VASCULAR TRAUMA

(EXTREMITY)
 INTRODUCTION

• VASCULAR INJURY MECHANISMS ARE DIVIDED INTO

PENETRATING OR BLUNT. FOLLOWING BLUNT TRAUMA,
TISSUE INJURY IS PRODUCED BY LOCAL COMPRESSION,
RAPID DECELERATION, AND THE RESULTING SHEAR
FORCES.
• INJURY SEVERITY IS PROPORTIONAL TO THE AMOUNT OF
KINETIC ENERGY (KE) TRANSFERRED TO THE TISSUES,
WHICH IS A FUNCTION OF THE MASS ( M ) AND VELOCITY ( V
); KE =( M × V2 )/2.
• SMALL CHANGES IN VELOCITY ALTER THE KINETIC ENERGY
TRANSFER MORE SIGNIFICANTLY THAN DO CHANGES IN
MASS.
• THIS IS CRITICAL WHEN EVALUATING HIGH- AND LOW-
VELOCITY GUNSHOT WOUNDS AND THEIR CORRESPONDING
INJURY POTENTIAL.
• VASCULAR INJURIES OF THE LOWER EXTREMITY POSE
SOME OF THE MOST CHALLENGING PROBLEMS FACED BY
VASCULAR SURGEONS FOR A NUMBER OF REASONS
• WHILE THESE INJURIES ARE NOT TYPICALLY LIFE-
THREATENING, THE RISK OF LIMB LOSS IN A YOUNG
TRAUMA PATIENT AMPLIFIES THE IMPORTANCE OF MAKING
A COMPLEX SERIES OF CORRECT CLINICAL DECISIONS WITH
LIMITED DATA UNDER THE PRESSURE OF TIME.
MECHANISM OF VASCULAR
INJURY
ANATOMY
 EPIDEMIOLOGY & PATTERN OF
INJURY

• VASCULAR INJURIES  1-2% OF INJURED PATIENTS

• VASCULAR INJURIES TO EXTREMITIES  20-50% OF
ALL VASCULAR INJURIES.
• HIGHER MORBIDITY, MORTALITY, AND RESOURCE
UTILIZATION
• AVERAGE AGE 30 YO, PREDOMINANTLY MALE (70-
90%)
EPIDEMIOLOGY & PATTERN OF
INJURY

• MORTALITY & AMPUTATION

RATES HIGHER IN BLUNT
COMPARED WITH PENETRATING
TRAUMA
• LOCATION OF INJURY :
• CONCOMITANT VENOUS INJURY,
PERIPHERAL NERVE INJURY,
AND SOFT TISSUE DISRUPTION
DO NOT CORRELATE WITH
AMPUTATION RATES
DIAGNOSIS & WORKUP
HARD SIGN

• IN CASES IN WHICH A PATIENT

PRESENTS WITH “HARD SIGNS”
OF VASCULAR (PRIMARILY
PENETRATING ARTERIAL)
INJURY, THE EXISTENCE AND
LOCATION OF THE INJURY ARE
GENERALLY OBVIOUS, AND
THE NEXT STEP IN
MANAGEMENT IS OPERATIVE
EXPLORATION AND REPAIR.
 SOFT SIGN

• THE DIAGNOSIS OF INJURIES IN PATIENTS PRESENTING

WITH ONLY “SOFT SIGNS” OF VASCULAR INJURY IS MORE
CHALLENGING, AND SUCH PATIENTS TYPICALLY REQUIRE
SPECIFIC DIAGNOSTIC TESTING IN ADDITION TO THE
SECONDARY TRAUMA SURVEY
• CONVENTIONAL CATHETER-BASED ANGIOGRAPHY 
“GOLD STANDARD” (FOR THE PREOPERATIVE DIAGNOSIS
AND LOCALIZATION OF EXTREMITY VASCULAR INJURIES)
DIAGNOSIS & WORKUP
• PHYSICAL EXAMINATION
• WEAVER ET AL. 1990  DOPPLER-ABI < 0,9
HAS 82% SENSITIVITY AND 40%
SPECIFICITY
• SCHWARTZ ET AL. 1993, SENSITIVITY OF
86% FOR ABI <1,0
DIAGNOSIS & WORKUP
DUPLEX ULTRASONOGRAPHY
• TIME-CONSUMING & OPERATOR
SPECIFIC
• SENSITIVITY 50-95%, SPECIFICITY 98%
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY

• MOST FREQUENTLY USED

• LOCALIZE EXTREMITY ARTERIAL INJURIES
(REPLACE CONVENTIONAL CATHETER-BASED
ANGIOGRAPHY)
• IMAGING BONE AND SOFT TISSUES
SIMULTANEOUSLY
• DIAGNOSIS OF MAJOR VENOUS INJURIES
WITH DELAYED PHASE SCAN
• SENSITIVITY 95%, SPECIFICITY 90%
COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
TREATMENT PRINCIPLES
IMMEDIATE TREATEMENT
 TREATMENT
PRINCIPLES
NONOPERATIVE MANAGEMENT
• NO HARD SIGNS
• LACK OF DISTAL ISCHEMIA OR EXTRAVASATION
• DEFECT SMALLER THAN 2 CM
• SERIAL SURVEILLANCE WITH APPROPRIATE IMAGING SUCH
AS CTA OR DUS
 TREATMENT
PRINCIPLES
ENDOVASCULAR THERAPY
• HAS SIMILAR OR IMPROVED OUTCOMES COMPARED WITH
OPEN REPAIR
• LESS INVASIVE (ESPECIALLY INJURIES TO JUNCTIONAL
VESSELS SUCH AS SUBCLAVIAN AND ILLIAC)
• BALLOON / STENT GRAFTS / EMBOLIZATION WITH COILS &
GLUE
 TREATMENT
PRINCIPLES
OPEN SURGICAL MANAGEMENT
• MANAGEMENT OF MOST EXTREMITY VASCULAR INJURIES
• INCISIONS ARE TYPICALLY MADE LONGITUDINALLY,
DIRECTLY PROXIMAL AND DISTAL.
• LOCAL ANTICOAGULATION WITH HEPARINIZED SALINE 
PREVENT LOCAL THROMBOSIS
 TREATMENT
PRINCIPLES
OPEN SURGICAL MANAGEMENT
• COVER THE VASCULAR REPAIR TO PREVENT DESICCATION
AND ANASTOMOTIC BREAKDOWN
• BEFORE HEPARINIZATION AND REPAIR, THE INFLOW AND
OUTFLOW VESSELS  GENTLE BALLOON CATHETER
THROMBECTOMY TO CONFIRM PATENCY
• ACUTE LIGATION WITH PLAN FOR REVASCULARIZATION
WHEN THE PATIENTS CONDITION STABILIZES
 TREATMENT
PRINCIPLES
TEMPORARY SHUNTING
• SHUNTS USED TO ALLOW ORTHOPEDIC FIXATION, WITH
DWELL TIMES 1-3 HOURS, WITH PATENCY RATES
APPROACHING 100%
• DWELL TIMES 12 HOURS TO MORE THAN A DAY WHEN
SHUNTS ARE PLACED AS PART OF DAMAGE CONTROL
MANAGEMENT
 TREATMENT
PRINCIPLES
VENOUS REPAIR VERSUS LIGATION
• CONTROVERSIAL
• NO CONSISTENT ASSOCIATION, MAJOR
VENOUS LIGATION VS AMPUTATION
• 45% INCIDENCE OF ACUTE THROMBOSIS OF
VENOUS REPAIRS AT 72 HOURS
• LIMB EDEMA FOLLOWING LIGATION  90% OF
LIGATED POPLITEAL AND 50% OF LIGATED
FEMORAL. REPAIR REDUCES BY ABOUT HALF
 TREATMENT
PRINCIPLES
VENOUS REPAIR VERSUS LIGATION
• VTE (VENOUS THROMBO-EMBOLISM) RATE IN LIGATION
APPROXIMATELY TWICE OF REPAIR
• PE (PULMONARY EMBOLISM) RATE IS SIMILAR BETWEEN
LIGATION AND REPAIR
• THE DECISION TO REPAIR OR TO LIGATE MAJOR EXTREMITY
VEIN INJURY SHOULD BE MADE IN THE CONTEXT OF
PATIENTS OVERALL PHYSIOLOGIC CONDITION
 SPECIFIC ARTERIAL
INJURIES
AXILLARY ARTERY
• PENETRATING TRAUMA >>>
• NERVE INJURIES  1/3 PATIENTS
• LONGITUDINAL INCISION BEGINNING AT PROXIMAL EXTENT OF
BICIPITAL FOSSA EXTENDING THROUGH ANTERIOR AXILLA TO
CHEST WALL
• ENDOVASCULAR PROCEDURE CAN BE PERFORMED ANTEGRADE
BY FEMORAL APPROACH OR RETROGRADE BY IPSILATERAL
BRACHIAL APPROACH
 SPECIFIC ARTERIAL
INJURIES
BRACHIAL ARTERY
• MOST FREQUENTLY INJURED ARTERY OF UPPER
EXTREMITY (50%)
• MEDIAN NERVE INJURY IS FREQUENTLY ASSOCIATED.
• FREQUENTLY ASSOCIATED WITH FRACTURES OF HUMERUS
AND DISLOCATIONS OF ELBOW (ESPECIALLY IN CHILDREN)
• LONGITUDINAL INCISION ALONG THE COURSE OF THE
ARTERY IN THE BICIPITAL FOSSA, AVOID INJURING MEDIAN
NERVE IN THE BRACHIAL SHEATH WITH THE ARTERY
• “LAZY S” SKIN INCISION TO EXPOSE ARTERY DISTAL TO
THE ELBOW
 SPECIFIC ARTERIAL
INJURIES
RADIAL AND ULNAR ARTERY
• PENETRATING TRAUMA
• INJURY TO THE RADIAL AND ULNAR NERVE IN 25% OF CASES
• LONGITUDINAL INCISIONS DIRECTLY OVERLYING THEIR COURSES
• IF ONLY ONE OF THE FOREARM ARTERIES IS INJURED AND ALLEN
TEST REVEALS PATENT PALMAR ARCH, THE INJURY CAN BE SAFELY
LIGATED
• IF BOTH ARE INJURED, PREFERENCE SHOULD BE GIVEN TO REPAIR
ULNAR ARTERY AS DOMINANT CONTRIBUTOR TO HAND PERFUSION
SPECIFIC ARTERIAL
INJURIES
FEMORAL ARTERY
• SFA IS THE MOST COMMONLY
INJURED OF THE LOWER EXTREMITY
• CFA + PFA ONLY 10%
• PREDOMINANCE BY PENETRATING
TRAUMA
• ASSOCIATED NERVE INJURY
UNCOMMON (10%)
• MORTALITY RATE 10%, PATIENTS
FREQUENTLY PRESENT IN SHOCK
• EXPOSURE THROUGH LONGITUDINAL
INCISION, CAN BE EXTENDED
PROXIMALLY AND DIVIDE INGUINAL
LIGAMENT
SPECIFIC ARTERIAL
INJURIES
POPLITEAL ARTERY
• SECOND MOST FREQUENTLY
INJURED ARTERY OF LOWER
EXTREMITY (20%)
• PREDOMINANTLY INJURED BY
BLUNT TRAUMA
• OFTEN ASSOCIATED WITH TIBIAL
PLATEAU FRACTURE
• EXPOSURE THROUGH SEPARATE
MEDIAL ABOVE AND BELOW KNEE
INCISIONS
• MEDIAL EXPOSURE DIRECTLY
BEHIND THE KNEE SHOULD BE
AVOIDED BECAUSE DIVISION OF
SEMIMEBRANOSUS AND
SEMITENDINOSUS TENDONS
INVITES CONSIDERABLE
MORBIDITY DURING
REHABILITATION
 SPECIFIC ARTERIAL
INJURIES
TIBIAL ARTERIES
• OCCUR EQUALLY FROM BLUNT AND PENETRATING TRAUMA
• FRACTURES ARE PRESENT IN A THIRD PENETRATING
INJURIES AND NEARLY ALL BLUNT INJURIES
• NERVE INJURIES 25-50%
• IN MULTIPLE INJURIES OR SINGLE INJURY WITH CLINICALLY
ISCHEMIC LIMBS, REPAIR AT LEAST ONE
• EXPOSURE THROUGH FASCIOTOMY INCISION
ALGORITHM FOR EVALUATION
VASCULAR REPAIR
COMPLEX REPAIR AFTER
SEGMENTAL RESECTION
MANGLED SCORE SEVERITY SCORE
 CONCLUSION

• MALE (30 YEARS OLD) >>> FEMALE

• PRIMARY SURVEY  CIRCULATION VASCULAR TRAUMA
• HARD SIGN AND SOFT SIGN
• HARD SIGN (+)  EXPLORE AND IMMEDIATE OPERATION
• CT ANGIOGRAPHY  MOST FREQUENTLY USED
• APPROACH OF INCISION
Matur Suksma