下肢血管损伤的处理

本文报告美国波斯顿大学医院(1973～1981年)56例下肢钝性伤和穿透伤引起血管损伤的处理经验,特别对伴有骨折和广泛性软组织伤的处理有所改进。本组为腹股沟韧带以下69处血管损伤,其中36例仅有动脉损伤,7例仅有静脉损伤,13例动静脉同时损伤。动脉伤常见部位为股浅动脉和腘动脉。静脉伤常见部位为腘静脉。49例动脉伤修复中,19例采用最常用的静脉旁路移植法,12例作切除和端端吻合,1例作侧面修补,5例用静脉片修补,2例用人造血管移植,10例行动脉结扎。20例静脉伤修补术中,11例作常用的侧面修补,5例作切除和端端吻合,3例作静脉旁路移植,1例因腘静脉横断而作结扎。56例中21例术前作动脉造影;25例在完成手术时作术中动脉造影;12例需作正规筋膜切开术     

周围假性动脉瘤的外科治疗

目的　评价周围假性动脉瘤外科治疗的方法及其疗效。方法　总结1957 年8 月～1997 年8 月收治的周围假性动脉瘤64 例,手术方式包括:瘤体切除 动脉结扎21 例;瘤体切除 动脉破口修补28 例;瘤体切除 动脉端端吻合6 例;瘤体切除 血管移植9 例( 移植血管包括自体大隐静脉5 例,人造血管4 例) 。8 例合并动静脉瘘同时行静脉修补(1 例合并静脉瘘行股静脉人造血管移植) 。结果　55 例获随访,其中51 例效果满意,另4 例遗有不同程度的肢体远端缺血症状。结论　周围假性动脉瘤的诊断首选彩色B 超,必要时选用血管造影;手术治疗效果良好     

门静脉创伤;紧急结扎门静脉的作用

门静脉损伤虽罕见,但由于大量出血和可能合并的其他脏器损伤,死亡率高达50～70％。当前通常用的静脉损伤处理方法为Fish所提出:1.静脉端端吻合,2.静脉侧壁修补,3.自体静脉或人造血管间置移植,4.肠系膜上静脉与脾静脉吻合,5.门静脉结扎,同时作门一体静脉分流,6.单纯结扎门静脉。     

火器性四肢动脉伤：附50例报告

作者报告５０例５２条四肢火器性动脉伤，其中枪弹伤３７例，弹片伤１３例；急性动脉伤３２例（３３条），晚期动脉伤８例，假性动脉瘤７例，动静脉瘘３例（４条）。平均随访２４．２个月，无一例死亡，修复血管通畅率９３％，截肢率９．８％，肢体缺血性挛缩发生率１０．９％。作者强调，早期诊断、早期正确处理此类动脉伤是成功的关键。应争取在伤后６～１２小时内修复损伤血管。根据临床表现可作出诊断，急性动脉伤一般不做血管造影，对可疑肢体主要动脉伤应积极手术探查。根据伤情采用对端吻合或自体静脉移植修复血管，不主张用人造血管修复，血管部分断裂不宜做侧壁吻合。晚期动脉伤应争取修复血管以改善肢体循环。假性动脉瘤和动静脉瘘宜早期切除修复血管，待伤口愈合、组织柔软后即可手术。     

四肢主要血管严重损伤的治疗

各种原因所致的血管损伤中,部分病例由于损伤范围较广,血管缺损较长,直接修补或吻合比较困难。在此种情况下,采用自体大隐静脉移植,有助于四肢主要血管损伤的修复,对减少残废有重要价值。我院自1979年以来,用自体大隐静脉移植修复主要动脉损伤共13例。现报告如下: 手术方法 一般在非受伤侧下肢获取被移植的大隐静脉。于大腿上部作纵行切口,显露大隐静脉上段,选择分肢少的一段静脉,结扎和切断其各分枝。根据静脉缺损长度决定所需静脉的长度,取下的静脉段,高压注入生理盐水,使血管管腔适当扩张,将大隐静脉方向倒置后,移植到缺损处行两断端吻合。吻合时局部以稀释肝素液     

四肢动脉损伤诊治体会

目的探讨四肢动脉损伤的诊断和治疗方法。方法回顾分析我院1996年1月至2006年7月共诊治的23例四肢动脉损伤患者的临床资料。分别采用直接动脉修补、动脉结扎、端端吻合、自体大隐静脉移植及人工血管吻合。术中取栓6例,合并静脉损伤修复8例。结果截肢3例(13.0%)。获得随访12例,随访时间3个月～5年,11例多普勒超声证实损伤血管血流通畅,下肢肌肉挛缩1例;下肢血供不足1例。结论早期诊断是提高肢体存活率和避免假性动脉瘤发生的关键。手术方式的合理选择、Fogarty导管常规取栓和早期筋膜切开可提高治愈率。     

四肢主要动脉损伤的临床治疗

目的：总结四肢主要动脉损伤的诊治经验。方法：1989—2000年68例四肢主要动脉损伤患者，分别采用断端吻合、血管修补、自体静脉移植、残端结扎等方式修复损伤血管。结果：随访2--11年，62例肢体存活，6例截肢，2例出现轻度缺血性肌挛缩。结论：早期诊断是肢体抢救成活的关键，损伤动脉应尽可能在6—8h内进行修复，根据不同的损伤类型，分别采用不同的血管修复方法。积极治疗多发伤、及时处理并发症。     

四肢主干血管急性损伤的外科处理

目的 探讨四肢主干血管急性损伤的外科治疗方法。方法 回顾性分析我院收治四肢主干血管急性损伤患者100例。共行手术106次,其中行血管移植58条(人造血管移植40条,大隐静脉移植18条),血管断端直接吻合44条,血管裂口修复28条,单纯动脉结扎2条。结果 治愈94例,无血栓形成及肢体缺血。1例大隐静脉移植术后移植段静脉血栓形成,1例切口感染,3例下肢因挤压伤致大面积肌肉坏死,均治愈,另1例右小腿远端缺血截肢。结论 正确的现场处理、精细的血管外科技术、血管移植材料的合理选择是提高治疗效果的关键。     

四肢血管损伤的处理

本文收集1967年以来54例四肢血管损伤病例,其中有38例次行自体静脉移植修复损伤的血管,收到良好的效果。本文就有关问题分析讨论如下。临床资料本组54例中男50例,女4例。年龄7～82岁。伤后到手术时间为0.5～31小时,平均13小时。其中有10例因在外院已急诊处理,或因形成假性动脉瘤于伤后3天～1年手术,其中2例因动脉瘤破裂而急诊手术。致伤原因:钝性损伤29例,枪弹伤5例,锐器伤19例,医源性误伤1例,共损伤血管70条。治疗方法:行端端吻合16次,结扎血管8次,人工血管移植1次,截肢5次,修补2次,行静脉移植38次。血管修复情况:施行自体静脉移植38次中,修复动脉损伤34次,修复静脉4次。采用大隐静脉26次,头静脉8     

胸廓上口大血管损伤的外科治疗

目的 总结胸廓上口大血管损伤的外科治疗经验。方法 回顾性分析经手术治疗的32例胸廓上口大血管损伤患者的临床资料,其中男性24例,女性8例;年龄2－48岁。致伤原因为锐器伤、钝性或减速伤。损伤血管为颈总动脉、无名动脉、锁骨下动脉以及伴行的静脉。治疗方法为：急诊缝合动脉破口,或加涤纶片修补15例;动脉瘤切除6例;受损血管切除端端吻合5例;以Gore-Tex重建血管3例;大隐静脉移植3例。结果 治愈24例（75％）,死亡7例（21．9％）,1例致残。结论 胸廓上口大血管损伤患者,早期常因失血、脑缺氧或并存的多发伤致死;后期多演变成假性动脉瘤。手术多采用血管破口修复;在体外循环支持下实施假性动脉瘤切除,Gore-Tex人造血管或大隐静脉移植重建血管。     

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.     

Major vascular lesions associated with orthopaedic injuries.

Seventeen patients, aged 11-67 years (mean, 32.6), with major vascular injuries associated with traumatic orthopaedic injuries, were treated operatively in the authors' institution over a 4-year period. The most common mechanism of trauma was a high-energy injury (70.8%), and the rate of open injuries was 88.2%; 64.9% of the injuries were located in the lower extremities. The treatment protocol consisted of aggressive resuscitation; Doppler imaging and, when necessary, angiography; stable bone fixation with subsequent vascular repair; and extended wound debridement. The vascular repair for arterial lacerations consisted of (a) end-to-end anastomosis (47.2%); (b) interpositional homologous vein graft (23.6%); (c) vascular decompression through fracture distraction in one patient (5.9%); (d) xenograft interposition (in one patient; 5.9%); (e) venous repair (in three patients; 17.7%); and (f) embolectomy (in all patients). Three vascular reoperations (17.7%) were necessary because of rupture of the anastomosis. The authors' preferred bone stabilization method was external fixation, which was used in 47.2% of cases. Amputation was performed in three cases (17.7%) as a salvage operation. Although six patients (35.4%) were admitted with delayed shock (mean duration, 73.6 +/- 27.8 min), this led to a lethal outcome due to shock lung in only one patient. Another patient developed massive lung embolism 3 months postoperatively and died. The authors believe that this well-organized approach, based on a specific treatment protocol, for patients with severe orthopaedic trauma and concomitant vascular injury, not only improves outcome but gives good to excellent functional results in the majority of patients.     

Contemporary management of wartime vascular trauma

OBJECTIVE: The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries. METHODS: From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed. RESULTS: Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 [88%]) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts. Sixty-seven (63%) patients underwent diagnostic angiography. The most common indication was mechanism of injury (42%), followed by abnormal examination (33%), operative planning (18%), or evaluation of a repair (7%). CONCLUSIONS: This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.     

Optimal limb salvage in penetrating civilian vascular trauma

To evaluate current treatment of peripheral vascular trauma, we reviewed our recent experience with noniatrogenic penetrating vascular injuries of the extremities. Between 1979 and 1984, 139 patients sustained 204 vascular injuries inflicted by single gunshots (64%), stabbings (24%), and shotguns (12%). Eighty-four percent of patients underwent preoperative arteriography, which revealed occult arterial injury in 13 patients (9%). Compartmental hypertension necessitated fasciotomy in 19% of patients and was required more often after combined arterial and venous injuries (29%) than after isolated arterial injury (14%). Arterial continuity was restored by interposition grafting with reversed saphenous vein (62%), end-to-end anastomosis (19%), vein patch angioplasty (8%), or primary repair (4%). After arterial repair, completion angiography detected the need for revision in 8% of patients. Arterial ligation was performed in 7% of injuries and was only used in the treatment of tibial and distal profunda femoris injuries. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. No deaths occurred, and a single patient required amputation. We conclude that a protocol of preoperative arteriography, liberal. use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates that approach 100% after penetrating vascular trauma to the extremities.     

Overview of vascular injuries in Yemen: Experience from a single tertiary referral hospital

Background: Vascular injuries are seen in blunt and penetrating trauma. They have been well documented during wartime, but there have been few reviews of vascular trauma in civilian practice. In Yemen, gunshot injuries seen frequently where civilian violence is common. The present study aimed to describe our experience in the management of vascular injuries in civilian practice. Methods: A prospective study included 132 patients with 163 vascular injuries who were admitted to the surgical department at Al‐Thawra Teaching Hospital between December 1997 and March 2002. Results: Eighty‐seven per cent of the patients were males and the median age was 28.5 years. The most common cause of vascular injury was gunshot injury (59.8%), followed by stab wounds and car accidents. The commonest vessels injured were the common femoral arteries, followed by the brachial and popliteal arteries (19, 18 and 18 injuries, respectively). Associated injuries were recorded in 72 patients and included 47 fractures. Treatment included vein graft interposition in 67, ligation in 52 and end to end anastomosis or lateral primary repair in 34 injuries. Fasciotomy was performed for 39 patients and amputation performed in 11 cases. The mortality reached 9.8% and the commonest cause (nine out of 13 deaths) was due to gunshot wounds. The median hospital stay was 13.5 days. Conclusion: Gunshot wounds represent the majority of vascular injuries in Yemen. Shortage of vascular surgery services in most of the Yemeni Hospitals represents a major problem. Legislation and regulation to take up arms is of paramount importance for injury prevention in Yemen.     

四肢骨折伴主要血管损伤的临床治疗

目的探讨四肢骨折伴主要血管损伤急诊处理的临床效果。方法分别采用带锁髓内针、钢板螺钉和外固定支架固定骨折,根据血管损伤情况选择血管直接修补术、血管端端吻合术和血管移植术等方法治疗四肢骨折伴主要血管损伤45例。结果本组45例,肢体全部成活,伤口愈合好。随访6个月～3年。有6例骨不连,其余骨折愈合好;有7例因神经损伤恢复不理想,肢体感觉和运动功能部分障碍。结论四肢骨折合并主要血管损伤要早期诊断、及时和正确处理,才可能获得良好的临床治疗效果。     

Orthopedic trauma of limbs associated with vascular injuries

Objective： To evaluate the treatment for patients with major vascular injuries associated with traumatic orthopedic injuries. Methods： A total of 196 patients, aged from 4-67 years with the mean age of 29.88 years, had major vascular injuries associated with traumatic orthopedic injuries and were treated in our hospital in a period of 44 years. The most common mechanism of trauma was blunt trauma （67.3 % ）, open injuries accounted for 32.4 % and 54.5 % of the injuries were located in the lower extremities. The vascular injury frequently happened in the femoral artery （26. 7 % ） and popliteal artery （ 20. 3 % ）. The treatment principle consisted of aggressive resuscitation, Doppler imaging and stable bone internal fixation with subsequent vascular repair and debridement. The vascular repair for injuries included end-to-end anastomosis （80 cases, 39.6 % ）, interpositional vein graft （94, 46.5 % ）, vascular decompression through fracture distraction （ 18, 8.9% ）,arterial ligation （6, 3.0% ）, vein patch （2, 1. 0%）, bypass graft （ 2, 1.0% ）, venous repair including autogenous vein graft （9, 24. 3%） and ligation （28, 75.7% ） and prophylactical fasciotomy （15. 7. 4%）. Postoperative amputation was performed in 16 cases （16.3%）. Results： No intraoperative death was observed and all fractures united within 6 months. Limbs were salvaged in 180 patients （91. 8% ）. Among these patients, early complications were found in 19 patients （9. 7 % ） and late complications were observed in 8 patients （4.1% ）. Conclusions： A well-organized approach, based on a specific treatment principle, not only improves clinical outcome but also does good to excellent functional recovery for patients with severe orthopedic injuries and concomitant vascular lesion.     

The utility of physical examination in proximity penetrating extremity trauma.

This study assessed the efficacy of physical examination as a screening modality for the diagnosis of surgically significant arterial injury in proximity penetrating extremity trauma (PPET). All cases of PPET were assessed and admitted per established protocol over a 30-month period from January 1, 1993, to June 30, 1995. No patients were excluded if other body regions were also injured. Landmarks defining upper extremity injuries were the deltopectoral groove to the wrist and for lower extremities from the inguinal ligament to the ankle. Patients admitted with PPET fell into one of three categories: 1) no hard signs of vascular injury present-admitted for 24-hour observation; 2) presence of at least one hard sign of vascular injury-taken immediately to the operating room; 3) positive sign of arterial injury that requires angiography (i.e., diminished but appreciable pulse by physical examination or doppler, large nonexpanding hematoma, bilateral pulse deficit, no appreciable pulse with unreconstructable trajectory). Four hundred six patients with 489 injured extremities secondary to PPET were admitted over a 30-month period. Sixty-two extremities suffered multiple injuries. Of the extremities injured, 83 per cent were secondary to gunshot wounds, 12 per cent were attributed to stabs/lacerations, and 5 per cent were due to shotgun injuries. Four hundred twenty-one extremities with PPET fell into Group 1. There were four missed injuries (specificity, 99%) in this group (one ulnar artery, one radial artery, one posterior tibial artery, and one anterior tibial artery). Two of these injuries were considered surgically significant. None of the patients suffered limb or functional loss as a consequence of their missed arterial injury. Thirty-nine extremities were entered into Group 2, with two patients found to have no arterial injury. Twenty-nine extremities were placed into Group 3 with 10 (35%) found to have surgically significant injury on angiogram. The overall sensitivity and specificity for physical examination was 92 per cent and 95 per cent, respectively, for surgically significant injury. Physical examination is a highly sensitive and specific screening modality for the identification of surgically significant arterial injury in PPET. Patients who present with diminished, but appreciable, pulses by physical examination or doppler, large nonexpanding hematomas as the only sign, bilateral pulse deficits and nonappreciable pulses with unreconstructable trajectory benefit from further investigation with angiography.     

Noniatrogenic pediatric vascular trauma

Twenty-four noniatrogenic pediatric vascular injuries in 20 patients (75% male; mean age, 14 years) were treated during a 3-year period. Of 18 arterial and six venous injuries, 65% were penetrating and 35% were blunt injuries. Eighty percent of all patients had significant associated injuries that required repair. Angiography was performed in 13 of 20 patients, with four performed during surgery. Repair methods were ligation in two of six venous injuries and three of 18 arterial injuries, primary repair in three of six venous injuries and six of 18 arterial injuries, and autogenous saphenous vein graft in seven of 18 arterial injuries. Exploration and debridement, thrombectomy, and nonoperative management were used in one arterial injury each. Fasciotomy was employed in six of 13 arterial injuries in the extremities. There was one operative death, no reoperations, and no early or late amputations. Mean follow-up of 27 months demonstrated normal palpable and Doppler pulses (by noninvasive testing) distal to all arterial repairs. This study supports an aggressive approach to the diagnosis and treatment of noniatrogenic pediatric vascular trauma, emphasizing the liberal use of fasciotomy and meticulous vascular repair for the successful management of these challenging injuries.