Extremity Vascular Injuries

Popliteal Arterial InjuriesJoel Arudchelvam

Consultant Vascular and Transplant SurgeonTeaching Hospital Anuradhapura

Extremity Vascular InjuriesInjury to the vessels of the limbs

Common (at THA – 95% of vascular injuries)

Results in limb loss at times loss of life

Economic burden

Causes Road Traffic injuries – 60%Trap GunIatrogenic - 25%

Penetrating / SharpBlunt

Mechanism of disruption of flow at arterial level

Transection

Laceration

Contusion

Kink

Intimal flap

Clinical featuresHard signs

Active bleeding Thrills, Bruits Distal ischemia

Pain Pallor Pulse – absent Perishing cold Paresthesia /anaesthesia Paresis / paralysis

Expanding hematoma

Soft signs

Hematoma Injury close to a known neurovascular bundle

Injury to Popliteal VesselsCommon

Amputation rates are high.

Our experience At NHSL

Popliteal arterial injury – 32.5% of all injuries –commonest

Vascular injuryVessel Number Mechanism

Iliac artery 2 Blunt

Femoral artery 5 Iatrogenic – 3blunt (RTA) – 2

Femoral vein 1 Penetrating

Popliteal artery 5 blunt (RTA) -4

Popiteal vein 1 Penetrating

Tibial arteries 4 blunt (RTA)

Brachial artery 2 blunt (RTA)

Vascular injuryVessel Number Mechanism

Iliac artery 2 Blunt

Femoral artery 5 Iatrogenic – 3blunt (RTA) – 2

Femoral vein 1 Penetrating

Popliteal artery 5 (25%) blunt (RTA) -4

Popiteal vein 1 Penetrating

Tibial arteries 4 blunt (RTA)

Brachial artery 2 blunt (RTA)

AnatomyFixed

Proximally - Adductor Hiatus

Distally- Soleal Arch.

Collaterals – Not Very Effective

Supplies Blood To Heavy Muscle Load

HISTORY

Ligation – common practice during world War I /

II

Amputation Rate – 72.5%

Korean War / Vietnam Conflict -32%

Reasons givenLack of

Transport Sterility Conditions / Antibiotics Lack of Blood For Transfusion Anesthesia

Prevented Repair on a Large Scale.

PROGNOSTIC FACTORSTime Interval – Common Cause Of Limb Loss In Most

Series In Our Series – THA – 8.2 Hours

MechanismPenetrating Wounds Better Outcomes Than From Blunt

Injury Because Surrounding Tissue Damage To Be Less Severe. Difficult To Diagnose Because Associated Organ And

Tissue Injuries

Associated Injuries - Skeletal Injuries (Knee Dislocation , Popliteal Vein, Nerve, And Soft Tissue And Tendon)

Clinical featuresHard signs

Active bleeding Thrills, Bruits Distal ischemia

Pain Pallor Pulse – absent Perishing cold Paresthesia /anaesthesia Paresis / paralysis

Expanding hematoma

Soft signs

Hematoma Injury close to a known neurovascular bundle

Clinical features Hard signs

Active bleeding Thrills, Bruits

Distal ischemiaPainPallorPulse – absentPerishing coldParesthesia /anaesthesiaParesis / paralysis

Expanding hematoma

Soft signs

Hematoma Injury close to a known neurovascular bundle

Investigations Investigations

• Hard signs • urgent intervention

• Soft signs • Observe• Investigate

Investigations Imaging modalities

Duplex scan

AngiographyCT angiographyCatheter angiography

Investigations Imaging modalities

Duplex scanDifficult in trauma due to

pain, dressing, wound, patient not cooperating

AngiographyCT angiographyCatheter angiography

Investigations Arteriography

On table

TREATMENTSurgical RepairABCD / resuscitation

Repair as soon as possible

General anesthesia

Cleaning entire leg and be able to visualize the foot and palpate distal pulses.

Contra lateral limb – for venous harvest

Fasciotomy

Medial approach

Surgical RepairArterial Ends TrimmedBalloon ThrombectomySystemic And Distal

HeparinisationInterposition Graft

Unit Experience NHSL - 93.3% RSVG ANP– RSVG Upto Now

? Prosthesis InfectionLower Patency

Surgical Repairlateral injury – patch angioplasty

Our series – none underwentExtra-anatomic bypass

Severe soft tissue injuryOur series – none underwent

Skeletal fixationWhen to fix depends on the urgency of

vascular repair, generally skeletal fixation first is preferred

Compartment SyndromeReduced organ perfusion due to increased

compartment pressure.

Causes,Vascular injuryReperfusionHaematomacontusion

Compartment Syndrome

Treatment – Fasciotomy

Who should do it?

Reperfusion effectsLocal

Reperfusion injury – paradoxical death of already dying muscles after reperfusion

SystemicReperfusion syndrome;

Hypotension ARDS Lactic acidosis Hyperkalemia Kidney shut down

Reperfusion effectsMangement

Fasciotomy

Hydration Mannitol, allopurinolO2InotropesLigation of vessel if not responding to above

measures

Primary Amputation

Extensive soft tissue damage / multiple skeletal

fractures with bone loss “Mangled limb”

Summary

Vascular injury;

ResuscitateAssess viability and extent of injuryAssess need for fasciotomyEarly intervention and post intervention monitoringRehabilitation

Thank You