vascular trauma, mannar medical association, causes,Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016, pathology, signs and symptoms, hard and soft signs, investigations, management

1. Vascular Trauma
Joel Arudchelvam
Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura
Sri Lanka.
Mannar Medical Association
Monthly Clinical Meeting

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. Extremity Vascular Injuries
• Unexpected
• Young and fit
• Results in limb loss at times loss of life
• Loss of earning capacity
• Economic burden

5. Causes
• Road Traffic Accidents – 38.5%
• Trap Gun – 7.5%
• Home Accidents - 7.5%
• Cuts and Stabs
• Iatrogenic - 46.1%
Mechanism of injury
• Sharp / penetrating
• Blunt
Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016

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

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

8. Signs of a vessel injury
• Soft signs
– Hematoma
– Injury close to a known neurovascular bundle
– Reduced pulse
• Paresis / paralysis and paresthesia / anaesthesia - late
signs
• Paresis and paresthesia
– viability of the limb is in immediate threat
• Anaethesia and paralysis
– not viable.

9. Problems with diagnosing ischaemia after
trauma
• Pain
– Due to injury itself
• Pallor
– Pallor due to blood loss
• Absent pulse
– Absent due to low blood pressure. Compare with othe
limb
• Paresthesia , paresis
– Due to associated nerve, muscle injury or unresponsive
patient

10. Investigations
Investigations
•Hard signs
• Urgent intervention
•Soft signs
• Observe
• Investigate

11. 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

12. Investigations
• Angiography
– CT angiography
– Catheter angiography

13. CT ANGIOGRAPHY

14. 3D Reconstruction

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

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

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

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

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

20. How soon we should we repair
• At Teaching Hospital Anuradhapura 2015-
2016;
• – 1 year
– 13 cases
– Commonest artery popliteal 53.8 %
– Mean ischaemic time – 12.67 hrs
– 4 clinically dead limb (mean time 15.75 hrs)
Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016

21. 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

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

23. Surgical repair (cont..)

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

25. 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

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

27. Shunting

28. Compartment syndrome
Recognize
Remove the cause
Surgery – fasciotomy

29. Compartment Syndrome
Treatment – Fasciotomy

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

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

32. Thank You