UC UC SF SF Vascular Trauma @ SFGH: Practical Lessons Learned Shant M. Vartanian, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery Priscilla and Mark Zuckerberg San Francisco General Hospital and Trauma Center VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Disclosures: Vascular Trauma • None • Blunt aortic injury • Balloon occlusion • Cerebrovascular trauma • Pelvic vascular injuries • Iatrogenic Trauma • Blunt vs. Penetrating injuries • Endovascular treatments • Combined orthopedic and vascular injuries of the limbs VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 1
UC UC SF SF Patterns of Orthopedic Vascular Combined Skeletal and Vascular Trauma Injuries • Not just limited to the battlefield! • Clavicle fracture subclavian artery • Proliferation of motor vehicles • Shoulder dislocation axillary artery • Distracted pedestrian safety • Supracondylar humerus fx brachial artery • Urban violence and terrorism • Elbow dislocation brachial artery • Fall from standing in the elderly • Pelvic fracture gluteal arteries • Sports injuries • iliac arteries • Femoral shaft fx femoral artery • ~3% of long bone fractures are associated with arterial • Distal femur fracture AK popliteal artery injury • Knee dislocation BK popliteal artery • Blunt trauma predominant mechanism in civilian series • Tibial shaft fx tibial arteries VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Patterns of Orthopedic Vascular Patterns of Orthopedic Vascular Injuries Injuries • Distal femur fracture Above knee popliteal artery • Clavicle fracture Subclavian artery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 2
UC UC SF SF Patterns of Orthopedic Vascular Patterns of Orthopedic Vascular Injuries Injuries • Femoral shaft fx SFA • Supracondylar humerus fx brachial artery • Tibial shaft fx tibial arteries • Elbow dislocation brachial artery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Patterns of Orthopedic Vascular Patterns of Orthopedic Vascular Injuries Injuries • Types of injury • Knee dislocation popliteal artery - Spasm - Intimal flaps - Subintimal hematoma - Laceration - Transection - Thrombosis/Occlusion - A-V fistula Some require treatment, some do not • VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 3
UC UC SF SF Case Presentation Case Presentation • 58 year old window washer falls 11 stories during morning rush hour commute VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Case Presentation Case Presentation: Plain films • Aggitated, tachycardic and hypotensive pre transport • HR 100 SBP 90 • GCS 13 (disorientation) and unable to move RLE • FAST negative • Right arm tourniquette applied in field • Access including femoral sheath • Intubation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 4
UC UC SF SF Case Presentation Case Presentation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Case Presentation Case Presentation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 5
UC UC SF SF Case Presentation Case Presentation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Case Presentation Case Presentation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 6
UC UC SF SF Case Presentation Case Presentation • CT Head/Chest/Abd/Pelvic • Discharged to rehab day #28 neurologically intact and full function of his right hand • Pelvic ex-fix - Multiple pelvic injuries • Humerus repair - Transverse process spine fractures - Kidney and liver laceration • Interposition saphenous vein to repair brachial artery - Sternal fracture • Thrombectomy of radial artery - Bilateral rib fractures, clavicle fracture - Pulmonary contusions • Transposition of radial artery into brachial artery graft - Bilateral subdural hematoma • Forearm fasciotomy - PE VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Complex Extremity Trauma Initial Management • Resuscitation and management of all life-threatening • Lack of Class I evidence guiding management injuries takes priority over extremity problems - Rational approach Life over limb - - Best available evidence - Expert consensus opinion • Control of active extremity hemorrhage - Direct pressure • American College of Surgeons Committee on Trauma - Tourniquet • Eastern Association for the Surgery of Trauma (EAST) - Direct clamping of visible vessels practice guidelines - Blind clamping in wounds is discouraged and potentially harmful VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 7
UC UC SF SF Hard Signs of Vascular Injury Hard Signs of Vascular Injury Up to 75% of hard signs are not due to vascular injury • Active hemorrhage • - Soft tissue or bone bleeding • Large, expanding or pulsatile hematoma - Traction of intact arteries with pulse loss • Bruit or thrill over the wound - Skeletal deformity with pulse loss that corrects with traction Distal Ischemia (the 5 P ’ s) • Absent distal pulses - Compartment syndrome • • Hard signs mandates ruling out vascular injury Applebaum R, Yellin AE, Weaver FA, et al. Role of Routine Arteriography in Blunt Lower Extremity VASCULAR SURGERY • UC SAN FRANCISCO Trauma. Am J Surg 160: 221-225, 1990. VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Imaging Asymptomatic Arterial Injuries Absence of hard signs in an injured extremity excludes a • • Imaging with hard signs can avoid unnecessary limb surgically significant vascular injury as reliably as any exploration in up to 70% of cases imaging modality • Most patients with hard signs are going to the OR - Non occlusive vascular injuries with a benign history may occur - Vascular C arm table vs hybrid room - Ipsilateral micropuncture sheath w/ side arm - Non-selective subtraction angiogram • Soft signs of vascular injury - Contralateral femoral puncture w/ selective subtraction angiogram - Neurologic deficit - Proximity of injury to vessels • Depending on the clinical situation, CTA and DUS have - Significant hemorrhage by history been used for evaluating peripheral vascular injuries with high sensitivity and specificity Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Attebery LR, Dennis JM, Russo-Alesi F, et al. Changing Physical Examination in the Evaluation of Penetrating Patterns of Arterial Injuries Associated with Fractures and Extremity Trauma for Vascular Injury: Results at One Year. Dislocations. J Am Coll Surg 183: 377-383, 1996. Bongard FS, White GH, Klein SR. Management Strategy of J Trauma 31: 502-522, 1991. Complex Extremity Injuries. Am J Surg 158: 151-155, 1989. VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 8
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