Statistics:

incidence of vascular injury: 1-2% of people, most often men 20 - 40 years (risk activities)

most often limbs (80%), then neck, less thoracic and abdominal cavity

Note: Injuries to the upper limb - less often the cubite and forearm arteries; lower limb injuries - often iatrogenic injuries

Mechanisms of vascular injury

- in peacetime - car accident, motor accident, fall from a height (work accidents, sports accidents, more rarely suicide, criminal trauma, more often within polytrauma)

- military trauma - few vascular traumas, but the cause of 80% of deaths, high-energy injuries, the most serious are torso injuries (thoracic and abdominal cavities)

3.1 Classification of vascular injuries:

open wounds (penetrating) - stabbing, cutting, gunshot (also secondary projectile, cavitation), iatrogenic

closed injuries (non-penetrating, non-bleeding, blunt) - contusion of the artery by impact, traction (stretching of the vessel) along bone structures in fractures, dislocations (popliteal artery in dislocation of the knee, a. axillaris in humeral dislocation etc.), indirectly by deceleration (car accidents, falls from a height) – may be followed by the development of intimal dissection or complete rupture of the artery

3.2 Symptomatology:

external bleeding (obvious)

internal bleeding (into body cavities, complicated stopping of bleeding)

ischemia - occlusion by intimal injury or arterial thrombosis in blunt injury with intimal injury and intact adventitia

formation of pulsating resistance (pseudo-aneurysm) or A-V fistula

3.3 Diagnostics

history - complicated in a traumatized patient

physical examination:

hard signs: pulsing external bleeding, increasing hematoma, absence of peripheral pulsation, murmur / vortex, ischemic limb + signs of hemorrhagic shock

so-called soft signs: wound near the vascular bundle, condition after bleeding or shock, stationary hematoma, weaker peripheral pulsation of the limb, injury to the nerve near the arteries

 - in case of vasoconstriction and thrombosis of the vessel, even larger injured vessels may be overlooked

penetrating injury – worse prognosis, delayed diagnosis, only according to signs of circulatory instability (development of hemorrhagic shock)

blunt non-penetrating injury - most often traumatic artery occlusion, peripheral ischemia, and possible vascular oppression with peripheral edema, nerve compression with pain

3.4 Vascular trauma in polytrauma:

Polytrauma - hypovolemic hemorrhagic shock, centralization of the circulation, involvement of vital organs, it is possible to overlook e.g. a blunt traumatic occlusion of the limb artery

Note in general: patient with polytrauma - bleeding and centralized (hypotension, hypothermia and peripheral hypoxia), with coagulopathy (all polytraumatized), with acidosis (in hypoxia)

3.5 Imaging methods - according to the type of injury, location, availability, time space

Ultrasound - limits (thoracic aorta only TEE), detection of indirect signs of injury (hemoperitoneum, limited hematoma), eFAST (extended Focused Assessment with Sonography for Trauma) in polytrauma - both hemithoraxes, mediastinum, abdomen and pelvis, presence of fluid (blood?) or air, sensitivity 50-80%

CT - the most effective, method of first choice, in polytrauma whole body CT with administration of a contrast agent for the diagnosis of parenchymal injuries, but can also be used for CTAG, when suspended for injuries of the thoracic aorta or coronary arteries and with ECG synchronization (to exclude movement artifacts); displayed arteries up to 1mm in diameter

DSA (angiography) - formerly the gold standard of diagnosis, today more of a therapeutic indication

MRAG - not a method of first choice, necessary time for examination; blunt injuries of the neck, limbs in children with pink ischemia (vascular injuries, but blood circulation is sufficient, without signs of acute limb ischemia)

3.6 Other diagnostic tools:

pulse oximetry, measurement of intramuscular pressure, etc. - marginal

Chest X-ray - indirect signs of vascular trauma – e.g. mediastinal enlargement, tracheal and esophageal dislocation on the left, left hemothorax and specific skeletal fractures

3.7 Iatrogenic arterial injury

- usual approach: Seldinger's method

direct injury of access artery X injury of remote vessel (dissection, occlusion)

·        central venous catheter (CVK)

·        arterial line (monitoring of blood pressure in the radial artery, femoral artery in unstable patients)

·        angioplasty (PTA, PCI)

·        venous / arterial / prosthetic thrombolysis

·        thermoablation of the heart, kidneys

·        introduction of caval filters

- injury with traumatologic tools (nail, wire, screw)

- trocar injury during laparoscopy (aorta), intervertebral disc surgery

- visceral vascular injury during abdominal surgery

3.8 Therapy of vascular trauma

Primary tretment: arterial compression (compression bandage, pneumatic cuff, pressure points against bone structures), arterial compression directly in the wound (especially carotid arteries), tourniquet, temporary vascular shunt insertion, correction of coagulopathy, complex shock therapy

The therapy is complex, most injuries can be reconstructed, BUT in a polytraumatized patient, a long revascularization procedure reduces the chances of survival - rules: Life before Limb + Damage Control Surgery - if the limb cannot be saved (evaluated by an experienced surgeon) - primary amputation

The therapy of vascular trauma comprises 2 phases: to stop the bleeding + subsequent reconstruction or ligation of the artery

3.8.1 Definitive treatment of vascular injury:

To restore flow OR close the bleeding vessel, rarely thrombolysis

direct communication of the anesthesiologist with the vascular surgeon of the patient's vitality

Surgical methods:

always dissection of an artery or vein above and below the site of injury, heparin, application of vascular clamps, evaluation of the condition of the injured vessel

a) perforating wall injuries (punctures, transverse incision) - direct suture with monofilament non-absorbable atraumatic suture

b) longitudinal perforating injury - direct suture (less suitable for the risk of artery stenosis), often autologous venous patch angioplasty

c) more extensive injuries - resection of the affected section of the vessel, bypass (in case of trauma preferentially with a venous graft due to the risk of infection), in situ or extra-anatomic reconstruction, as little as possible vascular prosthesis, event. silver and rifampicin impregnated prosthesis, arterial or venous allograft ...

d) blunt injuries - revision of the lumen of the entire affected section from longitudinal arteriotomy, event. arterial endarterectomy and venous patch, or resection of the affected area and replacement with a venous graft, in some cases ligation of the injured vessel

Notes on the surgical treatment of vascular injuries:

• anastomosis - without any tension, in a healthy arterial wall

• patch - in case of trauma preferentially venous graft (from the great saphenous vein and its branches, small saphenous vein, superficial veins of the upper limbs)

• tissue adhesives - easy application, but arterial dissection complicated in the future

• for major injuries it is necessary to rule out peripheral thrombosis with a Fogarty catheter of perioperative angiography

• use an artificial vascular prosthesis only in extreme cases, if autologous replacement is not available, antibiotic prophylaxis is always necessary

• in case of large tissue devastation, it is advisable to ligate the injured artery and use extra-anatomic routing of the bypass (outside the wound area)

• ligation of the artery is suitable only on the calf or forearm, where the remaining arteries provide sufficient blood supply, except for situations where we perform primary amputation

Endovascular methods:

- cooperation of a traumatologist, vascular surgeon and interventional radiologist, suitable treatment combination, possibly also as a temporary solution and after stabilization of the patient we will perform a definitive surgical treatment

- some localities unsuitable for endovascular treatment (distal superficial femoral artery, popliteal artery etc.)

Options:

• stent, stent graft, occluder implantation - eg blunt trauma of the aorta - percutaneously or from a dissected artery

• event. hybrid procedures - a combination of an endovascular approach and surgery

• embolization (microspheres, spirals) for bleeding from small blood vessels, or even traumatic AV fistula

• unstable patient - temporary occlusion of the lesion by a balloon catheter, bridging the time to stabilization of basic vital functions, then possible surgical treatment ...

Therapy - remarks:

Concomitant injuries:

• close anatomical relationship of arteries, veins and nerves (especially on limbs) often leads to associated structural injuries

• simultaneous vein injury - try revascularization - the same techniques as for arteries, proximal to the knee or elbow joint should be reconstructed, distal veins can be ligated

• in case of simultaneous bone injury, reduction and fixation of the fracture or dislocation should be performed first, then vascular reconstruction, in case of severe ischemia revascularisaton can be prioritized, or a temporary intraluminal shunt can be inserted

• nerve injury should be treated at the same time as the vascular structures

Conservative therapy of vascular injuries

in the case of some blunt vascular traumas - in case of a stabilized finding on the limb, antiplatelet or anticoagulation is used to prevent subsequent thrombosis, vasodilators are given – e.g. in children with pink ischemia (supracondylar fractures of the humerus with injury of the brachial artery, etc.)