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Uploaded byJoel Arudchelvam MBBS, MD, MRCS, FCSSL
Arterial trauma
This document discusses extremity vascular injuries, which can result in limb loss or death if not properly treated. The most common causes are road traffic injuries. Clinical features include signs of active bleeding, ischemia, pain, pallor, and pulse absence. Imaging like duplex scans and angiography can help diagnose the injury. Early surgical repair of damaged blood vessels is needed to restore blood flow. Complications include compartment syndrome, which requires fasciotomy to reduce pressure. Close monitoring is also needed after reperfusion to watch for systemic effects. With proper emergency treatment and surgery, many extremities can be saved from amputation.
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Arterial trauma
- 1. Joel Arudchelvam Consultant Vascularand Transplant Surgeon Teaching Hospital Anuradhapura
- 2. Extremity Vascular Injuries Injury to the vessels of the limbs Common (at THA – 95% of vascular injuries) Results in limb loss at times loss of life Economic burden
- 3. Causes Road Trafficinjuries – 60% Trap Gun Iatrogenic - 25% Penetrating / Sharp Blunt
- 4. Mechanism of disruptionof flow at arterial level Transection Laceration Contusion Kink Intimal flap
- 5. Clinical features Hardsigns Active bleeding Thrills, Bruits Distal ischemia Pain Pallor Pulse – absent Perishing cold Paresthesia /anaesthesia Paresis / paralysis Expanding hematoma Soft signs Hematoma Injury close to a known neurovascular bundle
- 6. Injury to PoplitealVessels Common Amputation rates are high. Our experience At NHSL Popliteal arterial injury – 32.5% of all injuries –commonest
- 7. Vascular injury Vessel NumberMechanism Iliac artery 2 Blunt Femoral artery 5 Iatrogenic – 3 blunt (RTA) – 2 Femoral vein 1 Penetrating Popliteal artery 5 blunt (RTA) -4 Popiteal vein 1 Penetrating Tibial arteries 4 blunt (RTA) Brachial artery 2 blunt (RTA)
- 8. Vascular injury Vessel NumberMechanism Iliac artery 2 Blunt Femoral artery 5 Iatrogenic – 3 blunt (RTA) – 2 Femoral vein 1 Penetrating Popliteal artery 5 (25%) blunt (RTA) -4 Popiteal vein 1 Penetrating Tibial arteries 4 blunt (RTA) Brachial artery 2 blunt (RTA)
- 9. Anatomy Fixed Proximally- Adductor Hiatus Distally- Soleal Arch. Collaterals – Not Very Effective Supplies Blood To Heavy Muscle Load
- 10. HISTORY Ligation –common practice during world War I / II Amputation Rate – 72.5% Korean War / Vietnam Conflict -32%
- 11. Reasons given Lackof Transport Sterility Conditions / Antibiotics Lack of Blood For Transfusion Anesthesia Prevented Repair on a Large Scale.
- 12. PROGNOSTIC FACTORS TimeInterval – Common Cause Of Limb Loss In Most Series In Our Series – THA – 8.2 Hours Mechanism Penetrating Wounds Better Outcomes Than From Blunt Injury Because Surrounding Tissue Damage To Be Less Severe. Difficult To Diagnose Because Associated Organ And Tissue Injuries Associated Injuries - Skeletal Injuries (Knee Dislocation , Popliteal Vein, Nerve, And Soft Tissue And Tendon)
- 13. Clinical features Hardsigns Active bleeding Thrills, Bruits Distal ischemia Pain Pallor Pulse – absent Perishing cold Paresthesia /anaesthesia Paresis / paralysis Expanding hematoma Soft signs Hematoma Injury close to a known neurovascular bundle
- 14. Clinical features Hardsigns Active bleeding Thrills, Bruits Distal ischemia Pain Pallor Pulse – absent Perishing cold Paresthesia /anaesthesia Paresis / paralysis Expanding hematoma Soft signs Hematoma Injury close to a known neurovascular bundle
- 15. Investigations Investigations • Hard signs •urgent intervention • Soft signs • Observe • Investigate
- 16. Investigations Imaging modalities Duplexscan Angiography CT angiography Catheter angiography
- 17. Investigations Imaging modalities Duplexscan Difficult in trauma due to pain, dressing, wound, patient not cooperating Angiography CT angiography Catheter angiography
- 18.
- 19. TREATMENT Surgical Repair ABCD/ resuscitation Repair as soon as possible General anesthesia Cleaning entire leg and be able to visualize the foot and palpate distal pulses. Contra lateral limb – for venous harvest Fasciotomy Medial approach
- 20. Surgical Repair ArterialEnds Trimmed Balloon Thrombectomy Systemic And Distal Heparinisation Interposition Graft Unit Experience NHSL - 93.3% RSVG ANP– RSVG Upto Now ? Prosthesis Infection Lower Patency
- 21. Surgical Repair lateralinjury – patch angioplasty Our series – none underwent Extra-anatomic bypass Severe soft tissue injury Our series – none underwent Skeletal fixation When to fix depends on the urgency of vascular repair, generally skeletal fixation first is preferred
- 22. Compartment Syndrome Reducedorgan perfusion due to increased compartment pressure. Causes, Vascular injury Reperfusion Haematoma contusion
- 23. Compartment Syndrome Treatment –Fasciotomy Who should do it?
- 24. Reperfusion effects Local Reperfusion injury – paradoxical death of already dying muscles after reperfusion Systemic Reperfusion syndrome; Hypotension ARDS Lactic acidosis Hyperkalemia Kidney shut down
- 25. Reperfusion effects Mangement Fasciotomy Hydration Mannitol, allopurinol O2 Inotropes Ligation of vessel if not responding to above measures
- 26. Primary Amputation Extensivesoft tissue damage / multiple skeletal fractures with bone loss “Mangled limb”
- 27. Summary Vascular injury; Resuscitate Assess viability and extent of injury Assess need for fasciotomy Early intervention and post intervention monitoring Rehabilitation
- 28.