American College of Surgeons

Management of Peripheral Vascular Trauma Committee on Trauma

David V. Feliciano, MD, FACS Subcommittee on Publications 2002

SUSPICION OF INJURY ROLE OF DIAGNOSTIC STUDIES

CAUSES REASONS FOR DIAGNOSTIC STUDIES
Penetrating wounds Prevent unnecessary operation
Gunshot, stab, or shotgun Document presence of surgical lesion
IV drug abuse
Localize surgical lesion to plan operative
Blunt trauma approach
Joint displacement
Bone fracture
Contusion } Adjacent to major artery ARTERIOGRAPHY
Can be performed by radiologist using intra-
Invasive procedures arterial digital subtraction angiography or CT
Arteriography angiograph
Cardiac catheterization Can be performed by surgeon in emergency
Balloon angioplasty room or operating room
HARD SIGNS OF ARTERIAL INJURY ARTERIAL LESIONS DOCUMENTED BY
(Immediate surgery) ARTERIOGRAPHY
External arterial bleeding
Rapidly expanding hematoma
Palpable thrill, audible bruit
Obvious arterial occlusion (pulseless, pallor,
paresthesia, pain, paralysis, poikilothermia,
especially after reduction of dislocation or
realignment of fracture)
SOFT SIGNS OF ARTERIAL INJURY
Contusion Partial transection
(Consider arteriogram, serial examination, duplex)
History of arterial bleeding at the scene
Proximity of penetrating wound or blunt
trauma to major artery
Diminished unilateral distal pulse
Small nonpulsatile hematoma
Neurologic deficit
Abnormal ankle-brachial pressure index (<0.9) Transection Arteriovenous fistula
Abnormal flow-velocity waveform on
Doppler ultrasound DUPLEX SCAN
IMPORTANCE OF PHYSICAL Definition: Real-time B-mode (brightness)
EXAMINATION image and pulsed-wave Doppler image (flow
Palpable distal pulse, even if diminished, determination)
suggests that proximal arterial injury is Duplex scan should be performed by a competent
limited vascular technologist or surgeon
Serial examinations are mandatory
 MANAGEMENT
NONOPERATIVE MANAGEMENT ADJUVANT TECHNIQUES FOR
Appropriate for nonocculsive wall or intimal LIMB SALVAGE
lesions Intraluminal shunts during orthopaedic
stabilization
FINE POINTS IN PERIPHERAL VASCULAR
REPAIR Extraanatomic bypass around associated
soft tissue injury
Small vascular clamps or vessel loops
Intraarterial vasodilators, such as papaverine
Pass balloon catheters into artery proximal or tolazoline, to reverse spasm
and distal to repair
Intravenous low molecular weight dextran,
Regional heparin (50 units/mL), 1015 mL 500 mL every 12 hours
into artery proximal and distal to repair
Thrombolytic therapy with intraarterial tissue
Completion arteriography plasminogen activator (tPA) by interventional
Fasciotomy for compartment pressure >3035 radiologist
Hg (suspect compartment syndrome if prolonged Specialized soft tissue coverage of exposed
period of shock or arterial occlusion, combined arterial repair using local myocutaneous or
arteriovenous injuries, need for arterial or free flap
venous ligation, or massive crush or swelling
is present) SPECIAL CONSIDERATIONS FOR
VENOUS REPAIR
Popliteal vein is repaired rather than ligated
Ligation of femoral or iliac vein, if necessary,
is usually tolerated if elastic wraps are applied
to extremity, which is elevated for 710 days
Complex venous repairs (extensive patches,
panel grafts, small-sized venous interposition
grafts, externally supported PTFE grafts) function
as temporary conduits in many patients but
often show narrowing or occlusion on later
venograms
POSTOPERATIVE CARE
Monitor distal arterial pulses by portable
OPTIONS FOR PERIPHERAL VASCULAR Doppler unit
REPAIR Continue intravenous antibiotics for 24 hours
Lateral arteriorrhaphy or venorrhaphy if significant contamination of wound or if
interposition graft has been inserted for
Patch angioplasty arterial or venous repair
Resection with end-to-end anastomosis Consider use of antiplatelet agent for 3
Resection with interposition graft months whenever vein graft or synthetic
Bypass graft graft has been inserted (based on laboratory
data and data from patients with aortocoronary
Extraanatomic bypass bypass grafts)
Ligation

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1989 American College of Surgeons