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Peripheral Vascular Injuries Follow-up

  • Author: Niels K Rathlev, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 08, 2015
 

Further Outpatient Care

See the list below:

  • 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.
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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. Endovascular repair with stent placement is now used with increased frequency.[18]

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.

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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.[19]

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. 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 arterArteriovenous 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 require surgical intervention.
  • Approximately 10% of patients with nonocclusive, clinically occult injuries require repair within one month of the initial injury.[20] The remaining 90% of patients do not report symptoms or see a physician for vascular problems during long-term follow-up.[21]
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Prognosis

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  • Most non-occlusive injuries presenting without "hard" signs resolve over time.[17] Long-term follow-up with scheduled, repeat physical examinations is a safe and effective approach.
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Patient Education

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  • 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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Contributor Information and Disclosures
Author

Niels K Rathlev, MD, FACEP Professor and Chair, Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center

Niels K Rathlev, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine, Association of Academic Chairs of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association

Disclosure: Partner received salary from Pfizer for employment.

References
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  11. Hood DB, Weaver FA, Yellin AE. Changing perspectives in the diagnosis of peripheral vascular trauma. Semin Vasc Surg. 1998 Dec. 11(4):255-60. [Medline].

  12. Busquets AR, Acosta JA, Colon E, et al. Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities. J Trauma. 2004 Mar. 56(3):625-8. [Medline].

  13. Rieger M, Mallouhi A, Tauscher T, et al. Traumatic arterial injuries of the extremities: initial evaluation with MDCT angiography. AJR Am J Roentgenol. 2006 Mar. 186(3):656-64. [Medline].

  14. Soto JA, Munera F, Morales C, et al. Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis. Radiology. 2001 Jan. 218(1):188-94. [Medline].

  15. Seamon MJ, Smoger D, Torres DM, Pathak AS, Gaughan JP, Santora TA. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma. 2009 Aug. 67(2):238-43; discussion 243-4. [Medline]. [Full Text].

  16. Bodanapally UK, Dreizin D, Sliker CW, Boscak AR, Reddy RP. Vascular Injuries to the Neck After Penetrating Trauma: Diagnostic Performance of 40- and 64-MDCT Angiography. AJR Am J Roentgenol. 2015 Oct. 205 (4):866-72. [Medline].

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  18. Mousa A, Chong B, Aburahma AF. Endovascular repair of subclavian/axillary artery injury with a covered stent. A case report and review of literature. Vascular. 2013 Mar 14. [Medline].

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  20. Criado E, Marston WA, Ligush J, et al. Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas. Ann Vasc Surg. 1997 May. 11(3):256-63. [Medline].

  21. Dennis JW, Frykberg ER, Veldenz HC, et al. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma. 1998 Feb. 44(2):243-52; discussion 242-3. [Medline].

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Pseudoaneurysm of the axillary artery.
Arteriovenous fistula between common femoral artery and vein.
 
 
 
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