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Australia and New Zealand

Region-Specific Epidemiology Australia and New Zealand have a combined population of approximately 30 million people (approximately the population of Texas) spread over a very large land mass of nearly 8 million square kilometers (roughly the size of the continental United States). In Australia and New Zealand, ownership and use of firearms and, in particular, handguns is limited by strict laws. With large farming areas in both…

Vascular Surgery in the Austere Environment

Introduction Vascular surgery is normally conducted in a highly technical environment with a full complement of specialized equipment including noninvasive ultrasound technology, state-of-the-art computed tomography (CT), modern fluoroscopy, specialized instruments for open surgery, and postoperative intensive care units and wards staffed with experienced vascular nurses and junior doctors. Performing vascular surgery in an austere environment is the antithesis to this. Faced with major vascular injury, the…

Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury

Introduction Extremity injuries involving significant trauma to bone, soft tissue, and major vessels are relatively uncommon outside of the wartime setting. This constellation of injuries may also be referred to as the mangled extremity. Much of the difficulty encountered in managing patients with a mangled extremity is due to the fact that few surgeons gain much experience in dealing with this challenging injury pattern. In order…

Management of Pediatric Vascular Injury

Introduction In the United States, injuries account for approximately 10,000 childhood fatalities every year. Unintentional injury results in one in four pediatric medical visits, and the direct cost of these injuries is estimated to be over $50 billion annually. Vascular injuries represent a small proportion of this disease burden (0.6%–1%), and the incidence of noniatrogenic pediatric vascular injury rates may be decreasing due principally to public…

Considerations for Conduit Repair of Vascular Injury

Introduction In 1949, Jean Kunlin performed the first saphenous vein bypass in the lower extremity of a patient suffering from ischemia. The work was not the result of chance alone as his predecessors in vascular surgery had been working on perfecting the technique of arterial surgery. Individuals such as Alexis Carrel developed the technique of a meticulous anastomosis, as well as experimenting with venous interposition grafts…

Surgical Damage Control and Temporary Vascular Shunts

Introduction Since the turn of the century, there have been major changes in the management of the severely injured patient. Perhaps most notable is the adoption of damage control or staged procedures. Stone and colleagues provided the landmark description of a staged operation in 1983. With intent to limit the physiologic burden on an already threatened patient, they demonstrated a survival advantage in a series of…

Lower Extremity Vascular Trauma

Introduction and Scope In this chapter we present the workup and surgical management of vascular trauma to the lower extremities spanning from the common femoral vessels in the groin to the tibial vasculature at the ankle. The term “vascular injury” is used primarily to denote injury to a named artery of the leg. Venous injuries will be considered separately from arterial injuries and both in the…

Upper Extremity and Junctional Zone Injuries

Epidemiology of Upper Extremity Vascular Injury Reports from civilian and military settings have shown the distribution and outcomes of major vascular injuries going as far back as the Civil War ( Table 21.1 ). Although some publications comment on and provide details related to vascular injury in the upper extremity, it is often difficult to discern specific epidemiology and outcomes of upper extremity vascular injuries. An…

Neck and Thoracic Outlet

Introduction Perhaps no other anatomic region contains so many vital structures in such a compact space as the neck and thoracic outlet. Injuries in this region can result in hemorrhage, stroke, upper and/or lower extremity paralysis, loss of airway, and digestive tract injury. Consequently, the clinician must adopt a thorough approach and maintain a high index of suspicion when caring for patients with injuries in this…

Inferior Vena Cava, Portal, and Mesenteric Venous Systems

Introduction Injury to the large veins of the abdominal cavity, including the inferior vena cava (IVC) and the portal and the superior mesenteric veins is uncommon occurring in 5% of penetrating and 1% of blunt trauma cases. Because prehospital mortality associated with injury to these large veins ranges between 30% and 50%, there are relatively few patients who survive to have surgical repair. As such, even…

Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries

Introduction Major vascular injuries may be seen in up to 25% of abdominal trauma and are associated with a high mortality. Following penetrating abdominal trauma, vascular injuries are the most common causes of death. Intra-abdominal hemorrhage can be catastrophic due to the difficulty of rapidly accessing the retroperitoneal vessels. It is for this reason that early recognition of a possible vascular injury is essential and transfer…

Blunt Thoracic Aortic Injury

Introduction The screening, definitive diagnosis, and the method and timing of definitive management of blunt thoracic aortic injuries (BTAI), have undergone revolutionary changes over the last few years. A routine chest CT scan has replaced plain x-rays for screening purposes; CT angiography (CTA) has replaced formal angiography as a method of definitive diagnosis; semielective definitive repair of BTAI instead of emergency repair has now become the…

Cardiac, Great Vessel, and Pulmonary Injuries

Introduction Penetrating injuries to the heart and great vessels result in significant prehospital mortality (50% to 75% for cardiac wounds), so the numbers of patients undergoing operations for such injuries are small even in the busiest civilian centers or wartime hospitals. The presentation is different for penetrating wounds to the nonhilar vessels of the lung parenchyma. With a systolic pressure of 25 mm Hg in the…

Gathering the Evidence: Clinical Study of New Technologies

Why This Chapter? Vascular and endovascular trauma management is a rapidly developing field, which is dominated by medical devices. The preceding chapters in this section have highlighted key developments, such as stentgrafts, coils, plugs, resuscitative endovascular balloon occlusion of the aorta (REBOA), selective aortic arch perfusion (SAAP), and extracorporeal life support (ECLS) systems. New devices (and modifications of existing ones) are being developed and brought to…

Endovascular to Extracorporeal Organ Support for Vascular Trauma and Shock

Introduction Mechanical trauma to major arteries often leads to significant vascular compromise to large tissue beds which then results in the reduction in oxygen delivery, cellular dysoxia, and cell death. This occurs in varying degrees, depending on the robustness of collateral blood flow to every anatomic region and organ in the body (e.g., muscle, kidney, lungs, liver, intestines, etc.). Regardless, it has been well documented that…

Selective Aortic Arch Perfusion

Introduction Selective aortic arch perfusion (SAAP) is an emerging endovascular resuscitation technique that provides temporary extracorporeal perfusion to the heart and brain during cardiac arrest. The aim of SAAP is to reverse the cardiac arrest, resulting in restoration of intrinsic cardiac output with a palpable pulse (a return of spontaneous circulation [ROSC]), with a good neurological outcome. SAAP was developed specifically as a cardiac arrest therapy…

Endovascular Variable Aortic Control

Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly utilized for patients with exsanguinating truncal hemorrhage. This treatment has proven effective at rapidly restoring perfusion to the heart and brain, while simultaneously minimizing hemorrhage below the level of occlusion. However, this intervention is encumbered by the progressive ischemic burden that begins at the moment of balloon occlusion. To address these issues, partial flow strategies…

Resuscitative Endovascular Balloon Occlusion of the Aorta

Introduction Uncontrolled hemorrhage is the leading cause of preventable death in both the civilian and military settings. Thus, to achieve zero preventable deaths following trauma, prompt and effective control of noncompressible torso hemorrhage is essential. This may require aortic occlusion to prevent exsanguination and allow for resuscitative efforts. Historically, this has involved emergent thoracotomy with aortic cross clamping. However, advances in medical technology have resulted in…

Stent-Grafts, Coils, and Plugs

Introduction Hemorrhage is the leading cause of preventable death in trauma patients, with 96% of those patients dying from noncompressible torso or junctional hemorrhage. As endovascular techniques have become more ubiquitous for elective and emergent vascular cases, there has been a shift toward endovascular interventions for trauma patients. Angioembolization devices, such as particulate, plug, or coil embolization have been the standard of care for nonoperative management…

Endovascular Suites and the Emergency Vascular Service

Introduction Hemorrhage control is a critical component of any facility that manages trauma patients. This core capability exists in many forms, from mechanical devices, such as tourniquets for extremity hemorrhage to invasive surgical procedures. Within the domain of hospital care, operative exploration is the gold standard for hemodynamically unstable patients, whereas catheter-based endovascular techniques are reserved for stable patients who can tolerate transfer to a remote…