Arterial TraumaAuthor: Zacharias Cora

Coordinators: Prof. Suciu Horatiu, MD

Stroe Valentin, MD, PhD

Introduction• Acute injuries of vessels constitute an important therapeutic problem, representing a serious threat to life.

Approximately 75% of all vascular injuries are located to the extremities and more than 50% to the leg.

PERIPHERAL VASCULAR INJURIES:

Carotid Artery Injury Symptoms: headache, cervical pain and cerebral or retinal ischemia

Subclavian and Axillary Artery Injuries

Usually associated with first-rib or clavicular fractures that cause occlusion of the artery

Brachial Artery Injuries Implicated in iatrogenic catheter-related injuries

Radial and Ulnar Artery Injuries Trauma caused by industrial and domestic accidents

Palmar Artery Injuries Plastic surgery

Iliac Artery Injuries Associated with damages of pelvic region.

Common, Profunda and Superficial Femoral Artery Injuries

Most often , secondary to angiography

Popliteal Artery, Anterior Tibial, Posterior Tibial and Peroneal Artery Injuries

The most common segments implicated in trauma due sports, domestic and industrial activities.

Plantar Artery Injuries Plastic surgery

Ethiology Causes:

• penetraiting injuries are usually caused by knives and gunshots

• blunt injuries occur in road trafic accidents because of fracture and joint dislocation

• iatrogenic injuries can be caused by catheterization and during surgical dissection

Most common location for combinedorthopedic and vascular injuries:

ORTHOPEDIC INJURY VASCULAR INJURY

Femoral shaft fracture Superficial femoral artery

Knee dislocation Popliteal artery

Fractured clavicle Subclavian artery

Supracondylar fracture of the humerous.Elbow dislocation

Brachial artery

Shoulder dislocation Axillary artery

Types of arterial injuries which can occur, can be devided into 5 groups:

• laceration • transection• contusions (hematomas,

trombosis)• spasm (rare)• arteriovenousus fistulas.

Clinical Signs and Symptoms

As with all injuries it is important to interview the rescue personnel about information such as:

• Type of injury• Type of bleeding • Estimation of the blood loss • The exact time when the injury happend (the ideal time period for repair of an arterial injury is within 6 to 8 hours after injury)

• Information about diseasis and medication

There are 4 factors which significantly influence the degree of ischemia/the semnificance of time lag:

• The size of the artery injured: in general, the larger the artery, the more severe the ischemia

• The degree of impairment of collateral circulation from associated soft tissue injury

• The degree and duration of shock • Ambient temperature: a cold extremity will

naturally tolerate ischemia longer than a warm one.

“Hard signs”:

• Active hemorrhage• Hematoma

(large, pulsating, expanding)• Distal ischemia: the six Ps (pain, pallor,

paralysis, pulse deficit, paresthesia, poikilothermia)

• Bruit (over the wounded area to reveal a possible arteriovenosus fistula)

The physical examination should include:

• Examination and auscultation of the injured area

• Palpation of pulses in both legs and arms

• Assesment of skin temperature, motor function and sensibility

• “Soft signs” (history of significant bleeding, small hematoma, adjacent nerve injury, proximity of wound to vessel location, unexplained shock)

DiagnosisDuplex UltrasoundIt has not been universally accepted for diagnosis of vascular trauma, despide the fact that it is noninvasive. But it is a method of choice for diagnosis of most of the late cosequences of vascular injuries: arteriovenous fistulas, pseudoaneurysms and hematomas.

AngiographyThe purpose is to identify and locate lesions such as occlusions, narrowing and intimal flaps and it also serves to provide a road mape before surgery.

Management and Treatment

• Team work: Vascular Surgeon

Orthopedic Doctor

Plastic Surgeon

Anesthesist Doctor

PREOPERATIVE FACTORS

1. Control of hemorrhage2. Resuscitation from the shock3. Minimizing time lag from injury to arterial repair

OPERATIVE FACTORS

1. Debridement of injured tissues and irrigation to minimize infection2. Arterial repair:(debridement of injured artery , removal of distal thrombi, arterial reconstruction, soft tissue coverage)3. Management of associated injuries (vein, bone, nerve, soft tissue)

POSTOPERATIVE CONSIDERATION

1. Patency of arterial repair2. Muscle necrosis3. Wound infection

SEVERE INJURY LESS SEVERE INJURY

• Major external bleeding should immediately be controlled with digital pressure or bandages.

• Before transfer to the operating room the following can be done:

give the pacient oxygen initiate monitoring of vital signs

(heart rate, blood presure, respiration, SpO2)

place at least one IV line consider administering analgesics draw blood for hemoglobin and

hematocrit, prothrombin time, creatinine, sodium and potassium

consider administering antibiotics and tetanus profylaxis

obtain informed consent

• Duplex Ultrasound/Arteriography to rule out or verify vascular damage. • Discussing the priority of management: vascular injuries shoud be given higher priority than skeletal and soft tissue injury and temporary restoration of blood flow can be achived by shunting.

• Patients with normal physical examination (little suspicion of vascular injury) can be monitored in the ward (hourly assessment of pulses the first 4-6 h).

Primary amputation:

For a few patients, primary amputation is a better option.

This is often a difficult decision.

Primary amputation is favorable for the pacient if:• the leg/arm is massacred• duration of ischemia >6 h !!!• multitrauma patients, patients with severe comorbid disease

and those in whom the leg/arm was already paralyzed at the time of injury

Surgical Technique

• Arterioraphy/Patch Arterioplasy

• Reconstruction by Interposition

- venous grephon

- sintetic grephon

• By-pass Reconstruction

- venous grephon

- sintetic grephon

• End-to-end anastomosis

Complications

• Trombosis• Infection• Stenosis• Miscellaneous complications: -edema

-embolisation

- disseminated intravascular coagulopathies

- chronic pain

- decreased function

- ischemic changes

- arteriovenous fistulas

- arterosclerotic changes

Matherial and methods

The clinical study was made between

March 2010 and March 2014.

The average age for iatrogenic injury was on patients between 50 and 70 years.

The mean age for traumatic injuries such as domestic, industrial, road trafic accidents and penetrating injury was on young patients between 17 and 45 years.

123 patients:

Iatrogenic Injury 91 patients (74%)

0102030405060708090

100

Results

Iatrogenic Injury:

They were all Post-Catherization Pseudoaneurysms using the Seldinger tehnique, with or without hematomas.

The procent was aproximately the same into men and women: -46 male cases

-45 female cases

There were 83 (67,5%) cases of iatrogenic leg injury:

-right femural artery 76 cases -left femural artery 3 cases

-the iliac artery 4 cases And there were 8 ( 6,5%) cases arm injury:

-right brachial artery 6 cases-left brachial artery 2 cases

LegArm

• The surgical therapy was represented by vascular arterioraphy and hematoma evacuation with good restauration of blood flow.

• There was one death caused by cardiopulmonary failure, without arterioraphy-related problems.

Traumatic injuries:There were 25 (20%) penetrat-ing injuries cases caused by in-dustrial, domestic, agresion and

autoagresion trauma.And 7 (5,7) blunt injuries that

caused politrauma.

PATIENTS WITH PANATRATING INJURIES

PATIENTS WITH BLUNT INJURIES

Surgical Techniques:

Interposition Grapht

End-to-end Anastomosis

Arterial Bypass Other Surgical Aproaches

0

2

4

6

8

10

12

14 1214

24

Reconstruction by Interposition12 patients (37,5%)

End-to-End Anastomosis14 patients (43,75%)

Arterial Bypass with Synthetic Grapht (Dacron)

2 patients (6%)

Arterial Reconstruction with Safenous Vein after Orthopedic-

Vascular Severe Trauma3 pacients (9%)

• Early lower and upper extremity fasciotomies were performed for compartment syndrome after acute ischemia and revascularization in 8 patients (25%) with arterial trauma.

• All patients had more than one accepted indication for fasciotomy: fracture or dislocation, compartment tenseness and extensive soft tissue injury.

• Two patients needed multiple skin grafting procedures or myocutaneous flaps to close the wound.

• 2 amputations were required for limb ischemia. Both involved injury below-the-knee, to the tibial artery. Both patients were involved in routier accidents (blunt trauma).

• 2 deaths caused by penetrating injuries: one suicidal pacient and one with a complex industrial trauma. Both arrived with a Glasgow Coma Score of 4 despite the absence of head injury and no blood pressure.

Conclusions

1. A multidisciplinary approach to the management of the arterial trauma patient will help create circumstances in which optimal care can be provided.

2. Early fasciotomy has been cited as a major factor contributing to limb salvage and preservation of function, especially in politraumatic injuries with multiple fractures and dislocations.

3. Primary amputation must be taken into consideration if the duration of ischemia is >6 h, so the pacient’s life can be saved.

4. Trauma with arterial injury has a nearly 10% rate of mortality or limb loss. Primary amputation is more common with blunt distal vascular injury. In contrast, mortality is associated with penetrating mechanism and early shock, likely resulting from prehospital proximal arterial hemorrhage.

Bibliography

• Emergency Vascular Surgery (Springer) – E. Wahlbert, P. Olofsson, J. Goldstone

• Peripheral vascular injury-related deaths – S. Bilgen, N. Turkmen, B. Eren, R. Fedak

• Vascular Trauma (Sauders Company) – Norman M. Rich, Frank C. Spencer

• Blunt vascular trauma in the extremity: diagnosis, management and outcome (J. Trauma. 2003) – G.S. Rozycki, L.N. Tremblay, D.V. Feliciano, W.B. McClelland

• Rutherford’s Vascular Surgery 7th Edition (SVS) - Jack L. Cronenwett, K. Wayne Johnston

• Haimovici’s Vascular Surgery 5th Edition – Larry H. Hollier, D.E. Strandness, J.B. Towne, K. Calligaro, K.C. Kent, G.L. Moneta, J.J. Ricotta

• http://www.ncbi.nlm.nih.gov/pubmed/21514772• http://trauma.org/archive/vascular/PVTintro.html

Thank you!