RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in
Éirinn
Title Vascular Emergencies
Class Senior Cycle I
Course Acute Vascular Emergencies
Vascular Emergencies
Part 1 : Acute Limb Ischemia
Part 2 : Vascular Trauma
Part 3 : Ruptured AAA
Acute Limb Ischemia
Any sudden decrease in limb perfusion causing a
potential threat to limb viability
Acute Limb Ischemia
Classification
categories
Acute Limb Ischemia
Aetiology
Acute Limb Ischemia
ALI is the result of occlusion of a native
artery or vascular/endovascular
prosthesis.
In situ thrombosis
or embolism can cause native arterial
occlusion
Acute Limb Ischemia
Embolism : Greek “Embolos” “Plug”
Atrial fibrillation due to ischaemic heart disease 80% mural thrombus
Aortic aneurysms
Atheroembolism
Rheumatic mitral valve disease
Aetiology of acute lower limb ischaemia
Thrombosis
• Atherosclerosis
• Popliteal aneurysm
• Bypass graft occlusion
• Endovascular stent or stent graft occlusion
• Iatrogenic (localised arterial dissection post endovascular
intervention, e.g. arterial closure device failure)
• Pro-thrombotic conditions
Aetiology of acute lower limb ischaemia
Embolism
• Atrial fibrillation
• Mural thrombosis
• Vegetations
• Proximal aneurysms
• Atherosclerotic plaque
Aetiology of acute lower limb ischaemia
Rare causes
• Dissection
• Trauma (including iatrogenic)
• Illicit drug use
• External compression
• Popliteal entrapment
• Cystic adventitial disease
• Iliac endofibrosis
Acute Limb Ischemia
6 P's
Department of Surgery
RCSI
Acute Limb Ischemia
The pain is severe and frequently resistant to analgesia
Calf pain and tenderness with a tense muscle compartment indicates severe
muscle ischaemia or necrosis and often
irreversible ischaemia
Sensorimotor deficit including muscle paralysis and paraesthesia is indicative of
muscle and nerve ischaemia with the potential for salvage if treated promptly
Department of Surgery
RCSI
Acute Limb Ischemia
Initial management
High mortality rate
Dehydration, cardiac failure, hypoxia and pain should all be managed
Department of Surgery
RCSI
Acute Limb Ischemia
Time
0-6 hrs Painful, marble white foot Neurosensory deficit (Reversible)
6-12 hrs Mottled appearance due to capillary pooling (Partly reversible)
Blanches on digital pressure
Over 12 hrs Fixed staining: mottled areas coalesce and no longer blanch to pressure,
Anterior compartment red and tender (Irreversible)
Department of Surgery
RCSI
Acute Limb Ischemia
Irreversible (category III) leg ischaemia
Surviving patients should be resuscitated and stabilized
before considering amputation
Department of Surgery
RCSI
Acute Limb Ischemia
Revascularisation
Viable (category I ischaemia)
Threatened (category IIa ischaemia)
Immediately threatened (category IIb ischaemia)
Department of Surgery
RCSI
Acute Limb Ischemia
CT Angiogram
Angiography
Acute Limb Ischemia
Surgery ( Embolectomy / Thrombectomy )
Emergency Bypass
Thrombolysis
Acute Limb Ischemia
Thrombolysis
Technique
rTPA
Acute Limb Ischemia: tPA Contra-
Indications
Contraindications to thrombolysis
• Active internal bleeding
• Pregnancy
• Stroke within 2 months
• Transient ischaemic attack within 2 months
• Known intracerebral tumour, aneurysm or arteriovenous
malformation
• Severe bleeding tendency
• Craniotomy within 2 months
• Vascular surgery within 2 weeks
• Abdominal surgery within 2 weeks
• Puncture of a non-compressible vessel or biopsy within
10 days
• Previous gastrointestinal haemorrhage
• Trauma within 10 days
Part 2: Vascular Trauma
Vascular Trauma
Fewer than 10% of patients with polytrauma have
associated vascular injuries, but these injuries can
cause significant morbidity and mortality
Vascular Trauma
Blunt
Thrombosis
Penetrating
Bleeding
Vascular Trauma
Sequelae of vascular injuries
•
Acute haemorrhage
•
• Overt external bleeding
•
• Contained bleeding (e.g. in muscle compartment)
•
• Concealed bleeding (e.g. pleural cavity)
•
Hypovolaemia, shock
•
Haematoma with or without secondary infection
•
Delayed bleeding and rebleeding
•
Thrombosis: acute or delayed
•
Ischaemia: acute or delayed
•
Arteriovenous fistula
•
Pseudoaneurysm formation
Vascular Trauma
Types Of Injury
Intimal tear
Pseudoaneurysm
Dissection
thrombosis
Vascular Trauma: Clinical Presentation
Clinical presentation
Hard Signs
Severe bleeding
Shock
Expanding hematoma
Absent or weak pulses
bruit
Soft signs
Local stable hematoma
Minor continuous bleeding
Mild hypotension
Proximity to large vessels
Periclavicular trauma
Vascular Trauma
Normal pulse does not exclude injury
Upper limb rarely suffer from ischemia
Brachial plexus injury (Blunt , penetrating, OR)
Vascular Trauma
Diagnostic Evaluation
Unstable ----------immediate exploration
Stable
----------Contained
Vascular Trauma
Resuscitation A,B,C
Fluids
Crossmatch
Blood transfusion
Vascular Trauma
Diagnostic Evaluation
CT Angiogram
Angiography
*Plain Radiography (Fractures, dislocations {knee} )
Vascular trauma
Management options:
Medical
Endovascular (Embolization, Stent)
Surgical (Repair, Bypass, Ligation)
Thoracic Aorta
Caused by Penetrating 90%
Blunt
Proximal Descending
8000 death/y US
2nd Brain injury
Subintimal to total tear
CXR
CTA
Direct
Extravasation
Pseudoaneurysm
Intimal flap
Filling defect
Indirect
Periaortic hematoma
Mediastinal hematoma
Aortography
TEE
MRA
Pathogenesis Of Aortic Injury
Mobile ascending
Weak isthmus
Fixed descending
Mechanism Of Injury
Stretching
Sudden increase in BP
Osseous Pinch
Water Hammer Effect
Clinical presentation
MVA 80%
Falls 3m
Young
Seat belt
Airbags
Ejection
Steering wheel
Associated injuries
•
Closed head injury 51%
•
Multiple rib Fx 46%
•
Pulmonary contusion 38%
•
Pelvic 31%
•
Femoral 24%
•
Tibial 22%
•
Liver 22%
•
Upper limb 20%
•
Splenic injury 14 %
•
Other abdominal 14%
•
Maxilofacial 13%
•
Flail chest 12%
•
Diaphragmatic rupture 7%
•
Small bowel injury 7%
•
Lumbar spine 4%
•
Cervical spine 4%
•
Thoracic spine 4%
•
Spinal cord 4%
•
Myocardial contusion 4%
•
None 0%
Patients triage
Unstable mortality 90%
Stable
mortality 25%
Goal Sys BP 100mmhg mean less 80mmhg
HR less 100 B/M
Management Options
Surgical
Thoracotomy
Proximal Clamp (Lt CCA –Lt SC)
Distal Clamp (as proximal as possible )
Management Options
TEVAR
Neck Zones
Neck Zones
• Zone 2 injuries are explored by the standard carotid incision overlying
the anterior border of the sternocleidomastoid muscle.
• Zone 1 injuries may require a median sternotomy.
• Various techniques have been described to improve exposure of the
distal internal carotid artery in zone 3 injuries, including subluxation
of the mandible, mandibular osteotomy, excision of the styloid process,
etc.
Abdominal Vascular trauma zones
Abdominal Vascular Trauma Zones
Central retroperitoneal haematomas (zone 1) are formally explored due to the high incidence of
associated major vascular, pancreatic or duodenal injuries, and the high morbidity and mortality if
these are overlooked.
Flank/perinephric haematomas (zone 2) caused by penetrating injuries should routinely
be explored, whilst haematomas caused by blunt trauma can be left alone if they are not expanding
and the urogram on contrast-enhanced CT scan is normal.
Zone 3 injuries, which are confined to or originate from the pelvis, are most often associated
with pelvic fractures; exploration in these cases can be hazardous and is usually avoided.
Retroperitoneal haematomas following penetrating injuries are usually explored to exclude major
vascular injuries.
Part 3 : Ruptured AAA
Ruptured AAA
Most patients with a ruptured abdominal aortic aneurysm
(RAAA) die before they can be operated upon
A contained rupture refers to blood outside the aneurysm sac that is
confined to the retroperitoneal space, tamponaded by the surrounding
tissues.
A free rupture refers to bleeding into the peritoneal cavity, without
tamponade.
Ruptured AAA: size associated risk
Screening programs :
Size & Risk of rupture 5.5 cm
AAA Diameter (cm) 12-Month Rupture Risk (%)
3.0-3.9 0.3
4.0-4.9 0.5-1.5
5.0-5.9 1-11
6.0-6.9 11-22
>7 >30
Ruptured AAA
Clinical presentation
The classic presentation of rAAA is a male patient older than 60 years
complaining of acute-onset abdominal and back pain.
On examination, the patient is usually pale, diaphoretic, and hypotensive with a
tender, expansile abdominal mass.
Rarely, there may be flank ecchymosis
Ruptured AAA: Differential Diagnosis
renal colic
diverticulitis
Pancreatitis
gastrointestinal hemorrhage
Inferior myocardial infarction
perforated ulcer.
Ruptured AAA: How to diagnose?
Clinical suspicion
Ultrasound
Computed Tomography Angiogram CTA
Ruptured AAA: Management
INITIAL MANAGEMENT STRATEGIES
Patient Triage and Transfer to Appropriate Institutions
Permissive Hypotension
Fluid resuscitation is minimized to maintain consciousness, to prevent ST depression,
and usually to maintain a systolic pressures of 70 to 80 mm Hg
Operative Preparation
Crossmatched
Large-bore access
arterial line
Foley catheter
draped awake before anesthesia
Ruptured AAA: which operation?
Open Surgical Repair
EVAR EndoVascular Aneurysm Repair
Ruptured AAA: Complications
Local Complications Bleeding, Thrombosis/Ischemia
Colonic Ischemia
Spinal Ischemia
Systemic Complications
Cardiac Complications
Respiratory Failure
Renal Dysfunction
Multisystem Organ Failure/ Death
