Management of Vascular Trauma

Threatening the Extremities at

Network Hospital
dr. I Gusti Agung Bagus Krisna Wibawa, Sp.B(K)V
Department of Vascular Surgery, Faculty of Medicine, Udayana University, Denpasar, Indonesia
Descriptions
Vascular Injury Mechanism are divided into Pentretrating or Blunt . Following
tissue injury is produced by local compression, rapid deceleration, and the
resulting shear forces.

6 hours of the limb ischemia, irreversible changes occur in the nervous and
musculatory systems, though it is important to precisely evaluate the onset
time.

Pitfall in preoperative, operative and postoperative conditions in the treatment of

vascular trauma should be avoided

As the front line, surgeons at network hospitals are expected to be able to

provide prompt and appropriate treatment to avoid a poor prognosis
Epidemiology Region Of Injury

Section Break
Insert the title of your subtitle Here
Anatomy
 Diagnosis
Hard signs and Soft signs remain a significant challenge to help identify
vascular injuries in a timely manner.

ABI has a sensitivity of 100% for identifying vascular lesions of

penetrating origin.

Doppler ultrasound (Index 0.99 or less  sign of arterial injury)

CT angiography.

Angiography  gold standard to identify vascular trauma injuries,

as well as enabling endovascular or temporary control therapy with
angioplasty catheters until a definitive solution is achieved.
 Hard Sign Soft Sign
Hard Sign Soft Sign

Pulsatile bleeding Asymmetric limb temperat

ure
Expanding hematoma
Asymmetric pulses
Thrill at injury site
Injury to anatomically-rela
Pulseless limb ted nerve

History of bleeding imme

diately after injury
Evaluation Algorithm
Initial treament

ABCDE dan stop bleeding

Primary control bleeding by direct compression or

installing a Foley catheter. Blind clamping is not
recommended. Tourniquet, if needed two with
8 cm distance.

Compartment syndrome: emergency fasciotomy.

Unstable hemodynamic with clear hard signs: emergency

exploration.

Stable hemodynamic: workup diagnostic.

 Initial treament

• Head: Hemostatic suture

• Neck: Compression or balloon catheter
• Chest: Occlusive dressing
• Abdomen: Resuscitative endovascular balloon occlusion of the aorta Pelvic: pelvi
c belt, hemostatic foam
• Extremities: compression
• After the bleeding control, the focus should be directed on the chances of the limb
salvage. The MESS score is the most popular tool in assessment of the extremity
salvage chance.
 Non-operative management

• No hard signs

• Lack of distal ischemia or extravasation

• Defect smaller than 2 cm

• Serial surveillance with appropriate imaging such as CT Angiography or

DUS (Duplex Ultrasonography)
Computed Tomographic Angiography
Endovascular and Open Surgery
Endovascular management
The endovascular modality is limited only to cases with
preserved continuity of the vessel, which can be visualiz
ed only in CT angiography.
Highly recommended in hemodynamically stable patient
with injuries to the subclavian or carotid arteries.

Open surgery
The general principles of establishing proximal and distal
vascular control and restoring in-line flow to a suitable outf
low bed are the same for the treatment of traumatic lesion
s as for any other vascular defect.

Wide debridement of contaminated and nonviable tissue

within the zone of vascular injury.

Primary amputation may be considered in the unstable pa

tient with a mangled extremity (Mangled Extremity Severit
y Score > 7)
Mangled Extremity Severity Score

A score of ≤6 reliably predicts limb

salvage for both upper and lower
extremity PVI (Peripheral vascular
injury )

A MESS of >7 has been used as a

cut off point for predicting the need
for early amputation.
Open Surgery

• Larger sterile drapping

To avoid scar contractures at the anterior should
er (axillobrachial exposure), elbow (brachial expo
sure) and knee (medial or posterior popliteal
exposure), curvilinear incisions are appropriate.

When a large pulsatile hematoma is present, two

separate short longitudinal incisions are made
to obtain proximal and distal vascular control p
rior to completing the middle aspect of the inci
sion and entering the hematoma.
 SPECIFIC ARTERIAL INJURIES

Axillary Artery
• Penetrating trauma >>>
• Nerve injuries  1/3 patients.
• Longitudinal incision beginning at proximal extent of bicipital fossa
extending through anterior axilla to chest wall.
• Endovascular procedure can be performed antegrade by femoral
approach or retrograde by ipsilateral brachial approach.
 SPECIFIC ARTERIAL INJURIES

Brachial Artery
• Most frequently injured artery of upper extremity (50%).
• Median nerve injury is frequently associated.
• Frequently associated with fractures of humerus and dislocations
of elbow (especially in children).
• Longitudinal incision along the course of the artery in the bicipital
fossa, avoid injuring median nerve in the brachial sheath with the
artery.
• “Lazy S” skin incision to expose artery distal to the elbow.
 SPECIFIC ARTERIAL INJURIES

Radial and Ulnar Artery

• Penetrating trauma.
• Injury to the radial and ulnar nerve in 25% of cases.
• Longitudinal incisions directly overlying their courses.
• If only one of the forearm arteries is injured and Allen test
reveals patent palmar arch, the injury can be safely ligated.
• If both are injured, preference should be given to repair ulnar artery as
dominant contributor to hand perfusion.
SPECIFIC ARTERIAL INJURIES

Femoral Artery
• SFA is the most commonly injured of t
he lower extremity
• CFA + PFA only 10%
• Predominance by penetrating trauma
• Associated nerve injury uncommon (1
0%)
• Mortality rate 10%, patients frequently
present in shock
• Exposure through longitudinal incision,
can be extended proximally and divide
inguinal ligament
SPECIFIC ARTERIAL INJURIES

Popliteal Artery
• Second most frequently injured artery of lower
extremity (20%).
• Predominantly injured by blunt trauma.
• Often associated with tibial plateau fracture.
• Exposure through separate medial above and below
knee incisions.
• Medial exposure directly behind the knee should be
avoided because division of semimebranosus and
semitendinosus tendons invites considerable morbid
ity during rehabilitation
SPECIFIC ARTERIAL INJURIES

Tibial Arteries
• Occur equally from blunt and penetrating trauma.
• Fractures are present in a third penetrating injuries and
nearly all blunt injuries.
• Nerve injuries 25-50%.
• In multiple injuries or single injury with clinically ischemic li
mbs, repair at least one.
• Exposure through fasciotomy incision.
Vascular repair
Principle of anastomosis
Basic Vascular Set
 01 03
Potts-Smith Forceps
Potts-Smith Vascular Scissors

02 04
JohnsHopkins Bulldog clam DeBakey neddle holder
ps
 05 06
LoupeBinocular Surgical Ma
De bakey Satinsky clamp gnifier
Simple Suture
Kunlin suture
●If an endarterectomy has been performed, there
is a risk of intimal flap dissection at the
downstream edge.

●To eleminate this risk, sutures are inserted to

secure the intima.

●The needle passes from outside to inside

through an endarterectomized part of the wall
and back from inside to outside through the
atheroma to be finally tied on the outside.
End to end anastomosis: interrupted and continuous suture
End to end anastomosis: single-stitch method

● Used when there is a difficulty in rotating

the vessels, for example at a large
bifurcation.

Your Text Here

●Commensing on the side nearest the

operater,the sutures are inserted from
within the lumen to complete the deep
or posterior aspect and then continue
across the anterior aspect to the start
point.
Inlay parachute technique
●The double ended suture is
left untied in order to allow
a number of stitches to be pla
ced on each side before the
graft is pulled down onto the
artery.
Buttressing sutures

●Sutures may be buttressed

with Dacron pieces when the
wall of the artery is friable
and may cut out causing hem
orrhage.
 Quadrant Parachute
Technique

End to side anastomosis: End to side anastomosis:

four quadrant technique parachute technique
Venous patch?
 Conclusion

• Primary survey  CIRCULATION Vascular trauma

• HARD SIGN AND SOFT SIGN
• HARD SIGN (+)  explore and immediate operation
• USG & CT ANGIOGRAPHY  most frequently used
• Approach of incision
Thank you