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
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

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…