The vascular surgeon is trained in the management of diseases affecting all parts of the vascular system except that of the heart and brain whereas cardiothoracic surgeons manage surgical diseases of the heart and its vessels. Although vascular surgery is previously a field within general surgery, it is now considered a specialty on its own right in many countries such as the UK and the United States. Other countries such as Iraq have a mixed practice in which the cardiac or thoracic surgeon performs vascular surgery. Programs of training in vascular surgery are slightly different depending on the region of the world one is in. In the United States, a 5-year general surgery residency is followed by 2 years training in vascular surgery. In Iraq, the time table allocated for the general surgical trainee in vascular surgery is unfortunately short (1 - 3 months). This period is hardly enough for the candidate to grasp the decision-making and technical skills of vascular surgery. We believe that general surgeons need to have adequate training and expertise in vascular surgery particularly in areas and situations lacking this facility to deal with the life- and/or limb-threatening emergencies. This review article aims to orient the general surgical trainee about the scope of vascular surgery and enable them to correctly diagnose and treat common vascular emergencies such as extremity and abdominal vascular injuries (AVI).
Vascular surgery is a well established subspecialty for many decades. Although it was previously considered a field within general surgery, vascular surgery is now considered a specialty in its own right [
In many countries, UK for example, vascular surgery is now practiced separately from general, thoracic and cardiac surgery [
Before the emergence of cardiothoracic surgery in Iraq, vascular surgery was practiced by other surgeons mainly general and sometimes orthopedic surgeons. And even after the beginning of cardiothoracic surgery, vascular surgery continued to be practiced by interested general surgeons in areas that lack the facility of cardiothoracic surgery.
In Iraq, most of the cardiothoracic and vascular surgeons are graduates of the Iraqi Board for Medical Specializations (IBMS) that was established in 1988 whereas minority has a high Diploma in thoracic and vascular surgery. From 1992 to 2012, there were 149 graduates of IBMS in cardiothoracic and vascular surgery. Unfortunately, many graduates have left the country due to lack of security while some of them were killed. Hence, the number of active vascular surgeons in Iraq is small compared to its population (estimated to be 31,234,000 in 2009). In 2008, the ratio of active thoracic surgeons per 100,000 Iraqi populations was 0.47; much lower than the American ratio of 1.36. This calculated ratio is based on all the graduates and does not take into consideration the number of surgeons who were either killed or left the country for one reason or another. Moreover, we have to take into account that the remaining surgeons unlike their colleagues in other countries are not fully committed to vascular surgery as they have an additional practice in thoracic and/or cardiac surgery.
In our opinion, the general as well as the orthopedic surgeon need to have an adequate training and a good expertise in vascular surgery particularly in areas and situations lacking the facility of proper vascular surgery to deal with emergency cases of vascular trauma in the extremities and/or the abdomen to save the life and limbs of patients [
Vascular surgery is a specialty of surgery in which diseases of the vascular system (arteries, veins, and lymphatics) are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction [
Programs of training in vascular surgery are slightly different depending on the region of the world one is in [
Therefore; there is a need to focus on the common emergencies such as acute limb ischemia due to vascular trauma as well as abdominal vascular injuries (AVIs). It is crucial for any trauma surgeon to be able to make an early diagnosis of vascular injuries on clinical bases, order and use bed-side procedures such as a portable Doppler examination, start an effective initial management to stop bleeding, treat shock and stabilize fractures and/or dislocations and embark on definitive management to repair the vessels or if not capable to do so; refer the patient as soon as possible to a vascular surgical center to have a timely limb revascularization and thus prevent limb loss.
Vascular trauma of the limbs is a common emergency both in civil and war time. It accounts for approximately 1% - 3% of total civilian trauma in various studies [
Extremity vascular injuries can result from blunt and penetrating mechanisms. The penetrating agents may be a knife, sharp object, bullet, pellet, shrapnel… Blunt trauma can follow a road traffic accident, falling from a height… Beware of the association between fractures and/or dislocations and vascular injuries. Examples include posterior knee dislocation and popliteal artery injury, supracondylar humeral fracture and brachial artery injury. Iatrogenic vascular injuries are increasingly encountered with the increase in conventional peripheral angiography and cardiac catheterization [
The trauma can involve arteries, veins or both. Venous injuries can bleed profusely and may be complicated by air embolism particularly when the central veins are involved. Moreover, the thin wall of the vein renders them difficult to handle, therefore, the seriousness of vein injuries should not be under-estimated [
Arterial injuries are classified into total transaction, partial tear, arterial contusion, false or pseudoaneurysm and arterio-venous fistula (AVF) (Figures 1(A)-(G)). External bleeding results from complete and partial tear. On the other hand, there is no bleeding from arterial contusion or AVF. Hence, absence of bleeding does not exclude a vascular injury. In complete arterial cut, there is retraction, vasoconstriction and thrombosis which can
arrest the bleeding after a while. In contrast, vessel retraction in a lateral arterial tear increases the size of the rent and the amount of bleeding. One sequel of lateral tear is the formation of pseudoaneurysm (pulsating hematoma). This results from local bleeding into the nearby soft tissues (local hematoma). The outer wall of the hematoma gets organized over time forming a fibrous wall while blood flow continues through the artery and preserves the distal pulses. In arterial contusion, there is an intimal damage, subintimal hematoma and local thrombus formation. The blood flow ceases although there is no arterial discontinuity. The site of contusion is darkly discoloured with a bounding proximal and absent distal pulse. In AVF, an adjacent artery and vein are injured resulting in a short-circuiting of blood from the artery to the vein. In this serious injury, there is no bleeding and the blood flow is not interrupted and hence the limb viability is not affected. However, there are 2 cardinal signs of this injury, namely thrill and bruit which should be sought by the examining doctor; otherwise AVF can be easily missed. Arterial spasm may result from compression of the artery by a piece of fractured bone and usually resolves with fracture reduction. It should not be mixed with arterial contusion that can similarly follow bone compression but has a different pathology and treatment. Arterial contusion is a real damage that requires resection of the damaged segment and end to end anastomosis whereas arterial spasm is usually managed conservatively with a local application of a vasodilator agent such as papaverine and sometimes by using a Fogarty catheter for dilation [
・ Understanding the pathology of different types of arterial injury is important to know the symptoms and signs. Interruption of arterial blood flow results in acute limb ischemia that is manifested by 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia). Paralysis and paresthesia are ominous signs as they indicate ischemia of skeletal muscles and somatic nerves; both are the most tolerant tissues to ischemia. Loss of muscle softness (woody limb) is a bad sign indicating an irreversible muscle necrosis.
・ The time interval between injury and revascularization of injured limb is an important factor in determining the outcome of repair [
・ Acute limb ischemia is considered to exist when Doppler signal in the extremity is absent on multiple attempts after resuscitation, warming and reduction of fractures. The signs of acute vascular injury are classified into hard and soft signs [
・ The state of the pulse deserves elaboration; a normal pulse may exist despite a significant vascular injury [
Although significant vascular injuries may present with no external bleeding, arterial and/or venous hemorrhage is an alarming and serious presentation of most acute vascular injuries. Injury to the common femoral artery is often fatal because hemorrhage control in the field is difficult. Haemostasis can be achieved by digital pressure over the proximal artery, pressure dressing, tourniquet and clamping of visible bleeders by a vascular clamp if this is feasible. When a tourniquet is used be cautious of its disadvantages such as increasing venous bleeding, nerve injuries and missed tourniquet (always report the time of its application). When these measures fail to stop the bleeding, operative control is necessary. Associated limb fractures should be stabilized and shock and other bodily injuries if present should be dealt with accordingly.
The diagnosis of acute vascular injuries is straightforward in most cases due to the presence of hard or soft signs mentioned before. Frykberg et al. found that accurate physical examination was highly sensitive and specific in the diagnosis with a negative predictive value of 99% [
However, significant vascular injuries may present with viable limbs, intact distal pulses and no bleeding (AVF and false aneurysm). Therefore, do not forget to put your hand on the site of injury feeling for a thrill and put your stethoscope listening to a bruit.
Fractures and/or dislocations may be problematic! Always ask yourself is there an associated vascular injury? If doubt still exists after reducing the fracture and/or the dislocation, then Doppler ultrasonography and/or angiography are necessary to make the diagnosis. If these two techniques are not available or inconclusive, then surgical exploration is mandatory and should not be unnecessarily delayed. A negative surgical exploration is by far much better and safer than missing a vascular injury and losing a limb.
・ Work-up may be needed in doubtful cases. A portable Doppler device can be used to detect a pulse wave when pulse palpation is uncertain. Hussein et al used Doppler ultrasonography and pressure studies in his doubtful cases, because of non-availability of angiography in Emergency room of their hospital [
・ Recently duplex ultrasonography has emerged as a valuable diagnostic tool for the diagnosis of potential vascular injuries [
・ Arteriography is very helpful in doubtful cases providing the patient is hemodynamically stable and it does not delay the repair. Carrillo et al. [
・ Meissner et al. [
Anatomical knowledge of the vascular system is essential. For every vessel in the body (neck, thorax, abdomen, pelvis and limbs) there is one or more approach. Familiarity of the surgeon with these approaches is very important. Faced with a bleeding from a wound in the neck, axilla, groin and etc., the surgeon most unlikely has time to go and read about the most suitable approach to isolate and fix the injured vessel. Instead, he should know and immediately go through the standard approach. Otherwise, more time and blood would be lost if a wrong approach is chosen and ultimately the patient may be lost as well. Such a detailed knowledge of vascular exposure can be found in formal texts of vascular surgery and lectures [
・ A general surgical set together with few vascular clamps, dissecting scissors, vascular bens and a right-angle forceps is fair enough to carry out the vascular repair. Other important tools are the Fogarty catheter, Polypropylene sutures (5-0 and 6-0 are suitable for most limb vessels) and heparinized saline (
・ After choosing the approach, proximal and distal control of the injured vessel should be accomplished quickly so that vascular clamps are applied to stop the bleeding. Sharp dissection is done in the perivascular plane using a good pair of scissors and atraumatic vascular bens. The adventitia should be cleared from the artery and the damaged arterial tissue should be excised to finish with completely healthy arterial ends. Fogarty catheter of proper size (6F for lower limb and 3F or 4F for upper limb) is passed proximally to dilate the artery and get a good antegrade flow [
・ Temporary arterial shunting has been advocated for complex wounds, for which fracture fixation and extensive debridement is required [
・ If the gap in the artery is less than 3 cm, tension-free end to end anastomosis is possible (
・ However, if there is a greater loss, grafting is necessary (the best is the great saphenous vein of the uninjured limb) (
・ Venous injuries alone or in association with arterial injuries are better repaired [
tibials [
・ Fasciotomy is a very important adjuvant operation in vascular repair and it should be used liberally [
・ Vascular injuries associated with fractures need repair of the vessels and reduction and fixation of the fracture. The sequence of repair (vessel or bone first) depends on the individual case. If the patient presents late, the priority is for vessel repair. Otherwise, the fracture can be managed first followed by vascular repair.
・ Repair of arterial injury is contra-indicated when the limb is frankly dead. Such a limb needs a primary amputation i.e. amputation without repair. This is in contradistinction to secondary amputation which follows unsuccessful vascular repair. It is very important to diagnose a dead limb and avoid its revascularization as this would result in acute tubular necrosis subsequent to myoglobin effect on the kidney.
・ Primary amputation or ligation is an acceptable damage control technique when other life-threatening injuries are present [
・ Mangled extremity refers to a severely injured limb for which attempted salvage would be futile and a primary amputation is a potential outcome. Mangled Extremity Severity Score (MESS) is one scoring system used to identify such limbs and anticipate their prognosis [
・ Wound debridement is an essential step (all devitalized tissues should be excised). The arterial repair should be covered by viable tissue. A drain is advised after securing the hemostasis. Complete primary closure of the wounds is carried out in the very clean cases only, otherwise partial closure is preferred as the wounds are usually contaminated and carry the risk of infection.
Bleeding and thrombosis of repair are the 2 potential postoperative complications. The most gratifying result after an arterial repair is to feel a strong distal pulse. Palpable pulses obtained in the operating room should remain palpable post-operatively [
The outcome of vascular repair in extremity vascular trauma is measured by limb salvage rate. Until World War II, arterial ligation was the mainstay of treatment with an amputation rate of 49%. On account of continuous improvements in trauma care system and formal vascular repair, amputation rate declined to 13% in Korean and Vietnam conflict. At present, these injuries are associated with amputation rate of less than 10% of the cases [
The general surgeon is frequently involved in the management of abdominal trauma. Alone or as a member of the trauma team, the general surgeon should always be prepared to correctly diagnose and treat abdominal vascular injuries (AVIs). One of the common scenarios in our surgical practice is to perform an exploratory laparotomy for a patient with acute abdomen due to trauma and unexpectedly discover a major bleeding and/or retroperitoneal hematoma (RPH) with or without other injuries; a situation that necessitates the help of the vascular surgeon. Meanwhile, the hemodynamic state of the patient usually gets worse due to uncontrolled hemorrhage awaiting the arrival of the vascular surgeon. The purpose of this mini-monograph is to enable the general surgeon to make a clinical diagnosis or at least to suspect AVIs preoperatively so that surgical exploration is performed in optimum operating conditions with a vascular surgeon and vascular instruments available to ensure patient’s recovery in these technically challenging injuries.
DeBakey and Simeone (1946) reported 49 AVIs out of 2,471 arterial injuries (2%) during WWII [
Up to one fourth of patients with abdominal trauma may have a major vascular injury (arteries and veins are equally involved). AVIs are mostly (up to 95%) caused by penetrating trauma. Aortic injury is most common, occurring in one fourth of patients while the inferior vena cava (IVC) is the vein most often involved, representing approximately one third of patients with vascular injury of the abdomen [
All vessels in the abdomen are susceptible to injury with penetrating trauma [
In penetrating trauma, fifteen % die before any surgery can be attempted. Overall mortality is greater than 50% [
Retroperitoneal hematoma occurs in more than 90% of abdominal vascular injuries. Wounded veins bleed at low pressure into contained spaces and spontaneous hemostasis can be seen. Contained hematomas are not expansive and are more common on the right. RPH of arterial origin is bright red, rapidly expansive and more commonly occurs on the left [
・ Major vascular injury should be suspected when the penetrating wound (entry and/or exit) is located between the root of the thigh and the nipples [
・ When the trajectory of the projectile passes through the abdomen and/or the pelvis, or when it is betrayed by externalized bleeding [
・ Shock out of proportion to the extent of external injury suggests abdominal vascular injury.
・ Isolated abdominal injury in patients with shock suggests major vascular injury that requires emergency laparotomy for control [
・ Abdominal distension in association with signs of acute anemia and/or hemorrhagic shock is a strong indicator of major vascular injury.
・ Abdominal wounds near the midline are suggestive of caval or aortic injury; in particular, a periumbilical wound should lead to suspicion of a lesion at the bifurcation of these two vessels.
・ Even the slightest hypotension noted in the setting of an abdominal penetrating wound should suggest the possibility of a vascular injury and should lead to surgical intervention unless proven otherwise [
Hemodynamic stability determines whether there is time for pre-operative investigations and governs therapeutic choices [
After the abdomen is entered, immediate control of the supraceliac aorta should be considered before continuing the operation. Retroperitoneal hematomas should not be explored right away unless they are actively bleeding. Stopping the procedure after the initial exploration for damage control to allow time for resuscitation in the intensive care unit is often a reasonable initial treatment [
Several vessels are notoriously difficult to expose. These include the retrohepatic IVC; suprarenal aorta; the celiac axis; the proximal SMA; the junction of the SMV, splenic, and portal veins; and the bifurcation of the vena cava. Maneuvers have been described to aid in the exposure of all of these vessels [
In surgery for AVIs, control of hemorrhage takes priority over avoiding organ ischemia [
Management of RPH depends upon location: central RPHs should be explored; retrohepatic RPH need packing; perirenal RPH should be explored, unless hematoma is stable in an otherwise unstable patient. RPH in the pelvis is managed by surgical packing and/or endovascular techniques [
These are increasingly used in the acute phase of abdominal trauma. Endovascular treatment is reserved for stable patients, particularly for those with iatrogenic injury, contained RPH, and certain instances of hepatic lesions. This less-invasive alternative can decrease the complexity of surgery. In the unstable patient, endovascular management can complement the surgical gesture, performed before, during or after the operation. In pelvic lesions or in the case of isolated vessel injury, with a contained RPH, this modality can be as effective as surgery [
General surgeons used to manage vascular trauma before the emergence of vascular surgery as a separate specialty from general surgery. There is good evidence in the literature that general surgeons adequately exposed to trauma surgery are able to safely manage extremity vascular trauma achieving limb salvage rate comparable to that obtained by proper vascular surgeons. Abdominal vascular injuries can be encountered in up to one quarter of abdominal trauma. Unless the general surgeon is well prepared, the management of such challenging injuries can be a nightmare. In Iraq, and many other developing countries with limited number of proper vascular sur- geons, there is a need to extend the time table allocated for the general surgical trainee in vascular surgery to cope with the increasing terrorism-related casualties.
I wish to thank my lovely daughter Aumnia A Taha for drawing
Abdulsalam Y.Taha, (2015) Vascular Surgery and the General Surgeon: Review Article。 International Journal of Clinical Medicine,06,132-143. doi: 10.4236/ijcm.2015.63018