The management of arterial injuries caused by penetration of zone III of the neck.

Penetrating trauma of the neck has been divided into three anatomic locations. Zone III, the subject of this paper, is defined as the area between the base of the skull and the lower border of the mandible. Management of these injuries remains problematic. Clinical assessment may be misleading, exploration may damage surrounding neurovascular structures, and injuries may go undetected. This has led us and others to advocate mandatory angiography before any surgical exploration. This report reviews 46 patients with Zone III injuries with respect to types of injuries, therapy and outcome. Angiography was normal in 22 patients who were treated conservatively with no complications. The remaining 24 patients sustained 39 arterial injuries diagnosed by contrast studies. Eighteen internal carotid injuries were identified in 16 patients. At operation ligation was performed in four patients and revascularization in two patients. One of the repairs subsequently thrombosed. Ten patients were managed nonoperatively by observation (seven patients) or angiographic embolization (three patients). Catheter embolization of the external carotid or its branches was performed to control bleeding (eight vessels) or close arteriovenous fistulas (two patients). Seven nonbleeding external vessels were successfully managed by observation. Two vertebral artery injuries were diagnosed. One required proximal embolization and distal ligation via occipital craniectomy to control a fistula between the vertebral artery and the jugular vein. Overall mortality was 8.6%. Three of the four deaths were in patients with neurologic deficit on admission. Another died of respiratory arrest. An air embolism resulting in hemiparesis was the only complication of the angiographic studies. We conclude that angiography is essential in Zone III neck wounds. It facilitates triage decisions and, combined with transcatheter embolization, enables the majority of these injuries to be managed without surgical exploration.