Vascular Injuries of the Extremities

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Vascular Injuries of the Extremities

• Rutherford 6th ed, Chp. 73
• Maureen Tedesco, MD
• October 31, 2005

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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)

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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

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Diagnostic Evaluation

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

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Diagnostic Evaluation

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

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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 1251256,
  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 68269, 2002)

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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 137585, 2002)

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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
• ABIlt0.9
• 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 ABIlt0.9
  (n17)
• 16/17 with positive arteriograms
• 7 underwent reconstruction
• 83 limbs with ABIgt0.9 underwent duplex f/u
• 5 minor arterial injuries (4 pseudos, 1 fistula)
• 0 major arterial injuries missed

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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 lt 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

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Treatment of Arterial Injuries Nonoperative
Approach

• Nonoperative approach
• Low-velocity injury
• Minimal arterial wall disruption (lt5 mm) for
  intimal defects and pseudoaneurysms
• Adherent or downstream protrusion of intimal
  flaps
• Intact distal circulation
• No active hemorrhage
• Follow up required

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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

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

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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

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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)

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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

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Treatment of Arterial Injuries Operative
Management

• Reperfusion injury
• Mannitol
• Allopurinol
• superoxide dismutase
• catalase
• Systemic Heparin

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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)

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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

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External Iliac-Femoral Artery Injury

• Iliac injuries mortality rate 20-40
• External iliac retroperitoneal approach

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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

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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

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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

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Tibial Artery Injury

• Isolated injury, rare limb ischemia no repair
  necessary
• tibioperoneal trunk or two infrapopliteal
  arteries injured repair is required

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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

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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

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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)

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Orthopedic, Soft Tissue and Nerve Injuries
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Inadvertant Intraarterial Drug Injection (IADI)

• Illicit street drugs, anesthetics
• Complications
• acute arterial occlusion
• distal thromboembolism
• mycotic aneurysms
• soft tissue abscesses
• gangrene
• chronic ischemia

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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

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Inadvertant Intraarterial Drug Injection (IADI)

• Treatment soft tissue abscess
• Parenteral Abx
• Incision and Drainage/ debridement
• Prior to ID, CFD ultrasonography to rule out the
  presence of a mycotic aneurysm

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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

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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

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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

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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

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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

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Iatrogenic False Aneursyms

• Significant number close spontaneously
• Compression therapy 10-150 minutes (variable
  success rates)
• Percutaneous thrombin injection (gt95 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