2. PERIPHERAL VASCULAR
INJURIES
Dr Latif Khan
PGR-1
Surgical Unit-1
Services Hospital Lahore

3. INTRODUCTION
 Peripheral injuries account for 80% of all cases of
vascular trauma.
 The lower extremities are involved in two thirds of
all patients with vascular injuries.
 90% of patients with vascular trauma are male
 Complex extremity trauma involving both arterial
and skeletal injuries is rare, comprising only 0.2%
of all military and civilian trauma, and only 0.5%-
1.7% of all extremity fractures and dislocations
 Combined arterial and skeletal extremity trauma
imparts a substantially higher risk of limb loss and
limb morbidity than do isolated skeletal and arterial
injuries.

4. CHALLENGES OF VASCULAR INJURIES
 most dramatic challenges facing trauma surgeons because
the repair is often urgent
 Gaining control of and reconstructing a major arterial injury
can be technically demanding.
 Limited exposure to vascular surgery in the general surgery
training curriculum,
 Major vascular trauma remains a crucial element of trauma
surgery, and every general surgeon must be prepared to deal
with them either definitively or using so-called bail-out
vascular damage control tactics.
 The fundamental difference between elective vascular
surgery and vascular trauma is the physiology of the wounded
patient

5. CONT’D…..
 A lacerated major vessel is typically only one component of the
multi trauma complex that includes injuries to other organs and
systems. These patients are often critically ill and rapidly
approaching a point of physiologic irreversibility. In these
dramatic clinical circumstances, the key to a favorable outcome
is maintaining correct priorities.
 The surgeon must keep in mind that although major hemorrhage
(typical of trunkal vascular injuries) is an immediate threat to the
patient's life, ischemia (commonly from peripheral arterial injury)
is a threat to limb viability, a much lower priority.
 Furthermore, although control of hemorrhage is usually
mandatory and life-saving, the reconstruction of an injured vessel
may be neither. As the injured patient is approaching the
boundaries of his or her physiologic envelope, a simpler,
sometimes temporary technical solution is often a safer option
than a complex and time-consuming re construction. In the
severely traumatized patient, the best technically feasible
definitive solution is not always in the patient's best interest

6. AETIOLOGY
 Gunshot wounds, 70-80%
of all vascular injuries
requiring intervention.
 Stab wounds (5-10% of
cases require intervention)
 Blunt trauma (5-10% of
cases): Presence of fracture
or dislocation increases the
risk.
 Iatrogenic injury (5% of
cases):
 Endovascular
procedures
 central line placement

7. INITIAL ASSESMENT
• Airway
• Breathing/ventilation
• Circulation
• Disability
• Exposure

8. Immediate treatment
• Control bleeding
• Replace volume loss
• Cover wounds
• Reduce
fractures/dislocations
• Splint
• Re-evaluate

9. HARD SIGNS
 Active or pulsatile hemorrhage
 Pulsatile or expanding hematoma
 Signs of limb ischemia and elevated
compartment pressure including the 5
"P's“:
 Pallor
 paresthesia
 pulse deficit
 paralysis
 pain
 Diminished or absent pulses
 Bruit or thrill is( present in 45% of
patients with an arteriovenous fistula)

10. SOFT SIGNS
 Hypotension or shock
 Neurologic deficit due to primary
nerve injury occurs immediately after
injury. In contrast, ischemic
neuropathy is delayed in onset
(minutes to hours).
 Stable, non pulsatile or small
hematoma
 Proximity of the wound to major
vascular structures ( Beware of bone
fr. ! )

11. COMPLICATIONS
 Delayed diagnosis and treatment may result in
 Thrombosis
 Embolization
 Rupture with hemorrhage.
 Risk factors for amputation include
 Elevated compartment pressure
 Arterial transection
 Associated open fractures
 The combination of injuries above and below the knee.

12. CHRONIC PRESENTATION OF
VASCULAR INJURY
 Arteriovenous fistulae
typically take months to mature and often
require surgical repair.
 Pseudoaneurysms
may resolve completely or grow over time
presenting months to years later. They may
cause neuropathy due to compression or
embolization , or they may present as a
growing pulsatile mass.
 Intimal tears and flaps
generally heal spontaneously.

13. CONTINUED…
 Segmental narrowing
 can present with diminished flow but intact pulses. This
injury may resolve spontaneously with fluids and rest, or
it occasionally may require surgical intervention.
N.B.
Approximately 10% of patients with non occlusive,
clinically occult injuries require repair within a month
of initial injury.
The remaining 90% of patients do not report symptoms
or see a physician for vascular problems during long-
term follow-up

14. Pathology
1. Spasm (or
compression)
2. Intimal injury
3. Transection
4. Intramural
haematoma
5. Pseudoaneurysm

15. Time
Pathophysiology
Ischaemia
Rapid resuscitation
Urgent exploration
Ischaemia
revascularisation
Tissue necrosis
Reperfusion injury
Compartment syn
? fasciotomy

16. MANAGEMENT

17. Immediate referral
• Hard signs
– Immediate (vascular)
surgery referral
– Early transfer to theatre
– Angiography
– Immediate exploration

18. Soft signs, other injuries
• Resusitate
• Apply compression
• Immobilise
• Reduce
• Reassess
– asymmetry
• Consult

19. INVESTIGATIONS

20.  Pulse Oximetry:
 A reduction in oximeter
readings from one limb,
as compared to
another is suggestive
of, but neither confirms
nor excludes a
significant vascular
injury

21.  Doppler Ultrasound
 Evalution of the affected extremity with hand held doppler
ultrasound should be performed routinely.
 Absent doppler signals need further examination- either
with angiography or duplex scan.
 Every doppler examination whether normal or abnormal
should be followed by Ankle Brachial Pressur Index(ABPI)
 An ABPI > 1 is normal
 Any measurement < 0.9 need
further evalution with
angiography

22.  Duplex Ultrasound
 Duplex can detect intimal
tears, thrombosis, false
aneurysms and
arteriovenous fistulae.
 Although it is limited by
operator dependent
 It has senitivity of 95% and
specificity of 99% with
overall accuracy of 98%

23.  Angiography
 Angiography remains the gold-
standard investigation for the further
investigation and delineation of
vascular injury. In most traumatic
injury settings, angiography is best
performed in the operating room,
with the surgeon exposing the vessel
proximal to the injury for control and
expediency
 Sensitivity 92-96%
 Specificity above 96%
 Accuracy 98%

24. CT ANGIOGRAM
 With the advent of improved CT scan, detection
of vascular injuries has greatly improved
 In fact CTA is becoming a viable
alternative to angiography
 Occasionally CTA be non-diagnostic due
to significant artifact from bullet
fragements or other foreign bodies
 Sensitivity 90-100%
 Specificity 98-100 %

25. MAGNETIC RESONANCE
ANGIOGRAPHY
 MRA is used less frequently in acute settings
 Metal implants such as cerebral aneurysm clips and
cardiac pacemakers preclude the use of MRI or it is
difficult to acertain whether the patient have such
devices in emergency situation
 Additionally MRI takes longer and needs more co-
operation from patient than CT.

26. TREATMENT

27. IMMEDIATE TREATMENT
Control of haemorrhag:
 Direct pressure over the
site of injury
 One individual manually
compress the site of
haemorrhage.
 Deep knife or gunshot
track → catheter
 If angiography is
performed prior to
surgery, it may be
possible to obtain
proximal control by
passing an angioplasty
balloon catheter into the
proximal vessel and
inflating the balloon

28. VOLUME RESUSCITATION
 Prior to haemorrhage control :
 Minimal fluids should be administered
 Raising the blood pressure will increase haemorrhage
from the vessel injury and dislodge any clot that has
already formed.
 Systolic blood pressure can be maintained at a level
that is appropriate for perfusion of the brain
 After:
 aggressive volume resuscitation to restore circulating
blood volume.
 Warm fluids -crystalloid, blood or clotting factors as
necessary -are administered to correct acidosis,
hypothermia and coagulopathy,

29. OPERATIVE TREATMENT

30. OPERATIVE PRINCIPLES
 The patient is positioned on the operating table to allow on-table
angiography of the affected region and distal perfusion.
 The entire affected limb is prepped and draped, as well as proximal
structures if control has to be gained more proximally. The hand or foot is
prepped so that intra-operative assessment of distal perfusion is
possible. An entire uninjured limb should also be prepped so that a vein
graft can be harvested as required. Often the person applying manual
compression at a bleeding site will have to be temporarily prepped into
the operative field until scrubbed personnel can take over.
 Gain proximal and distal control of injured vessel before investigating the
site of injury. It is achieved by a separate incision away from site of injury.
Direct exploration of site of injury lead to failure of haemostasis and
damage to adjacent tissue.
 Control is best achieved by passing slings twice around the vessels. If
clamps are used they should be applied with minimum force to obstruct
the flow of blood not racked closed to damage the vessel.

31. CONT’D…
 Once the injured vessel is identified, then debride devitalised tissue.
 Asses the inflow and outflow at both end of vessel, if inadequate pass
forgatry at proximal and distal end to disloge any thrombus.
 Instill heparinized saline at proximal and distal ends to locally
anticoagulate the vessel.
 Use an arterial shunt if temporizing is required or delay is anticipated,
e.g. to stabilize fracture.
 Obtain an on-table angiogram if suspecting further injury or chronic
disease.
 If necessary select a more distal site for anastomosis of bypass graft.
 Harvest vein for a conduit. Avoid synthetic material in a potentially
contaminated operative field.
 Perform appropriate bypass using inlay, end-to-end, or end-to-side
anastamoses.
 Consider fasciotomies.
 Co-ordinate wound closure and dressings with orthopaedic/plastics
teams. Ensure at least soft tissue cover of vessels.

32. POSTOPERATIVE CARE
 Standard limb observations with pulse check and
Doppler probe insonation if necessary. Record
ABPI at least once in postoperative period if
possible.
 Check for compartment syndrome, even if
fasciotomies were performed (they are sometimes
inadequate).
 Monitor urinary output.
 Consider heparin anticoagulation (with great
caution) or aspirin.
 Plan wound inspections with delayed closure (3-5
days) of fasciotomies/wounds with or without skin
graft.

33. LACERATION
 Direct Suturing: Small, clean,
transverse wounds to vessels
that involve only part of the
circumference can be repaired
with a direct suture technique
 Vein or synthetic graft:A vein
(or synthetic) patch may be
required where there is a larger
defect in the vessel wall where
direct sutuing may lead to
narrowing of the vessel lumen.
While vein grafts probably have
a longer patency, the graft
infection rates are the same for
both vein and synthetic grafts,
regardless of wound
contamination

34. TRANSECTION
 Direct suturing(end to
end anastomosis):The
ends of a transected
artery usually retract. If
the ends can be
approximated without
tension, a direct end-to-
end anastomosis repair
can be employed.
Mobilisation of the two
ends may be necessary,
and aided by division of
minor arterial branches

35. TRANSECTION
 Graft: Where
approximation of the
vessels is not possible, a
reversed vein graft, or
synthetic graft is used to
repair the defect. If there
is a concomitant vein
injury, this should usually
be repaired first, if
possible to avoid low-flow
thrombosis of the arterial
repair.

36. CONTUSION- THROMBOSIS
 Managed in a similar way to transection
 In either way ,
 Thrombectomy is Part of the Procedure

37. DAMAGE CONTROL SURGERY
 The principles of damage control surgery can be
applied to vascular trauma. The basic damage
control techniques are :
 ligation
 and shunting.

38. LIGATION
 There are very few vessels that cannot be ligated in extremis, at
varying risk to life and limb. The common and external carotid,
subclavian, axillary, internal iliac can be ligated with few
consequences.
 Ligation of the internal carotid artery carries a 10-20% risk of
stroke.
 Ligation of the exteral iliac artery, common femoral or superficial
femoral have a signficant risk of critical limb ischaemia following
ligation. Ischaemia is more likely if there is significant soft tissue
injury and distruction of supporting collateral circulation.
 Arteries of the celiac axis can be ligated but ligation of the
superior or inferior mesenteric artery will almost inevitably lead to
gut necrosis in the young trauma patient.
 Almost all veins, including the inferior vena cava, can be ligated
where necessary, with the consequence of lower limb oedema.
Ligation of the portal vein is possible but bowel oedema with
massive 'third-space' fluid losses will ensue..

39. SHUNTING
 Where there is a significant risk of limb
loss, or other serious consequence of
ligation, intraluminal shunts may be
employed to temporarily restore flow.
 shunts can be rapidly constructed out of
sterile intravenous tubing or chest tubes
for larger calibre vessels.
 Where there is a vascular injury
associated with a fracture, and there is a
risk of orthopaedic manoeuvers disrupting
an arterial repair, shunts may be
employed to temporarily restore flow to
an injured limb.

41. ASSESING THE PATIENT AND INJURY
 The anatomic extent of injury is revealed only when the
traumatized vessel is carefully explored and opened, specially
in blunt trauma. The entire length of the injured segment must
be precisely delineated at operation because leaving proximal
or distal intimal damage will result in early failure of the
reconstruction.
 The selection of the repair technique is heavily influenced not
only by the anatomic situation but also by the patient's
physiologic condition, associated injuries, and overall clinical
trajectory. The massively bleeding patient incurs a rapidly
increasing burden of physiologic insults.
 The marker of an irreversible (and lethal) physiology is a self-
propagating triad of
 Hypothermia,
 Coagulopathy,
 Acidosis.

42. CONT’D
 The hypothermia-coagulopathy-acidosis syndrome
effectively marks the boundaries of the patient's
physiologic envelope beyond which there is
irreversible shock.
 The operative management of a vascular injury
must therefore focus not only on restoration of
anatomic integrity but also, more importantly, on the
patient's physiologic envelope.
 The complexity and duration of the planned repair
must be inversely proportional to the physiologic
insult that the patient has already sustained.

43. MANGLED EXTREMITY
The mangled extremity is defined as injury that involves at least three of
the four major tissue systems of a limb, consisting of bone, soft tissue,
vessels, and nerves.
The decision to immediately amputate a severely wounded extremity
(rather than attempt salvage) is difficult and emotionally charged,
especially because vascular reconstruction is usually technically feasible,
being one of the less problematic aspects of the injury.
Several scoring systems have been proposed to predict the ultimate
fate of the limb based on the severity of injury and the patient's
associated injuries and comorbid factors. e.g mangled extremity
syndromes index (MESI), predictive salvage index(PSI), mangled
extremity severity score(MESS), or limb salvage index(LSI).
However, in practice, the decision to proceed with amputation hinges on
surgical judgment and the patient's specific circumstances. It is a team
decision and is made only after careful examination and consideration.
The decision is usually made in the operating room, where the extremity
is examined under optimum conditions
As a general rule, a totally interrupted distal innervation, extensive soft
tissue destruction, and bone loss exceeding 6 cm in length all portend a
grave prognosis for the limb.

44. MANGLED EXTREMITY SEVERITY SCORE
(MESS)

45. UPPER LIMB VASCULAR INJURIES

46. UPPER LIMB VASCULAR INJURIES
 Vascular injuries to upper extremity are relatively
common representing 30 to 40% of vascular trauma
in urban civilian settings
 Vessels of upper extremity are defined as those
coursing through axilla to wrist
 Injuries to subclavian artery are commonly reported
with axillery artery and their management is similar.
 The most commonly injured vessel in upper limb is
brachial artery with an incidence of 50%, followed by
radial and ulnar arter(25% each), least commonly
injuried artery being axillosubclavian vessels(3-5%).
 The most common mechanism of injury is penetrating
trauma.

47. AXILLO-SUBCLAVIAN ARTER INJURIES
 Accounts for 3-5 % of upper limb vascular injuries
 Aetiology
 Clinical presentation
 Hard signs
 Soft signs
o Diagnosis
Chest x-ray
CT angiogram
Conventional angiogram

48. MANAGEMENT

49. OPERATIVE EXPOSURE (TRAPDOOR INCION)

50. BRACHIAL ARTERY INJURIES
 Accounts for 50% of upper limb vascular injuries
 Clinical presentation
 Dignosis
 Management
 Operative exposure:The artery is exposed through
a medial arm incision in the groove between the
biceps and triceps muscles. The first structure
encountered in the neurovascular bundle is the
median nerve, which must be isolated and
preserved. If the brachial artery is exposed in the
proximal arm, the deep brachial artery is identified
and controlled at the lateral border of the teres
major muscle.

51. RADIAL OR ULNAR ARTERY INJURY
 Most isolated ulnar or radial artery injuries can be ligated.
 An ischemic hand (due to an incomplete palmar arch or injury
to both arteries) requires an arterial reconstruction.
 In the presence of associated bone and soft tissue injury, it is
often safest to begin the exposure of a radial artery proximally
at the brachial bifurcation and then proceed distally to the
injured segment.
 A lower medial arm incision is carried into the antecubital
fossa in an S-shaped configuration to avoid a longitudinal
incision across the antecubital skin crease. The bicipital
aponeurosis is divided to expose the brachial bifurcation, and
the radial artery is identified and isolated.
 Exposure of the ulnar artery in the proximal forearm is more
difficult because of the deeper location of the artery at this
level. It is found deep to the antebrachial fascia, between the
flexor carpi ulnaris and flexor digitorum superficialis muscles.

52. LOWER LIMB VASCULAR INJURIES

53. LOWER LIMB VASCULAR INJURIES
 Lower extremity injuries are defined as those occuring
below inguinal ligament.
 The most commonly injured artery is femoral artery.
 Injuries to common femoral artery, superficial femoral
artery, profunda femoris, and popliteal artery above and
below the knee represents the bulk of injuries requiring
revascularization procedures or surgical exploration.
 Because of blood supply to calf and foot with anterior
tibial artery, posterior tibial artery and peroneal artery,
one or two of these artery can be disrupted without loss
of distal perfusion and limb ischemia.
 Bleeding from these vessels can lead to elevated
compartment pressure causing compartment synd.,

54. POPLITEAL ARTERY INJURY
 Popliteal artery injuries result in limb loss more
often than any other peripheral vascular injury.
 Amputation rates as high as 20% especially from
blunt trauma.
 The collateral arterial system around the knee is not
well developed and is very susceptible to
interruption by significant trauma, making delays in
diagnosis and treatment particularly unforgiving

55. AETIOLOGY
 Posterior dislocation of the knee- 3 out of 5 pts
 Bumper to proximal tibia
Clinical presentation
Hard signs
Soft signs
Diagnosis
Doppler
Angiography

56. OPERATIVE EXPOSURE
 The proximal popliteal artery is exposed through an
incision along the anterior border of the sartorius muscle
above the knee. The deep fascia is incised, and the
sartorius is retracted, providing access to the popliteal
space between the semimembranosus muscle and the
adductor magnus tendon.
 The distal artery is approached through a medial
incision immediately behind the posterior border of the
tibia. The crural fascia is incised, and the popliteal space
is entered between the medial head of the
gastrocnemius and the soleus muscles. Wide exposure
of the entire length of the popliteal artery can be
achieved by joining the incisions and dividing the
tendons of the semitendinosus, semimembranosus,
gracilis, and sartorius and then dividing the medial head
of the gastrocnemius.

57. FACIOTOMY
 Lateral incision:A
longitudinal incision is
made about 2
fingerbreadths lateral
to the tibial crest,
beginning immediately
below the tibial
tuberosity and
extending to the ankle
 It decompress anterior
compartmen

58. CONT’D
 Medial incision
The posterior compartments are decompressed
through a separate medial incision placed
immediately posterior to the posterior edge of the
tibia, carefully avoiding injury to the long saphenous
vein. The superficial posterior compartment is
decompressed by incising the deep fascia.

59. THANK YOU