INCIDENCE AND MANAGEMENT OF COMPLEX VASCULAR INJURY

AMONG YEMENI PATIENTS

DR ABDULKAREM ALAMERI

ENDOVASCULAR AND VASCULAR SURGEON CONSULTANT

ASS. PROF. SANAA UNIVERSITY

14th Congress of Asian Society for vascular Surgery & 8th Asian Venous Forum , Istanbul, Turkey, October 26-29, 2013

Introduction

• Complex extremity trauma involving arteries, veins, nerves, bones and soft tissues injuries remains challenging.

• Vascular and trauma surgeons are more likely to encounter these injuries.

• In past years, the great majority of complex extremity injuries in the civilian sector have been caused by blunt trauma, although in some recent series penetrating trauma has caused a majority of these injuries.

Introduction

• Combined arterial and skeletal extremity, peripheral nerves, main venous and major soft tissues trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated arterial injuries.

• Even in the most experienced trauma centers, where amputation rates approaching 70%, while less than 5% of limbs currently are lost following isolated arterial trauma.

• Limb loss most commonly is attributed to delay in diagnosis and revascularization in most published series of this unique trauma. Major nerve damage, extensive soft tissue injury which disrupts collaterals and prevents adequate vessel coverage, infection, and compartment syndrome are other reasons for such a high rate of loss of these severely compromised limbs.

Introduction

• In our prospective study, we review 850 patients in the period between January 1999 and December 2012(14years) , most commonly complex vascular injury of the extremities.

PATIENTS & METHODS

• Prospective study of 850 patients in the period between January 1999 and Desember 2012 .

• 300 patients 1999 – 2006 ( 8 years )• 250 patients 2007 – 2010 ( 4 years )• 300 patients 2011 – 2012 ( 2 years )• 760 male : 90 female (8:1).

PATIENTS & METHODS

• The diagnosis based on clinical evaluation by noting whether any hard signs are present (i.e. active hemorrhage, large expanding or pulsatile hamatoma, bruit or thrill over wound, absent distal pulses, and signs of distal ischemia—the 5 P’s: pain, pallor, paralysis, paresthesias, poikilothermy, or coolness), X-rays, Doppler,C-T angio. and angiography if needed

• Resuscitation and management of all life-threatening injuries was taken as priority over any extremity problems. Only active extremity hemorrhage was controlled by direct pressure, tourniquet, or direct clamping of visible vessels .

PATIENTS & METHODS

• Management based on Resuscitation,vascular reconstruction , fracture stabilization and fixation and rehabilitation.

• Vascular reconstructions includes ; primary repair, interposition vien or synthetic grafts,temporary intraluminal shunting, ligation of artery or vein, depridement and prophylactic fasciotomy.

• fracture stabilization and fixation mostly done by external fixation and some of them by enternal fixation.

PATIENTS & METHODS

• All patients received pre-intra-and-postoperative prophylactic antibiotics.

• Most of patients received blood transfusion ranging between 1 to 16 units(m=5u).

• Admesion in the hospital ranging between 1 day to 94 days(m=17days) and one third of total patients was admeted in intensive care unit; 1-7 days(m=2days).

• 530(62.3%) patients were referred postoperatively for management and follow-up by neurosurgeon due to associated nerve injury.

• All patients were adviced to be followed-up after discharge for vascular , orthopedic and physiotherapy (rehabilitation) management.

RESULT & DISCUSSION

• From 850 patients ; 89.4%(760) male, and 10.6%(90) female.

• Age between 5 and 75 years (mean=26 years).

Penetrating trauma

Gun-shot 560 (75%)

Stabbing 46 (6%)

R.T.A. 38 (5%)

Pump explosion 87 (12%)

Iatrogenic injury

Total

12 (2%)

743 (87 %)

Blunt trauma

R.T.A. 82 (77%)

Falling 14 (13%)

Trauma by rock

Total

11 (10%)

107 (13%)

Clinical Presentation Arrive at the Emergency Department

Acute Ischemia 279 33 %

Active hemorrhage 464 55 %

Expanding hematoma 62 7 %

Limb swelling by A-V fistulae

45 5%

Total 850 100 %

Type of Vascular Reconstruction Interposition v. graft 554 48 %

Primary artery repair 120 10 %

Synthetic graft 59PTFE=20 D=39

5 % P=2%D=3%

Legation of artery 45 4 %

Legation of vein 92 8 %

Primary vein repair 70 6 %

Vein repair by v. graft 62 5 %

Fasciotomy 162 14 %

Total 1164 100 %

Frequency of Skeletal trauma Open Comminuted Fracture

(225) 76 %

(from 297 patients)

Close Comminuted Fracture

(40) 13 %

(from 297 patients)

Joint Dislocation (32) 11 %

(from 297 patients)

Total (297) 35 % (from850 patients)

Skeletal stabilization & fixation

External fixation 231 78 %

Enternal fixation 20 7 %

P.O.P. 46 15 %

Total 297 100 %

Morbidity & Mortality RateRe-operation 36 4.2 %

Renal failure 23 2.7 %

Graft rupture (infection) 23 2.7 %

Primary amputation 28 3.3 %

Secondary amputation 34 4.0 %

Death (Mortality rate) 28 3.3 %

Con. RESULT & DISCUSSION

• The common vascular injury were femoral, popliteal, brachial, post. Tibeal, auxiliary, radial, ant.tibeal, ulnar, iliac, subclavian, carotid arteries , consecutively.

• Legation of arteries done in cases of good collateral circulation distally , in graft rupture due to sever infection and in shocked patients.

• Synthetic (Dacron or PTFE) grafts were done in situation of unavailable suitable venous grafts .

• From 23 cases of graft ruptures , 9 synthetic graft due to staphylococcus infection, and 14 were due to rupture in the body of venous graft by strepto. And staphylococcus infection.

Con. RESULT & DISCUSSION

• Legation of injured veins, while repair consuming time, commonly done in shocked patients, and in non-main veins.

• Fasciotomy commonly done in extremities with combined arterial and venous injuries, significant blunt soft tissue injury, more than 6 hours of limb ischemia, or occlusive popliteal injuries are susceptible to compartment syndrome.

• The causes of reoperations were bleeding from anastamosis, wound or rupture graft, and developing of ischemia due to anastamosis occlusion.

Con. RESULT & DISCUSSION

• Primary amputation was usually decided when associated with a worse prognosis for limb salvage; like Prolonged ischemia (>4-6 hours)/muscle necrosis, Crush or destructive soft tissue injury, neurovascular injury with bone fracture or mangled extremity.

• The 34 Secondary amputation was usually decided after initial attempts at limb salvage when any adverse in extremity on the patient’s health, i.e. sepsis, rhabdomyolysis, hyperkalemia, ARDS, or other life-threatening problems mandate immediate secondary amputation.

• Common causes of mortality; irreversible hemorrhagic shock, septic shock, DIC or cardiogenic shock.

risk factors increase morbidity & mortality rate

• Far distance injured patients.

• difficulty in transportations and Late arriving.

• Shortage of vascular surgeons and facilities especially in civilian wars and crisis .

• consuming the time by patients, relatives and/or medical staff.

• jumping several hospitals.

• Miss diagnosis of vascular injury.

• rare blood group.

• cost effectiveness.

• refuse decision of management and Lake of confidence .

Conclusions & recommendations

• Vascular injuries need urgent decision making in diagnosis and management.

• The importance of expert vascular surgeons with good facilities in different areas of the country to cover the urgent vascular intervention in time and place.

• Urgent vascular intervention within the golden time will decrease the morbidity and mortality rate.

• To be familiar with the criteria for early amputation in complex extremity trauma will minimize the complications on the patient’s health and life salvage .

• higher rate of limb salvage among combined vascular and skeletal extremity injuries in which revascularization is performed first.

• Long follow up with team work of vascular , orthopedic, neurosurgeon , psychologist and physiotherapist doctors.