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Vascular Trauma

Vascular trauma can result from either blunt or penetrating injury 

  1. Types of vascular injury
    1. Contusion/ Puncture/ Laceration/ Transection  
  2. Pathophysiology
    1. Haemorrhage is the prime consequence of vascular injury.
    2. Bleeding may be obvious, with visible arterial haemorrhage, or it may be concealed.
    3. Ischaemia results from an acute interruption of flow of blood to a limb or organ.
    4. Peripheral nerves are more sensitive to ischaemia, and prolonged neurological deficit may result from relatively short periods of tissue ischaemia.
    5. If arterial supply is restored to ischaemia tissue, the sudden release of inflammatory mediators, lactic acid, potassium and other intracellular material into the circulation can cause profound myocardial depression, generalised vasodilatation and initiate a systemic inflammatory response.
  3. Clinical features
    1. Depends on site, mechanism and extent of injury
    2. Signs classically divided into 'hard' and 'soft' sign  
  4. Hard signs of vascular injury
    1. Pulsatile bleeding
    2. Expanding haematoma
    3. Absent distal pulses, cold, pale limb- Distal ischaemia.
    4. Audible Bruit or palpable thrill
    5. Active haemorrhage
The presence of hard signs of vascular injury mandates immediate operative intervention without prior investigation.  
  1. Soft signs of vascular injury
    1. Haematoma
    2. History of haemorrhage at site of accident
    3. Unexplained hypotension
    4. Peripheral nerve deficit
    5. Decreased pulse compared to the contralateral extremity
    6. Bony injury or in proximity penetrating wound
Softer signs require close observation and monitoring. If the ABI is higher than 0.9, close observation is advocated, but if the ABI is lower than 0.9, further evaluation is warranted. Q 
  1. Investigation
    1. Arteriography should be considered:
    2. To confirm extent of injury in stable patient with equivocal signs
    3. To exclude injury in patient without hard signs but strong suspicion of vascular injury  
  2. Diagnostic Adjuncts
    1. Pulse Oximetry: A reduction in oximeter readings from one limb, as compared to another is suggestive   of significant vascular injury. Q 
  3. Doppler Ultrasound:
    1. The diagnosis of a significant (ie. requiring intervention) vascular injury has been shown to be related to the presence or absence of a palpable pulse.
    2. Similarly, a reduction in the ankle-brachial pressure index (ABPI) in the presence of a palpable pulse does not indicate the presence of a vascular injury requiring intervention.
    3. Doppler ultrasound is therefore adds little to careful clinical examination.
    4. Duplex Ultrasound: Duplex imaging is a non-invasive examination combining B-mode and Doppler   ultrasound. Duplex can detect intimal tears, thrombosis, false aneurysms and arteriovenous fistulae.
    5. Angiography: Angiography remains the gold-standard investigation for the further investigation and delineation of vascular injuryQ. Proximal control may be possible with an angioplasty catheter prior to transfer to the operating room. 
  4. Management
    1. The priorities of vascular injury are arrest of haemorrhage and restoration of normal circulation.
    2. Airway control and respiratory assessment take priority over management of the circulation. Q 
  5. Immediate Haemorrhage Control:
    1. By direct pressure or where haemorrhage is welling up from a deep knife or gunshot track, control may be temporarily achieved by passing a urinary catheter into the track as far as possible, inflating the balloon.
    2. 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.  
  6. Volume resuscitation:
    1. Prior to haemorrhage control, minimal fluids should be administered.
    2. Raising the blood pressure will increase haemorrhage from the vessel injury.
    3. No inotropes should be given to the hypovolaemic patient as this will effectively deplete myocardial tissue oxygen and increase myocardial work.
    4. Once haemorrhage control is achieved, aggressive volume resuscitation is done. 
  7. Operative Strategy
    1. The basic principle of vascular repair is to gain proximal and distal control of the relevant vessel before investigating the site of injury.
    2. Proximal control is best achieved through a separate incision away from the site of injury.
    3. Distal control similarly is best achieved via a second incision.
    4. Once proximal and distal control is achieved, the site of injury can be explored and control made closer to the injury site.
    5. Once the vessel injury is identified, the first step is debridement of devitalized tissue and definition of the edges of the wound.
    6. Next an assessment of inflow and outflow is made. If it is inadequate, a balloon (Fogarty) catheter is passed proximally and distally to extract any thrombus.
    7. Following extraction, heparinized saline is instilled proximally and distally to locally antcoagulate the vessel.
    8. Small, clean, transverse wounds to vessels that involve only part of the circumference can be repaired with a direct suture technique.
    9. A vein or synthetic patch may be required where there is a larger defect in the vessel wall where direct suturing may lead to narrowing of the vessel lumen.
    10. While vein grafts probably have a longer patency, the graft infection rates are the same for both vein and synthetic grafts, regardless of wound contamination. 
  8. Compartment syndrome
    1. Prolonged interruprion of blood flow to a limb leads to cellular ischaemia, activation of cellular and humoral inflammatory responses and alterations in vascular permeability.
    2. Subsequent reperfusion of the limb leads to generalised tissue oedema.
    3. When this occurs in a limited, enclosed space - such as the fascial compartments of the lower limb, the pressure in the compartment may rise above capillary and venous pressure and cause vascular stasis, cellular ischaemia and death.
    4. The pressure in the compartments is rarely above arterial pressure and distal pulses are preserved.
    5. If the patient is awake, there is intense, disproportionate pain in the limb, worsened by passive flexion of the muscle groups.
    6. In measurement of compartment pressures values over 30mmHg are diagnostic of compartment syndrome. Q
    7. Fasciotomy is best performed at the time of initial surgery, rather than as a subsequent procedure for a second episode of limb ischaemia. Q
Aims of surgery are to:
  1. Control life-threatening haemorrhage
  2. Prevent limb ischaemia
  3. If surgery is delayed more than 6 hours, revascularisation is unlikely to be successful Q
  1. Vascular repair
    1. Usually performed after gaining proximal control and wound debridement
    2. Options include :
      1. Simple suture of puncture hole or laceration
      2. Vein patch angioplasty
      3. Resection and end-to-end anastomosis
      4. Interpositional graft
    3. Contralateral saphenous vein is the ideal Interpositional graft Q
    4. Prosthetic graft material may be used if poor vein or bilateral limb trauma
  2. Complications of vascular injury
    1. Thrombosis of the graft remains the most common complication of vascular injury. Q
    2. Narrowing of the vessel with primary repair or kinking of the graft, may require revision of the repair.
  3. False aneurysm"
    1. Most commonly occurs following catheterisation of femoral artery
    2. Often presents with pain, bruising and a pulsatile swelling
    3. Diagnosis can be confirmed by doppler ultrasound
    4. Suturing of puncture site/ Vein patching may be required  
  4. Arteriovenous fistula 
    1. Most common cause is penetrating trauma
    2. Arterialisation of veins (tortuous, dilated, thick walled)
    3. Leak from high pressure system to low pressure system-
    4. Increase in pulse rate, cardiac output, pulse pressure,- enlargement of left ventricle- cardiac failure
    5. In a young child there is overgrowth of a limb
  • Etiology-
  • Congenital, Traumatic, Surgical 
Nicoladoni’s Sign or BRANHAM’s Sign: Pressure over an artery proximal to the fistula will  lead to decrease in the size of the swelling, decreased pulse rate and cessation of thrill or bruit.
  1. Duplex scan or Angiography for confirmation.
  2. Machinery type bruit (continuous) often present throughout cardiac cycle Q
  3. RxOC- Therapeutic embolisation
  4. Open surgical method for treatment is Quadruple ligation
  5. Fistula can be divided an both the vein and artery sutured
  6. Flap of fascia can be interposed between vessels to reduce risk of recurrence.

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