uc sf pdfs... · • ct head/chest/abd/pelvic • pelvic ex-fix • humerus repair •...

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UCSF

VASCULAR SURGERY • UC SAN FRANCISCO

Vascular Trauma @ SFGH: Practical Lessons Learned

Shant M. Vartanian, MDAssistant Professor of Surgery

Division of Vascular and Endovascular Surgery

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Priscilla and Mark Zuckerberg San Francisco General Hospital and Trauma Center

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Disclosures: • None

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Vascular Trauma

• Blunt aortic injury

• Balloon occlusion

• Cerebrovascular trauma

• Pelvic vascular injuries

• Iatrogenic Trauma

• Blunt vs. Penetrating injuries

• Endovascular treatments

• Combined orthopedic and vascular injuries of the limbs

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Combined Skeletal and Vascular Trauma• Not just limited to the battlefield!

• Proliferation of motor vehicles• Distracted pedestrian safety• Urban violence and terrorism

• Fall from standing in the elderly• Sports injuries

• ~3% of long bone fractures are associated with arterial injury

• Blunt trauma predominant mechanism in civilian series

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Patterns of Orthopedic Vascular Injuries

• Clavicle fracture subclavian artery

• Shoulder dislocation axillary artery

• Supracondylar humerus fx brachial artery

• Elbow dislocation brachial artery

• Pelvic fracture gluteal arteries

• iliac arteries

• Femoral shaft fx femoral artery

• Distal femur fracture AK popliteal artery

• Knee dislocation BK popliteal artery

• Tibial shaft fx tibial arteries

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• Clavicle fracture Subclavian artery

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Patterns of Orthopedic Vascular Injuries• Distal femur fracture Above knee popliteal artery

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• Femoral shaft fx SFA

• Tibial shaft fx tibial arteries

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• Supracondylar humerus fx brachial artery

• Elbow dislocation brachial artery

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• Knee dislocation popliteal artery

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• Types of injury

- Spasm

- Intimal flaps

- Subintimal hematoma

- Laceration

- Transection

- Thrombosis/Occlusion

- A-V fistula

• Some require treatment, some do not

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Case Presentation• 58 year old window washer falls 11 stories during

morning rush hour commute

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Case Presentation

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Case Presentation• Aggitated, tachycardic and hypotensive pre

transport• HR 100 SBP 90• GCS 13 (disorientation) and unable to move RLE• FAST negative• Right arm tourniquette applied in field

• Access including femoral sheath• Intubation

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Case Presentation: Plain films

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Case Presentation UCSF


Case Presentation

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Case Presentation

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Case Presentation

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Case Presentation

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Case Presentation• CT Head/Chest/Abd/Pelvic

• Pelvic ex-fix

• Humerus repair

• Interposition saphenous vein to repair brachial artery

• Thrombectomy of radial artery

• Transposition of radial artery into brachial artery graft

• Forearm fasciotomy

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Case Presentation• Discharged to rehab day #28 neurologically intact and full

function of his right hand

- Multiple pelvic injuries

- Transverse process spine fractures

- Kidney and liver laceration

- Sternal fracture

- Bilateral rib fractures, clavicle fracture

- Pulmonary contusions

- Bilateral subdural hematoma

- PE

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Complex Extremity Trauma• Lack of Class I evidence guiding management

- Rational approach

- Best available evidence

- Expert consensus opinion

• American College of Surgeons Committee on Trauma

• Eastern Association for the Surgery of Trauma (EAST)

practice guidelines

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Initial Management• Resuscitation and management of all life-threatening

injuries takes priority over extremity problems

- Life over limb

• Control of active extremity hemorrhage

- Direct pressure

- Tourniquet

- Direct clamping of visible vessels

- Blind clamping in wounds is discouraged and potentially

harmful

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Hard Signs of Vascular Injury• Active hemorrhage

• Large, expanding or pulsatile hematoma

• Bruit or thrill over the wound

• Absent distal pulses

• Distal Ischemia (the 5 P’s)

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Hard Signs of Vascular Injury• Up to 75% of hard signs are not due to vascular injury

- Soft tissue or bone bleeding

- Traction of intact arteries with pulse loss

- Skeletal deformity with pulse loss that corrects with traction

- Compartment syndrome

• Hard signs mandates ruling out vascular injury

Applebaum R, Yellin AE, Weaver FA, et al. Role of Routine Arteriography in Blunt Lower Extremity Trauma. Am J Surg 160: 221-225, 1990.

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Imaging• Imaging with hard signs can avoid unnecessary limb

exploration in up to 70% of cases

• Most patients with hard signs are going to the OR - Vascular C arm table vs hybrid room

- Ipsilateral micropuncture sheath w/ side arm

- Non-selective subtraction angiogram

- Contralateral femoral puncture w/ selective subtraction angiogram

• Depending on the clinical situation, CTA and DUS have been used for evaluating peripheral vascular injuries with

high sensitivity and specificity

Bongard FS, White GH, Klein SR. Management Strategy of Complex Extremity Injuries. Am J Surg 158: 151-155, 1989.

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Asymptomatic Arterial Injuries• Absence of hard signs in an injured extremity excludes a

surgically significant vascular injury as reliably as any imaging modality

- Non occlusive vascular injuries with a benign history may occur

• Soft signs of vascular injury

- Neurologic deficit

- Proximity of injury to vessels

- Significant hemorrhage by history

Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year. J Trauma 31: 502-522, 1991.

Attebery LR, Dennis JM, Russo-Alesi F, et al. Changing Patterns of Arterial Injuries Associated with Fractures and Dislocations. J Am Coll Surg 183: 377-383, 1996.

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Asymptomatic Arterial Injuries• Non-occlusive asymptomatic vascular injuries

– Dissection

– Small pseudoaneurysm

– AVF

– Isolated tibial thrombosis

• Three series totaling 98 asymptomatic combined arterial

+ orthopedic injuries without hard signs

- Single operative repair (which may not have been necessary)

• Series of 15 asymptomatic combined injuries followed for 6 months

- No intervention requires

Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year. J Trauma 31: 502-522, 1991.

Attebery LR, Dennis JM, Russo-Alesi F, et al. Changing Patterns of Arterial Injuries Associated with Fractures and Dislocations. J Am Coll Surg 183: 377-383, 1996.

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Who Goes First? • Skeletal repair is priority or selective vascular repair when

ischemia is clinically evident- Disruption of fresh vascular anastomosis by orthopedic surgeons

during reduction

- Length discrepancy of vascular repair after reducing unstable skeletal injuries

• Snyder et al- Combined vascular + orthopedic repair in 29 patients- Two patients requiring repair at index operation- Did not effect outcome

• Howe et al- Combined vascular + orthopedic repair in 21 patients- No episodes of vascular disruption

Snyder WH. Vascular Injuries Near the Knee: An Updated Series and Overview of the Problem. Surgery 91: 502-506, 1982.Howe HR, Poole GV, Hansen KJ, et al. Salvage of Lower Extremities Following Combined Orthopedic and Vascular Trauma: A Predictive Salvage Index. Am Surg 53: 205-208, 1987.

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Who Goes First? • Significantly lower amputation rates in those undergoing

revascularization first in comparison to orthopedic repair first

- Lim et al- McCabe et al

• “Restoration of blood flow should always take priority over skeletal repair’

- Eastern Association for the Surgery of Trauma Practice Guidlines

- Temporary shunting to allow stabilization of unstable fractures

- Immediate definitive arterial repair while skeletal injury is stable and not significantly displaced

Lim LT, Michuda MS, Flanigan DP, et al. Popliteal Artery Trauma. Arch Surg 115: 13071313, 1980.McCabe CJ, Ferguson CM, Ottinger LW. Improved Limb Salvage in Popliteal Artery Injuries. J Trauma 23: 982-985, 1983.

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Definitive Repair vs. Shunt• Physiologic parameters

- Hemodynamic Instability

- Coagulopathy

- Acidosis

- Hypothermia

• Other life threatening injuries requiring urgent management

- Head injuries, pelvic fractures, etc.

• Major wound contamination

• Extensive soft tissue defects precluding wound coverage

• Requirements for complex repair - Bypass rather than primary repair

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Definitive Repair vs. Shunt• +/- distal thrombectomy before placing a shunt

• Types of shunts

- Commercially available

- Any Silastic tubing

• Secure with shunt clamp or silk ties

- Will need to debride artery beyond level of ties/clamp during definitive repair

• Regular monitoring flow through the shunt

- If easily accessible, may doppler shunt itself

- Otherwise distal pulse exam

• Systemic heparinization

- If no contraindications, may prevent shunt thrombosis

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Factors Influencing Limb Salvage• Time

- Direct relationship between delay in revascularization and limb loss

• Mechanism- Blunt trauma worse outcomes than low-velocity penetrating trauma

• Anatomy- Popliteal artery has the overall single worst prognosis for salvage

• Associated injuries• Age • Comorbid conditions• Clinical Presentation

- Patients in shock with worse outcomes than stable

patients

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Risk Factors for Amputation• Gustillo III C injuries

- Comminuted, open tib-fib fractures with vascular injury

• Significant nerve injury- Transection of sciatic/tibial nerve, 2 of 3 major upper extremity

nerves

• Prolonged ischemia (> 6 hours)- Direct correlation between delay in revascularization and limb loss

• Crush injury or significant loss of soft tissue • Significant wound contamination• Severely comminuted fractures or segmental bone loss• Age and severity of comorbid conditions

• Futility of revascularization or failed revascularization

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Primary Amputation• Early amputation

- Appropriate level above the destructive wound

- Without attempt to close primarily- Photographs may be useful to document severity of injury

- Marginally viable tissue is preserved- Copiously irrigated and debridement of contaminated debris- A two attending decision

• Scoring systems predicting the need for early amputation have not shown sufficient prospective reliability to permit a solid decision for amputation

• If the need for amputation is not clear…

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Secondary Amputation• Limb salvage is attempted • Close observation for 24-48 hours

- Soft tissue viability- Skeletal stability- Sensorimotor function

• Secondary amputation- Adverse impact on patients health

– Sepsis

– Rhabdomyolysis– Hyperkalemia– ARDS

- No hope for a functional outcome

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Complex Skeletal Vascular Injury Outcomes

• On average 5 – 7 operative procedures

• If “successful” only 30 – 50% are usefully employed

• Eventual amputation rate of 30% of Gustilo IIIC fractures

at time of injury

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Case Presentation• 57 y.o. dragged by Tesla

• Open joint with significant blood loss

• Tourniquette applied at the scene

• SBP 90 HR 100

• Neurologically intact but insensate left lower extremity

• No other identified injuries on primary and secondary

assesment

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Case Presentation

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Case Presentation

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Case Presentation

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Case Presentation• Ligation saphenous vein, repair femoral vein

• Saphenous interposition graft popliteal artery

• 4 compartment fasciotomy

• Ex-Fix

• Plan- Tertiary survey

- Return to OR tomorrow for washout, debridement

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Summary• Hard signs prompt vascular imaging

• Most hard signs with combined skeletal trauma are not

vascular

• Revascularization takes priority over skeletal repair

- Consideration of physiologic parameters and associated

injuries

• Difficult to accurately identify which patients will do best

with early primary amputation

uc sf pdfs... · • ct head/chest/abd/pelvic • pelvic ex-fix • humerus repair •...

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