Download - Vascular Trauma OCT 14

8/11/2019 Vascular Trauma OCT 14

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Vascular Trauma

The Old, The New and The Unusual


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Outline/Objectives

Carotid

Popliteal

Abdominal Aortic and Iliac

Thoracic Aortic


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Carotid Trauma

A rare but serious problem in vascular

trauma

Incidence of 0.08% to 0.86% of blunt

trauma admissions

Routine screening of high-risk patients can

reveal an incidence of up to 2%


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Actually represents a spectrum of injury

Minor intimal tear to acute occlusion

RISK: evolution of dissection,

pseudoaneurysm , thrombosis


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Potentially, a devastating event

Mortality rates of 20 to 40%

Permanent, severe neurologic morbidity of up to

50% in survivors

Often presents 24 or more hours following injury


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Mechanism of Injury

Classic stretch

Direct trauma

At the end of the day, what matters is the

degree of carotid injury and neurologic status


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Presentation

Arterial hemorrhage from nose/mouth/neck

Cervical bruit or expanding hematoma

Focal neuro deficit (TIA, Horners, etc)

Neuro deficit not compatible with CT findings


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High energy mechanism with: Le Forte II or III

Basilar skull fracture involving the carotid canal

CHI with DAI and GCS < or = 8

Clothesline injury or near hanging

Cervical vertebral body fx, subluxation orligamentous injury at any level, C1 to C3 fx


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Diagnostic Imaging

US: Not useful for vertebral injury, misses at

least 20% of carotid injuries

CTA: 16 or 32 slice CTA is the study of choice

Angio: Often difficult, always expensive,

sometimes morbidstill the gold standard?


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Grading the Injury

Grade I: Less than 25% luminal narrowing

from wall irregularity of dissection

Grade II: More than 25% lumen compromise

from dissection or intramural hematoma,

thrombus or intimal flap

Grade III: Pseudoaneurysm


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GradingMore

Grade IV: Occlusion

Grade V: Transection with free extravasation


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Therapy

No Level I evidence, because there are no

prospective, randomized trials

All recommendations are based on

observational studies and expert opinion

If there is profound neurologic compromise,

no therapy has been shown to be of benefit


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Any Meaningful Literature?

Western Trauma Association Critical Decisions

in Trauma: Screening for and Treatment of

Blunt Cerebrovascular Injuries

Biffl, et al

J Trauma, Dec 2009


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Whats More

Blunt Cerebrovascular Injury Practice

Management Guidelines: the Eastern

Association for the Surgery of Trauma

Bromberg et al

J Trauma, Feb 2010


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Therapy:

The consequences of BCI are so significant,

treatment is warranted in all patients without

overwhelming contraindications

For grade I and II injuries, initial heparinization

with long term antiplatelet therapy is

indicated


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For Grade I and II:

Follow up angiography at 7 to 10 days postinjury (or in the face of worsening symptoms)is indicated

Length of antiplatelet therapy is controversial,but probably should not be less than 90 days

Follow up imaging is important, leading to achange in therapy in 50% of patients


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More Therapy

Grade III injuries: angiography and possible

percutaneous intervention

Grade IV: Rarely is intervention indicated

Grade V: Immediate surgical intervention ifaccessible; most require an endovascular

approach


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PEARLS

1) Carotid injuries are potentially devastatingand easily missed

2) Find it by thinking to look for it

3) US isnt a good way of looking

4) Treat it when you do find it


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Popliteal Artery Trauma

HOW MANY times did you see this?

Wait, you were what?

Maybe I should check one of these

So, now what do I do about it?


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Frequency

Incidence of popliteal artery injuries withfracturesabout the knee was 3 per cent

16 per cent of patients with posterior kneedislocationshad vascular injuries

Amputations were required in 14 of the 38injured limbs (36%). None of these patientshad a pulse or Doppler signal on admission


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Frequency

Most common with posteriordislocations

(more force needed to produce the injury)

Fractures of the distal femur or tibial plateau

may cause arterial contusion, with intimal

disruption and thrombosis


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- note that the worst error to make is to

underestimate the need to promptly treat

these injuries;

- there are anecdotal reports of patientswho ended up with AKA (from vascular injury)

who were reported to have diminished but

"dopplerable pulses


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Popliteal Injury: Activities

Water skiing

Snow skiing

Longboarding

Parasailing

MVA

Horseback riding


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Why is Shear an Issue?


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I think, therefore I.

Examine the pulses

Obtain an ABI

Consider duplex US

Order an angio???


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So, Now What?

Watchful waiting

Open bypass with contralateral GSV

Percutaneous stenting


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PEARLS

Pulses count (in the ER and later)

If there is significant femur/knee trauma,suspect popliteal injury

ABIs are your friend


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Blunt Aortic & Iliac Trauma

It happened how?

Why should I care?

What do I do about it?


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JVS 2012 Sep;56(3):656-60.

Associated injuries, management, and

outcomes of blunt abdominal aortic injury

De Mestral, C; Dueck, AD et al


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All patients age 16 years with ISS 16 from

blunt trauma, treated at US level 1 or 2

trauma centers, 2007 to 2009.

436 patients from 180 centers

84% of patients were injured in an MVA.


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394 patients (90%) managed nonoperatively; 42(10%) underwent repair

42 repaired: 29 (69%) had endovascular repair, 11patients were done open, two had extra-anatomic bypass

Median time to repair was 1 day

Overall mortality was 29%


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Patients with MAI are at low risk: observe withserial physical exams and US

Injuries associated with bleeding, malperfusion,or thromboembolism require intervention, mostoften endovascular

For observed patients, long-term surveillance isrequired; document complete resolution as evenMAI can progress


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PEARLS

Sohow did it happen?

Why should I care?

What do I do about it?


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Thoracic Aorta

Things just arent what they used to be


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Open Thoracic Repair

Complications of thoracotomy!

of heparin

paralysis rates of 2-20%

emergent OR in the face of polytrauma


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New Approaches.

Treat them like an aortic dissection

Endovascular operation once clinically

opportune


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Bad Drive Home

60 yo male professional

Restrained driver of a small SUV

Hits an ice patch at highway speed


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Multiple rib fractures, bilaterally

CHI with LOC and intracranial bleed

Extensive bilateral pulmonary contusions

Various bumps, lumps and fractures


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Hes just arrested

Has significant intracranial injury

Significant thoracic cage and pulmonary injury

Who wants to do a thoracotomy right now?


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To the unit he goes.

IV betablockers

IV cleviprex

Keep MABP ~ 60

Keep Pulse


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4 days later

Hes still alive

In fact, getting better

Neurosurgery twitching less


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To the OR.

Almost two weeks post injury.


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Three months later

Seen in the office

Initial follow up CTA of chest looks great

Still with mild discomfort from his chest wall

Walked in, walked out and walked back to hiscar to return to work.


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Download - Vascular Trauma OCT 14

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