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  • Vascular Trauma

    Abdominal Vascular Trauma

    The fellow should be able to:

    • Describe the zones of the retroperitoneum and how management differs between blunt and penetrating injuries
    • Describe the operative exposures for retroperitoneal injuries
    • Understand the role, indications, and controversies as related to the use of REBOA
    • Describe techniques for repair of the aorta
    • Describe techniques for repair of the iliac arteries
    • Describe techniques for repair of the IVC and iliac veins
    • Understand the role of ligation in the management of venous injuries and complications associated with ligation

    Resources

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    Extremity Vascular Trauma (General Concepts)

    The fellow should be able to:

    • Demonstrate an understanding of the evaluation of extremity vascular trauma including the role of arterial pressure index, CT, ultrasound, and angiography
    • Describe the role of tourniquets in extremity vascular trauma
    • Understand the role of temporary arterial shunts in extremity vascular trauma
    • Describe the options for shunts and the technique for shunt placement
    • Understand the difference in outcomes between vein and prosthetic grafts in vascular trauma
    • Describe the role and technique of Fogarty thrombectomy in vascular trauma
    • Understand the pharmacologic adjuncts that can be used in vascular trauma including papaverine, heparin, tPA
    • Discuss the role of intraoperative angiography, describe technique, and demonstrate ability to interpret completion angiograms
    • Understand the management of combined vascular and skeletal trauma

    Resources

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    Upper Extremity Vascular Trauma

    The fellow should be able to:

    • Describe techniques for exposure and repair of upper extremity arteries
    • Describe the indications and technique for forearm and hand fasciotomies
    • Understand the role of endovascular techniques in upper extremity trauma
    • Describe the complications associated with upper extremity vascular trauma
    • Understand the importance of long-term surveillance following upper extremity vascular trauma

    Resources

    • Topic Summary - Bracial Artery Injury
    • Topic Summary -Subclavian and Auxillary Injury
    • AAST Education Module - Upper Extremity Vascular Injury
    • AAST Education Module - Penetrating Subclavian Vessel Injuries
    • Additional Resources:
      • Asensio JA, Kessler JJ 2nd, Miljkovic SS, Kotaru TR, Dabestani PJ, Kalamchi LD, Wenzl FA, Sanford AP, Rowe VL. Brachial Artery Injuries Operative Management and Predictors of Outcome. Ann Vasc Surg. 2020 Nov;69:146-157.
      • W. Franz, R.B. Goodwin, Hartman, M.L. Wright. Treatment of upper extremity arterial trauma in a level I urban trauma center. Ann Vasc Surg, 23 (2009), pp. 8-16.
      • Zellweger, F. Hess, Nicol, J. Omoshoro-Jones, D. Kahn, P. Navsaria. An analysis of 124 surgically managed brachial artery injuries. Am J Surg, 188 (2004), pp. 240-245.
      • Vu T, Asensio JA, Mazzinin FN, Sciarretta JD, Chandler J, Lieberman EH, Ksycki M, Pizano L. Brachial vessel injuries: High morbidity and low mortality injuries. Eur J Trauma Emerg Surg 2011;7:459e67.
      • Alexis AL, Bowyer MW, Propper BW. Upper extremity vascular injury (73-82). Vascular Injury In Vascular Injury: Endovascular and Open Surgical Management. Dubose JJ, Teixeira PG, Rajani RR 2023.
      • Rasmussen T, Tai N. Imaging for the Evaluation and Treatment of Vascular Trauma (44-55); Upper extremities and Junctional Zone Injuries (149-167). In Rich's Vascular Trauma. Third Edition. 2016.
      • Boudreau S, Schucht J, Sigdel A, Dwivedi AJ, Wayne EJ. Contemporary Review of Traumatic Axillary and Subclavian Artery Injuries at an Urban Level One Trauma Center. Vasc Endovascular Surg. 2024 Jan 29:15385744241230151.
      • Torres IO, Lourenço de Andrade RC, Apoloni R, Simão da Silva E, Puech-Leão P, De Luccia N. Editor’s Choice – In Hospital and Longterm Outcomes After repair of Subclavian and Axillary Artery Injuries. Eur J Vasc Endovasc Surg. 2023 Dec;66(6):840-847.
      • Angus LDG, Gerber N, Munnangi S, Wallace R, Singh S, Digiacomo J. Management and outcomes of isolated axillary artery injury: a five-year national trauma data bank analysis. Ann Vasc Surg. 2020;65:113-123.
      • Branco BC, Boutrous ML, DuBose JJ, Leake SS, Charlton-Ouw K, Rhee P, Mills JL Sr, Azizzadeh A. Outcome comparison between open and endovascular management of axillosubclavian arterial injuries. J Vasc Surg. 2016 Mar;63(3):702-9.
      • Weaver FA, Herscu G. Upper Extremity and Junctional Zone Injuries. In: Rasmussen TE, Tai NR, Eds; Rich’s Vascular Trauma, 3rd Edition, p 149-167.
      • Waller CJ, Cogbill TH, Kallies KJ, Ramirez LD, et al. Contemporary management of subclavian and axillary artery injuries-A Western Trauma Association multicenter review. J Trauma Acute Care Surg. 83(6), December 2017, p 1023-1031
      • Asensio JA, Falcone RE, Valenziano CP, Grosh JD: Management of penetrating neck injuries. The controversy surrounding Zone II injuries. In Surgical Clinics of North America. 1991;71(2):267-296.
      • Sciarretta JD, Asensio JA, Vu T, et al. Subclavian vessel injuries: difficult anatomy and difficult territory. European Journal of Trauma and Emergency Surgery. 2011;37(5):439- 450.
      • Mazzini FN, Vu T, Prichayudh S, Sciarretta JD, Chandler J et al. Operative exposure and management of axillary vessel injuries. European Journal of Trauma and Emergency Surgery. 2011;37(5):451- 457.
      • Weinberg JA, Moore AH, Magnotti LJ, et al. Contemporary management of civilian penetrating cervicothoracic arterial injuries. J Trauma Acute Care Surg. 2016 Aug;81(2):302-6.
      • Matsagkas M, Kouvelos G, Peroulis M, Xanthopoulos D, Bouris V, Arnaoutoglou E. Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment. Injury. 2016 May;47(5):1051-6.
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    Lower Extremity Trauma

    The fellow should be able to:

    • Describe techniques for exposure and repair of lower extremity arterial injury
    • Understand the unique nature of popliteal artery injuries and management of these injuries
    • Describe indication and technique for lower extremity fasciotomies including thigh and buttock fasciotomy
    • Understand role of endovascular repair in lower extremity trauma
    • Describe the complications associated with lower extremity vascular trauma
    • Understand the importance of long-term surveillance following vascular trauma

    Resources

    • Topic Summary - Extremity Vascular Injury
    • Topic Summary - Femoral Artery Injury
    • Topic Summary - Popliteal Artery Injury
    • AAST Education Module - Femoral Artery Injuries
    • AAST Education Module - Popliteal Artery Injuries
    • Overview Articles: 
      • Scott DJ, Rasmussen TE. Surgical damage control and temporary vascular shunts (pgs. 198-205). Rasmussen TE, Tai NR, Eds; Rich’s Vascular Trauma, 3rd Edition, 2016.
      • Singh N, Quan RW. Damage control: Considerations for vascular conduit in the repair of vascular injury (pgs. 206-214). Rasmussen TE, Tai NR, Eds; Rich’s Vascular Trauma, 3rd Edition, 2016.
      • Feliciano DV, Asensio JA. Abdominal Vessels (pg 747-771), Feliciano Mattox Moore 9th edition Trauma, 2021.
      • Peripheral Vascular Injury. Current Therapy of Trauma and Surgical Critical Care. Asensio, Meredith, Trunkey. 3rd edition
      • Kumar NG, Knipp BS, Gillespie DL. Lower extremity vascular trauma. In: Rasmussen TE, Tai NR, Eds; Rich’s Vascular Trauma, 3rd Edition, p 168-182.
      • Skarupa D, Dennis j, Dubose J. Common Femoral and Profunda (Deep) Femoral Artery Injuries (pg 145-153). Vascular Injury: Endovascular and Open Surgical Management. Dubose JJ, Teixeira PG, Rajani RR 2023
    • Additional Resources:
      • Feliciano DV. Pitfalls in the management of peripheral vascular Injuries. Trauma Surg Acute Care Open. 2017 Aug 28;2(1).
      • Parry NG, Feliciano DV, Burke RM, Cava RA, Nicholas JM, Dente CJ, Rozycki GS. Management and short-term patency of lower extremity venous injuries with various repairs. Am J Surg2003;186:631–5.
      • Subramanian A, Vercruysse G, Dente C, et al. A decade’s experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma. 2008;65:316-324.
      • Ruiz G et al. Femoral vessel injuries; high mortality and low morbidity injuries. Eur J Trauma Emerg Surg. 2012 Aug;38(4):359-71.
      • Sciarretta JD et al. Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. Eur J Trauma Emerg Surg (2012) 38:373–391.
      • Single center experience:
        • Asmar S et al. Traumatic Femoral Artery Injuries and Predictors of Compartment Syndrome: A Nationwide Analysis. J Surg Res. 2021 Sep:265:159-167.
        • Sciarretta et al. Management of femoral vessel injuries: 6-year single center experience. Am Surg. 2015 Jan;81(1):86-91.
        • Pediatric trauma: Lyons NB et al. Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center. Trauma Surg Acute Care Open. 2024 Feb 7;9(1):e001263.
        • Potter  HA, Alfson  DB, Rowe  VL,  et al. Endovascular versus open repair of isolated superficial femoral and popliteal artery injuries. J Vasc Surg.2021;74(3):814–822.
        • Sciarretta JD, Macedo FI, Otero CA, Figueroa JN, Pizano LR, Namias N. Management of Traumatic Popliteal in a level I trauma center: A 6-year experience. Int J Surg. 2015 Jun;18:136-41.
        • Branco BC, Linnebur M, Boutrous ML, et al. The predictive value of multidetector CTA on outcomes in patients with below-the-knee vascular injury. Injury. 2015;46(8)1520-1526.
        • Abdou H, Edwards J, Stonko D, Ottochian M, Dubose JJ, Scalea TM, Morrison JJ, Kundi R. The role of endovascular repair of popliteal artery injuries in the acute setting. Ann Vasc Surg. 2022 Nov:87:522-528.
        • Grigorian, SE Wilson N et al. Decreased national rate of below the knee amputation in patients with popliteal artery injury Ann Vasc Surg, 57 (2019), pp. 1-9.
      • Multicenter Study:
        • DuBose J et al.; AAST PROOVIT Study Group. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015 Feb;78(2):215-22.
        • Romagnoli AN et al.; AAST PROOVIT Study Group. Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury. J Trauma Acute Care Surg. 2021 Jan 1;90(1):1-10.
        • DuBose J et al.; AAST PROOVIT Study Group. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015 Feb;78(2):215-22.
        • Romagnoli AN et al.; AAST PROOVIT Study Group. Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury. J Trauma Acute Care Surg. 2021 Jan 1;90(1):1-10.
    • EAST Guidelines
    • Western Trauma Association
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    Extremity Trauma (Non-Vascular)

    The fellow should be able to:

    • Demonstrate an understanding of open fracture management and initial treatment
    • Describe the classification categories for open fractures
    • Understand the complexities of the management of a mangled extremity
    • Recognize the controversies associated with prognostic scoring systems in mangled extremities
    • Describe the management of crush injuries and recognition and management of compartment syndrome

    Resources

    • Topic Summary
    • Overview Articles:
      • Ferrer et el.
      • McNally et al
    • Additional Resources:
      • Emergency Vascular Surgery in Special Populations: Warner et al. 2023
      • Role of Rural Surgeons in Vascular Surgical Emergencies: Ang et al. 2020
      • Safety of Transfer in Acute Limb Ischemia: Hemingway et al. 2019
      • Effectiveness of treatments in phlegmasia cerulea dolens. Li et al. 2023
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