Experience in management of complicated vascular injury

1. INCIDENCE AND MANAGEMENT OF
COMPLEX VASCULAR INJURY
AMONG YEMENI PATIENTS
DR ABDULKAREM ALAMERI
ENDOVASCULAR AND VASCULAR SURGEON CONSULTANT
ASS. PROF. SANAA UNIVERSITY
14th
Congress of Asian Society for vascular Surgery & 8th
Asian Venous
Forum , Istanbul, Turkey, October 26-29, 2013

2. Introduction
• Complex extremity trauma involving arteries,
veins, nerves, bones and soft tissues injuries
remains challenging.
• Vascular and trauma surgeons are more likely to
encounter these injuries.
• In past years, the great majority of complex
extremity injuries in the civilian sector have been
caused by blunt trauma, although in some recent
series penetrating trauma has caused a majority
of these injuries.

3. Introduction
• Combined arterial and skeletal extremity, peripheral
nerves, main venous and major soft tissues trauma
imparts a substantially higher risk of limb loss and limb
morbidity than do isolated arterial injuries.
• Even in the most experienced trauma centers, where
amputation rates approaching 70%, while less than 5%
of limbs currently are lost following isolated arterial
trauma.
• Limb loss most commonly is attributed to delay in
diagnosis and revascularization in most published series
of this unique trauma. Major nerve damage, extensive
soft tissue injury which disrupts collaterals and prevents
adequate vessel coverage, infection, and compartment
syndrome are other reasons for such a high rate of loss
of these severely compromised limbs.

4. Introduction
• In our prospective study, we review 850
patients in the period between January
1999 and December 2012(14years) ,
most commonly complex vascular injury of
the extremities.

5. PATIENTS & METHODS
• Prospective study of 850 patients in the
period between January 1999 and
Desember 2012 .
• 300 patients 1999 – 2006 ( 8 years )
• 250 patients 2007 – 2010 ( 4 years )
• 300 patients 2011 – 2012 ( 2 years )
• 760 male : 90 female (8:1).

6. PATIENTS & METHODS
• The diagnosis based on clinical evaluation by noting
whether any hard signs are present (i.e. active
hemorrhage, large expanding or pulsatile hamatoma,
bruit or thrill over wound, absent distal pulses, and signs
of distal ischemia—the 5 P’s: pain, pallor, paralysis,
paresthesias, poikilothermy, or coolness), X-rays,
Doppler,C-T angio. and angiography if needed
• Resuscitation and management of all life-threatening
injuries was taken as priority over any extremity
problems. Only active extremity hemorrhage was
controlled by direct pressure, tourniquet, or direct
clamping of visible vessels .

7. PATIENTS & METHODS
• Management based on Resuscitation,vascular
reconstruction , fracture stabilization and fixation
and rehabilitation.
• Vascular reconstructions includes ; primary
repair, interposition vien or synthetic
grafts,temporary intraluminal shunting, ligation of
artery or vein, depridement and prophylactic
fasciotomy.
• fracture stabilization and fixation mostly done by
external fixation and some of them by enternal
fixation.

8. PATIENTS & METHODS
• All patients received pre-intra-and-postoperative
prophylactic antibiotics.
• Most of patients received blood transfusion ranging
between 1 to 16 units(m=5u).
• Admesion in the hospital ranging between 1 day to
94 days(m=17days) and one third of total patients
was admeted in intensive care unit; 1-7
days(m=2days).
• 530(62.3%) patients were referred postoperatively for
management and follow-up by neurosurgeon due to
associated nerve injury.
• All patients were adviced to be followed-up after
discharge for vascular , orthopedic and
physiotherapy (rehabilitation) management.

9. RESULT & DISCUSSION
• From 850 patients ; 89.4%(760) male, and
10.6%(90) female.
• Age between 5 and 75 years (mean=26
years).

10. Penetrating trauma
Gun-shot 560 (75%)
Stabbing 46 (6%)
R.T.A. 38 (5%)
Pump explosion 87 (12%)
Iatrogenic injury
Total
12 (2%)
743 (87 %)

11. Blunt trauma
R.T.A. 82 (77%)
Falling 14 (13%)
Trauma by rock
Total
11 (10%)
107 (13%)

12. Clinical Presentation Arrive at the
Emergency Department
Acute Ischemia 279 33 %
Active hemorrhage 464 55 %
Expanding hematoma 62 7 %
Limb swelling by A-V
fistulae
45 5%
Total 850 100 %

13. Type of Vascular Reconstruction
Interposition v. graft 554 48 %
Primary artery repair 120 10 %
Synthetic graft 59
PTFE=20 D=39
5 %
P=2%D=3%
Legation of artery 45 4 %
Legation of vein 92 8 %
Primary vein repair 70 6 %
Vein repair by v. graft 62 5 %
Fasciotomy 162 14 %
Total 1164 100 %

14. Frequency of Skeletal trauma
Open
Comminuted
Fracture
(225) 76 %
(from 297 patients)
Close
Comminuted
Fracture
(40) 13 %
(from 297 patients)
Joint
Dislocation (32) 11 %
(from 297 patients)
Total (297) 35 %
(from850 patients)

15. Skeletal stabilization & fixation
External fixation 231 78 %
Enternal fixation 20 7 %
P.O.P. 46 15 %
Total 297 100 %

55. Morbidity & Mortality Rate
Re-operation 36 4.2 %
Renal failure 23 2.7 %
Graft rupture (infection) 23 2.7 %
Primary amputation 28 3.3 %
Secondary amputation 34 4.0 %
Death (Mortality rate) 28 3.3 %

56. Con. RESULT & DISCUSSION
• The common vascular injury were femoral, popliteal,
brachial, post. Tibeal, auxiliary, radial, ant.tibeal, ulnar,
iliac, subclavian, carotid arteries , consecutively.
• Legation of arteries done in cases of good collateral
circulation distally , in graft rupture due to sever infection
and in shocked patients.
• Synthetic (Dacron or PTFE) grafts were done in situation
of unavailable suitable venous grafts .
• From 23 cases of graft ruptures , 9 synthetic graft due to
staphylococcus infection, and 14 were due to rupture in
the body of venous graft by strepto. And staphylococcus
infection.

57. Con. RESULT & DISCUSSION
• Legation of injured veins, while repair consuming
time, commonly done in shocked patients, and in
non-main veins.
• Fasciotomy commonly done in extremities with
combined arterial and venous injuries, significant
blunt soft tissue injury, more than 6 hours of limb
ischemia, or occlusive popliteal injuries are
susceptible to compartment syndrome.
• The causes of reoperations were bleeding from
anastamosis, wound or rupture graft, and
developing of ischemia due to anastamosis
occlusion.

58. Con. RESULT & DISCUSSION
• Primary amputation was usually decided when
associated with a worse prognosis for limb salvage; like
Prolonged ischemia (>4-6 hours)/muscle necrosis, Crush
or destructive soft tissue injury, neurovascular injury with
bone fracture or mangled extremity.
• The 34 Secondary amputation was usually decided after
initial attempts at limb salvage when any adverse in
extremity on the patient’s health, i.e. sepsis,
rhabdomyolysis, hyperkalemia, ARDS, or other life-
threatening problems mandate immediate secondary
amputation.
• Common causes of mortality; irreversible hemorrhagic
shock, septic shock, DIC or cardiogenic shock.

59. risk factors increase morbidity &
mortality rate
• Far distance injured patients.
• difficulty in transportations and Late arriving.
• Shortage of vascular surgeons and facilities especially in civilian wars
and crisis .
• consuming the time by patients, relatives and/or medical staff.
• jumping several hospitals.
• Miss diagnosis of vascular injury.
• rare blood group.
• cost effectiveness.
• refuse decision of management and Lake of confidence .

60. Conclusions & recommendations
• Vascular injuries need urgent decision making in diagnosis and
management.
• The importance of expert vascular surgeons with good
facilities in different areas of the country to cover the urgent
vascular intervention in time and place.
• Urgent vascular intervention within the golden time will
decrease the morbidity and mortality rate.
• To be familiar with the criteria for early amputation in complex
extremity trauma will minimize the complications on the
patient’s health and life salvage .
• higher rate of limb salvage among combined vascular and
skeletal extremity injuries in which revascularization is
performed first.
• Long follow up with team work of vascular , orthopedic,
neurosurgeon , psychologist and physiotherapist doctors.