Peripheral Vascular Injuries

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Background

Peripheral vascular injuries may result from penetrating or blunt trauma to the extremities. If not recognized and treated rapidly, injuries to major arteries, veins, and nerves may have disastrous consequences resulting in the loss of life and limb.

See Medscape's Vascular Surgery Resource Center and Trauma Resource Center for related information.

Pathophysiology

In the upper extremity, the areas of greatest concern include the axilla and the area from the deltopectoral groove distally across the elbow to the proximal forearm. The axilla, medial and anterior upper arm, and antecubital fossa particularly are considered high-risk areas because of the superficial location of the axillary and brachial arteries in these regions.[1, 2]

Wounds distal to the bifurcation of the brachial artery are less likely to result in serious limb ischemia, as long as either the ulnar or radial artery remains intact. Injuries to a single distal artery can often be managed by ligation alone if the palmar arches are complete and no prior injury is present. This is the case in 95% of these patients.

In the lower extremity, the area of greatest concern extends from the top of the leg marked by the inguinal ligament anteriorly and by the inferior gluteal fold posteriorly, across the knee inferiorly to the level of the mid calf. The inguinal region, medial thigh, and popliteal fossa particularly are considered high-risk locations.[3, 4]

Below the knee, the popliteal artery trifurcates to form the anterior and posterior tibial arteries and the peroneal artery. Arterial wounds affecting a single vessel distal to the trifurcation are unlikely to produce serious limb ischemia. If distal collateralization is adequate, injuries to a single branch may therefore be managed by ligation.

The highest risk of serious vascular injury is associated with high-energy gunshot wounds such as those produced by military rifles and shotguns. Explosives are a frequent cause of vascular injury in military combat. The rate of vascular injury in modern combat (ie, the wars in Iraq and Afghanistan) is 5 times greater than in the past.[5] Blunt and penetrating trauma resulting in extremity fractures also have a high incidence of concomitant vascular injuries, even in the absence of clinical signs. The likelihood of serious vascular injury is lower in patients who sustain low-energy wounds such as those produced by handguns and knives.

Epidemiology

Frequency

United States

Peripheral injuries account for 80% of all cases of vascular trauma. The lower extremities are involved in two thirds of all patients with vascular injuries.

Penetrating trauma accounts for 70-90% of vascular injuries. In the past, iatrogenic injuries related to endovascular procedures accounted for less than 10% of all cases. This percentage is increasing due to the growing use of endovascular procedures for diagnostic and therapeutic purposes.

Mortality/Morbidity

Death due solely to peripheral vascular injuries is uncommon, but does occur due to exsanguination or development of a necrotizing myofascial infection. Major venous injuries accompany 13-51% of significant arterial injuries.

Compartment syndrome may result from ischemia of a muscle compartment. Limb survival is threatened by delays in diagnosis and treatment, particularly when limb perfusion is compromised for more than 6 hours at body temperature ("warm" ischemia).

Extensive concurrent musculoskeletal, nerve, and skin injuries indicate a poor prognosis. Concomitant peripheral nerve injuries may be missed and can lead to long-term disability and deformity.[6]

Crush injuries associated with open tibial fractures are particularly likely to result in loss of the lower leg and amputation.

Sex

Ninety percent of patients with peripheral vascular injuries are male.

Age

Vascular injuries most often occur in patients aged 20-40 years.

History

In peripheral vascular injury, the mechanism is an important prognostic factor. Shotgun and military rifle injuries, as well as knee dislocations, are particularly high risk for vascular injury.

The time interval between injury and evaluation must be considered. "Warm" ischemia at body temperature for more than 6 hours results in irreversible nerve and muscle damage in 10% of patients. Cooling the extremity may avoid this complication.

Other risk factors include previous history of vascular injury or disease, extensive or pulsatile external hemorrhage, anticoagulation therapy or impaired hemostatic function, and prior venous thrombosis or embolism in the patient or a family member.

Physical

Deciding whether the injury requires surgical intervention is a major priority of initial management.

The presence of "hard" signs of vascular injury has a 92-95% sensitivity for injuries requiring intervention. The vast majority of patients exhibiting the following "hard" signs require intervention with a positive predictive value of 95%.

The following "soft" signs are much less useful in predicting or excluding major vascular injuries that require intervention. The positive predictive value of "soft" signs indicating abnormal findings on an arteriogram is only 35%. The vast majority of these lesions do not require emergent repair.

Causes

Causes of peripheral vascular injuries include the following:

Laboratory Studies

The arterial pressure index is useful in detecting patients with major vascular injury and pulses that appear normal. Systolic blood pressure in the affected extremity is divided by systolic pressure in the contralateral normal extremity. A value of less than 90% is considered abnormal.

The sensitivity of the arterial pressure index for injuries requiring intervention ranges from 75-95%, depending on the circumstances. The arterial pressure index is highly sensitive in ruling out popliteal artery injury in patients with knee dislocation. Most injuries that present with an arterial pressure index greater than 90% heal spontaneously.[7]

The ankle-brachial index is equivalent to the arterial pressure index and may be used when multiple extremity injuries are present. This is calculated by dividing the higher of the systolic dorsalis pedis or posterior tibial artery pressure by the ipsilateral brachial artery pressure.

The Allen test is useful for detecting injuries distal to the brachial artery bifurcation. Persistence of pallor of the hand when the radial artery is manually compressed suggests occlusion of the ulnar artery and vice versa.

Imaging Studies

Conventional angiography remains the criterion standard for evaluation of vascular injuries in trauma patients.[8, 9] The disadvantages include cost, significant time delay in preparation for the test, and a 0.6% major complication rate. Contrast dye load and renal function are important pre-study considerations. Only 1-1.5% of proximity angiograms performed in patients lacking "hard" signs of vascular injury reveal injuries that require intervention. Duplex ultrasonography is a noninvasive technique used to investigate injuries with a high-risk mechanism or location but without "hard" signs or obvious indications for surgical management.

Small, prospective studies suggest that the sensitivity of ultrasonography is 95-100% for diagnosing vascular injuries that lack "hard" signs but require intervention. These results were obtained by highly qualified teams that maintain a high clinical index of suspicion.[10] Recent studies have found color-flow duplex ultrasonography to be a low-yield strategy for predicting therapeutic intervention.[1] The examination is highly operator dependent, and the negative predictive value has been as low as 50% in some series. Duplex ultrasonography is of limited use in the evaluation of poorly accessible vessels, such as the subclavian, profunda femoris, and profunda brachii arteries. Duplex ultrasonography can play a role in the evaluation of patients presenting with "soft" signs of injury; however, its use has largely been supplanted by multidetector CT angiography.

Multidetector helical CT (MDCT) angiography is emerging as a highly sensitive method of diagnosing arterial injuries when compared with conventional angiography and surgical exploration as criterion standards.[11] Studies using 4- and 16-slice MDCT angiography have demonstrated a sensitivity of 90-95% for significant arterial injuries.[12, 13, 14] . A study by Seamon et al demonstrated a sensitivity and specificity of 100% for clinically significant injury using 16-slice and 64-slice technology.[15]

Higher-resolution (64-slice and greater) MDCT angiography and greater institutional experience will further improve the diagnostic accuracy of the modality. In comparison with conventional angiography, MDCT angiography is considerably faster, less expensive and less invasive, and does not require the involvement of interventional radiology. Studies support MDCT angiography as the diagnostic study of choice for blunt and penetrating vascular trauma patients who have do not have obvious indications for immediate operative intervention.[3]

In a retrospective evaluation of 51 patients with penetrating neck injury, MDCT angiography as initial evaluation was found to help guide management decisions if an external carotid artery injury was detected. Sensitivity of CTA for detecting arterial injuries ranged from 75.7% to 82.2%, and specificity ranged from 96.4% to 98.4%. However, according to the authors, negative findings should not preclude close clinical follow-up, repeat CTA evaluation, or, in the presence of high suspicion of arterial injury due to clinical findings or wound trajectory, evaluation with digital subtraction angiography.[16]

Prehospital Care

Perform the following for peripheral vascular injuries:

Emergency Department Care

Immediately reduce displaced or angulated fractures if any evidence or suspicion of vascular compromise exists. Promptly reduce dislocations of the elbow and knee to prevent further injury to neurovascular structures.

External hemorrhage usually can be controlled with direct pressure, but a blood pressure cuff or tourniquet should be applied proximally to the injury if compression fails or is not possible.

Once the patient has been stabilized, identify peripheral vascular injuries and restore normal circulation as rapidly as possible.

Do not apply clamps or hemostats to vascular structures, since this may make definitive repair more difficult and damage surrounding tissues.

Consultations

A vascular surgeon must be consulted whenever a major vascular injury is a concern.

Vascular injury sustained during battlefield combat is often managed via revascularization. Reconstruction methods should be a focus of combat surgery training. Ligation is also an effective intervention.[17]

Further Outpatient Care

See the list below:

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.

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:

Prognosis

See the list below:

Patient Education

See the list below:

Author

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

Disclosure: Nothing to disclose.

Specialty Editors

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

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

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

Disclosure: Partner received salary from Pfizer for employment.

References

  1. Mollberg NM, Wise SR, Banipal S, et al. Color-flow duplex screening for upper extremity proximity injuries: a low-yield strategy for therapeutic intervention. Ann Vasc Surg. 2013 Jul. 27(5):594-8. [View Abstract]
  2. de Mooij T, Duncan AA, Kakar S. Vascular injuries in the upper extremity in athletes. Hand Clin. 2015 Feb. 31 (1):39-52. [View Abstract]
  3. Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics. 2005 Oct. 25 Suppl 1:S133-42. [View Abstract]
  4. Neagoe RM, Bancu S, Muresan M, Sala D. Major vascular injuries complicating knee arthroscopy. Wideochir Inne Tech Maloinwazyjne. 2015 Jul. 10 (2):266-74. [View Abstract]
  5. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in iraq and afghanistan. Ann Surg. 2011 Jun. 253(6):1184-9. [View Abstract]
  6. Van Waes OJ, Van Lieshout EM, Hogendoorn W, Halm JA, Vermeulen J. Treatment of penetrating trauma of the extremities: ten years' experience at a Dutch level 1 trauma center. Scand J Trauma Resusc Emerg Med. 2013 Jan 14. 21:2. [View Abstract]
  7. Nassoura ZE, Ivatury RR, Simon RJ, et al. A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study. Am J Emerg Med. 1996 Mar. 14(2):151-6. [View Abstract]
  8. Espinosa GA, Chiu JC, Samett EJ. Clinical assessment and arteriography for patients with penetrating extremity injuries: a review of 500 cases with the Veterans Affairs West Side Medical Center. Mil Med. 1997 Jan. 162(1):19-23. [View Abstract]
  9. Gahtan V, Bramson RT, Norman J. The role of emergent arteriography in penetrating limb trauma. Am Surg. 1994 Feb. 60(2):123-7. [View Abstract]
  10. Knudson MM, Lewis FR, Atkinson K, Neuhaus A. The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma. Arch Surg. 1993 Sep. 128(9):1033-7; discussion 1037-8. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]
  17. Hoffer EK, Sclafani SJ, Herskowitz MM, Scalea TM. Natural history of arterial injuries diagnosed with arteriography. J Vasc Interv Radiol. 1997 Jan-Feb. 8(1 Pt 1):43-53. [View Abstract]
  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. [View Abstract]
  19. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg. 2001 Jun. 33(6):1212-9. [View Abstract]
  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. [View Abstract]
  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. [View Abstract]

Pseudoaneurysm of the axillary artery.

Arteriovenous fistula between common femoral artery and vein.

Pseudoaneurysm of the axillary artery.

Arteriovenous fistula between common femoral artery and vein.