Section 28: Vascular Trauma

Question 1

What are the 2 main types of vascular trauma?

Answer 1

Blunt and Penetrating

Question 2

What lower extrimity trauma mechanism is more lethal?

Answer 2

Blunt injuries experience mortality rates between 2% and 5%, whereas penetrating injuries generally result in fewer deaths.

Question 3

What lower extremity arterial injury results in greater mortality?

Answer 3

Proximal arteries

Question 4

What factors and injuries predict amputation?

Answer 4

Blant trauma.
Involvment of fracture.
Arterial injury.

Venous and nerve injuries do not predict amputation!!!

Question 5

“Hard Signs” of Extremity Arterial Injury?

Answer 5

• Absent distal pulse
• Palpable thrill or audible bruit
• Actively expanding hematoma
• Active pulsatile bleeding

Question 6

“Soft Signs” of Extremity Arterial Injury?

Answer 6

• Diminished distal pulse
• History of significant hemorrhage
• Neurologic deficit
• Proximity of wound to named vessel

Question 7

What is the management of patient with lower extremity Hard sign?

Answer 7

Operative exploration and repair.

Question 8

What is the management of patient with lower extremity Soft sign?

Answer 8

Complete pulse examination and Doppler pressures.
If the index is < 1.0, a further diagnostic and localization
study should be performed.

The proximity of wound to named vessel alone (without the findings above) should not prompt a localization study.

Question 9

What is the modality of choice to localization of injury in a stable patient with lower extremity soft signs.

Answer 9

CTA initial diagnostic and localization modality of choice with soft signs of extremity arterial injury.

Question 10

What arterial injuries do not mandate surgical theraphy

Answer 10

injuries that produce no active hemorrhage or distal ischemia:
small (non–flow-limiting) intimal defects and flaps.
small pseudoaneurysms.
small arteriovenous fistulas.

Keep high index of suspicion!!!

Question 11

When is endovascular treatmnet is most appropriate in extremity trauma?

Answer 11

There is no clear EBM to favore endovascular treatment.

Can be used when the morbidity difference between open and endovascular is greatest:

• Injuries to junctional vessels (such as the subclavian and iliac).
• If the traumatic vascular lesion can be safely traversed with a guide wire.
• Catheter-directed embolization in smaller
  vessels, small pseudoaneurysms and arteriovenous fistulas of the crural and deep femoral branch arteries.

Question 12

What are the 3 option for extremity arterial injury repair?

Answer 12

• End to End anastomosis.
• Debridement of artery with patch angiplasty.
• Interposition graft.

Question 13

Whan is it acceptable to use prosthetic graft as interposition graft in extremity arterial injury?

Answer 13

Arterial injury to porximal vessel (axillary or CFA) where size match with GSV may be problematic.

Question 14

Arterial demage control shunts have a very low patency in which atreries?

Answer 14

Forarm

Tibial

Question 15

What is the patency of venous demage control shunts?

Answer 15

93%

Question 16

Ligation of major extremity veins will be done if?

Answer 16

patient’s condition will not tolerate the additional operative time.

Question 17

What physical examination should be preformed before ligation of forarm artery?

Answer 17

Allen test to reveal patent palmar arch.

Question 18

If both the radial and ulnar arteries are injured. Preferance to repair what artery should be made?

Answer 18

Unlar is most commonly the dominant contributor.

Question 19

When would you consider fasciotomy after arterial injury?

Answer 19

All patients with restoration of distal perfusion after ischemia. Especially after multiple fractures or arterial injuries is present.

Thigh and upper arm for proximal arterial injury if proximal venous occlusion and outfloe is not restored.