Vascular emergencies

Classifications of vascular emergencies:

1-Vascular emergencies can be classified according to the involved
structure into
a)-Emergencies related to the arteries
Arterial trauma
Arterial embolism
Arterial thrombosis
Wrong intra-arterial injection
Dissecting aortic aneurysm
Rupture aneurysm
b)-Emergencies related to the veins
Venous injuries
Acute DVT
c)-Emergencies related to both arteries and veins
Bleeding or rupture arteriovenous fistula
Acute thrombosed arteriovenous fistula
d)-Emergencies related to vascular grafts
Bleeding from arterial grafts
Acute thrombosed graft
Infected graft
e)-Miscellaneous
Compartmental syndrome
Gangrene
Diabetic foot

2- Vascular emergencies can be classified according to presentation

into
1-Bleeding (external or internal bleeding )
2-Acute obstruction of the deep veins ( acute DVT-PE)
 3-Acute ischemia
4-Chronic critical limb ischemia
5-Gangrene
6-Diabetic foot
7-Diabetic foot complications (necrotizing fasciitis)

Peripheral arterial trauma

Incidence
Peripheral arterial injury accounts for 80% of all the cases of vascular trauma

Causes of arterial trauma ( in general)

1. Penetrating injury e.g.
a. Bullets :
• Low-velocity bullets
• High-velocity missiles
• Close range shotgun blasts systems
b. Stabs :
Knives (low-velocity agents) produce damage to the vessels in their
pathway.
"Butcher's thigh " occurs when the boning knife slips and enter the
groin.

2-Blunt injuries
Examples as in
road traffic accidents, and
fall from height.
Blunt forces may cause vascular injury through :
1. Direct injury to major vessels.
2. Plaster or tourniquet compression.
 3. Fracture or dislocation such as :
- Supracondylar fracture of humerus and brachial artery.
- Supracondylar fracture of femur or posterior dislocation of the knee
and popliteal artery.

3-Iatrogenic :
a. Following arterial cannulation during
angiography, cardiac catheterization or haemodialysis.
b.Due to open surgery
Injury of the iliac vessels may occur during pelvic operations.

Clinical types of arterial injuries ( in general )

1-Complete cut of the artery
-At first there will be manifestations of external bleeding , then the bleeding will
stope.
The bleeding will stope because of curling of the intima , contraction of the media ,
retraction of the divided stumps and clots formation and propagation.
-There is absence of pulsation distal to the injured artery.

2-Partial cut:
-There is manifestations of bleeding (either external or internal )
-The bleeding will continue (Why? )
-The bleeding will continue (externally or internally because contraction of the media
will cause more widening of the tear.

3-Contusion
-There is no manifestations of external or internal bleeding.
-There is no manifestations of ischemia
-Arterial contusion can be diagnosed intraoperatively.

4-Contusion with thrombosis:

-There is no manifestations of external or internal bleeding.
-There is manifestation of ischemia

5-Arterial spasm
-There is no manifestations of external or internal bleeding.
-There is manifestations of ischemia
Clinical manifestations of arterial injury ( in general )
A)From the history
1-History of trauma ( everything about trauma )
-Time
-Mechanism of trauma
-Site
2-History of bleeding
3-History of prehospital period

B)From examination
1-General examination
General condition (Al items of general condition )
-.Pallor
- Motor behavior ( restlessness )
Vital signs
-Pulse
-Blood pressure
-Temperature
-Respiration
Systematic examination
Head, neck, chest, abdomen ,,,,,,,
2-Local peripheral examination
Manifestations of external arterial bleeding
-Arterial jet
-Large amount of blood
-Bright red in color
-At anatomical site of artery
Compression of the artery proximal to the wound will decrease bleeding
Manifestations of interstitial arterial bleeding
-Large hematoma
-Expanding hematoma
-Pulsating hematoma
-Palpable thrill
-Audible murmur
Manifestations of arteriovenous fistula
-Pulsating swelling
 -Palpable thrill
-Audible murmur
Manifestations of acute limb ischemia
-Absence of peripheral pulse
-Pain
-Coldness
-Pallor
-paralysis
-paresthesia
Manifestations of peripheral nerves injuries
-In upper limb
( Median nerve-radial nerve-ulnar nerve injuries )
-In lower limb
( Sciatic nerve- Common perineal nerve -Tibial nerve )
Manifestations of associated injuries in the limbs
-Bone fracture
-Joint dislocation
-Tissue loss
Local examination of the wound and surrounding area
-Site of the wound
-Proximity to neurovascular structures
-Size of the wound
-Shape of the wound
-Type of the wound ( inlet or exit in case of firearm injury )
-evaluation of the deep fascia
-Evaluation of the surrounding skin
Hard signs : These are sure signs of arterial injury.
1. External arterial bleeding in open wound.
2. Loss of distal pulsations.
3. Any of the classic manifestations of acute ischaemia.
4. Large rapidly pulsating haematoma with weak distal pulse in closed
wound with partial division.
5. A palpable thrill or an audible bruit heard with a stethoscope at or
distal to the area of injury.
Soft signs : These are less specific (equivocal signs) :
1. Small or moderate sized haematoma that is not pulsating and not
expanding.
 2. Proximity of penetrating wound to a major vascular structure.
3. Adjacent nerve injury, producing neurological deficit.
4. History of pre-hospital haemorrhage that has stopped,
or presentation with shock that cannot be explained by other injuries.

Complications :
1. Haemorrhage :
primary, secondary, or reactionary.

2. Ischaemia
ranging from recovery with ischaemic manifestations to definite gangrene.

3. Aneurysm formation,
-Arterial or arterio-venous.
-False aneurysm

Investigations:
Investigations to diagnose the presence of arterial injuries
• In patients with hard signs :
Immediate surgical exploration is indicated without any diagnostic studies.
Diagnostic studies in these patients are usually unnecessary and the delay in
treatment is dangerous
• In patients with soft signs : Urgent investigations are needed.
1-Arterial and venous duplex
- Duplex Doppler examination is mostly used as a screening test, in the absence of hard
signs s well as for follow-up evaluation in patients managed expectantly.
-It van diagnose ischemia and false aneurysm.
2-CTA with venous phase
CTA should be considered the initial diagnostic and localization modality of choice in
stable patients with blunt or penetrating extremity trauma presenting with soft signs of
extremity arterial injury.
3- Arteriography
Conventional angiography should be reserved for unique cases and intraoperative use.
N.B. If the soft sign is "shock" no diagnostic studies should be done. Resuscitation is
the first priority.
Arteriography can be done in the operating room.
Investigations to diagnose related issues
• plain x ray
To diagnose:
- Bone fracture
- Joint dislocation
- Foreign body ( bullet )

Investigations to evaluate general condition

1-ECG
2-Complete blood picture
3-Randoum blood sugar
4-Abdominal sonar

Treatments
Immediate treatment
Some rules
-Follow basic live support (A,B,C )
-Embedded knives or haematomas should not be disturbed prior to arrival in the
operating room as this may precipitate major bleeding.
Temporary stopping of bleeding
1-Direct pressure over bleeding site
2-Packing of the wound
3-Proximal pressure over the artery against bone
4-Using of tourniquet
a) Simple tourniquet
-piece of gauze is applied and tied. This is further tightened by using a rod which is
rotated.
-Elastic bandage
-Foley's catheter
b) Rubber torniquet
-"Esmarch " tourniquet
-Combat Application Tourniquet (CAT)
-Special Operations Forces Tactical Tourniquet (SOFTT).
-Emergency and Military Tourniquet (EMT)
c) Pneumatic tourniquet
Resuscitation
Resuscitation by blood and IV fluids follows the standard measures
 Systemic heparinization ( yes or no ? )
-Systemic heparinization is contraindicated in multiple traumatized patients or in
association with brain trauma or internal bleeding.
-Systemic heparinization can be of value in isolated vascular injury in extremities

Prophylactic antibiotics
-Prophylactic antibiotic must be given to all patients with arterial injuries.
Definitive treatment
Some rules
-Time is the most important element in management of arterial injuries to avoid limb
ischemia or postoperative compartment syndrome.
-Arterial repair should be performed only by surgeons experienced in the techniques
of vascular repair.
-Any associated fracture should be fixed before the performance of a vascular anastomosis
-Good wound management.
-Good and sufficient exposure of the blood vessel.
-Proximal and distal control of the injured artery.
-Damaged edges or segments should be excised.
-The proximal and distal segments should be cleansed from clots by Fogarty catheter,
flushed with heparinized saline, then clamped again
- consider temporary vascular shunting if there will be any delay in arterial repair due to
reasonable causes for example in association with orthopedic fracture at the same site of
injury or there is multiple arterial injuries.
Restore continuity of the artery
Complete cut
-If the cut ends can be approximated without tension do end to end anastomosis.
-If the cut ends can not be approximated do interposition graft.
Partial cut
-Longitudinal cut
Longitudinal cut or tear can be closed by direct lateral repair or better by using venous
patch to avoid lumen narrowing
-Transverse cut
• If the transverse tears is less than one half of the circumference then do direct repaired.
• If the transverse tears is more than half of the circumference of the lumen , convert it
into complete cut and manage it as complete cut.
Arterial contusions.
Excision of the whole contused segment and reconstruction with an interposition graft.
 Contusion with thrombosis
Excision of the whole contused segment and reconstruction with an interposition graft.
Arterial spasm.
we can use the following options
- Local application of papaverine is used first.
- forcible dilatation using Fogarty balloon catheter or vessel dilator is done.
Ligate some arteries.
Some arteries can be ligated if needed for example:
-Small arteries
-Muscular branches
-Radial artery ( with intact ulnar artery)
-Ulnar artery (with intact radial artery)
-Dorsalis pedis artery
-Anterior tibial artery (with intact posterior tibial artery).
-Posterior tibial artery (with intact anterior tibial artery)
Avoid ligation of theses arteries
-Popliteal artery
Fasciotomy
Indications of fasciotomy
I) In late cases ( > 6 hours).
2) In the presence of muscle oedema.
3) Postoperative compartement syndrome

Complications of vascular repair

1- Immediate postoperative:
• Thrombosis of repaired vessels
• Reperfusion injury

2- Early postoperative:
•Venous thrombosis
• Infection in the area of vascular reconstruction
• Disruption of suture line and hemorrhage

3- Late complications:
• Aneurysmal changes in the vein graft used
• Chronic venous insufficiency after venous thrombosis or ligation.
 Venous injuries
Clinical manifestations of peripheral venous injuries:
External bleeding characterized by:
-Continuous flow of blood.
-Dark red in color.
-Bleeding more from distal wound than from proximal.
Internal bleeding :
-Small, moderate or large hematoma.
-Expanding hematoma

Management of peripheral venous injuries

Immediate treatment
-Stope of bleeding (Limb elevation-compression )
-Resuscitation
- Antibiotics
Definitive treatment
1-Superficial vein
Superficial vein can be ligated safely.
2-Deep veins
-Distal vein below the cubital or popliteal fossa can be ligated safely.
-Proximal veins injuries has two options , venous reconstruction or ligation

Venous reconstruction
Advantages of venous reconstruction
1-Restoration of normal anatomy and physiology
2-Avoidance of acute limb swelling, compartment syndrome ,chronic venous
insufficiency
Disadvantages of venous reconstruction
1-Time consuming
2-May be complex operation
3-Early thrombosis of the vein

Ligation of the deep vein

Advantages of ligation of the deep vein
1-Rapid stopping of bleeding
2-Time saving specially in unstable patient.
Disadvantages of ligation of deep vein
1-Sever limb swelling
2-Compartement syndrome (so do fasciotomy )
3-Post operative limb swelling