Vascular injury

Vascular injury

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Overview

• Hard signs of vascular injury: expanding hematoma, bruit, thrill, active bleeding, severely ischemic extremity.
• Soft signs of vascular injury: proximity of wound to major vessels, hx of hemorrhage/shock, non-expanding hematoma, diminished pulse and anatomically related nerve injury.
• Prep contralateral saphenous vein in field, direct pressure (DP) to control bleeding (tourniquet only if DP fails).
• Duplex scan when available.
• Observe for evidence of compartment syndrome, change in vascular status. Ensure at least one follow-up vascular examination is performed.
• Injured extremity to non-injured extremity systolic Doppler pressure ratio:

• With the patient supine (for at least 10 minutes prior), take blood pressures (B/P) in both arms. Use the higher systolic pressure as the brachial pressure in the ratio.
• Place the B/P cuff on the patient’s leg just above the maleoli, and the Doppler probe at 45 degrees to the dorsal pedis or posterior tibial artery.
• Inflate the cuff until the Doppler signal stops. Slowly deflate the cuff until the signal returns and record the numbers as the ankle systolic pressure.
• To get the ABI ratio, divide the highest ankle pressure by the highest brachial pressure. For example, with systolic brachial pressures of 120 and 129 and an ankle systolic of 65, the ABI is 0.5. Perform on both right and left extremities. Farther from the heart, leg pressure is supposed to be higher than or at least equal to arm pressure. Interpret your ABI results based on these guidelines:

• 0.9: Normal
• 0.5 to 0.9: Claudication mild to moderate
• < 0.5: Resting ischemic pain, claudication
• < 0.2: Gangrenous extremity; suggests near total occlusion

Basic Principles

• it is important to know the patients total trauma burden and physiology when deciding how to manage

their vascular injury

• surgeons should become familiar with the key anatomical landmarks for several vascular exposures so

they can be performed rapidly in the injured patient

• vascular trauma is the art of dealing with healthy arteries it is similar but different than dealing with

vascular disease in the elderly

• get proximal control outside of the hematoma / one level above the injury
• once controlled, define the full extent of the vascular injury
• gradually develop and optimize your work space so your hands are free to work
• decide between complex vascular repair and damage control
• the safest place when dissecting out arteries is in the periadvential plane immediately next to the artery.
• When performing vascular trauma systemic anticoagulation is not always possible if the patient has

multisystem injuries, in these cases consider local heparinized saline infusion (10 units heparin in 1000 cc of normal saline), proximally and distally

• clear the inflow and outflow tracts before performing vascular repair or shunt insertion, using an

appropriately sized Fogarty balloon embolectomy catheter, generally #5 for large arteries and #3 for small ones

• Do not pass embolectomy catheters too much, you will be rewarded with intense vasospasm and

worse outcomes

• Healthy traumatized arteries often exhibit intense vasospasm when manipulated, this may effect post

repair perfusion and can be relieved using local inta-arterial papaverine and nitroglycerin as the patients overall condition allows.

• Completion arteriography is not always possible but some form of assessment is required, such as

improvement in pulse or doppler examination without this be suspect

• ligation is not an admission of defeat
• transected artery = interposition graft
• vein repair is a luxury not a must
• use an intraluminal balloon for problematic distal control
• Bleeding and ischemia are different priorities
• balloon tamponade controls external bleeding in transition zones
• intra-arterial shunts are good damage control options in unstable patients, this can be accomplished

using Rummel tourniquets and either internal shunts (Argyle) or external shunts (Javid)

• External shunts that are placed entirely in the artery usually thrombose
• sometimes despite you doing everything right to improve perfusion to the extremity (including

fasciotomies) the arm/leg still dies

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