lower limb vascular trauma
TRANSCRIPT
Lower Limb Vascular Trauma
Dr Saeed Al-Shomimi
Vascular Unit
KFHU – Khobar – Saudi Arabia
2006
Introduction
Complex extremity trauma involving both arterial and skeletal injuries is rare, comprising only 0.2% of all military and civilian trauma, and only 0.5%-1.7% of all extremity fractures and dislocations
Combined arterial and skeletal extremity trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries.
Debakey and Simeone documented this in WWII battle casualties, in which all injured arteries were ligated, reporting amputation in 60% of all combined injuries and 42% in isolated arterial injuries
Norman Rich , collecting further data
The amputation rate from vascular injury in the Korean War and the Vietnam War dropped to approximately 15%
Peripheral injuries account for 80% of all cases of vascular trauma.
The lower extremities are involved in two thirds of all patients with vascular injuries.
90% of patients with vascular trauma are male
Etiology
Gunshot wounds, 70-80% of all vascular injuries requiring intervention.
Stab wounds (5-10% of cases require intervention)
Blunt trauma (5-10% of cases): Presence of fracture or dislocation increases the risk.
Iatrogenic injury (5% of cases): Endovascular procedures central line placement
Clinical Presentation
Hard Signs Active or pulsatile hemorrhage Pulsatile or expanding hematoma Signs of limb ischemia and elevated compartment
pressure including the 5 "P's“: Pallor paresthesia pulse deficit paralysis pain
Diminished or absent pulses Bruit or thrill is( present in 45% of patients with an
arteriovenous fistula)
Soft Signs
Hypotension or shock Neurologic deficit due to primary nerve injury occurs
immediately after injury. In contrast, ischemic neuropathy is delayed in onset (minutes to hours).
Stable, nonpulsatile or small hematoma Proximity of the wound to major vascular structures
( Beware of bone fr. ! )
Complications Delayed diagnosis and treatment may result in
thrombosis Embolization Rupture with hemorrhage.
Risk factors for amputation include elevated compartment pressure arterial transection associated open fractures the combination of injuries above and below the knee.
CAN VASCULAR TRAUMA HAVE A CHRONIC PRESENTATION?
Arteriovenous fistulae typically take months to mature and often require
surgical repair.
Pseudoaneurysms may resolve completely or grow over time
presenting months to years later. They may cause neuropathy due to compression or embolization, or they may present as a growing pulsatile mass.
Intimal tears and flaps generally heal spontaneously.
Segmental narrowing can present with diminished flow but intact pulses.
This injury may resolve spontaneously with fluids and rest, or it occasionally may require surgical intervention.
N.B. Approximately 10% of patients with nonocclusive, clinically
occult injuries require repair within a month of initial injury.
The remaining 90% of patients do not report symptoms or see a physician for vascular problems during long-term follow-up.
Patterns of Vascular Injury
Complete TransectionPartial Tear
Contusion-ThrombosisSpasm
Diagnosis
Hard signs of Vascular Injury
Diagnostic Adjuncts
Pulse Oximetry: A reduction in
oximeter readings from one limb, as compared to another is suggestive of, but neither confirms nor excludes a significant vascular injury
Doppler Ultrasound A diminished, but palpable pulse is a soft sign of
vascular injury. Similarly, a reduction in the anle-brachial pressure index (ABPI) in the presence of a palpable pulse does not indicate the presence of a vascular injury requiring intervention. Doppler ultrasound is therefore adds little to careful clinical examination.
Duplex Ultrasound Duplex can detect intimal
tears, thrombosis, false aneurysms and arteriovenous fistulae. Its place in the assessment of vascular injury is as yet not completely definded, but it has a high sensitivity and may be appropriate for use as a screening tool.
Angiography Angiography remains the gold-
standard investigation for the further investigation and delineation of vascular injury. In most traumatic injury settings, angiography is best performed in the operating room, with the surgeon exposing the vessel proximal to the injury for control and expediency
Management
Immediate Haemorrhage Control
Direct pressure over the site of injury One individual to manually compress the site of
haemorrhage. Deep knife or gunshot track → catheter If angiography is performed prior to surgery, it
may be possible to obtain proximal control by passing an angioplasty balloon catheter into the proximal vessel and inflating the balloon
Volume resuscitation
Prior to haemorrhage control :minimal fluids should be administered Raising the blood pressure will increase
haemorrhage from the vessel injury and dislodge any clot that has already formed.
Systolic blood pressure can be maintained at a level that is appropriate for perfusion of the brain
After:aggressive volume resuscitation to restore
circulating blood volume. Warmed fluids -crystalloid, blood or clotting
factors as necessary -are administered to correct acidosis, hypothermia and coagulopathy,
Operative Strategy Laceration:
Suturing vein (or synthetic) patch
Transection Direct suturing
Transection graft
Contusion- Thrombosis
Managed in a similar way to transection In either way ,
Thrombectomy is Part of the Procedure
Damage Control Surgery
Ligation Ligation of the exteral iliac artery, common femoral or
superficial femoral have a signficant risk of critical limb ischaemia following ligation.
Ischaemia is more likely if there is significant soft tissue injury and distruction of supporting collateral circulation
Almost all veins, including the inferior vena cava, can be ligated where necessary
Shunting : Where there is a significant risk of limb loss, or other
serios consequence of ligation, intraluminal shunts may be employed to temporarily restore flow.
shunts can be rapidly constructed out of sterile intravenous tubing or chest tubes for larger calibre vessels.
Where there is a vascular injury associated with a fracture, and there is a risk of orthopaedic manoeuvers disrupting an arterial repair, shunts may be employed to temporarily restore flow to an injured limb.
Lower Limb Vascular Trauma
Feb – March KFU Experience
))Combined Orthopaedic + Vascular Trauma((
38 yrs Indian male 2 hrs Hx of brick wall falling on his Rt L.L Presented to ER
Hemodynamically stable Open Fr. Rt tibial plateau (small puncture
wound in lateral aspect of the leg) Cold & pale Rt foot No associated injuries • Intra-cranial
• Intra-thoracic• Intra-abdominal
CASE 1
The Pt referred to Ortho team initially Back slab applied to stabilize the Fr. The vascular team was called
Prompt initial assessment revealed Absent pedal pulses on Rt lower limb Preserved sensations despite other signs of acute
ischemia PulselessPalorParasthesiaPain
Prompt Doppler assessment revealed no detectable flow over D.pedis & P.tibial
CT angiogram showed Normal flow till segment 2 of Popliteal artery Cut off contrast @ trifurcation Then refill of only distal P.T artery No visualization of A.Tibial artery
Conventional angiogram confirmed the findings (Extent / Pedal arches)
Intra-operatively
Totally transected A.Tibial atrey (crushed distally)
Contusion thrombosis T.P trunk Ligation of A.Tibial artery Excision of the contused T.P trunk Embolectomy with Fogarty cath Interposition vein grafting
Progress
Pt did well The vascularity remained intact He developed foot drop (torn muscles)
Not ischemic neuropathy Skin grafting was done He was discharged with the Ex Fix He regained intact P.tibial pulse & well
perfused foot
CASE 2
26 yrs Saudi, Male RTA, intoxicated Brought to ER Conscious, drowsy
VS stable Bilateral knee pain & bruises Fracture Lt inferior ramus (pelvis) L.L. x-rays showed Rt tibial plateau fracture
CT angiogram was done It showed
Vascular injury @ the level of segment 2 of the Popliteal artery
No distal run off
PD
PD
P D
P D
Post OP
He had arterial spasm Confirmed by CT angiogram He recovered form the spasm in few
hours The limb was warm with palpable pulses
Both P.tibial & D.pedis With good Doppler signals Transferred to KFMC
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