Evaluation and Treatment of Vascular Injury and Treatment of... · Lynch et al Ann Surg 1991, Mills...
Transcript of Evaluation and Treatment of Vascular Injury and Treatment of... · Lynch et al Ann Surg 1991, Mills...
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Evaluation and Treatment of Vascular Injury
Jason A. Lowe, MD September 2014
Prior versions
Timothy McHenry, MD; March 2004 Heather Vallier, MD; January 2006
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Goals
Identify vascular injuries Confidently and accurately evaluate
vascular injury Coordinate treatment
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A Rare Injury 1-3% of all extremity
trauma
Occurs more with penetrating trauma
GSW 46% Blunt 19% Stabbing 12%
Hafez et al J Vas Surg 2001
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Pathology of Injury Spasm Intimal flap External compression
Compartment syndrome Hematoma
Thrombus Laceration/transsection
External projectiles Bone fragments
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Successful diagnosis and management of extremity vascular
injuries requires:
*Thorough history and physical *High index of suspicion
*Rapid administration of care
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Mechanism of injury heightens the surgeon’s awareness of potential
vascular insult
Considerations: *Fracture Personality
*Presence of dislocation *Blunt trauma vs penetrating trauma
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High Risk Fractures Open fractures Segmental diaphyseal
fractures Floating limbs Associated crush
injuries
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Fracture Specific Vascular Injuries
Clavicle Supracondylar
humerus Pelvic ring Distal femur Tibia plateau Tibia shaft
Subclavian Brachial
Gluteal, Iliac, Obturator Popliteal Popliteal
tibial
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Dislocations Associated with Vascular Injury
Scapulothoracic dissociation 64-100% Knee dislocation 16%
Flanagin et al OCNA 2013, Miranda et al JTrauma 2002
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Blunt Trauma Stretching or shearing of vessels
Intimal damage/dissection, thrombus
Subtle clinical findings
27% amputation rate
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Penetrating Injury
Direct injury to vessel: Laceration/transsection
Exam findings: May not always be obvious
Delayed pseudo-aneursym and AVF
9% amputation rate
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Physical Exam
Hard Signs Pulsatile bleeding Expanding hematoma Thrill at injury site Pulseless limb
Soft Signs Asymmetric limb temperature Asymmetric pulses Injury to anatomically-related
nerve History of bleeding
immediately after injury
Hafez et al J Vas Surg 2001
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Important
Vascular injuries are dynamic injuries!
Repeat examinations
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Emergency Department Management
Control Bleeding Compressive dressing Judicious tourniquet
Fluid resuscitation
Reduce & splint fractures
Re-evaluate
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Ankle Brachial Index Indications Asymmetric pulses Soft exam findings High energy tibia plateau fractures All knee dislocations Vascular consult and advanced imaging for
ABI <0.9
ABI does not define extent or level of injury
Lynch et al Ann Surg 1991, Mills et al JOT 2004
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Ankle Brachial Index Benefits
Cheap Easy Negative predictive value between 96% and
100%
Limited diagnosis Venous injuries False positive with arterial spasm Injuries can preclude cuff placement
Lynch et al Ann Surg, Mills et al Injury 2004
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Duplex Scan Technician dependent
Time intensive
Steep learning curve
Limited indication in acute trauma patients
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Angiography Historical Gold Standard Localizes the lesion Defines type and extent of lesion
Active hemorrhage vs occlusion
Allows treatment planning embolization vs bypass
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Angiography Disadvantages Patient risks Renal insult Anaphylaxis Iatrogenic vessel injury Expensive Difficult to resuscitate patients Delays operative intervention
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Multi-Detector CT Angiography (MDCTA)
Replacing angiography as standard of care 95% sensitivity and 87% specificity
Decreased contrast load
Fast Effective costwise
Reiger et al AJR 2006, Peng et al Am Surg 2008, Wallin Et al Ann Vasc Surg
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MDCTA Disadvantages
Cannot exclude all arterial dissections -May still require angiography
Limited resolution in presence of -Foreign bodies -Vascular calcifications
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Surgical Exploration Indications:
Frank vascular injury Vascular injury not amenable to endovascular repair
Expanding/pulsatile hematoma Thrill at injury site Pulseless limb
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Evaluation Algorithm
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Sequence of Surgical Treatment
Who goes first? Vascular or Orthopaedics
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Who Goes First?
Meta-analysis shows sequence of fixation (vascular vs orthopaedic) does not affect amputation rate
Traction upon vascular repair is not
shown to lead to vascular compromise
Fowler et al Injury 2009
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Treatment
Have a protocol in place
Consider each patient individually Restore blood flow Debride devitalized tissue Stabilize fractures
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Indications for Fasciotomy Diagnosis of acute compartment syndrome Arterial injury requiring repair
Combined arterial venous injury Warm ischemia > 6hr Cold ischemia > 12hr
Faber et al Injury 2012
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Prognostic Factors Soft tissue injury (crush) Level of vascular injury Collateral circulation Ischemia time Patient factors
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Complications of Vascular Injury
Blood Loss Compartment syndrome Tissue necrosis Infection Amputation Death
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Case Example 30 yr old presents with elbow dislocation and report of bleeding at the scene
Arterial bleeding is observed in ED
Vascular is consulted
Patient to OR within 3 hours of injury
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Direct arterial repair of brachial artery
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Ligament repair of
elbow
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Case Example 29 yr old MVC with bilateral open lower extremity injuries Cold feet bilateral mangled RLE No pulses
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No pulse with traction Foot perfusion improves CT angiogram ordered/vascular consult Normal LLE Patient taken to OR for I&D ex-fix left and guillotine amputation right Pulse returns LLE Q2 hour vascular checks
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12 hours post op patient loses pulse Taken to OR emergently by vascular for on-table angio and endovascular bypass of intimal flap Infection develops HD #4, sepsis, and AKA is performed
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Vascular Injuries: Summary Maintain high index of suspicion
*Recognize common injury patterns *Thorough, repeated examination
Rapid recognition and treatment is paramount Have a protocol for evaluation and treatment
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