Grand Rounds:

Vascular Trauma
Emily Lenart, DO
PGY-5
• Requires prompt recognition and management
• Most literature and evidence based
improvements come from the military/combat
casualty care
• Organized approach with well-planned and
implemented practice guidelines are necessary
• Requires both skill and experience in open
vascular techniques and the capability to perform
timely endovascular techniques
– Maintaining the skill level needed for open vascular
procedures has been proven a challenge
 Mechanism of Injury and
Pathophysiology
• Blunt or penetrating mechanism
– Blunt trauma – more diffuse injuries, along with
injury to vascular structures, can include injuries
to bone, muscle, nerves
• Affects not only major vessels, but also smaller vessels
that provide collateral flow – ischemia can be worsened
– Penetrating trauma – more focal injuries
• Split into projectile (GSW), stab wound, impalement
 GSW Classifications
• Penetrating GSW injury
– Kinetic energy – Energy = mass x velocity
– Classified as:
• Low velocity (<2500 ft/sec)
– I.e. hand gun
• High velocity (>2500 ft/sec)
– Military rifle
• Close range – within 6 ft
– Devastating injuries, lethal
• Intermediate range – 6-18ft
– Severe but less lethal
• Long range - >18 ft
– More mild
– Special considerations
• Shotgun wounds
– Proximity to gun barrel, gunpowder load, size of the shot
– Highly variable injury pattern
 Hemorrhage
• Vascular trauma – wide range of findings
– Life threatening hemorrhage to no overtly detectable findings
– Hemorrhage produced
• All vessel layers are disrupted or lacerated
– Intima, media, adventitia
• If bleeding contained, hematoma develops
• If bleeding not contained, exsanguination can occur
– Completely transected extremity vessels
• Can retract and constrict 2/2 spasm of muscular middle layer of vessel
wall
• Surrounding adventitia – highly thrombogenic
– Partially transected vessels
• Cannot retract and thrombose, causes more extensive hemorrhage
 Partial/complete occlusion
• Arterial thrombosis
– Occurs with damage to the underlying intima
• Exposes the media, causing local thrombosis which may
propagate/occlude the lumen or embolize
• Injured intima can prolapse into the lumen 2/2 blood flow dissecting
the layer which can partially or completely occlude the lumen
• Bone injuries
– External compression of nearby vessels
• Occludes flow, cause thrombosis
• Vessel spasm
– External trauma to vessel stimulates release of mediators that
constrict the vascular smooth muscle, causing decreased flow
 Sequela
• Can produce subacute, chronic, or occult injuries
– MC result in:
• AV fistula
– Penetrating injury to artery and vein in close proximity
– High pressure flow from artery will follow path of least resistance
to the low pressure vein
» Causes local tenderness, edema, regional ischemia from
“steal”, CHF if fistula enlarges
• Pseudoaneurysm
– Puncture or laceration of artery with bleeding into the
surrounding tissues
– Can enlarge and produce local compressive symptoms, erode into
adjacent structures, be a source of distal emboli
 Clinical Presentation
• Wide range of clinical manifestations
• Trauma pts who present in hemorrhagic shock
must be assumed to have a major vascular
injury until proven otherwise
• 5 anatomic areas to consider
– Head and neck
• Mostly external hemorrhage due to the small and tight tissues planes
– Chest
• Each hemithorax can accommodate lethal amounts of hemorrhage from
cardiac, pulmonary, or great vessel arterial and venous injuries
– Abdomen
• Aortic injuries, mesenteric vessel injuries
– Pelvis
• Iliac artery injuries
– Extremities
• External hemorrhage
• High association with bone fractures
– Supracondylar humerus fracture – brachial artery injury
– Posterior knee dislocation – popliteal artery injury
• Delayed presentation without initial findings
– Thrombosis of a previously partially disrupted but
initially patent vessel
– Distal emboli from an intimal tear of arterial wall with
platelet debris
– Rupture or expansion of PSA
• With such a broad range of clinical findings
– Assume vascular injury present with:
• All pts in hemorrhagic shock
• AND all pts with extremity fractures until proven otherwise
 Diagnosis
• ABCs per ATLS protocol
• Secondary survey
– Thorough history
• Hemorrhage sufficient to produce hypotension can be
followed by thrombosis
• Hx of hypotension, large amount of blood at scene, pulsatile
bleeding all point to significant vessel injury
– Physical exam
• Careful inspection of injured sites and wounds
• Complete sensory and motor assessment
• Pulse exam of each extremities
• Look for hematoma, bruit, or thrill
• Distal pulses absent or diminished
– Obtain wrist/ankle systolic blood pressure with
continuous wave doppler device and compared to
the uninjured side
– Difference in systolic blood pressure (>10mmHg)
• Indication of vascular injury
 Hard and Soft Signs of Vascular Injury
• Hard signs – take directly to OR • Soft signs – Can use vascular imaging to
• Hard signs further r/o need for OR
– Pulsatile bleeding • Soft signs
– Expanding hematoma – History of moderate hemorrhage
– Palpable thrill or audible bruit – Proximity fracture, dislocation, or penetrating
– Evidence of extremity ischemia wound
– Pallor – Diminished but palpable pulse
– Paresthesia – Level of peripheral nerve deficit in proximity
to major vessel
– Paralysis
– Wounds in proximity to extremity or neck
– Pain vessels in patients with unexplained
– Pulselessness hemorrhagic shock
– Poikilothermia
• Pt with soft signs of vascular injury
– Routing operative exploration not
recommended
• 5-30% incidence of morbidity, possible
mortality
• Low diagnostic yield
– These pts benefit from formal vascular
imaging
 Vascular Imaging
• CT angiography • Arteriogram
– Highly accurate – Can intervene
– Easily performed endovascularly
– Less time consuming, – Can be done in
less costly conjunction in the OR
– Obviates delay caused by – Some delay with
mobilizing angio suite mobilizing angio
– Cannot intervene
• US Duplex color flow
– Not used for acute assessment
• More for follow up of treated lesions or in the role of
nonoperative management of minimal vascular injury
 Minimal Vascular Injuries
and Nonop Management
• With widespread application of CT
angiography
– Increased detection of clinically insignificant
lesions
– Minimal vascular injuries
• Intimal irregularity
• Small nonocclusive intimal flaps
• Focal spasm with minimal narrowing
• Small pseudoaneurysm
• MC clinically insignificant minimal vascular injury
– Small, nonocclusive intimal flap
– Likelihood it will progress to occlusion or distal embolization is 10% or
less
– If progresses, will be early in post injury course
• Spasm
– Resolve promptly after initial identification
– If return of normal extremity perfusion pressure does not occur, will
require further intervention
• Small pseudoaneurysm
– More likely to progress to needing repair
– Followed closely with duplex color flow imaging
• AV fistulas
– Will always progress, should be promptly repaired
 Endovascular Management
• Important component of vascular trauma
• Best when used in a balanced approach when
supported by evidence, although all studies have
mostly involved atherosclerotic arterial disease
• For best outcomes, recommend “hybrid” OR
– Difficult to fund, train, and staff
– Can create “hybrid” ORs by using an OR large enough
for a C-arm, mobile cabinets, and an orthopedic
operating room table
 Endovascular Management of Torso
Vascular Injuries
• Intra-arterial catheter-directed embolization
– Solid organ hemorrhage
• Liver, spleen, kidney
• Retrograde endovascular balloon occlusion of the aorta
(REBOA)
– Exsanguinating abdominal hemorrhage in which an aortic
cross clamp in the chest is required
• Stent graft management of great vessel injuries
– Need lifelong surveillance with CT scans
– Most effective in those torso injuries that are surgical
inaccessible with the potential for significant hemorrhage
in stable pts
 Endovascular Management of
Cerebrovascular Vascular Injuries
• Endovascular techniques offer advantages in
anatomic regions that are difficult to access
– Can place catheter-directed coils, balloons, or
hemostatic agents in the injured carotid or
vertebral artery for control
– Stent placement originally appeared less effecting
than anticoagulation in partially occluded injured
without associated hemorrhage
• Role of stents is still being defined
• Requires significant expertise and experience
 Endovascular Management of
Extremity Vascular Injuries
• Using stent grafts in extremity vascular injuries
becoming more commonplace
• Long-term results have not been documented
• Best for:
– Hemodynamically stable patients with contained
hemorrhage, difficult to access proximal
subclavian or iliac artery injuries
– Injuries distal to these vessels – open technique
with autologous vein interposition grafts still the
gold standard
 Open Surgical Management
• Successful operative management of vascular
injuries requires a systematic and well prepared
approach
• ABCs under ATLS
– Blood products to not be given until hemorrhage is
controlled unless the pt is profoundly hypotensive
– If BP is <80-90 systolic, volume infusion should be
given to stabilized the pt to be transported to the OR
without delay
• Restoration of a BP to 90-100 systolic is sufficient
• “Permissive hypotension”
• Give preop antibiotics
• Tetanus toxoid if penetrating injury
• Special consideration
– Isolated extremity injury without significant
hemorrhage should be given 5000u heparin
• Avoid in pt with torso injuries, head injuries, or multiple
extremity injuries
• Most commonly omitted step – failure to
document preop extremity neurologic exam
• Treatment of extremity vascular injuries
– Damage control vs definitive repair
• Depends on the clinical status of the pt
• Decision should be made as soon as possible
• Specialists should be calls asap as well to coordinate
operative efforts
 Vascular Exposure and Control
• Place pt on fluoroscopy-capable operating
table
– Allows the adjunct of endovascular techniques as
needed
• Provide a generous sterile field
• Extremity injuries
– Prep uninjured extremity should autologous vein
be required
• First priority is PROXIMAL control
– Thoracotomy with aortic clamp
– Intra-abdominal
• Clamp at just below the aortic hiatus
– REBOA
• Temporary proximal thoracic aortic control in the presence
of the high intra-abdominal aortic artery injury
– Proximal extremity injures
• First incision site is chosen to give fastest exposure of inflow
vessels for clamping
• Hemorrhage control
– DO NOT FORGET ABOUT DIRECT PRESSURE
– Tourniquet
– Insertion of foley catheter, fogarty balloon
• Generous incision for adequate exposure
 Vascular Damage Control
• Rapid control of hemorrhage
• Must decide between time consuming
vascular repair vs temporary measures that
achieve control
– Ligation
– Placement of intraluminal shunts
• Ligation
– Must have adequate distal collateral flow
• Subclavian, innominate arteries
• Celiac artery
• IMA
• Proximal injuries of the axillary artery
• Distal injuries of the radial or ulnar artery
• Tibial artery
• Peroneal artery
– Avoid ligation
• SMA
• Brachial artery
• External iliac artery
• SFA
• Popliteal artery
• Any concern for distal perfusion compromise
– Place intraluminal shunt
• Condition of patient determines timing of definitive repair
– Hemorrhage must be controlled, coagulopathy/acidosis corrected, temperature normalized
Choice of Repair and Graft Material
• Vessel injuries unable to be repaired with a
primary end-to-end anastomosis
– Requires interposition graft
– Most desirable
• Autologous great saphenous vein harvested from an
uninjured leg
• PTFE grafts – improved outcomes, even in contaminated
wounds
– Early rates of patency proximal to the popliteal artery and in the
brachial artery are similar to the vein
– Distal to those levels, PTFE is far inferior to vein
– PTFE <6mm should not be used
– Vein/graft should be covered
 Intraoperative Imaging
• Recommend intraoperative radiographic
imaging
– Completion arteriography after vascular repair will
note significant findings in 10% of patients
 Role of Fasciotomy
• MC cause of preventable limb loss
– Failure to perform adequate fasciotomy after
revascularization of an acutely ischemic limb
• MC indication for fasciotomy
– Calf compartment syndrome
– Compartment syndrome
• Manifested immediately or delayed up to 12-24 hours after
reperfusion
• 1st clinical finding
– Loss of light touch sensation in the distribution of the nerve in the
compartment
• Early diagnosis with compartment pressures
– Nml 0-9 mmHg
– Compartment syndrome >25 mmHg
 Role of Immediate Amputation
• Very limited role
• Considered in pt with extensive soft tissue loss, neurologic
deficit, extensive fractures, and vascular injuries, and also
with the above along with life threatening torso injuries
– Scoring systems have not proving helpful in decision making
• Evaluate collaboratively
• May be best to proceed with damage control with shunting
and second look in 24 hours if able
• If deemed necessary, recommend extensive photo
documentation to help discussion with pt and family later
on
 Errors and Pitfalls
• Most common errors include:
– Lack of recognition of extremity vascular injury in a pt with
multiple torso injuries
– Lack of recognition and treatment of compartment syndrome
– Failure to adequately expose and control torso injuries to the
great vessels
– Failure to recognize need for damage control and rapid
completion of operation in an unstable pt
• Three most common factors that generate errors
– Fatigue
– Distraction
– Familiarity
 Specific Injuries
• Head, Neck, and
Thoracic Outlet
– Principles of
management pf
penetrating trauma to
this region are based on
location within 3 zones
of the neck
• Stable pt
– Zone 1/3 – Vascular
imaging
– Can do same for Zone 2,
however if pt is unstable or
has hard signs of injure, pt
goes to OR for exploration
– Zone 1/3 – amenable to
endovascular techniques
• Unstable pt
– Goes to OR for exploration
• Blunt trauma
– Often occult and
asymptomatic
– Most common with:
• Displaced midface fractures
• Basilar skull fractures with
carotid canal involvement
• CHI with diffuse axonal
injury and GCS <6
• Blunt neck trauma from
hanging or seat belt
injuries
– Pts who fulfill the Denver
criteria should undergo
CTA of neck
• Treatment
– Anticoagulation if no
contraindication
– ASA only other
alternative in pt who
cannot be safely
anticoagulated
– Injury grades II-V may
require operative or
endovascular
intervention
• Injuries to the thoracic
outlet
– Difficult to expose and control
– Unstable pt
• To OR
– Stable pt
• CTA vs angiography
• Subclavian/axillary arteries
– Very fragile
• Endovascular balloon
occlusion useful adjunct
• Incision
– Supraclavicular incision
• Distal subclavian artery
– Sternotomy
• Proximal innominate artery
• Proximal right subclavian
artery
• Proximal right carotid artery
– Thoracotomy
• Proximal left subclavian artery
– Combo of any
 Intrathoracic Great Vessels
• Intrathoracic Great • Incision
Vessels – Sternotomy
– Aorta • Ascending aorta
– Superior and Inferior Vena • SVC/IVC
Cava • Pulmonary arteries/veins
– Pulmonary arteries and – Left or right anterolateral
veins thoracotomy
• Pulmonary arteries/veins
• Cause death usually at • Left posterolateral
time of injury thoracotomy – descending
aorta
– Clamshell
• Most versatile
• Blunt injury to the
intrathoracic great vessels
– MC blunt thoracic aortic
injury (BTAI)
• High energy blunt trauma
• Aorta injured at locations
where it is fixed
– Root of aorta
– Ligamentum arteriosum
– Diaphragmatic hiatus
– Majority die at scene – 85-
90%
• Initial management
– BP control
• Esmolol
– Short acting beta blocker
• Titrate to BP <110 mmHg
• HR <100
– Addressing associate injuries
• Most require repair
– Delayed fashion once pt is
stabilized
– Early repair – increased
mortality
• Open (spinal protective with
bypass) vs endovascular
 Abdominal Vascular Injury
• Laparotomy
– Supraceliac control of aorta
– Exposure of aorta
• Left medial visceral rotation
– Stab wounds – primary repair
– GSW – patch, interposition graft
– Exposure of IVC
• Right medial visceral rotation
– Anterior/lateral injuries – repair primarily as long as there is no
narrowing >50%
– Posterior injures – repaired through anterior, or mobilized after
ligating and division of lumbar veins
– Complex injuries – patch, interposition graft, shunting with
delayed reconstruction, or ligation
• Right common, external,
and internal iliac arteries
and veins
– Exposed by mobilization of
cecum
• Left common, external,
and internal iliac arteries
and veins
– Exposed by mobilization of
sigmoid
• Common and external
iliac arteries
– Often require synthetic
interposition graft
• Internal iliac artery
– Can ligate
• Simple injuries can be
repaired primarily
• Complex repairs of
destructive injuries
should not be attempted,
and the veins should be
ligated
• Mesenteric vessel injuries
– Celiac trunk
• Wide left medial visceral rotation that mobilizes the
spleen and tail of pancreas
• Injuries should be ligated
• SMA
– Management based on Fullen
Classification
– Zone I/II
• Exposed and repaired through
lesser sac with division of
gastrocolic ligament
– Zone III/IV
• Refection of transverse colon
and mesentery
– All injuries (except distal Zone
IV) should be repaired
primarily, end-to-end
anastomosis, or interposition
graft of reversed saphenous
vein
• IMA may be ligated if there is sufficient
collateral flow
• SMV should be repaired when possible
– Able to ligate when pt is in extremis
• IMV can be ligated if required
• Portal vein injuries • Should be repaired
– Right medial visceral primarily or
rotation reconstructed
– Extensive Kocher • Shunting or delayed
maneuver
repair if necessary
– Must mobilize the CBD,
hepatic artery • Ligation only for pt in
extremis
• Renal injuries
– Exposure on either side
through medial visceral
rotation
– Gerota fascia is opened
and kidney is brought into
the wound
• Repair renal veins with:
• Repair renal arteries with:
– Primary repair
– End-to-end anastomosis
– Vein patch
– Interposition graft
– Nephrectomy
• Must confirm normal
contralateral kidney
– Primary repair
– Ligation
• Ligation of right renal vein
will require nephrectomy
 Upper Extremity
• Penetrating trauma
– Hemorrhage
• Blunt trauma
– Thrombosis
• Diagnosis made through physical
exam alone
• Penetrating trauma with obvious
concern for vessel injury, blunt
trauma with hard signs
– Goes to OR for exploration
• No role for endovascular techniques
for brachial or forearm vessels
• Open technique with
repair/thrombectomy still gold
standard
– Repair primarily
– Interposition graft with vein or PTFE
graft
• Veins can be ligated unless there is
extensive soft tissue injury and loss of
venous collaterals
– Venous reconstruction should be
considered
• Injuries often associated with
significant musculoskeletal,
neurologic, and soft tissue injuries
– Require multidisciplinary approach
• Surgical exposure requires generous incisions
– Brachial artery
• Longitudinal incision along the medial aspect of the
upper arm over the groove btwn the triceps and biceps
• May be extended distally through a “S” shaped incision
across the antecubital fosse from ulnar to radial aspect
and onto the forearm
– Radial or ulnar arteries
• One must be repaired
– Ulnar artery larger in proximal forearm
– Distal repair should be through the larger vessel
 Lower Extremities
• Penetrating injuries more common
• Blunt trauma difficult to diagnose and treat
• Common femoral artery
– Longitudinal incision overlying its course from
the inguinal ligament inferiorly for 8-12 cm
• SFA
– Longitudinal groin incision
• Mid SFA
– Oblique incision over the sartorius muscle
– Junction of SFA/popliteal artery can be
exposed by extending the oblique incision
• Popliteal artery
– Medical incision at the knee joint with
division of the medial head of the
gastrocnemius muscle and the
semimembranosus and semitendinosus
muscles
• Distal popliteal artery
– Incision along the posterior margin of the
tibia
• Repair of LE injuries
– Usually require interposition graft
• Especially true for popliteal artery
– 1st choice – contralateral saphenous vein
– For common femoral – PTFE acceptable, but should not be used for
below-knee popliteal arteries
• Injuries below popliteal artery at the level of the tibial vessels
– Ligation if two of the three calf vessels are patent and there is
sufficient collateral flow
– If posterior/anterior tibial artery injured/occluded, will need repair as
peroneal not sufficient
• Damage control techniques with shunting and delayed repair
utilized with major torso injuries and hemodynamic instability
 Post op Management
• Close monitoring of changes in vascular exam
– Vital signs
– Distal extremity pulses
– Doppler signal
– Capillary refill
– Neurologic examination of injure extremity
• Failure of graft repair 2/2 thrombosis
– MC within 48 hours of repair
• Monitor for compartment syndrome
• Any new post op neurologic change
– Prompt assessment of both patency of vascular repair and
compartment pressures
 Outcomes and Follow-ups
• MC cause of amputation • Eval for:
after vascular injury – Aneurysmal dilation
– Direct insult from direct – Segmental stenosis of vein
trauma to the nerve or grafts
ischemia – Venous insufficiency from
• Functional outcome venous ligation
– Related to severity of – Thrombosis of
associated injuries of muscle, pseudoaneurysm
bone, and nerve – AV fistula
• Yearly follow up • Pulse exam
recommended • Imaging with doppler when
indicated
• CTA/angio if complication
suspected
• Torso vascular injuries
– Relatively few late complications
– If venous interposition graft used, follow with
regular noninvasive testing and CTA if indicated
– Aortic/iliac arterial repairs
• Follow for symptoms of arterial occlusive disease
– Upper/lower extremity claudication
– Synthetic grafts used
• Pt should be counseled on need for antibiotics for
dental work or invasive procedures
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