1. Lower Limb Vascular Trauma Dr Saeed Al-Shomimi Vascular Unit KFHU – Khobar – Saudi Arabia 2006

2. 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.

3. 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

4. Norman Rich , collecting further data The amputation rate from vascular injury in the Korean War and the Vietnam War dropped to approximately 15%

5. 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

6. 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

7. Clinical Presentation

8. 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)

9. 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. ! )

10. 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.

11. CAN VASCULAR TRAUMA HAVE A CHRONICPRESENTATION ? 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.

12. 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.

13. Patterns of Vascular Injury Complete Transection Partial Tear Contusion-Thrombosis Spasm

14. Diagnosis Hard signs of Vascular Injury Diagnostic Adjuncts

15. 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

16. 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.

17. 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.

18. 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

19. Management

20. 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

21. 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

22. 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,

23. Operative Strategy Laceration: Suturing vein (or synthetic) patch

24. Transection Direct suturing

25. Transection graft

26. Contusion- Thrombosis Managed in a similar way to transection In either way , Thrombectomy is Part of the Procedure

27. 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

28. 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.

30. Lower Limb Vascular TraumaFeb – March KFU Experience (( Combined Orthopaedic + Vascular Trauma ))

32. Intra-thoracic

33. Intra-abdominalCASE 1

35. 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 Pulseless Palor Parasthesia Pain

36. 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)

42. 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

44. 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

45. 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

47. CT angiogram was done It showed Vascular injury @ the level of segment 2 of the Popliteal artery No distal run off

50. D P

51. P D

52. P D

53. D P

54. 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

55. THANK YOU