1.

Vascular Injury
2. Vascular Repair
3. Vascular Healing
Open fracture
Irreducible dislocations
Vascular injury
Compartment syndrome
Unstable pelvic fracture/ hemodynamic instability
Multiply-injured patient
Spinal cord injury
Displaced femoral neck and talar neck fractures
 “the clock starts ticking”
• Blood loss
• Progressive ischemia
• Compartment syndrome
• Tissue necrosis

Irreversible damage after 6 hours

Increased incidence with:
 Proximity of vessels to bone
 Tethering of vessels at joints
 Superficial location of vessels
Clavicle fracture subclavian artery
Shoulder fx/dislocation axillary artery
Supracondylar humerus fx brachial artery
Elbow dislocation brachial artery
Pelvic fracture gluteal arteries
iliac arteries
Femoral shaft fx femoral artery
Distal femur fracture popliteal artery
Knee dislocation popliteal artery
Tibial shaft fx tibial arteries
Uncommon
• 3% of long bone fractures
Specific circumstances
• Fractures with Gun Shot Wound (GSW)
(up to 38%)
• Knee dislocations (16-40%)
  Penetrating trauma
 GSW
 Stab
 Blunt trauma
 High energy
 Low energy
 Iatrogenic

Blunt trauma with 27% amputation rate vs 9% for

penetrating in Natl Trauma Database,
Mullenix PS, et al. J Vasc Surg 2006
 Vascular Injuries

 Orthopedic Injuries

 Wound Management

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 Spasm
 Intimal flaps
 Subintimal hematoma
 Laceration
 Transection
 Thrombosis/Occlusion
 A-V fistula

Some require treatment, some do not

 Blood loss
 Ischemia
 Compartment syndrome
 Tissue necrosis
 Amputation
 Death
 Physical exam
 Doppler pressure (Ankle/brachial systolic
pressure index (ABI))
 Duplex scanning
 Arteriogram
 Exploration
 Physical exam
 Doppler pressure (Ankle/brachial systolic
pressure index (ABI))
 Duplex scanning
 Arteriogram
 Exploration
Careful physical exam and high
index of suspicion are most
important !
 Major hemorrhage/hypotension
 Arterial bleeding
 Expanding hematoma
 Altered distal pulses
 Pallor
 Temperature differential between
extremities
 Injury to anatomically-related
nerve
 ABI < 0.90 is 87% sensitive and 97% specific for arterial injury
 Hard signs
 Observed pulsatile bleeding
 Arterial thrill by manual palpation
 Bruit auscultated over or near area of arterial injury
 Absent distal pulse
 Visible expanding hematoma
 Soft signs
 Significant hemorrhage by history
 Neurologic abnormality
 Diminished pulse compared to contralateral extremity
 In proximity to bony injury or penetrating wound
 Decreased capillary refill
 Hemorrhage
 Pulsatile
 Exsanguinating
 Expanding hematoma

 Bruit

 Thrill

 Ischemia (“6 P’s”)

 Absent pulse
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 History of significant hemorrhage

 Hematoma: small, non-expanding

 Neurologic deficit (non-progressive)

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 Pressure Index: Ankle Bracheal Index(ABI)
 Sensitivity: 45-95% for wounds requiring OR
 The ABI is an easy to perform non-invasive test which
compares the highest systolic brachial pressure to the
highest ankle pressure by dividing the ankle pressure by
the brachial pressure.
 The resulting number is the Ankle Brachial Index.
 A number below .99 shows the presence of decreased
arterial blood flow.

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 Arteriogram
 Sensitivity: 98%
 Specificity: 99%
 Too Sensitive:
 4% False Pos --> unecessary OR
 Expensive
 Thrombosis / Allergic reaction Risk
 Duplex
 Sensitivity: 50-60% (compared to angio)
 Sensitivity: 100% (wounds requiring OR)
 Specificity: 99-100%

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 Asymmetric pulses warrant doppler
examination (determine ABI)

 Absentpulses warrant emergent

vascular consultation/surgical
exploration
 Determine presence/absence of arterial supply
 Assess adequacy of flow

PRESENCE OF SIGNAL DOES NOT EXCLUDE

ARTERIAL INJURY !
 Abnormal ABI < 0.90
 Does not define extent or level of injury
 Abnormal values warrant further evaluation
 ABI > 0.90 can be observed (i.e. no arteriogram)

Mills, et al. J. Trauma 2004

 Noninvasive
 Safe
 Rapid
 Reliable for
 Injury to arteries and veins
 A-V fistulas
 Pseudoaneurysms
 Requires technician and scanner availability

 Not all surgeons will operate based on duplex

information alone
 Locates site of injury
 Characterizes injury
 Defines status of vessels
proximal and distal
 May afford therapeutic
intervention
Identify and control (i.e.
embolization) bleeding
from pelvic fractures
 Expensive
 Time-consuming
 Difficult to monitor/treat trauma patient in
angiography suite
 Procedural risks
 Renal burden from dye
 Possibility of anaphylaxis
 Injury to proximal vessels
 Alternative to conventional angiography
 Good sensitivity and specificity
 Costs much more

ANGIOGRAPHY WILL DELAY

REVASCULARIZATION. It is not indicated in
cases with absent pulses/complete transection,
which should go immediately to surgery

Redmond, et al. Orthopedics 2008

 Level and type of vascular injury
 Collateral circulation
 Shock/hypotension
 Tissue damage (crush injury)
 Warm ischemia time
 Patient factors/medical conditions
 Rapid resuscitation
 Complete, rapid
evaluation
 Urgent surgical
treatment

PROTOCOL IS ESSENTIAL !
 Control bleeding
 Replace volume loss
 Cover wounds
 Reduce
fractures/dislocations
 Splint
 Re-evaluate
 Reduce, stabilize, resuscitate

No pulses Asymmetric pulses Normal exam

Injury Multilevel Doppler

obvious injury ?

ABI <0.9 ABI >0.9

Angiography
or duplex
Observation
Surgery
Modified from Brandyk, CORR 2005
 Who goes first?
 Temporary shunts
 Fracture stabilization
 Salvage vs amputation
 Fasciotomies
 Who goes first? Discuss with vascular surgeon

 Temporary shunts Will benefit some patients

 Fracture stabilization Consider provisional ex fix

 Salvage vs amputation Trend toward salvage

 Fasciotomies Prophylactic after Ischemia

 Single view in operating
room
 Rapid
 Excellent for detecting
site of injury
Immediate exploration is
indicated for:
 Obvious arterial injury on exam
 No doppler signal
 Site of injury is apparent
 Prolonged warm ischemia time
 Minimal arterial injury
 Nonocclusive intimal flap
 Segmental arterial narrowing
 Small false aneurysms
 Small AV fistulas

 Only 10% end up requiring intervention

 No objective criteria to define

 Likelihood of patient follow - up is most critical in decision

to treat (also overall burden of trauma, size of defect)
 Obtain proximal and distal control outside of hematoma and
away from area of active bleeding
 Use extensile exposure that can be carried proximally and distally
 Examine full extent of injury
 Key factor is integrity of the intima
 Most require end - to - end anastamosis or interposition graft –
transected artery retracts a surprising distance
 Fogarty thrombectomy of proximal and distal end of injury is required
prior to repair
 Intraop arteriogram indicated if outflow questionable
 Contralateral saphenous vein preferred, though ePTFE can be used
above the knee (more resistant to infection than other grafts)
Arterial Injuries – Iliac / Femoral

• Iliac artery injuries are among the most

lethal (up to 50% mortality)
• Deep femoral artery injuries should be
repaired
Arterial Injuries - Popliteal
• Popliteal artery injuries result in limb loss more often
than any other peripheral vascular injury. Amputation
rate up to 20% - mainly from associated soft tissue/bone
injuries
• Poorly developed collaterals around knee – delays in
diagnosis and treatment can be unforgiving
• Up to 40% have associated popliteal vein, tibial artery(s )
or tibial nerve injury
• Posterior dislocation of the knee is associated with
popliteal artery injury in one of every 3 to 5 patients, but
other types of blunt trauma around the knee, such as a
bumper injury to the proximal tibia or any injury that
causes an unstable knee joint, are also likely to damage
the artery.
 Arterial Injuries - Popliteal

• The key to avoiding undue delays is a high index of

suspicion and a low threshold for angiography whenever
significant blunt trauma has affected the area around the
knee.
• In the absence of associated injuries, some surgeons
administer IV heparin preoperatively to prevent thrombosis
of the distal capillary bed, a major concern with popliteal
injuries
• In the absence of active bleeding from the injured popliteal
artery, a more expedient approach is a bypass and exclusion
technique.
• Abnormal pedal pulse 85% sensitive and 93% specific for
pop A injury
• Postop anticoagulation improves limb salvage rates
Arterial Injuries - Tibial

• Can generally ligate/embolize single vessel

injuries
• Injury to TP trunk or more than one
infrapopliteal artery requires repair
• Associated nerve, bone and soft tissue
injuries typically determine success of limb
salvage
Arterial Injuries – Upper Extremity
• Subclavian/axillary arteries are usually associated with
major fractures and brachial plexus and venous injuries
– High (40 - 75%) mortality with subclavian a. injury
– First rib fracture/dislocation – high incidence of subclavian injury
• Only 20% of patients will have diminished/absent pulse
• Brachial a. injuries are most commonly associated with
supracondylar humeral fractures
– Penetrating injuries are frequently iatrogenic
• Most isolated ulnar or radial artery injuries can be ligated
with impunity. An ischemic hand (due to an incomplete
palmar arch or injury to both arteries) requires an
arterial reconstruction, preferably the ulnar
Venous Injuries
• Most commonly injured veins:
– Superficial femoral = 42%
– Popliteal = 23%
– Common femoral = 14%
• If injury is localized, patient is stable and end - to - end
repair or lateral venorrhaphy is possible then should
repair
– Interposition or spiral graft repairs are more controversial
• 40% of venous repairs will thrombose within 1 week
(60% if interposition graft used)
• Patency is proportional to proximity to heart (due to
higher flow rates)
• Limb salvage is typically 100% regardless of status of
repair
• Low rates of chronic edema (2%) – independent of
whether vein was repaired or ligated
Complex Injuries
(bone, nerve, soft tissue)
• 5% incidence of combined bone/vascular
• Duration of ischemia is critical to outcome, thus
perform arterial repair first (and reinspect after
fixation prior to closure)
• For massive trauma where limb is too unstable,
place temporary shunt prior to rapid orthopedic
external fixation followed by definitive vascular
repair if hemodynamically stable
– Shunt can remain patent for over 3 hours without
systemic anticoagulation
• Must debride nonviable tissue at initial procedure
• Low threshold for takeback in 1 - 2 days
Complex Injuries
(bone, nerve, soft tissue)
• Nerve injury usually determines long term
functional status of the extremity
– 50% of upper extremity and 25% of lower
extremity vascular injuries
• Clean nerve transection repair primarily
at initial procedure
• Other nerve injuries – tag each end with
nonabsorbable suture for future
repair/graft
Complex Injuries: Mangled Extremity
• Mangled extremity = injury involving three of
four tissues (bone, soft tissue, vessel, nerve)
• Decision to amputate is a team decision
(vascular, ortho , plastics) typically made in the
OR after full assessment:
– Nerve continuity/function is most critical
– Vascular injury is usually less critical
– Must be able to cover vascular reconstruction with
viable soft tissue
– Total ischemic time
• A totally interrupted distal innervation , extensive
soft tissue destruction, and bone loss exceeding
6 cm in length all portend a grave prognosis for
the limb.
 Vascular injuries are dynamic

 Evaluation should continue after the initial injury or

surgery

 Additional debridement and/or fixation undertaken

after successful revascularization
 Circulation
 Neurologic function
 Compartment pressures
1. Adequate exposure
2. Proximal & distal control
3. Careful & gentle handling of the tissues
4. Heparinization before clamping the vessels
5. Appropriate diameter of the anastomosis in
relation to the vessel size
6. Endothelium to endothelium approximation
7. Monofilament non absorbable sutures
8. Full thickness sutures
9. Small bites, evenly displaced along the
anastomosis
10. No tension at the anastomosis line or knots
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 Arterial- Arterial anastomosis
 End to end
 End to side
 Side to side
 Interposition prosthetic graft
 Arterial- Veinous anastomosis
 End vein to side artery
 End vein to end artery
 Veinous- veinous anastomosis
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I. Interrupted sutures technique
II. Continuous single suture techniques
 Open
 Closed
III. Continuous double suture technique
 Open
 Closed

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Closed

57
closed

58
open

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60
61
62
63
I. Technical factors
II. Graft related factors
III. Patient related factors
IV. Drug management

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The most significant factor in
patency of vascular anastomosis is
flawless surgical technique

- Small pieces of adventia caught in the

anastomosis can cause platelet thrombus
formation
- large bites may decrease the diameter of
the lumen& invites thrombus formation
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 Gentle handling of the tissues
 Heparinization before clamping
 Full thickness bites
 Approximation of the endothelium
 Avoid tension on the anastomosis
 Appropriate anastomosis diameter
compared to the vessel size
 Size, shape & type of needles & sutures

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Mechanical factors related to the needle:

◦ Needle tip configuration

◦ Needle body configuration
◦ Needle curvature
◦ Suture diameter

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68
Surgical Skill:
 Approximation of intima to intima
 Angle of the needle
 Bite of suture
 Suture tension
 Number of stitches
 Knots tension
** Clip applicators (new trends)
• Improved results especially with artificial grafts
• Higher coast compared to sutures

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71
iii. Vessel Preparation:
– Proper shape of the graft end (lazy S shape
)
– Proper size of the graft end
– Avoid mechanical dilatation
– Avoid intimal injury and manipulation
– Appropriate length of arteriotomy incision
– Use atraumatic clamps & instruments
– Reduce the duration of clamp application

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73
 Arterial conduits
 LIMA & RIMA
 Radial artery
 Gastro-epiploec artery
 Vein conduits
 Great saphenous vein
 Umbilical vein
 Prosthetic grafts
 PTFE (Gore Tex)
 Dacron (woven, netted, +/- velour)
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 Vessel size (less than 1.5 mm)
 Vessel quality (thin or friable vessels)
 Disease proximal to the anastomosis (in
flow)
 Disease at the site of the anastomosis
 Disease distal to the anastomosis (out
flow)

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 Heparin
 papaverine
 Aspirin
 Clopidogrel (plavix)
 Persantine (dipyridamole)
 Cardiazem
 Verapamil
 warfarin

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1. Adequate exposure
2. Proximal & distal control
3. Careful & gentle handling of the tissues
4. Heparinization before clamping the vessels
5. Appropriate diameter of the anastomosis in
relation to the vessel size
6. Endothelium to endothelium approximation
7. Monofilament non absorbable sutures
8. Full thickness sutures
9. Small bites, evenly displaced along the
anastomosis
10. No tension at the anastomosis line or knots
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 Ischaemic muscle is highly
sensitive to stretch, it should be
tested by stretching them – when
the toes or fingers are passively
hyperextended there is increase
pain in the calf or forearm.
 The presence of a pulse does not
exclude the diagnosis.
 In doubtful cases the diagnosis
can be confirmed by measuring
the intracompartmental
pressure.
 The threatened compartment must
be promptly decompressed. Cast,
bandage and dressing must be
completely removed.

 A differential pressure between

diastolic and compartment should be
monitored, if it falls below 30 mmHg,
immediate open fasciotomy is
performed
 Complications:
 Hemorrhage
 Thrombosis / Emoblism
 Aneuryism / pseudoaneuryism
 Compartment syndrome

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 Low Velocity
 Drill Hole
 Divot
 High Velocity
 Complicated
 Comminuted
 Fragments act as 2o missiles
 Stab wounds

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Needle type Description Typical application
Intestinal The hole made by this needle is Gastrointestinal tract;
no larger than the diameter of the biliary tract; dura;
needle. The hole is then filled by the peritoneum;
material, which reduces the risk of urogenital tract;
leakage. vessels; nerve
Heavy In some situations where particularly Muscle; subcutaneous
strong needles are required, a heavy fat; fascia; pedicles
wire diameter needle would be
appropriate
Blunt taperpoint Where needlestick injury is a major Uterus; pedicles;
concern, the blunt taperpoint needle muscle; fascia
virtually eliminates accidental glove
puncture

Blunt point This needle has been designed for Liver; spleen; kidney;
suturing extremely friable vascular uterine cervix for
tissue. incompetent cervix
84
Needle type Description Typical
application
Tapercut™ This needle combines the initial Fascia; ligament;
penetration of a cutting needle with uterus; scar
the minimised trauma of a round- tissue.
bodied needle. The cutting tip is
limited to the point of the needle,
which then tapers out to merge
smoothly into a round cross-
section.
Cutting This needle has a triangular cross- Skin; ligament;
section with the apex on the inside nasal cavity;
of the needle curvature. The tendon; oral.
effective cutting edges are restricted
to the front section of the needle.
Reverse cutting The body of this needle is triangular Skin; fascia;
in cross-section with the apex on ligament; nasal
the outside of the needle curvature cavity; tendon;
oral.
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