26例锐器刺伤致腋动脉损伤的诊治

目的 探讨锐器刺伤致腋动脉损伤的诊治体会.方法 对26例腋动脉刺伤入院时均处于不同程度休克状态的急诊患者,在积极杭休克治疗的同时,急诊进行清创探查及血管神经修复术.其中行腋动脉直接吻合16例,腋动脉修补6例,自体大隐静脉移植修复腋动脉4例.结果 伤后12h内26例腋动脉损伤修复再通,无病例发生肢体坏死、截肢或死亡.伤口一期愈合,桡动脉搏动良好.结论 积极抗休克同时对腋动脉刺伤早期诊断、及时手术探查、术中止血、修复血管再通是枪救生命、控制休克、获得良好疗效的关键.     

合并肱动脉损伤的儿童肱骨髁上骨折的手术治疗

目的探讨合并肱动脉损伤的儿童肱骨髁上骨折的手术治疗疗效。方法 2006年2月至2010年12月手术治疗合并肱动脉损伤的儿童肱骨髁上骨折8例,术前检查患侧桡动脉搏动消失的6例患儿行急诊探查、内固定术;桡动脉搏动减弱的2例患儿先行保守治疗。观察12h后桡动脉搏动无明显恢复,患儿前臂进行性肿痛加重,则行急诊切开探查、内固定治疗。术中可见骨折近端压迫肱动静脉致血管痉挛6例,肱动脉血栓形成1例,肱动脉部分破裂1例。6例血管痉挛者在骨折复位后血管搏动恢复正常。肱动脉血栓形成者给予切开取栓,动脉部分破裂者给予直接缝合。术毕两者肱动脉搏动均恢复正常。术后肘关节屈曲90°石膏固定。结果 8例患儿全部得到随访,随访时间5个月～2年,平均16个月。所有患儿桡动脉搏动均正常。骨折均在术后4～6个月愈合,拔除克氏针。无伤口感染、肘内翻畸形等发生。结论对于合并肱动脉损伤的儿童肱骨髁上骨折,术前桡动脉搏动是一个重要的判断指征。一旦怀疑肱动脉损伤,应尽早手术。     

膝部超时限腘动脉损伤的治疗

目的 总结超时限胭动脉损伤的诊治经验和教训。方法 1995年2月～2006年1月，收治28例胭动脉损伤时间超过8h的患者。其中男25例，女3例；年龄3～53岁。车祸伤12例，高处坠落伤3例，火器伤2例，锐器伤3例，绞扎伤2例，其他6例。20例未扪及动脉搏动，8例动脉搏动减弱。2例见裸露胭动脉和／或活动性喷血，8例直接手术探查，18例彩色多普勒检查示胭动脉及分支有彩色血流信号通过。7例胭动脉缺损〈5cm，9例缺损〉5cm。损伤至血管再通时间8～150h，平均31．8h。采用端端吻合、大隐静脉移植修复16例，截肢12例。结果 行动-静脉吻合或桥接术的16例患者，15例血管再通，肢体存活，其中12例1年内下肢功能基本恢复，3例遗留不同程度足下垂和踝关节挛缩，另1例枪伤患者因吻合血管术后1d再次栓塞，行二期截肢；血管吻合术后肢体存活率94％（15／16）。28例患者均获随访6个月～11年，平均4．2年。无死亡患者，截肢率43％，病残率54％。结论 胭动脉损伤的预后主要取决于血管再通时间和侧支循环的血氧代偿能力；延误诊断和治疗是严重胭动脉损伤截肢率居高不下的主要原因。     

闭合性腘动脉损伤的诊治

目的探讨闭合性胭动脉损伤的诊治方法和效果。方法13例闭合性胭动脉损伤患者，10例采取动-静脉吻合和桥接术治疗，2例因肌肉缺血坏死行一期截肢术，1例行保守治疗。结果动-静脉吻合和桥接术10例中血管再通肢体成活9例。血循环重建时间3．5～35h，其中8h以内重建血循环8例，肢体功能恢复良好，1例遗留不同程度的缺血性挛缩，另1例术后26h再次栓塞，保守治疗无效而行二期截肢。保守溶栓治疗成功1例。13例中3例截肢。病残病废共5例，其中1例腓总神经损伤肢体功能部分恢复。结论闭合性胭动脉损伤应尽早明确诊断，在8h内修复者效果好，超过这一时限病残率及截肢率均明显上升。     

锁骨下动脉损伤的外科处理

目的 探讨锁骨下动脉损伤的外科治疗特点。方法 1990年7月～2006年1月，对12例锁骨下动脉损伤患者，取锁骨上下联合切口，充分显露锁骨下动脉全段，分别采用动脉破口修补、包裹修复、血管吻合及人造血管移植修复重建损伤动脉。均为男性，年龄18～36岁，平均22.6岁。损伤部位：锁骨下动脉第1段1例，第2段4例，第3段7例。损伤类型：均为不完全断裂及破损，其中动脉破损区小于动脉周径1／3者4例，小于动脉周径2／3者5例，大于动脉周径2／3者3例。伴全臂丛神经损伤1例，神经干缺损5cm；部分臂丛神经损伤3例，其中2例仅前束损伤，神经缺损分别为4cm和6cm；正中神经完全损伤及尺神经不完全损伤1例，神经缺损4cm。损伤至手术时间3h～1.5个月。结果 术后无死亡及肢体坏死。获随访2个月～12年，平均5年2个月。10例桡动脉搏动恢复良好，2例桡动脉搏动不明显，均为动脉直接吻合者。4例合并臂丛神经损伤患者，前束损伤者术后肢体功能基本恢复正常，屈肘肌力Ⅳ级；全臂丛神经完全损伤者术后上肢功能基本无改善。结论 锁骨下动脉解剖位置特殊，动脉损伤后显露、修复均较困难。锁骨上下联合切口可在直视下显露动脉全段，修复重建安全可靠。     

四肢主要动脉损伤的修复

我院 1992年～ 2 0 0 1年 1月共收治 14例四肢主要动脉损伤的患者 ,分别采用血管修补术、端端吻合和静脉移植术进行血供重建。术后获得满意效果 ,报告如下。1　临床资料　　本组 14例 ,男 12例 ,女 2例。年龄 2 3～ 6 2岁。压砸伤 8例 ,切割、刺伤 5例 ,枪击伤 1例。闭合性损伤 5例 ,开放性损伤 9例。均为单侧肢体主要动脉损伤 ,其中股动脉 10例 ,胫前、胫后动脉 2例 ,腋动脉 1例 ,尺、桡动脉 1例。动脉完全断裂 7例 ,挫伤血栓形成 5例 ,不全断裂 2例。本组合并骨折 7例 ,休克 4例。 12例为急性动脉损伤 ,2例为外伤性动脉瘤。11例伤肢远端动…     

锁骨下及腋动脉损伤合并臂丛神经损伤的急救与外科治疗(附10例报告)

目的：探讨锁骨下及腋动脉损伤合并臂丛神经损伤的治疗方法：方法：分析10例锁骨下动脉及腋动脉损伤合并臂丛神经损伤的治疗结果。结果：10例均存活，也未出现患肢坏死，但有6例仍存在锁骨下动脉、腋动脉主干闭塞其中2例发生缺血性肌挛缩。臂丛损伤可二期修复。结论：在抢救生命的原则下，迅速探查血管神经，尽可能地修复血管损伤，重建上肢血供，是保留患肢功能的基础。二期探查修复臂丛损伤应审慎进行。     

无骨折闭合性四肢主干动脉损伤的早期诊断及治疗

目的研究无骨折闭合性四肢主干动脉损伤的早期诊断和治疗。方法1998年5月一2008年7月,对24例无骨折闭合性四肢主干动脉损伤的患者,在入院后,进行体格检查,结合脉搏血氧饱和度监测仪监测,做出早期诊断,并急诊手术探查,修复损伤动脉。结果23例均一次修复成功,1例术后发生栓塞,术后4h再次探查修复后,动脉获得通畅。术后随访6个月～2年。22例患肢血液循环恢复良好,肢体功能恢复满意。1例经2次手术后,出现中度缺血性肌挛缩,1例合并肘关节半脱位的患者出现轻度肘关节伸直障碍。结论体格检查结合脉搏血氧饱和度监测仪监测,可对无骨折闭合性四肢主干动脉损伤做出早期诊断,及时修复损伤动脉,是挽救受伤肢体,减轻伤残的有效手段。     

闭合性腘动脉损伤的诊断与治疗

目的探讨闭合性腘动脉损伤的诊断与治疗。方法收治26例闭合性腘动脉损伤患者,13例采用彩色多普勒超声检查明确血管损伤部位,8例DSA检查明确损伤部位,5例直接手术探查。11例行断端吻合,14例大隐静脉移植,25例均行预防性小腿切开减张。术后应用激素、甘露醇等治疗。结果 22例15h内手术者均成功保肢,并且功能良好,3例24～36h内手术者2例保肢成功,1例截肢,72h明确诊断者肢体坏死直接行截肢手术。结论闭合性腘动脉损伤只要肢体不出现坏死,一旦确诊均应尽早修复血管以求保肢可能。     

臂丛神经损伤早期修复的临床研究

目的研究臂丛神经损伤早期行神经修复的可行性和优点。方法2004年2月-2005年10月，对5例早期臂丛神经损伤患者行神经探查修复术。其中2例为臂丛神经束支部损伤，3例为臂丛神经根性撕脱伤。受伤后至手术时间最短为4h，最长为25d，平均为5．8d（140h）。4例伴有锁骨下动脉或腋动脉损伤，2例伴有锁骨骨折，均在修复神经的同时行血管和骨折的处理。结果5例患者在术中及术后均未出现严重的并发症。术后随访时间为12—24个月。臂丛神经功能均有不同程度的恢复，血管通畅性良好。结论臂丛神经损伤早期行探查修复手术有利于神经的再生，但需严格掌握手术适应证，并需具备相应的医疗能力。     

Modern management of traumatic subclavian artery injuries: a single institution's experience in the evolution of endovascular repair

Background

Subclavian artery injuries traditionally require morbid surgical procedures. Repair by way of an endovascular approach can potentially decrease the morbidity and mortality associated with these injuries.

Methods

A 2-year retrospective review of trauma patients with subclavian artery injuries was performed at our institution. Relevant data were extracted from patient records and analyzed. These results were then used to develop an algorithm for the management of trauma patients with subclavian artery injuries.

Results

Fifteen patients with subclavian artery injuries were identified. Five patients died in the emergency room. Of the 10 surviving patients, 8 had their diagnosis made at arteriogram. Six patients underwent endovascular repair, and 4 of these repairs were successful. Three patients were managed by way of open repair. Two deaths occurred in the endovascular group, and 1 death occurred in the open group.

Conclusions

Our findings suggest that endovascular management of subclavian artery injuries is an acceptable technique in appropriate candidates and compares favorably with open repair. However, as with open repair, the associated morbidity and mortality remains quite high. We propose an algorithm whereby hemodynamically stable patients with hard signs of vascular injury proceed directly to angiography, whereas open repair is reserved for those patients who are unstable or in whom a catheter-based approach has previously failed.     

Axillary Artery Injury Secondary to Anterior Shoulder Disclocation: Report of Two Cases

Vascular injuries secondary to isolated shoulder dislocation are rare. Unawareness for closed axillary artery trauma by many physicians treating shoulder dislocations, counts often for missed or delayed diagnosis. The authors describe two cases that presented with an anterior shoulder dislocation, complicated by a disruption of the axillary artery with subsequent thrombosis.

The various pathogenic mechanisms are discussed. The pathognomic triad consists of anterior shoulder dislocation, absent or diminished distal pulse and an axillary protruding hematoma. Prompt surgical arterial repair is mandatory.     

Axillary artery injury secondary to anterior shoulder dislocation: report of two cases

Vascular injuries secondary to isolated shoulder dislocation are rare. Unawareness for closed axillary artery trauma by many physicians treating shoulder dislocations, counts often for missed or delayed diagnosis. The authors describe two cases that presented with an anterior shoulder dislocation, complicated by a disruption of the axillary artery with subsequent thrombosis. The various pathogenic mechanisms are discussed. The pathognomic triad consists of anterior shoulder dislocation, absent or diminished distal pulse and an axillary protruding hematoma. Prompt surgical arterial repair is mandatory.     

Stent-graft repair of traumatic thoracic aortic disruptions

OBJECTIVE: Blunt traumatic thoracic aortic disruption results in pre-hospital death in 80% to 90% of patients. Because of the significant surgical morbidity and mortality associated with open operative repair, endovascular stent-graft repair has been investigated. The objective of this study was to evaluate the efficacy of thoracic aortic disruptions treated with commercially available proximal aortic extension cuffs. METHODS: Nine patients with multiple system trauma (age range, 16-42 years) were seen after motor vehicle accidents between January 1, 2003, and April 1, 2004. Chest x-ray findings warranted thoracic computed tomography scans, which revealed disruptions of the thoracic aorta. Aortograms delineated the extent of the aortic injuries and identified a "landing zone" (neck length range, 1.5-2.0 cm) distal to the subclavian artery but proximal to the tear. The repairs were performed with AneuRx (n= 8) and Excluder (n = 1) proximal aortic extension cuffs. A left femoral artery approach was used in 6 patients, a suprainguinal retroperitoneal approach with an iliac conduit in 2 patients, and direct tunnel in 1 patient. An Amplatz super-stiff wire was placed in the right axillary artery to enable easy tracking of the endografts, and left brachial artery access was used for arch arteriography. RESULTS: In each patient the stent-graft cuff was deployed adjacent to the left subclavian artery, with successful exclusion of traumatic disruptions verified at intraoperative arteriography and on computed tomographic scans obtained within 48 hours of initial repair. One patient required a second cuff for exclusion of a type I endoleak at the distal attachment site 1 month after the initial endograft repair. There were no procedure-related deaths; 1 patient, however, died of other injuries. CONCLUSIONS: Stent-graft repair of traumatic thoracic aortic disruptions is technically feasible. Placement of a stiff wire in the right axillary artery and percutaneous left brachial artery access for arteriography are useful adjuncts during endograft deployment. Endovascular stent grafts may enable definitive repair or serve as a bridge until the patient is stable enough to undergo an operation, if necessary. This technique warrants further investigation.     

Surgical treatment strategy for multiple injury patients in ICU

Objective: To investigate the surgical treatment for patients with multiple injuries in ICU.Methods: Clinical data of 163 multiple injury patients admitted to ICU of our hospital from January 2006 to January 2009 were retrospectively studied, including 118 males and 45 females, with the mean age of 36.2 years (range, 5-67 years). The injury regions included head and neck (29 cases),face (32 cases), chest (89 cases), abdomen (77 cases), pelvis and limbs (91 cases) and body surface (83 cases). There were 57 cases combined with shock. ISS values varied from 10 to 54, 18.42 on average. Patients received surgical treatments in ICU within respectively 24 hours (10 cases), 24-48 hours (8 cases), 3-7 days (7 cases) and 8-14 days (23 cases).Results: Forthe 163 patients, the duration of ICU stay ranged from 2 to 29 days, with the average value of 7.56 days. Among them, 143 were cured (87.73%), 11 died in the hospital (6.75%) due to severe hemorrhagic shock (6 cases),craniocerebral injury (3 cases) and multiple organ failure (2 cases), and 9 died after voluntarily discharging from hospital (5.52%). The total mortality rate was 12.27%.Conclusions: The damage control principle should be followed when multiple injury patients are resuscitated in ICU. Surgical treatment strategies include actively controlling hemorrhage, treating the previously missed injuries and related wounds or surgical complications and performing planned staging operations.     

Cannulation of the right axillary artery for surgery of acute type A aortic dissection.

OBJECTIVE: The optimal choice of the arterial inflow site during operations for type A aortic dissection is not clearly defined. The aim of the prospective study was to identify whether cannulation of the right axillary artery instead of the femoral artery may improve the results of surgery for acute type A aortic dissection. METHODS: Seventy consecutive patients were operated on because of acute type A aortic dissection from January 2000 to February 2002. The only difference in surgical strategy was the site of arterial cannulation: the right axillary artery was used in 20 patients [axillary group] and the left femoral artery in 50 patients [femoral group]. All patients had aortic surgery with open distal anastomosis during deep hypothermic arrest and retrograde cerebral perfusion. The mean age was 58.7 +/- 12 years with a range from 28 to 88 years (axillary group, 56.6 +/- 13 years; femoral group, 59.4 +/- 12 years; P = 0.435). Preoperatively evident organ malperfusion was identified in five (25%) patients of the axillary group and in seven (14%) of the femoral group. RESULTS: There was no perioperative death. The hospital mortality rate was 5.0% for the axillary group and 22% for the femoral group (all patients, 17%). Major neurological complications occurred postoperatively in 5% of patients from the axillary group (one out of 20 patients) and in 8% of patients from the femoral group (four out of 50 patients) (all patients, 7%). CONCLUSION: Cannulation of the right axillary artery improved the outcome of surgery for acute type A aortic dissection. However, postoperative complications occurred after both axillary and femoral artery cannulation.     

Penetrating injuries to the subclavian and axillary vessels

BACKGROUND: Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels. STUDY DESIGN: Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period. RESULTS: Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location. CONCLUSIONS: Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.     

Covered stents for injuries of subclavian and axillary arteries

INTRODUCTION: Injury to the subclavian and axillary arteries is uncommon. Exposure of these vessels is associated with significant morbidity, and mortality ranges from 5% to 30%. Endovascular methods may offer an alternative approach to these technically challenging injuries. METHODS: We retrospectively studied patients with blunt or penetrating (including iatrogenic) injuries to the subclavian or axillary artery between January 1, 1996 and July 30, 2002. Demographic data, mechanism of injury, concomitant injuries, angiographic findings, and treatment method and outcome were recorded. RESULTS: Twenty-seven patients with injury to the subclavian or axillary artery were seen at our institution during the study. Twenty-three patients underwent interventions. Eleven patients required open repair; 12 patients had lesions amenable to endovascular repair. Depending on the preference of the surgeon, 5 patients with injuries amenable to endovascular repair underwent open repair, and 7 underwent endovascular repair. A Wallgraft endoprosthesis was used in all patients; two grafts were required in 1 patient. Endovascular repair was associated with shorter operative time (P =.04) and less blood loss (P =.01). One-year patency was similar between the two groups. CONCLUSION: Covered stents are a feasible alternative to open repair in properly selected patients with subclavian or axillary artery injury, resulting in shorter procedure time and less blood loss.     

Diagnosis and treatment of open thoraco-abdominal injuries

From January 1954 to December 1987, 42 cases with open thoracoabdominal injuries were surgically treated. The causes of trauma were gun shot in 11, stabbing in 28, and buffalo horn injury in 3 cases. 24 cases were complicated with shock and 29 cases had more than two thoracoabdominal organs injured. 3 patients died postoperatively, an operative mortality rate of 7.1%. The authors discussed the problems of nomenclature, diagnosis and treatment and emphasized that: (1) open wound with thoracic and abdominal cavities and diaphragm involved simultaneously should be called open thoraco-abdominal injury; (2) surgical treatment is often delayed if diagnosis depends solely on X-ray examination; (3) operative approach should be carefully selected according to circumstances.     

Upper extremity arterial injuries: Factors influencing treatment outcome

Objective

The aim of the study was to identify factors influencing surgical treatment outcome following upper extremity arterial injuries.

Methods

This 15-year study (January 1992 to December 2006) included 167 patients with 189 civilian, iatrogenic or military upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into a vascular trauma database and retrospectively analysed.

Results

The most frequently damaged vessel was the brachial artery (55% of injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Three primary amputations (1.8%) were performed because of extensive soft-tissue destruction and signs of irreversible ischaemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft-tissue and nerve damage. Fasciotomy was required in 9.6% of cases. Operative mortality was 2.4% (four deaths). Early graft failure, compartment syndrome, associated skeletal and brachial plexus damage and a military mechanism of injury were found to be significant risk factors for limb loss (p < 0.01).

Conclusion

Although careful physical examination should diagnose the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Prompt reconstruction is essential for optimal results. Nerve trauma is the primary cause of long-term functional disability.