Lower extremity Vascular Trauma: Challenges & Pitfalls

In this presentation, the most life/ limb-threatening problems in vascular injury of the lower extremities and their managements are presented.

1. Vascular trauma, Lower extremity: Challenges & Pitfalls Dr. Pezhman Kharazm Vascular Surgeon Golestan University of Medical Sciences

2. The first priority in vascular trauma? Bleeding control

3. Bleeding control 1. Junctional zone: Manual compression Endovascular control Tourniquet Open surgical proximal control Direct approach New devices (JETT & CRoC)

4. Manual compression

5. Endovascular control

6. Endovascular control Axillary Artery Femoral Artery

7. Open surgical proximal control

8. Open surgical proximal control

9. Junctional Emergency Treatment Tool (JETT)

10. Combat Ready Clamp (CRoC)

11. Combat Ready Clamp (CRoC)

12. Bleeding control 2. Non junctional: Manual compression Temporary wound closure Proximal control Tourniquet ( proximal or distal) Direct approach

13. Arterial injury: repair, ligation or shunt? Decision making depends on: Patient hemodynamic Limb viability Surgeon’s experience Instruments availability Specific arteries Estimated transport time

14. Decision making Ligation Internal iliac deep femoral (repair if stable) Muscular branches Single tibial artery Pedal branches Shunt/ Repair Common iliac External iliac Superficial femoral Popliteal Two or more tibial arteries

15. Common & external iliac arteries injury Ligation has a high likelihood of proximal limb loss Interval repair is poorly tolerated Then: shunt in complex cases ( 14F chest tube) ***securing sutures

16. Common & external iliac arteries injury If ligation is inevitable: Consider fasciotomy Monitor the patient’s condition Monitor the patient’s musculature

17. Shot gun trauma

18. Shot gun trauma

19. Femoral & Popliteal injuries The deep femoral artery often is not sufficient to prevent ischemia of the lower leg. The continuous-wave Doppler should be used in these scenarios to assess the perfusion. Ischemic limb should be repaired or shunted, otherwise later reconstruction is acceptable.

20. Tibial level injuries Control bleeding, reduce any fractures, warm and resuscitate the patient, and examine the foot with continuous-wave Doppler. ligation and Doppler assessment is the maneuver of choice for isolated tibial vessel trauma. If there is no Doppler signal after these steps, consider injury to more than one tibial vessel or to the tibial peroneal trunk.

21. Tibial level injuries Options for ischemic limbs: Attempt to restore flow with a shunt Perform vascular reconstruction Accept ligation and to continue expectant management. (consider 1 or 2 if no improvement)

22. Tibial level injuries Single tibial artery injury: consider ligation (Doppler confirmation) Tibial peroneal trunk or both tibial vessels injury: consider repair or shunt ( doppler assessment)

23. Venous injuries Repair is recommended for: Common femoral vein Popliteal vein Both femoral & deep femoral veins injury ****shunt if unstable or… ****anti coagulation is necessary if shunting for more than a few hours

24. Venous injuries Regardless of whether ligation or repair is performed, a period of leg elevation and gentle compression can help reduce the incidence of postoperative edema and possibly eventual venous insufficiency. Controversies exist.

25. Temporary vascular shunt Indications: Damage control surgery Complex skeletal injury requiring fixation Temporary restoration of flow during vein harvest Management of other injuries Multiple vascular injuries prolonged ischemia (>6 hours) Reimplantation of avulsed limbs Temporary flow for delayed reevaluation in a mangled extremity

26. Insertion Technique The injured blood vessel should be carefully dissected Fogarty balloon catheter thrombectomy Instillation of a heparinized saline solution into the proximal and distal ends of the injured vessels The vessel ends debridement Selection of an appropriately sized and contoured shunt Shunt insertion into the distal end, secured with thick (size 0) silk tie, and allowed to back-bleed proximal end insertion and secure with a silk tie and antegrade flow reestablishment Hand-held Doppler evaluation of flow

27. Insertion Technique Additional steps for transporting patients: splinting of the joint soft-tissue coverage of the shunted vessel Stapling the wound edges Vacuum dressings should not be applied directly to the vessel. The need for fasciotomy should be considered

28. Dwell Time Shunt-related complications such as thrombosis or dislodgement increase with time Shunt should be removed as soon as circumstances allow for definitive vascular repair Patency depends on the type of vessel shunted and the clinical scenario Patency rates as long as 52 hours have been documented

29. Anticoagulation May cause life-threatening bleeding from associated injuries. Most studies do not support the need for systemic anticoagulation Temporary vascular shunts remain patent and effective without systemic doses of heparin. Then: Generous use of regional heparin, using full anticoagulation only in rare cases of isolated vascular injury with close monitoring for bleeding complications.

30. Prophylactic Fasciotomy  The development of extremity compartment syndrome has profound implications for limb salvage Recognizing the onset is challenging, especially in patients who are being moved through multiple levels of care often at different medical facilities.

31. Prophylactic Fasciotomy Prophylactic fasciotomy should be considered in patients requiring shunt placement and any of the following: Severe extremity injuries (Abbreviated Injury Scale [AIS] score of ≥3 or Mangled Extremity Severity Score [MESS] of ≥5) Combined arterial and/or venous injury Prolonged ischemia or tourniquet time (>1 to 2 hours) Penetrating or crush mechanisms of injury Injury to proximal below-knee vasculature Associated open fractures or nerve injuries Significant intraoperative blood loss.

32. Thank you