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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

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Vascular trauma in extremities

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  1. Vascular trauma in extremities Dr Angela Kong Princess Margaret Hospital

  2. 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

  3. Diagnoses – Physical Examination • Identify patients who have HARD signs • Need immediate surgical exploration

  4. Diagnoses – Physical Examination Signs of BLEEDING + ISCHAEMIA • Hard signs which need immediate surgery • Pulsatile bleeding • Expanding haematoma • 6P • pallor • paresthesia • paralysis • pain • pulselessness • poikilothermia

  5. Diagnoses – Physical Examination • Patients who have suspected vascular injuries do not need immediate surgery • Look for SOFT signs

  6. Diagnoses – Physical Examination • History of moderate haemorrhage • Diminished pulse • Peripheral nerve deficit • Soft signs – still have time for further Ix Further Imaging modality

  7. Diagnoses – Imaging • Role of USG Duplex • Non invasive investigation • Drawbacks: • Operator dependent • Sonographer not always available • Role limited in both penetrating and blunt vascular injuries

  8. 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.

  9. 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

  10. Hard signs Soft signs

  11. 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

  12. 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

  13. Interpretation of Angiogram – Minimal vascular injuries Focal narrowing or constriction

  14. Interpretation of Angiogram – Minimal vascular injuries Intimal flap without flow limit Raised luminal surface In either proximal or distal orientation Flow present , no extravasation

  15. 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

  16. CTA - Who needs intervention

  17. Interpretation of Angiogram – injuries that warrant exploration Extravasation • Coarse , irregular accumulation of contrast that persist in to venous phase

  18. Interpretation of Angiogram – injuries that warrant exploration Occlusion Absence of flow beyond a focal point Preexisting atherosclerotic disease

  19. Interpretation of Angiogram – injuries that warrant exploration Intraluminal filling defect • Intimal flap, emboli, intramural haematoma • Intraluminal thrombus • Intravascular FB

  20. Interpretation of Angiogram – injuries that warrant exploration AV fistula Persistent communication between high pressure-artery to low-pressure vein

  21. Management – Repair techniques

  22. Simple repair techniques • Lateral repair • Repair with maintaining perpendicular orientation as to avoid stenosis

  23. Simple repair techniques Can be Cannot be SFA Popliteal Axillary artery SMA CFA EIA Ligature Not all arteries in extremities can be ligated • High brachial • One of the forearm • Profundas femoris • Single below knee • Subclavian artery beyond first part

  24. Simple repair techniques • Temporary Intraluminal shunt • Used when bone and joint should be fixed first • Prosthetic conduit placed within the vessel lumenacross 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

  25. Complex repair techniques • Patch repair – venous graft/ synthetic graft • End to end anastomosis

  26. Complex repair techniques • Interpositional graft

  27. 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

  28. THANK YOU

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