Nasser Algharem MD, FRCR, EBIR · MD, FRCR, EBIR. Safi 2 Endovascular Management of arterial injury can be divided in A •Embolization. B •Stentgraft. C •Others. Safi 3

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Nasser Algharem, MD, FRCR, EBIR.

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Endovascular Management of arterial injury can be divided in

A•Embolization.

B•Stentgraft.

C•Others.

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Blast injuries are not as unique to battle as we would hope, however, as they are unfortunately becoming more common worldwide outside the battlefield environment.

Disasters, explosions, and shootings can happen in all types of settings and can occur anywhere.

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There are several types of explosive ordinance seen in modern combat:.

IED: Improvised Explosive Device that is home-made from

everyday materials.

The harmful projectiles include anything from paperclips, screws,

pins/nails and spent bullet shells to automobile parts (especially

when the car is part of the bomb).

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There are several types of explosive ordinance seen in modern combat:

RPG: Rocket Powered Grenade:

a grenade that is shot from a

rocket to explode on impact of a

human, group, or structure to

inflict damage.

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There are several types of explosive ordinance seen in modern combat worthy of discussing:

Landmines: an explosive device concealed under or on the ground

and designed to destroy or disable enemy targets, ranging from

combatants to vehicles and tanks, as they pass over or near it.

Such a device is typically detonated automatically by way of

pressure when a target steps on it or drives over it, although other

detonation mechanisms are also sometimes used.

A land mine may cause damage by direct blast effect, by fragments

that are thrown by the blast, or by both.

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There are several types of explosive ordinance seen in modern combat worthy of discussing:

Mortar is a device that fires projectiles at low velocities and

short ranges.

The mortar has traditionally been used as a weapon to propel

explosive mortar bombs in high-arcing ballistic trajectories.

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There are several types of explosive ordinance seen in modern combat worthy of discussing:

Rockets and warheads missiles.

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There are four types of blast injury depending on proximity, severity, type of explosive, and surrounding environment:

Primary: Blast wave: hollow organs essentially burst due to

overpressure

Secondary: debris and projectiles that have ballistic

properties(most common, IED, other blasts)

Tertiary: happens when the patient’s body becomes the

flying object and collides with other objects (walls, objects,

vehicles..)

Quaternary (or miscellaneous): injury comes from burns

from the blast heat or inhalation of gases and smoke released

in the explosion.

Many casualties have a combination of these injury types.

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CASE #1

27 year old male involved in

combat injury by flying

debris and projectiles in

battlefield after a landmine

explosion .

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• Large area of penetrating FB and

laceration more in the left leg with

comminuted fractures and skin loss.

• Blood loss was continuous and CT shows

a pseudoaneurysm at the Lt SFA mid-third.

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Angiography was done and

therapeutic intervention was done

by a PTFE heparinized Viabahn

stentgraft was done successfully.

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CASE #2

27 year old male involved in

combat injury by flying debris

and projectiles in battlefield

after a landmine explosion

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• Large area of penetrating FB and

laceration more in the left leg with

comminuted fractures and skin loss.

• Same patient in Case 8, after one

monthe presented with pulsatile lump

above and medil to the left knee.

• US show an aneurysm.

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• Blood loss was continuous and CT

shows a pseudoaneurysm at the Lt

SFA distal third/P1 with AVF.

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• Angiography and therapeutic

intervention was done by a PTFE

heparinized Viabahn stentgraft

was done successfully.

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One month later,, Pulsatile mass!!!

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1500 IU Thrombin injection.

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CASE 3

24 year old male involved in

combat injury by snipper attack

his right thight with a bullet

causing active arterial bleeding.

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• Angiography was done and therapeutic

intervention was done by a PTFE

heparinized Viabahn stentgraft was done

successfully.

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CASE 4

18 year old female involved in

mortar grenade injury falling on

her house, flying debris and

objects cutting and crossing her

right proximal thigh and perineum.

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• She bleeds a lot and arrived to the local health

facility with irrecordable pulse and BP,

resuscitated with fluids and given 8 units of blood

and plasma and referred to our hospital.

• Her Hb on arrival was 4..

• 6 units given and 8 FFP and emergency CTA was

done vascular surgeon was planning to interfere

with high risk of amputation as patient was

unstable and wound was difficult to control and

family was seeking better chance foe the young

girl..

• Patient then was referred to me for opinion by

ICU team in the midnight..

• I decide to shift her for angio..

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CASE 5

25 year old male involved in

combat injury by gunshot at the

Right shoulder

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• Undergo uneventful hospital stay,

except for heaviness and hotness of

the forearm and hand more on using

it,, and ongoing swelling.

• He was diagnosed as a traumatic AV

fistula and surgery was done but failed to

locate it.

• He was referred to my hospital and after

US check I prepare him to angio and

stenting.

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CASE 6

21 year old male involved in

combat injury by gunshot at

the left thigh.

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CASE # 7

22 year old male involved

in combat injury by flying

debris and projectiles in

the abdomen

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• Primary laparotomy was done in a near field hospital and bowel repair, patient still dropping his Hb and abdomen becomes tenser.

• Second laparotomy was done in a second hospital and surgeon was frustrated by bleeding and he tried to control and close.

• Patient continued bleeding and yet consumed around 40 units of blood in the last 2 days.

• He was referred to me for CT and opinion.

• CT was done and showed the continuous jet of splenic artery bleeding.

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CASE 8

21 year old male involved

in combat injury by a

snippers’ gunshot at the

Rt side of neck..

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CASE 9

23 year old male involved in

combat injury by a snippers’

explosive gunshot at the Rt

side of neck.

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Computed Tomography Scans..

Hemodynamically stable patients.

Identification and classification of injuries.

Sensitivity: 92 to 98 %.

Specificity: 99%.

CT has a high negative predictive value to allow immediate discharge from the emergency department.

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Vascular Injury-Lessons

Control of haemorrhage.

Vascular repair – maintain blood supply.

Prevention of infection.

Speed.

85% of early deaths are due to blood loss.

Early blood loss has a significant effect on late deaths.

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• Arterial cut-off

• Mural irregularities or flap

• Laceration

• Thrombosis

• Dissection

• Free-flow contrast extravasation

• Stagnant intraparenchymal accumulation of contrast

• Parenchymal blush

• Stagnant arterial or venous flow

• Diffuse vasoconstriction

• Pseudoaneurysm

• Arteriovenous fistula

• Vessel displacement

The angiographic manifestations of vessel injury

Angiographic manifestations of vessel injury:

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Angiographic Manifestations of Bleeding

• Free-flow contrast extravasation.

• Stagnant intraparenchymal accumulation of contrast.

• Disruption of visceral contour.

• Displaced organ.

• Intraparenchymal avascular zones.