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Vascular Emergencies
Vascular Surgery UnitVascular Surgery UnitAMNCHAMNCH
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Vascular emergencies (surgical)
• Abdominal aortic aneurysm
• Ischaemia– Acute occlusion
• Thrombosis• Embolism
– Arterial trauma
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Presentation
• Abdominal pain • Back pain• Collapse• Hypotension• High index of
suspicion
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Presentation
• Abdominal pain • Back pain
Differential diagnosis•Renal colic•Diverticulitis•Appendicitis
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Imaging
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Imaging
After Consultation with Vascular Surgery•Stable patient•Uncertainty•EVAR
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Where to…
Theatre Radiology
Morgue
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• Immediate transfer to theatreImmediate transfer to theatre• Paint and drape before intubationPaint and drape before intubation• Central access if feasibleCentral access if feasible• Early clamp saves livesEarly clamp saves lives
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Open surgery
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Aortic Aneurysm repair
• DuBost – first homograft repair 1951
• Modern graft materials 1953
Postoperative• 5 year survival = 63-84% disease matched control
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Mortality
• N=222• Age 74 years (range 57–96 years) • Female = 43 • No surgery = 39• Surgery = 183
– In-hospital mortality = 48.0% • 14.9% intra-operatively (14.9%), • 8.3% died within 24 h
• Total mortality 55%
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New technology
Parodi et al Ann Vasc 1991
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Anaesthesia & position
• Epidural/spinal• Occasionally GA• Possible under LA
Central access• Arterial line
• OSI (radiolucent) table
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Position
• Arms tucked in by sides
• Contrast pressure injector (angio)
• C Arm
• 2 tables – open/endo
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Set up & equipment
1
2
Scrub/N 1
C-arm
Monitors
Injector
Scrub/N 2
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Draping & incision
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Exposure
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Tri Fab design
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Closure
• Arteriotomy closure
• 6/0 prolene
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Open vs EVAR
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History
Welch Halsted Osler Kelly
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The Problem
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The Problem
• 1992-2005• 35 patients• Mean age 26 (3-80)• RTA 43%• Associated # in 47%• Brachial artery 36%• Low mortality (n=1, IVC)
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Mechanism
• Blunt– Orthopaedic #– Dislocation (knee)– Isolated
• Penetrating– High velocity– Low velocity
• Iatrogenic
http://www.facs.org/trauma/publications/peripheralvasctrauma.pdf
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Initial assessment
• Airway• Breathing/ventilation• Circulation• Disability• Exposure
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Immediate treatment
• Control bleeding
• Replace volume loss
• Cover wounds
• Reduce fractures/dislocations
• Splint
• Re-evaluate
Credit: http://www.ota.org/
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Signs of arterial injury hard signs
• External (arterial bleeding)
• Rapidly expanding haematoma
• Palpable thrill/audible bruit
• Obvious ischaemia– 5 P’s
Credit: http://www.ota.org/
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Index of suspicion soft signs
• History of arterial bleeding• Proximity of #/wound to
artery• Diminished pulse (BP)• Small non-pulsatile
haematoma• Neurologic deficit
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Time
Pathophysiology
Ischaemia
Rapid resuscitation
Urgent exploration
Ischaemia
revascularisation
Tissue necrosis
Reperfusion injury
Compartment syn
? fasciotomy
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Operative management
• Angiography– In theatre– Diagnostic– Therapeutic
• Covered stent• Embolisation
• Open exploration– Repair– Bypass
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Operative strategy - 1
• Position– Access– Angio
• Maintain compression
• Exposure & Control– Separate (anatomical)
incision– Distal
• Damage limitation– intraoperative shunt
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Endovascular treatment
Katsanos K et al Emerg Radiol. 2009
Case series only; no convincing data
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Procedure
• Thrombectomise• Heparinise
– Multisystem trauma– Coagulopathy
• Repair deficit • Lateral suture• Resection and end-end• Interposition
– autologous vein– Synthetic
• Ligation
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Compartment syndrome
Pearse et al. BMJ 2002 2002
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Penetrating neck trauma
• Don’t explore in ED• Assess other injuries• Early transfer to
theatre – multidisciplinary– ?CT
• Systematic approach
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Carotid trauma
I
cricoid
2
3
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Acute limb ischaemia
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Immediate management
ResuscitateABC…ECG
Intravenous heparinBolusStart an infusion
Do not use LMWH
Heparin•Reduce risk of further embolisation•Reduce fragmentation and distal embolisation•Prevents thrombus formation propagation•Mitigate secondary venous thrombosis
* Creager et al NEJM 2012
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What next?
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What next?
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Agonal event
http://slinkingtowardretirement.com/wp-content/uploads/2011/04/00407501.jpghttp://slinkingtowardretirement.com/wp-content/uploads/2011/04/00407501.jpg
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Therapeutic options
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Hybrid approach
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Fogarty embolectomy
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Percutaneous techniques
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…Image
* Creager et al NEJM 2012 * www.straubmedical.com/case-reports-en.html
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..thrombectomise
* www.straubmedical.com/case-reports-en.html
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..thrombectomise
* www.straubmedical.com/case-reports-en.html
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…restore flow
* www.straubmedical.com/case-reports-en.html
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…correct abnormality
* www.straubmedical.com/case-reports-en.html
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Catheter directed thrombolysis
* Creager et al NEJM 2012
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… Bypass
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Ischaemia reperfusion
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Outcome
1 yr mortality15-20%1
Major amputation10-15%2
1 Creager et al NEJM 20122EarnshawJ Vasc Surg 2004
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Sean Tierney
@theseant
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Vascular Trauma
Vascular Surgery UnitVascular Surgery UnitAMNCHAMNCH
http://goo.gl/U3DnR
