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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 )

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

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 Blunt Trauma Gunshot wounds
Cut wounds Blunt Trauma Motor vehicle accidents Fall

6 Types of Vascular Injury

7 Early treatment 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 Secondary Survey : Clinical Findings

10 Diagnostic evaluation

11 Diagnostic evaluation
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

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 Arterial Injuries Treatment
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

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

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

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


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


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

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

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

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


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

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

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

36 Other Acute Care for Vascular Cases


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


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