Clinical Challenges in Trauma Surgery - Stabbed in the Back - Decision Making in a Penetrating Junctional Vascular Injury

Welcome to our first trauma Subspecialty podcast with a challenging clinical case from London in the uk. We're excited to bring some more British voices to the behind the Knife catalog. Today we'll discuss ca, a case from the UK's longest established major trauma center and one of the busiest in Europe.

I'm PR ach, a surgical trainee similar to PGY five in the Edinburgh rotation. Former medical student down in London, and a trauma sciences MSC student at Queen Mary's university of London slash the Royal London. Joining me today is Rashe Kelly. Hi, I'm Roshin Kelly. I'm a clinical fellow similar to PGY three, working in the major trauma department at the Royal London Hospital.

We also have with us my colleague Matt Marsden. Thanks, rashe. My name's Max Marsden. I'm a trauma fellow in resuscitated trauma surgery here at the Royal London. And I also work for the British Army. And lastly, we have my colleague, Mr. Chris Awin. Thank you, max. Yes. Hello everyone. I'm Chris Awin.

I'm a

consultant or attending trauma surgeon at the Royal London Hospital. I'm also a clinical academic and I head up the master's program in trauma sciences at our local university, queen Mary, university of London. So thanks very much for the introductions team. We've got a lot to unpick from today's case.

So without further ado, Rasheen, would you start us off with this patient's journey? Yes, of course. So our patient is an 18-year-old male. He was assaulted with a bladed weapon on a Saturday afternoon, and remarkably managed to walk into a store having sustained a stab wound to his posterior left auxiliary region.

Alarm bells were immediately ringing as bystanders noticed. Large amounts of bleeding. This is when the clock really starts ticking. The initial nine nine nine call came in at 1607 as bystanders waved down a passing ambulance, who upon completing a dynamic risk assessment called for immediate assistance.

It happened that one of the bystanders was a GP who

happened to be on the scene, and they assisted paramedics in packing the wound with some goals, which is an excellent example of immediate and effective first aid from a trained professional. The paramedics also gained IV access, a crucial step for this bleeding patient.

15 minutes after the initial nine, nine, nine call and London Air Ambulance arrive on scene where the more advanced pre-hospital interventions began. This team had an emergency medicine consultant and advanced paramedic with them. The team applied 1.5 packs of clocs gaze to the stab wound, and a pressure dressing whilst completing a full stop check.

At this point, the patient's clinical picture was concerning with a significant volume of blood on the floor. Radial pulses were not palpable bilaterally, and the patient was clammy, however, did have a GCS of 15. Given this clinical picture, the team decided to transfuse one unit of packed red cells, one unit of FFP, and two grams of TXA.

With a credible efficiency. The team left the scene just 11 minutes later on route to the Royal London Hospital arriving at 1650. This is a total pre-hospital time of 43 minutes from the initial nine, nine nine call to hospital arrival in trauma. Every minute counts, and this was an impressively swift transfer.

Okay. Thanks very much Rasheen for taking us through the pre-hospital journey. This sounds like a really sick patient who's going to need a quick response from the trauma team at the London major trauma center, which is equivalent to a level one major trauma center in the us. There are a few topics for us to unpick from the pre-hospital journey.

Firstly, this patient has a junctional injury and we know that junctional vascular injuries carry increased mortality compared to vascular injuries to the extremities. These are relatively common injuries. That's another London major trauma center, and most commonly present out of hours when staffing is reduced, and they tend to be resource

intensive, especially in terms of blood product use, imaging use, and theater, which is the operating room usage.

A key issue includes that we can't get a tourniquet around them in the pre-hospital world as easily as an extremity vascular injury, meaning that proximal control is more challenging. There is some novel experimental research into specific auxiliary and groin tourniquet to see if these will help hemorrhage control in the pre-hospital world and in the emergency department, which is the emergency room.

The, these aren't yet in routine clinical practice. The air ambulance team gave this patient some prehospital blood, which is an intervention not universally seen in trauma systems. Could you tell us a bit more about prehospital blood? Yes, of course. Since 2012, the London Air Ambulance Trauma response teams Kari, both red cells and thaw fresh frozen plasma.

The most recent systematic review on pre-hospital blood in 2019 suggests a reduction in

mortality with pre-hospital blood product resuscitation. However, an issue is that we haven't yet standardized decision making in who gets pre-hospital blood, nor in what order to give these products. So what happened next when they arrived in the ed?

So when the patient arrived in the emergency department, the major hemorrhage protocol was activated, which released two packs of blood products. So you have pack A and pack B pack A contains four units of red blood cells, four units of fresh frozen plasma, and pack B. Contains a further four units of red blood cells, four units of fresh frozen plasma, one unit of platelets, and two pools of cryoprecipitate.

The blood bank continues to thaw group and antigen specific pack B blood products in a one-to-one to-one ratio until the call is deactivated and the hospital resources this with a dedicated porter to keep bringing blood to the trauma bay. This is based off

a number of papers over the past 20 years, focusing on the one-to-one to-one ratio of blood products.

There have been a few studies run from our center, finding no benefit to earlier increased volume use of cryoprecipitate compared with one to one to one standard of care, nor the use of BJs versus conventional coagulation tests in the primary outcome of 24 hour survival or any secondary outcome other than in the specific subgroup of 28 day mortality in severe traumatic brain injury.

Okay, thanks very much Rasheem. So just for the listeners, vha are viscoelastic, hemostatic assays like M and tes. So if you are interested in some of the papers we've talked about, we'll reference them in the transcript, but moving swiftly on this patient's in the trauma vein, there's ongoing blood product resuscitation and the on-call trauma surgeons are present to review the patient.

Could you take us through the surgical decision making for this patient and your thought process when you saw him in the trauma bay?

Thanks Prash. So, I had been pre alerted by the pre-hospital team that this was a hemorrhagic or hemorrhaging patient. And he was met then in the emergency department with a full trauma team, which included surgeons physicians from the emergency department and, and anesthetists, as well as nurses with rapid infusers ready to go. So we repeat the primary survey when the patient arrived. And the first thing we look for is evidence of catastrophic hemorrhage. This patient had a posteriorly placed wound just around the scapular as you mentioned before which had been really well packed and, and wasn't actively bleeding by the prehospital team.

So, his sort of initial hemodynamics were reassuring compared to what we were told. His initial pre-hospital hemodynamics status had been like, so he had a heart rate of 110. He had a blood pressure with a systolic greater than 110 as well. And he'd only really received one unit of red cells and one unit of

plasma in the preschool phase of care.

So we are quite reassured by that. He had a head to toe search for other penetrating wounds. And none for him were found. The rest of the primary survey was remarkably normal. So he had a normal examination of his chest and the primary survey chest x-ray was also relatively normal.

His abdomen was also normal. An extended fast examination for him wa was normal as well. With that information, we decided he was a fluid responder and we had a little bit more time to try and understand the exact anatomical nature of this injury. And so opted to take him through to the CT scanner which in our hospital is right next to the emergency department resuscitation bay.

So really only a matter of moving the patient a few meters. Once we understood exactly where the injury was, plan our operation, and, and also brings into play potentially endovascular options or even a hybrid option. And, and I think

that's only really possible once you've imaged the, the injury.

I think if this patient wasn't a fluid responder and were hemodynamically deteriorating we take the patient immediately to the operating room and do a rapid dissection down onto the subclavian artery. Yeah, thanks very much for talking through that difficult decision making and the trauma bay from the surgical team Max.

Interestingly, the paramedics had mentioned that there were no radial pulses palpated. And of course this guy has a, auxiliary artery injury as well. So your absence of a pulse is a hard vascular sign, which would usually mean let's go straight to the operating theater. But obviously here we decided to take them through the CT scanner.

But what do you think about that? Yeah, I think that's a really good point. We had a hard sign of vascular injury because, as you say, on the injured side, he, he still didn't have a radial pulse. And on the uninjured side, he'd now restored if you like, a radial pulse. So it wasn't due to hypoperfusion.

I think the really remarkable thing about this case is that this junctional injury had been sufficiently packed with a topical hemostatic that we'd got hemorrhage control. And in that context with normal hemodynamics. I think whilst we potentially did break the rules we did have a hard vascular sign.

The additional information from CT scanning was helpful. Okay, max, thanks very much for talking us through the decision making. So now onto the juicy bit, the operation itself. So what did you do? What did you find? How did you fix it? Thanks, Prash. So, we transferred the patient to the operating room and I called in a trauma vascular colleague to help with this as my training up to this point has been largely general surgery.

It's interesting because, you know, the packing and the wound was all from the patient's posterior aspect. So lying the patient's supine and approaching the wound from the front just took me a second to kind of get my head around. The incision was an infraclavicular incision and using, you know, standard trauma strategy.

We

got proximal and distal control before entering the zone of injury. There's a really good video in the behind the knife trauma atlas. On how you do this. It can be a bit fiddly and you have to sort of dissect through PEC major take down PEC minor. For this patient, his injury was actually directly below the PEC minor.

So, once we got proximal in distal control we then found a, a transected auxiliary artery. And we're fortunate that the two ends seemed to come together without undue tension and performed a, a primary repair with Prolene. And again, I think what's really remarkable about this case is that the packing had managed to completely stop the bleeding.

And so that that packing could then be removed from the posterior aspect of the patient. Once weed's got surgical hemorrhage control. Okay, so thanks Max. Quite a lot of points to unpick there actually. So maybe bringing in your vascular colleague max and Mr. Elwin could

you talk us briefly through sort of the choice of incision for quite this quite tricky junctional injury, pros and cons of different vascular repairs in this area as well?

Should I take this max? Yeah, that would be great, Mr. Chairman. Okay. So I was not the operating surgeon, but these sort of areas. Can be really challenging even for the most experienced vascular and or trauma surgeon. And I think it's probably worth saying or at least backing up the decision making for CT angiogram in this patient with hard vascular signs, which as our teaching tells us, should normally mean that we proceed directly to the operating theater for.

For expiration and repair. So with these sort of cases, you don't know necessarily where the injury is, and depending on which part of the artery is injured, could drastically change your surgical approach. So for, you know,

pure auxiliary arteries or very proximal brachial arteries, getting an infraclavicular control of the auxiliary artery is absolutely standard and fine.

But the more you become proximal, then you're gonna have to think about getting subclavian control at the supraclavicular approach, which in itself can be quite challenging. Avoiding things like phrenic nerves and fat pads and ous anterior, et cetera. Can make things quite difficult or all, or worried of a particularly long bladed weapon.

It's not outta the rounds of possibility that a more proximal great vessel injury could have been injured, in which case you are looking at get gaining proximal control by sternotomy. So, I think a, a CT angiogram in patients whose physio physiology allow it as in this case is, is a. Very sensible and completely worthwhile procedure.

Thanks very

much for talking me through that. So you've now found the auxiliary artery injury. What's your thought process in the choice of repair? So, there's some useful guidelines and I happen to be sitting, or we are sitting with one of the authors of the European Society of Vascular Surgeons who have written guidelines for managing traumatic vascular injuries.

And for this case with a tension free anastomosis as possible. That's exactly what was performed. So, here we, did, I think it was 5.0 Prolene end-to-end. Anastomosis, I guess other options that we can consider would include interposition grafts where you can either use a synthetic or a a, a piece of vein reversed vein graft or the endovascular approaches that we sort of touched on earlier.

So, I, I guess the other thing to consider as a last resort would be an extra anatomical bypass Once we'd

repaired this gentleman's axi auxiliary artery we tested distal flow with ultrasound at the wrist and had good doppler signals, which was reassuring with the clinical signs of a worn well perfused hand.

Okay. Thanks very much for talking us through what sounds like quite a challenging operation. So you've successfully done your repair. Here's a slightly controversial topic. What's your thought on heparin? Either in or after the operation in vascular repairs? Thanks, Prash. I mean, that is a fairly controversial topic and I'm at risk of somewhat embarrassing myself by quoting the guidelines back to the author here.

But my understanding of the European guidelines is that they say that we should be doing this on a case by case basis, and that if the patient is you know, frankly coagulate pathic or has a significant head injury as well as their vascular injury. Then we should probably be thinking about avoiding anticoagulation in the ve period.

But the guidelines do recommend using antiplatelets

such as aspirin for these vascular repairs. I guess there's some literature that can help us here. So, there's a study in 2020 which is a meta-analysis of just over 1,300 patients. And they looked at seven retrospective cohort studies that thought that, in a isolated traumatic vascular injury intraoperative systemic anticoagulation led to better outcomes in terms of amputation rates thrombosis, which clearly is what we're trying to avoid here reoperation and the risk of deep venous thromboembolism. However in the in a, in a different cohort study from 2022 of over a thousand patients from the Prove IT database.

Found that there was no significant benefit or harm from intraoperative systemic anticoagulation after peripheral vascular injury. So, so at the moment I'd be guided then by the European guidelines and try and tailor the approach to the patient in front of us. Yeah, and I, and I think it's probably

worth saying that as in a lot of trauma, there isn't a huge evidence base out there and.

From the European side at least, and I know the Society of Vascular Surgery are going through a similar vascular trauma review and guideline process is that we try to keep things as pragmatic and also as evidence-based as we were able to. And there is no real evidence, high quality evidence suggesting one therapy other than over the other.

Other than obviously as we discussed, patients who are profoundly coagulopathic who have got significant brain injury probably would not benefit from systemic intraoperative anticoagulation. Thanks very much both carefully navigating through that leading question. So you've now successfully got outta the operating theater rashe and Mr.

Elwin. So coming onto the postoperative journey of this patient, Rasheen, could

you talk us through the major events of his postoperative state? Yes, of course. So the patient was extubated postoperatively and transferred onto the trauma intensive care unit where he had one overnight stay on the ICU the following day.

Day one postop was reported to have a warm, well perfused hand. And so we stepped down to the trauma ward. Day two postoperatively. There was some concern on the trauma consultant ward round that the left radial. Or radial artery pulse was difficult to palpate. However, the left arm remained warm and well perfused.

And so decision was made for an ultrasound ju black to ace assess the auxiliary artery patency. This reported monophasic flu of brachial radial and ulnar arteries with limited view of the auxiliary artery due to swelling and dressings, which were in place. Therefore, the on trauma consultant decided

to request a CT angio, which subsequently reported stenosis at the site of repair and poor vessel, a ification on day four postoperatively.

In the early hours, the patient was taken back to theater for take down of the previous repair and short synthetic interposition graft. Great. Thanks very much, rashe. So some careful examination on the ward rounds and then some investigation. So once again, a lot to unpack in terms of postoperative observation and take back procedure.

So onto you, Mr. Erwin. Do you have a favorite way to observe your repairs postoperatively? I do pr it's called clinical acumen. I think is is the best way. Obviously, you know, you, you, you need to take into consideration the patient's status immediately postoperatively. Was there a pulse there?

Was there not a pulse there? Was there? Flow at the wrist only on handheld Doppler, et cetera, et cetera. But assuming that a

patient hopefully will have a palpable pulse at some point postoperatively, and sometimes weirdly, they don't necessarily immediately post-op as the vessels sort of, ease outta their vaso constrictive state that pulse often will return.

So, you know, if you've got a pulse there, it means that you have to assess the pulse at regular intervals. The pulse stops being there, something has happened and that requires further investigation. I wouldn't routinely personally use a handheld doppler. I think, you know, and some evidence would suggest that handheld dopplers are not that sensitive in picking up.

Issues mainly because a lot of people don't really truly understand or are able to tell the difference between the different audible waveforms, which can be quite subtle. So, for me it's feel a pulse. If things have changed in that limb, then it's depending on availability, it would be a duplex

ultrasound scan, which is incredibly sensitive in the right hands or a CT angiogram, which is probably still the gold standard.

As things stand. Thanks very much for talking us through that decision making, which investigation to go for, how to pick up potential repair that's gone down. So let's say you were taking this patient back to theater. Could you talk us through your approach to the previous repair how you'd get proximal and distal control, and what's your choice of redo repair?

Yeah, sure. So I would say it depends on the timing. So here we're on day two and day two is. It's obviously not a perfect time, but it is a good time to go back in because the planes are still fresh. If you're talking more than a week, 10 days, two weeks, life becomes a lot more difficult in terms of your surgical approach.

But fortunately in this case we're on day two, so it is simply just reopening a very fresh

wounds and actually getting control at the previous site is normally very straightforward. So again, you would gain proximal and distal control. At this stage I would be heparinized the patient cons, assuming that there is no other contraindication in, in other words, his coagulopathy has been resolved and this particular patient hasn't got a brain injury.

So I would fully anticoagulating before clamping the arteries. And then it's a question of taking down. The anastomosis with a pair of pot, scissors, angle, pot scissors, and seeing what's happening. So is it a technical issue or, or is there too much tension? And seeing what the options are and the options are restoring inflow and backflow with the use of Fogarty balloons and making a decision and a judgment there whether to repeat the repair, the previous primary repair.

Cutting your losses and going

for an interposition graft. And in this case they decided on the latter which, you know, I am not going to say was the wrong thing to do. Because it's purely on what the operative surgeon finds at surgery and their preference. Certainly again, citing the European guidelines.

The, the, the advice is that using synthetic short interposition grafts are no worse than using autologous fame. And this was used in this particular case. We could talk about extra anatomical bypasses. That's, that's getting into areas that in a trauma scenario is probably less optimal. The, the patency long term is probably significantly less than if you can keep a short interposition graph within the actual field of, of injury itself.

Very

much for talking us through that. So you've touched on quite a controversial topic there, which is the 2025 ESVS guidelines do suggest that there's no trauma specific evidence to show that a synthetic graft is inferior to autologous vein in a short interposition graft. But it's been historically accepted that especially in inclusive disease context, in the military context, that synthetic graft might be more likely to become infected or occluded.

However, the most recent guideline suggestion is that a synthetic graft is much more likely to fail predictably at the suture lines rather than a vein graft sort of disintegrating all over the place, which may then make it a more difficult redo procedure as well. I dunno if you either max or Mr.

Elwin, you've got anything more to add to synthetic versus vein. I think, you know, it is unquestionably I suspect for people outside of the writing group and even perhaps within the writing group a slightly controversial topic here. You know, we as vascular surgeons have had it drummed into

us from the day one of training.

That vein is always best. And most vascular surgeons would say, do your best. Bypass, repair, whatever. It certainly in an elective setting do your best bypass with the best graft that you possibly can, which traditionally is always vain. But the evidence doesn't necessarily back that up in trauma.

And what we, what the ESVS guidelines stress is that. It needs whatever repair you do the shortest graft possible is going to give you the better outcome, and that in a short graft, synthetic is no worse. Either in terms of patency or certainly in infected complications worse than vein, and has the advantage of potentially

reducing your operative time and therefore allowing, hopefully, normalization of physiology to occur at an earlier and better stage of the patient's journey.

The other. Suggestion is that a, as you've touched upon PR, is that a synthetic graft is likely to fail in a more predictable way and a slower way and a better way than potentially a vein. And so, you know, it will tend to fail slower and then give you other options should it then fail. Down the line in however many months or hopefully years of the patient's life.

So for me I still, I'll be honest, I still struggle sometimes depending on the patient's physiology with using synthetic graft. But yeah, the evidence, certainly, at least from the ESVS guidelines or the recommendation is fairly clear.

On that, and it'd be interesting to see what the SVS if they come up with a similar or competing viewpoint.

See, that brings us towards the end of this patient's journey. However, in the London Beach trauma system where big proponents of holistic care, from primary prevention to pre-hospital, to the emergency department, to the operating theater, to postoperative care and rehabilitation, and onto secondary prevention.

So Rasheem, could you briefly tell us about this patient's postoperative rehabilitation and the role of secondary prevention organizations like the Royal London Hospitals After Trauma Team, or St. Johns's Trust. So as, as you mentioned, beyond the immediate life saving interventions or crucial aspect of the trauma service does involve these secondary prevention organizations, such as the after trauma team and St.

Giles. The after trauma team is a group of experienced nurses and physios and St. Giles service is a trauma

service, violence, youth reduction project. And this patient also had input from the trauma psychology team. In this particular case, our patient benefited significantly from the St.

Giles Trauma Service. This team specializes in supporting 11 to 25 year olds who are admitted after interpersonal injuries, and their core mission is to reduce readmission rates. They provide vital pastoral care and ensure the patient has a safe place to return to act as advocates for the patient's needs, and assist with employment, education and reintegration into the community.

Additionally, the patient received invaluable input from the after trauma team and the major trauma psychology team, recognizing the profound emotional and psychological impact of a traumatic event. And it's these collaborations which truly underscore our commitment, not just to saving lives, but rebuilding them.

So thank you very much team for talking through this

challenging case. We've unpicked a lot there. Discussed a lot of controversial topics, and also brought out some areas of excellence as well. So summing it all up for our audience, there's a quick hit summary for the Behind the Knife podcast. So, firstly.

Junctional vascular injuries carry, carry a higher mortality risk than isolated torso or extremity injuries. The fact that this patient got through to the ED and then even physiologically fit enough to get through the CT scanner and then buying the in-hospital clinician's vital time to plan their procedure.

It's entirely down to the pre-hospital clinicians being able to successfully pack this difficult junctional injury. And the pre-hospital interventions of pre-hospital blood and goal-driven transfusion to try and get the physiology better, to get us to the best possible state after arrival at the, the trauma bay.

So, secondly pre-hospital blood product resuscitation was likely beneficial for the traumatic injured patient with hemorrhagic shock. Next, a one

to one to one major hemorrhage. Protocol for goal-driven balanced transfusion is the current standard of care and the trauma bay. Next, the CT trauma series in a fluid responder may help the surgeon make operative planning decisions in these tricky junctional injuries, as well as open the possibility of endovascular interventions as well.

Next. At the index procedure, opt for a primary direct repair, such as a suture or patch repair, then an interposition graft, then an extra anatomical bypass as a last resort. Try and keep your repair as short as possible, as long as it's tension free. Next, consider using synthetic graft materials for interposition graphs and bypasses, which may be quicker.

They, this is still controversial as we've touched on already. Next. Consider systemic ization on a case by case basis as long as there are no contraindications and aspirin. Single antiplatelet therapy for patients who have had a

vascular injury repaired. And lastly, remember, victims of violent crime, but there's little point in your painstaking, technically perfect repair if the patient doesn't get rehabilitation support and attempts at secondary trauma prevention and they just bounce straight back into your ED a few days later with another injury.

I. So thank you very much for listening and looking forward to joining you again in a few months time for our first trauma subspecialty journal review. We've talked about a lot about different papers, referenced them throughout our podcast and also picked up on some guidelines. If you're interested in reading through the resources, please see our reference list alongside the transcript.

And if you're interested in learning more, then the Queen Mary University of London, MSC and Trauma Sciences covers all of these such cases. And, the literature behind some of the decision making as well For our American listeners, dominate the day and for our UK listeners, Cheerio.