Michael J. Sise and Steven R. Shackford
Vascular trauma in the extremities is challenging to manage. The risk to life and limb is high and the margin for error is very thin. The presentation varies from obvious life-threatening external hemorrhage to limb ischemia in the unconscious patient with multisystem injury. An organized approach with well-planned and implemented practice guidelines converts an error-prone process into one of opportunity for effective treatment (Table 41-1). Planning and preparation are essential to the success of this approach in view of the numerous causes of delayed recognition and lack of timely treatment. The need for an organized approach is made even more compelling by the advent of trauma systems and improved prehospital care with the resulting increase in the number of patients with what were previously fatal vascular injuries arriving at trauma centers still alive, but in immediate danger of death.1,2
TABLE 41-1 Potential Errors in the Recognition, Preoperative Preparation, and Operative Management of Extremity Vascular Trauma
This chapter reviews the pathophysiology, clinical presentation, diagnostic workup, management, and outcome of extremity vascular injuries. The educational objectives of this review include the following:
1. To identify the mechanisms of extremity vessel injury and the resulting clinical manifestations;
2. To describe an organized approach to rapidly assess injured patients for the presence of extremity vascular injuries;
3. To present management guidelines and examples of checklists to assist in the decision of which treatment options best apply and how to effectively implement them;
4. To articulate management guidelines that result in improved clinical outcomes following extremity vascular injuries; and
5. To present illustrative cases that demonstrate the principles of evaluation and management of peripheral injuries.
THE LESSONS OF WAR
The history of the surgical management of extremity vascular injury is laced with the lessons of war. In the beginning of the 20th century, the evolving science and practice of surgery included initial attempts at repairing injured blood vessels. Armed conflicts in the first two decades including the war in the Balkans and the Great War saw large numbers of limbs lost to the ligation of injured vessels with the resulting ischemic tissue loss.3,4 There were reports of successful lateral suture repair and anastomosis of injured vessels, but these techniques were not widely adopted.3 During World War II ligation continued to predominate the management of injured vessels.4,5 It was not until the Korean War that vessel repair by combat surgeons was employed on a widespread basis.6 The timing of arrival of casualties to combat hospital was, in part, a determinant of this successful change in management. Korea was the first conflict in which aeromedical evacuation was widely used. Casualty arrival times decreased significantly and injuries that were previously fatal were managed successfully by surgeons in mobile hospital units.6 In the Vietnam War, the practice of vascular repair coupled with an even more efficient evacuation system led to the development of many of the current techniques and management guidelines in the care of extremity vascular injuries. The Vietnam Vascular Registry maintained by Rich et al. proved a valuable clinical research tool in this process.7
The civilian experience in the subsequent three decades following the Vietnam War further improved the care of extremity vascular injury. The epidemic of urban violence in the 1990s provided urban trauma centers with extensive experience in the management of these injuries.8 The management guidelines and recommendations that resulted steadily advanced the practice of trauma vascular surgery. Surgeons trained in civilian trauma centers went to war in Operations Enduring Freedom and Iraqi Freedom prepared to manage extremity vascular injuries. These combat surgeons took the clinical management one step further with the widespread use of vascular damage control techniques including intraluminal shunt placement and delayed primary repair.9 The experience gained was brought home to civilian centers with valuable applications in the management of patients with extremity vascular injuries. The lessons of war coupled with the organized approach to trauma management in civilian trauma centers resulted in the guidelines and recommendations included in this chapter.
Vascular injuries of the extremities are infrequent but not uncommon in both civilian and military trauma patients.1,9 They are predominantly a problem in young men in their third and fourth decades.1,2Whether blunt or penetrating mechanisms, they occur in association with high-risk behavior.1,10 Substance abuse, violence, and late night hours are commonly associated factors in civilian extremity vascular injuries. The trauma center’s rates of blunt versus penetrating injury will largely determine the most common local causes of these injuries. Civilian centers have a distinctly different pattern of extremity vascular injuries compared with combat medical facilities. Blunt trauma with extremity fractures, small-caliber handguns, and knives cause the vast majority of civilian extremity vascular injuries. In military series, high-caliber rounds and explosive ordinance with shrapnel are the predominant wounding agents. The force, trajectory, and tissue damage associated with military injuries are much more devastating than those seen in civilian series.1,7,9
Survivable vascular injuries are most common in the extremities because of the lethality of torso vascular wounds. Both combat wounds and interpersonal civilian violence yield a significant rate of extremity vascular injuries. Vascular trauma occurs in less than 2% of combatants in military series and in less than 4% of patients in civilian series.1,8,10,11 Overall, vascular injuries occur most commonly in the extremities. This is due partly to selection bias because great vessel injuries of the torso, head, and neck are highly lethal and the patients succumb before arrival at the trauma center.
The great majority of vascular injuries are due to penetrating trauma. In the recent military experience in the Middle East, 89% of vascular injuries were due to a penetrating mechanism, either fragment wounds from explosive devices (64%) or gunshot wounds (25%).8 Penetrating trauma also predominates in the civilian setting, particularly in some urban environments where the incidence can be as high as 90%, most of which are due to gunshot wounds.1Rural settings have a higher proportion of blunt injuries, but they still make up less than 45% of the total.10 Vascular injuries do not occur in isolation. Because the vascular structures often lie in close proximity to nerves and bones, associated skeletal and nerve injury occurs in approximately 25% of patients.1,6,7,9
Mattox et al. documented a 400% increase in civilian cardiovascular injuries in Houston between 1958 and 1988, with 50% of all vascular injuries over this 30-year period occurring in the last 10 years of this study.1 The recent decline observed in urban violence has mitigated this trend somewhat, but random shootings with multiple casualties still occur.
Iatrogenic arterial injuries continue to increase. This increase parallels the rapid rise in endoluminal procedures, which increased 40% between 1996 and 2003.12 The postprocedure iatrogenic arterial injury rate is now 0.6% and appears to be specialty related.13 Cardiologists have a significantly higher rate (1.3%) than either the interventional radiologists (0.9%) or the vascular surgeons (0.5%).13
Arteries and veins are composed of three tissue layers including the outer adventitia of connective tissue, the central media of smooth muscle and elastic fibers, and the inner intima or endothelial cell layer. Trauma to a blood vessel (artery or vein) can produce hemorrhage, thrombosis, or spasm, either alone or in combination, depending on the magnitude of the force applied to the vessel. Hemorrhage occurs when there is a transmural defect—all of the layers (intima, media, and adventitia) are disrupted or lacerated. If the bleeding is controlled by the surrounding tissue (i.e., muscle or fascia), a hematoma is produced, which may or may not be pulsatile. If bleeding is not controlled or tamponaded, exsanguination can occur. Thrombus or thrombosis is produced if there is damage to the intima and the subendothelial tissues are exposed to the bloodstream. Local thrombus may embolize or propagate and eventually occlude the lumen. The injured intima may form a flap that can prolapse into the lumen (as a result of blood flow dissecting under it) producing partial or complete obstruction. Trauma to surrounding bony structures may cause external compression of the vessel, interrupting flow and producing thrombosis. Spasm or segmental narrowing is the result of mechanical trauma, such as occurs if the vessel is stretched or contused (Fig. 41-1). Severe spasm can also be produced by bleeding adjacent to a vessel due to the vasoconstrictive effects of hemoglobin. Spasm, by reducing the cross-sectional area of the vessel, reduces flow.
FIGURE 41-1 Severe spasm of tibial vessels following blunt force tibia and fibula fracture and internal fixation. After catheter-based nitroglycerin drip for 24 hours, normal ankle pulses and normal CT angiogram with normal caliber and no occlusion of all three calf vessels. Patient made a full recovery.
Penetrating injury has a much different pathophysiology than blunt injury. These injuries tend to be more discrete or focal, while blunt injury is more diffuse with injury not only to the vascular structures but also to the adjacent bone, muscle, and nerves. The diffuse nature of the blunt injury not only affects the major arteries and veins but also disrupts smaller vessels that would normally provide collateral flow around an occluded or narrowed vessel. As a result, ischemia is worsened or exaggerated. Penetrating injury is generally classified as low velocity (<2,500 ft/s). This includes stab wounds, fragment injuries, and low-velocity gunshot wounds. High-velocity (>2,500 ft/s) wounds, such as those caused by a military assault rifle wound, produce significantly more tissue damage than low-velocity weapons due to the energy imparted. The kinetic energy of a wounding missile equals the mass of the projectile multiplied by the velocity squared. The missile creates a rapidly expanding and rapidly contracting cavity that can reach a size equal to 30 times the diameter of the projectile. This occurs at right angles to the missile tract and stretches and tears the adjacent tissue. Fragments of the deteriorating projectile become missiles themselves and cause additional injuries.14
In addition to the acute pathophysiology produced by hemorrhage and thrombosis, trauma can produce subacute or chronic injuries, which may not become apparent for years. The most common of these chronic injuries are arteriovenous fistula and pseudoaneurysm. An arteriovenous fistula typically occurs after penetrating trauma that causes injury to both an artery and a vein in close proximity. The high-pressure flow from the artery will follow the path of least vascular resistance into the vein producing local, regional, and systemic signs and symptoms (Fig. 41-2). These include local tenderness and edema, regional ischemia from “steal,” and congestive heart failure if the fistula enlarges.15 A pseudoaneurysm is a result of a puncture or laceration of an artery that bleeds into and is controlled by the surrounding tissue (see Section “Case 6,” Fig. 41-21). The artery remains patent; blood flows into and out of the pseudoaneurysm—much like the ebb and flow of ocean water into and out of a tide pool. They can enlarge and produce local compressive symptoms, erode adjacent structures, or, rarely, be a source of distal emboli.15Initially, they can be clinically occult, but with time become symptomatic.
FIGURE 41-2 Acute axillary artery pseuodoaneurysm and arteriovenous fistula following stab wound in right axilla. Vessels repaired by simple closure.
Not all arterial injuries require an intervention. During the past two decades, it has been convincingly demonstrated that many asymptomatic traumatic vascular injuries have a benign natural history and either completely resolve or remain stable.8,16 At the present time it is impossible to predict which lesions will heal, which will progress and remain asymptomatic, and which will eventually develop either acute or chronic symptoms.
Acute interruption of blood flow to an extremity results in a number of systemic pathophysiologic disturbances that may threaten life as well as the affected limb. Ischemia results from a failure of oxygen delivery to meet tissue metabolic needs. The vulnerability of a tissue to ischemia depends on its basal energy requirement, substrate stores, and duration and severity of the ischemic insult. Peripheral nerves are most vulnerable to ischemia because they have a high basal energy requirement and virtually no glycogen stores. Therefore, motor and sensory deficits are often the first manifestations of arterial occlusion. Skeletal muscle is more tolerant of decreased blood flow; histologic changes are not evident unless ischemia has been present for ≥4 hours. Reversible changes occur in 4–6 hours following onset of ischemia if reperfusion is established by the end of that interval. The more complete the interruption of arterial inflow, such as occurs with occlusion of a major arterial conduit and disruption of collateral vessels, and the longer the duration of interrupted flow, the greater the potential for irreversible ischemic damage. After prolonged complete ischemia, damage may be extended rather than reversed by reperfusion.
Reperfusion injury is initiated with the reintroduction of oxygen and the conversion of hypoxanthine, a metabolite of ATP in ischemic tissue, to xanthine with the generation of the highly reactive superoxide and hydroxyl radicals. Leukocytes are thought to be the major source of free radicals in reperfused muscle. Such radicals and reactive oxygen species attack cell membrane lipids, proteins, and glycosaminoglycans, disrupting the integrity of the capillary, resulting in microvascular occlusion and elevated interstitial fluid pressure. This leads to a “no-reflow” phenomenon, and, ultimately, to irreversible ischemia and necrosis of both nerve and muscle.17 With muscle necrosis or rhabdomyolysis, myoglobin and potassium are released into the circulation, which may lead to fatal arrhythmias and renal failure. Thus, in addition to potential local and regional effects on limb dysfunction and limb loss, acute interruption of extremity blood flow can have systemic consequences of organ failure and death if not recognized promptly and treated aggressively.18,19
One of the most devastating early complications of extremity vascular injury is compartment syndrome. All muscle compartments in the extremities are vulnerable to intracompartmental hypertension that can lead to muscle necrosis. This may occur primarily from decreased perfusion and ischemia, secondary to intracompartmental hemorrhage from direct trauma, or after successful revascularization with reperfusion edema. Compartment syndrome results from swelling of muscle in a confined space (i.e., bound by inflexible structures such as fascia and bone) due to either reperfusion or crush injury. This swelling increases the tissue pressure within the confined space or “compartment” compressing both venous and lymphatic outflow as well as arteriolar inflow, further increasing tissue pressure and reducing perfusion, ultimately resulting in ischemic neurolysis and myonecrosis if unrecognized and not treated promptly. Compartment syndrome occurs most commonly in the muscle compartments of the lower leg. It may be life threatening because of the systemic effect of rhabdomyolysis, myoglobin-induced renal failure, and hyperkalemia.8,19
Proximal extremity venous obstruction accentuates the rise in compartmental pressure and is often a major contributing factor to compartment syndrome The anterior compartment of the calf is the least compliant area of muscle surrounded by fascia in the extremities and is the most vulnerable to compartment syndrome. Acute complete traumatic occlusion or ligation of the popliteal vein may cause enough increase in compartment pressure to cause compartment syndrome, particularly in the anterior compartment. The upper extremity has more extensive venous drainage and is less prone to develop compartment syndrome than the lower extremity following venous occlusion or ligation. Compartment syndrome follows less than 10% of brachial artery injuries and is not a complication of upper extremity venous ligation unless there is extensive soft tissue injury.20,21 Although the anterior compartment and forearm are the most susceptible areas, compartment syndrome may occur in any area of extremity muscle including the foot, hand, thigh, upper arm, and buttocks.
Intravascular migration of bullets, shotgun pellets, and other foreign bodies is uncommon and occurs in less than 1% of extremity vascular injuries.22,23 The most common occurrence is the migration of small-caliber shotgun pellets from the proximal extremity veins through the right side of the heart and into the pulmonary circulation. Larger bullets may enter arteries and embolize to distal vessels causing ischemia. Bullets that enter the great veins may embolize proximally to the heart or, by the force of gravity, travel in a retrograde fashion into the lower extremity veins.
Diagnosis requires a high index of suspicion and a thorough peripheral vascular examination. Entrance wounds without associated bullets on radiographs should raise the alert that bullet embolism may have occurred. Extremity radiographs or fluoroscopy should be performed to rule out bullet embolism when they are unaccounted for in proximity to entrance wounds or along suspected trajectories within the patient.
Acute limb ischemia requires prompt operation for bullet retrieval. In the absence of limb threat, angiography and snare deployment under fluoroscopy can be successful in bullet retrieval. A cutdown under local anesthesia at the snare introduction site is usually required to remove the retrieved bullet. Asymptomatic small-caliber shotgun pellets in the extremities are best left alone.
There are a number of factors that are significant in determining the outcome of extremity vascular injury. These include the location of the injury and mechanism, amount of hemorrhage, severity of associated musculoskeletal injury, time interval between injury and control of hemorrhage and restoration of flow, and the preexisting health status of the patient. All of these factors influence outcome and need to be considered in the management of extremity vascular injury. However, the most critical factor remains the time between injury and control of hemorrhage and restoration of flow. This generates a time urgency in the diagnostic workup and treatment of these injuries that must always be part of the management strategy.
Both recent military and civilian series demonstrate the importance of timely treatment in successful limb salvage following vascular injury in the extremities.1,7,9,24 Delays beyond 6–12 hours were associated with a rise in limb loss from 22% to 93% in a recent combat series. The association with musculoskeletal and soft tissue trauma also impacts this salvage rate because of the loss of collateral circulation. These recent reports reaffirm the tradition concept of a “golden period” of 6–8 hours following extremity vascular injury in which adequate flow must be established to avoid limb loss.
Not only do blunt mechanisms of injury cause greater damage to extremity vessels and surrounding structures than penetrating trauma, but their effects are also more widely distributed up along the course of the extremity and often involve associated significant torso injuries. These injuries are more likely to be difficult to diagnose than more clinically obvious and often localized penetrating injuries. Major torso injuries divert attention away from the extremities and the overall trend is for a delay in the recognition of blunt vascular injuries. This delay compounds the already worsened outcome because of the commonly associated soft tissue and musculoskeletal blunt force injuries.
In penetrating injuries, the wound force of gunshot wounds varies according to the type of projectile and, more importantly, its velocity. High-velocity, assault weapon–style injuries are extremely destructive in the extremities and have a high associated limb loss rate. Civilian handgun wounds with their low velocity have a much better prognosis. Knife wounds remain the least destructive mechanism of vascular injury and are often the easiest to manage. However, in the upper extremity, the association of median nerve injury with brachial artery lacerations negatively impacts overall functional outcome.
The muscle mass and collateral flow is significantly different in the upper versus lower extremities. The arm tolerates arterial occlusion much better than the lower extremity with its large muscle groups, greater length, and relatively poor collateral flow. Amputation rates in the lower extremity are approximately double those in the lower extremity following traumatic arterial occlusion in both military and civilian series.1,7,9 Both brachial artery and popliteal artery occlusions, however, have a very high risk of eventual limb loss and require the same expeditious workup and treatment. The disparity in size and collateral blood flow between the extremities also makes complications including compartment syndrome and the venous insufficiency more likely and more morbid in the lower extremity. However, because of the importance of hand function, the long-term effects of nerve damage are much more consequential in the upper extremity.
The presentation of extremity vascular injury varies from obvious life-threatening external hemorrhage from penetrating injury to occult extremity ischemia from blunt force arterial disruption and occlusion. A history of active bleeding, hematoma, or the findings of arterial occlusion and ischemia are present in most extremity vascular injuries.1,7,9,25–27 Less commonly, extremity vascular occlusion is masked by the presence of multisystem torso and extremity injuries. Failure to systematically evaluate the extremities with a clinical vascular exam augmented by Doppler studies is one of the most common causes of preventable limb loss. Blunt force injury resulting in extremity fracture must always be assumed to place the regional vascular structures at risk for injury. Fracture and dislocation patterns are also key indicators of the risk of extremity vascular injury. In the upper extremity, supracondylar humerus fracture is associated with a risk of brachial artery laceration. In the lower extremity, posterior knee dislocation carries a high risk of popliteal artery injury.
The presence of unexplained hemorrhagic shock in patients without evidence of head, neck, or torso injury should redirect attention to apparently trivial extremity lacerations. This is particularly important in wounds in the antecubital fossa, groin, and popliteal fossa. Initial external hemorrhage from laceration of the regional vessels may have led to hypotension with subsequent thrombosis and cessation of bleeding. There is the potential for large extremity dressings to mask recurrent hemorrhage after restoration of circulating blood volume and these should be promptly removed to assess the underlying wounds.
Delayed presentation of major complications of extremity vascular injury, although uncommon, should be considered in all blunt and penetrating extremity wounds. The tertiary survey later on the day of admission or the next morning should include a reassessment of extremity blood flow. This includes palpation of the distal pulses, assessment of the extremity for hematoma or muscle tenderness, and, if appropriate, Doppler interrogation of flow. No cast or dressing placed by an orthopedic surgery colleague should be left in place if there is any question about the adequacy of blood flow or the possibility of a missed vascular injury.
Compartment syndrome may develop insidiously. Irreversible tissue damage can occur in the absence of clinical signs and symptoms. When present, pain on passive stretch or pain out of proportion to findings should alert the examining physician to the possibility of compartment syndrome. Palpable distal pulses remain intact long after muscle blood flow has ceased in the compartment with tissue pressures above 25 mm Hg. Muscle and nerve necrosis can occur well before major arterial inflow is occluded. Therefore, the pulse examination is not sufficient to detect the development of a compartment syndrome. Measurement of compartment pressure is the only reliable means of detecting the presence of compartment syndrome.
A thorough physical examination with careful palpation of extremity pulses remains the basis for accurate and timely diagnosis of extremity vascular injury. This includes a vascular and neurologic examination of each extremity with careful palpation of peripheral pulses, assessment of color, warmth, and capillary refill. There is an unfortunate tendency to “overcall” the presence of pedal pulses. Once any examiner calls a pulse present when it is, in fact, absent, a cascade of errors may be initiated that result in limb-threatening ischemia. When in doubt, declare the pulse absent and add adjunctive assessment measures to make certain adequate perfusion is present.
There are very distinct physical findings that clearly indicate the presence of extremity vascular injury. In addition to these “hard signs,” there are less obvious but equally important “soft signs” that should bring attention to the possibility of extremity vascular injury (Table 41-2). The hard signs indicate a high probability of major vascular injury requiring immediate surgical repair.25–27 Lack of recognition of these hard signs of vascular trauma on the initial evaluation of injured extremities is the most common reason for the development of limb-threatening complications.1,19,24 The presence of soft signs of vascular injury mandates further workup with vascular imaging techniques and, less frequently, surgical exploration.25,26
TABLE 41-2 “Hard” and “Soft” Signs of Vascular Injury
Doppler assessment of pulsatile flow in the extremity is the primary adjunctive measure to physical examination. The experienced examiner can assess flow based on the character of the audible Doppler signals. However, the best way to use the Doppler device is in conjunction with a systolic blood pressure determination. The manual blood pressure cuff is placed at the wrist or ankle in the injured extremity and the probe placed over the distal vessel. The cuff is slowly inflated and the cessation of signal indicates the systolic blood pressure at the level of the cuff. The uninjured contralateral extremity and an uninjured arm pressure are determined. The normal ankle–brachial index is 1.1. Unless the patient has preexisting peripheral vascular occlusive disease, the ankle–brachial index should be at least 0.9 and there should be less than a 20 mm Hg difference between extremities.28 An absolute pressure below 50–60 mm Hg at the wrist or ankle indicates immediate limb-threatening ischemia in the patient with a normal systemic blood pressure.
Beware the patient with advanced peripheral vascular disease, particularly if it is related to diabetes. Calcified extremity vessels are noncompressible and cannot be occluded by inflation of the blood pressure cuff (even with inflation pressures of 200–300 mm Hg), resulting in a falsely elevated systolic pressure. Physical examination may be unreliable in the detection of compartment syndrome. This is particularly true in patients with altered mental status from injury, intoxication, or medication and who have a lower extremity neurologic deficit. When present, pain on passive stretch or pain out of proportion to findings should alert the clinician to the possibility of compartment syndrome. In such cases it is best to directly measure the compartment pressures.
The traditional debate over the role of preoperative arteriography for patients with extremity vascular injury was based on two key facts. First, there are many injuries easily and accurately diagnosed by physical examination and, second, time can be lost in obtaining formal catheter angiography leading to prolonged ischemia and poor outcome. There remain a significant number of extremity vascular injuries that are best managed by immediate operation and in which arteriography may be a needless waste of time and resources. There is an arteriogram time equation that should be considered in the workup of these injuries. Is the information obtained worth the time delay in restoring flow in the ischemic limb? Even if there is an angiogram suite on standby, ready to go, it requires a minimum of 90 minutes to obtain formal arteriography. The second part of this calculation answers the question: will the arteriogram direct the choice of operative versus nonoperative therapy or focus the operative approach to improve outcome? Multilevel blunt extremity injuries associated with ischemia and multiple penetrating injuries to an extremity (such as occurs with wide pattern shotgun blast injury) fall into this category and, thus, necessitate contrast imaging.
The advent of widely available high-resolution multidetector CT angiography has radically changed the approach to contrast imaging for extremity vascular trauma and made the old debate largely irrelevant. Catheter arteriography for the evaluation of injured extremities has become relatively uncommon at most trauma centers. High-resolution CT scanning with the appropriate imaging protocols produces rapidly available visualization of extremity vessels that rivals that of catheter arteriography (see Section “Case 6”). This results in images available in minutes rather than hours. The reluctance to perform catheter angiography in the past because of this delay has been replaced with a liberal use of CT angiography. The indications remain the same for both methods of vascular imaging (Table 41-3). However, in diffuse extremity injury from shotgun wounds, catheter-based angiogram may be more accurate than CT angiography because of the scatter effect of the numerous metal projectiles that obscure the arterial lumen. Also, catheter angiography remains essential in those patients who may require an endoluminal therapy, such as infusion of a vasodilator or placement of a covered stent, at the time of the diagnostic angiogram. Patients with spasm without significant arterial wall injury may benefit from this added capability.
TABLE 41-3 Indications for Arteriography in Patients with Extremity Injuries
Single-injection arteriogram in the trauma room or operating room is a quick and accurate method of definitive imaging in unstable patients with associated torso injuries or multilevel extremity injuries who require immediate operation. This simple and direct technique is quickly performed and effective in the unstable patient with multiple injuries who needs prioritization of management by evaluating extremity blood flow (see Section “Case 7,” Figure 41-27). The technique of trauma resuscitation room arteriogram is described in Table 41-4.
TABLE 41-4 Technique for “Single-Shot” Extremity Arteriography
The widespread availability of duplex scanning led to its application in the workup of vascular imaging.28 However, it has not proven useful in the diagnosis of acute arterial injury because it requires the presence of a skilled vascular technologist to perform the test and an experienced provider to interpret the study—neither of which is usually available on an expedient basis. Duplex color flow imaging has great usefulness in the diagnosis of chronic injuries, such as pseudoaneurysms and arteriovenous fistulae, and in the postoperative follow-up of vascular repairs.
Practice Recommendation for Extremity Vascular Diagnostic Evaluation
An outline of the recommended approach to the prompt diagnosis of extremity vascular injury is detailed in Fig. 41-3. Physical examination remains the most important element of this process. Common sense dictates that those with obvious injury go directly to the operating room to delineate and repair the injury. Imaging with either high-resolution CT angiogram or catheter arteriography must make sense in terms of the expense of time and the value of the results in deciding and directing the operative approach.
FIGURE 41-3 Diagnostic evaluation of extremity vascular injury.
Minimal Vascular Injury and Nonoperative Management
The widespread application of arteriography in the evaluation of injured extremities results in the detection of clinically insignificant lesions. There is now an extensive body of experience with lesions that are not clinically significant. These minimal vascular injuries include intimal irregularity, focal spasm with minimal narrowing, and small pseudoaneurysms. They are often asymptomatic and usually do not progress.
A small, nonocclusive intimal flap is the most common clinically insignificant minimal vascular injury. The likelihood that it will progress to cause either occlusion or distal embolization is approximately 10–15%.16,29 This progression, if it occurs, will be early in the postinjury course. Spasm is another common minimal vascular injury. This finding should resolve promptly after initial discovery. Failure of the return of normal extremity perfusion pressure indicates that a more serious vascular injury is present and intervention is needed. Small pseudoaneurysms are more likely to progress to the point of needing repair and must be actively followed with duplex color flow imaging. Arteriovenous fistulae always enlarge over time and should be promptly repaired. Considerable evidence suggests that nonoperative therapy of many asymptomatic lesions is safe and effective. However, successful nonoperative therapy requires continuous surveillance for subsequent progression, occlusion, or hemorrhage. Operative therapy is required for thrombosis, symptoms of chronic ischemia, and failure of small pseudoaneurysms to resolve.
The use of endovascular therapy for the treatment of atherosclerotic arterial disease has become widespread. What began as a simple balloon dilation in the common iliac arteries over 30 years ago has grown to include a wide variety of techniques. Whether it is endoluminal stent deployment for occlusive lesions or aortic aneurysms, there is a strong tendency to generalize from the elective use in nontrauma patients to the treatment of acute vascular injuries. Almost every major trauma center has its share of cases successfully treated with the use of elective techniques for acute vascular lesions. However, the evidence to support these approaches is not well developed and there have been problems. A review of available evidence combined with common sense should help define the current role of endovascular management of traumatic injuries.8,30,31
Extremity vascular injury resulting in hemorrhage is best treated by promptly performed open surgical techniques. The use of stent grafts in the extremity vascular injuries is becoming more common.30,31However, the results are not yet well documented. Caution may well be the best approach. Covered stents are easily placed in partially occluded vessels and although they have initially favorable early patency rates, they are prone to occlusion. In comparison, autologous vein interposition grafts have excellent long-term patency rates and remain the gold standard for vascular repairs in the extremities.
Catheter-directed therapies for hemorrhage from branch vessels in the extremities can be effective in successfully managing these injuries. These measures, in addition to ultrasound-guided thrombin injection, are effective in iatrogenic acute pseudoaneurysms following invasive procedures; this approach is not effective in most extremity vascular injuries. The small hole in the artery following removal of an arterial sheath is very different than the larger defects seen with vascular trauma. The risk of complete arterial thrombosis or distal emboli is high with this approach.8,19
Who Should Perform Endovascular Repairs
Have the right person do the right thing in the right place at the right time. This simple rule needs to apply at all times. Endovascular surgery, like all operations, should be performed by readily available trained clinicians. In most centers this includes the interventional radiologist. Other centers have catheter-trained vascular surgeons and a few others have trauma surgeons who are capable of performing catheter-based vascular interventions.
It does not require a fully capable endovascular operating room suite to perform endovascular techniques. A modern digital C-arm with digital subtraction angiography capability for fluoroscopy, lead aprons for the OR team, and the appropriate guidewires and catheters turns any OR into an endovascular capable room. However, this cannot be improvised the first time it is needed. Planning and preparation are essential for success. A team approach is essential to be ready for the opportunity to perform endovascular techniques when indicated. This approach is most successful in centers with an active elective endovascular program.
The successful operative management of extremity vascular injuries requires both prompt control of hemorrhage and timely restoration of adequate perfusion. These priorities must be orchestrated with the overall care of the patient. Both adequate resuscitation and the role of damage control are important factors in the management of extremity vascular injuries. Secondary considerations include adequate tissue coverage of repair sites, orthopedic surgical procedures, the prevention of compartment syndrome, early recognition of thrombosis of repaired vessels, and wound management. Minimal vascular injuries may be successfully managed nonoperatively with careful observation. There is also a limited, but emerging, role for endovascular therapy.
Who Should Perform Vascular Trauma Surgery
In an era of fewer open vascular procedures and falling numbers of major vascular cases performed during surgical training, the repair of extremity vascular injury may not be within the reasonable practice capabilities of many trauma surgeons. Operative procedures to manage vascular injuries should be limited to those surgeons who are capable, experienced, and qualified. This is not a trivial matter. Board certification in vascular surgery is not enough to qualify a surgeon as capable to handle these injuries just as the lack of certification does not necessarily disqualify a surgeon. Many surgeons who perform elective vascular surgery are not sufficiently experienced in the management of vascular trauma. Conversely, there are many trauma surgeons who are very skilled in vascular technique by virtue of their interest and experience. Surgeons with experience in vascular techniques and management of vascular injuries need to be available at all trauma centers to deal with these challenging injuries. This may be provided by members of the primary trauma on-call panel or vascular surgery specialists available on a backup call panel.
Successful operative management of extremity vascular injuries requires a systematic approach with careful preparation. This process is very amenable to a checklist to assure thorough preparation and to avoid errors (Fig. 41-4). There is considerable risk involved if the care of the extremity vascular injury is not properly orchestrated with the overall care of the patient. This begins with airway control, adequate intravenous access, and availability of blood products. The administration of these blood products, however, should not begin before obtaining control of hemorrhage unless the patient is profoundly hypotensive.32–34
FIGURE 41-4 Preparation checklist for extremity vascular repair.
Damage control resuscitation with permissive hypotension, avoiding unnecessary fluid infusion, prompt hemorrhage control, and restoration of blood volume with blood products is the best approach in patients with hemorrhagic shock. If the blood pressure remains below 80–90 mm Hg, the goal should be to provide adequate volume restoration with type O-negative packed cells and type AB fresh frozen plasma infusion to support prompt transport to the operating room for definitive hemorrhage control. Volume infusion that raises the blood pressure above a systolic of 90–100 mm Hg may increase bleeding and negatively impact outcome particularly if the infusion delays transport to the operating room.33,34 Crystalloid infusion risks causing both recurrent hemorrhage and dilutional coagulopathy and should be avoided. There is evidence that, once hemorrhage is controlled, restoring blood volume by transfusion with equal ratios of units of packed cell, fresh frozen plasma, and platelets improves outcomes.35
Extremity hemorrhage from vascular injuries requires prompt control. There are a variety of commercially available disposable tourniquets that are very effective in providing temporary control. The favorable results from the widespread use of tourniquets in Operations Enduring Freedom and Iraqi Freedom are compelling.9 There should be no hesitation to use them when indicated in the care of civilian injuries. However, proper use requires appropriate placement on the extremity proximal to the area of injury with sufficient pressure to occlude flow without crushing tissue. The time of placement should also be carefully recorded to keep track of occlusion time and avoid permanent damage from ischemia and delayed restoration of adequate flow. There is no role and no need for blind clamp placement in the injured extremity with active hemorrhage. Properly placed tourniquets or a gloved hand compressing the bleeding site during transfer to the operating room is the only appropriate measure. There is also no role and clear danger involved in local wound exploration in the trauma resuscitation bay for vascular control. The operating room with all its capabilities is the proper place for exposure and control.
Preoperative preparation should include the administration of broad-spectrum preoperative antibiotics and, if there is a penetrating wound or open fracture, tetanus toxoid. If there is an isolated extremity injury without significant hemorrhage, a bolus of 5,000 U of heparin should also be given intravenously. However, avoid systemic heparinization in patients with head, torso, or multiple extremity injuries. The most commonly omitted step in preparation to repair extremity vascular injury is a failure to document preoperative extremity neurologic examination findings. The presence of a neurologic deficit after operative vascular repair without knowing the preoperative status presents a very difficult management challenge. This may prompt unnecessary reexploration. A new neurologic deficit after vascular repair merits investigation and, possibly, reoperation. Therefore, a thorough preoperative neurologic examination and careful documentation are needed to compare with postoperative status and effectively manage potential complications.
Early involvement of orthopedic surgery and plastic and reconstructive surgery colleagues is essential in the presence of fractures or extensive soft tissue injuries associated with extremity vascular injuries. Consultation should be undertaken immediately on recognition of these injuries to involve these specialists in preoperative planning and intraoperative decision making. The sequencing and conduct of the operation should also be discussed with these colleagues.36 For example, the initial use of temporary vascular shunts to reperfuse an injured extremity followed by orthopedic stabilization can remove the sense of urgency to definitively restore blood flow. Extensive soft tissue injuries may compromise the proper coverage of vascular repairs and fracture fixation. The choice of definitive internal fixation versus external fixation of fractures requires consideration of both the vascular repair and the extent of soft tissue injury and plans for coverage and reconstruction. The discussion and subsequent decision making is a preoperative step that cannot be deferred without risking the ultimate successful outcome.
Once operative priorities have been established in patients with extremity vascular injuries, it is important to communicate with the operating room. Proper preparation includes the availability of the appropriate instrument sets, appropriate positioning of the patient, availability of sutures and graft material, and other ancillary equipment, such as loupe magnification and coaxial lighting. Communication with the anesthesiologist involved in the planned operation should also occur and include an assessment of the patient’s resuscitation needs, estimated duration of operative intervention, plans for multispecialty approach, need for blood products and a cell saver device, and estimated duration of operation. Vascular repairs in the extremities require general anesthesia, an arterial line for blood pressure monitoring, and adequate venous access. Warming devices are also essential to prevent hypothermia. Even the most experienced vascular surgeon plans on a considerably long operative time to complete these repairs.
Specific equipment, suture, and graft material requests should be communicated as soon as possible to the operating room team. Most operating rooms have major vascular instrument sets for the extremities. Ask to have them opened and ready. Prepare heparinized saline (5,000 U of heparin per 500 mL of saline for injection for a 10 U/mL solution) for locally flushing vessels. Low-molecular-weight Dextran (40,000) and papaverine hydrochloride (30 mg/mL) for treatment of vascular spasm should also be available in the operating room. Also request the appropriate vascular sutures. For suture repair, 5-0 Prolene on a C-1 needle is very useful. A variety of sutures should be available for vascular anastomosis. Request 5-0 Prolene on a BV-1 and C-1 needle or 6-0 Prolene on a BV-1 needle. For tibial and forearm vessels, either a 6-0 Prolene on a BV-1 needle or a 7-0 Prolene on a BV-175 needle should be available. All sutures should be of appropriate length and be on double-armed needles. PTFE graft material of various sizes (6 and 8 mm diameter) with external rings should also be readily available if saphenous vein is not of sufficient size or an extra-anatomic bypass is needed in injuries associated with extensive soft tissue loss.
Preparation also includes personal supervision of positioning, prepping, and draping. Proximal areas of the torso including the chest and shoulder for upper extremity injuries and the abdomen for lower extremity injuries should be prepped and draped with the injured extremity. Always prep and drape an uninjured leg for saphenous vein harvest if needed. Review the instrument trays, sutures, graft material, and presence of heparinized saline to make certain that the operative procedure can proceed smoothly without unnecessary interruption. Plan ahead and have a standard set of equipment, sutures, and graft material routinely prepared and frequently checked by experienced operating room staff. The middle of the night is not the time to pull together this equipment from various parts of the operating room to manage a patient who is actively bleeding from an extremity vascular injury.
Vascular injury in the extremities associated with major torso injuries must be managed in an orchestrated fashion to achieve operative goals in a timely fashion. It may require two teams operating simultaneously, particularly if damage control measures, including temporary shunt placement, are used in the ischemic extremity form vascular injury associated with life-threatening torso injuries. The planning before beginning the operation must be carefully done to achieve a successful outcome. This requires both effective teamwork and communication. The use of checklists is essential to properly complete this phase of the care of these challenging injuries.
Principles of Operative Management
The key factors in successful operative management of extremity vascular injuries are exposure and vascular control, debridement of injured vessel wall, proximal and distal balloon catheter thrombectomy, and a tension-free repair or interposition graft of appropriate size. Soft tissue coverage, fracture fixation, and timely fasciotomy are also essential to complete management. Each of these steps is prone to error and must be thoughtfully and effectively completed.
Exposure and Control
The incisions for exposure of extremity vascular injuries should be both appropriately placed and generous in length to expose noninjured adjacent proximal and distal segments of the injured vessels for vascular control. There is a tendency of some surgeons to use the small incisions for elective extremity vascular surgery. This leads to the risk of inadequate exposure and incomplete hemorrhage control. In proximal extremity injuries with active hemorrhage, the first incision site is chosen to give the fastest exposure of inflow vessels for clamping. For proximal upper extremity injuries in the axilla, this should include incisions over the infraclavicular region of the chest for access to the proximal axillary vessels. For injuries in the groin, prepare to enter the lower quadrant of the abdomen for access to the external iliac vessels.
In mid and distal extremity vascular injuries where tourniquets have been applied to obtain control in the trauma resuscitation room, a sterile tourniquet can be placed. In the operating room, have one team member precisely compress the bleeding site with a gloved hand and a sponge, remove the tourniquet, and prep the extremity. A 5,000 U heparin bolus is then given if this is an isolated injury. The extremity is prepped and draped and a sterile tourniquet is placed proximal to the wound and inflated. The injury site can then be explored in a controlled fashion and clamps or vessel loops placed above and below the vascular injury. The tourniquet can then be deflated.
Incisions for vascular exposure in the extremities are discussed in Section “Vascular Injuries by Anatomic Region.” It is worth reemphasizing that the use of small incisions may lead to error in identifying the extent of vascular injury, adequately controlling branch vessel hemorrhage, and identifying associated venous lacerations.
There are important considerations at other extremity joints for both adequate control and a good functional outcome. In general, dividing the inguinal ligament in the groin, dividing the pectoralis major muscle in the axilla, and removing the midportion of the clavicle are not often required. However, in life-threatening hemorrhage that cannot be controlled by any other approach, they should not stand in the way of adequate exposure and control. In the upper extremity, incisions across the antecubital fossa should be crafted in an “S” shape across the joint to prevent wound contracture and limitation of elbow joint movement.
There are a variety of adjunctive measures that can obtain temporary control in the operating room. Insertion of an appropriately sized Fogarty balloon-tip catheter on a three-way stopcock under direct vision in the artery above or below the level of injury with balloon inflation at the site of injury may gain control in difficult to reach anatomic areas. Insertion of balloon catheters in the operating room under fluoroscopy for control in centers with immediately available equipment and trained personnel by the surgeon with endovascular skills also has a role. However, this capability is uncommon and limited to a few centers. However, this minimally invasive adjunct to vascular control will probably become a routine part of managing extremity and torso vascular injuries in the future.
Control of proximal and distal flow is best achieved by double passing silastic vessel loops around the vessel above and below the area of injury and gently retracting until flow ceases. Place the vessel loops a sufficient distance away from the injury to allow them to not slide to the area of injury. Bleeding side branches should be occluded with removable metal clips. If clamps are needed, choose the appropriately sized noncrushing vascular clamp and apply closing the ratcheted handle only as much as needed to occlude the vessel. Carefully support the clamps to avoid twisting and inadvertent stretching of the vessels. Clamp trauma can cause intimal disruption and early thrombosis or the late development of stenosis.
Once adequate exposure and vascular control has been obtained, a systematic approach in choosing the technique of arterial repair needs be quickly used (Fig. 41-5). The injured ends of the vessel should be sharply debrided to a level of normal arterial wall. Fogarty balloon catheters must be carefully passed proximally and distally to clear thrombus and insure adequate flow. Heparinized saline in a syringe with a vessel irrigator should then be gently flushed proximally and distally after first aspirating blood to insure that the tip is in the lumen. Care should be used flushing the proximal brachial artery. As little as 10 mL flushed vigorously may force thrombus or air back up the proximal vessels to the origin of the vertebral arteries and cause a posterior circulation stroke.
FIGURE 41-5 Decision making in extremity arterial and venous repairs in stable patients.
The debrided and appropriately flushed artery should then be assessed to select the method of repair that should be tension free and of adequate diameter. Normal arteries in the extremities of young patients are highly elastic and retract a remarkable distance. There is a significant risk of stenosis and thrombosis when undue tension is placed in an attempt to perform a primary repair. Transverse or short oblique lacerations without vessel wall disruption from knife wounds may be repaired with simple sutures. The laceration should be extended transversely to inspect the intima and debride as needed. The arteriotomy is then closed with a transverse running suture or interrupted sutures. Longitudinal and long oblique lacerations cannot be closed without compromising luminal diameter. The injured site should be opened longitudinally a sufficient length to inspect and debride vessel wall. An oval vein patch can then be used to close the arterial defect without compromising the diameter of the lumen. A PTFE patch is an acceptable alternative in the common superficial femoral arteries if vein is not available.
When there is complete vessel transaction, there is a commonly quoted “2 cm” rule that implies that up to 2 cm of brachial and superficial femoral artery length may be resected followed by primary anastomosis. This is very misleading. Even if there is minimal debridement, the vessel ends should be spatulated to assure a nonstenotic anastomosis. The ≥2 cm vessel length is quickly lost. Additional vessel length may be obtained for a tension-free anastomosis by mobilizing proximal and distal segments of normal artery. Care should be taken however to limit this dissection to a reasonable length. When in doubt about length and the amount of tension, perform an interposition graft.
Vessel injuries that cannot be repaired by primary end-to-end technique require an interposition graft. The optimal interposition graft material is autologous greater saphenous vein harvested from an uninjured leg.8 Native vein graft is preferable because it has elastic properties that make it very compliant with the normal pulsatile flow of an artery. It also has a diameter that approximates that of an extremity artery and produces an adequate size match for grafting in the arm and leg. Venous intima is less likely to be thrombogenic and it has superior long-term patency when compared with prosthetic material when used with smaller vessels (popliteal and tibial). Cephalic vein and lesser saphenous vein have been suggested as suitable second choices, but cephalic vein is less muscular than the greater saphenous. Both the cephalic vein and the lesser saphenous vein are difficult to harvest in trauma patients.19
Saphenous vein is not always suitable because of inadequate size or extensive bilateral lower extremity injuries, or because it has been harvested previously for elective cardiac or peripheral vascular bypass.37A synthetic graft is an acceptable second choice. Initial experiences with the use of prosthetic material (Dacron) in traumatic vascular injuries were disappointing. Reports from the Vietnam War revealed a complication rate of over 75% and infection and thrombosis were the most common.38 However, more recent experience with PTFE has shown improved patency of 70–90% in short term and infections are rare even in contaminated wounds.37,39,40 It is clear that patency with PTFE is equivalent to vein for injuries proximal to the popliteal artery, but inferior to vein for popliteal and more distal vessels and that PTFE grafts of at least 6 mm diameter should not be used.39,40 Both PTFE and vein grafts must be covered or there is a significant risk of hemorrhage from desiccation of the vein with subsequent autolysis or breakdown of the anastomosis.41
Single-vessel arterial injuries in the distal forearm and distal calf may be ligated if there is sufficient collateral flow through the remaining vessels. This is best assessed by observing backflow through the distal cut end of the vessel. Doppler signals in the hand or forefoot vessels are a reassuring sign of adequate peripheral perfusion. When in doubt, perform an intraoperative arteriogram.
The decision to repair major venous injuries in the extremities is based on the physiologic status of the patient and whether or not the operating surgeon is capable of performing venous reconstruction. The decision to ligate major venous injuries is discussed in Section “Vascular Damage Control.” The skill and experience of the operating surgeon must also be considered. Lateral venorrhaphy without creating significant stenosis is possible in very few venous injuries. Vein patch closure or panel graft interposition is frequently required (Fig. 41-5). These procedures, while not beyond the technical ability of all trauma surgeons, require previous experience if they are to be performed in a timely and effective fashion. Consequently, many vein injuries, if not most, are ligated. In the lower extremity, major venous ligation leads to venous hypertension in the calf and places the patient at a higher risk for compartment syndrome. As discussed in Section “Vascular Damage Control,” calf fasciotomy should be performed in this setting.
Lateral venous repair, when possible, is best performed with a 6-0 or 7-0 Prolene running suture, taking care to avoid undue tension and purse-stringing. Autologous vein patch angioplasty should be considered in more extensive injuries with sufficient remaining uninjured vein wall. The vein patch needs to be of a generous size to maintain adequate luminal diameter. Uncommonly, stab wounds result in a transversely oriented transaction that may be primarily repaired by simple anastomosis of the cut ends without causing significant stenosis. More extensive circumferential injuries require a saphenous vein panel graft interposition. This is performed by harvesting a long segment of saphenous vein, opening it longitudinally, wrapping it around a large chest tube or other appropriate large cylindrical structure, and sewing it in a spiral fashion to create a panel graft. This large-diameter graft is a suitable conduit for venous reconstruction. This technique is tedious and requires significant vascular technical ability and experience. It should not be tried without the help of an experienced colleague.
The continuous passive motion device used in major joint surgery is an excellent adjunct in improving venous draining in bed-bound patients after major venous injury and either repair or ligation. This device has proven effective in reducing the risk of deep venous thrombosis following major orthopedic trauma in the lower extremity.42 It markedly improves venous drainage and should be considered in any patient with significant lower extremity venous trauma.
Intraoperative Assessment of Vascular Repairs
On completion of a vascular repair, local and distal pulse examination should be performed. Handheld Doppler interrogation of the repair site and distal flow should also be performed. Constant high-pitched signals indicate the presence of stenosis and should prompt inspection for technical problems at the sutures line. Ankle or wrist Doppler pressure measurements may be misleading because of regional vasospasm in the proximal injured extremity resulting in a reduced distal pressure compared with the uninjured leg. Intraoperative duplex scanning is useful but requires significant training and experience to perform it adequately. Unexpected problems at the suture line occur in as many as 10% of vascular repairs.19 The presence of early platelet thrombus, kinking, or an intimal flap may cause early failure. In distal repairs or those of questionable patency, an intraoperative arteriogram is essential.19 Either single-injection radiography or fluoroscopy is effective in providing images in the operating room (see Section “Case 7,” Fig. 41-27). Intraoperative radiographic imaging remains the most accurate and useful method to detect technical problems with a vascular repair or to determine the presence of thrombus in the runoff vessels distal to a repair.
Role of Tissue Coverage
No vascular repair will be successful if it is not covered with healthy tissue, preferably muscle. Desiccation or superficial infection in the inadequately covered repair leads to suture disruption and hemorrhage or thrombosis of the vascular repair site. In crushed or badly mangled extremities, this can be a difficult challenge. Tissue avulsion from automobile or motorcycle crashes with extremities dragged along the pavement or close-range shotgun blasts are the most common causes of these injuries in civilian centers (see Section “Case 4,” Fig. 41-17). Rotation of regional muscle or skin flaps may be required for coverage of vessel repair sites. The early involvement of a plastic and reconstructive surgeon is essential to obtain tissue coverage when there is extensive soft tissue injury or loss. Local muscle should be advanced into the wound at the initial operation. For extensive tissue loss, a pedicled transposed muscle flap, free tissue transfer, myocutaneous flap, or fasciocutaneous flaps may be indicated.43 However, complex myocutaneous flaps or free tissue transfer are rarely indicated or appropriate at the initial operation because they are very time consuming and put the patient at risk for hypothermia and metabolic derangements. These are more safely performed in a delayed fashion when the patient has recovered from the initial physiologic effects of injury.
In wounds with significant contamination and questionable local muscle viability (such as may occur following a shotgun wound or blast injury) temporary coverage can be obtained using cadaver skin homograft or porcine xenograft.44 The homograft or xenograft will be temporarily adherent, provide coverage, and often can stay in place for 5–7 days or longer. This biologic dressing allows time for local tissue inflammation to decrease. Subsequent split-thickness skin graft application, tissue rotation, or, in limbs with extensive tissue loss, pedicle flaps or free tissue transfer can then be performed.
In extreme cases of tissue loss or subsequent disruption of an inadequately covered vascular repair, extra-anatomic bypass may be required. Preferably, an autologous vein bypass can be routed through adjacent healthy tissue in the extremity. Less commonly, externally supported PTFE grafts are tunneled around the vascular injury site to supply distal perfusion. The synthetic bypass may be definitive revascularization or a temporizing step to allow healing and later placement of a vein graft through the site of injury.45
Role of Fasciotomy
Failure to perform an adequate fasciotomy after revascularization of an acutely ischemic limb is the most common cause of preventable limb loss.8,19 Calf compartment syndrome is the most common indication for fasciotomy. The primary major goal of management is prompt detection and treatment before tissue damage has occurred. There are a variety of settings in which preemptive fasciotomy should be performed. In patients with prolonged ischemia, crush injury, or combined arterial and venous injury, especially if major veins have been ligated, fasciotomy should be performed in conjunction with the initial vascular repair.
Compartment pressure should be measured early and often in patients at risk. The handheld solid state transducer device (Stryker Surgical, Kalamazoo, Michigan) should be used. If not available, pressure tubing on a three-way stopcock with a blood pressure cuff monometer may be used to create an improvised device that accurately measures pressure (Fig. 41-6). Normal tissue pressures are below 15 mm Hg and any pressure above 25 mm Hg mandates immediate intervention.46,47
FIGURE 41-6 (A) Stryker pressure measurement device (Stryker Surgical). (B) Pressure measurement device constructed of connection tubing, syringe, stopcock, and manometer from blood pressure cuff.
Fasciotomy should be performed by someone with knowledge and experience with performing the procedure. Most trauma surgeons have experience with fasciotomies in the calf. However, forearm fascitomies are usually performed by orthopedic surgeons and, unless experienced in this technique, trauma surgeons should call for help in this area. The same applies to fasciotomy in the upper arm, thigh, hand, foot, and buttocks.
There are four compartments in the calf that need to be released (Fig. 41-7). These include the anterior and lateral compartments on the anterior lateral aspect of the calf and the deep and superficial posterior compartments. The best approach for release is two long incisions, one each on the lateral and medial aspects of the calf. Although isolated anterior compartment syndrome occurs in some settings, four-compartment release is usually required (see Section “Case 5,” Fig. 41-19).
FIGURE 41-7 Cross-section of mid-calf showing the four fascial compartments and their contents. Open arrows show sites of double-incision fasciotomy; closed arrow shows site of single-incision fasciotomy. (Reproduced with permission from Frykberg ER. Compartment syndrome. In: Cameron JL, ed. Current Surgical Therapy. 5th ed. St. Louis, MO: Mosby-Yearbook; 1995:850, © Elsevier.)
The lateral incision needs to be generous. It should start 2 cm anterior to the fibula and no higher proximally than 4 cm below the fibular head in order to avoid the peroneal nerve. The incision should be taken distally to within 2–3 cm of the lateral malleolus. The fascia of both the anterior and the lateral compartments should be incised in the same region. Take care not to carry the incision beyond the limits of the skin incision proximally to avoid the peroneal nerve. Make certain that the anterior compartment is fully released by visualizing and palpating the tibia anteriorly beneath the incised fascia. Misplacing the incision posterior to the interosseous membrane can lead to mistaking the lateral compartment for the anterior compartment. This results in failing to release the anterior compartment with devastating consequences. The use of a checklist is helpful in preventing the many errors that can occur in performing this procedure (Fig. 41-8).
FIGURE 41-8 Four-compartment calf fasciotomy checklist.
The medial calf incision should be made 2–3 cm behind the posterior margin of the tibia to avoid lacerating the greater saphenous vein. The fascia over the gastrocnemius should be fully incised proximally and distally. The gastrocnemius and soleus muscles are retracted posteriorly in the distal calf to expose the deep posterior fascia. This layer needs to be incised under direct vision to avoid lacerating the posterior tibial artery.
Once all four compartments are adequately released and adequate hemostasis is obtained, a loose dressing is applied. Care should be taken to avoid tight dressings that will recreate the syndrome when muscle swelling occurs. Postoperatively, the extremity should remain elevated above the level of the patient’s heart to reduce edema formation and facilitate wound closure, which can occur in 48–72 hours. Split-thickness skin graft may be required.
Thigh fasciotomy is uncommonly required. There are three compartments to release: lateral, medial, and posterior. Two incisions, one lateral for the lateral compartment and one medial for the other two compartments, are sufficient. These need to be generous in their length. If one is unfamiliar with thigh muscle anatomy, consult an orthopedic surgery colleague. Loose dressings should be applied to avoid recreating the compartment syndrome.
Forearm and Upper Arm Fasciotomy
The forearm and upper arm are areas of multiple motor and sensory nerves important to hand function and a lack of familiarity with the anatomy when performing a fasciotomy can lead to significant nerve damage. Call an orthopedic surgery colleague for help if you do not have experience performing this procedure. Generous dorsal and volar incisions are required to release the dorsal and volar compartments and the mobile wad. Each major muscle group fascia must be incised. There are numerous superficial cutaneous nerves that must be carefully avoided. Upper arm fasciotomy is best performed through medial and lateral incisions. There are medial and lateral muscle compartments to release and the deltoid compartment at the proximal extent of the lateral incision must also be addressed.
Vascular Damage Control
Damage control principles and techniques have gained widespread acceptance in trauma surgery. In torso trauma, they are directed at rapid control of hemorrhage and closure of enteric wounds so that the patient can be warmed and resuscitated. In the extremity, damage control involves temporary restoration of blood flow with intraluminal shunts and selective ligation of major vessels.8,9,19 Fasciotomy also has a role in damage control in the extremities. The choice between definitive time-consuming vascular repairs and temporary measures that achieve hemorrhage control and restoration of perfusion must be made early in the care of patients with vascular injury and hypovolemic shock. This is particularly important when an extremity vascular injury is associated with major torso injuries.
Ligation should be reserved for vessels with adequate distal collateral flow. In the upper extremity, proximal injuries of the axillary artery and distal injuries to either the radial or ulnar arteries may be ligated provided there is evidence of adequate distal collateral flow assessed by either physical exam or continuous-wave Doppler interrogation. Similarly, in the lower extremity, ligation of a single tibial vessel or the peroneal can be performed following a similar assessment. If distal perfusion is compromised, an intraluminal shunt should be inserted, rather than ligating the vessel. Ligation of the brachial, external iliac, and superficial femoral or popliteal arteries has a high likelihood of producing limb-threatening ischemia resulting in amputation and should be avoided.
There are a variety of commercially available shunts that can be used for damage control. The 10 or 12 French straight carotid shunts are the most commonly used for this purpose. If these are not available, sterile intravenous tubing or endotracheal suction tubing of adequate size is used as a shunt material for both the artery and the vein of the extremities. Venous shunt placement instead of ligation may improve extremity perfusion and lower the risk of compartment syndrome. The common femoral vein may be shunted with a larger plastic catheter to achieve adequate luminal diameter.
Damage control shunt placement begins with obtaining adequate proximal and distal control. Thrombus should be cleared with a Fogarty embolectomy catheter followed by the instillation of regional heparinized saline (10 U/mL). The shunt should be placed in a straight line and long enough to remain safely held in place in the proximal and distal vessels with a tied umbilical tape or 2-0 silk tie at each end. Long, looped shunts run the risk of becoming dislodged during subsequent dressing changes and should be avoided. For patients who will be transported to another facility, ties around the center of the shunt with each tied to the proximal and distal shunt holding ties will insure that they do not become dislodged or migrate. The ties securing the shunt cause arterial wall and intimal damage and those portions of the artery will need to be debrided at the time of definitive vascular repair. Avoid unnecessarily damaging proximal and distal artery wall remote to the site of injury and place ties to secure the shunt as close to the injury site as is safely possible.
Ligation of proximal lower extremity vein should be performed for damage control only when subsequent venous obstruction is not anticipated. Shunts should be placed in the common femoral and superficial femoral veins whenever possible. This allows the option of repair versus ligation at a later time when the patient is stable. Ligation results in local thrombosis and subsequent venous repair will not be possible. However, in dire situations with a profoundly unstable patient, venous ligation may be the best option. Add calf fasciotomy in this damage control setting to forestall the development of compartment syndrome.
The early postinjury course and condition of the patient determines the timing of definitive vascular repair following damage control procedures. Hemorrhage must be controlled and hypothermia, coagulopathy, and acidosis corrected prior to performing definitive repair. The treatment of torso injuries should also be factored in during planning for a return to the operating room. However, there is a significant risk of shunt thrombosis and limb ischemia if repair is unnecessarily delayed.
Combined Arterial and Skeletal Extremity Trauma
Complex extremity trauma with both vascular injury and fractures or dislocations is infrequent.1,48,49 However, this combination presents one of the most significant management challenges. There is a difference in perspective between orthopedic surgeons and trauma surgeons with regard to this complicated type of injury. Vascular injury complicated less than 2% of extremity fractures and dislocations, but skeletal trauma is present in over 10–70% of series of extremity vascular injuries.49 The majority of these injuries in civilian trauma centers are due to blunt force trauma.1,10 In military series, high-velocity penetrating injuries are the most common cause.7,9 In both civilian and military series, combined arterial and skeletal extremity trauma carries a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries. A 10-fold increase has been noted in most studies, including those recently reported.9,26,48–55
Successful management requires both prompt diagnosis and effective early management with coordination of surgical consultants from orthopedics, neurosurgery, and plastic surgery. This requires that a high index of suspicion of arterial trauma be applied to every injured extremity by performing a careful physical examination augmented by Doppler pressure measurements at the ankle or wrist. When indicated, CT angiography is extremely helpful in detecting the presence of arterial injuries in these mangled extremities. In certain injuries that require extensive exposure for orthopedic surgery techniques, operative exploration of potential injured vessels may be appropriate. An intraoperative plain film single shot angiography, or fluoroscopy is helpful in delineating anatomy and identifying injury in this setting.
Combined injuries require team work and coordination of the efforts of both the orthopedic and vascular surgeons. Timing of their fracture fixation and the vascular repairs should be discussed. Clinical series have shown a substantially higher rate of limb salvage in combined injuries when the vascular repair is performed first compared with those in which it follows skeletal fixation.53 It may be appropriate to place temporary intraluminal shunts prior to the orthopedic fracture fixation and soft tissue debridement. Once the extremity is stabilized, the definitive vascular repair can be performed. In most complex injuries, external fixation is commonly used because of the commonly associated soft tissue injuries and open fractures.48–54 However, internal fixation has been increasingly used successfully in this setting if the patient’s condition permits.48,54 Damage control in complex combined injuries in unstable patients requires rapid placement of intravascular shunts, fasciotomy, and rapid external fixation.
There are two particularly devastating combined skeletal and vascular extremity injuries that have a high risk for poor functional outcome. They are posterior knee dislocation with popliteal artery and vein disruption and the scapulothoracic dissociation injury with axillary artery injury. The combination of severe ligament disruption with complex vascular injury in the knee leads to significant permanent impairment even if the vascular repair is performed in a timely and appropriate fashion with an associated calf fasciotomy. Management of these injuries often involves delay in revascularization or early thrombosis of the repair with worsened outcome including a significant risk of limb loss.24
Scapulothoracic dissociation is a devastating injury of the upper extremity and shoulder girdle caused by blunt force stretch injury. It is rarely complete, which involves separation of the musculoskeletal attachments of the shoulder girdle in addition to avulsion of the cervical nerve roots and transaction of the brachial artery and vein. More commonly, it is a partial avulsion or stretching of the nerve roots and axillary artery disruption (Fig. 41-9). The outcome is uniformly poor because of the neurologic injury and less likely due to the arterial injury.8,55 Poor prognosis in brachial plexus stretch injuries is associated with proximal location of neurologic injury, injury of multiple roots, and complete brachial plexus palsy.8,55 Acutely, the artery should repaired and the limb followed for return of neurologic function. Many patients ultimately request amputation because of the burden of an insensate and paralyzed arm that sustains repeated injury.
FIGURE 41-9 Arteriogram in patient with blunt left should injury with transaction and thrombosis of brachial artery and brachial plexus stretch injury with insensate and paralyzed arm.
Role of Immediate Amputation
Immediate amputation is limited to devastating extremity injuries with extensive soft tissue avulsion or crush wounds. With the application of damage control techniques and plastic and reconstruction surgery options, primary, early, or immediate amputation has become less common in the management of complex extremity injuries. Patients with extensive soft tissue loss, neurologic deficit, comminuted fractures, and vascular injuries should be evaluated collaboratively with orthopedic, neurosurgical, and plastic and reconstructive surgery colleagues to determine if primary amputation is the best initial management. The use of scoring systems to predict the need for amputation has not been consistently useful.48,56–58 There are objective data showing a higher limb salvage rate than would be predicted by many scoring systems.56–58 It may be best to proceed with initial intraoperative evaluation and documentation with pictures, radiographs, and consultation and then perform damage control using intravascular shunts for the vascular injuries. Plan a second look in 24 hours. The key decision-making factors in early amputation are the extent of skeletal and soft tissue injury, absence of plantar or palmar sensation, and the need for vascular repair.58 This second look allows for a reconsideration of limb salvage. Marginally viable tissue often takes hours to demarcate or declare and tissue loss will be more apparent at the second operation. The interval of time allows communication with the patient and the family with support for the emotional impact of losing a limb. Allowing the patient to see the devastating wounds prior to amputation often allows better acceptance of the loss and prompts healthy grieving. If immediate amputation is required at the first operation, extensive documentation of the extremity injury with photographs placed in the chart will be helpful in later explaining the decision to the patient and family and will help with their acceptance of this drastic surgical procedure.59,60 The decision to perform immediate or early amputation is one of the most compelling clinical decision-making processes that any surgeon can face. It requires a collaborative approach and honest discussion between vascular, orthopedic, plastic and reconstructive, and trauma surgery colleagues. It is not easily made and is based on the collective experience and wisdom of surgeons dedicated to the care of the injured.
Early Postoperative Management
The successful management of extremity vascular injury includes an organized approach to the postoperative phase of care, particularly during the first 24 hours when technical problems are most likely to present. Close clinical surveillance of the injured limb is critical. This includes not only distal pulse examination and, if indicated, Doppler pressure determinations but also frequent assessment of the extremity for compartment syndrome. Physical examination alone may not detect the presence of a compartment syndrome. Frequent compartment pressure measurement is the only way to accurately assess the injured extremity in patients who are not conscious and cooperative. New-onset neurologic deficits are an important indicator of ongoing ischemia and should prompt assessment of both the patency of the vascular repair and the pressure within muscle compartments. The most important element of this clinical surveillance is the willingness to return to the operating room for reexploration as soon as there are any indications of problems with the repair or the presence of early postinjury complications.
The use of anticoagulation or antiplatelet agents in the early postoperative period may be of value in preventing early thrombus formation in the area of vascular repair. Full anticoagulation with heparin is reserved for isolated extremity injuries with tenuous repair of small vessels. Low-molecular-weight Dextran (40,000) infused at 40 mL/h over the first 24 hours has a beneficial rheologic and mild antiplatelet effect in small vessel repairs. Long-term antiplatelet agents and anticoagulants are not of proven benefit.
Any suggestion of thrombosis, hemorrhage, or compartment syndrome should prompt an immediate return to the operating room. A second operation should never be seen as a sign of failure. Reoperation is inevitably required in 5–10% of vascular repairs to achieve an overall successful outcome. Most experienced vascular surgeons will accept a certain rate, although low, of reexploration without needing to revise anything in order to remain vigilant enough to avoid a missed opportunity to salvage the repair.
The failure of vascular repairs from thrombosis usually occurs within the first 24–48 hours. Infection is usually delayed beyond the first 72 hours and is usually manifested by either hemorrhage or, less commonly, thrombosis. Dessication and erosion of the exposed vessel from inadequate soft tissue coverage presents in a fashion similar to infection. Both require an immediate return to the operating room and a complete resection of the repair, a new repair, and adequate coverage of the repair with viable muscle. Extra-anatomic bypass may also be required.
Common Management Errors and Pitfalls
The most common errors in the operative management of extremity vascular injury are inadequate exposure and control, failure to recognize the need for damage control techniques, failure to perform fasciotomy, and failure to recognize an early postoperative thrombosis (Table 41-1). Each of these errors can be mitigated with the use of guidelines and checklists. These organizational tools are of little use unless they are actively used and regularly revised with the lessons learned in their application. They became a repository of not only the intended plan of action but also lessons learned from experience. They help insure the best possible outcome following extremity vascular repair.
VASCULAR INJURIES BY ANATOMIC REGION
Upper Extremity Vascular Injuries
Penetrating injury is the most common etiology of upper extremity vascular injuries and usually presents with a history of significant bleeding or active, ongoing bleeding. Blunt injury is often associated with fractures or dislocations and is usually evident with signs of acute arterial occlusion and ischemia. Significant neurologic injury is present in 60% of patients with upper extremity arterial injury.1,9,10,55 The median nerve is most commonly involved due to its course in close proximity to the brachial artery throughout the upper arm. Concomitant venous injury is also commonly associated with arterial injury in the arm.
Upper extremity arterial occlusion is easily missed in the setting of multisystem injury. However, all significant vascular injuries of the upper extremity result in clinical findings that are apparent on thorough physical examination.61Distraction by focusing on associated severe torso or lower extremity injuries can lead to a failure to recognize the upper extremity injury. Delays in diagnosis and treatment are common in collected series of patients with upper extremity arterial injury following blunt force trauma.24,55
The diagnosis of upper extremity arterial injury is usually made on physical exam alone. Patients with obvious arterial or venous laceration from penetrating trauma or those with blunt trauma and “hard findings” (Table 41-2) should be taken directly to the operating room. The upper extremity arteries are very sensitive to the effects of agents that produce vasoconstriction. Thus, intense vasoconstriction to the point of diminished or absent peripheral pulses can occur following hypovolemic shock, severe pain, or the ingestion of illicit drugs, such as cocaine and methamphetamine. Complex fractures or crush injuries of the upper extremity associated with absent pulses are an indication for CT angiogram or catheter angiogram to assess patency.
Bleeding from a partially transected arm or forearm vessel can be significant. The senior surgeon should make certain that adequate control is obtained and maintained during resuscitation, transportation to the operating room, and surgical prep and drape. Pneumatic tourniquets should be used appropriately and placed and carefully monitored for adequacy of compression and duration of application by the senior surgeon.
Subclavian and Axillary Vascular Injuries
Penetrating trauma is more common than blunt trauma as the cause of these proximal upper extremity vascular injuries. Injuries to the most proximal portion of the subclavian are discussed in the thoracic trauma chapter 24 of this book. Supraclavicular subclavian and proximal axillary artery injuries with active hemorrhage are very challenging. They require immediate operative management for control of hemorrhage and repair. Occlusion of the subclavian and axillary vessels is well tolerated because of the extensive collateral vessels. If there is evidence of satisfactory distal perfusion, management of a thrombosed axillary or subclavian artery may be delayed to complete management of other life- or limb-threatening injuries.
Surgical exposure requires a wide prep and drape of the shoulder, chest, and ipsilateral arm. Supraclavicular injuries of the left subclavian vessels may require an anterolateral thoracotomy through the third intercostal space for proximal control. On the right, a sternotomy may be required for proximal control. Distal control may require an infraclavicular incision to clamp the axillary vessels. The site of injury is then approached directly through a supraclavicular incision. An effect adjunct to proximal control in partial arterial wall laceration is the introduction of an occluding balloon-tip catheter retrograde through the axillary artery to the site of injury. The subclavian may then be directly approached. The portion of the subclavian vessels directly behind the clavicle may be exposed by dividing the clavicle medially and retracting it inferiorly to be reattached later. A portion of the middle of the clavicle may also be resected if needed.
Exposure of the axillary vessels is obtained through a transverse infraclavicular incision carried down to the pectoralis minor muscle by muscle-splitting incision carried through the pectoralis major muscle. The pectoralis minor tendon is divided at its insertion on the coracoid process. The axillary artery and vein are located immediately below the muscle (Fig. 41-10). Care must be taken to avoid the cords of the brachial plexus, which are in close proximity to the axillary vessels. More distal exposure may require completely dividing the pectoralis muscle; however, this is uncommonly needed.
FIGURE 41-10 Approach to the axillary artery for proximal arterial control. (A) Location of infraclavicular incision. (B) Division of pectoralis minor muscle at coracoid process. (C) Exposure and control of axillary artery. (Reproduced, with permission, from Rutherford RB, ed. Atlas of Vascular Surgery: Basic Techniques and Exposures. Philadelphia: WB Saunders; 1993. © Elsevier.)
Injuries of the subclavian and axillary vessels are rarely amenable to simple suture repair. Subclavian arterial injuries may be repaired with an interposition of PTFE. The axillary artery is best repaired with a vein conduit. Venous injuries may be ligated unless there is extensive soft tissue injury with disruption of collaterals. Occasionally, vein or PTFE patch repair is possible. The risk of venous hypertension is low and ligation should be used unless the vein repair can be done expeditiously. Forearm or upper arm fasciotomy is rarely required with vascular injuries at the subclavian and axillary level. However, close follow-up in the postoperative period for the development of compartment syndrome is mandatory.
Brachial Artery Injuries
Penetrating injuries from interpersonal violence or punching a hand through a window with laceration from glass shards are the most common causes of brachial artery injuries. Blunt trauma with fracture and arterial laceration or contusion leading to thrombosis is much less common. Supracondylar humerus fracture is the most commonly associated orthopedic injury with brachial artery occlusion. Both blunt and penetrating injuries are easily diagnosed on physical examination. Angiography is rarely indicated unless there are multilevel musculoskeletal or crush injuries.
Active bleeding should be controlled by tourniquet application or direct pressure while the patient is transported to the operating room. Exposure is obtained though a longitudinal incision over the course of the artery on the medial aspect of the upper arm. Proximal control for high brachial artery injuries may require proximal control at the level of the axillary artery in the infraclavicular region. Distally, the incision can be extended with an “S”-shaped extension across the antecubital fossa from ulnar to radial aspect and onto the forearm to expose the origins of the forearm vessels.
Proximal control for injuries of the distal brachial artery and the forearm vessels may be temporarily obtained with a sterile pneumatic tourniquet. This adjunct, however, should be removed as soon as vessel loops or vascular clamps can be applied in close proximity to the injury in order to restore collateral flow.
Vascular repair requires attention to detail. Simple laceration may be repaired by direct suture repair if the repair can be performed without tension. Saphenous vein interposition should be chosen whenever vessel injury is extensive or if primary tension-free repair is not possible. PTFE has no role in the upper extremity below the shoulder and should be a reluctant second choice when autologous vein is not available. There is no role for brachial vein repair unless there is extensive soft tissue injury. Repair of associated median nerve injuries is an important part of over 50% of operations for brachial artery laceration. This should be accomplished by an experienced surgeon with loupe magnification and fine sutures. Postoperative splinting in a forearm flexed position is important in combined brachial artery and median nerve injuries.
Forearm fasciotomy, particularly in the setting of prolonged ischemia, must always be considered prior to completion of the operation for brachial artery repair. Intraoperative compartment pressure measurements may help in the decision making. However, if normal pressures are obtained, eventual reperfusion edema and subsequent swelling may produce a delayed compartment syndrome. Postoperative follow-up is essential to prevent and identify this late development.
Forearm Arterial Injuries
The brachial artery gives rise to the ulnar and radial arteries after crossing the antecubital fossa. The ulnar artery is larger than the radial artery in the upper arm and gives rise to the interosseus artery. Although the radial artery is more superficial and easily palpated at the wrist, the ulnar artery is the dominant blood supply to the hand in 60% of patients. Both vessels contribute to the superficial and deep palmar arches. The ulnar artery is the dominant supply to the palmar aspect of the hand and the radial artery is the dominant supply to the dorsum. The palmar arches are incomplete in up to 30% of patients. Surgical exposure is obtained through a longitudinal incision on the volar aspect of the forearm, taking care to avoid the many cutaneous nerves in this area.
Combined ulnar and radial artery injuries in the forearm require repair of at least one vessel (Fig. 41-11). The ulnar artery is usually larger in the proximal forearm and is a better target for direct repair or saphenous vein bypass. Distally, the vessel repair should be performed in whichever vessel is largest or amenable to simple repair. Collateral flow should be evaluated by either completion arteriogram or Doppler flow examination.
FIGURE 41-11 Guideline for management of upper extremity arterial injury.
Isolated ulnar or radial artery injuries can be managed with simple ligation only if there is absolute certainty that flow through the remaining vessel is adequate. Close inspection of the forearm and hand with palpation of pulses augmented by Doppler examination is essential. Isolated forearm arterial injury may be repaired if the patient is stable and there are no other pressing management priorities (Fig. 41-11).
Lower Extremity Vascular Injuries
Vascular injuries in the legs are less common in civilian practice than they are in military series (20% vs. 30–40%).1,7,9,26 All lower extremity vascular injuries are highly morbid. Penetrating injuries are more common than blunt force trauma. Hemorrhage may be life threatening from penetrating wounds and blunt force injuries with occlusion have a high risk of ultimate limb loss. Venous injuries with major vein occlusion have a significant risk of causing calf compartment syndrome and there is also a significant risk of deep venous thrombosis and pulmonary embolism.
Physical examination is usually sufficient to make the diagnosis of lower extremity arterial injury.61 Venous injuries are less obvious unless associated with external bleeding. There is a high rate of associated fractures in blunt force vascular injuries in the leg. The calf muscle compartments are always at risk for compartment syndrome in lower extremity vascular injury and should be carefully monitored. There is a role for liberal use of prophylactic compartment release in combined femoral or popliteal arterial and venous injuries or when there has been prolonged ischemia.
Amputation remains relatively common after lower extremity vascular injury. Limb loss rates vary from 15% to 35%.1,7,9,26 Rapid diagnosis and prompt restoration of blood flow is the best way to reduce the threat of limb loss. Failure to perform fasciotomy in patients who develop compartment syndrome is the most common reason for preventable limb loss.1,7–9,26,47 Associated musculoskeletal and soft tissue injuries are also an important determining factor in limb loss. Decision-making needs to be well organized in treating lower extremity vascular injury to maximize the chances for a good outcome (Fig. 41-5).
Common Femoral Vascular Injuries
Common femoral vascular injuries are frequently encountered in both civilian and military series. Penetrating injuries are more common than blunt. Hemorrhage is often severe with these injuries. Less commonly, hemorrhage is contained with thrombosis within the femoral sheath. Combined arterial and venous injuries are common. Diagnosis is made almost exclusively by physical examination. Active hemorrhage is common and many patients require direct pressure for hemorrhage control and immediate transfer to the operating room.
Proximal vascular control may require an incision above the inguinal ligament for exposure of the external iliac artery in the retroperitoneum (Fig. 41-12). A longitudinal incision over the common femoral vessels should be generous enough to expose the superficial femoral artery and vein to gain control below the injured common femoral vessels. The proximal common femoral, profunda femoral, and superficial femoral arteries are best controlled with encircling double-passed silastic vessel loops. Primary arterial repair is occasionally possible, but most injuries are complex and require either a saphenous vein or PTFE interposition graft. Venous injuries are also more often complex. They usually require careful clamp placement for vascular control. There are numerous side branches that must be controlled. Vein clamping results in venous hypertension if the artery is not also occluded. Vein patch repair or saphenous vein panel interposition graft may be required. In unstable patients, venous ligation may be the best course of action. Calf fasciotomy should always be considered when the major veins of the lower extremity are ligated.
FIGURE 41-12 Approach to the external iliac artery in the retroperitoneum for proximal arterial control. (A) Location of right lower quadrant incision. (B) Retroperitoneal approach by retracting away peritoneum and contents. (C) Exposure of external iliac artery. (Reproduced, with permission, from Rutherford RB, ed. Atlas of Vascular Surgery: Basic Techniques and Exposures. Philadelphia: WB Saunders; 1993. © Elsevier.)
The profunda femoral artery is well collateralized by branches of the hypogastric artery to the gluteal and upper thigh region. Although simple lacerations should be repaired, more extensive injuries should be ligated unless there is extensive soft tissue injury and loss of collaterals in the buttock and upper thigh. Patients with preexisting stenosis or occlusion of the superficial femoral artery should undergo repair of the profunda femoral artery because of its important role in providing collateral flow to the lower extremity.
Superficial Femoral Vascular Injuries
Penetrating injuries are much more common than blunt trauma vascular injuries in the thigh. The superficial femoral is located just behind sartorius muscle as it spirals from superior lateral to inferior medial in the thigh. Distally, it passes through the adductor canal to become the popliteal artery. It remains relatively superficial and significant hemorrhage is common with penetrating arterial injuries. Consequently, diagnosis is usually made in the operating room while gaining control of the bleeding.
Exposure is obtained through an incision over the artery in its course down the anterior–medial aspect of the thigh. The sartorius muscle is retracted either anteriorly or posteriorly to expose the superficial femoral artery and vein. The incision should be long enough to obtain both proximal and distal control. Although simple repair may be possible in some wounds, most require an interposition graft. Reversed autologous saphenous vein from the uninjured leg should be used if at all possible. The superficial femoral vein should be repaired if possible. However, it is usually ligated. Consideration should always be given to calf fasciotomy in any patient with superficial femoral arterial injury with prolonged occlusion and those with ligation of the superficial femoral vein. If fasciotomy is not performed, compartment pressures should be measured both before leaving the operating room and frequently in the early postoperative period.
Popliteal and Tibial Artery Injuries
The relationship of the popliteal artery with the adductor magnus muscle in the lower thigh and the gastrocnemius muscle in the upper calf as it transits the knee joint places it at risk for severe injury in dislocation of the knee joint. In full knee extension, the popliteal artery is under considerable tension. The back of the tibial plateau, as it moves posteriorly in a dislocation, impacts and stretches the popliteal artery, often completely disrupting it. The popliteal vein may suffer the same fate. There is a 20–30% rate of popliteal artery occlusion with posterior dislocation of the knee.1,8,9,19,26 This injury merits a CT angiogram of the leg even if distal pulses are present.
Penetrating injury from gunshot wounds and shotgun wounds is also an important cause of popliteal disruption. Hemorrhage is not as common as thrombosis in popliteal and tibial artery injuries. A pair of popliteal veins accompanies the artery and complete venous disruption is uncommon. Blunt trauma from a bumper strike in pedestrian trauma is also an important cause of injury. This is particularly true when a pedestrian is pinned between the bumpers of two automobiles. Distal popliteal or proximal tibial vessel injury is common in this setting.
Adequate exposure of the popliteal artery for injuries associated with posterior knee dislocations requires a medial incision from the proximal popliteal space to the distal popliteal space with division of the medial head of the gastrocnemius muscle and the semimembranosis and semitendonosis muscles with full view of the popliteal artery and vein and the tibial nerve. This insures adequate vascular control and the opportunity for successful repair. When closing the wound, approximation of the divided muscle yields with absorbable sutures will insure an excellent functional result. Distal popliteal and proximal tibial vessel injuries are approached through a medial incision below the knee along the posterior margin of the tibia. This may be extended distally by dividing the soleus muscle over the course of the tibial-peroneal trunk and the posterior tibial vessels.
Popliteal and tibial artery injuries are usually complex and primary repair is rarely possible. Saphenous vein interposition grafts are the best method of reconstruction. PTFE is to be avoided in all but the most dire circumstances when no lower extremity or upper extremity vein conduit is available. It has a high late failure rate. These injuries are often associated with orthopedic injuries. The vascular repair should be performed first or, if absolutely necessary, shunts should be placed while the orthopedic procedure is performed. Four-compartment calf fasciotomy should be added in most popliteal artery injuries in view of the common finding of thrombosis and an interval of ischemia. It should always be performed in the setting of combined popliteal arterial and venous injuries.
Tibial vessel injuries may be ligated if there is adequate flow through the remaining vessels. When in doubt, an intraoperative arteriogram should be obtained. In multiple tibial vessel injuries, a saphenous vein interposition should be performed to the distal tibial vessel that best supplies the foot and that can be most easily covered with healthy soft tissue.
COMPLICATIONS AND OUTCOME
The most immediate and dangerous early complication of extremity vascular repair is thrombosis with distal ischemia.1,7,8,9,19 Postoperative vascular checks need to be performed frequently and effectively. There is a tendency of inexperienced examiners to imagine that a pulse is present when it is not. Doppler devices should be used and ankle or wrist pressure should be determined often to make certain that repaired vessels remain patent. If there is any evidence of occlusion or any doubt about patency, the patient should be returned to the operating room for direct inspection of the repair. Early return to the operating room for revision or replacement of the vascular repair is essential to restore flow and preserve limb viability.
The most common causes of early repair failure are technical errors.1,8,10,19,26 These include intimal flaps, kinking, undue tension, and stenosis at the repair site. Less commonly, platelet thrombus accumulates on a technically adequate repair site. This may occur from the generalized platelet activation of injury. It is often associated with extensive muscle injury or crush injury. Less commonly it is a manifestation of a heparin allergic reaction and activation in the process of heparin-induced thrombocytopenia. This is a crisis to be managed aggressively. Low-molecular-weight Dextran (40,000) should be given as a 40 mL bolus and then infused at 40 mL/h for 24 hours. Once the repair has been reopened by thrombectomy, it needs to be followed very closely for recurrent occlusion. A laboratory study to rule out heparin-induced thrombocytopenia should also be obtained.
Postoperative anticoagulation is not usually helpful in arterial repairs for vascular trauma. However, it may have a role in venous repairs and should be considered in otherwise stable patients.62 Antiplatelet agents are of little use unless there is platelet-induced thrombosis. Long-term antiplatelet therapy may be helpful in preventing saphenous vein interposition graft failure. However, there is no compelling evidence to support these drugs in vascular trauma repairs.
Infection at the site of an arterial repair is a devastating complication. Early wound problems in the area of vascular repairs should be explored in the operating room for infection, debrided aggressively, and reclosed with health tissue. In complicated wounds, a muscle flap to cover the vascular repair site is the best way to avoid infection and vessel erosion with hemorrhage. Once a repair has eroded and bled, it should be ligated and replaced with an extra-anatomic bypass. Prevention is the key to avoiding this unfortunate complication with its high rate of ultimate limb loss.
The ultimate outcome from extremity vascular injury is largely determined by the associated musculoskeletal and neurologic injuries.48,50,53,56–58 Long after vessel repairs have healed, the insensate foot or hand will severely limit the patient with associated severe neurologic injury. Modern physical therapy techniques have resulted in excellent functional outcomes for many patients with devastating injuries. Delayed soft tissue and bone reconstruction also serve to optimize recovery.
Late sequelae from venous injuries are more troublesome than those of arterial injuries.1,8,10,26 Venous insufficiency can be disabling if not adequately treated. Support stockings are essential in patients with the postplebitic syndrome. Patient education is an important part of gaining their cooperation in pursuing measures to limit venous hypertension and its complications.
Late neurologic sequelae are also uncommon.63,64 Causalgia, burning pain within 24 hours of injury in a specific nerve distribution, is rare.63,64 Few patients progress to the point of requiring sympathetic nerve blocks. Complex regional pain syndromes are also very uncommon and rarely require intervention. Modern pain management and physical therapy help mitigate the effects of posttraumatic peripheral neuropathy.63,64
Late development of either a pseudoaneurysm or an arteriovenous fistula is very uncommon.1,8,10,26 This is most likely due to early recognition and effective management of most extremity vascular injuries. Aggressive CT imaging has also limited the number of missed injuries that present later in their course. Vein interposition grafts are at risk for late development of stenosis or aneurysmal dilatation. Patients who have undergone complex vascular repairs should be followed yearly for the rest of their lives in order to detect complications early in their course. All of these complications are amenable to effective surgical and endovascular treatment.
EXTREMITY VASCULAR TRAUMA CASE PRESENTATIONS
History. An 18-year-old male was stabbed in the right axilla with pulsatile bleeding. Paramedics arrive at the trauma resuscitation bay with direct pressure on the axilla.
Exam. BP 70/40, HR 120, Resp 28, temperature 37°C, GCS 12. Absent pulses, paralysis, and paresthesias in right arm with active arterial bleeding when direct pressure released from wound in right axilla. This is an isolated injury.
Decision Making. Obvious axillary artery injury with hard signs present. Significant volume loss has occurred. Patient needs protection of the airway, direct control of hemorrhage, and immediate operation. Permissive hypotensive is indicated with immediate infusion of type O-negative packed red blood cells to raise systolic BP to no higher than 80–90 mm Hg. This may begin on the way to the operating room, but should not cause any delay. Proximal vascular control will require access to the axillary artery in the infraclavicular region. Saphenous vein interpostition graft may be required.
Operative Management. Sterile prep and drape right arm with senior team member keeping direct pressure on injury site to control bleeding. Prep right shoulder and chest wall, and entire right leg to give access to saphenous vein if needed. First incision in the infraclavicular region carried down by muscle-splitting pectoralis major muscle. Pectoralis minor tendon divided at coracoid process to expose axillary artery and vein that are encircled with double-passed silastic vessel loops. Systemic heparin given in view of isolated injury and temporary control and gently occluded. Attention turned to axilla where longitudinal incision made while direct pressure held on upper arm to occlude venous inflow and arterial backflow. Lacerated axillary artery identified; take care to avoid median and ulnar nerves. Vein found to be intact. Small vascular clamp placed proximally and distally to injured artery and vessel loops in proximal vessels and pressure on upper arm released. No other injuries present (Fig. 41-13).
FIGURE 41-13 Incisions for proximal control axillary artery in the infraclavicular region and exposure of brachial artery injury in the upper arm and axilla.
One centimeter segment of proximal brachial artery lacerated longitudinally. Local Fogarty catheter thrombectomy performed and heparinized saline (10 U heparin/mL) flushed, taking care to limit infusion volume and avoid air and debris flush into level of vertebral origin. Debridement and spatulation of proximal and distal artery leads to over 2 cm defect with undue tension when approximation assessed with tension on clams. Saphenous vein segment harvest from left ankle region and interposition graft placed (Fig. 41-14).
FIGURE 41-14 Saphenous vein interposition graft for repair of brachial artery laceration.
Distal pulses and Doppler flow assessed and found to be normal. Wound closed primarily. Thin sponge and tape dressing applied.
Postoperative Plan. Serial right arm pulse examinations, neurologic examinations, and assessment muscle compartments in addition to inspection of right axillary wound site for presence of hematoma.
Outcome. Fully recovered without neurologic deficit and with normal upper extremity blood flow.
History. A male in his 70s presents to the emergency department with a dog bite in the left arm. This occurred 2 hours ago and he reports rapid onset of severe pain and inability to move his arm. His pit bull has bitten him on two other extremities within the last 2 weeks. The patient has a history of hypertension, hyperlipidemia, cigarette smoking, and coronary artery disease.
Exam. BP 180/90, HR 80, Resp 20, temperature 37°C. Nonbleeding puncture wounds in left medial aspect upper arm. Absent pulses below the level of the puncture wounds, paralysis, and paresthesias in right arm. Superficial wounds in left arm and left leg with normal neurovascular examination (Fig. 41-15).
FIGURE 41-15 Right upper arm puncture wounds from pet pit bull bite.
Decision Making. Obvious brachial artery injury with thrombosis and occlusion occurred. Now 2 hours of ischemia with limb threat to right arm. Patient needs expeditious restoration of blood flow. Physical examination indicates extent of injury and further imaging unnecessary and time consuming, increasing risk of prolonged ischemia and risk of limb loss. Patient needs to go directly to the operating room. Comorbidities place him at increased risk and the anesthesiologist needs to be alerted regarding patient’s medical history.
Operative Management. Sterile prep and drape right arm, shoulder, and right leg for possible saphenous vein harvest. Incision made along medial aspect of arm from above to below; puncture wounds made avoiding including wounds to reduce wound infection risk. Vessel injury site and sufficient uninjured proximal and distal brachial artery exposed. Thrombosis of brachial artery segment deep to the largest puncture wound found (Fig. 41-16).
FIGURE 41-16 Thrombosis of brachial artery deep to the largest puncture wound from the dog bite.
Saphenous vein interposition graft performed. Distal pulses and Doppler flow assessed and found to be normal. Wound closed primarily. Thin sponge and tape dressing applied.
Postoperative Plan. Serial right pulse examinations, neurologic examinations, and assessment of muscle compartments in addition to inspection of upper arm wound axillary wound site for presence of hematoma.
Outcome. Fully recovered without neurologic deficit and normal upper extremity blood flow.
History. A 42-year-old male, restrained driver of sport utility vehicle crashes head-on into tree. Aspirated in the field and arrives 40 minutes after injury. He has been intubated in the field.
Exam. BP 120/80, HR 110, Resp 18, temperature 37°C, GCS 8T, no wrist pulses in right arm, wrist Doppler pressure 70 mm Hg, FAST, x-rays, and CT imaging reveal severe head injury, chest injuries, Grade II splenic laceration, complex pelvis fractures with hematoma, and right humerus fracture. To angiogram for embolization hypogastric arteries, right arm arteriogram obtained (Fig. 41-17).
FIGURE 41-17 Thrombosis of brachial artery at fracture site with profunda brachial artery collateral flow to distal brachial artery. Wrist pressure 70 mm Hg.
Decision Making. Brachial artery injury with collateral flow generated wrist pressure of 70 mm Hg is not immediate limb threat. There are multiple potentially life-threatening injuries that preclude immediate extremity vascular repair.
Management. Stabilized with critical care management of his multiple injuries including placement of intracranial pressure monitor. Right arm splinted and followed closely for adequacy of collateral flow. Compartment pressures in forearm measured daily and remained normal. Temporized for 72 hours, overall status improved. To operating room for saphenous vein interposition brachial artery and fixation humerus.
Outcome. Slow recovery with mild central neurologic deficit. Normal motor and sensory exam in right arm, full function and normal upper extremity blood flow.
History. A 20-year-old man suffers close-range shotgun wound to the left arm while bird hunting with his father and brother. He presents 1 hour after injury with severe pain and a pressure dressing and splint on this left arm.
Exam. BP 130/80, HR 120, Resp 20, temperature 37°C. Isolated shotgun wound in left arm with extensive tissue loss. The arm is insensate, paralyzed, and pulseless below the level of the elbow. He has extensive bone and tissue loss (Fig. 41-18).
FIGURE 41-18 Shotgun wound to left arm. No sensation or motor function and wrist pulses and Doppler signals absent.
Decision Making. Obvious severe loss of major vascular and neurologic structures and extensive musculoskeletal tissue in left forearm. This patient needs to go directly to the operating room with orthopedic surgery, vascular surgery, and plastic and reconstructive surgery colleagues to perform an assessment and determine whether limb salvage or amputation needs to be performed.
Operative Management. Examination under anesthesia in the operating room by the trauma surgeon and specialty colleagues confirms extensive tissue loss including loss of long segments of the median, ulnar, and radial nerves. The prognosis for limb salvage is extremely grave and there is no chance for functional recovery even if extensive vascular artery and vein grafting and free tissue transfer are performed. This is not a salvageable limb and immediate amputation just above the elbow is performed. The trauma surgeon talks with family to explain the situation. A complete series of pictures of the extremity injury is taken and copies placed in the chart.
Outcome. Patient recovers rapidly and is fitted with robotic arm prosthesis. He returns to college the next semester.
History. A 23-year-old male struck in left groin by shrapnel from exploding gas canister aboard a Navy ship; transected femoral artery and vein were ligated aboard ship. Now, 13 hours later he arrives by helicopter transport.
Exam. BP 120/80, HR 100, Resp 20, temperature 37°C. Isolated left groin injury packed with moist gauze. Left leg is cool, anesthetic, paralyzed, and pulseless. Calf compartments are tense.
Decision Making. The patient is not well beyond the “golden period” of 6–8 hours and already has signs of compartment syndrome. The risk of limb loss is very high. The only hope for limb salvage is the prompt restoration of blood flow and calf compartment fasciotomy.
Operative Management. Patient is given 5,000 U heparin bolus. A four-compartment fasciotomy of the calf is performed first. Generous incisions are made and the muscle appears ischemic (Fig. 41-19).
FIGURE 41-19 Fasciotomy incisions: (A) lateral incision releasing anterior and lateral compartments and (B) medial incision for release of posterior compartments.
Exploration of the femoral region reveals that the superficial femoral artery and the common femoral vein have been ligated. Clamps placed above and below ligation sites, ligatures removed, Fogarty catheter thrombectomy performed, heparin saline flushed, and 12 French shunt inserted in superficial femoral artery. Copious amounts of thrombus flushed out of distal veins by tightly wrapping the leg with an Esmark bandage from the foot to the upper thigh. Proximal femoral vein back flushed copiously to clear small amount of thrombus. Small chest tube cut to fashion suitable size shunt and placed in the common femoral vein.
Long segment of vein harvested from uninjured right leg. Interposition graft performed in the superficial femoral artery. Panel graft fashioned by opening long segment of saphenous vein longitudinally and sewing it in a spiral around a 36 French chest tube. This graft is interposed in the common femoral vein (Fig. 41-20).
FIGURE 41-20 Left groin repair site. Common femoral artery, profunda femoral artery, vein interposition in superficial femoral artery, and spiral vein graft in the common femoral vein.
Femoral wound closed and fasciotomy wounds loosely wrapped. Central line placed to follow volume status and maintain high urine output because of risk of acute renal failure from myoglobinuria. Leg placed in continuous passive motion device. Full anticoagulation with heparin begun 12 hours following operation.
Outcome. Early to mild myoglobinuria without significant increase in creatinine. Rapid swelling muscles of calf but all remained viable. Rapid return of motor and sensory function in first week. However, postischemic neuropathic pain continued for 4 weeks. Fasciotomy wounds covered with split-thickness skin grafts at 7 days. Muscles remained viable and, by 6 weeks, neurologic function returned to 90% of normal with mild residual sensory deficit. Postoperative screening using duplex scan of veins of lower extremity weekly—no thrombus formation. Patient remained on warfarin for 3 months.
History. A 27-year-old male construction worker grinding steel fitting felt stinging sensation in left mid thigh and rapid onset of pain and swelling. Small tear in jeans and puncture wound on mid-left anterior–medial thigh.
Exam. BP 130/80, HR 90, Resp 20, temperature 37°C. Firm swelling in area of puncture wound and obliquely from mid upper thigh to lower anterior–medial thigh. Normal pulses throughout left leg and ankle–brachial index normal and equal to right leg. CT angiogram of left leg obtained (Fig. 41-21).
FIGURE 41-21 CT angiogram. (A) Cross-section and (B) VTR views revealing lacerated left superficial femoral artery with acute pseudoaneurysm within the sartorius muscle.
Decision Making. Partial injury of superficial femoral artery with acute pseudoaneurysm requires immediate exploration and repair. Depending on status of the vessel wall, local repair, vein patch angioplasty, or interposition graft will be required.
Operative Management. Left and right legs prepped and draped. Incision made along course of artery of sufficient length for proximal and distal control. Longitudinal 15 mm laceration with remainder of artery wall normal and no vein injury found. Vein patch angioplasty performed. Hematoma evacuated and wound closed with closed suction drain (Figs. 41-22 to 41-24).
FIGURE 41-22 Left leg preparation and draping. Landmarks marked on leg to outline site injury, course of artery, sartorius muscle, and margin femur leg. Incision made over course of sartorius muscle.
FIGURE 41-23 Longitudinal 15 mm laceration from shrapnel wound to left superficial femoral artery.
FIGURE 41-24 Saphenous vein patch repair with preservation of normal luminal diameter of superficial femoral artery.
Outcome. Discharged home on day 4 following operation. Returned to work at 1 month.
History. A 30-year-old male police officer shot close range with shotgun at scene of domestic violence call. Through-and-through wound in upper right calf. Minimal blood loss at scene and pressure dressing in place with bleeding controlled.
Exam. BP 110/60, HR 100, Resp 16, temperature 37°C. Isolated through and through right calf wound. Extensive tissue damage (see below). Pulses and Doppler signals absent at ankle. Plantar sensation intact but diminished. Dorsiflexion of foot intact, plantar flexion present but diminished. Catheter arteriogram obtained (Fig. 41-25).
FIGURE 41-25 Arteriogram revealing occlusion of proximal posterior tibial and peroneal arteries and at mid-anterior tibial artery. Associated fracture of tibia and extensive loss in midportion of fibula.
Decision Making. Although severe vascular and musculoskeletal injury, nerve damage is limited with partial motor and sensory deficit. Saphenous vein bypass to distal tibial vessel and orthopedic stabilization with external fixation has favorable prognosis for limb salvage and recovery of function.
Operative Management. Patient is given 5,000 U heparin bolus in trauma bay. Both legs prepped and draped. Injury has decompressed the anterior and lateral compartments. Medical compartments decompressed through same long medial incision on calf to expose distal posterior tibial artery. Saphenous vein bypass to distal posterior tibial artery performed. Extensive debridement wounds and external fixation performed by orthopedic surgery colleague. Partial closure of wounds with application of Wound Vac™ dressings. Split-thickness skin graft applied at 5 days after initial operation. Compartment fasciotomy of the calf is performed first (Figs. 41-26 and 41-27).
FIGURE 41-26 (A) Medial calf entrance wound and (B) lateral exit wound in shotgun injury.
FIGURE 41-27 Intraoperative completion angiogram at distal anastomosis of reverse saphenous vein popliteal to posterior tibial bypass.
Outcome. At 3 weeks, discharged home with external fixation tibia, continued physical therapy. Ultimately recovered with mild weakness in plantar flexion of foot and mild sensory deficit in heel and plantar aspect of foot. Promoted to sergeant and given desk job.
History. A 35-year-old male bag handler at the airport distracted, drives tractor into a flatbed baggage trailer. Open right knee and proximal tibial fracture with active bleeding. Tourniquet and pressure dressing applied.
Exam. BP 100/50, HR 120, Resp 25, temperature 37°C, GCS 15. Complain of severe right leg pain. Tourniquet in place. Dressing taken down. No sensation or movement of foot and calf and no pedal pulses or Doppler tones present at ankle. Lines placed, intubated, and taken directly to the operating room. X-rays reveal extensive disruption of femoral condyles, patella, tibial plateau, and proximal tibia (Fig. 41-28).
FIGURE 41-28 Open fractures with bone fragments missing distal femur, tibial plateau, proximal tibia, and severe soft tissue injuries.
Decision Making. Extensive soft tissue and skeletal trauma and associated vascular injury with need for tourniquet need immediate operative management. Portable x-rays and intraoperative angiogram can be performed as needed. Orthopedic surgery colleague needs to be involved as soon as possible to manage injuries, assess chances of limb salvage, and decide if immediate amputation needed. Trauma surgeon needs to discuss preoperatively with patient and family, if at all possible, the threat of limb loss and the possible need for immediate amputation. The status of the peroneal and tibial nerves will be one of the most important determinants of the possibility of limb salvage.
Operative Management. Prep and drape of both legs, proximal control of popliteal vessels above the knee obtained, and tourniquet removed. Exploration of knee and upper calf reveals transaction and maceration of popliteal artery, vein, tibial nerve, and peroneal nerve. Extensive open fractures with bone fragments completely avulsed femoral condyles, tibial plateau, and proximal tibia. The decision is made to perform guillotine amputation above the knee and delay closure for 48 hours to assess extent of further muscle necrosis (Fig. 41-29).
FIGURE 41-29 Exploration reveals complete transaction and maceration popliteal vessels and tibial and peroneal nerves and extensive open fractures. Patient required an above knee amputation.
Outcome. Recovered and was fitted with dynamic above-knee prosthesis. Returned to work with some limitations 4 months later.
1. Mattox KL, Feliciano DV, Burch J, et al. Five thousand seven hundred sixty vascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987: Ann Surg. 1989;209:698–707.
2. Davis TP, Feliciano DV, Rozycki GS, et al. Results with abdominal vascular trauma in the modern era. Am Surg. 2001;67:565–571.
3. Soubbotitch V. Military experiences of traumatic aneurysms. Lancet. 1913;2:720.
4. Makins GH. Injuries to the blood vessels. In: Official History of the Great War Medical Services: Surgery of the War. London, England: His Majesty’s Stationery Office; 1922:170.
5. De Bakey ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg. 1946;123:534.
6. Hughes CW. Arterial repair during the Korean War. Ann Surg. 1958; 147:555.
7. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma. 1970;10:359–369.
8. Sise MJ, Shackford SR. Extremity vascular trauma. In: Rich NM, Mattox KL, Hischberg A, eds. Vascular Trauma. 2nd ed. Philadelphia: Elsevier-Saunders; 2004:353–389.
9. Fox CJ, Gillespie DL, O’Donnell SD, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41:638–644.
10. Oller DW, Rutledge R, Clancy T, et al. Vascular injuries in a rural state: a review of 978 patients from a state trauma registry. J Trauma. 1992;32:740–746.
11. Rich NM, Manion WC, Hughes CW. Surgical and pathological evaluation of vascular injuries in Vietnam. J Trauma. 1969;9:279–291.
12. Giswold ME, Landry GJ, Taylor LM. Iatrogenic arterial injury is an increasingly important cause of arterial trauma. Am J Surg. 2004;187: 590–593.
13. Eslami MH, Csikesz N, Schanzer A, Messina LM. Peripheral arterial interventions: trends in market share and outcomes by specialty, 1998–2005. J Vasc Surg. 2009;50:1071–1078.
14. Amato JJ, Rich NM, Billy LJ, et al. High-velocity arterial injury: a study of the mechanism of injury. J Trauma. 1971;11:412–416.
15. Rich NM. Historic review of arteriovenous fistulas and traumatic false aneurysms. In: Rich NM, Mattox KL, Hirshberg A, eds. Vascular Trauma. Philadelphia: Elsevier Saunders; 2004:457–524.
16. Dennis JW, Frykberg ER, Veldenz HC, et al. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma. 1998;44:243–253.
17. Menger MD, Pelikan S, Steiner D, et al. Microvascular ischemia–reperfusion injury in striated muscle: significance of “reflow paradox.” Am J Physiol. 1992;263:H-1901–H-1906.
18. Cambria RA, Anderson RJ, Dikdan G, et al. Leukocyte activation in ischemia–reperfusion injury of skeletal muscle. J Surg Res. 1991;51:13–17.
19. Frykberg ER, Schinco MA. Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, eds. Trauma. 6th ed. New York: McGraw-Hill; 2004:941–971.
20. Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin North Am. 1983;63:539–565.
21. Williams AB, Luchette FA, Papconstantinou HT, et al. The effect of early versus late fasciotomy in the management of extremity trauma. Surgery. 1997;122:861–866.
22. Patel KR, Cortes LE, Semel L, et al. Bullet embolism. J Cardiovasc Surg. 1989;30:584–590.
23. Rich NM, Collins GJ, Anderson CA, et al. Missile emboli. J Trauma. 1978;18:236–239.
24. Perry MO. Complications of missed arterial injuries. J Vasc Surg. 1993; 17:399–407.
25. Frykberg ER, Dennis JW, Bishop K, et al. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma. 1991;31:502–511.
26. Feliciano DV, Herskowitz K, O’Gorman RB, et al. Management of vascular injuries in the lower extremities. J Trauma. 1988;28:319–328.
27. Gonzalez RP, Falimirski ME. The utility of physical examination in proximity penetrating extremity trauma. Am Surg. 1999;65:784–789.
28. Johansen K. Vascular diagnostic options in extremity and cervical trauma. In: Rich NM, Mattox KL, Hischberg A, eds. Vascular Trauma. 2nd ed. Philadelphia: Elsevier-Saunders; 2004:125–136.
29. Dennis JW. Minimal vascular injury. In: Rich NM, Mattox KL, Hischberg A, eds. Vascular Trauma. 2nd ed. Philadelphia: Elsevier-Saunders; 2004: 85–96.
30. Cothren CC, Moore EE, Ray CE Jr, et al. Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits. Arch Surg. 2005;140: 480–486.
31. Xenos ES, Freeman M, Stevens S, et al. Covered stents for injuries of the subclavian and axillary arteries. J Vasc Surg. 2003;38:451–454.
32. Harbrecht BG, Forsythe RM, Peitzman AB. Management of shock. In: Feliciano DV, Mattox KL, Moore EE, eds. Trauma. 6th ed. New York: McGraw Hill; 2008:213–233.
33. Jansen JO, Thomas R, Loudon MA, Brooks A. Damage control for resuscitation for patients with major trauma. BMJ. 2009;338: 1436–1440.
34. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105–1109.
35. Duchesne JC, Islam TM, Stuke L, et al. Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy. J Trauma. 2009;67:33–39.
36. Hirschberg A, Scott BG. Vascular damage control. In: Rich NM, Mattox KL, Hischberg A, eds. Vascular Trauma. 2nd ed. Philadelphia: Elsevier-Saunders; 2004:165–179.
37. Vertrees A, Fox CJ, Quan RW, et al. The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy for patients with severely limited autologous conduit. J Trauma. 2009;66:980–983.
38. Rich NM, Hughes CW. The fate of prosthetic material used to repair vascular injuries in contaminated wounds. J Trauma. 1972;12:459–467.
39. Martin LC, McKenney MG, Sosa JL, et al. Management of lower extremity arterial trauma. J Trauma. 1994;37:591–599.
40. Feliciano DV, Mattox KL, Graham JM, et al. Five-year experience with PTFE grafts in vascular wounds. J Trauma. 1985;25:71–82.
41. Lau JM, Mattox KL, Beall AC, et al. Use of substitute conduits in traumatic vascular injury. J Trauma. 1977;17:541–546.
42. Fuchs S, Heyse T, Rudofsky G, et al. Continuous passive motion in the prevention of deep-vein thrombosis: a randomized comparison in trauma patients. J Bone Joint Surg Br. 2005;87:1117–1122.
43. Mellisinos EG, Parks DH. Post-trauma reconstruction with free tissue-transfer—analysis of 442 consecutive cases. J Trauma. 1989;29:1095–1102.
44. Ledgerwood AM, Lucas CE. Biologic dressings for exposed vascular grafts: a reasonable alternative. J Trauma. 1975;15:567–574.
45. Feliciano DV, Accola KD, Burch JM, et al. Extraanatomic bypass for peripheral arterial injuries. Am J Surg. 1989;158:506–510.
46. McDermott AGP, Marble AE, Yabsley RH, et al. Monitoring acute compartment pressures with the STIC catheter. Clin Orthop. 1984;190: 192–198.
47. Feliciano DV, Cruse PA, Spjut-Patrinely V, et al. Fasciotomy after trauma to the extremities. Am J Surg. 1988;156:533–536.
48. Howe HR, Poole GV, Hansen KJ, et al. Salvage of lower extremities following combined orthopaedic and vascular trauma: a predictive salvage index. Am Surg. 1987;53:205–208.
49. Bishara RA, Pasch AR, Lim LT, et al. Improved results in the treatment of civilian vascular injuries associated with fractures and dislocations. J Vasc Surg. 1986;3:189–195.
50. Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990; 30:568–573.
51. Palazzo JC, Ristow AB, Cury JM, et al. Traumatic vascular lesions associated with fractures and dislocations. J Cardiovasc Surg. 1986;27: 688–696.
52. Rozycki GS, Tremblay LN, Feliciano DV, et al. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma. 2003; 55:814–824.
53. Romanoff H, Goldberger S. Combined severe vascular and skeletal trauma: management and results. J Cardiovasc Surg. 1979;20: 493–498.
54. Zalarvares CG, Marcus RE, Levin LS, Patzakis MJ. Management of open fractures and subsequent complications. J Bone Joint Surg Am. 2007; 89:884–895.
55. McCready RA. Upper-extremity vascular injuries. Surg Clin North Am. 1988;68:725–740.
56. Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am. 2001;83:3–14.
57. Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg. 1996;172:569–574.
58. Swiontkowski MF, MacKenzie EJ, Bosse MJ, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002;52:641–649.
59. Singh R. The rapid resolution of depression and anxiety symptoms after lower limb amputation. Clin Rehabil. 2007;21:754–759.
60. Singh R, Ripley D, Pentland B, et al. Depression and anxiety symptoms after lower limb amputation: the rise and fall. Clin Rehabil. 2009;23: 281–286.
61. Rutherford RB. Diagnostic evaluation of extremity vascular injuries. Surg Clinic North Am. 1988;68:683–691.
62. Parry NG, Feliciano DV, Burke RM, et al. Management and short-term patency of lower extremity venous injuries with various repairs. Am J Surg. 2003;186:631–635.
63. Pollawski ZJ, Wiley AM, Murray JF. Post-traumatic dystrophy of the extremities. J Bone Joint Surg. 1983;65:642–655.
64. Wasner G, Backonja MM, Baron R. Traumatic neuralgias—complex regional pain syndromes (reflex sympathetic dystrophy and causalgia): clinical characteristics, pathophysiologic mechanisms and therapy. Neurol Clin. 1998;16:851–868.