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Journal Review in Vascular Surgery: Vascular Extremity Trauma · Behind The Knife: The Surgery Podcast

• Journal Review in Vascular Extremity Trauma === [00:00:00] Hello, everyone, and welcome back to another episode of Behind the Knife. Today, we're talking about a topic that every trauma and general surgeon needs to be comfortable with, vascular extremity trauma, and the evolution of our assessment and management of these types of injuries. Let's kick things off with a level one trauma activation. A twenty-eight-year-old male with an isolated gunshot wound to the proximal left thigh is being rolled into the trauma bay. EMS reports massive blood loss at the scene. The patient appears pale and diaphoretic. Vitals show tachycardia to the one tens, and blood pressure is nineties systolic. There's a tourniquet in place at the proximal thigh, and the patient isn't actively bleeding from the gunshot wound. Dr. Hazer, how do you approach this patient? Well, Christian, as with any trauma patient, you should start with the ABCs. In fact, according to the most recent edition of, uh, ATLS, XABC, with X being control of obvious exsanguination. In this case, the tourniquet is in place and appears to be functioning properly.[00:01:00] After ensuring a patient's airway and bilateral breath sounds, the next step is to secure bilateral large bore IV. I always stress to the resident before removing the tourniquet. A lot of the time, our first instinct is to dive right in and assess the severity of the main injury. In this case, the obvious gunshot wound to the thigh. But in this setting, bleeding should be assumed the cause of hypotension till proven otherwise. I would start by initiating transfusion of two units of uncrossed PRBCs. I would also have a low threshold to activate massive transfusion protocol, depending on their response to the two units. Finally, I think it's important to mention that although it's been reported as an isolated gunshot wound, it's extremely important to expose the patient and confirm there's no other injuries, especially to the back, groin, axilla, which are often frequently missed areas. Only after all this is done and the blood is running, I would approach then the question of removing the tourniquet and assessing the injury itself. Excellent points, Dr. Hazer. I have been in a [00:02:00] position where we took down the tourniquet, and then we were playing catch up with transfusions. A small note on tourniquets is that ATLS eleven strongly supports the use of tourniquets in extremity trauma if bleeding cannot be controlled with direct pressure or packing. Early placement of tourniquets in situations of massive extremity trauma or multiple injuries leading to exsanguination has been associated with improved outcomes. This is a change over the years, as previously tourniquets were a controversial topic as there were concerns for causing ischemia. However, ATLS eleven explicitly states that tourniquets left in place for less than two hours have not been associated with tourniquet-related complications. Although longer durations carry increasing risk. Tourniquets should be applied two to three inches proximal to the injury and not over a joint. It is also preferable to remove any clothing prior to application if possible, although obviously that might not always be the case. Uh, the time the tourniquet is in-inflated should also be recorded. The tourniquet works [00:03:00] most effectively when it overcomes systolic blood pressure, so a pulse generally should not be palpable distal to a tourniquet. Okay, back to our scenario. So we've gotten access and started transfusing. The patient's vital signs improve. We confirm that this is an isolated gunshot wound to the proximal anterior medial thigh. Time to take down the tourniquet and assess the injury. Dr. Flores, before we do that, what are you thinking about? What are you specifically looking for when the tourniquet comes down? Well, this is a patient who sustained a gunshot wound associated with significant bleeding in the proximal part of extremity. Is manual compression unable to control the bleeding? Consideration should be done to a balloon occlusion in proximal injuries. Junctional injuries are very challenging, where the limb connect to the torso, specifically at the groin, armpit, or base of the [00:04:00] neck. In these cases, it's important to obtain proximal control. Using balloon occlusion proximal to the injury minimize the bleeding and facilitate repair The use of tourniquet distal to the injury may help to control retrograde bleeding, and this is seen frequently when there is association of arterial and venous injuries. Excellent. So we have proximal and distal control in mind, and we're anticipating that taking down the tourniquet could c- uncover significant hemorrhage. And we're gonna be performing a careful vascular exam once that tourniquet comes down. Dr. Harrington, let's say we take down the tourniquet and there's immediate brisk pulsatile bleeding from the wound. The patient develops an expanding hematoma of the proximal thigh. The left foot is cool, and there are no palpable distal pulses. Massive transfusion protocol is already underway. What's your next [00:05:00] move? So when it comes to trauma, especially situations where you have a life-threatening vascular injury, uh, it's essential to recognize which of these patients are gonna need immediate exploration. Uh, the patient you're describing is showing classic HARD signs which make the decision to go to the OR an easy one. When these HARD signs are present an ABI, CTA, those aren't really needed here. Um, for the learners out there, the HARD signs are active bleeding, palpable thrill, audible bruit, or absent distant pul- distal pulses. When any or of these are present, the safest place for the patient is in the operating room. In this patient's case, where they actually have active brisk pulsatile bleeding from the wound, I probably would also put the tourniquet back up. Fair enough. And, uh, thanks for recapping those signs, Dr. Harrington. I remember a previous chief resident, [00:06:00] um, had me, like, get a way to remember the HARD signs by saying think of the senses. Like, things you feel, things you see, things you hear. I guess nothing for things you smell or taste, but we'll leave that alone. Let's change the scenario a bit. Let's say we take down the tourniquet, and the already present hematoma doesn't expand. Pulses are palpable distally. Uh, however, they are a bit weaker than on the uninjured leg. How do you approach this patient? All right. So this requires a little bit more thinking. Um, the patient's vital signs improve with the transfusion, and there's no hard indications for the operating room. Now is a good time to use our adjuncts like ABI and CTA. Angiography, uh, was also historically used as sort of the gold standard in these situations. The simplest way to identify and evaluate, um, if there's significant injuries with ABI, and if it's less than zero point nine, additional diagnostic imaging is necessary. [00:07:00] For the patient who has a pulse discrepancy, I would also want to get additional imaging no matter what the ABI is. A great point, Dr. Hangton. And this is where one of the papers that really changed the management of extremity vascular trauma comes into play. Before we had widespread access to modern CT, the question was, do we need to perform angiography on every patient who might have an arterial injury? Uh, Lynch and Johansson published a landmark study in 1991 looking at the use of arterial pressure indices to identify occult extremity and arterial injuries. Their findings supported, as you said, an arterial pressure index of 0.9 as an important threshold. Patients with an index of less than 0.9 had a sensitivity of 87% and specificity of 97% for arterial disruption in this series, and this helped establish the selective approach we still use today. Normal exam, normal pressure index, no routine angiography. Dr. Flores, can you tell us about the evaluation of these types of [00:08:00] injuries from your perspective? Well, with the classification of, uh, hard signs and soft sign, that helped us a lot to elucidate and orchestrate our approach. ABI, arterial duplex CTA are used in very selective cases as well, uh, angiography. The incidence of vascular injuries in patients with soft, soft signs have been reported low in the 10% or so, and usually are not disruption, but lesions that are in the wall or intraluminal, and all depends upon the type of injuries. Intimal tears, pseudoaneurysm, arteriovenous fistula, injury to the branches, spasm, contusions are these lesions usually [00:09:00] present in patients who have soft signs and no disruption of the arterial wall. Thanks for that explanation, Dr. Flores. Just a question. So in these kinds of situations, I'm guessing that back in the day, you used to be doing angiography on almost everybody. Is that right? We were selected doing angiography. Be- in the past, angiography was the only way to assess the lesions, so we were doing a lot of angiography, in many cases unnecessary. But gradually, we become more selective and maybe super selective in indication of an- of angiography. Okay. Thank you. For all the residents at home, an ABI or ankle brachial in- index is calculated by getting a Doppler and placing it on the bilateral brachial arteries and raising a blood pressure cuff until the signal is no longer heard. Then do [00:10:00] the same thing while placing the Doppler probe on the DP and PT of the injured extremity. The higher pressure between the DP or PT is then divided by the higher pressure of the brachial Dopplers. That number gives you your ABI. Okay, let's give our patient some numbers. Dr. Hazer, let's say we calculated an ABI of 0.96. Are we done? Christian, you know, we've mentioned before about the fact that there could be venous injury, there could be intimal flap injury, and also I think understanding that the ABI comes from the inline flow, but there's a major vessel, the profunda, and even smaller branches that come off that have to be considered and that have to be evaluated as well because people can have significant injury to these vessels and lose a lot of blo- blood from them even though their ABI is normal So let's say that the, the ABI is zero point eight two. Uh, I'm guessing the next [00:11:00] step would be a CTA? As long as the patient's stable, I think that that's a very good way to go nowadays. We didn't use to have that, and s- as you s- mentioned before, we used to do a lot more angiograms in those cases because we could look... Now, now we can assess for the CTA, and we can even do venous phase to look for what's going on in the venous circulation at the same time. Okay. What if I told you that this patient who has a small non-expanding hematoma, a pulse differential ABI greater than zero point nine, and on the CTA, uh, there's only a, a, a hematoma with no major vascular injury. Is that somebody that you would be comfortable to discharge, or do you think that they should definitely be observed, no question? I think it's important to do serial exams on those patients and at least to give them twenty-four hours. Sometimes it could be that they have a small pseudoaneurysm and that that's not appreciated. And especially, you know, we're going back to our initial presentation, this patient was reported to have significant bleeding in the field, [00:12:00] so they may even be in spasm in that area. Mm. Let's close that down. And it could be that just watching them, being able to give serial exams, including serial ABI, is important. Great. Thank you. One of the studies that I'd like to highlight here is the prospective work by Inaba and colleagues evaluating multi-detector CT for vascular extremity trauma. The important finding wasn't that s- uh, simply that CTA could identify arterial injuries. It was that CTA was sufficiently accurate to function as a rapid, non-invasive alternative to conventional angiography for most patients who required imaging. A caveat mentioned in the study was that CTA could be non-diagnostic with the presence of artifact from ballistic injury, which is not uncommon with these kinds of, uh, injuries. So now the algorithm becomes physical exam, ABI when appropriate, CTA with- when indicated, rather than physical exam and then conventional angiography for everyone. Dr. Harrington, when you're standing in the trauma bay today, is there still a role for conventional [00:13:00] ang- angiography as a diagnostic study? Yeah. You know, I think there is. I will say that, um, uh, you know, I usually say, you know, nothing comes for free, right? So it's not just like you do your angio, and that's a totally benign thing to do. Um, Dr. Hazer, when I first started working with him, always told me a story about someone who... a young person where a diagnostic angio was done, and they actually clotted the common femoral artery because their artery spasmed after having been accessed. So even, even diagnostic studies can come with a cost if you're not careful. But in terms of you know, ignoring that, that kind of issue, I think there is a role for conventional angiography, especially in patients who have isolated injuries, meaning that they're not [00:14:00] gonna require additional CT scans, right? So we're talking about the guy who just has an injury to the leg or just to the arm and isn't gonna need CT scans anyway of other parts of their body. In that scenario, it might make sense to do go directly to angiogram to reduce the amount of radiation exposure. Nice. I think one also caveat is that the CT is generally a little bit more sen-- uh, or should I say less sensitive to vessels below the knee. So I guess that might be a situation where you would be leaning a little bit more towards angiography sooner or even- Uh- ... with a fairly normal CT, I guess. Yeah. So that's a great point. It depends on the scenario again. So let's say I'm already getting that CT angiogram, and I have, um, you know, y- our excellent vascular lab to be able to evaluate those tibial [00:15:00] vessels. Uh, then I might use those as sort of like combined imaging modalities as opposed to subjecting them to the additional radiation and also the additional risk of doing the conventional angiography. Sure. But yes, there-- If you're gonna be in the operating room already, then it, it probably makes more sense to be doing that angiography as the diagnostic procedure. But it, it becomes quite complicated quickly. Yeah. Fair enough. Before we move on, uh, let's say we decided to take this patient to the OR. Dr. Flores, I was hoping you could quickly describe tips on efficiently performing an open femoral cut down and maybe your plan once you've a- uh, established proximal and distal control in the OR. Yeah. Currently, I'm using less and less femoral cut down in order to control the bleeding. We're using tourniquet, sometimes manual compression in a [00:16:00] good position balloon occlusions, and so forth. If I'm not able to control, for whatever reason, the bleeding, then I like to do the control by cut down proximal to the injury, and the superficial femoral artery probably is very accessible. In a thin individual, an up and down incision. In an obese individual, a transverse. Occasionally, you are dealing with a scar grown from previous surgery. In those cases, I like to do a external iliac artery as a Source of control I see. Dr. Hazer, can you add anything to that? I think Dr. Harrington mentioned that one case, it was, uh, quite awful because the injured extremity was sa- salvaged, but the accessed extremity for control was not, unfortunately. And so we do have to keep that in mind, [00:17:00] particularly in our younger trauma patients, where they can have significant amount of spasm. You don't really wanna be giving someone who's hypotensive nitroglycerin or papaverine intra-arterially at the time, but you do have to keep that in mind and keep the sheaths flushed, et cetera. That said, you know, if you can get quick access, even putting up an intra-aortic balloon temporarily, like a REBOA type device, can be lifesaving for some of these patients because they may be very behind, and you may have to give multiple units of blood. They may have lost almost all their, uh, blood in the street at the time before they even approached. So there's, there's nothing wrong with doing that. But I think uh, I, I tend to be a little bit more along the same school as Dr. Flores and that you, you've already demonstrated, for, for instance, in this patient, that you have good control with the tourniquet, so why not use that? And then as they used to say, "If you want the money, you gotta go to the bank." So you can just track down, uh, where the gunshot wound was and do a standard medial [00:18:00] exposure, uh, during that time. Thanks. Okay. Let's move on to another scenario then. Uh, let's say we have a thirty-two-year-old male who presents after a gunshot wound to the medial aspect of the distal upper arm. EMS reports significant bleeding at the scene that was controlled with direct pressure. The upper arm clearly has a bony deformity. On arrival, the patient is hemodynamically stable. There is a three centimeter wound over the medial distal arm with a small non-expanding hematoma. He has diminished sensation in the hand and weakness with finger flexion. The radial and ulnar pulses are non-palpable. Dr. Hazer, how would you approach this patient? We're gonna do the same thing as before, the XABC. You know, make sure that the patient has large bore IVs. You clearly don't wanna have one in that extremity. Yeah. And we're gonna also make sure that we have hand surgery and orthopedics, and sometimes orthopedics is hand as well available because of that bony [00:19:00] deformity and because what might be happening in the hand as well. I think as long as you have a stable patient, is what you're describing in this scenario, that it's okay, uh, under these circumstances to consider doing a, a CT angiogram as well The caveat is that the arm imaging is not always as good, and particularly when you have a deformity not only from the ballistic shadowing that may occur, but even from the position of the patient's arm during the time of the CTA. Mm-hmm. All that, all that said, I think it's still very worthwhile to do that, and I, I do think under th- this kind of presentation, you're gonna want to plan to, to explore this patient in the operating room, and at the very least do a, an on-table angiogram. Great. Um, okay. Sounds good. So let's say after going through our entire algorithm, we've established that this patient needs emergent intervention. Uh, the injury is associated with an obvious comminuted [00:20:00] humerus fracture that was seen on a spot X-ray. Before wheeling this patient up to the OR, the orthopedics resident asks if they could put on a quick XFix. He insists that it won't take more than 30 minutes. Dr. Harrington, how would you respond to that situation? Yeah, so I would not let them put the XFix on first. The rationale is they almost certainly have a significant injury probably to their brachial artery. Um, the bony injury obviously has to be fixed, but the most important thing here is reestablishing blood flow in an efficient manner. If the patient's not actively bleeding and is stable, sometimes people get the misconception that, you know, the vascular injury is, quote-unquote, "under control". But this could mean a lot of things. It could mean the vessel's in spasm, and more importantly, the hand is still, uh, getting progressively ischemic. So when you have this [00:21:00] combined, you know, bony vascular injury, my, my practice is usually to get control of the vascular injury, both proximal-distal control. Now, then there's a couple of things that go into it. I certainly would consider placing a shunt depending on where the injury is, unless play say-- unless the, I think the XFix may interfere with my being able to expose the actual injuries and perform the bypass. But the most important thing here is to reestablish some flow back to the distal arm Sounds good. One of the more interesting developments in modern vascular trauma has been the increasing use of temporary intravascular shunts. A multi-center study by Puls and colleagues looked at nearly seven hundred civilian extremity vascular injuries and found that patients who received a temporary shunt [00:22:00] had lower rates of early amputation despite being more severely injured. After propensity adjustment, patients managed without a shunt had about three point six times the odds of amputation. Uh, th-this study supports the role of a temporary shunting as a strategy for rapidly restoring perfusion in severely injured patients. Although the observational nature of the data makes causality difficult to establish. This is especially important in patients with multiple injuries, prolonged operative times, or an unstable physiology. You don't necessarily have to perform definitive reconstruction immediately. A temporary intravascular shunt can restore flow, control ischemia, and allow you to move on to hemorrhage control and other life-threatening injuries in other places in the body. Then you can come back and perform your definitive vascular reconstruction once the patient is more stable. With that being said, when do you actually reach for a shunt? So for me, it's, it's rare. I would say it's, it's really under the specific circumstance where I cannot repair [00:23:00] things in the moment. So there's really, there's two scenarios where I do it. One is the patient who's too unstable to get a definitive vascular repair. If I could shunt them, I would. And then the other scenario is goes back to the case with the X Fix. Sometimes, you know, it does make sense to put on the X Fix but not tighten it. So you have the X Fix in position, and while before they put-- start to put that in place, you have a shunt going so that you're not losing time, ischemia time. And then you can come back and do your definitive bypass. That, that's, that's really the two scenarios where, where I think about doing it. Dr. Flores, what about with you? When do you use a shunt? Well, I will use a shunt when I'm doing, uh, combined injuries, intracavitary and extremity, in [00:24:00] which the general surgeon may be working a few hours or, and there's a lot of blood loss, and you are dealing with extremity is, that is going to be ischemic, I will place a shunt and wait for the thing to, to finish. I will also consider doing a shunt when, uh, the patient is hemodynamically unstable. Hypotensive shock, inadequate resuscitation, or whatever factors are, are there, I would consider that. I would also consider shunt when you have complex fractures. Not only one, but at two or three levels that's in a blunt trauma, and, uh, that would require some degree of stabilization, and I will use a shunt under those circumstances. Or [00:25:00] patients who are in DIC, disseminated intravascular coagulation, in which you are not able to control the bleeding, just able to, you know, put a shunt and perfuse extremity. Yeah, one thing I wanted to add too is, uh, especially in the upper extremities, I oftentimes will use the carotid shunt that has the extension off of it. The Inahara-Pruitt shunt. It, uh, allows you to make sure that you're getting flow through there, and you can even draw blood gases from it at the same time. Sometimes can be helpful. And, uh, they, they do have those. They also have balloon balloons on either side versus having to secure them with vessel loops on, on either side. So gives you a little bit more, more room to play with Uh, I think that's a nice segue into our repair and reconstruction options. Uh, let's say we explore the wound and find a segmental transection of the brachial artery with approximately three centimeter segment of arterial destruction. Let's also assume that in all these, uh, situations, the patient is stable. Dr. [00:26:00] Flores, how are you thinking about reconstruction for that injury? Well, you have a three centimeter defect, that would require a vein bypass. Uh, the options are a saphenous vein or cephalic vein if you have an adequate cephalic vein. That are my, my options. Would you ever use a prosthetic like PTFE in that situation, or generally no? No. I will use PTFE for a axillary artery if the injury is in that location. But you would still choose a vein over, uh, PTFE if you had the choice? Even for axillary. Yeah. Distal to the axillary, yes. Yeah. Okay. And if, let's say the, the cephalic was ad- adequate, but you also have GSV, you would say that it's okay to just take the cephalic, or is it always preferable to go for a GSV? No. No. I would say if the cephalic is adequate, it's, uh, it's appropriate to use that for [00:27:00] a... Especially if you are dealing injuries for below the elbow and with the caliber is small. I s- If it's above the elbow, I would use the, uh, saphenous vein. Okay. Let's say the, let's say the brachial vein was also injured, but you're able to get a segment of brachial vein, you can also use that too, I imagine. I- You're ligating, let's say you ligated the brachial vein from- I, I, I don't know. Histology of the brachial vein and the cephalic vein are different. Hmm. The cephalic vein mimic more the saphenous vein in term of histology than the brachial vein. I see. Okay, that's interesting. I didn't know that. Okay. Thanks, Dr. Flores. There a- actually isn't a randomized trial telling us how to reconstruct a traumatic brachial artery injury. Uh, most of the evidence comes from large retrospective series. One of the more contemporary series by Ascencio and colleagues looked at 131 brachial artery injuries. The vast majority were penetrating, and [00:28:00] most were treated with either reversed saphenous vein, uh, interposition or end-to-end repair, with nearly 98% limb salvage among, uh, patients who survived the initial operation. Uh, when talking about proximal control in these injuries, it's generally easier to get control of the brachial artery versus, say, a proximal axillary, uh, or subclavian artery by an open approach. This is a time where proximal endovascular control can come in very handy. I know we've done a couple of those together, Dr. Hazer. Yeah, that's very true. Especially if it's subclavian, but even axillary as well. It's, it's very handy to have that available for you. You can do that as, as well as use it to shoot your angiogram post, uh, repair. And it, it just kind of makes it easy there. The important things to remember, one, you wanna have a long sheath available, and you wanna have that hooked up to an arterial pressure bag so that it does not clot during that time. Because you are gonna probably, once you have good control, you're gonna give some anticoagulation. But in the [00:29:00] meantime, while you're doing the initial work, and even afterwards, it may be that the patient could develop some clot around there, and then you've sort of spoiled the operation that you were going to do. Yeah. But it comes in quite handy during that time. And I think the other things to keep in mind when you're considering that is the access. So you want to make sure that the patient's on the table in a spot where, for instance, the, the stand underneath it is not gonna interfere with your C-arm. There have been times in, in traumas where we've sort of winged it, I, I s- I guess that's the word. Been very careful to put up a, a catheter because we could not image other than with ultrasound, we couldn't image the groin or the lower abdomen. And so we've sort of just hoped that the, the catheter and the wires were not gonna go into one of the small side branches kidney or, or mesenteric vessels or, and such, and were gonna wind up in the upper thoracic aorta where we'd have imaging. But those, those are things to keep in [00:30:00] mind as well. Yeah. Thanks. So let's move on to our final case. A 27-year-old male is involved in a high-speed motor vehicle collision. He has no life-threatening injuries and is hemodynamically stable. Upon further workup, he's found to have a posterior knee dislocation, which was reduced in the trauma bay. After reduction, the foot is warm. He does have palpable dorsalis pedis and posterior tibial pulses. Dr. Harrington, in this situation, are we done? Uh, no, we are not done. Uh, the pulse exam could be normal, but with a, you know, an, an intimal tear, a small not completely visualized, um, flow-limiting dissection even if it does not require, you know, doesn't necessarily require intervention, it may require surveillance or even medication like aspirin to prevent future complications. Yeah, and this is one of the classic teaching points in vascular trauma, I think. A, a palpable distal pulse does [00:31:00] not completely exclude a popliteal artery injury, especially with, uh, posterior knee dislocations. In fact, there are several studies looking specifically at this question. An older series of patients with complete knee dislocations found that even among patients with palpable pedal pulses, a subset had popliteal artery intimal injuries, as you mentioned. More importantly, a systematic review of two hundred and eighty-four knee dislocations found that abnormal pedal pulses alone had only seventy-nine percent sensitivity for surgically significant arterial injury. So the question becomes: What should we add to the pulse exam? As we've previously mentioned, ABI is an invaluable tool in this situation. This is especially true when it comes to knee dislocations and popliteal artery injuries. There was a prospective study by Mills and colleagues that looked specifically at this. They evaluated thirty-eight patients with knee dislocations using pulse exam and ABI. Patients with an ABI below zero point nine underwent arteriography, while patients with an ABI of zero point nine or greater were admitted for serial [00:32:00] exams and delayed duplex. All eleven patients with an ABI below zero point nine had arterial injuries requiring surgical treatment, while none of the patients in the other group had a clinically significant vascular injury. Keep in mind with this data, though, that it is a relatively small cohort of only eleven patients. Uh, more recent data support combining these findings rather than relying on the pulse exam alone. In a study of a hundred and ten knee dislocations, Weinberg and colleagues found that the combination of palpable DP and PT pulses with an ABI of at least zero point nine had a one hundred percent sensitivity for excluding vascular injury based on follow-up at six months. All these studies help to establish the concept that ABI can be used to selectively identify which knee dislocation patients, uh, need vascular imaging rather than performing angiography or even CTA on everybody. To bring this point home, we can do a few variations of this scenario. Dr. Hazer, if this patient has a palpable DP and PT pulses and an ABI of zero point nine six, [00:33:00] are you comfortable discharging him? No, honestly I'm not. Given the fact that, you know, up to 50% of patients will have some form of arterial injury even if it's minor, I, I, I believe that observing the patient for at least 24 hours is very important. And I don't feel comfortable sending them home until I have an arterial duplex that- Mm ... really documents that there's no intimal injury or that the intimal injury is very minor. And then I can discharge them home on a antiplatelet like a, a baby aspirin. Does that change at all if the patient's ABI was 0.72 instead of 0.96? In, in those cases I would definitely want to get a CT angiogram to take a look, and probably also a duplex scan, and observe the patient because there's something else going on there with a, with an ABI of 0 .72, especially if the other leg has a normal ABI. So that brings me to my next question, actually. You said there's definitely something going on there. So let's say we get the [00:34:00] CT and it turns out to be negative. What, what would you do next? I would still observe the patient, and then I would repeat a duplex scan or, or provide one if the next day they may not have been able to get it that day. But I would, I would definitely do that, and then... I don't know. That's a good question. If, if it still was 0.72 and the other side was normal, I, I would not wanna do a- anything Okay. Dr. Harrington, would you take that patient for an angio, let's say the 0.72 on the CT was negative, or would you just get him a duplex like Dr. Heiser? Okay, so I'm gonna go back a couple of steps. Sure. So number one, so we're saying this patient has pulses, or someone's saying they have pulses, I guess. Um- Yeah. I can almost guarantee I would not feel pulses on that person. I don't believe that a person has an ABI of 0.72 and would have palpable pulses that are equal to the other side. So I just don't buy that [00:35:00] at all. Right. Now, if I can see an injury on the CT scan, either that patient's going for an angio, or if I have it readily available, I'm doing a duplex. Okay. I will say that sometimes, especially in these younger guys or gi- or gals- Mm-hmm ... uh, you do the duplex and it's totally fine. It's triphasic all the way down, no injury seen, and you ... and then you wait a few hours and their, their pulses come back and they're nice and strong, and their ABI normalizes. But most of those patients are probably gonna need the angiography. That ... I w- I don't, I don't think I'd feel comfortable observing them if the A- ABI is reduced and or I would doubt the ABI, meaning that the ABI ... there's a, there's something wrong with the ABI if it keeps getting that low number. I see. Meaning ... Yeah, so there's an error in the, in the- In the performance of the test, yeah. It ... Either there's an error in the performance of the test or there's an error in the performance of the exam. Fair enough. [00:36:00] What about an absent a patient that has pulses, the ABI is more than 0.9, um, before, before reduction of the dislocation. Dislocation is reduced, and now you can't feel the pulses. Yeah, so that's a good question. So that patient either now they have an injury or they're spasmed, right? So then that patient, I think you have to re go through your algorithm. So you don't feel pulses, so then you're, you're, you're repeating your ABI. Mm-hmm. Uh, you're probably getting a CT scan as well. Um, you may just go straight to get the CT scan. Yeah. And if there's no injury on the CT scan and your pulses continue to be absent, I certainly would consider doing angiography. Yeah, fair enough. I think that that makes sense. May I say something? I very liberal in angiography in patient with [00:37:00] knee dislocation. Not everybody, but I'll divide this young patients, older patients. It's a difference. In knee dislocation, older person has more chance to have an intimal flap- Yeah ... than Younger patients. The detection on the intimal flap on CTA is not that accurate. So if I suspected for whatever means of ABIs or changing pulses not quite similar, I will get an angiogram. Great. Uh, Dr. Flores, you've been doing vascular trauma for a long time. When you look at how we manage these patients today compared when earlier in your car- career, what do you think has changed the most? Well, the concept of hard and soft science have been present for a long, long, long time. New trends [00:38:00] in term of resuscitation, massive blood transfusion that usually get together in patients, especially with combined injuries. The reintroduction of the concept of vascular shunts is very important. The use of CTA now in the assessment of peripheral trauma. The use of, uh, balloon occlusions will become more and more popular are important, especially in order to minimize the massive bleeding and help with the control of the vascular injuries And damage control that, uh, we tend to use very frequently in general surgery as well as vascular with the temporizing use of the shunt. What about, uh, rates of, um, extremity salvage? [00:39:00] Would you say that that has greatly improved, let's say, over the past 20, 30 years, or it's fairly similar, you think? You guys were still pretty good then. Oh, no, definitely has improved. Yeah. Proof of that is in the work in Iraq in which they're able to do, you know, limb salvage, usage and transportation from one unit to another unit, able to provide the proper care. Great. Dr. Hazer, from the general surgeon's perspective, what are the vascular trauma mistakes that you see residents make most often? I think feeling for a pulse in their own fingers versus in the patient's extremity is a- Yeah ... not an uncommon one. And sort of to the point Dr. Harrington mentioned before, if the ABI is .7, you shouldn't be having a palpable pulse. So- Fair ... counting out, honestly, the heartbeats, uh, or, or feeling from both extremities at the same time is very, very helpful. I think [00:40:00] also some of the general surgeons can sometimes make the mistake of not getting proximal control because they're worried about doing extensive surgeries or things like that. If, if they're not comfortable cutting down on the femoral artery, for instance, or the, or the, uh, brachial, it's, there's no shame in going to much more proximal and getting control in the axilla or getting control in the groin, uh, and giving time for the vascular surgeons to, to come in. Uh, it's just a small incision, and you've saved that person's life. So even as I mentioned at the start, getting proximal aortic control is, is very helpful. And some of the general surgeons who didn't have a lot of vascular trauma exposure in Iraq, I know used to do that initially, is go in initially to the abdomen, because they were very comfortable there. They get control of the distal aorta and then give people time to provide the massive transfusion, et cetera, and save that person's life. Great. [00:41:00] Uh, what about technical aspects from a resident perspective? Uh, working with so many residents over the years. I think understanding the importance of second assisting and first assisting. A- and by that I mean even getting a chance to observe as a second or third person in the field to see where the surgeon and the first assist are moving their hands, moving their elbows whether they're holding things, uh, in a certain way or providing the angulation. And I often will tell the residents, it's a bit like a dance. You know, you move here, I move here, and it's constantly moving and anticipating what, what the motion is to be, to provide the best exposure and also to, to understand that if I can't see, I, I, probably the surgeon can't see. So you wanna make sure that you can see and the surgeon can see at the same time. Thanks for those points. Dr. Harrington, if you could give a resident three things to remember when they're faced with an extremity [00:42:00] vascular injury at 2:00 AM, what would they be? Uh, sure. So I think this really boils down to two broad categories, and the second one I'll break down into two things. That way you get, you know, three points for the resident. Okay. Uh, so the first one you need to know when the patient needs to go straight to the OR. So that, that is, uh, you know, sort of knowing what your hard signs are. And then the, the second sort of broad area is know when saving the limb is not appropriate. And I think we didn't really touch on this, so I'll, I'll touch on it now. So, mangled extremities um, may be inappropriate to save and, uh, may be dangerous to save for the patient. And then the other category where the limb, saving the limb may not be salvageable may be in the context of having significant other injuries. Uh, the limb [00:43:00] is not as important as their head or their life, and that needs to be-- And you shouldn't get so focused on an extremity injury that you're taking care of it at the expense of them having a stroke or the patient dying. Yeah. Great. Thanks for those points, Dr. Harrington. Um, and I think that's probably the perfect way to bring this episode to an end. Vascular extremity trauma can look intimidating, but the initial decision-making is actually very structured. We'll end with some quick hits to help bring all the main points home from this episode. So when it comes to vascular extremity trauma, the first step is always to control hemorrhage by direct pressure packing or a tourniquet if necessary. Recognize the hard signs and understand that these indicate serious vascular injury that requires emergent operative exploration. Uh, when in doubt, use ABI and CTA selectively. These are excellent adjuncts, but don't forget that the [00:44:00] clinical exam and overall picture is the most important, and don't let a normal pulse falsely reassure you. I think Dr. Harrington brought that point home, uh, pretty well earlier. When vascular and orthopedic injuries coexist, establish vascular control before definitive skeletal manipulation wherever possible. Uh, thanks again to Dr. Flores, Dr. Hazer, and Dr. Harrington for joining me. And to everyone at home, thanks for tuning in to this episode. Hopefully, this section makes it a bit easier to understand the evaluation and, and management of vascular extremity trauma. From all of us here at Behind the Knife, dominate the- Dominate the day.