Principles for Evaluation and Treatment of Patients with Vascular Injury Timothy McHenry, MD

OverviewEpidemiologyTypes of InjuryEvaluationTreatment

Mechanisms of Vascular Injury in the ExtremitiesGunshot wound 54%Stab wound 15%Shotgun wound 12%Blunt trauma 15%Iatrogenic 3%

Feliciano et al., J Trauma, 1988

Types of InjuriesActive HemorrhageLaceration

Partial transection

Complete Transection

Types of InjuryPotentially non-occlusiveContusion with:

Segmental Spasm

Thrombosis

True Aneurysm

Types of InjuryPotentially non-occlusivePseudoaneurysm

Arteriovenous Fistula

Intimal Flap

Presentation of Vascular InjuryFirst priority is hemorrhage control followed by appropriate diagnostic work-up

Presentation of Vascular InjuryDislocations and displaced or angulated fractures: realigned immediately if vascularity is compromised

Evaluation for Vascular InjuryPhysical ExaminationDoppler FlowmeterDuplex UltrasonographyArteriogramLocal wound exploration should not be done in an uncontrolled settingClose coordination with a general or vascular surgeon recommended

Physical ExaminationHard Signs

Absent or diminished distal pulsesActive hemorrhageLarge, expanding or pulsatile hematomaBruit or thrillDistal ischemia (pain, pallor, paralysis, paresthesias, coolness)

Frykberg, Surgical Clinics of North America, 1995

Physical ExaminationSoft Signs

Small, stable hematomaInjury to anatomically related nerveUnexplained hypotensionHistory of hemorrhage no longer presentProximity of injury to major vessel

Frykberg, Surgical Clinics of North America, 1995

Doppler ExaminationNon-invasive adjunct to physical examinationSmall, hand-held (non-directional) Doppler flowmeter provides for subjective interpretation of audible signalUseful as modality for determining the Ankle-Brachial Index (ABI)

Rutherford (ed.), Vascular Surgery, 1989

DopplerNormal arterial signals are triphasic or biphasic

DopplerFlow distal to a transection may be absent or monophasic and low-pitched due to collateral circulation

Determination of Ankle-Brachial IndexAppropriate sized blood pressure cuff is placed above the ankle or wristDoppler derived opening pressure of distal arteryCalculate by dividing ankle pressure by brachial pressureMeasure injured/ uninjured sidesNormal ABI is 1.00 or greater

ABI CriteriaABI > 0.9 AdvantagesStrong negative predictor for major vascular injuryObjective noninvasive evidence of vascular competenceDisadvantagesDoes not exclude all injuriesNot useful in presence of vascular disease

Johansen et al., J Trauma, 1991

Duplex (B-mode) UltrasonographyDirection-sensing Duplex (B-mode) ultrasound allows for visual waveform analysisHighly operator dependent96-98% accurate in experienced handsGenerally not available during peak trauma times

Frykberg, Surgical Clinics of North America, 1995

ArteriographyGold standard for evaluation of peripheral vascular injuriesFormal arteriograms done in radiology may cause critical delays in diagnosis or interventionSingle-shot arteriograms done in the emergency room or operating room should be considered in cases where arteriography is indicated.

Indications for Arteriography

Multiple potential sites of injury (shotgun wounds)Missile track parallels vessel over long distanceBlunt trauma with signs of vascular traumaChronic vascular diseaseExtensive bone or soft tissue injuryThoracic outlet woundsEvaluation of equivocal results from non-invasive testsProximity (gsw, knife wound) (controversial)ABI < .9

Frykberg, Surgical Clinics of North America, 1995

Single-shot Arteriogram21 or 20 gauge angiocatheter ( at least 2 long) or single lumen central line or a-line kit3 way stop-cock30 cc syringes (x2)Iodinated contrast (full strength)Heparinized saline (1,000 IU/liter)IV extension tubingConsider inflow and/or outflow occlusion

Courtesy of W. Dorlac, MD

Single-shot Arteriogram in the Emergency or Operating Room

Courtesy of W. Dorlac, MD

Summary of EvaluationInitial priority is to control hemorrhageDirect PressurePressure PointsTourniquetIf penetrating injury with one or more hard signs of vascular injury then immediate surgical exploration is usually warrantedIf hard signs present with blunt mechanism or multi-site penetrating mechanism then an arteriogram may be warrantedIf soft signs present, consider further diagnostic modalities (usually initially non-invasive)

TreatmentOperative RepairIndications:injuries with hard signs of vascular injury

OR

arteriogram showing occlusion or extravasation

TreatmentNon-operative ObservationCertain non-occlusive injuries without hard signs (often occult injuries) can be managed conservativelyCriteria:Low-velocity injuryMinimal arterial wall disruptionIntact distal circulationNo active hemorrhageSerial arteriography or duplex scanning recommendedClose coordination with a vascular or general surgeon is recommended

Modrall et al., Emergency Medicine Clinics of North America, 1998

Non-operative ManagementIntimal injuries and segmental narrowing are most amenable to conservative care and may resolve over timeSmall pseudoaneurysms sometimes enlarge, become symptomatic and require operative repairAsymptomatic acute AV fistulas may be less certain to resolve and should be followed closely

Sequelae of Missed Arterial InjuriesDeterioration of arterial injury can lead to:Intimal dissection with resulting occlusionArteriovenous fistulaThromboemboliStenosisThese can cause distal ischemia with significant morbidity:PainGangreneAmputation

Perry, J Vasc Surg, 1993

Penetrating Arterial InjuryLimb Salvage RatesWorld War II (Debakey and Simeone, 1946)2,471 cases51% salvage for ligation64.2% salvage for repairViet Nam War (Rich et al, 1970)1000 cases28.5% with concomitant fractures87% overall salvageRecent civilian (Trooskin et al, 1993)50 arterial and 17 venous injuries in 51 patients22% with concomitant fractures100% salvageOther recent civilian studies approach a 100% salvage rate as well

Blunt Arterial Injury Salvage RatesHave a high amputation rate due to associated soft-tissue and nerve injuries (the mangled extremity)These injuries may result in a non-functional limb in spite of a successful revascularization

Mangled ExtremityIndications for Primary AmputationAnatomically complete disruption of sciatic or posterior tibial nerves in adult even if vascular injury is repairableProlonged warm ischemia time Life threatening sequelaerhabdomyolysis

Mangled ExtremityRelative Indications for Primary AmputationSerious associated polytraumaSevere ipsilateral foot traumaloss of plantar skin/weight bearing surfaceAnticipated protracted course to obtain soft-tissue coverage and skeletal reconstruction

Variables in Consideration of Limb ViabilitySkin/Muscle InjuryBone InjuryIschemia (time, degree)Type of Vascular InjuryShockAgeInfectionAssociated injuries (pulmonary, abdominal, head, etc.)Comorbid Disease (peripheral vascular disease, diabetes mellitus, etc.)

Classification SystemsMangled Extremity Syndrome Index (MESI)10 variablesPredictive Salvage Index (PSI)4 variablesMangled Extremity Severity Score (MESS)4 variablesLimb Salvage Index (LSI)7 variables NISSSA scoring system5 variables

Mangled Extremity Scoring SystemFactor ScoreSkeletal/soft-tissue injuryLow energy (stab, fracture, civilian gunshot wound)1Medium energy (open or multiple fracture)2High energy (shotgun or military gunshot wound, crush)3Very high energy (above plus gross contamination)4Limb Ischemia (double score for ischemia > 6 hours)Pulse reduced or absent but perfusion normal1Pulseless, diminished capillary refill2Patient is cool, paralyzed, insensate, numb3ShockSystolic blood pressure always >90 mm Hg0Systolic blood pressure transiently

Mangled Extremity Severity ScoreAll information for classification available at time of ER presentationSimplest to apply of all scoring systemsMost thoroughly studiedA score of less than 7 is supposed to predict limb salvageability

LEAP Data 556 lower extremity injuriesprospectively scoredMESS, PSI, LSI, NISSSA, HFS-97High specificity (84-98%)LOW SENSITIVITY (33-51%)Not a substitute for clinical judgment and experience for salvage vs amputation decision making

Bosse et al, JBJS, 83-A, 2001

Mangled Extremity ManagementInvolves a determination of both the feasibility (restoring viability) and advisability (restoring function) of salvaging the limbShould be a coordinated effort of the orthopaedic, vascular and plastic surgeons starting at the initial evaluation of the patient

FasciotomiesProphylactic fasciotomies after vascular repair have been credited as being a major reason for increased limb salvage rates in recent yearsFasciotomies after prolonged ischemia prevent compartment syndrome that may result from reperfusion injuryThe reperfusion injury is delayed and may manifest after the patient leaves the operating room

Indications for FasciotomiesNo absolute clinical indications for fasciotomy existSubjective criteriaExtensive soft-tissue or bony injuryProgression of swellingCompartment tightnessObjective criteriaIschemia time greater than 6 hoursCompartment pressure within 20 mm Hg of diastolic blood pressure

Morbidity of FasciotomiesIncreased risk of infectionExposure of injured or ischemic muscleDecreased fracture healingPotentially converting a closed to an open fractureIatrogenic injuryNeuromaChronic venous insufficiency

Pharmacologic Treatment of Reperfusion InjuryFollowing reperfusion, byproducts of anaerobic metabolism may be released causing local and systemic effects Administration before reperfusionMannitolFree radical scavengingHeparinAnti-coagulantAnti-inflammatoryMay be contraindicated in acute trauma

Issues Concerning Surgical OrderThe order of surgical repair in penetrating injuries requiring both vascular repair and orthopaedic fixation is controversial:Delayed revascularization until after orthopaedic stabilization may adversely effect limb salvageFractures instability or subsequent orthopaedic stabilization may disrupt a vascular repair

Surgical OrderIn general, revascularization takes precedence over definitive orthopaedic fixationIn cases with gross fracture instability a temporary vascular shunt can be placed and vascular repair deferred until after orthopaedic fixationIf the ischemia time is short, consideration can be given to application of a provisional unilateral external fixator prior to revascularization

Temporary Vascular Shunt

Definitive Vascular Repair

Definitive FixationDefinitive orthopaedic fixation should be internal in most casesConsider external fixation for:Pediatric fracturesExtensive soft-tissue injuriesContaminated woundsHemodynamically unstable patients

Penetrating Superficial Femoral Artery Injury with Femur Fracture

SummaryThe treatment of fractures or dislocations with vascular injury requires close coordination between the orthopaedic surgeon and the vascular or general surgeon to facilitate optimal limb outcome.Return to General Index

Feliciano DV, Herskowitz K, OGormon RB, et al: Management of vascular injuries to the lower extremities. J Trauma 28: 319-328, 1988.

Furthermore, 38% of fractures associated with gunshot wounds have arterial injuries. (Gahtan et al., Am Surg 60: 123-127, 1994)Potentially non-occlusive injuries present with varying degrees of occlusion that may or may not be clinically significant. The injuries that do not cause clinically significant ischemia can potentially be managed by close observation. Late progression of these lesions, however, may cause delayed ischemia requiring surgical intervention. These injuries do not typically present with active hemorrhage.Modrall JG, Weaver FA and Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America, 16: 129-144, 1998.Frequently nonocclusive arterial injuries are surrounded by a contained hematoma. If the hematoma is disrupted, exigent hemorrhage may ensue. Local wound exploration is therefore ill advised.The presence of one or more hard signs is an indication for immediate surgical exploration.

Frykberg ER. Advances in the diagnosis and treatment of extremity vascular trauma. Surgical Clinics of North America 75: 207-223, 1995.In general, soft signs may indicate the need for further evaluation. Their significance is controversial and their presence alone do not constitute an indication for surgical intervention. Proximity refers to penetrating wounds less than 1 cm to a major vessel. Proximity is very controversial. Some centers now rely on non-invasive methods to initially evaluate injuries less than 1 cm from a major vessel.Modrall JG, Weaver FA and Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emergency Medicine Clinics of North America, 16: 129-144, 1998.Recent studies have demonstrated that in the absence of objective clinical findings (e.g., fracture, hematoma, nerve injury), arteriograms performed for proximity alone demonstrate an arterial injury in only 6 to 9% of patients. More significantly, the injuries that are clinically occult but detected only by arteriography are invariably insignificant and do not require surgical repair.Frykberg ER, Crump JM, Vines FS, McLellan GL, Dennis JW, Brunner RG, Alexander RH. A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study. J Trauma, 29: 1041-50, 1989.152 injuries from penetrating proximity extremity trauma were studied by either immediate or delayed arteriography. 27 radiographic abnormalities found with 16 in major vessels. 1 acute AV fistula was immediately repaired. The remaining 15 were observed (7 cases of segmental narrowing, 6 intimal flaps and two small pseudoaneurysms). One pseudoaneurysm enlarged and underwent repair at 10 weeks. The remaining 14 were successfully managed non-operatively (9 resolved, 2 improved and 3 unchanged) over an average of 2.7 months. Conclusions: 1. The natural history of clinically occult arterial injuries was predominantly benign, 2. Arteriogram could be safely delayed up to 24 hours, 3. soft signs were not clinically useful predictors of vascular injury, 4. Arteriography not a cost-effective modality for screening proximity injuries (a possible exception is shotgun wounds because this mechanism was found to have the greatest risk of significant injury).

Rutherford RB (ed.) Vascular Surgery (3rd ed.). W.B. Sanders Co., 1989.For triphasic flow the first sound corresponds to high frequency flow during systole. The second sound corresponds to reverse flow in early diastole. The third sound corresponds to a smaller, low velocity flow in late diastole.Other authors have found that an ABI of 1.0 has a higher sensitivity for excluding major arterial injury:

Schwartz MR, Weaver FA, Bauer M, Siegel A, Yellin AE. Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis. J Vasc Surg 17: 116-22, 1993.

ABI Sensitivity SpecificityPPVNPV