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The term ‘vascular trauma’ refers to damage or injury to a blood vessel- an artery, which carries blood away from the heart, or a vein, which carry blood back to the heart from different organs. These injuries are categorized by the type of trauma that cause them: blunt or penetrating injury.
• Blunt injury can occur if a blood vessel is crushed or stretched.
• penetrating injury can occur if a blood vessel is punctured, torn or severed.
Both the types of vascular trauma can cause the blood vessel to clot (thrombosis) and interrupt blood flow to an organ, or cause bleeding, leading to life-threatening hemorrhage.
Vascular trauma results from a wide range of causes:
Injury (accidents, falls, cuts, etc.)
Pinching of a vein or artery
Dislocation of a bone
Piercing of a vein, such as with insertion of an IV.
Vascular injury has two main consequences- hemorrhage and ischemia. Unrecognized and uncontrolled hemorrhage can lead to demise of the trauma patient while unrecognized and untreated ischemia can lead to stroke, limb loss, bowel necrosis and multiple organ failure.
Chronic Venous Insufficiency and Varicose veins are the most frequent blood vessel abnormalities occurring in people and affects approximately one third of the population. The treatment of these disorders depends on many factors. Mild and moderate symptoms can be successfully treated with the use of compression stocking therapy but for severe symptoms medical surgeries are done either to remove varicose veins or to close them which includes: Vein stripping, Vein ablation, Sclerotherapy, Laser Surgery, Endoscopic Vein Surgery, Ambulatory Phlebectomy.
Vascular diseases of the lower limb include: Peripheral Arterial disease of the legs and Chronic Arterial Insufficiency of the lower extremities. PAD is the condition of blood vessels that supply the legs and feet. It includes the narrowing and hardening of the arteries that results in decreased blood flow, which can injure nerve and other tissues. This problem occurs due to the buildup of fatty material (plaque) on the inside wall of arteries. Plaque is made up of extra cholesterol, calcium in blood. Blood carries the oxygen to the lower extremities but plaque buildup starves the tissues and muscles in lower limb. The underlying mechanism is usually atherosclerosis. The main risk factors include cigarette smoking, diabetes, high blood cholesterol and high blood pressure.
The carotid arteries are the blood vessels (coronary arteries) that carry oxygenated blood to the head, brain and face. They are located on each side of the neck. These arteries supply oxygen-rich blood to the large front part of the brain which control thought, personality, speech, as well as our sensory and motor functions. Carotid Artery disease occurs due to the narrowing of these arteries mostly due to atherosclerosis (plaque buildup). These plaques may break and block smaller arteries in the brain. The arteries are the source of oxygenated blood to the brain but this blockage interrupts the blood flow thus increasing the risk of stroke. A stroke can cause lasting brain damage, long-term disability, such as vision, speech problems or paralysis; or death.
Upper extremity vascular disease is relatively uncommon compared to lower extremity vascular disease but represents a unique diagnostic challenge for the physicians. The most common causes of upper extremity vascular disease are atherosclerosis and Embolic disease, but there are other systemic diseases and anatomic abnormalities such as vasculitis, arteritis, Takayasu’s Arteritis, Thoracic Outlet Compression Syndrome, Acute occlusive arterial disease and Aneurysm of upper limb artery. Some of the typical symptoms of upper extremity vascular disease include: discomfort or pain in arms, tightness, heaviness, weakness or cramping in one or both arms.
An Abdominal Aortic Aneurism (AAA) is an enlarged area in the lower part of the aorta- the major blood vessel that supplies blood from the heart up to head and arms and down to abdomen, legs and pelvis. As aorta is the body’s main supplier of blood, a ruptured abdominal aortic aneurysm can cause life threatening bleeding. Large aneurysms are rare but are usually fetal. The bulging occurs when the walls of the aorta weakens. The reason of weakness is thought to be smoking, high blood pressure, high cholesterol level. Rupture of the abdominal aorta may result in pain in the abdomen, low blood pressure or loss of consciousness and often results in death. AAA most commonly occurs in men over 50 years of age and among those with a family history. Surgery is normally recommended with enlarged AAA, and repair may be either by open surgery or Endovascular Aneurysm Repair (EVAR).
Thoracic Aortic Aneurysm is an expansion or ballooning of a section of aorta within the chest (thorax) that slowly degenerates. Thoracic Aortic Aneurysms are rare, occurring in approximately 6-10 per every 100,000 people. Surgery is often suggested if the risk of rupture is higher. The procedure for Thoracic Aortic Vascular Surgery is called Thoracic Endovascular Aortic Repair (TEVAR). TO fix the aorta, a device made of a fabric- covered metal mesh known as stent graft is inserted through a small hole. The device repairs the diseased aorta, helps to keep it open and allows blood to flow easily to rest of the body. The alternative to TEVAR is refer to as ‘open repair’, which requires a large incision through the breastbone or side of the chest.
Thoracoabdominal Aortic Aneurysm (TAAA) refers to the abnormal widening of the aorta involving both the thoracic and abdominal segments. These aneurysms are primarily the results of age related degeneration and weakening of the aortic wall. Elective surgical interventions are considered when the aortic size exceeds 5-6 cm. There are three surgical operative techniques for TAAA repair: open, endovascular and hybrid.
Open TAAA repair involves surgical removal of the diseased section of the aorta and replacing it with an artificial graft by making an incision extending from the upper back on the left side, curving around under the shoulder blade around to the front of abdomen.
Endovascular approach includes much less invasion with small incisions to access the blood vessels in the groin. A catheter is inserted and is used to deploy a stent graft within the aneurysm.
Hybrid approach uses a combination of the two techniques.
Thrombolytic therapy, surgical thrombectomy, and placement of inferior vena cava filters are adjunctive treatments that can be suggested for patients with extensive and complicated venous thromboembolism. For patients with saphenous vein valvular insufficiency vein stripping, endovenous laser treatment and radiofrequency ablation therapies are implemented. Concomitant varicose veins may be managed with compression therapy, sclerotherapy and phlebectomy.
Vascular imaging is a test that enables to access and evaluate the body’s circulatory system and help identify blockages in veins and arteries and detect blood clots. Non-optical methods that are widely used for vascular images includes X-ray/CT, MRI, ultrasound and positron emission tomography. These techniques are most popularly used for macrovascular imaging but due to poor spatial contrast these are not effective for microvascular imaging. Optical methods recommended for microvascular imaging are single-photon fluorescence microscopy (1PFM), two-photon fluorescence microscopy, orthogonal polarization spectral imaging (OCSI), laser speckle contrast imaging (LSCI), diffusive imaging, diffuse optical tomography, etc.
Vascular malformations are abnormal clusters of blood vessels that occur during fetal development. These malformations are thought to result from developmental errors during embryogenesis such as abnormal signaling processes that control apoptosis, maturation and growth of vascular cells. Although these kinds of lesions are present at birth, they may not be visible until weeks or several years but typically grow in proportion to the growth of the child. Vascular malformations are characterized under four types based on their flow characteristics: slow flow (capillary malformations, venous malformation, lymphatic malformation) and fast-flow (arteriovenous malformation). Proper identification and multidisciplinary approach is paramount for proper treatment.
Acute limb ischaemia is defined as a sudden decrease in limb perfusion that results in potential threat to the viability of the limb. It results from a sudden obstruction in the arterial flow mainly due to embolism or thrombosis and rarely by dissection or trauma. The occurrence of this case is almost 1.5 cases per 10,000 persons per year. Symptoms begins over a period of hours or days from new or worsening intermittent claudication to pain in foot or leg, muscle weakness, and paralysis of the affected limb. The rapid onset of limb ischemia results from sudden blockage of blood supply and nutrients to tissues and nerves of the limb; threatening limb viability due to insufficient time for new blood vessel growth to compensate for loss of perfusion. The primary intervention for acute limb ischemia is emergency embolectomy or vascular bypass to route the blood flow.
Renal artery is the vessel through which blood passes to the kidney to remove the body’s waste. These renal arteries originate in the heart and are also responsible for carrying oxygenated blood to the kidneys. Like other arteries the renal arteries also become blocked, the condition which is called renal artery stenosis. These arteries are affected due to several diseases such as atherosclerosis, renal artery aneurysm, fibromuscular dysplasia and vasculitis. Decreased blood flow to the kidneys often lead to hypertension. If untreated, renovascular hypertension may lead to cardiovascular and kidney problems. Treatments for renovascular hypertension refer to restore the normal blood flow to the kidney. This may be done by balloon angioplasty, use of stent to keep the artery open. Surgical technique in case of atherosclerosis include endarterectomy or bypass grafting.
Mesenteric Ischemia is a condition caused by poor blood supply to the small intestine, colon or both and eventually results in gangrene of the bowel wall. It may also affect other organs in the digestive system. Due to poor circulation blockages may form that compromises the function of those organs. Mesenteric ischemia has both acute and chronic forms. Acute ischemia seeks a surgical emergency. It is associated with both embolic and thrombotic occlusions. 40-50% of the cases are related to embolic occlusions whereas 20-35% of the cases are due to thrombotic occlusions. Mesenteric ischemia is rare but is potentially a life-threatening condition. Treatment is by embolectomy, revascularization of viable segment or resection and sometimes vasodilator therapy is successful.
Congenital vascular anomalies are rare. Congenital vascular anomalies occur in barely 1% of all births. These are the vascular malformations or vascular tumors i.e., abnormally formed blood vessels present by birth. Congenital vascular diseases include vascular malformations and vascular tumor known as hemangioma; both of which are commonly called “birthmarks”. Most of these birth marks represent vascular malformation, consisting of abnormal collection of small blood vessels near the skin. Normally vascular malformations are not a health threat as they grow proportionately with the growth of the child. But hemangioma may be alarming during their growth phase called the ‘juvenile hemangiomas’ and requires immediate treatment.
Lymphedema, or lymphatic obstruction, is a long-term condition where excess fluid collects in tissues causing swelling (edema). The main symptom is swelling in arm, or leg that may be accompanied by pain or discomfort. Lymph is a clear, thin fluid that circulates throughout the body to remove wastes, bacteria, and other substances from tissues. Edema is the buildup of excess fluids. So, lymphedema occurs when too much lymph gets collected in an area. The cause of lymphedema is generally cancer treatment where one or two lymph nodes are removed. Normally lymph nodes filter fluids that flow through them, so without normal lymph drainage, fluid can build up in the affected arm or leg and lymphedema develops. Lymphedema can also be present by birth or can develop during puberty.
Venous insufficiency is a condition where the flow of blood in the veins is inadequate, which causes blood to pool in the legs. In these states valve in the veins don’t work and venous blood refluxes backward down the veins into an already congested leg. Chronic venous insufficiency is a long-term condition. It is commonly due to malfunctioning (incompetent) valves in the veins. It may also result from the blood clot in the veins. Usually it is treated by compression stockings, exercise and weight loss, but in some cases require vein ablation or vein stripping.
Bypass grafting is a surgical procedure to redirect blood flow from one area to another in an area of blockage by reconnecting vessels. It is performed due to ischemia (inadequate blood flow) caused by atherosclerosis or other vascular diseases. In this procedure, an alternate channel is created for blood flow by replacing a damaged vessel. The graft is generally taken from one’s own healthy region (autograft), or a graft material such as Teflon or Dacron. The lifespan of a surgical bypass depends on the health of the arteries, the type of graft used- natural vein graft last longer than synthetic ones.
Some of the open vascular surgeries are:
Arterial graft- it is performed to bypass a diseased or blocked part of an artery in order to restore proper blood flow and reduce the risk of complications. The graft is taken from healthy part of the body such as arms or legs.
Carotid endarterectomy- it begins with an incision in the neck, exposing the narrowed carotid artery where the surgeon opens the artery to remove the plaque.
Surgical aneurysm repair- aneurysm is an abnormal bulge in the wall of an artery, they are extremely risky: if they burst it can lead to life threatening internal hemorrhage. Open aneurysm repair includes replacement of weakened part of the artery with a tube-like structure.
Abdominal aortic aneurysm surgery- It involves the incision to open the abdomen, removing the aneurysm and replacement of the excised portion with synthetic tube.
A vascular surgical procedure can be performed under local, regional or a general anesthesia, or a combination of these techniques based upon the complexity of the vascular pathology. Anesthesia is a risk factor which contributes to perioperative morbidity and mortality of vascular patients. Minimally invasive approaches to vascular surgery are developing gradually allowing the use of more localized anesthesia. It is often supposed that undergoing a procedure with local or regional anesthesia results in lower mortality and morbidity and results in earlier recovery.
Lower limb amputation in relation to vasculature means the surgical removal of leg or foot from the body as a result of peripheral vascular diseases. It is a life-saving procedure done to remove ischemic, infected, or necrotic tissue. Peripheral arterial diseases alone or in combination with diabetes mellitus contributes to more than half of the amputations. Major amputations are due to PAD ranging from 12 to 50 per 100,000 individuals per year.
Endovascular surgery is used to treat vascular diseases from inside the blood vessels. A small incision is created to gain access to the diseased area (veins and arteries) inside the body. This technique results in less pain and faster recovery. These are the minimally invasive techniques to repair vascular aneurysms with the help of intravascular sheaths, wires, catheters, balloons, stents and stent grafts. The most common and advanced form of endovascular surgery going on today is an endovascular repair of aortic aneurysms and dissections by use of stent grafts inserted into vasculature via arteries in the groin.