Tomáš Novotný II. chirurgická klinika LF MU a FN u sv. Anny Vascular trauma [USEMAP] •most vascular diseases may be observed and treated during prolonged periods • •Vascular trauma is the opposite • •very short time intervals for diagnosis and intervention • •often incomplete and imperfect information Vascular trauma [USEMAP] •The advances and developments are related to major conflicts or war • •vascular trauma is associated with hemorrhage –surgical practice evolved around the control of bleeding – •Ligation of both arterial and venous injuries –the standard of care through World War II –World War I - repair attempted in 3.2 % of injuries –World War II - repair attempted in 5 % of injuries Vascular trauma an its evolution [USEMAP] •Korean War –88 % of injuries undergoing a vascular repair attempt • •Vietnam War –repair attempted in 93% of injuries • •Iraq and Afghanistan –high rate of extremity injury (53 %) –decreased rate of major truncal injury (15 %) –devastating nature of the extremity injuries and the inclusion of distal arterial injuries probably explain the increase in vascular ligations (35 %) Vascular trauma an its evolution [USEMAP] •historically relatively rare • •the development of machinery and motorized vehicles •the increase in urban violence and weaponry •increased incidence of civilian vascular trauma • •incidence 1-4% of all injuries (likely an underestimate) –does not include patients who die at the trauma scene or before or immediately after hospital arrival • •The majority of immediate deaths from vessel disruption are due to aortic injury (55%) –78% leading to death within 15 minutes of injury Vascular trauma in the civilian setting Source: http://www.secondscount.org/heart-condition-centers/info-detail-2/cardiac-embolism-stroke [USEMAP] •trauma as a cause of death (USA 2010) –63% of patients aged 1 – 24 years –42 % of patients aged 25 – 44 years – •incidence of vascular injury –1.6 % for adults –0.6 % for children – –60 – 90 % due to penetrating mechanisms (mainly guns) –blunt vascular injuries are uncommon – •iatrogenic injuries –percutaneous endovascular procedures –laparoscopy Current Epidemiology of Vascular Injury Source: http://www.secondscount.org/heart-condition-centers/info-detail-2/cardiac-embolism-stroke [USEMAP] •Epidemiologic trends –The average age of all trauma patients is increasing – –“young and healthy” trauma patient replaced with elderly patients with a preexisting vascular disease – –more severely injured patients with major vascular injury reaching a hospital alive – –damage control surgery – –endovascular techniques Current Epidemiology of Vascular Injury [USEMAP] •Direct – –penetrating injury (sharp) – –blunt injury – •Indirect • –traction injury – –deceleration injury – – – Mechanism of Injury [USEMAP] •grade I –no bleeding –no peripheral ischemia –aneurysm might develop – •grade II –bleeding –pseudoaneurysm formation –with or without peripheral ischemia – •grade III –bleeding –peripheral ischemia Penetrating injury (sharp) [USEMAP] • •contusion • •compression/strangulation • Blunt injury [USEMAP] •traction injury • • • • • •deceleration injury • Indirect injury [USEMAP] •has yet to be developed • •Three-tier system – –tier 1 (peripheral or extremity) •distal to axillary of common femoral vessels – –tier 2 (proximal groin or axillary wounds) •junctional wounds – –tier 3 (intracavitary wounds) •thorax, abdomen, pelvis Vascular Injury Classification and Scoring [USEMAP] •highly variable –hard signs of vascular injury •arterial bleeding •pulsatile hematoma •absence of pulses or limb ischemia •bruit or thrill indicative of arteriovenous fistula –soft signs •non-pulsatile hematoma •decreased pulses or pressure index •unexplained anemia or hypotension •injury to closely associated structures (typically nerves) •injury close to the vessel • Clinical presentation [USEMAP] •hard signs of vascular injury –100 % specific, particularly with penetrating limb trauma –nearly 100 % specific in penetrating neck trauma but present in only 20 % of patients – –much less applicable in intracavitary vascular injury –hypotension will be the primary indicator – –are present in less than 10 % of vascular injuries –majority will have soft signs, delayed presentation or be asymptomatic Clinical presentation [USEMAP] •Head –intracranial injury is typically a combination of vessel and brain parenchyma injury • •Face –penetrating injuries to branches of external carotid artery –blunt trauma associated with major facial fractures – –usually obvious with external or intraoral/intranasal bleeding Clinical presentation [USEMAP] •Vascular injury incidence is –20 % in penetrating trauma –clinical examination is very reliable –missed injury rate 0.7 % – –1 % in blunt trauma –usually no hard signs –immediate neurological deficits (up to 28 %) –delayed neurological deficits (up to 78%) –entirely asymptomatic (up to 40 %) –CT angiography is study of choice Clinical presentation - neck [USEMAP] •Noncompressible truncal hemorrhage (NCTH) –high associated mortality – •Critical concepts for NCTH –minimize delays in transfer to operating room –permissive hypotension until vascular control –balanced resuscitation with early use of plasma –use of procoagulant drugs –use of damage control surgery Clinical presentation - torso [USEMAP] •Extremities –vascular injury is common in penetrating or blunt mechanism –incidence is 1 – 2 % of all trauma patients –more common on lower (66 %) vs. upper (34 %) extremities –clinical examination is very reliable in penetrating injuries –missed injury rate is of 0.7 % – –blunt trauma –hard signs in 66 % of patients; mainly absent distal pulses / limb ischemia –in 95 % associated bone fracture or dislocation –CT angiography is study of choice – – Clinical presentation [USEMAP] •History – •mechanism of trauma •time interval •vascular symptoms • •prior vascular injury •anticoagulation therapy •Physical findings •hard and soft signs of vascular injury •ankle-brachial index • •Imaging •none •CT angiography •duplex ultrasound Clinical assessment [USEMAP] •Conservative (observation + surveillance) • •Vessel repair – –suture – –patch repair – –interposition graft / bypass – –endovascular repair • Treatment [USEMAP] •suture Vessel repair R:\DistCOVID\pics\003.JPG [USEMAP] •vein patch angioplasty Vessel repair R:\DistCOVID\pics\DSC_0079.JPG [USEMAP] •interposition graft Vessel repair R:\DistCOVID\pics\DSC_0009.JPG R:\DistCOVID\pics\DSC_0003.JPG [USEMAP] R:\DistCOVID\pics\FPBdistDistAna.JPG •bypass Vessel repair http://ars.els-cdn.com/content/image/1-s2.0-S0020138312002343-gr1.jpg [USEMAP] •temporary shunting Vessel repair Source: Cristián Salas, D. Trauma vascular, visión del cirujano vascular. https://doi.org/10.1016/S0716-8640(11)70481-3 https://ars.els-cdn.com/content/image/1-s2.0-S0716864011704813-gr1.jpg [USEMAP] •endovascular repair Vessel repair Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •endovascular repair Vessel repair Source: Ruhterford‘s Vascular Surgery 8th Edition [USEMAP] •Conservative (observation) • •Vessel repair –direct arterial repair (suture) –patch repair –interposition graft repair –bypass repair –endovascular repair – •Vessel ligation • •Amputation • Treatment [USEMAP] Thank you for your attention! R:\DistCOVID\pics\011.JPG [USEMAP]