Complex lower limb arterial injuries; definitive management Joel Arudchelvam SLSVS limb.pptx

Complex lower limb arterial injuries; definitive management Joel Arudchelvam

1. Complex lower limb arterial injuries; definitive management Dr. Joel Arudchelvam MBBS (COL), MD (SUR). MRCS (ENG) Senior Lecturer, Department of Surgery, University of Colombo, Consultant Vascular and Transplant Surgeon, The National Hospital of Sri Lanka, Colombo.

2. Vascular injuries Young and fit Results in loss of limb or life Loss of earning capacity, economic Our experience Incidence – 1.6% Patients with skeletal injuries – 4.4% Mean age - 36.9 years (17–69 ) Arterial injury following trap gun - 25% amputation rate. Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8 Arudchelvam , J., Gamage , S. and Ranaweera , R.S. (2024) ‘Extremity vascular injuries following skeletal fractures, a tertiary care centre experience from Sri Lanka’, Sri Lanka Journal of Surgery, 42(01), p. 29-32. 

3. Causes Road Traffic Accidents – 54.2% Trap Gun – 33.3% Iatrogenic - 8.33% Other- 4.2% Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8

4. Complex injuries Injuries to the arteries associated with Deep vein injury Bone injury Soft tissue Skin injury Nerve injury Contamination Plus Ischaemic time Patients condition ( Age, Shock ) Co-morbidity

5. Scoring systems Mangled Extremity Syndrome Index (MESI); Mangled Extremity Severity Score (MESS); Predictive Salvage Index (PSI); Limb Salvage Index (LSI); Nerve injury, ischemia, soft tissue injury, skeletal injury, shock, age of patient score (NISSSA); Ganga Hospital Open Injury Severity Scoring (GHOISS)

6. Scoring systems

7. Investigations

8. Surgical Repair Resuscitation “Early recognition” Multidisciplinary approach Prompt transport to operating room Clean the entire limb Thigh prepared – for venous harvest Assess the extent of trauma

9. Surgical repair Control of proximal and distal ends and trimming Interposition graft / direct repair Native / Synthetic graft Our experience – 7 6.5% RSVG, 17.6% direct Tissue cover Parathan, S., Arudchelvam, J. and Marasinghe, A., 2019. Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Sri Lanka Journal of Surgery, 37(4), pp.14–17. DOI: http://doi.org/10.4038/sljs.v37i4.8642

10. Combined Vascular and Skeletal Trauma Revascularization / skeletal fixation Bone fixation first if limb is not threatened – apply EF antero laterally

11. Skeletal fixation methods External fixation - 34 (58.6%) Internal fixation - 15 (25.8%) Plaster cast - 9 (15.5%)

12. Venous injuries Controversial Repair / ligate? Expected problems Transient oedema Permanent oedema Limb loss

13. Venous injuries Local experience (NHSL / ANP) Total - 18 Male - 13 (72.2%) Female - 5 (27.8%) Mean age - 35.0 years (4- 61)

14. Venous injuries Local experience (NHSL / ANP) PA injury was associated with PV injury in 20% ( esp following trap gun injury) Vein Number External Iliac vein EIV 5 (27.8%) Femoral vein FV 4 (22.2%) Popliteal vein PV 8 (44.4%)

15. Venous injuries Type of repair Direct 11 (61.1%) panel vein graft 2 (11.1%) Vein interposition 2 (11.1%)

16. Primary Amputation Extensive crush injuries and soft tissue damage – “ M angled limb” No need to transfer – discuss / photo

17. How soon we should we repair As soon as possible - ? “ 6 “ hours To minimise the ischaemic and Reperfusion effects Delay in presentation due to Delay in recognition Delay in transfer Multiple centres Some series – ischemic time - 11.3 hours (range 0.5 to 48) Arudchelvam, J. (2017) ‘Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries’, Ceylon Medical Journal, 62(3), p. 203-204.

18. Endovascular Therapy For proximal control Placement of a stent graft to patch the site of arterial injury Treatment of false aneurysm Not readily available Hybrid facilities

19. Future direction Key trauma centres Minimising delay Developing the infrastructure – including the endovascular facilities

20. Thank You