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INTRODUCTION

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Injury to a major peripheral artery can be limb threatening. If active hemorrhage is present and not urgently controlled, vascular trauma can be life threatening. In either case, diagnosis and management must be expeditious. This chapter reviews the epidemiology, pathophysiology, clinical presentation, management, and outcome of extremity vascular injuries.

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EPIDEMIOLOGY

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Vascular injuries of the extremities are not very common. In urban trauma centers, peripheral vascular injuries are present in less than 5% of admissions; in rural centers they are even less common, occurring in 1% of admissions.1,2 Most are penetrating and occur predominantly in males in their third and fourth decades. Blunt trauma sufficient to produce fractures or dislocations, handguns, and knives cause the vast majority of civilian extremity vascular injuries. High-velocity projectiles and shrapnel are the predominant wounding agents in the military experience.3

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Because of the increase in endoluminal procedures, the number of iatrogenic arterial injuries increased 40% between 1996 and 2003.4 Iatrogenic arterial injuries occur in approximately 0.6% of patients undergoing endoluminal therapies and appear to be specialty related. Most of these injuries involve the groin where access is most commonly obtained for interventional procedures. Iatrogenic vascular injuries can also occur during open operations on the extremities, such as during total joint procedures, intramedullary and external fixation, and during plate osteosynthesis. They can present as hemorrhage or ischemia during the procedure or immediately after (usually in the recovery room) or they can present months or years later as claudication or acute limb threatening ischemia due to thrombosis or emboli.5 They are definitely not benign; a recent report documented a 5.2% mortality following iatrogenic injury.6

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PATHOPHYSIOLOGY

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Arteries and veins are composed of three tissue layers: the outer adventitia of connective tissue, the central media of smooth muscle and elastic fibers, and the inner intima or endothelial cell layer. Trauma to a blood vessel (artery or vein) can produce hemorrhage, thrombosis, or spasm, either alone or in combination, depending on the mechanism and the magnitude of the force applied to the vessel. Hemorrhage occurs when there is a laceration or puncture of all of three layers. If the bleeding is tamponaded by the surrounding tissue (ie, muscle or fascia), a localized hematoma will form, which may be pulsatile. If local tamponade is ineffective, or only temporarily effective, immediate or delayed hemorrhage ensues, which can be life threatening. Damage solely to the intima occurs when an artery is acutely deformed or angulated. The intima is the least compliant of the vascular layers and it fractures when the more flexible layers bend when deformed by an adjacent broken bone or joint dislocation. Intimal injury exposes the subendothelial matrix, which is rich in tissue factor, resulting in activation of the clotting cascade and subsequent thrombus formation. The thrombus may enlarge or propagate and occlude the vessel or embolize and produce a ...

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