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Dr. R. Suhartono SpB (K) V Alamat Kantor : Divisi Vaskular FK UI/RSCM Telp/Fax Kantor : 021-3910487 Alamat Rumah : Jl. Pulomas II/120 – Kayu Putih, Pulogadung.

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Presentation on theme: "Dr. R. Suhartono SpB (K) V Alamat Kantor : Divisi Vaskular FK UI/RSCM Telp/Fax Kantor : 021-3910487 Alamat Rumah : Jl. Pulomas II/120 – Kayu Putih, Pulogadung."— Presentation transcript:

1 Dr. R. Suhartono SpB (K) V Alamat Kantor : Divisi Vaskular FK UI/RSCM Telp/Fax Kantor : Alamat Rumah : Jl. Pulomas II/120 – Kayu Putih, Pulogadung Telp/Fax rumah : - No.HP : Tempat/Tgl Lahir : Jakarta, 25 Desember Profesi : Dokter Spesialis Bedah Vaskular & Endovaskular Departemen Medik Ilmu Bedah Jabatan : 1. Staf Divisi Vaskular & EndoVaskular FKUI/RSCM 2. Anggota Kolegium Bedah Vaskular & Endovaskular 3. Anggota PESBEVI ( Perhimpunan Dokter Spesialis Vaskular & Endovaskular Indonesia )

2 MANAGEMENT OF VASCULAR TRAUMA R. Suhartono, dr., SpB(K)V Vascular & Endovascular Surgeon - FKUI/RSCM R. Suhartono, dr., SpB(K)V Vascular & Endovascular Surgeon - FKUI/RSCM The 5 th Annual Indonesian Symposium on Acute Care Surgery Bandung, February 18 th, 2015

3 Vascular Emergency Cases Vascular Trauma Ruptured aneurysm Acute Limb Ischemia DVT  – Compartement Syndrome – Phlegmasia Cerulea Dolens Ascending Infection (Diabetic Foot)

4 Vascular Trauma 90% of all peripheral arterial injuries occur in extremity Extensive associated musculoskeletal injury is common

5 Mechanism of Injury Penetrating trauma – Gunshot wounds – Cut wounds Blunt Trauma – Motor vehicle accidents – Fall

6 Types of Vascular Injury

7 Primary survey : ABCD STOP BLEEDING – Local compression – Tourniquet – Foley catheter – Clamping & ligation

8 Damage control Where by a rapid “bailout” operation  Control hemorrhage & spillage  Delayed reconstruction after the patient’s physiology has been stabilized  Aim : to save the patient’s life

9 Clinical Findings Secondary Survey :

10 Diagnostic evaluation

11 Color Flow Duplex Ultrasound – Non invasive, save, painless, easy to use, relatively inexpensive – Highly operator dependent CT Angiography – 3D, high-resolution images – specificity & sensitivity > 90%

12 Angiography Popliteal artery injury Filling defect in popliteal artery Popliteal artery injury Filling defect in popliteal artery

13 Arterial Injuries Treatment 1. Non-operative management  low-velocity Injury  minimal (<5 mm) disruption for intimal defects and pseudoaneurysm  adherent or downstream protrusion of intimal flaps  intact distal circulation  no active hemorrhage

14 2. Operative Management General principles  Perioperative  antibiotics  Initial goal  obtaining proximal control  Incisions are placed longitudinally  Debridement injured tissue  Remove intraluminal thrombus  Forgarty  Saline & heparin Arterial Injuries Treatment

15 Operative Management Repair of injured vessels: lateral suture patch angioplasty end-to-end anastomosis interposition graft bypass graft Monofilament 5.0 or 6.0 sutures are suitable for most peripheral vascular repairs All repairs should be tension free & covered by viable soft tissue

16 Vein Graft Graft: Greater saphenous vein from uninjured extremity  most durable arterial graft expanded polytetrafluoroethylene (ePTFE)  prosthetic autogenous grafts Graft: Greater saphenous vein from uninjured extremity  most durable arterial graft expanded polytetrafluoroethylene (ePTFE)  prosthetic autogenous grafts

17 Arterial Injuries Treatment 3. Endovascular management  Trans Catheter embolization (coil / balloon) ◦ low-flow arteriovenous fistulae ◦ false aneurysm ◦ active bleeding from noncritical arteries  Endograft ◦  endoluminal repair of false aneurysms or large arteriovenous fistulae

18 Large peroneal artery false aneurysm (left) that was successfully treated by coil embolization (right) Trans Catheter Embolization

19 Embolization for Visceral Organ Trauma KIDNEY

20 SPECIFIC ARTERIAL INJURIES

21 1. Axilary Artery  Injury of axillary artery is more common than injury to the subclavian artery  Causes: penetrating trauma, anterior shoulder dislocation, fracture of the humeral neck  Upper extremity critical ischemia : uncommon  Endovascular therapy : high success rate  Surgically approached : infraclavicular incision  Injury of axillary artery is more common than injury to the subclavian artery  Causes: penetrating trauma, anterior shoulder dislocation, fracture of the humeral neck  Upper extremity critical ischemia : uncommon  Endovascular therapy : high success rate  Surgically approached : infraclavicular incision

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23 2. Brachial, Radial, & Ulnar Arteries Brachial artery injuries  usually due to penetrating trauma & frequently iatrogenic Blunt injuries  supracondylar fractures of the humerus Single-vessel injury in the forearm  need not be repaired but may be ligated or embolized Must be repaired if either the radial or ulnar artery, was previously traumatized or ligated Brachial artery injuries  usually due to penetrating trauma & frequently iatrogenic Blunt injuries  supracondylar fractures of the humerus Single-vessel injury in the forearm  need not be repaired but may be ligated or embolized Must be repaired if either the radial or ulnar artery, was previously traumatized or ligated

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25 3. Femoral Artery Blunt/penetrating injuries to the superficial femoral artery  very common Injuries to the proximal deep femoral artery should always be repaired in hemodynamically stable patients

26 4. Popliteal Artery The most challenging of all extremity vascular injuries The amputation rate for gunshot wounds 20%; stab wounds near 0% The popliteal vein, infrapopliteal arteries, & tibial nerve are frequently involved in penetrating injuries The most challenging of all extremity vascular injuries The amputation rate for gunshot wounds 20%; stab wounds near 0% The popliteal vein, infrapopliteal arteries, & tibial nerve are frequently involved in penetrating injuries

27 4. Popliteal Artery Above the knee joint  medial thigh incision Below-knee injury  leg incision Injury directly behind the knee  approached from behind

28 5. Tibial Artery Isolated infrapopliteal injury rarely results in limb ischemia  does not require therapeutic intervention A single actively bleeding traumatized vessel  simple ligation or angiographic embolization Tibioperoneal trunk or two infrapopliteal arteries are injured  repair is required Isolated infrapopliteal injury rarely results in limb ischemia  does not require therapeutic intervention A single actively bleeding traumatized vessel  simple ligation or angiographic embolization Tibioperoneal trunk or two infrapopliteal arteries are injured  repair is required

29 5. Tibial Artery

30 Extremity Venous Injuries Most commonly injured: – Superficial femoral vein (42%) – Popliteal vein (23%) – Common femoral vein (14%) When localized  end-to-end or lateral venorrhaphy should be performed if possible unless the patient is unstable  ligation When more extensive venous injuries exist, an interposition, panel, or spiral graft can be configured for repair When venous injury occurs with an ischemic arterial injury  vein should be repaired before the arterial repair is initiated Most commonly injured: – Superficial femoral vein (42%) – Popliteal vein (23%) – Common femoral vein (14%) When localized  end-to-end or lateral venorrhaphy should be performed if possible unless the patient is unstable  ligation When more extensive venous injuries exist, an interposition, panel, or spiral graft can be configured for repair When venous injury occurs with an ischemic arterial injury  vein should be repaired before the arterial repair is initiated

31 Orthopedic Injuries The incidence of combined injury  0.3% to 6.4% The arterial repair should be performed first before orthopedic stabilization addressed Massive musculoskeletal trauma  external fixation must be accomplished before vascular procedure  intraluminal shunts Inspect the vascular reconstruction before final wound closure The incidence of combined injury  0.3% to 6.4% The arterial repair should be performed first before orthopedic stabilization addressed Massive musculoskeletal trauma  external fixation must be accomplished before vascular procedure  intraluminal shunts Inspect the vascular reconstruction before final wound closure

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33 Soft Tissue Injury Major soft tissue injuries, debridement is mandatory Unexplained fever & leukocytosis  assumed to be due deep tissue infection until proved otherwise Delayed primary closure, rotational flaps, or free tissue transfer  minimizes the risk of invasive sepsis Major soft tissue injuries, debridement is mandatory Unexplained fever & leukocytosis  assumed to be due deep tissue infection until proved otherwise Delayed primary closure, rotational flaps, or free tissue transfer  minimizes the risk of invasive sepsis

34 Primary Amputation vs. Reconstruction Durham and colleagues  Mangled Extremity Syndrome Index, MESS, Predictive Salvage Index, and Limb Salvage Index  None of the indices could predict functional outcome Extremity salvage: – 90%  < 6 hours of ischemia – 50%  12 to 18 hours of ischemia – 20%  > 24 hours for ischemia Durham and colleagues  Mangled Extremity Syndrome Index, MESS, Predictive Salvage Index, and Limb Salvage Index  None of the indices could predict functional outcome Extremity salvage: – 90%  < 6 hours of ischemia – 50%  12 to 18 hours of ischemia – 20%  > 24 hours for ischemia

35 Primary Amputation vs. Reconstruction Primary amputation done on patients with :  Massive orthopedic, soft tissue, & nerve injuries  Hemodynamically unstable patients in whom a complex vascular repair might lessen survival rate Primary amputation done on patients with :  Massive orthopedic, soft tissue, & nerve injuries  Hemodynamically unstable patients in whom a complex vascular repair might lessen survival rate

36 Other Acute Care for Vascular Cases

37 AAA/TAA

38 Critical Limb ischemia Our Experience on Iliac Angioplasty

39 Critical Limb ischemia Our Experience on SFAAngioplasty

40 Critical Limb ischemia Our Experience on BTK Angioplasty

41 Embolization for Bleeding of Vascular Malformation

42 IVC Filter for Deep Vein Trombosis

43 Venoplasty for Central Venous Hypertension

44 Fistuloplasty for Malfunction AV Fistula

45 THANK YOU…


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