Üst Ekstremite Vasküler Yaralanmaları
Özet
Üst ekstremite damar yaralanmaları tüm vasküler yaralanmaların %30’unu oluşturmakta olup önemli ölçüde amputasyon ve morbidite sebebi olabilmektedir. Genellikle sebep penetran travmalar olup en sık ön kol arterleri etkilenmektedir. Sinir hasarı da eşlik edebildiğinden preoperatif iskemi muayenesi yanında detaylı nörolojik muayene de yapmak gereklidir. Tanı için genellikle doppler ultrasonografi ve BT anjiyografi kullanılmaktadır. Proksimal ve merkezi yaralanmalarda endovasküler girişim seçenekleri de mevcutken cerrahi yaklaşım genel olarak uç uca anastomoz ya da greft interpozisyonu şeklinde olmaktadır. Üst ekstremitede ciddi iskemi varlığında geçici vasküler şantlar kullanılabilmekte olup distal kol perfüzyonu sağlanabilir. Açık ve kirli yaralarda ölü dokuların debride edilmesi ve greftlerin açıkta bırakılmaması greft enfeksiyonlarının önlenmesi açısından önemlidir. Üst ekstremite venöz yaralanmalarında çoğu zaman ligasyon uygulanabilmekte olup brakial, bazilik ve sefalik venlerin hepsinde hasar mevcutsa en az biri tamir edilmelidir. Postoperatif dönemde ekstremite elevasyonu, erken rehabilitasyon ve antitrombotik tedavi üst ekstremite vasküler tamiri yapılan hastalarda uygulanmalıdır.
Upper extremity vascular injuries account for 30% of all vascular injuries and can cause significant amputation and morbidity. Penetrating trauma is the most common mechanism of injury and the forearm arteries are most frequently affected. Since nerve damage may accompany the injury, a detailed neurological examination is necessary in addition to preoperative ischaemia examination. Doppler ultrasonography and CT angiography are generally required for diagnosis. Endovascular intervention options are also available for proximal and central injuries, whereas the surgical approach is generally end-to-end anastomosis or graft interposition. In the presence of severe ischaemia in the upper extremity, temporary vascular shunts can be used and distal arm perfusion can be maintained. For open and contaminated wounds, it is important to debride the necrotic tissues and not to leave the grafts uncovered in order to prevent graft infections. In upper extremity venous injuries, ligation can be performed in most cases and at least one of the brachial, basilic and cephalic veins should be repaired if all of them are injured. In the postoperative period, limb elevation, early rehabilitation and antithrombotic therapy should be provided in patients undergoing upper extremity vascular repair.
Referanslar
Todd E. Rasmussen MD, FACS and Nigel R.M. Tai MB, BS, MS, FRCS, Rich’s vascular trauma, fourth edition, Philadelphia, PA 19103-2899, 2022
Kakkos SK , Tyllianakis M , Panagopoulos A , Kokkalis Z , Lianou I , Koletsis E , et al. Outcome predictors in civilian and iatrogenic arterial trauma. World J Surg 2021;45:160–7 Epub 2020 Sep 25. PMID: 32978663 .
Hughes CW . Arterial repair during the Korean War. Ann Surg 1958;147:555–61 PMID: 13521671 .
Rich NM , Baugh JH , Hughes CW . Acute arterial injury in Vietnam: 1,0 0 0 cases. J Trauma 1970;10:359–69 PMID: 4909463 .
Rich NM , Baugh JH , Hughes CW . Significance of complications associated with vascular repairs performed in Vietnam. Arch Surg 1970;100:646–51 PMID: 54 4 4 479 .
Gorman JF . Combat arterial trauma. Analysis of 106 limb threatening injuries. Arch Surg 1969;98:160–4 PMID 5765663 .
Clouse WD , Rasmussen TE , Perlstein J , Sutherland MJ , Peck MA , Eliason JL , et al. Upper extremity vascular injury: a current in theater wartime re- port from Operation Iraqi Freedom. Ann Vasc Surg 2006;20:429–34 PMID: 16799853 .
Vuoncino M , Soo HOOAJ , Patel JA , White PW , Rasmussen TE , White JM . Epidemiology of upper extremity vascular injury in contemporary combat. Ann Vasc Surg 2020;62:98–103 PMID: 3134 4 461 .
Lindsay K. Gallo, Christopher R. Ramos, Ravi R. Rajani, Jaime Benarroch-Gampel, Management and Outcomes after Upper Versus Lower Extremity Vascular Trauma, Annals of Vascular Surgery, Volume 76, 2021, Pages 152-158, ISSN 0890-5096
Shah SR , Wearden PD , Gaines BA . Pediatric peripheral vascular injuries: a re- view of our experience. J Surg Res 2009;153:162–6 Epub 2008 Apr 9. PMID: 18541266 .
Koman LA , Smith BP , Smith TL , Ruch DS , Li Z . Vascular disorders. In: Wolfe SW, editor. Green’s operative hand surgery. United States: Elsevier; 2011. p. 2197–240
McHenry TP, Holcomb JB, Aoki N, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: implications ofsurgical sequence. J Trauma 2002;53(4):717-21.
Ratnayake AS, Bala M, Howard R, Rajapakse K, Samarasinghe B, Worlton TJ. Identification of risk factors for arterial repair failures and lessons learned: ex- periences from managing 129 combat vascular extremity wounds in the Sri Lankan War. J Trauma Acute Care Surg 2019;87(1S Suppl 1):S178–83 PMID: 31246924. doi: 10.1097/TA.0 0 0 0 0 0 0 0 0 0 0 02260
Quan RW, Gillespie DL, Stuart RP, Chang AS, Whittaker DR, Fox CJ: The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries. J Vasc Surg 2008; 47: pp. 571-577.
Kragh JF, Walters TJ, Baer DG, et. al.: Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009; 249: pp. 1-7.
Kragh JF, Walters TJ, Baer DG, et. al.: Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008; 64: pp. S38-S49. discussion S50
Lakstein D, Blumenfeld A, Sokolov T, et. al.: Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003; 54: pp. S221-S225.
Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA, Wheeler JR, et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma 1985;25(12):1147-50.
Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009;124(6):1965-1973.
Markgraf E, Bohm B, Bartel M, Dorow C, Rimpler H, Friedel R. Traumatic peripheral vascular injuries. Unfallchirurg 1998;101(7):508-19.
Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs D: Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 1996; 172: pp. 569-573. discussion 573–574
Slauterbeck JR, Britton C, Moneim MS, Clevenger FW: Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma 1994; 8: pp. 282-285.
Togawa S, Yamami N, Nakayama H, Mano Y, Ikegami K, Ozeki S: The validity of the mangled extremity severity score in the assessment of upper limb injuries. J Bone Joint Surg Br 2005; 87: pp. 1516-1519.
Georgescu AV, Battiston B. Mangled upper extremity: our strategy of reconstruction and clinical results. Injury 2021;52(12):3588-3604.
Endean ED, Veldenz HC, Schwarcz TH, Hyde GL: Recognition of arterial injury in elbow dislocation. J Vasc Surg 1992; 16: pp. 402-406.
Hollinshead WH . Anatomy for surgeons: volume 3. The back and limbs, Hager- stown, Maryland: Harper & Row Pubishers; 1969. 2ne edLC 67-27163 .
Koman LA , Siegel DB . Management of arterial injuries. In: Chapman MW, edi- tor. Operative orthopaedics. Philadelphia: JB Lippincott; 1993. p. p1033–45
Ua-Anusorn K , Tocharoenchok T , Subtaweesin T .Using bilateralradial arter- ies in coronary artery bypass grafting is safe. Asian Cardiovasc Thorac Ann 2020;28(8):470–5 PMID: 32674585 .
Manabe S , Tabuchi N , Tanaka H , Arai H , Sunamori M . Hand circulation af- ter radial artery harvest for coronary artery bypass grafting. J Med Dent Sci 2005;52:101–7 PMID: 16187615
McClinton MA: Reconstruction for ulnar artery aneurysm at the wrist. J Hand Surg [Am] 2011; 36: pp. 328-332.
Dennis JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS: Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma 1998; 44: pp. 243-252. discussion 2–3
Stain SC, Yellin AE, Weaver FA, Pentecost MJ: Selective management of nonocclusive arterial injuries. Arch Surg 1989; 124: pp. 1136-1140. discussion 40–41
Referanslar
Todd E. Rasmussen MD, FACS and Nigel R.M. Tai MB, BS, MS, FRCS, Rich’s vascular trauma, fourth edition, Philadelphia, PA 19103-2899, 2022
Kakkos SK , Tyllianakis M , Panagopoulos A , Kokkalis Z , Lianou I , Koletsis E , et al. Outcome predictors in civilian and iatrogenic arterial trauma. World J Surg 2021;45:160–7 Epub 2020 Sep 25. PMID: 32978663 .
Hughes CW . Arterial repair during the Korean War. Ann Surg 1958;147:555–61 PMID: 13521671 .
Rich NM , Baugh JH , Hughes CW . Acute arterial injury in Vietnam: 1,0 0 0 cases. J Trauma 1970;10:359–69 PMID: 4909463 .
Rich NM , Baugh JH , Hughes CW . Significance of complications associated with vascular repairs performed in Vietnam. Arch Surg 1970;100:646–51 PMID: 54 4 4 479 .
Gorman JF . Combat arterial trauma. Analysis of 106 limb threatening injuries. Arch Surg 1969;98:160–4 PMID 5765663 .
Clouse WD , Rasmussen TE , Perlstein J , Sutherland MJ , Peck MA , Eliason JL , et al. Upper extremity vascular injury: a current in theater wartime re- port from Operation Iraqi Freedom. Ann Vasc Surg 2006;20:429–34 PMID: 16799853 .
Vuoncino M , Soo HOOAJ , Patel JA , White PW , Rasmussen TE , White JM . Epidemiology of upper extremity vascular injury in contemporary combat. Ann Vasc Surg 2020;62:98–103 PMID: 3134 4 461 .
Lindsay K. Gallo, Christopher R. Ramos, Ravi R. Rajani, Jaime Benarroch-Gampel, Management and Outcomes after Upper Versus Lower Extremity Vascular Trauma, Annals of Vascular Surgery, Volume 76, 2021, Pages 152-158, ISSN 0890-5096
Shah SR , Wearden PD , Gaines BA . Pediatric peripheral vascular injuries: a re- view of our experience. J Surg Res 2009;153:162–6 Epub 2008 Apr 9. PMID: 18541266 .
Koman LA , Smith BP , Smith TL , Ruch DS , Li Z . Vascular disorders. In: Wolfe SW, editor. Green’s operative hand surgery. United States: Elsevier; 2011. p. 2197–240
McHenry TP, Holcomb JB, Aoki N, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: implications ofsurgical sequence. J Trauma 2002;53(4):717-21.
Ratnayake AS, Bala M, Howard R, Rajapakse K, Samarasinghe B, Worlton TJ. Identification of risk factors for arterial repair failures and lessons learned: ex- periences from managing 129 combat vascular extremity wounds in the Sri Lankan War. J Trauma Acute Care Surg 2019;87(1S Suppl 1):S178–83 PMID: 31246924. doi: 10.1097/TA.0 0 0 0 0 0 0 0 0 0 0 02260
Quan RW, Gillespie DL, Stuart RP, Chang AS, Whittaker DR, Fox CJ: The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries. J Vasc Surg 2008; 47: pp. 571-577.
Kragh JF, Walters TJ, Baer DG, et. al.: Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009; 249: pp. 1-7.
Kragh JF, Walters TJ, Baer DG, et. al.: Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008; 64: pp. S38-S49. discussion S50
Lakstein D, Blumenfeld A, Sokolov T, et. al.: Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003; 54: pp. S221-S225.
Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA, Wheeler JR, et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity. J Trauma 1985;25(12):1147-50.
Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009;124(6):1965-1973.
Markgraf E, Bohm B, Bartel M, Dorow C, Rimpler H, Friedel R. Traumatic peripheral vascular injuries. Unfallchirurg 1998;101(7):508-19.
Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs D: Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 1996; 172: pp. 569-573. discussion 573–574
Slauterbeck JR, Britton C, Moneim MS, Clevenger FW: Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma 1994; 8: pp. 282-285.
Togawa S, Yamami N, Nakayama H, Mano Y, Ikegami K, Ozeki S: The validity of the mangled extremity severity score in the assessment of upper limb injuries. J Bone Joint Surg Br 2005; 87: pp. 1516-1519.
Georgescu AV, Battiston B. Mangled upper extremity: our strategy of reconstruction and clinical results. Injury 2021;52(12):3588-3604.
Endean ED, Veldenz HC, Schwarcz TH, Hyde GL: Recognition of arterial injury in elbow dislocation. J Vasc Surg 1992; 16: pp. 402-406.
Hollinshead WH . Anatomy for surgeons: volume 3. The back and limbs, Hager- stown, Maryland: Harper & Row Pubishers; 1969. 2ne edLC 67-27163 .
Koman LA , Siegel DB . Management of arterial injuries. In: Chapman MW, edi- tor. Operative orthopaedics. Philadelphia: JB Lippincott; 1993. p. p1033–45
Ua-Anusorn K , Tocharoenchok T , Subtaweesin T .Using bilateralradial arter- ies in coronary artery bypass grafting is safe. Asian Cardiovasc Thorac Ann 2020;28(8):470–5 PMID: 32674585 .
Manabe S , Tabuchi N , Tanaka H , Arai H , Sunamori M . Hand circulation af- ter radial artery harvest for coronary artery bypass grafting. J Med Dent Sci 2005;52:101–7 PMID: 16187615
McClinton MA: Reconstruction for ulnar artery aneurysm at the wrist. J Hand Surg [Am] 2011; 36: pp. 328-332.
Dennis JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS: Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma 1998; 44: pp. 243-252. discussion 2–3
Stain SC, Yellin AE, Weaver FA, Pentecost MJ: Selective management of nonocclusive arterial injuries. Arch Surg 1989; 124: pp. 1136-1140. discussion 40–41
