Patients with extremity vascular traumas present daily in emergency departments (EDs) and trauma centers worldwide. While much of the current state-of-the-art information is the result of wartime observations, the incidence of civilian extremity vascular trauma is significant. A basic understanding of both blunt and penetrating injuries to the extremities and the resultant vascular abnormalities that occur with these injuries helps minimize mortality and morbidity in these patients.
[ Crushed and mangled foot of a person who was involved in a motor vehicle accident ]
Problem
Civilian extremity vascular injury, as with the wartime experience, is most prevalent in cases of penetrating trauma; however, unlike the military experience, this penetrating trauma is usually due to knife wounds or low-velocity handgun injuries.4 Fortunately, high-velocity assault weapon injuries and explosive injuries are rare in the United States.
In many parts of the world, regional conflicts in which antipersonnel mines are used has given rise to a large population of children and civilian adults with extremity vascular and soft tissue injuries resulting in amputations. Civilian trauma surgeons expecting to render aid and services in these areas can refer to references such as Husum and colleagues' War Surgery Field Manual to augment their knowledge of civilian wartime injuries.5
Frequency
The actual frequency of extremity vascular injuries worldwide is difficult to quantify.
In the United States, it is possible to separate iatrogenic vascular injury from traumatic injury and to reference hospital discharge data for the frequency of diagnosis codes. However, this method may significantly underestimate the actual frequency based on the method used to code the diagnosis and the importance and ranking attached to the diagnosis. In many cases, government report forms only record the top 3 discharge diagnostic codes, enough to potentially miss codes due to iatrogenic injury.
With the increased interest in the United States, more precise incidence numbers may be observed in the next few years. Mattox et al6 and Feliciano et al7 have shown an increasing number of iatrogenic vascular injuries occurring in Houston over the last few decades, an observation that is probably mirrored nationwide.
Data on blunt and penetrating injury are somewhat easier to derive. In wartime circumstances, the number of injuries may be extreme. Sherif reported 224 extremity vascular injuries in 18 months during the Afghanistan War, roughly 150 per year.8 Fasol et al reported 94 patients in 3 months (ie, approximately 376/y) on the Thailand-Cambodia border.9 In both studies, antipersonnel mines caused the majority of civilian extremity vascular injuries.
Extremity vascular injury may result from penetrating injury (eg, gunshot wounds,16 knife injuries), but not all penetrating injuries are violent in nature. Many penetrating extremity injuries reported in the literature are from industrial accidents (eg, nail guns) or are iatrogenic complications of vascular access procedures for other medical problems.
Blunt injuries causing vascular injury typically result from motor vehicle accidents but may include falls, assaults, and crush injuries. Fractured long bones or dislocated joints frequently increase the overall risk of vascular injury, but certain injuries (eg, posterior knee dislocation) are more likely to cause vascular injury than other injuries (eg, a Colles fracture of the wrist, which rarely results in radial or ulnar artery injury).
The worldwide increase in explosive-type injuries constitutes an emerging third modality that combines the pathology of both blunt and penetrating injury to the extremities. Terrorist bombings, civilian land mine injuries, and combat-related injuries are becoming more common, and all physicians will undoubtedly encounter these patients sometime in their career.
Presentation
Worldwide, patients with extremity vascular injuries most frequently present after a penetrating injury to an extremity. In the United States, high-speed motor vehicle accidents, often with fractures or dislocations, result in the next largest group of patients. In patients with large lacerations or open wounds, persisting or increasing hemorrhage with resuscitation is an early indication of vascular injury requiring operative exploration.
Vascular injuries can be classified clinically into hard signs and soft signs of injury based on examination.
Classic so-called hard signs of vascular injury include the following : -
Observed pulsatile bleeding
Arterial thrill (ie, vibration) by manual palpation
Bruit over or near the artery by auscultation
Signs of distal ischemia
Visible expanding hematoma
These signs are used to identify patients requiring surgical intervention. A finding of cool, cold, and pulseless extremities may be attributable to a low systemic blood pressure, but isolated pulse abnormalities and significant variation in pulse quality from side to side are strong indicators of underlying proximal vascular injury. Neurologic deficit, delayed capillary refill, and bony abnormalities should increase the suspicion of extremity vascular injury and the need for emergent arteriography or surgical exploration and repair.
Soft signs of vascular injury include the following : -
Significant hemorrhage found on history
Decreased pulse compared to the contralateral extremity
Bony injury or proximity penetrating wound
Neurologic abnormality
Indications
In general, hard signs (eg, change in pulse quality compared to the opposite extremity, loss of pulse in the extremity) are absolute indications for further diagnostic studies (eg, arteriogram, exploration and direct visualization in the operating room). Softer signs (eg, temperature change, color change, delayed capillary refill, neurologic deficit) should alert the clinician to the need for close observation and monitoring. If the ABI is higher than 0.9, many authors advocate observation, but if the ABI is lower than 0.9, further evaluation is warranted. In these cases, many authors now recommend duplex Doppler vascular studies as a rapid, noninvasive method of assessing vascular injury. However, an arteriogram in stable patients and operative exploration in unstable or bleeding patients remain the criterion standards of care.
Laboratory Studies
Baseline blood work should consist of a CBC count with platelet count, electrolytes, BUN, and creatinine evaluations.
Typing and crossmatching of packed red blood cells for 4-8 U, depending on the severity of injury and hemorrhage, is also recommended.
Prothrombin time and activated partial thromboplastin time may be helpful in patients who are comatose and unable to provide an adequate medical history, although statistically, findings are rarely abnormal when the medical history documents no medications (eg, warfarin) or a history of bleeding problems.
In acute hemorrhage without equilibration, remember that the hematocrit or hemoglobin level may appear to be within the laboratory reference range even though there may be a significant cellular volume loss.
Imaging Studies
Plain x-ray films of the injured extremity are a rapid means of determining the presence of fractured bones and foreign bodies. Certain fractures (eg, supracondylar femur fractures) have a higher incidence of vascular injuries, and recognition of these types of injuries alerts the clinician to the risk of vascular injury.
CT scanning has been used in extremity trauma to visualize bony anatomy and soft tissues but still is not proven as a diagnostic modality in peripheral vascular injury. As such, CT scanning should not be used except in unusual circumstances.
Arteriography in the angiography suite is reserved for patients who are hemodynamically stable and preferably without renal failure or insufficiency. Most interventional radiologists require preprocedural BUN and creatinine measurements before proceeding with these studies. As soon as practicable, blood for these assays should be drawn in the resuscitation area to avoid delays in angiography, which may lead to delays in operative intervention.
In many cases, the surgeon can perform on-table angiography in the operating room with minimal risk to the patient. Surgeons should be familiar with arterial access points and the contrast materials available in their institution. Knowledge of total dye load and baseline renal status minimizes complications in this situation.
Duplex Doppler ultrasound studies of injured extremities have been shown to be a viable alternative to angiography in many centers. This study can be performed by the surgeon in the ED or in the resuscitation bay and can provide immediate and valuable information regarding patient vascular status or injury. Duplex Doppler ultrasound may be of limited use in patients with splints, extensive orthopedic hardware, areas of large tissue and skin loss, and when used by inexperienced personnel. Johansen et al offer a more detailed discussion of noninvasive tests in a screening situation.17
Other Tests
Ankle-brachial index
Measurement of the ABI is useful with atherosclerotic peripheral vascular disease and may be helpful in determining vascular insufficiency, but ABI cannot localize the site of injury.
Measurement of the ABI is a helpful component of the evaluation of penetrating arterial injury; however, the ABI cannot localize the site of injury.
A prospective study by Lynch and Johansen18 suggests that measurement of the ABI approaches the accuracy of arteriogram in identifying arterial injuries, and, more importantly, accurately identifies injuries needing intervention. Nassoura and colleagues supported this finding in a subsequent prospective trial.19
No diagnostic test is perfect; nevertheless, measurement of the ABI offers a noninvasive, simple, and reproducible method to accurately screen for penetrating arterial injury.
Assessing for a Doppler signal in peripheral vessels is more sensitive than manual palpation and is helpful in assessing for total occlusion or transection of the arterial tree.
Staging
Organ injury scaling may be helpful in the acute setting but should not override clinical experience and individual patient needs. Vascular injury scaling is also helpful for epidemiological study, peer review, and coding and billing. For information regarding organ injury scaling of peripheral vascular injuries currently sanctioned by the American Association for the Surgery of Trauma, see the study by Moore et al.20
Treatment
Medical Therapy
Medical therapy alone is rarely an option in penetrating or blunt trauma to the extremity vasculature with hard signs.
Asymptomatic patients or patients with only soft signs can often be observed, but this is best performed by a surgeon who is prepared to operate if the clinical examination changes. The observation must be performed with the understanding that if the examination findings change or if hard signs develop, surgical intervention is necessary.
While pharmacologic anticoagulation is a viable therapy for arterial thrombosis in some situations, acute injury of the arteriovenous tree usually requires surgical intervention and mechanical repair. Limited anticoagulation or antiplatelet drugs may be helpful after vascular repair, especially with prosthetic material, but carefully weigh the benefit of these drugs against the potential for hemorrhage in other injured tissue, especially with concurrent brain or spinal injury.
Surgical Therapy
Surgical intervention when suspecting peripheral vascular injuries can be as minor as operative visualization of normal vascular anatomy for diagnostic purposes or as extensive as reconstruction and replacement of entire segments of injured vessels.21 Timing of surgical intervention can be critical to outcome in extremity vascular injury. Vascular reconstruction that occurs within 3 hours of injury is generally accepted to have the best outcome. While this can frequently be accomplished in urban Level 1 Trauma Centers, it becomes more difficult in rural areas where availability of rapid EMS transport, geographic location of the hospital, and availability of interventional radiology and surgical subspecialists may be limited.
In most cases in which the injured segment is 1 cm or less, dissecting and freeing edges and performing a primary anastomosis is frequently possible. Take care to avoid traction on perforating branches or excessive dissection, which may devascularize surrounding tissue. Attention to vascular surgical technique should minimize tension on the vessel and stricture at the anastomotic site.
In more severe cases with multiple associated injuries, hemorrhage control by ligation of actively bleeding arterial or venous vessels may be all that is possible. Tissue viability distal to an arterial ligation depends on regional arterial anatomy, collateral blood flow, preexisting atherosclerotic disease, competent venous outflow, and volume status.
Although venous ligation is counter-intuitive, it may carry a higher risk than arterial ligation. Certain vessels, such as the popliteal vein, carry a high postligation amputation rate, while the rate for femoral or external iliac vein ligation is statistically lower. The risk of subsequent amputation after any ligation is much higher than after vascular repair, but patients with severe brain injury or hemodynamic instability may not tolerate a 2- to 3-hour operation to repair a vascular injury, and damage-control techniques with arterial or venous ligation may save lives. Use of intravenous chemical vasoconstrictors (phenylephrine [Neo-Synephrine, norepinephrine) should be minimized in the postoperative period.
If the patient's condition and hemodynamic status allow prolonged operative intervention, general replacement of an injured peripheral arterial segment is accomplished with an autologous vein. The saphenous or cephalic veins harvested from the same or contralateral extremity are the most commonly used vein segments. Polytetrafluoroethylene (PTFE) can be used in some situations but is usually reserved for above-knee or above-elbow applications. PTFE has been successfully used in contaminated fields with a low infection rate22 for both venous and arterial reconstruction. In some trauma centers, PTFE is the preferred conduit and has replaced the use of an autologous vein in above-knee, below-knee, and elbow reconstruction. Stevens et al23 summarize the causes of failure of arterial reconstruction.
Typically, in most acute situations, venous injuries are primarily ligated, but, in a select number of injuries in hemodynamically stable patients, venous reconstruction may be an option. Very little prospective data is available in the trauma literature, but readers are directed to an older but more pertinent retrospective review in the Journal of Vascular Surgery for more information.24
After reconstruction in the stable patient or vascular ligation in damage-control situations has been completed, the surgeon should consider the risk of reperfusion injury and the potential for compartment syndrome.25 While this is more common in distal lower extremities, it is also possible in proximal compartments and the upper extremities (see Image). Fasciotomies increase the risk of infection, increase fluid and blood loss, and eventually require reoperation for either skin closure or skin grafting.26 These complications should be weighed against the risk of compartment syndrome with risk of limb loss, renal failure from myoglobin release, and tissue gangrene. Monitoring compartment pressures in the postoperative period in conjunction with the clinical examination is possible, but prophylactic fasciotomies, even with the attendant risks noted above, are to be recommended in the more severe cases.
The most challenging injuries are those of the mangled extremity, with concurrent bony, soft tissue, nerve, and vascular injury. The treatment of these complex injuries precludes detailed description in a short review, but many authors have evaluated the factors that determine the risk of amputation.
Scoring systems have been developed as a means to predict amputation and functional outcome. Scoring systems such as Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS),27 Predictive Salvage Index (PSI), and Limb Salvage Index (LSI) have been reviewed by Durham et al.28 Prediction of amputation was sensitive and specific, but prediction of functional outcome was universally poor.
The MESS score appears to be the most commonly used method and is based on criteria that include (1) degree of skeletal/soft tissue injury, (2) limb ischemia, (3) shock, and (4) patient age.29
Note that some authors have been unable to validate individual scoring systems, and no one system is universally accepted.30
Interventional radiologic techniques should also be noted as an option in acute injury, but the indications and timing are still being developed. Coil embolization of complications of vascular trauma, such as arteriovenous malformations and pseudoaneurysms, are more commonplace and are described in more detail in Follow-up care. Endovascular stenting has been reported for acute traumatic injuries since 1994, but it is not yet available in most facilities.31,32 Long-term outcome and complication rates have not been calculated, and although the technique is promising, more long-term follow-up study is necessary.
Preoperative Details
If planning reconstruction, the best results have been reported in patients who are hemodynamically stable with normal laboratory findings and preoperative arteriography to localize the injury.
In some cases, operative intervention is primarily performed for life-saving hemorrhage control rather than for operative repair with limb salvage.
Intraoperative Details
Initial ligation of life-threatening vascular hemorrhage may allow stabilization of patients and subsequent exploration and repair of the injured vessels. In the patient who remains hemodynamically unstable, the surgeon should balance the desire to save the limb with that of preserving the patient's life.
Postoperative Details
Frequent monitoring and vascular checks (eg, pulse presence, quality, capillary refill) should continue for the first 24-48 hours. Consideration of anticoagulation and antiplatelet agents should be balanced with the risk of fatal hemorrhage from other injuries (eg, head and chest injuries).
Maintain adequate hydration, especially after administration of contrast dye, after episodes of hypotension, and in the presence of concomitant renal injury. A urine output of 20 mL/h or more is ideal in adult patients.
Follow-up
Vascular repair with palpable pulses in the postoperative period rarely requires repeat angiography. If a completion angiogram was not performed in the operating room, duplex Doppler ultrasound may provide a less invasive method of monitoring graft status.
Advise patients of the risks and symptoms of thrombosis or vascular occlusion so that they may quickly contact the surgeon or obtain evaluation in a local ED if problems occur. The surgeon should consider the need for anticoagulation or antiplatelet medications (eg, coumadin, aspirin), balancing the overall risk to patients with the needs of the graft and vascular repair.
Complications
Thrombosis of the graft remains the most common complication of vascular injury and blood vessel repair. Narrowing of the vessel with primary repair or kinking of the graft, especially after repetitive orthopedic intervention may compromise volume of flow and may require revision of the repair. Ligation of vessels for emergent hemorrhage control may result in ischemia, leading to amputation more frequently than vascular repair.
One of the more difficult situations for patients and surgeons occurs when permanent nerve injury ensues but is diagnosed late because of concurrent head or other injury. Functional vasculature with significant irreparable denervation of motor and sensory components of the extremity usually results in a useless appendage, which causes more problems or complications than amputation. Splinting or bracing the extremity occasionally provides an acceptable functional result and should be considered, but many patients opt for amputation and a functional prosthesis rather than a nonfunctional insensate extremity that requires constant care and monitoring.
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