MANAGEMENT OF PERIPHERAL VASCULAR INJURI

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ROY VARGHESE ASWINI HOSPITAL ,TRISSUR PERIPHERAL VASCULAR PROBLEMS AND ORTHOPEDIC SURGERY

VASCULAR INJURY AS A DEFINING MOMENT : 

VASCULAR INJURY AS A DEFINING MOMENT ORTHOPEDIC SURGERY VASCULAR SURGERY

VASCULAR INJURIESCOMMONLY ENCOUNTERED : 

VASCULAR INJURIESCOMMONLY ENCOUNTERED ISOLATED ORTHO AND VASCULAR POLYTRAUMA LIFE TAKES PRIORITY OVER LIMB

VASCULAR PROBLEMSCOMMONLY ENCOUNTERED : 

VASCULAR PROBLEMSCOMMONLY ENCOUNTERED CHRONIC LIMB ISCHEMIA WITH ULCERS VENOUS INSUFFICIENCY AND LOWER LIMB EDEMA DEEP VEIN THROMBOSES

HISTORICAL PERSPECTIVE : 

HISTORICAL PERSPECTIVE MURPHY 1886 -FIRST END TO END VASCULAR ANASTOMOSES CURRENT’ONLINE” PERSPECTIVE DELAY IN REPAIR OF AN ARTERIAL INJURY BEYOND 4-6 HOURS INCREASES THE INCIDENCE OF SEVERE COMPLICATIONS

CHARACTERISTICS OF VARIOUS TYPES OF TRAUMA CAUSING VASCULAR INJURY : 

CHARACTERISTICS OF VARIOUS TYPES OF TRAUMA CAUSING VASCULAR INJURY PENETRATING INJURIES-commonly sharps MISSILES-CAVITATION INJURY BLUNT TRAUMA-AUTOMOBILES, WORK SITES-CRUSH INJURIES Elbow and knee injuries particularly vulnerable to vascular injuries

TYPES OF VESSEL DAMAGE : 

TYPES OF VESSEL DAMAGE LACERATION-EXSANGUINATION LIKELY VESSEL TRANSECTION CONTUSION-OCCLUSION OF LUMEN- USUALLY FROM INTIMAL FLAP- FALSE ANEURISM-PERIVASCULAR HEMATOMA AV FISTULA SPASM IF DISTAL ISCHEMIA PERSISTS AFTER REDUCTION OF # VESSEL DAMAGE OR THROMBOSIS SHOULD BE SUSPECTED AND STICK ANGIO DONE

PATHOPHYSIOLOGY OF VASCULAR INJURIES : 

PATHOPHYSIOLOGY OF VASCULAR INJURIES HYPOTENSION- VASOCONSTRICTION- LOCALLY-HEMATOMA TISSUES CONSEQUENCES VARY ACCORDING TO SENSITIVITY OF TO ISCHEMIA BRAIN 4 MIN,EXTREMITY UPTO 4 HRS

DIAGNOSIS OF VASCULAR INJURIES-HARD &SOFT SIGNS : 

DIAGNOSIS OF VASCULAR INJURIES-HARD &SOFT SIGNS PHYSICAL EXAM DIFFICULT IN HYPOTENSIVES HISTORY OF BLOOD SPURTS HEMATOMA,ABSENT PULSES PERIPHERAL PULSES ARE PRESENT IN UPTO 25% OF VASCULAR INJURIES(ANN.SURG.1971) ABI/ANKLE PULSES ON DOPPLER RELIABLE SIGNS OF ISCHEMIA ?PULSE OXIMETER

SIGNS AND SYMPTOMS SUGGESTING VASCULAR INJURY : 

SIGNS AND SYMPTOMS SUGGESTING VASCULAR INJURY MASSIVE BLEED,SHOCK,HEMATOMA WITH THRILL OR PULSATION, PAIN,PALLOR,PULSELESSNESS, PARALYSIS/PARESIS/PARESTHESIA ? TOO LATE(neuro or vascularcause) POIKILOTHERMIA TRAUMA RESPECTS NO TIME OR SPACE BARRIERS

NON INVASIVE STUDIES : 

NON INVASIVE STUDIES HAND DOPPLER->20 MMHG COMPARED TO OPPOSITE LIMB ABI<0.9 DUPLEX STUDY HAMPERED BY ASSOCIATED BONE AND SOFT TISSUE INJURY PREVENTING PROPER POSITIONING UNSTABLE PTS WITH SUSPECTED VASCULAR INJURY SHOULD NOT BE SENT TO OR , NEVER TO RADIO DEPT

PREHOSPITAL/CARE IN ER OF BLEEDING INJURIES : 

PREHOSPITAL/CARE IN ER OF BLEEDING INJURIES DIGITAL PRESSURE OR COMPRESSION ,RIBBON PACK AT SITE OF BLEED SPHYGMOMANOMETER ABOVE SYSTOLIC PRESSURE SPLINTING/REDUCTION OF #,COMPRESSION BANDAGE AVOID BLIND PLACEMENT OF CLAMPS FAILURE TO PROMPTLY REDUCE #/DISLOCATION MAY RESULT IN EXTENSIVE TISSUE NECROSIS

CORRECTION OF HYPOVOLEMIA : 

CORRECTION OF HYPOVOLEMIA HYPOXIA,HYPOVOLEMIA LEADS TO RESTLESSNESS OPIODS FOR ANALGESIA CONTROLLED HYPOTENSION A SINGLE DOSE OF NSAID IN A HYPOTENSIVE PATIENT-ARF PULSE OXIMETER MAY GIVE A FALSE SENSE OF SECURITY UNRELIABLE BELOW 87% GOOD PERIPHERAL PULSES NEEDED DOES NOT DIFFERENTIATE BETWEEN CARBOXY AND OXYHEMOGLOBIN NO INDICATION OF ACID BASE STATUS

Emergency SurgeryUnstable pts with vascular injury or threatened limbs : 

Emergency SurgeryUnstable pts with vascular injury or threatened limbs TO ARREST BLEEDERS TO RESUSCITATE TO REDUCE # SPASM AS A CAUSE FOR ISCHEMIA IS RARE FORGET RADIOLOGY ,THEATER FIRST!!!!!

ANGIOGRAPHY GUIDELINES : 

ANGIOGRAPHY GUIDELINES PENETRATING WOUNDS-SIGNS &SYMP TOMS OF VASCULAR INJURY OR AN ISCHEMIC LIMB BLUNT TRAUMA -SIGNS &SYMP TOMS OF VASCULAR INJURY OR AN ISCHEMIC LIMB ,MULTIPLE #LONG BONE #, SUPRACONDYLAR INJURY TO KNEE,HUMERUS SINGLE STICK OR FORMAL CATH LAB/DSA ANGIO IS PROBABLY MANDATORY IN MULTIPLE #S IN LONG BONES,FLOATING KNEE INJURY,AXILLA,NECK

COMPLICATIONS OF ANGIOGRAPHY : 

COMPLICATIONS OF ANGIOGRAPHY COMPLICATIONS IN 2-6% PTS GROIN HEMATOMAS, DISSECTION OF INTIMAL FLAP EMBOLI PSEUDOANEURISM DYE ALLERGY 14-16 CAVAFIX , OMNIPAQUE OR UROGRAFFIN ,20 CCSYRINGE AND C ARM/FLUOROSCOPE !

OTHER INVASIVE STUDIES : 

OTHER INVASIVE STUDIES VENOGRAM ESPECIALLY FOR FB LODGED IN VEINS,LARGE VENOUS INJURIES 99mTc SCAN FOR ARTERIAL INJURY(POLYTRAUMA) IADSA A LIMB THAT HAS BEEN ISCHEMIC FOR MORE THAN 6 HRS HAS HISTOLOGIC INJURIES,MAY CAUSE SYSTEMIC REPERFUSION INJURY SYMPTOMS

OPERATIVE MANAGEMENT : 

OPERATIVE MANAGEMENT CONTROL OF BLEEDING –SPONGE STICK FOLEYS CATHETER,CENTRAL LINE,SNP,NTG/DOBUTAMINE,HEPARINE NO BLIND CLAMPS,GOOD LIGHT AND WORKING SUCTION AVOID LIMB TOURNIQUETS FOLEYS CAN BE USED TO OCCLUDE LARGE VESSELS,USE DYE TO INFLATE BULB TILL BLEED STOPS

OPERATIVE MANAGEMENT : 

OPERATIVE MANAGEMENT SCRUB AND FREE DRAPE BOTH LIMBS TO ALLOW RAPID PROXIMAL AND DISTAL CONTROL OF VESSELS,AND TO HARVEST VEIN CONDUIT UMBILICAL TAPE,GLOVE OR RUBBER BAND SLINGS AS TOURNIQUET FOR BLOOD VESSELS PREVENTION OF INFECTION PREFERABLY VEINS AS VASCULAR CONDUITS

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USE OF RUBBER BAND SLING SHUNTS,T TUBE USE PTS OWN BLOOD FOR COATING SHUNT

OPERATING TIPS : 

OPERATING TIPS BIPOLAR CAUTERY,GOOD SUCTION LINE OF INCISION ALONG NEUROVASCULAR BUNDLE AS YOU GET VESSEL CONTROL ASK ANESTHESIOLOGIST TO RESUSCITATE PT INJECT HEP SALINE(1000 UNITS /L)INTO DISTAL VESSELTILL SPASM IS RELIEVED/NTG DRIP REWARM PT AND MAINTAIN INTRAVASCULAR VOLUME KIDNEY IS THE POOR MANS TRANSDUCER OF CARDIAC FUNCTION

OPERATING TIPS : 

OPERATING TIPS VESSEL DEBRIDEMENT AVOID RESECTION AND END TO END ANASTOMOSES/LATERAL REPAIRS UNDERTENSION OPERATE UNDER MAGNIFICATION MOST PERIPHERAL VESSELS BEST REPAIRED WITH 6.0 PROLENE SPATULATE VESSEL ENDS USE EYE INSTRUMENTS

OPERATING TIPS : 

OPERATING TIPS REPAIR DEEP VEINS POPLITEAL VEIN UPWARDS EXTRA ANATOMIC ROUTE FOR CONDUITS IF THERE IS GROSS INFECTION IN COMBINED ORTHO/VASCULAR INJURIES OBTAIN CHECK REDUCTION WITH EXT FIXATORS IF VESSEL EXPOSURE IS A PROBLEM WITH EXT FIXATORS REMOVE CONNECTING RODS AS NECESSARY IN PERSISTENT VASOCONSTRICTION BELOW KNEE INFUSE HEP SALINE WITH NTG/ VIA A INFUSION CATHETER.

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UPPER EXTREMITY INJURIES 30-40% AXILLARY ARTERY 40% BRACHIAL 20-30% LIGATION OF BRACHIAL ARTERY NO INDICATION RUTHERFORD 1991

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LINE OF INCISION ALONG NEUROVASCULAR BUNDLE AXILLARY EXPLORATION SHOULD BE NOT DONE WITHOUT PROXIMAL AND DISTAL CONTROL

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ALL FLOATING KNEES SHOULD HAVE AN ANGIO EXPLORE POP FOSSA REPAIR POP VEIN

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FOGARTY CATHETER SIZE3,AK 4 BK

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CAROTID INJURY SHOULD BE REPAIRED UNLESS IT IS GROSSLY OCCLUDED WITH THROMBUS

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AXILLA MUST NEVER BE EXPLORED UNLESS PROXIMAL AND DISTAL CONTROL IS OBTAINED IT CAN CONTAIN >2LITERS OF BLOOD

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POSTEROLATERAL THORACOTOMY FOR SUBCLAVIAN VESSEL INJURY EXPLORE URGENTLYCHEST IF BLEEDS >300 ML/HOUR

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AVOID THESE REPAIRS!!!!!

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PATCH REPAIRS,6.0 PROLENE,DOUBLE ARM

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AV FISTULA INCOMBIED DEEP VESSEL INJURIES COMMON IN THIGH AND NECK

COMPLICATIONS OF VASCULAR PROCEDURES : 

COMPLICATIONS OF VASCULAR PROCEDURES HEPARIN >>>> HEMATOMA THROMBOSIS INFECTION>>SECONDARY HEMORHAGE DELAYED COMPLICATIONS –OCCLUSION,STENOSIS, MYCOTIC ANEURISMS,INFECTION AMPUTATION

COMPARTMENT SYNDROME : 

COMPARTMENT SYNDROME I AVOID CLOSING SKIN AND FASCIA AFTER A VASCULAR OR ANY PROCEDURE IN BELOW KNEE POSITION UNDER TENSION AVOID CLOSED FASCIOTOMY BB SPLINT,PILLOW UNDER MATTRESS PROPHYLATIC FASCIOTOMY IN PTS ON VENTILATOR,PROLONGED ANESTHESIA,AT RISK OF DVT CARELESS FASCIOTOMY DESTROYS PERIPHERAL NERVES AND VEINS LEARN,UNLEARN AND RELEARN

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EARLY PREVENTIVE FASCIOTOMY CARE OF VEIN,NERVES

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THE TREATMENT OF DVT IS PREVENTION VENOUS INSUFFICIENCY VENOARTERIAL REFLEX

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SOME PICTURES

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PREVENTION OF IATROGENIC VENOUS INJURIES AVOID SUTURING UNDER TENSION AVOID TOURNIQUET AVOID UNNECESSARY TRANSFUSION KEEP LIMB ELEVATED UNFRACTIONATED HEPARIN POP CAST/EDEMA USE THE SIMPLEST AND FASTEST SURGICAL OPTION IN CRITICAL PATIENTS

Avenues and Streets in Vascular Surgery : 

Avenues and Streets in Vascular Surgery

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BULLET INJURY TO ILIOFEMORAL VESSELS,FEMORAL ARTERY

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POST THROMBOTIC LEG

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ISCHEMIA REPERFUSION SYNDROME AFTER EMBOLECTOMY

WHEN WILL YOU AMPUTATE ? : 

WHEN WILL YOU AMPUTATE ? TO SAVE THE LIFE TANDEM INJURIES CRUSH INJURIES TAKE A SECOND OPINION,PHOTO,CONSENT ON WHITE PAPER IN RELATIONS HANDWRITING

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THIS PRESENTATION IS FROM THE DEPT OF ORTHO,VASCULAR AND INTERNAL MEDICINE ASWINI HOSPITAL THRISSUR THANK YOU