1. DR. ahmed Abanamy hospital DOCTOR Nazih Mohammed Alothman Vascular Surgeon

2. management of peripheral vascular trauma

3. Suspicion of injury

4. CAUSES penetrating wounds Blunt trauma Invasive procedures  gunshot  Stab wound  Shotgun  Iv drug abuse  Joint displacement  Bone fracture  contusion  Arteriography  Cardiac catheterization  Balloon angioplasty

5. Hard signs of arterial injury Obvious arterial occlusion Palpated thrill, audible bruit External arterial bleeding Rapidly expanding hematoma  Pulse less  Pallor  Paresthesia  Pain  Paralysis  Poikilothermia Immediate surgery

6. Soft signs of arterial injury History of arterial bleeding at the scene Abnormal ankle –brachial pressure index <(0.9) Proximity of penetrating wound or blunt trauma to major artery Abnormal flow – velocity waveform on Doppler ultrasound Diminished unilateral distal pulse Small non Pulsatile hematoma Neurologic deficit  Consider arteriogram  Serial examination  duplex

7. Role of diagnostic studies

8. Reasons for diagnostic studies Prevent unnecessary operation Document presence of surgical lesion Localized surgical lesion to plan operation approach

9. Arteriography  Can be performed by radiologist using intra-arterial digital subtraction angiography or CT angiograph  Can be performed by surgeon in emergency room or operating room

10. Duplex scan  Definition : Real – time B mode(brightness) image and pulsed – wave Doppler image (flow determination)  Duplex scan should be performed by a competent vascular technologist or surgeon

11. Management

12. Points in peripheral vascular repair Small vascular clamps or vessel loops Pass balloon catheter into artery proximal and distal to repair Regional heparin into artery proximal and distal to repair Completion arteriography Fasciotomy for compartment syndrome

13. Options for peripheral vascular repair 1.Lateral arteriorrhaphy or venorrhaphy 2.Patch angioplasty 3.Resection with end- end anastomosis 4.Resection with interposition graft 5.Bypass graft 6.Extra anatomic bypass 7.ligation

14. Adjuvant techniques for limb salvage  Intra luminal shunt during orthopedic stabilization  Extra anatomic bypass around associated soft tissue injury  Intra arterial vasodilators (papaverin) to reverse spasm  Intra venous low molecular weight dextran 500MLevery 12 hours  Thrombolytic therapy with intra arterial tissue plasminogen activator (TPA) by intervention radiologist

15. Special considerations for venous repair  Popliteal vein is repaired rather than ligation  Ligation of femoral or iliac vein if necessary is usually tolerated if elastic wraps are applied to extremity, witch is elevated for 7-10 days

16. Postoperative car Monitor distal arterial pulses by portable Doppler unit Continue intravenous antibiotics for 24 hours if significant contamination of wound or if interposition graft has been inserted for arterial or venous repair Consider use of antiplatelet agent for 3 months whenever vein graft or synthetic graft has been inserted

17. DR. nazih Mohammed al -othman thanks