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vasc trauma

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by

Michael Costanza

on 1 March 2016

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Transcript of vasc trauma


Small areas
Injuries on borderline
Skin entry does not always correlate with underlying injury
Unnecessary Zone 2 explorations
Drawbacks of Zone Algorithm
(cc) image by nuonsolarteam on Flickr
Superficial
Hard Signs
Stable
No major injury
Selective Approach
Does not penetrate platysma
External bleeding
Expanding hematoma
Neuro deficit
No hard signs
Diagnostic imaging

Neuro status
No deficit: repair
Severe deficit: ligate
Backbleeding?
Yes: repair
No: ligate
Nature of injury
Simple; common carotid: repair
Complex; internal carotid: ligate
Carotid Injury: Repair vs. Ligate

Non-operative
Blunt, minor injuries
In conjuction with anti-coagulation
Limited experience with penetrating; more risk, higher likelihood of significant injury
Carotid stents
Used for inaccessible lesions
Reasonable results in limited experience
Verterbral artery embolization
Preferred treatment for stable patients
Alternatives to Surgery
Nerves
Hypoglossal: anterior to carotid bifurcation
Facial: superficial to styloid process
Glossopharyngeal: deep to stylohyoid/pharyngeus

Carotid
Simple: primary repair
One surface: patch (vein)
Circumferential: bypass (great saph. vein)
Internal jugular vein
Stable: repair (primary)
Unstable: suture ligate
Surgical Repair

Innominate & left common carotid:
Proximal: sternotomy
Distal: neck/supraclavic. incision
Left subclavian
Proximal: left thoracotomy
Distal: supraclavic; trap door; clavicle resection
Base of neck injuries
I
II
III
Zone Algorithm
Surgical
exploration

Incision anterior to SCM
Cephalad extension behind earlobe
Avoid marginal mandibular nerve
Access to: carotid sheath, cervical esaphagus; pharynx
Retract IJ laterally; suture ligate facial vein
Proximal control
Divide omohyoid muscle
Chest prepped in; sternotomy
Distal control
Retract hypoglossal n.; divide occipital artery & ansa cerv.
Other maneuvers
: nasotrach intubation; mandible sublux./resection; divide stylohyoid ligament; styloglossus &stylopharyngeus muscles

Angiographic embolization
Preferred treatment
Surgical exposure
Proximal: lateral to IJ or supraclavicular incision
Mid: approach artery in bony foramina; use rongeur; proximal ligation and balloon
Distal: divide SCM at origin; protect spinal accessory n.
Vertebral Artery
What are the anatomic zones of the neck?
How do they affect management?
Penetrating Neck Injury
A 65-year-old woman was the driver in a high-speed motor vehicle crash. The clinical examination is unremarkable, except for a seatbelt sign on the left side of the neck.
Uncommon findings (good for screening)
Bleeding from ears, nose, mouth
Expanding cervical hematoma
Horner's syndrome
Basilar skull fx involving carotid canal
Carotid bruit in pt <50
Cerebral infarction
Common findings (too sensitive)
Mechanism (hyperextension, rotation, flexion)
Neuro findings with negative CT
Diffuse axonal injury
Near hanging
Seat belt abrasion / soft tissue injury
Cervical vertebral body fracture
Screening for Blunt Carotid Injury
Diagnosis: Angio or CTA
Not Duplex or MRA
Grade
Description
Treatment
I
<25% narrowing
Anti-coagulation
II
>25% narrowing
Anti-coagulation
III
Pseudoaneurysm
Stent if enlarging
IV
Thrombosis
Anti-coagulation
V
Transection
Anti-coagulation (stent)
Inaccessible Blunt Carotid Injury
Surgical repair for Grade II-V accessible injuries
Anti-coagulation: heparin or aspirin; 3-6 mos.
A 19-year-old man with gunshot wound to zone II of the left neck. Systolic blood pressure of 80 mm Hg, GCS 8, and no localizing neurologic signs. In the OR, near-complete transection of the left internal carotid artery, just above the bifurcation of the common carotid artery.
A 26-year-old man with a stab wound to zone I of the neck, just above the middle of the clavicle. His blood pressure is 70/50, HR is 124, and there is continuous dark bleeding from the wound. Chest x-ray shows a large left hemothorax. The radial pulse is palpable.
A 62-year-old, previously healthy woman is involved in a high-speed motor vehicle crash. She is hemodynamically stable, the GCS is 14, and there are no neurologic deficits. She has some bruising and a stable, large hematoma in zone III of the left side of the neck. CT scan of the head, face, chest, and abdomen were normal and a CT angio of the neck showed a large intimal tear of the left internal carotid artery just below the base of the skull.
A 28-year-old man has a through-and-through gunshot wound of the medial thigh.
Active hemorrhage
Expanding hematoma
Bruit or thrill
Absent distal pulses
Distal ischemia
Hard Signs
Proximity injury
Peripheral nerve deficit
Hemorrhage at scene
Non-expanding hematoma
Reduced / unequal pulses
Soft Signs
Ankle Brachial Index
87% Sensitive; 97% Specific
Injury to non-axial artery
Profunda
Non-occlusive injury
Intimal flap
Transection held in place with connective tissue
AV Fistula
Normal ABI with Injury
Musculoskeletal stabilization
Temporary shunt
Conduit: contralateral great saphenous vein
Distal injury: ligate artery if flow adequate
Venous injury: repair if possible; ligate proximally if necessary
Extremity Vascular Trauma: Surgery
How will you approach the evaluation and management of a patient with a painful, swollen lower leg 12 hours after successful revascularization of a popliteal artery injury?
*RW Kendall, et al. J Trauma 1993;35:875
Popliteal artery fixed proximally & distally behind joint
Ligamentous injury and posterior dislocation can cause intimal tear which is thrombogenic: subsequent thrombosis
Incidence of injury as high as 40%
Approach
ABI adjunct to physical exam in asymptomatic patients*
Low threshold for other imaging exams; unclear role for screening angiography
Mechanism
Knee Dislocation
Intimal injuries
Shorter than 2mm; <50% lumen: anti-plt and observe
Anti-coagulation
No definitive data; may improve patency
Endovascular
Not standard of care (young patients; minimal data)
Timing: ortho vs. vascular
Need stable platform
Role for shunts
Mangled extremity
Amputation: individualize decision; multi-disciplinary
Extremity Vascular Trauma Issues

A young woman was hit by a car as a pedestrian. Her left lower leg has a severe open displaced tibial fracture with extensive soft tissue disruption, absent distal pulses, and a cold pale foot.
You are in the operating room to repair documented injuries to both the popliteal artery and vein.
Bleeding is not from aorta
Treat abdominal or intracranial hemorrhage first
Control BP
SBP <100; HR <100
use esmolol first then nitroprusside
Blunt Aortic Injury
Clamp between left carotid and subclavian
Distal aortic perfusion
Heparinize
Less risk for spinal ischemia vs. clamp and sew (more time)
Interposition graft
Open Repair
A 25-year-old man arrives in the emergency room with a gunshot wound in the left lower quadrant, a systolic blood pressure of 80 mm Hg, and a wavering pulse in the left common femoral artery.
A 65-year-old patient is involved in a high-speed motor vehicle crash. He is found to have a widened mediastinum on supine anteroposterior chest radiography and is hemodynamically stable.

Proximal Control
Left visceral rotation
Divide left crus
Distal thoracic aorta
Distal control
May ligate & divide celiac axis
Repair
Aorta: primary vs. patch vs. graft
Celiac: OK to ligate
Proximal SMA: bypass from distal aorta; protect from pancreatic injury
SMV: ligate; resuscitate; 2nd look laparotomy
Midline; Supramesocolic

Proximal Control
Same as AAA: transv. colon superior; small bowel to right; below left renal vein
Distal control
Aortic bifurcation
Watch for IMA
Aortic repair
Primary vs. patch vs. graft
Cover with omentum
Midline; Inframesocolic

Exposure
Right medial visceral rotation
Kocher maneuver
Control
Local clamps; sponge sticks
Proximal & distal clamps poorly tolerated
Repair
Primary; roll for posterior injury
Damage control: ligate, resucitate, lwr ext fasciotomy, compression
Difficult anatomic areas
Confluence of iliac veins
Junction of renal veins & IVC
Injury to IVC

Blunt mechanism with intact kidney: do not explore
Penetrating injury: repair vs. nephrectomy
Control options:
Central: both arteries; left renal vein
Peripheral: elevate kidney and clamp hilum
Zone 2 Injuries

Arterial: nephrectomy common if contralateral kidney functional
Intimal injury: observe and anti-coagulate if non-obstructive; endovascular possible
Blunt occlusion: consider repair if <6 hours
Vein: ligate (always need nephrectomy on right)
Renal Vascular Injury

Proximal control: distal aorta and IVC (eviscerate small bowel to right; incise retroperitoneum)
Distal control: external iliac proximal to inguinal ligament
Still have internal iliac backbleeding
Iliac art. ligation: 40-50% amputation; repair or shunt if possible
Zone 3 Injuries

Vascular injury and enteric contamination: consider ligation and extra anatomic bypass
Internal iliac artery: OK to ligate bilaterally (young pts)
Iliac vein injuries: repair if possible
Iliac vein ligation: anti-coagulate; compression; leg elevation
Zone 3 Issues

Pringle maneuver before entering hematoma
Separate CBD before definitive repair
Common hepatic artery can be ligated
Cholecystectomy if right hepatic ligated
Portal vein: repair vs. ligate; may have to divide pancrease for proximal exposure
Porta hepatis

Non-expanding hematoma: pack and leave undisturbed
Active hemorrhage: compress liver over hematoma; Pringle; get blood in room
Direct repair (mobilize liver); may need atriocaval shunt or liver isolation
Retrohepatic area
Imaging
Vascular Trauma
1.What surgical exposure should be used to obtain proximal control of the left subclavian artery?
a.Median sternotomy
b.Left infraclavicular
c.Left thoracotomy
d.Left sternoclavicular dislocation
2.What is the preferred treatment for a hemodynamically stable patient with a penetrating injury to the right vertebral artery?
a.Anti-coagulation and observation
b.Angiographic embolization
c.Interposition bypass
d.Cervical exposure and ligation
3.What artery can sustain a significant injury or occlusion without a significant decrease in the ankle brachial index (ABI)?
a.Common femoral
b.Superficial femoral
c.Popliteal
d.Profunda
4.What is the most likely etiology of hypotension in a patient who sustained the following injuries from a motor vehicle crash: cerebral contusion; thoracic aortic transection; splenic laceration; humerus fracture?
a.Hemoperitoneum from splenic laceration
b.Hemothorax from aortic injury
c.Spinal shock from closed head injury
d.Baroreceptor dysfunction
5.What type of retroperitoneal hematoma should be treated with surgical exploration and repair?
a.Zone 1 due to blunt trauma
b.Peri-hepatic due to penetrating trauma
c.Zone 3 due to pelvic fracture
d.Zone 2 due to gun shot wound
How do you manage a patient with a gunshot wound to the upper arm?
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