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Vascular
This document discusses various types of vascular injuries. It covers the basic principles of vascular injury including anatomy, type of injury, mechanisms, clinical manifestations, investigations and management. It describes different types of vascular injuries like laceration, transection, dissection, crush and thrombosis. It discusses evaluation and investigations like Doppler, duplex ultrasound, angiography, CT angiography and MRI. It covers management of vascular injuries in different body regions like neck, chest, abdomen and extremities. It provides guidelines on treatment approaches including operative versus endovascular management.
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Vascular
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- 3. Vascular injury • Arterial •Venous • Combined
- 4. Basic principle • • • • • • • Anatomy Type ofinjury Mechanism of injury Clinical manifestation Clinical evaluation Investigation Management
- 5. Types of injury •Laceration • Transection – Defect – No defect • • • • Dissection Crush Thrombosis/Embolus Spasm
- 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. Type • (1) intimalinjuries (flaps, disruptions, or subintimal/ intramural hematomas);
- 8. Type • (2) completewall defects with pseudoaneurysms or hemorrhage;
- 9. Type • (3) complete transectionswith hemorrhage or occlusion;
- 10. Type • (4) arteriovenousfistulas; • (5) spasm
- 11. Mechanism of injury •Penetrating – Knife – Jambia – GSW • Sharpnel • Blunt – – – – Direct (contusion) Traction (avulsion( Deceleration Torsion
- 12. Hard sign – Activepulsatile haemorrhage – Pulsatile or expanding haematoma – Sign of limb ischaemia • 5ps – Diminished or absent pulse – Bruit and thrill
- 13. Soft sign • • • • Hypotension/shock Neurological deficit Stable,non pulsatile small haematoma Proximity of wound to major vessel
- 14. Investigation • Doppler • Duplexultrasound – As screening test • Angiography gold standard • CT angiography • MRI
- 15. Doppler/Duplex • Sound • Coloredduplex • First line investigation •
- 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. Angiography • • • • • • Advantage Gold standard Detect occultinjury Exclude need for OR Operative planning Endovascular repair
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- 19. Neck • Anatomy – Carotid –Vertebral – Jugular – Subclavian – Innominate
- 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. Neck • • • • • Zone I andIII are difficult to assess Image the stable patient Mandatory exploration unstable patient Exclude : Associated injuries on the – cervical spine, – airway, and – digestive tract
- 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. Neck exposure • • • • • • • Venous injuriesexploration 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.
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- 25. Chest • • • • • • • Aerodigestive tract. Air bubblesin the wound Respiratory distress Subcutaneous emphysema Hoarseness Hemoptysis Hematemesis
- 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. Aorta • Usually resultsfrom deceleration injury-fatal unless false aneurysm develops in mediastinum Back pain, hypotension; systolic murmur or signs of tamponade in some cases; characteristic
- 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
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- 31. Approach to Chest •Posterolateral thoracotomy • Median sternotomy • Anterolateral (4th)
- 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. Rates • Major abdominalvascular 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. Abdomen • Aorta andits branches, • IVC, portal and iliac veins – Indication for laparotomy – Damage control – Re-explore – Control bleeding – Avoid prosthesis
- 35. Abdomen • Contron – Supradiaphragmatic – Supr-celiac – Infra-renal – Ballon, occlusion • Exposure – From the left – From the right
- 36. Boundaries of theRetroperitoneal 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. 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. 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. 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)
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- 41. Therapeutic Implications of RetroperitonealZones • •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. Limbs • Vascular injuriesassociated 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. Prehospital • As manualcompression 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. Immediate measure • • • • • • Control bleeding Replacevolume lost Cover wound Reduce fracture Splint Re-evaluate
- 45. Post op • Postoperativemonitoring 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. Complication • Delayed diagnosisand 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. Lower limb • • • • • Doppler Doplex CT angio MRI(MRA) Angiography
- 48. In theatre • Alwaysestablish 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. Shunting • Intra-luminal shunttemporary save limb – Simple tume can be constructed – Transfer – Manipulation of bonw
- 50. Management • Conservative • Endovascular •Operative – Local • • • • • Suture Patch Primary anastomosis autogenous Prosthetic – Fasciotomy
- 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. Extremities • • • • • Ligation may beacceptable in rare circumstances If major Musculo-skeletal, neurological injury Popliteal have the highest rate Repair vein first Compaerment syndrome
- 53. Others • Catheter injury •Intra-arterial drug injuries • Cold Injury – Frost bite – Immersion (trench) foot – Frostnip