Blunt abdominal aortic injuries are rare and account for no more that 5 % of all traumatic aortic injuries. The aorta’s deep placement in the abdomen and its secure relationship to the lumbar spine and retroperitoneum mean that it is much less susceptible to decelerative shearing injuries than the thoracic aorta [4]. On the other hand, its relative prominence over the normal lumbar lordosis sees it prone to compressive injuries such as those that occur with lap seat belts in severe road traffic crashes (Fig. 17.2).

The presentation can be elusive. Arterial insufficiency is reasonably common while an acute abdomen, usually secondary to associated injuries, may precipitate a laparotomy at which the injury is discovered. The diagnosis is commonly made by abdominal CT as part of the overall evaluation of a patient with potentially serious injuries and repair traditionally open with replacement of the damaged aorta with an interposition Dacron graft. However, recent experience with stent-grafting thoracic aortic injuries has seen this approach also used in the abdomen. A recent review based on the US National Trauma Data Bank saw 29 of the 42 patients (out of a total of 436 patients who had blunt abdominal aortic injuries) having endoluminal placement of a stent graft [5].

Penetrating abdominal aortic trauma is a highly morbid condition with mortality rates approaching 80 % [6]. The ratio of GSW to stab injuries depends on the prevailing epidemiology of the area of the world in which the injury occurs. Patients usually present in profound shock with a severe acidosis and coagulopathy, and unless they are taken directly to intervention while receiving a permissive resuscitation regime, the outcome is inevitably poor. Open surgery with direct suturing or local arteriorrhaphy has been the standard approach to managing these injuries, usually with a damage control philosophy and often temporary abdominal closure. Recently, however, there have been reports of initial management involving endoluminal stent grafting [7], and this approach is most effectively employed when the patient is able to be managed in a hybrid operating suite. Regardless of the approach taken to the aorta, these patients usually need a laparotomy as they will have suffered a penetrating wound that has transgressed the abdominal cavity.

The abdominal inferior vena cava (IVC) is rarely injured by a blunt mechanism. Avulsion of the hepatic veins from the IVC is the most common decelerative mechanism that involves the IVC and any other blunt mechanism that damages the IVC worthy of a case report. Such injuries are either discovered at laparotomy in conjunction with other severe injuries and managed surgically, or in the rare situation that they are discovered radiologically, they may be able to be treated nonoperatively [8].

Penetrating IVC injury is a highly lethal injury with mortality of over 30 % even in expert hands [9]. The presentation is usually in association with an RPH which will be midline. Unroofing the hematoma may rapidly render the patient from a state of hemodynamic stability to being grossly unstable. Proximal and distal control of the IVC can be achieved by manual compression or the use of a sponge and forceps following adequate right medial visceral rotation for exposure. Stab wounds usually present IVC injuries which are amenable to lateral venorrhaphy, but a pitfall is to ignore the possibility of a through and through laceration with a second laceration on the back wall of the IVC. In areas of the world where gunshot wounds (GSW) are common, this mechanism will be a more common cause of penetrating IVC injury. GSW produce a more devastating IVC wound and local repair is often not possible. While graft replacement of a section of IVC is possible, these patients often present with the so-called “triad of death”: hypothermia, acidosis, and coagulopathy. In this situation a damage control approach is necessary and ligation of the IVC the most expeditious form of hemorrhage control. This is surprisingly well tolerated although thigh-high compression stockings are recommended to avoid massive edema which can develop in the early postoperative phase.

Blunt iliac artery injury is usually associated with a severe pelvic fracture but occasionally focal blunt trauma. For example, injury may occur when a patient is struck by the handlebar of a motorcycle. This usually results in occlusion of the vessel rather than rupture and the presentation is that of extremity ischemia. The overall approach will be predicated by concomitant injuries and generally replacement of the damaged segment with some form of graft will be required.

Penetrating iliac artery injury is another high-mortality lesion with death rates of over 25 % [10]. A damage control approach is usually required, and the increased difficulty of accessing the vessels in the pelvis means that this approach is usually required for both GSW and stab injuries. Arterial shunting may be required to maintain flow to the extremity. Where the vessel is completely divided, an interposition graft of either appropriately sized vein or Dacron will be required. While a direct arterial or venous lateral repair can be done at the time of initial surgery, definitive grafting must usually wait until the patient has been physiologically resuscitated.

Blunt iliac vein injury in the pelvis is almost always associated with severe pelvic trauma and initial treatment may involve packing. If ongoing severe bleeding occurs, ligation is appropriate with management of subsequent extremity edema. Reconstruction is not usually practicable in this setting.

Penetrating iliac venous injury may occur either in association with iliac artery injury, or as an isolated injury. Surgical intervention is appropriate and as for IVC trauma, simple injuries may be repaired by lateral venorrhaphy, whereas more complex injuries will require venous ligation.