1. Vascular Injuries of the Extremities
Rutherford 6th ed, Chp. 73
Maureen Tedesco, MD
October 31, 2005

2. History Civilian: UE arterial injuries more common
Military: LE arterial injuries more common
World War II extremity arterial injuries were ligated (popliteal artery injury amputation rate 73%)
Korean and Vietnam wars: amputation rate for popliteal artery injuries 32% (Hughes and Rich)
limb loss in most civilian series now less than 10% to 15%
long-term disability for 20% to 50% (soft tissue and nerve injury)

3. Mechanism of Injury In penetrating arterial injuries
gunshot wounds in 64%
knife wounds in 24%
shotgun blasts in 12%
Motor vehicle accidents, falls most common causes of blunt injury
High velocity firearms
dissipation of energy into the surrounding tissues
fragmentation of the projectile or of bone
blast effect
combination of penetrating and blunt tissue injury

4. Diagnostic Evaluation
"hard signs" of arterial disruption:
pulsatile external bleeding
an enlarging hematoma
absent distal pulses
an ischemic limb
Proceed to OR

6. Diagnostic Evaluation
Soft signs:
Significant hemorrhage by history
neurologic abnormality
Diminished pulse compared to contralateral extremity
In proximity to bony injury or penetrating wound

7. Diagnostic Evaluation
elective rather than routine arteriography is appropriate for patients who may have an occult extremity arterial injury
Weaver FA et al: selective use of arteriography is appropriate and safe (Arch Surg 125:1256, 1990)
Conrad et al:
Pts with normal PE and doppler pressure indices (DPI) can be safely discharged
Diagnostic arteriography is only indicated for asymptomatic patients with abnormal DPI
(Am Surg 68:269, 2002)

8. Diagnostic Evaluation
For blunt extremity trauma, the indications for arteriography parallel indications for penetrating injuries
Abou-Sayed et al.
clinical examination can define a subset of high-risk patients who need an arteriogram, and possibly surgical repair
(Arch Surg 137:585, 2002)

9. University of Washington Criteria Johansen et al, J Trauma, 1991 Lynch et al, Ann Surg, 1991
100 consecutive injured limbs in 93 trauma patients
All patients underwent arteriography
ABI<0.9
1 false negative (NPV 99%), 2 false positives
Sensitivity 87%, specificity 97%
Increases to 95% and 97% with clinical outcomes
100 traumatized limbs (84 penetrating, 16 blunt) in 96 consecutive patients
Arteriography only in those patients with ABI<0.9 (n=17)
16/17 with positive arteriograms
7 underwent reconstruction
83 limbs with ABI>0.9 underwent duplex f/u
5 minor arterial injuries (4 pseudos, 1 fistula)
0 major arterial injuries missed

10. Diagnostic Evaluation
penetrating or blunt injury, normal extremity pulse examination, minimum ankle brachial index (MABI) of ≥1.00 does not require arteriography
Observe for hours
Pts that have extremities with a distal pulse deficit or an MABI < 1.00  diagnostic arteriography useful, greatest yield
Role for Color Flow Duplex (CFD) ultrasonography
Noninvasive, painless, portable, low morbidity, inexpensive
Operator dependent
MRA
Image multiple anatomic areas, noninvasive
Not widely accessible

12. Treatment of Arterial Injuries: Nonoperative Approach
Low-velocity injury
Minimal arterial wall disruption (<5 mm) for intimal defects and pseudoaneurysms
Adherent or downstream protrusion of intimal flaps
Intact distal circulation
No active hemorrhage
Follow up required

13. Treatment of Arterial Injuries: Endovascular Management
Transcatheter embolization with coils or balloons
low-flow arteriovenous fistulae
false aneurysms
active bleeding from non-critical arteries
Stent-grafts:
endoluminal repair of false aneurysms
large arteriovenous fistulae
Requires sufficient experience and available personnel

14. Treatment of Arterial Injuries: Endovascular Management
Peroneal a. false aneurysm treated with coil embolization

15. Treatment of Arterial Injuries: Operative Management
preparation and draping of the entire injured extremity
drape contralateral uninjured lower or upper extremity (autogenous vein graft)
extremity incisions: longitudinal, directly over the injured vessel, extended proximally or distally as necessary
Proximal and distal arterial control is obtained prior to exposure of the injury
endoluminal balloon occlusion: when proximal control of the traumatized vessel is problematic, place under fluoroscopic guidance for temporary control

16. Treatment of Arterial Injuries: Operative Management
debride injured vessels to macroscopically normal arterial wall
remove any intraluminal thrombus with Fogarty catheters (proximal and distal to the arterial injury)
Flush with heparinized saline solution: proximal and distal arterial lumina
Systemic heparinization: prevent thrombosis or thrombus propagation (if systemic anticoagulation not contraindicated)
Consider temporary intraluminal shunting: debridement, fasciotomy, fracture fixation, nerve repair, or vein repair, before arterial reconstruction, in controlled setting

17. Treatment of Arterial Injuries: Operative Management
Types of Repair
lateral suture patch angioplasty
end-to-end anastomosis
interposition graft
bypass graft
Extra-anatomic bypass graft (sepsis or extensive soft tissue injury)
Autogenous vein graft, PTFE
Monofilament 5-0 or 6-0 sutures
repairs tension free
covered by viable soft tissue (flaps if needed)
Intraoperative completion arteriography
Intra-arterial vasodilators (papaverine or tolazoline)

18. Treatment of Arterial Injuries: Operative Management
risk factors for amputation after arterial repair
occluded bypass graft
combined above- and below-knee injury
a tense compartment
arterial transection
associated compound fracture

19. Treatment of Arterial Injuries: Operative Management
Reperfusion injury
Mannitol
Allopurinol
superoxide dismutase
catalase
Systemic Heparin

20. Brachial, Radial and Ulnar Artery Injury
Single-vessel injury in the forearm: need not be repaired but may be ligated or embolized
Repair is mandatory when one of the vessels was previously traumatized or ligated or when the palmar arch is incomplete
If both radial and ulnar arteries injured  the ulnar artery should be repaired ( dominant vessel)

21. Subclavian-Axillary injury
High mortality rate (39%)
fracture-dislocation of the posterior portion of the 1st rib subclavian a. injury likely
High collateral flow in UE makes absent pulses unlikely high index of suspicion
Mulitple chest incisions:
median sternotomy for proximal control
left anterolateral or "trapdoor" thoracotomy

22. External Iliac-Femoral Artery Injury
Iliac injuries: mortality rate 20-40%
External iliac: retroperitoneal approach

23. External Iliac-Femoral Artery Injury
common femoral, proximal deep femoral, and superficial femoral artery injuries: longitudinal thigh incision over the femoral triangle.
Interposition vein graft for repair of SFA

24. Popliteal Artery Injury
Challenging injury
injury above the knee joint: medial thigh incision
below-knee injury: a leg incision
isolated penetrating injury directly behind the knee: incision behind knee

25. Popliteal Artery Injury
Positive predictors of limb salvage
systemic anticoagulation (heparin)
laterally or end to end arterial repair
palpable pedal pulses within the first 24 hours
negative predictors of limb salvage
severe soft tissue injury
deep soft tissue infection
preoperative ischemia
Important: Attention to possibility of compartment syndrome and rapid treatment by complete dermotomy-fasciotomy if present

26. Tibial Artery Injury
Isolated injury, rare limb ischemia: no repair necessary
tibioperoneal trunk or two infrapopliteal arteries injured: repair is required

27. Pediatric Arterial Trauma
Management considerations:
severity of arterial spasm
unknown long-term consequences of autogenous grafts placed in children
long-term effects of diminished blood flow on limb length
papaverine (injected topically or into the adventitia), nitrates, or warm saline to impede vasoactivity

28. Extremity Venous Injuries
Most common injured veins:
superficial femoral vein (42%)
popliteal vein (23%)
common femoral vein (14%)
When venous injury is localized
end-to-end or lateral repair (stable pt)
an interposition, panel, or spiral graft can be configured for repair (extensive venous injuries)
the indication and benefit of vein repair is controversial
Ligation in unstable patient
Postoperative: extremity elevation and wrapping

29. Orthopedic, Soft Tissue and Nerve Injuries
arterial repair should be performed first to restore circulation to the limb before the orthopedic stabilization is addressed
inspect vascular reconstruction before final wound closure and before pt leaves OR
injured nerve should be tagged with nonabsorbable suture at the initial operation
Consider primary amputation for limbs with massive orthopedic, soft tissue, and nerve injuries
Consider primary amputation in hemodynamically unstable patients (repair might jeopardize survival)

30. Orthopedic, Soft Tissue and Nerve Injuries

31. Inadvertant Intraarterial Drug Injection (IADI)
Illicit street drugs, anesthetics
Complications
acute arterial occlusion
distal thromboembolism
mycotic aneurysms
soft tissue abscesses
gangrene
chronic ischemia

32. Inadvertant Intraarterial Drug Injection (IADI)
Soft tissue cellulitis/abscess pathogens:
Staphylococcus aureus
oral flora (streptococcal species)
anaerobic species (Peptostreptococcus and Bacteroides )
Findings:
severe, unremitting pain
edema
Numbness
discoloration
cyanosis or mottling
Diagnosis: history, clinical exam, CFD ultrasonography

33. Inadvertant Intraarterial Drug Injection (IADI)
Treatment soft tissue abscess:
Parenteral Abx
Incision and Drainage/ debridement
Prior to I&D, CFD ultrasonography to rule out the presence of a mycotic aneurysm

34. Inadvertant Intraarterial Drug Injection (IADI)
Goal: preserve all collateral circulation
Therapy:
Heparin sodium 10,000 units/hour IV (PTT 1½ to 2 times control) to prevent further clotting
Dexamethasone 4 mg IV q 6 hrs to reduce inflammation
Dextran 40 IV at 20 mL/hr to prevent platelet aggregation and thrombosis
Appropriate pain control, including opiates prn
Elevation of the extremity to reduce edema
Aggressive physical therapy to minimize contractures

35. Iatrogenic False Aneursyms
one of the most common complications after an invasive arterial procedure
Also termed pseudoaneurysm, pulsatile hematoma, or communicating hematoma
direct leakage of blood from the artery into the surrounding tissue
no walls of the artery involved
Post arterial catheterization 0.2-9%

36. Iatrogenic False Aneursyms
positive risk factors
Age older than 60 years
female gender
periprocedural anticoagulation
operator inexperience
underlying peripheral vascular disease
postprocedure arterial closure devices should see decline in rate

37. Iatrogenic False Aneursyms
Sign/symptoms
pulsatile mass
significant ecchymosis over the area of cannulation
sudden drop in the postprocedure hematocrit
newly auscultated bruit
newly palpable thrill
the new onset of neurologic deficits

38. Iatrogenic False Aneursyms
Duplex Scan
Noninvasive
Size of false aneurysm
Neck diameter and length
Architecture of native vessel
Velocity within native vessel and false aneurysm

39. Iatrogenic False Aneursyms
Significant number close spontaneously
Compression therapy minutes (variable success rates)
Percutaneous thrombin injection (>95% success)
Endovascular repair
Open surgical repair (gold standard):
failure of other treatment modalities
suspected secondary infection
evidence of vascular compromise
ongoing or imminent hemorrhage and skin erosion
necrosis due to false aneurysm expansion