4. vascular trauma

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  • MUHAMMAD NURALIM MALLAPASI

  • Vascular traumaVascular trauma can result from either blunt or penetrating injuryPenetrating injury is more common in the USA than EuropePattern of injury differs according to the mechanism of injuryBlunt vascular trauma is associated with an increased amputation rateResults from blunt injury being associated with significant fractures and tissue lossThe diagnosis of blunt vascular trauma is often delayed

  • Types of vascular injuryContusionPunctureLacerationTransection

  • Clinical featuresDepends on site, mechanism and extent of injurySigns classically divided into 'hard' and 'soft' sign

  • Hard signs of vascular injuryAbsent pulsesBruit or palpable thrillActive haemorrhageExpanding haematomaDistal ischaemia

  • Soft signs of vascular injuryHaematomaHistory of haemorrhage at seen of accidentUnexplained hypotensionPeripheral nerve deficit

  • InvestigationHard signs often require urgent surgical exploration without prior investigationArteriography should be considered: To confirm extent of injury in stable patient with equivocal signsTo exclude injury in patient without hard signs but strong suspicion of vascular injuryThe role of doppler ultrasound in vascular trauma remains to be defined

  • ManagementOften requires a multidisciplinary approach with orthopaedic and plastic surgeonsAims of surgery are to: Control life-threatening haemorrhagePrevent limb ischaemiaIf surgery is delayed more than 6 hours revascularisation is unlikely to be successfulThe use of arterial shunts is controversialMay reduce ischaemic time and allow early fixation of fractures

  • Vascular repairUsually performed after gaining proximal control and wound debridementOptions include : Simple suture of puncture hole or lacerationVein patch angioplastyResection and end-to-end anastomosisInterpositional graftContralateral saphenous vein is the ideal interpositional graftProsthetic graft material may be used if poor vein or bilateral limb trauma

  • Primary amputationUsually considered in two situations Severe injury with significant risk of reperfusion injuryThe limb is likely to be painful and useless

  • Complications of vascular injuryFalse aneurysmMost commonly occurs following catheterisation of femoral arteryOften presents with pain, bruising and a pulsatile swellingDiagnosis can be confirmed by doppler ultrasoundMay respond to ultrasound guided compression therapySuturing of puncture site may be requiredVein patching may be required

  • Arteriovenous fistulaOften presents several weeks after the injuryPatient complains of a swollen limb with dilated superficial veinsMachinery type bruit often present throughout cardiac cycleDiagnosis can be confirmed by angiographyFistula can be divided an both the vein and artery suturedFlap of fascia can be interposed between vessels to reduce risk of recurrence