Rich’s Vascular Trauma E-Book

For more than 40 years, Rich's Vascular Trauma has been surgeons’ #1 reference for the diagnosis and treatment of vascular injury in both civilian and military settings across the globe. Published in association with the Society for Vascular Surgery (SVS), the fully updated 4th Edition reflects recent changes in vascular injury patterns, wounds, and trauma care, drawing from current research and a wide variety of peer-reviewed publications to keep you up to date with the latest evidence-based management strategies and techniques. Written and edited by vascular surgeons who are also trauma specialists—civilian and military experts who have proficiency in both open-surgical and endovascular techniques—this must-have reference offers a global perspective on every aspect of the broad spectrum of vascular trauma. Covers all vascular surgery procedures required to stop hemorrhage and restore perfusion in vessels in the limbs, junctional areas, torso and neck, including damage control techniques such as shunting, and endovascular techniques such as REBOA and stenting. Addresses pre-hospital, emergency department, surgical, and endovascular stages of treatment in developed, austere and deployed settings, including a rich section on vascular trauma in multiple international settings that provides important context for the global surgical community. Includes nine new chapters covering prehospital management, endovascular suites, stent-grafts, selective aortic arch perfusion, extracorporeal systems and gathering evidence in vascular trauma, and more. Presents surgical techniques in step-by-step, highly illustrated detail, as well as high level, strategic decision-making such as the logistics of setting up an endovascular trauma service. Includes a new, rapidly digestible "Tips and Tricks" section summarizing how to execute essential vascular maneuvers and management steps to ensure that patients get the best outcomes. Emphasizes the current management of civilian vascular injuries while drawing upon the best available evidence, experience, and lessons learned from Afghanistan, Iraq, and the “urban battlefield.” Contains an innovative chapter on the systems approach and quality improvement in vascular trauma, offering information and tactics for all providers wishing to understand how clinical systems underpin patient outcome and recovery. Front Cover Rich’s Vascular Trauma Copyright Page List of Contributors Foreword Preface to the Fourth Edition of Rich’s Vascular Trauma Table of Contents Surgical Trainee’s Perspective Introduction Subject: Critical First Steps and Damage Control Resuscitation General Surgical Approach Surgical Tactics in the ED Subject: Injury Identification and Diagnostic Workup General Diagnostic Approach Tactics Subject: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) General Surgical Approach Surgical Tactics Subject: Temporary Vascular Shunts General Surgical Approach Surgical Tactics Subject: Neck Injury General Surgical Approach Surgical Tactics Subject: Upper Extremity and Junctional Zone Injuries General Surgical Approach Surgical Tactics Subject: Blunt Thoracic Aortic Injury General Surgical Approach Surgical Tactics Subject: Cardiac, Great Vessel and Pulmonary Injuries General Surgical Approach Surgical Tactics Subject: Aortic, Iliac and Visceral Arterial Injuries General Surgical Approach Surgical Tactics Subject: Inferior Vena Cava, Portal and Mesenteric Venous Injuries General Surgical Approach Surgical Tactics Subject: Lower Extremity Vascular Trauma General Surgical Approach Surgical Tactics Subject: Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury General Surgical Approach Surgical Tactics Subject: Management of Pediatric Vascular Injury General Surgical Approach Surgical Tactics 1 Setting the Stage 1 The Vascular Injury Legacy Initial Control of Hemorrhage Early Vascular Surgery World War I Experience World War II Experience Experiences During the Korean War Experience In Vietnam Vietnam via Gulf War 1991 to Afghanistan and Iraq Civilian Experience Conclusion References 2 Epidemiology of Vascular Trauma Principles of Vascular Epidemiology Context and Categorization of Vascular Trauma 1. Military Conflict Vascular Trauma in Combat Troops Vascular Trauma among Local National Populations 2. Civilian Vascular Injury Urban Populations Rural Populations Lifestyle and Socioeconomic Factors 3. Trauma at the Extremes of Age Pediatric Trauma Geriatric Trauma 4. Iatrogenic Vascular Injury Summary References 3 Systems of Care in the Management of Vascular Injury Trauma Systems Overview Key Components of a Trauma System Trauma Center Function Trauma Systems in Combat Casualty Care Organization of the Joint Theater Trauma System Challenges of Vascular Injury Care Ownership and Responsibility Data Collection and Comparison Clinical Practice Guidelines Introduction and Tracking of New Technology REBOA Whole Blood Point of Injury Therapy and Community Outreach Conclusion References 4 Training Paradigms for Vascular Trauma Introduction Graduate Medical Education Graduate Medical Education/Residency Training in General Surgery Graduate Medical Education/Residency Training in Vascular Surgery Ways Forward for Vascular Trauma Training Vascular Trauma Training Tools Team-Based Training for Vascular Trauma Simulation-Based Training for Vascular Trauma Vascular Trauma Surgery Short Courses The Definitive Surgical Trauma Care Course Definitive Surgical Trauma Skills Advanced Trauma Operative Management Advanced Surgical Skills for Exposures in Trauma (ASSET) European Vascular Masterclass Basic Endovascular Skills for Trauma (BEST) Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) Endovascular Resuscitation and Trauma Management (EVTM) Workshop Summary References 2 Immediate Management and Diagnostic Approaches 5 Prehospital Management of Vascular Injury Introduction Stopping the Bleeding Extremity Hemorrhage Principles Practicalities Junctional Hemorrhage Principles Practicalities in the Management of Junctional Hemorrhage Axillae and Groins. Neck. Hemostatic Dressings Complex or Novel Options Methods Relying on Local Effect. Methods for Gaining Proximal Control of Bleeding. Noncompressible Torso Hemorrhage Considerations for All Torso Hemorrhage Thoracic Hemorrhage Abdominal Hemorrhage Pelvic Hemorrhage Maxillofacial Hemorrhage Summary Replacing Lost Volume General Concepts Permissive Hypotension Alternative Resuscitation Strategies Acute Traumatic Coagulopathy (ATC) Novel Hybrid Resuscitation Practical Application What To Use During Resuscitation Choice of Fluid Pharmacological Adjuncts Transport Destination Summary References 6 Damage Control and Immediate Resuscitation for Vascular Trauma Introduction Damage Control Definitions Pathophysiology of Coagulopathy/Trauma-Induced Coagulopathy (TIC) Hypothermia Hemodilution Acidosis Tissue Trauma Endothelial Dysfunction Emergency Department Reception Initial Priorities in Management C—Catastrophic Hemorrhage Control A—Airway (and C-Spine Protection) B—Breathing: Optimizing Gas Exchange C—Circulation: Volume Resuscitation D—Disability and “Cardio-Stable” Induction Strategies E—Everything Else (Including Transfer) Management Beyond the Emergency Department Cardiovascular Management Optimizing Coagulation Facilitating Surgical Treatment Ethics of Resuscitation Future Development of DCR Summary References 7 Diagnosis of Vascular Injury Introduction The Mechanism, Setting, and Patterns of Injury Injury Pattern Recognition Head and Neck Vascular Injuries Thoracic Vascular Injuries Abdominal Vascular Injuries Upper Extremity Vascular Injuries Lower Extremity Vascular Injuries Other High-Risk Injury Patterns Physical Examination Doppler Ultrasound Adjunctive Measures Clearing the Trauma Patient for the Presence of Vascular Injury Definitive Diagnosis of Vascular Injury Surgical Exploration for Vascular Injury Portable Angiography in the Trauma Bay or Operating Room Multidetector CT Angiography Catheter Angiography Compartment Syndrome Summary References 8 Imaging for the Evaluation and Treatment of Vascular Trauma Background Imaging Modalities Angiography Indications Preparation Pitfalls and Danger Points Operative Strategy Operative Technique for Angiography Patient Care Following Angiography Complications Ultrasound Indications Preparation Pitfalls and Danger Points Strategy Technique Complications Computed Tomography Indications Preparation Pitfalls and Danger Points Strategy Technique Postexamination Care Complications References 3 Emerging Technologies and New Approaches to Vascular Trauma and Shock 9 Endovascular Suites and the Emergency Vascular Service Introduction Endovascular Suites Principle Room Design Organizational Issues Imaging Capability Emergency Vascular Service Clinical Need Practical Implementation Training Issues Conclusions References 10 Stent-Grafts, Coils, and Plugs Introduction Principles of Endovascular Hemorrhage Control Embolization Agents Temporary Embolization Agents Permanent Embolization Agents Thrombin Coils Plugs Stents-Grafts Balloon-Expanding Stents Self-Expanding Stents Management of Solid Organ Injury Splenic Injury Liver Renal Postintervention Management Pelvic Bleeding Cervical Vascular Injury Junctional Vascular Trauma Extremity Vascular Trauma References 11 Resuscitative Endovascular Balloon Occlusion of the Aorta Introduction History of Thoracic Aortic Occlusion for Resuscitation History of REBOA Physiologic Limitations Clinical Outcomes Technical Aspects of REBOA Tools and Materials Step-By-Step Placement Arterial Access Positioning of the Balloon Balloon Inflation Balloon Deflation Balloon and Sheath Removal Treatment Algorithm Extended Applications of REBOA Complications of REBOA Arterial Access Complications Placement-Related Complications Reperfusion Complications Future Advances References 12 Endovascular Variable Aortic Control Introduction The Problems With REBOA Partial Flow as a Strategy to Address Limitations of Reboa EVAC Concept—Automated Partial Aortic Flow Control Regional Perfusion Optimization Limitations of REPO With EVAC and Alternate Approaches Future Directions Disclosure References 13 Selective Aortic Arch Perfusion Introduction A Description of SAAP The Rationale for SAAP Cardiac Arrest Survival Limitations Of CPR and Standard Resuscitation Rationale for Endovascular Resuscitation Sequential SAAP Interventions Clinical Decision-Making In Endovascular Resuscitation Sequential Escalating SAAP Interventions SAAP With an Oxygenated Exogenous Oxygen Carrier SAAP With Oxygenated Autologous Blood Limited Whole Body SAAP Catheter Perfusion Support Transition From SAAP Catheter to VA-ECLS Advantages and Limitations of SAAP SAAP In Medical Cardiac Arrest SAAP In Hemorrhage-Induced Traumatic Cardiac Arrest Laboratory Animal SAAP Studies SAAP In Ventricular Fibrillation Cardiac Arrest SAAP In Hemorrhage-Induced Traumatic Cardiac Arrest Where Does SAAP Fit in Endovascular Resuscitation Implications for Trauma and Vascular Surgery Summary References 14 Endovascular to Extracorporeal Organ Support for Vascular Trauma and Shock Introduction Advances in Renal Support Advances in Lung Support Combining Techniques Acknowledgments References 15 Gathering the Evidence: Clinical Study of New Technologies Why This Chapter? Medical Devices Are Not Parachutes The Evaluation of Surgical Innovation Complex Interventions The Ideal Stages of Surgical Innovation Methodological and Practical Challenges The Role of Innovative Clinical Trial Designs Conclusion References 4 The Management of Vascular Trauma 16 Cardiac, Great Vessel, and Pulmonary Injuries Introduction Evaluation and Management in the Emergency Center Mechanism of Injury Advanced Trauma Life Support (Atls): Primary Survey, Initial Resuscitation, Emergency Center Thoracotomy The Injured Heart History Incidence Penetrating Trauma Blunt Trauma Presentation Penetrating Trauma Blunt Trauma Diagnosis Penetrating Trauma Blunt Trauma Nonoperative Management of BCI Operative Management in the Emergency Department and Operating Room Incisions Pericardiotomy Control of Hemorrhage From the Heart Restoring a Cardiac Rhythm Suturing Techniques Acute Need for Cardiopulmonary Bypass Treatment in the Operating Room After Cardiorrhaphy Major Complications Cardiac Failure Delayed Diagnosis of Intracardiac Lesions Survival Injuries to the Great Vessels Definition/Classification History Incidence Penetrating Trauma Blunt Trauma Etiology Penetrating Trauma Blunt Trauma Presentation Penetrating Trauma Blunt Trauma Diagnosis Penetrating Trauma Blunt Trauma Endovascular Management Operative Management in the Emergency Department and Operating Room Finger Control of External Hemorrhage Incisions Control of Hemorrhage/Vascular Repair Major Complications Cardiac Compression with Sternal Closure Cerebral Ischemia Associated Neurological Deficits Survival Injuries to the Lungs Classification History Incidence Penetrating Trauma Blunt Trauma Etiology Penetrating Trauma Blunt Trauma Presentation Pneumothorax Hemothorax Diagnosis Nonoperative Management Tube Thoracostomy Analgesia Supportive Care After Pulmonary Contusion Operative Management in the Emergency Department and Operative Room Indications Incisions Proximal Vascular Control Control of Hemorrhage From the Lung Thoracic Damage Control Complications Air Leak Ventilator-Associated Pneumonia Pulmonary Pseudocyst Retained Hemothorax Empyema Survival References 17 Blunt Thoracic Aortic Injury Introduction History Epidemiology Site and Type of Aortic Injury Natural History of BTAI Screening and Diagnosis Management Initial Management of Thoracic Aortic Injuries Timing of Definitive Management Definitive Management of Thoracic Aortic Injuries Open Surgical Repair Endovascular Aortic Repair Advances in Endograft Design Nonoperative Management Summary References 18 Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries Introduction Mechanism of Injury Penetrating Injury Blunt Injury Anatomy Clinical Presentation Investigations Surgical Techniques Aortic Injuries Investigations Treatment Follow-Up Injuries to the Visceral Arteries Celiac Artery And Branches Superior Mesenteric Artery Inferior Mesenteric Artery Renal Artery Injuries Endovascular Treatment Mortality Injuries to the Iliac Artery Anatomy Mechanism of Injury Clinical Presentation Investigations Surgical Management Complications of Vascular Trauma Endovascular Treatment of Intra-abdominal Trauma Control of Bleeding by Embolization Endovascular Treatment of Solid Organs and Pelvic Trauma Complications of Embolization Endovascular Balloon Occlusion References 19 Inferior Vena Cava, Portal, and Mesenteric Venous Systems Introduction Preoperative Preparation Operative Management The Inferior Vena Cava Exposure and Mobilization Bleeding Control Considerations for Venous Repair Ligation Reconstructive Techniques The Portal Vein Exposure and Mobilization Bleeding Control Repair of Portal Venous Injuries Portal Vein Ligation The Superior Mesenteric Vein Exposure and Mobilization Bleeding Control and Repair Ligation of the Superior Mesenteric Vein Endovascular Options Alternative Management Options Pitfalls and Points Postoperative Care and Complications Conclusion References 20 Neck and Thoracic Outlet Introduction Indications Preoperative Preparation Pitfalls and Danger Points Operative Strategy and Technique Carotid Vertebral Subclavian Postoperative Care, Complications, and Outcomes References 21 Upper Extremity and Junctional Zone Injuries Epidemiology of Upper Extremity Vascular Injury Addressing Complex Upper Extremity Vascular Injury General Considerations Tourniquets in Upper Extremity Vascular Injury Considerations for Management of Upper Extremity Vascular Trauma Temporary Vascular Shunts in Upper Extremity Vascular Injury Mangled Extremity Scores in Upper Extremity Vascular Trauma Surgical Management for Upper Extremity Vascular Injury Subclavian Artery Subclavian Artery Injuries Anatomy of the Junctional Zone and Subclavian Artery Operative Management of Junctional Zone and Subclavian Artery Operative Technique Axillary Artery Axillary Artery Injuries Axillary Artery Anatomy Operative Management of Axillary Artery Injuries Operative Technique Brachial Artery Brachial Artery Injuries Brachial Artery Anatomy Operative Management of Brachial Artery Injuries Operative Technique Radial and Ulnar Arteries Radial and Ulnar Artery Injuries Radial and Ulnar Artery Anatomy Operative Management of Radial and Ulnar Artery Injuries Operative Technique Upper Extremity Venous Injury Endovascular Management of Upper Extremity Vascular Injuries Nonoperative Management in Upper Extremity Injury Postoperative Care Monitoring Wound Care Rehabilitation Complications After Upper Extremity Vascular Injury Compartment Syndrome Outcomes after Treatment of Upper Extremity Vascular Injury Conclusion References 22 Lower Extremity Vascular Trauma Introduction and Scope Injury Characteristics Level of Injury Mechanism of Injury Arterial Pathology Patient and Limb Outcomes Mortality Amputation Limb Complications Functional Outcomes and Quality of Life Concomitant and Isolated Vein Injury Presentation, Diagnosis, and Workup Technical Aspects of Vascular Reconstruction General Considerations Conduit, Tunneling, Twisting, and Measuring Techniques for Anastomosis Injuries to Named Vessels Common Femoral Artery Superficial Femoral Artery Isolated Profunda Femoris Injuries Popliteal Artery Tibial Arteries Fasciotomy References 23 Surgical Damage Control and Temporary Vascular Shunts Introduction Historical Use of Intravascular Shunts Modern Use of Intravascular Shunts Military And Combat Experience Civilian Trauma Experience Indications Shunt Materials Insertion Technique Removal Technique Dwell Time Special Considerations Anatomic Location (Vessel Size) Anticoagulation Venous Shunting Role In Limb Salvage Fasciotomy (Prophylactic) Vascular Branch Points Truncal Vascular Injuries Conclusion References 24 Considerations for Conduit Repair of Vascular Injury Introduction Identification of the Optimal Vascular Conduit Types of Conduit Autologous Conduit Prosthetic Conduits Biologic Conduits Decision Making in the Choice of Conduit Location and Nature of the Injury Thoracic and Abdominal Injuries Extremity Vessels Ideal Conduit for Vascular Trauma Conduit in Austere and Military Settings Autologous Conduits Prosthetic Conduits Future Considerations Bioengineered Blood Vessels Improvements in Storage and Harvest Conclusion References 25 Management of Pediatric Vascular Injury Introduction Epidemiology Anatomic and Physiologic Considerations Diagnosis and Evaluation Therapeutic Approach Open Surgical Exploration and Repair Of Extremity Vascular Injuries Cervical and Torso Vascular Injuries Pediatric Vascular Anastomotic Technique Endovascular Options Adjuncts to Management: Anticoagulation, Papaverine, Thrombolysis, And Shunts Special Situations ECMO Supracondylar Humerus Fractures and Brachial Artery Injuries Compartment Syndrome and Fasciotomy Postinjury Surveillance and Outcomes Future Directions Conclusions References 26 Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury Introduction Epidemiological Factors Grading of Open Fractures Salvage Versus Amputation Strategies in Managing the Severely Injured Limb Sequencing of Interventions Major Limb Amputation for Trauma Assessment of the Injured Extremity Initial Surgical Management Reconstruction Timing of Reconstruction Choice and Type of Reconstruction Flap Reconstruction Free Flaps Commonly Used Flaps for Lower Limb Wounds Commonly Used Flaps for Upper Limb Wounds Outcomes of Limb Salvage Summary References Bibliography 27 Vascular Surgery in the Austere Environment Introduction Fundamentals Neck Injuries Carotid Injuries Associated Neck Injuries Operative Management of Zone III Injuries Operative Management of Zone i Injuries Upper Limb Vascular Injuries Subclavian and Axillary Vessel Brachial and Forearm Vessels Abdominal Vascular Injuries Resuscitative Thoracotomy Lower Limb Vascular Injuries Futility of Treatment Soft-Tissue Injury Vascularized Composite Muscle Flaps for Coverage of Vascular Reconstruction Brachioradialis Flap Rectus Abdominus Flap Soleus and Gastrocnemius Muscle Flaps Fasciocutaneous Flaps Cross-Leg Flap Radial Forearm Flap Forequarter Amputation Working in Austere Environments References 5 Global Perspectives on Vascular Trauma 28 Australia and New Zealand Region-Specific Epidemiology Region-Specific Systems of Care Surgical Training and Certification Access to Care Prehospital Care Region-Specific Considerations for Diagnosis Region-Specific Treatment Strategies Strategies to Sustain and Train the Next Generation of Trauma Surgeons References 29 Sri Lanka Introduction Epidemiology of Wartime Injury Combat-Related Geography, Terrain, and Weather War Tactics and Weapons Demographics System of care Medical Administrative Structure Considerations for Diagnosis Treatment strategies Hemorrhage Control Mitigating Ischemic Insult (Prophylactic Fasciotomy and Temporary Intraluminal Shunting) Resuscitation Strategy Definitive Vascular Reconstruction Managing Infections Concomitant Injuries Complications Sustaining and Training the Next Generation Challenges Military-Related Strategies General Strategies Conclusion References 30 Vascular Trauma in Finland Introduction Finland as a Northern European Example in Trauma and Trauma Care Vascular and Trauma Surgery Vascular and Endovascular Trauma Surgery Training, Availability, and Challenges Summary References 31 Sweden Introduction The Swedish Trauma System The Swedish Trauma and Vascular Registries Trauma in Sweden Vascular Trauma in Sweden New Developments in Vascular Trauma Management: the Concept of Endovascular Resuscitation and Trauma Management (EVTM) Education in Vascular Trauma Future Aspects References 32 Russia Historical Background Epidemiology Specific Systems of Care Specific Considerations for Diagnosis Specific Treatment Strategies Strategies to Sustain and Train the Next Generation of Trauma Surgeons Conclusion References 33 Serbia Introduction Lesson 1: War Versus Civil Vascular Trauma Lesson 2: Strategy During Management of Vascular Trauma Lesson 3: Primary Bleeding Control Lesson 4: Vascular Repair or Primary Amputation? Lesson 5: Diagnosis Lesson 6: Vascular Repair Lesson 7: Venous Injury Lesson 8: Complex Injuries Lesson 9: Late Revascularization Lesson 10: Early Complications After Vascular Repair Lesson 11: Endovascular Repair of Injured Vessels Lesson 12: Pediatric Vascular Trauma Lesson 13: Long-Term Complications After Repair of Vascular Trauma Conclusion References 34 Israel References 35 South Africa Region-Specific Epidemiology Region-Specific Systems of Care Techniques of Care Management of Acute Vascular Hemorrhage Management of Acute Ischemia Region-Specific Considerations for Diagnosis Region-Specific Treatment Strategies Neck Cervicomediastinal Injuries Transmediastinal or Transabdominal Torso Injuries Cardiac Injuries Strategies to Sustain and to Train the Next Generation of Trauma Surgeons References 36 Colombia: Don’t Dread the Popliteal and Axillary Fossa Don’t Dread the Fossa: The Posterior Popliteal Artery Approach Don’t Dread the Fossa: The Axillary Artery Approach References 37 Brazil Introduction Epidemiology Urban Setting Rural Setting Automobile Crashes Evaluation and Diagnosis of Vascular Injury in Brazil Vascular Injury Patterns and Treatment Strategies Endovascular Facilities Specific Considerations Carotid Injuries Subclavian Injuries Cardiac Injuries Thoracic Vascular Trauma Abdominal Vascular Trauma Extremity Vascular Trauma Training the Next Generation of Trauma Surgeons References Index