27.1

Vascular Injuries

Chapter 27

Vascular Injuries

Introduction

 History.

ο World War II: Popliteal artery injuries were routinely

ligated with a 73% amputation rate.

ο Korean War: Formal repair of peripheral arterial injuries

instituted.

ο Vietnam War: Further refinements in arterial repair; amputation rate for popliteal artery injuries is reduced to 32%.

 There are various types of wounds seen in combat.

ο Low-velocity missile damages a blood vessel lying directly

in its path.

ο High-velocity missile blast effect causes fragmentation of

the missile or bone and widespread destruction, including

vascular injury at a distance.

ο Blunt trauma, often resulting from sudden deceleration in

motor vehicle accidents, falls, rail and air disasters.

ο Popliteal artery injury associated with posterior knee

dislocations.

Evaluation and Diagnosis

 Physical examination — detailed examination is paramount.

ο Hard signs of arterial injury (pulsatile external bleeding,

enlarging hematoma, absent distal pulses, a thrill/bruit,

or ischemic limb) should lead to immediate surgical

exploration, without further preoperative studies.

♦ The 6 Ps of acute ischemia are: pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis.

♦ Degree of injury and adequacy of collateral flow will

determine the severity of distal ischemia. Remember:

Warm ischemia of striated muscle for > 4–6 hours will

likely lead to myonecrosis and major amputation.
27.2

Emergency War Surgery

♦ Falsely attributing loss of pulse, diminished pulse, or

asymmetry of pulses to arterial spasm may cause delay

in detection/repair of limb-threatening arterial injury.

♦ Distal pulses may be intact in up to 20% of patients with

arterial injuries.

ο Soft signs of arterial injury that require additional

diagnostic evaluation include proximity of wound to major

vessels, history of hemorrhage/shock, nonexpanding

hematoma, diminished pulse, and anatomically related

nerve injury.

 Doppler examination.

ο A patient with penetrating or blunt trauma who has a

normal distal pulse exam and ankle-brachial index (ABI)

> 1.0 does not require arteriography.

ο In the patient without a palpable pulse distal to the injury,

perform a Doppler examination and an ABI. ABI < 0.9 or a

difference in ABI between extremities of > 0.1 indicate an

arterial injury until proven otherwise. Because of extensive

collateral flow, injuries to the deep femoral or deep brachial

artery are not ruled out by this technique.

 Duplex ultrasound (US).

ο Color flow duplex ultrasonography has demonstrated high

sensitivity and specificity for detecting arterial injuries. It

is noninvasive, portable, and painless, and repeated exams

are easily performed.

ο Duplex is highly operator-dependent and may fail to detect

all arterial injuries (eg, deep femoral or tibial injuries).

 Contrast angiography.

ο Precise localization of vascular injury is useful in patients

with multiple pellet wounds (eg, shotgun blast), fractures,

and penetrating injuries to the neck and thoracic outlet.

ο Consider with high-velocity wounds, where arterial injury

may occur outside the path of the missile, or in the presence

of soft signs of arterial injury.

ο Consider as routine for knee dislocations where occult

arterial injuries may occur, and undetected delayed

popliteal artery thrombosis may lead to major amputation.
27.3

Vascular Injuries

Management Aspects

 Initial management.

ο Control external bleeding immediately! Blind or

imprecise placement of vascular clamps in a bloody field

is discouraged. Direct pressure to the bleeding wound is

preferable; temporary tourniquet (BP cuff) placed

proximal to the injury site and inflated above systolic blood

pressure may be useful.

ο Administer IV antibiotics, tetanus toxoid, and analgesia.

ο In most long-bone fractures, resuscitation and fracture

alignment will restore distal flow.

ο Indications for operation for a suspected vascular injury:

♦ Hard signs as discussed above.

♦ Soft signs confirmed by duplex US and/or angiography.

 Operative management.

ο Preparation and draping of injured extremity as well as

contralateral uninjured lower or upper extremity in case

repair requires autogenous vein graft.

ο Surgical approaches to the femoral popliteal, and brachial

arteries are shown in Figures 27-1–Figure 27-5.

Fig. 27-1. Inguinal anatomy.

Inguinal Ligament

Rectus

Femoris

Sartorius

Saphenous Vein

Femoral Nerve

External Iliac Artery
27.4

Emergency War Surgery

Fig. 27-2. Exposure of distal femoral and popliteal vessels.

a

b

Vastus Medialis

Adductor Magnus

Sartorius

Medial Head

Gastrocnemius

Fig. 27-3. Medial approach to popliteal vessels.

Medial Head Gastrocnemius

Insertions of Sartorius,

Gracilis, Semitendinosus
27.5

Vascular Injuries

Fig. 27-4. Posterior approach to popliteal vessels.

Semimembranosus

Semitendinosus Biceps Femoris

Lesser Sapnenous Vein

Medial Head

Gastrocnemius

Lateral Head

Fig. 27-5. Exposure of brachial and radial arteries.

a

b

b
27.6

Emergency War Surgery

ο Longitudinal incisions usually directly over injured vessel

followed by proximal and distal control. A tourniquet (eg,

blood pressure cuff) may occasionally be useful to obtain

proximal control or to improve intraoperative visualization.

ο Once control is obtained, perform the following steps:

♦ Debride injured vessels to macroscopically normal wall.

♦ Pass balloon catheters proximal and distal to remove

any residual thrombus.

♦ Flush both directions with heparinized saline.

ο Consider temporary intraluminal shunting.

♦ Successful shunt placement allows ample time for wound

debridement and copious irrigation, identification of

nerve injuries, and careful consideration of reconstruction

vs primary amputation.

 Shunt placement technique.

ο Proximal and distal vessel control with Silastic vessel loops

or Rumel tourniquet.

ο Release proximal control to flush clot and place Argyle shunt.

ο Distal thrombectomy (Fogarty catheter) until no clot is returned.

ο Instill heparinized saline (20 U/mL) into distal vessel.

ο Place shunt into distal end and secure.

ο Check for distal pulse/perfusion.

 In injuries to both artery and vein in which no shunt is used,

repair artery first to minimize ischemic time, followed by

venous repair.

 Suture: 5-0 or 6-0 Prolene; 7-0 Prolene for small arteries. All

completed repairs must be tension free.

 Upon completion, forward and back bleed repaired segment

until clear of air and debris prior to final closure.

 Type of repair will depend on the extent of injury.

ο Lateral suture repair: Required for minimal injuries that,

when repaired, will not compromise the lumen > 25%,

result in a thrill, nor decrease pulse or Doppler signal.

ο Patch angioplasty: Needed for larger, tangential wounds;

to prevent stenosis.

ο End-to-end anastomosis: Excise extensively damaged

segments and perform anastomosis if able to mobilize ends

(generally, < 2 cm gap) without tension. An oblique

anastomosis is less likely to stenose.
27.7

Vascular Injuries

ο Interposition graft: Required if the vessel cannot be

primarily repaired without undue tension.

♦ Autogenous vein grafts preferred, usually the contralateral greater saphenous vein (GSV).

◊ Harvest vein from the contralateral limb, if possible.

The reason for this is in the injured limb, superficial

veins may be an important source of venous outflow

if deep veins are injured.

◊ Order of preference vein harvest for arterial conduit

is contralateral GSV, ipsilateral GSV (if no concomitant deep venous injury), contralateral lesser

saphenous vein (LSV), ipsilateral LSV (if no deep

venous injury), cephalic vein, and basilic vein.

♦ Prosthetic grafts may be required when autogenous

vein is inadequate or unavailable, expeditious repair is

indicated, or for large vessels (aortoiliac system) for

which there is a large size discrepancy.

◊ Polytetrafluoroethylene (PTFE) grafts are more resistant to infection than Dacron and have acceptable

patency rates when used in the above-knee position.

◊ The use of prosthetic grafts can hasten the completion of a procedure in patients whose physiology

requires expeditious surgery.

◊ Prosthetics can also be used in areas of extensive

soft-tissue debridement as a “prolonged shunt”

where planned revision days to weeks later, out of

theatre, will be expected.

 Graft coverage: Exposed vein grafts will desiccate, leading

to graft blow-out and potential exsanguination. They must

be covered by soft tissue or muscle; superficial muscles such

as sartorius or gracilis in the thigh may be mobilized to cover

a graft. If coverage is not possible, an alternate subcutaneous

or subfascial route through uncontaminated viable tissue

must be chosen.

 Prolonged shunting: If the above techniques are unsuccessful

or precluded by patient physiology or the tactical environment, shunting (as outlined above) with the following

modifications can be used for up to 72 hours.

ο Replace silastic loops with suture, and secure firmly.
27.8

Emergency War Surgery

ο Systemic heparinization is not required.

ο Monitor distal perfusion hourly.

ο Re-evaluate/evacuate early for definitive repair.

 Ligation of artery: If the above options for repair are

unsuccessful or unavailable, vessels can be ligated in light of

known rates of morbidity. Emphasis is Save Life Over Limb.

 Intraoperative completion angiogram or duplex US (if

available) should be done to evaluate the technical adequacy

of the repair, visualize the runoff, and detect any missed distal

clot.

ο Full strength contrast 30–60 cc.

ο 20 gauge Angiocath.

ο Inflow occlusion.

 Venous repair: Options are similar to arterial repairs outlined

above.

ο Ligation of major veins is acceptable in life-threatening

situations, although in a stable patient and time permitting,

venous repair should be performed and may enhance

arterial repair patency.

 Compartment syndrome: Muscle compartments of the

forearm and palm in the upper extremity and anterior

compartments of the lower leg are particularly susceptible.

ο Indications for fasciotomy:

♦ 4–6 hour delay after vessel injury.

♦ Combined vein and artery injury.

♦ Arterial ligation.

♦ Concomitant fracture/crush, severe soft-tissue injury,

muscle edema or patchy necrosis.

♦ Tense compartment/compartment pressures exceeding

40 mm Hg.

♦ Prophylactic for patients with prolonged transport times

or long periods without observation (no surgical care

available enroute).

ο A standard two-incision, four-compartment approach for the

calf is simple and effective (see Chapter 22, Soft-Tissue Injury).

ο Arm fasciotomy will consist of a longitudinal centrally

placed incision over the extensor compartment and a

curvilinear incision on the flexor aspect beginning at the

antecubital fossa.
27.9

Vascular Injuries

 Post-op care.

ο Palpable pulses obtained in the operating room (OR)

should remain palpable post-op.

♦ Pulse changes, even if Doppler signals remain, may

indicate graft thrombosis and should be investigated.

ο Consider low-dose heparin as deep vein thrombosis (DVT)

prophylaxis.

♦ Use with caution in multiply injured and head-injured

patients.

ο Slight elevation of injured extremity improves post-op

edema.
27.10

Emergency War Surgery