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Vascular emergencies tcd sjh 2017

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Vascular surgery, emergencies

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Vascular emergencies tcd sjh 2017

  1. 1. www.perfuse.net www.amnch.ie Vascular Emergencies Vascular Surgery UnitVascular Surgery Unit AMNCHAMNCH
  2. 2. www.perfuse.net www.amnch.ie Vascular emergencies (surgical) • Abdominal aortic aneurysm • Ischaemia – Acute occlusion • Thrombosis • Embolism – Arterial trauma
  3. 3. www.perfuse.net www.amnch.ie Presentation • Abdominal pain • Back pain • Collapse • Hypotension • High index of suspicion
  4. 4. www.perfuse.net www.amnch.ie Presentation • Abdominal pain • Back pain Differential diagnosis •Renal colic •Diverticulitis •Appendicitis
  5. 5. www.perfuse.net www.amnch.ie Imaging
  6. 6. www.perfuse.net www.amnch.ie Imaging After Consultation with Vascular Surgery •Stable patient •Uncertainty •EVAR
  7. 7. www.perfuse.net www.amnch.ie Where to… Theatre Radiology Morgue
  8. 8. www.perfuse.net www.amnch.ie • Immediate transfer to theatreImmediate transfer to theatre • Paint and drape before intubationPaint and drape before intubation • Central access if feasibleCentral access if feasible • Early clamp saves livesEarly clamp saves lives
  9. 9. www.perfuse.net www.amnch.ie Open surgery
  10. 10. www.perfuse.net www.amnch.ie Aortic Aneurysm repair • DuBost – first homograft repair 1951 • Modern graft materials 1953 Postoperative • 5 year survival = 63-84% ∀ ≈ disease matched control
  11. 11. www.perfuse.net www.amnch.ie Mortality • N=222 • Age 74 years (range 57–96 years) • Female = 43 • No surgery = 39 • Surgery = 183 – In-hospital mortality = 48.0% • 14.9% intra-operatively (14.9%), • 8.3% died within 24 h • Total mortality 55%
  12. 12. www.perfuse.net www.amnch.ie New technology Parodi et al Ann Vasc 1991
  13. 13. www.perfuse.net www.amnch.ie Anaesthesia & position • Epidural/spinal • Occasionally GA • Possible under LA ∀ ± Central access • Arterial line • OSI (radiolucent) table
  14. 14. www.perfuse.net www.amnch.ie Position • Arms tucked in by sides • Contrast pressure injector (angio) • C Arm • 2 tables – open/endo
  15. 15. www.perfuse.net www.amnch.ie Set up & equipment 1 2 Scrub/N 1 C-arm Monitors Injector Scrub/N 2
  16. 16. www.perfuse.net www.amnch.ie Draping & incision
  17. 17. www.perfuse.net www.amnch.ie Exposure
  18. 18. www.perfuse.net www.amnch.ie Tri Fab design
  19. 19. www.perfuse.net www.amnch.ie Animation - 1
  20. 20. www.perfuse.net www.amnch.ie Closure • Arteriotomy closure • 6/0 prolene
  21. 21. www.perfuse.net www.amnch.ie Open vs EVAR
  22. 22. www.perfuse.net www.amnch.ie History Welch Halsted Osler Kelly
  23. 23. www.perfuse.net www.amnch.ie The Problem
  24. 24. www.perfuse.net www.amnch.ie The Problem • 1992-2005 • 35 patients • Mean age 26 (3-80) • RTA 43% • Associated # in 47% • Brachial artery 36% • Low mortality (n=1, IVC)
  25. 25. www.perfuse.net www.amnch.ie Mechanism • Blunt – Orthopaedic # – Dislocation (knee) – Isolated • Penetrating – High velocity – Low velocity • Iatrogenic http://www.facs.org/trauma/publications/peripheralvasctrauma.pdf
  26. 26. www.perfuse.net www.amnch.ie Initial assessment • Airway • Breathing/ventilation • Circulation • Disability • Exposure
  27. 27. www.perfuse.net www.amnch.ie Immediate treatment • Control bleeding • Replace volume loss • Cover wounds • Reduce fractures/dislocations • Splint • Re-evaluate Credit: http://www.ota.org/
  28. 28. www.perfuse.net www.amnch.ie Signs of arterial injury hard signs • External (arterial bleeding) • Rapidly expanding haematoma • Palpable thrill/audible bruit • Obvious ischaemia – 5 P’s Credit: http://www.ota.org/
  29. 29. www.perfuse.net www.amnch.ie Index of suspicion soft signs • History of arterial bleeding • Proximity of #/wound to artery • Diminished pulse (BP) • Small non-pulsatile haematoma • Neurologic deficit
  30. 30. www.perfuse.net www.amnch.ie TimeTime Pathophysiology Ischaemia Rapid resuscitation Urgent exploration Ischaemia revascularisation Tissue necrosis Reperfusion injury Compartment syn ? fasciotomy
  31. 31. www.perfuse.net www.amnch.ie Operative management • Angiography – In theatre – Diagnostic – Therapeutic • Covered stent • Embolisation • Open exploration – Repair – Bypass
  32. 32. www.perfuse.net www.amnch.ie Operative strategy - 1 • Position – Access – Angio • Maintain compression • Exposure & Control – Separate (anatomical) incision – Distal • Damage limitation – intraoperative shunt
  33. 33. www.perfuse.net www.amnch.ie Endovascular treatment Katsanos K et al Emerg Radiol. 2009 Case series only; no convincing data
  34. 34. www.perfuse.net www.amnch.ie Procedure • Thrombectomise • Heparinise – Multisystem trauma – Coagulopathy • Repair deficit • Lateral suture • Resection and end-end • Interposition – autologous vein – Synthetic • Ligation • Lateral suture • Resection and end-end • Interposition – autologous vein – Synthetic • Ligation
  35. 35. www.perfuse.net www.amnch.ie Compartment syndrome Pearse et al. BMJ 2002 2002
  36. 36. www.perfuse.net www.amnch.ie Penetrating neck trauma • Don’t explore in ED • Assess other injuries • Early transfer to theatre – multidisciplinary – ?CT • Systematic approach
  37. 37. www.perfuse.net www.amnch.ie Carotid trauma I cricoid 2 3
  38. 38. www.perfuse.net www.amnch.ie Acute limb ischaemia
  39. 39. www.perfuse.net www.amnch.ie Immediate management Resuscitate ABC… ECG Intravenous heparin Bolus Start an infusion Do not use LMWH Heparin •Reduce risk of further embolisation •Reduce fragmentation and distal embolisation •Prevents thrombus formation propagation •Mitigate secondary venous thrombosis * Creager et al NEJM 2012
  40. 40. www.perfuse.net www.amnch.ie What next?
  41. 41. www.perfuse.net www.amnch.ie What next?
  42. 42. www.perfuse.net www.amnch.ie Agonal event http://slinkingtowardretirement.com/wp-content/uploads/2011/04/00407501.jpghttp://slinkingtowardretirement.com/wp-content/uploads/2011/04/00407501.jpg
  43. 43. www.perfuse.net www.amnch.ie Therapeutic options
  44. 44. www.perfuse.net www.amnch.ie Hybrid approach
  45. 45. www.perfuse.net www.amnch.ie Fogarty embolectomy
  46. 46. www.perfuse.net www.amnch.ie Percutaneous techniques
  47. 47. www.perfuse.net www.amnch.ie …Image * Creager et al NEJM 2012 * www.straubmedical.com/case-reports-en.html
  48. 48. www.perfuse.net www.amnch.ie ..thrombectomise * www.straubmedical.com/case-reports-en.html
  49. 49. www.perfuse.net www.amnch.ie ..thrombectomise * www.straubmedical.com/case-reports-en.html
  50. 50. www.perfuse.net www.amnch.ie …restore flow * www.straubmedical.com/case-reports-en.html
  51. 51. www.perfuse.net www.amnch.ie …correct abnormality * www.straubmedical.com/case-reports-en.html
  52. 52. www.perfuse.net www.amnch.ie Catheter directed thrombolysis * Creager et al NEJM 2012
  53. 53. www.perfuse.net www.amnch.ie … Bypass
  54. 54. www.perfuse.net www.amnch.ie Ischaemia reperfusion
  55. 55. www.perfuse.net www.amnch.ie Outcome 1 yr mortality 15-20%1 Major amputation 10-15%2 1 Creager et al NEJM 2012 2 EarnshawJ Vasc Surg 2004
  56. 56. www.perfuse.net www.amnch.ie Sean Tierney sean.tierney@amnch.ie @theseant www.perfuse.net
  57. 57. www.perfuse.net www.amnch.ie Vascular Trauma Vascular Surgery UnitVascular Surgery Unit AMNCHAMNCH http://goo.gl/U3DnR

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