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Peripheral vascular injuries account for the majority of all vascular trauma cases, potentially leaving patients with severe disability or even resulting in death. Vascular injuries are more common in the lower extremities than the upper extremities and notably are typically a result of penetrating mechanisms rather than blunt ones.1 There is abundant research on patients who have suffered from lower extremity arterial injuries but only a small proportion of publications address below the knee arterial injury (BKAI).

BKAI leads to some of the most complex and challenging decision-making in surgery.2 The ability to diagnose and treat vascular injury has improved over the last decade, especially with the rapid evolution of endovascular treatments. Nonetheless, there is a significant although a minority of such patients who will either require primary amputation or secondary amputation despite vascular repair.2 Limb salvage relies on multiple factors, including rapid diagnosis, degree of injury, familiarity with the surgical and endovascular approaches, bone and soft tissue reconstruction, and anticipation of postoperative complications. The emphasis of this chapter is to discuss the elements of care related to medical and surgical management of BKAI.


The literature concerning lower extremity vascular trauma is largely derived from wartime experience. Amputation rates associated with lower extremity vascular trauma exceeded 70% in World War II3 in an era when most injured arteries were ligated. Even though the number has decreased over the decades with the vast improvements in transport and vascular repair near the battlefield, a persistent need for amputation exists. Numerous protocols and techniques have been adopted from military surgeons and implemented in the civilian setting.

The true incidence of BKAI is unknown since the majority of such injuries are probably unrecognized, unreported, or remain clinically silent. Data from the National Trauma Data Bank from 2002 to 2006 revealed that the most commonly injured vessel in lower extremity trauma was the popliteal artery (35%) followed by the superficial femoral artery (27%), the common femoral artery (18%), the posterior tibial artery (13%), and the anterior tibial artery (9%).3 At the time of the study there was no independent ICD-9 code for peroneal artery injury; however, this has changed with the new ICD-10 coding system.

Although the majority of lower extremity vascular injuries result from penetrating mechanisms, BKAI represents a unique divergence since most are a consequence of blunt injury (63%).4 Identifying the mechanism is critical not only in planning the repair but also in predicting secondary injuries that will frequently accompany extremity traumas such as tibial or fibular fractures (64%), severe soft tissue injury (32%), and nerve injury (36%).4,5 The most common etiology of BKAI is a motor vehicle accident, usually from a posterior knee dislocation resulting in intimal injury and thrombosis. Bony fragments from lower leg fractures may also produce vascular injury.6 Additionally, males predominate in the population ...

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