Vascular injuries

1. Principles for Evaluation and
Treatment of Patients with
Vascular Injury
DR.SANDEEP SARAF AGARWAL, MS
ASSISTANT PROFESSOR
ORTHOPAEDICS

2. Overview
• Epidemiology
• Types of Injury
• Evaluation
• Treatment

3. Mechanisms of Vascular Injury
in the Extremities
• Gunshot wound – 54%
• Stab wound – 15%
• Shotgun wound – 12%
• Blunt trauma – 15%
• Iatrogenic – 3%

4. Types of Injuries
Active Hemorrhage
• Laceration
• Partial
transection
• Complete
Transection

5. Types of Injury
Potentially non-occlusive
• Contusion with:
– Segmental Spasm
– Thrombosis
– True Aneurysm

6. Types of Injury
Potentially non-occlusive
• Pseudoaneurysm
• Arteriovenous Fistula
• Intimal Flap

7. Presentation of Vascular Injury
• First priority is
hemorrhage
control followed
by appropriate
diagnostic work-
up

8. Presentation of Vascular Injury
• Dislocations and
displaced or
angulated
fractures:
realigned
immediately if
vascularity is
compromised

9. Evaluation for Vascular Injury
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Physical Examination
Doppler Flowmeter
Duplex Ultrasonography
Arteriogram
Local wound exploration should
not be done in an uncontrolled
setting
Close coordination with a general
or vascular surgeon recommended
•

10. Physical Examination
Hard Signs
• Absent or diminished distal pulses
• Active hemorrhage
• Large, expanding or pulsatile hematoma
• Bruit or thrill
• Distal ischemia (pain, pallor, paralysis,
paresthesias, coolness)

11. Physical Examination
Soft Signs
• Small, stable hematoma
• Injury to anatomically related nerve
• Unexplained hypotension
• History of hemorrhage no longer present
• Proximity of injury to major vessel

12. Doppler Examination
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•
Non-invasive adjunct to physical examination
Small, hand-held (non-directional) Doppler flowmeter
provides for subjective interpretation of audible signal
Useful as modality for determining the Ankle-Brachial
Index (ABI)
•

13. Doppler
• Normal arterial signals are triphasic or
biphasic

14. Doppler
• Flow distal to a transection may be absent
or monophasic and low-pitched due to
collateral circulation

15. Determination of Ankle-Brachial
Index
• Appropriate sized blood pressure cuff is
placed above the ankle or wrist
• Doppler derived opening pressure of distal
artery
• Calculate by dividing ankle pressure by
brachial pressure
• Measure injured/ uninjured sides
• Normal ABI is 1.00 or greater

16. ABI Criteria
• ABI > 0.9
– Advantages
• Strong negative predictor for major vascular injury
• Objective noninvasive evidence of vascular
competence
– Disadvantages
• Does not exclude all injuries
• Not useful in presence of vascular disease

17. Duplex (B-mode) Ultrasonography
• Direction-sensing Duplex (B-mode)
ultrasound allows for visual waveform
analysis
• Highly operator dependent
• 96-98% accurate in experienced hands
• Generally not available during peak trauma
times

18. Arteriography
• Gold standard for evaluation of peripheral
vascular injuries
Formal arteriograms done in radiology may cause
critical delays in diagnosis or intervention
Single-shot arteriograms done in the emergency
room or operating room should be considered in
cases where arteriography is indicated.
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•

19. Indications for Arteriography
• Multiple potential sites of injury (shotgun
wounds)
Missile track parallels vessel over long distance
Blunt trauma with signs of vascular trauma
Chronic vascular disease
Extensive bone or soft tissue injury
Thoracic outlet wounds
Evaluation of equivocal results from non-invasive
tests
Proximity (gsw, knife wound) (controversial)
ABI < .9
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20. Single-shot Arteriogram
• 21 or 20 gauge angiocatheter ( at least 2”
long) or single lumen central line or a-
line kit
3 way stop-cock
30 cc syringes (x2)
Iodinated contrast (full strength)
Heparinized saline (1,000 IU/liter)
IV extension tubing
Consider inflow and/or outflow occlusion
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21. Single-shot Arteriogram in the
Emergency or Operating Room

22. Summary of Evaluation
• Initial priority is to control hemorrhage
– Direct Pressure
– Pressure Points
– Tourniquet
If penetrating injury with one or more hard signs
of vascular injury then immediate surgical
exploration is usually warranted
If hard signs present with blunt mechanism or
multi-site penetrating mechanism then an
arteriogram may be warranted
If soft signs present, consider further diagnostic
modalities (usually initially non-invasive)
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23. Treatment
Operative Repair
Indications:
• injuries with hard signs of vascular injury
OR
• arteriogram showing occlusion or extravasation

24. Treatment
Non-operative Observation
• Certain non-occlusive injuries without hard signs
(often occult injuries) can be managed
conservatively
Criteria:
– Low-velocity injury
– Minimal arterial wall disruption
– Intact distal circulation
– No active hemorrhage
Serial arteriography or duplex scanning
recommended
Close coordination with a vascular or general
surgeon is recommended
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25. Non-operative Management
• Intimal injuries and segmental narrowing are most
amenable to conservative care and may resolve
over time
Small pseudoaneurysms sometimes enlarge,
become symptomatic and require operative repair
Asymptomatic acute AV fistulas may be less
certain to resolve and should be followed closely
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26. Sequelae of Missed Arterial
Injuries
• Deterioration of arterial injury can lead to:
– Intimal dissection with resulting occlusion
– Arteriovenous fistula
– Thromboemboli
– Stenosis
• These can cause distal ischemia with
significant morbidity:
– Pain
– Gangrene
– Amputation

27. Penetrating Arterial Injury
Limb Salvage Rates
• World War II (Debakey and Simeone, 1946)
– 2,471 cases
– 51% salvage for ligation
– 64.2% salvage for repair
Viet Nam War (Rich et al, 1970)
– 1000 cases
– 28.5% with concomitant fractures
– 87% overall salvage
Recent civilian (Trooskin et al, 1993)
– 50 arterial and 17 venous injuries in 51 patients
– 22% with concomitant fractures
– 100% salvage
– Other recent civilian studies approach a 100% salvage rate as
well
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28. Blunt Arterial Injury Salvage
Rates
• Have a high amputation rate due
to associated soft-tissue and
nerve injuries (the mangled
extremity)
These injuries may result in a
non-functional limb in spite of a
successful revascularization
•

29. Mangled Extremity
• Indications for Primary Amputation
– Anatomically complete disruption of sciatic or
posterior tibial nerves in adult even if vascular
injury is repairable
– Prolonged warm ischemia time
– Life threatening sequelae
• rhabdomyolysis

30. Mangled Extremity
• Relative Indications for Primary
Amputation
– Serious associated polytrauma
– Severe ipsilateral foot trauma
• loss of plantar skin/weight bearing surface
– Anticipated protracted course to obtain soft-
tissue coverage and skeletal reconstruction

31. Variables in Consideration of
Limb Viability
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Skin/Muscle Injury
Bone Injury
Ischemia (time, degree)
Type of Vascular Injury
Shock
Age
Infection
Associated injuries (pulmonary, abdominal, head, etc.)
Comorbid Disease (peripheral vascular disease, diabetes
mellitus, etc.)

32. Classification Systems
• Mangled Extremity Syndrome Index (MESI)
– 10 variables
Predictive Salvage Index (PSI)
– 4 variables
Mangled Extremity Severity Score (MESS)
– 4 variables
Limb Salvage Index (LSI)
– 7 variables
NISSSA scoring system
– 5 variables
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33. Mangled Extremity Scoring System
Factor
Skeletal/soft-tissue injury
Low energy (stab, fracture, civilian gunshot wound)
Medium energy (open or multiple fracture)
High energy (shotgun or military gunshot wound, crush)
Very high energy (above plus gross contamination)
Limb Ischemia (double score for ischemia > 6 hours)
Pulse reduced or absent but perfusion normal
Pulseless, diminished capillary refill
Patient is cool, paralyzed, insensate, numb
Shock
Score
1
2
3
4
1
2
3
Systolic blood pressure always >90 mm Hg 0
Systolic blood pressure transiently <90 mm Hg 1
Systolic blood pressure persistently <90 mm Hg 2
Age, yr
<30 0
30-50 1
>50 2

34. Mangled Extremity Severity
Score
• All information for classification available
at time of ER presentation
• Simplest to apply of all scoring systems
• Most thoroughly studied
• A score of less than 7 is supposed to predict
limb salvageability

35. LEAP Data
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556 lower extremity injuries
prospectively scored—MESS, PSI, LSI, NISSSA,
HFS-97
High specificity (84-98%)
LOW SENSITIVITY (33-51%)
Not a substitute for clinical judgment and
experience for salvage vs amputation decision
making
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Bosse et al, JBJS, 83-A, 2001

36. Mangled Extremity Management
• Involves a determination of both the
feasibility (restoring viability) and
advisability (restoring function) of
salvaging the limb
• Should be a coordinated effort of the
orthopaedic, vascular and plastic surgeons
starting at the initial evaluation of the
patient

37. Fasciotomies
• Prophylactic fasciotomies after vascular repair
have been credited as being a major reason for
increased limb salvage rates in recent years
Fasciotomies after prolonged ischemia prevent
compartment syndrome that may result from
reperfusion injury
– The reperfusion injury is delayed and may manifest
after the patient leaves the operating room
•

38. Indications for Fasciotomies
• No absolute clinical indications for fasciotomy
exist
Subjective criteria
– Extensive soft-tissue or bony injury
– Progression of swelling
– Compartment tightness
Objective criteria
– Ischemia time greater than 6 hours
– Compartment pressure within 20 mm Hg of diastolic blood
pressure
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39. Morbidity of Fasciotomies
• Increased risk of infection
– Exposure of injured or ischemic muscle
• Decreased fracture healing
– Potentially converting a closed to an open fracture
• Iatrogenic injury
– Neuroma
– Chronic venous insufficiency

40. Pharmacologic Treatment of
Reperfusion Injury
• Following reperfusion, byproducts of anaerobic
metabolism may be released causing local and
systemic effects
Administration before reperfusion
– Mannitol
• Free radical scavenging
– Heparin
• Anti-coagulant
• Anti-inflammatory
May be contraindicated in acute trauma
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41. Issues Concerning Surgical Order
• The order of surgical repair in penetrating
injuries requiring both vascular repair and
orthopaedic fixation is controversial:
– Delayed revascularization until after
orthopaedic stabilization may adversely effect
limb salvage
– Fractures instability or subsequent orthopaedic
stabilization may disrupt a vascular repair

42. Surgical Order
• In general, revascularization takes precedence
over definitive orthopaedic fixation
• In cases with gross fracture instability
• a temporary vascular shunt can be placed and vascular
repair deferred until after orthopaedic fixation
• If the ischemia time is short, consideration can be given to
application of a provisional unilateral external fixator prior
to revascularization

43. Temporary Vascular Shunt

44. Definitive Vascular Repair

45. Definitive Fixation
• Definitive orthopaedic fixation should be
internal in most cases
• Consider external fixation for:
– Pediatric fractures
– Extensive soft-tissue injuries
– Contaminated wounds
– Hemodynamically unstable patients

46. Penetrating Superficial Femoral
Artery Injury with Femur Fracture

47. Summary
• The treatment of fractures or dislocations
with vascular injury requires close
coordination between the orthopaedic
surgeon and the vascular or general surgeon
to facilitate optimal limb outcome.
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