Vascular TraumaJoel Arudchelvam
Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.
Vascular trauma /injury
• Injury to – Arteries– Veins
• Anatomical regions– Extremity – limbs– Abdomen and pelvis– Thorax– Head and neck
Extremity Vascular Injuries
• Common
• Results in limb loss at times loss of life
• Loss of earning capacity
• Economic burden • Our experience (2011/2012 – NHSL)
– Popliteal arterial injury - 34.8% amputation rate.
Causes
• Road Traffic accidents• Fractures and dislocations• Trap gun• Cuts and stabs• Home accidents• Iatrogenic
• Mechanism of injury– Sharp / penetrating– Blunt
Mechanism of disruption of flow at arterial level
• Transection
• Laceration
• Contusion
• Kink
• Intimal flap
Vascular traumaSigns of a vessel injury• Hard signs• Soft sign
Hard signs– Active bleeding– Thrills, Bruits– Signs of distal ischaemia
• Absent pulse• Pain• Pale• Perishing Cold• Paresthesia / anaesthesia• Paresis / Paralysis
– Expanding hematoma
Signs of a vessel injury
• Soft signs– Hematoma– Injury close to a known neurovascular bundle– Reduced pulse
• Paresis / paralysis and paresthesia / anaesthesia - late signs• Paresis and paresthesia
– viability of the limb is in immediate threat • Anaethesia and paralysis
– not viable.
Problems with diagnosing distal ischaemia after trauma
• Pain – could be due to injury itself, may not have pain due to associated nerve inj
ury
• Pallor – may be pale due to blood loss
• Absent pulse– may be absent due to low blood pressure. Compare with othe limb
• Paresthesia , paresis – may occur due to associated nerve, muscle injury or unresponsive confused
patient
Investigations
Investigations
•Hard signs • urgent intervention
•Soft signs • Observe• Investigate
Investigations • Hand held doppler
• Absent doppler flow• Quality of signal
• Duplex scan (uss + doppler)
• Difficult to image in trauma• Due to
• Pain• Non cooperative patient• Dressings
Investigations
• Angiography– CT angiography– Catheter angiography
CT ANGIOGRAPHY
Contrast into peripheral vein
CT ANGIOGRAPHY
3D Reconstruction
Conventional angiography / DSA
• Contrast directly into artery• Traumatic • DSA – Digital subtraction angiography
– done though a software after obtaining initial images
Conventional angiography / DSA
Conventional angiography / DSA
Investigations
• Arteriography
– On table / DSA – for multi level injury
Investigations
• Patient presenting with– Soft signs– Delayed presentation– Avf– False aneurysm
– Pre-op angiography
TREATMENTSurgical Repair
• Prompt transport to operating room• General anesthesia• Cleaning entire limb and be able to visualize the distal end and
palpate distal pulses.• Thigh prepared – for venous harvest • Mobilisation and control of proximal and distal arterial ends
and trimming
Surgical repair (cont..)
• Balloon thrombectomy• Systemic and distal heparinisation• Interposition graft / Direct
approximation– Unit experience – 88.2% RSVG
• Prosthesis – lower patency– infection
Surgical repair (cont..)
Complications of vascular injury
• Death • Limb loss• Compartment syndrome• Reperfusion effects• Volkmann ischemic contracture• Intimal flaps and narrowing• False aneurysms• Traumatic AVF
Complications of vascular injury
• Death • Limb loss• Compartment syndrome• Reperfusion effects• Volkmann ischemic contracture• Intimal flaps and narrowing• False aneurysms• Traumatic AVF
Volkmann ischaemic contracture
False aneurysms
Traumatic Arterio Venous Fistula
Combined Vascular and Skeletal Trauma
– Revascularization / skeletal fixation (external Fixator – EF)
• Bone fixation first if limb is not threatened• Revascularisation first if limb is threatened
Primary Amputation • Extensive crush injuries and soft tissue damage
– “mangled limb”• life-threatening problems
Compartment syndrome
Reduced organ perfusion due to increased intra compartment pressure.
Causes;– Trauma (muscle contusion)– Haematoma– Reperfusion – Intracompartmental extravasation of fluids– Tight bandage, cast
Compartment syndrome
Clinical features
• Excessive pain - pain on passive movements of the muscles.
• Numbness -e.g. anterior compartment results in numbness at first toe web i.e. deep peroneal nerve distribution)
• Tense swollen compartment
Compartment syndromeTreatment
Recognize
Remove the cause
Surgery – fasciotomy
Compartment Syndrome
Treatment – Fasciotomy
In hospitals wherefacilities for repair is not available
• ABCD• Fasciotomy• Discuss• Transfer
Reperfusion effects
• Local– Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
• Systemic– Reperfusion syndrome;
• Hypotension• ARDS• Lactic acidosis• Hyperkalemia• Renal failure
Reperfusion effects
• Mangement– Fasciotomy
– Hydration – Mannitol, allopurinol– O2– Inotropes– Ligation of vessel if not responding to above
measures
Summary
• Vascular injury;
– Resuscitate
– Assess viability and extent of injury
– Assess need for fasciotomy
– Early intervention and post intervention monitoring
– Rehabilitation
Thank You
Top Related