Extremity Vascular Trauma 

Updated: Nov 12, 2019
Author: H Scott Bjerke, MD, FACS; Chief Editor: Vincent Lopez Rowe, MD 

Overview

Practice Essentials

Patients with extremity vascular trauma present daily in emergency departments (EDs) and trauma centers worldwide.[1, 2]  Although much of the current state-of-the-art information is the result of wartime observations, the incidence of civilian extremity vascular trauma is significant. A basic understanding of both blunt and penetrating injuries to the extremities and the resultant vascular abnormalities that occur with these injuries helps minimize mortality and morbidity in these patients.

Civilian extremity vascular injury, as with the wartime experience, is most prevalent in cases of penetrating trauma[3] ; however, in contrast to the military experience, penetrating trauma in the civilian setting is usually due to knife wounds or low-velocity handgun injuries.[4]  Fortunately, high-velocity assault weapon injuries and explosive injuries are less common in the United States.

In many parts of the world, regional conflicts in which antipersonnel mines are used has given rise to a large population of children and civilian adults with extremity vascular and soft-tissue injuries resulting in amputations. Civilian clinicians expecting to render aid and services in these areas can refer to references such as Husum and colleagues' War Surgery Field Manual to augment their knowledge of civilian wartime injuries.[5]

Vascular injuries can be classified clinically into hard signs and soft signs of injury on the basis of examination (see Presentation). Both hard and soft signs help direct the clinician to the best diagnostic and treatment options for an individual patient.

Medical therapy alone is rarely an option in penetrating or blunt trauma to the extremity vasculature when hard signs of injury are present. Patients who are asymptomatic or who have only soft signs can often be observed, but such observation is best performed by a surgeon who is prepared to operate if changing circumstances require it. The observation must be performed with the understanding that if the examination findings change or if hard signs develop, surgical intervention is necessary. Surgical intervention can be as minor as operative visualization of normal vascular anatomy for diagnostic purposes or as extensive as reconstruction and replacement of entire segments of injured vessels

Improved Emergency Medical Services (EMS) systems, faster transport times, availability of interventional radiologic techniques, improved surgical technique, and new vascular conduits may further reduce the morbidity and mortality of extremity vascular injury. The future of limiting the morbidity and mortality of these injuries probably lies with advances in other areas, such as motor vehicle safety, worldwide control and cleanup of antipersonnel mines, and injury prevention programs.

Anatomy

A thorough knowledge of basic medical-school anatomy of the extremities is essential in the evaluation and management of extremity vascular injuries. Although it is often possible to visualize an arterial injury directly through an open wound, obtaining proximal and distal control for vascular reconstruction requires intimate knowledge of vascular, muscular, and bony anatomy to allow rapid access to the arterial tree proximally and distally while incision length and surgical tissue dissection are minimized.

Frequently, especially in cases of blunt trauma and arterial trauma with ongoing hemorrhage, the normal tissue planes are destroyed, and the smooth muscle in both the artery and the vein cause retraction of the vessels into the depths of the wound. Operative identification of arterial and venous injury as a prelude to repair often requires proximal and distal control of the artery or vein, which may require extending the wound in both directions or making counterincisions.

Temporary vascular control can be achieved by simply applying pressure to the vessel proximal to the injury (eg, femoral pressure in a lower-extremity wound). The application of tourniquets, while helpful in the operating room, should be limited to patients at risk for exsanguination in the prehospital and field environments who are not responsive to direct pressure for hemorrhage control.

The use of tourniquets, especially those left for prolonged periods, markedly increases the incidence of amputation of an injured extremity. Any medical personnel applying a prehospital tourniquet for extremity vascular injury should clearly document its necessity as a lifesaving antiexsanguination device when direct pressure fails and should understand that, in most cases, a tourniquet saves a life but results in loss of an extremity.

Pathophysiology

As noted by the preponderance of penetrating injury in the published medical literature, the vascular tree, both arterial and venous, appears to have some limited natural protection from stretching and bending, which results in fewer blunt injuries to the extremity vasculature following trauma. The smooth muscle of the arterial media protects the patient from both stretch-type injuries and minor puncture wounds, which heal spontaneously in most cases. The smooth-muscle layer also offers mild protection from death due to ongoing hemorrhage.

When the arterial vessel is transected, vascular spasm coupled with low systemic blood pressure appears to promote clotting at the site of injury and to preserve vital organ perfusion better than is the case with ongoing uncontrolled hemorrhage. This partially explains the prehospital finding that in the subset of penetrating trauma, limited or no fluid resuscitation until arrival at the hospital may improve patient survival and outcome.

Etiology

Extremity vascular injury may result from penetrating injury (eg, gunshot wounds[6]  or knife injuries), but not all penetrating injuries are violent in nature. Many penetrating extremity injuries reported in the literature are from industrial accidents (eg, nail guns) or are iatrogenic complications of vascular access procedures for other medical problems.

Blunt injuries causing vascular injury typically result from motor vehicle accidents but may include falls, assaults, and crush injuries. Fractured long bones or dislocated joints frequently increase the overall risk of vascular injury, but certain injuries (eg, posterior knee dislocation) are more likely to cause vascular injury than other injuries (eg, a Colles fracture of the wrist, which rarely results in radial or ulnar artery injury).

The worldwide increase in explosive-type injuries constitutes an emerging third modality that combines the pathology of both blunt and penetrating injury to the extremities. Terrorist bombings, civilian land mine injuries, and combat-related injuries are becoming more common, and all clinicians will undoubtedly encounter these patients at some time in their career.

Epidemiology

The actual frequency of extremity vascular injuries worldwide is difficult to quantify.

In the United States, it is possible to separate iatrogenic vascular injury from traumatic injury and to reference hospital discharge data for the frequency of diagnosis codes. However, this method may significantly underestimate the actual frequency, depending on the method used to code the diagnosis and the importance and ranking attached to the diagnosis. In many cases, government report forms only record the top three discharge diagnostic codes, with the result that codes due to iatrogenic injury may be missed.

The increased interest in the United States has led to efforts to derive more precise incidence figures. In the late 1980s, Mattox et al[7] and Feliciano et al[8] documented an increasing number of iatrogenic vascular injuries occurring in Houston over the preceding few decades, an observation that is probably mirrored nationwide.

Data on blunt and penetrating injury are somewhat easier to derive. In wartime circumstances, the number of injuries may be extreme. Extremity vascular injuries have been documented during episodes of armed conflict as far back as the Greek and Roman civilizations and undoubtedly occurred before those eras.

Extremity amputations were the most common procedure performed by military surgeons in the US Civil War and World War II. DeBakey and Simeone calculated the amputation rate from vascular injuries in World War II as greater than 40%.[9] Amputation was primarily a means of saving the life of the soldier in an era with no antibiotics, limited surgical technology, and no critical care.

With the advance of general medical and surgical science and a concomitant improvement in military technology, the amputation rate from vascular injury in the Korean War and the Vietnam War dropped to approximately 15%. Rich et al collected the vascular database information that has provided modern surgeons with an invaluable source of data that set the standard for management of extremity vascular injury.[10, 11]

Sherif reported 224 extremity vascular injuries in 18 months during the Afghanistan War, roughly 150 per year.[12] Fasol et al reported 94 patients in 3 months (ie, ~376/year) on the Thailand-Cambodia border.[13] In both studies, antipersonnel mines caused the majority of civilian extremity vascular injuries.

Using data from The Joint Theater Trauma Registry, one study evaluated the epidemiology of vascular injury in the wars of Iraq and Afghanistan by identifying the categorization of anatomic patterns, management of casualties, and mechanism of injury, including explosive, gunshot, and other injuries.[14] The study found that the rate of vascular injury in modern combat is five times higher than that in previous wars and varies according to operational tempo, mechanism of injury, and theater of war.

Newer methods of reconstruction, including endovascular surgery, are now applied to nearly half of all vascular injuries and should be a focus of training for combat surgery.

At a university teaching hospital in Australia, Tobin[15] reported 10 cases per year of extremity vascular injuries; in Tbilisi, Georgia, Razmadze[16] reported 10.5 cases per year; in Sweden, Kjellstrom and Risburg[17] reported 8.2 cases per year; and in Oxford, United Kingdom, Magee et al[18] reported 4.7 cases per year. Penetrating injuries, both violent and nonviolent, predominated as the causes of vascular injuries in these reviews.

In the United States, the situation is similar, though numbers are generally higher. Humphrey et al[19] reported 12.4 extremity vascular injuries per year at a rural trauma center in Missouri; Feliciano et al[8] reported approximately 55 lower-extremity vascular injuries per year at Ben Taub General Hospital (a high-volume urban trauma center) in Houston, Texas. In both extremes, the predominant cause of injury, especially in isolated vascular injury, was penetrating trauma.

As Mattox et al[7] and Feliciano et al[8]  pointed out, the number of iatrogenic vascular injuries increased significantly after 1958 as more and varied physician specialties began to access the vascular tree.[20]

Prognosis

In 1986, Floyd and Kerstein[21] documented 10 patients with successful vascular reconstructions; however, in every case, the patients' outcome included a permanent disability that was moderately severe to severe. In most cases, the disability was due to concurrent partial or complete nerve injury. In addition, whereas no early amputations were necessary, there was a 40% amputation rate.

In 1994, Humphrey et al[19] noted a reduction in the amputation rate from 18% to 7%, with a stable 4.8% patient mortality, after the institution of a helicopter transport system in rural Missouri.

In 1996, Magee et al[18] reported a 6% amputation rate and a 19% complication rate at 6-month follow-up in the United Kingdom. However, no information was noted regarding disability.

In 1999, Razmadze[16] reported a 16% early and late amputation rate, with a 7.6% patient mortality in the former Soviet republic of Georgia.

Siddique and Bhatti studied 54 patients who underwent vascular surgical intervention at a military hospital in Ralwalpindi, India, from 2008 to 2010.[22] Penetrating trauma was the cause in 34 patients. The study concluded that early recognition and revascularization were the keys to saving more than 90% of the limbs.

Scott et al surveyed 214 patients about long-term quality of life and function after wartime extremity vascular trauma.[23] They found that severe injury and chronic pain resulted in unfavorable physical and mental outcomes.

These data clearly show that extremity vascular injury, especially those with concomitant nerve, bone, and significant soft-tissue injury, can be disastrous to patients. Early and aggressive vascular repair improves patient outcome but cannot reverse the effects of some injuries. Amputation and disability rates remain high, even with optimal transport, trauma care, and successful operative intervention.

 

Presentation

History and Physical Examination

Worldwide, patients with extremity vascular injuries most frequently present after a penetrating injury to an extremity. In the United States, high-speed motor vehicle accidents, often with fractures or dislocations, result in the next largest group of patients. In patients with large lacerations or open wounds, persisting or increasing hemorrhage with resuscitation is an early indication of vascular injury requiring operative exploration.

Vascular injuries can be classified clinically into hard signs and soft signs of injury on the basis of examination. Classic so-called hard signs of vascular injury include the following:

  • Observed pulsatile bleeding
  • Arterial thrill (ie, vibration) by manual palpation
  • Bruit over or near the artery by auscultation
  • Signs of distal ischemia
  • Visible expanding hematoma

These signs are used to identify patients requiring surgical intervention. A finding of cool, cold, and pulseless extremities may be attributable to a low systemic blood pressure, but isolated pulse abnormalities and significant variation in pulse quality from side to side are strong indicators of underlying proximal vascular injury. Neurologic deficit, delayed capillary refill, and bony abnormalities should increase the suspicion of extremity vascular injury and the need for emergency arteriography or surgical exploration and repair.

Soft signs of vascular injury include the following:

  • Significant hemorrhage found on history
  • Decreased pulse compared to the contralateral extremity
  • Bony injury or proximity penetrating wound
  • Neurologic abnormality

Clinical examination and reexamination remain the mainstays for identifying and treating these wounds. Clinical examination and findings should determine the need for adjunctive studies such as noninvasive Doppler ultrasonography (US) and arteriography.

The physical examination may be augmented by measurement of the ankle-brachial index (ABI), also referred to as the arterial pressure index. Measurement of the ABI is a standard component in the evaluation of atherosclerotic peripheral vascular disease, and its value extends to the identification of penetrating injuries to extremity vessels.

Both hard and soft signs help direct the clinician to the best diagnostic and treatment options for an individual patient.

 

Workup

Approach Considerations

In general, hard signs of injury (eg, a change in pulse quality compared to the opposite extremity or a loss of pulse in the extremity) are absolute indications for further diagnostic studies (eg, arteriography or exploration and direct visualization in the operating room). Softer signs (eg, temperature change, color change, delayed capillary refill, or neurologic deficit) should alert the clinician to the need for close observation and monitoring.

If the ankle-brachial index (ABI) is higher than 0.9, many authors advocate observation, but if the ABI is lower than 0.9, further evaluation is warranted. In these cases, many authors now recommend duplex Doppler vascular studies as a rapid, noninvasive method of assessing vascular injury. However, an arteriogram in stable patients and operative exploration in unstable or bleeding patients remain the criterion standards of care.

Preexisting renal insufficiency and allergies (eg, to seafood, iodine, or contrast dye) are relative contraindications for arteriography in the assessment of vascular injury of an extremity. Preangiography volume resuscitation and sodium bicarbonate may help minimize complications.

Persistent massive hemorrhage and hemodynamic instability are the principal contraindications for any diagnostic studies, and patients with these conditions require urgent operative exploration for diagnostic and therapeutic measures. Duplex Doppler studies may provide important information regarding vascular injury in most stable patients who have contraindications to arteriography.

Laboratory Studies

Baseline blood work should consist of a complete blood count (CBC) with platelet count, electrolytes, blood urea nitrogen (BUN), and creatinine evaluations.

Typing and crossmatching of packed red blood cells for 4-8 units, depending on the severity of injury and hemorrhage, is also recommended.

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) may be helpful in patients who are comatose and unable to provide an adequate medical history, though statistically, findings are rarely abnormal when the medical history documents no medications (eg, warfarin) or a history of bleeding problems.

In acute hemorrhage without equilibration, remember that the hematocrit or hemoglobin level may appear to be within the laboratory reference range even though there may be a significant cellular volume loss.

Imaging Studies

Plain radiography

Plain radiography of the injured extremity is a rapid means of determining the presence of fractured bones and foreign bodies. Certain fractures (eg, supracondylar femur fractures) have a higher incidence of vascular injuries, and recognition of these types of injuries alerts the clinician to the risk of vascular injury.

Computed tomography

Computed tomography (CT) has long been used in extremity trauma to visualize bony anatomy and soft tissues. Several studies found multidetector CT angiography (MDCTA) to be a useful modality for assessing lower-extremity vascular injuries.[24, 25, 26]  This modality is considered to be the first-line investigation for evaluating the extremities in vascular emergencies.[27]

Angiography

Arteriography in the angiography suite is reserved for patients who are hemodynamically stable and preferably are not experiencing renal failure or insufficiency. Most interventional radiologists require preprocedural BUN and creatinine measurements before proceeding with these studies. As soon as is practicable, blood for these assays should be drawn in the resuscitation area to avoid delays in angiography, which may lead to delays in operative intervention.

In many cases, the surgeon can perform on-table angiography in the operating room with minimal risk to the patient. Surgeons should be familiar with arterial access points and the contrast materials available in their institution. Knowledge of total dye load and baseline renal status minimizes complications in this situation.

Duplex ultrasonography

Duplex Doppler ultrasonography (US) of injured extremities has proved to be a viable alternative to angiography in many centers. This study can be performed by the surgeon in the emergency department or in the resuscitation bay and can provide immediate and valuable information regarding patient vascular status or injury. Duplex Doppler US may be of limited use in patients with splints, extensive orthopedic hardware, or areas of large tissue and skin loss, as well as when it is performed by inexperienced personnel. Johansen et al offer a more detailed discussion of noninvasive tests in a screening situation.[28]

Other Tests

Measurement of the ABI is useful with atherosclerotic peripheral vascular disease and may be helpful in determining vascular insufficiency, but ABI cannot localize the site of injury. Measurement of the ABI is a helpful component of the evaluation of penetrating arterial injury, but again, the ABI will not be able to localize the site of injury.

A prospective study by Lynch and Johansen[29] suggests that measurement of the ABI approaches the accuracy of arteriography in identifying arterial injuries and, more important, accurately identifies injuries needing intervention. Nassoura et al supported this finding in a subsequent prospective trial.[30]  No diagnostic test is perfect; nevertheless, measurement of the ABI offers a noninvasive, simple, and reproducible method to accurately screen for penetrating arterial injury.

Algorithms for the management of blunt lower-extremity trauma have recommended additional imaging in patients presenting with soft signs of vascular injury and an ABI below 0.9. A single-center retrospective review by Hemingway et al (N = 125; 133 injured limbs) suggested that a lower ABI threshold (0.6) in these patients might avoid unnecessary imaging without missing vascular injuries requiring intervention.[31] Further prospective studies are needed to validate the safety and effectiveness of a lower ABI threshold.

Assessing for a Doppler signal in peripheral vessels is more sensitive than manual palpation and is helpful in assessing for total occlusion or transection of the arterial tree.

Staging

Organ injury scaling may be helpful in the acute setting but should not override clinical experience and individual patient needs. Vascular injury scaling is also helpful for epidemiological study, peer review, and coding and billing. For information regarding organ injury scaling of peripheral vascular injuries currently sanctioned by the American Association for the Surgery of Trauma, see the study by Moore et al.[32]

The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower- or upper-extremity injury. An MESS of 7 or higher has been used as a cutoff point for amputation prediction. Prichayudh et al examined the result of upper-extremity vascular injury management and amputation rate as related to MESS in 52 patients.[33] Seven of 52 patients underwent amputation (overall amputation rate, 13.46%).

Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS.[33] No amputations were performed in 33 patients who had a MESS lower than 7. Secondary amputations (amputation after primary operation) were done in four of 49 patients (8.16%). All amputation patients suffered blunt injuries and had a MESS of 7 or higher (range, 7-11). Amputation was avoided in 12 of 19 patients who had a MESS of 7 or higher.

A MESS of 7 or higher does not always indicate that amputation is required; however, MESS is a better predictor for patients who do not require amputation when the score is below 7. The decision regarding whether or not to amputate should be made individually on the basis of clinical signs and intraoperative findings of irreversible limb ischemia.

 

Treatment

Medical Therapy

Medical therapy alone is rarely an option in penetrating or blunt trauma to the extremity vasculature when hard signs of injury are present. Patients who are asymptomatic or who have only soft signs can often be observed, but such observation is best performed by a surgeon who is prepared to operate if changing circumstances require it. The observation must be performed with the understanding that if the examination findings change or if hard signs develop, surgical intervention is necessary.

Nonocclusive injuries diagnosed on computed tomography (CT) angiography (CTA) can often be managed nonoperatively.[1] Temporary vascular control can be achieved by simply applying pressure to the vessel proximal to the injury (eg, femoral pressure in a lower-extremity wound). The application of tourniquets, while helpful in the operating room, should be limited to patients at risk for exsanguination in the prehospital and field environments who are not responsive to direct pressure for hemorrhage control.

The use of tourniquets, especially those left for prolonged periods, markedly increases the incidence of amputation of an injured extremity. Any medical personnel applying a prehospital tourniquet for extremity vascular injury should clearly document its necessity as a lifesaving anti-exsanguination device when direct pressure fails and should understand that, in most cases, a tourniquet saves a life but results in loss of an extremity.

Some studies suggest that lessons from military use of emergency tournquets can be applied to civilian settings to achieve better results than have previously been reported.[34, 35]

Whereas pharmacologic anticoagulation is a viable therapy for arterial thrombosis in some situations, acute injury of the arteriovenous tree usually necessitates surgical intervention and mechanical repair. Limited anticoagulation or antiplatelet drugs may be helpful after vascular repair, especially with prosthetic material, but the potential benefit of these drugs must be carefully weighed against the potential for hemorrhage in other injured tissue, especially with concurrent brain or spinal injury.

Surgical Therapy

Surgical intervention for suspected peripheral vascular injuries can be as minor as operative visualization of normal vascular anatomy for diagnostic purposes or as extensive as reconstruction and replacement of entire segments of injured vessels.[36]

The timing of surgical intervention can be critical to outcome in extremity vascular injury. Vascular reconstruction that occurs within 3 hours of injury has generally been accepted as having the best outcome. This can frequently be accomplished in urban level 1 trauma centers, but it becomes more difficult in rural areas, where the hospital may be geographically distant and the availability of rapid Emergency Medical Services (EMS) transport and of interventional radiology and surgical subspecialists may be limited.

In a study of 4406 patients with lower-extremity arterial injuries, Alarhayem et al found that optimal limb salvage was achieved when revascularization of these injuries took place within 1 hour of injury.[37] The amputation rate was 6% for those undergoing repair within 60 minutes, 11.7% for those undergoing repair after 1-3 hours, and 13.4% for those undergoing repair after 3-6 hours. 

In most cases in which the injured segment is 1 cm or less, dissecting and freeing edges and performing a primary anastomosis is frequently possible. Take care to avoid traction on perforating branches or excessive dissection, which may devascularize surrounding tissue. Attention to vascular surgical technique should minimize tension on the vessel and stricture at the anastomotic site.

In more severe cases with multiple associated injuries, hemorrhage control through ligation of actively bleeding arterial or venous vessels may be all that is possible. Tissue viability distal to an arterial ligation depends on regional arterial anatomy, collateral blood flow, preexisting atherosclerotic disease, competent venous outflow, and volume status.

Although venous ligation is counterintuitive, it may carry a higher risk than arterial ligation. Certain vessels, such as the popliteal vein, carry a high postligation amputation rate, whereas the rate for femoral or external iliac vein ligation is statistically lower. The risk of subsequent amputation after any ligation is much higher than that after vascular repair, but patients with severe brain injury or hemodynamic instability may not tolerate a 2- to 3-hour operation to repair a vascular injury, and damage-control techniques with arterial or venous ligation may save lives.

Use of intravenous (IV) chemical vasoconstrictors (eg, phenylephrine or norepinephrine) should be minimized in the postoperative period.

If the patient's condition and hemodynamic status allow prolonged operative intervention, general replacement of an injured peripheral arterial segment is accomplished with an autologous vein. The saphenous or cephalic veins harvested from the same or contralateral extremity are the most commonly used vein segments.

Polytetrafluoroethylene (PTFE) can be used in some situations but is usually reserved for above-the-knee or above-the-elbow applications. PTFE has been successfully used in contaminated fields with a low infection rate[38] for both venous and arterial reconstruction. In some trauma centers, PTFE is the preferred conduit and has replaced the use of an autologous vein in above-the-knee, below-the-knee, and elbow reconstruction. Stevens et al[39] summarize the causes of failure of arterial reconstruction.

Typically, in most acute situations, venous injuries are primarily ligated, but for a select number of injuries in hemodynamically stable patients, venous reconstruction may be an option. Little in the way of prospective data is available in the trauma literature, but readers are directed to an older but more pertinent retrospective review in the Journal of Vascular Surgery for more information.[40]

After reconstruction in the stable patient or vascular ligation in damage-control situations has been completed, the surgeon should consider the risk of reperfusion injury and the potential for compartment syndrome.[41] This is more common in distal lower extremities but is also possible in proximal compartments and the upper extremities.

Fasciotomies increase the risk of infection, increase fluid and blood loss, and eventually require reoperation for either skin closure or skin grafting.[42, 43] These complications should be weighed against the risk of compartment syndrome with risk of limb loss, renal failure from myoglobin release, and tissue gangrene. Monitoring compartment pressures in the postoperative period in conjunction with the clinical examination is possible, but prophylactic fasciotomies, even with the attendant risks noted above, are to be recommended in the more severe cases.

The most challenging injuries are those of the mangled extremity, with concurrent bony, soft-tissue, nerve, and vascular injury (see the image below). The treatment of these complex injuries precludes detailed description in a short review, but many authors have evaluated the factors that determine the risk of amputation.

Crushed and mangled foot of a person who was invol Crushed and mangled foot of a person who was involved in a motor vehicle accident.

Scoring systems have been developed as a means to predict amputation and functional outcome. Scoring systems such as the Mangled Extremity Syndrome Index (MESI), the Mangled Extremity Severity Score (MESS),[44] the Predictive Salvage Index (PSI), and the Limb Salvage Index (LSI) have been reviewed by Durham et al,[45]  who found that prediction of amputation was sensitive and specific but prediction of functional outcome was universally poor.

The MESS score appears to be the most commonly used method and is based on criteria that include the following[46] :

  • Degree of skeletal/soft tissue injury
  • Limb ischemia
  • Shock
  • Patient age

Note that some authors have been unable to validate individual scoring systems, and no one system is universally accepted.[47]

Interventional radiologic techniques should also be noted as an option in acute injury, but the indications and timing are still being developed. Coil embolization of complications of vascular trauma (eg, arteriovenous malformations and pseudoaneurysms) is relatively commonplace.

Endovascular stenting has been reported for acute traumatic injuries since 1994, but not all facilities have access to it.[48, 49] Long-term outcomes and complication rates remain to be defined; more long-term follow-up study is necessary.[50, 51, 52]

The use of a temporary intravascular shunt (TIVS) for vessel injury has primarily been associated with military as opposed to civilian settings; however, there is some evidence to suggest that it might reasonably be considered as a damage-control measure for a patient in extremis or as a temporizing measure for orthopedic fixation.[53, 54]

Procedural details

When reconstruction is planned, the best results have been reported in patients who are hemodynamically stable with normal laboratory findings and who underwent preoperative arteriography to localize the injury. In some cases, operative intervention is primarily performed for life-saving hemorrhage control rather than for operative repair with limb salvage.

Initial ligation of life-threatening vascular hemorrhage may allow stabilization of patients and subsequent exploration and repair of the injured vessels. In the patient who remains hemodynamically unstable, the surgeon should balance the desire to save the limb with the desire to preserve the patient's life.

Postoperative Care

Frequent monitoring and vascular checks (eg, pulse presence, quality, and capillary refill) should continue for the first 24-48 hours. Consideration of anticoagulation and antiplatelet agents should be weighed against the risk of fatal hemorrhage from other injuries (eg, head and chest injuries).

Adequate hydration must be maintained, especially after administration of contrast dye, after episodes of hypotension, and in the presence of concomitant renal injury. A urine output of 20 mL/hr or higher is ideal in adult patients.

Complications

Thrombosis of the graft remains the most common complication of vascular injury and blood vessel repair. Narrowing of the vessel with primary repair or kinking of the graft, especially after repetitive orthopedic intervention, may compromise volume of flow and may necessitate revision of the repair. Ligation of vessels for emergency hemorrhage control may result in ischemia, leading to amputation more frequently than vascular repair.

One of the more difficult situations for patients and surgeons occurs when permanent nerve injury ensues but is diagnosed late because of concurrent head or other injury. Functional vasculature with significant irreparable denervation of motor and sensory components of the extremity usually results in a useless appendage, which causes more problems or complications than amputation.

Splinting or bracing the extremity occasionally provides an acceptable functional result and should be considered, but many patients opt for amputation and a functional prosthesis rather than a nonfunctional insensate extremity that requires constant care and monitoring.

Long-Term Monitoring

Vascular repair with palpable pulses in the postoperative period rarely warrants repeat angiography. If a completion angiogram was not performed in the operating room, duplex Doppler ultrasonography (US) may provide a less invasive method of monitoring graft status.

Advise patients of the risks and symptoms of thrombosis or vascular occlusion so that they may quickly contact the surgeon or obtain evaluation in a local emergency department if problems occur. The clinician should consider the need for anticoagulation or antiplatelet medications (eg, warfarin or aspirin), balancing the overall risk to patients against the requirements posed by the graft and vascular repair.