3 Signs of Arterial Injury Hard Signs (Operation Mandatory)Soft Signs (Further Evaluation Desirable)Pulsatile hemorrhageProximitySignificant hemorrhageMinor hemorrhageThrill or bruitSmall hematomaAcute ischemiaAssociated nerve injurySoft signs….angio?
4 Injury patterns Penetrating Blunt Fully transected vs partially transected vesselBluntSmall intimal flap vs transmural damageFree vs contained bleed (pseudoaneurysm)Arteriovenous fistulaIatrogenic injuryFully transected may retract and thrombose, partially may bleed more
5 General Definitive therapy vs damage control Open vs endovascular Control hemorrhageMaintain distal perfusionOpen vs endovascularTrauma patients tend to be healthier and younger than most vascular patients? Ligate artery
6 What are your options? Observation Ligation Lateral suture Ok to ligate external carotid, celiac axis, internal iliacMaintain one major vessel to extremityLateral sutureEnd-to-end anastomosisInterposition graftsVeinArteryPTFEDacronExtra-anatomic bypassInterventional radiology
7 Endovascular management Can be considered in hemodynamically stable patient with no active bleedingExamples:Access to vertebral arteryRepair renal artery injuryRepair subclavian artery injuryRepair of blunt injury to descending thoracic aortaBenefits are obvious: low morbidity, better in patients with compromised physiologyGood for inaccessible sitesLack of prospective trials/poor long term follow up
8 Operative PrinciplesObtain proximal and, if possible, distal control
9 Neck InjuriesMajor vascular injury occurs in 1 of every 4 patients with penetrating cervical injuryAirway, airway, airwayAsymptomatic patients with penetrating injury to zones require 4 vessel angiographyAsymptomatic patients with zone 2 injuries may get angiography or immediate surgical exploration
10 Blunt Cerebrovascular Injuries Incidence of clinically significant injuries to carotid/vertebral arteries is 1-3 per patients admitted to trauma centerWith increased screening protocols, incidence of injury is 1%Usually an intimal tearMost patients are treating with systemic anticoagulationAgain, f/u is keyResults with endovascular repair unclear and disturbing
11 Thoracic Vascular Injuries Choice of incisionIf unsure about location of injury, anterolateral thoractomyJust below nipples in men; below retracted breast in women.On R side consider ex lap for liver injury first.
12 Thoracic vascular injury – choice of incision Median sternotomyAscending aortaInnominate arteryProximal R subclavian arteryInnominate veinProximal L common carotidLeft thoracotomyL subclavian arteryDescending aortaDistal R subclavian artery – midclavicular incisionMedian sternotomy-R sided vesselsThoracotomy- L subclavian
13 Management of specific thoracic injuries Pulmonary hilar injuriesMortality is 70%Usually pneumonectomy with linear stapler is indicated
14 Blunt Thoracic Aortic Injury Cause of 10-15% of motor vehicle deathsMost commonly seen injury to proximal descending thoracic aortaPatients invariably have associated injuries:50% head46% rib fxs38% lung contusions20-35% orthopedic injuries
15 Blunt thoracic aortic injuries Mechanism is commonly sudden deceleration with shear force between mobile and fixed portion of the thoracic aortaA contained injury is almost NEVER the cause of hemodynamic instability – look elsewhere!
16 CXR findings Widened mediastinum (>8cm) Obscured or indistinct aortic knobDeviation of L mainstem bronchusObliteration of aortopulmonary window
17 Operative management of blunt thoracic aortic injury Traditional therapy has always been prompt operative repairConsider non operative therapy with severe head injury or multi organ traumaEstimated risk for free rupture is 1%/hourControl BP and afterload reductionRemember follow up imaging when necessary
18 Endovascular repair Increasingly being used despite poor clinical data Open repairMortality 13% (0-55%)Paraplegia 10% (0-20%)Endovascular repairMortality 3.8%Paraplegia <1%Technical ObstaclesSize of graft vs aortaAngulation of aorta
19 Abdominal Vascular Injuries Definitive repair vs damage controlAortic cross clamping (easiest is supraceliac aorta)Profound physiologic consequences of aortic crossclamping
20 Cattell-Braasch maneuver With regards for retroperitoneal exposure match the corresponding action with the maneuver.Mattox maneuverKocher maneuverCattell-Braasch maneuverMedial reflection of the right colon and duodenum by incising their lateral peritoneal attachments.The lateral peritoneal attachment of the sigmoid and left colon are incised.Used for extensive retroperitoneal exposure by detaching the posterior attachments of the small bowel mesentery toward the duodenojejunal ligament.Used for SMA exposure
21 Retroperitoneal exposure Can see all but R renal a.
22 Retroperitoneal hematomas Zone 1 injuryMandates exploration for both blunt and penetrating injuryZone 2 injuryExploration for penetratingObservation for stable blunt traumaZone 3 injurySame as zone 2
23 Retrohepatic IVC injuries Atrio-caval, or Schrock, shuntMortality in excess of80%
24 Peripheral Vascular Trauma Assess neurologic status of affected extremityLook for signs of compartment syndromeTraditional window of opportunity ≤ 6 hoursHand held DopplerArteriography indicated for any >10 mm Hg difference between extremities6 P’s: pain out of proportion to exam, parathesias, passive stretch pain, pulselessness, paralysis, pressure on passive movement
25 Role of Arteriography No use in actively bleeding patient Questionable use in patient with proximity injury but normal PEHelpful for identification of area of injury prior to going to ORRemember soft signs of arterial injury
26 Operative Repair Usually bony injuries are repaired first Consider temporary shunt if neededSmall arteries of arm and below the knee usually preclude use of synthetic graftPTFE may be ok in contaminated fieldPrinciples include soft tissue coverage
27 Fasciotomy Why elevated compartment pressures? Difficult to diagnose Direct muscular traumaHypotensionReperfusion of ischemic extremityLigation of injured veinsDifficult to diagnose
28 FasciotomyThe anterior and lateral compartments are approached through a lateral longitudinal incision following the anterior margin of the fibula. The superficial and deep posterior compartments are decompressed through a medial incision slightly posterior to the edge of the tibia.
29 Iatrogenic Injury Hemorrhage/hematoma from puncture site Usually related to inadequate compression following puncture or removal of catheterPseudoaneurysmUS guided compression effective 80-90%Arterial thrombosis
30 Peripheral vascular injuries Popliteal injuries have highest rate of limb loss (20%)Posterior dislocation of kneeBrachial artery most commonly injured peripheral artery (20-30% of cases)
31 Vascular Trauma Review Always remember ABC’sCompression, control hemorrhageImaging if indicated and patient stableTry to think about operative approach/incision ahead of timeFollow up imaging when indicated