Epidemiology. 16% incidence in knee. dislocation

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2 Epidemiology Highest risk group: Young male between 15 and 45 years (USA) Mortality Ratio after trauma : male/female: 7/1 Peripheral vascular injuries : 70%-80% of all cases of vascular trauma : Vascular injuries secondary to extremity trauma is rare: 1% incidence in long bone fracture dislocation 16% incidence in knee

3 Epidemiology Abdominal vascular injuries: up to 20% of all cases of vascular trauma(penetrating trauma) Thoracic aortic injuries: rare. 70% to 90% mortality 10% to 20% reach the hospital Vascular injuries in the neck: rare but the incidence is increasing due to the use of screening test, following blunt and penetrating trauma. Incidence : 0,1% to 0,3%

4 Trauma mechanisms Penetrating trauma: Gunshots, Stabs, Piercing instrument Blunt trauma: Contusion,Bone fracture, Joint displacement(luxation) Iatrogenic trauma: Arteriography, Catheterization, PCI, PTA/Stenting

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13 Physical examination Localized trauma or multitrauma Conscious or unconscious Assesment of airway, breathing,circulation Examination of all the extremities Vascular examination prior to any intervention : Puls palpation Capillary refill and color Temperature Doppler examination AND comparison with the contralateral side

14 Hard and Soft Signs of Vascular Injury associated with Extremity trauma Hard Signs: Pallor Paresthesia Pain Pulslessness (doppler) Paralysis Rapidly expanded hæmatoma External pulsatil bleeding Soft Signs: History of arterial bleeding Proximity related injury Hæmatoma over a named artery Diminished distal puls, Doppler flow Neurological deficit

15 Hard and Soft Signs of Vascular Injury associated with Extremity trauma Soft signs of vascular injury are associated with vascular injury in 3% to 25% of cases Data suggest that physical examination may be less reliable than initially thought

16 IMAGING : DIAGNOSTIC STUDIES Reasons for diagnostic evaluation: Document presence of surgical vascular lesion Prevent unnecessary operation Localize the vascular læsion to plan operativ approach

17 IMAGING : DIAGNOSTIC STUDIES Duplex sonography: Non invasive bedside Identify vascular lesion No complication Require equipement and trained technicians/physicians

18 IMAGING : DIAGNOSTIC STUDIES CT ANGIOGRAPHY : Quick Cost effective Reliable option for diagnosis, status of the vessels proximal and distal. software equipment/physician

19 IMAGING : DIAGNOSTIC STUDIES D.S.ARTERIOGRAPHY : Invasive examination 1%-2% complications : bleeding, hæmatoma, pseudoaneurysm, thrombosis, emboli. radiologist Proximity related injury / missile injury : not an indication for arteriography in the setting of normal physical examination. But signs of bleeding in case of blunt trauma indicate necessity of further investigation, i.e. arteriography in intention to treat.

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21 Reduce, stabilize, resuscitate No pulses Asymmetric pulses Normal exam Injury obvious Multilevel injury? Doppler Surgery Angiography or duplex ABI <0.9 ABI >0.9 Observation

22 Management of traumatic vascular injuries Goals : Stop bleeding decreasing ischæmia time Stabilization of the extremity, protection of vascularisation or vascular repair optimizing care and outcome Strategy : Vascular intervention before Orthopædic repair : limb salvage Orthopædic intervention before vascular repair: soft signs of vascular injury Stabilization of fracture,protection of vascular structures

23 Management of traumatic vascular injuries Irreversible damage after 6 hours : non functional limb secondary to neurological injury(ischæmia) Orthopædic fixation/stabilization may delay time to revascularization Delayed revascularisation Risk for compartment Risk for metabolic acidosis Myoglobinæmia Renal function impairment No stastistical difference in overall amputation rate whether vascular repair or orthopædic repair is performed first(fowler J, MacIntyre N, et al. Injury, Int.J.Care Injured 40(2009)72-76)

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25 Vascular Repair Non surgical management : Vascular lesion,assessed and diagnosed radiographically Intact distal circulation No active hæmorrhage Minimal wall lesion(<5 mm) CLOSE FOLLOW-UP AFTER ORTHOPÆDIC STABILIZATION

26 Vascular Repair Open Surgical Repair : Contralateral underextremity is placed in the surgical field for potentiel harvest of autogenous vein Proximal and distal kontrol of the vessel Debridement back to normal vessel, proximally and distally Removing intraluminal clots with Fogarthy catheter Local Heparinization

27 Vascular Repair Surgical Repair: Arterioraphy with or without patch (vein) Resection and end to end anastomosis (short transversal lesion < 1 cm) Graft interposition/by-pass, rather with vein than prosthesis

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30 Vascular Repair Endovascular Treatment : Coiling of branch artery to stop bleeding Covered stent-graft to seal the vascular lesion. Efficient and less invasive treatment Concerning covered stent-graft in peripheral vessels: no long term follow-up Patency?????? Requiring procedural expertise

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34 Conclusion Prompt recognition and assessment of vascular lesions is the key of limb salvage Arterial continuity should be restored in a warm ischæmia time of < 6 hours to avoid permanent soft tissue damage Coordinated management between the orthopædic, the trauma, and the vascular surgeon is mandatory

35 Efter hvor mange timer opstår der irreversible bløddelsskader på grund af iskæmi sekundær til karlæsion? 1)2 timer 2)6 timer 3)12 timer 4)24 timer