上肢热压伤合并主干血管损伤的治疗

目的探寻肢体热压伤合并主干血管损伤的治疗方案。方法对8例上肢严重热压伤合并骨筋膜室综合征患者实施减压术，但对肢体血运的改善不明显。行血管探查得知患肢均合并肱、桡、尺动脉或掌深、浅弓损伤，采用直接吻合、屈曲肢体吻合、大隐静脉移植等方式修复血管并移植中厚皮片或带蒂胸脐皮瓣封闭创面。结果l例肱动脉修复后创面植中厚皮片者因无良好的软组织覆盖，术后4周血管再度栓塞导致上臂中段截肢。7例血管修复后创面移植皮瓣的患者肢体血供完全恢复并得以完整保留。结论及时行血管探查和修复以及选择周围良好的软组织覆盖，是治疗热压伤合并主干血管损伤的关键措施。     

四肢主要血管损伤的显微外科修复

目的 通过对四肢主要血管损伤158例的诊治分析，探讨四肢主要血管损伤的早期诊断，提高疗效，降低截肢率。方法 应用显微外科技术修复四肢主要血管损伤158例，其中直接血管吻合88例，自体静脉移植修复32例，单纯修复38例。术后按显微外科方法监测治疗。结果 治愈145例，截肢13例，死亡1例。结论 严密观察伤肢缺血现象和综合分析临床表现对血管损伤的早期诊断至关重要，应用显微外科技术早期修复损伤血管有助于降低截肢率；缺损大于3cm应作静脉移植；术后注意骨筋膜室综合征的发生并及早切开减压是提高治愈率和功能恢复的关键。     

四肢主干血管损伤的诊治

目的探讨四肢主干血管损伤的早期诊断、治疗方法以及临床效果。方法2001年1月-2006年6月，收治72例四肢主干血管损伤患者。男50例，女22例；年龄5～60岁，中位年龄39岁。开放性损伤44例，闭合性损伤28例。动脉损伤部位：锁骨下动脉1例，股动脉23例，胭动脉20例，尺桡动脉同时损伤12例，肱动脉11例，腋动脉3例，胫前后动脉同时损伤2例。伤后至入院时间30min～27d。术中血管破口直接修补3例，端端吻合39例，自体大隐静脉移植修复30例，移植长度3～8cm。结果67例肢体成活，5例截肢。48例获6个月～5年随访，彩色多普勒血流仪检查血流速度及血管口径与健侧无明显差异。40例肢体功能恢复满意，8例残留不同程度功能障碍，其中4例行矫形或功能重建手术，功能及外形得到改善。结论了解损伤机制及受伤情况，认真体检，综合分析，是主干血管损伤早期诊断的关键；显微外科修复是提高血管通畅率的保障；术后筋膜间室综合征及肢体缺血时间超过4h的肱动脉、胭动脉以上的血管损伤，及时行筋膜间室切开是恢复肢体功能、避免伤残的有效手段。     

浮膝损伤合并血管损伤的处理

目的探讨浮膝损伤合并血管损伤患者的手术方法及临床疗效。方法浮膝损伤伴血管损伤19例,骨折复位固定同时行血管损伤大隐静脉移植修复术11例,人工血管修复3例,直接行端端吻合术3例,单纯修补术2例。对8例小腿严重创伤合并筋膜间室综合征者行小腿筋膜切开减压术,伤后3月修复交叉韧带损伤2例。结果1例患者合并严重挤压综合征死亡,2例在伤后48 h探查吻合血管患者二期截肢,肢体存活16例,此16例获随访0.5~2年。根据Karlstrm评价标准优6例,良7例,中2例,差1例,优良率为81.25%。人工血管修复的3例术后血流通畅。13例基本恢复正常生活和工作;2例足部感觉正常,肌力3级,生活基本自理;1例长期昏迷,生活不能自理。结论对于合并血管损伤的浮膝损伤,应尽早诊断及重建血液循环,防止严重并发症的产生,尽可能恢复患者功能。     

四肢血管伤显微外科修复失败原因分析

目的： 分析四肢血管伤显微外科修复失败的原因。方法： １３２ 例分别采用血管断口修补、端端吻合、自体大隐静脉移植、人造血管套接方法。结果： 失败２３ 例， 失败率为１７４ ％ 。结论： 四肢血管伤显微外科修复术后失败与伤后时间、损伤原因、损伤部位、损伤类型及手术方法的选择等有关。争取８ｈ 内修复是降低失败率的关键。     

叉型血管移植或转位在断指(肢)再植和血管损伤修复中的应用

目的 探讨叉型血管移植或转位在断指（肢）再植和血管损伤修复中的临床意义。方法 动脉缺损，切取移植的静脉时，在近心端带一个叉支，倒置后，用近心端一条供血动脉修复远心端两条动脉，静脉缺损，切取移植的静脉时，在远心端带上1-2个叉支，用近心端的一条静脉修复远心端2-3条静脉。结果 52例58个指（肢）中，坏死4指，成活54个指（肢）随访1-2年，伤指（肢）远端血运良好。结论 存在血管缺损的断指（肢）中，坏死4指，成活54个指（肢），随访1-2年，伤指（肢）远端血运良好。结论 存在血管缺损的断指（肢）再植和血管损伤的修复过程中，伤指（肢）两端可供吻合的血管条数不一致时，可以通过叉型血管移植及转位进行修复。     

四肢主要动脉损伤诊治体会

目的 探讨四肢主要动脉损伤的早期诊断方法和治疗效果。方法 对1991年1月～2003年10月36例四肢主要动脉损伤患者，分别采用端端吻合、血管修补、自体大隐静脉移植、残端结扎等方式修复损伤血管。结果1例血管吻合重建血循环后因肢体损伤严重，广泛坏死而截肢，其余35例全部存活。结论 ①早期诊断是肢体抢救成活的关键，诊断明确或疑有血管损伤者应尽早手术探查；②血管修补缝合术，血管端端吻合术是主要修复方法，血管缺损2cm以上者应行自体静脉移植术；③动脉血管修复的时限可根据伤情及全身情况适当延长。     

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     

面神经瘫痪外科治疗301例回顾

１９８２年２月至１９９６年６月，共收治各类面瘫病人３０１例，其中采用神经，肌肉移植修复１５７例，筋膜悬吊１１９例，其他２５例，包括（１）神经，肌肉移植，Ｉ期带血管神经肌瓣移植，Ⅱ期带血管，神经肌肉移植；（２）损伤面神经修复，面神经残端肌肉内种植以及舌下一面神经吻接；（３）动力性或静力性筋膜悬吊；（４）其他；面部畸形整形及其他肌肉移植等，认为：早期损伤的面神经吻接，舌下一面神经吻接等是早期外伤性面瘫     

纵向生物力学特性对动脉损伤修复方法选择的影响

目的 研究人体四肢主要动脉不同长度损伤与修复方法选择之间的关系，比较由于因管纵向性物力学特性面产生的修复差异，为临床修复效果及近，远期疗效评价提供依据。方法 回顾分析应用端端吻合法和自体静脉移植法修复的四肢主要动脉伤共１７７例１８５条血管，对相同损伤部位而不同修复方法的血管的真性缺损长度做ｔ检验比较，通过９５％置信区间分析两种修复方法的选取界限。对自体静脉移植修复血管中真性缺损长度做ｔ移植长度做线     

The effect of acute popliteal venous interruption.

Popliteal vascular trauma continues to be associated with a relatively high morbidity rate when compared to other major vascular injuries in extremities. There is continuing controversy regarding the management of popliteal venous injuries. The advocates of ligation of injured veins have postulated that there is an increased incidence in thrombophlebitis and pulmonary embolism associated with attempted venous repair. There is a paucity of valid statistics supporting either side of this controversy. Clinical experience documented in the Vietnam Vascular Registry and experimental work at Walter Reed Army Institute of Research have supported our more aggressive approach for venous repair. This study evaluates the management of 110 injured popliteal veins without associated popliteal arterial trauma. Nearly an equal number were ligated and repaired. Thrombophlebitis and pulmonary embolism were not significant complications in this series. The only pulmonary embolus occurred after ligation of an injured popliteal vein. However, there was a significant increase in edema of the involved extremity following ligation, 50.9% compared to 13.2% after repair.     

Surgical experience with expanded polytetrafluoroethylene (PTFE) as a replacement graft for traumatized vessels.

With the increased nationwide incidence of major vascular injuries, the need for interposition grafting has become quite common in major trauma centers. Despite extensive experience with such injuries, the choice of a substitute conduit remains controversial. Recent studies have demonstrated the potential of expanded polytetrafluoroethylene (PTFE) as a replacement graft for small arteries and veins. The surgical services at the Ben Taub General Hospital began to use PTFE grafts in traumatic vascular wounds approximately 2 years ago. Eight axillary arteries and 12 brachial arteries have had interposition grafting with PTFE prostheses. Eleven patients have required PTFE interposition grafts in repair of traumatized common, superficial, and profunda femoris arteries and common femoral veins; eight patients had reconstruction in the popliteal artery or vein. Three patients had renal artery revascularization procedures following blunt abdominal trauma, three patient had segmental replacement of the superior mesenteric artery following gunshot wounds, and one carotid artery, one iliac vein, and two axillary veins were grafted with PTFE. All patients with segmental repair of axillary, brachial, femoral, and popliteal vessels have maintained good distal pulses and viable extremities. No grafts have thrombosed, nor become infected, in spite of soft-tissue injury encountered at time or repair. In situations requiring interposition graft placement for reestablishment of distal flow in small arteries and veins, PTFE grafts appear to be an acceptable prosthesis.     

Iatrogenic Major Venous Injuries Incurred During Cancer Surgery

Purpose Iatrogenic operative injury to the major veins is associated with significant morbidity and mortality. This study was conducted to review the pattern, management, and outcome of iatrogenic major venous injuries incurred during cancer surgery. Methods We reviewed 24 patients with collective 30 venous injuries, evaluating clinical characteristics; operative and postoperative data, including location and type of venous injury, operative repair, blood loss, and transfusion requirements; and outcome. Results Thirty venous and 12 associated arterial injuries were identified. The two most common sites of venous trauma were the iliac and femoral veins with 10 (33.3%) and 9 (30.0%) injuries, respectively. Twenty-three (76.7%) of the venous injuries were repaired primarily or with end-to-end anastomosis, while the remaining injuries required interposition grafts, patch venoplasty, or venous ligation. Postoperative revision procedures were performed in 3 (12.5%) patients. Perioperative mortality was 16.7% and major complications developed in 11 (45.8%) patients. Conclusions Serious complications can be minimized by immediate recognition and prompt repair of iatrogenic vascular injuries. Close collaboration with a vascular surgeon during resection of tumors in proximity to the vascular structures may be helpful in preventing iatrogenic vascular injuries. In hospitals where tumor resection procedures are frequently performed, a vascular surgeon must be readily available.     

Management and short-term patency of lower extremity venous injuries with various repairs

BACKGROUND: Although several methods of repair of extremity venous injuries have been shown to be efficacious, patency rates have varied significantly from center to center. METHODS: A retrospective review was made of treatment outcomes of adult and pediatric patients with major venous injuries of the lower extremity. RESULTS: From 1997 to 2002, 82 patients sustained 86 major lower extremity venous injuries. Venous injuries were treated with primary repair in 27, complex repair in 37 (autogenous vein, 10, and ringed polytetrafluoroethylene [PTFE], 27) and ligation in 20. Prior to repair, temporary intraluminal venous shunts were used in 18 patients. Follow-up duplex imaging or venography or both were performed on 42 extremities at a mean of 10.9 +/- 7.1 days after repair with an overall patency rate of 73.8% (primary repair 76.5%; autogenous vein graft 66.7%; and PTFE 73.7%). CONCLUSIONS: Overall early patency rate of venous repairs performed by an experienced trauma team is similar irrespective of the type of repair. The use of temporary intraluminal shunts is acceptable in selected circumstances, while ringed PTFE grafts are reasonable alternatives when the contralateral saphenous vein is too small.     

Long-term results with autogenous tissue repair of traumatic extremity vascular injuries.

With extensive vascular injuries in which a vascular conduit is required, there is controversy as to whether an autogenous or prosthetic graft is preferable. The authors reviewed their experience with 91 extremity arterial injuries in which autogenous tissue was used to repair vascular injuries of the extremities. Twenty-two patients also had concomitant repair of associated venous injuries with autogenous vein grafts. Ten patients required amputations, despite patent grafts in five patients, because of severe muscle necrosis. Two patients had thrombosis of their vein grafts develop in the early postoperative period but did not require amputation. The authors identified only one late vein graft failure in a patient in whom an infected pseudoaneurysm developed. Three patients with extensive soft tissue injuries had infection develop in vein grafts, with subsequent massive bleeding that ultimately required arterial ligation. Among the 22 patients with repair of their venous injuries, occlusion of popliteal vein repairs was documented in two patients and suspected in three others. The remainder of patients had satisfactory results. The excellent results obtained in the vast majority of the authors' patients with extremity vascular injuries reinforces their preference for using autogenous tissue whenever a vascular conduit is required. Exceptions include patients with extensive soft tissue loss precluding adequate graft coverage, the repair of large vessels, and life-threatening emergencies when there is insufficient time to harvest and prepare a vein.     

Treatment of gunshot wounds of the veins in the first echelon of specialized surgical care

Results of first specialized aid to 26 wounded with injuries of the major veins are analyzed. Rate and nature of injuries of various major veins are regarded. Complete rupture of the vessel and its destruction with dehiscence of different length were seen in more than half of the cases (57.7%). In this case repair of venous vessel patency required various plastic methods. In lateral or incomplete transverse rupture it was possible to put lateral or circular vascular suture. Ligature of injured venous vessel was performed in half of the cases. Based on anatomic features of venous circulation in the extremities, immediate and long-term results of the treatment, 2 groups of injuries were identified: 1st - ligature of the veins did not lead to disorders of venous circulation and function of the extremity in the nearest and long-term period after surgery; 2nd - ligature of the vessel was dangerous due to serious disorders of venous circulation in the nearest period after surgery and might lead to disorders of extremity function and disability. In gunshot wounds of the major veins good results may be achieved in early reconstructive surgeries with individual approach allowing for general condition of the wounded and nature of vessel injury.     

Revascularization of the limbs using vein grafts after vascular injuries

We report on 32 patients with vascular injury of a limb undergoing a total of 41 revascularization procedures with interposition vein grafts. A combined arterial and venous injury was present in nine cases, an isolated venous injury in four, and an isolated arterial injury in 19 cases. Eighteen per cent of patients with arterial injuries had normal distal pulses on initial examination. Preoperative arteriography was performed in 12 cases, and intraoperative arteriography in four. All venous injuries were diagnosed at operation. In most cases, the contralateral greater saphenous vein was used for grafting. Four patients had postoperative thrombosis after arterial reconstruction resulting in below knee amputation in two cases. Two patients suffered from postoperative swelling caused by venous insufficiency, one after ligation of an injured axillary vein, and the other one following venous thrombosis of a superficial femoral vein repair. It is concluded that revascularization of arterial and venous injuries of the extremities with interposition vein grafts is successful in most cases resulting in low amputation rates, and should be attempted in all major vascular injuries in viable limbs.     

Vascular injuries in everyday practice

BACKGROUND: It was the objective of this retrospective study to analyse the causes of injury, surgical approaches, outcome, and complications in patients with vascular trauma and to report our experience with vein homografts for arterial reconstruction in the upper and lower limbs and cervicothoracic region in patients operated on over a period between 1981-2001. PATIENTS: In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 20 cases. In 4 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were aggravated by concomitant bone fractures, and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%), crural (22.6%), and ulnar and radial (13.2%) arteries. 16 patients with penetrating cervicothoracic arterial injuries were registered during this period. 8 patients underwent emergency exploration and 8 patients angiography prior urgent exploration. RESULTS: Saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene and Dacron grafts were used in eight cases, end to end anastomosis in 12 cases, venous bypasses in 5 cases, venous patches in 7 cases. 17 patients underwent arterial repair and 9 venous repair. Vein homografts as an arterial substitute were implanted in 8 patients. Five secondary amputations were performed and five patients died. The limb salvage rate was 95% and the primary patency rate of vein homografts was 75% (excluded primary amputations). The penetrating cervicothoracic injuries were all repaired with improvement in level of consciousness and neurological deficit when present. CONCLUSIONS: Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues. In the absence of suitable autologous vein grafts, homografts appear to be an interesting alternative for arterial repair. In penetrating cervicothoracic vascular injuries immediate operative repair offers the best chance of recovery.     

Vascular injury about the knee. Improved outcome

The records of 41 patients with 43 vascular injuries about the knee (34 popliteal artery, five tibial-peroneal trunk, one proximal anterior tibial artery, and three isolated popliteal veins) were analyzed. The etiology of the injuries were gunshot wounds (22), blunt trauma (11), shotgun wounds (4), and stab wounds (4). Associated injuries included fractures (67%), popliteal vein (54%), and nerves (32%). Arterial repairs consisted of primary repair (19), lateral repair (1), saphenous vein grafts (13), and saphenous vein patching (1). Five patients received polytetrafluoroethylene (PTFE) grafts. Fasciotomy was performed in 27 limbs. The associated venous injuries (21) and isolated venous injuries (3) were managed with ligation (14), primary repair (9), and vein patch (1). The amputation rate was 11 per cent for popliteal artery injuries (4/34). No other amputations were required. All four amputations were associated with massive limb injury (3) or diagnostic delay (1). One patient died during hemodialysis for renal failure resulting from prolonged shock and myoglobinuria. Successful management correlates best with prompt repair of both popliteal arterial and venous injuries and early fasciotomy. Vein repair (vs ligation) is associated with better long-term results.