Peripheral Vascular Trauma


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Peripheral Vascular Trauma


Yousef Abuhakmeh, DO1 and Jonathan Swisher, MD2


1 MAJ, MC US Army, Banner University Medical Center, University of Arizona College of Medicine, Tucson, AZ, USA


2 LTC, MC US Army, William Beaumont Army Medical Center, El Paso, TX, USA



  1. A 27‐year‐old man presents with an inflamed groin mass. It is swollen, tender to palpation, and the patient is febrile. He admits to a history of frequent intravenous drug abuse with injection at various sites. The best initial diagnostic study paired with the likely diagnosis is:

    1. Duplex ultrasound/subcutaneous abscess
    2. Duplex ultrasound/lymphoma
    3. Incision and drainage/subcutaneous abscess
    4. Duplex ultrasound/infected pseudoaneurysm
    5. Incision and drainage/infected pseudoaneurysm

    Infected pseudoaneurysms are common in younger patients who are addicted to illicit IV drugs and should be suspected if there is concern for abscess near any major vessel used as an injection site. Trauma is also a well‐known cause of pseudoaneurysms that may become infected by hematogenous seeding or direct inoculation. Initial imaging workup should include duplex ultrasound for evaluation of the underlying fluid collection or pseudoaneurysm. Incision and drainage should not be performed for presumed abscess without imaging to rule out pseudoaneurysm in the region of major vessels. Malignancy such as lymphoma would likely present with palpable lymphadenopathy in multiple nodal basins, likely not isolated with focal signs of infection.


    Answer: D


    Jacobowitz G, Cayne NS. Lower Extremity Aneurysms. Rutherford’s Vascular Surgery and Endovascular Therapy , 9th ed., (ed. Anton N Sidawy and Bruce A Perler ) Elsevier, 2019, pp. 1080–1083.


  2. A patient arrives to the trauma bay with report from EMS that he sustained a stab wound to the right lower extremity. He has had continuous bleeding of bright red blood throughout his ambulance transport, with a tourniquet in place. During the primary survey, the tourniquet is loosened, revealing pulsatile blood from the wound. You find no other injuries. The initial management goals should be:

    1. Fluid resuscitation and CT imaging with contrast
    2. Blood product resuscitation and immediate operative exploration
    3. Tetanus administration, intravenous gentamycin and bedside ankle‐brachial index
    4. Fluid resuscitation and bedside ankle‐brachial index
    5. Intravenous antibiotics and orthopedic trauma consultation

    This patient is presenting with an isolated penetrating trauma with hard signs of bleeding. Immediate blood product resuscitation and operative intervention are warranted with the goal of hemorrhage control and repair of the vessels. Hard signs of arterial extremity injury include active bleeding, expanding hematoma, signs of distal ischemia, lack of distal pulses, and palpable thrill or audible bruit. Any patient presenting with these signs/symptoms should forego any further workup (CT imaging and ankle‐brachial index) and proceed directly to immediate operative exploration and repair. While intravenous antibiotics and orthopedic consultation may be appropriate, it should not take priority over immediate operative exploration and resuscitation.


    Answer: B


    Callcut RA, Mell MW. Modern advances in vascular trauma. Surg Clin North Am. 2013; 93(4):941–961. doi: 10.1016/j.suc.2013.04.010. Epub 2013 Jun 13. Review. PubMed [citation] PMID: 23885939.


    Feliciano DV. Pitfalls in the management of peripheral vascular injuries. Trauma Surg Acute Care Open. 2017; 2(1):e000110. doi: 10.1136/tsaco‐2017‐000110. eCollection 2017. Review. PubMed [citation] PMID: 29766105, PMCID: PMC5877918.


    Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, Skarupa D, Frykberg E, Eastern Association for the Surgery of Trauma. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 Suppl 4):S315–S320. doi: 10.1097/TA.0b013e31827018e4. PubMed [citation] PMID: 23114487.


  3. A 25‐year‐old man sustains a gunshot wound to the left upper leg (pictured below). The patient is hypotensive, acidotic, and hypothermic, with absent pulses below the level of the injury. The massive transfusion protocol is initiated in the trauma bay and the patient is taken immediately to the operating room. The patient remains unstable. What is the appropriate operative sequence?

    1. Open reduction internal fixation of the femur followed by definitive vascular repair with reverse saphenous vein graft
    2. External fixator placement followed by definitive artery repair with prosthetic graft
    3. Temporary shunting of injured artery followed by external fixator placement and delayed vascular and bone repairs
    4. Open reduction internal fixation of the femur followed by definitive vascular repair with prosthetic graft
    5. External fixator placement, definitive artery repair, and delayed bone repairs

    Temporary intravascular shunting is now widely accepted as a bridge to definitive vessel repair, such as in combined orthopedic and vascular injuries. The indications for temporary shunting include open extremity fractures with extensive soft tissue injury and concurrent arterial injury, need for perfusion during complex vascular reconstruction, damage control for patients in extremis, perfusion prior to limb replantation, truncal vascular control, and complex repair of zone III neck injuries. As this patient is in extremis, damage‐control vascular (shunt) and orthopedic (external fixator) surgery techniques should be performed, and the patient returned to the intensive care unit for ongoing and aggressive resuscitation. The patient should return to the operating room as soon as endpoints of resuscitation have been met for definitive vascular and bone repairs. Answers A, B, D, and E are not damage‐control techniques and will potentially result in limb loss and death should the patient spend several hours in the operating room undergoing definitive procedures.

    Schematic illustration of an X-ray result.

    Answer: C


    Abou Ali AN, Salem KM, Alarcon LH, Bauza G, Pikoulis E, Chaer RA, Avgerinos ED. Vascular shunts in civilian trauma. Front Surg. 2017; 4:39. doi: 10.3389/fsurg.2017.00039. eCollection 2017. Review. PubMed [citation] PMID: 28775985, PMCID: PMC5517780.


    Liang NL, Alarcon LH, Jeyabalan G, Avgerinos ED, Makaroun MS, Chaer RA. Contemporary outcomes of civilian lower extremity arterial trauma. J Vasc Surg. 2016; 64(3):731–736. doi: 10.1016/j.jvs.2016.04.052. Epub 2016 Jul 18. PubMed [citation] PMID: 27444360, PMCID: PMC5002387.


    Woodward EB, Clouse WD, Eliason JL, Peck MA, Bowser AN, Cox MW, Jones WT, Rasmussen TE. Penetrating femoropopliteal injury during modern warfare: experience of the balad vascular registry. J Vasc Surg. 2008; 47(6):1259–1264; discussion 1264‐5. doi: 10.1016/j.jvs.2008.01.052. Epub 2008 Apr 14. PubMed [citation] PMID: 18407450.


  4. EMS brings a patient to the emergency department who has been stabbed in the left upper chest, just below the lateral portion of the clavicle. The patient is anxious, tachycardic, and has no other wounds. The wound is bleeding briskly once manual pressure is removed. At exploration, the axillary artery is found to be transected cleanly without tension from the ends. He is stable after initial resuscitation, with normal parameters on his ABG. The most appropriate method of repair is:

    1. Endovascular repair with stent graft
    2. Repair with interposition vein graft
    3. Repair with interposition prosthetic graft
    4. Primary repair
    5. Temporary shunting with delayed primary repair

    This patient has hard signs of bleeding and should be explored immediately. In addition, complete vessel transection has been shown to have high failure rates with endovascular repair. Caution is advised with primary repair, as tension with an end‐to‐end anastomosis increases the risk of suture line/anastomotic failure and thrombosis. In this patient with a sharp transection (and no undue tension) of the axillary artery from a penetrating knife injury, primary repair is most expeditious. Interposition graft is not necessary unless there is undue tension on the vessel ends. Shunting prior to repair is not necessary in this case as the patient is stable and adequately resuscitated in the operating room. Shunting would be appropriate if the patient was unstable, had ongoing resuscitation requirements, or had other life‐threatening injuries at the time of exploration.


    Answer: D


    Feliciano DV. Pitfalls in the management of peripheral vascular injuries. Trauma Surg Acute Care Open. 2017; 2(1):e000110. doi: 10.1136/tsaco‐2017‐000110. eCollection 2017. Review. PubMed [citation] PMID: 29766105, PMCID: PMC5877918.


    Klocker J, Bertoldi A, Benda B, Pellegrini L, Gorny O, Fraedrich G. Outcome after interposition of vein grafts for arterial repair of extremity injuries in civilians. J Vasc Surg. 2014; 59(6):1633–1637. doi: 10.1016/j.jvs.2014.01.006. Epub 2014 Feb 19. PubMed [citation] PMID: 24560243.


    Shalhub S, Starnes BW, Tran NT . Endovascular treatment of axillosubclavian arterial transection in patients with blunt traumatic injury. J Vasc Surg. 2011; 53(4):1141–1144. doi: 10.1016/j.jvs.2010.10.129. Epub 2011 Jan 26. PubMed [citation] PMID: 21276694.


  5. A middle‐aged man presents to the trauma bay after sustaining multiple gunshot wounds. He is hemodynamically unstable and massive transfusion is initiated. FAST exam is positive, and he has active bleeding from a proximal left thigh wound as well. In the operating room, his leg is explored simultaneously during laparotomy. In addition to a liver laceration and multiple bowel injuries, the proximal superficial femoral artery is transected. He is hypothermic. The most prudent course of action regarding the arterial injury is:

    1. Interposition graft with reversed contralateral saphenous vein
    2. Ligation
    3. Temporary shunt placement with systemic heparinization
    4. Interposition graft with PTFE prosthetic
    5. Temporary shunt placement

    Damage control surgery is a widely accepted method of management for patients in extremis. Patients with vascular injuries who are in extremis (hypothermia, acidosis, hemodynamic instability) should undergo temporary intravascular shunt placement rather than ligation, if possible, as ligation of major inflow vessels may lead to irreversible ischemia and subsequent limb amputation. Interposition repair would be time consuming in this case, making temporary shunt placement a better option for the patient overall until they are stabilized. Definitive vascular repair should be performed in a situation where the patient has a more normal and stable physiology. Although civilian trauma centers have reported higher rates of shunting in blunt trauma patients with concomitant orthopedic injuries, penetrating and blast injuries in patients who are unstable may warrant shunt placement as part of the index damage control operation. Studies have shown that shorter ischemic time (facilitated by shunt placement) may result in a lower incidences of fasciotomy, repeat operations, and shorter hospitalizations. Systemic heparinization in this patient is contraindicated in the setting of liver laceration and ongoing hemorrhage from penetrating trauma requiring massive transfusion.


    Answer: E


    Abou Ali AN, Salem KM, Alarcon LH, Bauza G, Pikoulis E, Chaer RA, Avgerinos ED . Vascular shunts in civilian trauma. Front Surg. 2017; 4:39. doi: 10.3389/fsurg.2017.00039. eCollection 2017. Review. PubMed [citation] PMID: 28775985, PMCID: PMC5517780.


    Hossny A. Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified? J Vasc Surg. 2004; 40(1):61–66. PubMed [citation] PMID: 15218463.


    Sharrock AE, Tai N, Perkins Z, White JM, Remick KN, Rickard RF, Rasmussen TE . Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort. J Vasc Surg. 2019; 70(1):224–232. doi: 10.1016/j.jvs.2018.11.024. Epub 2019 Feb 18. PubMed [citation] PMID: 30786987.


    Wahlgren CM, Riddez L. Penetrating vascular trauma of the upper and lower limbs. Curr Trauma Rep. (2016); 2 :11–20. https://doi.org/10.1007/s40719‐016‐0035‐1.


  6. A patient presents to the emergency department with a shotgun injury to the left upper extremity. There is grossly devitalized soft tissue around the humerus, without active hemorrhage. The radial pulse is palpable, but clearly diminished when compared to the contralateral arm. What is the most appropriate imaging for accurate diagnosis of presumed vascular injury in this extremity?

    1. Conventional angiography
    2. Duplex ultrasound
    3. CT angiogram
    4. Wrist‐to‐brachial index measurement
    5. Pulse volume recording (PVR)

    Arteriogram proves helpful in the setting of shotgun injuries and may offer better diagnostic capability than CTA. Although CT angiogram will likely be performed initially in most trauma centers, the imaging will often be negatively impacted by image artifact from the numerous bullet particles near the injury in question. Duplex ultrasound will not show the extent of vessel and tissue injury in this setting. Wrist‐to‐brachial index and PVRs will not give the detail needed to identify and repair focal vessel lesions, especially in the setting of a devastating trauma such as this. Shotgun injuries, particularly at close range, are more devastating than other low‐velocity gunshot wounds. These patients will typically require more operations, and plastic surgery reconstruction may be warranted. Vascular injury from shotgun blasts may be direct, from bullet particles, or indirect, from nearby blast effect. Patients typically have injuries involving arteries, veins, bones and nerves of the affected limb.


    Answer: A


    Aydın H, Okçu O, Dural K, Sakıncı U . Management of community‐based shotgun injuries of the extremities: impact of emergent vascular repair without angiography. Ulus Travma Acil Cerrahi Derg. 2011; 17(2):152–158.


    Dozier KC, Miranda MA, Kwan RO, Cureton EL, Sadjadi J, Victorino GP . Despite the increasing use of nonoperative management of firearm trauma, shotgun injuries still require aggressive operative management. J Surg Res. 2009; 156(1):173–176. doi: 10.1016/j.jss.2009.04.019.


    Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, Skarupa D, Frykberg E, Eastern Association for the Surgery of Trauma. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 Suppl 4):S315–S320. doi: 10.1097/TA.0b013e31827018e4. PubMed [citation] PMID: 23114487.


    Kauvar DS, Kraiss LW. Vascular Trauma: Extremity. Rutherford’s Vascular Surgery and Endovascular Therapy

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Peripheral Vascular Trauma

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