Vascular TraumaJoel Arudchelvam

Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura

Sri Lanka.

Mannar Medical AssociationMonthly Clinical Meeting

Vascular trauma /injury

• Injury to – Arteries– Veins

• Anatomical regions– Extremity – limbs– Abdomen and pelvis– Thorax– Head and neck

Vascular trauma /injury

• Injury to – Arteries– Veins

• Anatomical regions– Extremity – limbs– Abdomen and pelvis– Thorax– Head and neck

Extremity Vascular Injuries

• Unexpected

• Young and fit

• Results in limb loss at times loss of life

• Loss of earning capacity

• Economic burden

• Our experience (2011/2012 – NHSL)– Popliteal arterial injury - 34.8% amputation rate.

Causes

• Road Traffic Accidents – 38.5%• Trap Gun – 7.5%• Home Accidents - 7.5%• Cuts and Stabs• Iatrogenic - 46.1%

Mechanism of injury• Sharp / penetrating• Blunt

Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016

Mechanism of disruption of flow at arterial level

• Transection

• Laceration

• Contusion

• Kink

• Intimal flap

Vascular traumaSigns of a vessel injury• Hard signs• Soft sign

Hard signs– Active bleeding– Thrills, Bruits– Signs of distal ischaemia

• Absent pulse• Pain• Pale• Perishing Cold• Paresthesia / anaesthesia• Paresis / Paralysis  

– Expanding hematoma

Signs of a vessel injury• Soft signs

– Hematoma– Injury close to a known neurovascular bundle– Reduced pulse

• Paresis / paralysis and paresthesia / anaesthesia - late signs• Paresis and paresthesia

– viability of the limb is in immediate threat • Anaethesia and paralysis

– not viable.

Problems with diagnosing ischaemia after trauma

• Pain – Due to injury itself

• Pallor – Pallor due to blood loss

• Absent pulse– Absent due to low blood pressure. Compare with othe l

imb

• Paresthesia , paresis – Due to associated nerve, muscle injury or unresponsive patient

Investigations

Investigations

•Hard signs

• Urgent intervention

•Soft signs

• Observe• Investigate

Investigations • Hand held DOPPLER

• Absent doppler flow• Quality of signal• ABPI

• Presence of doppler flow does not exclude vascular injury

• Duplex scan (USS + DOPPLER)

• Difficult to image in trauma• Due to

• Pain, Non cooperative patient, Dressings

• Patent distal vessels does not exclude a proximal injury

Investigations

• Angiography– CT angiography– Catheter angiography

CT ANGIOGRAPHY

3D Reconstruction

Conventional angiography / DSA

• Contrast directly into artery• Traumatic • DSA – Digital subtraction angiography

– done though a software after obtaining initial images

Conventional angiography / DSA

• Contrast directly into artery• Traumatic • DSA – Digital subtraction angiography

– done though a software after obtaining initial images

Investigations

• Arteriography

– On table / DSA – for multi level injury

Investigations

• Patient presenting with– Soft signs– Delayed presentation– Avf– False aneurysm

– Pre-op angiography

How soon we should we repair – As soon as possible– Effects of ischaemia

How soon we should we repair

• At Teaching Hospital Anuradhapura 2015- 2016;

• – 1 year– 13 cases– Commonest artery popliteal 53.8 %– Mean ischaemic time – 12.67 hrs– 4 clinically dead limb (mean time 15.75 hrs)

Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016

Surgical Repair

• Prompt transport to operating room• General anesthesia• Clean the entire limb• Thigh prepared – for venous harvest • Control of proximal and distal ends and trimming

Surgical repair (cont..)• Balloon thrombectomy• Systemic and distal heparinisation• Interposition graft / Direct

approximation– Unit experience – 88.2% RSVG

• Prosthesis – lower patency– infection

Surgical repair (cont..)

Principles of arterial repair

• Cut / laceration _ suture transversely• Heparin – depends on clinical situation

Combined Vascular and Skeletal Trauma

– Revascularization / skeletal fixation (external Fixator – EF)

• Bone fixation first if limb is not threatened – apply EF antero laterally

• Revascularisation first if limb is threatened

Primary Amputation • Extensive crush injuries and soft

tissue damage – “mangled limb”• No need to transfer – discuss / photo

Shunting

Compartment syndrome

Recognize

Remove the cause

Surgery – fasciotomy

Compartment Syndrome

Treatment – Fasciotomy

In hospitals where facilities for repair is not available

• ABCD • Fasciotomy • Discuss• Transfer• Do not apply tight dressings

Summary

• Vascular injury;

– Resuscitate

– Assess viability and extent of injury

– Assess need for fasciotomy

– Early intervention and post intervention monitoring

– Rehabilitation

Thank You