Management Of Vascular Injuries Research Articles

A survey of entry techniques and complications of members of the Australian Gynaecological Endoscopy Society.

To identify various aspects of laparoscopic entry technique and visceral injury experienced by members of the Australian Gynaecological Endoscopy Society (AGES). A retrospective mailed survey. All members of the Australian Gynaecological Endoscopy Society (AGES). Numbers of bowel and major retroperitoneal vascular injuries experienced, entry techniques utilised, alternative entry sites. Of the respondents, 73% use a Veress needle entry. In subjects with an increased risk of peri-umbilical adhesions 83% of respondents use an alternate site of entry, 66% of which use Palmer's point. Sixty-four per cent of respondents had experienced one or more bowel injuries, 21% had experienced major retroperitoneal vascular injury, 33% of respondents had no plan in place for the management of vascular injury and 51% of respondents would alter their clinical practice if accepted entry technique guidelines were available. The majority of respondents use the Veress needle method of entry, have had at least one entry-related bowel injury and use Palmer's point as an alternative entry site in high-risk subjects. The majority of subjects would alter their clincal practice if accepted entry technique guidelines were available.

Role of Vascular and Interventional Radiology in the Diagnosis and Management of Acute Trauma Patients

Vascular and interventional radiology provides an important service in the diagnosis and management of the acute trauma patient. Historically angiography was used primarily as a diagnostic tool for both vascular and solid organ injuries. However, with technological advances, such as the advent of stents, stent grafts, newer embolization materials and sophisticated delivery devices, micro-catheters, and steerable guide wires, vascular and interventional radiology can now offer definitive treatment in selected cases. Transcatheter embolization can effectively treat acute hemorrhage and is useful in locations that are difficult to access surgically, or when surgical disruption of fascial planes, which may eliminate a tamponade effect, is less desirable. Stents and stent grafts have been used to preserve, rather than sacrifice, an injured blood vessel. In splenic, hepatic, and renal trauma, a trend in nonoperative management has been developed by traumatologists. Transcatheter embolization can increase the success rate of nonoperative management in selected injuries. In general, despite the injury grade, if evidence of ongoing hemorrhage is present, angiography and transcatheter embolization should be considered. Peripheral vascular injuries can be treated with transcatheter embolization or stents and stent grafts. Transcatheter embolization in trauma was first applied to bleeding associated with pelvic fractures and dislocations, and continues to be an important treatment option. Carotid and vertebral artery injuries can now be repaired using stents or stent grafts, although the experience of this treatment strategy is somewhat limited. Likewise, acute traumatic aortic injury has been successfully treated with stent grafts in small series. Conventional catheter thoracic aortography is now used as an adjunctive diagnostic test for indeterminate or questionable findings on noninvasive imaging studies, primarily computed tomography scans of the chest. In summary, vascular and interventional radiology maintains an important role in the diagnosis and management of acute vascular and solid organ injury. The following review illustrates its current status in acute trauma.

Diagnosis and management of thoracic and abdominal vascular injuries

Thoracic and abdominal vascular injuries present a formidable challenge to the most experienced surgeon. As prehospital care improves, more patients with these injuries are reaching the hospital alive. Thus, the trauma surgeon must be prepared to deal with them rapidly and precisely. Hemodynamically unstable patients should be transferred directly to the operating room. In stable patients with penetrating thoracic wounds, chest X-ray and arteriography are typically employed to exclude vascular injury. Patients sustaining blunt chest trauma can be screened effectively with CT scanning. Incisions are chosen based on the injured vessel. Hemorrhagic shock is the usual presentation for abdominal vascular trauma. A high index of suspicion is critical in diagnosing occult injuries. This presentation reviews the etiology, diagnosis, and treatment of major thoracic and abdominal vascular injuries.

An historical tour of vascular injury management: From its inception to the new millennium

Advances have been made in times of war. Lessons learned from these experiences should be studied in order to avoid the costly mistakes made previously. Fortunately, major conflicts have not been common recently. Therefore, military surgeons depend on the stable environment of civilian trauma and research to lead the way. Documentation and careful record keeping such as the Vietnam Vascular Registry are vital in assisting surgeons with lessons to be learned.

Civilian Gunshot Injuries to the Spine: Diagnostic Procedures and Therapeutic Concepts

Background: While gunshot injuries to the spine represent a well-recognized entity in the United States, they remain a rare injury pattern in Central Europe. Thus, many European trauma centers lack a routine in diagnostic algorithms and therapeutic concepts for these injuries. Patients and Methods: This retrospective study was designed to analyze the overall injury pattern, the extent of spinal instability and neurologic deficit, and the incidence of spinal infections in all patients admitted to the Division of Trauma Surgery at the University Hospital of Zurich, Switzerland, between 1992 and 1999. During this 8-year period, 822 patients were admitted for spinal injuries, of which twelve cases (1.5%) were due to gunshot wounds. Of these, ten patients had a primary neurologic impairment (paraplegia: n = 7; partial neurologic deficit: n = 3), and only two patients were neurologically normal. The initial therapeutic concept consisted in stabilization of vital functions; in particular, the management of concomitant vascular, thoracic, and abdominal injuries had the highest priority. All wounds were surgically debrided and systemic antibiotics were applied for a limited time, approximately for 3 days after trauma. Laminectomies were performed in five patients. Only one patient with spinal instability required internal fixation. Results: No neurologic recovery was seen in any of the patients with primary neurologic deficits, and neither early laminectomy nor the application of steroids had a positive effect. No spinal infection was noted in any of these patients. Conclusions: We recommend early stabilization, aggressive surgical debridement, and periopertive antibiotic prophylaxis for all spinal gunshot injuries. Decompressive laminectomy and the application of steroid do not seem to have a positive effect on the neurologic recovery of these patients.

Abdominal impalement injuries

Impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. With reference to our own seven patients we discuss the initial management and the operative treatment of this rare injury. Further we demonstrate the imminent problems after impalement injuries such as removal of the impaled object, treatment of colon- and other abdominal organ injuries, and management of vascular injuries.

Vascular complications in high-performance athletes

Purpose: The purpose of this study was to evaluate our experience with the diagnosis and management of vascular injuries in a group of high-performance athletes. Methods: Between June 1994 and June 2000, we treated 26 patients who sustained vascular complications as a result of athletic competition. Clinical presentation, type of athletic competition, location of injury, type of therapy, and degree of rehabilitation were analyzed retrospectively. Results: The mean age of the patients was 23.8 years (range, 17-40). Twenty-one (81%) patients were men, and five (19%) were women. Athletes included 8 major-league baseball players, 7 football players, 2 world-class cyclists, 2 rock climbers, 2 wind surfers, 1 swimmer, 1 kayaker, 1 weight lifter, 1 marksman, and 1 volleyball player. There were 14 (54%) arterial and 12 (46%) venous complications. Arterial injuries included 7 (50%) axillary/subclavian artery or branch artery aneurysms with secondary embolization, 6 (43%) popliteal artery injuries, and 1 (7%) case of intimal hyperplasia and stenosis involving the external iliac artery. Subclavian vein thrombosis (SVT) accounted for all venous complications. Five of the seven patients with axillary/subclavian branch artery aneurysms required lytic therapy for distal emboli, and six required operative intervention. All popliteal artery injuries were treated by femoropopliteal bypass graft with autogenous saphenous vein. The external iliac artery lesion, which occurred in a cyclist, was repaired with limited resection and vein patch angioplasty. All 12 patients with SVT were treated initially with lytic therapy and anticoagulation. Eight patients required thoracic outlet decompression and venolysis of the subclavian vein. Thirteen arterial reconstructions have remained patent at an average follow-up of 31.9 months (range, 2-74). One patient with a popliteal artery injury required reoperation at 2 months for occlusion of his bypass graft. Eleven of the patients with an arterial injury were able to return to their prior level of competition. All of the patients with SVT have remained stable without further venous thrombosis and have returned to their usual level of activity. Conclusions: Athletes are susceptible to a variety of vascular injuries that may not be easily recognized. A high level of suspicion, a thorough workup including noninvasive studies and arteriography/venography, and prompt treatment are important for a successful outcome. (J Vasc Surg 2001;33:935-42.)

Thoracic Vascular Injuries: A Major Problem in Trauma

Objective - We present a review of our experience in the management of thoracic vascular injuries during the past 10 years in one of Sweden's busiest emergency departments, with morbidity and mortality as the main outcome measures. Design - Of eight patients who sustained chest trauma with thoracic vascular injuries, six presented with shock. Angiography was the gold standard in diagnosing aortic and subclavian injuries. Results - Lesions of the inferior vena cava, left internal mammary artery, and intercostal vessels were detected only at surgery. Two patients died of exsanguination. Managing thoracic vascular injuries is still difficult and challenging for thoracic and trauma surgeons. Conclusion - Early thoracotomy is important for salvage of patients with chest-wall vascular injury. Despite our limited experience, which is characteristic for Scandinavian and European countries, our results were satisfactory.

Aortic pseudoaneurysm in the L3–L4 disc space after lumbar disc surgery

We report a patient who developed an aortic pseudoaneurysm in the L3–L4 disc space after lumbar disc surgery. The diagnosis was made by MRI and aortography, and repair using a prosthetic graft and anterior fusion was successful. We discuss the predisposing factors, the clinical picture and management of vascular injuries during disc excision.

Aggressive management of vascular injuries of the thoracic outlet

Purpose: We present a review of 35 patients who underwent an operation for subclavian (n = 18) or axillary (n = 17) vessel injury. In some patients, both an artery and a vein were damaged, resulting in a total of 30 arterial and 16 venous injuries. Methods: The wounding source included a gunshot (n = 19), a stab wound (n = 9,) and blunt trauma (n = 7). Seven patients had hypotension and were taken immediately to the operating room. Seventeen patients had diminished or absent pulses, whereas 13 patients had normal pulses despite an arterial injury. Associated injuries included nerve injury (n = 15), pneumohemothorax (n = 5), and fractures (n = 7). Angiography in 21 patients demonstrated an intimal flap (n = 8), extravasation (n = 5), a pseudoaneurysm (n = 3), an arteriovenous fistula (n = 2), and occlusion (n = 1). Two angiograms were normal. Arterial repair was accomplished by interposition graft (n = 17), primary repair (n = 9), patch angioplasty (n = 3,) and ligation (n = 1). Results: No functional deficits occurred in patients with an isolated vascular injury. Seven patients with associated brachial plexus injuries experienced severe disability. One arm of a patient was amputated. Two patients died. Conclusions: The use of angiography helps to confirm and localize injuries. Prompt correction of the vascular injury avoids disability resulting from ischemia. Although the amputation rate is low with vascular repair, the functional disability resulting from associated nerve injuries can be devastating. (J Vasc Surg 1998;27:880-5.)

Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up.

To establish by long-term follow-up the safety and efficacy of nonoperative management of clinically occult arterial injuries and the use of physical examination (PE) alone in determining treatment of penetrating extremity trauma (PET). Two groups of patients were studied: (1) all patients with PET, arterial abnormalities on arteriograms, and no hard signs of vascular injury treated nonoperatively from 1986 to 1989; and (2) all patients with PET to the extremities managed by PE alone from 1989 to 1991. Telephone contact, PE, and duplex ultrasonography (US) were attempted in all group 1 patients, and telephone interviews were attempted in all group 2 patients. Group 1 had 43 patients with 44 clinically occult penetrating injuries to extremity arteries. Arteriography identified 21 intimal flaps/irregularities, 19 narrowings, 2 pseudoaneurysms, and 1 arteriovenous fistula. Four patients (9%) had clinical deterioration within 1 month and required surgery, with good results. Twenty-three of the other 39 patients (58%) were able to be contacted, and 17 (43%) with 18 injuries underwent PE and US. All were asymptomatic and had normal PE, and one had mild residual narrowing on US. The other 6 patients (four in prison, two out of state) reported no symptoms of vascular insufficiency and never sought medical attention for vascular problems. Mean follow-up was 9.1 years (range, 8.6-11.1 years). Group 2 had 287 patients (309 injuries) with PET treated by observation based on PE alone. Four patients (1.3%) required delayed surgery within the first week, and 78 with 90 injuries (29%) were able to be contacted. No patient reported any vascular symptoms or ever saw a physician for vascular problems. Mean follow-up was 5.4 years (range, 2.2-6.0 years). This is the first long-term follow-up of nonoperative management of clinically occult arterial injuries of the extremities and the use of PE alone in the initial management of PET. The results show these approaches to be safe, effective, and now a proven standard of care.

Management of severe proximal vascular and neural injury of the upper extremity

Purpose: Early amputation has been suggested to be the optimal treatment for severe combined vascular and neural injuries of the proximal upper extremity. This retrospective study was done to evaluate the long-term clinical outcome of our policy of limb salvage by revascularization and delayed treatment of neural injuries. Methods: Forty-six patients with neural and vascular trauma to the upper extremity were treated at our institution. All of these patients had aggressive treatment directed at limb salvage with restoration of vascular supply and nerve function. Long-term vascular and neurologic outcomes were recorded. Neurologic deficits were validated by the American Medical Association's standardized disability impairment scale (0% to 100%). Results: The rate of preoperative disability was 83%, which improved to 52% ( p < 0.01) after treatment (mean follow-up, 43 months). Overall, 87% showed improvement. Conclusions: These results suggest that early amputation should not be performed unless there is massive tissue loss or an attempt at limb salvage might endanger life. Final outcomes cannot be predicted on the basis of initial clinical presentation. As a group, the majority of these patients improved with aggressive intervention. (J Vasc Surg 1998;27:43-9.)

Thoracic Outlet Vascular Injuries

Management of vascular injuries at the thoracic outlet and neck continues to be a major problem to the trauma surgeon. Of 47 patients treated over an eighteen-year period, 45 were due to penetrating injuries (41 gunshot [87.2%], 4 stab wounds [8.5%]). In 16 patients shock was present at the time of admission. Five patients were operated on in comatose condition. In 37 patients immediate, and in 10 cases delayed, operation was performed. In 13 patients with arterial injuries, end-to-end anastomosis; in 24, saphenous vein graft; in 6, synthetic graft; in 2, lateral suture; and in 2, ligation were performed. Three subclavian arterial injuries repaired by saphenous vein graft occluded owing to thrombosis, requiring synthetic graft replacement. In 3 axillary arterial injuries, ligation was performed following the operation because of infection. One of these patients underwent amputation. Only 3 of 14 brachial plexus injuries (BPI) were primarily repaired. In only 1 of 3 repaired patients did complete function return. Overall mortality was 5 including 3 comatose patients with carotid injuries and 2 with axillary arterial injuries. In conclusion: (1) Subclavian and axillary artrial injuries may be overlooked by physical examination in the absence of critical ischemia. (2) We recommend ligation instead of revascularization in comatose carotid injury cases. (3) Synthetic grafts may be used, in cases of size discordance or in unstable patients, to end the operation as soon as possible. (4) In associated venous injuries, repair should be preferred to ligation. (5) In the presence of BPI due to gunshot wounds the results are not good in spite of nerve repair, and serious sequelae may remain.

Validation of Nonoperative Management of Occult Vascular Injuries and Accuracy of Physical Examination Alone in Penetrating Proximity Trauma

s Of Papers To Be Presented At The Joint Meeting Of The American Association For The Surgery Of Trauma (Fifty-Seventh Annual Meeting) And The Japanese Association For Acute Medicine; The Hilton Waikoloa Village, Waikoloa, Hawaii September 24-27, 1997

90th Anniversary of the Development by Nikolai S. Korotkoff of the Auscultatory Method of Measuring Blood Pressure

Every day, all over the world, many thousands of physicians, nurses, and paramedics measure systemic arterial pressure by applying a cuff with an inflatable bladder around the patient's arm and using a stethoscope to listen to the sounds in the brachial artery. Many care providers know that they are listening to “Korotkoff sounds,” but very few know that the method was introduced 90 years ago by a Russian doctor and scientist, Nikolai Sergeevich Korotkoff (Fig 1⇓). Indeed, a report on a new method of measurement of arterial pressure1 was presented on November 8, 1905, at a scientific seminar of the Imperial Military Medical Academy, Saint Petersburg, Russia, by Korotkoff, a young surgeon from the clinic of Prof Sergei P. Fedorov. (The authors found the date of the presentation mentioned in Korotkoff's dissertation.2(p116)) An English translation of the text of Korotkoff's presentation1 was published by W.H. Lewis, Jr, in 1941.3 In the 90 years since Korotkoff presented the new method to measure the arterial pressure, medical science and medical technology have made big strides. However, because of its simplicity and high degree of accuracy, the method of auscultatory measurement of arterial pressure remains the most acceptable in everyday medical practice. Moreover, this method is one of only a few techniques for clinical examination of patients that has not undergone significant changes since it was introduced. Very little is known, even in his native Russia, about the life and work of this doctor and scientist.4 Outside Russia, even less is known about Korotkoff. Some biographical information by Segall was published in English in 1965.5 However, because of differences between the Russian and American systems of education, Segall misinterpreted some facts of Korotkoff's life. Information in the present article was based on materials available in the …

Proximity penetrating extremity trauma: the role of duplex ultrasound in the detection of occult venous injuries.

The diagnosis and management of occult vascular injuries caused by penetrating proximity extremity trauma (PPET) remains controversial. Over 18 months, we prospectively screened 37 patients (43 lower extremities) with PPET for occult arterial and venous injuries using noninvasive studies (physical examination, ankle-brachial indices, color-flow duplex ultrasonography (CFD)) and angiography (arteriography, venography). Eight isolated, occult venous injuries were detected (incidence, 22%). CFD detected seven of eight (88%) venous injuries. Venography was technically difficult to perform in this patient population and failed to detect four femoral-popliteal vein injuries. Major thromboembolic complications (pulmonary embolism, symptomatic deep vein thrombosis, venous claudication) occurred in 50% of the patients identified with femoral-popliteal vein injuries. Arterial injuries were detected in 4 of 42 (10%) extremities (arteriography, n = 3; CFD, n = 1) and were clinically benign. We conclude that following PPET, (1) isolated, occult venous injuries are common and are associated with significant complications and (2) CFD is useful for screening for occult venous injuries.

Gunshot Wounds to the Upper Extremity: Evaluation and Management of Vascular Injuries

Gunshot wounds to the upper extremity are uncommonly life threatening but are associated with a high incidence of significant long-term disability. The identification of vascular injuries is dependent on careful clinical examination and the liberal use of arteriography. Standard techniques of vascular repair should be followed for arterial reconstruction. The rate of successful vascular repair is in excess of 90%, but long-term function is limited by a high incidence of associated nerve injury.

Minimally invasive operative and endovascular management of acute vascular brain injuries

Minimally invasive operative and endovascular management of acute vascular brain injuries

Arteriography in the evaluation of penetrating pediatric extremity injuries

The routine use of arteriography for evaluating penetrating extremity injuries is undergoing reevaluation in the adult literature. Its role in children is less clear. Eighty-seven children treated for penetrating extremity trauma over a 5-year period were studied retrospectively to define the usefulness of arteriography. The ages ranged from 2 to 16 years. Twenty-four arteriograms were performed. Twelve were for patients who exhibited physical signs of vascular injury (diminished pulse, distal ischemia, expanding hematoma, or bruits/thrills over the wound). The other 12 were performed on asymptomatic children with wounds in proximity to major vessels. Two other patients with ongoing hemorrhage were taken directly to the operating room. Of the 12 arteriograms performed for abnormal physical signs, eight (67%) showed vascular injuries. None of the studies performed for proximity alone had abnormal results ( P < .01). Ten of 10 patients with vascular injuries had abnormal physical findings, whereas only four of 77 patients without vascular injuries had abnormal findings (sensitivity 100%, specificity 95%). Eighty-five percent of patients have had follow-up in the pediatric surgery clinic, and no missed injuries or complications have been discovered. Timely diagnosis and repair is the cornerstone for successful management of vascular injuries. While the arteriogram is an important adjunct in patients who have abnormal physical findings, proximity to major vessels alone fails to identify patients at risk for significant injuries. Angiography may not be warranted in patients whose physical examination results are normal. Noninvasive modalities such as B-mode ultrasound and Doppler may have future application in the evaluation of these cases.

Effectiveness of Transcatheter Embolization in the Control of Hepatic Vascular Injuries

The authors describe their 11-year experience with transcatheter embolization (TCE) in the treatment of patients with hemorrhagic hepatic injuries. Twenty-eight TCE procedures were performed in 24 patients between 1980 and 1991. Injuries in 21 patients were due to vehicular or criminal trauma; in three patients, injuries were iatrogenic. There were 21 male and three female patients (age range, 6-64 years). All patients underwent angiography and had evidence of active hemorrhage, pseudoaneurysm, or arteriovenous fistula (AVF). All embolizations were performed with use of Gianturco coils, microcoils, or gelatin sponge. TCE was technically successful in occluding hepatic vascular lesions in 21 of 24 patients (88%). Technical failures were due to the inability to select the appropriate vessel for embolization in two cases and due to a persistent AVF that did not occlude despite further attempts at embolization. Lesions recurred in two patients who underwent initially successful TCE. Both patients were treated effectively with repeated TCE. Only two catheter-related complications were encountered, both after successful TCE. Twenty-one patients survived to be discharged from the hospital. Two patients among the group treated successfully and one from the group in whom treatment failed died. This experience demonstrates that TCE is effective in the management of hepatic vascular injuries due to trauma.