final 3Vascular injury management fev 2016 (1).pptx

Gives summarized information about peripheral vascular managment

1. Vascular injury management Prepared by :Dr Feven Moderator : Dr mehari

2. Outline Introduction Incidence Types of vascular injury Clinical manifestation Principle of management Post op complication` 5/28/2024 Vascular trauma 2024 2

3. Introduction Lower limb arterial injuries more common 2x upper limb injuries Brachial Artery most common injured lower limb Veins injured more than arterial Ligation is commonest mgt Previously 5/28/2024 Vascular trauma 2024 3

4. Mechanism of vascular injury Penetrating trauma –GSW –Stab Blunt trauma –High energy –Low energy Iatrogenic 5/28/2024 Vascular trauma 2024 4

5. Risk of amputation Vascular injury of upper limb more salvageable In oldest era ligation principle of mgt Ligation vs repair 5/28/2024 Vascular trauma 2024 5

6. Major clinical reasons for an amputation 1.Delay in diagnosis and revascularization; 2.Inability to perform vascular repair due extensive soft-tissue damage 3.Infection 4.Crush injury 5.Compartment syndrome 5/28/2024 Vascular trauma 2024 6

7. Golden hour The critical period before irreversible nerve and muscle damage due to acute ischemia occurs is 6 – 12 hours. Vascular injury Consequences: Blood loss Progressive ischemia Compartment syndrome Tissue necrosis Amputation Death 5/28/2024 Vascular trauma 2024 7

8. Clinical presentation and investigation 1.History 2.Physical examination 3.Baseline investgations – CBC, B/G & Rh. 4.Imaging/investigations A.Doppler US/Duplex scanning -Doppler pressure (Ankle/brachial systolic pressure index) B.Arteriogram C.X-ray for fractures 5.Exploration 5/28/2024 Vascular trauma 2024 8

9. H/E and P/E Hx Hx of trauma Hx of bleeding Mechanism of trauma P/E Tachychardia /hypotension Visible Arterial bleeding Expanding hematoma Altered distal pulses Pallor Temperature differential between extremities Injury to anatomically-related nerve 5/28/2024 Vascular trauma 2024 9

10. Clinical ……. Hard sign vs soft signs 5/28/2024 Vascular trauma 2024 10

11. Investigations 1.Doppler US Detects Presence /absence of flow Adequacy of flow Abscent pulse –Exploration Asymetric pulse –ABI N.B presence of signal doesn’t rule out injury 5/28/2024 Vascular trauma 2024 11

12. Duplex … Noninvasive Rapid Reliable for –Injury to arteries and veins –A-V fistulas – Pseudoaneurysms Requires technician and scanner availability N.B : Not all surgeons will operate based on duplex information 5/28/2024 Vascular trauma 2024 12

13. Arteriogram Characterizes injury Defines status of vessels proximal and distal Locates site of injury Expensive Time-consuming May afford therapeutic intervention Procedural risks –Renal burden from dye –Possibility of anaphylaxis –Injury to proximal vessels Operative angiography Single view in OR , Rapid & Excellent for detecting site of injury. 5/28/2024 Vascular trauma 2024 13

14. X-RAY Fractures associated vascular injury Clavicle fracture - subclavian artery Shoulder fx /dislocation - axillary artery Supracondylar humerus fracture - brachial artery Elbow dislocation - brachial artery Pelvic fracture - gluteal arteries Femoral shaft fracture - femoral artery Distal femur fracture - popliteal artery Knee dislocation - popliteal artery Tibial shaft fracture - tibial arteries 5/28/2024 Vascular trauma 2024 14

15. Management of vascular injury 5/28/2024 Vascular trauma 2024 15

16. Guideline of vascular injury 5/28/2024 Vascular trauma 2024 16

17. Basic principles 1.Definitive haemorrhage control 2.Resuscitation 3.Early arterial repair 4.Coverage of the arterial repair with appropriate soft tissue 5.Repair of venous injury when possible 6.Fasciotomy in most cases 7.Proper wound care, stabilization of any fractures, and physiotherapy. 5/28/2024 Vascular trauma 2024 17

18. Preoperative preparation: ABC of life/PHTLS/ATLS Compression and tourniquet application if possible If BP < 90mmhg – transfusion with O-ve blood Broad spectrum antibiotics TAT if indicated Heparin 5000 iu sc if the injury is isolated to the extremity only Assessment of neurologic status of the peripheral nerves – very important 5/28/2024 Vascular trauma 2024 18

19. Damage control /shunt Simple ligation Shunt Applies for veins ? For 48 hrs Temporary shunt to bridge arterial gap Indication Hemodynamic unstable in polytrauma Large soft tissue wound with difficulty neurovasc Wound with major fracture Repair skill ?? Mass casualities Veinus graft 5/28/2024 Vascular trauma 2024 19

20. Shunt Technique Distal embolectomy with fogarty Heparinzed saline Fasciotomy done Iv line, suction tube , ng tube ,T-tube ,cut fill with h eparinized saline Insert to arterial end ,kept in p lace with ligature Pulsation bent : mid ligature with soft tissue 5/28/2024 Vascular trauma 2024 20

21. Supplies 1.Vascular loops or umbilical tapes or a penrose drain to improvise a rummel tourniquet 2.Fogarty or ureteric catheters of different sizes 3.Heparin 4.Contrast material if possible. 5. Appropriate Suture materials 5/28/2024 Vascular trauma 2024 21

22. 5/28/2024 Vascular trauma 2024 22

23. The main principles of vascular management are: Gentle handling : adjacent vein with proper Avoid blind clamping of bloody field. Adequate proximal (quick) & distal control by mobilization, thoracotomy or laparotomy . Vessel should be held with vessel loops. Monofilament non-absorbable synthetic suture ( Polypropylene 3.0-7.0, 1-2 needle (toe & heel)). Principles of surgical management 5/28/2024 23 Vascular trauma 2024

24. Heparin use: commonly used. 5000 IU if heparin SC given if no trauma to head & solid organ Before application of clamps 5000 IU of heparin is given intravenously. Heparinised saline solution should be used for irrigation of opened vessels Protamine sulphate Often used to reverse but not necessarily always. Needle should be passed from within outside of the artery . Principles of surgical management 5/28/2024 24 Vascular trauma 2024

25. Arterial ligation is done in different methods: Direct ligature Trans fixation sutures Over sew technique Each clamp is released once and reapplied to check the forward flow and backflow. Segment distal to the procedure is palpated for adequate pulsation. Heparin should be given for 5–10 days ?? Immobilisation for 2 weeks. Principles of surgical management 5/28/2024 25 Vascular trauma 2024

26. 10. Classification of Arterial Substitutes: A. Vascular/natural graft : the Veins undergo arterialisation . Arterial allograft – Not used. Arterial autograft – Internal mammary artery (common), internal iliac artery. Arterial xenograft – Bovine carotid artery graft – not used. Venous autograft – LSV(common), SSV, basilic vein, cephalic vein. Venous allograft – Umbilical vein graft. B. Prosthetic grafts: A. Textile grafts - - Dacron graft – Knitted or woven or crimping or velour types. - Teflon graft – Knitted or woven or crimping or velour types. B. Non-textile semi - inert polymer graft - - ePTFE graft – Expanded polytetrafluoroethylene graft. Principles of surgical management 5/28/2024 26 Vascular trauma 2024

27. The methods of arterial suturing are: All layer simple lateral sutures : Carrel’ s triangulation technique Single stitch, end-to-end suturing Inlay method of suturing End-to-side suturing of the arteries Four quadrant technique Parachute end-to-side suturing Kunlin suture Nonsutured anastomosis : New method Principles of surgical management 5/28/2024 27 Vascular trauma 2024

28. 5/28/2024 Vascular trauma 2024 28 Types of vascular injury

29. 1. Spasm Reflex contraction of the vessel wall Diagnosis can only be made on angiography or surgical exploration/an arteriotomy . Can be Intimal detachments: the only way to find out is to “open and look”. M gt Local application of warm saline or injection into the adventitia of papaverine or lidocaine may help in relieving the spasm. 5/28/2024 29 Vascular trauma 2024

30. 2. Intimal flaps/tear The artery is stretched and compressed against the wall of the temporary cavity Results adventitial haemorrhage first, then breaks in the tunica media, and finally disruption of the intima with or without the prolapse of an intimal flap. Causes thrombosis Minor degrees of contusion may give no clinical signs and heal spontaneously. Surgical intervention in case of Progressive ischemia. 5/28/2024 30 Vascular trauma 2024

31. 3. Subintimal hematoma Contained intramural hematoma. Can have occlusive effect if it is circumferential. Intimal damage is usually too extensive to allow for resection and anastomosis . Resection back to healthy tissue and replacement with a vein graft is the operation of choice. 5/28/2024 31 Vascular trauma 2024

32. 4. Dissection of vascular walls A focal intimal tear or injury usually triggers a dissection A dissection involves an abnormal blood flow which separates the layers of the vessel wall. Can Occludes the vessel lumen and its branches. The extent and clinical severity of a dissection depend on multiple factors including: Location and size of the intimal injury: common in aorta. Systemic blood pressure, and Preexisting vascular disease Devastating effect if it is around the renal arteries Options of management: medical and surgical. 5/28/2024 32 Vascular trauma 2024

33. 5. Lateral Laceration / punctate wound/side hole Vessel continuity remains intact but a portion of the wall is torn open or punctured, this bleeds continuously and significantly than transected resulting in a pulsating haematoma . Direct repair by suture is possible only for small, clean-cut lacerations of large arteries, except if there is a risk of stenosis . Options: over sew or patching. Sutures should be inserted 1 mm apart and about 1 mm from the wound edge using continuous 5/0 – 6/0 synthetic vascular suture. 5/28/2024 33 Vascular trauma 2024

34. 6. Complete Transection The vessel wall is completely transected transversely and causes localized hematoma commonly non- pulsatile . Hemostasis achieved by vascular contraction and bleeds less. Option: End-to-end anastomosis or graft repair is done. 5/28/2024 34 Vascular trauma 2024

35. 7. Pseudo aneurysm Patients presenting late or in cases of missed diagnosis. They tend to occur more often with low-energy small fragment wounds, may not have large entry wounds. The patient presents with a pulsating haematoma . Options: simple suture, vein patch or resection of the damaged segment and replacement with interposition of a vein graft. Extra-anatomic bypas with prosthetic or venous graft is also best option. 5/28/2024 35 Vascular trauma 2024

36. 8. A-V fistula (AVF: Arteriovenous fistula) Abnormal communication of artery and vein leading to steal syndrome, where arterial blood goes to vein or viceversa . limb be viable and show no signs of ischaemia , an A-V fistula may be allowed to “mature”, rendering the surgical approach easier and giving time for the full development of collateral circulation; or allowing for referral to a skilled vascular surgeon if possible. Options: simple repair, resection and grafting (venous of prosthetic) A flap of soft tissue must be placed between the repaired artery and vein. 5/28/2024 36 Vascular trauma 2024

37. Conservative mgt Small pseudoaneurysm ,intimal dissections,small intimal flaps ,small AVF in extremity Confirm healing with serial imaging 1-2wk 5/28/2024 Vascular trauma 2024 37

38. Venous injury more difficult to diagnose than arterial injury The only signs may be dark and steady bleeding from a wound or, in a closed wound, a massive haematoma . Acute venous insufficiency usually presents within 24 hours as massive oedema in a cool, bluish limb. chronic insufficiency manifests itself with the signs of venous stasis: oedema , skin discolouration , and even ulceration. 5/28/2024 Vascular trauma 2024 38

39. Venous repair Venous injuries are inherently more difficult to reconstruct due to their propensity to thrombose . Small injuries without loss of tissue can be treated with lateral suture repair. More complex repairs with interposition grafts may thrombose but this typically occurs gradually over 1 to 2 weeks. During this time adequate collateral circulation develops, which is sufficient to avoid acute venous hypertension. 5/28/2024 Vascular trauma 2024 39

40. Venous injuries repair is mandatory for Superior Vena cava , inferior vena cava proximal to renal veins and portal vein ?? SMV should be repaired ,>80% survive following ligation Left renal vein ligated close to IVC due collateral collection 5/28/2024 Vascular trauma 2024 40

41. Commonly injured by penetrating. All the 3 parts are injured with equal frequency. 1/3 has brachial plexus injury Proximal control at subclavian artery/supra/infra/ clavicular . Options: repair , graft or bypass & endovascular technique. 1. Axillary artery injury 5/28/2024 41 Vascular trauma 2024

42. 2. Brachial artery injury 50% UE vascular injury. Injury of ulnar or median nerve are present in up to 50%. Commonest cause of UE Amputation. 21% develop Compartment syndrome Most (82%) are managed with vein grafts or primary repair, with outcomes of infected graft (4.7%), graft thromboses (9%), and amputation (9%). 5/28/2024 42 Vascular trauma 2024

43. 3. Ulnar , Radial artery injury Majority of upper extremity vascular injuries. 81% are by penetrating (stab is more common). Blunt is associated with fracture or elbow dislocation. Allen's test done before ligation. All Radial & most Ulnar arteries can be safely ligated if isolated trauma. 5/28/2024 43 Vascular trauma 2024

44. 6. Femoral artery injury Mostly with penetrating trauma SFA is the most commonly injured 10% has nerve injury Hemorrhage is the feared complication if not treated 46% femoral vein involvement. Options: repair, graft & endovascular techniques. 5/28/2024 44 Vascular trauma 2024

45. 7. Popliteal artery injury Mostly by blunt trauma. 30% with knee joint dislocation Limb ischemia is the feared complication. Options: repair, graft reconstruction and endovascular techniques. 5/28/2024 45 Vascular trauma 2024

46. 8. Anterior, posterior tibial & peroneal artery injury Clinically silent & true incidence is unknown. PTA injured in 13% of lower extremity vascular traumas. (ATA in 8.6%, both-1.1%) 64% has TF fracture 10% causes amputation Ligation is tolerable. Options: observation, ligation (only 1) & repair. 5/28/2024 46 Vascular trauma 2024

47. Post-op complications & follow up (24-72hrs) Intimal flap dissection is an on table problem - procedure may be insufficient and on table decision may be taken to change over to graft interposition. Neointimal fibrous hyperplasia at suture lines of the graft Haematoma Torrential bleeding Infection/surgical site and graft infection (2%) Reblock /occlusion/ Stenosis : (early <30days, late>30days) Suture breakdown/Leak / Graft failure: A revision procedure tried. Gangrenous change & amputation Reperfusion injury are the complications Thrombosis formation/limb ischemia, stoke, MI, DVT & PTE. 5/28/2024 47 Vascular trauma 2024

48. Complex limb injuries High rate of amputation “Reperfusion is priority before fracture immobilization “ Bone first?? Case 1: stable # with vascular injury- Repair + fasciotomty  Ex fix Case 2 : unstable # ,segmental loss Shunt + fasciotomy Ex fix+debridment repair 5/28/2024 Vascular trauma 2024 48

49. Thrombosis: Thrombosis of an anastomotic suture line can be due to infection but is usually due to a technical error ]at peration . Such errors include: Inadequate arterial debridement in war wounds Residual distal arterial thrombus Severe stenosis at the suture line Twisting, kinking, or external compression of a vein graft. Subintimal injury The corrective is to re-operate and perform a new repair. Post-op complications & follow up (24-72hrs) 5/28/2024 49 Vascular trauma 2024

50. Fasciotomy indications : 1.Delay of more than 4 hours between injury and restoration of flow; 2.Prolonged period of hypotension or shock; 3.Obvious oedema pre-operatively or developing during or after the surgical procedure; 4.Combined venous and arterial injury in major vessels; 5.Massive associated soft-tissue injury; 6.Arterial ligation or obvious failure of the repair; 7.Isolated major venous injury. 5/28/2024 Vascular trauma 2024 50

51. fasciotomy may be performed once the vessels have been isolated and clamped and before vascular repair Delay can cause venous congestion poor outflow and compromise repair ICRC: distal fasciotomy for all vascular injury 5/28/2024 Vascular trauma 2024 51

52. Post op care Check perfusion regularly Limb splinted Limb elevation Active isometeric exerscise Systemic anticoagulants ?? 5/28/2024 Vascular trauma 2024 52

53. Prognosis Level and type of vascular injury Collateral circulation Shock/hypotension Tissue damage (crush injury) Warm ischemia time Patient factors/medical conditions 5/28/2024 Vascular trauma 2024 53

54. Reference SRB surgical operations text and atlas Trauma 7 th edition Schwartz principles of surgery, 11 th edition, Sabiston text book of surgery, 20 th edition 5/28/2024 Vascular trauma 2024 54

55. Upper limb vasculature E xposure 5/28/2024 Vascular trauma 2024 55

56. Lower limb vasulature approach 5/28/2024 Vascular trauma 2024 56