World J. Surg. 16, 930-937, 1992

World Journal of Surgery O 1992 by the Soci~t~ lnternationale ~le Chirurgi¢

Advances in Treatment of Vascular Injuries from Blunt and Penetrating Limb Trauma R. Russell Martin, M . D . , K e n n e t h L. Mattox, M.D., Jon M. Burch, M . D . , and R o b e r t J. Richardson, M.D. Department of Surgery, Baylor College of Medicine and The Ben Taub General Hospital, Houston, Texas, U.S.A. Military and civilian experience has contributed to the current state of the art in management of extremity vascular injuries. Thorough physical examination and judicious use of emergency center arteriography and formal arteriography provide means for prompt diagnosis and treatment which is critical is limb loss and disability are to be avoided. Prosthetic graft material has provided an alternative to vein grafting in many circumstances for arterial and venous injuries. Compartment syndrome should be anticipated when an ischemic extremity is revascularized and fasciotomy should be used liberally. Vascular repairs are the first priority in extremity wounds, but associated injuries to bones, joints, soft tissues, and nerves are often critical determinants of rehabilitation once blood supply has been re-established. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, neurosurgery, and plastic surgery.

The major advances in the history of trauma surgery have often been the result of experience gained by the military surgeon and the history of vascular surgery is no exception. For centuries, the most sophisticated vascular technique was the ligature, described by Galen and derived from his experience as physician to the gladiators of Rome [1]. Ligation continued as the most common form of treatment through World War I and World War II [2]. The Korean Conflict provided the first large, successful experience with repair of acute arterial injuries with a dramatic decrease in the amputation rate associated with repair from 36% reported in World War II and 13% [3]. The military experience in Vietnam produced a report of 1,000 arterial injuries, 85% of which were repaired. The higher rates of limb salvage from this era were attributed to lessons learned in previous wars and progress in pre-hospital evacuation, resuscitation, blood transfusion, antibiotics, new suture materials, and surgical techniques [4]. Experience in the last 20 years has come from the domestic war zones in Memphis [5], New Orleans [6], Dallas [7], Chicago [8], and Denver [9]. The scope of this civilian experience is illustrated by the recent report from Houston of 5,207 vascular injuries treated over a 29 year period at one institution ll0]. The current vascular trauma registry at the Ben Taub Hospital in Houston documents more Reprint requests: R. Russell Martin, M.D., Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030, U.S.A.

than 6,000 injuries, which exceeds the combined reported military experience in both world wars, Korea, and Vietnam [10]. This report will focus on the specific advances in management and the philosophy that has developed during this civilian urban warfare. Diagnosis

The primary survey of the trauma patient must be directed toward detecting injuries that are immediately life threatening. Thus the first priorities must be the establishment of an airway, control of hemorrhage, and maintenance of circulating volumeIn nearly all instances in civilian extremity injuries, hemorrhage can be controlled with direct pressure over the injury and tourniquets should not be used. The possibility of multiple injuries and occult hemorrhage into the chest or abdomen must be considered, in which case control of hemorrhage and resuscitation must occur simultaneously in the operating room. Physical examination remains the cornerstone of diagnosis for vascular injuries of the extremities. In contrast to abdominal and thoracic vascular injuries, the extremities readily lend themselves to inspection, auscultation, palpation, and other maneuvers which can be performed repeatedly at no cost or risk to the patient. The presence of any of the "hard signs" of vascular injury in the extremities (Table 1) is usually sufficient indication for immediate exploration [11, 12]. The "soft signs" of arterial injury may be caused by trauma to adjacent strut" tures, such as nerves, and exploration for these indications without prior arteriogram to confirm the presence of injury haS resulted in high rates of negative exploration [13, 14]. Since early repair of arterial injuries in an ischemic extremity is necessary to maintain a functional extremity, diagnostic studies such as arteriography may contribute to the delay of operative repair and are contra-indicated when the presence and location of the arterial injury are obvious [12]. Indications for arteriography are controversial [11, 12, 15]. We find the procedure useful in the presence of the soft signs of arterial injury where, by definition, the extremity is not isch" emic and there is more time for evaluation. In other cases, such as patients with shotgun wounds or blunt injuries where the location of the arterial injury can be difficult to ascertaiN,

R.R. Martin et al.: Extremity Vascular Injuries

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Ta.__ble1. Physical signs of arterial injury• Cool, ischemic extremity Absent or decreased pulses Bruit or thrill Expanding or pulsatile hematoma Pulsatile bleeding "Soft signs" Non-expanding Paresthesias or paresis Unexplained shock Proximity of wound to neurovascular bundles

arteriography is also used, even if the extremity is ischemic (Fig. 1). The information provided can expedite operative repair and restoration of blood flow in some instances. For certain blunt injuries such as posterior dislocation of the knee, arteriography is performed routinely unless hard signs of injury are present because of the high incidence of vascular injury associated with these injuries. Finally, arteriography can aid in Planning the sequence of combined procedures in patients with multiple injuries. Arteriography in our hospital is usually performed by surgeons in the emergency center. A direct arterial injection is Performed, and a single exposure is made using standard Portable x-ray equipment. The procedure can be performed in tess than 10 minutes, is inexpensive, and does not delay Operative repair of injuries. In 515 patients with suspected Vascular injury, the necessary information was obtained in 513 Patients and the delay and cost of calling in a radiology team Was avoided in all but 2 patients. There were no complications With the technique [16]. Arteriography for proximity of injury alone, in the absence of the previously mentioned physical findings, or "exclusion artenography,, has recently been questioned [17-20]. The exclusion arteriogram evolved as an alternative to the earlier recommendation to explore all injuries in proximity to major neurovascular bundles. This was based on experience in military conflicts Where the cavitation effect from high velocity missiles damaged arteries and veins even when the missile passed some distance from vascular structures [2, 21]. Because a high incidence of .negative exploration occurred when this approach was applied in the civilian setting, arteriography replaced routine exploration in these patients and many series have proven contrast Studies to be reliable in excluding injuries [13, 14, 22, 23]. COntroversy now centers on whether exclusion angiography is necessary or cost effective. The incidence of abnormal arteriogram When performed for proximity of a wound to major Vessels is approximately 17% [24]. However, many of these injuries, i.e., intimal flaps, segmental narrowing, small arteriovenous fistulas, and small pseudoaneurysms, may resolve without SUrgical intervention [17, 18, 20, 25]. Advocates of exclusion arteriogra P h y argue that data on the outcom e of observation a' ' • ~one for a large number of these injuries are lacking, and there ~s no agreement on exactly which injuries may be observed safely. Late or delayed repair of pseudoaneurysms or established arteriovenous fistulas is difficult and places the patient at greater risk than prompt diagnosis and treatment [26]. But with estinaates that the detection of a single vascular injury requiring SUrgical repair costs $66,420, the future of the use of formal

Fig. 1. Distal popliteal artery injury and associated tibial plateau fracture from shotgun wound to the knee. This emergency center arteriogram did not delay treatment of the ischemic leg and provided valuable information on the location of the injury. A below knee incision was used. exclusion arteriography seems doubtful [17]. We continue to use emergency center arteriography for this indication because it is inexpensive, patients are discharged after a negative study, eliminating the need for admission and observation, and our patient population does not return for follow-up evaluation. An advantage to this method is the identification of lesions that, even if treated expectantly, require follow-up studies (Fig. 2). Intra-arterial digital subtraction angiography has been used with some success in the evaluation of traumatic vascular injuries and requires less time, x-ray exposure, and contrast than conventional studies [27]. However, the procedure is not as sensitive for detecting small intimal defects, only allows for examination of a limited area per injection, and requires a co-operative patient. Thus digital studies are not suited for excluding injuries from high velocity missile wounds, blunt trauma, or shotgun injuries [12, 28, 29]. Other noninvasive and invasive procedures are currently under investigation for the diagnosis of vascular trauma. Doppler ankle pressures have been used with success to detect vascular injuries from wounds in proximity to vessels [20, 30].

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World J. Surg. Vol. 16, No. 5, Sept./Oct. 1992

Fig. 3. Shunts in place restoring flow through the popliteal artery and vein. Successful repairs with vein grafts were accomplished after orthopedic procedures and the ischemic time of the extremity was minimized.

Fig. 2. This digital subtraction study showing a pseudoaneurysm of the peroneal artery illustrates the benefits of emergency center arteriography. The patient sustained a gunshot wound to the knee which fractured the tibia. No signs of arterial injury were present on admission, but an emergency center arteriogram showed a cut-off of the peroneat artery. Orthopedic procedures were performed and this follow-up arteriogram was obtained 7 days later. The aneurysm was successfully embolized. It is questionable whether non-invasive studies would have detected this injury. If undetected and untreated, limb loss may have resulted from rupture of the aneurysm and the development of acute compartment syndrome.

Duplex scanning for vascular injuries is also under investigation [30]. Angioscopy allows direct inspection of the intimal surfaces but is difficult unless operative control of the vessels has been obtained. Blood flow must be interrupted to allow for irrigation of the vessel [31]. These modalities may play a greater role as they are perfected. Diagnosis of venous injuries is usually made at exploration for suspected arterial injuries. Noninvasive studies are not useful for preoperative diagnosis of venous injuries [11]. Venography is not recommended since the natural history of asymptomatic venous injuries is unknown but probably benign. Management Vascular injury in an extremity is frequently associated with other injuries. These include injury to bones, ligaments, joints, peripheral nerves, and soft tissues. F o r salvage of a functional extremity, thoughtful and realistic planning and prioritization for repair is essential. This involves a multidisciplinary ap-

proach involving plastic surgeons, orthopedic surgeons, and neurosurgeons [11]. In general, the vascular injuries take priority since restoration of blood flow to an ischemic limb must be accomplished expeditiously if disability or amputation is to be avoided. Six hours is an often quoted time limit for salvage o f an ischemic extremity, but an absolute interval has not been established [12, 32]. It must be kept in mind that nerve and muscle tissues are the most sensitive to ischemia, and devastating neurologic damage may occur before the skin appears nonviable. Associated orthopedic and vascular injuries can be difficult management problems. In the case of an ischemic extremity, the first priority is to re-establish arterial blood flow; the vascular repairs in these circumstances are done first. There are some situations in which the manipulation required for the orthopedic procedure is so extensive that the fragile vascular anastomoses are at risk of being disrupted. In other cases it may be difficult to judge the length o f graft material required in a severely foreshortened extremity until some degree of reduction has been accomplished. It may be necessary to perform the vascular repair first with an estimated length of graft and to revise the repair if necessary. An alternative is to place a shunt in the artery and/or vein (Fig. 3) until the orthopedic procedure is completed [33, 34]. The orthopedic injury is addressed in some fashion in all patients since the vascular repair is protected by a stabilized extremity. In a severely injured patient, however, prolonged orthopedic procedures are injudicious and a simple splint may be indicated. Peripheral nerve injuries can be managed at the time of vascular repair if the injury is a clean transection and full microsurgical resources are available, However, the majority of nerve injuries are not amenable to early repair, and even in the case of transected nerves the ends may be brought near each other and tacked to surrounding tissue anticipating repair at a later date [35]. Unless the patient is unstable, the physician who will be treating the nerve injury is given the opportunity to evaluate the patient in the operating room when the injury is

R.R. Martin et al.: Extremity Vascular Injuries

933 Table 2. Indications for polytetrafluoroethylene (PTFE) graft in vascular trauma. 1. Saphenous vein of inadequate size 2. Saphenous vein of poor quality 3. Saphenous vein provides only venous outflow to injured extremity 4. Multiply injured patient in whom rapid reconstruction is required 5. Arteries of ->6 mm diameter

Fig. 4. Vein graft replacing segment of brachial artery destroyed by shotgun injury.

exposed and to participate in the decision about appropriate timing of repair. Extensive soft tissue wounds can greatly complicate the management of vascular injuries and are seen frequently with shot gun blasts, blunt, shearing-type injuries, industrial accidents, and wounds from military weapons. Pre-operative consultation with plastic surgeons in the operating room is helpful in planning exposure and repair of vessels so as not to compromise possible muscle flaps which may be helpful for coverage [36, 37]. Vascular repairs must be covered, preferably with viable soft tissue to avoid infection, dehiscence, and exsanguinating hemorrhage although xenografts have been used SUccessfully as a temporary measure [38]. It is an exercise in futility and a disservice to the patient to restore viability to a limb rendered useless due to bone, joint, or never damage [39]. Misguided, heroic attempts at limb salvage may result in loss of life or produce a result inferior to that of amputation and a properly fitted prosthesis [40, 41]. The assessment of future function of an injured extremity is aided by COnsultation with orthopedic surgeons [36, 37, 39, 40]. Yet the decision of primary amputation for extremity trauma is often extra-ordinarily difficult, especially in view of the desire of the SUrgeon to help the patient, lay expectations produced by achievements in limb reimplantation, and the litigious nature of OUr society. Criteria for predicting failure of reconstruction include major injury to 3 of the 4 major components of the extremity, the bone, soft tissues, blood vessels, and nerves, and Objective scoring systems have been developed to select patients who warrant primary amputation [36, 40, 41]. Vascular injury alone is almost never an indication for primary amputation Unless the limb is dead [12, 42]. Severe nerve injury alone, rendering the limb paralyzed and anesthetic, is an indication for anaputation unless the nerve is found to be contused and not destroyed at exploration [36, 39, 40]. Techniques of Repair !n selected cases of arterial injuries detected angiographically, Injuries may be observed or embolized at the time of arteriography. The authors observe occlusions, intimal flaps, or small

defects due to shotgun wounds where there may be multiple injuries to vessels the same magnitude as the puncture wound made by the angiography catheter. These injuries most often heal without incident [18]. Follow-up angiography is performed at 10 days and 6 weeks post-injury to detect late aneurysm or arteriovenous fistula. Arteriovenous fistulas or false aneurysms of terminal vessels such as the profunda femoris, deep brachial, or peroneal arteries may be embolized. Viability of the extremity must be diligently monitored to detect acute thrombosis of an injured artery. Techniques for operative repair of traumatized arteries have paralleled advances in elective vascular surgery. Broad spectrum antibiotics and tetanus prophylaxis are administered preoperatively. Positioning, skin preparation, and draping are accomplished so vein donor sites are accessible. Proximal and distal control of the vessel may require some creative incisions or techniques. For example, supra-inguinal incisions are sometimes used to control hemorrhage from multiple vascular injuries high in the groin. Infractavicular incisions are necessary for access to the axillary artery for proximal upper extremity injuries. Fogarty balloon catheters may also be used for vascular control. Debridement of the damaged vessel is kept to a minimum. Suture lines are placed with the aid of magnifying lenses and provide precise approximation of the vessel edges. Anastomoses are constructed without undue tension. Fogarty catheter thrombectomy is routinely performed both proximal and distal to the site of injury, and local heparin irrigation of the vessel is used liberally. Systemic heparinization is usually contra-indicated in the multiply injured patient. Primary repair includes lateral arteriorrhaphy or re-anastomosis after adequate debridement. To obtain a tension free anastomosis it is frequently necessary to mobilize several centimeters of artery. Grafting is necessary when a lateral repair of a large defect would narrow the vessel or insufficient length of artery remains for comfortable anastomosis after debridement. The conduit of choice is autogenous saphenous vein of good quality, taken from the contralateral leg to preserve venous outflow in the injured extremity (Fig. 4). However, quality saphenous vein is not always available, and in these circumstances (Table 2), expanded polytetrafluoroethylene (PTFE) graft has been shown to function satisfactorily (Fig. 5) [24, 37, 43, 44]. The degree of contamination in traumatic injuries is debatable, but resistance of PTFE graft to infection has been demonstrated in clinical and laboratory studies and the infected prosthesis may be easier to manage than an infected vein graft [37, 43, 45, 46]. Infection is rare if wounds are thoroughly debrided and grafts are covered with viable tissue [37, 43]. The material is not recommended for vessels

Advances in treatment of vascular injuries from blunt and penetrating limb trauma.

Military and civilian experience has contributed to the current state of the art in management of extremity vascular injuries. Thorough physical exami...
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