Vascular

Vascular injury

• Vessel

• Site

• Type

• Pathology

• Investigation

• Management

Vascular injury

• Arterial

• Venous

• Combined

Basic principle

• Anatomy

• Type of injury

• Mechanism of injury

• Clinical manifestation

• Clinical evaluation

• Investigation

• Management

Types of injury

• Laceration

• Transection – Defect

– No defect

• Dissection

• Crush

• Thrombosis/Embolus

• Spasm

Type of injury

• (1) intimal injuries (flaps, disruptions, or subintimal/ intramural hematomas);

• (2) complete wall defects with pseudoaneurysms or hemorrhage;

• (3) complete transections with hemorrhage or occlusion;

• (4) arteriovenous fistulas; and

• (5) spasm

Type

• (1) intimal injuries (flaps, disruptions, or subintimal/ intramural hematomas);

Type

• (2) complete wall defects with pseudoaneurysms or hemorrhage;

Type

• (3) complete transections with hemorrhage or occlusion;

Type

• (4) arteriovenous fistulas;

• (5) spasm

Mechanism of injury

• Penetrating – Knife

– Jambia

– GSW • Sharpnel

• Blunt – Direct (contusion)

– Traction (avulsion(

– Deceleration

– Torsion

Hard sign

– Active pulsatile haemorrhage

– Pulsatile or expanding haematoma

– Sign of limb ischaemia

• 5ps

– Diminished or absent pulse

– Bruit and thrill

Soft sign

• Hypotension/shock

• Neurological deficit

• Stable, non pulsatile small haematoma

• Proximity of wound to major vessel

Investigation

• Doppler

• Duplex ultrasound

– As screening test

• Angiography gold standard

• CT angiography

• MRI

Doppler/Duplex

• Sound

• Colored duplex

• First line investigation

•

Magnetic Resonance Angiography

• MRA has the advantage of not requiring iodinated contrast agents to provide vessel opacification

• Gadolinium is used as a contrast agent for MRA studies, and as it is generally not nephrotoxic, it can be used in patients with elevated creatinine.

Angiography

• Advantage

• Gold standard

• Detect occult injury

• Exclude need for OR

• Operative planning

• Endovascular repair

Site

• Neck

• Chest

• Abdomen

• Lower limb

Neck

• Anatomy

– Carotid

– Vertebral

– Jugular

– Subclavian

– Innominate

Neck injury classification

• Zone I: base of neck, thoracic outlet to 1cm above clavicle .

• Zone II : 1 cm above clavicle to angle of jaw

• Zone III : above angle of mandible

Neck

• Zone I and III are difficult to assess

• Image the stable patient

• Mandatory exploration unstable patient

• Exclude :

• Associated injuries on the

– cervical spine,

– airway, and

– digestive tract

Management guideline

• 1. Immediate operation is indicated for unstable patients with active bleeding not responsive to vigorous resuscitation or with rapidly expanding hematoma or airway obstruction, irrespective

• of anatomical zone.

• 2. Injuries in zone II not penetrating the platysma need no further examination.

• 3. All others require further diagnostic evaluation with angiography, duplex ultrasound, and CT to determine whether critical structures have been injured.

• If angiography or high-quality duplex ultrasound is not available, injuries in zone II need to be surgically explored

Neck exposure

• Venous injuries exploration of a neck injury can be treated either

• by repair using simple or running sutures or by ligation.

• In bilateral injuries to the

• internal jugular veins, however,

• reconstruction of one of the sides

• is indicated to avoid

• severe venous hypertension.

Chest • Anatomy:

• Aorta,

• supra-aortic trunk,

• intercostal

IVC, SVC,

brachiocephali/

subclavian

Chest

• Aerodigestive tract.

• Air bubbles in the wound

• Respiratory distress

• Subcutaneous emphysema

• Hoarseness

• Hemoptysis

• Hematemesis

Chest

Indication for thoracotomy

• Penetrating unstable, unresponsive to resuscitation

• Chest tube

• Deterioration of vital signs when the drain is started

• 1.500–2.000 ml of blood within the first 4–8 h

• Drainage of blood exceeding 300 ml/h for more than 4 h

• More than half of pleural cavity filled with blood on x-ray despite a well functioning chest tube

Aorta

• Usually results from

deceleration injury-fatal

unless false aneurysm

develops in mediastinum

Back pain, hypotension;

systolic murmur or

signs of tamponade

in some cases; characteristic

Investigation

• Chest x-ray : widened mediastinum, frac. Rib 1,2

• Apical pleural effusion (cap)

• Tracheal deviation

• Obliteration of descending aorta

• CT scan

• Angiography

• MRI

Wide mediastinum

Stent insertion

Approach to Chest

• Posterolateral thoracotomy

• Median sternotomy

• Anterolateral (4th)

Rupture of aorta

• widening of mediastinum on chest X-ray; diagnosis confirmed by arteriography

• Urgent thoracotomy and Dacron graft or minimal-access stent graft if available

Rates • Major abdominal vascular injury is seen in up to 25% of

patients admitted with vascular trauma.

• Blunt trauma/penetrating trauma.

• Abdominal injury represents 10–20% of all traumas to the body caused by road traffic accidents.

• Major vascular injury is estimated to occur in about 10% of cases of penetrating stab wounds in the abdomen

• and in about 25% of gunshot wounds.

• Blunt abdominal trauma affects major vessels less frequently, estimates of below 5% is common in the literature

Abdomen

• Aorta and its branches,

• IVC, portal and iliac veins

– Indication for laparotomy

– Damage control

– Re-explore

– Control bleeding

– Avoid prosthesis

Abdomen

• Contron

– Supra diaphragmatic

– Supr-celiac

– Infra-renal

– Ballon, occlusion

• Exposure

– From the left

– From the right

Boundaries of the Retroperitoneal Region

• Above: T12 and 12th rib

• Below: Base of the sacrum, the iliac crest, the upper rami of the pubic bones, and the pelvic diaphragm

• Anterior: parietal peritoneum of the retroperitoneal space, part of the liver and its bare area, part of the duodenum, part of the ascending colon, part of the descending colon, and much of the pancreas within the lesser sac.

ZONES

• Zone I (centromedial)

• Upper: Diaphragmatic, esophageal, and aortic openings

• Lower: Sacral promontories

• Lateral: Psoas muscles

• Contents: Abdominal aorta, inferior vena cava, pancreas, duodenum (partial) .

Zone II (lateral)

• Upper: Diaphragm

• Lower: Iliac crests

• Lateral: Psoas muscles

• Contents: Kidneys and their vessels, ureters and their abdominal parts, ascending and descending colon, hepatic and splenic flexure

Zone III (pelvic)

• Anterior: Space of Retzius (symphysis pubis and pubic bones, separated from the bladder by the space of Retzius)

• Posterior: Sacrum

• Lateral: Bony pelvis

• Contents: Pelvis in content, pelvic wall, rectosigmoid colon, iliac vessels, urogenital organs (partial)

Retro peritoneal zone

Therapeutic Implications of Retroperitoneal Zones

• •Zone I: highest risk of vascular injury. Investigate with

surgery unless small and stable.

• •Zone II: second most common site of retroperitoneal hemorrhage, predominantly renal injuries.

• •Penetrating: selective •Exploration or angiographic embolization

• •Blunt: Observation and follow-up imaging hemodynamically stable and no active bleeding

• •Zone III: Most common location of retroperitoneal hemorrhage, associated with pelvic fracture

• •No exploration in blunt pelvic trauma

• •Surgery for penetrating trauma

Limbs

• Vascular injuries associated with fractures are rare, occurring in only 0.5 to 3% of all patients with extremity fractures.

• The importance of a careful neurologic examination is important .

• Three different mechanisms can produce paralysis and numbness in an injured extremity: ischemia, nerve injury, and compartment syndrome.

Prehospital

• As manual compression or the application of a pressure dressing and

• Elevation of the extremity can almost always control arterial bleeding from an extremity in the field,

• Loss of life should be infrequent in an urban setting.

Immediate measure

• Control bleeding

• Replace volume lost

• Cover wound

• Reduce fracture

• Splint

• Re-evaluate

Post op

• Postoperative monitoring of hand perfusion and radial pulse is recommended at least every 30 min for the first 6 h. When deteriorated function of the repaired artery is

suspected, duplex scanning can verify or exclude postoperative problems.

• Occausion ......reoperation

• Compartment syndrome

Complication

• Delayed diagnosis and treatment may lead

– Thrombosis

– Embolisation

– Rupture with hge.

• Risk factor for amputation

– Elevated compartment pressure

– Arterial transection

– Associate open fracture

– Combination above and below knee

Lower limb

• Doppler

• Doplex

• CT angio

• MRI (MRA)

• Angiography

In theatre

• Always establish good exposure

• Establish proximal then distal arterial control

• Use a shunt if the bones need to be fixed first to buy you some time

• Use local heparin flush

• Make your arterial repair tension-free

• Use autogenous vein

• Repair concomitant venous injury if patient is stable

Shunting

• Intra-luminal shunt temporary save limb

– Simple tume can be constructed

– Transfer

– Manipulation of bonw

Management

• Conservative

• Endovascular

• Operative – Local

• Suture

• Patch

• Primary anastomosis

• autogenous

• Prosthetic

– Fasciotomy

Limbs

• Operative Principle

– Proximalldistal control

– Primary repair where possible

– Graft autogenous vein (contralateral limb)

– Temporary shunt

– Fixation of ortho-injury

– Coverage of repair (muscle, soft tissue)

– Fasciotomy

Extremities

• Ligation may be acceptable in rare circumstances

• If major Musculo-skeletal, neurological injury

• Popliteal have the highest rate

• Repair vein first

• Compaerment syndrome

Others

• Catheter injury

• Intra-arterial drug injuries

• Cold Injury

– Frost bite

– Immersion (trench) foot

– Frostnip