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

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)

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

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

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

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)

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)

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

Diagnostic Evaluation penetrating or blunt injury, normal extremity pulse examination, minimum ankle brachial index (MABI) of ≥1.00 does not require arteriography Observe for 12-24 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

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

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

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

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

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

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)

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

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

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)

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

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

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

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

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

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

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

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

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)

Orthopedic, Soft Tissue and Nerve Injuries

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

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

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

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

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%

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

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

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

Iatrogenic False Aneursyms Significant number close spontaneously Compression therapy 10-150 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