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Vascular Injuries of the Extremities Rutherford 6 th ed, Chp. 73 Maureen Tedesco, MD October 31, 2005.

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Presentation on theme: "Vascular Injuries of the Extremities Rutherford 6 th ed, Chp. 73 Maureen Tedesco, MD October 31, 2005."— Presentation transcript:

1 Vascular Injuries of the Extremities Rutherford 6 th ed, Chp. 73 Maureen Tedesco, MD October 31, 2005

2 History Civilian: UE arterial injuries more common Civilian: UE arterial injuries more common Military: LE arterial injuries more common Military: LE arterial injuries more common World War II extremity arterial injuries were ligated (popliteal artery injury amputation rate 73%) World War II extremity arterial injuries were ligated (popliteal artery injury amputation rate 73%) Korean and Vietnam wars: amputation rate for popliteal artery injuries 32% (Hughes and Rich) Korean and Vietnam wars: amputation rate for popliteal artery injuries 32% (Hughes and Rich) limb loss in most civilian series now less than 10% to 15% limb loss in most civilian series now less than 10% to 15% long-term disability for 20% to 50% (soft tissue and nerve injury) long-term disability for 20% to 50% (soft tissue and nerve injury)

3 Mechanism of Injury In penetrating arterial injuries In penetrating arterial injuries –gunshot wounds in 64% –knife wounds in 24% –shotgun blasts in 12% Motor vehicle accidents, falls most common causes of blunt injury Motor vehicle accidents, falls most common causes of blunt injury High velocity firearms High velocity firearms –dissipation of energy into the surrounding tissues –fragmentation of the projectile or of bone –blast effect –combination of injury –combination of penetrating and blunt tissue injury

4 Diagnostic Evaluation "hard signs" of arterial disruption: "hard signs" of arterial disruption: –pulsatile external bleeding –an enlarging hematoma –absent distal pulses –an ischemic limb Proceed to OR Proceed to OR

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6 Diagnostic Evaluation Soft signs: Soft signs: –Significant hemorrhage by history –neurologic abnormality –Diminished pulse compared to contralateral extremity –In proximity to bony injury or penetrating wound

7 Diagnostic Evaluation elective rather than routine arteriography is appropriate for patients who may have an occult extremity arterial injury Weaver FA et al: selective use of arteriography is appropriate and safe (Arch Surg 125:1256, 1990) Conrad et al: Conrad et al: –Pts with normal PE and doppler pressure indices (DPI) can be safely discharged –Diagnostic arteriography is only indicated for asymptomatic patients with abnormal DPI (Am Surg 68:269, 2002)

8 Diagnostic Evaluation For blunt extremity trauma, the indications for arteriography parallel indications for penetrating injuries For blunt extremity trauma, the indications for arteriography parallel indications for penetrating injuries Abou-Sayed et al. Abou-Sayed et al. –clinical examination can define a subset of high-risk patients who need an arteriogram, and possibly surgical repair (Arch Surg 137:585, 2002) (Arch Surg 137:585, 2002)

9 University of Washington Criteria Johansen et al, J Trauma, 1991 Lynch et al, Ann Surg, consecutive injured limbs in 93 trauma patients 100 consecutive injured limbs in 93 trauma patients –All patients underwent arteriography –ABI<0.9 1 false negative (NPV 99%), 2 false positives 1 false negative (NPV 99%), 2 false positives Sensitivity 87%, specificity 97% Sensitivity 87%, specificity 97% –Increases to 95% and 97% with clinical outcomes 100 traumatized limbs (84 penetrating, 16 blunt) in 96 consecutive patients 100 traumatized limbs (84 penetrating, 16 blunt) in 96 consecutive patients –Arteriography only in those patients with ABI<0.9 (n=17) 16/17 with positive arteriograms 16/17 with positive arteriograms 7 underwent reconstruction 7 underwent reconstruction –83 limbs with ABI>0.9 underwent duplex f/u 5 minor arterial injuries (4 pseudos, 1 fistula) 5 minor arterial injuries (4 pseudos, 1 fistula) 0 major arterial injuries missed 0 major arterial injuries missed

10 Diagnostic Evaluation penetrating or blunt injury, normal extremity pulse examination, minimum ankle brachial index (MABI) of ≥1.00 does not require arteriography penetrating or blunt injury, normal extremity pulse examination, minimum ankle brachial index (MABI) of ≥1.00 does not require arteriography –Observe for hours Pts that have extremities with a or an MABI < 1.00  diagnostic arteriography useful, greatest yield Pts that have extremities with a distal pulse deficit or an MABI < 1.00  diagnostic arteriography useful, greatest yield Role for Color Flow Duplex (CFD) ultrasonography Role for Color Flow Duplex (CFD) ultrasonography –Noninvasive, painless, portable, low morbidity, inexpensive –Operator dependent MRA MRA –Image multiple anatomic areas, noninvasive –Not widely accessible

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12 Treatment of Arterial Injuries: Nonoperative Approach Nonoperative approach Nonoperative approach –Low-velocity injury –Minimal arterial wall disruption (<5 mm) for intimal defects and pseudoaneurysms –Adherent or downstream protrusion of intimal flaps –Intact distal circulation –No active hemorrhage Follow up required Follow up required

13 Treatment of Arterial Injuries: Endovascular Management Transcatheter embolization with coils or balloons – – low-flow arteriovenous fistulae – – false aneurysms – –active bleeding from non-critical arteries Stent-grafts: – –endoluminal repair of false aneurysms – –large arteriovenous fistulae Requires sufficient experience and available personnel

14 Treatment of Arterial Injuries: Endovascular Management Peroneal a. false aneurysm treated with coil embolization

15 Treatment of Arterial Injuries: Operative Management preparation and draping of the entire injured extremity preparation and draping of the entire injured extremity drape contralateral uninjured lower or upper extremity (autogenous vein graft) drape contralateral uninjured lower or upper extremity (autogenous vein graft) extremity incisions: longitudinal, directly over the injured vessel, extended proximally or distally as necessary extremity incisions: longitudinal, directly over the injured vessel, extended proximally or distally as necessary Proximal and distal arterial control is obtained prior to exposure of the injury Proximal and distal arterial control is obtained prior to exposure of the injury endoluminal balloon occlusion: when proximal control of the traumatized vessel is problematic, place under fluoroscopic guidance for temporary control endoluminal balloon occlusion: when proximal control of the traumatized vessel is problematic, place under fluoroscopic guidance for temporary control

16 Treatment of Arterial Injuries: Operative Management debride injured vessels to macroscopically normal arterial wall debride injured vessels to macroscopically normal arterial wall remove any intraluminal thrombus with Fogarty catheters (proximal and distal to the arterial injury) remove any intraluminal thrombus with Fogarty catheters (proximal and distal to the arterial injury) Flush with heparinized saline solution: proximal and distal arterial lumina Flush with heparinized saline solution: proximal and distal arterial lumina Systemic heparinization: prevent thrombosis or thrombus propagation (if systemic anticoagulation not contraindicated) Systemic heparinization: prevent thrombosis or thrombus propagation (if systemic anticoagulation not contraindicated) Consider temporary intraluminal shunting: debridement, fasciotomy, fracture fixation, nerve repair, or vein repair, before arterial reconstruction, in controlled setting Consider temporary intraluminal shunting: debridement, fasciotomy, fracture fixation, nerve repair, or vein repair, before arterial reconstruction, in controlled setting

17 Treatment of Arterial Injuries: Operative Management Types of Repair Types of Repair –lateral suture patch angioplasty –end-to-end anastomosis –interposition graft –bypass graft –Extra-anatomic bypass graft (sepsis or extensive soft tissue injury) Autogenous vein graft, PTFE Autogenous vein graft, PTFE Monofilament 5-0 or 6-0 sutures Monofilament 5-0 or 6-0 sutures repairs tension free repairs tension free covered by viable soft tissue (flaps if needed) covered by viable soft tissue (flaps if needed) Intraoperative completion arteriography Intraoperative completion arteriography Intra-arterial vasodilators (papaverine or tolazoline) Intra-arterial vasodilators (papaverine or tolazoline)

18 Treatment of Arterial Injuries: Operative Management risk factors for amputation after arterial repair risk factors for amputation after arterial repair – occluded bypass graft – combined above- and below-knee injury – a tense compartment – arterial transection – associated compound fracture

19 Treatment of Arterial Injuries: Operative Management Reperfusion injury Reperfusion injury –Mannitol –Allopurinol –superoxide dismutase –catalase –Systemic Heparin

20 Brachial, Radial and Ulnar Artery Injury Single-vessel injury in the forearm: need not be repaired but may be ligated or embolized Single-vessel injury in the forearm: need not be repaired but may be ligated or embolized Repair is mandatory when one of the vessels was previously traumatized or ligated or when the palmar arch is incomplete Repair is mandatory when one of the vessels was previously traumatized or ligated or when the palmar arch is incomplete If both radial and ulnar arteries injured  the ulnar artery should be repaired ( dominant vessel) If both radial and ulnar arteries injured  the ulnar artery should be repaired ( dominant vessel)

21 Subclavian-Axillary injury High mortality rate (39%) High mortality rate (39%) fracture-dislocation of the posterior portion of the 1st rib  subclavian a. injury likely fracture-dislocation of the posterior portion of the 1st rib  subclavian a. injury likely High collateral flow in UE makes absent pulses unlikely  high index of suspicion High collateral flow in UE makes absent pulses unlikely  high index of suspicion Mulitple chest incisions: Mulitple chest incisions: –median sternotomy for proximal control –left anterolateral or "trapdoor" thoracotomy

22 External Iliac-Femoral Artery Injury Iliac injuries: mortality rate % Iliac injuries: mortality rate % External iliac: retroperitoneal approach External iliac: retroperitoneal approach

23 External Iliac-Femoral Artery Injury common femoral, proximal deep femoral, and superficial femoral artery injuries: longitudinal thigh incision over the femoral triangle. common femoral, proximal deep femoral, and superficial femoral artery injuries: longitudinal thigh incision over the femoral triangle. Interposition vein graft for repair of SFA

24 Popliteal Artery Injury Challenging injury Challenging injury injury above the knee joint: medial thigh incision injury above the knee joint: medial thigh incision below-knee injury: a leg incision below-knee injury: a leg incision isolated penetrating injury directly behind the knee: incision behind knee isolated penetrating injury directly behind the knee: incision behind knee

25 Positive predictors of limb salvage Positive predictors of limb salvage –systemic anticoagulation (heparin) –laterally or end to end arterial repair –palpable pedal pulses within the first 24 hours negative predictors of limb salvage negative predictors of limb salvage –severe soft tissue injury –deep soft tissue infection –preoperative ischemia Important: Attention to possibility of compartment syndrome and rapid treatment by complete dermotomy-fasciotomy if present Important: Attention to possibility of compartment syndrome and rapid treatment by complete dermotomy-fasciotomy if present Popliteal Artery Injury

26 Isolated injury, rare limb ischemia: no repair necessary Isolated injury, rare limb ischemia: no repair necessary tibioperoneal trunk or two infrapopliteal arteries injured: repair is required tibioperoneal trunk or two infrapopliteal arteries injured: repair is required Tibial Artery Injury

27 Management considerations: Management considerations: –severity of arterial spasm –unknown long-term consequences of autogenous grafts placed in children –long-term effects of diminished blood flow on limb length –papaverine (injected topically or into the adventitia), nitrates, or warm saline to impede vasoactivity Pediatric Arterial Trauma

28 Most common injured veins: Most common injured veins: –superficial femoral vein (42%) –popliteal vein (23%) –common femoral vein (14%) When venous injury is localized When venous injury is localized – end-to-end or lateral repair (stable pt) –an interposition, panel, or spiral graft can be configured for repair (extensive venous injuries) the indication and benefit of vein repair is controversial the indication and benefit of vein repair is controversial Ligation in unstable patient Ligation in unstable patient Postoperative: extremity elevation and wrapping Postoperative: extremity elevation and wrapping Extremity Venous Injuries

29 arterial repair should be performed first to restore circulation to the limb before the orthopedic stabilization is addressed arterial repair should be performed first to restore circulation to the limb before the orthopedic stabilization is addressed inspect vascular reconstruction before final wound closure and before pt leaves OR inspect vascular reconstruction before final wound closure and before pt leaves OR injured nerve should be tagged with nonabsorbable suture at the initial operation injured nerve should be tagged with nonabsorbable suture at the initial operation Consider primary amputation for limbs with massive orthopedic, soft tissue, and nerve injuries Consider primary amputation for limbs with massive orthopedic, soft tissue, and nerve injuries Consider primary amputation in hemodynamically unstable patients (repair might jeopardize survival) Consider primary amputation in hemodynamically unstable patients (repair might jeopardize survival) Orthopedic, Soft Tissue and Nerve Injuries

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31 Inadvertant Intraarterial Drug Injection (IADI) Illicit street drugs, anesthetics Illicit street drugs, anesthetics Complications Complications –acute arterial occlusion –distal thromboembolism –mycotic aneurysms –soft tissue abscesses –gangrene –chronic ischemia

32 Soft tissue cellulitis/abscess pathogens: –Staphylococcus aureus –oral flora (streptococcal species) – anaerobic species (Peptostreptococcus and Bacteroides ) Findings: Findings: –severe, unremitting pain –edema –Numbness –discoloration –cyanosis or mottling Diagnosis: history, clinical exam, CFD ultrasonography Diagnosis: history, clinical exam, CFD ultrasonography Inadvertant Intraarterial Drug Injection (IADI)

33 Treatment soft tissue abscess: – –Parenteral Abx – –Incision and Drainage/ debridement – –Prior to I&D, CFD ultrasonography to rule out the presence of a mycotic aneurysm Inadvertant Intraarterial Drug Injection (IADI)

34 Goal: preserve all collateral circulation Goal: preserve all collateral circulation Therapy: Therapy: – 10,000 units/hour IV (PTT 1½ to 2 times control) to prevent further clotting –Heparin sodium 10,000 units/hour IV (PTT 1½ to 2 times control) to prevent further clotting Heparin sodium –Dexamethasone 4 mg IV q 6 hrs to reduce inflammation Dexamethasone –Dextran 40 IV at 20 mL/hr to prevent platelet aggregation and thrombosis Appropriate pain control, including opiates prn Appropriate pain control, including opiates prn Elevation of the extremity to reduce edema Elevation of the extremity to reduce edema Aggressive physical therapy to minimize contractures Aggressive physical therapy to minimize contractures Inadvertant Intraarterial Drug Injection (IADI)

35 one of the most common complications after an invasive arterial procedure one of the most common complications after an invasive arterial procedure Also termed Also termed pseudoaneurysm, pulsatile hematoma, or communicating hematoma direct leakage of blood from the artery into the surrounding tissue direct leakage of blood from the artery into the surrounding tissue no walls of the artery involved no walls of the artery involved Post arterial catheterization 0.2-9% Post arterial catheterization 0.2-9% Iatrogenic False Aneursyms

36 positive risk factors positive risk factors –Age older than 60 years –female gender –periprocedural anticoagulation –operator inexperience –underlying peripheral vascular disease postprocedure arterial closure devices  should see decline in rate postprocedure arterial closure devices  should see decline in rate Iatrogenic False Aneursyms

37 Sign/symptoms Sign/symptoms –pulsatile mass –significant ecchymosis over the area of cannulation –sudden drop in the postprocedure hematocrit –newly auscultated bruit –newly palpable thrill –the new onset of neurologic deficits

38 Iatrogenic False Aneursyms Duplex Scan Duplex Scan –Noninvasive –Size of false aneurysm –Neck diameter and length –Architecture of native vessel –Velocity within native vessel and false aneurysm

39 Iatrogenic False Aneursyms Significant number close spontaneously Significant number close spontaneously Compression therapy minutes (variable success rates) Compression therapy minutes (variable success rates) Percutaneous thrombin injection (>95% success) Percutaneous thrombin injection (>95% success) Endovascular repair Endovascular repair Open surgical repair (gold standard): Open surgical repair (gold standard): –failure of other treatment modalities –suspected secondary infection –evidence of vascular compromise –ongoing or imminent hemorrhage and skin erosion –necrosis due to false aneurysm expansion


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