Markgraf E, Böhm B, Bartel M, Dorow C, Rimpler H, Friedel R
Klinik für Unfallchirurgie, FSU Jena.
Unfallchirurg. 1998 Jul;101(7):508-19.
2-4% of vascular injuries need operative reconstruction. In polytraumatized patients the rate is even 10%. Arterial vascular repair should precede venous reconstruction and orthopaedic stabilization due to limb threatening ischemia. Penetration or blunt vascular trauma result either in acute blood loss, ischemia or compartmental compression. Reperfusion syndrome leads to vital threat of patient. Clinical assessment, measurement of limb pressures using a Doppler device and use of duplex ultrasonography are reliable adjuncts in the rapid evaluation. Arteriography is rarely indicated and should be spared for patients with abnormal physical examination. Minimizing ischemia (6-8 h) is an important factor in maximizing limb salvage. Vascular repair include direct anastomosis or lateral suture repair mostly combined with primary shortening of the extremity. In most cases autogenous vein graft is required. Rethrombosis, arteriovenous fistula and pseudoaneurysms are possible complications. Stabilisation of the fracture has priority over vascular reconstruction. The initial steps to success are surgical debridement, adequate bony stabilization mostly by external fixation, revascularisation of vascular injury, immediate fascial decompression and early soft-tissue reconstruction. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, vascular surgery and plastic surgery.
2%至4%的血管损伤需要进行手术重建。在多发伤患者中，这一比例甚至达到10%。由于肢体存在缺血威胁，动脉血管修复应先于静脉重建和骨科固定。穿透性或钝性血管创伤可导致急性失血、缺血或骨筋膜室综合征。再灌注综合征会对患者的生命构成威胁。临床评估、使用多普勒设备测量肢体血压以及运用双功超声检查都是快速评估中可靠的辅助手段。动脉造影很少有必要进行，对于体格检查异常的患者应避免使用。尽量减少缺血时间（6至8小时）是最大限度挽救肢体的一个重要因素。血管修复包括直接吻合或侧方缝合修复，大多还会结合肢体的一期短缩。在大多数情况下，需要使用自体静脉移植物。再血栓形成、动静脉瘘和假性动脉瘤是可能出现的并发症。骨折固定优先于血管重建。成功的初始步骤包括手术清创、主要通过外固定进行充分的骨固定、修复血管损伤、立即进行筋膜减压以及早期软组织重建。当采用多学科方法，结合骨科手术、血管外科和整形外科的专业知识时，能取得最佳效果。
