Transcript APPROACH TO VASCULAR INJURY - wickUP

APPROACH TO
VASCULAR INJURY
BY DR SIKHOSANA
Mechanisms of injury
Penetrating
 Blast
 Blunt
 iatrogenic
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Pathophysiology
Missile damage is related to the velocity
 Shotgun causes multiple perforations and
can cause embolization
 Blunt trauma results from shearing or
distraction
 Vascular spasm occurs at or distal to the
injury due to the unapposed sympathetic
constriction, it is not the cause for
ischaemia
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Hard signs
Pulsatile bleeding
 Expanding haematoma
 Thrill or bruit
 Pulse deficit
 ischaemia
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Soft signs
History of a significant bleed
 Small non expanding haematoma
 Associated nerve injury
 Proximity to a major vessel
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Unclear presentation
Thorax injuries- suspect if there is a
widened mediastinum, persistent shock,
large haemothorax
 Intimal injury- the pulses maybe intact but
the exposed collagen is very thrombogenic
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Indications for investigation: neck
Zone I and III
 All gunshots
 Suspicion post doppler of zone II
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Mediastinum
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Fracture of 1st,2nd ribs, sternum and scapula
Sterno clavicular joint dislocation
Trans axial gunshot
Widened mediastinum
Obliteration of aortic notch, left apical pleural
cap, aorto-pulmonary window
Left haemothorax
Oesophageal and tracheal deviation to the right
Depression of left main bronchus
Limbs
Multiple fractures
 Multiple penetrating injuries
 Shotgun
 Knee/elbow dislocation
 Degloving injury
 Gunshot tract along the long axis of the
vessel
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Imaging modalities
Duplex ultrasound
 Angiography
 CT angiography
 MRA
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Duplex ultrasound
Combines pulsed doppler and real time B
mode ultrasound imaging
 Advantages- non invasive, cheap, no
radiation and sensitive
 Locally used for neck zone II and single
peripheral injuries
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Angiography
Gold standard imaging and there is a
therapeutic option, although it is invasive
 Features suggestive of injuryextravasation of contrast, dilatation due to
intimal injury, narrowing, occlusion, filling
defects and AV fistula
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CT angiography
Sensitivity and specificity of 90-100%
 Advantage is that it is non invasive and
rapid
 Disadvantages – lack of therapeutic
options, artifacts from foreign bodies,
streak artifacts simulating intimal tears
and the imaging of the arch not good on
CT
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MRA
Has good sensitivity
 Not ideal due to the time taken for the
investigation
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Bleeding control
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Pressure
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balloon
Management
All vascular injuries should be repaired as
ASAP to avoid delayed bleeding,
compressive haematoma and limb
compromise
 We do not believe in conservative
management of minimal arterial injuries
because the history is unpredictable, poor
patient compliance and too late
presentation of complications
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Mangled extremity severity score
Skeletal/soft tissue injury
 Limb ischaemia
 Shock
 Age
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Score of >7 is accurate for predicting
eventual need for amputation
Diagnostic fasciotomy
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More than 6 hours presentation
Prophylatic fasciotomy
Prolonged hypotension
 Extensive soft tissue injury
 Arterial and venous injury
 Bone plus vascular injury
 Delayed vascular repair
 Inability to assess the patient, e.g.
head/spinal injury
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Therapeutic fasciotomy
Increased tissue turgor
 Extensive deep haematoma in the
presence of ischaemia
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FASCIOTOMY BEFORE VASCULAR REPAIR
Principles of vascular repair
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Digital or sponge pressure and catheter to
control bleeding
Prophylatic antibiotics
Access available to the groin for the graft
Wide exposure with proximal and distal control
Edges debrided to healthy intima
Embolectomy and flushing with heparin saline
Vascular repair before ortho
Adequate tissue cover of the vascular repair
Techniques of repair
Lateral – for wide calibre vessels
 Patch- to prevent stenosis
 End to end- single tethering stitch should
hold and < 4mm vessel should have
interrupted sutures
 Interposition graft- NB similar size with
the injured vessel
 Ligation- gross contamination and
unstable patient
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Types of grafts
Vein- no cost and low infection rate
 Arterial- same advantages as the vein but
the donor site may need to be replaced
 Synthetic- ? Higher infection risk,
expensive and poor patency across joints
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Causes of graft thrombosis
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In flow
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Anastomosis – intimal injury, adventitia,
tension, stenosis, poor graft
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Run off
Primary amputation
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Dead leg
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2 or more dead compartments
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Mangled limb
Endovascular
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Embolisation
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Stenting
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Balloon occlusion
Conclusion
All vascular injuries should be repaired as
soon as they are identified
 We do not have enough man power to
treat minimal injuries consevatively
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