Principles for Evaluation and Treatment of Patients with Vascular Injury

1
Principles for Evaluation and Treatment of
Patients with Vascular Injury

• Timothy McHenry, MD

2
Overview

• Epidemiology
• Types of Injury
• Evaluation
• Treatment

3
Mechanisms of Vascular Injury in the Extremities

• Gunshot wound 54
• Stab wound 15
• Shotgun wound 12
• Blunt trauma 15
• Iatrogenic 3

4
Types of InjuriesActive Hemorrhage

• Laceration
• Partial transection
• Complete Transection

5
Types of InjuryPotentially non-occlusive

• Contusion with
• Segmental Spasm
• Thrombosis
• True Aneurysm

6
Types of InjuryPotentially non-occlusive

• Pseudoaneurysm
• Arteriovenous Fistula
• Intimal Flap

7
Presentation of Vascular Injury

• First priority is hemorrhage control followed by
  appropriate diagnostic work-up

8
Presentation of Vascular Injury

• Dislocations and displaced or angulated
  fractures realigned immediately if vascularity
  is compromised

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Evaluation 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

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Physical ExaminationHard Signs

• Absent or diminished distal pulses
• Active hemorrhage
• Large, expanding or pulsatile hematoma
• Bruit or thrill
• Distal ischemia (pain, pallor, paralysis,
  paresthesias, coolness)

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Physical ExaminationSoft Signs

• Small, stable hematoma
• Injury to anatomically related nerve
• Unexplained hypotension
• History of hemorrhage no longer present
• Proximity of injury to major vessel

12
Doppler 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)

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Doppler

• Normal arterial signals are triphasic or biphasic

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Doppler

• Flow distal to a transection may be absent or
  monophasic and low-pitched due to collateral
  circulation

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Determination 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

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ABI 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

17
Duplex (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

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Arteriography

• 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.

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Indications 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

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Single-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

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Single-shot Arteriogram in the Emergency or
Operating Room
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Summary 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)

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TreatmentOperative Repair

• Indications
• injuries with hard signs of vascular injury
• OR
• arteriogram showing occlusion or extravasation

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TreatmentNon-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

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Non-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

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Sequelae 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

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Penetrating 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

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Blunt 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

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Mangled 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

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Mangled 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

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Variables 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.)

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Classification 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

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Mangled 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

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Mangled 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

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LEAP 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
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Mangled 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

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Fasciotomies

• 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

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Indications 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

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Morbidity 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

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Pharmacologic 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

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Issues 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

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Surgical 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

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Temporary Vascular Shunt
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Definitive Vascular Repair
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Definitive 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

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Penetrating Superficial Femoral Artery Injury
with Femur Fracture
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Summary

• 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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