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Vascular Injuries of the Extremities

Vascular Injuries of the Extremities. Rutherford 6 th ed, Chp. 73 Maureen Tedesco, MD October 31, 2005. History. Civilian: UE arterial injuries more common Military: LE arterial injuries more common

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Vascular Injuries of the Extremities

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

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

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

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

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

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

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

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

  9. Diagnostic Evaluation • penetrating or blunt injury, normal extremity pulse examination, minimum ankle brachial index (MABI) of ≥1.00 does not require arteriography • Observe for 12-24 hours • Pts that have extremities with a distal pulse deficit or an MABI < 1.00  diagnostic arteriography useful, greatest yield • Role for Color Flow Duplex (CFD) ultrasonography • Noninvasive, painless, portable, low morbidity, inexpensive • Operator dependent • MRA • Image multiple anatomic areas, noninvasive • Not widely accessible

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  28. Orthopedic, Soft Tissue and Nerve Injuries

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

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

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

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

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

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

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

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

  37. Iatrogenic False Aneursyms • Significant number close spontaneously • Compression therapy 10-150 minutes (variable success rates) • Percutaneous thrombin injection (>95% success) • Endovascular repair • Open surgical repair (gold standard): • failure of other treatment modalities • suspected secondary infection • evidence of vascular compromise • ongoing or imminent hemorrhage and skin erosion • necrosis due to false aneurysm expansion

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