Clinical Studies in Vascular Trauma

Abstract

This thesis focuses on the management of traumatic vascular injuries. It provides insights in new treatment strategies and technical possibilities. Next, it provides added information on outcomes after vascular trauma.

Traumatic injuries affecting the major vessels are life-threatening injuries, requiring early intervention in order to save both life and limb. Vascular trauma patients can be divided into those diagnosed with penetrating or blunt vessel wall injuries. Penetrating trauma, caused by a variety of trauma mechanisms (e.g. stab wounds, gunshot wounds), may lead to perforation of all vessel wall layers and result in extravasation. Blunt injuries, usually occurring due to either fractures, joint displacements or a direct blow to the vessel, may cause separation of vessel wall layers leading to lacerations, but more often lead to dissections, pseudoaneurysm formation and occlusions in otherwise ‘healthy’ arteries.

Since each of the arteries (and veins) that may be affected by traumatic injury has a different role in terms of end-organ perfusion, each of these potentially affected blood vessels can be studied separately. Treatment principles and potential end-organ complications of frequently occurring vascular injuries in the cervical region, thoraco-abdominal region and the pelvic/lower extremity region were studied and results are depicted in this thesis.

In general, diagnostic and therapeutic approaches in vascular trauma patients have evolved and mortality has decreased due to recent technological advancements, particularly in the field of computed tomography angiography (CTA) scanning and endovascular interventions.

Management of severe injuries including vascular trauma, requires emergent intervention by multidisciplinary teams preceded by adequate pre-hospital care and resuscitation begun at the scene of trauma. A regional trauma system optimizes outcomes of injured patients of defined populations, and includes pre-hospital care, transportation and acute management of injuries. In this system, trauma surgeons are considered to be the leaders of trauma teams that are responsible for patient resuscitation and management, and provide the majority of surgical care necessary in trauma patients. In addition, they prioritize and manage the treatment of injuries demanding expertise from other health-care professionals. In the Dutch setting vascular surgeons embody the expertise for extensive vascular repairs, including endovascular treatments. However, who will be the responsible primary physicians for vascular trauma patients will be highly dependent on local circumstances and training curriculums.

This thesis demonstrates that a team based approach to vascular trauma will be a future proof management strategy for the studied Dutch situation, as well as other (European) centers with comparable training curriculums and resources. Since more endovascular procedures are employed in vascular trauma patients, and this technology is continuously subjected to further development, combined trauma surgery, vascular surgery and interventional radiology expertise in the case of vascular trauma will be necessary. Future studies and debate should determine to what extent existing trauma and vascular surgery training curriculums should be altered or combined in order to maintain open vascular emergency skills among future trauma and vascular surgeons.