1. APPROACH TO VASCULAR INJURY
BY DR SIKHOSANA

2. Mechanisms of injury
Penetrating
Blast
Blunt
iatrogenic

3. Pathophysiology Missile damage is related to the velocity
Shotgun causes multiple perforations and can cause embolization
Blunt trauma results from shearing or distraction
Vascular spasm occurs at or distal to the injury due to the unapposed sympathetic constriction, it is not the cause for ischaemia

4. Hard signs Pulsatile bleeding Expanding haematoma Thrill or bruit
Pulse deficit
ischaemia

5. Soft signs History of a significant bleed
Small non expanding haematoma
Associated nerve injury
Proximity to a major vessel

6. Unclear presentation
Thorax injuries- suspect if there is a widened mediastinum, persistent shock, large haemothorax
Intimal injury- the pulses maybe intact but the exposed collagen is very thrombogenic

7. Indications for investigation: neck
Zone I and III
All gunshots
Suspicion post doppler of zone II

8. Mediastinum Fracture of 1st,2nd ribs, sternum and scapula
Sterno clavicular joint dislocation
Trans axial gunshot
Widened mediastinum
Obliteration of aortic notch, left apical pleural cap, aorto-pulmonary window
Left haemothorax
Oesophageal and tracheal deviation to the right
Depression of left main bronchus

9. Limbs Multiple fractures Multiple penetrating injuries Shotgun
Knee/elbow dislocation
Degloving injury
Gunshot tract along the long axis of the vessel

10. Imaging modalities
Duplex ultrasound
Angiography
CT angiography
MRA

11. Duplex ultrasound
Combines pulsed doppler and real time B mode ultrasound imaging
Advantages- non invasive, cheap, no radiation and sensitive
Locally used for neck zone II and single peripheral injuries

12. Angiography
Gold standard imaging and there is a therapeutic option, although it is invasive
Features suggestive of injury- extravasation of contrast, dilatation due to intimal injury, narrowing, occlusion, filling defects and AV fistula

13. CT angiography Sensitivity and specificity of 90-100%
Advantage is that it is non invasive and rapid
Disadvantages – lack of therapeutic options, artifacts from foreign bodies, streak artifacts simulating intimal tears and the imaging of the arch not good on CT

14. MRA Has good sensitivity
Not ideal due to the time taken for the investigation

15. Bleeding control
Pressure
balloon

16. Management
All vascular injuries should be repaired as ASAP to avoid delayed bleeding, compressive haematoma and limb compromise
We do not believe in conservative management of minimal arterial injuries because the history is unpredictable, poor patient compliance and too late presentation of complications

17. Mangled extremity severity score
Skeletal/soft tissue injury
Limb ischaemia
Shock
Age
Score of >7 is accurate for predicting eventual need for amputation

18. Diagnostic fasciotomy
More than 6 hours presentation

19. Prophylatic fasciotomy
Prolonged hypotension
Extensive soft tissue injury
Arterial and venous injury
Bone plus vascular injury
Delayed vascular repair
Inability to assess the patient, e.g. head/spinal injury

20. Therapeutic fasciotomy
Increased tissue turgor
Extensive deep haematoma in the presence of ischaemia
FASCIOTOMY BEFORE VASCULAR REPAIR

21. Principles of vascular repair
Digital or sponge pressure and catheter to control bleeding
Prophylatic antibiotics
Access available to the groin for the graft
Wide exposure with proximal and distal control
Edges debrided to healthy intima
Embolectomy and flushing with heparin saline
Vascular repair before ortho
Adequate tissue cover of the vascular repair

22. Techniques of repair Lateral – for wide calibre vessels
Patch- to prevent stenosis
End to end- single tethering stitch should hold and < 4mm vessel should have interrupted sutures
Interposition graft- NB similar size with the injured vessel
Ligation- gross contamination and unstable patient

23. Types of grafts Vein- no cost and low infection rate
Arterial- same advantages as the vein but the donor site may need to be replaced
Synthetic- ? Higher infection risk, expensive and poor patency across joints

24. Causes of graft thrombosis
In flow
Anastomosis – intimal injury, adventitia, tension, stenosis, poor graft
Run off

25. Primary amputation
Dead leg
2 or more dead compartments
Mangled limb

26. Endovascular
Embolisation
Stenting
Balloon occlusion

27. Conclusion
All vascular injuries should be repaired as soon as they are identified
We do not have enough man power to treat minimal injuries consevatively