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 Telp/Fax rumah : - No.HP : 08158751962 Tempat/Tgl Lahir : Jakarta, 25 Desember 1962 Email : - 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 )

MANAGEMENT OF VASCULAR TRAUMA 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

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

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

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

Types of Vascular Injury

Early treatment Primary survey : ABCD STOP BLEEDING Local compression Tourniquet Foley catheter Clamping & ligation

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

Secondary Survey : Clinical Findings

Diagnostic evaluation

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%

Angiography Popliteal artery injury Filling defect in popliteal artery

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

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

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

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

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

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

Embolization for Visceral Organ Trauma KIDNEY

Specific artErial injuries

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

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

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

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

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

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

5. Tibial Artery

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

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

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

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

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

Other Acute Care for Vascular Cases

AAA/TAA

Critical Limb ischemia Our Experience on Iliac Angioplasty

Critical Limb ischemia Our Experience on SFAAngioplasty

Critical Limb ischemia Our Experience on BTK Angioplasty

Embolization for Bleeding of Vascular Malformation

IVC Filter for Deep Vein Trombosis

Venoplasty for Central Venous Hypertension

Fistuloplasty for Malfunction AV Fistula

THANK YOU…