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Vascular trauma
Vascular Trauma A Review of 250 Cases
CHARLES H. MOORE, MD, Galveston, Texas FRED J. WOLMA, MD, Galveston, Texas RICHARD W. BROWN, RTCA, Galveston, Texas JOHN R. DERRICK, MD, Galveston, Texas
An analysis of 250 vascular injuries in patients treated at the University of Texas Medical Branch Hospitals in Galveston, Texas from January 1960 through January 1970 indicates that the location, type, and severity of the injuries in this experience are comparable to those in series of civilian vascular trauma reported by others [l-.4]. (Table I.) The severity of the injury is reflected by the 34 per cent of multiple injuries involving nerves, veins, and bones. The complication rate was 21 per cent and the mortality was 2.4 per cent (six deaths) in the series. Clinical
Data
The method of diagnosis in the majority of cases was by history and physical findings alone. The presence or absence of peripheral pulsations was not found to be an accurate assessment of vascular injury. In some patients with a palpable distal pulse, a significant vascular injury was discovered at exploration ; whereas a few patients presented with absent distal pulses, and vascular spasm proved to be the cause. Arteriography was performed in twenty-two patients and was of considerable value in defining delayed injuries such as false aneurysms and arteriovenous fistulas. Preoperative arteriography was not performed routinely because the findings were often misleading in acute arterial injury. On the other hand, intraoperative and postoperative angiographic studies were found to be of great value in management. From the Division of Thoracic and Cardiovascular Surgery and the Division of General Surgery, University of Texas Medical Branch, Galveston, Texas 77550. Reprint requests should be addressed to Dr Moore. Presented at the Twenty-Third Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 19-22, 1971. * Present address: Department of Surgery, Womack Army Hospital STC, Fort Bragg, North Carolina 28307.
576
The basic technics of surgical vascular repair included end to end anastomosis, lateral repair, saphenous vein or Dacron@ graft r8eplacement, patch graft angioplasty, ligation, and thrombectomy. Factors that were important for a successful vascular repair included minimizing the time from injury to repair, adequate debridement, removal of proximal and distal thrombus, adequate resection of the area of vessel injury, repair without tension, repair of concomitant venous injury, fixation of associated fractures, and protection of vascular repair with viable muscle. In the most severe cases, the skin and subcutaneous tiasue wer’e left open initially and secondarily closed five days later. Ancillary procedures that were important in successful vascular repair in certain cases included fasci’otomy, sympathectomy, anticoagulation, immobilization, and early skin grafting. The most seri’ous complications in our series leading to increased morbidity and mortality were uncontrollled hemorrhage, infection, thrombosis, technical errors, vascular spasm, and complications related to associated injuries. Two types of injury in the series deserve special attention : (1) iatrogenic vascular injuries ; (2) delayed vascular injuries that presented with false aneurysms or arteriovenous fistula. There were twenty-five iatrogenic injuries in the series. (Table II.) Cardiovascular angiography has been reported to be associated with an incidence of less than 1 per cent serious complications [5]. In the past five years, at the University of Texas Medical Branch, more than 3,000 cardiovascular radiographic procedures have been performed. There were sixteen patients in this series operated upon for acute arterial thrombosis. With the patient under local anesthesia thrombectomy was performed with the use of Fogarty catheters. The
The American
Journal
of Surgery
Vascular
TABLE
I
Location and Type of 250 Cases of Vascular Trauma _
Location
Per cent 10 16 15 14 45 100
Head and neck Thoracic outlet Chest Abdomen Extremities Total
Type Gunshot wound Stab wound Blunt latrogenic Other
TABLE
II
Twenty-Five
Cases of latrogenic
39 25 13 10 13 100
Vascular
Penetrating (not explored) Blunt trauma Total
Fracture of humerus closed reduction Subclavian catheterization Total
Volume
122, November
1971
Injury
Aneurysm
Arteriovenous Fistula
Mortality
Total
15 3 18
5 3 8
2 2 4
20 6 26
versity of Texas Medical Branch Hospitals with delayed vascular injury. (Table III.) Eighteen patients had false aneurysms and eight patients had arteriovenous fistulas. The most common sites of injury included the vessels of the thoracic outlet, the brachial and femoral arteries, and vessels in the head and neck. (Table IV.) The common denominator in all these cases was failure to explore a significant wound in the area of major vessels. Four of the six deaths occurred in this group of patients. Two died from delayed rupture of a thoracic aortic false aneurysm resulting from blunt trauma to the chest. A similar patient presented ten days after an auto accident and collapsed in shock in the office while waiting to be examined. After emergency resuscitation, the patient was taken to the operating room and placed on left atriofemoral bypass. Bleeding was controlled and the aneurysm was repaired by resection and graft. The patient made an uneventful recovery. The management of peripheral vascular injuries can well be illustrated by the following case : A thirty year old white man was shot in the popliteal space with a high velocity rifle. Emergency treatment consisted of control of the bleeding and shock. At exploration, the popliteal artery and vein were found to be transected. Extensive soft tissue injury was present and the distal femur fractured. The sciatic nerve
Injuries
Procedure Central venous catheterization Lumbar laminectomy Osteotomy of hip Renal hemodialysis arteriovenous shunts Pelvic irradiation
Delayed Vascular
Per cent
morbidity that results from an ischemic arm or leg, or the loss of a limb, can be avoided by early operative intervention. There were three cases of arteriovenous fistulas after lumbar disk operations [S] . In all three cases the fistula occurred between the iliac artery and vein. One case of multiple arteriovenous fistulas after an orthopedic procedure on the hip could not be repaired because of the extensive vascularization. Renal hemodialysis arteriovenous shunts resulted in two false aneurysms that required correction. One case of acute rupture of the femoral artery secondary to necrosis after pelvic irridiation for cancer was successfully corrected by an emergency extraperitoneal aortofemoral bypass. A Fogarty balloon catheter was used to temporarily control bleeding in the contaminated groin while the definitive bypass was constructed. In another patient a subclavian arteriovenous fistula developed as a result of percutaneous subclavian catheterization. In this instance, tamponade of the proximal subclavian artery with a Fogarty balloon catheter permitted repair of the arteriovenous fistula from a supraclavicular approach without subjecting the patient to thoracotomy. The use of the balloon catheter for intraluminal control of bleeding was found to be of great value in the management of vascular injury. Twenty-six patients were admitted to the UniTABLE
III
Trauma
Injury
Treatment
Thrombosis Arteriovenous Arteriovenotis
fistula fistula
Thrombectomy Repair of fistula Repair of fistula
False aneurysm Femoral artery rupture
Resection of aneurysm Aortofemoral bypass
Volkmann’s
Open reduction; free artery and fasciotomy Repair of fistula
Arteriovenous
ischemia fistula
Number 16 3 1 2 1
1 25
577
Moore
et al
Location of Delayed Vascular
TABLE IV
Location
Aneurysm/Fistula
injury Mortality
4
Head and neck Thoracic outlet
Chest
11 3
1 2
Abdomen Extremity Total
1 7 26
1
--
4
was intact.. Popliteal artery resection and saphenous vein graft replacement were carried out and lateral repair of the injured vein was completed. After extensive wound debridement and fasciotomies, the leg was immobilized in skeletal traction. Eight hours postoperatively, loss of pedal pulses occurred. immediate re-exploration revealed a kinked redundant vein graft, which was revised, and thrombectomjt was carried out along with lumbar sympathectomy. Five days later, a split thickness skin graft was applied to the wound. The patient made a satisfactory recovery.
Comment: This case illustrates the need for constant surveillance of distal pulses after vascular repair. Re-exploration of the vascular repair should be performed without hesitancy if there is any question regarding the status of the repair. Postoperative arteriography has been found to be of great value in making the decision to re-explore. Summary Two
hundred fifty vascular injuries of all types seen at the University of Texas Medical Branch,
578
Galveston, Texas during the period from January 1960 through January 1970 have been reviewed. Methods of evaluation and management of the primary injury are discussed along with the complications. The mortality was 2.4 per cent (6 deaths) in this series and two-thirds (four deaths) were in the group in which treatment was delayed. Emphasis is placed on immediate exploration of all penetrating wounds in the region of major vessels. Early recognition and prompt repair of the vascular injury is paramount for reduced morbidity and mortality. Twenty-six cases of delayed vascular injury are reviewed. Also, twenty-five cases of iatrogenic vascular injury are reviewed and their management is discussed. The management of special and difficult problems is briefly illustrated. References 1. Morris GC. Creech 0, DeBakey
ME: Acute arterial injuries in civilian practice. Amer J Surg 93: 565, 1957. 2. Williams GD: Peripheral vascular trauma report of 90 cases. Amer J Surg 116: 725, 1968. 3. Shires GT, Patman RD: The management of civilian arterial injuries. Surg Gynec Obstet 118: 725, 1964. 4. Morton JH, Southgate WA, DeWeese JA: Arterial injuries of the extremities. A collective review. Surg Gynec Obstet 123: 611,1966. 5. Moore CH, Wolma FJ, Brown RW, Derrick JR: ComplicaEi;slo9f7;rdiovascular radiology. Amer J Surg 120: 6. Schreibir MH, Wolma FJ, Morrettin LB: Angiographic ings in arteriovenous fistulas following lumbar surgery. Amer J Roentgen01 101: 957, 1967.
finddisc
The American Journal of SuWy
CHARLES H. MOORE, MD, Galveston, Texas FRED J. WOLMA, MD, Galveston, Texas RICHARD W. BROWN, RTCA, Galveston, Texas JOHN R. DERRICK, MD, Galveston, Texas
An analysis of 250 vascular injuries in patients treated at the University of Texas Medical Branch Hospitals in Galveston, Texas from January 1960 through January 1970 indicates that the location, type, and severity of the injuries in this experience are comparable to those in series of civilian vascular trauma reported by others [l-.4]. (Table I.) The severity of the injury is reflected by the 34 per cent of multiple injuries involving nerves, veins, and bones. The complication rate was 21 per cent and the mortality was 2.4 per cent (six deaths) in the series. Clinical
Data
The method of diagnosis in the majority of cases was by history and physical findings alone. The presence or absence of peripheral pulsations was not found to be an accurate assessment of vascular injury. In some patients with a palpable distal pulse, a significant vascular injury was discovered at exploration ; whereas a few patients presented with absent distal pulses, and vascular spasm proved to be the cause. Arteriography was performed in twenty-two patients and was of considerable value in defining delayed injuries such as false aneurysms and arteriovenous fistulas. Preoperative arteriography was not performed routinely because the findings were often misleading in acute arterial injury. On the other hand, intraoperative and postoperative angiographic studies were found to be of great value in management. From the Division of Thoracic and Cardiovascular Surgery and the Division of General Surgery, University of Texas Medical Branch, Galveston, Texas 77550. Reprint requests should be addressed to Dr Moore. Presented at the Twenty-Third Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 19-22, 1971. * Present address: Department of Surgery, Womack Army Hospital STC, Fort Bragg, North Carolina 28307.
576
The basic technics of surgical vascular repair included end to end anastomosis, lateral repair, saphenous vein or Dacron@ graft r8eplacement, patch graft angioplasty, ligation, and thrombectomy. Factors that were important for a successful vascular repair included minimizing the time from injury to repair, adequate debridement, removal of proximal and distal thrombus, adequate resection of the area of vessel injury, repair without tension, repair of concomitant venous injury, fixation of associated fractures, and protection of vascular repair with viable muscle. In the most severe cases, the skin and subcutaneous tiasue wer’e left open initially and secondarily closed five days later. Ancillary procedures that were important in successful vascular repair in certain cases included fasci’otomy, sympathectomy, anticoagulation, immobilization, and early skin grafting. The most seri’ous complications in our series leading to increased morbidity and mortality were uncontrollled hemorrhage, infection, thrombosis, technical errors, vascular spasm, and complications related to associated injuries. Two types of injury in the series deserve special attention : (1) iatrogenic vascular injuries ; (2) delayed vascular injuries that presented with false aneurysms or arteriovenous fistula. There were twenty-five iatrogenic injuries in the series. (Table II.) Cardiovascular angiography has been reported to be associated with an incidence of less than 1 per cent serious complications [5]. In the past five years, at the University of Texas Medical Branch, more than 3,000 cardiovascular radiographic procedures have been performed. There were sixteen patients in this series operated upon for acute arterial thrombosis. With the patient under local anesthesia thrombectomy was performed with the use of Fogarty catheters. The
The American
Journal
of Surgery
Vascular
TABLE
I
Location and Type of 250 Cases of Vascular Trauma _
Location
Per cent 10 16 15 14 45 100
Head and neck Thoracic outlet Chest Abdomen Extremities Total
Type Gunshot wound Stab wound Blunt latrogenic Other
TABLE
II
Twenty-Five
Cases of latrogenic
39 25 13 10 13 100
Vascular
Penetrating (not explored) Blunt trauma Total
Fracture of humerus closed reduction Subclavian catheterization Total
Volume
122, November
1971
Injury
Aneurysm
Arteriovenous Fistula
Mortality
Total
15 3 18
5 3 8
2 2 4
20 6 26
versity of Texas Medical Branch Hospitals with delayed vascular injury. (Table III.) Eighteen patients had false aneurysms and eight patients had arteriovenous fistulas. The most common sites of injury included the vessels of the thoracic outlet, the brachial and femoral arteries, and vessels in the head and neck. (Table IV.) The common denominator in all these cases was failure to explore a significant wound in the area of major vessels. Four of the six deaths occurred in this group of patients. Two died from delayed rupture of a thoracic aortic false aneurysm resulting from blunt trauma to the chest. A similar patient presented ten days after an auto accident and collapsed in shock in the office while waiting to be examined. After emergency resuscitation, the patient was taken to the operating room and placed on left atriofemoral bypass. Bleeding was controlled and the aneurysm was repaired by resection and graft. The patient made an uneventful recovery. The management of peripheral vascular injuries can well be illustrated by the following case : A thirty year old white man was shot in the popliteal space with a high velocity rifle. Emergency treatment consisted of control of the bleeding and shock. At exploration, the popliteal artery and vein were found to be transected. Extensive soft tissue injury was present and the distal femur fractured. The sciatic nerve
Injuries
Procedure Central venous catheterization Lumbar laminectomy Osteotomy of hip Renal hemodialysis arteriovenous shunts Pelvic irradiation
Delayed Vascular
Per cent
morbidity that results from an ischemic arm or leg, or the loss of a limb, can be avoided by early operative intervention. There were three cases of arteriovenous fistulas after lumbar disk operations [S] . In all three cases the fistula occurred between the iliac artery and vein. One case of multiple arteriovenous fistulas after an orthopedic procedure on the hip could not be repaired because of the extensive vascularization. Renal hemodialysis arteriovenous shunts resulted in two false aneurysms that required correction. One case of acute rupture of the femoral artery secondary to necrosis after pelvic irridiation for cancer was successfully corrected by an emergency extraperitoneal aortofemoral bypass. A Fogarty balloon catheter was used to temporarily control bleeding in the contaminated groin while the definitive bypass was constructed. In another patient a subclavian arteriovenous fistula developed as a result of percutaneous subclavian catheterization. In this instance, tamponade of the proximal subclavian artery with a Fogarty balloon catheter permitted repair of the arteriovenous fistula from a supraclavicular approach without subjecting the patient to thoracotomy. The use of the balloon catheter for intraluminal control of bleeding was found to be of great value in the management of vascular injury. Twenty-six patients were admitted to the UniTABLE
III
Trauma
Injury
Treatment
Thrombosis Arteriovenous Arteriovenotis
fistula fistula
Thrombectomy Repair of fistula Repair of fistula
False aneurysm Femoral artery rupture
Resection of aneurysm Aortofemoral bypass
Volkmann’s
Open reduction; free artery and fasciotomy Repair of fistula
Arteriovenous
ischemia fistula
Number 16 3 1 2 1
1 25
577
Moore
et al
Location of Delayed Vascular
TABLE IV
Location
Aneurysm/Fistula
injury Mortality
4
Head and neck Thoracic outlet
Chest
11 3
1 2
Abdomen Extremity Total
1 7 26
1
--
4
was intact.. Popliteal artery resection and saphenous vein graft replacement were carried out and lateral repair of the injured vein was completed. After extensive wound debridement and fasciotomies, the leg was immobilized in skeletal traction. Eight hours postoperatively, loss of pedal pulses occurred. immediate re-exploration revealed a kinked redundant vein graft, which was revised, and thrombectomjt was carried out along with lumbar sympathectomy. Five days later, a split thickness skin graft was applied to the wound. The patient made a satisfactory recovery.
Comment: This case illustrates the need for constant surveillance of distal pulses after vascular repair. Re-exploration of the vascular repair should be performed without hesitancy if there is any question regarding the status of the repair. Postoperative arteriography has been found to be of great value in making the decision to re-explore. Summary Two
hundred fifty vascular injuries of all types seen at the University of Texas Medical Branch,
578
Galveston, Texas during the period from January 1960 through January 1970 have been reviewed. Methods of evaluation and management of the primary injury are discussed along with the complications. The mortality was 2.4 per cent (6 deaths) in this series and two-thirds (four deaths) were in the group in which treatment was delayed. Emphasis is placed on immediate exploration of all penetrating wounds in the region of major vessels. Early recognition and prompt repair of the vascular injury is paramount for reduced morbidity and mortality. Twenty-six cases of delayed vascular injury are reviewed. Also, twenty-five cases of iatrogenic vascular injury are reviewed and their management is discussed. The management of special and difficult problems is briefly illustrated. References 1. Morris GC. Creech 0, DeBakey
ME: Acute arterial injuries in civilian practice. Amer J Surg 93: 565, 1957. 2. Williams GD: Peripheral vascular trauma report of 90 cases. Amer J Surg 116: 725, 1968. 3. Shires GT, Patman RD: The management of civilian arterial injuries. Surg Gynec Obstet 118: 725, 1964. 4. Morton JH, Southgate WA, DeWeese JA: Arterial injuries of the extremities. A collective review. Surg Gynec Obstet 123: 611,1966. 5. Moore CH, Wolma FJ, Brown RW, Derrick JR: ComplicaEi;slo9f7;rdiovascular radiology. Amer J Surg 120: 6. Schreibir MH, Wolma FJ, Morrettin LB: Angiographic ings in arteriovenous fistulas following lumbar surgery. Amer J Roentgen01 101: 957, 1967.
finddisc
The American Journal of SuWy