Iatrogenic Vascular Injuries: A Review

Vascular injuries provide a significant challenge to emergency room staff because they call for quick action to avert loss of life or limb. Sometimes only modest or latent indications or symptoms of significant vascular damage are present. The patient may show signs of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula, etc., weeks or months after the initial damage. Although gunshot wounds, stabbings, and blast injuries account for the majority of vascular injuries, patients who have displaced long bone fractures, crush injuries, prolonged immobilization in a fixed position due to tight casts or bandages, and various invasive procedures should be evaluated for the possibility of vascular injury. Further investigations are required to help identify risk variables that might put a patient at more risk of suffering harm than benefiting from an intervention.

Procedures and, as a result, to the risk of problems as a result of the numerous intrusive methods for diagnosis, treatment, or monitoring that have been developed as a result of medical advancements. Healthcare professionals must carefully weigh the possible benefits of any intervention against any potential risks. This implies that the costs and dangers of intervention are constantly calculated. As a result, health care professionals must be aware of the dangers and hazards when planning diagnostic tests and treatments [5]. The aim of this review is to describe and emphasize the published literature on iatrogenic vascular lesions. The review also investigates the main components including the history, epidemiology, pathophysiology, manifestations, outcomes diagnosis, and management.

History
Vascular injury and the need to control bleeding have been important considerations in human survival throughout history [6]. The earliest documented accounts of this practice date to the 1600s BC, when the Egyptians utilized mixes of mineral oil or plant material, such as lead sulfate, antimony, or copper sulfate, to stop bleeding, according to the Ebers papyrus, which was found by Ebers near Luxor in 1873 [7]. On the other hand, the Chinese documented using tight bandages and metalized substances to control bleeding around 1000 BC [8]. Wars have played a crucial role in the growth of knowledge, experience, and advancement in the treatment of vascular trauma. In order to give himself more time to apply the ligature, a military physician named Morel put a rod into the bandage in 1674. As a result, controversial tourniquet came out for the first time [9]. The first vascular procedure described by the Englishman Hallowell was carried out in 1759. He stitched an eight-shaped suture over a pin inserted through the artery's walls to hold the edges of the humeral artery together as he treated the damage. In this approach, significant advancements in knowledge, homeostatic procedures, and vascular repair have been made from minor but consistent discoveries and from the results of warlike acts [10].

Epidemiology
Iatrogenic injuries in medicine were not widely understood until the latter half of the 20th century. Despite advances in knowledge of worldwide general trauma epidemiology, traumatic vascular damage is still poorly understood. This is less well defined, especially in the civilian sphere. Lack of regional or global datasets, ill-defined populations at risk, and a study emphasis on particular injury subtypes rather than a broad viewpoint are the main causes of this pause. Vascular damage may have occurred in as much as 12% of recent military operations in Iraq and Afghanistan. In comparison to earlier South East Asian campaigns, this represents a fivefold increase [11]. Although it varies greatly by region, the occurrence of vascular trauma in civilians is substantially lower. The prevalence of vascular trauma is still largely unclear despite the fact that torso injuries are more frequent than in military settings in the majority of countries due to the lack of extensive registry data. Vascular trauma experts face populationspecific difficulties due to vascular injuries in patients' juvenile and geriatric cohorts [11]. Worldwide, earlier studies estimated yearly incidence in civilians ranges from 0.9 to 2.3 per 100,000 [12].

Pathophysiology
The initial effect of vascular trauma is bleeding, which can either be visible or controlled. 8 When blood flow to the extremities or organs is suddenly cut off, ischemia results. As a result of the decrease in oxygen supply to the tissues, anaerobic metabolism is created, resulting in the formation of lactic acid and inflammatory mediators [13]. Activated cellular and humoral inflammatory pathways may result in cell death if the tissue is not provided with enough oxygen once more [14,15]. Depending on the tissue, hypoxemia can cause different types of injuries over time. For example, muscular tissue can experience hypoxic pain for up to three hours before recovering its function, whereas nerve tissue can sustain gradual, irreversible damage in much less time [16]. An unexpected and massive release of inflammatory mediators, lactic acid, potassium, and other intracellular debris occurs as a result of reperfusion when ischemia is reversed. This can result in severe myocardial depression and generalized vasodilation, which in turn can lead to systemic inflammatory response syndrome (SIRS) and death [14,15]. Iatrogenic injuries can happen during procedures including angiography, placing a central catheter, and laparoscopic surgery. Depending on the nation and the socioeconomic status of the population, the trauma mechanism can vary greatly. IAI is described as damage to an artery sustained during a procedure or percutaneous intervention. Up to 33% of the present vascular trauma in civilian patients is caused by it. Interventional and surgical methods are advanced and often used. As IAI occurs more frequently, numerous catheter-based treatments have been developed [17,18]. Community vascular and general surgeons are responsible for the great majority of iatrogenic arterial injuries in hospitals serving the local area. A vascular surgical approach is required for the treatment or complication prevention of about 50% of IAIs [19].

Signs and symptoms
During many types of interventions, an IVI can happen at any time and without warning and usually needs prompt management. A vascular surgeon should be aware of a wide range of symptoms that the injuries may present with, including open or closed bleeding, thrombosis, or an intimal flap dissection with poor circulation and ischemic symptoms from the injured organ or limb. A fake aneurysm (pseudoaneurysm) may develop in circumstances of arterial injury with self-stopping bleeding as a result of counterpressure in the surrounding tissues. An IVI can have moderate early symptoms with a chance of delayed diagnosis [5,20]. Ischemia or bleeding are two symptoms of IVI. The diagnosis is frequently obvious when there is visible bleeding; however, the diagnosis might not be as straightforward when there is internal bleeding. Although access site issues, primarily groin hemorrhage, are frequent and repeating adverse events (AE) (Studies II and IV), they seem challenging to identify if there is no overt bleeding or visible edema in the groin. One rationale could be the danger of normalizing deviation, i.e., that access site issues are common and there is no cause for concern. Retroperitoneal hemorrhage, internal bleeding in a cavity, is difficult to identify because there are no obvious external symptoms except for pain and hypovolemia, which causes a drop in blood pressure [5,21].

Outcomes
In vascular surgery, the results of IVI and AE can lead to serious morbidity, including paresis, limb amputation, and death. The reported mortality rates ranged from 1.9 to 7.1% [22][23][24]. Iatrogenic vascular lesions cause more deaths than non-IVIs do. IVI has a greater probability of fatal outcomes in an older population with more co-morbidities [22,23]. IVI that affects larger, more central (such as abdominal) arteries is more frequently deadly and typically requires more involved treatments, like by-passes and interposition grafts, but with fewer successful outcomes (graft occlusions and reoperations due to bleeding) [25]. The majority of fatal IVIs are caused by vascular injuries from intraabdominal surgery, percutaneous endovascular or cardiovascular interventions, and vascular injuries; however, death within 30 days is more frequently related to the conditions and diseases that the patients had rather than the IVI itself. Iatrogenic carotid artery injuries frequently result in death, according to registry data. However, additional case record analysis showed that patients with IVI of the carotid artery frequently died from the condition they had before the damage, not the injury itself [5].

Diagnosis
The gold standard for evaluating vascular damage is angiography; however, its utility is constrained by the method's invasiveness. Given that this method is noninvasive, colour-Doppler is advantageous for imaging the vessels in the extremities, as shown by numerous studies [26]. There are some drawbacks to colordoppler; the main one is being dependent on the investigator's expertise. The rapid advancements in Doppler technology are anticipated to result in better tools for vascular tree visualization [27]. The use of magnetic resonance (MR) angiography is becoming more widespread in the investigation of elective patients, although trauma cases have not yet been extensively studied [27]. The value of routine angiography and the treatment of any treatable diseases discovered are the current topics of discussion in the management of vascular injuries. It is uncommon to perform a routine surgical investigation of penetrating wounds close to major blood vessels but without obvious vascular damage. Angiography is frequently used to identify or rule out vascular damage and is thought of as conventional medical practice. The premise behind this is that even minor artery damage eventually leads to blockage [28,29].

Management Prevention
Vascular trauma can be classified into several kinds, primarily based on how the injury was caused. The most typical types of vascular injury are those caused by blunt and penetrating trauma. Vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection, and localized wall defects with pseudoaneurysm or bleeding are a few examples of vascular injury types [30]. Treatment Iatrogenic damage is a regrettable side effect of medical treatment. Procedure problems are not entirely preventable, although they can be reduced with the right education, experience, and visual assistance (such as real-time ultrasonography). Patient outcomes can be improved by prompt identification of iatrogenic damage and proper triage for additional treatment. For individuals with IVI, minimally invasive endovascular therapy may be an alternative [31].

Endovascular treatment
The concepts of reconstruction established for elective vascular surgery are used to treat vascular injuries. Due to continuing bleeding, circulatory instability, and challenging exposure, surgical procedures in emergency situations can be highly complicated. The potential of lessening the operating burden, ischemia time, and bleeding makes the idea of minimally invasive repair appealing. It is desirable to immediately stop a bleeding vessel via catheterdirected balloon occlusion. Regardless of the controversy surrounding whether or not angiograms are necessary for penetrating injuries to the extremities, there are many more situations in which angiography is obviously required. Clearly, angiography is necessary before endovascular therapy [27,31]. Endovascular and minimally invasive procedures are increasingly used in the transitional stage of vascular surgery. This has effects on how vascular injuries are treated as well. The constraints are that endovascular techniques are not frequently employed, and there might not be an institutional or regional organization for emergency operations, even though it is likely that many instances are appropriate for endovascular repair [27].

Primary anastomosis
This is carried out when there is no or little segmental loss. The segmental loss sets the primary anastomosis in danger, and if the anastomosis is under tension, there is a hazard of thrombosis or blowout [32].

Reverse Saphenous Vein Graft
If the segmental loss is greater than 2 cms. The limb on the other side should be used to harvest the saphenous vein. When repairing arteries, the vein should be utilized upside down. There should be no kinks in the graft or stress on the suture line [32].

Lateral repair
If only a lateral tear is present, sutures are primarily placed at the site of the vessel tear.

Conclusion
IVI registration is growing, and delayed diagnosis and treatment can have a detrimental impact on the prognosis. Given the nature of the iatrogenic injury, a large portion of the examined research consisted of case reports or retrospective studies, which limited its use. More studies are required to help identify risk variables that might put a patient at more risk of suffering harm than benefiting from an intervention. A better definition of outcomes for patients with IVI treated with minimally invasive endovascular procedures as opposed to conservative care, or surgical intervention requires additional research.