Acute vascular trauma

Acute Vascular Trauma A Fifteen Year Study RICHARD

L. TREIMAN, M.D.,* DONALD

I)OTY, M.D., ~ AND MAX

R. GASPAR, M.D.,

Los Angeles, California

From the Vascular Surgery Services, University of Southern California and Loma Linda University, and Los Angeles County General Hospital, Los Angeles, California.

TABLE

Missile Sharp instrument Blunt trauma Total

trauma at the Los Angeles C o u n t y General Hospital [1 ]. T h a t experience spanned a decade during which the technics for repair of blood vessels were greatly improved. This report demonstrated that with improved technics early surgical exploration for control of hemorrhage and restoration of vascular continuity was preferable to nonoperative management. Accordingly, an aggressive surgical approach toward vascular trauma was initiated. We now think it timely to report the results obtained during the past five years and to summarize our fifteen year experience with acute vascular trauma in a civilian population.

192 PATIENTS

~1948-1958~ No. %

Type

we (R. L. T. and M. R. G.) reported I Na 1960 ten year experience with acute vascular

I

MODALITY OF INJURY IN

32 52 18 102

31 51 18

~1958-1963~ No. % 34 34 22 90

38 38 24

the modalities of injury and compares the recent experience with the one previously reported. The patients ranged in age from one to eigthy-nine years. One hundred seventy-one patients were male and twenty-one were female; one hundred nineteen injuries occurred in Caucasians, seventy in Negroes, and three in orientals. ARTERIAL TRAUMA

Table II lists the sites of 159 major arterial injuries. Approximately the same number of arterial injuries were encountered in the past five years as in the previous ten years. The axillary-brachial and femoral arteries have been involved most frequently. The high incidence of injury to these arteries has been noted in reports from military hospitals [2-4] as well as from those treating civilian populations [5,6]. The operative procedures used in the management of acute arterial injuries are shown in Table Ill. In accordance with the principle t h a t the artery should be repaired and pul-

CLINICAL MATERIAL

During the fifteen year period 379 acute vascular injuries have been treated in 315 patients at the Los Angeles County General Hospital. One hundred twenty-eight injuries involved the vessels of the forearm, wrist, or leg. Injuries to these smaller vessels usually were treated by simple ligation, and the functional result was dependent on injury to nerve and tendon rather than on circulatory disruption. Excluding injuries to these smaller vessels, there remained 251 major vascular injuries in 192 patients. One hundred fifty-nine wounds were arterial and ninety-two were venous. Table I lists

* I n s t r u c t o r in Surgery, University of S o u t h e r n California School of Medicine; Attending Surgeon, Los Angeles

County Hospital. Former Resident Physician-Surgery, Los Angeles County Hospital. Resident Physician-Surgery, Los Angeles County Hospital. :~Clinical Professor of Surgery, Loma Linda University School of Medicine; Senior Attending Surgeon, Los Angeles County Hospital. Former Resident Physician-Surgery, Los Angeles County Hospital. Vol. 111. M a r c h 1966

469

470

Treiman, Doty, and Gaspar TABLE II ARTERIAL INJURIES

MAXAGEMENT

,Number of Injuries 1948-1958 1958-1963 1948-1963

Artery Head and neck Axillary-brachial Subclavian Innominate Aorta Iliac Femoral Popliteal Major visceral Total

6 31 0 0 5 7 21 8 2 80

4 23 4 1 6 4 18 10 9 79

10 54 4 1 11 11 39 18 11 1.59

satile flow established unless extenuating circumstances are prohibitive, there has been a significant decrease in ligation as a primary procedure and a concomitant increase in attempts to restore arterial continuity. We found during our previous review that direct anastomosis offered the best results in the treatment of the severed artery. During the past five years this technic has been used more frequently. Graft procedures have been used sparingly and only when long segments of artery have been destroyed. In such eases autogenous vein grafts are preferred. If a suitable vein is not available, a prosthetic graft m a y be used. In this series prosthetic

T A B L E Ill O F 159 A R T E R I A L \ V O U N D S

Operation Exploration only Simple ligation Repair Direct anastomosis Lateral suture repair Autogenous vein graft Autogenous arterial graft Synthetic prosthesis Remove thrombus No exploration Total

1948-1958 No. %

1958-1963 No. %

4 23 37

2 12 51 26 7 6 1 4 7 14 79

6 29 45 20 13 1 1 0 2

16 80

20

3 15 64

18

grafts were used in four patients, with restoration of pulsatile flow in three. During the past five years fourteen patients with major arterial wounds were not operated upon (Table Ill), eight of whom died. Of the six patients who survived, one required emergency operation for hemorrhage from an infecte d false aneurysm, arteriovenous fistulas developed in three, ischemia of the hand developed in one, and one patient required amputation. These poor results underscore the need for early surgical exploration of all wounds in which arterial injury is suspected. During the fifteen year period nineteen pa-

TABLE IV AMPUTATION AFTER ARTERIALREPAIR Distal PulseWithin Surgical Procedure Completion Twentyof Four Operation Hours

Sympathectomy

Sympathetic Block

Re-Exploration

No Yes No No

No No No No

No No No No

No No Yes No

Yes

No

No

Yes

No

Not started Yes Yes No Yes Yes No Yes

No

Yes

Yes

No

No No No No No ' No No

No No No No Yes No Yes

No No No No No Yes No

No No No No No No No

Artery

Cause

Brachial Braehiai Axillary Superficial femoral Superficial femoral Popliteal

Blunt trauma Missile Blunt trauma Blunt trauma

Direct anastomosis Direct anastomosis Removal of thrombus Removal of thrombus

Yes Yes Yes Yes

Blunt trauma

Dacron ® prosthesis

Blunt trauma

Direct anastomosis

Popliteal Popliteal Popliteal Popliteal Popliteal Popliteal Popliteal

Blunt trauma Blunt trauma Blunt trauma Missile Missile Missile Sharp instrument

Removal of thrombus Autogenous vein graft Exploration only Direct anastomosis Autogenous vein graft Direct anastomosis Direct anastomosis

American Jo~trnat of Surgery

Acute Vascular Trauma TABLE V VENOUS INJIJ~IES

T A B L E VI

MANAGEMENT OF NINETY-TWO VENOUS~VOUNDS

. N u m b e r of I n j u r i e s - - - - . 1948195819481958 1963 1963

Vein

Axillary-brachial Innominate-subclavian Superior v e n a c a v a

8 3 1

5 5 0

13 8 1

Inferior vena eava Iliac

8 7

4 4

12 11

11 14 52

6 16 40

17 30 92

Femoral Other Total

tients required amputation, in six of whom the arterial wound was not explored. Five of these six occurred during our earlier experience and only one during the past five years. In the remaining thirteen patients arterial repair was a t t e m p t e d b u t failed. (Table Iv.) On review of these surgical failures we found t h a t in all except one patient the distal pulse was noted to be absent within twenty-four hours after operation. Despite known loss of distal pulse, the arterial repair was not re-explored. M a n y patients were extremely ill, and the arterial wounds were associated with extensive soft tissue damage and fracture. Nevertheless, it is our present policy to re=explore the arterial repair immediately if there is evidence t h a t the repair has failed, providing the patient's condition permits reoperation. T h e popliteal artery was involved in eight of the thirteen failures; emphasizing the danger of popliteal arterial injuries. The average time from injury to operation was fifteen hours in those patients in whom arterial repair was not successful. The average time in patients with surviving limbs was nine hours. S y m p a t h e c t o m y or sympathetic block was performed in five of thirteen patients in whom arterial repair failed and a m p u t a t i o n was later required. At present we do not rely upon sympathetic ablation in the t r e a t m e n t of the ischemic limb due to trauma. VENOUS TRAUMA

Ninety-two injuries to major veins were encountered and are listed in Table v. T h e thirty injuries listed under "other" refer to injuries to veins of the head and neck and to visceral veins. Since our review of the managem e n t of injuries to m a j o r veins [7], we have Vol. 111, M a r c h 1966

471

Operation

Simple ligation Repair Direct anastomosis Lateral suture repair Other No exploration

1948-1958 No. %

1958--1963 No. %

27 10

14 19

0 10 0 15 52

52 19

35 48 2 16 1

29

7 40

17

Total undertaken a more aggressive surgical approach to venous trauma. (Table vI.) More injured veins are being repaired and fewer are being ligated. The n u m b e r of unexplored venous injuries has shown an impressive decrease although the percentage in which surgery was not performed is still excessive and corresponds closely to t h a t of unexplored arterial injuries. The n u m b e r of arteriovenous fistulas has been reduced b y the increased incidence of exploration of known or suspected venous wounds. MORTALITY

There were twenty-two deaths during the past five years. Nineteen patients who died had severe concomitant injury to the head, neck, chest, and abdomen. In fourteen patients the great vessels of the chest and abdomen were involved. Fifty-five per cent of deaths were associated with blunt t r a u m a as a mode of injury which accounts for the severity of some of the wounds. In contrast, only two of the eighteen deaths in the earlier series were due to severe concomitant injury. Ten of the twenty-two patients who died were not operated upon. Five of these ten died from uncontrolled hemorrhage within two hours after admission to the hospital. Only two of the ten patients lived longer than twenty-four hours. One patient had a laceration of the thoracic aorta from blunt trauma. He refused to undergo surgery and died thirtytwo hours after admission to the hospital. T h e other patient died three days after admission to the hospital from cardiac contusion and unrecog-nized laceration of the internal jugular vein. Fifty per cent of patients who died without surgery had injury to the thoracic or abdominal aorta. Twelve patients who died had been operated

472

Treiman, Dory, and Gaspar

upon; three had simple ligation for the control of hemorrhage and nine had repair of an arterial or venous wound. Postmortem examination was performed in seven of the nine patients who had vascular repaired. In five the repaired vessel was found to be patent without complication, in one the artery had thrombosed, and in one hemorrhage had occurred from disruption of the anastomosis. These twelve patients who died after operation which included vascular repair had had extensive injury to other organ systems in addition to the vascular wound. These associated injuries were primarily responsible for the patient's death. COYIMENTS

The single most important factor in the successful treatment of acute vascular trauma is early recognition of major vascular injury. Diagnosis can usually be made clinically; however, if the clinical signs are indefinite, an arteriogram m a y be valuable. Once the diagnosis has been made, prompt exploration for control of hemorrhage and restoration of vascular continuity is imperative. If the patient is in shock and does not respond to rapid infusion of plasma and electrolytes, surgical exploration should be undertaken immediately. Operation should not be delayed to await completion of blood cross-matching. The technics used for repair of injured arteries and veins have been described by others [6,8,9]. Lateral suture repair is excellent for repair of the arterial wound when there is no loss of arterial wall. However, lateral suture repair should not be pursued at the expense of adequate debridement or luminal constriction. In particular, in gunshot wounds the debridemerit must be extensive because of the bursting effect of the bullet. Under such conditions an autogenous vein patch or end to end anastomosis usually will be required. If a long segment of an artery has been damaged, an autogenous vein graft using the saphenous vein is recommended. A prosthetic graft m a y be used if a suitable vein is not available. We prefer autogenous grafts because they are safer from the standpoint of infection and long-term patency. Strict attention to the details of operative technie is the best insurance against failure of vascular repair. A modified catheter technic for arterial embolectomy has been described b y Fogarty and Cranley [10]. The catheter they employ

for embolectomy is extremely useful in traumatic arterial surgery. Prior to completion of the repair the catheter can be passed distally as far as the wrist or ankle. Frequently, clot is recovered especially in cases of blunt trauma in which thrombosis of a contused intact vessel is found. Retrograde bleeding does not insure the absence of major block due to clot in the distal artery. Operative arteriography should be performed to demonstrate pateney of the repair and of distal vessels. Arteriotomy of the distal vessels m a y be necessary if thrombosis is demonstrated, but often clots can be removed with the embolectomy catheter. After surgery the pulses distal to the arterial repair should be observed closely. Loss of pulse or presence of isehemia is an indication that the repair has failed. There should be no hesitancy to re-explore the arterial repair providing the patient's condition permits reoperation. Reoperation must be performed early to prevent irreversible damage. SUMMARY

Three hundred seventy-nine acute vascular injuries occurring over a fifteen year period are reviewed. During the past five years the incidence of vascular trauma has doubled in comparison with t h a t of the previous ten years and has been associated with more severe injuries and an increasing frequency of wounds due to missiles and blunt trauma. We are disappointed that our mortality has increased 6.8 per cent during the past five years. The majority of patients who died had extensive injuries involving multiple organ systems. Nevertheless, five patients who died from hemorrhage were in the hospital more than two hours and were not operated upon. Improvement in survival can result only from prompt recognition of vascular injury, rapid institution of resuscitative measures, and operative control of hemorrhage. Despite a marked decrease in ligation of wounded arteries and concomitant increase in attempts at surgical repair, we have not significantly altered our amputation rate. Most of the poor results have been due to the severity of the local injury with irreversible damage to the limb. Some limbs, however, m a y be saved from amputation by use of the Fogarty emboleetomy catheter to remove distal clot and operative arteriography to insure pateney of the American Journal of Surgery

Acute Vascular Trauma arterial runoff. Prompt reoperation, if the initial repair fails, m a y be the most important measure in salvaging an extremity. In conclusion, we think the aggressive surgical approach undertaken during the past five years has been justified and must be extended if the results from acute vascular trauma are to be improved. REFERENCES 1. TREIMAN, R. L. and GaSPAR, M. R. Acute vascular trauma. West Y. Surg., 68: 187, 1960. 2. MAI~INS, G. H. Gunshot Injuries to the Blood Vessels. Bristol, England, 1919. John Wright & Sons, Ltd. 3. ELKIN, D. C. and DEBAKEY, M. E. Surgery in World W a r II, Vascular Surgery, Office of the Surgeon General, Dept. Army, Washington, D. C., 1955.

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4. HUGHES, C. W. Arterial repair during the Korean War. Am. Surgeon, 147: 555, 1958. 5. MORRIS, G. C., BEALL, A. C., ROOF, W. R., and DEBa~:EY, NI. D. Surgical experience with 220 acute arterial injuries in civilian practice. Am. Y. Surg., 99: 775, 1960. 6. PATMAN, R. D., POULOS, E., and SmRLBS, G. T. The management of civilian arteriaI injuries. Surg. Gynec. & Obst., 118: 725, 1964. 7. GASPAR, M. R. and TREIMAN, R. L. The management of injuries to major veins. Am. Y. Surg., 100: 171, 1960. 8. SMITH, L. L., FORAN, R., and GASpAa, M. R. Acute arterial injuries of the upper extremity. Am. Y. Surg., 106: 144, 1963. 9. QUAST, D. C., SHIRKEY, A. L., FITZGeRaLD, J. B., BEALL, A. C., and DEBAKSY, M. E. Vena caval repair without Iigation. Y. Trauma, 5: 3, 1965. 10. FOGARTV, T. J. and CRANLEY, J. J. Catheter technique for arterial embolectomy. Ann. Surg., 161: 325, 1965.