1. VASCULAR SURGERY

2. Trauma Penetrating injuries Stab wounds
Relatively clean, with minimal soft tissue destruction
In the upper extremity nerve injury is usually a problem
Low velocity missiles (<250m/s)
Injury to tissue through which they pass
–High velocity missiles (>750 m/s)
Extensive tissue damage, and extensive bone comminution
Range at which the gun is fired determine the extent of tissue damage

3. Trauma
Blunt trauma
with or without concomitant fracture (supracondylar, knee dislocation, high tibial fracture)
Spasm
– Contusion
– Intimal tear
– Transection

4. Trauma Signs of vascular injury Soft signs Hematoma (small)
Signs of vascular injury
Hard signs
Absent pulses
Bruit or thrill
Active hemorrhage
Hematoma (large and /or expanding )
Distal ischemia
Soft signs
Hematoma (small)
History of hemorrhage at scene
Unexplained hypotention
Peripheral nerve deficit

5. Indications of arteriography in extremity trauma
Hemodynamic stability
Blunt trauma with signs of vascular injury
Intra operative or postoperative evaluation
Delayed diagnosis
Follow up of non operatively managed arterial injuries
Penetrating trauma with hard signs plus one of the following
Multiple potential sites of injury (i.e. shotguns)
Missile parallels vessel over long distance
Chronic vascular disease
Extensive bone or soft tissue injury
Thoracic outlet wounds

6. Algorithm of injured extremity Management
History & physical examination
Initial Resusitation
Soft signs
Hard signs
Penetrating
trauma
Negative
Blunt trauma
Arterigraphy
Non –operative
managment
Operative
Exploration
+ ve with extravasation
Or occlusion

7. Algorithm of injured extremity Management
Hard signs
Blunt trauma
Penetrating
trauma
If one of the following
Shotgun wound
Missile parallel vessel
Thoracic outlet injury
Chronic vascular disease
Extensive soft tissue injury
Severe bone fracture
Delayed presentation
Arterigraphy
+ ve with extra-vasation
Or occlusion
Negative
Operative
Exploration
Non –operative
managment

8. Non –operative Management
Usually
No active hemorrhage
Minimal arterial wall disruption
<5mm intimal tear
pseudo-aneurysm
Methods
Observation
repeated arteriography
Trans-catheter embolisation of metal coils covered with Dacron mainly to occlude arteriovenous fistulae, or to occlude a vessel

9. Operative management Principles of emergency vascular repair
–Control life threatening hemorrhage
–Prevent limb ischemia
–Time is important during diagnosis and treatment
Techniques used
Evacuate hematoma & remove all devitalized tissue ]
Expose the vessel and managements include
Simple lateral sutures
Vein patch
Remove damaged segment and reconstruct
If segment < 2 cm
End to end anastomosis
If segment > 2 cm
Interposition graft with vein or synthetic material
Compromised muscle fibers swell in a confined compartment will lead to ischemia (fasciotomy should be used)
Primary amputation
Badly damaged limb with impossible revascularisation that may cause further hemorrhage
Multiple structures injuries causing the limb to be useless

10. Trauma (femoral gun shot wound)