Vascular Repair

The approach depends on the vessel, injury type, and patient stability:

1. Before Surgery Evaluation:
   
   • Diagnosis:
     
     • Clinical exam: Signs of vascular injury include absent pulses, pale/cold limb, expanding hematoma, or active bleeding.
     • Doppler ultrasound or ankle-brachial index (ABI) assesses flow; ABI <0.9 suggests arterial injury.
     • CT angiography (CTA) or conventional angiography confirms vessel injury, location, and extent.
     • Blood tests evaluate hemoglobin (for bleeding) and coagulation status.
   • IV fluids, blood transfusions, and anticoagulation (e.g., heparin, if not contraindicated) stabilize the patient.
   • Fasciotomy may be planned if compartment syndrome is suspected (e.g., prolonged ischemia).
2. Surgical Techniques:
   
   • Open Vascular Repair:
     
     • Performed under general or regional anesthesia, lasting 1–3 hours.
     • An incision is made over the injured vessel (e.g., femoral artery in the groin, brachial artery in the arm).
     • Proximal and distal control: The vessel is clamped above and below the injury to stop bleeding.
     • Primary Repair:
       
       • Small lacerations are sutured directly (end-to-end anastomosis) using fine sutures (e.g., 6-0 polypropylene).
       • Suitable for clean, sharp injuries with minimal tissue loss.
     • Patch Angioplasty:
       
       • A patch (e.g., vein, synthetic material like Dacron) repairs larger defects.
     • Interposition Graft:
       
       • A segment of vein (e.g., saphenous vein) or synthetic graft (e.g., PTFE) replaces a damaged vessel section.
     • Ligation:
       
       • Used in non-critical vessels (e.g., veins) or as a last resort in unstable patients; may lead to edema or ischemia.
     • Associated injuries (e.g., fractures, nerve damage) are addressed simultaneously.
   • Endovascular Repair:
     
     • Minimally invasive, often for stable patients or specific injuries (e.g., pseudoaneurysms, aortic injuries).
     • Performed under local anesthesia with sedation, lasting 1–2 hours.
     • A catheter is inserted via a peripheral artery (e.g., femoral) under fluoroscopy.
     • Techniques: Stent-graft placement (e.g., for aortic dissection), embolization (e.g., for bleeding control), or balloon angioplasty.
     • Faster recovery, but not suitable for all injuries (e.g., complete vessel transection).
   • Damage Control Approach:
     
     • In unstable patients (e.g., hemorrhagic shock), temporary shunting is used: A plastic tube (shunt) is inserted to maintain flow, allowing resuscitation in ICU before definitive repair (24–48 hours later).
3. After Surgery:
   
   • Patients are monitored in the ICU or ward for 1–5 days.
   • Doppler ultrasound or CTA confirms vessel patency and flow.
   • Anticoagulation (e.g., heparin, then warfarin) or antiplatelets (e.g., aspirin) prevent thrombosis.
   • Pain is managed with analgesics (e.g., paracetamol, tramadol).
   • Fasciotomy wounds (if performed) are managed with dressings or vacuum-assisted closure (VAC).