1. ProfessorAbdulsalam Y TahaSchool of MedicineFaculty of Medical SciencesUniversity of SulaimaniIraqhttps://sulaimaniu.academia.edu/AbdulsalamTaha

2. INTRODUCTION Extremity vascular injuries are fairly common in bothwar and civilian times. The aim of a vascular surgeon managing vasculartrauma in an extremity is to save the limb and the lifeof the patient. The current strategies employed in the management ofthe patient with vascular trauma have been developedover the past century from both civilian and militaryexperience. 3. INTRODUCTION DeBakey reported an amputation rate of 72.5%in a review of popliteal artery injuries in the eraof World War 1. Following the introduction ofvascular reconstruction techniques amputationrates for similar injuries fell to 32% in the KoreanWar. By the end of the Vietnam conflict theamputation rate had fallen again. Today, most major centres report limb salvagerates of 70-95% in patients with limb arterialtrauma . 4. INTRODUCTION Herein, we present selected cases of extremity vascularinjuries managed in our unit. The aim is to emphasize the principles of proper careof such patients to ensure constant good results interms of limb and life salvage. 5. Case 1BRACHIAL ART INJURY 6. BRACHIAL ART REPAIR 7. Case 2Antecubital Fossa Wound 8. Brachial Art Injury and Repair 9. End to End RepairA deep wound in ante-cubitalfossa caused byA machine.Transaction of brachialartery.Division of flexor muscles.Division of Median nerve.Primary repair of bothartery and nerve.Good outcome.Signs of median nerveinjury; on physiotherapy. 10. Case 3Multiple Pellet Injuries Axillary ArtRepair by RGSV Graft 11. Case 4EXTENSIVELY DEEP WOUND 12. TERROUBLE INJURY INDEED! 13. Still salvageablelimb!Exploration ofwound.Repair of majorlaceration ofbrachial artery.Repair of dividedmuscles.Fasciotomy. 14. Case 5: Brachial ArtMajor LacerationAn 18 yr old girl referredfrom Kirkuk with shockdue to profuse bleedingfrom R upper arm bulletwounds (inlet andoutlet).R chest tube forhemothorax and acuteabdomen.Resuscitation followedby urgent exploration.Brachial art majorlaceration, vein injuriesand median nerveneurotemesis. 15. UNJUSTIFIEDAND RISKYREFERRAL! 16. MANAGEMENTDebridement ofentrance and exitwounds.Repair of art by RGSVgraft.Ligation of veins.Median n repair.Partial closure ofwounds.Forearm fasciotomy.Laparotomy: suturing ofliver and diaphragminjuries.Secondary closure offasciotomy wound after2 weeks. 17. Case 6CRUSHED UPPER LIMB 18. CRUSHED UPPER LIMB A 40 yrs old man sustained a crush injury to his leftupper limb due to road traffic accident. He hadpresented with a big contaminated wound of the volaraspect of the upper arm and forearm. There was adeformity of the elbow region. X-ray revealed a severecomminuted fracture of humerus. There was suspicionof vascular injury due to extensive soft tissue injuryand absent distal pulses as well as impaired movementand sensation. 19. Multi-disciplinarymanagementApproach. 20. CRUSHED UPPER LIMB The patient had an exploration of the wound under GA. Thewound was copiously irrigated by normal saline. Most of the dirtand metallic fragments were removed. Then a thorough wounddebridement was done. The brachial artery was explored. Threeareas of contusion were found. The diseased segment wasexcised leaving a gap of about 10 cm. The injured venaecomitantes were ligated. A Fogarty catheter size 4 F passedproximally and distally. Good back bleeding was obtained.Irrigation of the distal arterial bed by heparinized saline wasdone. A segment of GSV was harvested from thigh and used asreversed interposition graft for the brachial artery. Goodpulsation was obtained distal to the anastomosis. The graft wascovered by a viable muscle tissue. The fracture was stabilized byexternal fixation. 21. Case 7: Primary AmputationExtensive softtissuedamage dueto crushinginjury.Impossible tosave suchlimb! 22. Case 8SUBCLAVIAN AVFA 52 yr old man sustained a bulletinjury to R infraclavicular fossa( inlet and outlet).Presentation 1 week after injury.An audible bruit + moderate swellingof R upper limb.Doppler ultrasound and angiographyconfirmed the diagnosis ofSUBCLAVIAN AVF. 23. Surgical Management The approach was via median sternotomy with rightsupraclavicular extension, resection of medial third ofthe clavicle and extension of the wound along thedeltopectoral groove. After tedious dissection, due tothe presence of adhesions and venous engorgement,proximal control of right subclavian artery wasachieved. Distal control of proximal axillary artery andvein was also achieved following division of overlyingpectoral muscles and fascia. The fistula was ultimatelyfound between a branch of subclavian artery and vein.It was controlled by oo silk ligature. 24. REPAIR VIA MEDIANSTERNOTOMYEXTENDED INTOSUPRACLAVICULARAREA 25. UneventfulRecovery. 26. Case 9RIGHT GROINBULLET INJURYThis old mansustained bulletinjury to his rightgroin presentedwith acuteabdomen as wellas profusebleeding fromthe groin wound. 27. ExploratoryLaparotomywith Extensioninto VerticalGroin Incision.External IliacArtery Injuryfixed by Endto EndRepair. 28. Case 10SFA INJURY STAB WOUND 29. Case 10SFA AND VEIN MAJOR LACERATION 30. End to End Repair of Art and VeinLigation 31. Case 12SFA AND VEIN MAJOR LACERATION 32. Multiple BulletInjuriesRight scapularfracture.Left SFA and VeinMajor laceration. 33. Repair of SFA byEnd to EndAnastomosis.Ligation of Vein.Excellentoutcome. 34. Case 13: Left Thigh Hematoma A male teenager referred to our hospital casualty about 8 hoursfollowing a terrorist explosion in Taza, a small city near Kirkuk. Hehad sustained a wound at lateral aspect of his left thigh possiblycaused by a penetrating piece of glass. On arrival, he had a hugeswelling of mid lateral thigh with no active bleeding. The lowerlimb 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 fractureor retained foreign body. A vascular injury was suspected like alateral tear of femoral artery, venous injury or an injury to amuscular arterial branch. Standard exploration of CFA, SFA and PFA was done. All wereintact. The hematoma was then entered and evacuated completely.No significant bleeder was identified. The source could be amuscular branch. 35. LEFT THIGH HEMATOMA 36. Standard exploration of CFA, SFA and PFA was done.All were intact. The hematoma was then entered andevacuated completely. 37. Case 14: SFA FALSE ANEURYSM 38. Iatrogenic SFAAneurysmA 58 yr oldmanunderwent Rtrans-femoralAngiography17 days beforepresentation.IATROGENIC SFA FALSE ANEURYSM 39. Elective Exploration and LateralRepair 40. Huge Hematoma Evacuated 41. Case 15: TraumaticCFA False AneurysmAn 8*3 cmaneurysm of R CFAwith extensiveechymosis few daysfollowing trans-femoralangiographyin 40 yrs old man.Audible bruit.Admitted forsurgery butdisappeared! 42. IATROGENIC CFA FALSE ANEURYSM 43. Case 16POPLITEAL ARTINJURYA 26 yr. old man sustained a crushinjury to his right knee,presented with a wound inpopliteal fossa + signs& symptomsof leg ischaemia. He had beenexplored 7 hours after theaccident becauseof his family initial refusal to havesurgery. Contusion of art. Andcrushed muscles were found.Fasciotomy, thorough wounddebridementand repair of art. by resection ofdamaged segment and end to endanastomosis were done. 44. POPLITEAL ART INJURY 45. Case 17POPLITEAL ARTERY CONTUSION 46. Popliteal Art Contusion; History A young chap referred from Kalar after sustaining acrush injury to the popliteal fossa. The limb wascrushed between the chair and the dashboard. He haspresented with severe pain, tense swelling of leg andknee region associated with extensive echymosis oflower thigh and popliteal region. The time intervalbetween injury and intervention was about 9 hours. At time of examination, he was in great pain. Thedistal pulses were absent but sensation and movementwere still preserved. 47. Popliteal Art Contusion Urgent exploration was done. GSV was harvestedfrom right thigh in supine position. Then he wasturned into prone position. An S-shaped incisionwas made over popliteal fossa extended over thecalf for fasciotomy of posterior compartment. Thegastronomies muscle was completely dead.Muscles were transected at the level of kneeregion. The veins were transected. 48. Popliteal Art ContusionThe popliteal artery was contused for adistance of 5 cms. The dead muscle wasexcised completely. The veins wereligated. The artery was repaired byresection of the contused segment andan interposition of reversed GSV graft.The wound was partially closed. Theoutcome of the limb was excellent. 49. PostoperativeDoppler Study ofGrafted PoplitealArtery. 50. Etiology Gunshot wounds, cause 70-80% of all vascularinjuries requiring intervention. Stab wounds (5-15% of cases) Blunt trauma (5-10% of cases): Presence of fractureincreases risk. Iatrogenic injury (5% of cases): Cardiaccatheterization and line placement 51. DIAGNOSIS Physical exam Doppler pressure (Ankle/brachial systolic pressureindex) Duplex scanning Arteriogram Exploration 52. Physical Examination Clinical assessment by an experienced clinician with ahigh index of suspicion will identify the majority ofclinically significant vascular injuries. Initial physical examination is normal in 15% of casesof vascular injury so frequently repeated physicalassessment is essential if the injury is not to be missed 53. The single most important factordetermining the fate of the limb withvascular compromise is the duration oflimb ischaemia. A warm limb ischaemictime of less than 6 hours was associatedwith an amputation rate of 6.7 %compared to 33% in limbs with warmischaemic time of more than 6 hours inone recent series 54. The ABI isobtained by using a bloodpressure cuff to measure thesystolic pressure at the largestpoint of the ankle anddividing it by the systolicpressure of either arm. If theABIis more than 0.9, observationis recommended; if less than0.9, furtherevaluation is warranted withcontrast arteriography in astable patient and operativeexploration in ahemodynamicallyunstable or hemorrhagingpatientDOPPLER ULTRASOUND 55. Duplex Ultrasonography Is a promising noninvasive technique Sensitivity of ultrasound can be up to 95-100% fordiagnosing vascular injuries. Extremely operator dependent. In extremity trauma a positive duplex ultrasoundscan or a reduced Doppler ABI to less than 0.9 isan absolute indication for an angiogram andpossible intervention. 56. AngiographyLocates site of injuryCharacterizes injuryDefines status of vesselsproximal and distalMay afford therapeuticintervention 57. Angiography Gold Standard for evaluation of vascular injuries intrauma. Disadvantages include cost, time delay, and a 0.6%major complication rate. Only 1 to1.5% of angiograms in patients lacking hardsigns will reveal injuries requiring intervention. 58. Surgical ExplorationImmediate exploration is indicated for: Obvious arterial injury on exam No Doppler signal Site of injury is apparent Prolonged warm ischemia time 59. TYPES OF REPAIR 60. FASCIOTOMY Fasciotomy is an important adjuvant operation inmanaging the patient with extremity vascular traumato 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). 61. The Two Incisions FourCompartments Fasciotomies 62. Vascular and Bone Injury The management of patients with vessel and boneinjury requires a team of a vascular and orthopaedicsurgeon operating on the patient in one session. Thesequence of repair (vessel or bone first ) depends onthe individual case . 63. Severely injured limbs for which attempted salvagewould be futile can be identified using the MangledExtremity Severity Score (MESS), and require primaryamputation. A truly mangled extremity is one in which amputationis a potential outcome. 64. MESS: MANGLED EXTREMITY SEVERITY SCOREComponents of Score PointsSkeletal/Soft tissue injuryLow energy ( stab, simple #,civilianGSW1Medium Energy ( open or multiple #s,dislocation)2High energy ( close-range shotgun,millitary GSW, crush injury)3Very high energy ( Above+ grosscontamination, soft tissue avulsion)4Limb IschaemiaPulse reduced or absent but normalperfusionPulseless, paraesthesias, reducedcapillary refillCool, paralyzed, insensate limb1+2+3+ShockSystolic BP always more than 90 mmHgHypotensive transientlyPersistent hypotension012AgeLess 30 than yrs30-50More than 50+ score is doubled for ischaemia morethan 6 hrs.012 65. CONCLUSIONS To achieve a good limb salvage rate ,there is a need toemphasize the importance of clinical awareness amongdoctors to early diagnose and promptly refer the suspectedcases . Control of hemorrhage takes priority over limb perfusion. Needless to say ,meticulous technique is essential toachieve constantly good result Orthopaedic as well as general surgeons should haveadequate training in vascular surgery so that they canmanage patients with vascular trauma in areas andsituations where no vascular surgeon is present . 66. CONCLUSIONS Whenever possible ,venous injuries should be repairedas proximal vein ligation is often followed bysignificant morbidity. However; in the extremity, veinligation does not increase amputation rates. The golden principle of repairing limb arterial injuriesor not is the limb viability; viable limb deservesrevascularization regardless the time while a dead limbshould not be revascularized . 67. CONCLUSIONS The choice between primary and secondaryamputation in extremity vascular trauma may bedifficult. Heroic attempts to save the limb which isbadly injured may not succeed, on the contrary, it mayterminate in secondary amputation and/ or death ofthe patient. If one decides on limb salvage, he shouldexpect prolonged hospitalization, increased number ofoperations, increased rate of sepsis, psychologicalattachment to the limb, poor functional outcome andeven death sometimes (primary amputation can be lifesaving). 68. THANK YOU