Comparison of conservative and operative treatment for blunt carotid injuries: Analysis of the National Trauma Data Bank

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1 From the Society for Vascular Surgery Comparison of conservative and operative treatment for blunt carotid injuries: Analysis of the National Trauma Data Bank Wei Li, MD, MPH, a Marcus D Ayala, MD, a Asher Hirshberg, MD, b William Briggs, PhD, a Leslie Wise, MD, a and Anthony Tortolani, MD, a Brooklyn, NY Objectives: Blunt carotid injury (BCI) is uncommon but potentially devastating. The best treatment modality for this injury remains undetermined. We conducted this study to better understand the hospital course and treatment outcomes for patients with BCI who received different interventions. Methods: BCI and related vascular procedures were identified by ICD-9-CM codes from the National Trauma Data Bank 1 using data gathered from 2002 to Conservative and operative treatment groups were compared by variables of patient demographics, initial assessment in the emergency department (ED), hospital course, and treatment outcomes. Open surgical and endovascular interventions were further compared. Results: A total of 842 BCI were identified from 1,633,126 discharged blunt trauma patients (0.05%). Of these, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between these treatment groups. On initial assessment, no differences between conservative and operative treatment groups were noted with regard to vital signs, Glasgow coma scale, presence of drugs or alcohol in blood, or Trauma Related Injury Severity Score survival probability. Significant differences were seen in terms of the presence of a base deficit ( vs ; P.01), likelihood of a positive head computed tomography (CT) scan (58.6% vs 26.1%; P.003), and total Injury Severity Score ( vs ; P.02). Hospital course and treatment outcomes were comparable, with no differences in hospital length of stay ( days vs days; P.86), total Functional Independence Measure ( vs ; P.38), progression of original neurologic insult (7.5% vs 4.6%; P.61) or mortality (28.1% vs 19%; P.08). When comparing open surgical to endovascular interventions (46 open, 34 endovascular, including 3 combined), the only significant differences were in the total Injury Severity Score ( vs ; P.01) and length of intensive care unit (ICU) and hospital stay ( days vs days; P.01, and days vs days; P.01). Multivariate regression analysis confirmed that neither Functional Independence Measure (FIM) nor mortality was associated with conservative or operative treatment. Conclusion: BCI is rare and carries a poor prognosis. Operative intervention is not associated with functional improvement or a survival advantage. This study was unable to support that less invasive endovascular treatment improves treatment outcome when compared to open surgery. (J Vasc Surg 2010;51:593-9.) Blunt carotid artery injury (BCI) is a rare but serious clinical problem in vascular trauma. Although the reported incidence of BCI ranges between 0.08% and 0.86% of blunt trauma admissions, 1-3 routine screening of patients with significant trauma to the head and neck has established the From the Department of Surgery, New York Methodist Hospital, a and Kings County Hospital Center, SUNY Downstate Medical Center. b Competition of interest: none. Presented at the annual meeting of the Society for Vascular Surgery, June 11-14, 2009, Denver, Colo. Disclaimer: Committee on Trauma, American College of Surgeons, NTDB Version 7.1, Chicago, Ill, The content reproduced from the NTDB remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures. Additional material for this article may be found online at Reprint requests: Marcus D Ayala, MD, Department of Surgery, New York Methodist Hospital, 506 Sixth Street, Brooklyn, NY ( mdd9004@nyp.org). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest /$36.00 Copyright 2010 by the Society for Vascular Surgery. doi: /j.jvs presence of BCI in up to 2% of patients. 4-6 Although rare, BCI is associated with mortality rates of 20% to 40% and significant neurologic morbidity in up to 50% of survivors. 6-9 Despite increased awareness of the clinical significance of BCI in the last decade, there is no general agreement on the best diagnostic and therapeutic approach. 10,11 BCI represents a spectrum of disease from an intimal flap to dissection, with more severe injuries leading to pseudoaneurysm formation, carotid occlusion, or complete transection. 12 Such diverse arterial injuries may be associated with differences in clinical presentation and may require a different therapeutic approach. 13 Furthermore, prompt diagnosis is often delayed by the presence of severe associated injuries, lack of a standardized screening protocol, and by the delayed onset of a neurologic deficit. 2 In fact, up to 50% of patients with BCI may initially present without symptoms, but then subsequently develop neurologic complications more than 24 hours after injury. 14 Although most patients diagnosed with BCI are treated conservatively with systemic anticoagulation or antiplatelet therapy, a small subset may benefit from operative intervention either through an open surgical or endovascular approach

2 594 Li et al JOURNAL OF VASCULAR SURGERY March 2010 However, prospective randomized studies comparing various management strategies are currently unavailable. Given that BCI is rare and experience in the management of these injuries is limited, there is currently no consensus on the preferred treatment and it is not clear whether open surgical or endovascular interventions affect the outcome The aim of this study was to examine BCI using a large national database to better understand differences in hospital course and outcomes for patients who received conservative, operative, or endovascular treatments. Specifically, our goal was to compare the conservative management of BCI to operative treatment to determine differences in hospital length of stay, functional outcome, progression of original neurologic insult, and mortality. We also compared these same variables in patients undergoing open surgery vs an endovascular intervention. METHODS Patient data was obtained from the National Trauma Data Bank (NTDB, v 7.1), with permission from the American College of Surgeons (ACS). This database is derived from the trauma registries of over 900 trauma centers across the United States, and represents the largest and most complete trauma database available. 21 Trauma admissions from the years between 2002 and 2006 were included in this analysis. Patient selection was based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for traumatic carotid arterial injury (Appendix I, online only). Patients with identified traumatic carotid arterial injuries admitted to participating centers were stratified by injury type variable as either penetrating or blunt, according to the NTDB. Patients with BCI not receiving any operative intervention were included in the conservative treatment group. Patients with blunt traumatic carotid arterial injuries receiving perative intervention were identified by ICD-9-CM procedure codes (Appendix II and III, online only). Utilizing individual ICD-9-CM procedure code, each patient in the operative treatment group was further distributed to the corresponding open surgical or endovascular treatment groups. Demographic data collected included age, gender, and race. Emergency department (ED) baseline variables included were as follows: systolic pressure, first unassisted respiratory rate, lowest Glasgow eye component, lowest Glasgow verbal component, lowest Glasgow motor component, total Glasgow coma scale, base deficit/excess, alcohol or drugs present in blood, positive head computed tomography (CT) scan result, positive abdominal evaluation, total Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) survival probability, recalculated revised trauma score by ACS, and recalculated TRISS survival probability. The Charlson score was used to profile the impact of comorbid conditions on the outcome of BCI. 22 The hospital course and outcome variables were identified as: length of stay in hospital, days of total stay in the intensive care unit (ICU), ventilator support days, total Functional Independence Measure (FIM) score, progression of original neurologic insult, and in-hospital mortality. As one of the major functional outcome measurements in the NTDB, the FIM scoring system was utilized to determine the degree of disability that patients experience and the progress that they make through programs of medical rehabilitation. This scoring system has been validated in the literature and assesses functional status in three categories: feeding, locomotion, and expression Each clinical assessment is scored from 1 to 4: 1 represents full dependence on assistance, and 4 represents full independence. We use the total score of the three categories, ranging from A higher total FIM score is therefore associated with a better functional outcome. Progression of original neurologic insult, another important outcome variable used in this study, is defined in the NTDB as deterioration of additional loss of function from that noted on arrival in the ED. Statistical analysis was performed using commercially available software (SAS 9.1, SAS Institute Inc, Cary, NC; The unpaired t test was used for continuous variables, and a 2 test was performed for categoric variables. Tests of normality of the continuous variables were conducted using normal Q-Q plots. No significance discrepancies were found and the (robust) t test was judged adequate. All mean values were reported along with their SD. We first compared demographic and ED baseline variables between the operative and conservative groups. We then further compared these same variables in patients undergoing open surgery vs an endovascular procedure. The main outcome variables were length of hospital stay, total FIM score, progression of original neurologic insult, and in-hospital mortality. To compare in-hospital mortality between treatment groups, we used a 2 test. Using linear regression for continuous outcome variables and logistic regression for categoric outcome variables, we controlled for age, gender, comorbidities, head CT scan status, TRISS score, ISS score, and procedure type. Variables with significance less than 0.05 were not included in the final model. In all models, gender, and comorbidity were never significant and so were excluded from the remaining analysis. Linear regression was further used for length of hospital stay, ICU stay, ventilator support days, and total FIM score. Logistic regression was used for progression of original neurologic insult and in-hospital mortality. Due to the small sample size in the open surgical and endovascular intervention groups, multivariate regression was only used to assess the independent association between conservative and operative treatment, and two main outcome variables, the total FIM score, and in-hospital mortality. Finally, we performed separate analysis of the factors associated with the mortality of BCI according to the discharge status, alive or dead as dependent variables in the NTDB. Using stepwise logistic regression, we further eliminated variables that were not predictive for mortality, and retained only significant variables except for conservative vs operative intervention which was always retained. All continuous variables checked met the test for normality.

3 JOURNAL OF VASCULAR SURGERY Volume 51, Number 3 Li et al 595 Table I. Demographic and ED assessment variables between treatment groups Variables Conservative treatment (1) Operative intervention (2) P value (1) vs (2) Open surgery (3) Endovascular procedure (4) P value (3) vs (4) Age Male gender 64.4% 81.3% % 60%.08 Systolic blood pressure First unassisted respiratory rate Lowest Glasgow eye component Lowest Glasgow verbal component Lowest Glasgow motor component Glasgow coma scale total Base deficit/excess Alcohol or drugs present in blood 69.4% 79.3% % 88.2%.15 Positive head CT results 58.6% 26.1% % 25%.93 Positive abdominal evaluation 33.7% 26.1%.46 20% 37.5%.25 Charlson comorbidity score Total ISS TRISS survival probability Recalculated revised trauma score by ACS Recalculated TRISS survival probability by ACS CT, Computed tomography; ISS, injury severity score; ACS, American College of Surgeons; TRISS, Trauma Related Injury Severity Score. RESULTS A total of 842 BCIs were identified from among 1,633,126 discharged blunt trauma patients reported in the NTDB from 2002 to 2006, for an overall incidence of 0.05%. Of the 842 patients with BCI, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between the conservative and operative treatment groups (Table I). Additionally, the two treatment groups had similar Charlson comorbidity scores. On initial ED assessment, no differences were noted between the conservative and operative treatment groups with regard to baseline variables, except for the presence of a positive head CT scan and a higher total ISS, both of which were more commonly found in the conservative treatment group. The only other difference noted between the conservative and operative treatment groups was the presence of a higher base deficit in the operative treatment group. The hospital course and treatment outcomes were also similar for the conservative and operative treatment groups with no significant differences in hospital length of stay, days of ICU stay, ventilator support days, total FIM score, progression of original neurologic insult, and in-hospital mortality (Table II). The overall mortality for patients with BCI was 27% (228 deaths). The mortalities for the conservative and operative treatment groups were 28% and 19%, respectively. Additionally, there were no differences with regards to hospital charges between treatment groups (Table II). The operative intervention group was more likely to be discharged home and have lower rehabilitation requirements when compared to the conservative treatment group. However, multivariate regression analysis did not show an independent association between conservative or operative treatment and outcome using either the total FIM score or mortality. When comparing the open surgical and endovascular treatment groups, no differences in demographics or in the Charlson comorbidity scores were found between these two groups (Table I). Of the 80 operative procedures, 46 patients received open surgery, and 34 received endovascular interventions, including 3 patients who received combined procedures (Table III). Of the 3 patients with combined procedures, 1 underwent open thrombectomy and angioplasty with stent placement, 1 had open thrombectomy and coil embolization, and 1 had open repair with graft and angioplasty. On initial ED assessment, the only significant difference between groups was the total ISS, which was higher for the endovascular group. The length of hospital stay and number of days in the ICU were lower in the open surgery group when compared to the endovascular group. No differences were found in the total FIM score or in-hospital mortality between these groups (Table II). Because of the small sample size in the open surgical and endovascular groups, multivariate regression was unable to assess an independent association between operative or endovascular intervention and outcome variables (total FIM score or mortality). We further analyzed adjusted outcome differences with their associated beta coefficients. For in-hospital mortality, the coefficients are expressed in the form of odds ratios because we used a logistic regression model. Table IV shows the regression coefficients and P values. An ns means nonsignificant and the variable was removed from the model. For the linear regression models, the coefficients are presented unadjusted, comparing the operative intervention vs the conservative treatment, and the open surgery vs endovascular procedure. The coefficients associated with ISS and TRISS have the following interpretation: for every unit increase in these variables, the outcome variable changes by the value of the coefficient.

4 596 Li et al JOURNAL OF VASCULAR SURGERY March 2010 Table II. Hospital course and treatment outcomes Variables Conservative treatment (1) Operative intervention (2) Length of stay in hospital (days) ICU stay (days) Ventilator support days Total FIM score Progression of original neurological insult 7.5% 4.6% Hospital cost/charge (US Dollars) 132, , , ,359.6 Discharge disposition Death 23% 12.5% Death (dead on arrival) 0.1% 0% Died during treatment 0.5% 0% Discharged skilled nursing facility 2.4% 6.2% Home 23.2% 41.2% Home health 4.3% 5% Hospital transfer 6.3% 7.5% Nursing home 1% 1.2% Unable to complete treatment 0.5% 0% Rehabilitation 29.7% 17.5% Other 6.6% 7.5% In-hospital mortality 28.1% 19% ICU, Intensive care unit; FIM, Functional Independence Measure. For the logistic regression models, the coefficients are presented in the forms of odds ratios. The coefficients associated with ISS and TRISS have the following interpretation: for every unit increase in these variables, the odds of the outcome variable changes multiplicatively by the value of the coefficient. Thus, for example, for the outcome in-hospital mortality, after controlling for ISS and TRISS, patients in the operative intervention were 0.69 times less likely to die than in patients undergoing conservative treatment. This difference was not statistically significant, however (P.64). Controlling for these variables did not change the results of our study in any major way. When using discharge status, alive or dead, and analyzing the factors associated with the mortality of BCI, we found some significant differences among demographic and ED assessment variables (Table V). Stepwise regression analysis established the following as potentially predictive for mortality: a high total Glasgow coma scale, a high total ISS, and a longer total stay in the ICU. DISCUSSION The goal of our study was to use a large national database to study BCI, so as to determine differences in hospital course and treatment outcomes. Our analysis showed that there were no differences in functional outcome or mortality between treatment groups. Most patients with BCI were young, otherwise healthy males with multiple associated injuries and were managed conservatively. On initial assessment in the ED, patients treated conservatively were more likely to have a positive head CT scan result and a higher total ISS. This is not surprising, because more severely injured patients would be less attractive candidates for any kind of surgical intervention. Contrary to our expectations, patients treated by operative intervention had a higher base deficit. Although we cannot explain the significance of a higher base deficit in the operative treatment group, the data would otherwise imply that the conservative treatment group had more severe injuries and would, therefore, be expected to have a worse prognosis. However, no difference in the functional outcome or mortality was noted between the conservative and operative treatment groups. When comparing open surgery to endovascular interventions, patients undergoing endovascular interventions had a higher total ISS. These patients had a longer hospital and ICU stay, but again no difference in functional outcome or mortality was observed. These findings confirm the poor prognosis associated with BCI, irrespective of treatment modality. The incidence of BCI is difficult to determine with certainty, as it is conceivable that some injuries remain asymptomatic or undiagnosed. However, it is clear that BCI is uncommon. Our analysis established an incidence of BCI of 0.05% in patients with blunt trauma. Because the true incidence of BCI may be substantially higher, efforts have been made toward the identification of these injuries before the onset of stroke with the expectation that early diagnosis and treatment will improve outcome. These efforts have resulted in various screening protocols (Appendix IV, online only). 5,26,27 Screening protocols to date have used a combination of mechanism of injury involving the head and neck, physical findings, and presence of associated injuries to identify a population of patients at high risk for BCI who should, therefore, undergo radiologic imaging. Although these screening criteria have been revised over time, there is currently no generally accepted protocol As for the ideal treatment of BCI, there is also a lack of uniform agreement, although most authors would agree that anticoagulation serves as first line therapy for BCI and antiplatelet therapy as secondary treatment if anticoagulation is not feasible. 12,17,31,32 Although anticoagulation has been shown to decrease the mortality and stroke rate asso-

5 JOURNAL OF VASCULAR SURGERY Volume 51, Number 3 Li et al 597 Table II. Continued. P value (1) vs (2) Open surgery (3) Endovascular procedure (4) P value (3) vs (4) % 7.1% , , , , % 17.0% % 0% 1 0% 0% % 4.3% % 46.8% % 4.3% % 8.5% 1 1 0% 2.1% 1 1 0% 0% % 12.8% % 4.3% % 13.3%.36 Table III. Operative interventions for BCI Intervention Number Percentage Open surgery Embolectomy/thrombectomy Endarterectomy Vascular bypass with graft Other repair of vessel Endovascular procedures Percutaneous angioplasty Embolization or occlusion Endovascular repair with stent/endograft Total % ciated with BCI, most of these patients have multiple associated injuries and anticoagulation may be contraindicated. Several studies have reported no significant difference in the stroke rate between anticoagulation and aspirin, and a recent review failed to establish the superiority of anticoagulation over antiplatelet therapy, 33,34 with the implication that aspirin may be as effective as anticoagulation with a lower risk of hemorrhage. However, there are no randomized clinical trials comparing anticoagulation to antiplatelet therapy in the management of BCI. In our study, we could not provide specific data regarding the proportion of patients receiving anticoagulation or antiplatelet therapy, as this data is not included in the NTDB. Surgical repair has been advocated for some patients with BCI. 4 Because a large number of these injuries involve the distal third of the internal carotid artery, endovascular approaches are gaining favor in this area where open surgical repair is particularly difficult Several factors, including the nature and location of the carotid injury, are important considerations in the management of BCI. Operative or endovascular management may be favored for patients with carotid pseudoaneurysms, injuries which are unlikely to improve with conservative management. 16 Although carotid transections are almost invariably fatal irrespective of treatment, operative or endovascular interventions may also be preferable for patients with carotid dissection who develop progression of their neurologic injury despite anticoagulation therapy. 10 The neurologic status of the patient is also an important factor in the management of BCI. In general, patients with a fixed, dense neurologic deficit are managed conservatively. However, when analyzing the NTDB, we found no significant difference in the initial neurologic status between patients treated conservatively and those managed operatively. Currently, experience with open surgical and endovascular interventions for BCI is limited, and patient-related or anatomic factors favoring one approach over another have not been established. 18 Although this study, we believe, represents the largest series of patients with BCI reported in the literature, it has several limitations that should be noticed. Our study is a retrospective analysis and subject to the errors generally associated with retrieving information from a large administrative database. Commonly recognized in any administrative database, its data vetting process is subject to entry errors and selection and reporting bias. Additionally, the sample size of operative intervention group is small and a type 2 error is a possible explanation for our findings. We utilized ICD-9-CM diagnostic and procedure codes that can be vague and lack of specificity. Given the constraints of the NTDB, information such as the medical treatment of BCI, anticoagulation vs antiplatelet therapy, and the nature and severity of the carotid injuries could not be obtained. The registry data collected by the NTDB is pooled data from volunteer hospitals and, therefore, is not a population-based sample. Furthermore, this patient population represents BCI from a group of trauma centers using widely

6 598 Li et al JOURNAL OF VASCULAR SURGERY March 2010 Table IV. Beta coefficients for predictor variables in regression model between treatment groups Conservative vs operative treatment ISS (P value) TRISS (P value) Open vs endovascular procedure (P value) ISS (P value) TRISS (P value) Length of stay in hospital (days) 1.1 (.54).21 (.001) ns 5.75 (.061).36 (.0009) ns ICU stay (days).24 (.85).21 (.001) ns 4.2 (.033).19 (.009) ns Ventilator support days.93 (.81).39 (.0003) 8.6 (.02) 4 (.073).17 (.024) ns Total FIM score.79 (.19).09 (.001) 1.9 (.04) 1.03 (.36).03 (.51) 6.3 (.007) Progression of original neurological insult.43 (.044) 1.02 (.045) ns 3.7 (.086) 1.07 (.01) ns In-hospital mortality.69 (.64).95 (.049) ns.001 (.98) ns ns ISS, Injury Severity Score; TRISS, Trauma Related Injury Severity Score; ICU, intensive care unit; ns, not significant; FIM, Functional Independence Measure. Beta coefficients (and P value). Table V. Demographic and ED assessment between discharge status groups (alive/dead) Variables Alive (1) Dead (2) P value (1) vs (2) Male gender (%) Systolic blood pressure (mean) First unassisted respiratory rate (mean) Lowest Glasgow eye component (mean) Lowest Glasgow verbal component (mean) Lowest Glasgow motor component (mean) Glasgow coma scale total (mean) Base deficit/excess (mean) Alcohol present in blood (%) Drug present in blood (%) Positive head CT results (%) Positive abdominal evaluation (%) Charlson comorbidity score (mean) Total Injury Severity Score (ISS) (mean) TRISS survival probability (mean) Recalculated revised trauma score by ACS (mean) Recalculated TRISS survival probability by ACS (mean) CT, Computed tomography; ACS, American College of Surgeons; TRISS, Trauma Related Injury Severity Score. varying screening protocols and diagnostic and treatment modalities. In conclusion, BCI is a rare but potentially lethal problem. Although most patients are treated conservatively, disagreement persists in the literature regarding the best management strategy for this challenging problem. It is unclear which patients benefit from open surgery or endovascular interventions as our analysis did not show any differences in functional outcome or survival between treatment groups. AUTHOR CONTRIBUTIONS Conception and design: WL, MD, AH Analysis and interpretation: WL, MD, AH, LW, AT Data collection: WL Writing the article: WL, MD Critical revision of the article: MD, AH, LW, AT Final approval of the article: WL, MD, AH, WB, LW, AT Statistical analysis: WB, WL Obtained funding: N/A Overall responsibility: MD REFERENCES 1. Fabian TC, Patton JH Jr, Croce MA, Minard G, Kudsk KA, Pritchard FE. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 1996;223:513-22; discussion Laitt RD, Lewis TT, Bradshaw JR. Blunt carotid arterial trauma. Clin Radiol 1996;51: Davis JW, Holbrook TL, Hoyt DB, Mackersie RC, Field TO Jr, Shackford SR. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma 1990;30: Biffl WL, Moore EE, Ryu RK, Offner PJ, Novak Z, Coldwell DM, et al. The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg 1998;228: Miller PR, Fabian TC, Bee TK, Timmons S, Chamsuddin A, Finkle R, Croce MA. Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma 2001;51:279-85; discussion Rogers FB, Baker EF, Osler TM, Shackford SR, Wald SL, Vieco P. Computed tomographic angiography as a screening modality for blunt cervical arterial injuries: preliminary results. J Trauma 1999;46: Utter GH, Hollingworth W, Hallam DK, Jarvik JG, Jurkovich GJ. Sixteen-slice CT angiography in patients with suspected blunt carotid and vertebral artery injuries. J Am Coll Surg 2006;203: Schneidereit NP, Simons R, Nicolaou S, Graeb D, Brown DR, Kirkpatrick A, et al. Utility of screening for blunt vascular neck injuries with computed tomographic angiography. J Trauma 2006;60:209-15; discussion Cogbill TH, Moore EE, Meissner M, Fischer RP, Hoyt DB, Morris JA, et al. The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma 1994;37: Biffl WL, Moore EE, Offner PJ, Burch JM. Blunt carotid and vertebral arterial injuries. World J Surg 2001;25: Stein DM, Boswell S, Sliker CW, Lui FY, Scalea TM. Blunt cerebrovascular injuries: does treatment always matter? J Trauma 2009;66:132-43; discussion Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr, Johnson JL, et al. Anticoagulation is the gold standard therapy for blunt carotid

7 JOURNAL OF VASCULAR SURGERY Volume 51, Number 3 Li et al 599 injuries to reduce stroke rate. Arch Surg 2004;139:540-5; discussion Biffl WL, Ray CE Jr, Moore EE, Franciose RJ, Aly S, Heyrosa MG, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg 2002;235: ; discussion Biffl WL, Moore EE, Elliott JP, Brega KE, Burch JM. Blunt cerebrovascular injuries. Curr Probl Surg 1999;36: Baker WE, Servais EL, Burke PA, Agarwal SK. Blunt carotid injury. Curr Treat Options Cardiovasc Med 2006;8: Singh RR, Barry MC, Ireland A, Bouchier Hayes D. Current diagnosis and management of blunt internal carotid artery injury. Eur J Vasc Endovasc Surg 2004;27: Wahl WL, Brandt MM, Thompson BG, Taheri PA, Greenfield LJ. Antiplatelet therapy: an alternative to heparin for blunt carotid injury. J Trauma 2002;52: DuBose J, Recinos G, Teixeira PG, Inaba K, Demetriades D. Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience. J Trauma 2008;65: Berne JD, Reuland KR, Villarreal DH, McGovern TM, Rowe SA, Norwood SH. Internal carotid artery stenting for blunt carotid artery injuries with an associated pseudoaneurysm. J Trauma 2008;64: Cothren CC, Moore EE, Ray CE Jr, Ciesla DJ, Johnson JL, Moore JB, Burch JM. Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits. Arch Surg 2005;140:480-5; discussion NTDB ACoS. National Trauma Data Bank, NTDB Research Data Set v. 7.1 User Manual Sheikh K, Jiang Y, Bullock CM. Effect of comorbid and fatal coexistent conditions on sex and race differences in vascular surgical mortality. Ann Vasc Surg 2007;21: Zhu XL, Poon WS, Chan CC, Chan SS. Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Inj 2007;21: Stineman MG, Shea JA, Jette A, Tassoni CJ, Ottenbacher KJ, Fiedler R, Granger CV. The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories. Arch Phys Med Rehabil 1996;77: Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil 1996;77: McKevitt EC, Kirkpatrick AW, Vertesi L, Granger R, Simons RK. Identifying patients at risk for intracranial and extracranial blunt carotid injuries. Am J Surg 2002;183: Biffl WL, Moore EE. Identifying the asymptomatic patient with blunt carotid arterial injury. J Trauma 1999;47: Cothren CC, Moore EE, Ray CE Jr, Ciesla DJ, Johnson JL, Moore JB, Burch JM. Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg 2005;190: Kerwin AJ, Bynoe RP, Murray J, Hudson ER, Close TP, Gifford RR, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001;51: Mayberry JC, Brown CV, Mullins RJ, Velmahos GC. Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg 2004;139:609-12; discussion Carrillo EH, Osborne DL, Spain DA, Miller FB, Senler SO, Richardson JD. Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event. J Trauma 1999;46: Miller PR, Fabian TC, Croce MA, Cagiannos C, Williams JS, Vang M, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 2002;236:386-93; discussion Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev 2003:CD Beletsky V, Nadareishvili Z, Lynch J, Shuaib A, Woolfenden A, Norris JW, Canadian Stroke Consortium. Cervical arterial dissection: time for a therapeutic trial? Stroke 2003;34: Maras D, Lioupis C, Magoufis G, Tsamopoulos N, Moulakakis K, Andrikopoulos V. Covered stent-graft treatment of traumatic internal carotid artery pseudoaneurysms: a review. Cardiovasc Intervent Radiol 2006;29: Fleischer AS, Guthkelch AN. Management of high cervical-intracranial internal carotid artery traumatic aneurysms. J Trauma 1987;27: Pozzati E, Giuliani G, Poppi M, Faenza A. Blunt traumatic carotid dissection with delayed symptoms. Stroke 1989;20: Welling RE, Kakkasseril JS, Peschiera J. Pseudoaneurysm of the cervical internal carotid artery secondary to blunt trauma. J Trauma 1985;25: Submitted Jun 18, 2009; accepted Oct 18, Additional material for this article may be found online at

8 599.e1 Li et al JOURNAL OF VASCULAR SURGERY March 2010 Appendix I, online only. ICD-9-CM diagnostic codes for carotid injury 900 Injury to blood vessels of head and neck Carotid artery Carotid artery, unspecified Common carotid artery External carotid artery Internal carotid artery Appendix II, online only. ICD-9-CM procedure codes used to define open surgical procedures in the study population Code Procedure description Incision of vessel, embolectomy, thrombectomy Endarterectomy Resection of vessel with anastomosis Resection of vessel with replacement Excision of vessel Surgical occlusion of vessels Aorta-subclavian-carotid bypass Extracranial-intracranial (EC-IC) vascular bypass Repair of vessel with tissue patch graft Repair of vessel with synthetic graft Repair of vessel with unspecified graft Other repair of vessel

9 JOURNAL OF VASCULAR SURGERY Volume 51, Number 3 Li et al 599.e2 Appendix III, online only. ICD-9-CM procedure codes used to define endovascular procedures in the study population Code Procedure description Endovascular repair or occlusion of head and neck vessels, including coil embolization or occlusion, endografts, endovascular grafts, liquid tissue adhesive (glue) embolization or occlusion, other implant or substance for repair, embolization or occlusion Endovascular embolectomy, endovascular thrombectomy of pre-cerebral and cerebral vessels, mechanical embolectomy or thrombectomy Angioplasty or atherectomy of noncoronary vessel Insertion of non-drug-eluting stent, peripheral vessel Percutaneous angioplasty or atherectomy of precerebral (extracranial) vessel(s) Insertion carotid artery stent(s) Insertion of drug-eluting peripheral vascular stents, endografts, endovascular grafts or stent grafts Appendix IV, online only. Denver screening criteria for BCVI 28 Signs/symptoms of BCVI Arterial hemorrhage Cervical bruit Expanding cervical hematoma Focal neurologic deficit Neurologic examination incongruous with head CAT scan findings Stroke on secondary CAT scan Risk factors for BCVI High-energy transfer mechanism with 1. LeForte II or III fracture 2. Cervical-spine fracture patterns: subluxation, fractures extending into the transverse foramen, fractures of C1 C3 3. Basilar skull fracture with carotid canal involvement 4. Diffuse axonal injury with GCS 6 5. Near hanging with anoxic brain injury BCVI, Blunt cerebrovascular injury (including carotid artery injury or vertebral artery injury; CAT, computerized axial tomography; GCS, Glasgow Coma Score.