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INTRODUCTION

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The world of surgery is constantly changing as new and novel technologies are applied to diagnosis and treatment modalities. Over just the last few years, vascular surgery has seen a major paradigm shift following the endovascular explosion and the minimally invasive trends established in general surgery and gynecology. The reductions in surgical stress, shortened lengths of stay and of convalescence, and equivalent or improved outcomes have made endovascular operations and minimally invasive surgery a standard of care.

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Minimally invasive vascular surgery, however, poses even a new set of anatomic and physiologic hurdles beyond even the technical challenges of endovascular surgery. Dealing with not only the injury or disease itself, minimally invasive vascular techniques must be technically sound as to avoid loss of vascular control, sufficiently brief so as to avoid interruption of tissue oxygenation and immediately safe from the devastating vascular complications possible such as embolism or thrombosis.

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It is likely that endovascular techniques will replace open surgical techniques (if they have not already replaced) because of the benefits of the minimally invasive approach. Over the next few years, the practice of vascular trauma will likely bear this out and not the scientific outcome parameters. The problem is that the therapeutic interventions are changing at a rapid pace, the surgeons are becoming more facile with the techniques, and the endovascular equipment arena is constantly changing.

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The final chapter is unlikely to be written for some time, and in trauma, as always, will never be validated by strict evidence-based medicine. Also looming on the horizon for vascular disease is the possibility of avoiding surgery altogether with gene manipulation. Unfortunately, this modality is unlikely to be temporally adequate to deal with the topic of this chapter, and there will always be a need for immediate vascular intervention in trauma, yet the reconstructions may be manipulated postrepair to assure patency.

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HISTORY

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Experience with vascular injuries predates any recorded history as our species developed from not only the gatherers but also the hunters. Understanding vascular anatomy for a quick and successful kill is still passed on orally in non-Western and nonliterate cultures. Understanding vascular anatomy is essentially for appropriate dressing of the carcass and understanding vascular anatomy for the harvesting of blood as a renewable food resource in some cultures is necessary. Lastly, the reality of war has driven the knowledge of vascular anatomy not only for killing one's opponent but also for the salvage of the injured combatant.

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The first medical discussions of vascular injury are found in the Edwin Smith Papyrus from approximately 3000 bc. Galen may be the best resource for his descriptions of arterial and venous injuries in the wounds seen by the gladiators. He advises ligature for arterial injuries and styptic for venous wounds. Galen and his remaining theories remained in practice through the Dark Ages, when surgical care was left ...

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