Vascular injury : The commonest cause of permanent disability in India

Dr KK Pandey *

Simplified diagram of the human Circulatory system in anterior view :: Pix - Wikipedia/ LadyofHats, Mariana Ruiz Villarreal

If an artery or a blood-carrying pipe in the body, gets damaged due to any reason, the oxygen supply to various organs of body including limbs becomes jeopardized, this may result into a loss of your hand or foot. In our country, a lot of ignorance, apathy and myths about vascular injury, are prevalent among common people and even among majority of physicians.

According to one estimate, in India 50 percent of patients receiving vascular injury during accidents lose their foot or hand because of ignorance and lack of adequate treatment, whereas in developed countries hardly only 5% cases of vascular injury undergo amputation of limbs.

In our country, lack of awareness and carelessness play a most significant role in the development of disability caused by vascular injury. Quite often, people and even attending general or orthopedic surgeons do not pay much attention to vascular injury received during a road traffic accident; this eventually results into amputation of foot or hand even loss of a precious human life.

Vascular injury may cause loss of limb and life as well

In road-traffic accidents, stab injury by knife and trishul, assault by sharp weapons like sword and firearm injuries due to explosives like bomb and hand-grenade, arteries are usually damaged, sometimes so severely that they are completely disrupted. This complete arterial disruption leads to massive bleeding and blood loss in the body. Because of this excessive blood loss, various organs like kidney, brain, heart and lung are deprived of essential oxygen, which is necessary for their vital functions and survival.

In such a situation, death of the patient is an eventual outcome, if he is not shifted promptly to a large and modern hospital equipped with their own 24-hour blood bank facility, angiography’s facility and availability of a full-time cardiovascular surgeon or a vascular surgeon. Such patients need an urgent operation otherwise loss of limbs and sometimes of life as well, becomes inevitable.

Bone fracture is the major cause of vascular injury in India

It has been observed that in a case of accidental fracture of upper and lower limbs bones, majority of the treating bone specialists by and large ignore co-existing vascular injury. They pay more attention to bone injury, and therefore treatment of vascular injury gets delayed, this results into irreparable damage to wall of the artery. In such situations, delayed restoration of blood supply is almost impossible even after operation.

Therefore any person sustaining bone injury during a road traffic accident should consult, as a precautionary measure both Orthopedic Surgeon as well as a vascular Surgeon, so that the treatment of the vascular injury if present should not be unnecessarily delayed. If a patient even after successful treatment of his previous bone fracture continues to complain of tingling sensation or pain in the same limb, it may be indicative of a missed vascular injury. Such complaints should be looked into seriously and an active advice of a cardiovascular surgeon or a vascular surgeon should be definitely sought without delay.

Sometimes, in accidental bone fracture cases, instead of complete arterial disruption, only a part or side of the arterial wall is severely damaged. This condition of partial injury is often overlooked as blood flow is not totally cut off, and oxygen supply to limbs continues during initial days. But later on, in subsequent months, without treatment, this damaged wall gets shrunk and leads to a reduced blood flow.

Sometime this damaged and weak wall, instead of shrinking, bulges out due to high pressure of the blood flow in the artery. This bulging assumes the size of a tumor which is called, in medical terms as vascular aneurysm. This may eventually burst out, if not treated in time and may lead to unsuspecting catastrophic bleeding and massive blood loss.

The role of wrongly – administered intravenous injection in causing vascular injury

In our country, one of the important reasons of disability is the vascular injury caused by wrongly – administered intravenous injection. Quite often, it has been observed that untrained and incompetent paramedical personnel or medical quacks, either due to ignorance or carelessness wrongly administer what is supposed to be an intravenous injection into an artery in place of a vein. In such a situation, a severe pain suddenly develops in the fingers and hand followed by tingling sensation. Gradually skin colour of fingers and toes begin to turn black and later on the whole hand becomes dark black.

To save the life of such patient, amputation of the hand remains the only choice left. Therefore, never allow your physician or paramedical personnel to administer any intravenous injection on the front surface of your elbow. An intravenous injection should preferably be administered either on the hairy back of your hand or forearm near the wrist far below the elbow crease. Because on the back of the hand and forearm, chances of inadvertent administration of an intravenous injection into an artery are very remote.

What to do in case of a suspected vascular injury ?

Quite frequently, it has been observed people after receiving injury go for massage; that further damages an already injured artery, and in the process obviates any chance of a successful arterial repair. If a person after sustaining limbs injures, continues to have pain, tingling sensation and coldness of hand or feet, or there appear red patches over the skin of hand & feet or he feels as if his fingers and toes have become powerless and dead, all these complaints are strongly indicative of a vascular injury.

For investigation of a vascular injury, Doppler study, conventional angiography and digital subtraction angiography are very much helpful. Without these specialized investigations or tests it becomes almost impossible to assess the correct nature and extent of vascular injury. Doppler study only indicates and confirms about the existence of an injured artery, but it is the angiography, which tells correctly all the information required in a case of a vascular injury.

On the basis of angiographic results only, the further management strategies are decided. Therefore it is mandatory for a patient of vascular injury to go to a hospital where facility for angiography is available, as angiographic result decides about the type of surgical management. However, in case of dire emergency and to save precarious time and a human life as well, an experienced Vascular surgeon may perform vascular operations directly without angiography.

Due to availability of modern investigations like angiography and free access to artificial tubes, bypass operations in cases of vascular injury have become very effective and successful. With modern surgical techniques, injured artery is repaired or reconstructed. For, arterial reconstruction, either a natural vein of other leg is taken out and grafted in the injured area, or an artificial tubes is used instead of patient’s natural vein. These artificial blood pipes (prosthetic grafts) are imported from US and Germany. If repair or reconstruction of the damaged artery is not possible by any means, another specialized surgical technique of arterial bypass is used.

The success of operation in a vascular injury depends entirely upon the fact that how soon after injury you have consulted a vascular surgeon and the condition of the damaged muscles in the area of injury. If a patient immediately after limb injury with suspected vascular trauma has reached a cardiovascular or a vascular surgeon in time, there stands a good chance of the limb salvage. Delay in treatment result into the death of muscle because of prolonged lack of oxygen supply, and then surgical repair or reconstruction of the damaged artery becomes meaningless.