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Vascular Trauma
The Old, The New and The Unusual
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Outline/Objectives
Carotid
Popliteal
Abdominal Aortic and Iliac
Thoracic Aortic
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Carotid Trauma
A rare but serious problem in vascular
trauma
Incidence of 0.08% to 0.86% of blunt
trauma admissions
Routine screening of high-risk patients can
reveal an incidence of up to 2%
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Actually represents a spectrum of injury
Minor intimal tear to acute occlusion
RISK: evolution of dissection,
pseudoaneurysm , thrombosis
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Potentially, a devastating event
Mortality rates of 20 to 40%
Permanent, severe neurologic morbidity of up to
50% in survivors
Often presents 24 or more hours following injury
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Mechanism of Injury
Classic stretch
Direct trauma
At the end of the day, what matters is the
degree of carotid injury and neurologic status
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Presentation
Arterial hemorrhage from nose/mouth/neck
Cervical bruit or expanding hematoma
Focal neuro deficit (TIA, Horners, etc)
Neuro deficit not compatible with CT findings
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High energy mechanism with: Le Forte II or III
Basilar skull fracture involving the carotid canal
CHI with DAI and GCS < or = 8
Clothesline injury or near hanging
Cervical vertebral body fx, subluxation orligamentous injury at any level, C1 to C3 fx
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Diagnostic Imaging
US: Not useful for vertebral injury, misses at
least 20% of carotid injuries
CTA: 16 or 32 slice CTA is the study of choice
Angio: Often difficult, always expensive,
sometimes morbidstill the gold standard?
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Grading the Injury
Grade I: Less than 25% luminal narrowing
from wall irregularity of dissection
Grade II: More than 25% lumen compromise
from dissection or intramural hematoma,
thrombus or intimal flap
Grade III: Pseudoaneurysm
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GradingMore
Grade IV: Occlusion
Grade V: Transection with free extravasation
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Therapy
No Level I evidence, because there are no
prospective, randomized trials
All recommendations are based on
observational studies and expert opinion
If there is profound neurologic compromise,
no therapy has been shown to be of benefit
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Any Meaningful Literature?
Western Trauma Association Critical Decisions
in Trauma: Screening for and Treatment of
Blunt Cerebrovascular Injuries
Biffl, et al
J Trauma, Dec 2009
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Whats More
Blunt Cerebrovascular Injury Practice
Management Guidelines: the Eastern
Association for the Surgery of Trauma
Bromberg et al
J Trauma, Feb 2010
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Therapy:
The consequences of BCI are so significant,
treatment is warranted in all patients without
overwhelming contraindications
For grade I and II injuries, initial heparinization
with long term antiplatelet therapy is
indicated
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For Grade I and II:
Follow up angiography at 7 to 10 days postinjury (or in the face of worsening symptoms)is indicated
Length of antiplatelet therapy is controversial,but probably should not be less than 90 days
Follow up imaging is important, leading to achange in therapy in 50% of patients
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More Therapy
Grade III injuries: angiography and possible
percutaneous intervention
Grade IV: Rarely is intervention indicated
Grade V: Immediate surgical intervention ifaccessible; most require an endovascular
approach
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PEARLS
1) Carotid injuries are potentially devastatingand easily missed
2) Find it by thinking to look for it
3) US isnt a good way of looking
4) Treat it when you do find it
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Popliteal Artery Trauma
HOW MANY times did you see this?
Wait, you were what?
Maybe I should check one of these
So, now what do I do about it?
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Frequency
Incidence of popliteal artery injuries withfracturesabout the knee was 3 per cent
16 per cent of patients with posterior kneedislocationshad vascular injuries
Amputations were required in 14 of the 38injured limbs (36%). None of these patientshad a pulse or Doppler signal on admission
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Frequency
Most common with posteriordislocations
(more force needed to produce the injury)
Fractures of the distal femur or tibial plateau
may cause arterial contusion, with intimal
disruption and thrombosis
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- note that the worst error to make is to
underestimate the need to promptly treat
these injuries;
- there are anecdotal reports of patientswho ended up with AKA (from vascular injury)
who were reported to have diminished but
"dopplerable pulses
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Popliteal Injury: Activities
Water skiing
Snow skiing
Longboarding
Parasailing
MVA
Horseback riding
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Why is Shear an Issue?
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I think, therefore I.
Examine the pulses
Obtain an ABI
Consider duplex US
Order an angio???
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So, Now What?
Watchful waiting
Open bypass with contralateral GSV
Percutaneous stenting
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PEARLS
Pulses count (in the ER and later)
If there is significant femur/knee trauma,suspect popliteal injury
ABIs are your friend
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Blunt Aortic & Iliac Trauma
It happened how?
Why should I care?
What do I do about it?
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JVS 2012 Sep;56(3):656-60.
Associated injuries, management, and
outcomes of blunt abdominal aortic injury
De Mestral, C; Dueck, AD et al
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All patients age 16 years with ISS 16 from
blunt trauma, treated at US level 1 or 2
trauma centers, 2007 to 2009.
436 patients from 180 centers
84% of patients were injured in an MVA.
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394 patients (90%) managed nonoperatively; 42(10%) underwent repair
42 repaired: 29 (69%) had endovascular repair, 11patients were done open, two had extra-anatomic bypass
Median time to repair was 1 day
Overall mortality was 29%
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Patients with MAI are at low risk: observe withserial physical exams and US
Injuries associated with bleeding, malperfusion,or thromboembolism require intervention, mostoften endovascular
For observed patients, long-term surveillance isrequired; document complete resolution as evenMAI can progress
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PEARLS
Sohow did it happen?
Why should I care?
What do I do about it?
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Thoracic Aorta
Things just arent what they used to be
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Open Thoracic Repair
Complications of thoracotomy!
of heparin
paralysis rates of 2-20%
emergent OR in the face of polytrauma
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New Approaches.
Treat them like an aortic dissection
Endovascular operation once clinically
opportune
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Bad Drive Home
60 yo male professional
Restrained driver of a small SUV
Hits an ice patch at highway speed
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Multiple rib fractures, bilaterally
CHI with LOC and intracranial bleed
Extensive bilateral pulmonary contusions
Various bumps, lumps and fractures
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Hes just arrested
Has significant intracranial injury
Significant thoracic cage and pulmonary injury
Who wants to do a thoracotomy right now?
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To the unit he goes.
IV betablockers
IV cleviprex
Keep MABP ~ 60
Keep Pulse
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4 days later
Hes still alive
In fact, getting better
Neurosurgery twitching less
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To the OR.
Almost two weeks post injury.
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Three months later
Seen in the office
Initial follow up CTA of chest looks great
Still with mild discomfort from his chest wall
Walked in, walked out and walked back to hiscar to return to work.
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