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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3745_Библиотеки_им_академика_М_И_Перельмана
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112 Vascular Surgery
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a
Fig. 11.1. a Embolic occlusion of the left popliteal artery; treatment consisted of percutaneous aspiration
thromboembolectomy. b Normal patency of the popliteal, anterior tibial and peroneal arteries.
postoperatively for evolving compartment syndrome. As described in different textbooks, there are several ways of performing an adequate fasciotomy. The most
important point here is that all four compartments should be decompressed.
Although concomitant fasciotomy can be preferable in some cases of prolonged
acute ischaemia, the more conservative approach might avoid unnecessary fasciotomy and unaesthetic scars. Since a Fogarty catheter embolectomy can easily be
carried out under local anaesthesia, this wait-and-see approach eliminates the need
for systematic general anaesthesia, particularly for patients in a poor general
condition [15].
Despite the fact that the value of postoperative compartmental pressure measurements has been documented by several teams [16, 17], the decision regarding subsequent fasciotomy is most frequently based upon individual preferences and prior
clinical experience. [Q5: D]
Every effort should be made in the postoperative period to minimise the incidence of recurrent emboli. The patient should be treated with heparin or oral anticoagulants until the source of the embolus has been taken care of. [Q6: B] If
b
Arterial Embolism 113
extensive investigation fails to show any correctable source, then long-term anticoagulation is indicated, except in the case of major contraindications.
References
1. Panetta T, Thompson JE, Talkinton CM, Garrett WV, Smith BL. Arterial embolectomy: a 34-year
experience with 400 cases. Surg Clin North Am 1986;66:339.
2. Thompson JE, Sigler L, Raut PS, Austin DJ, Patman RD. Arterial embolectomy: a 20-year experience.
Surgery 1970;67:212–20.
3. Mills JL, Porter JM. Basic data related to clinical decision making in acute limb ischemia. Ann Vasc
Surg 1991;5:96.
4. Keating EC, Gross SA, Schlamowitz RA. Mural thrombi in myocardial infarctions. Am J Med
1983;74:989.
5. Reber PU, Patel AG, Stauffer E, Muller MF, Do DD, Kniemeyer HW. Mural aortic thrombi: an important cause of peripheral embolization. Vasc Surg 1999;30:1084–9.
6. Abbott WM, Maloney RD, McCabe CC, Lee CE, Wirthlin LS. Arterial embolism: a 44 year perspective. Am J Surg 1982;143:460–4.
7. Beard JD, Nyamekye I, Earnshaw JJ, Scott DJ, Thompson JF. Intraoperative streptokinase: a useful
adjunct to balloon-catheter embolectomy. Br J Surg 1993;80:21–4.
8. Heymans S, Vanderschueren S, Verhaeghe R, Stockx L, Lacroix H, Nevelsteen A, et al. Outcome and
one year follow-up of intra-arterial staphylokinase in 191 patients with peripheral arterial occlusion.
Thromb Haemost 2000;83:666–71.
9. Sniderman KW, Kalman PG, Quigley MJ. Percutaneous aspiration embolectomy. J Cardiovasc Surg
(Torino) 1993;34:255.
10. Haimovici H. Muscular, renal and metabolic complications of acute arterial occlusions: myonephropathic-metabolic syndrome. Surgery 1979;85:461.
11. Fischer RD, Fogarty TJ, Morrow AG. Clinical and biochemical observations of the effect of transient
femoral artery occlusion in man. Surgery 1970;68:323.
12. Rubin BB, Walker PM. Pathophysiology of acute skeletal muscle injury: adenine nucleotide metabolism in ischemic reperfused muscle. Semin Vasc Surg 1992;5:11.
13. Pattwell D, McArdle A, Griffiths RD, Jackson MJ. Measurement of free radical production by in vivo
microdialysis during ischemia/reperfusion injury to skeletal muscle. Free Radic Biol Med
2001;30:979–85.
14. Padberg FT, Hobson RWII. Fasciotomy in acute limb ischemia. Semin Vasc Surg 1992;5:52.
15. Rush DS, Frame SB, Bell RM, Berg EE, Kerstein MD, Haynes JL. Does open fasciotomy contribute to
morbidity and mortality after acute lower extremity ischemia and revascularization? J Vasc Surg
1989;10:343–50.
16. Whitesides TE, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J
Am Acad Orthop Surg 1996;4:209–18.
17. Janzing HMJ. The acute compartment syndrome, a complication of fractures and soft tissue injuries
of the extremities. A clinical study about diagnosis and treatment of the compartment syndrome.
Doctoral thesis, Leuven University, 1999.
12. Blast Injury to the Lower Limb
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Paul H. B. Blair, Adrian K. Neill and
Christopher T. Andrews
A 40-year-old male was admitted to the emergency room approximately one and
a half hours after sustaining a blast injury to both lower limbs. He had been
resuscitated at his local accident and emergency department prior to transfer. On
arrival, his pulse was 120 bpm and his blood pressure 80/40 mm Hg.
Examination revealed that the patient had sustained significant blast injuries
to both lower limbs with no obvious torso injuries. The left leg had sustained
neurovascular damage above and below the knee with concomitant bone and soft
tissue injury; there was no tissue perfusion below the knee. On the right side
there was a large wound in the thigh extending anteriorly to the knee joint with
profuse bleeding; bony fragments could be seen in the wound and the right foot
was pale with no palpable pulses and slight reduction in sensation.
Question 1
The priorities for the care of this patient include:
A. Secure an airway, commence oxygen therapy and obtain adequate intravenous
(IV) access.
B. Complete a full survey of the patient before transferring for further management.
C. Wait for blood result before deciding on transfer out of the emergency room.
D. Transfer the patient to theatre for definitive management during primary
resuscitation.
E. Discuss treatment options with relatives.
Question 2
Which of the following are “hard” signs of vascular injury?
A. Limb pain.
115
116 Vascular Surgery
B. Absence of pulses.
C. Pallor or cyanosis.
D. Cool to the touch.
E. Bruit or thrill.
Question 3
Which of the following statements relating to angiography are true?
A. Angiography should be performed in all patients to target surgery.
B. Angiography may be a useful tool in trauma patients with no hard signs of
vascular injury.
C. Angiography is reserved for stable patients.
D. Angiography should only be performed in a radiology department.
E. The patient’s pre-morbid condition should not influence the decision to
perform angiography.
Question 4
For how long will the lower limb tolerate ischaemia?
A. 20–30 minutes.
B. 90–120 minutes.
C. 6–8 hours.
D. 16–20 hours.
E. 24–36 hours.
The patient was resuscitated as per ATLS (advanced trauma life support) protocol. Supplementary oxygen was administered in addition to obtaining additional IV
access. Pressure dressings were applied to the open wounds and further assessment
revealed an injury to the patient’s right hand; no other significant injuries were
present. The patient was transferred to the operating theatre.
Question 5
What are the primary aims of surgery in such a case?
A. To control life-threatening haemorrhage.
B. To prevent end-organ ischaemia.
C. To restore vascular continuity.
Blast Injury to the Lower Limb 117
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D. To preserve limb function.
E. To detect occult injuries.
Question 6
What factors will influence the decision to perform an amputation?
A. Patient’s age.
B. Mechanism of injury.
C. Time to treatment.
D. Degree of contamination.
E. All of the above.
Question 7
Which of the following statements about complex vein repair are true?
A. Complex vein repair should never be undertaken in the trauma patient.
B. Complex vein repair should only be performed in the absence of major arterial
injury.
C. Complex vein repair should be used to improve venous return in unstable
patients.
D. Complex vein repair may prevent long-term limb dysfunction.
E. Intraluminal venous shunting is an acceptable intraoperative temporising
measure.
In the operating theatre, under general anaesthesia, the patient was placed in the
supine position. The lower abdomen and both legs were prepared and draped
widely and intravenous broad spectrum antibiotics were administered. Closer
examination revealed that the left leg had sustained extensive injuries. The foot and
distal calf were cold, pale and mottled. There was a compound injury to the left
femur and tibia with complete disruption of the superficial femoral artery,
superficial femoral vein and extensive injury to the sciatic nerve. It was decided that
primary amputation of the left limb was required. On examination of the right leg
there was complete disruption of the distal superficial/popliteal artery, a ragged laceration of the popliteal vein and significant bruising to branches of the sciatic nerve.
There was a shrapnel injury to the right hand involving the thumb and middle
finger.
Immediate surgical steps were as follows: (i) a proximal thigh tourniquet was
placed on the left leg to arrest haemorrhage prior to formal amputation. The laceration to the right lower leg was then extended distally to facilitate exposure of the
neurovascular structures. Control of the superficial femoral and below-knee
popliteal artery was obtained and a careful distal embolectomy performed. A Javid
118 Vascular Surgery
Fig. 12.1.
Extended wound, medial aspect of right leg with a temporary intraluminal shunt between superficial
femoral and below-knee popliteal arteries.
shunt was then placed between the right superficial femoral artery and right belowknee popliteal vessel (Fig. 12.1). Significant bleeding from a large defect in the
popliteal vein occurred following shunt insertion; this was repaired using a lateral
suture. The long saphenous vein was harvested from the left leg, prior to performing above-knee amputation. While the left above-knee amputation was being performed, the orthopaedic surgeons carefully assessed the right lower limb and placed
a temporary fixation device traversing the right knee joint (Fig. 12.2). Having
obtained bony stability, with an external fixator device, the temporary intraluminal
shunt was removed and a definitive bypass performed using reversed left long
saphenous vein graft. Formal fasciotomy was performed of the right lower leg using
a standard lateral and medial approach; distal pulses were confirmed in the right
foot. Further debridement of necrotic muscle was performed and the wound on the
medial aspect was partially closed; the anterolateral wounds were debrided and irrigated, as were the fasciotomy sites, with sterile dressings being applied to both.
Fig. 12.2.
A multidisciplinary approach. Bony stabilisation of right leg (after temporary intraluminal shunt place-
ment) by the orthopaedic surgeons, simultaneous with left above-knee amputation by the vascular surgeons.
Blast Injury to the Lower Limb 119
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Question 8
In the absence of obvious haemorrhage, when is it appropriate to reinspect the
wounds in the postoperative period?
A. 1–2 hours.
B. 4–6 hours.
C. 12–16 hours.
D. 24–48 hours.
E. 5+ days.
Postoperatively the patient was transferred to the intensive care unit where the
right limb was elevated to reduce swelling. The right foot was left exposed to allow
access for pedal pulses. Broad spectrum IV antibiotics were continued in addition
to standard prophylaxis for deep vein thrombosis, and urine was checked for myoglobinuria. The patient was returned to the operating theatre within 48 hours for
wound inspection and change of dressing. Eventually skin coverage of the right
limb was obtained using a combination of split skin grafting and healing by delayed
primary intention. Over the next few months the patient required complex
orthopaedic surgery including the use of an Ilizarov frame device (Fig. 12.3). He was
fitted with an above-knee prosthesis for his left leg and is now fully independent
(Fig. 12.4).
Commentary
Lower limb injuries, due to penetrating trauma, can be devastating and occasionally
may distract the clinician from less obvious but potentially life-threatening injuries
to the head, neck and torso. It is important that some form of resuscitation protocol
is followed such as the ATLS system to detect less obvious injuries. Time is of the
Fig. 12.3.
Recovery. Healed traumatic and fasciotomy wounds after skin grafting; Ilizarov frame still in place.
120 Vascular Surgery
Fig. 12.4.
Rehabilitation. An excellent result for limb salvage (right leg) and learning to function with a prosthe-
sis (left).
essence when managing vascular injuries. While delays rarely occur in patients with
obvious haemorrhage, it is the prompt instigation of life-saving measures and
ongoing diagnosis in parallel with transfer to the operating theatre for definitive
care that reduces morbidity and mortality. [Q1: A, D]
The clinical manifestations of vascular injury have traditionally been divided into
“hard” and “soft” signs (Table 12.1). [Q2: B, E]
Table 12.1. Signs of vascular injury. Updated
Hard signs Soft signs
Absent pulse Haematoma (small)
Bruit or thrill History of haemorrhage at scene
Haematoma (large or expanding) Peripheral nerve deficit
Distal ischaemia
Blast Injury to the Lower Limb 121
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In general, preoperative arteriography may be used in the following situations:
(1) to confirm the site and extent of vascular injury in stable patients whose clinical
signs and symptoms are equivocal; and (2) to exclude vascular injury in patients
with no hard signs, but who are considered to be at risk because of the proximity of
the injury. The majority of patients with penetrating extremity trauma and the presence of a single hard sign should be transferred directly to the operating theatre.
Possible exceptions to this rule include stable patients with multiple levels of injury,
extensive bone or soft tissue injury, blast or shotgun injuries, potential injuries to
the subclavian or axillary arteries and the pre-existence of peripheral vascular
disease. Some centres report excellent results with emergency room angiography [1]
while recent advances in endovascular technique facilitate high-quality imaging in
the operating theatre. [Q3: B, C]
Inadequate tissue perfusion due to major vessel disruption is aggravated by
hypovolaemic shock and associated bone and soft tissue injury. The resulting fall in
tissue pO
increases capillary membrane permeability, with increased exudation of
2
fluid into the interstitial space. Compromised muscle fibres swell within the fascial
compartments, causing further resistance to blood flow, and swelling becomes traumatic when arterial repair and restoration of flow brings about reperfusion injury.
The degree of reperfusion injury depends on the duration of ischaemia, and is
mediated by the generation of free radicals, activation of neutrophils, and production of arachidonic acid metabolites. Eventually, the microvascular bed of the
extremity may undergo widespread thrombosis [2]. It is generally accepted that a
warm ischaemia time of more than 6–8 hours makes limb survival unlikely. [Q4: C]
To achieve optimal results from emergency vascular repair, and to avoid complications such as compartment syndrome or contracture due to prolonged warm
ischaemia and reperfusion injury, surgical exploration should be undertaken
expeditiously.
A patient with complex lower limb injuries should be placed in a supine position
on an operating table suitable for on-table angiography, if required, when clinical
stability has been reached. Some form of warming device should be employed to
maintain adequate body temperature. In lower limb trauma, both limbs should be
prepared from umbilicus to toes; donor saphenous vein harvesting may be required
from the contralateral limb, particularly if ipsilateral venous injury is suspected.
Careful attention should be given to correct hypothermia, blood loss, electrolyte
imbalance and coagulopathy.
The principal aims of emergency vascular surgery are to control life-threatening
haemorrhage and prevent end-organ ischaemia. [Q5: A, B] An assistant should
control haemorrhage using a pressure dressing until the patient is prepared and
draped appropriately. Haemorrhage control can be difficult if the proximal vessels
are not immediately apparent, and the use of a cephalad incision through virgin territory may be a reasonable alternative to obtain rapid proximal control. Care should
be taken when making additional incisions, particularly if it seems likely that plastic
surgery will be required at a later date. When access to the proximal or distal vessel
is difficult, temporary control can be gained by careful cannulation and inflation of
an embolectomy catheter. It is important that the surgeon cooperates fully with the
anaesthetist during surgery as it may be necessary to pack the wound for a few
minutes to facilitate intravenous fluid resuscitation before proximal vascular
control can be obtained. Complex lengthy operations should be avoided in unstable
patients and damage limitation surgery should be considered in patients with
significant metabolic acidosis, coagulopathy and/or hypothermia.
122 Vascular Surgery
The use of a temporary intraluminal vascular shunt should be considered in the
majority of limb vascular injuries and is particularly important in complex cases
with associated bone and soft tissue injury.
Temporary shunts for arterial and venous injuries have been employed in Belfast
since the late 1970s [2]. A considerable body of evidence continues to support the
use of these intravascular shunts in the management of both penetrating and blunt
major vascular trauma [3–6]. Before securing the shunt between the proximal and
distal arteries, a careful embolectomy should be performed to remove any thrombus in the distal vessel. If a venous injury is encountered, then an additional shunt
can be employed to facilitate venous return. In the absence of coagulopathy or
ongoing haemorrhage we use intravenous heparin routinely. Recent evidence has
shown clearly that delayed renewal of venous flow in combined arterial and venous
injury compounds ischaemia–reperfusion injury and causes remote lung injury [7].
The advantages of shunting artery and vein are the early restoration of blood flow
and venous return, respectively, thus avoiding the complications of prolonged
ischaemia and ischaemia–reperfusion injury while ensuring that an optimal vascular repair can be performed.
In patients with concomitant fractures, accurate internal or external fixation of
the fracture can be performed with the shunt secured carefully with sloops before
definitive vascular repair is performed. This avoids the dilemma of unnecessary
haste for both the orthopaedic and vascular surgeons, ensures that a vein graft will
be of optimal length, and eliminates the risk of graft disruption during fracture
manipulation. Autologous vein is our preferred bypass conduit in the majority of
cases because of its durability and suitability in a potentially contaminated wound.
Satisfactory results, however, have been reported using synthetic grafts and in critically ill, unstable patients this may be a preferable option [8].
The acute management of high energy limb trauma can be challenging and
significant morbidity and mortality can occur following failed attempts at limb salvage.
A number of scoring systems have been devised in an attempt to assist the clinician’s
decision to either amputate or perform a limb-salvage procedure [9–13]. In each of the
systems, a score is assigned based on a range of differing criteria including patient age,
“mechanism of injury”, time to treatment, degree of shock, warm ischaemia time and
the presence of local injuries to the following structures: major artery, major vein,
bone, muscle, nerve, skin, and degree of contamination. [Q6: E] All of these scoring
systems demonstrate a much higher degree of specificity than sensitivity and are more
useful in highlighting the patients who should be considered for a limb-salvage procedure, than identifying those who should proceed straight to primary amputation.
Indeed a number of studies have challenged their use at all [14, 15].
It is the authors’ opinion that scoring systems can help the surgeon perform a
detailed assessment of a complex limb injury. However, the decision to perform a
primary amputation must be judged individually in each case. Extensive nerve
injuries have a particularly poor prognosis and it is important that such injuries,
where possible, are documented before taking the patient to the operating theatre.
The patient’s life should never be put at risk in a futile attempt to save a severely
compromised limb. Where possible, additional specialties such as orthopaedics and
plastic surgery should be involved in the decision to perform a primary limb amputation, particularly in a case of upper limb trauma.
Venous injuries can be difficult to manage. Prior to World War II, the traditional
treatment for lower extremity venous injuries was ligation. This custom was challenged by Debakey & Simeone [16] in 1946 with an analysis of WWII battle injuries.
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