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Vascular Trauma
Symposium on Trauma
Vascular Trauma Bruce E. Brink, MD.*
Numerous articles have appeared in the surgical literature concerning vascular trauma. Most of these have addressed the problem of arterial injuries. Only recently have vascular and trauma surgeons been emphasizing the importance of also repairing the venous side of the circulation," 7 although venous gangrene has been a recognized entity for many years. In this article we will deal with arterial and venous injuries of the peripheral vasculature and their repair. Shotgun blasts and their resultant problems are covered elsewhere in this symposium. This article is organized in the following way: 1. Type of Injury
2. 3. 4. 5.
Initial Evaluation Initial Therapy Operative and Postoperative Management Management of Specific Vessel Injury
TYPE OF INJURY In the United States, most civilian vascular injuries are secondary to penetrating trauma. 9 The common offending weapons are guns and knives, with a small proportion of penetrating wounds being secondary to industrial accidents and freak home accidents. Most knife wounds cause simple lacerations and/or transections of vessels and are relatively easily handled. Gunshot wounds frequently cause much more extensive vascular and soft tissue damage. The severity of damage is influenced by the mass and velocity of the offending missile, the physical properties of the missile, and the range from which the missile was fired. Most civilian injuries are secondary to low velocity missiles, although it must be remembered that high velocity, high mass missiles can cause cavitary damage far removed from the obvious site of injury. Missile injuries carry a higher incidence for the need of some type of interposition arterial conduit than do stab wounds. Blunt vascular trauma is frequently secondary to motor vehicular accidents. The vascular injury may be due to the vessels being compressed between two immovable ':'Associate Professor of Surgery, Southwestern Medical School, University of Texas Health Science Center at Dallas, Dallas, Texas; Formerly Assistant Professor of Surgery, Wayne State University School of Medicine, Detroit, Michigan
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objects, rapid deceleration, fractures, dislocations, and fracture-dislocations of the bony skeleton.
INITIAL EVALUATION Time is of the essence in all vascular trauma! This is true either because of the threat of loss of life secondary to exsanguination or because of the threat of loss of limb or organ secondary to interruption of its blood supply. Experience has shown and common sense dictates that the earlier hemorrhage is controlled and flow restored, the better the chance for survival and functional usefulness of the devascularized area. Patients with vascular injuries can usually be grouped into one of three categories: Category I:
Patients with obvious life-threatening vascular injuries, e.g., those with a rapidly distendin,g abdomen, shock, and those in whom it is obvious that emergency exploration is mandatory. Category II: Patients with obvious vascular impairment to a body part, in whom the in,jury may be limb or organ threatening, but not life-threatening. Category III: Patients with in,juries in anatomic approximation to major vascular channels but in whom, at the time of presentation, no obvious vascular in,jury has occurred.
The management of patients in the above-mentioned categories is indeed different. A rapid, thorough physical examination must be performed on all trauma patients, especially on those with obvious injuries, so that concomitant injuries are not overlooked. Saving a life always takes precedence over saving a limb and the reversal of the aforementioned has no place in trauma surgery. The initial evaluation includes notation of the classical signs of vascular injury. These are external bleeding, large/or enlarging hematoma, absent or decreased pulses distal to the site of injury, pallor, coldness, absent or decreased motor and/or sensory function, presence of a thrill and bruit if an arteriovenous fistula has developed, and ischemic pain. Arteriography is one of the most useful diagnostic aids in the management of patients with vascular injury. Smith and associates, in a well documented presentation, have shown that a significant number of patients witJ:~ normal appearing distal pulses will have proximal arterial injury and conversely, a significant number of patients with absent distal pulses will not have proximal arterial injury.9 The decision as to whether or not to obtain preoperative arteriography is frequently a difficult one. The ciecision to obtain preoperative arteriograms should only be entertained in patients in Category II or Category III, who have stable vital signs, and in whom the time delay involved in obtaining arteriograms will not jeopardize the life or limb of that patient.
INITIAL THERAPY All of the aspects of the care of the patient with vascular trauma are intimately intertwined and the presentation here should not be viewed
I
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as a "cookbook" approach to patient management. Initial therapy must include the well-known ABC's of resuscitation of the trauma patient. At times this may only involve control of the airway, intravenous access for administration of fluids, and immediate transport to the operating suite for control of hemorrhage. Patients with potential vascular injuries in association with obvious fractures of the long bones should be splinted to prevent further injury to the neurovascular structures. Patients with absent distal pulses or ischemia in association with dislocations or fracture dislocations (e.g., 90 eversion dislocations of the ankle, anterior dislocations of the shoulder, supracondylar femur fractures, tibial plateau fractures, or posterior dislocations of the knee) require immediate reduction of the dislocation to relieve the arterial entrapment or compression which may be present. The return of distal pulses and signs of viability of the portions of the extremity distal to the vascular compromise do not rule out the possibility of arterial damage and an arteriogram should be obtained in these patients. Passive and active (if indicated) immunization against tetanus should be instituted in the emergency theater as should broad spectrum antibiotic coverage. 0
INTRAOPERATIVE AND POSTOPERATIVE MANAGEMENT Control of hemorrhage is the most important intraoperative maneuver and takes priority. In penetrating wounds of the extremities this can usually be accomplished by digital pressure on the injured vessel with the surgical prepping, draping, and incision performed around the occluding finger. It is imperative in all vascular trauma, especially that of the extremities, to prep and drape both lower extremities and at least one upper extremity so that the saphenous veins and a cephalic vein are available for reconstruction purposes. Nothing is more frustrating than to need autogenous vein and not have access to it! Until we have a prosthetic material that is superior to autogenous vein in long-term patency rates, resistance to infection, and the ease with which it can be tailored to the situation at hand, it is imperative that access to autogenous veins be available when operating on patients with vascular injuries. One of the more common errors in the operative management of vascular injuries is to either not prep an extensive enough area or to drape oneself out of the operation. Once the patient has been properly prepped and draped, exposure is the next important facet. Proximal and distal control of the vessel being operated on is the sine qua non of the vascular surgery. Most major arterial injuries may be approached by longitudinal incisions overlying the course of the artery, being certain to allow oneself adequate exposure for proximal and distal control. Small incisions which compromise the ability for proximal and distal control have no place in the operative management of vascular injuries and operating through a "key-hole" is to be avoided. There are certain vessels, such as the subclavian artery and vein, which do not lend themselves to easy operative access by overlying longitudinal incisions. Access to these vessels will be covered below. When proximal and distal control has been obtained, the injured
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area of the vessel should be exposed and the extent of the injury evaluated. Branches of the vessel in the proximity of the injury should also be exposed and preserved if at all possible, especially in older individuals in whom collateral supply to the area distal to the injury may be of paramount importance. Following exposure and dissection of the injured vessel, the decision as to type of repair is made. Most longitudinal lacerations secondary to stab wounds with a knife can be repaired by lateral suture. Transected vessels can frequently be repaired by primary end-to-end anastomosis and at times it will be necessary to do quite extensive proximal and distal mobilization in order to perform the anastomosis without undue tension at the suture line. Rather than to perform an anastomosis under tension, or if large gaps are present between the ends of the injured vessel, autogenous vein should be interposed and sutured in place. Ipsilateral and/or contralateral superficial saphenous vein is available in most patients. It is imperative in all individuals to have adequate venous drainage following completion of arterial repair and this makes it important, especially in those individuals who have massive injury around the knee, to repair the major venous trunks if, indeed, they are injured and also to preserve the saphenous system on the side of the injury and to use the contralateral saphenous vein as an autogenous graft. Suture material should be synthetic monofilamentous and 5-0 caliber or smaller in most peripheral vascular repair. In those patients without severe concomitant injuries (e.g., severe closed head injuries) systemic heparinization with 5000 to 10,000 units should be employed prior to the application of vascular clamps. In those patients with concomitant injuries in whom systemic heparinization cannot be used, small amounts of dilute heparin (100 units per ml) may be injected both prOximally and distally prior to the application of vascular clamps. Proximal and distal thrombus should be removed either by flushing or the Fogarty embolectomy catheters. Most proximal thrombus can be flushed from the artery, but it must be remembered that just because there is back-bleeding from the distal segment does not mean that no distal thrombus is present and the distal segment should be cleared of all thrombus with the Fogarty embolectomy catheters. The embolectomy catheters must be inserted and used with extreme care as they can be inserted subintimally and can also damage the intima, especially in individuals who have advanced arteriosclerotic processes in their vessels.
MANAGEMENT OF SPECIFIC VESSELS Upper Extremity Vessels Isolated injury of either the radial artery or the ulnar artery infrequently leads to compromise in the blood supply to the hand. Either of these arteries can usually be ligated without undue consequences. If there is obvious impairment of the blood supply distal to the injury, it becomes imperative to repair the injured vessel. This can usually be accomplished by direct end-to-end anastomosis. Brachial artery injuries
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distal to the takeoff of the deep brachial can also usually be safely ligated but a small percentage of these patients will have rest pain and/or intermittent ischemic pain during exercise. As a general rule, restoration of blood flow is preferable to ligation of the vessel, although extenuating circumstances may make it more expeditious to ligate the vessel. If after healing of the wound, intermittent ischemic pain is a problem, a secondary procedure may be performed to restore arterial continuity. This is usually accomplished with a vein graft bypassing the area of occlusion. All axillary artery and subclavian artery injuries should be explored and arterial continuity accomplished. Trauma in and about the axillary artery poses some unique problems, especially in those individuals with the presence of distal pulses. These patients may have numbness of the forearm and hand, usually in the distribution of the median and ulnar nerves, which is secondary to contained hematoma within the facial sheath surrounding the neurovascular bundle and compressing the nerves. These patients should have immediate surgical decompression and evacuation of the hematoma around the axillary neurovascular bundle. 5 Exposure of the subclavian vessel may at times be troublesome. At times partial claviculectomy is necessary in order to adequately visualize the vessel or to obtain proximal or distal control. The proximal portion of the right subclavial artery may usually be approached from an incision in the supraclavicular position, being certain to leave the anterior chest prepped and exposed in case an extension into a medial sternotomy incision is needed. The proximal portion of the left subclavial artery is, in my opinion, best approached through a median sternotomy incision, although many of my colleagues prefer a left anterior thoracotomy. Neck Vessels The vertebral artery in its lower cervical portion, may be exposed through a transverse supraclavicular incision if the site of injury is in its proximal portion. When the injured portion of the vessel lies in the area of the vertebral bodies C2 through C6, a longitudinal incision paralleling the anterior border of the sternocleidomastoid muscle is employed. The sternocleidomastoid muscle is retracted laterally and the carotid bundle along with the larynx and pharynx are retracted medially. This exposes the longus colli which is then freed up from its attachments and retracted laterally, thus exposing the costal part of the transverse process. Resecting the anterior portion of the bony transverse process overlying the vertebral canal gives exposure to the vertebral artery.4 Certain aspects of the management of carotid artery injuries remain controversial. Carotid injuries without neurologic deficit are repaired and flow re-established. There is controversy as to how to handle the patient with carotid injury and neurologic deficit. The debate over whether to re-establish flow with carotid arterial repair or to ligate the carotid artery has not been resolved. Patients who present with no serious symptoms (Category III) but with wounds which could have possibly damaged the carotid artery should have arteriography performed.
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Lower Extremity Proximal control of the injured femoral artery may at times be a problem, especially if the injury is just distal to the inguinal ligament. In this setting, proximal control through a lower abdominal incision with a retroperitoneal approach to the external iliac artery is the best approach. Every effort should be made to re-establish flow through both the superficial artery and the deep femoral artery. This may necessitate reimplantation of the deep femoral artery into the superficial femoral artery, the vein graft, or fabrication of a compound saphenous vein graft.3 In order to accomplish a technically good result, the artery to be repaired should be mobilized proximally and distally for at least 2 cm and the ends beveled and "spatulated." The popliteal artery may be approached through either a medial skin incision or posterior skin incision. The medial approach to the popliteal vessel is recommended because it allows easier exposure of the superficial femoral artery proximally and the continuation of the popliteal artery into the posterior tibial-peroneal trunk and anterior tibial trunk distally; the exposure and securing of a greater saphenous vein segment is much easier; and last but not least, the patient is in the supine rather than prone position and untoward events are more easily dealt with. The popliteal area is probably the area where venous repair is most important. It is interesting to note that even with the experience garnered from the Korean War and with the advances that were made in vascular surgery in the 50's and early 60's, the Vietnam Vascular Registry reported a 29.5 per cent amputation rate following popliteal artery trauma. This is compared to the overall amputation rate of approximately 13 per cent. 6 Obviously, there are numerous parameters which contribute to this high amputation rate. Venous patency is probably one of the more important parameters and every effort should be made to establish venous patency following popliteal artery repair. This may mean the insertion of an autogenous vein graft in the popliteal vein area, although most popliteal vein injuries will be amenable to primary suture without the need for a vein graft. In patients with extensive popliteal artery damage, insertion of a Javid shunt proximally in the popliteal artery or distal superficial femoral artery and distally in the popliteal artery or its continuation into the posterior tibial-peroneal trunk will decrease the ischemia time and may lead to a lower failure rate in popliteal artery trauma. In patients with popliteal artery and vein damage and repair of same, fasciotomy should be routinely performed. These patients have had ischemia of all four compartments and fibulectomy-fasciotomy as described by Ernst and Kaufer should be undertaken. 2 Patients with associated fractures should have stabilization of these fractures either by internal fixation or external fixation. Ideally, it would be nice to have all fractures stabilized prior to vascular repair. Realistically, an extremity with skeletal fixation and no vascular supply places the patient in more jeopardy than a revascularized extremity without skeletal fixation. If the vascular repair is accomplished prior to skeletal fixation, care must be taken to protect the repair from bony fragments
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and from excessive tension secondary to the skeletal fixation, be it external or internal.
ABDOMINAL INJURIES Significant vascular injury with blunt trauma to the abdomen is relatively uncommon when compared to intra-abdominal vascular injuries secondary to penetrating wounds. Preoperative evaluation and diagnosis of significant vascular injury in blunt trauma is not as obvious nor as easy to make as it is in penetrating trauma. Abdominal lavage has definitely increased the surgeon's ability to diagnose hemoperitoneum in blunt trauma. Arteriography is not routinely used in abdominal vascular injuries with the exception of those patients with hematuria and in whom an intravenous pyelogram does not visualize one or both of the kidneys. These patients, if they are in a stable condition, undergo selective arteriography to determine side and site of injury. Patients who have upper abdominal penetrating wounds or blunt trauma to the abdomen are explored through a vertical midline incision. The anterior thorax should be prepped and draped so that the incision may be extended into the chest through a median sternotomy or thoracotomy. The median sternotomy extension allows for control of the supradiaphragmatic descending aorta, the inferior vena cava and right atrium, and also allows for exposure of the hepatic veins and intrahepatic vena cava if these vessels must be controlled. Lower abdominal penetrating wounds are explored through an infraumbilical transverse incision or a lower abdominal vertical midline incision. In injuries of the aorta above the renal vessels, proximal control may at time's be difficult and it may be expedient to approach the distal descending thoracic aorta in the left chest rather than to attempt to gain proximal abdominal aortic control through the gastrohepatic ligament. Most aortic injuries can be repaired with direct suturing and every effort is made to do direct arterial repair without having to resort to prosthetic material. Penetrating arterial and venous injuries may have a wound of entrance and of exit and it is important to expose the entire circumference of the injured .vessel so as not to miss an injury which may later become the site of a false aneurysm. If preoperative diagnosis of renal artery injury is made, it is best to approach the renal arteries in their proximal portion at their origin from the aorta. This is accomplished by elevating the transverse colon and moving the small bowel to the right and thus exposing the anterior surface of the aorta through an incision directly over and paralleling the aorta. This approach gives excellent control of the vessels and is more efficacious than mobilizing either the right or left colon. Injuries to the celiac trunk, superior mesenteric artery, and inferior mesenteric artery should be repaired by direct arterial suture. If this is not possible, hemostasis should be accomplished by suture ligature proximally and distally and if areas of ischemia of the gastrointestinal tract are observed, an autogenous vein bypass graft should be employed
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between the aorta and one of the branches of the vessels (e. g., hepatic artery, middle colic artery, left colic artery).
SUMMARY The word "spasm" has been purposefully omitted as it is essentially a nonentity in vascular trauma. The surgeon's ability to repair and salvage extremities has increased greatly in the last 30 years. Problem areas still exist, especially in those patients with carotid trauma and neurologic deficit and patients with massive trauma to the extremities with involvement of bone, arteries, veins, nerves, and soft tissue. There is a place and a time for primary amputation, but its role in trauma surgery has definitely decreased and should continue to do so, as long as in so doing we do not jeopardize the life of the patient.
REFERENCES 1. Barcia, P. J., Nelson, T. G., and Whelon, T. J., Jr.: Importance of venous occlusion in arterial repair failure: An experimental study. Ann. Surg., 175:223-227, 1972. 2. Ernst, C. B., and Kaufer, H.: Fibulectomy-fasciotomy: An important adjunct in the management of lower extremity arterial trauma. J. Trauma, 11 :365-380, 1971. 3. Hardy, J. D., Seshadri, R., Neely, W. A., and Berry, D. W.: Aortic and other arterial injuries. Ann. Surg., 181 :640-653,1975. 4. Henry, A. K.: Extensile Exposure. Edinburgh and London, Churchill Livingstone, 1973. 5. Molnar, W., and Paul, D. J.: Complications of axillary arteriotomies-An analysis of 1,762 consecutive studies. Radiology, 104:269-276, 1972. 6. Rich, N. M., Bauch, J. H., and Hughes, C. W.:·Acute arterial injuries in Vietnam: 1,000 cases. J. Trauma, 10:359-369, 1970. 7. Rich, N. M., Jarstfer, B. S., and Greer, T. M.: Popliteal artery repair failures: Causes and possible prevention. J. Cardiovasc. Surg., 15:340-351, 1974. 8. Rich, N. M., Johnson, E. V., and Dimond, F. C., Jr.: Wounding power of missiles used in the republic of Vietnam. J.A.M.A., 199:157, 160-61, 168, 1967. 9. Smith, R. F., Elliott, J. P., Hageman, J. H., et al.: Acute penetrating arterial injuries of the neck and limbs. Arch. Surg., 109:198, 1974.
Department of Surgery Southwestern Medical School University of Texas Health Science Center at Dallas 5323 Harry Hines Boulevard Dallas, Texas 75235
Vascular Trauma Bruce E. Brink, MD.*
Numerous articles have appeared in the surgical literature concerning vascular trauma. Most of these have addressed the problem of arterial injuries. Only recently have vascular and trauma surgeons been emphasizing the importance of also repairing the venous side of the circulation," 7 although venous gangrene has been a recognized entity for many years. In this article we will deal with arterial and venous injuries of the peripheral vasculature and their repair. Shotgun blasts and their resultant problems are covered elsewhere in this symposium. This article is organized in the following way: 1. Type of Injury
2. 3. 4. 5.
Initial Evaluation Initial Therapy Operative and Postoperative Management Management of Specific Vessel Injury
TYPE OF INJURY In the United States, most civilian vascular injuries are secondary to penetrating trauma. 9 The common offending weapons are guns and knives, with a small proportion of penetrating wounds being secondary to industrial accidents and freak home accidents. Most knife wounds cause simple lacerations and/or transections of vessels and are relatively easily handled. Gunshot wounds frequently cause much more extensive vascular and soft tissue damage. The severity of damage is influenced by the mass and velocity of the offending missile, the physical properties of the missile, and the range from which the missile was fired. Most civilian injuries are secondary to low velocity missiles, although it must be remembered that high velocity, high mass missiles can cause cavitary damage far removed from the obvious site of injury. Missile injuries carry a higher incidence for the need of some type of interposition arterial conduit than do stab wounds. Blunt vascular trauma is frequently secondary to motor vehicular accidents. The vascular injury may be due to the vessels being compressed between two immovable ':'Associate Professor of Surgery, Southwestern Medical School, University of Texas Health Science Center at Dallas, Dallas, Texas; Formerly Assistant Professor of Surgery, Wayne State University School of Medicine, Detroit, Michigan
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objects, rapid deceleration, fractures, dislocations, and fracture-dislocations of the bony skeleton.
INITIAL EVALUATION Time is of the essence in all vascular trauma! This is true either because of the threat of loss of life secondary to exsanguination or because of the threat of loss of limb or organ secondary to interruption of its blood supply. Experience has shown and common sense dictates that the earlier hemorrhage is controlled and flow restored, the better the chance for survival and functional usefulness of the devascularized area. Patients with vascular injuries can usually be grouped into one of three categories: Category I:
Patients with obvious life-threatening vascular injuries, e.g., those with a rapidly distendin,g abdomen, shock, and those in whom it is obvious that emergency exploration is mandatory. Category II: Patients with obvious vascular impairment to a body part, in whom the in,jury may be limb or organ threatening, but not life-threatening. Category III: Patients with in,juries in anatomic approximation to major vascular channels but in whom, at the time of presentation, no obvious vascular in,jury has occurred.
The management of patients in the above-mentioned categories is indeed different. A rapid, thorough physical examination must be performed on all trauma patients, especially on those with obvious injuries, so that concomitant injuries are not overlooked. Saving a life always takes precedence over saving a limb and the reversal of the aforementioned has no place in trauma surgery. The initial evaluation includes notation of the classical signs of vascular injury. These are external bleeding, large/or enlarging hematoma, absent or decreased pulses distal to the site of injury, pallor, coldness, absent or decreased motor and/or sensory function, presence of a thrill and bruit if an arteriovenous fistula has developed, and ischemic pain. Arteriography is one of the most useful diagnostic aids in the management of patients with vascular injury. Smith and associates, in a well documented presentation, have shown that a significant number of patients witJ:~ normal appearing distal pulses will have proximal arterial injury and conversely, a significant number of patients with absent distal pulses will not have proximal arterial injury.9 The decision as to whether or not to obtain preoperative arteriography is frequently a difficult one. The ciecision to obtain preoperative arteriograms should only be entertained in patients in Category II or Category III, who have stable vital signs, and in whom the time delay involved in obtaining arteriograms will not jeopardize the life or limb of that patient.
INITIAL THERAPY All of the aspects of the care of the patient with vascular trauma are intimately intertwined and the presentation here should not be viewed
I
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as a "cookbook" approach to patient management. Initial therapy must include the well-known ABC's of resuscitation of the trauma patient. At times this may only involve control of the airway, intravenous access for administration of fluids, and immediate transport to the operating suite for control of hemorrhage. Patients with potential vascular injuries in association with obvious fractures of the long bones should be splinted to prevent further injury to the neurovascular structures. Patients with absent distal pulses or ischemia in association with dislocations or fracture dislocations (e.g., 90 eversion dislocations of the ankle, anterior dislocations of the shoulder, supracondylar femur fractures, tibial plateau fractures, or posterior dislocations of the knee) require immediate reduction of the dislocation to relieve the arterial entrapment or compression which may be present. The return of distal pulses and signs of viability of the portions of the extremity distal to the vascular compromise do not rule out the possibility of arterial damage and an arteriogram should be obtained in these patients. Passive and active (if indicated) immunization against tetanus should be instituted in the emergency theater as should broad spectrum antibiotic coverage. 0
INTRAOPERATIVE AND POSTOPERATIVE MANAGEMENT Control of hemorrhage is the most important intraoperative maneuver and takes priority. In penetrating wounds of the extremities this can usually be accomplished by digital pressure on the injured vessel with the surgical prepping, draping, and incision performed around the occluding finger. It is imperative in all vascular trauma, especially that of the extremities, to prep and drape both lower extremities and at least one upper extremity so that the saphenous veins and a cephalic vein are available for reconstruction purposes. Nothing is more frustrating than to need autogenous vein and not have access to it! Until we have a prosthetic material that is superior to autogenous vein in long-term patency rates, resistance to infection, and the ease with which it can be tailored to the situation at hand, it is imperative that access to autogenous veins be available when operating on patients with vascular injuries. One of the more common errors in the operative management of vascular injuries is to either not prep an extensive enough area or to drape oneself out of the operation. Once the patient has been properly prepped and draped, exposure is the next important facet. Proximal and distal control of the vessel being operated on is the sine qua non of the vascular surgery. Most major arterial injuries may be approached by longitudinal incisions overlying the course of the artery, being certain to allow oneself adequate exposure for proximal and distal control. Small incisions which compromise the ability for proximal and distal control have no place in the operative management of vascular injuries and operating through a "key-hole" is to be avoided. There are certain vessels, such as the subclavian artery and vein, which do not lend themselves to easy operative access by overlying longitudinal incisions. Access to these vessels will be covered below. When proximal and distal control has been obtained, the injured
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area of the vessel should be exposed and the extent of the injury evaluated. Branches of the vessel in the proximity of the injury should also be exposed and preserved if at all possible, especially in older individuals in whom collateral supply to the area distal to the injury may be of paramount importance. Following exposure and dissection of the injured vessel, the decision as to type of repair is made. Most longitudinal lacerations secondary to stab wounds with a knife can be repaired by lateral suture. Transected vessels can frequently be repaired by primary end-to-end anastomosis and at times it will be necessary to do quite extensive proximal and distal mobilization in order to perform the anastomosis without undue tension at the suture line. Rather than to perform an anastomosis under tension, or if large gaps are present between the ends of the injured vessel, autogenous vein should be interposed and sutured in place. Ipsilateral and/or contralateral superficial saphenous vein is available in most patients. It is imperative in all individuals to have adequate venous drainage following completion of arterial repair and this makes it important, especially in those individuals who have massive injury around the knee, to repair the major venous trunks if, indeed, they are injured and also to preserve the saphenous system on the side of the injury and to use the contralateral saphenous vein as an autogenous graft. Suture material should be synthetic monofilamentous and 5-0 caliber or smaller in most peripheral vascular repair. In those patients without severe concomitant injuries (e.g., severe closed head injuries) systemic heparinization with 5000 to 10,000 units should be employed prior to the application of vascular clamps. In those patients with concomitant injuries in whom systemic heparinization cannot be used, small amounts of dilute heparin (100 units per ml) may be injected both prOximally and distally prior to the application of vascular clamps. Proximal and distal thrombus should be removed either by flushing or the Fogarty embolectomy catheters. Most proximal thrombus can be flushed from the artery, but it must be remembered that just because there is back-bleeding from the distal segment does not mean that no distal thrombus is present and the distal segment should be cleared of all thrombus with the Fogarty embolectomy catheters. The embolectomy catheters must be inserted and used with extreme care as they can be inserted subintimally and can also damage the intima, especially in individuals who have advanced arteriosclerotic processes in their vessels.
MANAGEMENT OF SPECIFIC VESSELS Upper Extremity Vessels Isolated injury of either the radial artery or the ulnar artery infrequently leads to compromise in the blood supply to the hand. Either of these arteries can usually be ligated without undue consequences. If there is obvious impairment of the blood supply distal to the injury, it becomes imperative to repair the injured vessel. This can usually be accomplished by direct end-to-end anastomosis. Brachial artery injuries
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distal to the takeoff of the deep brachial can also usually be safely ligated but a small percentage of these patients will have rest pain and/or intermittent ischemic pain during exercise. As a general rule, restoration of blood flow is preferable to ligation of the vessel, although extenuating circumstances may make it more expeditious to ligate the vessel. If after healing of the wound, intermittent ischemic pain is a problem, a secondary procedure may be performed to restore arterial continuity. This is usually accomplished with a vein graft bypassing the area of occlusion. All axillary artery and subclavian artery injuries should be explored and arterial continuity accomplished. Trauma in and about the axillary artery poses some unique problems, especially in those individuals with the presence of distal pulses. These patients may have numbness of the forearm and hand, usually in the distribution of the median and ulnar nerves, which is secondary to contained hematoma within the facial sheath surrounding the neurovascular bundle and compressing the nerves. These patients should have immediate surgical decompression and evacuation of the hematoma around the axillary neurovascular bundle. 5 Exposure of the subclavian vessel may at times be troublesome. At times partial claviculectomy is necessary in order to adequately visualize the vessel or to obtain proximal or distal control. The proximal portion of the right subclavial artery may usually be approached from an incision in the supraclavicular position, being certain to leave the anterior chest prepped and exposed in case an extension into a medial sternotomy incision is needed. The proximal portion of the left subclavial artery is, in my opinion, best approached through a median sternotomy incision, although many of my colleagues prefer a left anterior thoracotomy. Neck Vessels The vertebral artery in its lower cervical portion, may be exposed through a transverse supraclavicular incision if the site of injury is in its proximal portion. When the injured portion of the vessel lies in the area of the vertebral bodies C2 through C6, a longitudinal incision paralleling the anterior border of the sternocleidomastoid muscle is employed. The sternocleidomastoid muscle is retracted laterally and the carotid bundle along with the larynx and pharynx are retracted medially. This exposes the longus colli which is then freed up from its attachments and retracted laterally, thus exposing the costal part of the transverse process. Resecting the anterior portion of the bony transverse process overlying the vertebral canal gives exposure to the vertebral artery.4 Certain aspects of the management of carotid artery injuries remain controversial. Carotid injuries without neurologic deficit are repaired and flow re-established. There is controversy as to how to handle the patient with carotid injury and neurologic deficit. The debate over whether to re-establish flow with carotid arterial repair or to ligate the carotid artery has not been resolved. Patients who present with no serious symptoms (Category III) but with wounds which could have possibly damaged the carotid artery should have arteriography performed.
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Lower Extremity Proximal control of the injured femoral artery may at times be a problem, especially if the injury is just distal to the inguinal ligament. In this setting, proximal control through a lower abdominal incision with a retroperitoneal approach to the external iliac artery is the best approach. Every effort should be made to re-establish flow through both the superficial artery and the deep femoral artery. This may necessitate reimplantation of the deep femoral artery into the superficial femoral artery, the vein graft, or fabrication of a compound saphenous vein graft.3 In order to accomplish a technically good result, the artery to be repaired should be mobilized proximally and distally for at least 2 cm and the ends beveled and "spatulated." The popliteal artery may be approached through either a medial skin incision or posterior skin incision. The medial approach to the popliteal vessel is recommended because it allows easier exposure of the superficial femoral artery proximally and the continuation of the popliteal artery into the posterior tibial-peroneal trunk and anterior tibial trunk distally; the exposure and securing of a greater saphenous vein segment is much easier; and last but not least, the patient is in the supine rather than prone position and untoward events are more easily dealt with. The popliteal area is probably the area where venous repair is most important. It is interesting to note that even with the experience garnered from the Korean War and with the advances that were made in vascular surgery in the 50's and early 60's, the Vietnam Vascular Registry reported a 29.5 per cent amputation rate following popliteal artery trauma. This is compared to the overall amputation rate of approximately 13 per cent. 6 Obviously, there are numerous parameters which contribute to this high amputation rate. Venous patency is probably one of the more important parameters and every effort should be made to establish venous patency following popliteal artery repair. This may mean the insertion of an autogenous vein graft in the popliteal vein area, although most popliteal vein injuries will be amenable to primary suture without the need for a vein graft. In patients with extensive popliteal artery damage, insertion of a Javid shunt proximally in the popliteal artery or distal superficial femoral artery and distally in the popliteal artery or its continuation into the posterior tibial-peroneal trunk will decrease the ischemia time and may lead to a lower failure rate in popliteal artery trauma. In patients with popliteal artery and vein damage and repair of same, fasciotomy should be routinely performed. These patients have had ischemia of all four compartments and fibulectomy-fasciotomy as described by Ernst and Kaufer should be undertaken. 2 Patients with associated fractures should have stabilization of these fractures either by internal fixation or external fixation. Ideally, it would be nice to have all fractures stabilized prior to vascular repair. Realistically, an extremity with skeletal fixation and no vascular supply places the patient in more jeopardy than a revascularized extremity without skeletal fixation. If the vascular repair is accomplished prior to skeletal fixation, care must be taken to protect the repair from bony fragments
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and from excessive tension secondary to the skeletal fixation, be it external or internal.
ABDOMINAL INJURIES Significant vascular injury with blunt trauma to the abdomen is relatively uncommon when compared to intra-abdominal vascular injuries secondary to penetrating wounds. Preoperative evaluation and diagnosis of significant vascular injury in blunt trauma is not as obvious nor as easy to make as it is in penetrating trauma. Abdominal lavage has definitely increased the surgeon's ability to diagnose hemoperitoneum in blunt trauma. Arteriography is not routinely used in abdominal vascular injuries with the exception of those patients with hematuria and in whom an intravenous pyelogram does not visualize one or both of the kidneys. These patients, if they are in a stable condition, undergo selective arteriography to determine side and site of injury. Patients who have upper abdominal penetrating wounds or blunt trauma to the abdomen are explored through a vertical midline incision. The anterior thorax should be prepped and draped so that the incision may be extended into the chest through a median sternotomy or thoracotomy. The median sternotomy extension allows for control of the supradiaphragmatic descending aorta, the inferior vena cava and right atrium, and also allows for exposure of the hepatic veins and intrahepatic vena cava if these vessels must be controlled. Lower abdominal penetrating wounds are explored through an infraumbilical transverse incision or a lower abdominal vertical midline incision. In injuries of the aorta above the renal vessels, proximal control may at time's be difficult and it may be expedient to approach the distal descending thoracic aorta in the left chest rather than to attempt to gain proximal abdominal aortic control through the gastrohepatic ligament. Most aortic injuries can be repaired with direct suturing and every effort is made to do direct arterial repair without having to resort to prosthetic material. Penetrating arterial and venous injuries may have a wound of entrance and of exit and it is important to expose the entire circumference of the injured .vessel so as not to miss an injury which may later become the site of a false aneurysm. If preoperative diagnosis of renal artery injury is made, it is best to approach the renal arteries in their proximal portion at their origin from the aorta. This is accomplished by elevating the transverse colon and moving the small bowel to the right and thus exposing the anterior surface of the aorta through an incision directly over and paralleling the aorta. This approach gives excellent control of the vessels and is more efficacious than mobilizing either the right or left colon. Injuries to the celiac trunk, superior mesenteric artery, and inferior mesenteric artery should be repaired by direct arterial suture. If this is not possible, hemostasis should be accomplished by suture ligature proximally and distally and if areas of ischemia of the gastrointestinal tract are observed, an autogenous vein bypass graft should be employed
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between the aorta and one of the branches of the vessels (e. g., hepatic artery, middle colic artery, left colic artery).
SUMMARY The word "spasm" has been purposefully omitted as it is essentially a nonentity in vascular trauma. The surgeon's ability to repair and salvage extremities has increased greatly in the last 30 years. Problem areas still exist, especially in those patients with carotid trauma and neurologic deficit and patients with massive trauma to the extremities with involvement of bone, arteries, veins, nerves, and soft tissue. There is a place and a time for primary amputation, but its role in trauma surgery has definitely decreased and should continue to do so, as long as in so doing we do not jeopardize the life of the patient.
REFERENCES 1. Barcia, P. J., Nelson, T. G., and Whelon, T. J., Jr.: Importance of venous occlusion in arterial repair failure: An experimental study. Ann. Surg., 175:223-227, 1972. 2. Ernst, C. B., and Kaufer, H.: Fibulectomy-fasciotomy: An important adjunct in the management of lower extremity arterial trauma. J. Trauma, 11 :365-380, 1971. 3. Hardy, J. D., Seshadri, R., Neely, W. A., and Berry, D. W.: Aortic and other arterial injuries. Ann. Surg., 181 :640-653,1975. 4. Henry, A. K.: Extensile Exposure. Edinburgh and London, Churchill Livingstone, 1973. 5. Molnar, W., and Paul, D. J.: Complications of axillary arteriotomies-An analysis of 1,762 consecutive studies. Radiology, 104:269-276, 1972. 6. Rich, N. M., Bauch, J. H., and Hughes, C. W.:·Acute arterial injuries in Vietnam: 1,000 cases. J. Trauma, 10:359-369, 1970. 7. Rich, N. M., Jarstfer, B. S., and Greer, T. M.: Popliteal artery repair failures: Causes and possible prevention. J. Cardiovasc. Surg., 15:340-351, 1974. 8. Rich, N. M., Johnson, E. V., and Dimond, F. C., Jr.: Wounding power of missiles used in the republic of Vietnam. J.A.M.A., 199:157, 160-61, 168, 1967. 9. Smith, R. F., Elliott, J. P., Hageman, J. H., et al.: Acute penetrating arterial injuries of the neck and limbs. Arch. Surg., 109:198, 1974.
Department of Surgery Southwestern Medical School University of Texas Health Science Center at Dallas 5323 Harry Hines Boulevard Dallas, Texas 75235