extremity vascular injury, arterial injury, causes of arterial injury, mechanisms of arterial injury, investigations for arterial injury, treatment of arterial injury, , extremity vascular injuryfor medical students

1. Vascular Trauma
Joel Arudchelvam
Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura.

2. Vascular trauma /injury
• Injury to
– Arteries
– Veins
• Anatomical regions
– Extremity – limbs
– Abdomen and pelvis
– Thorax
– Head and neck

3. Extremity Vascular Injuries
• Common
• Results in limb loss at times loss of life
• Loss of earning capacity
• Economic burden
• Our experience (2011/2012 – NHSL)
– Popliteal arterial injury - 34.8% amputation rate.

4. Causes
• Road Traffic accidents
• Fractures and dislocations
• Trap gun
• Cuts and stabs
• Home accidents
• Iatrogenic
• Mechanism of injury
– Sharp / penetrating
– Blunt

5. Mechanism of disruption of flow at arterial level
• Transection
• Laceration
• Contusion
• Kink
• Intimal flap

6. Vascular trauma
Signs of a vessel injury
• Hard signs
• Soft sign
Hard signs
– Active bleeding
– Thrills, Bruits
– Signs of distal ischaemia
• Absent pulse
• Pain
• Pale
• Perishing Cold
• Paresthesia / anaesthesia
• Paresis / Paralysis
– Expanding hematoma

7. Signs of a vessel injury
• Soft signs
– Hematoma
– Injury close to a known neurovascular bundle
– Reduced pulse
• Paresis / paralysis and paresthesia / anaesthesia - late
signs
• Paresis and paresthesia
– viability of the limb is in immediate threat
• Anaethesia and paralysis

8. Problems with diagnosing distal
ischaemia after trauma
• Pain
– could be due to injury itself, may not have pain due to associated
nerve injury
• Pallor
– may be pale due to blood loss
• Absent pulse
– may be absent due to low blood pressure. Compare with othe limb
• Paresthesia , paresis
– may occur due to associated nerve, muscle injury or unresponsive
confused patient

9. Investigations
Investigations
•Hard signs
• urgent intervention
•Soft signs
• Observe
• Investigate

10. Investigations
• Hand held doppler
• Absent doppler flow
• Quality of signal
• Duplex scan (uss + doppler)
• Difficult to image in trauma
• Due to
• Pain
• Non cooperative patient
• Dressings

11. Investigations
• Angiography
– CT angiography
– Catheter angiography

12. CT ANGIOGRAPHY
Contrast into
peripheral vein

13. CT ANGIOGRAPHY

14. 3D Reconstruction

15. Conventional angiography / DSA
• Contrast directly into artery
• Traumatic
• DSA – Digital subtraction angiography
– done though a software after obtaining initial
images

16. Conventional angiography / DSA

17. Conventional angiography / DSA

18. Investigations
• Arteriography
– On table / DSA –
for multi level injury

19. Investigations
• Patient presenting with
– Soft signs
– Delayed presentation
– Avf
– False aneurysm
– Pre-op angiography

20. TREATMENT
Surgical Repair
• Prompt transport to operating room
• General anesthesia
• Cleaning entire limb and be able to visualize the distal end and
palpate distal pulses.
• Thigh prepared – for venous harvest
• Mobilisation and control of proximal and distal arterial ends
and trimming

21. Surgical repair (cont..)
• Balloon thrombectomy
• Systemic and distal heparinisation
• Interposition graft / Direct
approximation
– Unit experience – 88.2% RSVG
• Prosthesis
– lower patency
– infection

22. Surgical repair (cont..)

23. Complications of vascular injury
• Death
• Limb loss
• Compartment syndrome
• Reperfusion effects
• Volkmann ischemic contracture
• Intimal flaps and narrowing
• False aneurysms
• Traumatic AVF

24. Complications of vascular injury
• Death
• Limb loss
• Compartment syndrome
• Reperfusion effects
• Volkmann ischemic contracture
• Intimal flaps and narrowing
• False aneurysms
• Traumatic AVF

25. Volkmann ischaemic contracture

26. False aneurysms

27. Traumatic Arterio Venous Fistula

28. Combined Vascular and Skeletal
Trauma
– Revascularization / skeletal fixation (external
Fixator – EF)
• Bone fixation first if limb is not threatened
• Revascularisation first if limb is threatened

29. Primary Amputation
• Extensive crush injuries and soft tissue damage
– “mangled limb”
• life-threatening problems

30. Compartment syndrome
Reduced organ perfusion due to increased intra
compartment pressure.
Causes;
– Trauma (muscle contusion)
– Haematoma
– Reperfusion
– Intracompartmental extravasation of fluids
– Tight bandage, cast

31. Compartment syndrome
Clinical features
• Excessive pain - pain on passive movements
of the muscles.
• Numbness -e.g. anterior compartment results
in numbness at first toe web i.e. deep peroneal
nerve distribution)
• Tense swollen compartment

32. Compartment syndrome
Treatment
Recognize
Remove the cause
Surgery – fasciotomy

33. Compartment Syndrome
Treatment – Fasciotomy

34. In hospitals wherefacilities for
repair is not available
• ABCD
• Fasciotomy
• Discuss
• Transfer

35. Reperfusion effects
• Local
– Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
• Systemic
– Reperfusion syndrome;
• Hypotension
• ARDS
• Lactic acidosis
• Hyperkalemia
• Renal failure

36. Reperfusion effects
• Mangement
– Fasciotomy
– Hydration
– Mannitol, allopurinol
– O2
– Inotropes
– Ligation of vessel if not responding to above
measures

37. Summary
• Vascular injury;
– Resuscitate
– Assess viability and extent of injury
– Assess need for fasciotomy
– Early intervention and post intervention monitoring
– Rehabilitation

38. Thank You