OPERATIVE STRATEGIES FOR MANAGEMENT OF ABDOMINAL AORTIC GUNSHOT WOUNDS

Background. Although management of penetrating abdominal trauma has gr eatly improved, abdominal aortic gunshot wounds (AAGSWs) remain a high ly lethal injury. Our experience with AAGSWs was reviewed to define op erative strategies that may improve survival. Methods. Forty-one patie nts with AAGSs were treated between 1976 and 1996. Preliminary thoraco tomy was performed in seven patients. Thirty-nine patients had at leas t one major associated injury (average, 3.2). Results. Twenty-one pati ents died. Six of seven patients who underwent preliminary thoracotomy died; all developed coagulopathy, which appeared to contribute to dea th. Four patients had missed vascular lesions, two of which contribute d to their death. Associated injuries are currently managed by ''damag e control'' strategy, in which some injuries are left untreated to foc us on hemorrhage control. Conclusions. We have identified seven operat ive principles and procedures that we believe may improve survival: (1 ) thorough Knowledge of supraceliac exposure; (2) rapid aortic control at the hiatus rather than by a preliminary thoracotomy; (3) use damag e control or abbreviated laparotomy; (4) use packing and mesh closure when coagulopathy and hypothermia are present; (5) primary concern sho uld be cessation of hemorrhage rather than the maintenance of flow; (6 ) delayed reconstruction using extraanatomic bypass can restore flow; and (7) use angiography to detect missed vascular lesions or problems with vascular repair.