Jaffna Medical Association

Annual Scientific Sessions September, 2022

Professor C.Sivagnanasundaram memorial oration

By
Dr. Joel Arudchelvam.
MBBS (COL), MD (SUR). MRCS (ENG), FCSSL
Senior lecturer in Surgery, faculty of medicine,
University of Colombo.
Consultant Vascular and Transplant Surgeon,
National Hospital of Sri Lanka.

Professor C.Sivagnanasundram is known as a legend with

multiple talents. He was also a simple and humble gentleman.
He was born in Jaffna on 30th of March, 1928. He was
married to madam Shanthi and had four daughters. He
graduated from the University of Ceylon in 1955 with
Bachelor of Medicine, Bachelor of Surgery (MBBS), and
served in various parts of the country in various posts i.e.
General Hospital Kurunegala, Peripheral unit Hiripitiya, Lady
Ridgeway Hospital for children Colombo, Nawalapitiya and
Jaffna. From 1965 to1967 he was a lecturer in the department
of Preventive and Social Medicine at the Faculty of Medicine,
University of Ceylon at Peradeniya.

He obtained DPH (London) in 1967 and obtained a PhD in

1971from the University of London.

After his return from London in 1971, he continued to work at

the Faculty of Medicine, Peradeniya. During this period he

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was promoted to associate professor. In 1978 he moved to
the University of Jaffna, to the department of community
medicine, as the founder Professor of Community
Medicine. Here he worked until his retirement in 1994. He
passed away in June 2005.

Professor C.Sivagnanasundram has contributed immensely to

the development of the Faculty of Medicine, University of
Jaffna. He was also an eminent researcher and has published
in both local and international journals. He has also
published many books, both in medicine and other fields.

Therefore I am honoured to deliver this memorial oration on

“Extremity Vascular Trauma in Sri Lanka, where are we
now and how do we improve?” in memory of an academic, a
researcher and a kind human i.e. Professor
C.Sivagnanasundram.

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Extremity Vascular Trauma in Sri Lanka, where are we
now and how do we improve?

Introduction

Vascular injuries are potentially life or limb threatening.

Vascular trauma occurs in 1.6% of civilian injuries (1) and
6.8% to 10.8% in war related injuries (Afghanistan, Iraq and
Lebanon war). In a study done at the National hospital of Sri
Lanka Colombo (NHSL) out of 5802 trauma admissions there
were 93 patients with vascular injuries (VI). Therefore the
incidence of VI in civilian trauma is 1.6% (1). After the end
of civil war in Sri Lanka in 2009 there is a reduction in the
number of war related vascular injuries. But due to the
increase in the number of Road Traffic Accidents (RTA), the
number of vascular trauma also increased (i.e. from 1938 to
2013 road traffic injuries increased from 35.1 to 98.6 per 100
000 population in Sri Lanka). One of the reasons for this is
the increased number two and three wheeled vehicles which
are involved more with accidents (2). Trauma and vascular
injuries often involve young males. They are the
breadwinners of the family. In one study done at the Teaching
Hospital Anuradhapura (THA) among patients presenting
with popliteal arterial injuries, 18 (90%) were males with a
mean age of 38.7 years (2). And in another study done at the
same institution among patients with major lower limb
arterial injuries, 22 (87.5%) were males and the mean age was
36.9 years (3). These studies confirm the fact of young males
often getting involved with vascular injuries.

“Vascular injury” is a nonspecific term. Because this is used

to describe the injuries to blood vessels in all parts of the
body and injuries to the arteries and veins. Injuries to the
blood vessels of the limbs are called extremity vascular
injuries (EVI).
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Causes and mechanisms of vascular injuries

Causes of EVI vary depending on whether it is an upper

or lower limb injury and also depending on the region of
the country. The common causes for the lower limb
vascular injuries (LLVI) include (3) (4)

 Road traffic accidents (54.2%) (Figure 1)

 Trap gun injuries (33.3%) (Figure 2)
 Iatrogenic injuries (8.3%)

Figure 1 Road traffic accident resulting in groin injury

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 Figure 2 Trap gun injury

Whereas in a study conducted at NHSL the causes of upper

limb vascular injuries (ULVI) were (5);

 Cuts (36%)
 Fractures (34%)
 Iatrogenic injuries (22%)

As mentioned above the commonest cause of major LLVI at

our centre is the RTA, which accounts for 54.2% of the
cases .Whereas in upper limb the commonest cause of
arterial trauma is cut injury (36%).

Iatrogenic vascular injury (IVI) occurs when a vessel is

accessed for a diagnostic or therapeutic purpose. Incidence
of IVI is also on the rise due to the increase in the proportion
of percutaneous endovascular interventions.

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In addition even though rare, accidental intra-arterial
injection of drugs presents with disastrous consequences
often in the forearm and hand (6).

Mechanisms of injury

The above mentioned causes for vascular injuries are

classified into either a “Blunt” or “Penetrating (Sharp)” type
of injuries. In blunt injury there is no penetration of the skin
by the injurious agent. Sharp injury means there is penetration
wounds on the skin. Anyhow this classification does not
explain the type of injury which occurs at the vascular level.
For example following a blast injury the pellets cause
multiple penetrating wounds but the artery is often lacerated
or contused. Therefore a practical way of classifying the
vascular injuries would depend on the findings at the vascular
level. Because the injury at the vascular level is the main
factor which influence the management rather than the
division of causes into “Penetrating” and “Blunt” injuries.

The following types of injuries (Figure 4) occur to the blood

vessels following trauma;

 Contusion - This results from blunt trauma to the

vessel wall resulting in thrombosis of the vessel
(Figure 3).

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Figure 3 Arterial Contusion

 Laceration and transection - Here the injured vessel

ends are separated. In laceration the edges of are
irregular whereas in transection the vessel edges are
regular (occur due to sharp cut). At the THA and at
NHSL, contusions and lacerations are common in the
injured vessel wall in the lower limbs. In a study done
at the THA on lower limb arterial injuries, 40% had
conclusion and 40% had lacerations. In cases of trap
gun injury 75% had laceration of the artery (7). This
is due to multiple pallets released from the trap gun.
In another series of patients with upper limb arterial
injuries (ULVI) at NHSL, 39% of patients had
transection of the arteries and only 17% had arterial
laceration (5). This is probably because the upper
limb injuries are commonly caused by sharp agents
(glass, knife, etc.)

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Figure 4 Types of injuries

Other mechanisms by which distal flow is interrupted are;

 Kinking - Here the vessel wall is not injured

physically but it is caught between the fractured bone
ends, resulting in interruption of the distal blood flow.
Kinking occurs rarely.

 Intimal flaps - here the intima is injured and raised as

a flap resulting in dissection and occlusion of the
arteries (Figure 5).

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 Figure 5 Intimal flap

 Side wall injury - The vessel wall is partially cut or

injured. This results in bleeding (Figure 6).

Figure 6 Side wall injury

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  In addition distal limb blood flow is interrupted by
spasm of the artery at the site of injury. In a study
done on lower limb arterial injuries, of 31 patients
included in the analysis 18 (58.1%) had arterial spasm
(8) (9). Arterial spasm is one of the common causes of
diagnostic dilemma and increased workload of a
vascular unit. This is common in young patients. An
underlying injury should be excluded before
diagnosing arterial spasm. All the patients suspected
of arterial spasm following trauma should have an
angiography confirmation of the spasm.

Clinical features and diagnosis

Traditionally the signs and symptoms of vascular injury are

classified into” Hard signs” and “Soft signs”.

Hard signs include;

 Active haemorrhage
 Expanding Hematoma
 Thrill or bruit at the site of injury
 Signs of distal ischemia. which includes 6 'P's
 Absent distal pulse
 Perishing coldness of the distal limb
(poikilothermia)
 pallor of hands and feet
 Pain
 Paresthesia or anaesthesia
 Paresis or paralysis

Soft Signs include;

 History of bleeding at the time of injury.

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  Injury close to a known neurovascular bundle or
injury to the nerve in a neurovascular bundle e.g.
brachial plexus injury and associated axillary arterial
injury.
 Non-expanding hematoma.

Following trauma assessing the signs of distal ischaemia may

be difficult and should be interpreted carefully. For example,

 Following trauma pulse may be absent due to

haemorrhagic shock. Therefore the pulse of the non-
injured limb should also be examined. In addition
patients with proximal arterial injury may have distal
pulses in 5 to 15% of patients, due to the presence of
collaterals or a sidewall injury. Again comparing the
volume of the pulse with the opposite limb is helpful.
And measuring the Ankle Brachial Pressure Index
(ABPI) in both limbs will also help (ABPI = Systolic
blood pressure (SBP) of either dorsalis paedis or
posterior tibial whichever has the higher value / SBP
of the brachial artery). ABPI of less than 0.9 is
significant especially when compared with the non-
injured limb. And this situation should be
investigated with Computed Tomographic
Angiography (CTA) or Doppler Ultrasound
evaluation.
 The paresis or paralysis, paresthesia or anaesthesia
may occur as a result of associated nerve, head or
spinal injury. Therefore the presence of these signs
should be evaluated carefully and documented. In
addition paresthesia or anaesthesia, paresis or
paralyses are late signs indicating that the limb
viability is in immediate threat or the limb is not
viable.

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Studies show that the presence of a hard sign indicates nearly
100% chance of having a major vascular injury. Therefore
urgent intervention should be done when a hard sign is
present. Whereas the presence of a single soft sign indicates
the probability of having a vascular injury in about 10% and
the presence of two soft signs indicates the chance of having
a major vascular injury of about 25%.

During the assessment of vascular trauma it is essential to

document the clinical findings which also have legal
implications. But the documentation is often poor in our local
setting. In a retrospective study done recently on clinical
notes of the vascular trauma patients at the Teaching Hospital
Anuradhapura Sri Lanka, the cause of injury was properly
documented only in 82.6%, and the limb viability on initial
assessment was documented only in 30.7% (10). This
indicates that the importance of documentation of these
findings should be emphasized. And computerized
documentation system with web-based links would make this
documentation procedure easier.

Initial management of an injured patient and transfer

Trauma patients should be assessed and managed according

to the Advanced Trauma Life Support (ATLS) protocol
(ABCD). Airway and breathing takes priority before
circulation. But if there is an on-going bleeding, control can
be achieved temporarily by direct pressure and then can
proceed with the rest of the resuscitation and assessment
(cABCD). Only well resuscitated patients, who are suitable
for vascular intervention (viable, non-mangled limbs) should
be transferred to a vascular centre after discussing with the

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 vascular team. In a series done at the NHSL (11) out of 39
transfers only 8 (20.5%) were notified before transfer. And
in another series done at the same institution (1) out of 81
limb vascular injuries, 8 transfers were unnecessary i.e. 4
(4.9%) non-viable, 2 (2.5%) mangled and 2 (2.5%) traumatic
amputations not suitable for re-implantation. All these
transfers could have been avoided with prior communication
and electronic transfer of images.

Investigations

In vascular trauma the general principle is that if the hard

signs are present and the viability of the limb is threatened,
immediate exploration and repair of the vessels should be
done. But imaging may be needed even in these situations
especially if the injuries are at multiple levels i.e. multiple
fractures, trap gun injury with multiple penetrating sites, etc.

Computed Tomographic Angiography (CTA) is the “gold

standard” investigation following vascular trauma. Because it
demonstrates the whole arterial system (Figure 7) including
the intra-abdominal and intra-thoracic vessels. It is non-
invasive. And it can show associated injuries e.g. fractures.
Also a 3D reconstruction would give a better idea about the
site of the injury (Figure 8). The disadvantages of CTA
include; it is not freely available, artefacts may disturb the
visualization of the site of injury e.g. bone spicules, external
fixators of the bone. Also poor timing of the imaging may
interfere with the interpretation e.g. non visualization of the
vessels. The administration of contrast agent may predispose
to renal impairment. In local setting the CTA is performed
when there are soft signs or when there are multilevel
injuries on the limb and the limb viability is not threatened.
CTA also helps to avoid unnecessary exploration of the

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arteries. For example in a study done at the NHSL among 31
patients 18 were found to have spasm of the artery. Of these
all except 3, who had injuries above proximal tibia had their
diagnosis of spasm detected by CTA and unnecessary
exploration was avoided (8) (12) (9).

Figure 7 Computed Tomographic Angiography (CTA)

showing the injured site

Figure 8 Computed Tomographic Angiography (CTA) 3D

reconstruction

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 Doppler ultrasonography (Duplex Scan) combined with
colour (Colour Duplex) is a useful tool in case of extremity
vascular trauma. But duplex scanning is operator dependent,
and the limb with extremity vascular injury is covered with
dressings which interfere with scanning and the patient may
not be cooperative and the scanning probe induces pain. Also
finding an expert ultra-sonographer in the nights when
vascular injury commonly presents is difficult in our
hospital. For these reasons in the centre where the author
works, Duplex Scanning is not routinely done on an urgent
basis in patients with extremity vascular injuries. But
patients who develop false aneurysms and traumatic
arteriovenous fistula often present late. In these patients
ultrasound scanning is useful in confirming the diagnosis and
for follow-up.
Conventional catheter angiography is done when the patient
is on the operating table (On-Table Angiography). This is
done when the limb viability is threatened but there are
multiple level injuries to the limb (if the patient has multiple
level fractures and in trap gun injuries which produces
multiple pellet injuries) (Figure 9). In this situation the CTA
is not done because it is time consuming, but the site of
vascular injury has to be visualized to plan the exploration
and repair. Here the contrast is directly injected into the
artery. But performing an on-table angiogram requires a
radiolucent operating table and a radiographer available
during the time of the procedure. And it is a relatively
invasive procedure. For the above mentioned reasons in
authors experience the on table angiogram is very rarely done.

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Figure 9 Trap gun injury with multiple penetrations

Management of vascular injuries

The management and the outcome of the vascular injuries have

improved dramatically over time. Experience gained from
various war injuries has contributed dramatically to the
improvement of the management and the outcome of the
vascular injuries. During World War 1 and 2 the vascular
injuries were managed with ligation of the injured vessels. This
resulted in very high amputation rate. For example during
World War 2 the amputation rate was 40%. This situation
improved during Vietnam and Korean wars
(amputation rate of 15%), mainly due to rapid evacuation and
repair. During the Iraq and Afghanistan wars the amputation
rate reduced to 8%. In addition to the advances in vascular
repair methods, antibiotics, advances in trauma care have also
contributed to the improved outcome.

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Principles of vascular repair in vascular trauma

General principle following vascular injury is that patients

with “hard signs” and threatened limb should undergo
immediate surgical exploration and intervention. Patients
who present with “soft signs” of vascular injury and patients
who present late with false aneurysms and traumatic
arteriovenous fistulas can undergo further imaging and can be
managed as semi urgent or elective cases.

All patients should be resuscitated before the patient is

transferred to the operating room unless there is continuous
bleeding which requires surgical intervention.

Following vascular injury and ischemia, vascular repair and

reperfusion should be done as soon as possible. With long
ischemic time the muscles become progressively nonviable
and there is a high chance of having severe reperfusion
effects. Miller and welch reported in 1947 in canine vascular
occlusion / limb ischemia model, that the limb salvage rate
was 90% if the ischemic time was less than 6 hours. And the
salvage rate reduced when it was more than 6 hours.
Therefore a “Golden period” of 6 hours as a threshold for
intervention was suggested. In practice in the centre where
the author works, the patients are transferred from long
distance hospitals and often reach the vascular centre well
beyond 6 hours (3) (13). Traditionally in lower limbs if more
than two of the four leg compartments are non-viable the
limb was not revascularised, due to the risk of reperfusion
effects. But at the centre where the author works, we receive
patients after long delays and about a third of them have two
or more compartments non-viable. Revascularization was
attempted on such patients at THA despite having longer

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than 6 hours of ischemia, provided the patients were
consenting, systemically well, the limb was not mangled and
there was no sepsis. Because outcome after a vascular trauma
not only depends on ischemic time but on other factors such
as associated soft tissue and skeletal injuries,contamination,
systemic status of the patient, etc. In long-term follow-up of
such patients all were happy to have a limb. All reported
improvement in sensory function. But only had partial
recovery of motor functions (14) (15) (16).

The vascular surgical repairs are generally done under general

anaesthesia. The whole limb is cleaned and prepared. The
whole limb should be kept exposed (to assess distal
circulation after the intervention and to perform fasciotomy
before or after the vascular repair and to facilitate the skeletal
stabilization). The contralateral groin and the thigh is also
cleaned and prepared for the harvest of the saphenous vein
graft (RSVG). Reason for getting the RSVG from
contralateral thigh is because in the injured side the deep
veins may also be injured therefore compromising the
superficial veins may impair the venous drainage further (12).

During the surgical exploration of the injured arteries, the

proximal pulse will act as a guide to the presence of proximal
end of the injured vessel. The proximal and distal control
should be achieved (especially the proximal) before exposing
the injured segment to avoid dislodgement of the clot and
inducing further bleeding. After achieving proximal and
distal control the damaged area is exposed and the damage to
the blood vessels is assessed. Also at the time of surgical
exploration the damage to the soft tissues, nerves are also
assessed. Unhealthy soft tissues, foreign bodies and
contaminants are removed.

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The main principles of vascular repair after vascular injury
are that the healthy arterial ends should be anastomosed
without tension in a non-contaminated and non-infected field.
The lacerated arterial ends are trimmed until the healthy
intima is seen (Figure 10). After trimming the proximal and
distal arterial ends, Fogarty catheter is inserted into the distal
and the proximal arterial ends to remove the thrombus
(Thrombus may have formed during the time when the blood
flow was absent or stagnant following vascular injury). Back
flow from the distal end is noticed. And the proximal end
should have pulsatile bleeding. Absence of normal pulsatile
bleeding from the proximal end indicates that there may be
further injuries proximally. The distal arterial end is injected
with heparin saline (10 IU /ml concentration). The distance
between the trimmed arterial ends are assessed. After
trimming, the arterial ends retract and the distance between
the ends increases. General principle is that if the arterial ends
can be approximated without tension a direct end to end
anastomosis repair can be done (less than 1 cm gap). If not an
interposition graft repair is done (Figure 11) (Figure 12). In
authors' experience the RSVG is commonly used (2) (7). For
large arteries (e.g. subclavian, axillary, brachial, iliac,
common and superficial femoral), anastomosis is done with
6/0 or 5/0 polypropylene sutures. For small arteries (radial
and ulnar) 7/0 polypropylene sutures are used. After repair the
anastomosis should be covered with skin and soft tissues
(12).

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Figure 10 Trimmed arterial ends

Figure 11 "Reversed" saphenous vein graft (RSVG)

repair

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Other grafts used for repair include;
 Short saphenous vein (SSV)
 Arm veins – Cephalic / Basilic veins
 Superficial femoral vein (SFV) - If there is a
mismatch in size of the saphenous vein graft in larger
arteries e.g. subclavian, iliac arteries.
 Biological grafts - Bovine graft
 Synthetic grafts ( PolyTetraFluoroEthylene –PTFE,
Polyester)

In trauma vascular repair, synthetic grafts are not preferred.

Because the injured field is already contaminated and synthetic
grafts have a high chance of infection and poor outcome. And
also long term patency of the grafts is poorer than the native
grafts. In a recent study conducted at the NHSL, out of 72
patients with limb injuries, 46(63.9%) patients underwent
vascular interventions. Out of these patients only one (2.1%)
patient with iliac artery injury had Polyester graft repair (1)

For side wall injuries, a patch repair can be done after

trimming the edges (Figure 13).

Figure 12 Technique of repair

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Figure 13 Patch repair

Injuries to the peripheral veins

Associated venous injury may result in haemorrhage or

thrombosis. It is also associated with increased risk of limb
loss. Venous injury is common after certain types of trauma.
For example in a study done at the Teaching Hospital
Anuradhapura on patients with popliteal vascular injury, out
of 20 patients 4 (20%) had associated popliteal venous injury.
Venous trauma was common after trap gun injury (3/7 -
42.8%) and having associated venous trauma was
significantly associated with the risk of amputation (p 0.0316)
(2) (17). Generally major lower limb veins (iliac, femoral and
popliteal) are repaired. And major upper Limb veins
(subclavian and axillary) are also repaired. Small injured
veins can be ligated.

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 Complications of vascular injuries

The worse complications of the vascular injuries are limb loss

and the death of the patient.

In addition vascular injuries can result in;

 Traumatic false aneurysm

 Traumatic Arterio Venous Fistula (AVF) (Figure 14)
 Volkmann ischaemic contracture when ischemia is
neglected especially in the upper limbs
 Compartment syndrome
 Effects of reperfusion (post perfusion)
 Reperfusion injury
 Reperfusion syndrome

Figure 14 Traumatic Arterio Venous Fistula

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As mentioned above the post perfusion / reperfusion effects
are divided into 2 types. They are; (Figure 15)

 Local - Reperfusion injury

 Systemic - Post perfusion syndrome

 Reperfusion injury - This is paradoxical death of

already dying muscles. This happens due to
accumulation of reactive oxygen radicals resulting in
oxidative stress of the reperfused cells (Figure 15).
Oxygen free radicals cause membrane peroxidation,
cytoskeletal destruction, and stimulation of the
inflammatory cell migration into the reperfused
tissues. This results in muscle death, swelling and
compartment syndrome.

 Post perfusion syndrome - This includes systemic

abnormalities, multi organ dysfunction syndrome and
death of the patient. It occurs as a result of release of
mediators into the circulation after reperfusion. The
main clinical features are; Acute Respiratory Distress
Syndrome (ARDS), myocardial dysfunction resulting in
hypotension and coagulation abnormalities
(Disseminated Intravascular Coagulation (DIC)). Other
effects are renal impairment and hepatic dysfunction. In
addition hyperkalaemia, acidosis and myoglobinuria are
some other features.

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Figure 15 Mechanism of reperfusion effects

Management of reperfusion effects

Management is aimed at prevention and organ support.
Reperfusion of ischaemic muscles as early as possible is the
main stay of prevention. And ligation of vessels and early
amputation of the revascularised limb should be considered if
the patient develops severe reperfusion effects. Severe
reperfusion syndrome occurs in about 7.1% of revascularised
patients. In authors’ experience in a study done at NHSL, 3 out
of 42 (7.1%) repaired vessels were ligated following
revascularization due to severe reperfusion syndrome. In this
series the mean ischemic time was 7.25 hours (11).

Organ support strategies include;

 Hemodynamic stabilization
 Hydration
 Oxygen and ventilatory support
 Renal support and renal replacement therapy if
needed

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  In addition antioxidants and free radical
scavengers e.g. mannitol are also given to reduce
the effects of the oxygen free radicals
 Anticoagulants are administered to minimise
thrombosis of the reperfused capillaries
 Also fasciotomy is also done to treat or prevent
compartment syndrome.

Compartment syndrome

Compartment syndrome is increased intra compartmental

pressure resulting in reduced tissue perfusion within the
compartment (Figure 16).

The causes of compartment syndrome following trauma

and vascular injury include;

 Fractures and haematoma formation

 Muscle ischaemia and swelling of the muscles
 Reperfusion injury
 Infections and inflammation of the muscles
 Capillary leak as a result of Systemic
Inflammatory Response Syndrome (SIRS) and
excessive fluid resuscitation
 Tight bandages and Casts

The rise in intra compartmental pressure leads to ischemia at

the capillary level which further induces swelling of the
tissues, which in turn results in the increase in the intra
compartmental pressure. This vicious cycle continues and
finally results in death of the contents of the compartment e.g.
muscles and nerves. The clinical features of compartment
syndrome include;

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  Excessive pain not explained by the degree of trauma
or the fracture
 Swollen, tense, tender compartments / leg
 Pain on passive movements and reduced movements
 Numbness in the area of the nerve distribution
running through the compartment e.g. deep peroneal
nerve and 1st toe web numbness

Figure 16 Compartments of the leg

Recognition and immediate removal of the cause and

fasciotomy are the main modes of management of the
compartment syndrome. Performing pre- transfer fasciotomy
is lacking in Sri Lanka. In a series at the Teaching Hospital
Anuradhapura, of patients after popliteal arterial injury, no
patients underwent fasciotomy before the transfer (7). But
this situation should improve. And the fasciotomy (Figure 17)
should be performed as much as possible before the transfer.

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Figure 17 Fasciotomy

Use of tourniquets in extremity vascular injuries

Following injuries to the extremity vessels one of the

important cause of death is bleeding. Tourniquet if correctly
applied at the right time has been shown to reduce the
mortality and the need for blood transfusions.

But it has been shown that patients who had tourniquets had
higher amputation rates, need for fasciotomy and acute
kidney injury. This could be due to the fact that the limb
needing a tourniquet is already severely injured i.e. mangled.
The tourniquet is used in the pre hospital care. Once the
patient is in the hospital, and if there is uncontrollable
bleeding from the trauma site, direct pressure should be
applied followed by immediate surgical exploration and tying
or repair of the vessels should be done. In other words no
patients should be transferred with the tourniquet for
"vascular intervention".

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Systemic heparinization following traumatic arterial
injuries
Intended benefits of systemic heparinization are;

 Prevention of clotting of the stagnant vessels

 Prevention of thrombosis at the site of arterial repair
 Reduction of clotting tendency arising as a result of
ischemia-reperfusion injury of the endothelium.

Disadvantages of heparinization following trauma include;

 The risk of bleeding into the injured tissue and

haematoma formation
 Bleeding into other internal organs which may have
associated trauma e .g. splenic injury, intracranial
injuries, etc.

Therefore clinical judgement is recommended in

administering the heparin in case of trauma. In a patient with
polytrauma heparinization is not recommended. Whereas in a
patient with an isolated injury e.g. cut injury to the distal
forearm vessel, heparin may be given.
Factors affecting the outcome of extremity vascular
injuries
After traumatic extremity vascular injury, in addition to the
ischemic time there are other factors which influence the
outcome (i.e. limb salvage / amputation, complications,
death, etc.). Some of these factors include; age, presence of
circulatory shock, bone injury, soft tissue injury, nerve injury,
deep vein injury, amount of contamination, comorbid
conditions, etc. Various scoring systems have been developed
to objectively document the degree of injury to the limb. One
such scoring system is the Mangled Extremity Severity Score
(MESS).

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Figure 18 A mangled limb

Table 1 Mangled Extremity Severity Score

Factors Points
Skeletal/ Soft Tissue Low energy - simple 1
Injury fractures, stabs
Medium energy - open 2
fractures, dislocation
High energy - gunshot 3
wounds, crush injuries
Very high energy - injury 4
with gross contamination and
/or severe soft of tissue injury
Limb Ischemia Reduced or absent pulse, no 1
(Points doubled if immediate limb threat
ischemia is more Absent pulse, threatened 2
than 6 hours) viability
Paralyzed / anaesthetic limb 3
Shock Systolic pressure always 0
maintained above 90mm/Hg
Transient hypotension 1
Persistent shock 2
Age Less than 30 years 0
30 to 50 years 1
More than 50 years 2

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According to MESS, if the value is 7 or more the limb salvage
rate is poor. In a recent study done at the National hospital of
Sri Lanka Colombo (1), out of 81 vascular injuries, two
(2.5%) limbs were mangled (Figure 18). Unnecessary
transfers and futile attempt at revascularization and
reconstruction should not be considered endangering the life
in these patients.
Outcome after limb vascular injuries

In studies done at NHSL and THA the overall limb salvage

rates after extremity vascular injuries were between 75.0% -
98.6% (1) (2).

Following trauma about 2.5% of the limbs having vascular

injuries are mangled (1). Primary amputation needs to be
done for these types of injury.

Due to prolonged delay in transfer to the vascular surgical

centres about 4.9% to 30.8% of the limbs are non-viable
when they reach the vascular surgical centre (1) (15) (14). In
a study done at the Teaching Hospital Anuradhapura, 4/9
(30.8%) limbs were either non-viable or marginally viable
due to delay in transfer and prolonged ischemia (14). Such
limbs will usually end up in amputation if not revascularised.
However revascularization of such non-viable or marginally
viable limbs was carried out at the Teaching Hospital
Anuradhapura in young, haemodynamically stable,consenting
patients (14). In this series all such limbs were salvaged. On
long follow up of such patients, all were happy to have the
limb and all had some recovery of the sensory nerve function
and some of them had partial recovery of motor functions
(16).

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How to improve the situation, recommendations and
conclusions

Extremity vascular injury involves young and fit individuals.

They are the breadwinners of the family. And patients with
extremity vascular injuries often have associated injuries. All
these patients should be assessed according to the Advanced
Trauma Life Support protocol and resuscitated. All the
clinical findings including the pulse status, the injuries and
the viability of the limb should be documented.
Outcome of the extremity vascular injuries not only depends
on the duration of ischemia but also on many other factors as
well. Therefore ischemic time alone should not be taken as
the only factor when deciding on revascularization or
amputation.
As described above the outcome following extremity vascular
injuries has improved over time including in our local setting.
But prevention of injuries, establishment of dedicated trauma
centres with surgeons trained on vascular repair, improved
pre-hospital care and transport of patients to trauma centres
and improvement in postoperative care will improve the
outcomes further in the future. This is because all the
recommendations suggested above, will reduce the ischemia
time therefore will reduce the number of non-viable limbs at
presentation and will minimise the effects of reperfusion.
Also improvement in pre-transfer communication will
prevent unnecessary transfer of injured patients (e.g. with
mangled, on re-implantable limbs) adding to unnecessary
workload.
At present there are no dedicated level 1 trauma centres
(According to American College of Surgeons criteria)
available in Sri Lanka. Vascular surgeons in Sri Lanka cover

32 Jaffna Medical Association, Annual Scientific Sessions

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elective vascular surgeries, transplantation surgeries, and
non-traumatic vascular emergencies in addition to the
vascular trauma. This will result in compromise in vascular
trauma patient care. But at present there are only ten vascular
and transplant surgeons in the Ministry of Health. With the
available number it would be impossible at present to appoint
vascular surgeons to many trauma centres to provide 24 hour
cover. One suggestion to overcome this problem would be to
train and give accreditation to surgeons appointed to these
trauma centres to handle the traumatic vascular emergencies.
By doing this we can improve the care of the patient with
vascular injury and avoid unnecessary delays and
unnecessary transfers of these ill patients.
Also allocation of other staff members in the ministry of
health is not equally distributed all over the country e.g.
medical officers and nurses. This results in increased burden
for the understaffed hospitals. In the decentralized system if
it is planned to establish many trauma centres it would be
impossible to staff all the centres adequately. Therefore
establishing few trauma centres in the main parts of the
country with adequate staff would overcome this problem.
The transportation of injured patient should also be
strengthened. This involves developing the roads and also
providing hospitals with more ambulances. And pre-transfer
care should be improved to optimise the patient and to
improve the outcome of vascular intervention (e.g.
resuscitation, fasciotomy, haemostasis, etc.). And unnecessary
transfer should be avoided through communication.

With these changes we can expect to improve the outcome

following vascular injuries further and also improve the
quality of the patients and the staff.

33
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References

1. Extremity Vascular trauma workload of a single vascular

unit in a tertiary care Centre; it is time to establish a
dedicated trauma vascular surgery unit. Kapilan, G and
Arudchelvam, J. Colombo : s.n., 2020.
2. Outcome of popliteal arterial injuries presenting to the
Teaching Hospital, Anuradhapura. Parathan, S and
Arudchelvam, J. 4, 2019, Sri Lanka Journal of Surgery, Vol.
37, pp. 14–17.
3. Factor affecting the outcome of Major lower Limb arterial
injuries; a single unit experience in a peripheral setting.
Sriharan, P and Arudchelvam, J. Anuradhapura : s.n., 2019.
Anuradhapura Clinical Society , 13th Annual scientific
sessions, September 2019. p. 77.
4. Lower Limb Vascular Injuries - a Single Unit Experience in
a Tertiary Centre . Kapilan, G and Arudchelvam, J.
Colombo : s.n., 2020. Sri Lanka Medical Association 133rd
Anniversary International Medical Congress, 2020. p. 63.
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Unit Experience in a. Kapilan, G and Arudchelvam, J.
Colombo : s.n., 2020. Sri Lanka Medical Association 133rd
Anniversary International Medical Congress, 2020. p. 17.
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with Radial Artery Variation; A Rarity Leading to a Disaster.
Arudchelvam, J. 2, 2019, J Clinical Case Rep Case Stud,
Vol. 2019, pp. 66-68.
7. Outcome of major lower limb arterial injuries presenting to
a single unit in a peripheral setting in Sri Lanka. Sriharan, P
and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg ,
Vol. 6, pp. 266-8.
8. Lower Limb Arterial Spasm following Trauma: a Common
and an Important Cause. Kapilan, G and Arudchelvam, J.

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Colombo : s.n., 2020. Sri Lanka Medical Association 133rd
Anniversary International Medical Congress, 2020. p. 63.
9. Post- Traumatic Lower Limb Arterial Spasm: A Common
Entity and an Important Cause for Diagnostic Dilemma: A
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10. Completeness of documentation of patients with vascular
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s.n., 2019. Anuradhapura Clinical Society , 13th Annual
scientific sessions. p. 74.
11. Injury profiles, Referral delay, management options and
Short Term Outcome Of Traumatic Acute Limb Ischaemia
(ALI) Managed At A Tertiary Referral Center. JD,
Arudchelvam and JASB, Jayasundara. Colombo : s.n.,
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Surgeons Of Sri Lanka August 2011. pp. 185-186.
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14. Outcome after revascularisation of marginally viable
limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63,
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and marginally viable limbs. Anton, Swarnan and Joel,
Arudchelvam. Issue Supplement S1, 2016, The Sri Lanka
Journal of Surgery, Vol. 34, p. 51. 1391-491X.

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16. Revascularisation of Marginally Viable Limbs; A Long-
Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.
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scientific sessions, September 2019. pp. 76-77.

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