downstatesurgery · 29 yo M BIBEMS as a trauma code on 10/14/2010 Multiple GSW: right chest, RUE, RLE VS: 98, 165/90, 110, 22, 100% A&O, agitated, c/o severe pain in RLE, oozing from

Irina Kovatch, PGY 4Kings County Medical Center

Morbidity and MortalityDecember 9, 2010

downstatesurgery.org

29 yo M BIBEMS as a trauma code on 10/14/2010 Multiple GSW: right chest, RUE, RLE VS: 98, 165/90, 110, 22, 100% A&O, agitated, c/o severe pain in RLE, oozing from

wounds in RUE and chest with nonexpanding hematomas PMH: denied PSH: s/p ex-lap, left nephrectomy for GSW 11 years ago

at Brookdale Hospital Intubated for airway protection IVFs/PRBCs transfusion initiated

Case Presentationdownstatesurgery.org

Head: NC/AT, intubated Abd: soft, NT/ND, BS+, midline laparotomy scar Wounds - 10Right chest: anterior and posterior axillary folds, axilla RUE: medial and lateral proximal arm, lateral distal

arm, lateral and medial forearm - no radial pulse, fingers warm, pink with good cap refill

RLE: anterior proximal thigh, posterior distal thigh -gross deformity, thigh swelling, good distal foot pulses

Physical Examdownstatesurgery.org

CBC - 10.0/14.4/42.4/216 BMP - 136/3.8/100/22/19/1.47/144 LFTs - 7.7/4.4/52/21/47/0.4 Amylase/Lipase - 65/52 Lactic Acid - 5.5 VBG - 7.21/69/24/20.8/-0.2 EtOH <10 UA neg Utox positive for cocaine, not confirmed

Labsdownstatesurgery.org

CXR - 2 bullets projecting over the right acromion process

and mid clavicle with associated comminuted fxs, no PTX Right humerus XRay - metallic shrapnel adjacent to

humeral head and comminuted fracture of the greater tubercle

R forearm XRay - no fxs Pelvis XRay - neg Femur XRay - severely comminuted fracture of the mid

femoral shaft with associated metallic shrapnel Transfer to IR for angiogram of RUE and RLE Vascular surgery and orthopedic surgery consults

Imagingdownstatesurgery.org



RUE vasospasm and injury to the distal brachial artery, no

bleeding, no other injuries the area of injury bridged and a 6 mm x 5 cm Viabahn

stent graft deployed distal runoff with vasospasm - 4 boluses of 200 mcg of

nitroglycerine achieved temporary relief, however spasm returned

observe, if limb threat becomes apparent - exploration right hand viable, good cap refill

RLE no major vascular injury

Angiogramdownstatesurgery.org





Serial doppler and compartment checks Flexor compartment 10 mm Hg Ortho - RLE traction Total transfusion: 10 Units PRBC and 5U FFP Stable overnight

HD 1 - ICUdownstatesurgery.org

Forearm SBP: left 120, right 70 - possibly occluded stent

graft, no compartment, good cap refill Repeat angiogram - thrombosis of the stent with distal

filling of the radial and ulnar arteries via collaterals OR for vascular repair Ortho: External fixation of right femur – awaiting ICU

clearance for definitive fixation IVC filter placement by IR

HD 2downstatesurgery.org


Exploration of right brachial artery via lazy S incision Arterial injury identified: blast effect and ~ 1.5 cm

destruction of the intima (vein completely transected) Stent-graft removed, artery transected to attain healthy

intima at proximal and distal ends Proximal Fogarty thrombectomy 3 cm basilic vein harvested, reversed Proximal anastomosis Distal thrombectomy and anastomosis, SubQ and skin closed, JP left Excellent radial pulse, no compartment

Vascular Surgerydownstatesurgery.org

HD 3 - extubated, sling for RUE HD 5 – Ortho: removal of ex-fix, IM nailing of right femur POD 1 - RLE WBAT

HD 6 – Transfer to floor, neuro and rehab consults Neuro: exam limited due to pain, decreased motion of the

RUE, decreased grip - pain control, rehab, EMG in 2-3 weeks as outpatient

Dispo: acute rehab placement

Hospital Coursedownstatesurgery.org


Questions


Initial assessment and care control of external hemorrhage diagnosis of limb ischemia neurologic status of the injured extremity compartment syndrome

Identifying the arterial segment involved Window of opportunity for salvage varies site and nature of injury the presence of efficient collaterals patient's age and hemodynamic status

Peripheral Vascular Traumadownstatesurgery.org

Presence of hard signs mandates immediate intervention Pulsatile bleeding Expanding hematoma Absent distal pulses Cold, pale limb Palpable thrill Audible bruit

If the site of injury is obvious angiography is unnecessary Otherwise, angiography can be performed emergently in

the OR, unnecessary interventions and investigations should be avoided to minimize the delay of definitive care

Hard Signs of Vascular Injury


Investigation or exploration of patients with soft signs

alone is not warranted peripheral nerve deficit history of moderate hemorrhage at scene reduced but palpable pulse injury in proximity to a major artery

Patients should be admitted and observed for 24 hours

Soft Signs of Vascular Injury


Pulse oximetry reduction in readings in one limb is suggestive of, but

neither confirms nor excludes a significant vascular injury Doppler Ultrasound presence of a doppler signal in a pulseless limb does not

imply a less severe or less urgent injury reduction in the ABI in the presence of a palpable pulse

does not indicate the presence of a vascular injury requiring intervention

Duplex Ultrasound can detect intimal tears, thrombosis, false aneurysms and

arteriovenous fistulae and has a high sensitivity

Noninvasive Diagnostic Adjuncts


Remains the gold-standard for investigation and

delineation of vascular injury Best performed in the operating room, with the

surgeon exposing the vessel proximal to the injury for control

Transfer to the radiology suite should be restricted to hemodynamically stable patients with proximal injuries

Angiography may be used to treat certain selected injuries, where expertise and technical facilities are available

Angiographydownstatesurgery.org

Pros can evaluate multiple levels of injury in the same blood vessel can be used to image vascular structures within the thorax,

abdomen, retroperitoneum, or extremities at the same time allows for control of vascular injury at the time of diagnostic

angiography Cons may not necessarily grade the severity of vascular injury

accurately does not image all vascular structures, therefore does not

evaluate venous injury very well

Angiography Pros & Consdownstatesurgery.org

Definitive hemostasis - embolization Torso – pelvic, lumbar, peripancreatic, perinephric, hepatic Extremity injuries – limited use due to distal ischemia, may be used

for profunda femoris, axillary and popliteal artery branches Vascular control - balloon occlusion Mediastinal vascular injuries – left subclavian, axillary Neck – Zone 1 and Zone 3 Lower extremity – for injury at the level of inguinal ligament

Vascular repair - limited experience with transcatheter stenting for trauma, theoretical therapeutic options include use for Zone 3 carotid injury from blunt trauma traumatic aortic and popliteal vascular injury

Surgical Clinics of North America - Volume 81, Issue 6 (December 2001)Interventional Techniques in Vascular TraumaScalea T, Sclafani S.


Prospective, multicenter, nonrandomized registry trial with a

historical control to surgical management 62 patients treated with Wallgraft Endoprosthesis for arterial

trauma (1997 – 2003) Endpoints exclusion success at procedure and at 12-months primary patency and freedom-from-bypass at 12-months major adverse events

Locations of arterial injuries iliac (33), subclavian (18), femoral (11)

Indication for treatment perforation/rupture (33) acute pseudoaneurysm (10) AV fistula (16) and dissection (3)

The Journal of Trauma: Injury, Infection, and Critical CareIssue: Volume 60(6), June 2006, pp 1189-1196Results of a Multicenter Trial for the Treatment of Traumatic Vascular Injury with a Covered StentWhite R, Krajcer Z, Johnson M, et al.


Results post-procedure exclusion in 58 of 62 cases (93.5%) 1-year exclusion rates - 91.3% iliac, 90.0% subclavian, and

62.3% femoral 1-year primary patency rates - 76.4% iliac, 85.7% subclavian,

and 85.7% femoral freedom-from-bypass - in 74.3% iliac and 100% femoral and

subclavian injuries most common adverse events - stenosis 4.8%, occlusion 7.9% no device- or procedure-related deaths rates and severity of complications - less than those

associated with surgical repair

The Journal of Trauma: Injury, Infection, and Critical CareIssue: Volume 60(6), June 2006, pp 1189-1196Results of a Multicenter Trial for the Treatment of Traumatic Vascular Injury with a Covered StentWhite R, Krajcer Z, Johnson M, et al.


29 yo M s/p fall from a bucket truck (height - 7 m) Multiple injuries to the left arm, right leg, and pelvis EvaluationVS: 90/60, 98, 24 extensive soft tissue laceration on the left arm and axilla no distal pulses in the LUE left forearm and hand were cold, pale, and edematousmultiple fractures in the pelvis and right tibia and fibula

The Journal of Trauma: Injury, Infection, and Critical CareIssue: Volume 56(6), June 2004, pp 1336-1341Endovascular Repair of Brachial Artery Transection Associated with Trauma - Case 1Maynar M, Baro M, Qian Z, et al


Angiography - brachial artery transection above elbow

with extravasation and non-visualization of distal arteries 6 × 58-mm Teflon-covered Jostent deployed over a wire Repeat angiogram - no extravasation, distal runoff intact Patient started on LMW heparin for 3 months Immediate return of pulses, increased temperature,

shorter capillary refill time, and improved skin color Segmental blood pressure, Doppler ultrasound, tissue

oximetry - significant improvement of distal circulation Penetrating wound surgically repaired, ortho repairs,

patient continued on antibiotics throughout hospital stay




Patient required repeated LUE wound debridements in OR HD 16 – paresthesia/intense pain in left forearm and hand PE - diminished pulse in the left forearm Angiography - complete occlusion at the level of the

proximal end of the stent-graftOccluded segment was dilated with angioplasty balloon

and a second Jostent was placed over the original one Repeat angiogram showed a fully patent graft with

excellent runoff in the radial and ulnar arteries






Fibrinolytic therapy was initiated (urokinase) for partially occluded interosseous artery

Next day, a patent interosseous artery was demonstrated Discharged from the hospital 8 weeks after the event Last follow-up (7 months) the stent-graft is patent, with

good distal runoff Patient remains free of vascular symptoms and continues

to receive PT for his injured hand


67 yo F s/p fall PMH: Parkinson’s disease, s/p multiple bilateral

shoulder dislocations VS: BP 182/84, HR 95 Conscious but anxious, agitated, pale, and sweating Right axillary hematoma 18 × 25 cm Right arm and hand pale, swollen, and pulseless Xray - right shoulder dislocation, no fracture



Angiography - abrupt discontinuation of the right

proximal end of the brachial artery with opacification of the distal artery via collaterals (45 mm segment)

Attempts to cross the injured segment via femoral approach were unsuccessful

A guidewire was advanced to subclavian artery via a retrograde approach from the ipsilateral brachial artery

Repeat angiogram - contrast extravasation suggestive of a partial transection





Two covered stents (Jostent) used to repair the injury (6 × 58 mm and 7 × 58 mm with 20 mm overlap)

Post-procedural angiography - complete bridging of the partially transected brachial artery, no leak

Urokinase bolus given for slow distal runoff with improved blood flow after injection

Distal pulses, limb temperature, and skin color improved Significant improvement in segmental blood pressure,

Doppler ultrasound, and tissue oximetry Patient transferred for orthopedic treatment the next day 1 month post-procedure - excellent flow across the stented

segment by Doppler ultrasound



Catheter-based therapy has an increasing role in the

management of vascular trauma to the extremity Described areas of treatment of arterial injury with

application of covered stents include subclavian, brachial, iliofemoral, and infrageniculate arteries

Application of these techniques is fairly new, long-term results remain to be seen

Endovascular treatment of arterial lesions should be considered in centers with sufficient experience and available personnel to perform the procedure expediently

Conclusiondownstatesurgery.org

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downstatesurgery · 29 yo M BIBEMS as a trauma code on 10/14/2010 Multiple GSW: right chest, RUE, RLE VS: 98, 165/90, 110, 22, 100% A&O, agitated, c/o severe pain in RLE, oozing from