Vascular

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Vascular

  1. 1. Vascular
  2. 2. Vascular injury • • • • • • Vessel Site Type Pathology Investigation Management
  3. 3. Vascular injury • Arterial • Venous • Combined
  4. 4. Basic principle • • • • • • • Anatomy Type of injury Mechanism of injury Clinical manifestation Clinical evaluation Investigation Management
  5. 5. Types of injury • Laceration • Transection – Defect – No defect • • • • Dissection Crush Thrombosis/Embolus Spasm
  6. 6. Type of injury • (1) intimal injuries (flaps, disruptions, or subintimal/ intramural hematomas); • (2) complete wall defects with pseudoaneurysms or hemorrhage; • (3) complete transections with hemorrhage or occlusion; • (4) arteriovenous fistulas; and • (5) spasm
  7. 7. Type • (1) intimal injuries (flaps, disruptions, or subintimal/ intramural hematomas);
  8. 8. Type • (2) complete wall defects with pseudoaneurysms or hemorrhage;
  9. 9. Type • (3) complete transections with hemorrhage or occlusion;
  10. 10. Type • (4) arteriovenous fistulas; • (5) spasm
  11. 11. Mechanism of injury • Penetrating – Knife – Jambia – GSW • Sharpnel • Blunt – – – – Direct (contusion) Traction (avulsion( Deceleration Torsion
  12. 12. Hard sign – Active pulsatile haemorrhage – Pulsatile or expanding haematoma – Sign of limb ischaemia • 5ps – Diminished or absent pulse – Bruit and thrill
  13. 13. Soft sign • • • • Hypotension/shock Neurological deficit Stable, non pulsatile small haematoma Proximity of wound to major vessel
  14. 14. Investigation • Doppler • Duplex ultrasound – As screening test • Angiography gold standard • CT angiography • MRI
  15. 15. Doppler/Duplex • Sound • Colored duplex • First line investigation •
  16. 16. Magnetic Resonance Angiography • MRA has the advantage of not requiring iodinated contrast agents to provide vessel opacification • Gadolinium is used as a contrast agent for MRA studies, and as it is generally not nephrotoxic, it can be used in patients with elevated creatinine.
  17. 17. Angiography • • • • • • Advantage Gold standard Detect occult injury Exclude need for OR Operative planning Endovascular repair
  18. 18. Site • • • • Neck Chest Abdomen Lower limb
  19. 19. Neck • Anatomy – Carotid – Vertebral – Jugular – Subclavian – Innominate
  20. 20. Neck injury classification • Zone I: base of neck, thoracic outlet to 1cm above clavicle . • Zone II : 1 cm above clavicle to angle of jaw • Zone III : above angle of mandible
  21. 21. Neck • • • • • Zone I and III are difficult to assess Image the stable patient Mandatory exploration unstable patient Exclude : Associated injuries on the – cervical spine, – airway, and – digestive tract
  22. 22. Management guideline • 1. Immediate operation is indicated for unstable patients with active bleeding not responsive to vigorous resuscitation or with rapidly expanding hematoma or airway obstruction, irrespective • of anatomical zone. • 2. Injuries in zone II not penetrating the platysma need no further examination. • 3. All others require further diagnostic evaluation with angiography, duplex ultrasound, and CT to determine whether critical structures have been injured. • If angiography or high-quality duplex ultrasound is not available, injuries in zone II need to be surgically explored
  23. 23. Neck exposure • • • • • • • Venous injuries exploration of a neck injury can be treated either by repair using simple or running sutures or by ligation. In bilateral injuries to the internal jugular veins, however, reconstruction of one of the sides is indicated to avoid severe venous hypertension.
  24. 24. Chest • • • • Anatomy: Aorta, supra-aortic trunk, intercostal IVC, SVC, brachiocephali/ subclavian
  25. 25. Chest • • • • • • • Aerodigestive tract. Air bubbles in the wound Respiratory distress Subcutaneous emphysema Hoarseness Hemoptysis Hematemesis
  26. 26. Chest Indication for thoracotomy • Penetrating unstable, unresponsive to resuscitation • Chest tube • Deterioration of vital signs when the drain is started • 1.500–2.000 ml of blood within the first 4–8 h • Drainage of blood exceeding 300 ml/h for more than 4h • More than half of pleural cavity filled with blood on x-ray despite a well functioning chest tube
  27. 27. Aorta • Usually results from deceleration injury-fatal unless false aneurysm develops in mediastinum Back pain, hypotension; systolic murmur or signs of tamponade in some cases; characteristic
  28. 28. Investigation • • • • Chest x-ray : widened mediastinum, frac. Rib 1,2 Apical pleural effusion (cap) Tracheal deviation Obliteration of descending aorta • CT scan • Angiography • MRI
  29. 29. Wide mediastinum
  30. 30. Stent insertion
  31. 31. Approach to Chest • Posterolateral thoracotomy • Median sternotomy • Anterolateral (4th)
  32. 32. Rupture of aorta • widening of mediastinum on chest X-ray; diagnosis confirmed by arteriography • Urgent thoracotomy and Dacron graft or minimal-access stent graft if available
  33. 33. Rates • Major abdominal vascular injury is seen in up to 25% of patients admitted with vascular trauma. • Blunt trauma/penetrating trauma. • Abdominal injury represents 10–20% of all traumas to the body caused by road traffic accidents. • Major vascular injury is estimated to occur in about 10% of cases of penetrating stab wounds in the abdomen • and in about 25% of gunshot wounds. • Blunt abdominal trauma affects major vessels less frequently, estimates of below 5% is common in the literature
  34. 34. Abdomen • Aorta and its branches, • IVC, portal and iliac veins – Indication for laparotomy – Damage control – Re-explore – Control bleeding – Avoid prosthesis
  35. 35. Abdomen • Contron – Supra diaphragmatic – Supr-celiac – Infra-renal – Ballon, occlusion • Exposure – From the left – From the right
  36. 36. Boundaries of the Retroperitoneal Region • Above: T12 and 12th rib • Below: Base of the sacrum, the iliac crest, the upper rami of the pubic bones, and the pelvic diaphragm • Anterior: parietal peritoneum of the retroperitoneal space, part of the liver and its bare area, part of the duodenum, part of the ascending colon, part of the descending colon, and much of the pancreas within the lesser sac.
  37. 37. ZONES • Zone I (centromedial) • Upper: Diaphragmatic, esophageal, and aortic openings • Lower: Sacral promontories • Lateral: Psoas muscles • Contents: Abdominal aorta, inferior vena cava, pancreas, duodenum (partial) .
  38. 38. Zone II (lateral) • • • • Upper: Diaphragm Lower: Iliac crests Lateral: Psoas muscles Contents: Kidneys and their vessels, ureters and their abdominal parts, ascending and descending colon, hepatic and splenic flexure
  39. 39. Zone III (pelvic) • Anterior: Space of Retzius (symphysis pubis and pubic bones, separated from the bladder by the space of Retzius) • Posterior: Sacrum • Lateral: Bony pelvis • Contents: Pelvis in content, pelvic wall, rectosigmoid colon, iliac vessels, urogenital organs (partial)
  40. 40. Retro peritoneal zone
  41. 41. Therapeutic Implications of Retroperitoneal Zones • •Zone I: highest risk of vascular injury. Investigate with surgery unless small and stable. • •Zone II: second most common site of retroperitoneal hemorrhage, predominantly renal injuries. • •Penetrating: selective •Exploration or angiographic embolization • •Blunt: Observation and follow-up imaging hemodynamically stable and no active bleeding • •Zone III: Most common location of retroperitoneal hemorrhage, associated with pelvic fracture • •No exploration in blunt pelvic trauma • •Surgery for penetrating trauma
  42. 42. Limbs • Vascular injuries associated with fractures are rare, occurring in only 0.5 to 3% of all patients with extremity fractures. • The importance of a careful neurologic examination is important . • Three different mechanisms can produce paralysis and numbness in an injured extremity: ischemia, nerve injury, and compartment syndrome.
  43. 43. Prehospital • As manual compression or the application of a pressure dressing and • Elevation of the extremity can almost always control arterial bleeding from an extremity in the field, • Loss of life should be infrequent in an urban setting.
  44. 44. Immediate measure • • • • • • Control bleeding Replace volume lost Cover wound Reduce fracture Splint Re-evaluate
  45. 45. Post op • Postoperative monitoring of hand perfusion and radial pulse is recommended at least every 30 min for the first 6 h. When deteriorated function of the repaired artery is suspected, duplex scanning can verify or exclude postoperative problems. • Occausion ......reoperation • Compartment syndrome
  46. 46. Complication • Delayed diagnosis and treatment may lead – Thrombosis – Embolisation – Rupture with hge. • Risk factor for amputation – Elevated compartment pressure – Arterial transection – Associate open fracture – Combination above and below knee
  47. 47. Lower limb • • • • • Doppler Doplex CT angio MRI (MRA) Angiography
  48. 48. In theatre • Always establish good exposure • Establish proximal then distal arterial control • Use a shunt if the bones need to be fixed first to buy you some time • Use local heparin flush • Make your arterial repair tension-free • Use autogenous vein • Repair concomitant venous injury if patient is stable
  49. 49. Shunting • Intra-luminal shunt temporary save limb – Simple tume can be constructed – Transfer – Manipulation of bonw
  50. 50. Management • Conservative • Endovascular • Operative – Local • • • • • Suture Patch Primary anastomosis autogenous Prosthetic – Fasciotomy
  51. 51. Limbs • Operative Principle – Proximalldistal control – Primary repair where possible – Graft autogenous vein (contralateral limb) – Temporary shunt – Fixation of ortho-injury – Coverage of repair (muscle, soft tissue) – Fasciotomy
  52. 52. Extremities • • • • • Ligation may be acceptable in rare circumstances If major Musculo-skeletal, neurological injury Popliteal have the highest rate Repair vein first Compaerment syndrome
  53. 53. Others • Catheter injury • Intra-arterial drug injuries • Cold Injury – Frost bite – Immersion (trench) foot – Frostnip

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