Vascular injuries occur • Unexpected • Young and fit • Results in loss of limb or life • Loss of earning capacity, economic Our experience at Anuradhapura Mean age - 36.9 years (17–69) Arterial injury following trap gun - 25% amputation rate (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 Causes - Road Traffic Accidents – 54.2%,Trap Gun – 33.3%,Iatrogenic - 8.33%,Other- 4.2% (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) Mechanism of injury • Sharp / penetrating • Blunt “Vascular injury” is a nonspecific term. Because this is used to describe the injuries to blood vessels in all parts of the body that includes neck vascular injuries, thoracic and abdominal vascular injuries, and injuries to the blood vessels of the limbs. And in addition vascular injury also describes injuries to the arteries and veins. Injuries to the blood vessels of the limbs are called extremity vascular injury. This chapter will concentrate on the extremity vascular injuries.

1. Managing the vascular
compromised lower limb
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.
Sri Lanka Surgical Congress 2021 - The Golden Jubilee

2. Vascular injuries
• Unexpected
• Young and fit
• Results in loss of limb or life
• Loss of earning capacity, economic
• Our experience at Anuradhapura
• Mean age - 36.9 years (17–69)
• Arterial injury following trap gun - 25% amputation rate.
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

3. Causes
• Road Traffic Accidents – 54.2%
• Trap Gun – 33.3%
• Iatrogenic - 8.33%
• Other- 4.2%
• Mechanism of injury
• Sharp / penetrating
• Blunt
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

4. Mechanism of disruption of flow at arterial level
• Transection
• Laceration
• Contusion
• Kink
• Intimal flap
• Our experience
• Contusion and laceration – 80%
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

5. Extremity vascular trauma
Signs of a vessel injury
• Hard signs
• Soft sign

6. Extremity vascular trauma
• Hard signs
• Active bleeding
• Thrills, Bruits
• Signs of distal ischaemia
• 6 “P”s
• Absent Pulse
• Pain
• Pallor
• Perishing cold
• Paresthesia / Anaesthesia
• Paresis / Paralysis
• Expanding hematoma

7. Signs of a vessel injury
• Soft signs
• History of bleeding
• Hematoma
• Injury close to a known neurovascular bundle
• Weak pulse
• Hard signs – nearly 100% chance of 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

8. Signs of a vessel injury
• Paresis / Paralysis / Paresthesia / Anesthesia - late signs
• Paresis and paresthesia
• Viability of the limb is in immediate threat
• Anesthesia and paralysis - Not viable

9. Problems with diagnosing ischaemia after trauma
• Pain
– Due to injury itself
• Pallor
Pallor due to blood loss, Compare with contralateral limb
• Absent pulse
– Absent due to low blood pressure. Compare with contralateral limb
• Paresthesia , paresis
– Due to associated nerve, muscle injury or unresponsive patient

10. Investigations
•Immediate viability threat / Hard signs
• Urgent intervention
•Soft signs
• Investigate

11. Investigations
Hand held Doppler
• Doppler flow, Quality of signal, ABPI
• Presence of Doppler flow does not exclude a proximal
vascular injury
Duplex scan (USS + Doppler)
• Difficult to image in trauma
• Due to - Pain, dressings
• Patent distal vessels does not exclude a proximal injury

12. Investigations
• Angiography
–CT angiography
–Catheter angiography

13. CT Angiography
• Site of Injury
• Soft tissue and bone
• 3D reconstruction

14. Conventional angiography
• Contrast directly into artery
• Traumatic , difficult to perform , need “C” arm/ radiographer/
radiolucent table

15. Surgical Repair
• Prompt transport to operating room
• General anesthesia
• Clean the entire limb
• Thigh prepared – for venous harvest
• Control of proximal and distal ends and trimming

16. Surgical repair
• Thrombectomy
• Distal heparinisation
• Interposition graft / direct repair
• Our experience – 55.0% RSVG, 5% direct
• Synthetic graft
• 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

17. Principles of arterial repair
• Cut / laceration _ suture
transversely
• Heparin – depends on clinical
situation

18. How soon we should we repair
–As soon as possible
– “ 6 “ hours
–Effects of ischaemia

19. Combined Vascular and Skeletal Trauma
• Revascularization / skeletal fixation (external Fixator – EF)
• Bone fixation first if limb is not threatened – apply EF antero laterally
• Revascularisation first if limb is threatened

20. Endovascular Therapy
• Exclusion of the arterial injury from the circulation
• End-organ arterial vessels, selective embolization
• Placement of a stent graft to patch the site of arterial
injury
• Percutaneous thrombin injection

21. Primary Amputation
• Extensive crush injuries and soft tissue damage –
“mangled limb”
• No need to transfer – discuss / photo

22. Mangled Extremity Severity Score (MESS)
Factors Points
Bone / tissue Simple fracture / stab 1
Open fractures / dislocations 2
gun shot / crush 3
severe Soft tissue injury / contamination 4
Ischaemia Weak pulse 1
Absent pulse / threatened viability 2
Anesthetic / paralytic limb 3
Shock SBP more than 90 mm/Hg 0
Transient hypotension 1
Persistent shock 2
Age <30 years 0
30-50 years 1
> 50 years 2
Sri Lanka Surgical Congress 2021 - The Golden Jubilee MESS Score =/> 7 – not suitable for revascularisation

23. Reperfusion effects
• Reperfusion injury
• paradoxical death of already dying cells when
reperfused
• Post perfusion syndrome
• systemic effects of reperfusion

24. Compartment syndrome
Reduced organ perfusion due to increased intra compartment
pressure
• Compartment Perfusion Pressure (CPP)
• Mean Arterial Pressure (MAP)
• Intra Compartmental Pressure (ICP)
CPP = MAP – ICP

25. Fasciotomy

26. Summary
• Vascular injury;
• Resuscitate
• Assess viability and extent of injury
• Assess need for fasciotomy
• Early intervention and post intervention monitoring
• Rehabilitation

27. Thank You