This document discusses a case of vascular trauma to the knee from a gun injury. It describes the signs and symptoms observed in the patient including absent distal pulses, numbness, and reduced movement. The key investigations discussed are Doppler, angiography, and X-rays. Principles of vascular repair are described, including preparation, heparinization, and grafting or direct repair. Risks of reperfusion like hypotension and compartment syndrome are also covered. The management outlined is resuscitation, exploration, potential fasciotomy, and repair or discussion of transfer if not possible locally.

1. Vascular Trauma
Joel Arudchelvam
Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura.

2. Vascular trauma /injury
• Injury to
– Arteries
– Veins
• Anatomical regions
– Extremity – limbs
– Abdomen and pelvis
– Thorax
– Head and neck

3. Vascular trauma /injury
• Injury to
– Arteries
– Veins
• Anatomical regions
– Extremity – limbs
– Abdomen and pelvis
– Thorax
– Head and neck

4. CASE
• 23 Year old male
• Trap gun injury around knee joint
• Heavy bleeding at the time of injury
• Admitted to Teaching Hospital Anuradhapura
after 8 hours
• No Distal Pulses
• Pulse rate – 100 / min

5. CASE
• Reduced movements
• Numbness
• BP – 80 / 50 mm / Hg
• Clinical evidence of fracture around knee joint

6. CASE

7. Case
• Is there an arterial injury ?
• Why ?
• What are the signs and symptoms?

8. Mechanism of disruption of flow at arterial level
• Transection
• Laceration
• Contusion
• Kink
• Intimal flap

9. Vascular trauma
Signs of a vessel injury
• Hard signs
• Soft sign
Hard signs
– Active bleeding
– Signs of distal ischaemia
• Absent pulse
• Pain
• Pale
• Perishing Cold
• Paresthesia / anaesthesia
• Paresis / Paralysis
– Expanding hematoma
– Thrill, Bruits

10. Signs of a vessel injury
• Soft signs
– Hematoma
– Injury close to a known neurovascular bundle
– Reduced pulse

11. Case
• Is this late?
• Will you Repair?

12. Late Signs of a vessel injury
• Paresis / paralysis and paresthesia / anaesthesia
- late signs
• Paresis and paresthesia
• viability of the limb is in immediate threat
• Anaethesia and paralysis
• not viable.

13. Case
• What are the alternative explanations for the
above signs and symptoms

14. Problems with diagnosing ischaemia after
trauma
• Pain
– due to injury itself, may not have pain due to associated
nerve injury
• Pallor
– may be pale due to blood loss
• Absent pulse
– absent due to low blood pressure. Compare with othe
limb
• Paresthesia , paresis
– occur due to associated nerve, muscle injury or
unresponsive confused patient

15. CASE
• What do you do ?

16. CASE
• What do you do ?
– Resuscitate

17. CASE
• What do you do ?
– Resuscitate
– Explore immediately

18. CASE
• What do you do ?
– Resuscitate
– Explore immediately
– ? fasciotomy

19. CASE
• What do you do ?
– Resuscitate
– Explore immediately
– ? fasciotomy
– Investigate

20. CASE
• Two units of blood transfused
• BP – 110 / 70
• No distal pulse
• Now what
• Any investigations ?

21. X Ray

22. Investigation
• Hard signs
– Resuscitate and explore
• Soft sign
– Can investigate
• What other investigations are available?

23. Investigations
Investigations
•Hard signs
• urgent intervention
•Soft signs
• Observe
• Investigate

24. Investigations
• Hand held DOPPLER
• Absent doppler flow
• Quality of signal
• ABPI
• Presence of doppler flow does not exclude
vascular injury
• Duplex scan (USS + DOPPLER)
• Difficult to image in trauma
• Due to
• Pain, Non cooperative patient,
Dressings
• Patent distal vessels does not exclude a proximal
injury

25. Investigations
• Angiography
– CT angiography
– Catheter angiography

26. CT ANGIOGRAPHY

27. 3D Reconstruction

28. Conventional angiography / DSA
• Contrast directly into artery
• Traumatic
• DSA – Digital subtraction angiography
– done though a software after obtaining initial
images

29. Conventional angiography / DSA
• Contrast directly into artery
• Traumatic
• DSA – Digital subtraction angiography
– done though a software after obtaining initial
images

30. Investigations
• Arteriography
– On table / DSA –
for multi level injury

31. Investigations
• Patient presenting with
– Soft signs
– Delayed presentation
– Avf
– False aneurysm
– Pre-op angiography

32. Case
• In this patient – What investigations you
would request

33. X Ray

34. How soon we should we repair
– As soon as possible
– Effects of ischaemia

35. How soon we should we repair
• At ANP – 1 year
– 13 cases
– Commonest artery popliteal 53.8 %
– Mean ischaemic time – 12.67 hrs
– 4 clinically dead limb (mean time 15.75 hrs)

36. Case
• Will he need fasciotomy ?

37. WHAT ARE THE LEG COMPARTMENTS

38. LEG COMPARTMENTS

39. FASCIOTOMY

40. FASCIOTOMY

41. FASCIOTOMY

42. FASCIOTOMY

43. Fasciotomy
• 3 compartments dead
• Distal pulse absent
• Will you repair the artery ?

44. Surgical Repair
• Exploration done
• Contused artery
• What re the principles of repair

45. Surgical Repair
• Prompt transport to operating room
• General anesthesia
• Clean the entire limb
• Thigh prepared – for venous harvest
• Control of proximal and distal ends and trimming

46. Surgical repair (cont..)
• Balloon thrombectomy
• Systemic and distal heparinisation
• Interposition graft / Direct
approximation
– Unit experience – 88.2% RSVG
• Prosthesis
– lower patency
– infection

47. Surgical repair (cont..)

48. Principles of arterial repair
• Cut / laceration _ suture transversely
• Heparin – depends on clinical situation

49. Reperfused ..
• Tachycardia
• Transient lowering of blood pressure
• Recovered with fluid resuscitation
• Mannitol given
• At ICU alkaline diuresis

50. POST PERFUSION EFFECTS
• REPERFUSION INJURY
• REPERFUSION SYNDROME

51. • Local – reperfusion injury
– Paradoxycal death of already dying muscles after
reperfusion
• Systemic- Reperfusion syndrome
– Hypotension
– ARDS
– Lactic acidosis
– Hyperkalemia
– Renal failure
Reperfusion effects

52. • Fasciotomy
• Hydrate the patient
• Mannitol
• O2
• Inotropes
• Ligation of vessel if not responding to above
mesures
• Bicarbonate diuresis
Reperfusion syndrome- Management

53. • If urine out-put is adequate
– 5% Dextrose 800 ml + 8.4% NaHCO3 100 ml +20%
Manitol 100 ml
– 100 cc/hr for 12 hours
• If UOP is inadequate
– N/2 saline 500ml + 8.4% NaHCO3 35 ml
– Over 6 hours
– Do SE
Bi-carbonate diuresis/ forced alkaline
diuresis

54. What else can we do
• Compartment excision ?
• Ligation
• Amputation

55. Fracture
• What about bone

56. Combined Vascular and Skeletal
Trauma
– Revascularization / skeletal fixation (external
Fixator – EF)
• Bone fixation first if limb is not threatened – apply
EF antero laterally
• Revascularisation first if limb is threatened

57. Case
• Do you repair all injuries

58. Primary Amputation
• Extensive crush injuries and soft
tissue damage – “mangled limb”
• No need to transfer – discuss / photo

59. Case
• What will you do if threre are no facilities to
repair

60. In hospitals where facilities for
repair is not available
• ABCD
• Fasciotomy
• Discuss
• Transfer
• Do not apply tight dressings
• ? shunt

61. Summary
• Vascular injury;
– Resuscitate
– Assess viability and extent of injury
– Assess need for fasciotomy
– Early intervention and post intervention monitoring
– Rehabilitation

62. Thank You