Vascular Trauma Basic Science Conference May 31, 2006

Which of the following is the most common location for a blunt injury to the abdominal aorta? a) Pelvic retroperitoneum b) By the renal vessels due to sheering injury of the aorta c) Origin of the celiac axis d) Origin of the inferior mesenteric artery

C. Although rare, blunt injury to the abdominal aorta is usually the result of impingement of the steering wheel or a seatbelt. The origin of the IMA is the most common location with clinical presentation of acute aortic thrombosis secondary to intimal disruption.

During initial assessment of a hemodynamically stable patient with peripheral vascular trauma which of the following characteristics conveys the greatest urgency for repair? a) A cool limb b) A sensorimotor deficit c) Time greater than 4 hours since the initial insult d) Diminished arterial pulse e) Patient age greater than 60

B.) A sensorimotor deficit, although all the characteristics are important during evaluation of limb ischemia, a change in neurologic function conveys the greatest urgency because it signifies an imminent threat of irreversible ischemic insult to the limb.

A young male trauma patient has a penetrating deep stab wound to the medial side of upper left arm in close to the axilla, the patient has full radial and brachial pulses and no neurosensory deficits. With regards to arteriography in ruling out arterial trauma what should be the next step in management? a. Patient needs immediate surgical exploration without angiography b. Arteriography should be performed due to the location and proximity to the neurovascular bundle c. Arteriography is not indicated for this patient.

C. Routine arteriography in asymptomatic patients is no longer indicated, due to evidence demonstrating that physical exam is very accurate in detecting arterial injuries that would require operative repair.

With regards for retroperitoneal exposure match the corresponding action with the maneuver. a. Mattox maneuver b. Kocher maneuver c. Cattell-Braasch maneuver 1. Medial reflection of the right colon and duodenum by incising their lateral peritoneal attachments. 2. The lateral peritoneal attachment of the sigmoid and left colon are incised. 3. Used for extensive retroperitoneal exposure by detaching the posterior attachments of the small bowel mesentery toward the duodenojejunal ligament. 4. Used for SMA exposure

With regards for retroperitoneal exposure match the corresponding action with the maneuver. a. Mattox maneuver b. Kocher maneuver c. Cattell-Braasch maneuver 1. Medial reflection of the right colon and duodenum by incising their lateral peritoneal attachments. 2. The lateral peritoneal attachment of the sigmoid and left colon are incised. 3. Used for extensive retroperitoneal exposure by detaching the posterior attachments of the small bowel mesentery toward the duodenojejunal ligament. 4. Used for SMA exposure

True or False As a general rule for a traumatic extremity injury that involves both vascular and orthopedic injuries, bone alignment should take place before vascular reconstruction.

True Orthopedic manipulation and reconstruction may disrupt vascular repair, if the limb is ischemic, a temporary intraluminal shunt can be inserted to maintain perfusion while the orthopedic procedure is being performed.

Describe the two longitudinal incisions used in a four compartment fasciotomy of the leg and the corresponding comparments that are decompressed for each incision.

The anterior and lateral compartments are approached through a lateral longitudinal incision following the anterior margin of the fibula. The superficial and deep posterior compartments are decompressed through a medial incision slightly posterior to the edge of the tibia.

True or False Bleeding from a groin puncture wound is often the result of inadequate groin compression after catheter removal.

TRUE. Important to keep in mind after femoral catheterization.

Describe the incision made to explore a traumatic injury to the brachial artery.

Brachial artery is exposed through a medial arm incision in the groove between the biceps and triceps muscles. The brachial artery is the most frequently injured artery in the body.

Following a motorcycle crash, a 43 yom with an open ankle fracture and significant soft tissue injury. He has no pulses or Doppler signals detectable, consideration for limb salvage would depend on all of the following factors except: a. Anatomic continuity of major nerves b. Degree of bony destruction c. Previous diagnosis of DM II d. Degree of soft tissue loss e. Limb length discrepancy

C. Previous diagnosis of DM II. Factors cited by surgeons in making the decision to reconstruct or amputate include: nerve integrity/plantar sensation, limb ischemia, soft tissue coverage, and vascular supply. Patient characteristics, including co- morbidities, are rarely considered.