Combat Extremity Vascular Trauma

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1 Combat Extremity Vascular Trauma Training teams to be a TEAM Chatt A. Johnson LTC, MC, USA 08 March 2010 US Army Trauma Training Center Core Discussion Series

2 Outline: Combat Vascular Injury Physiologic consequences of extremity vascular injury Efficient assessment and triage of vascular injuries Surgical principles and temporizing interventions in vascular injuries 2

3 Wartime Vascular Injuries : Vietnam Vascular Registry* Extremity injuries predominate (> 90%) Superficial femoral and popliteal artery injuries most common Popliteal injuries associated with the highest amputation rate (29.5%) Associated injuries common Nerves (42.4%), Veins (37.7%), Bone (28.5%) *Rich et al. J Trauma,

4 Ischemia from Vascular Injury Irreversible injury after 6 to 8 hours. Local effect = limb threat Systemic effects Shock Myoglobinuria Disseminated intravascular coagulopathy Reperfusion can lead to same metabolic effects. 4

5 Life Over Limb Danger from active hemorrhage Danger from ischemia and reperfusion Impact of limb-salvage procedure on patient and resources 5

6 Extremity Vascular Trauma Diagnosis History Pulsatile bleeding Amount of blood loss at the scene Physical Exam Findings extremely variable Hard signs, soft signs, ABI Distal pulses intact in 20% of arterial injuries 6

7 Diagnosis: Hard Signs Pulsatile bleeding Expanding hematoma Palpable thrill Audible bruit Evidence of ischemia (6 P s) Pain, pallor, parasthesias Pulseless, paralysis, poikilothermia 7

8 Diagnosis: Soft Signs History of moderate hemorrhage Injury in proximity (fracture, dislocation, or penetration) Diminished but present pulse Associated peripheral neurological deficit ABI < 0.9 Reduce fracture in affected limb before ABI 8

9 Extremity Vascular Trauma Diagnosis: Ankle Brachial Index Systolic pressure in injured extremity Systolic pressure in uninvolved arm 9

10 Diagnosis: ABI Measured with Doppler ABI >.90 ABI <.90 Normal Abnormal 10

11 Diagnosis: Arteriography Gold Standard for diagnosis when available Useful with: Hard signs involving multiple levels Soft signs/abnormal ABI <0.9 Not indicated for hard signs and single level penetrating injury 11

12 Technique of Arteriography 19 gauge butterfly 3 way stop-cock 20-30cc Syringe Full strength contrast for field use Inflow occlusion if possible Timing toward end of injection 12

13 On-table Angiogram 13

14 Angiogram Interpretation 14

15 Angiogram for Fragmentation Wound Shotgun Wound to Distal Thigh Need 2 views when fragments overlie the vessel to rule out injury 15

16 Management Options Mandatory exploration Selective exploration Non-operative management 16

17 Mandatory Exploration Hard signs of arterial injury Significant arteriographic finding (may not require immediate exploration): Occlusion/extravasation A-V fistula Pseudoaneurysm 17

18 Selective Exploration Soft signs of vascular injury Arteriogram results Ankle-Brachial Index (ABI) <.9 with pulse Need close observation for nonsurgical management 18

19 Non-Operative Management Palpable pulses and ABI >0.9 Life over limb 19

20 Surgical Principles Be prepared! 20

21 Surgical Principles Prep and drape contralateral leg Use longitudinal incisions Obtain proximal and distal control BP cuff may be useful proximally 21

22 Proximal and Distal Control: Right Common Carotid 22

23 Surgical Principles Debride injured vessels to normal wall Pass embolectomy catheters Heparinized saline in proximal and distal vessel Intraluminal shunting (artery or vein) Argyle vs Sundt shunts Restore flow while dealing with other injuries 23

24 Embolectomy 24

25 Shunts Rapidly placed, technically simple Maintains flow while more immediate injuries are addressed Reduces ischemic injury Can be used during transport Documentation key Complications Shunt thrombosis Compartment syndrome 25

26 Sundt Shunt 26

27 Argyle Shunt: Left SFA 27

28 Extremity Vascular Trauma Surgical Principles Use 6-0 suture Tension-free anastomosis Repairs Primary repair if lumen not compromised > 25% Patch angioplasty End-to-end anastomosis <2cm defect 28

29 End-to-end Anastomosis 29

30 Extremity Vascular Trauma Surgical Principles Repairs (continued) Interposition graft Preferred: contralateral reversed saphenous vein Flush with heparinized saline (10,000 U/Liter, 10U/cc) Not preferred: prosthetic PTFE Extra-anatomic bypass Graft coverage Full thickness musculocutaneous coverage 30

31 Vein Graft: Right Common Carotid 31

32 Left SFA Repair with GSV 32

33 Arteriotomy 33

34 Surgical Principles Technique Tissue handling Gerald forceps Minimal manipulation of intima Fine, monofilament suture (6-0 prolene) Magnification Low-threshold for fasciotomy 34

35 Fasciotomy: Artery and Venous Injury 35

36 Surgical Principles Selective use of heparin U/kg Selective use of mannitol 12.5 g IV Lytics: 2-5 mg t-pa Objective assessment of result ABI Venous injuries 36

37 Case 37

38 Injuries to Right Leg Open, comminuted proximal tibia fracture Open knee joint Transected peroneal nerve Injury to popliteal artery at level of tibial plateau 38

39 Arteriogram 39

40 Case Presentation R popliteal artery resection Reversed interposition saphenous vein graft Intraoperative power failure 40

41 Intraoperative Power Failure 4 compartment fasciotomy Await return of power 41

42 Completion Arteriogram 42

43 Case Thrombectomy utilizing PA catheter Streptokinase Palpable DP and PT Debridement and lavage Right leg immobilization 43

44 CONCLUSIONS: Vascular Injuries Priority is life, then limb Diagnosis depends on clinical exam and ABIs. Standard vascular repair techniques apply. Shunts are helpful for damage control. Fasciotomy should be routinely performed 44

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