Peripheral Vascular Injuries Follow-up
- Author: Niels Rathlev, MD, FACEP; Chief Editor: Rick Kulkarni, MD more...
Further Inpatient Care
- Surgical exploration and repair is performed as soon as possible for patients with "hard" signs of vascular injury, refractory hypotension, and obvious limb ischemia. Conventional arteriography to further define the injury may be performed preoperatively at the discretion of the vascular surgeon.
- Patients with "soft" signs of injury should preferentially be further evaluated by MDCT angiography, or, alternatively by duplex ultrasonography. Certain high-risk injuries, such as shotgun wounds and major vessel proximity injuries, may undergo MDCT or conventional arteriography despite the absence of "hard" or "soft" signs. Low-risk injuries without "hard" and "soft" signs should be observed for possible progression of injury either in the hospital or on an outpatient basis. Major venous injuries of the lower extremities are typically repaired because this improves wound healing and decreases the incidence of compartment syndrome, venous thrombosis, and chronic edema.
Further Outpatient Care
- Low-risk injuries without "hard" or "soft" signs may be managed on an outpatient basis with careful follow-up and a strict schedule for repeat evaluations.
- All other patients should be admitted for either definitive repair or further evaluation or observation.
Complications
Delayed diagnosis and treatment may result in thrombosis, embolization, or rupture with exsanguinating hemorrhage.
Risk factors for amputation include elevated compartment pressure, arterial transection, concomitant open fractures, and the combination of injuries above and below the elbow or knee in the same extremity.[12]
Non-occlusive injuries do not disrupt flow and include the following:
- Pseudoaneurysms may resolve completely or grow over time presenting months to years later. They may cause neuropathy due to compression or embolization, and can present as a growing pulsatile mass. See the image below.
Pseudoaneurysm of the axillary artery. - Arteriovenous fistulae typically take months to mature and often require surgical repair. (See the image below)
Arteriovenous fistula between common femoral artery and vein. - Intimal tears and flaps generally heal spontaneously over time.
- Segmental narrowing can cause diminished flow, but pulses may remain intact. This injury may resolve spontaneously with fluids and rest, or, rarely may require surgical intervention.
Prognosis
- Most non-occlusive injuries presenting without "hard" signs resolve over time.[15] Long-term follow-up with scheduled, repeat physical examinations is a safe and effective approach.
Patient Education
- Patients must be given explicit instructions to present for neurovascular checks of the extremities on a scheduled basis. Instruct patients to return to the ED if they experience increased pain, edema, or active bleeding from the wound or if any weakness, numbness, or paresthesias develops in the injured extremity.
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