Arterial Injuries

Penetrating Injuries

• • 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

Blunt Injuries

• • 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

Epidemiology

• • 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)

Symptoms and Signs

Hemorrhage

• • 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)

Ischemia

• • 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

False Aneurysm

• • 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

Arteriovenous Fistula (AVF)

• • 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 ...