VASCULAR INJURY

Dr.Subagjo SpB(K)TKV

Background
Result from - penetrating - blunt If not recognized and treated rapidly, resulting ; - loss of life - loss of limb

Frequency
US : Pheripheral injuries, 80% all cases of vascular trauma. The lower extremities in two thirds of all vascular injuries. Penetrating trauma, 70 90% of vascular injury.

Sex
90% of patients with vascular trauma are male
Age

Vascular trauma most often occurs in patients aged 20-40 years.

Mortality/Morbidity
Death due to extremity vascular trauma is uncommon ( except by exsanguination or development of a necrotizing myofascial infection. Limb survival is threatened by delays in diagnosis and treatment ( more than 6 hours) Extensive assosiated musculoskeletal, nerve and skin injuries indicate a poor prognosis.

History
The mehanism of injury is an important prognostic factor. Shotgun and military rifle injuries as well as knee dislocations are particularly high risk. The time interval between injury and evaluation must be considered. > 6 hours, irreversible nerve and muscle damage in 10 % of patients. Previous history of vascular injury or disease Extensive or pusatile external hemorrhage Anticoagulation therapy or impaired hemostatic function Prior venous thrombosis or embolism in the patient or family member

Pathophisiology
Upper extremity High-risk areas: axilla, medial/anterior upper arm, and antecubital fossa. Injuries to a single distal artery can often be managed by ligation ( 95% the palmar arches are complete) Lower extremity High-risk locations: inguinal, medial thigh, and poplitea fossa. Injury to a single distal trifucation are unlikely to produce serious limb ischaemia.

Pathophisiology
Lesion depend on cause and trauma mechanism, trauma:
contusion puncture laceration transection thrombosis

Pathophisiology
- total/ transection spasme ,constriction, retraction clotting
-partial/incomplite bleeding >>

-intima contusion, trombosis.

Patofisiologi

The three basic patterns of arterial injury

Pathophisiology
Hypoxia : is a pathological condition in which the body as a whole (generalized hypoxia) or region of the body (tissue hypoxia) is deprived of adequat oxygen supply. Ischemia : a medical term for hypoxia where there is a restriction in blood supply, generally due factors in blood vessels.

Pathophisiology
Ischemia tissue hypoxia or anoxia Metabolism of glucose (glycolysis) 2 molecules of piruvic acid If suffucient oxygen available, piruvic acid converted in to acetyl coenzym A main input for Krebs cycle 36 ATP.

2ADP Glucose

2ATP Glucose Piruvic acid

Acetyl CoA

Acetyl CoA O2 CO2

O2

O2 CO2 + H2O

36ADP ATP

36 ATP

H2O
Cell membrane

H2O

Mitochondrion

Pathophisiology
If insufficient oxygen is available, piruvic acid is broken down anaerobically to Lactic acid using enzym Lactate dehydrogenase and Coenzym NADH. Ischemia

Lack of Oxygen
Cell normal process for making ATP for energy fail

Anaerobic metabolism
Producing Lactic acid

Anaerob metabolism

ATP reliant ion transport pump fail

Active transport Na+ and K+ throught cell membrane diminished

Na+ and K+ intracelluler increased

Cell begin to swell

ATP reliant ion transport pump fail

Ion Ca2+ flow in to cell

Increased Ca2+ intracelluler

Released of harmful chemical like free radicals, phospolipase, and Calcium dependent enzym such as Calpain, endonuclease, ATPase

Necrosis Initiating Insult

Increased Ca2+

Calpains

Released Cathepsins protease

Pathophisiology
Cell membrane is broken down by phospolipase more permeable more ions flow in to cell Mitochondrial breakdown, releasing toxins and apoptotic factors in to cell The caspase dependent apoptosis cascade is initiated, causing cell to commit suicide necrosis cell.

What is ischemia reperfusion ( I/R) injury ?

Reperfusion injury refers to damage to tissue cause when blood supply returns to the tissue after a period of ischemia. The absence of oxygen and nutrients from blood create a condition in which the restoration of circulation result in inflamation and oxidative damage from the oxygen rather than restoration of normal function.

What is the clinical relevance of reperfusion injury ?

Relevant to many fields of medicine For cardiologist I / R injury can occurs following every successfully balloon angioplasty induced thrombolysis. For the plastic surgeon I/R injury threatens the integrity of every free flap. For the orthopaedist it may take the form of a decompression fasciotomy for a severe compartment syndrome.

What is the mechanism for reperfusion injury ?

During an ischemia episode, hypoxanthine is formed as breakdown product of ATP metabolism. With the restoration of normoxia, hypoxhantine substrate is combine with oxygen to produce xanthine and oxygen radical.
Xanthine oxidase

Hypoxanthine + O2

Xanthine + Oxygen radical

mechanism

Leukocyte polimorphonuclear ( neutrophil ) carried to the area by blood flow release a host inflamatory factors such as interleukin as well as free radical Neutrophyl contain an NADPH oxidase that reduces molecular oxygen to the superoxide anion. Damage to cells membrane may turn cause the release of more free radicals. Leukocyte may also build up in small capillaries, obstructing them and leading to more ischemia.

Physical
The presence of hard signs has a 92-95% sensitivity for injuries requiring intervention: - bruit or thrill - active or pulsatile hemorrhage - pulsatile or expanding hematoma - signs of limb ischaemia and elevated compartement pressure including the 5P: pallor, paresthesias, pulse deficit, paralysis, and pain.

Physical
Soft sign, predicting abnormal findings 35% - hypotension or shock - neurologic deficit due to primary nerve injury occurs immediately after injury. - stable, nonpulsatile or small hematoma - proximity of the wound to major vascular structures

Other Problems to be Considered:

Embolic vaso-occlusive disease Vasospasm ( due to cocaine or extravasated dopamine)

Lab Studies
The arteriel pressure index is useful in detecting patients with major vascular injury: systolic affected is divided normal extremity, < 90% is abnormal ABI, is calculated by dividing the higher of the systolic dorsalis pedis or posterior tibial pressure by the ipsilateral brachial artery pressure The Allen test is useful for injuries distal to the brachial artery bifurcation

Lab Studies
Angiography, for evaluation of vascular injuries: - the disadvanges include cost, significant time delay. - dye load and renal function are important presudy considerations Duplex ultrasonography currently plays a role in the evaluation of patient presenting with soft signs. Helical CT Angiography sensitivity 90 - 100%

Prehospital Care
Stabilize the extremity in the anatomic position Control hemorrhage with direct pressure Apply a tourniquet proximal to the injury if direct pressure is not effective in controlling hemorrhage.

Emergency Departement Care

Immediately reduce displaced or angulated fractures if any evidence or suspicion of vascular compromise exists. External hemorrhage can be controlled with direct pressure. Once the patient has been stabilized, identify peripheral vascular injuries and restore normal circulation as rapidly as possible. Do not apply clamps or hestats to Vascular structures, since this may make definitive repair more difficult and damage surrounding tissues

Further Inpatient Care

Surgical exploration and repair is performed as soon as possible for patients with hard sign of vascular injury Patients with soft signs of injury can be further evaluated by either duplex ultrasonography or helical CT arteriography -Certain high-risk injuries, such as shotgun wounds and major vessel proximity injuries. -Low-risk injuries without hard and soft sign should be observed for possible progression of injury either in the hospital or on an outpatient basis.

Reconstruction
End to end anastomosis > 1,5 cm Vein / vascutex graft Brachial artery, femoral artery and popliteal artery ligation Mistake

The arterial repair

end-to-end anastomosis

Complications
Delayed diagnosis and treatment may result in thrombosis, embolization, or rupture with exsanguinating hemorrhage. Risk factors for amputation include elevated compartment pressure, arterial transection, associated open fractures and the combination of injuries above and below the elbow and knee. Nonocclusive injuries do not disrupt flow and include the following: - AV fistule. - Pseudoaneurysms - Intimal tears. - Segmental narrowing

Medical/Legal Pitfals
Failure to appreciate the severity of injury is a major risk. Failure to recognize that injuries may require repair even when pulses are intact. Inappropiate delay in radiographic evaluation and surgical intervention. Failure to perform an appropiate examination, including objective test, in all patients including those who lack hard signs of vascular injury Clamping vascular structures.