Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVIII: Vascular Injuries

Surgical Repair

United States Department of Defense

Lateral suture repair is suitable for small, clean-cut lacerations of large arteries. For larger tangential wounds, an autogenous vein patch should be used to prevent stenosis of the repair site. If damage to the affected artery is extensive or irregular, the damaged segment should be excised and continuity reestablished by end-to-end anastomosis or an interposition graft.

After the artery has been adequately debrided, noncrushing vascular clamps are applied at about one centimeter from each end of the transected vessel. At this point, it is determined if the ends can be anastomosed without tension. Undue tension must be avoided as it is likely to result in dehiscence and hemorrhage, or anastomotic narrowing and thrombosis. In any case, undue tension will doom the repair to failure. The surgeon readily develops judgment concerning the amount of tension which can be safely applied to a vascular repair. When too much tension exists, further dissection is carried out proximally and distally. A moderate amount of dissection may compensate for a defect as long as two centimeters but rarely for one longer than this. Branches of the damaged artery generally should not be sacrificed since this practice gains little length while at the same time sacrificing important potential collaterals - collaterals that could be of critical importance should the primary repair fail.

Direct anastomoses are most often performed using a running technique A continuous suture is placed through the full thickness of the vessel wall with individual passes about 1.0 mm back apart and 1.0 mm from each cut end. In vessels the size of the radial, ulnar, or tibial arteries, an interrupted suture technique should be used. Although care should be taken to avoid pulling adventitia into the lumen as the needle passes from the outside to the inside of the vessel, it is not necessary to perform a formal excision of the adventitia, as doing so weakens the repair. To assure preciseness of coaptation, the vessel ends can be held in a constant relationship to one another by lateral stay sutures as the continuous anastomosis is performed. Synthetic monofilament vascular sutures of 5-0 or 6-0 on cardiovascular needles are most commonly used for venous and arterial repairs. Aortic injuries are more commonly repaired with 3-0 monofilament synthetic sutures. Braided arterial silk lubricated with sterile mineral oil or by passage through subcutaneous fat may be used if synthetic suture is not available, as may braided synthetic sutures with an external plastic coating which approximates the characteristics of a monofilament suture.

During repair, the lumen of the vessel should be inspected to assure that no local thrombi are present. If present, thrombi should be removed by flushing with heparinized physiologic saline (10 units/cc).

Small leaks from the suture line are usually controlled by pressure alone. Topical hemostatic agents, such as gelfoam, collagen powder or topical thrombin are also useful in controlling minor suture line leaks and leaks from needle holes. Larger leaks are best managed by carefully placed figure-of-eight or mattress sutures.

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Operational Medicine 2001

Health Care in Military Settings

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