Vascular Injury

Book Reading
dr. Ronald

Departemen Ilmu Bedah

FK KMK UGM
Juli 2020
Mechanism

Penetrating Injury Blunt Injury

• Focal • Diffuse  adjacent to bone,
muscle, nerve, collateral vessel
• Stab, gunshot, IV drug abuse • Joint displacement, bone
fracture, contusion

• Low/High velocity
Patophysiology
• Trauma to a blood vessel (artery or vein)  hemorrhage, thrombosis, or spasm,
either alone or
• Hemorrhage occurs when there is a laceration or puncture of all of three layers.
• If the bleeding is tamponaded by the surrounding tissue (ie, muscle or fascia), a
localized hematoma will form, which may be pulsatile.
• Intimal injury exposes the subendothelial matrix, which is rich in tissue factor,
resulting in activation of the clotting cascade and subsequent thrombus formation.
• The thrombus may enlarge or propagate and occlude the vessel or embolize and
produce a distal occlusion.
• The injured intima may also form a flap that can prolapse into the arterial lumen as
a result of the forward blood flow dissecting under it
Types
Type
Diagnosis (History taking)
• The history mechanism and the time elapsed since injury.
• A list of medications (as well the use of illicit drugs with
vasoconstrictive properties, such as cocaine and methamphetamine)
• Preexisting diseases in patients over the age of 50
• A history of claudication in either or both lower
Diagnosis (Physical Exam)
• Vital sign  hypotension  peripheral vasoconstriction
• Hypothermia  prolong capillary refill time
• Removed extremity dressings
• Hematoma
• Active bleeding
• Thrill / Bruit
• Distal pulse
• Examination contralateral extremity  comparison
Radiograph
• CT angiography
• Duplex Ultrasonography
• Angiography
• Digital Substraction Angiography (DSA)
Management
Non-Operative
• Minimal vascular injuries  asymptomatic and have the potential to
hea
• Manifested by the soft signs.
• Minimal vascular injury includes intimal irregularities (ie, intimal
• flap), small arteriovenous fistulae, focal spasm with minimal
• narrowing, and small pseudoaneurysms.
Management
Operative
• Operative therapy is required for thrombosis, ischemia (including
ischemic “steal” produced by an enlarging arteriovenous fistulae), and
failure of small pseudoaneurysms to resolve.
Interposition Graft
Bypass
Saphenous Vein Graft
Pre-Operative Preparation
• Broad-spectrum antibiotics and tetanus toxoid
• Systemic unfractionated heparin should be administered 70 U/kg) as
soon as possible after the diagnosis of ischemia is made.
• 5000 IU UFH/500mL  regional injection
• Clear thrombus  Fogarty catether
Post-Operative Care
• Monitor distal arterial pulses
• Continue IV antibiotics for 24 hours if contamination of wound or if
interposition graft is inserted
• Conseider use of antiplatellet agent for 3 months if vein graft or
synthetic graft is inserted
Heparinization
• Unfractioned Heparin
• dilute 25,000 units of heparin to 50mls (25,000 units heparin in 5mls
and 45mls of 0.9% sodium chloride) to produce a concentration of
500 units/ml. Administer via a syringe pump.
• Start the infusion at 2mls/hour (1,000 units/hour)
• Check APTT ratio/APTT (sec) 4 hours after infusion start.
Heparinization
Heparinization
TERIMAKASIH