Vascular injury

“the clock starts ticking”

• Blood loss
• Progressive ischemia
• Compartment syndrome
• Tissue necrosis

Irreversible damage after 6 hours

 Mechanism of Injury
• Penetrating trauma
– GSW
– Stab
• Blunt trauma
– High energy
– Low energy
• iatrogenic
 Arterial injuries associated with fractures or
dislocations
Clavicle
Claviclefracture
fracture subclavian
subclavianartery
artery
Shoulder
Shoulderfx/dislocation
fx/dislocation axillary
axillaryartery
artery
Supracondylar
Supracondylarhumerus
humerusfxfx brachial
brachialartery
artery
Elbow
Elbowdislocation
dislocation brachial artery
brachial artery
Pelvic
Pelvicfracture
fracture gluteal
glutealarteries
arteries
Femoral
Femoralshaft
shaftfxfx femoral
femoralartery
artery
Distal
Distalfemur
femurfracture
fracture popliteal
poplitealartery
artery
Knee
Kneedislocation
dislocation popliteal
poplitealartery
artery
Tibial
Tibialshaft
shaftfxfx tibial
tibialarteries
arteries
 Types of vascular injuries
• Spasm
• Intimal flaps
• Subintimal hematoma
• Laceration
• Transection
• A-V fistula

Some require treatment, some do not

Consequences of vascular injury
• Blood loss
• Ischemia
• Compartment syndrome
• Tissue necrosis
• Amputation
• Death
 Prognostic factors

• Level and type of vascular injury

• Collateral circulation
• Shock/hypotension
• Tissue damage (crush injury)
• Warm ischemia time
• Patient factors/medical conditions
Clinical manifestations vascular trauma

 active hemorrhage,
 large, expanding, or pulsetile hematome
 distal ischemia ( 6 P )
 Immediate treatment
• Control bleeding
• Replace volume loss
• Cover wounds
• Reduce
fractures/dislocations
• Splint
• Re-evaluate
 Speed is crucial

• Rapid resuscitation
• Complete, rapid
evaluation
• Urgent surgical
treatment

PROTOCOL IS ESSENTIAL !
 Doppler ultrasound

• Normal ABI > 0.95

• Abnormal < 0.90
• Does not define extent or level of injury
• Abnormal values warrant further evaluation

Mills, et al. J. Trauma 2004

 Indication of arteriography
1. No angio, straight to OR : obvious vascular
injury, unstable, unequivocal
2. Urgent angio or to OR : physical finding +
( expanding hematome, pulsetile
hemorrhage)
3. Elective angio : penetrating injury without
physical finding
 Angiography
• Locates site of injury
• Characterizes injury
• Defines status of vessels
proximal and distal
• May afford therapeutic
intervention
 Treatment of vascular trauma
 general principle
 assessed for presence other injuries
 life threatening injuries must be treated
 immediate control for hemorrhage : direct digital pressure, packing
and pressure dressing
 tourniquet should be discouraged  interupt venous return &
collateral
 hemorrhagic shock corrected
 Antibiotics broad-spectrum
 open wound explored only in OT
 all resuscitative, diagnostic effort must be minimizing time lag to
definitive treatment ( best within 6-8 h )
 Method of surgical repair
 Ligation
 Lateral suture
 Vein patch
 Resection with
- End-to-end anastomosis
- Autogenous vein graft
- Prosthetic graft
 Surgical repair procedure
 draping ( allowing to examined distal pulse ), prepare for vein
harvesting on uninjured extremity
 incision paralel to the course of injured artery
 sharp debridement
 exposure injured vessel, excised damaged vessel untiln
normal wall
 distal thrombus removed by fogarty catheter until
backbleeding occurs
 heparinized saline irrigated to distal
 systemic heparinization if absence massive tissue damage
( not routine )
 vascular repair
 Surgical repair procedure
 vascular repair
- running monofilament nonabsorbable suture,
interupted for small vesel to prevent purse-string
constriction
- primary repair is prefered
- no tension
- intraoperative arteriography after repair
- complete repair : pulse (+), patent in angio,
- soft tissue coverage is essential
- limb perfusion monitoring, thrombectomy or revision
if necessary
Prognostic factor for extremity vascular trauma

 time lag
 mechanical of injury
 anatomical location
 associated injury
 age and chronic medical problem
 Clinical presentation
 Time lag of vascular trauma
 the incidence of limb loss
1–6h : 10%
12 – 18 h : 50%
24 – 30 h : 80%
 Surgical considerations

• Who goes first?

• Temporary shunts
• Fracture stabilization techniques
• Salvage vs amputation
• Fasciotomies
The timing of the vascular repair in relation to fracture

• management has long been a source of controversy.

• The standard recommendation is for vascular repair to precede
orthopaedic management.
• Prevention of prolonged tissue ischemia is the objective.
• While no prospective studies exist, in a retrospective study,
suggested an increased need for fasciotomy when fractures are
stabilized before revascularization.
• No cases of disruption of vascular repair occurred in 22 cases of
subsequent fracture stabilization.
• Most fractures can be adequately stabilized with traction or
posterior plaster splinting but external fixation may be necessary in
some cases.
 Scoring systems
to predict amputation and functional outcome
• Mangled Extremity Syndrome Index (MESI)
• Mangled Extremity Severity Score (MESS)
• Predictive Salvage Index (PSI)
• Limb Salvage Index (LSI)
• Prediction of amputation was sensitive and specific, but prediction of
functional outcome was universally poor.
• The MESS score appears to be the most commonly used method and is based
on criteria that include
(1) degree of skeletal/soft tissue injury,
(2) limb ischemia,
(3) shock,
(4) patient age.
• no one system is universally accepted.
 The Mangled Extremity Severity Score
(MESS)
 Objective criteria for amputation prediction after lower or
upper extremity injury.
 A MESS of >7 has been used as a cutoff point for
amputation prediction.
 A MESS of >7 does not always indicate that amputation is
required; however, MESS is a better predictor for patients
who do not require amputation when the score is <7.
 The decision regarding whether or not to amputate
should be made individually based on clinical signs and
intraoperative findings of irreversible limb ischemia.