Mode of presentation and management of Carotid Artery injuries

Objective: To share experience of presentation and management of carotid artery injuries in tertiary care Hospitals Rawalpindi, Lahore and Quetta

Study Design: Cross sectional descriptive study

Place and Duration of Study: Combined Military Hospital Rawalpindi Lahore and Quetta, from Jun 2005 to Jul 2014

Material and Methods: The data of demography, mode of presentation, associated injuries and surgical procedures performed in the patients with penetrating neck injuries were collected and analyzed descriptively

Results: All 32 patients were male. Age ranged from 18 to 52 years [mean: 30.7 +/- 7.1 years]. Time of presentation to vascular surgeon ranged from 1 to 52 hours [mean: 4.4 +/- 2.3 hours]. Sixteen cases [50 Percent] resulted from shrapnel injuries. Thirteen patients [40.6 Percent] had bullet injuries and in three [9.3 Percent], stab wounds. In only 6 cases [18.7 Percent] carotid injury was confirmed on angiography preoperatively. Common carotid artery [CCA] was the most frequently injured artery in 15 cases [46.8 Percent]. There were 6 cases [18.7 Percent] of External carotid artery [ECA], 4 [12.5 Percent] cases of internal carotid artery [ICA] and 1 case [3.1 Percent] of injury to the carotid bifurcation. Two cases [6.2 Percent] had both ICA and ECA injuries. Four patients [12.5 Percent] had no carotid artery injury on surgical exploration

Conclusion: Surgical exploration of neck penetrating injuries on the basis of hard signs and platysmal penetration was found a safe procedure especially in patients who had history of hemodynamic instability

Arteriovenous access in children

Objective: To evaluate arteriovenous access [AVA] in children for patency and to compare our results with other studies

Study Design: Cross sectional descriptive study

Place and Duration of Study: Combined Military Hospital Rawalpindi and Combined Military Hospital Lahore, from 1[st] August 2005 to 15[th] June 2011

Patients and Methods: Total 35 AVA patients were included in the study. Record was made of age, weight, gender, physical examination of vein, findings of duplex venous mapping, plan of AVA and procedure performed. Twenty nine cases [82.8%] were already undergoing hemodialysis. Thirty [85.7%] cases were operated under general anesthesia and only 5 [14.2%] under local anesthesia. All end-to-side fistulae were made. Meticulous microsurgical technique was used. Patients were examined on 1st, 2nd and 10th postoperative days, and then every month for at least 12 months. Primary failure, complications and revision procedures were recorded. SPSS version 19.00 was used for statistical analysis. Primary and secondary patencies were calculated. Kaplan - Meier curve was used to express both primary and secondary patency

Results: Out of 35 AVA, 20 [57.1%] radiocephalic [RCAVA], 11[31.4%] brachiocephalic [BCAVA] and 4 [11.4%] brachiobasilic [BBAVA] were made. Three [8.5%] AVA thrombosed within 48 hours. Thrombectomy was done in all but only one [2.8%] was saved. Six [17.1%]presented with failure within next 6 months [4 RCAVA and 2 BCAVA].Only 1 [2.8%] RCAVA was saved. One RCAVA, BCAVA and BBAVA each presented with failure between 6 and 12 months. Again 1 RCAVA was saved. Primary failure occurred in 4 [11.4%] patients. Primary patency rate at 6 months and 12 months was 74.2% and 65.7% respectively while secondary patency rate was 80% and 74.2% at 6 and 12 months respectively

Conclusion: Primary and secondary patency rates of AVA in children in our study were comparable to most of the similar studies

Patterns of presentation and outcome in critical limb ischemia

The threatened limb due to peripheral occlusive arterial disease, embolism or trauma requires early recognition and urgent treatment if the limb is to be saved. To determine the pattern of presentation and outcome of surgery in cases of critical limb ischemia. Descriptive study. This study was conducted at surgical ward, Combined Military Hospital, Rawalpindi, from Dec 2006 to Dec 2007. A sample size of 30 patients was taken by convenience sampling. Informed written consent was obtained from all patients. Patients suffering from rest pain with ischemia features, trophic lesions, extensive gangrene, ulcers and demonstrable presence of occlusive arterial disease were included in the study. Moribund patients, extensive cardiopulmonary disease or advanced malignancy were not included in the study. Thirty patients were included in the study. The mean age was 56 +/- 13. There were 28 males [93.3%] and 2 females [6.7%]. They were all married and belonged to middle and low middle social economic class. Out of 30, there were 2 [6.7%] cases of trauma while 28 [93.3%] had peripheral vascular involvement secondary to thromboembolism. Vessels involved were femoral artery in 9 [30%] cases, popliteal artery in 18 [60%] cases and brachial artery in 2 [6.7%] cases. Rest pain was present as a primary feature in all the patients [100%], while tissue loss or gangrene was seen in 22 [73.33%] cases. A total of 14 [46.7%] amputations, 6 [20%] bypass procedures, 4 [13.3%] lumbar sympathectomies, and 2 [6.7%] embolectomies, were carried out, whereas 4 [13.3%] patients were managed conservatively. Of the patients having rest pain 46.7% were amputated, whereas of patients having ischemic tissue loss 73.3% were amputated. 13 patients who underwent primary amputation had ankle brachial pressure index [ABPI less than 0.4 [86.7%]. ABPI was more than 0.4 in 4 [13.3%] patients whereas it was less than 0.4 in 26 [86.7%] patients. Overall, critical leg ischemia has a very poor prognosis. If surgical, or endovascular, improvement of the blood supply to the leg is not provided in due course; half of the legs will be amputated within a year. One of the main goals of vascular surgery is to prevent major amputations

Missed vascular injuries

To evaluate vascular injuries for the cause, site of injury, presentation and treatment. Descriptive study. Surgical unit I, Combined Military Hospital, Rawalpindi. Surgical Unit 2, Combined Military Hospital, Lahore. 1st August 2005 to 30th June 2010. All cases of missed vascular injuries [MVI] who presented to a single vascular surgeon, between 1st August 2005 and 30th June 2010 were examined in detail. Only cases with viable limbs and reversible ischaemia were included in the study. Patients with gangrene of the limbs of any extent were excluded. Record was made of the cause, site, mode of presentation and treatment. MVI was defined as vascular injury which was missed in the initial evaluation, operative procedure or intervention. Out of 41 cases, 31[75.6%] were due to gunshot or splinter injuries, 3[7.3%] external fixator injuries, 2[4.8%] carotid stentings, 2[4.8%] cardiac angiographies, 1[2.4%] fine needle biopsy, 1[2.4%] metallic rod penetrating injury and 1[2.4%] elective lumbar disc surgery. Neck was affected in 9[21.9%], upper limb in 7[17%] and lower limb in 25[60.9%] patients. There were 20[48.7%] false aneurysms, 8[19.5%] traumatic arteriovenous fistula [AVF], 5 [12.1%] false aneurysms with traumatic AVF, 3[7.3%] thrombosis, 1[2.4%] stenosis, 3[7.3%] hematoma and 1[2.4%] hemorrhagic shock. In 39[95.1%] cases surgical intervention was done. In 2[4.8%] cases, vascular injury was missed in polytrauma and mass casualty situation while 3[7.3%] cases were of polytrauma only. Penetrating trauma was the commonest cause of MVIs. Lower limbs were mostly affected. Most of the cases presented with pseudoaneurysms. Few cases had polytrauma/mass casualty situation at the time of initial presentation indicating that vascular injuries were missed either due to low index of suspicion by clinician or not following the proper protocol to avoid these injuries

Pseudoaneurysms in intravenous drug abusers

lntravenous drug abuse can lead to vascular complications, most frequent of which is pseudoaneurysm. These pseudoaneurysms [false aneurysms] are prone to rupture, leading to profuse hemorrhage and death. To evaluate pseudoaneurysms in intravenous drug addicts for the site, mode of presentation, management and outcome. Descriptive study. Surgical unit I, Combined Military Hospital, Rawalpindi. Surgical unit 2, Combined Military Hospital, Lahore. January 2006 to September 2010. All cases of pseudoaneurysms in intravenous drug addicts who presented to a single vascular surgeon, between 1st January 2006 and 30 th September 2010, were evaluated for site, mode of presentation, treatment and the outcome. Surgical procedures included excision of pseudoaneurysm with interpositioning of graft, repair of vascular rent, ligation of vessel and debridement. All cases were referred to psychiatrist for management of drug addiction. Total 12 cases of pseudoaneurysms due to IV drug abuse were included in our study. Arteries affected included 9[75%] common femoral arteries [CFA]. ln 3[25%] cases, both common femoral artery and vein were involved with arteriovenous fistula between them. There was 1[8.3%] pseudoaneurysm each of external iliac artery, superficial femoral artery and brachial artery. Nine cases [75%] presented with recurrent hemorrhage from a swelling while in 3[25%] cases there was swelling with no history of hemorrhage. ln 7[58.3%] cases, repair/grafting, while in 5[41.6%] cases ligation and debridement was done. There was seroma formation in 1[8.3%] case after excision and grafting. ln none of the cases, in which artery was ligated, critical limb ischaemia occurred. Common femoral artery is the most frequent site of pseudoaneurysms in lV drug abuse. ln those cases where vascular reconstruction is not possible due to extensive skin necrosis or infection, ligation of affected vessel is not only a life saving procedure but a safe option also.

Experience of vascular trauma in a tertiary care hospital

To highlight the presentation and management of various vascular injuries and their outcome. Descriptive study. Surgical unit III, Combined Military Hospital, Rawalpindi, from September 2005 to October 2006. Thirty nine cases of vascular trauma were referred to vascular surgeon CMH Rawalpindi, in the above mentioned period. These cases were evaluated for mechanism of injury, age, gender and time of presentation. Out of these, only thirty cases were found suitable for surgical intervention. These thirty cases were evaluated for site of vascular injury, associated injuries, type of surgery performed and the outcome. Blunt trauma was the predominant cause of vascular injuries in our study 16/39 [41%]. Fourteen cases [35.8%] had gun shot wounds. Only thirty patients [76.9%] underwent various surgical procedures. Primary end to end anastomosis was possible in only 5/30 cases [16.6%] while reversed venous graft was used in 13/30 cases [43.3%]. Wound infection occurred in 2/30[6.6%] cases out of which 1 case [3.3%] ultimately had an amputation. The time period between injury and surgical intervention ranged between 1 to 20 hours for most of the vascular injuries while delayed presentation in the form of traumatic arteriovenous fistula or pseudoaneurysm was between 48 hours to 3 months. There are reasonable numbers of vascular trauma cases being referred to a tertiary care hospital. Most of these cases reach us quite late due to unnecessary investigations, delayed referral and transportation. Early intervention and revascularization definitely reduces amputation and complication rate. All gunshot wounds not only require thorough surrounding soft tissue debridement but also liberal excision of traumatised vessel itself, resulting in interposition graft repair