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Penetrating Injuries

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  • • Local and regional effects are determined by mechanism of vessel injury

    • Stab wounds, low-velocity (< 2000 ft/s) bullet wounds, iatrogenic injuries, and inadvertent intra-arterial injection of drugs produce less soft-tissue injury and less disruption of collateral circulation

    • High-velocity missiles produce more extensive vascular injuries, which involve massive destruction and contamination of surrounding tissues

    • Cavitational effect of high-velocity injury causes additional injury and may produce arterial thrombosis due to disrupted intima even when vessel not directly traumatized

    • Shotgun blasts produce widespread damage and have higher likelihood of infection

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Blunt Injuries

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  • • Motor vehicle accidents are a major cause of blunt arterial injuries

    • Most arterial injuries are indirect due to fractures

    • Especially likely near joints where vessels are relatively fixed and vulnerable to shear forces

    • Contusions or crush injuries may result in complete or partial disruption of arteries

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Epidemiology

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  • • Peripheral vascular trauma typically occurs in young men between the ages of 20 and 40 years

    • Blunt trauma is the principal cause of over 8000 cases of thoracic aortic injuries per year in United States

    • About 10-15% of deaths from MVA involve thoracic aortic rupture

    • Most aortic ruptures occur in patients aged 20-30 years, with a 9:1 male to female predominance

    • 10-20% of patients with acute thoracic disruption survive the initial trauma

    • -Of these, 30% will die within 6 hours, 40% with 24 hours, 72% in first week, and 90% within 10 weeks without treatment

    • Aortic disruption generally occurs at aortic isthmus (between left subclavian and ligamentum arteriosum)

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Symptoms and Signs

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Hemorrhage

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  • • When pulsatile external hemorrhage is present, diagnosis of arterial injury is obvious

    • When blood accumulates in deep tissues the only manifestation may be shock

    • Thrombus may form at ends of severed vessels making diagnosis difficult

    • Presence of pulses distal to injury DO NOT preclude arterial injury (as many as 20% of injuries will be associated with preserved distal pulses)

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Ischemia

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  • • Must be diagnosed promptly to prevent tissue loss

    • Must be suspected when patient has 1 or more of the "5 Ps": pain, pallor, paralysis, paresthesias, pulselessness

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False Aneurysm

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  • • Wall is primarily composed of fibrous tissue derived from nearby tissue (not arterial tissue)

    • May rupture at any time

    • Continue to expand due to absence of elastic fibers

    • Spontaneous resolution is unlikely if > 3 cm

    • Symptoms gradually appear with compression of surrounding nerves or collateral vessels from rupture or thrombosis

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Arteriovenous Fistula (AVF)

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  • • With simultaneous injury of adjacent artery and vein, a fistula may form that allows blood from the artery to enter the vein

    • Long-standing AVF can lead to cardiac failure

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Imaging Findings

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  • • Fractures or dislocations near joints or the known course of arteries should prompt careful consideration of possible arterial injury

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