Vascular injuries

Characteristics
Vascular injuries are injuries resulting from accidental trauma - criminal, traffic, industrial and iatrogenic injuries ( catheterization, surgery).

Open injuries

 * Disruption of a blood vessel - partial, tangential, lateral or complete.
 * Gunshot wounds – severe laceration; the degree of laceration is directly proportional to the speed of the bullet.
 * Iatrogenic - most commonly a. femoralis in catheterizations.
 * Injuries to the aorta and pelvic arteries during neurosurgery (laminectomy after disc herniation) and orthopedic surgery (hip alloplasty) are serious.
 * In abdomial and thoracic operations - injuries of the portal vein, vena cava, azygos vein are difficult to resolve.

Closed injuries

 * They are caused by contusion, hematoma compression, oppression or rupture by bone fragments.
 * Arterial thrombosis in fractures and dislocations of the knee and elbow joint are typical.
 * The main mechanisms - thrombosis, closure of the lumen by rupture of the intima, which detaches with blood pressure closes the lumen, vasospasm.
 * Thrombosis is the most common - that's why we consider every blunt injury to be thrombosis.
 * Deceleration injury - mainly affects the thoracic aorta (or mesenteric or renal arteries).
 * Wall ruptures up to total avulsion may occur.
 * In traumatic thrombosis, the time factor is very important - no collateral flow is developed.

Clinical picture

 * Pulsations reduction or disappearance, major bleeding with hypotension, large or increasing haematoma, murmur at the site of injury, neurological deficiency, ischemia → these symptoms are indications for surgical exploration or angiography.
 * After an artery rupture, the ends of the vessel may retract due to vasospasm.
 * When hypotension occurs, major bleeding may also occur spontaneously (usually temporarily).
 * Soft, fresh thrombus can also transmit pulsations over a certain distance.

Therapy

 * It is often part of polytrauma → we pay attention to the overall condition.
 * We usually administer an i. v. ATB, general heparinization is not usually recommended (unless it is isolated damage).
 * Exploration- in CA, skin incisions are made longitudinally (to allow them to be extended).

Arterial injuries

 * 1) Direct injuries
 * 2) *Sharp (penetrating - stabbing, cutting, shooting, iatrogenic, amputation…)
 * 3) **Grade 1 – injury of adventitia event. media.
 * 4) **Grade 2 – injury to all layers of the wall, does not affect the entire circumference of the artery.
 * 5) **Grade 3 – complete arterial rupture.
 * 6) *Blunt (contusion, compression, constriction)
 * 7) **Grade 1 – a tear in the intima, no bleeding, usually no ischemia.
 * 8) **Grade 2 – rupture in the intima and media, no bleeding, usually thrombosis with peripheral ischemia.
 * 9) **Grade 3 – the rupture affects all layers of the wall, thrombosis or closure of the intimal lobe causes ischemia, in large arteries it can perforate the hematoma in the adventitia with major bleeding.
 * 10) Indirect injuries
 * 11) *Deceleration, vasospasm,

Sharp arterial injuries

 * The damage begins from the surface of the artery towards the lumen.

Consequences and clinical symptoms:


 * Bleeding, leading to hemorrhagic shock (hypovolemia).
 * Peripheral ischemia.
 * Grade 1 injuries may result in secondary rupture or late false aneurysm.
 * Grade 2 injuries, the bleeding can stop spontaneously by the pressure of the surrounding tissues and hematoma.
 * Grade 3 injuries, bleeding can be stopped spontaneously by constriction of both ends of the broken artery.

Therapy:


 * First aid- applying compressive bandage or compression of artery in or above the wound (pressure points, tourniquet).
 * Definitive treatment - suturing of a bleeding vessel (usually straight edges).

Blunt artery injuries

 * Damage begins in the intima and goes to the media and adventitia, dissection can occur.
 * There is a simultaneous contusion of the soft tissues near the artery, often a concomitant injury to the bones and joints.
 * Signs of peripheral ischemia without signs of bleeding are typical.
 * Surgical reconstruction of the affected area is usually necessary.

Indirect arterial injuries

 * Deceleration of the thoracic aorta ( dissection, rupture).
 * Dragging of the artery - mostly in luxation of joints and dislocated fractures near arteries, the basis is the rupture of the intima and media, the injured artery does not bleed but there is ascending and descending thrombosis with peripheral ischemia.
 * Traumatic vasospasm – very rare, myogenic cause (spasm, subside within 24 hours), clinically peripheral ischemia lasting more than 3 hours and persistent; arteriography diagnostics and event. surgical revision; treatment with local application of papaverine or balloon dilatation.

Diagnosis of arterial injuries

 * Clinical - external or internal bleeding with shock, increasing hematoma, ischemia below the site of injury.
 * Imaging methods:
 * limbs: duplex ultrasound, Doppler pressure measurement on peripheral arteries, angiography, MRI;
 * chest: chest X-ray and CT, MRI, aortography, pericardial puncture, hemothorax puncture;
 * abdomen: ultrasound of the abdomen, aortography, diagnostic peritoneal lavage, laparoscopy.
 * Surgical revision of diagnostic uncertainties (especially blunt injuries with ischemia without bleeding).

Treatment of arterial injuries

 * 1) První pomoc – temporary stoppage of bleeding (pressure bandage, manual compression of the artery in the wound or above the wound - pressure points), volume therapy.
 * 2) Final treatment – the limb lasts 4-6 hours, then irreversible changes occur, during the reconstruction it is possible to maintain perfusion by inserting a plastic shunt, which is pulled out just before the completion of the suture.
 * 3) *Suture simple or with an operation with venous graft
 * 4) *Resection of the damaged part of the artery with an end-to-end anastomosis.
 * 5) *Reconstructive venous graft surgery (preferably v. Saphena magna ) - interpositum, bypass.
 * 6) *Exceptionally artery ligation (small arteries below the elbow or below the knee - but it is necessary to reconstruct at least one artery to maintain sufficient circulation, for large soft tissue defects preventing temporary arterial reconstruction cover, for mass accidents due to time pressure and polytrauma ).
 * 7) *In case of combined injuries of bones, veins and nerves:
 * 8) **stabilize fractures, treat dislocations;
 * 9) ** vein reconstruction;
 * 10) ** arterial reconstruction (if ischemia is significant and prolonged, the artery should be reconstructed first);
 * 11) ** nerve reconstruction;
 * 12) ** provide cover with vital surrounding tissues (muscle, skin).

Consequences of arterial injuries and their treatment

 * Posttraumatic occlusion (ligation, thrombosis).
 * Arterial aneurysm and pseudoaneurysm.
 * Traumatic AV fistula.
 * Arterial embolism.
 * Compartment syndrome.
 * Reperfusion syndrome.

Vein injuries
Injuries of limb veins - clinically large non-pulsating bleeding of dark blood from the site of penetrating injury, large non-pulsating hematomas.

Vein injury treatment
Compression with elevation of the limb is indicated in first aid, foreign bodies are removed from the wound only during the final treatment (venous reconstruction with venous grafts, ligaments very rarely), under the threat of compartment syndrome we perform fasciotomy, postoperative heparinisation and warfarinisation (if the nature of any associated injuries allows), full thromboembolic disease prevention.


 * 1) Temporary management of venous bleeding
 * 2) *Tamponade made from dressing soaked in warm physiological solution (up to several days - thrombosis of the injured vein).
 * 3) Definitive management of vein bleeding
 * 4) *Vein reconstruction:
 * 5) **plain or plastic suture (venous patch);
 * 6) **injured vein resection and end-to-end direct anastomosis;
 * 7) ** resection of injured vein with venous graft interposition.
 * 8) *Ligation:
 * 9) **limb veins - below the knee and elbow can be ligated, above the joints - at least one deep vein should be cleared;
 * 10) **superior vena cava – can be ligated (SVC syndrome, but collateral circulation gradually develops);
 * 11) **inferior vena cava– can be ligated subrenally event. between the renal and hepatic veins (collateral circulation), cannot be ligated over the hepatic veins;
 * 12) **inferior mesenteric vein and splenic vein – can be ligated;
 * 13) **superior mesenteric vein, portal vein – there is a risk of intestinal infarction, in portal vein hepatic encephalopathy may occur.

Consequences of vein injuries and their treatment

 * Postoperative venous bleeding.
 * Postoperative thrombosis reconstruction - collateral circulation is created, not indicated for reoperation, thromboembolic disease prophylaxis.
 * Infection of the reconstruction.
 * AV fistula in case of simultaneous injury of artery and vein.

Source

 * BENEŠ, Jiří. Study materials  [online]. [feeling. 6/28/2010]. < http://jirben.wz.cz >.