extremity vascular trauma / injury

Vascular TraumaJoel Arudchelvam

Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.

Vascular trauma /injury

• Injury to – Arteries– Veins

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

Extremity Vascular Injuries

• Common

• 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• Fractures and dislocations• Trap gun• Cuts and stabs• Home accidents• Iatrogenic

• Mechanism of injury– Sharp / penetrating– Blunt

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 distal ischaemia after trauma

• Pain – could be due to injury itself, may not have pain due to associated nerve inj

ury

• Pallor – may be pale due to blood loss

• Absent pulse– may be absent due to low blood pressure. Compare with othe limb

• Paresthesia , paresis – may occur due to associated nerve, muscle injury or unresponsive confused

patient

Investigations

Investigations

•Hard signs • urgent intervention

•Soft signs • Observe• Investigate

Investigations • Hand held doppler

• Absent doppler flow• Quality of signal

• Duplex scan (uss + doppler)

• Difficult to image in trauma• Due to

• Pain• Non cooperative patient• Dressings

Investigations

• Angiography– CT angiography– Catheter angiography

CT ANGIOGRAPHY

Contrast into peripheral vein

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

Conventional angiography / DSA

Investigations

• Arteriography

– On table / DSA – for multi level injury

Investigations

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

– Pre-op angiography

TREATMENTSurgical Repair

• Prompt transport to operating room• General anesthesia• Cleaning entire limb and be able to visualize the distal end and

palpate distal pulses.• Thigh prepared – for venous harvest • Mobilisation and control of proximal and distal arterial 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..)

Complications of vascular injury

• Death • Limb loss• Compartment syndrome• Reperfusion effects• Volkmann ischemic contracture• Intimal flaps and narrowing• False aneurysms• Traumatic AVF

Complications of vascular injury

• Death • Limb loss• Compartment syndrome• Reperfusion effects• Volkmann ischemic contracture• Intimal flaps and narrowing• False aneurysms• Traumatic AVF

Volkmann ischaemic contracture

False aneurysms

Traumatic Arterio Venous Fistula

Combined Vascular and Skeletal Trauma

– Revascularization / skeletal fixation (external Fixator – EF)

• Bone fixation first if limb is not threatened• Revascularisation first if limb is threatened

Primary Amputation • Extensive crush injuries and soft tissue damage

– “mangled limb”• life-threatening problems

Compartment syndrome

Reduced organ perfusion due to increased intra compartment pressure.

Causes;– Trauma (muscle contusion)– Haematoma– Reperfusion – Intracompartmental extravasation of fluids– Tight bandage, cast

Compartment syndrome

Clinical features

• Excessive pain - pain on passive movements of the muscles.

• Numbness -e.g. anterior compartment results in numbness at first toe web i.e. deep peroneal nerve distribution)

• Tense swollen compartment

Compartment syndromeTreatment

Recognize

Remove the cause

Surgery – fasciotomy

Compartment Syndrome

Treatment – Fasciotomy

In hospitals wherefacilities for repair is not available

• ABCD• Fasciotomy• Discuss• Transfer

Reperfusion effects

• Local– Reperfusion injury – paradoxical death of already

dying muscles after reperfusion

• Systemic– Reperfusion syndrome;

• Hypotension• ARDS• Lactic acidosis• Hyperkalemia• Renal failure

Reperfusion effects

• Mangement– Fasciotomy

– Hydration – Mannitol, allopurinol– O2– Inotropes– Ligation of vessel if not responding to above

measures

Summary

• Vascular injury;

– Resuscitate

– Assess viability and extent of injury

– Assess need for fasciotomy

– Early intervention and post intervention monitoring

– Rehabilitation

Thank You