Title: Principles for Evaluation and Treatment of Patients with Vascular Injury
1Principles for Evaluation and Treatment of
Patients with Vascular Injury
2Overview
- Epidemiology
- Types of Injury
- Evaluation
- Treatment
3Mechanisms of Vascular Injury in the Extremities
- Gunshot wound 54
- Stab wound 15
- Shotgun wound 12
- Blunt trauma 15
- Iatrogenic 3
4Types of InjuriesActive Hemorrhage
- Laceration
- Partial transection
- Complete Transection
5Types of InjuryPotentially non-occlusive
- Contusion with
- Segmental Spasm
- Thrombosis
- True Aneurysm
6Types of InjuryPotentially non-occlusive
- Pseudoaneurysm
- Arteriovenous Fistula
- Intimal Flap
7Presentation of Vascular Injury
- First priority is hemorrhage control followed by
appropriate diagnostic work-up
8Presentation of Vascular Injury
- Dislocations and displaced or angulated
fractures realigned immediately if vascularity
is compromised
9Evaluation for Vascular Injury
- Physical Examination
- Doppler Flowmeter
- Duplex Ultrasonography
- Arteriogram
- Local wound exploration should not be done in an
uncontrolled setting - Close coordination with a general or vascular
surgeon recommended
10Physical ExaminationHard Signs
- Absent or diminished distal pulses
- Active hemorrhage
- Large, expanding or pulsatile hematoma
- Bruit or thrill
- Distal ischemia (pain, pallor, paralysis,
paresthesias, coolness)
11Physical ExaminationSoft Signs
- Small, stable hematoma
- Injury to anatomically related nerve
- Unexplained hypotension
- History of hemorrhage no longer present
- Proximity of injury to major vessel
12Doppler Examination
- Non-invasive adjunct to physical examination
- Small, hand-held (non-directional) Doppler
flowmeter provides for subjective interpretation
of audible signal - Useful as modality for determining the
Ankle-Brachial Index (ABI)
13Doppler
- Normal arterial signals are triphasic or biphasic
14Doppler
- Flow distal to a transection may be absent or
monophasic and low-pitched due to collateral
circulation
15Determination of Ankle-Brachial Index
- Appropriate sized blood pressure cuff is placed
above the ankle or wrist - Doppler derived opening pressure of distal artery
- Calculate by dividing ankle pressure by brachial
pressure - Measure injured/ uninjured sides
- Normal ABI is 1.00 or greater
16ABI Criteria
- ABI gt 0.9
- Advantages
- Strong negative predictor for major vascular
injury - Objective noninvasive evidence of vascular
competence - Disadvantages
- Does not exclude all injuries
- Not useful in presence of vascular disease
17Duplex (B-mode) Ultrasonography
- Direction-sensing Duplex (B-mode) ultrasound
allows for visual waveform analysis - Highly operator dependent
- 96-98 accurate in experienced hands
- Generally not available during peak trauma times
18Arteriography
- Gold standard for evaluation of peripheral
vascular injuries - Formal arteriograms done in radiology may cause
critical delays in diagnosis or intervention - Single-shot arteriograms done in the emergency
room or operating room should be considered in
cases where arteriography is indicated.
19Indications for Arteriography
- Multiple potential sites of injury (shotgun
wounds) - Missile track parallels vessel over long distance
- Blunt trauma with signs of vascular trauma
- Chronic vascular disease
- Extensive bone or soft tissue injury
- Thoracic outlet wounds
- Evaluation of equivocal results from non-invasive
tests - Proximity (gsw, knife wound) (controversial)
- ABI lt .9
20Single-shot Arteriogram
- 21 or 20 gauge angiocatheter ( at least 2 long)
or single lumen central line or a-line kit - 3 way stop-cock
- 30 cc syringes (x2)
- Iodinated contrast (full strength)
- Heparinized saline (1,000 IU/liter)
- IV extension tubing
- Consider inflow and/or outflow occlusion
21Single-shot Arteriogram in the Emergency or
Operating Room
22Summary of Evaluation
- Initial priority is to control hemorrhage
- Direct Pressure
- Pressure Points
- Tourniquet
- If penetrating injury with one or more hard signs
of vascular injury then immediate surgical
exploration is usually warranted - If hard signs present with blunt mechanism or
multi-site penetrating mechanism then an
arteriogram may be warranted - If soft signs present, consider further
diagnostic modalities (usually initially
non-invasive)
23TreatmentOperative Repair
- Indications
- injuries with hard signs of vascular injury
- OR
- arteriogram showing occlusion or extravasation
24TreatmentNon-operative Observation
- Certain non-occlusive injuries without hard signs
(often occult injuries) can be managed
conservatively - Criteria
- Low-velocity injury
- Minimal arterial wall disruption
- Intact distal circulation
- No active hemorrhage
- Serial arteriography or duplex scanning
recommended - Close coordination with a vascular or general
surgeon is recommended
25Non-operative Management
- Intimal injuries and segmental narrowing are most
amenable to conservative care and may resolve
over time - Small pseudoaneurysms sometimes enlarge, become
symptomatic and require operative repair - Asymptomatic acute AV fistulas may be less
certain to resolve and should be followed closely
26Sequelae of Missed Arterial Injuries
- Deterioration of arterial injury can lead to
- Intimal dissection with resulting occlusion
- Arteriovenous fistula
- Thromboemboli
- Stenosis
- These can cause distal ischemia with significant
morbidity - Pain
- Gangrene
- Amputation
27Penetrating Arterial InjuryLimb Salvage Rates
- World War II (Debakey and Simeone, 1946)
- 2,471 cases
- 51 salvage for ligation
- 64.2 salvage for repair
- Viet Nam War (Rich et al, 1970)
- 1000 cases
- 28.5 with concomitant fractures
- 87 overall salvage
- Recent civilian (Trooskin et al, 1993)
- 50 arterial and 17 venous injuries in 51 patients
- 22 with concomitant fractures
- 100 salvage
- Other recent civilian studies approach a 100
salvage rate as well
28Blunt Arterial Injury Salvage Rates
- Have a high amputation rate due to associated
soft-tissue and nerve injuries (the mangled
extremity) - These injuries may result in a non-functional
limb in spite of a successful revascularization
29Mangled Extremity
- Indications for Primary Amputation
- Anatomically complete disruption of sciatic or
posterior tibial nerves in adult even if vascular
injury is repairable - Prolonged warm ischemia time
- Life threatening sequelae
- rhabdomyolysis
30Mangled Extremity
- Relative Indications for Primary Amputation
- Serious associated polytrauma
- Severe ipsilateral foot trauma
- loss of plantar skin/weight bearing surface
- Anticipated protracted course to obtain
soft-tissue coverage and skeletal reconstruction
31Variables in Consideration of Limb Viability
- Skin/Muscle Injury
- Bone Injury
- Ischemia (time, degree)
- Type of Vascular Injury
- Shock
- Age
- Infection
- Associated injuries (pulmonary, abdominal, head,
etc.) - Comorbid Disease (peripheral vascular disease,
diabetes mellitus, etc.)
32Classification Systems
- Mangled Extremity Syndrome Index (MESI)
- 10 variables
- Predictive Salvage Index (PSI)
- 4 variables
- Mangled Extremity Severity Score (MESS)
- 4 variables
- Limb Salvage Index (LSI)
- 7 variables
- NISSSA scoring system
- 5 variables
33Mangled Extremity Scoring System
- Factor Score
- Skeletal/soft-tissue injury
- Low energy (stab, fracture, civilian gunshot
wound) 1 - Medium energy (open or multiple fracture) 2
- High energy (shotgun or military gunshot wound,
crush) 3 - Very high energy (above plus gross
contamination) 4 - Limb Ischemia (double score for ischemia gt 6
hours) - Pulse reduced or absent but perfusion
normal 1 - Pulseless, diminished capillary refill 2
- Patient is cool, paralyzed, insensate, numb 3
- Shock
- Systolic blood pressure always gt90 mm Hg 0
- Systolic blood pressure transiently lt90 mm
Hg 1 - Systolic blood pressure persistently lt90 mm
Hg 2 - Age, yr
- lt30 0
- 30-50 1
- gt50 2
34Mangled Extremity Severity Score
- All information for classification available at
time of ER presentation - Simplest to apply of all scoring systems
- Most thoroughly studied
- A score of less than 7 is supposed to predict
limb salvageability
35LEAP Data
- 556 lower extremity injuries
- prospectively scoredMESS, PSI, LSI, NISSSA,
HFS-97 - High specificity (84-98)
- LOW SENSITIVITY (33-51)
- Not a substitute for clinical judgment and
experience for salvage vs amputation decision
making
Bosse et al, JBJS, 83-A, 2001
36Mangled Extremity Management
- Involves a determination of both the feasibility
(restoring viability) and advisability (restoring
function) of salvaging the limb - Should be a coordinated effort of the
orthopaedic, vascular and plastic surgeons
starting at the initial evaluation of the patient
37Fasciotomies
- Prophylactic fasciotomies after vascular repair
have been credited as being a major reason for
increased limb salvage rates in recent years - Fasciotomies after prolonged ischemia prevent
compartment syndrome that may result from
reperfusion injury - The reperfusion injury is delayed and may
manifest after the patient leaves the operating
room -
38Indications for Fasciotomies
- No absolute clinical indications for fasciotomy
exist - Subjective criteria
- Extensive soft-tissue or bony injury
- Progression of swelling
- Compartment tightness
- Objective criteria
- Ischemia time greater than 6 hours
- Compartment pressure within 20 mm Hg of diastolic
blood pressure
39Morbidity of Fasciotomies
- Increased risk of infection
- Exposure of injured or ischemic muscle
- Decreased fracture healing
- Potentially converting a closed to an open
fracture - Iatrogenic injury
- Neuroma
- Chronic venous insufficiency
40Pharmacologic Treatment of Reperfusion Injury
- Following reperfusion, byproducts of anaerobic
metabolism may be released causing local and
systemic effects - Administration before reperfusion
- Mannitol
- Free radical scavenging
- Heparin
- Anti-coagulant
- Anti-inflammatory
- May be contraindicated in acute trauma
41Issues Concerning Surgical Order
- The order of surgical repair in penetrating
injuries requiring both vascular repair and
orthopaedic fixation is controversial - Delayed revascularization until after orthopaedic
stabilization may adversely effect limb salvage - Fractures instability or subsequent orthopaedic
stabilization may disrupt a vascular repair
42Surgical Order
- In general, revascularization takes precedence
over definitive orthopaedic fixation - In cases with gross fracture instability
- a temporary vascular shunt can be placed and
vascular repair deferred until after orthopaedic
fixation - If the ischemia time is short, consideration can
be given to application of a provisional
unilateral external fixator prior to
revascularization
43Temporary Vascular Shunt
44Definitive Vascular Repair
45Definitive Fixation
- Definitive orthopaedic fixation should be
internal in most cases - Consider external fixation for
- Pediatric fractures
- Extensive soft-tissue injuries
- Contaminated wounds
- Hemodynamically unstable patients
46Penetrating Superficial Femoral Artery Injury
with Femur Fracture
47Summary
- The treatment of fractures or dislocations with
vascular injury requires close coordination
between the orthopaedic surgeon and the vascular
or general surgeon to facilitate optimal limb
outcome.
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