Emergency Vascular Surgery

200 Pages·2010·10.25 MB·English

by  Eric Wahlberg

Emergency Vascular Surgery
A Practical Guide
Eric Wahlberg Pär Olofsson Jerry Goldstone
Emergency
Vascular Surgery
A Practical Guide
With 68 Figures and 39 Tables
(cid:2)(cid:3)(cid:4)
Eric Wahlberg, MD, PhD
Associate Professor
Karolinska Institute and University Hospital
Department of Vascular Surgery
17176 Stockholm
Sweden
Pär Olofsson, MD, PhD
Associate Professor
Karolinska Institute and University Hospital
Department of Vascular Surgery
17176 Stockholm
Sweden
Professor Jerry Goldstone, MD
University Hospital of Cleveland
Case Western Reserve
Division of Vascular Surgery
Cleveland, Ohio 44106
USA
ISBN 978-3-540-44393-3 Springer Berlin Heidelberg New York
Library of Congress Control Number: 2006936731
This work is subject to copyright. All rights are reserved, whether the whole or part of the
material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data
banks. Duplication of this publication or parts thereof is permitted only under the provisions
of the German Copyright Law of September 9, 1965, in its current version, and permis-
sions for use must always be obtained from Springer. Violations are liable for prosecution
under the German Copyright Law.
Springer is a part of Springer Science + Business Media
springer.com
© Springer-Verlag Berlin Heidelberg 2007
The use of general descriptive names, registered names, trademarks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt
from the relevant protective laws and regulations and therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about
dosage and application contained in this book. In every individual case the user must check
such information by consulting the relevant literature.
Editor: Gabriele M. Schröder, Heidelberg, Germany
Desk Editor: Stephanie Benko, Heidelberg, Germany
Production: LE-TeX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany
Drawings: Medical Art, Gudrun and Adrian Cornford, Reinheim, Germany
Typesetting: am-productions GmbH, Wiesloch, Germany
Cover design: Frido Steinen-Broo, eStudio Calamar, Spain
Printed on acid-free paper 24/3180 YL – 5 4 3 2 1 0
Preface
Emergency Vascular Surgery – A Practical Guide provides a concise guide to
managing patients with all kinds of emergent vascular problems. It is not in-
tended to be a “classic” textbook, so the background information given is very
concise. The focus is instead on management and treatment, especially open
surgical strategies.
The text is written for newcomers to the vascular surgical field, for surgical
trainees, and for all doctors who treat emergent vascular surgical patients in
the emergency department. We believe the hands-on approach and the practi-
cal tips will be appreciated by these readers in the clinical situation, and we
hope the book may also serve as a quick review before a physician takes care of
a case. Medical students during surgical clerkships might find parts of the
book valuable, as will experienced vascular surgeons.
The book is organized into two sections: specific body areas and general
concepts. The former covers the body from head to toe and includes separate
chapters for injuries and for nontraumatic disease. In the second part, some
general principles related to emergency vascular surgical practice are dis-
cussed. Management of complications is difficult to cover in a book of this
scope, so the principles given in the chapter pertaining to this area are not very
detailed. The final chapter gives general vascular surgical guidelines for the
inexperienced surgeon.
All chapters are organized the same way. They start with a brief background
that aims to motivate the reader and give an idea of incidence and pathophysi-
ology. The rest of the chapter follows the patient’s course through the hospital:
The clinical presentation is followed by suggestions for work-up and diagnosis,
and the next part concerns management and treatment – emergency treat-
ment, selection of patients for emergency surgery, and ways to perform com-
mon vascular surgical procedures. Technical tips on complicated procedures
are also provided. Finally, the chapters end with a brief summary on manage-
ment after treatment, with some examples of outcome and results. Most chap-
ters also contain illustrations to facilitate the technical description of the surgi-
cal procedures and notes to highlight particularly important aspects. A few
references for further reading are also suggested; they have been selected to
give a better understanding of the issues and do not necessarily refer to infor-
mation given in the text.
The authors would like to acknowledge and thank a number of people in-
volved in the writing of this book. First, we are grateful to the initial authors of
the Swedish book from 1998 that gave us the idea to expand its contents and
write an English version of it. Thank you all for letting us continue in this
direction. We are also very grateful to all the residents, vascular trainees, and
vascular surgeons who have read chapters and given us valuable suggestions on
how to improve the content and structure. Last but not least, we acknowledge
the secretaries Annika Johansson and Synnove Nordstrom for all of their help
with this project.
Eric Wahlberg
Pär Olofsson
Jerry Goldstone
Stockholm and Cleveland 2007
Contents
Part A Specific Body Areas
Chapter 1 Vascular Injuries to the Neck 1
Chapter 2 Vascular Injuries to the Thoracic Outlet Area 15
Chapter 3 Vascular Injuries in the Arm 31
Chapter 4 Acute Upper Extremity Ischemia 41
Chapter 5 Abdominal Vascular Injuries 45
Chapter 6 Acute Intestinal Ischemia 65
Chapter 7 Abdominal Aortic Aneurysms 75
Chapter 8 Aortic Dissection 91
Chapter 9 Vascular Injuries in the Leg 101
Chapter 10 Acute Leg Ischemia 119
Part B General Concepts
Chapter 11 Vascular Access in Trauma 135
Chapter 12 Complications in Vascular Surgery 141
Chapter 13 Acute Venous Problems 159
Chapter 14 Acute Problems with Vascular Dialysis Access 167
Chapter 15 General Principles of Vascular Surgical Technique 179
Subject Index 191
A
Specific Areas
PART
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:17)
(cid:54)(cid:65)(cid:83)(cid:67)(cid:85)(cid:76)(cid:65)(cid:82)(cid:200)(cid:41)(cid:78)(cid:74)(cid:85)(cid:82)(cid:73)(cid:69)(cid:83)(cid:200)(cid:84)(cid:79)(cid:200)(cid:84)(cid:72)(cid:69)(cid:200)(cid:46)(cid:69)(cid:67)(cid:75)(cid:200) (cid:200) (cid:19)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:18)
(cid:54)(cid:65)(cid:83)(cid:67)(cid:85)(cid:76)(cid:65)(cid:82)(cid:200)(cid:41)(cid:78)(cid:74)(cid:85)(cid:82)(cid:73)(cid:69)(cid:83)(cid:200)(cid:84)(cid:79)(cid:200)(cid:84)(cid:72)(cid:69)(cid:200)(cid:52)(cid:72)(cid:79)(cid:82)(cid:65)(cid:67)(cid:73)(cid:67)(cid:200)(cid:47)(cid:85)(cid:84)(cid:76)(cid:69)(cid:84)(cid:200)(cid:33)(cid:82)(cid:69)(cid:65)(cid:200) (cid:200) (cid:17)(cid:21)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:19)
(cid:54)(cid:65)(cid:83)(cid:67)(cid:85)(cid:76)(cid:65)(cid:82)(cid:200)(cid:41)(cid:78)(cid:74)(cid:85)(cid:82)(cid:73)(cid:69)(cid:83)(cid:200)(cid:73)(cid:78)(cid:200)(cid:84)(cid:72)(cid:69)(cid:200)(cid:33)(cid:82)(cid:77)(cid:200) (cid:200) (cid:19)(cid:17)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:20)
(cid:33)(cid:67)(cid:85)(cid:84)(cid:69)(cid:200)(cid:53)(cid:80)(cid:80)(cid:69)(cid:82)(cid:200)(cid:37)(cid:88)(cid:84)(cid:82)(cid:69)(cid:77)(cid:73)(cid:84)(cid:89)(cid:200)(cid:41)(cid:83)(cid:67)(cid:72)(cid:69)(cid:77)(cid:73)(cid:65)(cid:200) (cid:200) (cid:20)(cid:17)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:21)
(cid:33)(cid:66)(cid:68)(cid:79)(cid:77)(cid:73)(cid:78)(cid:65)(cid:76)(cid:200)(cid:54)(cid:65)(cid:83)(cid:67)(cid:85)(cid:76)(cid:65)(cid:82)(cid:200)(cid:41)(cid:78)(cid:74)(cid:85)(cid:82)(cid:73)(cid:69)(cid:83)(cid:200) (cid:200) (cid:20)(cid:21)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:22)
(cid:33)(cid:67)(cid:85)(cid:84)(cid:69)(cid:200)(cid:41)(cid:78)(cid:84)(cid:69)(cid:83)(cid:84)(cid:73)(cid:78)(cid:65)(cid:76)(cid:200)(cid:41)(cid:83)(cid:67)(cid:72)(cid:69)(cid:77)(cid:73)(cid:65)(cid:200) (cid:200) (cid:22)(cid:21)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:23)
(cid:33)(cid:66)(cid:68)(cid:79)(cid:77)(cid:73)(cid:78)(cid:65)(cid:76)(cid:200)(cid:33)(cid:79)(cid:82)(cid:84)(cid:73)(cid:67)(cid:200)(cid:33)(cid:78)(cid:69)(cid:85)(cid:82)(cid:89)(cid:83)(cid:77)(cid:83)(cid:200) (cid:200) (cid:23)(cid:21)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:24)
(cid:33)(cid:79)(cid:82)(cid:84)(cid:73)(cid:67)(cid:200)(cid:36)(cid:73)(cid:83)(cid:83)(cid:69)(cid:67)(cid:84)(cid:73)(cid:79)(cid:78)(cid:200) (cid:200) (cid:25)(cid:17)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:25)
(cid:54)(cid:65)(cid:83)(cid:67)(cid:85)(cid:76)(cid:65)(cid:82)(cid:200)(cid:41)(cid:78)(cid:74)(cid:85)(cid:82)(cid:73)(cid:69)(cid:83)(cid:200)(cid:73)(cid:78)(cid:200)(cid:84)(cid:72)(cid:69)(cid:200)(cid:44)(cid:69)(cid:71)(cid:200) (cid:200) (cid:17)(cid:16)(cid:17)
(cid:35)(cid:72)(cid:65)(cid:80)(cid:84)(cid:69)(cid:82)(cid:200)(cid:17)(cid:16)
(cid:33)(cid:67)(cid:85)(cid:84)(cid:69)(cid:200)(cid:44)(cid:69)(cid:71)(cid:200)(cid:41)(cid:83)(cid:67)(cid:72)(cid:69)(cid:77)(cid:73)(cid:65)(cid:200) (cid:200) (cid:17)(cid:17)(cid:25)
1
Vascular Injuries to the Neck
CONTENTS 1.1 Summary
1.1 Summary ............................ 3
Severe vascular injury after blunt neck
1.2 Background ......................... 3 trauma can be present even in the absence
1.2.1 Causes and Mechanism ............. 4 of clinical signs.
1.2.1.1 Penetrating Trauma ................. 4 Be liberal with duplex or angiography after
1.2.1.2 Blunt Trauma ........................ 4 blunt trauma when cervical vessel injuries
1.3 Clinical Presentation ............... 4 cannot be ruled out.
1.3.1 M edical History . . . . . . . . . . . . . . . . . . . . . . 5 Associated injuries on the cervical spine,
1.3.2 Clinical Signs ........................ 6 airway, and digestive tract must always be
considered.
1.4 Diagnostics ......................... 6
Always stabilize the neck of patients in all
1.4.1 P enetrating Trauma ................. 6
types of severe cervical trauma until the
14.4.2 B lunt Trauma ........................ 7
entire spectrum of injuries is known.
1.5 Management and Treatment ...... 8 If the patient is stable angiography should
1.5.1 M anagement Before Treatment ..... 8 always be performed in penetrating inju-
1.5.1.1 M anagement in the Emergency ries to zones I and III.
Department ......................... 8 If available, duplex or angiography is rec-
1.5.1.2 Airway Obstruction ................. 8 ommended in zone II injuries in order to
1.5.1.3 Immediate Operation select between conservative and surgical
or Further Diagnostic Work-up? ..... 9 management.
1.5.1.4 Which Patients Can Be
Safely Transported? ................. 9
1.5.2 Operation ...........................10
1.5.2.1 Preoperative Preparation 1.2 Background
and Proximal Control ................10
1.5.2.2 Exposure and Repair ................ 11 Traumatic injuries to the cervical vessels are rela-
1.5.2.3 Exploration of Minor Injuries tively uncommon and constitute only about 5–10%
and Hematomas .....................12 of all vascular injuries. In about 25% of patients
1.5.2.4 Injuries to the Vertebral Artery ......12 with blunt head and neck trauma, the cervical ves-
1.5.2.5 Venous Injury ........................12 sels are involved. The most common mechanism
1.5.2.6 Endovascular Treatment ............12
is penetrating injuries, but the incidence of blunt
1.5.3 Management After Treatment ......12
vascular trauma is probably underestimated be-
1.5.4 Results and Outcome ...............13
cause related symptoms are often vague and not
Further Reading .....................13 recognized. The patients are mostly young, and
despite the low incidence, mortality and morbidity
are very high. Mortality is, in most series, between
5% and 40%, and persistent neurological conse-
quences are reported in up to 80% of patients.
Mortality is not only caused by massive bleeding
4 Chapter 1 Vascular Injuries to the Neck
and cerebral ischemia due to embolization or The internal carotid artery is involved in more
thrombotic occlusion associated with the vascular than 90% of these injuries, most commonly its
injury, but also secondary damage to the aerodi- distal parts. Three to ten percent of all carotid
gestive tract (e.g., airway compression from a large injuries are caused by blunt trauma. The true inci-
expanding hematoma). dence is unknown, but a few reports cite figures
The anatomical location and the often complex in the range of 0.1–1.1% of all blunt head and neck
associated injuries make traumatic cervical vascu- injuries. The variation is related to the type of
lar injuries extremely challenging. study performed and methodology used; some
studies are retrospective, while others use screen-
ing with angiography or computed tomography
1.2.1 Causes and Mechanism (CT). Blunt carotid injuries occur in motor vehi-
cle, industrial accidents or after assaults. Injuries
1.2.1.1 Penetrating Trauma to the vertebral artery are less common because
The most common mechanism for cervical vascu- they are well protected by osseous structures. In-
lar injuries is penetrating trauma. As shown in juries to the vertebral arteries are most commonly
Table 1.1, the common carotid is the most fre- caused by intraoral trauma dislocated fractures or
quently injured major artery. The type of penetrat- penetrating trauma. The mechanisms are the same
ing trauma is most often stab wounds by knives, as in the internal carotid artery.
but other mechanisms are high- or low-velocity The mechanism of injury is either a direct
projectile and gunshot wounds, and bone frag- blow or hyperextension and rotation of the neck.
ments from fractures. High-velocity penetrating In the latter type, the internal carotid artery is
trauma can also cause secondary “blunt” injuries stretched over the body of the C2 vertebra and
by a shock wave. the transverse process of C3, which causes an inti-
mal flap with subsequent risk for embolism or dis-
1.2.1.2 Blunt Trauma section and thrombotic occlusion. Other conse-
Blunt trauma to the cervical vessels is thought to quences are development of a pseudoaneurysm
be less than 0.5% of all blunt traumas to the body, or, in rare cases, even complete disruption of the
but recent reports indicate that many blunt vascu- internal carotid at the base of the skull. In some
lar injuries go undetected. reports, up to 50% of patients are reported to have
bilateral vascular injuries after blunt trauma to the
neck. Carotid dissection is also reported to occur
after minor head and neck trauma, and to be
associated with activities such as unaccustomed
Table 1.1. Frequency of vessel and associated organ physical exercise; “heading” a soccer ball and
injuries in penetrating injuries to the neck
childbirth.
Site of injury
Major vessels 1.3 Clinical Presentation
Arteries Common carotid artery 73%
(10–15%) Internal carotid artery 22%
Common to all neck trauma is that many patients
External carotid artery 5%
with severe vascular or other injuries present with
Veins External jugular 50%
a clinical picture deceptively lacking obvious
(15–25%) Internal jugular 50%
symptoms and signs of their injuries. Further-
Other organs more, significant associated intracranial lesions,
Digestive tract 5–15%
multiple organ injuries, and alcohol or drug in-
Airway 4–12%
toxication often confuse the clinical picture. The
Major nerves 3–8%
history and clinical examination must be per-
No involvement 40%
formed with a high level of suspicion in order to
of important
achieve a good platform for the diagnostic evalua-
structures
tion and management.