Jaffna Medical association Annual Scientific Sessions September, 2022 Professor C.Sivagnanasundaram memorial oration Introduction Vascular injuries are potentially life or limb threatening. Vascular trauma occurs in 1.6% of civilian injuries (1) and 6.8% to 10.8% in war related injuries (Afghanistan, Iraq and Lebanon war). In a study done at the National hospital of Sri Lanka Colombo (NHSL) out of 5802 trauma admissions there were 93 patients with vascular injuries (VI). Therefore the incidence of VI in civilian trauma is 1.6% (1). After the end of civil war in Sri Lanka in 2009 there is a reduction in the number of war related vascular injuries. But due to the increase in the number of Road Traffic Accidents (RTA), the number of vascular trauma also increased (i.e. from 1938 to 2013 road traffic injuries increased from 35.1 to 98.6 per 100 000 population in Sri Lanka). One of the reasons for this is the increased number two and three wheeled vehicles which are involved more with accidents (2). Trauma and vascular injuries often involve young males. They are the breadwinners of the family. In one study done at the Teaching Hospital Anuradhapura (THA) among patients presenting with popliteal arterial injuries, 18 (90%) were males with a mean age of 38.7 years (2). And in another study done at the same institution among patients with major lower limb arterial injuries, 22 (87.5%) were males and the mean age was 36.9 years (3). These studies confirm the fact of young males often getting involved with vascular injuries.

1. Dr Joel Arudchelvam
MBBS (COL), MD (SUR). MRCS (ENG), FCSSL.
Senior Lecturer, Department of Surgery, University of Colombo,
Consultant Vascular and Transplant Surgeon,
The National Hospital of Sri Lanka, Colombo.
Jaffna Medical association
Annual Scientific Sessions, 2022
Prof. C. Sivagnanasundram Memorial Oration

2. Professor C.Sivagnanasundram
 Legend with multiple talents.
 Simple and humble gentleman
 Born in Jaffna on 30th of
March, 1928
 Married madam Shanthi
 Father of four daughters

3. Professor C.Sivagnanasundram
 1955 - MBBS , University of Ceylon
 Served in various hospitals of the country in various
posts
 General Hospital Kurunegala
 Peripheral unit Hiripitiya
 Lady Ridgeway Hospital for children Colombo
 Nawalapitiya
 Jaffna

4. Professor C.Sivagnanasundram
 1965 – 1967 - lecturer ,department of Preventive and
Social Medicine, University of Ceylon, Peradeniya
 1967 - 1971 DPH (London), PhD (Uni. London)
 1978 - Professor of Community Medicine, University
of Jaffna
 1994 – Retired
 Passed away in 2005

5. Professor C.Sivagnanasundram
 Contributed immensely to the development of
the Faculty of Medicine, University of Jaffna.
 Eminent researcher
 Published in both local and international
journals.
 Published many books ( medicine and other
fields).

6. Extremity Vascular Trauma
in Sri Lanka, where are we
now and how do we
improve?

7. Vascular trauma /injury
• Injury to
 Arteries
 Veins
• Anatomical regions
 Extremity – limbs
 Abdomen and pelvis
 Thorax
 Head and neck

8. Vascular trauma /injury
• Injury to
 Arteries
 Veins
• Anatomical regions
 Extremity – limbs
 Abdomen and pelvis
 Thorax
 Head and neck

9. Vascular Injuries
 Unexpected .
 Young and fit
 Results in loss of limb or life
 Loss of earning capacity, economic
burden
Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a
peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8

10. Vascular Injuries
 Anuradhapura 2019*
 Male - 22 (87.5%)
 Mean age - 36.9 years (17–69)
 Following trap gun - 25% amputation rate
 Anuradhapura (THA) 2019 - popliteal arterial injuries
**
 Males - 90%
 Mean age - 38.7 years.
* Factor affecting the outcome of Major lower Limb arterial injuries; a single unit experience in a peripheral setting.
Sriharan, P and Arudchelvam, J. Anuradhapura : s.n., 2019. Anuradhapura Clinical Society , 13th Annual scientific
sessions, September 2019. p. 77
** Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Parathan, S and
Arudchelvam, J. 4, 2019, Sri Lanka Journal of Surgery, Vol. 37, pp. 14–17.

11. Vascular Injuries
 At the National hospital of Sri Lanka Colombo
(NHSL)
 5802 trauma admissions (for 3 months)
 93 vascular injuries (VI)
 Incidence of VI in civilian trauma is 1.6%*
 6.8% - 10.8% in war related injuries **
* Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is time to establish a dedicated
trauma vascular surgery unit. Kapilan, G and Arudchelvam, J. Colombo : s.n., 2020.
**Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Parathan, S and Arudchelvam,
J. 4, 2019, Sri Lanka Journal of Surgery, Vol. 37, pp. 14–17.

12. Causes
Overall *, **
Road Traffic Accidents
– 54.2%
Trap Gun – 33.3%
Iatrogenic - 8.3%
Other- 4.2% (Stab, etc.)
*Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting
to a single unit in a peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8

13. Trap gun
Made of a metal pipe, metal pallets and
explosives (from fire cracker)*
At THA;
 About 75 trap gun injury / year
 About 10 – 15 % with arterial injuries
 Multilevel injury
 25% amputation rate
* Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka.
Sriharan, P and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8

14. Causes
Causes of upper limb vascular injuries (ULVI) -
NHSL *
 Cuts (36%)
 Fractures (34%)
 Iatrogenic injuries (22%)
* Upper Limb Vascular Injuries, a Unique Problem. A Single Unit Experience in a. Kapilan, G and
Arudchelvam, J. Colombo : s.n., 2020. Sri Lanka Medical Association 133rd Anniversary International Medical
Congress, 2020. p. 17.

15. Causes
Accidental intra-arterial injection *
* Accidental Intra-Arterial Injection of a Drug in a Patient with Radial Artery Variation; A Rarity Leading
to a Disaster. Arudchelvam, J. 2, 2019, J Clinical Case Rep Case Stud, Vol. 2019, pp. 66-68

16. Mechanism of injury
 Sharp / penetrating
 Blunt

17. Mechanism of disruption at vascular level
 Transection
 Laceration
 Contusion
 Kink
 Intimal flap
*Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a
peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8

18. Contusion
Results from blunt trauma

19. Laceration
 The injured vessel ends are
separated
 Edges of are irregular

20. Side wall injury
Partial injury to the wall of the vessel

21. Intimal flap
 Due to injury the arterial
intima is raised as a flap
 Resulting in dissection and
occlusion

22. Mechanism of disruption at vascular level
Our experience *
THA ( lower limb arterial injuries)
 40% - Contusion
 40% - lacerations
Trap gun injury
 75% laceration
* Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka.
Sriharan, P and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8

23. Spasm
 Study done at NHSL with lower limb injuries and
absent pulses
 31 patients with absent pulses
 18 (58.1%) arterial spasm
 Arterial spasm -common causes of diagnostic
dilemma
.
* Lower Limb Arterial Spasm following Trauma: a Common and an Important Cause. Kapilan, G and Arudchelvam, J. Colombo
: s.n., 2020. Sri Lanka Medical Association 133rd Anniversary International Medical Congress, 2020. p. 63.
$ Post- Traumatic Lower Limb Arterial Spasm: A Common Entity and an Important Cause for Diagnostic Dilemma: A Case Series.
Kapilan G, Arudchelvam J. 1057, 2020, Ann Short Reports, Vol. 3.

24. Spasm
 Common in young patients
 An underlying injury should be excluded
 Confirmation with angiography is necessary
* Lower Limb Arterial Spasm following Trauma: a Common and an Important Cause. Kapilan, G and Arudchelvam, J. Colombo
: s.n., 2020. Sri Lanka Medical Association 133rd Anniversary International Medical Congress, 2020. p. 63.
$ Post- Traumatic Lower Limb Arterial Spasm: A Common Entity and an Important Cause for Diagnostic Dilemma: A Case Series.
Kapilan G, Arudchelvam J. 1057, 2020, Ann Short Reports, Vol. 3.

25. Signs of a vessel injury
Following vascular trauma – clinical features
are divided into;
 Hard signs
 Soft signs

26. Extremity vascular trauma
Hard signs
 Active bleeding
 Thrills, Bruits
 Signs of distal ischaemia
 6 “P”s
 Absent Pulse
 Pain
 Pallor
 Perishing cold
 Paresthesia / Anaesthesia
 Paresis / Paralysis
 Expanding hematoma

27. Signs of a vessel injury
Soft signs
 History of bleeding
 Hematoma
 Injury close to a known neurovascular bundle
 Weak pulse
 Hard signs – in sharp injury, 100% chance of Vascular
injury
 Soft signs – 10-25%
The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury:
results at one year. Frykberg, ER, et al., et al. 4, 1991, J Trauma, Vol. 31, p. 502.
Penetrating nontorso trauma: the extremities. Ball, CG. 4, 2015, Can J Surg, Vol. 58, pp. 286-8

28. Late Signs of a vessel injury
 Paresis and paresthesia
 Viability of the limb is in immediate threat
 Anesthesia and paralysis - Not viable
 Should be evaluated and documented

29. Documentation following trauma
Teaching Hospital Anuradhapura Sri Lanka (2019) *
 Cause of injury documented - 82.6%
 Limb viability documented only in - 30.7%
* Completeness of documentation of patients with vascular trauma. Sriharan, P and
Arudchelvam, J. Anuradhapura : s.n., 2019. Anuradhapura Clinical Society , 13th Annual
scientific sessions. p. 74.

30. Investigations
 Immediate viability threat /
Hard signs
 Urgent intervention
 Soft signs
 Can Investigate / intervene

31. Investigations

32. Investigations
Computerized
Tomographic
Angiography (CTA)

33. Investigations
Computerized
Tomographic
Angiography (CTA)

34. CT Angiography
Site of injury
 Soft tissue and bone
 3D reconstruction

35. CT Angiography
Site of injury
 Soft tissue and bone
 3D reconstruction

36. Vascular injuries - History
 Outcome of the vascular injuries have improved
dramatically over time
 Experience gained from various war injuries
 World Wars 1 / 2
 Ligation - Amputation rate - > 40%.
 Vietnam / Korean wars - repair - amputation rate - 15%
 Iraq / Afghanistan wars - Amputation rate - 8%.
 Advances in vascular repair methods
 Antibiotics
 Advances in trauma care

37. Surgical Repair
 Resuscitation
 General anesthesia
 Clean the entire limb
 Thigh prepared – for venous harvest
 Control of proximal and distal ends and trimming

38. Surgical repair - Trimming

39. Vascular repair techniques
Direct repair

40. Surgical repair - RSVG

41. Surgical repair
Our experience
Patients with Politeal
arterial injury (NHSL
2012)
RSVG - 88.2%
Arudchelvam, Joel. Popliteal artery trauma. Slideshare. [Online] Dec 5, 2015. [Cited: 9 9, 2022.]
https://www.slideshare.net/JoelArudchelvamMBBSM/popliteal-artery-trauma.

42. Vascular repair techniques
 Large arteries (e.g. subclavian, axillary, iliac) - anastomosis -
6/0 or 5/0 Polypropylene sutures
 Small arteries (radial and ulnar) - 7/0 Polypropylene

43. Venous injuries
 Saphenous vein graft – small for veins
 Need to reconstruct to match the size
 Panelled
 Spiral

44. Venous injuries
 Panelled grafts

45. Venous injuries
Spiral graft

46. Vein Patch Repair
JOEL

47. Surgical repair
Synthetic grafts
 Lower patency
 Infection
Parathan, S., Arudchelvam, J. and Marasinghe, A., 2019. Outcome of popliteal arterial injuries presenting to the Teaching
Hospital, Anuradhapura. Sri Lanka Journal of Surgery, 37(4), pp.14–17. DOI: http://doi.org/10.4038/sljs.v37i4.8642
Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka. Sriharan, P and
Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8.

48. Combined Vascular and Skeletal Trauma
Our experience (NHSL and THA)
 41 / 985 (4.2%) of lower limb fractures had vascular
injuries *
 17/ 150 (11.3%)of Humerus fractures had VI*
 17/20 (85%) with popliteal arterial injury had fractures or
dislocation (p0.003)**
• Vascular injuries associated with upper extremity skeletal trauma , a cross sectional study.
Ranaweera, RS, Arudchelvam , J. ,Priatharshan, M.Kandy : s.n., 2021. The Kandy Society of medicine,
43rd annual academic sessions. .p.96
• ** Parathan S, Arudchelvam J, Marasinghe A. Outcome of popliteal arterial injuries presenting to the
Teaching Hospital, Anuradhapura. Sri Lanka Journal of Surgery. 2019;37(4):14–7

49. 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

50. Primary Amputation
Extensive crush injuries and soft tissue
damage – “mangled limb”
No need to transfer – discuss / photo

51. Mangled limb
National hospital of Sri Lanka Colombo*
 Total vascular injuries – 81
 Limbs were mangled - 2 (2.5%) .
Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is
time to establish a dedicated trauma vascular surgery unit. Kapilan, G and Arudchelvam,
J. Colombo : s.n., 2020

52. How soon we should we repair
 Complications of delayed arterial repair
 Limb death
 Reperfusion syndrome

53. How soon we should we repair
 As soon as possible
 Canine vascular occlusion / ischemia model 1947
 Ischemic time < 6 hours - limb salvage rate
90%.
 “Golden period” of 6 hours as a threshold
 In practice patients often reach beyond 6 hours
* Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63, pp. 203-204.
£ Revascularisation of Marginally Viable Limbs; A Long-Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.

54. How soon we should we repair

55. How soon we should we repair

56. How soon we should we repair

57. How soon we should we repair

58. How soon we should we repair

59. How soon we should we repair

60. How soon we should we repair
At the teaching hospital Anuradhapura
13 cases
Mean ischaemic time – 11.3 hours (0.5 to 48)
4/9 (30.8%) limbs were either non-viable or
marginally viable
Arudchelvam, J., 2017. Outcome after revascularisation of marginally viable limbs and dead limbs following
lower limb arterial injuries. Ceylon Medical Journal, 62(3), pp.203–204.

61. Marginally viable limbs
 Revascularization was attempted on such patients
despite having > 6 hours of ischemia * £
 provided ;
 Patients consenting
 Systemically well and stable
 Limb not mangled
 Not infected
* Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63, pp. 203-204.
£ Revascularisation of Marginally Viable Limbs; A Long-Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.

62. Marginally viable limbs Outcome
 Long term follow-up
 All were happy to have a limb
 All reported improvement in sensory function
 Only had partial recovery of motor functions * £
* Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63, pp. 203-204.
£ Revascularisation of Marginally Viable Limbs; A Long-Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.

63. Marginally viable limb

64. Post perfusion syndrome
 Substances Released into circulation
 Lactic Acid
 K+
 Myoglobin
Resulting in organ failure and death of the
patient

65. Post perfusion syndrome
Study done at NHSL 2011 *
 Total arterial repairs – 42
 Mean ischemic time - 7.25 hours
 Severe reperfusion syndrome - 3 (7.1%)
 Treatment – ligation of repaired vessels
 Amputation
*. Injury profiles, Referral delay, management options and Short Term Outcome Of Traumatic Acute Limb
Ischaemia (ALI) Managed At A Tertiary Referral Center. JD, Arudchelvam and JASB, Jayasundara.
Colombo : s.n., 2011. Annual Academic Sessions Of The College Of Surgeons Of Sri Lanka August 2011. pp.
185-186.

66. Compartment syndrome
Reduced organ perfusion due to increased intra
compartment pressure
Mean Arterial Pressure
(MAP)
Intra Compartmental
Pressure (ICP)

67. Compartment syndrome

68. Compartment syndrome

69. Fasciotomy

70. Fasciotomy
 Teaching Hospital Anuradhapura . 2019
 Popliteal arterial injury – 24
 No patients underwent fasciotomy before the transfer*
* Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka.
Sriharan, P and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8

71. Vascular trauma how to improve the
situation
 Prevention of injuries
 Transfer of patients
 Improving infrastructure
 Establishment of dedicated trauma centres

72. Prevention of injuries
After 2009
 Reduction in war related vascular injuries
 But an increase in civilian injuries
 Increase Road Traffic Accidents (RTA) - i.e. from 1938 to
2013 - RTA injuries increased - 35.1 to 98.6 /100000
 Two and three wheeled vehicles
World Bank Group, GRSF

73. Prevention of injuries
 Study done at TH Anuradhapura 2019
 Patients with popliteal arterial injuries
 40 % - Motorcycle accidents
Parathan S, Arudchelvam J, Marasinghe A. Outcome of popliteal arterial injuries presenting to the
Teaching Hospital, Anuradhapura. Sri Lanka Journal of Surgery. 2019;37(4):14–7.

74. Prevention of injuries
Speed Limit
Seatbelt
Drink Driving
Limit the number of vehicles
World Bank Group, GRSF

75. Transfer of patients
Communication before transfer
Series at the NHSL 2011
 Transfers - 39
 Notified before - 8 (20.5%)
Injury profiles, Referral delay, management options and Short Term Outcome Of Traumatic Acute Limb
Ischaemia (ALI) Managed At A Tertiary Referral Center. JD, Arudchelvam and JASB, Jayasundara. Colombo :
s.n., 2011. Annual Academic Sessions Of The College Of Surgeons Of Sri Lanka August 2011. pp. 185-186.

76. Transfer of patients
In 2020 at NHSL
 Limb vascular injuries - 81
 Unnecessary transfers – 8 (9.9%)
 Non -viable - 4 (4.9%)
 Mangled - 2 (2.5%)
 Traumatic amputations not suitable for re-
implantation - 2 (2.5%)
Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is time to establish a dedicated trauma
vascular surgery unit. Kapilan, G and Arudchelvam, J. Colombo : s.n., 2020

77. Improving infrastructure and facilities
Improve the road systems and measures to reduce the
traffic

78. Improving infrastructure and facilities

79. Improving infrastructure and facilities
Both for patients and the staff

80. How to improve the situation
Establishment of dedicated trauma
centres with surgeons trained on
vascular repair

81. Dedicated
trauma
centres

82. The National Hospital of Sri Lanka

83. Accident service
The National Hospital of Sri Lanka

84. Accident service
The National Hospital of Sri Lanka
Overall mean delay in intervention - 2.6 hours (0.2-14.6).

85. Accident service
The National Hospital of Sri Lanka
 Delay due to;
 Lack / non availability of staff
 Lack of equipment
 Lack of protocol

86. Vascular and Transplant Surgeons
 At present only 10 vascular and
transplant surgeons in Ministry of
Health.
 Vascular and transplant work
(routine and emergency)
 Vascular trauma account for 63.9%
emergency surgeries* (NHSL 2021)
 ? Routine Vascular work
 ? Transplant Work
*Extremity vascular trauma workload of a single vascular unit in a tertiary care centre: vascular trauma contributes to significant
emergency workload, Bandara LMPM, Kapilan G, Arudchelvam J, s.n., 2021. The Kandy Society of medicine, 43rd annual academic
sessions

87. Vascular and Transplant Surgeons
 Train more Vascular and Transplant surgeons
 Train other surgeons to handle the traumatic vascular
emergencies

92. Exhausted staff

93. We need big teams / Better Centres

94. Outcome after limb vascular injuries
In studies done at NHSL and THA the overall limb salvage rates
after vascular trauma were 75.0% - 98.6% (1) (2).
1. Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is time to
establish a dedicated trauma vascular surgery unit. Kapilan, G and Arudchelvam, J. Colombo : s.n., 2020.
2. Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Parathan, S
and Arudchelvam, J. 4, 2019, Sri Lanka Journal of Surgery, Vol. 37, pp. 14–17.

96. Long way to go !!!

97. Acknowledgment