Vascular Trauma

1
Vascular Trauma

• General Surgery Teaching Rounds
• April, 2005

2
Overview

• Basic Principles
• Common Exam Questions
• Neck
• Chest
• Abdomen
• Extremities

3
Basic Principles

• Anatomy
• Types of Injury
• Mechanisms of Injury
• Clinical Manifestations
• Clinical Evaluation
• Investigations
• Management

4
Anatomy

• Know the named vessels arterial and venous in
  the vicinity of injury
• Know anatomic principles of proximal and distal
  control
• Appreciate the adjacent structures (nerves,
  organs etc)

5
Types of Injury

• Laceration
• Transection
• With or without defect
• Dissection
• Crush
• Thrombosis / Embolus
• Spasm

6
Mechanisms of Injury

• Penetrating
• Knife
• GSW/ Shrapnel (low/high velocity)
• Catheter (Iatrogenic)
• Blunt
• Direct (Contusion)
• Traction / Avulsion
• Deceleration
• Torsion

7
Clinical Manifestations

• Early
• Hemorrhage
• End-organ ischemia
• Fistula?
• Late
• Fistula
• False Aneurysm

8
Evaluation

• History and PE
• Type of weapon
• Time since injury
• 5 Ps
• Associated Injuries (neuro, MSK, GI, GU)

9
Evaluation

• Hard Findings
• Active Bleed
• Expanding Hematoma
• End-organ ischemia
• Loss of pulses
• A-V fistula
• Soft Findings
• Reduced pulses
• Neurologic deficits
• History of bleeding
• Shock
• Injury in proximity to major vessel

10
Investigations

• Plain Films
• Doppler
• Duplex
• Arteriography
• CT
• MRI

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Arteriography

• Recall hard vs soft findings
• Role
• Detect occult injury
• Exclude need for OR
• Operative planning
• Endovascular Repair
• Other modalities may obviate or complement
  arteriography

12
Management

• Conservative
• Endovascular
• Operative
• Local suture, patch, primary anast
• Bypass
• Anatomic, extra-anatomic
• Autogenous , prosthetic
• Adjunct
• Fasciotomies, MSK fixation

13
Common Questions
14
Neck

• Anatomy
• Carotid, Verterbrals, Subclavian Arteries
• Jugular, Subclavian, Innominate
• Mechanism
• gt95 are penetrating
• Blunt injuries often complex
• Clinical Presentation
• Bleed, hematomas
• End-organ ischemia (brain)

15
Neck

• Penetrating Trauma Zones I-III
• Zone I base of neck, thoracic outlet to 1cm
  above clavicle
• Zone II 1 cm above clavicle to angle of the jaw
• Zone III above angle of mandible
• Who to image? Who to explore?

16
Neck

• Imaging
• 4 vessel angiography
• Duplex
• CT head
• Zone I and III are difficult to assess clinically
  image the stable patient
• Zone II issue of mandatory exploration open to
  debate (40-60 are negative), various algorithms
  of clinical re-evaluations, duplex and angiography

17
Neck

• Management
• Remember endovascular options (especially for
  zone III , /- zones I,II)
• Repair in most (even if neuro deficit could be
  metabolic, drug / alcohol)
• Ligate only if known severe cerebral injury
  (hemorrhagic infarct , diffuse cerebral edema) or
  complex injury with uncontrollable bleed

18
Chest

• Anatomy Aorta, supra-aortic trunks,
  intercostals (including Adamkiwiecz), IVC, SVC,
  Innominate / subclavian (and Heart)
• Indication for Thoracotomy
• ER penetrating, unstable, unresponsive to
  resuscitation, blood in chest tube
• Chest tube output
• gt300 cc/hr for 2 or more hours
• 1500 to 2000 in 8 hours or less

19
Chest

• Exposures
• Posterolateral thoracotomy (traditional), good
  for L carotid, L subclavian and dec aorta but may
  reduce venous return, bleed into opp lung
• Median sternotomy asc aorta, arch, innominate
  and branches
• Anterolateral thoracotomy (4th i.s.) good for L
  side and ER control / resuscitation
• Other clamshell, trapdoor, clavicular resection

20
Chest

• Aortic Tear / Disruption / Transection
• Deceleration and shear stress results in
  disruption anteriorly (opposite to ligamentum
  arteriosum)
• Dx CXR, CT (angio), TEE, Angio (best?)
• CXR findings
• Widened medistinum, ribs 1,2, sternum, apical
  cap, pleural effusion, depression of L mainstem,
  tracheal deviation to R, obliteration of AP
  window, obliteration of descending aorta
• Repair
• Surgery timing? Graft vs suture
• Endovascular

21
Abdomen

• Anatomy Aorta and its branches mesenteric,
  renals, iliacs. IVC and iliac veins, Portal
  circulation
• Review indications for laparotomy peritonitis,
  DPL, imaging
• Operative principles
• 1st control bleeding and contamination
• Avoid complex vascular reconstruction whenever
  possible. Avoid prosthetics where possible
• Packing may be a good option (rewarm, resusciate
  and re-lap)
• Ligation and organ removal (spleen, one kidney)
  may be an option

22
Abdomen

• Control Options
• Supradiaphragmatic
• Supraceliac
• Infrarenal
• Balloons, Occlusion clamps
• Exposures
• Medial visceral rotation
• From left (Cattall)
• From right (Collis)

23
Abdomen

• Retroperitoneal Hematomas
• Penetrating (explore all?)
• Blunt (see below)
• Lim Zones 1-3
• 1 (central) explore all
• 2 (lateral) explore selectively (expansion,
  end-organ compromise)
• 3 (pelvic) best to pack (especially with
  fractures)

24
Extremities

• Most common vascular trauma
• Review and apply all basic principles (anatomy,
  type / mechanism of injury, clinical
  manifestation, evaluation, investigation)
• Goal rapid re-establishment of circulation
  (where appropriate)

25
Extremities

• Operative Principles
• Proximal / distal control
• Primary repair where possible
• If graft / patch use autogenous
• Leg, contralateral limb
• Consider temporary shunt
• Fixation of ortho injuries
• Coverage of repair (muscle, soft tissue)
• Fasciotomies

26
Extremities

• Ligation may be OK in rare circumstances
  (proximal upper extremities, distal forearm,
  tibials)
• If significant associated MSK, neurologic injury
  amputation may be best
• Popliteal injuries have the highest amputation
  rate
• Vein repair may improve limb salvage esp try to
  repair popliteal and common femoral veins. Repair
  vein before artery.
• Know the sequelae of compartment syndrome and
  reperfusion syndrome

27
Other

• Catheter injuries
• Intra-arterial drug injuries
• Cold Injury
• Frostnip
• Chilblains
• Immersion (Trench) foot
• Frostbite