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Vascular emergencies tcd sjh 2017
- 1. www.perfuse.net www.amnch.ie Vascular Emergencies Vascular Surgery UnitVascular Surgery Unit AMNCHAMNCH
- 2. www.perfuse.net www.amnch.ie Vascular emergencies (surgical) • Abdominal aortic aneurysm • Ischaemia – Acute occlusion • Thrombosis • Embolism – Arterial trauma
- 4. www.perfuse.net www.amnch.ie Presentation • Abdominal pain • Back pain • Collapse • Hypotension • High index of suspicion
- 5. www.perfuse.net www.amnch.ie Presentation • Abdominal pain • Back pain Differential diagnosis •Renal colic •Diverticulitis •Appendicitis
- 7. www.perfuse.net www.amnch.ie Imaging After Consultation with Vascular Surgery •Stable patient •Uncertainty •EVAR
- 9. www.perfuse.net www.amnch.ie • Immediate transfer to theatreImmediate transfer to theatre • Paint and drape before intubationPaint and drape before intubation • Central access if feasibleCentral access if feasible • Early clamp saves livesEarly clamp saves lives
- 11. www.perfuse.net www.amnch.ie Aortic Aneurysm repair • DuBost – first homograft repair 1951 • Modern graft materials 1953 Postoperative • 5 year survival = 63-84% ∀ ≈ disease matched control
- 12. www.perfuse.net www.amnch.ie Mortality • N=222 • Age 74 years (range 57–96 years) • Female = 43 • No surgery = 39 • Surgery = 183 – In-hospital mortality = 48.0% • 14.9% intra-operatively (14.9%), • 8.3% died within 24 h • Total mortality 55%
- 14. www.perfuse.net www.amnch.ie New technology Parodi et al Ann Vasc 1991
- 15. www.perfuse.net www.amnch.ie Anaesthesia & position • Epidural/spinal • Occasionally GA • Possible under LA ∀ ± Central access • Arterial line • OSI (radiolucent) table
- 16. www.perfuse.net www.amnch.ie Position • Arms tucked in by sides • Contrast pressure injector (angio) • C Arm • 2 tables – open/endo
- 17. www.perfuse.net www.amnch.ie Set up & equipment 1 2 Scrub/N 1 C-arm Monitors Injector Scrub/N 2
- 26. www.perfuse.net www.amnch.ie The Problem • 1992-2005 • 35 patients • Mean age 26 (3-80) • RTA 43% • Associated # in 47% • Brachial artery 36% • Low mortality (n=1, IVC)
- 27. www.perfuse.net www.amnch.ie Mechanism • Blunt – Orthopaedic # – Dislocation (knee) – Isolated • Penetrating – High velocity – Low velocity • Iatrogenic http://www.facs.org/trauma/publications/peripheralvasctrauma.pdf
- 28. www.perfuse.net www.amnch.ie Initial assessment • Airway • Breathing/ventilation • Circulation • Disability • Exposure
- 29. www.perfuse.net www.amnch.ie Immediate treatment • Control bleeding • Replace volume loss • Cover wounds • Reduce fractures/dislocations • Splint • Re-evaluate Credit: http://www.ota.org/
- 30. www.perfuse.net www.amnch.ie Signs of arterial injury hard signs • External (arterial bleeding) • Rapidly expanding haematoma • Palpable thrill/audible bruit • Obvious ischaemia – 5 P’s Credit: http://www.ota.org/
- 31. www.perfuse.net www.amnch.ie Index of suspicion soft signs • History of arterial bleeding • Proximity of #/wound to artery • Diminished pulse (BP) • Small non-pulsatile haematoma • Neurologic deficit
- 33. www.perfuse.net www.amnch.ie TimeTime Pathophysiology Ischaemia Rapid resuscitation Urgent exploration Ischaemia revascularisation Tissue necrosis Reperfusion injury Compartment syn ? fasciotomy
- 35. www.perfuse.net www.amnch.ie Operative management • Angiography – In theatre – Diagnostic – Therapeutic • Covered stent • Embolisation • Open exploration – Repair – Bypass
- 36. www.perfuse.net www.amnch.ie Operative strategy - 1 • Position – Access – Angio • Maintain compression • Exposure & Control – Separate (anatomical) incision – Distal • Damage limitation – intraoperative shunt
- 37. www.perfuse.net www.amnch.ie Endovascular treatment Katsanos K et al Emerg Radiol. 2009 Case series only; no convincing data
- 38. www.perfuse.net www.amnch.ie Procedure • Thrombectomise • Heparinise – Multisystem trauma – Coagulopathy • Repair deficit • Lateral suture • Resection and end-end • Interposition – autologous vein – Synthetic • Ligation • Lateral suture • Resection and end-end • Interposition – autologous vein – Synthetic • Ligation
- 39. www.perfuse.net www.amnch.ie Compartment syndrome Pearse et al. BMJ 2002 2002
- 40. www.perfuse.net www.amnch.ie Penetrating neck trauma • Don’t explore in ED • Assess other injuries • Early transfer to theatre – multidisciplinary – ?CT • Systematic approach
- 43. www.perfuse.net www.amnch.ie Immediate management Resuscitate ABC… ECG Intravenous heparin Bolus Start an infusion Do not use LMWH Heparin •Reduce risk of further embolisation •Reduce fragmentation and distal embolisation •Prevents thrombus formation propagation •Mitigate secondary venous thrombosis * Creager et al NEJM 2012
- 51. www.perfuse.net www.amnch.ie …Image * Creager et al NEJM 2012 * www.straubmedical.com/case-reports-en.html
- 56. www.perfuse.net www.amnch.ie Catheter directed thrombolysis * Creager et al NEJM 2012
- 59. www.perfuse.net www.amnch.ie Outcome 1 yr mortality 15-20%1 Major amputation 10-15%2 1 Creager et al NEJM 2012 2 EarnshawJ Vasc Surg 2004
- 61. www.perfuse.net www.amnch.ie Vascular Trauma Vascular Surgery UnitVascular Surgery Unit AMNCHAMNCH http://goo.gl/U3DnR