Chapter 3: General Open Vascular Repair for Trauma; Tools, and Techniques

INTRODUCTION

Vascular trauma is associated with significant morbidity and mortality and occurs in 1% to 2% of all trauma patients. Vascular trauma can be divided into several categories: central versus peripheral, penetrating versus blunt, and upper versus lower. Peripheral vascular injury is more common and offers more options for repair. Central vascular injuries are more frequently associated with blunt mechanisms and may often be managed nonoperatively. Penetrating trauma occurs far more frequently, especially in the peripheral vascular distribution, at nearly a 3:1 ratio. Over half of the penetrating peripheral vascular injuries are caused by ballistic injury, with stabbing covering approximately 30%, while blunt injuries make up the rest of the injuries. Lower extremity vascular injury (femoral and popliteal branches) is more common than upper extremity vascular injury (at around 55% versus 45%).¹

In determining when to operate, physical examination findings play a significant role in the work-up and management. For peripheral vascular injuries, these physical examination findings can be broken into two categories: hard signs and soft signs. Hard signs include pulsatile bleeding, an expanding hematoma, absent distal pulses with signs of ischemia, or palpable thrill or audible bruit. Hard signs mandate operative intervention. Soft signs of vascular injury include non-expanding hematoma, peripheral nerve deficit, history of blood loss, diminished pulse, or unexplained hypotension. Soft signs, however, may indicate a vascular injury and require further investigation to identify if injury exists.² Although these classic physical examination findings remain relevant, dividing vascular trauma into hemorrhagic and ischemic signs may have greater clinical utility, especially in the age of near ubiquitous computed tomographic (CT) imaging. Reviewing over 1000 cases of peripheral vascular injury if CT angiography was used, there was increased odds of endovascular or hybrid repair or observation in both hemorrhagic and ischemic groups without an increase in amputation rates, reintervention, hospital length of stay, or mortality.³ With this information, more work needs to be done to validate these proposed changes.

PRINCIPLES

Preparation

After a decision is made for operative management of vascular injury, patients should have appropriate preparation and positioning in the operating room. Before the patient arrives at the operating room, it should be prepared with a radiolucent operating room table to facilitate on-table angiography if needed. If a dedicated angiography table is not possible, the patient should be positioned in a way that fluoroscopy can be performed. In addition, the operating room staff should be alerted to a possible vascular injury and have vascular instruments, a Doppler machine with intraoperative capabilities, and an ultrasound available. After placement on the operating room table and induction of anesthesia, the patient should be positioned supine with the arms extended. If there is concern for upper extremity vascular injury, an arm table should be added to the affected side. The skin should be prepped with an alcohol-based skin preparation. All trauma patients should have skin ...