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INTRODUCTION

Disclaimer: The viewpoints expressed are those of the authors and do not represent official positions of the University of Michigan, the United States Air Force, or the Department of Defense

It is impossible to overlook the large amount of work and level of expertise that converged in the writing of this chapter on peripheral vascular injury. Dr. Shackford did a masterful job of providing a comprehensive update on all aspects of presentation and management of extremity vascular injury as well as addressing “hot button” topics, such as who is best suited to manage this injury pattern, the greater reliance on computed tomography (CT) imaging for diagnosis, and damage control surgical approaches. Like many types of trauma, the understanding of vascular injury has been advanced from experience and study during the recent wars in Iraq and Afghanistan.1,2 The sections of this chapter reinforce these lessons learned and make note of a number of still unsettled topics for which our understanding is evolving.

The use of catheter-based, endovascular tools for extremity vascular injury is limited, partly because of the increased use of contrast-enhanced CT angiography (CTA). For decades, traditional catheter-directed angiography has been the gold standard for the diagnosis of vascular trauma. The technique remains useful in some settings, such as the occasional “on the table” angiogram in the setting of an injured extremity. The ubiquitous presence, speed, and ability of CTA to provide a plethora of diagnostic information, however, has allowed it to replace invasive arteriography as the new de facto diagnostic standard. In this era, invasive catheter-based angiography is mostly reserved for instances in which an endovascular procedure (eg, a stent graft or coil embolization) is planned.3,4

Endovascular treatment of peripheral injuries is also uncommon and reserved for anatomic locations or patient scenarios in which open exposure and repair are more complicated or morbid. For example, the use of covered stents (ie, stent grafts) has been shown to be particularly useful in the management of select axillo-subclavian artery injuries.5 In many of these situations, open exposure and repair would be associated with significant blood loss and morbidity due to a combination of incisions and/or working near the brachial plexus. Improved vascular access, imaging, and stent graft technologies now allow for many of these injuries to be crossed and repaired from a transfemoral or transbrachial (ie, retrograde) approach.3-5

Most peripheral injuries distal to the thoracic outlet and the inguinal ligament are best managed using open repair techniques. One exception is the use of catheter-directed coil embolization to treat traumatic extremity arteriovenous fistulae. In these cases, if the fistula is large or symptomatic and there are no other indications for an open operation, arteriography can be performed with an eye toward coiling the inflow vessel as a means of treatment. There are also reports of the effective use of covered stents to treat popliteal ...

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