Surgery on vessels and

nerves
PhD, MD, professor
Viorel Nacu

Department of Operative Surgery and

Topographical Anatomy

Chişinău
Vascular (arterial) injury has two main
consequences –
Haemorrhage
Ischaemia.

An Czech surgeon sed: "Bloody vascular

trauma - it's either bleeding too much or it's
not bleeding enough".
 Probable arterial/venous/nerve injuries
associated with fractures or dislocations
Clavicle fracture subclavian artery/vein/br. plexus
Shoulder fr./dislocation axillary artery/vein/br. Plexus
Humerus fracture deep brachial artery/n.radialis
Supracondylar humerus fr brachial artery
Elbow dislocation brachial artery
Pelvic fracture gluteal arteries
Femoral shaft fracture femoral artery
Distal femur fracture popliteal artery
Knee dislocation popliteal artery
Tibial shaft fracture tibial arteries
Consequences of vascular injury
Blood loss
Ischemia
Compartment syndrome
Tissue necrosis
Amputation
Death
Prognostic factors depends of:
Level and type of vascular
injury
Collateral circulation
Tissue damage
Ischemia time
Patient factors
Medical conditions
(equipment, personnel)
1.A. iliaca communis;
2. A. iliaca interna;
3. A. iliaca externa;
4. A. obturatoria;
5. A. glutea inferior;
6. a. glutea superior;
7. R. ascendens a. circumflexa femoris
lateralis;
8. R. descendens a. circumflexa femoris
lateralis;
9. A. profunda femoris;
10. A. circumflexa femoris medialis;
11. rr. Perforantes a. profunda femoris;
12. A. genus descendens;
13. Aa. Genus superior medialis et lateralis;
14. Aa. Genus inferior medialis et lateralis;
15. A. recurents tibialis anterior;
16. A. poplitea;
17. A. tibialis posterior;
18. A. tibialis anterior; 19. A. tibialis posterior;
20. A. tibialis anterior; 21. A. plantaris;
22. A dorsalis pedis.
Unrecognised and
uncontrolled haemorrhage can
rapidly lead to the demise of
the trauma patient.
Unrecognised and untreated
ischaemia can lead to limb
loss, stroke, bowel necrosis
and multiple organ failure.
 Pulse Examination
Lower limp Upper limb
Femoral A Subclavian artery

Popliteal A Axillary artery

Dorsalis pedis A Brachial artery

Posterior tibial A Radial artery

 Figure 3.1

Femoral A
Popliteal A
 Figure 3.3

Dorsalis pedis A
Post tibial A
 Non-invasive Examination

Doppler Study
MRA
Spiral CT
Invasive Examination angiography
(Sildenger technique)
 Types of surgery
1. Arterial:
- Endartherectomy
- Profundoplasty (an operation to repair an
obstructing lesion in a deep blood vessel, for
example, of the deep femoral artery)
- Bypass graft
- Angioplasty (autogenous, allogenous,
xenogenous, Synthetic implant, patch-Dacron,
etc.)
- Sympathectomy
.
Management
The priorities of vascular injury are arrest
of haemorrhage and restoration of normal
circulation.
Principles of vascular reconstruction:
never risk life to save a limb.
 The bleeding stoppage
Immediate control is usually achievable by direct pressure over
the site of injury. It is better one individual to manually compress
the site of haemorrhage.
 The manually or tourniquet compression higher then
the place of injuries:
- On upper limb on can press (squeeze) a main artery
if necessary :
- (manually) subclavius artery on first rib;
- (manually or tourniquet) brachial artery the site of the arm at
humerus bone just above the elbow and just below the
armpit Squeeze the main artery in these areas against the
bone
- On lover limb on can press :
- (manually) the femoral artery on superior ramus of pubis
bone,
- (tourniquet) at the middle site of femoral bone
- (manually) popliteal artery in the popliteal fossa just behind
the knee
Where haemorrhage is welling up from a deep knif or
gunshot track, haemostasis may be temporarily achieved by
passing a urinary catheter into the track as far as possible,
inflating the balloon
Blind clamping with a haemostatic forceps in the depths of a
wound is dangerous and can be made only in the surgery room
Ligature technique on the arterial big vessel
in the wound

1.Proximal end of blood vessel,

2. Proximale ligature
3. Distale ligature transmurale,
4. ligature on distal end of the vessel
 Ligature technique on the arterial big vessel
proximally from the injury site

Indications:
- Purulent wounds, gangrena
- When the its impossible to find the end of
the vessel (a. glutea superioris – on
ligature on a. iliaca interna; a. lingualis –
ligature on external carotid artery.)
 Ligature
technique
on the
arterial
big
vessel
proximall
y from
the injury
site
The
wound
Technical principles on vascular
sutures
1. Aim for a smooth flow by a. Avoiding
loose flaps
2. Avoiding both intrinsic and extrinsic
constriction
3. Avoid narrowing at anastomoses
4. Handle all arteries and grafts with care
5. Strict asepsis
6. Peroperative anticoagulation
 Vascular suture

Manual vascular sutures

Mechanical vascular sutures
Small, clean, transverse wounds to vessels that
involve only part of the circumference can be
repaired with a direct suture technique
 To avoid tne narrowing of the
vessels some times is necessary to
use the:
Vein patch or Synthetic patch
 Synthetic angioplasty with Dacron

• Very good replacement for large vessels (> 10 mm)

Problems
• Tend to buckle across joints
• False aneurysms at anastomoses
• Thick intimal deposition (2-4 mm)
• Infection of implanted foreign material b.
PTFE (Goretex)
• Useful for smaller arteries (e.g. superficial femoral)
• Easy to suture and requires no pre-clotting
Problems
• High 3-year failure rate (> 30%) compared with vein infection
• Tendency to kink
Carrel's vascular
suture description:
End-to-end
anastomosis of
severed vessels
with triple-threaded
sutures.
Endarterectomy (Atherectomy): is a procedure to remove
plaque from arteries. Plaque is the buildup of fat,
cholesterol and other substances in an artery's inner
lining.
Carotid Artery Stenting
 Sympathectomy
Surgical
Chemical
 Grafting
By vein (best material, available from long
saphenous or cephalic veins)
Synthetic dacron (very good replacement
for large vessels (> 10mm)
RTFE
 Principles of management of
nerve injury
Exploration needs:
- Avascular field (tourniquet)
- Available facilities for microsurgery
- Good light
- Adequate anesthesia
- Preserve all viable skin and all tissue
around.
 The structure of the nerve

1 and 2) Epineurium;
3) Group of Fascicules;
4) perineurium;
5) Nervous fibers;
6) Endoneurium
Peripheral nerves contain sensory or motor axons
most of witch are myelinated. Each axon is
surrounded by fine collagen fibers, the endoneurium.
Groups of axons called fascicules are bound
together by the perineurium, which consists of thin
layers of specialized perineurial cells and fine
collagen fibrils.
The epineurium, made of thicker collagen fibrils,
surrounds the fasciculi. This layer is thought to
elaborate the fibroblastic reaction that is the primary
cause of fibrosis subsequent to nerve injury.
If removal of scarred ends leaves a gap
between the nerve ends, length can be
ganed by nerve transposition by
limitation on flexion or by bone
shortening to close the nerve gap.
The ulnar nerve length can be gained by anterior
transposition at the elbow.
Indications: dislocation of the nerve; defect of the
nerve.
Procedure: -
10cm incision following the ulnar nerve and
centered on the medial epicondyle.
Expose and mobilize the nerve, carefully
preserving its blood supply
Cut m. flexor carpe ulnaris, divide intermuscular
septum to expose the nerve
Separate the flexors from the medial epicondyle
and place the nerve anterior to the medial
epicondyle
Some lesions resulting from contusion or compression are
improved by neurolisis.
The procedure consists in separation of the neural structure
from fibrous cicatrices.
Carpal tunnel syndrome (CTS) is a medical condition
due to compression of the median nerve as it travels
through the wrist at the carpal tunnel.
The main symptoms are pain, numbness, and tingling, in
the thumb, index finger, middle finger, and the thumb
side of the ring finger.
Microsurgical sutures on the small vessels and
nerves in procedures of replantation
 Varicose Veins
Varicose veins result from an enlargement and
dilatation of veins just beneath the skin and occur
mainly in the legs.
This enlargement of the veins results from a
weakening in the vein wall, and a dysfunction of vein
valves which regulate blood flow through the vein.
The condition can be aggravated by pregnancy,
obesity, and occupations requiring long periods of
standing. Varicose veins range in severity from spider veins (telangiectasia) to severe, ropy, twisted veins accompanied with skin
sores (venous ulcerations).
 Varicose VeinsTreatment
 Stocking (Some of the symptoms of varicose veins
can be treated without intervention by wearing support
stockings during the day)
 Sclerotherapy is often used to treat spider veins,
smaller varicose veins, hemorrhoids and
hydroceles.- Sclerosing agents typically used
include: polidocanol; sodium tetradecyl sulfate;
hypertonic saline solutions to obliterates the vein.
 Foam sclerotherapy - the solutions that are injected are
exactly the same as those which are already used to treat varicose
veins. These are mixed with a gas to create a mousse or foam
consisting of very small bubbles

 Surgery
 VENOUS CATHETERISATION
Is provided by percutaneous insertion of one or two
intravenous plastic catheters.
Indications:
- operations or traumas associated with marked blood
loss for rapid administration of blood, fluids or
medications.
Insert the needle until it contacts the superior edge of the
clavicle.
Lower the needle tip below the clavicle and direct the needle
parallel to the floor.
Aspirate the syringe as the needle is inserted.
When blood appears in the syringe, thread the catheter into
the vein.
If no blood returns is obtained or if resistance is met, redirect
the needle toward the patient’s oposite shoulder. (do not, at
any time, direct the needle toward the patient’s feet.
 Regional anesthesia
Brachial plexus block is a regional anesthesia technique that is
sometimes employed as an alternative or as an adjunct to general
anesthesia for surgery of the upper extremity.
These techniques are classified by the level of injecting the local
anesthetic — interscalene block on the neck, supraclavicular
block immediately above the clavicle, infraclavicular block below
the clavicle and axillary block in the axilla (armpit)
Sciatic nerve blockade is useful for
postoperative pain, for lower
extremity surgery, and lower
extremity chronic pain syndromes
such as sciatic neuropathy.
Tenorrhaphy, [teno- + G. rhaphē, suture]
Suture of the divided ends of a tendon.
Synonyms tendinosuture, tendon suture,
tenosuture
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