Professor Abdulsalam Y Taha presents several cases of extremity vascular injuries managed at his medical unit to emphasize principles for proper care of such patients. Limb salvage rates of 70-95% are reported in major centers for patients with limb arterial trauma when prompt diagnosis, resuscitation, hemorrhage control, and revascularization are achieved. However, primary amputation may be necessary for limbs that are too severely damaged or when prolonged ischemia time makes salvage unlikely to succeed. The goal of vascular trauma management is to save both the patient's life and limb through early recognition, exploration, and appropriate repair or reconstruction of injured blood vessels.

1. Professor
Abdulsalam Y Taha
School of Medicine
Faculty of Medical Sciences
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. INTRODUCTION
 Extremity vascular injuries are fairly common in both
war and civilian times.
 The aim of a vascular surgeon managing vascular
trauma in an extremity is to save the limb and the life
of the patient.
 The current strategies employed in the management of
the patient with vascular trauma have been developed
over the past century from both civilian and military
experience.

3. INTRODUCTION
 DeBakey reported an amputation rate of 72.5%
in a review of popliteal artery injuries in the era
of World War 1. Following the introduction of
vascular reconstruction techniques amputation
rates for similar injuries fell to 32% in the Korean
War. By the end of the Vietnam conflict the
amputation rate had fallen again.
 Today, most major centres report limb salvage
rates of 70-95% in patients with limb arterial
trauma .

4. INTRODUCTION
 Herein, we present selected cases of extremity vascular
injuries managed in our unit.
 The aim is to emphasize the principles of proper care
of such patients to ensure constant good results in
terms of limb and life salvage.

5. Case 1
BRACHIAL ART INJURY

6. BRACHIAL ART REPAIR

7. Case 2
Antecubital Fossa Wound

8. Brachial Art Injury and Repair

9. End to End Repair
A deep wound in ante-
cubital fossa caused by
A machine.
Transaction of brachial
artery.
Division of flexor muscles.
Division of Median nerve.
Primary repair of both
artery and nerve.
Good outcome.
Signs of median nerve
injury; on physiotherapy.

10. Case 3
Multiple Pellet Injuries Axillary Art
Repair by RGSV Graft

11. Case 4
EXTENSIVELY DEEP WOUND

12. TERROUBLE INJURY INDEED!

13. Still salvageable
limb!
Exploration of
wound.
Repair of major
laceration of
brachial artery.
Repair of divided
muscles.
Fasciotomy.

14. Case 5: Brachial Art
Major Laceration
An 18 yr old girl referred
from Kirkuk with shock
due to profuse bleeding
from R upper arm bullet
wounds (inlet and
outlet).
R chest tube for
hemothorax and acute
abdomen.
Resuscitation followed
by urgent exploration.
Brachial art major
laceration, vein injuries
and median nerve
neurotemesis.

15. UNJUSTIFIED
AND RISKY
REFERRAL!

16. MANAGEMENT
Debridement of
entrance and exit
wounds.
Repair of art by RGSV
graft.
Ligation of veins.
Median n repair.
Partial closure of
wounds.
Forearm fasciotomy.
Laparotomy: suturing of
liver and diaphragm
injuries.
Secondary closure of
fasciotomy wound after
2 weeks.

17. Case 6
CRUSHED UPPER LIMB

18. CRUSHED UPPER LIMB
 A 40 yrs old man sustained a crush injury to his left
upper limb due to road traffic accident. He had
presented with a big contaminated wound of the volar
aspect of the upper arm and forearm. There was a
deformity of the elbow region. X-ray revealed a severe
comminuted fracture of humerus. There was suspicion
of vascular injury due to extensive soft tissue injury
and absent distal pulses as well as impaired movement
and sensation.

19. Multi-
disciplinary
management
Approach.

20. CRUSHED UPPER LIMB
 The patient had an exploration of the wound under GA. The
wound was copiously irrigated by normal saline. Most of the dirt
and metallic fragments were removed. Then a thorough wound
debridement was done. The brachial artery was explored. Three
areas of contusion were found. The diseased segment was
excised leaving a gap of about 10 cm. The injured venae
comitantes were ligated. A Fogarty catheter size 4 F passed
proximally and distally. Good back bleeding was obtained.
Irrigation of the distal arterial bed by heparinized saline was
done. A segment of GSV was harvested from thigh and used as
reversed interposition graft for the brachial artery. Good
pulsation was obtained distal to the anastomosis. The graft was
covered by a viable muscle tissue. The fracture was stabilized by
external fixation.

21. Case 7: Primary Amputation
Extensive soft
tissue
damage due
to crushing
injury.
Impossible to
save such
limb!

22. Case 8
SUBCLAVIAN AVF
A 52 yr old man sustained a bullet
injury to R infraclavicular fossa
( inlet and outlet).
Presentation 1 week after injury.
An audible bruit + moderate swelling
of R upper limb.
Doppler ultrasound and angiography
confirmed the diagnosis of
SUBCLAVIAN AVF.

23. Surgical Management
 The approach was via median sternotomy with right
supraclavicular extension, resection of medial third of
the clavicle and extension of the wound along the
deltopectoral groove. After tedious dissection, due to
the presence of adhesions and venous engorgement,
proximal control of right subclavian artery was
achieved. Distal control of proximal axillary artery and
vein was also achieved following division of overlying
pectoral muscles and fascia. The fistula was ultimately
found between a branch of subclavian artery and vein.
It was controlled by oo silk ligature.

24. REPAIR VIA MEDIAN
STERNOTOMY
EXTENDED INTO
SUPRACLAVICULAR
AREA

25. Uneventful
Recovery.

26. Case 9
RIGHT GROIN
BULLET INJURY
This old man
sustained bullet
injury to his right
groin presented
with acute
abdomen as well
as profuse
bleeding from
the groin wound.

27. Exploratory
Laparotomy
with Extension
into Vertical
Groin Incision.
External Iliac
Artery Injury
fixed by End
to End
Repair.

28. Case 10
SFA INJURY STAB WOUND

29. Case 10
SFA AND VEIN MAJOR LACERATION

30. End to End Repair of Art and Vein
Ligation

31. Case 12
SFA AND VEIN MAJOR LACERATION

32. Multiple Bullet
Injuries
Right scapular
fracture.
Left SFA and Vein
Major laceration.

33. Repair of SFA by
End to End
Anastomosis.
Ligation of Vein.
Excellent
outcome.

34. Case 13: Left Thigh Hematoma
 A male teenager referred to our hospital casualty about 8 hours
following a terrorist explosion in Taza, a small city near Kirkuk. He
had sustained a wound at lateral aspect of his left thigh possibly
caused by a penetrating piece of glass. On arrival, he had a huge
swelling of mid lateral thigh with no active bleeding. The lower
limb was viable with intact sensation, movement and pedal pulses.
There was no palpable thrill or audible bruit.
 The X-ray of the thigh showed a soft tissue swelling but no fracture
or retained foreign body. A vascular injury was suspected like a
lateral tear of femoral artery, venous injury or an injury to a
muscular arterial branch.
 Standard exploration of CFA, SFA and PFA was done. All were
intact. The hematoma was then entered and evacuated completely.
No significant bleeder was identified. The source could be a
muscular branch.

35. LEFT THIGH HEMATOMA

36. Standard exploration of CFA, SFA and PFA was done.
All were intact. The hematoma was then entered and
evacuated completely.

37. Case 14: SFA FALSE ANEURYSM

38. Iatrogenic SFA
Aneurysm
A 58 yr old
man
underwent R
trans-femoral
Angiography
17 days before
presentation.
IATROGENIC SFA FALSE ANEURYSM

39. Elective Exploration and Lateral
Repair

40. Huge Hematoma Evacuated

41. Case 15: Traumatic
CFA False Aneurysm
An 8*3 cm
aneurysm of R CFA
with extensive
echymosis few days
following trans-
femoral angiography
in 40 yrs old man.
Audible bruit.
Admitted for
surgery but
disappeared!

42. IATROGENIC CFA FALSE ANEURYSM

43. Case 16
POPLITEAL ART
INJURY
A 26 yr. old man sustained a crush
injury to his right knee,
presented with a wound in
popliteal fossa + signs& symptoms
of leg ischaemia. He had been
explored 7 hours after the
accident because
of his family initial refusal to have
surgery. Contusion of art. And
crushed muscles were found.
Fasciotomy, thorough wound
debridement
and repair of art. by resection of
damaged segment and end to end
anastomosis were done.

44. POPLITEAL ART INJURY

45. Case 17
POPLITEAL ARTERY CONTUSION

46. Popliteal Art Contusion; History
 A young chap referred from Kalar after sustaining a
crush injury to the popliteal fossa. The limb was
crushed between the chair and the dashboard. He has
presented with severe pain, tense swelling of leg and
knee region associated with extensive echymosis of
lower thigh and popliteal region. The time interval
between injury and intervention was about 9 hours.
 At time of examination, he was in great pain. The
distal pulses were absent but sensation and movement
were still preserved.

47. Popliteal Art Contusion
 Urgent exploration was done. GSV was harvested
from right thigh in supine position. Then he was
turned into prone position. An S-shaped incision
was made over popliteal fossa extended over the
calf for fasciotomy of posterior compartment. The
gastronomies muscle was completely dead.
Muscles were transected at the level of knee
region. The veins were transected.

48. Popliteal Art Contusion
The popliteal artery was contused for a
distance of 5 cms. The dead muscle was
excised completely. The veins were
ligated. The artery was repaired by
resection of the contused segment and
an interposition of reversed GSV graft.
The wound was partially closed. The
outcome of the limb was excellent.

49. Postoperative
Doppler Study of
Grafted Popliteal
Artery.

51. Etiology
 Gunshot wounds, cause 70-80% of all vascular
injuries requiring intervention.
 Stab wounds (5-15% of cases)
 Blunt trauma (5-10% of cases): Presence of fracture
increases risk.
 Iatrogenic injury (5% of cases): Cardiac
catheterization and line placement

52. DIAGNOSIS
 Physical exam
 Doppler pressure (Ankle/brachial systolic pressure
index)
 Duplex scanning
 Arteriogram
 Exploration

53. Physical Examination
 Clinical assessment by an experienced clinician with a
high index of suspicion will identify the majority of
clinically significant vascular injuries.
 Initial physical examination is normal in 15% of cases
of vascular injury so frequently repeated physical
assessment is essential if the injury is not to be missed

54.  The single most important factor
determining the fate of the limb with
vascular compromise is the duration of
limb ischaemia. A warm limb ischaemic
time of less than 6 hours was associated
with an amputation rate of 6.7 %
compared to 33% in limbs with warm
ischaemic time of more than 6 hours in
one recent series

56. The ABI is
obtained by using a blood
pressure cuff to measure the
systolic pressure at the largest
point of the ankle and
dividing it by the systolic
pressure of either arm. If the
ABI
is more than 0.9, observation
is recommended; if less than
0.9, further
evaluation is warranted with
contrast arteriography in a
stable patient and operative
exploration in a
hemodynamically
unstable or hemorrhaging
patient
DOPPLER ULTRASOUND

57. Duplex Ultrasonography
 Is a promising noninvasive technique
 Sensitivity of ultrasound can be up to 95-100% for
diagnosing vascular injuries.
 Extremely operator dependent.
 In extremity trauma a positive duplex ultrasound
scan or a reduced Doppler ABI to less than 0.9 is
an absolute indication for an angiogram and
possible intervention.

58. Angiography
Locates site of injury
Characterizes injury
Defines status of vessels
proximal and distal
May afford therapeutic
intervention

59. Angiography
 Gold Standard for evaluation of vascular injuries in
trauma.
 Disadvantages include cost, time delay, and a 0.6%
major complication rate.
 Only 1 to1.5% of angiograms in patients lacking hard
signs will reveal injuries requiring intervention.

60. Surgical Exploration
Immediate exploration is indicated for:
 Obvious arterial injury on exam
 No Doppler signal
 Site of injury is apparent
 Prolonged warm ischemia time

61. TYPES OF REPAIR

62. FASCIOTOMY
 Fasciotomy is an important adjuvant operation in
managing the patient with extremity vascular trauma
to prevent compartment syndrome .
The indications are:
 Crush injuries.
 Major associated injuries( bone, soft tissue).
 Concurrent arterial and venous injury.
 Delayed presentation ( greater than 6 hrs).

63. The Two Incisions Four
Compartments Fasciotomies

64. Vascular and Bone Injury
 The management of patients with vessel and bone
injury requires a team of a vascular and orthopaedic
surgeon operating on the patient in one session. The
sequence of repair (vessel or bone first ) depends on
the individual case .

65.  Severely injured limbs for which attempted salvage
would be futile can be identified using the Mangled
Extremity Severity Score (MESS), and require primary
amputation.
 A truly mangled extremity is one in which amputation
is a potential outcome.

66. Components of Score Points
Skeletal/Soft tissue injury
Low energy ( stab, simple #,civilian
GSW
Medium Energy ( open or multiple #s,
dislocation)
High energy ( close-range shotgun,
millitary GSW, crush injury)
Very high energy ( Above+ gross
contamination, soft tissue avulsion)
1
2
3
4
Limb Ischaemia
Pulse reduced or absent but normal
perfusion
Pulseless, paraesthesias, reduced
capillary refill
Cool, paralyzed, insensate limb
1+
2+
3+
Shock
Systolic BP always more than 90 mmHg
Hypotensive transiently
Persistent hypotension
0
1
2
Age
Less 30 than yrs
30-50
More than 50
+ score is doubled for ischaemia more
than 6 hrs.
0
1
2
MESS: MANGLED EXTREMITY SEVERITY SCORE

67. CONCLUSIONS
 To achieve a good limb salvage rate ,there is a need to
emphasize the importance of clinical awareness among
doctors to early diagnose and promptly refer the suspected
cases .
 Control of hemorrhage takes priority over limb perfusion.
 Needless to say ,meticulous technique is essential to
achieve constantly good result
 Orthopaedic as well as general surgeons should have
adequate training in vascular surgery so that they can
manage patients with vascular trauma in areas and
situations where no vascular surgeon is present .

68. CONCLUSIONS
 Whenever possible ,venous injuries should be repaired
as proximal vein ligation is often followed by
significant morbidity. However; in the extremity, vein
ligation does not increase amputation rates.
 The golden principle of repairing limb arterial injuries
or not is the limb viability; viable limb deserves
revascularization regardless the time while a dead limb
should not be revascularized .

69. CONCLUSIONS
 The choice between primary and secondary
amputation in extremity vascular trauma may be
difficult. Heroic attempts to save the limb which is
badly injured may not succeed, on the contrary, it may
terminate in secondary amputation and/ or death of
the patient. If one decides on limb salvage, he should
expect prolonged hospitalization, increased number of
operations, increased rate of sepsis, psychological
attachment to the limb, poor functional outcome and
even death sometimes (primary amputation can be life
saving).

70. THANK YOU