Transcript Vascular trauma in extremities

Vascular trauma in
extremities
Dr Angela Kong
Princess Margaret Hospital
Overview
• Diagnostic approach to patients with
vascular injuries in extremity
• Types of vascular injuries and subsequent
management
• Principle and method of vascular repair
• Concept of damage control surgery in
peripheral vascular injuries
Diagnoses – Physical
Examination
 Identify patients
who have HARD
signs
 Need immediate
surgical
exploration
Diagnoses – Physical
Examination
• Hard signs which need
immediate surgery
• Pulsatile bleeding
• Expanding haematoma
• 6P
• pallor
• paresthesia
• paralysis
• pain
• pulselessness
Signs of BLEEDING + ISCHAEMIA • poikilothermia
Diagnoses – Physical
Examination
• Patients who have
suspected vascular injuries
do not need immediate
surgery
• Look for SOFT signs
Diagnoses – Physical
Examination
• Soft signs – still have
time for further Ix
• History of moderate haemorrhage
• Diminished pulse
• Peripheral nerve deficit
Further Imaging modality
Diagnoses – Imaging
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Role of USG Duplex
Non invasive investigation
Drawbacks:
Operator dependent
Sonographer not always available
Role limited in both penetrating and blunt
vascular injuries
Diagnoses – Imaging
• Role of CTA
• Achieved sensitivity 82% and specificity 92%
• In the absence of artifacts, it achieved 100%
sensitivity and specificity
• Only in patients with soft signs of injury
Prospective evaluation of multidetector computed tomography for
extremity vascular trauma; Inaba K, Branco BC, J Trauma. 2011 Apr.
Diagnoses – Imaging
• For patients treated in the OR
• When do we need on-table arteriogram
• Unclear location or extent of vascular
injury
• Extensive soft tissue injury, Fracture or
dislocation
• Trajectory of penetrating injury parallel to
artery
• Multiple wounds
• Shotgun injury
Hard signs
Soft signs
Management – non operative
• Minimal vascular injuries can be treated
conservatively
The Natural History of Clinically Occult Arterial Injuries: A Prospective Evaluation;
FRYKBERG, ERIC; Journal of Trauma-Injury Infection & Critical Care: May 1989
Minimal vascular injuries
• Defined as identified damage to a blood
vessel, with no clinical hard sign
• Soft sign may not be present or not related to
the injury
• Diagnosed in arteriogram
• Demonstrate not limited contrast flow
no contrast outside normal vessel
• Conservative treatment given , avoid
necessary exploration
Interpretation of Angiogram – Minimal
vascular injuries
Focal narrowing or constriction
Interpretation of Angiogram – Minimal
vascular injuries
Intimal flap without flow limit
• Raised luminal surface
• In either proximal or distal
orientation
• Flow present , no
extravasation
Interpretation of Angiogram – Minimal
vascular injuries
Small Pseudoaneurysm
• Incomplete laceration
• < 2 cm safely watched
• Need for further
evaluation
• Determine the nature and
extent by further
Arteriogram 2 to4 weeks
later
CTA - Who needs intervention
Interpretation of Angiogram – injuries that
warrant exploration
Extravasation
• Coarse , irregular
accumulation of contrast
that persist in to venous
phase
Interpretation of Angiogram – injuries that
warrant exploration
Occlusion
• Absence of flow beyond a
focal point
• Preexisting
atherosclerotic disease
Interpretation of Angiogram – injuries that
warrant exploration
Intraluminal filling defect
• Intimal flap, emboli,
intramural haematoma
• Intraluminal thrombus
• Intravascular FB
Interpretation of Angiogram – injuries that
warrant exploration
AV fistula
• Persistent communication
between high pressureartery to low-pressure
vein
Management – Repair techniques
Simple Repair
Complex Repair
Quick and straightforward
No long suture line
Used in patients with
unfavourable physiology
Time consuming
For reconstruction
Unjustified in damage control
surgery
Lateral repair
Ligation of Vessels
Temporary intraluminal shunt
End to end anastomosis
Patch repair
Interpositional reconstruction
Simple repair techniques
• Lateral repair
• Repair with maintaining perpendicular
orientation as to avoid stenosis
Simple repair techniques
Ligature
Not all arteries in extremities can be ligated
Can be
Cannot be
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High brachial
One of the forearm
Profundas femoris
Single below knee
Subclavian artery beyond
first part
SFA
Popliteal
Axillary artery
SMA
CFA
EIA
Simple repair techniques
• Temporary Intraluminal shunt
• Used when bone and joint should be fixed first
• Prosthetic conduit placed within the vessel
lumen across the injured segment
• To establish blood flow to distal until a
definitive vascular reconstruction
• Patency can be maintained as late as 24-36
hours
• Protected by coagulopathy during deadly triad
phase
Complex repair techniques
 End to end anastomosis
 Patch repair – venous
graft/ synthetic graft
Complex repair techniques
 Interpositional graft
Conclusion
 Early diagnosis and prompt treatment are key to
successful Mx of vascular injury in extremities
 Arteriogram as the gold standard imaging modality
 Findings in arteriogram can help determine the need for
further exploration
 Definitive but lengthy reconstruction should be sacrificed
for poor physiological reserve before it becomes
irreversible
THANK YOU