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), 10–15 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 >30–35 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 7–10 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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to be comprehensive or to offer a defined standard of care. The user agrees to release and indemnify the American College of Surgeons from
claims arising from use of the publication.

©1989 American College of Surgeons