Vascular
trauma in the upper limb treated with extra-anatomic bypass: case report
(Portuguese
PDF version)
Leonardo
Ghizoni Bez1, Gláucio Silva de Souza2,
Kanthya Arreguy de Sena2, Daniel Mendes Pinto3,
Charles Simão Filho4
1.
Vascular Surgeon, Hospital João XXIII, Fundação
Hospitalar do Estado de Minas Gerais. Specialist in Angiology and
Vascular Surgery by SBACV.
2. Resident doctor in General Surgery, Hospital João
XXIII, Fundação Hospitalar do Estado de Minas Gerais.
3. Vascular Surgeon, Hospital João XXIII, Fundação
Hospitalar do Estado de Minas Gerais.
4. Head of the Division of Vascular Surgery, Hospital João
XXIII, Fundação Hospitalar do Estado de Minas Gerais.
Correspondence:
Dr. Leonardo Ghizoni Bez
Rua dos Otoni, 909/2002
CEP 30150-270 - Belo Horizonte - MG
Tel.: +55 31 3273.0599
E-mail: lgbez@terra.com.br
ABSTRACT
The
authors describe a patient with severe trauma in the upper limb
caused by motor vehicle accident, with brachial artery injury and
extended soft tissue damage. The patient was treated with primary
repair using anatomic venous interposition graft, resulting in infection
and rupture of the vascular repair. The outcome was satisfactory
after reoperation by extra-anatomic reconstruction. The extra-anatomic
bypass is an alternative to revascularization and limb salvage in
complex traumas.
Key
words: wounds and injuries, extremities, brachial artery
Palavras-chave: trauma, membros, artéria braquia.
J
Vasc Br 2003;2(2):141-44
Vascular
traumas have become increasingly important nowadays. Fast-speed means
of transportation, use of firearms and the ever-growing violence in
large urban centers have turned traumatic vascular lesions into commonplace
events.
Approximately
90% of peripheral arterial lesions are located at extremities, accounting
for remarkable morbidity and mortality among traumatized patients.1
Primary
repair of the vascular lesion at an anatomical site should be the first
choice for most cases. In some situations, due to adverse local conditions
such as infection and extensive tissue damage, extra-anatomical bypass
is the best alternative to limb salvage. The major pathogens involved
in the infection of a surgical wound after vascular repair are Staphylococcus
aureus and Streptococcus pyogenes. In wounds contaminated
by earth, anaerobic pathogens may be found, of which clostridia are
the most important.2
The present
study aims at reporting a case of complex trauma to the upper limb,
in which extra-anatomical bypass reconstruction was used for limb salvage.
CASE
REPORT
NTO, a
35-year-old patient suffered a motor vehicle accident (rollover) in
the state of Minas Gerais around 1:30 p.m. on January 13, 2002. He was
transferred to Hospital de Pronto Socorro João XXIII, in Belo
Horizonte, and admitted at 5 p.m. on that same day.
On physical
examination, the patient was hemodynamically stable, with a respiratory
rate of 16 breaths per minute, heart rate of 100 bpm and arterial pressure
of 120 x 80 mmHg. Extensive laceration was observed at the level of
the left cubital fossa, with muscular destruction, contamination by
asphalt and earth and complete section of the brachial artery (Figure
1); absence of distal pulses on the limb and absence of sound on the
Doppler ultrasonography in radial and ulnar arteries distally to the
lesion; signs of injury to the ligaments at the level of the elbow joint.
 Figure
1 - Extensive laceration at the cubital fossa.
The patient
was submitted to a surgery by a multidisciplinary team (orthopedist,
plastic surgeon, and vascular surgeon). The wound was exhaustively washed
with saline and large debridement of the devitalized tissue. After joint
stabilization through repair of the joint capsule and of ligaments,
the brachial artery was reconstructed at the cubital fossa with reverse
greater saphenous vein interposition graft (Figure 2). The repair was
covered with viable musculature and primary healing of the wound occurred.
Intravenous administration of antibiotics (cephalothin, gentamicin and
metronidazole) was widely used in the postoperative period.
Figure
2 - Reconstruction of brachial artery with interposition of reverse
greater saphenous vein.
There
was improvement in the postoperative period, with ample radial and ulnar
pulses. On the third postoperative day, the surgical wound showed bleeding
and signs that suggested infection (hyperemia, edema and calor), but
distal pulses and perfusion were adequate. The arteriography through
femoral catheterization revealed a large pseudoaneurysm due to rupture
at the level of the distal anastomosis (Figure 3). The patient was reoperated
on the same day, because of extensive infectious process in the wound,
with muscle necrosis and purulent secretion. The proximal and distal
brachial artery was ligated and extra-anatomic revascularization was
performed. Reverse greater saphenous vein graft was used from the proximal
brachial artery to the distal radial artery of the wrist. The vein graft
was positioned according to the subcutaneous tissue of the lateral faces
of the arm and forearm. The wound at the cubital fossa was left open
(secondary healing) (Figure 4).
Figure
3 - Rupture at the distal anastomosis.
Figure
4 - Reconstruction with extra-anatomical bypass. A: proximal sapheno-brachial
anastomosis. B: brachial artery at the rupture site.
The patient
showed favorable postoperative outcome, with pervious and palpable bypass
in the subcutaneous tissue. Secondary healing of the wound occurred
in the cubital fossa. Figure 5 shows the patient at approximately 60
days after surgery. Duplex scanning also evinced functional graft and
normal flow speeds. The patient shows functional recovery of the limb,
with movement of the fingers (pincer movement with the thumb and forefinger).
Figure
5 - Aspect 60 days after surgery. The path of the bypass is shown in
black lines up to the site of the distal anastomosis (DA).
DISCUSSION
The key
principles of the treatment of traumatic arterial lesions include immediate
control of bleeding and reestablishment of distal blood flow.3,4
The first option should be the primary repair of the lesion at an anatomical
site.
In some
cases, local adverse conditions such as extensive laceration of the
soft tissues and contamination of the repair site do not allow anatomical
reconstruction. In other cases, a successful repair shows a few complications
due to local infection, which do not allow for a second anatomical repair
at the infected site. Infection of the vascular repair site is dreaded
and might require ligation of the affected vessels and an extra-anatomical
bypass to maintain the viability of distal tissues. Attempts to repair
a vessel at a site that is possibly infected will only cause future
ruptures and may result in massive hemorrhage and life risk. If ligation
is deemed necessary and if the irrigation of the distal extremity is
compromised, an extra-anatomical bypass should be attempted, unless
it poses a high risk to that specific patient.5
In these situations, extra-anatomical reconstruction is imperative for
limb salvage. The strategy of placing the new conduit at an infection-free
site reduces the possibility of graft contamination and subsequent failure.6,7
The extra-anatomical
route was first described by Freeman & Leeds in 1952, who used a
crossed femoro-femoral bypass in a case of ischemia of lower extremities.7
Ever since, the extra-anatomical route has been very useful for patients
at great surgical risk with peripheral atherosclerotic disease.8
Similarly, we may use this route in patients with traumatic vascular
lesions with large tissue loss or extensive infectious processes at
the repair sites.9
An extra-anatomical
bypass requires proximal and distal dissection of the artery far from
the infection site, which should be isolated from the surgical field.
The graft should preferably be a vein; it may be inserted under the
skin or through a tunnel under a viable musculature.5
As illustrated
by the case in question, some important recommendations include the
following:
- The rupture
of posttraumatic arterial repairs often results from infection at the
surgical site. This infection may occur due to endogenous or exogenous
contamination. Endogenous contamination originates from the patient's
own skin, whereas exogenous contamination occurs at the moment of the
trauma, when diverse particles come in contact with the wound (clothing
fragments, earth, asphalt, etc). The "sentinel" hemorrhage,
as the one presented by the patient, is an important diagnostic sign.
- When performing
the first repair, the wound should be properly debrided and covered
with viable tissue.
- On reoperation
at the infected site, the artery should be ligated above and below the
infection site and the extra-anatomical route should be used, if necessary.4
CONCLUSION
The use
of extra-anatomical bypass for the treatment of traumatic vascular lesions
to the limbs seems to be a valuable alternative. This type of bypass
should be used in complex lesions with large tissue loss or in cases
of severe infections at the primary anatomical site.
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