1. Arterial Trauma Author: Zacharias Cora
Coordinators: Prof. Suciu Horatiu, MD
Stroe Valentin, MD, PhD

2. Introduction
Acute injuries of vessels constitute an important therapeutic problem, representing a serious threat to life.
Approximately 75% of all vascular injuries are located to the extremities and more than 50% to the leg.

3. PERIPHERAL VASCULAR INJURIES: Carotid Artery Injury
Symptoms: headache, cervical pain and cerebral or retinal ischemia
Subclavian and Axillary Artery Injuries
Usually associated with first-rib or clavicular fractures that cause occlusion of the artery
Brachial Artery Injuries
Implicated in iatrogenic catheter-related injuries
Radial and Ulnar Artery Injuries
Trauma caused by industrial and domestic accidents
Palmar Artery Injuries
Plastic surgery
Iliac Artery Injuries
Associated with damages of pelvic region.
Common, Profunda and Superficial Femoral Artery Injuries
Most often , secondary to angiography
Popliteal Artery, Anterior Tibial, Posterior Tibial and Peroneal Artery Injuries
The most common segments implicated in trauma due sports, domestic and industrial activities.
Plantar Artery Injuries

5. Ethiology
Causes:
penetraiting injuries are usually caused by knives and gunshots
blunt injuries occur in road trafic accidents because of fracture and joint dislocation
iatrogenic injuries can be caused by catheterization and during surgical dissection

6. Most common location for combined orthopedic and vascular injuries:
ORTHOPEDIC INJURY
VASCULAR INJURY
Femoral shaft fracture
Superficial femoral artery
Knee dislocation
Popliteal artery
Fractured clavicle
Subclavian artery
Supracondylar fracture of the humerous.
Elbow dislocation
Brachial artery
Shoulder dislocation
Axillary artery

7. Types of arterial injuries which can occur, can be devided into 5 groups:
laceration
transection
contusions (hematomas, trombosis)
spasm (rare)
arteriovenousus fistulas.

8. Clinical Signs and Symptoms
As with all injuries it is important to interview the rescue personnel about information such as:
Type of injury
Type of bleeding
Estimation of the blood loss
The exact time when the injury happend
(the ideal time period for repair of an arterial injury is within 6 to 8 hours after injury)
Information about diseasis and medication

9. There are 4 factors which significantly influence the degree of ischemia/the semnificance of time lag:
The size of the artery injured: in general, the larger the artery, the more severe the ischemia
The degree of impairment of collateral circulation from associated soft tissue injury
The degree and duration of shock
Ambient temperature: a cold extremity will naturally tolerate ischemia longer than a warm one.

10. “Hard signs”: Active hemorrhage Hematoma (large, pulsating, expanding)
Distal ischemia: the six Ps (pain, pallor, paralysis, pulse deficit, paresthesia, poikilothermia)
Bruit (over the wounded area to reveal a possible arteriovenosus fistula)

11. The physical examination should include:
Examination and auscultation of the injured area
Palpation of pulses in both legs and arms
Assesment of skin temperature, motor function and sensibility
“Soft signs” (history of significant bleeding, small hematoma, adjacent nerve injury, proximity of wound to vessel location, unexplained shock)

12. Diagnosis Duplex Ultrasound Angiography
It has not been universally accepted for diagnosis of vascular trauma, despide the fact that it is noninvasive. But it is a method of choice for diagnosis of most of the late cosequences of vascular injuries: arteriovenous fistulas, pseudoaneurysms and hematomas.
Angiography
The purpose is to identify and locate lesions such as occlusions, narrowing and intimal flaps and it also serves to provide a road mape before surgery.

13. Management and Treatment
Team work: Vascular Surgeon
Orthopedic Doctor
Plastic Surgeon
Anesthesist Doctor

14. POSTOPERATIVE CONSIDERATION
PREOPERATIVE FACTORS
1. Control of hemorrhage
2. Resuscitation from the shock
3. Minimizing time lag from injury to arterial repair
OPERATIVE FACTORS
1. Debridement of injured tissues and irrigation to minimize infection
2. Arterial repair:
(debridement of injured artery , removal of distal thrombi, arterial reconstruction, soft tissue coverage)
3. Management of associated injuries
(vein, bone, nerve, soft tissue)
POSTOPERATIVE CONSIDERATION
1. Patency of arterial repair
2. Muscle necrosis
3. Wound infection

15. LESS SEVERE INJURY SEVERE INJURY
Major external bleeding should immediately be controlled with digital pressure or bandages.
Before transfer to the operating room the following can be done:
give the pacient oxygen
initiate monitoring of vital signs (heart rate, blood presure, respiration, SpO2)
place at least one IV line
consider administering analgesics
draw blood for hemoglobin and hematocrit, prothrombin time, creatinine, sodium and potassium
consider administering antibiotics and tetanus profylaxis
obtain informed consent
Duplex Ultrasound/Arteriography
to rule out or verify vascular
damage.
Discussing the priority of
management: vascular injuries
shoud be given higher priority
than skeletal and soft tissue
injury and temporary restoration
of blood flow can be achived by
shunting.
Patients with normal physical examination (little suspicion of vascular injury) can be monitored in the ward (hourly assessment of pulses the first 4-6 h).

16. Primary amputation:
For a few patients, primary amputation is a better option.
This is often a difficult decision.
Primary amputation is favorable for the pacient if:
the leg/arm is massacred
duration of ischemia >6 h !!!
multitrauma patients, patients with severe comorbid disease and those in whom the leg/arm was already paralyzed at the time of injury

17. Surgical Technique
Arterioraphy/Patch Arterioplasy

18. Reconstruction by Interposition
- venous grephon
- sintetic grephon

19. By-pass Reconstruction - sintetic grephon End-to-end anastomosis
- venous grephon
- sintetic grephon
End-to-end anastomosis

20. Complications Trombosis Infection Stenosis
Miscellaneous complications:
-edema
-embolisation
- disseminated intravascular coagulopathies
- chronic pain
- decreased function
- ischemic changes
- arteriovenous fistulas
- arterosclerotic changes

21. Matherial and methods
The clinical study was made between March 2010 and March The average age for iatrogenic injury was on patients between 50 and 70 years. The mean age for traumatic injuries such as domestic, industrial, road trafic accidents and penetrating injury was on young patients between 17 and 45 years.

22. 123 patients:

23. Results
Iatrogenic Injury: They were all Post-Catherization Pseudoaneurysms using the Seldinger tehnique, with or without hematomas. The procent was aproximately the same into men and women: -46 male cases -45 female cases

25. The surgical therapy was represented by vascular arterioraphy and hematoma evacuation with good restauration of blood flow.
There was one death caused by cardiopulmonary failure, without arterioraphy-related problems.

27. Surgical Techniques:

28. Reconstruction by Interposition 12 patients (37,5%)

29. End-to-End Anastomosis 14 patients (43,75%)

30. Arterial Bypass with Synthetic Grapht (Dacron) 2 patients (6%)

31. Arterial Reconstruction with Safenous Vein after Orthopedic-Vascular Severe Trauma 3 pacients (9%)

32. Early lower and upper extremity fasciotomies were performed for compartment syndrome after acute ischemia and revascularization in 8 patients (25%) with arterial trauma.
All patients had more than one accepted indication for fasciotomy: fracture or dislocation, compartment tenseness and extensive soft tissue injury.
Two patients needed multiple skin grafting procedures or myocutaneous flaps to close the wound.

33. 2 amputations were required for limb ischemia
2 amputations were required for limb ischemia. Both involved injury below-the-knee, to the tibial artery. Both patients were involved in routier accidents (blunt trauma).
2 deaths caused by penetrating injuries: one suicidal pacient and one with a complex industrial trauma. Both arrived with a Glasgow Coma Score of 4 despite the absence of head injury and no blood pressure.

34. Conclusions
A multidisciplinary approach to the management of the arterial trauma patient will help create circumstances in which optimal care can be provided.
Early fasciotomy has been cited as a major factor contributing to limb salvage and preservation of function, especially in politraumatic injuries with multiple fractures and dislocations.
Primary amputation must be taken into consideration if the duration of ischemia is >6 h, so the pacient’s life can be saved.
Trauma with arterial injury has a nearly 10% rate of mortality or limb loss. Primary amputation is more common with blunt distal vascular injury. In contrast, mortality is associated with penetrating mechanism and early shock, likely resulting from prehospital proximal arterial hemorrhage.

35. Bibliography
Emergency Vascular Surgery (Springer) – E. Wahlbert, P. Olofsson, J. Goldstone
Peripheral vascular injury-related deaths – S. Bilgen, N. Turkmen, B. Eren, R. Fedak
Vascular Trauma (Sauders Company) – Norman M. Rich, Frank C. Spencer
Blunt vascular trauma in the extremity: diagnosis, management and outcome (J. Trauma. 2003) – G.S. Rozycki, L.N. Tremblay, D.V. Feliciano, W.B. McClelland
Rutherford’s Vascular Surgery 7th Edition (SVS) - Jack L. Cronenwett, K. Wayne Johnston
Haimovici’s Vascular Surgery 5th Edition – Larry H. Hollier, D.E. Strandness, J.B. Towne, K. Calligaro, K.C. Kent, G.L. Moneta, J.J. Ricotta

36. Thank you!