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 Management of Vascular Trauma

David Rosenthal, M.D., Robert Batson, M.D., Joseph Mills, M.D.

Includes:

  • Aortic Trauma
  • Carotid Trauma
  • Brachiocephalic Trauma
  • Visceral Arterial Trauma
  • Extremity Trauma
  • Venous Trauma
  • Diagnosis of Vascular Trauma - Arteriography /Duplex
  • Nonoperative Therapy
  • Traumatic A-V Fistulas
  • Iatrogenic Vascular Trauma
  • Additional Important/Non-Core Cirriculum Topics:
  • Associated Neural Injury

I. Etiology and Pathophysiology

1. To understand the mechanism of vascular injury to the upper extremity, thoracic aorta, abdominal aorta and its branches, and lower extremities.

2. To recognize the clinical importance of penetrating vascular trauma (penetrating objects), significance of different gunshot wounds (high/low velocity) and the blunt or crush injury to the vascular system.

3. To define how vascular reconstructive procedures and the failure of these procedures affect the circulatory system.

4. To understand the mechanism of iatrogenic vascular injury and its prevention.

II. Diagnostic Evaluation

1. To understand the characteristic signs and symptoms of acute vascular compromise.

2. To demonstrate an understanding of the wounding mechanism, assessment of the wound and characteristic findings of the affected extremity distal to the wound and associated injuries.

3. To understand the usefulness of alternative imaging techniques ( ie two plane x-ray, Doppler/duplex color flow ultrasonography , venography , angiography, MRI and CT scans) in the management of vascular trauma.

4. To define the characteristic diagnostic finding of imaging techniques in vascular trauma.

III. Acute Arterial Injuries

1. To understand the characteristic signs and symptoms of acute arterial injury.

2. To define the clinical features of major arterial injury.

3. To understand the indications for noninvasive (Doppler or duplex color flow ultrasonography CT, MRI) and invasive ( arteriography , venography ) diagnostic studies.

4. To define the preoperative assessment and management of the patient with a major arterial injury.

5. To understand the operative management of acute arterial injury and the management of concomitant venous or visceral injuries.

6. To define the operative approach for specific arterial injuries ( ie left and right subclavian ).

7. To understand the management of postoperative complications and the management of associated injuries.

IV. Venous Injuries

1. To understand the characteristic signs and symptoms of acute venous injury.

2. To define the clinical features of major venous injury.

3. To understand the indications for noninvasive (Doppler or duplex color flow ultrasonography CT, MRI) and invasive ( venography ) diagnostic studies.

4. To define the preoperative assessment and management of the patient with a major venous injury.

5. To understand the operative management of combined arterial and venous injuries, technical management of venous injuries ( ie ligation , lateral suture repair, end-to-end anastomosis , venous patch graft or venous replacement graft).

6. To define operative approach and appropriate management of specific major venous injuries ( ie management of retro hepatic IVC, subclavian vein).

7. To understand the management of postoperative complications, and associated injuries.

V. Arteriovenous Fistulas (AVF)

1. To understand the characteristic signs and symptoms of AVFs .

2. To understand the mechanism of injury associated with traumatic AVFs .

3. To define the pathophysiology of AVFs ( ie peripheral vascular resistance, heart rate, stroke volume, cardiac output and blood pressures).

4. To understand the indications for noninvasive and invasive diagnostic studies.

5. To define and understand treatment options ( ie invasive radiologic procedures, endovascular procedures, and operative techniques).

VI. Latrogenic Injuries

1. To define the mechanism of the iatrogenic injury.

2. To understand the clinical features associated with the iatrogenic injury.

3. To understand the indications for noninvasive and invasive diagnostic studies suspected iatrogenic injury.

4. To define the indications for nonoperative vs. operative treatment of iatrogenic injury.

5. To understand the management and potential complications associated with an iatrogenic injury.

VII. Concomitant Fracture and Neurologic Injuries

1. To understand the characteristic signs and symptoms of associated fractures and neurologic injuries with vascular trauma.

2. To understand the anatomic relations with fractures, neurologic injury and the vascular system.

3. To define the mechanism of injury from fracture, dislocation, or subluxation .

4. To understand the influence of penetrating, blunt and crush injuries on the vascular system.

5. To define the noninvasive and invasive diagnostic tests associated with fracture and neurologic injuries.

6. To define associated reconstructive procedures associated with fracture, neurologic injury and the vascular system.

7. To understand the postoperative management of the patient with combined vascular, fracture, or neurologic injury.

VIII. Nonoperative Management of Vascular Injuries

1. To define the clinical criteria and indications for nonoperative versus operative management of patients with vascular injuries.

2. To define the clinical pathology and mechanism of injury (penetrating, crush, blunt) associated with combined vascular and visceral injuries.

3. To define and understand the surgical anatomy in relationships of the abdominal aorta and its major branches to the abdominal organs.

4. To define the role of the surgical technique ( ie x-rays, peritoneal lavage , laparoscopic assessment, systoscopy , proctosigmoidoscopy , IVP, arteriography , etc) with suspected vascular and visceral injury.

5. To define the operative management of the patient with combined vascular and visceral injury.

6. To demonstrate an understanding of postoperative care for critically ill patients with combined vascular and visceral injuries, potential complications and their appropriate management.

References

Thoracic/Mediastinal

1. Eddy AC, Rusch VW, Marchioro T, Ashbaugh D, Verrier ED, Dillard D. Treatment of traumatic rupture of the thoracic aorta. Arch Surg 1990; 125:1351 - 56.

2. Richardson JD, Flint LM Jr , Snow NJ , Gray LA, Trinkle JK. MANAGEMENT of transmediastinal gunshot wounds. Surgery 1981; 90:671 - 76.

3. Weaver FA, Suda RW, Stiles GM, Yellin AE. Injuries to the ascending aorta, aortic arch and great vessels. Surg Gynecol Obstet 1989; 169:27 - 31.

Carotid/Subclavian/Vertebral

1. Brown MF, Graham JM, Feliciano DV, Mattox KL, Beall AC, DeBakey ME. Carotid artery injuries. Am J Surg 1982; 144:748 - 753.

2. Landreneau RJ, Whigelt JA, Megison SM, Meier DE , Fry WJ. Combined carotid - vertebral arterial trauma. Arch Surg 1992; 127:301 - 4.

3. Hiatt JR, Busuttil RW, Wilson SE. Impact of routine arteriography on management of penetrating neck injuries. J Vasc Surg 1984; 6:860 - 66.

4. Phillips EH, Rogers WF, Gaspar MR. First rib fractures: Incidence of vascular injury and indications for angiography. Surgery 1981; 89:42 - 7.

5. Perry MO, Snyder WH, Thal ER. Carotid artery injuries caused by blunt trauma. Ann Surg 1980; 192:74 - 7.

6. Krajewski WJ Jr , Hertzer NR. Blunt carotid artery trauma. Ann Surg 1980; 191:341 - 46.

7. Liekwig WJ Jr , Greenfield LJ. Management of penetrating carotid artery injury. Ann Surg 1978; 188:587 - 92.

8. Ledgerwood AM, Mullins RJ, Lucas CE. Primary repair versus ligation for carotid artery injuries. Arch Surg 1980; 115:488 - 93.

Renal

1. Brown MF, Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Renovascular trauma. Am J Surg 1980; 140:802 - 5.

2. Ivatury RR, Zubiwski R, Stahl WM. Penetrating renovascular trauma. J Trauma 1989; 29:1620 - 3.

3. Barlow B, Gandhi R. Renal artery thrombosis following blunt trauma. J Trauma 1980; 20:614 - 7.

Combined Othopedic/Vascular Injuries

1. Jones RE, Smith EC, Bone GE. Vascular and orthopedic complications of knee dislocation. Surg Gynecol Obstet 1979; 149:554 - 8.

2. Rich NM, Metz CW, Hutton JE Jr , Baugh JH, Hughes CW. Internal versus external fixation of fractures with concomitant vascular injuries in Vietnam . J Trauma 1971; 11:463 - 73.

Extremities

1. Feliciano DV, Herskowitz K, O'Gorman RB, Cruse PA, Brandt ML, Burch JM, Mattox KL. Management of vascular injuries int eh lower extremities. J Trauma 1988; 28:319 - 27.

2. Peck JJ, Eastman B, Bergan JJ, Sedwitz MM, Hoyt DB, McReynolds DG. Popliteal vascular trauma. Arch Surg 1990; 125:1339 - 44.

3. Lim LT, Michuda MS, Flanigan DP, Pankovich A. Popliteal artery trauma: 31 consecutive cases without amputation. Arch Surg 1980; 115:1307 - 13.

4. Roberts RM, String ST . Arterial injuries in extremity shotgun wounds: Requisite factors for successful management. Surgery 1984; 96:902 - 7.

5. Cikrit DF, Dalsing MC, Bryant BJ, Lalka SG, Sawchuck AP, Schulz JE. An experience with upper - extremity vascular trauma. Am J Surg 1990; 160:229 - 33.

6. Bunt TJ, Malone JM, Moody M, Davidson J, Karpman R. Frequency of vascular injury with blunt trauma - induced extremity injury. Am J Surg 1990; 160:226 - 8.

Venous Injury

1. Petersen Sr , Sheldon GF, Lim RC Jr. Management of portal vein injuries. J Trauma 1979; 19:616 - 20.

2. Rich NM. Principles and indications for primary venous repair. Surgery 1982; 91:492 - 6.

3. Wilson RF, Wienek RG, Balog M. Factors affecting mortality rate with iliac vein injuries. J Trauma 1990; 30:320 - 3.

4. Rich NM, Hobson RW, Wright CB, Fredde CW. Repair of lower extremity venous trauma: a more aggressive approach required. J Trauma 1974; 14:639 - 52.

Diagnostic Studies

1. Francis H, Thal ER, Weigelt JA, Redman HC. Vascular proximity: is it a valid indication for arteriography in asymptomatic patients? J Trauma 1991; 31:512 - 14.

2. Johansen K, Lynch K, Paun M, Copass M. Noninvasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma 1991; 31:515 - 22.

3. Richardson JD, Flint LM Jr. Penetrating arterial trauma. Analysis of missed vascular injuries. Arch Surg 1987; 122:678 - 83.

Posted June 2010