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

Neck Vasculature

• General Principles

• if possible try to get a baseline neurologic exam in your patient, this is one of the best predictors in the outcome of carotid trauma

• zone III (cephalad to the hyoid bone)

• arteriography or CT angio will help to define if there is a significant vascular injury

• zone II (between the hyoid bone and the sternal notch)

• injuries to this zone should be explored
• standard neck incision is made from the mastoid to the sternal notch on the anterior border of the sternocleidomastoid muscle
• identify the facial vein, and divide it this marks the bifurcation of the carotid artery, retract the internal jugular posteriorly using a self retaining retractor
• after fixing vascular injuries in this zone, have high index of suspicion and assess for esophageal and tracheal injuries
• Internal Jugular Vein
• injuries to the internal jugular vein can be repaired with lateral venorraphy or ligated.
• Common Carotid artery

• obtain proximal control outside of the hematoma at the base of the neck using a Rummel tourniquet on the CCA being careful not to ensnare the vagus nerve
• if possible obtain distal CCA control proximal to the CCA bifurcation, with this technique no shunt is needed
• repair injury using lateral arterrioraphy, patch angioplasty, end to end anastomosis or bypass
• if patient is in extremis the CCA may be ligated with a low incidence of stroke due to the perfusion of the ICA from the intact ECA

• External Carotid artery

• Injuries to the ECA may be repaired using standard techniques or ligated since this is usually well tolerated

• Internal carotid artery

• Injuries to the ICA should be repaired if at all possible, while ligation is possible the incidence of stroke is considerable
• If there is poor inflow from the injured carotid, carefully pass a #3 Fogarty balloon embolectomy catheter no more than 2-3cm past the bifurcation to retrieve any thrombus
• If there is still no inflow from the ICA, ligation may be your best answer (this is a controversial point)
• ICA injuries with segmental loss may be repaired using RGSV interposition graft or ECA transposition
• If the injury is to the high internal carotid artery exposure is facilitated by nasotracheal intubation, division of the omohyoid muscle, the descendans hypoglossal nerve or mandibular subluxation.
• In the case of a distal carotid injury that is too high for reconstruction then ligation is appropriate
• In the case of a distal ICA lesion that you cannot get distal control on at all, then insert a # 3 Fogarty embolectomy catheter into the distal end of the ICA, place 2 clips just below the balloon to keep it expanded and cut the short to leave the balloon in the ICA to tamponade it.

• Vertebral Artery

• Use bone wax to plug a hosing vertebral artery from the vertebral canal

• zone I

• obtain arteriogram or CT angio to assess for vascular injury
• see below for approach to repair intrathoracic CCA injury

Supra-Aortic Trunk Vascular Injuries

• General Principles

• Dissection in a mediastinal hematomas can be disorienting
• Often useful to open pericardium and trace vessels upward
• Divide the left Innominate vein to find the Innominate artery and continue north
• Be careful not to injure the right vagus nerve as it runs in front of the right subclavian artery
• When dissecting the left carotid artery in this plane BE CAREFUL not to injure the left vagus nerve as it descends in front of the aortic arch and gives off the left recurrent laryngeal nerve
• Do not plunge into a stable mediastinal hematoma for blunt trauma; this is often an avulsion of the Innominate artery
• The best management method for injuries to thoracic outlet arteries is usually bypass using a synthetic conduit such as Dacron
• Ligation of supra-aortic trunk arteries can be performed but may come at the cost of stroke

• left subclavian artery

• gain proximal control through a high left anterolateral thoracotomy in the 3rd intercostal space (above the nipple)
• once proximal control obtained expose the injured subclavian through a supraclavicular incision for repair (avoid injury to phrenic nerve and thoracic duct if possible)

• right subclavian artery

• gain proximal control through median sternotomy
• repair through right supraclavicular incision

• Subclavian veins

• May ligate if needed however, expect arm swelling, consider elevation and rarely fasciotomy
• May repair using standard techniques primary, lateral venorraphy, interposition graft
• Use infraclavicular incision for exposure

• Innominate artery

• Repair or bypass through median sternotomy

• Innominate Veins

• May ligate if needed however, expect arm swelling, consider elevation and rarely fasciotomy
• Ligation and division of left Innominate vein useful to expose arch vessel injuries
• May repair using standard techniques primary, lateral venorraphy, interposition graft
• Ligate or repair through median sternotomy, emergent bypass probably not necessary unless both veins injured
• If both Innominate veins injured may experience severe SVC syndrome with facial and upper airway edema