceiving that not many level I surgeons 
 responded with an opinion.

I'm sure a whole bunch of peripheral general  surgeons like me just acted 
like spectators because we didn't feel our opinion  would be of importance, and 
also because of the fact that we would'nt operate  on this anyway, leaving it 
to the thoracic/vascular surgeon of our closest  level I center.  In Canada, 
nobody gets as much penetrating trauma as you  guys (not even close!), so there 
aren't much do-it-all trauma  surgeons.

Very interesting.   I MUST respond with several  observations.  

1.    Penetrating injury to the innominate artery is  extremely rare.  Over 
90% of innominate artery injuries are from blunt  trauma.    Such an injury is 
actually an aortic arch injury and  the imaging just looks like innominate 
because that is where the rolled up  intima is seen.   

2.    One of the major advances during the 1990s was  the recognition that 
this injury does NOT need pumps, shunts, CPB, hypothermia  or heparinization.

3.    The peripheral general trauma acute care surgeon  is just as likely to 
have a successful result (if they have a prepared mind and  information) as 
would a thoracic, cardiac, or vascular surgeon.  Probably  MORESO.     Most 
Cardiac, thoracic, and vascular surgeons  have had NO experience with this lesion 
during their training and often LESS  during their practice.   

4.    In the case I have seen, the current available  stents make stenting 
most innominate artery injuries not an option.    Maybe in the future.    Some 
custom devices might be used, but  one must be very careful here as the simple 
ascending aorta to innominate bypass  to exclude the injured area has such 
good results.    

5.    Finally, for the lesion presented, when it is  caused by blunt trauma 
travels well.   I have NOT seen in the  morgue ruptures of such injury into the 
pleural cavities, in patients that were  not dead at the scene.   So.   If 
you see one of these in  your hospital, you have TIME to think, to communicate, 
to call, and to  plan.    I would be happy at any time to discuss such a case 
with  anyone, as I am sure would the other surgeons who wrote so eloquently on 
this  case.   You will note that we have proposed several different, albeit  
successful approaches.    

Great interaction, and great discussion.   

Thanks Sal

k

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