SLIDE 9 9
UC SF
VASCULAR SURGERY • UC SAN FRANCISCO
Asymptomatic Arterial Injuries
- Non-occlusive asymptomatic vascular injuries
– Dissection – Small pseudoaneurysm – AVF – Isolated tibial thrombosis
- Three series totaling 98 asymptomatic combined arterial
+ orthopedic injuries without hard signs
- Single operative repair (which may not have been necessary)
- Series of 15 asymptomatic combined injuries followed for
6 months
Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year. J Trauma 31: 502-522, 1991. Attebery LR, Dennis JM, Russo-Alesi F, et al. Changing Patterns of Arterial Injuries Associated with Fractures and Dislocations. J Am Coll Surg 183: 377-383, 1996.
UC SF
VASCULAR SURGERY • UC SAN FRANCISCO
Who Goes First?
- Skeletal repair is priority or selective vascular repair when
ischemia is clinically evident
- Disruption of fresh vascular anastomosis by orthopedic surgeons
during reduction
- Length discrepancy of vascular repair after reducing unstable
skeletal injuries
- Snyder et al
- Combined vascular + orthopedic repair in 29 patients
- Two patients requiring repair at index operation
- Did not effect outcome
- Howe et al
- Combined vascular + orthopedic repair in 21 patients
- No episodes of vascular disruption
Snyder WH. Vascular Injuries Near the Knee: An Updated Series and Overview of the Problem. Surgery 91: 502-506, 1982. Howe HR, Poole GV, Hansen KJ, et al. Salvage of Lower Extremities Following Combined Orthopedic and Vascular Trauma: A Predictive Salvage Index. Am Surg 53: 205-208, 1987.
UC SF
VASCULAR SURGERY • UC SAN FRANCISCO
Who Goes First?
- Significantly lower amputation rates in those undergoing
revascularization first in comparison to orthopedic repair first
- Lim et al
- McCabe et al
- “Restoration of blood flow should always take priority
- ver skeletal repair’
- Eastern Association for the Surgery of Trauma Practice Guidlines
- Temporary shunting to allow stabilization of unstable fractures
- Immediate definitive arterial repair while skeletal injury is stable and
not significantly displaced
Lim LT, Michuda MS, Flanigan DP, et al. Popliteal Artery Trauma. Arch Surg 115: 13071313, 1980. McCabe CJ, Ferguson CM, Ottinger LW. Improved Limb Salvage in Popliteal Artery Injuries. J Trauma 23: 982-985, 1983.
UC SF
VASCULAR SURGERY • UC SAN FRANCISCO
Definitive Repair vs. Shunt
- Physiologic parameters
- Hemodynamic Instability
- Coagulopathy
- Acidosis
- Hypothermia
- Other life threatening injuries requiring urgent
management
- Head injuries, pelvic fractures, etc.
- Major wound contamination
- Extensive soft tissue defects precluding wound coverage
- Requirements for complex repair
- Bypass rather than primary repair
