Vascular injuries in limbs are a significant problem in Sri Lanka, particularly among young males. Road traffic accidents and injuries from trap guns are major causes. There is often a delay in patients reaching care, resulting in increased risk of limb loss. Establishing dedicated trauma centers staffed by vascular surgeons could help minimize delays and improve outcomes. Currently limb salvage rates after repair are around 75-98% based on studies in Sri Lanka, but establishing dedicated trauma networks and protocols could help improve the situation for patients suffering vascular injuries.

1. Vascular injuries in limbs:
Sri Lankan perspective
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.
1

2. 2

3. Limb 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
3

4. Limb vascular injuries
▪Anuradhapura 2019*
▪ Male - 87.5%
▪ Mean age - 36.9 years (17–69)
▪ Following trap gun - 25% amputation rate
* 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.
4

5. Limb vascular injuries- incidence
▪ National hospital of Sri Lanka Colombo (NHSL)
▪ 5802 trauma admissions
▪ 93 vascular injuries (VI)
▪ Incidence of VI in civilian trauma is 1.6%*
▪ 88 vascular repairs / year (2022)
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.
5

6. Causes
▪Road Traffic Accidents - 54.2%
▪Trap Gun - 33.3%
▪Iatrogenic - 8.3%
*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
6

7. Causes
Causes of upper limb vascular injuries - NHSL 2020
▪ 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.
7

8. Clinical presentation
Hard signs
 Active bleeding
 Thrill, Bruit
 Signs of distal ischaemia
 6 “P”s
 Absent Pulse
 Paresthesia / Anaesthesia
 Paresis / Paralysis
 Expanding hematoma
8

9. Clinical presentation
Soft signs
 History of bleeding
 Injury close to a known neurovascular bundle
 Weak pulse
 Hard signs – single injury, 100% chance of Vascular injury
 Soft signs – 10-25% chance of Vascular injury
9

10. 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
10

11. 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.
11

12. Mechanism of disruption at vascular level
▪ Laceration
▪ Contusion
▪ Sidewall injury
▪ 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
12

13. Mechanism of disruption at vascular level
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
13

14. Vascular repair techniques
⚫ Interposition graft repair
⚫ RSVG
⚫ Synthetic
⚫ End to end repair
⚫ Direct lateral repair
⚫ Patch repair
14

15. Surgical repair
Our experience (NHSL 2012)
▪ Popliteal arterial injury
▪ 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.
15

16. 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.
16

17. Combined Vascular and Skeletal Trauma
Our experience (NHSL and THA)
▪ Lower limb fractures and vascular injuries * - 4.2% (41 / 985)
▪ Humerus fractures and vascular injuries * - 11.3% (17/ 150)
▪ Popliteal arterial injury and fractures or dislocation - 85.0% (17/20) (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
17

18. Mangled limb
National hospital of Sri Lanka Colombo*
▪ Total vascular injuries - 81
▪ Limbs were mangled - 02 (2.5%)
▪ No need to transfer – discuss / photo
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
18

19. How soon we should we repair
Complications of delayed arterial repair
 Limb death
 Reperfusion syndrome
19

20. How soon we should we repair
▪ As soon as possible
▪ “Golden period” of 6 hours as a threshold
▪ Canine vascular occlusion / ischemia model 1947
▪ Ischemic time < 6 hours - limb salvage rate 90%.
* 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.
20

21. How soon we should we repair
At the teaching hospital Anuradhapura
 In practice patients often reach beyond 6 hours
 Mean ischaemic time – 11.3 hours (0.5 to 48)
 5/9 (55.6%) limbs were 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.
21

22. Vascular trauma;
How to improve the situation
▪ Transfer of patients
▪ Improving infrastructure
▪ Establishment of dedicated trauma centres
22

23. Transfer of patients
Communication before transfer
Series at the NHSL 2011
▪ Transfers - 39
▪ Notified before - 08 (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.
23

24. Transfer of patients
Minimise Ineffective transfers (NHSL 2020)
▪ Limb vascular injuries - 81
▪ Ineffective transfers - 08 (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
24

25. How to improve the situation
Establishment of dedicated trauma centres
25

26. Dedicated trauma
centres
26

27. Accident service
The National Hospital of Sri Lanka
27

28. Accident service
The National Hospital of Sri Lanka
▪ Lack / non availability of staff
▪ Lack of equipment
▪ Lack of protocol
28

29. Establishing new trauma centres
•How many?
•Man power?
•Other resources?
29

30. Vascular and Transplant Surgeons
▪ At present only 12 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
▪ Migration
*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
30

31. We need big teams
Concentrate resources
Trauma centres at key locations
31

32. Outcome after limb vascular injuries
In studies done at NHSL and THA the overall limb salvage rates 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.
32

33. Long way to go !!!
33

34. Thank You
34