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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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