Management of abdominal vascular injury

abdominal vascular injury, abdominal aorta, ivc, mesenteric vessels, abdominal trauma

1. MANAGEMENT OF ABDOMINAL VASCULAR INJURY DR BASHIR BIN YUNUS GENERAL SURGRY UNIT AKTH 3/12/18

2. OUTLINE INTRODUCTION EPIDEMIOLOGY AETIOLOGY ANATOMY PRESENTATION MANAGEMENT RESUSCITATION INVESTIGATIONS SURGICAL APPROACHES CHALLENGES COMPLICATIONS PRONOSIS CONCLUSION REFERENCES

3. INTRODUCTION Uncommon but highly lethal Exsanguinating Haemorrhage is the most important cause of early death Incidence of blunt trauma is about 5-10% Stab wounds to the abdomen 10.3% Gunshot injuries 20-25% Iatrogenic – oncological operations, percutaneous vascular procedures- cumulatively 5-75%. Varies widely for location and expertise Associated non vascular injury is seen in over 90%

4. ANATOMY Major vessels of the abdomen are in the retroperitoneal space and are divide into zones Zone 1 (midline) Supramesocolic Inframesocolic Zone 2 (upper lateral) Zone 3 (pelvic retroperitoneum)

5. ANATOMY

6. ABDOMINAL AORTA Branches

7. collaterals Celiac trunk with superior mesenteric artery through gastroduodenal Superior and inferior mesenteric artery Inferior Epigastric artery and internal thoracic Inferior mesenteric and internal pudendal Lumber arteries and internal iliac

8. Some important relations of the aorta Celiac plexus 3 rd and ascending part of the duodenum Left crus of the diaphragm

9. The abdominal aorta's venous counterpart, the inferior vena cava (IVC), travels parallel to it on its right side . The aorta sending its right common iliac artery to cross the left common iliac vein anteriorly .

10. PRESENTATION Shock; predominates over physical findings. The sign of peritonitis are often absent. Abdominal pain is usually present. It is often focal and may be associated with palpable mass. NB; Signs of shock in the absence of generalized peritonitis or visceral perforation should prompt the consideration of a vascular emergency . major vascular injury present with Shock out of proportion to injury extent

11. RESUSCITATION Usually present in sock which requires immediate exploration . Venous access wide bore ; blood samples; hemogram , blood group, electrolyte (routine laboratory evaluation are less helpful) Commence; fluid- crystalloid, colloid, blood transfusion.

12. MANAGEMENT

13. INVESTIGATIONS Critical patient : exploratory laparotomy. Stable patient: FAST plain film: GSW trajectory and pelvic fractures. CT/Angiography : useful in late penetrating trauma Intraoperative angiography; central hematoma, non exsanguinating

14. PRINCIPLES OF SURGICAL MANAGEMENT Expose Achieve proximal control Assess injury Restore flow

15. SURGICAL APPROACH NB; Cleaning from suprasternal notch to mid-thigh Long midline incision Quadrant packing; place at each quadrant to localize hemorrhage. Intraoperative auto-transfusion Exsanguinating hemorrhage on entry; (usually from aorta, IVC, liver or iliac vessels) Liver – Pringles maneuver Aorta – midline retroperitoneal hemorrhage- direct pressure with pad, expose aorta at diaphragmatic hiatus and clamp.(applicable iliac vessel bleed. But infrarenal exposure and clamping is prefered ). Proper exposure of area of bleeding for repair.

16. VASCULAR EXPOSURE AND CONTROL Supraceliac exposure; Most important for control of aortic emergencies Can be achieved rapidly with little risk of damage to the pancreas,intestine , vena cava or other visceral vessels Also safer because this area is less likely to be aneurysmal or atherosclerotic.

17. APPROACHED THROUGH THE GASTROHEPATIC LIGAMENT

18. DIVISION OF THE LEFT CRUS OF THE DIAPHRAGM

19. Clear the anterior, medial and lateral aspects of the aorta prior to applying the clamp to prevent the clamp from slipping away anteriorly with loss of control and disastrous result. Once the crura are divided , the aorta is encircled between the thumb and index finger of the operating surgeon’s right hand, lifted off the spine to ensure it is completely mobilized. Use of the index finger and a straight aortic clamp is applied

20. EXPOSURE OF THE VISCERAL AORTA Left medial visceral rotation; Mattox maneuver Modified Mattox maneuver

21. MATTOX MANEUVER Mobilizes the splenic flexure of the colon inferio -medially and then allows mobilization of the kidney, spleen and pancreas superior-medially. Completely exposes the anterior and lateral aspect of the aorta, gives direct access to the celiac trunk, superior and inferior mesenteric arteries

22. MODIFIED MATTOX MANEUVER Modified mattox maneuver is performed by allowing the kidney to remain in Gerota’s fascia and selecting a dissection plane that includes the spleen and the pancreas. These organs are then rotated superiorly and medially. This approach give excellent exposure of the celiac trunk, and the superior mesenteric artery. It also gives ready access to the left renal pedicle vessels.

23. Mobilization of the left colon along Toldt’s line . Reflection begins at the distal descending colon and extending the incision past the splenic flexure, around the posterior aspect of the spleen, behind the gastric fundus, and ending at the oesophagus .

24. The spleen and pancreas are also mobilized. With reflection of the spleen, pancreas, and colon anteriorly toward the midline, the anterior aspect of the aorta is exposed along with the origins of the left renal, superior mesenteric, and celiac arteries . The aortic hiatus (left crus) may need to be incised to provide additional cephalad exposure

25. NB; If access to the posterior aspect of the aorta is required, the left kidney is mobilized outside Gerota’s fascia, along with the other viscera.

26. PITFALLS OF MATTOX MANUEVER Splenic injury Avulsion of Left descending lumbar vein ( comes off L renal vein)

27. INFRARENAL AORTIC EXPOSURE Involves incision of the ligament of Treitz and mobilization of the fourth portion of the duodenum superiorly and to the right The left renal vein serves as a reference to identify the superior extent of dissection.

28. EXPOSURE OF VENOUS STRUCTURE RIGHT MEDIAL VISCERAL ROTATION Kocher’s maneuver Extended Kocher's maneuver Super-Extended Kocher ( Cattell - Braasch Manuever )

29. KOCHER MANEUVER 1. Identify duodenum 2. Incise posterior peritoneum immediate lateral 3. Reflect the duodenum and pancreatic head from retroperitoneum 4. Allows access to infrahepatic IVC, distal CBD, duodenum, pancreatic head, right renal hilum

30. EXTENDED KOCHER MANEUVER Carry the classic Kocher incision caudally along white line of Toldt Access to entire infrahepatic IVC, right kidney/R hilum, right iliac vessels

31. Cattell - Braasch Manuever ; Super-Extended Kocher Extended Kocher+ incise line of fusion of small bowel mesentary to posterior peritoneum Swing small bowel and right colon out of abdomen

32. CATTELL-BRAASCH Exposes entire inframesocolic retroperitoneum, infrarenal aorta, IVC , L renal hila, L iliac vessels, superior mesenteric vessels.

33. CATTELL-BRAASCH The right colon, duodenum, and head of the pancreas are mobilized to expose the vena cava , the iliac veins, and the right renal artery and vein. The renal artery is exposed by retracting the vein either cephalic or caudal.

34. Control of vena cava. Pressure using digital compression or sponge sticks should be sufficient to control most venous injuries and avoids circumferential dissection.

35. Pitfalls of Cattell-Braasch Maneuver Injury to the SMV at the root of the mesentry

36. IVC BIFURCATION The bifurcation of the IVC is obscured by the right common iliac artery. This vessel should be divided to expose extensive vena caval injuries of this area. The artery MUST be repaired after the venous injury is treated or AMPUTATION occurs in as many as 50% of patients.

37. NOTORIOUSLY DIFFICULT: Retrohepatic IVC Suprarenal aorta Celiac axis Proximal SMA Junction of SMV, splenic and portal veins Bifurcation of IVC

38. TECHNIQUE OF CONTROL Different methods for controlling bleeding are demonstrated From left to right: doubly applied vessel loop, Bulldog (small metallic vascular clamp), balloon catheter, loop of ligature, vascular clamp

39. SATINSKY CLAMP

40. De Bakey Aortic Clamps Atraumatic clamps ; curve, straight or angled

41. AORTIC OCCLUDER

42. SIZES OF SUTURES FOR VARIOUS VESSELS TYPE ; POLYPROPYLENE AORTA ; 3-0 OR 4-0 ILIAC ATERIES; 5-0 RENAL ; 6-0 SMA/SMV; 5-0 IVC; 4-0 OR 5-0

43. PRINCIPLES OF ARTERIAL REPAIR Several factors dictate the approach to emergency arterial repair, including; the extent of contamination , size of the arterial defect , the adequacy of collateral circulation .

44. When possible, primary repair is indicated ( lateral repair, primary end-to-end anastomosis, or arterial reimplantation ). Associated with good long-term results and avoids use of a conduit. When adequate collateral circulation exists, ligation without repair is indicated . In the absence of contamination , prosthetic conduits provide the best choice for bypass of major intra-abdominal arteries. In the presence of anything in excess of minor contamination, autogenous material should be used when vascular reconstruction is required.

45. REPAIR OF SUPRARENAL AORTA OPEN Acess Exposure and control of bleeding Primary repair (does not narrow lumen more than 50%) Larger defect; patch angioplasty using prosthetic material, arterial autograft , aterial homograft In the presence of fecal contamination, biologic material is used Saphenous vein is inappropriate due to concern about strength and durability (deep veins of the leg are more appropriate)

46. ENDOVASCULAR THERAPIES Used selectively in patients with traumatic and iatrogenic abdominal vascular injury. The use of endostents ; Blunt intimal injury to the abdominal aorta Late hemorrhage from the abdominal aorta The presence of an aortocaval fistula Inferior vena cava (associated thrombosis) Control of Intimal flap in blunt renal and iliac artery injuries

47. DAMAGE CONTROL LAPAROTOMY Injuries to the great vessels of the abdomen are ideal candidates for damage-control laparotomy. They are uniformly hypothermic , acidotic, and coagulopathic on completion of the vascular repair, and a prolonged operation would lead to their demise . VASCULAR DAMAGE CONTROL INVOVES; Ligation of vessel Packing Placement of temporal shunts to restore continuity when arterial ligation will not be tolerated

48. COMPLICATIONS Thrombosis Dehiscence of suture line Infection Narrowing Vascular enteric fistular (use at the suture line) Endovascular complications; Endoleak Stent graft migration Failure of stent graft integaration Aneurysm

49. PROGNOSIS Mortality rates for abdominal vascular trauma vary depending on the vessel or vessels injured : Suprarenal aorta - 60% SMA - 40-80% Superior mesenteric vein (SMV) - 20% Combined injury to the suprarenal aorta and IVC – 100% Infrarenal abdominal aorta - 50% Infrarenal vena cava - 30% Renal artery - 15% Iliac artery - 40% Iliac vein - 30%

50. CHALENGES Failure to detect early Transport and Communication Trained Staff, ability to handle Case load and Infrastructure

51. CONCLUSION Abdominal vascular injuries are uncommon although lethal conditions following trauma, that requires prompt and expert management. High index of suspicion for major vascular injury in a patient with Shock out of proportion to injury extent

52. REFERENCES Cameron, JL. (2014). Abdominal Trauma. (11th Ed ). Current Surgical Therapy ( pp 1010-1026). Philadephia , PA: Elsevier Saunders Hirshberg A, Mattox KL: Top Knife: The Art and Craft of Trauma Surgery . tfm publishing Ltd, Harley, Shropshire , United Kingdom, 2005 John J R, Cameron M A. Abdominal vascular injury. Maingot’s abdominal operations. 12 th Ed. p p 261-275. The McGraw-Hill Companies. 2013 David V F. Injuries to the great vessels of the abdomen;Trauma And Thermal Injury . ACS Surgery: Principles and Practice. WebMD Inc. 2007

53. 5. Lenworth M J, Stephen S L. A dvance Trauma O perative M anagement. 2 nd Ed. American college of Surgeons 2010. 6. Stephen A T, John G, Brian J D. Abdominal vascular injury. www.emedicine.Medscape.com 7. Gustavo s. Jean M P, Hofer R N et al. iatrogenic operative injuries of abdominal and pelvic veins; a potential lethal complication. Journal of vascular surgery. 2004. 39:5. 931-935