Jaffna Medical association
Annual Scientific Sessions September, 2022
Professor C.Sivagnanasundaram memorial oration
Introduction
Vascular injuries are potentially life or limb threatening. Vascular trauma occurs in 1.6% of civilian injuries (1) and 6.8% to 10.8% in war related injuries (Afghanistan, Iraq and Lebanon war). In a study done at the National hospital of Sri Lanka Colombo (NHSL) out of 5802 trauma admissions there were 93 patients with vascular injuries (VI). Therefore the incidence of VI in civilian trauma is 1.6% (1). After the end of civil war in Sri Lanka in 2009 there is a reduction in the number of war related vascular injuries. But due to the increase in the number of Road Traffic Accidents (RTA), the number of vascular trauma also increased (i.e. from 1938 to 2013 road traffic injuries increased from 35.1 to 98.6 per 100 000 population in Sri Lanka). One of the reasons for this is the increased number two and three wheeled vehicles which are involved more with accidents (2). Trauma and vascular injuries often involve young males. They are the breadwinners of the family. In one study done at the Teaching Hospital Anuradhapura (THA) among patients presenting with popliteal arterial injuries, 18 (90%) were males with a mean age of 38.7 years (2). And in another study done at the same institution among patients with major lower limb arterial injuries, 22 (87.5%) were males and the mean age was 36.9 years (3). These studies confirm the fact of young males often getting involved with vascular injuries.
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Jaffna oration 2022.pdf
1. Dr Joel Arudchelvam
MBBS (COL), MD (SUR). MRCS (ENG), FCSSL.
Senior Lecturer, Department of Surgery, University of Colombo,
Consultant Vascular and Transplant Surgeon,
The National Hospital of Sri Lanka, Colombo.
Jaffna Medical association
Annual Scientific Sessions, 2022
Prof. C. Sivagnanasundram Memorial Oration
2. Professor C.Sivagnanasundram
Legend with multiple talents.
Simple and humble gentleman
Born in Jaffna on 30th of
March, 1928
Married madam Shanthi
Father of four daughters
3. Professor C.Sivagnanasundram
1955 - MBBS , University of Ceylon
Served in various hospitals of the country in various
posts
General Hospital Kurunegala
Peripheral unit Hiripitiya
Lady Ridgeway Hospital for children Colombo
Nawalapitiya
Jaffna
4. Professor C.Sivagnanasundram
1965 – 1967 - lecturer ,department of Preventive and
Social Medicine, University of Ceylon, Peradeniya
1967 - 1971 DPH (London), PhD (Uni. London)
1978 - Professor of Community Medicine, University
of Jaffna
1994 – Retired
Passed away in 2005
5. Professor C.Sivagnanasundram
Contributed immensely to the development of
the Faculty of Medicine, University of Jaffna.
Eminent researcher
Published in both local and international
journals.
Published many books ( medicine and other
fields).
7. Vascular trauma /injury
• Injury to
Arteries
Veins
• Anatomical regions
Extremity – limbs
Abdomen and pelvis
Thorax
Head and neck
8. Vascular trauma /injury
• Injury to
Arteries
Veins
• Anatomical regions
Extremity – limbs
Abdomen and pelvis
Thorax
Head and neck
9. Vascular Injuries
Unexpected .
Young and fit
Results in loss of limb or life
Loss of earning capacity, economic
burden
Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a
peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8
10. Vascular Injuries
Anuradhapura 2019*
Male - 22 (87.5%)
Mean age - 36.9 years (17–69)
Following trap gun - 25% amputation rate
Anuradhapura (THA) 2019 - popliteal arterial injuries
**
Males - 90%
Mean age - 38.7 years.
* Factor affecting the outcome of Major lower Limb arterial injuries; a single unit experience in a peripheral setting.
Sriharan, P and Arudchelvam, J. Anuradhapura : s.n., 2019. Anuradhapura Clinical Society , 13th Annual scientific
sessions, September 2019. p. 77
** Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Parathan, S and
Arudchelvam, J. 4, 2019, Sri Lanka Journal of Surgery, Vol. 37, pp. 14–17.
11. Vascular Injuries
At the National hospital of Sri Lanka Colombo
(NHSL)
5802 trauma admissions (for 3 months)
93 vascular injuries (VI)
Incidence of VI in civilian trauma is 1.6%*
6.8% - 10.8% in war related injuries **
* Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is time to establish a dedicated
trauma vascular surgery unit. Kapilan, G and Arudchelvam, J. Colombo : s.n., 2020.
**Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Parathan, S and Arudchelvam,
J. 4, 2019, Sri Lanka Journal of Surgery, Vol. 37, pp. 14–17.
12. Causes
Overall *, **
Road Traffic Accidents
– 54.2%
Trap Gun – 33.3%
Iatrogenic - 8.3%
Other- 4.2% (Stab, etc.)
*Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting
to a single unit in a peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8
13. Trap gun
Made of a metal pipe, metal pallets and
explosives (from fire cracker)*
At THA;
About 75 trap gun injury / year
About 10 – 15 % with arterial injuries
Multilevel injury
25% amputation rate
* Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka.
Sriharan, P and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8
14. Causes
Causes of upper limb vascular injuries (ULVI) -
NHSL *
Cuts (36%)
Fractures (34%)
Iatrogenic injuries (22%)
* Upper Limb Vascular Injuries, a Unique Problem. A Single Unit Experience in a. Kapilan, G and
Arudchelvam, J. Colombo : s.n., 2020. Sri Lanka Medical Association 133rd Anniversary International Medical
Congress, 2020. p. 17.
15. Causes
Accidental intra-arterial injection *
* Accidental Intra-Arterial Injection of a Drug in a Patient with Radial Artery Variation; A Rarity Leading
to a Disaster. Arudchelvam, J. 2, 2019, J Clinical Case Rep Case Stud, Vol. 2019, pp. 66-68
17. Mechanism of disruption at vascular level
Transection
Laceration
Contusion
Kink
Intimal flap
*Sriharan P, Arudchelvam JD, Marasinghe A. Outcome of major lower-limb arterial injuries presenting to a single unit in a
peripheral setting in Sri Lanka. Indian J Vasc Endovasc Surg 2019;6:266-8
21. Intimal flap
Due to injury the arterial
intima is raised as a flap
Resulting in dissection and
occlusion
22. Mechanism of disruption at vascular level
Our experience *
THA ( lower limb arterial injuries)
40% - Contusion
40% - lacerations
Trap gun injury
75% laceration
* Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka.
Sriharan, P and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8
23. Spasm
Study done at NHSL with lower limb injuries and
absent pulses
31 patients with absent pulses
18 (58.1%) arterial spasm
Arterial spasm -common causes of diagnostic
dilemma
.
* Lower Limb Arterial Spasm following Trauma: a Common and an Important Cause. Kapilan, G and Arudchelvam, J. Colombo
: s.n., 2020. Sri Lanka Medical Association 133rd Anniversary International Medical Congress, 2020. p. 63.
$ Post- Traumatic Lower Limb Arterial Spasm: A Common Entity and an Important Cause for Diagnostic Dilemma: A Case Series.
Kapilan G, Arudchelvam J. 1057, 2020, Ann Short Reports, Vol. 3.
24. Spasm
Common in young patients
An underlying injury should be excluded
Confirmation with angiography is necessary
* Lower Limb Arterial Spasm following Trauma: a Common and an Important Cause. Kapilan, G and Arudchelvam, J. Colombo
: s.n., 2020. Sri Lanka Medical Association 133rd Anniversary International Medical Congress, 2020. p. 63.
$ Post- Traumatic Lower Limb Arterial Spasm: A Common Entity and an Important Cause for Diagnostic Dilemma: A Case Series.
Kapilan G, Arudchelvam J. 1057, 2020, Ann Short Reports, Vol. 3.
25. Signs of a vessel injury
Following vascular trauma – clinical features
are divided into;
Hard signs
Soft signs
27. Signs of a vessel injury
Soft signs
History of bleeding
Hematoma
Injury close to a known neurovascular bundle
Weak pulse
Hard signs – in sharp injury, 100% chance of Vascular
injury
Soft signs – 10-25%
The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury:
results at one year. Frykberg, ER, et al., et al. 4, 1991, J Trauma, Vol. 31, p. 502.
Penetrating nontorso trauma: the extremities. Ball, CG. 4, 2015, Can J Surg, Vol. 58, pp. 286-8
28. Late Signs of a vessel injury
Paresis and paresthesia
Viability of the limb is in immediate threat
Anesthesia and paralysis - Not viable
Should be evaluated and documented
29. Documentation following trauma
Teaching Hospital Anuradhapura Sri Lanka (2019) *
Cause of injury documented - 82.6%
Limb viability documented only in - 30.7%
* Completeness of documentation of patients with vascular trauma. Sriharan, P and
Arudchelvam, J. Anuradhapura : s.n., 2019. Anuradhapura Clinical Society , 13th Annual
scientific sessions. p. 74.
36. Vascular injuries - History
Outcome of the vascular injuries have improved
dramatically over time
Experience gained from various war injuries
World Wars 1 / 2
Ligation - Amputation rate - > 40%.
Vietnam / Korean wars - repair - amputation rate - 15%
Iraq / Afghanistan wars - Amputation rate - 8%.
Advances in vascular repair methods
Antibiotics
Advances in trauma care
37. Surgical Repair
Resuscitation
General anesthesia
Clean the entire limb
Thigh prepared – for venous harvest
Control of proximal and distal ends and trimming
47. Surgical repair
Synthetic grafts
Lower patency
Infection
Parathan, S., Arudchelvam, J. and Marasinghe, A., 2019. Outcome of popliteal arterial injuries presenting to the Teaching
Hospital, Anuradhapura. Sri Lanka Journal of Surgery, 37(4), pp.14–17. DOI: http://doi.org/10.4038/sljs.v37i4.8642
Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka. Sriharan, P and
Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8.
48. Combined Vascular and Skeletal Trauma
Our experience (NHSL and THA)
41 / 985 (4.2%) of lower limb fractures had vascular
injuries *
17/ 150 (11.3%)of Humerus fractures had VI*
17/20 (85%) with popliteal arterial injury had fractures or
dislocation (p0.003)**
• Vascular injuries associated with upper extremity skeletal trauma , a cross sectional study.
Ranaweera, RS, Arudchelvam , J. ,Priatharshan, M.Kandy : s.n., 2021. The Kandy Society of medicine,
43rd annual academic sessions. .p.96
• ** Parathan S, Arudchelvam J, Marasinghe A. Outcome of popliteal arterial injuries presenting to the
Teaching Hospital, Anuradhapura. Sri Lanka Journal of Surgery. 2019;37(4):14–7
49. Combined Vascular and Skeletal Trauma
Revascularization / skeletal fixation (External
Fixator – EF)
Bone fixation first if limb is not threatened
Revascularisation first if limb is threatened
51. Mangled limb
National hospital of Sri Lanka Colombo*
Total vascular injuries – 81
Limbs were mangled - 2 (2.5%) .
Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is
time to establish a dedicated trauma vascular surgery unit. Kapilan, G and Arudchelvam,
J. Colombo : s.n., 2020
52. How soon we should we repair
Complications of delayed arterial repair
Limb death
Reperfusion syndrome
53. How soon we should we repair
As soon as possible
Canine vascular occlusion / ischemia model 1947
Ischemic time < 6 hours - limb salvage rate
90%.
“Golden period” of 6 hours as a threshold
In practice patients often reach beyond 6 hours
* Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63, pp. 203-204.
£ Revascularisation of Marginally Viable Limbs; A Long-Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.
60. How soon we should we repair
At the teaching hospital Anuradhapura
13 cases
Mean ischaemic time – 11.3 hours (0.5 to 48)
4/9 (30.8%) limbs were either non-viable or
marginally viable
Arudchelvam, J., 2017. Outcome after revascularisation of marginally viable limbs and dead limbs following
lower limb arterial injuries. Ceylon Medical Journal, 62(3), pp.203–204.
61. Marginally viable limbs
Revascularization was attempted on such patients
despite having > 6 hours of ischemia * £
provided ;
Patients consenting
Systemically well and stable
Limb not mangled
Not infected
* Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63, pp. 203-204.
£ Revascularisation of Marginally Viable Limbs; A Long-Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.
62. Marginally viable limbs Outcome
Long term follow-up
All were happy to have a limb
All reported improvement in sensory function
Only had partial recovery of motor functions * £
* Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries.
Arudchelvam, J. 3, 2017, Ceylon Medical Journal, Vol. 63, pp. 203-204.
£ Revascularisation of Marginally Viable Limbs; A Long-Term Follow-Up Study. Joel, Arudchelvam and Manel, De
Soyza. 1, 2020, J Surgery, Vol. 1, p. 1002.
64. Post perfusion syndrome
Substances Released into circulation
Lactic Acid
K+
Myoglobin
Resulting in organ failure and death of the
patient
65. Post perfusion syndrome
Study done at NHSL 2011 *
Total arterial repairs – 42
Mean ischemic time - 7.25 hours
Severe reperfusion syndrome - 3 (7.1%)
Treatment – ligation of repaired vessels
Amputation
*. Injury profiles, Referral delay, management options and Short Term Outcome Of Traumatic Acute Limb
Ischaemia (ALI) Managed At A Tertiary Referral Center. JD, Arudchelvam and JASB, Jayasundara.
Colombo : s.n., 2011. Annual Academic Sessions Of The College Of Surgeons Of Sri Lanka August 2011. pp.
185-186.
66. Compartment syndrome
Reduced organ perfusion due to increased intra
compartment pressure
Mean Arterial Pressure
(MAP)
Intra Compartmental
Pressure (ICP)
70. Fasciotomy
Teaching Hospital Anuradhapura . 2019
Popliteal arterial injury – 24
No patients underwent fasciotomy before the transfer*
* Outcome of major lower limb arterial injuries presenting to a single unit in a peripheral setting in Sri Lanka.
Sriharan, P and Arudchelvam, J. 2019, Indian J Vasc Endovasc Surg , Vol. 6, pp. 266-8
71. Vascular trauma how to improve the
situation
Prevention of injuries
Transfer of patients
Improving infrastructure
Establishment of dedicated trauma centres
72. Prevention of injuries
After 2009
Reduction in war related vascular injuries
But an increase in civilian injuries
Increase Road Traffic Accidents (RTA) - i.e. from 1938 to
2013 - RTA injuries increased - 35.1 to 98.6 /100000
Two and three wheeled vehicles
World Bank Group, GRSF
73. Prevention of injuries
Study done at TH Anuradhapura 2019
Patients with popliteal arterial injuries
40 % - Motorcycle accidents
Parathan S, Arudchelvam J, Marasinghe A. Outcome of popliteal arterial injuries presenting to the
Teaching Hospital, Anuradhapura. Sri Lanka Journal of Surgery. 2019;37(4):14–7.
75. Transfer of patients
Communication before transfer
Series at the NHSL 2011
Transfers - 39
Notified before - 8 (20.5%)
Injury profiles, Referral delay, management options and Short Term Outcome Of Traumatic Acute Limb
Ischaemia (ALI) Managed At A Tertiary Referral Center. JD, Arudchelvam and JASB, Jayasundara. Colombo :
s.n., 2011. Annual Academic Sessions Of The College Of Surgeons Of Sri Lanka August 2011. pp. 185-186.
76. Transfer of patients
In 2020 at NHSL
Limb vascular injuries - 81
Unnecessary transfers – 8 (9.9%)
Non -viable - 4 (4.9%)
Mangled - 2 (2.5%)
Traumatic amputations not suitable for re-
implantation - 2 (2.5%)
Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is time to establish a dedicated trauma
vascular surgery unit. Kapilan, G and Arudchelvam, J. Colombo : s.n., 2020
85. Accident service
The National Hospital of Sri Lanka
Delay due to;
Lack / non availability of staff
Lack of equipment
Lack of protocol
86. Vascular and Transplant Surgeons
At present only 10 vascular and
transplant surgeons in Ministry of
Health.
Vascular and transplant work
(routine and emergency)
Vascular trauma account for 63.9%
emergency surgeries* (NHSL 2021)
? Routine Vascular work
? Transplant Work
*Extremity vascular trauma workload of a single vascular unit in a tertiary care centre: vascular trauma contributes to significant
emergency workload, Bandara LMPM, Kapilan G, Arudchelvam J, s.n., 2021. The Kandy Society of medicine, 43rd annual academic
sessions
87. Vascular and Transplant Surgeons
Train more Vascular and Transplant surgeons
Train other surgeons to handle the traumatic vascular
emergencies
94. Outcome after limb vascular injuries
In studies done at NHSL and THA the overall limb salvage rates
after vascular trauma were 75.0% - 98.6% (1) (2).
1. Extremity Vascular trauma workload of a single vascular unit in a tertiary care Centre; it is time to
establish a dedicated trauma vascular surgery unit. Kapilan, G and Arudchelvam, J. Colombo : s.n., 2020.
2. Outcome of popliteal arterial injuries presenting to the Teaching Hospital, Anuradhapura. Parathan, S
and Arudchelvam, J. 4, 2019, Sri Lanka Journal of Surgery, Vol. 37, pp. 14–17.