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\title{Clinical Pattern and Outcomes of Neck Vascular Injuries at Aden Hospitals}
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             \author[1]{Ismail  Al-Shameri}

             \affil[1]{  Taiz University}

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\date{\small \em Received: 13 September 2021 Accepted: 30 September 2021 Published: 15 October 2021}

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\begin{abstract}
        


Introduction: Vascular trauma to the neck can result in life-threatening injuries, because it contains a high concreteness of vital organ structures. Therefore, trauma require prompt diagnosis and treatment. Objectives: To identify the different clinical pattern and outcome of traumatic neck vascular injury in Aden hospitals during 2015 â??" 2017. Patients and methods: A retrospective observational study of all patients admitted to hospital with traumatic neck vascular injuries (TNVIs) between 2015 -2017. Data was collected about demographics, pattern of injury, type of vascular injury, associated injuries, hospital stay, and mortality rate. Patients and methods:A retrospective observational study of all patients admitted to hospital with traumatic neck vascular injuries (TNVIs) between 2015 -2017. Data was collected about demographics, pattern of injury, type of vascular injury, associated injuries, hospital stay, and mortality rate.

\end{abstract}


\keywords{traumatic neck vascular injuries, penetrating injuries, clinical presentation.}

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\let\tabcellsep& 	 	 		 \par
Results: Of the total 52 TNVIs patients, male were 98.1 \%. The mean age was 28.63 ± 10.07 years. The majority of injuries were penetrating (96.2\%); gunshot was the predominant mechanism of injury (75\%). Injuries in zone II involved in (57.7\%). Of the TNVI S (65.4\%) were associated with other injuries most of theme aerodigestive tract injury (38.2\%). Patients presented with small non-pulsatile hematoma (28.8\%), external bleeding (26.9\%), rapid expanding hematoma (25\%), neurological deficit (13.5\%) and palpable thrill-audible bruit (5.8\%). There is significant difference between stability of patients and their presentation (P= 0.033), most of stable patients have small non-pulsatile hematoma (43.3\%), whereas an unstable patients have rapid expanding hematoma (36.4\%). Neck exploration was performed in (94.2\%). Arteries were more prone to injury (72.2\%) than veins (28.8\%).The common carotid artery is the commonest affected carotid arteries (41.5\%), followed by external carotid artery (14.6\%) and vertebral artery (12.2\%). The internal jugular vein was the commonest injured vein (61.9\%). Among those patients managed operatively; (55.9\%) of injuries were repaired while ligation was performed on (44.06\%). Complications were encountered in (50\%) of them (42.3\%) neurological deficit, wound infection (3.8\%), fistula and hoarseness (1.9\% for each). Overall mortality rate was (19.2\%). Most of deaths occurred when patients were unstable during presentation (p<0.012). 
\section[{Conclusion: TNVIs represent an alarming serious entity.}]{Conclusion: TNVIs represent an alarming serious entity.}\par
Dominant presentation is penetrating injuries, exclusively among young male, mainly exposed to gunshot wound. The need for operative intervention should be based on clinical features. Moreover, further researches and an institutional protocol guidelines management are requested. 
\section[{Introduction}]{Introduction}\par
he neck is a vulnerable area comprising different vital organs of multiple physiological systems. Due to juxtaposition of these anatomical structures, there is a high predisposition of multi-systemic injuries with potentially life threatening lesions of the major blood vessels that conceder most common injured structure. \hyperref[b0]{[1]}\hyperref[b1]{[2]}\hyperref[b2]{[3]} TNVI S represent 5-10\% of all severe trauma cases . \hyperref[b2]{[3]}\hyperref[b3]{[4]}\hyperref[b4]{[5]} The neck is a complex anatomical area because in a small space there are abundant critical aerodigestive, neurological, and vascular structures. \hyperref[b5]{6} over the neck injury does not usually occur in isolation, therefore trauma are potentially dangerous and require prompt diagnosis and treatment. \hyperref[b5]{6} Mostly injured components in cervical trauma related to vascular structures. \hyperref[b6]{7} The most common mechanism is penetrating injury which mostly involved the common carotid artery, while the vertebral artery was less common injured due to its anatomical position. \hyperref[b1]{2,}\hyperref[b7]{[8]}\hyperref[b8]{[9]}\hyperref[b9]{[10]} High velocity penetrating trauma can cause secondary injuries "blunt trauma" by shock wave. \hyperref[b9]{10} The major venous injuries seen after penetrating trauma are the internal jugular vein and external jugular vein, in such cases venous injuries are never recognized due to its lower pressure. \hyperref[b10]{11} Vascular injury is suggested by history and physical examination. Patient clinical presentation and symptoms still hold an important place in the management of penetrating neck injuries (PNIs), patients with signs of significant neck injury, particularly those with "hard" signs of vascular and/or aerodigestive injuries, require immediate surgical exploration. \hyperref[b11]{12} When an arterial injury is identified during neck exploration, current consensus agrees that primary repair of the artery is preferred than ligation, irrespective of any abnormality in focal preoperative neurologic examination findings. \hyperref[b12]{13} Optimal management of patients with PNIs remains a controversial issue. \hyperref[b1]{2} The treatment strategy of PNIs acquired from military surgical practice suggested mandatory exploration as a standard treatment to avoid missed injuries. However, civilian adoption of mandatory exploration in PNIs resulted in high negative exploration rate. \hyperref[b11]{12} Therefor in the last three decades, there has been a slow shift towards selective management for these injuries, which using zones of neck to guide investigations and management a ''zonebased'' approach or "no zone" approach. \hyperref[b12]{[13]}\hyperref[b13]{[14]}\hyperref[b14]{[15]} Injuries are classified by penetration site into the three anatomical zones. \hyperref[b13]{14,}\hyperref[b15]{16} Those patients should be evaluated using proper physical examination, selective use of investigations \hyperref[b16]{17,}\hyperref[b17]{18} and managed according to staff experience and resource availability. \hyperref[b13]{14} Ideally, war injuries should be treated by surgeons having military surgery experience. In fact, civilian surgeons may find themselves trapped in wars practicing military surgery without prior training or experience in this field. \hyperref[b18]{19} The purpose of this study was to review our experience with penetrating neck vascular injuries in Aden-Yemen, thereby focusing on surgical management, and early outcomes and to highlight lessons learned from that period. 
\section[{II.}]{II.} 
\section[{Method and Patients}]{Method and Patients}\par
This retrospectively study was conducted at Department of surgery in four main hospital in Aden city from 1st of April 2015 up to 31st December 2017. All patients of both gender and any age who fulfilling the inclusion criteria were enrolled in this study. During study period, the total number of patients admitted to surgical department in relation to vascular neck injury in Aden Hospitals were 52 patients. Any of the following was considered criteria for exclusion: death before admission, patients with superficial wound (which defined by injuries superficial to the plan of the platesma) or patients with minor neck injury who did not require hospital admission.\par
All patients were resuscitated in emergency room according to Advanced Trauma Life Support protocols in the hospital field. The clinical diagnosis was done at the time of the admission by history tacking, physical examination and investigations (laboratory, radiological and ultrasound), and/or confirmed during operative intervention.\par
The variable was collected retrospectively using a questionnaire and interviewing the patients including: age, sex, residence, clinical presentations that include detailed history of the injuries, hemodynamic status, external bleeding, expanding or large haematoma, neurological deficit and palpable thrill / audible bruit, associated injuries, operative finding, treatment option, and outcomes. Types of morbidity included neurological deficit, wound infection, A-V fistula and hoarseness.\par
Data and statistical analysis: data were presented as a proportion, medians or mean ± standard deviation as a appropriated and the analysis will be covered out using SPSS version 22 (SPSS Inc., Chicago, IL, USA). Quantitative variables like age and duration of symptoms were presented by calculating means ± standard deviation (SD). Qualitative variables like gender, symptoms and operative finding were presented by calculating frequencies and percentages. The statistical significance of differences between categorical variables were calculated by the chi-square test, Fisher's exact test. P-value of <0.05 was considered as statistically significant. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
During the study period from April 2015 to December 2017, the total number of patients with neck vascular injure was 52 patients. Most of the patients were male (98.1\%). The age ranges from 9 to 60 years with a mean age was 28.63 ± 10.07 years. The peak age of patients with neck vascular injury in this study was in second decade (46.2\%) followed by the third decade (26.9\%) of life.\par
The majority of injuries was penetrating (96.2\%); gunshot was the predominant mechanism of injury (75\%), followed by sharp object injury (15.4\%). Stab wound and road traffic accidents represent (3.8\%) for each, and iatrogenic injury (1.9\%). About (76.9\%) of patients presented within the first 6 hours to the hospital and (42.3\%) of the patients were unstable at the time of presentation. More than half of patients had their injuries on the right side; and the same percentage of injury in zone 2, while 17\% of the studied patients had their injury in multiple zones. Concerning presentation of patients, the highest percentage of them presented with small non pulsatile hematoma (28.8\%), followed by external bleeding (26.9\%) and pulsatile hematomas (25\%). Table \hyperref[tab_0]{I} In our study, we found arteries were the commonest injured vessel (71.2\%), followed by veins (28.8\%). Concerning type of injury, the most common finding was partial cut (55.9\%), complete cut (44.1\%).The commonest injured vessel is the carotid arteries, the common carotid artery represent (41.5\%), followed by external carotid artery (14.6\%) and vertebral artery in (12.2\%), whereas the internal jugular vein was the most common vein injured (61.9\%). Fig.  {\ref 1,2} About two third of our patients had another associated injuries, the most common associated injuries were aerodigestive tract injury (38.2\%), followed by brachial plexus injury (23.5\%).\par
The operative intervention was the main therapeutic option for most patients it represent (94.2\%) and only (5.8\%) of patients managed by non-operative procedures. Among those managed operatively, repair was performed in most of them (55.9\%), while the ligation performed in (44.06\%). The common type of repair was simple anatomical repair that represent (51.5\%) followed by using graft in (33.3\%) and end-toend anastomosis in (21.2\%) of patients.   Our study showed that neck vascular injury in the hospitals are associated with (19.2\%) mortality. Complications were found in (50\%) patients with vascular neck injury. The most common complications was the neurological deficit (42.3\%), while wound infection, A-V fistula, and hoarseness occur in (3.8\%), (1.9\%) and (1.9\%) of patients respectively. The hospital stay ranged from one to more than 15 days. About (50\%) of the studied patients stay in hospital 1-7 days, while (40.4\%) stay 8-14 days and (9.6\% ) of them stay more than 15 days, as shown in Table \hyperref[tab_1]{II}.  
\section[{Discussion}]{Discussion}\par
This study deliberate the first study in Yemen, could be due to the lack of national data. Therefore, we conducted this retrospective descriptive study to establish the frequencies of clinical patterns and the outcomes of TVNI S in population of Aden hospitals within two consecutive years; from 1 st April 2015 up to 31 st Dec 2017.\par
Analysis of the personal characteristics of patients in this study showing a high prevalence of TNVIs among young males (98.1\%), being similar to the studies reported by Martinakis et al 1 in Athens and Reva et al 2 in Russia.\par
The peak age for TNVIs in this study was in the second decade (46.2\%) follow by third decade of life (26.9\%). Similar observation was reported in other studies. \hyperref[b0]{1,}\hyperref[b2]{3} More than half of the patients in this study were solider (65.4\%) while the incidence of traumatic injuries in Civilian (34.6\%), showing a similarity to studies performed by White et al \hyperref[b19]{20} and Rasmussen et al \hyperref[b20]{21} reports that civilian traumatic injuries of neck vessels are relatively uncommon.\par
The predominant mechanism of injury to the neck in this study is PNIs; (75\% gunshot, 15.4\% sharp objects and 3.8\% stab wound) with a percentage of (96.2\%), which is consistent with almost all other studies. \hyperref[b0]{1,}\hyperref[b5]{6,}\hyperref[b12]{13,}\hyperref[b21]{22} The blunt injuries are rare and consist (3.8 \%) of studied patient as demonstrated by other studies. \hyperref[b2]{3,}\hyperref[b14]{15} Findings at emergency department are small non pulsatile hematoma (28.8\%), external bleeding (26.9\%), rapid expanding hematoma (25.0\%), neurological deficit (13.5\%) and palpable thrill-audible bruit (5.8\%), nearly similar result found by Reva et al 2 report cases on Physical examination reviled non pulsatile hematoma (36\%), active bleeding from neck wound (19.6\%), expanding or large hematoma in the injured area (19.6\%), neurological deficit (17.4\%), and asymptomatic injury (15.2\%), while Teixeira et al \hyperref[b18]{19} reports external Bleeding (64\%), expanding hematoma (22\%), and Nasr et al \hyperref[b22]{23}    {\ref (116)} in contrast to another study by Ghnnam et al \hyperref[b5]{6} that report commonly affected anatomical structures were the neck veins (24.5\%), followed by neck arteries (10.2\%). However other studies were reported venous injury more than arteries injury. \hyperref[b23]{24,}\hyperref[b24]{25} These differences may because majority of jugular venous injuries are probably unrecognized without exploration owing to the lowpressure venous system. \hyperref[b21]{22} In current study, a higher proportion of TNVIs had associated injuries (65.4\%), while (34.6 \%) of patients had isolated neck trauma. Biffl et al \hyperref[b25]{26} demonstrated similar incidence of associated injuries (33.1\%). The most common associated injuries were aerodigestive tract injury (38.2\%) similar to Pirrelli et al \hyperref[b26]{27} , in this study brachial plexus represent (23.5\%), spinal injury represent (14.7\%), and facial injury (11.8\%).\par
Our study shows that, the operative intervention was the therapeutic option for most patients it represent (94.2\%), only (5.8 \%) were managed by conservative management. One study report neck exploration was performed in (88.2\%) in his series while other demonstrated (84.4\%) surgical intervention. \hyperref[b2]{3,}\hyperref[b21]{22} In this series 49 patients, underwent exploration, for positive physical examination findings and workup, this is supported by a study by Thomas et al \hyperref[b27]{28} published a prospective study in which complementary diagnostic studies were used based on physical examination findings and no CTA was performed, showing good results. Furthermore, Mahmoodie et al \hyperref[b21]{22} and his group demonstrated that physical examination did not miss any major vascular or esophageal injuries that required intervention.\par
Among those managed operatively, repair was perform in most of them (55.9\%) whereas the ligation performed in (44.06\%). The common type of repair was simple repair that represent (51.5\%) follow by using graft (33.3\%) and end-to-end anastomosis (21.2\%). One study established surgical interventions mainly included simple repair (53\%). \hyperref[b2]{3} In the studied hospitals patients are treated with primary repair for carotid artery regardless of the degree of consciousness depression and preoperative condition similar to was found in Pirrelli et al \hyperref[b26]{27} study. Other author recommend repair for CAI only in the absence of severe neurologic deficit. The overall mortality rate was (19.2\%) this is high compared to other studies, in which mortality rates ranged from (11.8\%) as Al Thani et al \hyperref[b3]{4} as well Ghnnam et al \hyperref[b5]{6} (12.2\%).\par
The hospital stay ranged from one to more than fifteen days. About (50.5\%) of the studied patients stay 1 -7 days, while 8-14 days represent (40.4\%) and (9.6\%) they stay more than 15 days. Ghnnam et al \hyperref[b5]{6} proved the mean duration of hospital stay 6.6 days; it is similar to this series.\par
Complications found in (50\%) of the studied patient's. The common complications were the neurological deficit (42.3\%), wound infection (3.8\%), while A-V fistula and hoarseness (1.9\%) for each, similar finding was reported by Reva et al. \hyperref[b1]{2} V. 
\section[{Conclusion}]{Conclusion}\par
TNVIs represent an alarming serious entity. Dominant presentation is penetrating injuries, exclusively among young male, mainly exposed to gunshot wound. The need for operative intervention should be based on clinical features. Moreover, further researches and an institutional protocol guidelines management are requested.\begin{figure}[htbp]
\noindent\textbf{12}\includegraphics[]{image-2.png}
\caption{\label{fig_1}Figure 1 :Figure 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{I} \par 
\begin{longtable}{P{0.203544061302682\textwidth}P{0.3696360153256705\textwidth}P{0.06513409961685823\textwidth}P{0.06676245210727969\textwidth}P{0.14492337164750957\textwidth}}
\multicolumn{2}{l}{Variables}\tabcellsep \tabcellsep No.\tabcellsep \%\\
\tabcellsep Penetrating\tabcellsep \tabcellsep 50\tabcellsep 96.2\\
\tabcellsep \tabcellsep Gunshot\tabcellsep 39\tabcellsep 75.0\\
Mechanism of neck vascular injury\tabcellsep Type of penetrating\tabcellsep Sharp object Stab wound\tabcellsep 8 2\tabcellsep 15.4 3.8\\
\tabcellsep \tabcellsep Iatrogenic\tabcellsep 1\tabcellsep 1.9\\
\tabcellsep Blunt\tabcellsep \tabcellsep 2\tabcellsep 3.8\\
Time of presentation (hrs)\tabcellsep < 6 ? 6\tabcellsep \tabcellsep 40 12\tabcellsep 76.9 23.1\\
Hemodynamic state\tabcellsep Stable Unstable\tabcellsep \tabcellsep 30 22\tabcellsep 57.7 42.3\\
\tabcellsep Right\tabcellsep \tabcellsep 30\tabcellsep 57.7\\
Site of injury\tabcellsep Left\tabcellsep \tabcellsep 20\tabcellsep 38.5\\
\tabcellsep Bilateral\tabcellsep \tabcellsep 2\tabcellsep 3.8\\
\tabcellsep zone 1\tabcellsep \tabcellsep 6\tabcellsep 11.5\\
Zone of injury\tabcellsep zone 2 zone 3\tabcellsep \tabcellsep 30 7\tabcellsep 57.7 13.5\\
\tabcellsep Multiple zoon\tabcellsep \tabcellsep 9\tabcellsep 17.3\\
\tabcellsep \multicolumn{2}{l}{Small non pulsatile hematoma}\tabcellsep 15\tabcellsep 28.8\\
\tabcellsep External bleeding\tabcellsep \tabcellsep 14\tabcellsep 26.9\\
Presentation\tabcellsep \multicolumn{2}{l}{Rapid expanding hematoma}\tabcellsep 13\tabcellsep 25.0\\
\tabcellsep Neurological deficit\tabcellsep \tabcellsep 7\tabcellsep 13.5\\
\tabcellsep \multicolumn{2}{l}{Palpable thrill / Audible bruit}\tabcellsep 3\tabcellsep 5.8\end{longtable} \par
 
\caption{\label{tab_0}Table I :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{II} \par 
\begin{longtable}{P{0.26488372093023255\textwidth}P{0.31232558139534883\textwidth}P{0.09488372093023255\textwidth}P{0.17790697674418604\textwidth}}
Variables\tabcellsep \tabcellsep No.\tabcellsep \%\\
Morbidity\tabcellsep No Yes\tabcellsep 26 26\tabcellsep 50.0 50.0\\
\tabcellsep Neurological deficit\tabcellsep 22\tabcellsep 42.3\\
Type of morbidity\tabcellsep Wound infection A-V fistula\tabcellsep 2 1\tabcellsep 3.8 1.9\\
\tabcellsep Hoarseness\tabcellsep 1\tabcellsep 1.9\\
\tabcellsep 1-7\tabcellsep 26\tabcellsep 50.0\\
Hospital stay (days)\tabcellsep 8-14\tabcellsep 21\tabcellsep 40.4\\
\tabcellsep >15\tabcellsep 5\tabcellsep 9.6\\
Mortality\tabcellsep No Yes\tabcellsep 42 10\tabcellsep 80.8 19.2\\
IV.\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table II :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_2}}\end{figure}
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\end{document}
