Vascular TraumaVascular Trauma

Badr Aljabri, MD, FRCSCBadr Aljabri, MD, FRCSC

Associate professor and consultant Associate professor and consultant Vascular SurgeryVascular Surgery

General PrinciplesGeneral Principles

Always start with ABCAlways start with ABC Large IV pore lines Large IV pore lines External compression to control External compression to control

bleeding bleeding Look for hard signs of arterial Look for hard signs of arterial

injuries injuries

Try to answer !!Try to answer !! Is this blunt or penetrating injury ?Is this blunt or penetrating injury ? Is this Arterial or Venous injury ?Is this Arterial or Venous injury ? Should I take the patient to the operating room Should I take the patient to the operating room

or do further investigations?or do further investigations? Is it Hospital Vs community based vascular Is it Hospital Vs community based vascular

injury?injury?

Is this Arterial or Venous injury ?Is this Arterial or Venous injury ?

ArterialArterial- Pulse examinationPulse examination- Hard signs Hard signs

Pulsetile ext. bleedingPulsetile ext. bleeding Absent distal pulses.Absent distal pulses. Expanding hematomaExpanding hematoma Distal ischemiaDistal ischemia Thrill or bruit Thrill or bruit

Is this Arterial or Venous injury ?Is this Arterial or Venous injury ?

Venous Venous - Low pressure dark blood external bleeding Low pressure dark blood external bleeding - Non-expanding hematomaNon-expanding hematoma- Shock is rare unless associated with arterial Shock is rare unless associated with arterial

injury injury

Should I take the patient to the operating Should I take the patient to the operating room or do further investigations?room or do further investigations?

Any patients with these following signs should Any patients with these following signs should not wait !!!!not wait !!!!

- External bleeding External bleeding - Expanding hematoma with shockExpanding hematoma with shock- Limb ischemiaLimb ischemia

Hospital based traumaHospital based trauma

Venous : Central venous access hematomaVenous : Central venous access hematoma Guide wire dislodgmentGuide wire dislodgment

Arterial : catheterization Arterial : catheterization - Psudoaneurysm - Psudoaneurysm - Arterial dissection & Thrombosis- Arterial dissection & Thrombosis - AV Fistula formation- AV Fistula formation - Distal Embolization- Distal Embolization

PsudoaneurysmPsudoaneurysm

walled off extra- luminal circulation walled off extra- luminal circulation of the blood as a result of arterial of the blood as a result of arterial wall disruption.wall disruption.

PsudoaneurysmPsudoaneurysm

Conservative Conservative U/S guided compression U/S guided compression U/S guided thrombin injection U/S guided thrombin injection SurgerySurgery

PsudoaneurysmPsudoaneurysm

Indications for surgical intervention:Indications for surgical intervention: 1) Evidence of ongoing bleeding1) Evidence of ongoing bleeding 2) Associated limb ischemia2) Associated limb ischemia 3) Nerve compression3) Nerve compression 4) Need for aggressive anticoagulation4) Need for aggressive anticoagulation 5) Threatened skin viability5) Threatened skin viability 6) Psudoaneurysm surrounded by large hematoma6) Psudoaneurysm surrounded by large hematoma 7) Expanding7) Expanding

Community based traumaCommunity based trauma

Penetrating injury : most common Penetrating injury : most common cause cause

Blunt trauma: associated with Blunt trauma: associated with orthopedic injuries. orthopedic injuries.

Extremity vascular injuryExtremity vascular injury

10% following penetrating ext. 10% following penetrating ext. injury injury

1% following blunt ext. injury ( 25-1% following blunt ext. injury ( 25-75% of Popliteal are due to blunt 75% of Popliteal are due to blunt trauma)trauma)

What should you do in OR?What should you do in OR?

Keep in mind your inflow and Keep in mind your inflow and outflow arteries outflow arteries

Always think about your vascular Always think about your vascular conduit conduit

Be prepared to do on-table Be prepared to do on-table angiographyangiography

Do not hesitate to call for helpDo not hesitate to call for help

What should you do in OR?What should you do in OR?

Always establish good exposureAlways establish good exposure Establish proximal then distal arterial Establish proximal then distal arterial

controlcontrol Use a shunt if the bones need to be fixed Use a shunt if the bones need to be fixed

first to buy you some time first to buy you some time Use local heparin flush Use local heparin flush Make your arterial repair tension-free Make your arterial repair tension-free Use autogenous vein Use autogenous vein Repair concomitant venous injury if patient Repair concomitant venous injury if patient

is stable is stable

What should you do in OR?What should you do in OR?

Make your threshold low forMake your threshold low for

““Fasciotomy”Fasciotomy”

Vein patch angioplastyVein patch angioplasty

Tension-free primary Tension-free primary repairrepair

Interposition autogenous Interposition autogenous vein graftvein graft

Damage controlDamage control

Arteries that can be ligated with few Arteries that can be ligated with few consequences: consequences:

- The common and external carotid, The common and external carotid, subclavian, axillary , internal iliac subclavian, axillary , internal iliac arteries & Celiac axis.arteries & Celiac axis.

- ICA ligation : 10-20% stroke rate.ICA ligation : 10-20% stroke rate.- EIA,CFA & SFA: high risk of limb EIA,CFA & SFA: high risk of limb

ischemia.ischemia.- SMA & IMA : gut necrosisSMA & IMA : gut necrosis

Damage controlDamage control

Almost all veins including the IVC Almost all veins including the IVC can be ligated when necessary can be ligated when necessary

Blunt Thoracic Aortic Blunt Thoracic Aortic TraumaTrauma

Deceleration injury.Deceleration injury. Multiple trauma victimsMultiple trauma victims It is lethal if not recognize and It is lethal if not recognize and

treated promptly treated promptly Usually distal to left subclavian Usually distal to left subclavian

artery.artery.

Neck TraumaNeck Trauma

Most commonly penetrating type.Most commonly penetrating type. Associated vascular injury in > 30%Associated vascular injury in > 30%

Thank YouThank YouBadr Aljabri, MD, FRCSCBadr Aljabri, MD, FRCSC

Assistant professor and Assistant professor and consultant Vascular Surgeryconsultant Vascular Surgery