Skip to Main Content

KEY POINTS

KEY POINTS

  • Ischemia of greater than 3 hours can cause irreversible neuromuscular changes; expeditious diagnosis and management are essential to a good outcome.

  • Significant prognostic factors related to secondary amputation are duration of ischemia, significant soft tissue loss, blunt mechanism, compartment syndrome, and multilevel arterial injury.

  • Computed tomographic arteriograms have replaced catheter-based arteriography for diagnostic vascular imaging.

  • In the presence of protracted ischemia and the absence of intracranial or intracavitary hemorrhage, systemic preoperative or intraoperative heparinization should be considered.

  • In a stable patient with a bruit or thrill, catheter arteriography can provide both a diagnosis and treatment for an acute pseudoaneurysm or acute arteriovenous fistula.

INTRODUCTION

Injury to a major peripheral artery can be limb threatening. If active hemorrhage is present and not urgently controlled, peripheral 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. Recently, algorithms have been developed for the evaluation and management of vascular injury and are useful for quick reference for the topics discussed in this chapter.1,2

EPIDEMIOLOGY

Vascular injuries of the extremities are uncommon. In civilian urban trauma centers, peripheral vascular injuries are present in 1% to 5% of admissions; in rural centers, they are even less common, occurring in less than 1% of admissions.3,4 Most are penetrating, due to either gunshot or stab wounds, and occur predominantly in males in their third and fourth decades. Blunt trauma sufficient to produce fractures or dislocations is a much less frequent cause. Explosive ordnance and high-velocity projectiles are the predominant wounding agents in the recent military experience.5

Because of the increase in endoluminal procedures for diagnosis, vascular control, and therapy, the number of iatrogenic peripheral arterial injuries increased 40% between 1996 and 2003.6 Iatrogenic arterial injuries occur in approximately 0.6% of patients undergoing endoluminal therapies, and they appear to be specialty related.7 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 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.8 Iatrogenic arterial injuries are definitely not benign. Limb-threatening complications have occurred,9 and recent reports have documented a 5% to 7% all-cause mortality following iatrogenic arterial injury.6,10

PATHOPHYSIOLOGY

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. ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.