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ΑΝΤΙΜΕΤΩΠΙΣΗ ΤΩΝΑΝΤΙΜΕΤΩΠΙΣΗ ΤΩΝ
ΤΡΑΥΜΑΤΙΚΩΝ ΚΑΚΩΣΕΩΝΤΡΑΥΜΑΤΙΚΩΝ ΚΑΚΩΣΕΩΝ
ΠΕΡΙΦΕΡΙΚΩΝ ΑΓΓΕΙΩΝΠΕΡΙΦΕΡΙΚΩΝ ΑΓΓΕΙΩΝ
Παπαχριστοδούλου ΑΠαπαχριστοδούλου Α11
, Φιδάνης Θ, Φιδάνης Θ11
, Γαλάνης Σ, Γαλάνης Σ11
, Παπουλίδης Π, Παπουλίδης Π22
, Σκουμής Γ, Σκουμής Γ22
, Μεγαλόπουλος Α, Μεγαλόπουλος Α33
,,
Τρελλόπουλος ΓΤρελλόπουλος Γ33
, Δρόσος Γ, Δρόσος Γ22
1: Τμήμα Επεμβατικής Ακτινολογίας Γ.Ν.Θ. «Γ. Παπανικολάου»1: Τμήμα Επεμβατικής Ακτινολογίας Γ.Ν.Θ. «Γ. Παπανικολάου»
2: Θωρακοχειρουργική Κλινική Γ.Ν.Θ. «Γ. Παπανικολάου»2: Θωρακοχειρουργική Κλινική Γ.Ν.Θ. «Γ. Παπανικολάου»
3: Αγγειοχειρουργικό Τμήμα Γ.Ν.Θ. «Γ. Παπανικολάου»3: Αγγειοχειρουργικό Τμήμα Γ.Ν.Θ. «Γ. Παπανικολάου»
ΑΙΤΙΑ ΚΑΚΩΣΕΩΝΑΙΤΙΑ ΚΑΚΩΣΕΩΝ
 ΤΡΟΧΑΙΑΤΡΟΧΑΙΑ
 ΠΤΩΣΕΙΣΠΤΩΣΕΙΣ
 ΚΑΚΩΣΕΙΣ ΑΠΟ ΠΥΡΟΒΟΛΑ ΟΠΛΑΚΑΚΩΣΕΙΣ ΑΠΟ ΠΥΡΟΒΟΛΑ ΟΠΛΑ
 ΤΡΑΥΜΑ ΑΠΟ ΝΥΣΣΟΝ ΟΡΓΑΝΟΤΡΑΥΜΑ ΑΠΟ ΝΥΣΣΟΝ ΟΡΓΑΝΟ
 ΕΓΚΑΥΜΑΤΑΕΓΚΑΥΜΑΤΑ
 ΤΟ 80% ΟΛΩΝ ΤΩΝ ΑΓΓΕΙΑΚΩΝΤΟ 80% ΟΛΩΝ ΤΩΝ ΑΓΓΕΙΑΚΩΝ
ΚΑΚΩΣΕΩΝ ΑΦΟΡΟΥΝ ΤΑ ΑΚΡΑΚΑΚΩΣΕΩΝ ΑΦΟΡΟΥΝ ΤΑ ΑΚΡΑ
ΚΛΙΝΙΚΗ ΕΙΚΟΝΑΚΛΙΝΙΚΗ ΕΙΚΟΝΑ
 ΕΞΩΤΕΡΙΚΗ ΑΙΜΟΡΡΑΓΙΑΕΞΩΤΕΡΙΚΗ ΑΙΜΟΡΡΑΓΙΑ
 ΙΣΧΑΙΜΙΑΙΣΧΑΙΜΙΑ
 ΣΦΥΖΩΝ ΑΙΜΑΤΩΜΑΣΦΥΖΩΝ ΑΙΜΑΤΩΜΑ
 SHOCKSHOCK
DiagnosisDiagnosis ofof VascularVascular
injuryinjury
Hard signsHard signs
 Loss of distal pulseLoss of distal pulse
 Expanding hematomaExpanding hematoma
 Bruit or thrillBruit or thrill
 Visible arterial bleedingVisible arterial bleeding
 Distal ischemiaDistal ischemia
Soft signs
Distal neuroinjury
Diminished distal pulse/ABI ankle/
brachial index
Stable hematoma
Significant blood loss at scene
ΔΙΑΓΝΩΣΗΔΙΑΓΝΩΣΗ
 ΨΗΦΙΑΚΗ ΑΦΑΙΡΕΤΙΚΗΨΗΦΙΑΚΗ ΑΦΑΙΡΕΤΙΚΗ
ΑΓΓΕΙΟΓΡΑΦΕΙΑΑΓΓΕΙΟΓΡΑΦΕΙΑ
 ΙΣΧΑΙΜΙΑ –ΣΗΜΕΙΑ ΣΥΜΠΤΩΜΑΤΑΙΣΧΑΙΜΙΑ –ΣΗΜΕΙΑ ΣΥΜΠΤΩΜΑΤΑ
 ΑΙΜΟΡΡΑΓΙΑΑΙΜΟΡΡΑΓΙΑ
 ΚΝΗΜΟΒΡΑΧΙΟΝΙΟ ΔΕΙΚΤΗ <0,9ΚΝΗΜΟΒΡΑΧΙΟΝΙΟ ΔΕΙΚΤΗ <0,9
 ΠΟΛΛΑΠΛΑ ΔΙΑΤΙΤΡΑΙΝΩΝΤΑΠΟΛΛΑΠΛΑ ΔΙΑΤΙΤΡΑΙΝΩΝΤΑ
ΤΡΑΥΜΑΤΑΤΡΑΥΜΑΤΑ
ΘΕΡΑΠΕΙΑΘΕΡΑΠΕΙΑ
 ΕΝΔΟΑΓΓΕΙΑΚΗΕΝΔΟΑΓΓΕΙΑΚΗ
 ΤΟΠΟΘΕΤΗΣΗΤΟΠΟΘΕΤΗΣΗ STENT GRAFTSTENT GRAFT
 ΕΜΒΟΛΙΣΜΟΣΕΜΒΟΛΙΣΜΟΣ
ΘΕΡΑΠΕΙΑΘΕΡΑΠΕΙΑ
 ΧΕΙΡΟΥΡΓΙΚΗΧΕΙΡΟΥΡΓΙΚΗ
 ΑΠΛΗ ΑΡΤΗΡΙΟΡΑΦΗΑΠΛΗ ΑΡΤΗΡΙΟΡΑΦΗ
 ΤΕΛΙΚΟΤΕΛΙΚΗ ΑΝΑΣΤΟΜΩΣΗΤΕΛΙΚΟΤΕΛΙΚΗ ΑΝΑΣΤΟΜΩΣΗ
 ΠΑΡΑΚΑΜΨΗ ΜΕ ΦΛΕΒΙΚΟΠΑΡΑΚΑΜΨΗ ΜΕ ΦΛΕΒΙΚΟ
ΣΥΝΘΕΤΙΚΟ ΜΟΣΧΕΥΜΑΣΥΝΘΕΤΙΚΟ ΜΟΣΧΕΥΜΑ
ΑΙΜΟΡΡΑΓΙΑ ΕΠΙΠΟΛΗΣΑΙΜΟΡΡΑΓΙΑ ΕΠΙΠΟΛΗΣ
ΜΗΡΙΑΙΑΣ ΑΡΤΗΡΙΑΣΜΗΡΙΑΙΑΣ ΑΡΤΗΡΙΑΣ
ΑΙΜΟΡΡΑΓΙΑ ΕΣΩΑΙΜΟΡΡΑΓΙΑ ΕΣΩ
ΛΑΓΟΝΙΟΥ ΑΡΤΗΡΙΑΣΛΑΓΟΝΙΟΥ ΑΡΤΗΡΙΑΣ
ΔΙΑΧΩΡΙΣΜΟΣ ΒΡΑΧΙΟΝΙΟΥΔΙΑΧΩΡΙΣΜΟΣ ΒΡΑΧΙΟΝΙΟΥ
ΑΡΤΗΡΙΑΣΑΡΤΗΡΙΑΣ
ΧΕΙΡΟΥΡΓΙΚΗΧΕΙΡΟΥΡΓΙΚΗ
ΑΝΤΙΜΕΤΩΜΙΣΗΑΝΤΙΜΕΤΩΜΙΣΗ
ΠΑΡΑΚΑΜΨΗ ΜΕ ΦΛΕΒΑΠΑΡΑΚΑΜΨΗ ΜΕ ΦΛΕΒΑ
DiagnosisDiagnosis ofof VascularVascular
injuryinjury
Hard Signs ofHard Signs of
Distal ischemiaDistal ischemia
The 5 Ps:The 5 Ps:
 painpain
 pallorpallor
 paralysisparalysis
 paresthesiasparesthesias
 poikilothermypoikilothermy
or coolnessor coolness
Knee Dislocation
ManagementManagement of Complexof Complex
Extremity TraumaExtremity Trauma
 Initial Fracture Stabilization andInitial Fracture Stabilization and
FixationFixation
has been advocated in past years, duehas been advocated in past years, due
to concerns that an establishedto concerns that an established vascularvascular
repairrepair will be disrupted by subsequentwill be disrupted by subsequent
orthopaedic manipulationorthopaedic manipulation
ManagementManagement of Complexof Complex
Extremity TraumaExtremity Trauma
 If Revascularization is performed firstIf Revascularization is performed first
Clinical studies have shown a substantiallyClinical studies have shown a substantially
higher rate of limb salvagehigher rate of limb salvage
 compared with those in which it is delayedcompared with those in which it is delayed
until the skeleton is addresseduntil the skeleton is addressed
BUTBUT this is true only forthis is true only for
Undisplaced, stable blunt fracturesUndisplaced, stable blunt fractures
ManagementManagement of Complexof Complex
Extremity TraumaExtremity Trauma
Definitive vascular repair should beDefinitive vascular repair should be
delayeddelayed in cases ofin cases of
 unstable or severely comminuted fracturesunstable or severely comminuted fractures
 dislocationsdislocations
 segmental bone losssegmental bone loss
 severe soft tissue destruction andsevere soft tissue destruction and
contaminationcontamination
ManagementManagement of Complexof Complex
Extremity TraumaExtremity Trauma
Immediate restoration of perfusionImmediate restoration of perfusion
 Temporary intraluminal shunting untilTemporary intraluminal shunting until
skeletal stabilization and soft tissueskeletal stabilization and soft tissue
debridement has been completeddebridement has been completed
RTA, Open IIIc HumerusRTA, Open IIIc Humerus
FractureFracture
Vascular Surgeons – Orthopaedic Surgeons – Plastic Surgeons
Popliteal artery injury
Shunt in place
Αντιμετώπιση τραυματικών κακώσεων περιφερικών αγγείων
TheThe DDecision toecision to AAmputatemputate
TheThe DDecision toecision to AAmputatemputate
Risk factors for amputationRisk factors for amputation
 Gustilo III-C injuries—comminuted, open tibial-fibularGustilo III-C injuries—comminuted, open tibial-fibular
fractures with vascularfractures with vascular disruptiondisruption
 Sciatic or tibial nerve, or 2 of the 3 upper extremity nerves,Sciatic or tibial nerve, or 2 of the 3 upper extremity nerves,
anatomically transectedanatomically transected
 Prolonged ischemia (>4–6 hours)/muscle necrosisProlonged ischemia (>4–6 hours)/muscle necrosis
 Crush or destructive soft tissue injuryCrush or destructive soft tissue injury
 Significant wound contaminationSignificant wound contamination
 Multiple/severely comminuted fractures/segmental boneMultiple/severely comminuted fractures/segmental bone
lossloss
 Old age/severe comorbidityOld age/severe comorbidity

Orthopaedic ScoringOrthopaedic Scoring
SystemsSystems
 EEarlyarly TTotalotal CCareare (ETC)(ETC)
 IInjurynjury SSeverityeverity SScorecore (ISS), (NISS)(ISS), (NISS)
 MMangledangled EExtremityxtremity SSeverityeverity SScorecore (MESS)(MESS)
 DDamageamage CControlontrol OOrthopaedicsrthopaedics (DCO)(DCO)
G. Papanikolaou HospitalG. Papanikolaou Hospital
Vascular Surgeons – Orthopaedic Surgeons

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Αντιμετώπιση τραυματικών κακώσεων περιφερικών αγγείων

  • 1. ΑΝΤΙΜΕΤΩΠΙΣΗ ΤΩΝΑΝΤΙΜΕΤΩΠΙΣΗ ΤΩΝ ΤΡΑΥΜΑΤΙΚΩΝ ΚΑΚΩΣΕΩΝΤΡΑΥΜΑΤΙΚΩΝ ΚΑΚΩΣΕΩΝ ΠΕΡΙΦΕΡΙΚΩΝ ΑΓΓΕΙΩΝΠΕΡΙΦΕΡΙΚΩΝ ΑΓΓΕΙΩΝ Παπαχριστοδούλου ΑΠαπαχριστοδούλου Α11 , Φιδάνης Θ, Φιδάνης Θ11 , Γαλάνης Σ, Γαλάνης Σ11 , Παπουλίδης Π, Παπουλίδης Π22 , Σκουμής Γ, Σκουμής Γ22 , Μεγαλόπουλος Α, Μεγαλόπουλος Α33 ,, Τρελλόπουλος ΓΤρελλόπουλος Γ33 , Δρόσος Γ, Δρόσος Γ22 1: Τμήμα Επεμβατικής Ακτινολογίας Γ.Ν.Θ. «Γ. Παπανικολάου»1: Τμήμα Επεμβατικής Ακτινολογίας Γ.Ν.Θ. «Γ. Παπανικολάου» 2: Θωρακοχειρουργική Κλινική Γ.Ν.Θ. «Γ. Παπανικολάου»2: Θωρακοχειρουργική Κλινική Γ.Ν.Θ. «Γ. Παπανικολάου» 3: Αγγειοχειρουργικό Τμήμα Γ.Ν.Θ. «Γ. Παπανικολάου»3: Αγγειοχειρουργικό Τμήμα Γ.Ν.Θ. «Γ. Παπανικολάου»
  • 2. ΑΙΤΙΑ ΚΑΚΩΣΕΩΝΑΙΤΙΑ ΚΑΚΩΣΕΩΝ  ΤΡΟΧΑΙΑΤΡΟΧΑΙΑ  ΠΤΩΣΕΙΣΠΤΩΣΕΙΣ  ΚΑΚΩΣΕΙΣ ΑΠΟ ΠΥΡΟΒΟΛΑ ΟΠΛΑΚΑΚΩΣΕΙΣ ΑΠΟ ΠΥΡΟΒΟΛΑ ΟΠΛΑ  ΤΡΑΥΜΑ ΑΠΟ ΝΥΣΣΟΝ ΟΡΓΑΝΟΤΡΑΥΜΑ ΑΠΟ ΝΥΣΣΟΝ ΟΡΓΑΝΟ  ΕΓΚΑΥΜΑΤΑΕΓΚΑΥΜΑΤΑ  ΤΟ 80% ΟΛΩΝ ΤΩΝ ΑΓΓΕΙΑΚΩΝΤΟ 80% ΟΛΩΝ ΤΩΝ ΑΓΓΕΙΑΚΩΝ ΚΑΚΩΣΕΩΝ ΑΦΟΡΟΥΝ ΤΑ ΑΚΡΑΚΑΚΩΣΕΩΝ ΑΦΟΡΟΥΝ ΤΑ ΑΚΡΑ
  • 3. ΚΛΙΝΙΚΗ ΕΙΚΟΝΑΚΛΙΝΙΚΗ ΕΙΚΟΝΑ  ΕΞΩΤΕΡΙΚΗ ΑΙΜΟΡΡΑΓΙΑΕΞΩΤΕΡΙΚΗ ΑΙΜΟΡΡΑΓΙΑ  ΙΣΧΑΙΜΙΑΙΣΧΑΙΜΙΑ  ΣΦΥΖΩΝ ΑΙΜΑΤΩΜΑΣΦΥΖΩΝ ΑΙΜΑΤΩΜΑ  SHOCKSHOCK
  • 4. DiagnosisDiagnosis ofof VascularVascular injuryinjury Hard signsHard signs  Loss of distal pulseLoss of distal pulse  Expanding hematomaExpanding hematoma  Bruit or thrillBruit or thrill  Visible arterial bleedingVisible arterial bleeding  Distal ischemiaDistal ischemia Soft signs Distal neuroinjury Diminished distal pulse/ABI ankle/ brachial index Stable hematoma Significant blood loss at scene
  • 5. ΔΙΑΓΝΩΣΗΔΙΑΓΝΩΣΗ  ΨΗΦΙΑΚΗ ΑΦΑΙΡΕΤΙΚΗΨΗΦΙΑΚΗ ΑΦΑΙΡΕΤΙΚΗ ΑΓΓΕΙΟΓΡΑΦΕΙΑΑΓΓΕΙΟΓΡΑΦΕΙΑ  ΙΣΧΑΙΜΙΑ –ΣΗΜΕΙΑ ΣΥΜΠΤΩΜΑΤΑΙΣΧΑΙΜΙΑ –ΣΗΜΕΙΑ ΣΥΜΠΤΩΜΑΤΑ  ΑΙΜΟΡΡΑΓΙΑΑΙΜΟΡΡΑΓΙΑ  ΚΝΗΜΟΒΡΑΧΙΟΝΙΟ ΔΕΙΚΤΗ <0,9ΚΝΗΜΟΒΡΑΧΙΟΝΙΟ ΔΕΙΚΤΗ <0,9  ΠΟΛΛΑΠΛΑ ΔΙΑΤΙΤΡΑΙΝΩΝΤΑΠΟΛΛΑΠΛΑ ΔΙΑΤΙΤΡΑΙΝΩΝΤΑ ΤΡΑΥΜΑΤΑΤΡΑΥΜΑΤΑ
  • 7. ΘΕΡΑΠΕΙΑΘΕΡΑΠΕΙΑ  ΧΕΙΡΟΥΡΓΙΚΗΧΕΙΡΟΥΡΓΙΚΗ  ΑΠΛΗ ΑΡΤΗΡΙΟΡΑΦΗΑΠΛΗ ΑΡΤΗΡΙΟΡΑΦΗ  ΤΕΛΙΚΟΤΕΛΙΚΗ ΑΝΑΣΤΟΜΩΣΗΤΕΛΙΚΟΤΕΛΙΚΗ ΑΝΑΣΤΟΜΩΣΗ  ΠΑΡΑΚΑΜΨΗ ΜΕ ΦΛΕΒΙΚΟΠΑΡΑΚΑΜΨΗ ΜΕ ΦΛΕΒΙΚΟ ΣΥΝΘΕΤΙΚΟ ΜΟΣΧΕΥΜΑΣΥΝΘΕΤΙΚΟ ΜΟΣΧΕΥΜΑ
  • 9. ΑΙΜΟΡΡΑΓΙΑ ΕΣΩΑΙΜΟΡΡΑΓΙΑ ΕΣΩ ΛΑΓΟΝΙΟΥ ΑΡΤΗΡΙΑΣΛΑΓΟΝΙΟΥ ΑΡΤΗΡΙΑΣ
  • 12. DiagnosisDiagnosis ofof VascularVascular injuryinjury Hard Signs ofHard Signs of Distal ischemiaDistal ischemia The 5 Ps:The 5 Ps:  painpain  pallorpallor  paralysisparalysis  paresthesiasparesthesias  poikilothermypoikilothermy or coolnessor coolness Knee Dislocation
  • 13. ManagementManagement of Complexof Complex Extremity TraumaExtremity Trauma  Initial Fracture Stabilization andInitial Fracture Stabilization and FixationFixation has been advocated in past years, duehas been advocated in past years, due to concerns that an establishedto concerns that an established vascularvascular repairrepair will be disrupted by subsequentwill be disrupted by subsequent orthopaedic manipulationorthopaedic manipulation
  • 14. ManagementManagement of Complexof Complex Extremity TraumaExtremity Trauma  If Revascularization is performed firstIf Revascularization is performed first Clinical studies have shown a substantiallyClinical studies have shown a substantially higher rate of limb salvagehigher rate of limb salvage  compared with those in which it is delayedcompared with those in which it is delayed until the skeleton is addresseduntil the skeleton is addressed BUTBUT this is true only forthis is true only for Undisplaced, stable blunt fracturesUndisplaced, stable blunt fractures
  • 15. ManagementManagement of Complexof Complex Extremity TraumaExtremity Trauma Definitive vascular repair should beDefinitive vascular repair should be delayeddelayed in cases ofin cases of  unstable or severely comminuted fracturesunstable or severely comminuted fractures  dislocationsdislocations  segmental bone losssegmental bone loss  severe soft tissue destruction andsevere soft tissue destruction and contaminationcontamination
  • 16. ManagementManagement of Complexof Complex Extremity TraumaExtremity Trauma Immediate restoration of perfusionImmediate restoration of perfusion  Temporary intraluminal shunting untilTemporary intraluminal shunting until skeletal stabilization and soft tissueskeletal stabilization and soft tissue debridement has been completeddebridement has been completed
  • 17. RTA, Open IIIc HumerusRTA, Open IIIc Humerus FractureFracture Vascular Surgeons – Orthopaedic Surgeons – Plastic Surgeons
  • 20. TheThe DDecision toecision to AAmputatemputate
  • 21. TheThe DDecision toecision to AAmputatemputate Risk factors for amputationRisk factors for amputation  Gustilo III-C injuries—comminuted, open tibial-fibularGustilo III-C injuries—comminuted, open tibial-fibular fractures with vascularfractures with vascular disruptiondisruption  Sciatic or tibial nerve, or 2 of the 3 upper extremity nerves,Sciatic or tibial nerve, or 2 of the 3 upper extremity nerves, anatomically transectedanatomically transected  Prolonged ischemia (>4–6 hours)/muscle necrosisProlonged ischemia (>4–6 hours)/muscle necrosis  Crush or destructive soft tissue injuryCrush or destructive soft tissue injury  Significant wound contaminationSignificant wound contamination  Multiple/severely comminuted fractures/segmental boneMultiple/severely comminuted fractures/segmental bone lossloss  Old age/severe comorbidityOld age/severe comorbidity 
  • 22. Orthopaedic ScoringOrthopaedic Scoring SystemsSystems  EEarlyarly TTotalotal CCareare (ETC)(ETC)  IInjurynjury SSeverityeverity SScorecore (ISS), (NISS)(ISS), (NISS)  MMangledangled EExtremityxtremity SSeverityeverity SScorecore (MESS)(MESS)  DDamageamage CControlontrol OOrthopaedicsrthopaedics (DCO)(DCO)
  • 23. G. Papanikolaou HospitalG. Papanikolaou Hospital Vascular Surgeons – Orthopaedic Surgeons