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INTRODUCTION Peripheral injuries account for 80% of all cases of vascular trauma. The lower extremities are involved in two thirds of all patients with vascular injuries. 90% of patients with vascular trauma are male Complex extremity trauma involving both arterial and skeletal injuries is rare, comprising only 0.2% of all military and civilian trauma, and only 0.5%- 1.7% of all extremity fractures and dislocations Combined arterial and skeletal extremity trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries.
CHALLENGES OF VASCULAR INJURIES most dramatic challenges facing trauma surgeons because the repair is often urgent Gaining control of and reconstructing a major arterial injury can be technically demanding. Limited exposure to vascular surgery in the general surgery training curriculum, Major vascular trauma remains a crucial element of trauma surgery, and every general surgeon must be prepared to deal with them either definitively or using so-called bail-out vascular damage control tactics. The fundamental difference between elective vascular surgery and vascular trauma is the physiology of the wounded patient
CONT’D….. A lacerated major vessel is typically only one component of the multi trauma complex that includes injuries to other organs and systems. These patients are often critically ill and rapidly approaching a point of physiologic irreversibility. In these dramatic clinical circumstances, the key to a favorable outcome is maintaining correct priorities. The surgeon must keep in mind that although major hemorrhage (typical of trunkal vascular injuries) is an immediate threat to the patients life, ischemia (commonly from peripheral arterial injury) is a threat to limb viability, a much lower priority. Furthermore, although control of hemorrhage is usually mandatory and life-saving, the reconstruction of an injured vessel may be neither. As the injured patient is approaching the boundaries of his or her physiologic envelope, a simpler, sometimes temporary technical solution is often a safer option than a complex and time-consuming re construction. In the severely traumatized patient, the best technically feasible definitive solution is not always in the patients best interest
AETIOLOGY Gunshot wounds, 70-80% of all vascular injuries requiring intervention. Stab wounds (5-10% of cases require intervention) Blunt trauma (5-10% of cases): Presence of fracture or dislocation increases the risk. Iatrogenic injury (5% of cases): Endovascular procedures central line placement
Immediate treatment • Control bleeding • Replace volume loss • Cover wounds • Reduce fractures/dislocations • Splint • Re-evaluate
HARD SIGNS Active or pulsatile hemorrhage Pulsatile or expanding hematoma Signs of limb ischemia and elevated compartment pressure including the 5 "Ps“: Pallor paresthesia pulse deficit paralysis pain Diminished or absent pulses Bruit or thrill is( present in 45% of patients with an arteriovenous fistula)
SOFT SIGNS Hypotension or shock Neurologic deficit due to primary nerve injury occurs immediately after injury. In contrast, ischemic neuropathy is delayed in onset (minutes to hours). Stable, non pulsatile or small hematoma Proximity of the wound to major vascular structures ( Beware of bone fr. ! )
COMPLICATIONS Delayed diagnosis and treatment may result in Thrombosis Embolization Rupture with hemorrhage. Risk factors for amputation include Elevated compartment pressure Arterial transection Associated open fractures The combination of injuries above and below the knee.
CHRONIC PRESENTATION OFVASCULAR INJURY Arteriovenous fistulae typically take months to mature and often require surgical repair. Pseudoaneurysms may resolve completely or grow over time presenting months to years later. They may cause neuropathy due to compression or embolization , or they may present as a growing pulsatile mass. Intimal tears and flaps generally heal spontaneously.
CONTINUED… Segmental narrowing can present with diminished flow but intact pulses. This injury may resolve spontaneously with fluids and rest, or it occasionally may require surgical intervention. N.B. Approximately 10% of patients with non occlusive, clinically occult injuries require repair within a month of initial injury. The remaining 90% of patients do not report symptoms or see a physician for vascular problems during long- term follow-up
Pulse Oximetry A reduction in oximeter readings from one limb, as compared to another is suggestive of, but neither confirms nor excludes a significant vascular injury
Doppler Ultrasound Evalution of the affected extremity with hand held doppler ultrasound should be performed routinely. Absent doppler signals need further examination- either with angiography or duplex scan. Every doppler examination whether normal or abnormal should be followed by Ankle Brachial Pressur Index(ABPI) An ABPI > 1 is normal Any measurement < 0.9 needfurther evalution withangiography
Duplex Ultrasound Duplex can detect intimal tears, thrombosis, false aneurysms and arteriovenous fistulae. Although it is limited by operator dependent It has senitivity of 95% and specificity of 99% with overall accuracy of 98%
Angiography Angiography remains the gold- standard investigation for the further investigation and delineation of vascular injury. In most traumatic injury settings, angiography is best performed in the operating room, with the surgeon exposing the vessel proximal to the injury for control and expediency Sensitivity 92-96% Specificity above 96% Accuracy 98%
CT ANGIOGRAM With the advent of improved CT scan, detection of vascular injuries has greatly improved In fact CTA is becoming a viable alternative to angiography Occasionally CTA be non-diagnostic due to significant artifact from bullet fragements or other foreign bodies Sensitivity 90-100% Specificity 98-100 %
MAGNETIC RESONANCEANGIOGRAPHY MRA is used less frequently in acute settings Metal implants such as cerebral aneurysm clips and cardiac pacemakers preclude the use of MRI or it is difficult to acertain whether the patient have such devices in emergency situation Additionally MRI takes longer and needs more co- operation from patient than CT.
IMMEDIATE TREATMENTControl of haemorrhag: Direct pressure over the site of injury One individual manually compress the site of haemorrhage. Deep knife or gunshot track → catheter If angiography is performed prior to surgery, it may be possible to obtain proximal control by passing an angioplasty balloon catheter into the proximal vessel and inflating the balloon
VOLUME RESUSCITATION Prior to haemorrhage control : Minimal fluids should be administered Raising the blood pressure will increase haemorrhage from the vessel injury and dislodge any clot that has already formed. Systolic blood pressure can be maintained at a level that is appropriate for perfusion of the brain After: aggressive volume resuscitation to restore circulating blood volume. Warm fluids -crystalloid, blood or clotting factors as necessary -are administered to correct acidosis, hypothermia and coagulopathy,
OPERATIVE PRINCIPLES The patient is positioned on the operating table to allow on-table angiography of the affected region and distal perfusion. The entire affected limb is prepped and draped, as well as proximal structures if control has to be gained more proximally. The hand or foot is prepped so that intra-operative assessment of distal perfusion is possible. An entire uninjured limb should also be prepped so that a vein graft can be harvested as required. Often the person applying manual compression at a bleeding site will have to be temporarily prepped into the operative field until scrubbed personnel can take over. Gain proximal and distal control of injured vessel before investigating the site of injury. It is achieved by a separate incision away from site of injury. Direct exploration of site of injury lead to failure of haemostasis and damage to adjacent tissue. Control is best achieved by passing slings twice around the vessels. If clamps are used they should be applied with minimum force to obstruct the flow of blood not racked closed to damage the vessel.
CONT’D… Once the injured vessel is identified, then debride devitalised tissue. Asses the inflow and outflow at both end of vessel, if inadequate pass forgatry at proximal and distal end to disloge any thrombus. Instill heparinized saline at proximal and distal ends to locally anticoagulate the vessel. Use an arterial shunt if temporizing is required or delay is anticipated, e.g. to stabilize fracture. Obtain an on-table angiogram if suspecting further injury or chronic disease. If necessary select a more distal site for anastomosis of bypass graft. Harvest vein for a conduit. Avoid synthetic material in a potentially contaminated operative field. Perform appropriate bypass using inlay, end-to-end, or end-to-side anastamoses. Consider fasciotomies. Co-ordinate wound closure and dressings with orthopaedic/plastics teams. Ensure at least soft tissue cover of vessels.
POSTOPERATIVE CARE Standard limb observations with pulse check and Doppler probe insonation if necessary. Record ABPI at least once in postoperative period if possible. Check for compartment syndrome, even if fasciotomies were performed (they are sometimes inadequate). Monitor urinary output. Consider heparin anticoagulation (with great caution) or aspirin. Plan wound inspections with delayed closure (3-5 days) of fasciotomies/wounds with or without skin graft.
LACERATION Direct Suturing: Small, clean, transverse wounds to vessels that involve only part of the circumference can be repaired with a direct suture technique Vein or synthetic graft:A vein (or synthetic) patch may be required where there is a larger defect in the vessel wall where direct sutuing may lead to narrowing of the vessel lumen. While vein grafts probably have a longer patency, the graft infection rates are the same for both vein and synthetic grafts, regardless of wound contamination
TRANSECTION Direct suturing(end to end anastomosis):The ends of a transected artery usually retract. If the ends can be approximated without tension, a direct end-to- end anastomosis repair can be employed. Mobilisation of the two ends may be necessary, and aided by division of minor arterial branches
TRANSECTION Graft: Where approximation of the vessels is not possible, a reversed vein graft, or synthetic graft is used to repair the defect. If there is a concomitant vein injury, this should usually be repaired first, if possible to avoid low-flow thrombosis of the arterial repair.
CONTUSION- THROMBOSIS Managed in a similar way to transection In either way , Thrombectomy is Part of the Procedure
DAMAGE CONTROL SURGERY The principles of damage control surgery can be applied to vascular trauma. The basic damage control techniques are : ligation and shunting.
LIGATION There are very few vessels that cannot be ligated in extremis, at varying risk to life and limb. The common and external carotid, subclavian, axillary, internal iliac can be ligated with few consequences. Ligation of the internal carotid artery carries a 10-20% risk of stroke. Ligation of the exteral iliac artery, common femoral or superficial femoral have a signficant risk of critical limb ischaemia following ligation. Ischaemia is more likely if there is significant soft tissue injury and distruction of supporting collateral circulation. Arteries of the celiac axis can be ligated but ligation of the superior or inferior mesenteric artery will almost inevitably lead to gut necrosis in the young trauma patient. Almost all veins, including the inferior vena cava, can be ligated where necessary, with the consequence of lower limb oedema. Ligation of the portal vein is possible but bowel oedema with massive third-space fluid losses will ensue..
SHUNTING Where there is a significant risk of limb loss, or other serious consequence of ligation, intraluminal shunts may be employed to temporarily restore flow. shunts can be rapidly constructed out of sterile intravenous tubing or chest tubes for larger calibre vessels. Where there is a vascular injury associated with a fracture, and there is a risk of orthopaedic manoeuvers disrupting an arterial repair, shunts may be employed to temporarily restore flow to an injured limb.
ASSESING THE PATIENT AND INJURY The anatomic extent of injury is revealed only when the traumatized vessel is carefully explored and opened, specially in blunt trauma. The entire length of the injured segment must be precisely delineated at operation because leaving proximal or distal intimal damage will result in early failure of the reconstruction. The selection of the repair technique is heavily influenced not only by the anatomic situation but also by the patients physiologic condition, associated injuries, and overall clinical trajectory. The massively bleeding patient incurs a rapidly increasing burden of physiologic insults. The marker of an irreversible (and lethal) physiology is a self- propagating triad of Hypothermia, Coagulopathy, Acidosis.
CONT’D The hypothermia-coagulopathy-acidosis syndrome effectively marks the boundaries of the patients physiologic envelope beyond which there is irreversible shock. The operative management of a vascular injury must therefore focus not only on restoration of anatomic integrity but also, more importantly, on the patients physiologic envelope. The complexity and duration of the planned repair must be inversely proportional to the physiologic insult that the patient has already sustained.
MANGLED EXTREMITYThe mangled extremity is defined as injury that involves at least three of the four major tissue systems of a limb, consisting of bone, soft tissue, vessels, and nerves. The decision to immediately amputate a severely wounded extremity (rather than attempt salvage) is difficult and emotionally charged, especially because vascular reconstruction is usually technically feasible, being one of the less problematic aspects of the injury. Several scoring systems have been proposed to predict the ultimate fate of the limb based on the severity of injury and the patients associated injuries and comorbid factors. e.g mangled extremity syndromes index (MESI), predictive salvage index(PSI), mangled extremity severity score(MESS), or limb salvage index(LSI). However, in practice, the decision to proceed with amputation hinges on surgical judgment and the patients specific circumstances. It is a team decision and is made only after careful examination and consideration. The decision is usually made in the operating room, where the extremity is examined under optimum conditions As a general rule, a totally interrupted distal innervation, extensive soft tissue destruction, and bone loss exceeding 6 cm in length all portend a grave prognosis for the limb.
UPPER LIMB VASCULAR INJURIES Vascular injuries to upper extremity are relatively common representing 30 to 40% of vascular trauma in urban civilian settings Vessels of upper extremity are defined as those coursing through axilla to wrist Injuries to subclavian artery are commonly reported with axillery artery and their management is similar. The most commonly injured vessel in upper limb is brachial artery with an incidence of 50%, followed by radial and ulnar arter(25% each), least commonly injuried artery being axillosubclavian vessels(3-5%). The most common mechanism of injury is penetrating trauma.
AXILLO-SUBCLAVIAN ARTER INJURIES Accounts for 3-5 % of upper limb vascular injuries Aetiology Clinical presentation Hard signs Soft signso Diagnosis Chest x-ray CT angiogram Conventional angiogram
BRACHIAL ARTERY INJURIES Accounts for 50% of upper limb vascular injuries Clinical presentation Dignosis Management Operative exposure:The artery is exposed through a medial arm incision in the groove between the biceps and triceps muscles. The first structure encountered in the neurovascular bundle is the median nerve, which must be isolated and preserved. If the brachial artery is exposed in the proximal arm, the deep brachial artery is identified and controlled at the lateral border of the teres major muscle.
RADIAL OR ULNAR ARTERY INJURY Most isolated ulnar or radial artery injuries can be ligated. An ischemic hand (due to an incomplete palmar arch or injury to both arteries) requires an arterial reconstruction. In the presence of associated bone and soft tissue injury, it is often safest to begin the exposure of a radial artery proximally at the brachial bifurcation and then proceed distally to the injured segment. A lower medial arm incision is carried into the antecubital fossa in an S-shaped configuration to avoid a longitudinal incision across the antecubital skin crease. The bicipital aponeurosis is divided to expose the brachial bifurcation, and the radial artery is identified and isolated. Exposure of the ulnar artery in the proximal forearm is more difficult because of the deeper location of the artery at this level. It is found deep to the antebrachial fascia, between the flexor carpi ulnaris and flexor digitorum superficialis muscles.
LOWER LIMB VASCULAR INJURIES Lower extremity injuries are defined as those occuring below inguinal ligament. The most commonly injured artery is femoral artery. Injuries to common femoral artery, superficial femoral artery, profunda femoris, and popliteal artery above and below the knee represents the bulk of injuries requiring revascularization procedures or surgical exploration. Because of blood supply to calf and foot with anterior tibial artery, posterior tibial artery and peroneal artery, one or two of these artery can be disrupted without loss of distal perfusion and limb ischemia. Bleeding from these vessels can lead to elevated compartment pressure causing compartment synd.,
POPLITEAL ARTERY INJURY Popliteal artery injuries result in limb loss more often than any other peripheral vascular injury. Amputation rates as high as 20% especially from blunt trauma. The collateral arterial system around the knee is not well developed and is very susceptible to interruption by significant trauma, making delays in diagnosis and treatment particularly unforgiving
AETIOLOGY Posterior dislocation of the knee- 3 out of 5 pts Bumper to proximal tibiaClinical presentation Hard signs Soft signsDiagnosis Doppler Angiography
OPERATIVE EXPOSURE The proximal popliteal artery is exposed through an incision along the anterior border of the sartorius muscle above the knee. The deep fascia is incised, and the sartorius is retracted, providing access to the popliteal space between the semimembranosus muscle and the adductor magnus tendon. The distal artery is approached through a medial incision immediately behind the posterior border of the tibia. The crural fascia is incised, and the popliteal space is entered between the medial head of the gastrocnemius and the soleus muscles. Wide exposure of the entire length of the popliteal artery can be achieved by joining the incisions and dividing the tendons of the semitendinosus, semimembranosus, gracilis, and sartorius and then dividing the medial head of the gastrocnemius.
FACIOTOMY Lateral incision:A longitudinal incision is made about 2 fingerbreadths lateral to the tibial crest, beginning immediately below the tibial tuberosity and extending to the ankle It decompress anterior compartmen
CONT’D Medial incision The posterior compartments are decompressed through a separate medial incision placed immediately posterior to the posterior edge of the tibia, carefully avoiding injury to the long saphenous vein. The superficial posterior compartment is decompressed by incising the deep fascia.