Management of peripheral arterial injury:

Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma

OBJECTIVE

In orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients.

METHODS

Retrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded.

RESULTS

A total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty-three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study.

CONCLUSION

In orthopedic trauma, "Hard signs" and "soft signs" combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients' prognosis.

Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study

INTRODUCTION

The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used.

METHODS

The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP).

RESULTS

373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22).

CONCLUSIONS

Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.

Endovascular Embolization of a Perforated Deep Femoral Artery in a 15-Year-Old Boy

Trauma patients who are hemodynamically unstable or have certain signs of vascular injury should have immediate surgical exploration. For less severe signs of vascular injury, current literature states that endovascular intervention is optimal. This case presents the opportunity to review how signs of vascular injury were considered along with other diagnostic tools to inform decision-making after a penetrating stab wound injury to an extremity.  A 15-year-old male presented to the emergency department (ED) as a trauma activation after being stabbed in the left thigh. The patient had an approximately 5 cm long laceration over the lateral superior aspect of his left thigh with visible subcutaneous tissue and biceps femoris muscle upon probing. He had an initial blood pressure of 101/61 mm Hg. Shortly after the tourniquet was removed, the patient developed brisk bleeding from the wound and his blood pressure decreased to 88/55 mm Hg. He was taken expediently to computed tomography (CT) for an angiogram of the lower extremity which showed active bleeding from a posterior peripheral branch arising from the deep femoral artery in the posterolateral thigh. Interventional radiology performed intravascular embolization, and hemostasis was achieved. The patient was admitted for observation and then discharged 17 hours after admission without ambulatory difficulty. We present a case of penetrating extremity trauma (PET) where the patient had a presentation with mixed hard signs and soft signs of vascular injury. The patient responded well to endovascular embolization. Early detection and intervention in PET are critical in minimizing blood loss and ischemia to distal structures. While following professional organization guidelines can help guide care, a collaborative approach by multiple specialty care teams is critical in providing optimal care in PET.

S, T.R S, Sumanahalli CH. Femoral Artery Injuries in Closed Femur Shaft Fractures: Case Report

Case 1 and 2  Two young male patients, sustained injury to the superficial femoral artery (SFA) following a closed femur shaft fracture. The arterial injuries were confirmed by computed tomography angiography and both underwent fracture fixation and on SFA exploration; a thrombosed arterial segment was noted at the fracture site, addressed with arteriotomy and thrombectomy to restore the vascularity. At 1-year follow-up, both patients had good union at the fracture site and a well-perfused limb.

Conclusion  Thorough clinical examination and appropriate diagnostic studies can diagnose these rare vascular injuries in closed fractures and with early vascular repair potentially limb-threatening complications can be prevented.

In-hospital outcomes in autogenous vein versus synthetic graft interposition for traumatic arterial injury: A propensity-matched cohort from PROOVIT

BACKGROUND

The ideal conduit for traumatic arterial repair is controversial. Autologous vein was compared with synthetic interposition grafts in the acute setting. The primary outcome was in-hospital reoperation or endovascular intervention.

METHODS

The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry from November 2013 to January 2019 was queried for arterial injuries requiring interposition vein or graft repair. Patients with no recorded Injury Severity Score were excluded, and multiple imputation was used for other missing data. Patients treated with synthetic grafts (SGs) were propensity matched to patients with vein grafts (VGs) to account for preoperative differences.

RESULTS

Four hundred sixty from 19 institutions were identified, with 402 undergoing VG and 58 SG. In the SG group, 45 were PTFE grafts, 5 were Dacron, and 8 had other conduits. The SG group was more severely injured at admission with more gunshot wounds and higher mean Injury Severity Score, lactate, and first-24-hour transfusion requirement. In addition, the SG cohort had significantly lower admission systolic blood pressure, pH, and hemoglobin. After propensity matching, 51 patients with SG were matched with 87 patients with VG. There were no differences in demographics, clinical parameters, or diagnostic evaluation techniques postmatch. The need for reoperation or endovascular intervention between the matched groups was equivalent (18%; p = 0.8). There was no difference in any secondary outcome including thrombosis, stenosis, pseudoaneurysm, infection, or embolic event, and hospital and intensive care unit length of stay were the same.

CONCLUSION

American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry data demonstrate that SGs are used in more critically ill patients. After controlling for relevant clinical factors and propensity matching, there is no in-hospital difference in rate of reoperation or endovascular intervention, or any secondary outcome between VG and SG.

LEVEL OF EVIDENCE

Prognostic and Epidemiolgic, Level III.

Utility of computed tomography angiography in traumatic lower limb injury: Review of clinical impact in level 1 trauma centre

INTRODUCTION

CT angiography (CTA) is efficient and accurate in detecting lower limb vascular injury in the setting of trauma (1-6). Less clear is the in-practice correlation between appropriate indications for these examinations and subsequent clinical impacts.

MATERIALS AND METHODS

All CT leg angiography acquired from January 2016 through April 2019 were reviewed via retrospective search. Studies not acquired for trauma were excluded. Imaging and reports were reviewed to assess for vascular injury. Electronic medical records were reviewed to assess the presence or absence of classical 'hard' or 'soft' signs of vascular injury and whether vascular intervention was undertaken.

RESULTS

A total of 347 lower limb injuries were identified in 273 men and 74 women. Mean age was 41.5 years ranging from 15-95 years. 268 cases were fractures with 177 open injuries. 301 of injuries were secondary to blunt trauma, 31 penetrating injury occurred and 15 cases were ascribed to blast/gunshot injury. 74 (21.3%) studies were deemed to have a positive finding of vascular injury, 249 (71.8%) were reported as negative and 24 (6.9%) were indeterminate. Of the cases with positive findings, 26 underwent intervention (7.4% of all patients undergoing CTA). No patients with negative CTA required intervention, while three (3, 0.8% of total) with indeterminate findings required intervention. Where there were no clinical signs (absence of any hard or soft signs) 249 CTA's were performed and none required any form of intervention.

CONCLUSION

In the absence of clinical signs of vessel injury, CT angiography is unlikely to demonstrate vascular injury requiring intervention in the setting of lower limb trauma.

Yield of CT angiography in penetrating lower extremity trauma

PURPOSE

CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided.

METHODS

A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined.

RESULTS

A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001).

CONCLUSION

There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

Penetrating Extremity Trauma Endovascular versus Open Repair?

Penetrating extremity trauma (PET) accounts for an estimated 5-15% of trauma with vascular injury and these injuries are accountable for a significant percentage of trauma-related deaths. Historically, vascular injuries were best treated by open repair. While a defined selection criteria and a comprehensive algorithm have not been validated, the advancement of endovascular techniques, embolotherapy, and stent grafting have become viable options for the treatment of penetrating arterial extremity trauma in select patients. Advantages endovascular repair offers include decreasing mortality and morbidity associated with open repair, decreasing blood loss, decreasing iatrogenic injury such as nerve injury, and lower rate of wound infection. Patients stability, type of vascular injury, and lesion location are main factors help deciding between endovascular and open repair. Patient selection between endovascular and open repair should be determined by on a case-by-case situation, individual hospital guidelines, a multidisciplinary approach, and technical expertise.

Axillary Artery Injury Following Closed Reduction of an Age-Indeterminate Anterior Glenohumeral Dislocation

Introduction:

Axillary artery injury is a rare and potentially devastating sequelae of glenohumeral dislocation. While neurovascular exam is critical in all presentations, the presence of “soft” and/or “hard” signs should prompt a more thorough examination and possible employment of advanced imaging techniques.

Case Report:

We present a case of a 51-year-old male with an axillary artery injury associated with an anterior glenohumeral dislocation. The patient was initially evaluated at an outside hospital where the vascular injury was not immediately identified, and then was subsequently transferred to our institution where he underwent bypass grafting without significant sequela. Additional prophylactic fasciotomies were also performed due to concern for reperfusion compartment syndrome.

Conclusion:

Although rare, clinicians should actively rule out vascular injuries when evaluating shoulder dislocations, especially in the elderly patient with a known history of atherosclerotic disease, those with evidence of chronic joint instability, and in the setting of high energy injury mechanisms. Hard signs of vascular injury including diminished distal pulses are the hallmark of this complication, and should always prompt vascular surgery consultation.

Is It Really Mandatory to Harvest the Contralateral Saphenous Vein for Use in Repair of Traumatic Injuries?

Since the transition time in surgical technique of vascular repair to current civilian practice, the great saphenous vein (GSV) remains unarguably the preferred conduit for surgical reconstruction in the lower extremity. With qualities such as accessibility, expendability, and long-term durability, it is easy to understand the enthusiasm with using the GSV in arterial or venous vascular injuries. However, the question does arise whether these detailed benefits of the GSV warrant harvest from an uninjured limb for vascular reconstruction on an injured limb. For those ardent followers of surgical dogma, harvest of contralateral vein from the uninjured lower extremity traumatic vascular repair is mandated. Unfortunately, this principle is not supported by high-quality data and remains folklore at best.

Arterial Injury in the Upper Extremity: Evaluation, Strategies, and Anticoagulation Management

Trauma to the upper extremity can present with an associated arterial injury. After patient stabilization, thorough assessment with physical examination and various imaging modalities allows accurate diagnosis of the specific arterial injury. After diagnosis, efficient treatment is necessary to allow limb salvage. Treatment options include ligation, primary repair, graft reconstruction, endovascular repair, and amputation. The final treatment rendered is frequently dependent on injury location and mechanism. With any of the treatment options, complications may occur, including thrombosis. Currently, no validated anticoagulation protocol has been established for managing arterial injuries in the upper extremity.

Vascular Injury in Orthopedic Trauma

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].

[Diagnosis and management of peripheral vascular injuries]

Peripheral vascular injuries are the cause of high morbidity in trauma patients. Up to 5 % of all patients with injuries of the extremities present with concomitant vascular lesions. While open peripheral vascular injuries are associated with a high mortality at the scene of the accident, closed vascular injuries present the danger of developing critical tissue ischemia with a high risk of amputation and limb loss. Early diagnosis is crucial in order to rapidly restore and maintain adequate blood flow and downstream tissue perfusion. A correct diagnosis and early treatment of peripheral vascular injuries place enormous demands on interdisciplinary teams consisting of emergency physicians, orthopedic surgeons, vascular surgeons, anesthesiologists and radiologists. The top priority in the context of emergency care is hemorrhage control by applying direct pressure and dressings until definitive surgical treatment. Hypovolemic shock, reperfusion injury and compartment syndrome are complications of peripheral vascular injuries that must be recognized and treated in the early stages.

Critical Care for the Patient With Multiple Trauma

Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.

Management of Femoral Vessel Injuries: A 6-year Single-center Experience

Femoral vessel injuries are a familiar injury treated in busy urban trauma centers. The majority of peripheral vascular injuries to the lower extremity occur most commonly to the femoral vessels. The increasing incidence of civilian violence provides an opportunity to perform a comprehensive review and management of these injuries.

Assessment and treatment of the trauma patient in shock

High-volume crystalloid resuscitation is associated with increased length of stay, ICU and ventilator days, and organ failure and infection rates. Rapid evaluation of a hemodynamically unstable trauma patient is vital to diagnosis and treatment of the cause of shock. CT scanning should be used liberally in trauma patients to effect decreased mortality. Nonoperative management and catheter-based interventions are becoming the standard of care in appropriately selected patients with solid organ injuries.

Tourniquet use for peripheral vascular injuries in the civilian setting

BACKGROUND

Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early.

METHODS

The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion.

RESULTS

190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died.

CONCLUSIONS

Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.

Fracture of the shoulder girdle in multiply injured patients - an imperative for a high level of suspicion for associated neurovascular injuries

Background

The combination of a bony injury to the shoulder girdle and damage to the brachial plexus and the subclavian vessels is a rare finding. The cases of this combined injury pattern described in the literature are most notably reported in multiply-injured patients after high velocity trauma.

Findings

Three cases were admitted to our hospital after motorcycle accidents resulting in a combination of severe bony injuries to the shoulder girdle, to the subclavian artery and a lesion to the brachial plexus. Based on these three clinical cases the patterns of injury, as well as primary and secondary treatment approaches are presented.

Conclusion

The early detection of these injuries can be difficult in given acute, life threatening injuries addressed first in these multiply injured patients. A high level of suspicion, in conjunction with standardized ATLS based institutional protocols for secondary and tertiary survey, should increase the likelihood of a timely detection and early management of these rare but potentially devastating injuries.

Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Extremity arterial injury after penetrating trauma is common in military conflict or urban trauma centers. Most peripheral arterial injuries occur in the femoral and popliteal vessels of the lower extremity. The Eastern Association for the Surgery of Trauma first published practice management guidelines for the evaluation and treatment of penetrating lower extremity arterial trauma in 2002. Since that time, there have been advancements in the management of penetrating lower extremity arterial trauma. As a result, the Practice Management Guidelines Committee set out to develop updated guidelines.

METHODS

A MEDLINE computer search was performed using PubMed (www.pubmed.gov). The search retrieved English language articles regarding penetrating lower extremity trauma from 1998 to 2011. References of these articles were also used to locate articles not identified through the MEDLINE search. Letters to the editor, case reports, book chapters, and review articles were excluded. The topics investigated were prehospital management, diagnostic evaluation, use of imaging technology, the role of temporary intravascular shunts, use of tourniquets, and the role of endovascular intervention.

RESULTS

Forty-three articles were identified. From this group, 20 articles were selected to construct the guidelines.

CONCLUSION

There have been changes in practice since the publication of the previous guidelines in 2002. Expedited triage of patients is possible with physical examination and/or the measurement of ankle-brachial indices. Computed tomographic angiography has become the diagnostic study of choice when imaging is required. Tourniquets and intravascular shunts have emerged as adjuncts in the treatment of penetrating lower extremity arterial trauma. The role of endovascular intervention warrants further investigation.

Development of a simple algorithm to guide the effective management of traumatic cardiac arrest

BACKGROUND

Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest.

METHODS

We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician - paramedic pre-hospital trauma service.

RESULTS

The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax.

CONCLUSION

The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates.

Brachial vessel injuries: high morbidity and low mortality injuries

INTRODUCTION

Reports of arterial injuries from both the civilian and military arenas report the brachial artery as the most frequently injured vessel, accounting for approximately 25-33% of all peripheral arterial injuries. The brachial artery is surrounded by important peripheral nerves -the median, ulnar and radial, and also parallels the humerus and associated veins. Due to its close proximity to these structures, associated nerve and osseous injuries are frequent with residual neuropathy from such nerve injuries, often the main sources of permanent disability.

MATERIALS AND METHODS

Systematic review of the literature, with emphasis in the diagnosis, treatment and outcomes of these injuries, incorporating the authors experience.

CONCLUSIONS

The morbidity and mortality rates associated with brachial artery injuries depend on the cause of the injury itself, which vein or tendon is injured, and whether musculoskeletal and nerve injuries are also present. During the last 20 years, amputation associated with upper extremity arterial injuries has decreased to a rate of 3% because of advances in the treatment of shock, the use of antibiotic therapy, and increased surgical experience.