vascular injuries of the extremities rutherford 6 th ed, chp. 73 maureen tedesco, md october 31,...

Vascular Injuries of Vascular Injuries of the Extremities the Extremities

Rutherford 6Rutherford 6thth ed, Chp. 73 ed, Chp. 73

Maureen Tedesco, MDMaureen Tedesco, MD

October 31, 2005 October 31, 2005

History History

Civilian: UE arterial injuries more common Civilian: UE arterial injuries more common Military: LE arterial injuries more common Military: LE arterial injuries more common World War II extremity arterial injuries were World War II extremity arterial injuries were

ligated (popliteal artery injury amputation rate ligated (popliteal artery injury amputation rate 73%)73%)

Korean and Vietnam wars: amputation rate for Korean and Vietnam wars: amputation rate for popliteal artery injuries 32% (Hughes and Rich)popliteal artery injuries 32% (Hughes and Rich)

limb loss in most civilian series now less than limb loss in most civilian series now less than 10% to 15% 10% to 15%

long-term disability for 20% to 50% (soft tissue long-term disability for 20% to 50% (soft tissue and nerve injury)and nerve injury)

Mechanism of Injury Mechanism of Injury

In penetrating arterial injuriesIn penetrating arterial injuries– gunshot wounds in 64%gunshot wounds in 64%– knife wounds in 24%knife wounds in 24%– shotgun blasts in 12% shotgun blasts in 12%

Motor vehicle accidents, falls most common Motor vehicle accidents, falls most common causes of blunt injury causes of blunt injury

High velocity firearmsHigh velocity firearms– dissipation of energy into the surrounding tissuesdissipation of energy into the surrounding tissues– fragmentation of the projectile or of bonefragmentation of the projectile or of bone– blast effect blast effect – combination of combination of penetrating and blunt

tissue injury injury

Diagnostic EvaluationDiagnostic Evaluation

"hard signs" of "hard signs" of arterial disruption:arterial disruption:– pulsatile external pulsatile external

bleedingbleeding– an enlarging an enlarging

hematomahematoma– absent distal absent distal

pulsespulses– an ischemic limban ischemic limb

Proceed to OR Proceed to OR


Soft signs:Soft signs:– Significant hemorrhage by historySignificant hemorrhage by history– neurologic abnormality neurologic abnormality – Diminished pulse compared to Diminished pulse compared to

contralateral extremitycontralateral extremity– In proximity to bony injury or In proximity to bony injury or

penetrating woundpenetrating wound


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: Conrad et al: – Pts with normal PE and doppler pressure indices Pts with normal PE and doppler pressure indices

(DPI) can be safely discharged (DPI) can be safely discharged – Diagnostic arteriography is only indicated for Diagnostic arteriography is only indicated for

asymptomatic patients with abnormal DPI asymptomatic patients with abnormal DPI (Am Surg 68:269, 2002) (Am Surg 68:269, 2002)


For blunt extremity trauma, the For blunt extremity trauma, the indications for arteriography parallel indications for arteriography parallel indications for penetrating injuriesindications for penetrating injuries

Abou-Sayed et al.Abou-Sayed et al.– clinical examination can define a subset clinical examination can define a subset

of high-risk patients who need an of high-risk patients who need an arteriogram, and possibly surgical repairarteriogram, and possibly surgical repair

(Arch Surg 137:585, 2002) (Arch Surg 137:585, 2002)

University of Washington University of Washington CriteriaCriteriaJohansen et al, J Trauma, 1991Johansen et al, J Trauma, 1991Lynch et al, Ann Surg, 1991Lynch et al, Ann Surg, 1991

100 consecutive injured limbs in 93 trauma 100 consecutive injured limbs in 93 trauma patientspatients– All patients underwent arteriographyAll patients underwent arteriography– ABI<0.9ABI<0.9

1 false negative (NPV 99%), 2 false positives1 false negative (NPV 99%), 2 false positives Sensitivity 87%, specificity 97%Sensitivity 87%, specificity 97%

– Increases to 95% and 97% with clinical outcomesIncreases to 95% and 97% with clinical outcomes 100 traumatized limbs (84 penetrating, 16 100 traumatized limbs (84 penetrating, 16

blunt) in 96 consecutive patientsblunt) in 96 consecutive patients– Arteriography only in those patients with ABI<0.9 Arteriography only in those patients with ABI<0.9

(n=17)(n=17) 16/17 with positive arteriograms16/17 with positive arteriograms 7 underwent reconstruction7 underwent reconstruction

– 83 limbs with ABI>0.9 underwent duplex f/u83 limbs with ABI>0.9 underwent duplex f/u 5 minor arterial injuries (4 pseudos, 1 fistula)5 minor arterial injuries (4 pseudos, 1 fistula) 0 major arterial injuries missed0 major arterial injuries missed


penetrating or blunt injury, normal extremity pulse penetrating or blunt injury, normal extremity pulse examination, minimum ankle brachial index (MABI) of examination, minimum ankle brachial index (MABI) of ≥≥1.00 1.00 does notdoes not require arteriography require arteriography– Observe for 12-24 hoursObserve for 12-24 hours

Pts that have extremities with a Pts that have extremities with a distal pulse deficit or or an MABI < 1.00 an MABI < 1.00 diagnostic arteriography useful, diagnostic arteriography useful, greatest yield greatest yield

Role for Color Flow Duplex (CFD) ultrasonographyRole for Color Flow Duplex (CFD) ultrasonography– Noninvasive, painless, portable, low morbidity, Noninvasive, painless, portable, low morbidity,

inexpensiveinexpensive– Operator dependent Operator dependent

MRA MRA – Image multiple anatomic areas, noninvasiveImage multiple anatomic areas, noninvasive– Not widely accessibleNot widely accessible

Treatment of Arterial Treatment of Arterial Injuries: Nonoperative Injuries: Nonoperative ApproachApproach

Nonoperative approachNonoperative approach– Low-velocity injury Low-velocity injury – Minimal arterial wall Minimal arterial wall

disruption (<5 mm) for disruption (<5 mm) for intimal defects and intimal defects and pseudoaneurysms pseudoaneurysms

– Adherent or downstream Adherent or downstream protrusion of intimal protrusion of intimal flaps flaps

– Intact distal circulation Intact distal circulation – No active hemorrhageNo active hemorrhage

Follow up requiredFollow up required

Treatment of Arterial Treatment of Arterial Injuries: Endovascular Injuries: Endovascular ManagementManagement

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

Treatment of Arterial Treatment of Arterial Injuries: Endovascular Injuries: Endovascular ManagementManagement

Peroneal a. false aneurysm treated with coil embolization

Treatment of Arterial Treatment of Arterial Injuries: Operative Injuries: Operative ManagementManagement preparation and draping of the entire injured preparation and draping of the entire injured

extremityextremity drape contralateral uninjured lower or upper drape contralateral uninjured lower or upper

extremity (autogenous vein graft)extremity (autogenous vein graft) extremity incisions: longitudinal, directly over extremity incisions: longitudinal, directly over

the injured vessel, extended proximally or the injured vessel, extended proximally or distally as necessarydistally as necessary

Proximal and distal arterial control is Proximal and distal arterial control is obtained prior to exposure of the injuryobtained prior to exposure of the injury

endoluminal balloon occlusion: when endoluminal balloon occlusion: when proximal control of the traumatized vessel is proximal control of the traumatized vessel is problematic, place under fluoroscopic problematic, place under fluoroscopic guidance for temporary controlguidance for temporary control

Treatment of Arterial Treatment of Arterial Injuries: Operative Injuries: Operative ManagementManagement

debridedebride injured vessels to macroscopically injured vessels to macroscopically normal arterial wallnormal arterial wall

remove any intraluminal thrombusremove any intraluminal thrombus with with Fogarty catheters (proximal and distal to the Fogarty catheters (proximal and distal to the arterial injury) arterial injury)

Flush with Flush with heparinized salineheparinized saline solution: solution: proximal and distal arterial lumina proximal and distal arterial lumina

Systemic heparinization: Systemic heparinization: prevent thrombosis prevent thrombosis or thrombus propagation (if systemic or thrombus propagation (if systemic anticoagulation not contraindicated)anticoagulation not contraindicated)

Consider temporary intraluminal shunting: Consider temporary intraluminal shunting: debridement, fasciotomy, fracture fixation, debridement, fasciotomy, fracture fixation, nerve repair, or vein repair, before arterial nerve repair, or vein repair, before arterial reconstruction, in controlled settingreconstruction, in controlled setting

Treatment of Arterial Treatment of Arterial Injuries: Operative Injuries: Operative ManagementManagement

Types of RepairTypes of Repair– lateral suture patch angioplastylateral suture patch angioplasty– end-to-end anastomosisend-to-end anastomosis– interposition graft interposition graft – bypass graftbypass graft– Extra-anatomic bypass graft Extra-anatomic bypass graft

(sepsis or extensive soft tissue (sepsis or extensive soft tissue injury)injury)

Autogenous vein graft, PTFEAutogenous vein graft, PTFE Monofilament 5-0 or 6-0 sutures Monofilament 5-0 or 6-0 sutures repairs tension free repairs tension free covered by viable soft tissue (flaps if covered by viable soft tissue (flaps if

needed)needed) Intraoperative completion Intraoperative completion

arteriographyarteriography Intra-arterial vasodilators Intra-arterial vasodilators

(papaverine or tolazoline) (papaverine or tolazoline)

Treatment of Arterial Treatment of Arterial Injuries: Operative Injuries: Operative ManagementManagement risk factors for amputation after risk factors for amputation after

arterial repairarterial repair– occluded bypass graftoccluded bypass graft– combined above- and below-knee combined above- and below-knee

injuryinjury– a tense compartmenta tense compartment– arterial transectionarterial transection– associated compound fracture associated compound fracture

Treatment of Arterial Treatment of Arterial Injuries: Operative Injuries: Operative ManagementManagement Reperfusion injuryReperfusion injury

– Mannitol Mannitol – AllopurinolAllopurinol– superoxide dismutasesuperoxide dismutase– catalase catalase – Systemic Heparin Systemic Heparin

Brachial, Radial and Brachial, Radial and Ulnar Artery InjuryUlnar Artery Injury Single-vessel injury in the Single-vessel injury in the

forearm: need not be repaired forearm: need not be repaired but may be ligated or embolizedbut may be ligated or embolized

Repair is Repair is mandatorymandatory when one when one of the vessels was previously of the vessels was previously traumatized or ligated or when traumatized or ligated or when the palmar arch is incompletethe palmar arch is incomplete

If both radial and ulnar arteries If both radial and ulnar arteries injured injured the ulnar artery the ulnar artery should be repaired ( dominant should be repaired ( dominant vessel) vessel)

Subclavian-Axillary Subclavian-Axillary injury injury High mortality rate (39%)High mortality rate (39%) fracture-dislocation of the posterior fracture-dislocation of the posterior

portion of the 1st ribportion of the 1st rib subclavian a. subclavian a. injury likelyinjury likely

High collateral flow in UE makes absent High collateral flow in UE makes absent pulses unlikelypulses unlikely high index of suspicion high index of suspicion

Mulitple chest incisions:Mulitple chest incisions:– median sternotomy for proximal control median sternotomy for proximal control – left anterolateral or "trapdoor" thoracotomyleft anterolateral or "trapdoor" thoracotomy

External Iliac-Femoral External Iliac-Femoral Artery InjuryArtery Injury

Iliac injuries: Iliac injuries: mortality rate 20-mortality rate 20-40%40%

External iliac: External iliac: retroperitoneal retroperitoneal approach approach

External Iliac-Femoral External Iliac-Femoral Artery InjuryArtery Injury

common femoral, common femoral, proximal deep proximal deep femoral, and femoral, and superficial femoral superficial femoral artery injuries: artery injuries: longitudinal thigh longitudinal thigh incision over the incision over the femoral triangle.femoral triangle.

Interposition vein graft for repair of SFA

Popliteal Artery Injury Popliteal Artery Injury

Challenging injury Challenging injury injury above the injury above the

knee joint: medial knee joint: medial thigh incision thigh incision

below-knee injury: a below-knee injury: a leg incision leg incision

isolated penetrating isolated penetrating injury directly injury directly behind the knee: behind the knee: incision behind knee incision behind knee

Positive predictors of limb salvagePositive predictors of limb salvage– systemic anticoagulation (heparin) systemic anticoagulation (heparin) – laterally or end to end arterial repairlaterally or end to end arterial repair– palpable pedal pulses within the first 24 palpable pedal pulses within the first 24

hourshours negative predictors of limb salvagenegative predictors of limb salvage

– severe soft tissue injurysevere soft tissue injury– deep soft tissue infectiondeep soft tissue infection– preoperative ischemia preoperative ischemia

Important: Attention to possibility of Important: Attention to possibility of compartment syndrome and rapid treatment compartment syndrome and rapid treatment by complete dermotomy-fasciotomy if presentby complete dermotomy-fasciotomy if present

Popliteal Artery InjuryPopliteal Artery Injury

Isolated injury, rare limb Isolated injury, rare limb ischemia: no repair necessaryischemia: no repair necessary

tibioperoneal trunk or two tibioperoneal trunk or two infrapopliteal arteries injured: infrapopliteal arteries injured: repair is required repair is required

Tibial Artery InjuryTibial Artery Injury

Management considerations:Management considerations:– severity of arterial spasmseverity of arterial spasm– unknown long-term consequences of unknown long-term consequences of

autogenous grafts placed in childrenautogenous grafts placed in children– long-term effects of diminished long-term effects of diminished

blood flow on limb length blood flow on limb length – papaverine (injected topically or into papaverine (injected topically or into

the adventitia), nitrates, or warm the adventitia), nitrates, or warm saline to impede vasoactivitysaline to impede vasoactivity

Pediatric Arterial Pediatric Arterial Trauma Trauma

Most common injured veins:Most common injured veins:– superficial femoral vein (42%) superficial femoral vein (42%) – popliteal vein (23%) popliteal vein (23%) – common femoral vein (14%)common femoral vein (14%)

When venous injury is localizedWhen venous injury is localized– end-to-end or lateral repair (stable pt)end-to-end or lateral repair (stable pt)– an interposition, panel, or spiral graft can be an interposition, panel, or spiral graft can be

configured for repair (extensive venous injuries)configured for repair (extensive venous injuries) the indication and benefit of vein repair is the indication and benefit of vein repair is

controversialcontroversial Ligation in unstable patient Ligation in unstable patient Postoperative: extremity elevation and Postoperative: extremity elevation and

wrappingwrapping

Extremity Venous Extremity Venous InjuriesInjuries

arterial repair should be performed first to restore arterial repair should be performed first to restore circulation to the limb before the orthopedic circulation to the limb before the orthopedic stabilization is addressed stabilization is addressed

inspect vascular reconstruction before final wound inspect vascular reconstruction before final wound closure and before pt leaves OR closure and before pt leaves OR

injured nerve should be tagged with injured nerve should be tagged with nonabsorbable suture at the initial operationnonabsorbable suture at the initial operation

Consider Consider primary amputationprimary amputation for limbs with for limbs with massive orthopedic, soft tissue, and nerve injuriesmassive orthopedic, soft tissue, and nerve injuries

Consider primary amputation in hemodynamically Consider primary amputation in hemodynamically unstable patients (repair might jeopardize unstable patients (repair might jeopardize survival)survival)

Orthopedic, Soft Orthopedic, Soft Tissue and Nerve Tissue and Nerve InjuriesInjuries

Orthopedic, Soft Orthopedic, Soft Tissue and Nerve Tissue and Nerve InjuriesInjuries

Inadvertant Inadvertant Intraarterial Drug Intraarterial Drug Injection (IADI)Injection (IADI)

Illicit street drugs, Illicit street drugs, anestheticsanesthetics

Complications Complications – acute arterial acute arterial

occlusionocclusion– distal distal

thromboembolismthromboembolism– mycotic aneurysmsmycotic aneurysms– soft tissue abscessessoft tissue abscesses– gangrenegangrene– chronic ischemia chronic ischemia

Soft tissue cellulitis/abscess pathogens:– Staphylococcus aureusStaphylococcus aureus – oral flora (streptococcal species)oral flora (streptococcal species)– anaerobic species (anaerobic species (PeptostreptococcusPeptostreptococcus and and

BacteroidesBacteroides ) ) Findings:Findings:

– severe, unremitting painsevere, unremitting pain– edemaedema– NumbnessNumbness– discolorationdiscoloration– cyanosis or mottlingcyanosis or mottling

Diagnosis: history, clinical exam, CFD Diagnosis: history, clinical exam, CFD ultrasonographyultrasonography


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


Goal: preserve all collateral circulation Goal: preserve all collateral circulation Therapy: Therapy:

– Heparin sodium 10,000 units/hour IV (PTT 1½ to 2 10,000 units/hour IV (PTT 1½ to 2 times control) to prevent further clotting times control) to prevent further clotting

– Dexamethasone Dexamethasone 4 mg IV q 6 hrs to reduce 4 mg IV q 6 hrs to reduce inflammationinflammation

– DextranDextran 40 IV at 20 mL/hr to prevent platelet 40 IV at 20 mL/hr to prevent platelet aggregation and thrombosis aggregation and thrombosis

Appropriate pain control, including opiates prn Appropriate pain control, including opiates prn Elevation of the extremity to reduce edema Elevation of the extremity to reduce edema Aggressive physical therapy to minimize Aggressive physical therapy to minimize

contractures contractures


one of the most common complications one of the most common complications after an invasive arterial procedureafter an invasive arterial procedure

Also termed Also termed pseudoaneurysm, pulsatile hematoma, or communicating hematoma

direct leakage of blood from the artery direct leakage of blood from the artery into the surrounding tissueinto the surrounding tissue

no walls of the artery involved no walls of the artery involved Post arterial catheterization 0.2-9%Post arterial catheterization 0.2-9%

Iatrogenic False Iatrogenic False AneursymsAneursyms

positive risk factorspositive risk factors– Age older than 60 yearsAge older than 60 years– female genderfemale gender– periprocedural anticoagulationperiprocedural anticoagulation– operator inexperienceoperator inexperience– underlying peripheral vascular diseaseunderlying peripheral vascular disease

postprocedure arterial closure postprocedure arterial closure devicesdevices should see decline in rate should see decline in rate

Iatrogenic False Iatrogenic False AneursymsAneursyms

Iatrogenic False Iatrogenic False AneursymsAneursyms Sign/symptomsSign/symptoms

– pulsatile mass pulsatile mass – significant significant

ecchymosis over ecchymosis over the area of the area of cannulationcannulation

– sudden drop in the sudden drop in the postprocedure postprocedure hematocrithematocrit

– newly auscultated newly auscultated bruitbruit

– newly palpable newly palpable thrillthrill

– the new onset of the new onset of neurologic deficitsneurologic deficits

Iatrogenic False Iatrogenic False AneursymsAneursyms Duplex ScanDuplex Scan

– NoninvasiveNoninvasive– Size of false Size of false

aneurysmaneurysm– Neck diameter Neck diameter

and length and length – Architecture of Architecture of

native vesselnative vessel– Velocity within Velocity within

native vessel and native vessel and false aneurysmfalse aneurysm

Iatrogenic False Iatrogenic False AneursymsAneursyms Significant number close spontaneouslySignificant number close spontaneously Compression therapy 10-150 minutes (variable Compression therapy 10-150 minutes (variable

success rates)success rates) Percutaneous thrombin injection (>95% Percutaneous thrombin injection (>95%

success)success) Endovascular repairEndovascular repair Open surgical repair (gold standard):Open surgical repair (gold standard):

– failure of other treatment modalitiesfailure of other treatment modalities– suspected secondary infectionsuspected secondary infection– evidence of vascular compromiseevidence of vascular compromise– ongoing or imminent hemorrhage and skin erosionongoing or imminent hemorrhage and skin erosion– necrosis due to false aneurysm expansion necrosis due to false aneurysm expansion

vascular injuries of the extremities rutherford 6 th ed, chp. 73 maureen tedesco, md october 31,...

Documents