AAST - WSES Guidelines On Diagnosis and Management of Peripheral Vascular Injuries

Journal of Trauma and Acute Care Surgery, Publish Ahead of Print
DOI: 10.1097/TA.0000000000002967
AAST - WSES Guidelines on Diagnosis and Management of Peripheral
Vascular Injuries
Leslie Kobayashi, MD1, Raul Coimbra, MD, PhD2, Adenauer M. O. Goes Jr., MD, PhD3,
Viktor Reva, MD4, Jarrett Santorelli, MD1, Ernest E. Moore, MD5, Joseph Galante, MD6,
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Fikri Abu-Zidan, MD7, Andrew B. Peitzman, MD8, Carlos Ordonez, MD9,
Ronald V. Maier, MD10, Salomone Di Saverio, MD11, Rao Ivatury, MD12,
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Nicola De Angelis, MD13, Thomas Scalea, MD14, Fausto Catena, MD15,
Andrew Kirkpatrick, MD16, Vladimir Khokha, MD17, Neil Parry, MD18,
Ian Civil, BSc, MBChB19, Ari Leppaniemi, MD20, Mircea Chirica, MD21,
Emmanouil Pikoulis, MD22, Gustavo P. Fraga, MD23, Massimo Chiarugi, MD24,

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Dimitrios Damaskos, MD25, Enrico Cicuttin, MD26, Marco Ceresoli, MD27,
Belinda De Simone, MD28, Felipe Vega-Rivera, MD29, Massimo Sartelli, MD20,
Walt Biffl, MD31, Luca Ansaloni, MD32, Dieter G. Weber, MBBS33, Federico Coccolini, MD24
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Leslie Kobayashi and Raul Coimbra Contribute equally for the manuscript
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Corresponding Author:
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Raul Coimbra, MD, PhD, FACS
Riverside University Health System Medical Center
Comparative Effectiveness and Clinical Outcomes Research Center - CECORC
26520 Cactus Avenue, Moreno Valley, CA 92555
Phone: 1-858-337-5756
raulcoimbra62@yahoo.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Conflict of interest: All authors declare no source of funding or conflict of interest related to
this manuscript.
Disclosures of Funding: None
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Authors’ Detail:
1 Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of
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California San Diego, San Diego, California, USA
2 Riverside University Health System Medical Center and Loma Linda University School of
Medicine. Comparative Effectiveness and Clinical Outcomes Research Center. Riverside,
California, USA
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3 Vascular and Trauma Surgery- Universidade Federal do Pará/Centro Universitário do Estado

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do Pará; Belém-PA Brazil
4 Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian

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Federation
5 Ernest E. Moore Shock Trauma Center at Denver Health. Department of Surgery, University of
Colorado, Denver, Colorado, USA
6 Division Chief Trauma and Acute Care Surgery, Department of Surgery. University of
California Davis, Sacramento, California, USA

7 Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain,
United Arab Emirates
8 Division of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh
School of Medicine, Pittsburg, Pennsylvania, USA
9 Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili,
Cali - Universidad del Valle, Cali, Colombia
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10 Department of Surgery, University of Washington, Seattle, Washington, USA
11 Department of Surgery, University Hospital of Varese, University of Insubria, Italy
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12 Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University
Richmond, Virginia, USA
13 Unit of Digestive and HPB Surgery, CARE Department. Henri Mondor University Hospital
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(AP-HP) and Faculty of Medicine, University of Paris Est, UPEC , Creteil, France
14 R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
15 Emergency Surgery Department, Parma University Hospital, Parma, Italy
16 Department of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta,
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Canada
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17 Department of Emergency Surgery, City Hospital, Mozyr, Belarus
18 Departments of Surgery and Medicine, Schulich School of Medicine & Dentistry, Western
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University London Health Sciences Centre, London, Ontario, Canada
19 Trauma Services, Auckland City Hospital. Professor of Surgery, Faculty of Medical and
Health Sciences, University of Auckland, Auckland, New Zealand
20 Abdominal Center, Department of Surgery, University Hospital Meilahti, Helsinki, Finland
21 Department of Digestive Surgery, Grenoble University Hospital, Grenoble, France

22 3rd Department of Surgery, Attikon General Hospital, National & Kapodistrian University of
Athens, Greece
23 Division of Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas,
Campinas, Brazil
24 General, Emergency Surgery, and Trauma Center, University of Pisa, Pisa, Italy
25 Department of General and Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh,
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United Kingdom
26 Dipartimento di Scienze Clinico Chirurgiche, Diagnostiche e Pediatriche; University of Pavia,
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Pavia, Italy
27 General and Emergency Surgery Department. Milano-Bicocca University, School of
Medicine and Surgery, Monza, Italy

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28 Service de Chirurgie Generale, Digestive, Metabolique Centre Hospitalier de Poissy/St
Germain en Laye, France
29 Universidad Nacional Autónoma de México, Curso Universitario Posgrado de Cirugía,
Departamento de Cirugía, Hospital Angeles Lomas, Mexico

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30 Department of Surgery, Macerata Hospital (ASUR Marche), Macerata, Italy

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31 Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA
32 General Surgery Department, Bufalini Hospital, Cesena, Italy

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33 Trauma Service, Department of General Surgery, Royal Perth Hospital, The University of
Western Australia

Authors’ e-mail address:
Leslie Kobayashi MD - lkobayashi@health.ucsd.edu
Raul Coimbra MD PhD - raulcoimbra62@yahoo.com
Adenauer Goes Jr. MD - adenauerjunior@gmail.com
Viktor Reva MD - vreva@mail.ru
Jarrett Santorelli MD - jsantorelli@health.ucsd.edu
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Ernest E. Moore MD - Ernest.Moore@dhhd.org
Joseph Galante MD - jmgalante@ucdavis.edu
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Fikri Abu-Zidan MD – fabuzidan@uaeu.ac.ae
Andrew B. Peitzman MD – peitzmanab@upmc.edu
Carlos A. Ordonez MD – ordonezcarlosa@gmail.com

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Ronald V. Maier MD – ronmaier@uw.edu
Salomone Di Saverio MD – salo75@inwind.it
Rao Ivatury MD – raoivatury@gmail.com
Nicola De Angelis MD – nic.deangelis@yahoo.it

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Thomas Scalea MD – tscalea@som.umaryland.edu
Fausto Catena MD – faustocatena@gmail.com

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Andrew Kirkpatrick MD – andrewkirkpatrck@albertahealthservices.ca

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Vladimir Khokha MD – vladimirkhokha@gmail.com
Neil Parry MD – neil.parry@lhsc.on.ca
Ian Civil BSc, MBChB – icivil@xtra.co.nz
Ari Leppaniemi MD – Ari.Leppaniemi@hus.fi
Mircea Chirica MD – mirceaxx@yahoo.com

Emmanouil Pikoulis MD – mpikoul@med.uoa.gr
Gustavo P. Fraga MD – fragagp2008@gmail.com
Massimo Chiarugi MD – massimo.chiarugi@gmail.com
Dimitrios Damaskos MD – Dimitrius.Damaskos@nhslothian.scot.nhs.uk
Enrico Cicuttin MD – enrico.cqtn@gmail.com
Marco Ceresoli MD – marco.ceresoli89@gmail.com
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Belinda De Simone MD – desimone.belinda@gmail.com
Felipe Vega-Rivera MD – laparoscopia.y.trauma@gmail.com
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Massimo Sartelli MD – massimosartelli@gmail.com
Walter Biffl MD – Biffl.Walter@scrippshealth.org
Luca Ansaloni MD – luca.ansaloni@auslromagna.it

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Dieter G. Weber MBBS – dietergweber@gmail.com
Federico Coccolini MD – federico.coccolini@gmail.com

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ABSTRACT:
The peripheral arteries and veins of the extremities are among the most commonly injured
vessels in both civilian and military vascular trauma. Blunt causes are more frequent than
penetrating except during military conflicts and in certain geographic areas. Physical exam and
simple bedside investigations of pulse pressures are key in early identification of these injuries.
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In stable patients with equivocal physical exams, computed tomography angiograms have
become the mainstay of screening and diagnosis. Immediate open surgical repair remains the
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first line therapy in most patients. However, advances in endovascular therapies and more
widespread availability of this technology have resulted in an increase in the range of injuries
and frequency of utilization of minimally invasive treatments for vascular injuries in stable
patients. Prevention of and early detection and treatment of compartment syndrome remain
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essential in the recovery of patients with significant peripheral vascular injuries. The decision to
perform amputation in patients with mangled extremities remains difficult with few clear
indicators. The American Association for the Surgery of Trauma (AAST) in conjunction with the
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World Society of Emergency Surgery (WSES) seek to summarize the literature to date and
provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries.
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Level of Evidence: Level IV

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Keywords: extremity vascular, femoral artery, popliteal artery, tibial artery, peroneal artery,
brachial artery, radial artery, ulnar artery, operative, non-operative, guidelines, endovascular
repair, shunt, stent, ligation, vascular reconstruction, graft, bypass, amputation, fasciotomy,
anticoagulation, antiplatelet agents.

Abbreviations: World Society of Emergency Surgery (WSES); American Association for the Surgery of
Trauma (AAST); Vascular trauma (VT); Level of evidence (LE); National Trauma Data Bank (NTDB):
intensive care unit (ICU); Arterial injury (AI): Pseudoaneurysm (PSA); National Association of
Emergency Medical Technicians (NAEMT): Committee on Tactical Combat Casualty Care (CoTCCC);
Pre-hospital Trauma Life Support (PHTLS); Advanced Trauma Life Support (ATLS); Western Trauma
Association (WTA); Eastern Association for the Surgery of Trauma (EAST); Peripheral Vascular Injuries
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(PVI); Non-Operative management (NOM); Organ Injury Severity (OIS); Upper extremity arterial
injuries (UEAIs); Lower extremity arterial injury (LEAI) ; Superficial femoral arteries (SFA) ; Common
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femoral artery (CFA) ; Posterior tibial artery (PTA); Anterior tibial artery (ATA); Injury Severity Score
(ISS); Glasgow Coma Scale (GCS); Ankle brachial index (ABI); Arterial pressure index (API);
Computed tomography angiography (CTA); Physical examination (PEX); Arterio-venous fistulas (AVF);
False-negative results (FNR); Doppler ultrasonography (DUS); Magnetic resonance image (MRI);
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Magnetic resonance angiography (MRA); Near-infrared spectroscopy (NIRS); Mangled extremity
severity score (MESS); American College of Surgeons Committee on Trauma (ACS-COT); American
College of Emergency Physicians (ACEP); Temporary intravascular shunt (TIVS); Hours (h);
Polytetrafluoroethylene (PTFE); Grade of recommendation (GoR)

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Introduction and Background
Vascular trauma (VT) is relatively uncommon in the civilian setting but is increasingly
common in combat casualties (1-9). Vascular trauma of the extremities in particular has
increased as a source of morbidity and mortality in combat likely due to the increased utilization
and efficacy of body armor (8-11). Patients of all ages and genders are at risk for VT. However,
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it is less common among the elderly, children, and women (1, 2, 4, 5, 12-14). Blunt trauma is the
most common cause of VT among children and in most civilian trauma series with the exception
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of certain geographic areas (1, 3, 4, 12, 13, 15, 16).
Vascular injuries are unevenly distributed between body regions and many patients have
injured more than one vessel. Injuries occur in the thorax (25%) and abdomen/pelvis (25%),
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upper (25%) and lower extremities (20%) and less frequently in the neck (10%) (4). Among
military casualties, extremity injuries account for 70% or more of VTs with the lower extremity
as the most prevalent anatomic location (45-65%) (6, 9, 10, 17-19). Soft tissue destruction and
fractures are common in patients with extremity VT. Arterial injuries (AI) are diagnosed more
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often than venous injuries, however, combined arteriovenous injuries can occur and are three
times more frequent in military (55%) than civilian practice (18%) (2, 13). Among AIs, complete
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or partial transections account for half of the cases, while complete occlusion, pseudoaneurysm
(PSA) and other types of injuries occur less frequently (12). When they do occur, arteriovenous
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combined injures are associated with higher morbidity, particularly compartment syndrome and
mortality (20-28).

Prompt pre-hospital hemorrhage control, reduced pre-hospital transport times, timely
diagnosis and treatment along with adequate resuscitation remain crucial for better outcomes. A
paradigm shift in pre-hospital hemorrhage control has occurred during the last decade due to
extensive life-saving tourniquet applications and use of local hemostatic agents. Even in civilian
practice, every fifth patient with suspected VT received pre-hospital tourniquet application (12).
Aggressive hemorrhage control has led to significant improvements in mortality confirmed by
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many civilian and military studies. These achievements were summarized by the corresponding
societies National Association of Emergency Medical Technicians (NAEMT) and Committee on
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Tactical Combat Casualty Care (CoTCCC)) and established in Pre-hospital Trauma Life Support
(PHTLS) and Tactical Combat Casualty Care Protocols and Guidelines (29-31).
The Advanced Trauma Life Support (ATLS) protocols should be followed in the initial
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management of VT. Damage control resuscitation and surgical approaches should be utilized
early for patients presenting with hemorrhagic shock. Diagnostic and treatment strategies vary
depending on anatomic region of VT, associated injuries and physiological status of the patient.
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Initial diagnosis and treatment of VT have been the subject of debate over time and has been
addressed in several evidence-based guidelines. In 2011 and 2013, the Western Trauma
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Association (WTA) published two parts (Part I – Evaluation, Part II – Management) of a position
article detailing treatment of peripheral vascular injuries (32, 33). In 2012, the Eastern
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Association for the Surgery of Trauma (EAST) published the practice management guidelines
for penetrating lower extremity arterial trauma (34). In 2015, the WSES published a position
paper on vascular emergency surgery (35). The purpose of this document is to provide the
AAST-WSES recommendations for diagnosis and management of peripheral vascular injuries.
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Notes on the use of the guidelines
The guidelines are evidence-based, with the grade of recommendation based on the
evidence. The practice guidelines promulgated in this work do not represent a standard of
practice. They are suggested plans of care, based on best available evidence and the consensus of
experts, but do not exclude other approaches as being within the standard of practice. For
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example, they should not be used to compel adherence to a given method of medical
management, which method should be finally determined after taking account of the conditions
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at the relevant medical institution (staff levels, experience, equipment, etc.) and the
characteristics of the individual patient. However, responsibility for the results of treatment rests
with those who are directly engaged therein, and not with the consensus group.
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Methods
A computerized search was done by a bibliographer in different databanks (MEDLINE,
Scopus, EMBASE). Citations were included for the period between January 2007 and January
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2020 using the primary search strategy: trauma, blunt, penetrating, blood vessel, vascular injury,
extremity, femoral artery, popliteal artery, tibial artery, peroneal artery, brachial artery, radial
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artery, ulnar artery, amputation, fasciotomy, mangled extremity, classification, guidelines, injury,
surgery, diagnosis, operative, non-operative, shunting, shunt, endovascular management,

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anticoagulant, antiplatelet, combined with AND/OR. No search restrictions were imposed. The
dates were selected to allow comprehensive published abstracts of clinical trials, consensus
conference, comparative studies, congresses, guidelines, government publication, multicenter
studies, systematic reviews, meta-analysis, large case series, original articles, and randomized
controlled trials. Selected older articles felt to be landmark papers in the field were also included.
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The Level of evidence (LE) was evaluated using a modified form of the GRADE system (Table
1) (36). A group of experts in the field coordinated by a central coordinator was contacted to
express their evidence-based opinion on several issues about vascular trauma. The central
coordinator assembled the different answers derived from a round of discussion and created,
based on the evidence available, a set of recommendations. The recommendations were then
submitted for comments multiple times using an online modified Delphi process, until complete
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consensus was achieved. The definitive version reported herein represents the position of the
expert group from both the AAST and the WSES.
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Epidemiology of Peripheral Vascular Injuries (PVI)
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Extremity PVIs account for 45-80% of all VTs representing the majority of emergency
vascular cases in civilian trauma centers, community hospitals, and medical treatment facilities
in war zones (2-4, 9, 11-13, 37). In general, lower extremities are injured more often than upper
extremities in adults; this discrepancy is most dramatic among military cohorts (2, 4, 6, 9, 12-14,
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18, 38, 39). Conversely, a larger proportion of upper extremity vascular injuries have been
reported among pediatric populations (1, 15, 40, 41).

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Mechanism of injury varies by country or region. In many countries, especially in Europe

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and Asia, blunt mechanisms predominate in both adults and children (14, 15, 42-45). Among
adult penetrating injuries, GSW and SW account for the majority of VT cases in civilian practice
(23, 37, 40, 46-49). In children <6 years old, falls and road traffic accidents are the most
common causes of blunt trauma, while glass cuts are the most common cause of penetrating
injuries (48, 50).
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PVIs are graded by vessel in accordance with the AAST Organ Injury Scale (OIS)
grading of peripheral vascular injury (Table 2) and can be occlusive or non-occlusive depending
on vascular patency. Non-occlusive injuries are presented as an intimal irregularity/tear (Grade I:
<25% narrowing), dissection/intramural hematoma (Grade II: ≥25% narrowing) or partial
transection with PSA formation (Grade III). Occlusive injuries include thrombotic occlusion
(Grade IV: vessel wall is preserved) or complete transection (Grade V).
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Two-thirds of upper extremity arterial injuries (UEAIs) are distal (radial and ulnar
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arteries) and one-third are proximal (primarily brachial artery) (51). A NTDB analysis
demonstrated the most common lower extremity arterial injury (LEAI) to be the popliteal
(35.5%) and superficial femoral arteries (SFA) (27.8%), followed by the common femoral artery
(CFA) (18.4%), the posterior tibial artery (PTA) (12.6%), and the anterior tibial artery (ATA)
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(8.6%) (28). The femoral artery is also the most frequently injured vessel in combat (11, 52-54).
Delayed diagnosis and inappropriate treatment of injuries in the femoropopliteal arterial segment
can lead to devastating results. Post-mortem analysis has revealed that femoral artery and vein
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injuries account for the majority of patients deaths due to PVIs (55). The extent of blood loss and
rates of hemodynamic instability upon admission are higher in more proximal arterial injuries,
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which also have a larger proportion of severe associated injuries (49).
Approximately 12% of patients with LEAIs and 14% of patients with UEAIs have
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multiple arterial injuries (51, 56, 57). Concomitant vein and nerve injury are present in every
fourth and tenth LEAI patient, respectively (28, 58, 59). In children, UEAIs are frequently
associated with nerve injuries (1, 40, 50). Every fourth or fifth patent with UEAI or LEAI has an
associated orthopedic injury (28, 51, 56). In pediatric patients, isolated VT is more common, and
thus, children have less severe injuries compared to adults (1).
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Lower and upper extremity VT present differently due to morphological differences, e.g.
larger vessels, larger muscles, fewer collaterals, tighter compartments in the legs. Hemorrhage
from LEAI is more difficult to control, and patients are more critically ill upon hospital
admission, have higher Injury Severity Score (ISS) and lower Glasgow Coma Scale (GCS)
scores, and have significantly higher perioperative complication rates, including the need for
major limb amputation compared to patients with UEAIs (7.8% vs 1.3%) (20).
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Clinical Presentation and Diagnosis of PVI
 A structured physical examination is mandatory in the diagnostic work-up of an injured
extremity. Patients with “hard” and “soft” signs of PVI should be evaluated without delay.
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(Grade if recommendation [GoR 1B])
 Patients with hard signs of PVI should be transported directly to the operating room for
surgical exploration. Where available, patients with multi-level penetrating injuries and
those with blunt PVI may benefit from use of a hybrid operating room with the ability to
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perform on table angiography for both diagnostic and therapeutic purposes. When not
available C-arm can be used for on table angiography to augment surgical exploration and
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repair. (GoR 1B)
 Hemodynamically unstable patients with soft signs of PVI should be transported to the
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operating room, with or without endovascular capability, for resuscitation and appropriate
evaluation / intervention. (GoR 2B)
 Presence of peripheral pulses alone cannot reliably exclude arterial injury (AI). For
hemodynamically stable patients with concerning mechanism, proximity injury, or soft signs
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of PVI additional evaluation with ankle brachial index (ABI) or arterial pressure index (API)
measurements is required. (GoR 1B)
 ABI/API are effective screening methods for detecting major AI; an ABI/API
of >0.9 generally excludes the need for additional imaging. (GoR 1B)
 Patients with knee dislocations are at higher risk of occult popliteal artery injury. Normal
distal pulse upon physical examination does not exclude popliteal artery injury. Additional
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imaging including formal or computed tomography angiography (CTA) may be beneficial.
(GoR 2B)
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 CTA is recommended as the first line modality for investigating blunt and penetrating PVIs
in adults and children who are hemodynamically stable without active bleeding. (GoR 1B)
 Invasive catheter angiography should be reserved for patients in need of interventional

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procedures, if vasospasm is clinically suspected, or when CTA is unavailable, equivocal or
non-diagnostic due to artifact from retained metallic objects. (GoR 1B)
 Patients with penetrating extremity trauma (having no other injuries) who present with
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normal physical examination and normal ABI/API, may be safely discharged. (GoR 1B)
These patients, however, should be followed-up in an outpatient setting due to the risk of
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delayed pseudoaneurysm.
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PVIs represent two main threats: exsanguination and limb ischemia. Early recognition
followed by adequate and prompt treatment are critical for good outcomes. According to the
PHTLS/CoTCCC/ATLS protocols, hemorrhage should be temporarily addressed by direct
pressure followed by dressing, elastic bandage, local hemostatic agent or tourniquet application.
In-hospital, initial evaluation begins with primary survey using ATLS protocol followed by
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secondary survey and necessary radiographic evaluation of the injured limb, if indicated. On
admission, trauma patients may present with either spontaneously or medically controlled
hemorrhage. In such a scenario, history of pre-hospital blood loss or hypotension and the
presence of a tourniquet are especially important for further diagnosis and treatment strategy.
The patient’s hemodynamic status on arrival is important not only for complex assessment
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of limb salvageability, but also for defining treatment strategy and predicting outcomes.
Hemodynamically unstable patients (pediatric systolic blood pressure < [70 + 2 x age], adults
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systolic blood pressure <90, geriatric patients systolic blood pressure <100) suspected of PVI
should be taken immediately to the operating room for emergency exploration (60-62). In stable
patients structured physical examination (PEX) is critical for the primary evaluation of extremity
trauma in civilian and military practice. Although important, pulse evaluation is physician-
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dependent and cannot be the only investigation to diagnose PVI. Assessment of limb perfusion is
more important than pulse examination for outcome prediction. Limb perfusion is evaluated by
assessment of such markers of ischemia as pain, skin temperature and color, sensory and motor
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dysfunction, capillary refill evaluation in comparison to an uninjured limb. Abnormalities of
these markers, typically diagnosed as “six P’s”: pain, pallor, poikilothermia, pulselessness,
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paresthesia, and paralysis, indicate a certain degree of ischemia. PEX findings can be classified
into no signs, “soft” signs”, or “hard” signs. Although slight variations exist among guidelines
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and publications, there is a certain agreement on definitions of the “hard” and “soft” signs which
are summarized in Table 3 (32, 34, 63). Hard, soft and no signs of PVI were encountered in
5.5%, 11.5%, and 83% of 635 patients with extremity injury respectively (64).
Some studies confirm that PEX alone is reliable enough for exclusion of VT with overall
sensitivity and specificity for surgically significant injury of 92% and 95%, respectively (65-68).
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A systematic review and meta-analysis evaluating the accuracy of PEX in the diagnosis of
penetrating arterial injury (AI), found that when used in combination with normal ankle brachial
index (ABI), a normal PEX (no hard or soft signs) resulted in zero probability of AI (68). This
was confirmed by another large retrospective cohort study of penetrating PVIs showing that PEX
and ABI reliably excluded AIs and no angiography was required (69). Thus, patients with
completely normal PEX without any signs of VT and normal ABI, particularly after penetrating
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injuries, can safely be discharged in the absence of associated injuries. Unfortunately, sensitivity
and specificity of PEX is lower in blunt compared to penetrating PVI (67, 70). In a meta-analysis
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of 284 AIs caused by knee dislocations, it was demonstrated that abnormal pulse examination
had a sensitivity and a specificity in detection of AI of 79% and 91%, respectively, and PPV and
NPV of 75% and 93% (71). Because of the lack of sensitivity, particularly for detection of
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popliteal artery injury following knee dislocation, post-reduction imaging is recommended to
reliably exclude popliteal artery injury (26, 56, 58, 64, 71-74).
Hard signs of PVI are overt and reliably define major AI, while soft signs merely raise the
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index of suspicion for possible PVI. Loss of pulses and active bleeding are the most frequent
hard signs of AI found during PEX followed by expanding hematoma (38, 60, 66, 75). Nearly
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100% of patients (with rare exceptions), who present with hard signs on admission have a
confirmed major PVI (51, 62, 64, 66, 69, 75). Patients who present with hard signs on initial
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examination, should immediately undergo surgical exploration without being submitted to
radiological investigation; an exception to this rule is when the patient presents with multilevel
trauma to an extremity (e.g., a shotgun injury or an extremity with multiple fractures, or multiple
GSWs or SWs). In those cases, the level of AI may be uncertain, and contrast imaging may be
needed to define surgical planning. These cases may particularly benefit from the utilization of a
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hybrid operating room with angiographic capabilities where both diagnostic angiography and
open and endovascular intervention can be performed (76-80).
Compared to hard signs, soft signs are more subjective, and not all soft signs represent an
equal risk of injury. Proximity, defined as any penetrating wound in which the path of the
penetrating agent could potentially cross the normal anatomic position of a vascular bundle, is
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the most controversial soft sign having poor value in the diagnosis of VT (63, 81). Inaba et al.
found no patients with PVI who had a negative PEX on admission and proximity wounds to
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arteries who underwent CTA (64). In a cohort study of patients with 220 penetrating lower
extremity injuries (92% GSWs) presenting with normal PEX, 169 patients had proximity
injuries, and eight of them (5%) had a confirmed acute venous injury in the form of deep venous
thrombosis (DVT) and only two had arterio-venous fistulas (AVF) (81). Other soft signs have an
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important role in raising a high index of suspicion for VT and their presence warrants additional
imaging to reliably exclude or confirm an injury (17, 49, 51, 56, 57, 62-64, 68, 81, 82).
Nonexpanding and nonpulsatile hematoma is the most often encountered soft sign in PVI (35%),
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followed by diminished pulse and external bleeding (20% each) (64). Some reports have
estimated the risk of an AI to be as low as 3% if a single soft sign is detected, but it can reach as
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high as 25% if multiple soft signs are present (77).
For patients with soft signs of VT and without indication for immediate surgery,
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assessment of ankle brachial index (ABI) or arterial pressure index (API) in addition to formal
PEX were of high value to exclude AI (68, 70, 83). The ABI is the ratio of the blood pressure
(BP) at the ankle (defined by a Doppler device) to the BP in the arm. Similarly, the API is
calculated as the BP in injured limb divided by the BP in the corresponding uninjured limb. The
API cut-off value has been traditionally established as <0.9 (70, 76, 77, 84). In case of associated
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orthopedic injuries, traction to the extremity and limb realignment is recommended before
measuring the API to avoid false-negative results (FNR) (76). Both the ABI and the API have
limitations. These indices are focused on major arteries, but injuries to the profunda brachii,
profunda femoris, or peroneal arteries are not detected because no direct flow from these arteries
is measured distally; minor luminal injuries (that do not affect flow) such as small intimal flaps
may not be detected. The indices do not detect venous injuries and are also less sensitive in
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hypotensive and/or hypothermic patients, hence should be used with caution in those patients
(76). Given the reliability of PEX, ABI, and API in determining risk of PVI, these quick clinical
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tests should be undertaken as soon as possible to identify signs of PVI, and thus to determine
whether further imaging and treatment is required (Figure 1).
When concerning soft signs of injury are present or abnormal ABI and/or API
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measurements are encountered, several imaging modalities are available to diagnose PVI:
conventional angiography, Doppler ultrasonography (DUS), computed tomographic angiography
(CTA), magnetic resonance image (MRI) / magnetic resonance angiography (MRA) (76, 77, 81,
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82, 85-96). Continuous monitoring of bilateral limbs with near-infrared spectroscopy (NIRS) has
recently been proposed for detecting changes in limb perfusion but its role in primary evaluation
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and diagnosis of VT is not yet well defined (97).
Doppler US continues to have a role in screening for occult vascular injuries, but the
A
experience and time needed to assess for PVI can be a limitation in the acute trauma setting (92,
93). For extremity trauma, the “FAST” Doppler protocol (focused goal-directed Doppler
procedure) has been proposed as a triage tool for both pre- and in-hospital settings (90).
However, this protocol cannot differentiate whether the pathologic flow is caused by an acute or
19

a chronic lesion. Thus, in positive cases (presenting absent, monophasic or biphasic waveforms
at dorsalis pedis/fibular arteries) further immediate imaging evaluation is required (90).
CTA has emerged as an important and reliable tool in the diagnosis of PVI. CTA
sensitivity and specificity in identifying PVI exceeds 90% in many studies (64, 87, 88, 94, 98-
105). CTA has been shown to effectively detect injuries to small vessels in adults and children
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(99, 104, 106). Another advantage of CTA is the display of vascular injuries in the context of the
surrounding tissues, especially the relationship to bones. The CTA generates, in comparison to
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subtraction angiography, multi-purpose images that require post processing to reduce the
provided information to the targeted structure, i.e. vessels. Axial and multi-planar reformatted
images are usually accompanied by maximum intensity projections and a form of 3-dimensional
volume rendering. The goal of these additional methods is to provide overviews of the
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vasculature that are partially comparable to angiography (93). Institutional protocols for
performing CTA should be observed with 64-slice multi-detector scanner preferably used
(minimum 16 slices) (77).

C
For upper extremity CTA, a venous access should preferably be placed in the non-injured
arm and, ideally, the injured extremity should be raised above the head, decreasing beam-
C
hardening artifact from the torso. For a lower extremity CTA, legs should be secured to the table
and both limbs are to be included in the field of view, since the inclusion of the contralateral
A
extremity may be useful as a reference during interpretation of findings in the injured side (77,
107). CTA angiographic signs of injury can be classified into direct or indirect. Direct signs
relate to the vessel wall and often indicate significant VT that may require either surgical or
endovascular repair, and include occlusion, thrombosis, intimal dissection, spasm, external
compression, PSA, active arterial hemorrhage, and AVF. Indirect signs represent findings within
20

the perivascular soft tissues such as perivascular hematoma, a projectile tract near a
neurovascular bundle, and shrapnel in a distance of <5 mm from a vessel. The presence of
indirect signs secondary to vascular trauma should raise suspicion for an occult injury (91, 102,
105, 107). Sensitivity and specificity are consistently high in most modern series, thus defining
CTA as the primary imaging tool for the assessment of PVI in the daily trauma center routine
(93, 95).
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Prior to the wide adoption of CTA for diagnosis of VT conventional angiography
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represented the gold standard for diagnosis. Despite the many advantages of CTA, it continues
to have its limitations. CTA may become non diagnostic with poor timing of contrast material
injection, which may be seen in multi-trauma patients with circulatory compromise or multi-
level VT. Additionally, the presence of artifacts caused by metal fragments related to ballistic
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injury cause streaks that make the vessel in question difficult to evaluate. In such patients the
use of traditional or on table angiography with digital subtraction angiography (DSA) may prove
helpful in making a definitive diagnosis. Additionally, in patients with polytrauma, time to

C
diagnosis may be reduced with early operative intervention in a hybrid suite allowing for
simultaneous operative and diagnostic evaluation on multiple regions of injury (78-80, 108, 109).
C
The role of MRI and MRA, in the setting of acute trauma is limited due to the practicalities
of trauma patients in a MR scanner. In addition, a patient suffering from penetrating trauma may
A
have retained metal fragments, which are non-compatible with MRI and may result in artifacts
(91-93).
21

Treatment of PVI
NOM of PVI
 NOM can be considered in selected stable patients with AAST Grade 1 and 2 injuries
without active hemorrhage or signs of distal ischemia. (GoR 2C)
 NOM can also be considered for isolated AAST Grade 3 tibial and peroneal injuries
D
where either the anterior or posterior tibial artery remains intact and there is no active
hemorrhage or distal ischemia. (GoR 2C)
TE
Surgical dogma has long dictated that all VTs require operative intervention. Recently, a
prospective registry was formed capturing trauma related VTs. Within the report it was seen that
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injuries were initially treated with a variety of modalities, including NOM in 50.9% of cases
(12). A review of the literature lacks significant data on what injuries may safely undergo NOM.
A report by Dennis et al first questioned this paradigm after observing patients with penetrating
VT identified on angiography without clinically significant findings. The patients underwent an

C
average of 9 years of follow up with only 9% developing clinical deterioration requiring surgical
C
intervention (110). In 2009, Franz et al proposed that non-occlusive AIs may undergo an initial
period of observation (57). In 2011, Franz proposed that non-occlusive injuries may be
A
definitively managed non-operatively based on 4 criteria: <5mm intimal disruption, adherent
intimal flaps, intact distal circulation, and no active hemorrhage (56). A third report by Franz et
al in 2012 reported successful management of five AIs using the previously proposed criteria
(51). Additionally, Burkhardt et al demonstrated that a majority of patients (83%) with single
vessel tibial-level AIs in whom limb salvage was pursued could be managed without arterial
22

reconstruction (25). While there is not enough data to recommend NOM of proximal arterial
PVI, it appears branch vessels, single forearm vessels, and single tibial-level vessels may be
candidates for a trial of NOM. These patients should be monitored closely and any change in
clinical exam should be followed by immediate repeat imaging, endovascular, or operative
intervention (Figure 1). For the purposes of these guidelines we consider any endovascular
intervention to be a part of operative management. The decision to group both open and
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endovascular therapies into “operative” management was made for several reasons. First, many
trauma and vascular surgeons perform diagnostic and therapeutic angiography in interventional
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suites, in hybrid operating rooms, and in traditional operating rooms with the use of portable C-
arms. Second, even when performed by interventional radiologists, endovascular intervention
should be guided by the surgeon primarily responsible for the trauma patient. Lastly many
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sequelae and complications of endovascular therapy, as well as the failure of endovascular
management of ischemic or bleeding injuries must be treated with surgical repair and are best
identified and addressed by surgeons.

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Operative Management of PVI

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 In the presence of external hemorrhage, the use of direct pressure and tourniquets is
recommended in the prehospital setting. (GoR 1C)

A
 Isolated radial or ulnar arterial injuries without evidence of distal ischemia can be
managed with simple ligation. (GoR 2C)
 Isolated infrageniculate arterial injury where either the anterior or posterior tibial artery
is intact and there is no distal ischemia can be managed with simple ligation, unless there
is extensive soft tissue injury. (GoR 2C)
23

 Proximal and distal thrombectomy should be done with a Fogarty catheter for major
arterial injuries and the proximal and distal segments should be flushed with heparinized
saline. (GoR 1B)
 For AAST Grade 4-5 injuries tension free end to end primary repair is the procedure of
choice. (GoR 1C)
 Where primary repair is not technically possible, resection and interposition graft should
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be performed. When performing arterial reconstruction autologous saphenous vein is the
conduit of choice. (GoR 1C)
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 For complex injuries, injuries with significant ischemic time, and in damage control
situations intravascular shunts should be used to rapidly restore perfusion and bridge to
definitive repair. (GoR 2C)

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 Peripheral venous injuries should be repaired, if possible, to reduce the risk of
amputation and venous insufficiency. (GoR 2C)
 In unstable patients and in those with destructive venous injuries not amenable to repair,
C
ligation of peripheral veins is acceptable, but prophylactic fasciotomy or serial
monitoring of compartment pressures should be considered particularly in combined

C
arteriovenous injuries due to the high risk for compartment syndrome. (GoR 2C)
 Primary amputation may be considered in the unstable patient with a mangled extremity
A
(MESS>7) if presentation is significantly delayed (i.e. prolonged ischemic time with no
sensation or motor activity), and in injuries with irreparable soft tissue damage leading
to a functionally non-viable extremity. Optimally, this decision should be made by a
multidisciplinary team.(GoR 2C)
24

 Endovascular repair may be considered in the management of peripheral
pseudoaneurysms, arteriovenous fistula (AVF), and other small vessel injuries diagnosed
on CTA without hard signs of vascular injury. (GoR 2C)
 There is no evidence to support the use of systemic intra-operative heparinization or
post-operative antiplatelet agents or anticoagulation after most vascular repairs. The
exception is prolonged ischemic time with small vessel occlusions. (GoR 2C)
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Pre-hospital Treatment of PVI
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The management of PVI begins prior to arrival to the trauma center. Multiple studies
have demonstrated that tourniquets are a rapid, safe, effective, and lifesaving method for
hemorrhage control (111-113). Tourniquet use in civilian trauma scenarios has been increasing
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since 2008. Previous recommendations on use vary, however recent studies have emphasized
that waiting until trauma center arrival to apply a tourniquet is associated with lower blood
pressure, increased need for plasma transfusions, a higher rate of transfusion within the first
C
hour, and greater than 4.5-fold increase in mortality Both the American College of Surgeons
Committee on Trauma (ACS-COT) and the American College of Emergency Physicians (ACEP)
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now recommend that tourniquets be used when extremity hemorrhage presents a threat to life
(114). In these cases tourniquets should be applied as soon as significant bleeding is noted or
A
suspected and application should not be delayed waiting for shock or arrival at a medical
center.(111)
Particularly challenging are cases of junctional extremity bleeding in the groin or axilla
which are not amenable to tourniquet placement. Multiple devices have been developed to deal
with these challenging injuries including wound clamps, junctional tourniquets, pelvic
25

stabilizers, and self-expanding injectable hemostatic agents. Unfortunately, the evidence to
support their use remains low in volume and poor in quality (115). Simple direct pressure applied
to the site of injury with or with addition of hemostatic agents remains the best and easiest way
to reduce bleeding from junctional injuries in the pre-hospital setting. While multiple
retrospective studies have shown efficacy of hemostatic agents over simple gauze in both
military and civilian settings, no hemostatic agent has emerged as superior (116-118).
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Additionally a recent analysis using swine models by Littlejohn et al demonstrated standard
gauze dressing was just as efficacious as Celox-A, Chitoflex, and Combat Gauze in treating
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uncontrolled hemorrhage from small penetrating wounds not amenable to tourniquet placement
(119).
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Operative management of PVI
Lower Extremity
Patients with lower extremity injury often present with significant polytrauma
C
necessitating immediate operative intervention. In general, simple non-destructive injuries are
repaired and complex injuries are either ligated or shunted. Prepping and draping should include
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the foot, bilateral groins the lower abdomen with consideration of prepping the entire abdomen
and chest if the trajectory is unclear. The contralateral extremity should be prepped and draped
A
to facilitate saphenous vein harvest should more complex reconstruction of the injured extremity
be required. Access to the femoral vessel can be obtained by a vertical groin incision generous
enough to expose the bifurcation of the superficial femoral artery (SFA) and profunda femoris.
In the case of a high common femoral artery injury, the inguinal ligament may require division
and consideration to obtaining proximal control through a hockey stick incision with
26

retroperitoneal dissection and isolation of the external iliac artery should be given (120). In a
more distal injury, exposure of the proximal SFA is again obtained through a longitudinal
incision on the medial thigh as the mid portion of the vessel is located posterior to the Sartorius
muscle, which can be retracted posteriorly to improve exposure. When approaching the popliteal
vessels, the preferred approach is external rotation of the injured leg with elevation and flexing
of the knee. The artery is in a fixed position at the adductor tendon proximally and the
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gastrocnemius distally. The incision is made medially using the posterior edge of the femur as an
anatomical landmark. It is important to avoid injury to the greater saphenous vein. Division of
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the medial head of the gastrocnemius muscle and the semimembranosus and semitendinous
tendons is often required to provide a complete view of the artery and vein. To expose the below
knee popliteal artery the incision is extended below the knee along the posterior margin of the
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tibia. Division of the soleus may be required to isolate the tibio-peroneal trunk (121).
Primary repair is the procedure of choice for isolated AIs with low velocity penetrating
wounds as long as a tension free repair can be performed. However, this is often not possible
C
with high velocity injuries and injuries due to blunt trauma. When primary repair is not an
option, a decision needs to be made at the time of the initial surgery to proceed with immediate
C
reconstruction or switch to a vascular damage control approach. Patient physiology, blood
transfusion requirements, associated injuries, and time to reperfusion should all be considered
A
when determining if damage control techniques are necessary. If a damage control approach is
necessary, temporary intravascular shunt (TIVS) can be used to achieve temporary limb
perfusion and allow delayed reconstruction. Commercially available vascular shunts come in a
variety of types; if none are available, shunts can also be constructed using a piece of plastic
tubing from a high-flow intravenous line, nasogastric tube or chest tube, all of which are
27

inexpensive and immediately available. Multiple studies have shown that initial surgery with
TIVS does not worsen outcomes compared to definitive repair at the initial operation and is
associated with similar rates of amputation free survival (52, 122). Even when damage control is
not deemed necessary, TIVS can be useful if associated bony fractures and unstable joints are
present to reduce the risk of disruption of vascular repairs during orthopedic manipulation and
repair. Once vascular control has been obtained and TIVS utilized to restore distal perfusion the
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Orthopedic team can be called to stabilize associated fractures prior to shunt removal and
definitive vascular reconstruction (44). A meta-analysis by Fowler et al described no significant
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influence on the overall amputation rate by whether the bone or vascular repair was done first in
a large multicenter retrospective review of 213 patients with TIVS placement (123).
Furthermore, dwell times were compared over 4-patient groups including <6 hours, 6h-24h, 24h-
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48h, and >48h. In these groups there was no association between dwell time and shunt
thrombosis (124).
Choice of arterial bypass graft material has remained a topic of debate. While autologous
C
saphenous vein graft remains the best choice, this is not always an option. Stone et al. found that
Polytetrafluoroethylene (PTFE) maintained structural integrity even in the face of staphylococcal

C
infection with a low incidence of anastomotic disruption (125). Several studies have shown that
PTFE grafts resist infection more than other prosthetic conduits such as Dacron (126). A study
A
published by Watson et al demonstrated that overall PTFE and autologous vein had statistically
equal graft complication rates at 62-month follow up. However, when performing subgroup
analysis in the periphery, autologous vein demonstrated greater 8-year freedom from graft-
related complication (77%) compared to PTFE (31%) (125, 127, 128). Regardless of type of
repair performed, care should be taken to thoroughly clean the site of injury, remove all
28

devitalized tissue, and if possible, ensure the repair or graft is covered with layers of healthy
viable tissue prior to surgical completion.
There is much debate in the literature as to whether ligation or reconstruction should be
the method of choice for complex lower extremity venous injuries. Proponents of routine
ligation claim that venous stasis is mitigated by collaterals and multiple studies have
D
demonstrated no permanent sequelae of venous ligation including no difference in amputation
rates (22, 129, 130). Conversely, those in favor of repair report acceptable patency rates and
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theoretical reduction in venous hypertension after repair (131-134). Quan et al. reviewed combat
venous injuries and confirmed that the majority of patients (63%) were treated with ligation
without significant differences in postoperative thromboembolic complications compared to the
repaired vein group (132). Limited published civilian experience has shown that more distal
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repaired veins tend to thrombose early without effect on morbidity (131, 134). A recent NTDB
study of lower extremity venous injuries found that ligation was significantly associated with
increased rates of fasciotomy (44.6% vs 33.5%) and secondary amputation (6.1% vs. 3.4%)
C
when compared to repair. This study also found that patients undergoing ligation also had a
longer hospital length of stay, although mortality was unchanged. This association appeared to
C
be most strong with popliteal vein injuries, suggesting particular care should be given to
attempting popliteal vein repair when at all possible (135).

A
On a review of the literature, there appears to be a 30-71% fasciotomy rate in the case of
combined arterial and venous popliteal injuries (136). Compartment syndrome frequently
complicates severe lower extremity injury and is associated with prolonged ischemia time (> 4-6
h) in patients with arterial injury. Multiple reports have suggested the importance of prophylactic
29

fasciotomy as opposed to waiting for symptoms to perform therapeutic fasciotomy (44, 120, 137,
138). In a recent review of the NTDB, early fasciotomy was associated with shorter length of
stay, lower rates of infectious complication, and lower amputation rates (139). This result was
replicated in the combat setting with soldiers undergoing early fasciotomy having a 50%
decrease in amputation rate (140).
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The Mangled Extremity Severity Score (MESS), popularized by Johansen et al. is an
objective criterion that was first used for amputation prediction after lower extremity injury; it
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was later applied for amputation prediction in upper extremity injuries as well (27, 141). A score
of ≤6 reliably predicts limb salvage for both upper and lower extremity PVI (43, 142). A MESS
of >7 has been utilized as a cutoff point for predicting the need for early amputation but has not
proven reliable in predicting limb salvage in adults (22-24, 143, 144). The MESS appears even
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less reliable in children, in which all extremities with the score ≤ 6 and every third limb with
MESS ≥ 7 were salvaged (145). In major popliteal injuries, primary amputation should be
considered when there is more than 6 hours of ischemic time, disruption of the posterior tibial
C
nerve, severe lower leg and foot wounds, open comminuted fractures with segmental bone loss,
multiple injuries in an unstable patient, and injuries requiring overwhelming extensive soft tissue
C
coverage (24, 120, 122, 146). Patients with combat related blast injury demonstrate significant
risk for late amputation following discharge after the original injury. In these patients, open
A
fractures, multiple fractures, and large soft tissue defects are common and primary amputation as
opposed to limb salvage should be strongly considered (147).
30

Upper Extremity
The gold standard for VT to the upper extremity remains open surgical repair. Rapid
access can be gained to the brachial vessels by making an incision along the medial groove of the
biceps and triceps muscle. Extension of this incision obliquely across the antecubital fossa and
onto the volar forearm can be utilized to access the proximal radial and ulnar arteries. After
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obtaining proximal and distal control, repair is dependent on the severity and location of injury.
Techniques include lateral suture, patch angioplasty, tension free end-to-end anastomosis, and
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interposition graft. The majority of UEAIs can be repaired primarily with lateral arteriorrhaphy
or resection with end-to-end anastomosis. Isolated radial and ulnar injuries with an intact palmar
arch confirmed by Doppler examination after occlusion of the injured vessel can be ligated with
low rates of distal ischemia and amputation (51, 57, 144, 148, 149). Bypass grafts are required in
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approximately 20-30% of cases. When required, autologous vein graft from an uninjured
extremity is the preferred conduit (51, 57, 66, 144, 150-152). The combined presence of vascular
and orthopedic injuries creates a challenge for management and functional outcome of upper
C
extremity vascular injury (51). Ischemic time is of critical importance for outcomes and thus it is
generally recommended that vascular repair precedes orthopedic intervention (57, 121, 153-155).
C
However in the event of major musculoskeletal damage requiring external fixation, while
generally not utilized in the upper extremity, TIVS represents an important tool to restore
A
perfusion prior to definitive repair (51, 124, 144, 156).
Venous injuries in the upper extremity can generally be ligated due to the extensive
collateral venous system (131, 132, 134). In a review performed by Quan et al of 103 venous
injuries, there was no significant difference in postoperative thromboembolic complications in
the ligation group compared to the venous repair group (132). Although the need for fasciotomy
31

is markedly reduced in the upper extremity compared to the lower extremity PVI, if ischemic
time is long (>6h), forearm fasciotomy should be performed (20).
Perioperative anticoagulation
D
The use of perioperative systemic anticoagulation for traumatic vascular injury has been a
topic of significant debate. Multiple studies have shown that anticoagulation given to patients
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with traumatic arterial injury without absolute contraindication has not been reported to increase
the rate of bleeding complications (157, 158). Wagner et al. found no hemorrhagic
complications in patients receiving intraoperative anticoagulation (159). Additionally,
Humphries et al. found that use of intraoperative anticoagulation did not significantly change
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intraoperative blood loss or overall bleeding complications (157, 160). However, this study also
failed to demonstrate any improvement in rates of reoperation or limb salvage with systemic
anticoagulation and found a trend toward worse outcomes. A retrospective analysis performed by
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Wang et al matching patients given heparin, aspirin, and the use of no agents found no
statistically significant difference in the rates of bleeding, compartment syndrome, or mortality.

C
But again, also failed to demonstrate any improvement in rates of thrombosis or amputation
(161). Lastly, a recent study performed by Loja et al demonstrated systemic anticoagulation

A
given during an operation was not associated with improved graft patency or limb salvage, but
was associated with prolonged hospital stay and increased blood product use (160). Overall,
while systemic anticoagulation for vascular trauma does not definitively increase bleeding risk, it
also does not seem to improve outcomes and its routine use is not recommended.
32

Endovascular Management
Recently there has been increasing interest in the use of endovascular techniques for PVI.
The placement of endovascular stents and stent grafts has been demonstrated to be safe and is
considered an accepted alternative to open surgery for the management of peripheral artery
aneurysms and AVFs (162). Stents and stent grafts alone and in combination with embolization,
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although rare in PVI, have been described (163, 164). Reviews of case reports, and small case
series have demonstrated the safety of endovascular repairs and generally favorable outcomes.
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However, early and late stent thrombosis has been reported and long-term surveillance studies
are lacking (39, 163, 165-169). Additionally, concern remains regarding the feasibility of
obtaining follow-up and surveillance in the trauma population (167). Associated complications
of the endovascular approach include stent occlusion, deformation and kinking, loss of vessel
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branches after stent placement, and intimal hyperplasia (162, 163, 170).
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Outcomes and Complication of PVI
A variety of factors affect limb outcomes after PVI, including mechanism of injury,
C
associated orthopedic injury, number of vessels injured, location and type of vessel injured.
Patency rates of upper extremity PVI repairs are generally good, ranging from 93-97% (45, 171).
A
Functional deficits are common in upper extremity PVI. While ischemic time does impact
functional outcome, deficits appear to be more strongly associated with concomitant bony and
nerve injury, and need for fasciotomy rather than type and timing of arterial repair (149, 171,
172). Significant nerve and bone injury, and combined arterial and venous injury are associated
with increased need for fasciotomy, morbidity, and need for amputation (20-28). Blunt trauma
33

has also been reported to have a persistent long term effect on functional disability outcome in
both upper and lower extremity PVI (26, 44, 172, 173).
The restoration and preservation of vascular flow remains one of the most important
factors for subsequent success (43). Acceptable duration of total (tourniquet) and warm (no flow
in a major artery) ischemia is considered to be limited by two and six hours, respectively. It has
D
been demonstrated by modern studies that there is a negative association between duration of
ischemia and rate of complications and/or limb salvage. Kauvar et al, analyzing 455 patients
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with combat LEAIs with or without applied tourniquet, found that tourniquet dwell time of 60
minutes or longer was associated with more rhabdomyolysis, wound infection and neurologic
compromise (28). Timing of revascularization has long been considered to contribute to
amputation rates. A greater than 6-hour interval between injury and revascularization has often
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been quoted as increasing risk for amputation, however others have found a lack of correlation
between timing and vascular outcome (24, 26, 136, 159). Thus, while expedited reperfusion is
optimal, time of ischemia itself should not define treatment strategy (50, 73, 174).
C
Overall, patients sustaining PVI have an amputation rate of 1% and 11% for the upper
C
and lower extremity, respectively (1, 20, 22, 23, 45, 60, 150, 174-178). Amputation for upper
extremity PVI is much less common compared to lower extremity injuries and is associated with
A
severity and location of PVI and associated injuries (20, 45, 144). Ligation of the common
brachial artery carries the highest risk for amputation at 18-55% (120). The MESS scale has also
been applied to upper extremity PVI. Studies suggest that patients with a MESS of < 7 are
unlikely to require amputation (144). In the lower extremity, popliteal and femoral artery injuries
carry the highest risk of amputation reaching 28-37%, and as high as 70% for late presentations
34

(1, 42, 44, 73, 136, 177, 178). Studies have suggested that tibioperoneal trunk injury results in
even higher amputation rates than below-knee popliteal injuries. Anterior tibial artery injuries, in
particular, were considerably more likely to require amputation compared to posterior tibial or
peroneal artery injuries (21, 43). Additionally, there was a significantly higher rate of amputation
among patients undergoing bypass with tibioperoneal trunk targets, with these patients requiring
amputation at rates of approximately three times that of below knee popliteal targets (43). In
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general, the more vessels to the foot that remain patent, the higher chance for limb salvage (106,
179). In a subsequent multicenter study conducted by Branco et al it was noted that no
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amputations occurred in patients with two or more patent vessels to the foot whereas there was a
68.2% amputation rate documented for patients with no patent vessels, and 16.0% for those with
1 patent vessel (106). Blunt VT is associated with significantly higher amputation rate (6.7% vs
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1.3%) and mortality (4.8% vs 3.8%) compared to penetrating trauma (20, 23). Risk of
amputation for PVI is similar in military (excluding blast injuries) and pediatric populations (1,
9, 11, 41, 52, 54, 145, 180). Recent NTDB analysis demonstrated children with PVIs had
significantly lower amputation rate if treated in ACS-verified adult or pediatric trauma centers
C
(41). The geriatric population has a higher risk of lower limb amputation compared to adults (4).
C
A comparison of UEAI and LEAI using the NTDB has reported mortality of 2.2% for
UEAI and 7.7% for LEAI (20). LEAI was independently associated with a two-fold increase in
A
mortality for both blunt and penetrating injuries. Other authors reported mortality for LEAI of
1.5-5% in civilian and military PVI (22, 23, 43, 54, 136).
35

Conclusions
PVI represents a significant percentage of injuries in civilian and military trauma and
remains a significant source of morbidity and mortality. For patients not requiring urgent
operative intervention, physical exam supplemented with ABI/API adequately screen the
majority of patients. In those with equivocal findings, thin slice CTA is the diagnostic test of
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choice. Historically, the management of these injuries has been an open operative intervention.
While most injuries continue to be managed this way, over recent years use of endovascular
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techniques have increased. Risk of death, compartment syndrome and amputation depend on the
type of vessel injured, number of vessel injuries, and associated non-vascular injuries.
Prehospital tourniquet use, damage control resuscitation, and damage control surgical techniques
including TIVS have improved outcomes following PVI. As the landscape continues to change
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with emerging technology it is clear that rapid diagnosis and management with a
multidisciplinary approach is essential to optimize outcomes for these complex injuries.

C
C
A
36

Competing interest: All authors declare to have no competing interests
Authors’ contribution:
LK, RC, and JS: Study Design, Literature Search, Grading of evidence.
LK, RC, JS, AMOG Jr, VR: Literature Review, Writing of Manuscript
All Authors: Guideline Consensus, Critical Review of Manuscript
Conflict of interest: All authors declare to have no conflict of interest
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Source of funding: None
Ethics Approval and Consent to Participate: Not applicable
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Consent for publication: Not applicable
Availability of data and supporting materials: Not applicable
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C
A
37

References
1. Barmparas G, Inaba K, Talving P, David JS, Lam L, Plurad D, et al. Pediatric vs adult
vascular trauma: a National Trauma Databank review. J Pediatr Surg. 2010;45(7):1404-
12.
2. Branco BC, DuBose JJ, Zhan LX, Hughes JD, Goshima KR, Rhee P, et al. Trends and
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outcomes of endovascular therapy in the management of civilian vascular injuries. J Vasc
Surg. 2014;60(5):1297-307.e1.
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3. Friend J, Rao S, Sieunarine K, Woodroof P. Vascular trauma in Western Australia: a
comparison of two study periods over 15 years. ANZ J Surg. 2016;86(3):173-8.
4. Konstantinidis A, Inaba K, Dubose J, Barmparas G, Lam L, Plurad D, et al. Vascular

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trauma in geriatric patients: a national trauma databank review. J Trauma.
2011;71(4):909-16.
5. Muckart DJ, Pillay B, Hardcastle TC, Skinner DL. Vascular injuries following blunt
C
polytrauma. Eur J Trauma Emerg Surg. 2014;40(3):315-22.
6. Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of
C
temporary vascular shunts as a damage control adjunct in the management of wartime

A
vascular injury. J Trauma. 2006;61(1):8-12; discussion -5.
7. Stannard A, Brown K, Benson C, Clasper J, Midwinter M, Tai NR. Outcome after
vascular trauma in a deployed military trauma system. Br J Surg. 2011;98(2):228-34.
38

8. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE.
The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg.
2011;253(6):1184-9.
9. Patel JA, White JM, White PW, Rich NM, Rasmussen TE. A contemporary, 7-year
analysis of vascular injury from the war in Afghanistan. J Vasc Surg. 2018;68(6):1872-9.
D
10. Turner CA, Stockinger ZT, Gurney JM. Vascular surgery during U.S. combat operations
from 2002 to 2016: Analysis of vascular procedures performed to inform military training.
TE
J Trauma Acute Care Surg. 2018;85(1S Suppl 2):S145-s53.
11. Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theater
management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg.
EP
2007;204(4):625-32.
12. DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The
American Association for the Surgery of Trauma PROspective Observational Vascular

C
Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury
diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22;

C
discussion 22-3.
13. Markov NP, DuBose JJ, Scott D, Propper BW, Clouse WD, Thompson B, et al. Anatomic
A
distribution and mortality of arterial injury in the wars in Afghanistan and Iraq with
comparison to a civilian benchmark. J Vasc Surg. 2012;56(3):728-36.
14. Poyhonen R, Suominen V, Uurto I, Salenius J. Non-iatrogenic civilian vascular trauma in
a well-defined geographical region in Finland. Eur J Trauma Emerg Surg.
2015;41(5):545-9.
39

15. Wahlgren CM, Kragsterman B. Management and outcome of pediatric vascular injuries. J
Trauma Acute Care Surg. 2015;79(4):563-7.
16. Branco BC, Naik-Mathuria B, Montero-Baker M, Gilani R, West CA, Mills JL, Sr., et al.
Increasing use of endovascular therapy in pediatric arterial trauma. J Vasc Surg.
2017;66(4):1175-83.e1.
D
17. Al-Ganadi A. Management of Vascular Injury during Current Peaceful Yemeni
Revolution. Ann Vasc Surg. 2015;29(8):1575-80.
TE
18. Sohn VY, Arthurs ZM, Herbert GS, Beekley AC, Sebesta JA. Demographics, treatment,
and early outcomes in penetrating vascular combat trauma. Arch Surg. 2008;143(8):783-7.
19. Sharrock AE, Tai N, Perkins Z, White JM, Remick KN, Rickard RF, et al. Management
EP
and outcome of 597 wartime penetrating lower extremity arterial injuries from an
international military cohort. J Vasc Surg. 2019;70(1):224-32.
20. Tan TW, Joglar FL, Hamburg NM, Eberhardt RT, Shaw PM, Rybin D, et al. Limb
C
outcome and mortality in lower and upper extremity arterial injury: a comparison using
the National Trauma Data Bank. Vasc Endovasc Surg. 2011;45(7):592-7.

C
21. Scalea JR, Crawford R, Scurci S, Danquah J, Sarkar R, Kufera J, et al. Below-the-knee
arterial injury: the type of vessel may be more important than the number of vessels
A
injured. J Trauma Acute Care Surg. 2014;77(6):920-5.
22. Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period:
outcomes, risk factors, and management. Vasc Health Risk Manag. 2010;6:1103-10.
40

23. 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):731-6.
24. Simmons JD, Gunter JW, 3rd, Schmieg RE, Jr., Manley JD, Rushton FW, Jr., Porter JM,
et al. Popliteal artery injuries in an urban trauma center with a rural catchment area: do
D
delays in definitive treatment affect amputation? Am Surg. 2011;77(11):1521-5.
25. Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K, et al. Outcomes of
TE
selective tibial artery repair following combat-related extremity injury. J Vasc Surg.
2010;52(1):91-6.
26. Vielgut I, Gregori M, Holzer LA, Glehr M, Hashemi S, Platzer P. Limb salvage and
EP
functional outcomes among patients with traumatic popliteal artery injury: a review of 64
cases. Wien Klin Wochenschr. 2015;127(13-14):561-6.
27. Mullenix PS SS, Anderson SA, et al. . Limb salvage and outcomes among patients with
C
traumatic popliteal vascular injury: an analysis of the National Trauma Data Bank. J Vasc
Surg. 2006;44(94-100).
C
28. Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and
limb loss in isolated lower extremity vascular trauma. J Vasc Surg. 2011;53(6):1598-603.
A
29. Montgomery HR, Butler FK, Kerr W, Conklin CC, Morissette DM, Remley MA, et al.
TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03.
J Spec Oper Med. 2017;17(2):21-38.
41

30. Butler FK, Jr., Holcomb JB, Shackelford S, Barbabella S, Bailey JA, Baker JB, et al.
Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines
Change 18-01:14 October 2018. J Spec Oper Med.18(4):37-55.
31. Burlington M. PHTLS Prehospital trauma life support: military version, ninth edition. .
9th ed2020.
D
32. Feliciano DV, Moore EE, West MA, Moore FA, Davis JW, Cocanour CS, et al. Western
Trauma Association critical decisions in trauma: evaluation and management of peripheral
TE
vascular injury, part II. J Trauma Acute Care Surg. 2013;75(3):391-7.
33. Feliciano DV, Moore FA, Moore EE, West MA, Davis JW, Cocanour CS, et al.
Evaluation and management of peripheral vascular injury. Part 1. Western Trauma

EP
Association/critical decisions in trauma. J Trauma. 2011;70(6):1551-6.
34. Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, et al. Evaluation and
management of penetrating lower extremity arterial trauma: an Eastern Association for the
C
Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5
Suppl 4):S315-20.
C
35. Pereira BM, Chiara O, Ramponi F, Weber DG, Cimbanassi S, De Simone B, et al. WSES
position paper on vascular emergency surgery. World J Emerg Surg. 2015;10:49.

A
36. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al.
GRADE: an emerging consensus on rating quality of evidence and strength of
recommendations. BMJ. 3362008. p. 924-6.
42

37. Allen CJ, Straker RJ, Tashiro J, Teisch LF, Meizoso JP, Ray JJ, et al. Pediatric vascular
injury: experience of a level 1 trauma center. The Journal of surgical research.
2015;196(1):1-7.
38. Heis HA, Bani-Hani KE, Elheis MA. Overview of extremity arterial trauma in Jordan. Int
Angiol. 2008;27(6):522-8.
D
39. Worni M, Scarborough JE, Gandhi M, Pietrobon R, Shortell CK. Use of endovascular
therapy for peripheral arterial lesions: an analysis of the National Trauma Data Bank from
TE
2007 to 2009. Ann Vasc Surg. 2013;27(3):299-305.
40. Shah SR, Wearden PD, Gaines BA. Pediatric peripheral vascular injuries: a review of our
experience. J Surg Res. 2009;153(1):162-6.

EP
41. Prieto JM, Van Gent JM, Calvo RY, Checchi KD, Wessels LE, Sise MJ, et al. Pediatric
extremity vascular trauma: It matters where it is treated. J Trauma Acute Care Surg.
2020;88(4):469-76.
C
42. Gopinathan NR, Santhanam SS, Saibaba B, Dhillon MS. Epidemiology of lower limb
musculoskeletal trauma with associated vascular injuries in a tertiary care institute in

C
India. Indian J Orthop. 2017;51(2):199-204.
43. Fortuna G, DuBose JJ, Mendelsberg R, Inaba K, Haider A, Joseph B, et al. Contemporary
A
outcomes of lower extremity vascular repairs extending below the knee: A multicenter
retrospective study. J Trauma Acute Care Surg. 2016;81(1):63-70.
44. Lang NW, Joestl JB, Platzer P. Characteristics and clinical outcome in patients after
popliteal artery injury. J Vasc Surg. 2015;61(6):1495-500.
43

45. 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):1633-7.
46. Perkins ZB, Yet B, Glasgow S, Cole E, Marsh W, Brohi K, et al. Meta-analysis of
prognostic factors for amputation following surgical repair of lower extremity vascular
D
trauma. Br J Surg. 2015;102(5):436-50.
47. Perkins ZB, De'Ath HD, Aylwin C, Brohi K, Walsh M, Tai NR. Epidemiology and
TE
outcome of vascular trauma at a British Major Trauma Centre. Eur J Vasc Endovasc Surg.
2012;44(2):203-9.
48. Kirkilas M, Notrica DM, Langlais CS, Muenzer JT, Zoldos J, Graziano K. Outcomes of
EP
arterial vascular extremity trauma in pediatric patients. J Pediatr Surg. 2016;51(11):1885-
90.
49. Kim JJ, Alipour H, Yule A, Plurad DS, Koopmann M, Putnam B, et al. Outcomes after
C
External Iliac and Femoral Vascular Injuries. Ann Vasc Surg. 2016;33:88-93.
50. Jaipuria J, Sagar S, Singhal M, Bagdia A, Gupta A, Kumar S, et al. Paediatric extremity
C
vascular injuries - experience from a large urban trauma centre in India. Injury.
2014;45(1):176-82.
A
51. Franz RW, Skytta CK, Shah KJ, Hartman JF, Wright ML. A five-year review of
management of upper-extremity arterial injuries at an urban level I trauma center. Ann
Vasc Surg. 2012;26(5):655-64.
44

52. Woodward EB, Clouse WD, Eliason JL, Peck MA, Bowser AN, Cox MW, et al.
Penetrating femoropopliteal injury during modern warfare: experience of the Balad
Vascular Registry. J Vasc Surg. 2008;47(6):1259-64; discussion 64-5.
53. Siddique MK, Bhatti AM. A two-year experience of treating vascular trauma in the
extremities in a military hospital. J Pak Med Assoc. 2013;63(3):327-30.
D
54. Brusov PG, Nikolenko VK. Experience of treating gunshot wounds of large vessels in
Afghanistan. World J Surg. 2005;29 Suppl 1:S25-9.
TE
55. Bilgen S, Turkmen N, Eren B, Fedakar R. Peripheral vascular injury-related deaths. Ulus
Travma Acil Cerrahi Derg. 2009;15(4):357-61.
56. Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year review of
EP
management of lower extremity arterial injuries at an urban level I trauma center. J Vasc
Surg. 2011;53(6):1604-10.
57. Franz RW, Goodwin RB, Hartman JF, Wright ML. Management of upper extremity
C
arterial injuries at an urban level I trauma center. Ann Vasc Surg. 2009;23(1):8-16.
58. Sciarretta JD, Macedo FI, Otero CA, Figueroa JN, Pizano LR, Namias N. Management of
C
traumatic popliteal vascular injuries in a level I trauma center: A 6-year experience. Int J
Surg. 2015;18:136-41.
A
59. Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N. Management of
lower extremity vascular injuries in pediatric trauma patients: a single Level I trauma
center experience. J Trauma Acute Care Surg. 2014;76(6):1386-9.
45

60. Jaha L, Andreevska T, Rudari H, Ademi B, Ismaili-Jaha V. A decade of civilian vascular
trauma in Kosovo. World J Emerg Surg. 2012;7(1):24.
61. Waller CJ, Cogbill TH, Kallies KJ, Ramirez LD, Cardenas JM, Todd SR, et al.
Contemporary management of subclavian and axillary artery injuries-A Western Trauma
Association multicenter review. J Trauma Acute Care Surg. 2017;83(6):1023-31.
D
62. Chong VE, Lee WS, Miraflor E, Victorino GP. Applying peripheral vascular injury
guidelines to penetrating trauma. J Surg Res. 2014;190(1):300-4.
TE
63. Degiannis E, Bowley DM, Bode F, Lynn WR, Glapa M, Baxter S, et al. Ballistic arterial
trauma to the lower extremity: recent South African experience. Am Surg.
2007;73(11):1136-9.
EP
64. Inaba K, Branco BC, Reddy S, Park JJ, Green D, Plurad D, et al. Prospective evaluation of
multidetector computed tomography for extremity vascular trauma. J Trauma.
2011;70(4):808-15.
C
65. Dennis JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS. Validation of
nonoperative management of occult vascular injuries and accuracy of physical

C
examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma.
1998;44(2):243-52; discussion 2-3.

A
66. Ekim H, Tuncer M. Management of traumatic brachial artery injuries: a report on 49
patients. Ann Saudi Med. 2009;29(2):105-9.
67. Gonzalez RP, Falimirski ME. The utility of physical examination in proximity penetrating
extremity trauma. Am Surg. 1999;65(8):784-9.
46

68. deSouza IS, Benabbas R, McKee S, Zangbar B, Jain A, Paladino L, et al. Accuracy of
Physical Examination, Ankle-Brachial Index, and Ultrasonography in the Diagnosis of
Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and
Meta-analysis. Acad Emerg Med. 2017;24(8):994-1017.
69. Conrad MF, Patton JH, Jr., Parikshak M, Kralovich KA. Evaluation of vascular injury in
D
penetrating extremity trauma: angiographers stay home. Am Surg. 2002;68(3):269-74.
70. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing
TE
arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56(6):1261-5.
71. Barnes CJ, Pietrobon R, Higgins LD. Does the pulse examination in patients with
traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma.

EP
2002;53(6):1109-14.
72. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G, Jr., Robinson JT, Volgas DA.
Vascular injuries in knee dislocations: the role of physical examination in determining the
C
need for arteriography. J Bone Joint Surg Am. 2004;86(5):910-5.
73. Pourzand A, Fakhri BA, Azhough R, Hassanzadeh MA, Hashemzadeh S, Bayat AM.
C
Management of high-risk popliteal vascular blunt trauma: clinical experience with 62
cases. Vasc Health Risk Manag. 2010;6:613-8.

A
74. Coleman JJ, Tavoosi S, Zarzaur BL, Brewer BL, Rozycki GS, Feliciano DV. Arterial
Injuries Associated with Blunt Fractures in the Lower Extremity. Am Surg.
2016;82(9):820-4.
47

75. Ekim H, Basel H, Odabasi D. Management of traumatic popliteal vein injuries. Injury.
2012;43(9):1482-5.
76. Levy BA, Zlowodzki MP, Graves M, Cole PA. Screening for extermity arterial injury with
the arterial pressure index. Am J Emerg Med. 2005;23(5):689-95.
77. Callcut RA, Mell MW. Modern advances in vascular trauma. Surg Clin North Am.
D
2013;93(4):941-61, ix.
78. Kataoka Y MH, Kashimi F, Hanajima T, Yamaya T, Nishimaki H, Asari Y. Hybbrid
TE
treatment combining emergency surgery and intraoperative interventional radiology for
severe trauma. Injury. 2016;47(1):59-63.
79. Fehr A BJ, D'Amours S, Kirkpatrick A, Ball C. The potential benefti of ahybrid operating
EP
environment among severely injured patients with persistent hemorrhage: How often
could we get it right? J Trauma Acute Care Surg. 2016;80(3):457-60.
80. D'Amours S RP, Ball C. Utility of simultaneous interventional radiology and operative
C
surgery in a dedicated suite for seriosly injured patients. Curr Opin Crit Care.
2013;19(6):587-93.
C
81. Mollberg NM, Wise SR, Banipal S, Sullivan R, Holevar M, Vafa A, et al. Color-flow
duplex screening for upper extremity proximity injuries: a low-yield strategy for
A
therapeutic intervention. Ann Vasc Surg.. 2013;27(5):594-8.
82. Mollberg NM, Wise SR, Keyashian B, Ver MR, Lin FJ, Sullivan R, et al. The incidence of
acute venous injury as a result of proximity penetrating trauma screened with colour flow
duplex ultrasound. Injury. 2014;45(1):192-6.
48

83. Jordaan P, Roche S, Maqungo S. Computerised Tomographic Angiography (CTA) in
extremity trauma - A level one hospital experience. S Afr J Surg. 2016;54(4):11-6.
84. Hemingway J, Adjei E, Desikan S, Gross J, Tran N, Singh N, et al. Re-evaluating the
safety and effectiveness of the 0.9 ankle-brachial index threshold in penetrating lower
extremity trauma. J Vasc Surg. 2020.
D
85. Beyer C, Zakaluzny S, Humphries M, Shatz D. Multidisciplinary Management of Blunt
Renal Artery Injury with Endovascular Therapy in the Setting of Polytrauma: A Case
TE
Report and Review of the Literature. Ann Vasc Surg. 2017;38:318 e11- e16.
86. Adibi A, Krishnam MS, Dissanayake S, Plotnik AN, Mohajer K, Arellano C, et al.
Computed tomography angiography of lower extremities in the emergency room for

EP
evaluation of patients with gunshot wounds. Eur Radiol. 2014;24(7):1586-93.
87. Anderson SW, Foster BR, Soto JA. Upper extremity CT angiography in penetrating
trauma: use of 64-section multidetector CT. Radiology. 2008;249(3):1064-73.

C
88. Colip CG, Gorantla V, LeBedis CA, Soto JA, Anderson SW. Extremity CTA for
penetrating trauma: 10-year experience using a 64-detector row CT scanner. Emerg

C
Radiol. 2017;24(3):223-32.
89. Costantini TW, Bosarge PL, Fortlage D, Bansal V, Coimbra R. Arterial embolization for
A
pelvic fractures after blunt trauma: are we all talk? Am J Surg. 2010;200(6):752-7;
discussion 7-8.
49

90. Montorfano MA, Montorfano LM, Perez Quirante F, Rodriguez F, Vera L, Neri L. The
FAST D protocol: a simple method to rule out traumatic vascular injuries of the lower
extremities. Crit Ultrasound J. 2017;9(1):8.
91. Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM, et al. Imaging
vascular trauma. Br J Surg. 2012;99(4):494-505.
D
92. Doody O, Given MF, Lyon SM. Extremities--indications and techniques for treatment of
extremity vascular injuries. Injury. 2008;39(11):1295-303.
TE
93. Fleiter TR, Mervis S. The role of 3D-CTA in the assessment of peripheral vascular lesions
in trauma patients. Eur J Radiol. 2007;64(1):92-102.
94. Hamner CE, Groner JI, Caniano DA, Hayes JR, Kenney BD. Blunt intraabdominal arterial
EP
injury in pediatric trauma patients: injury distribution and markers of outcome. J Pediatr
Surg. 2008;43(5):916-23.
95. Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, et al. Evaluation and
C
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
C
Suppl 4):S315-20.
96. Gilbert F, Schneemann C, Scholz CJ, Kickuth R, Meffert RH, Wildenauer R, et al.
A
Clinical implications of fracture-associated vascular damage in extremity and pelvic
trauma. BMC Musculoskelet Disord. 2018;19(1):404.
50

97. Van Haren RM, Ryan ML, Thorson CM, Namias N, Livingstone AS, Proctor KG.
Bilateral near-infrared spectroscopy for detecting traumatic vascular injury. J Surg Res
2013;184(1):526-32.
98. DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The
American Association for the Surgery of Trauma PROspective Observational Vascular
D
Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury
diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22;
TE
discussion 22-3.
99. Hsu CS, Hellinger JC, Rubin GD, Chang J. CT angiography in pediatric extremity trauma:
preoperative evaluation prior to reconstructive surgery. Hand (N Y). 2008;3(2):139-45.

EP
100. Diamond IR, Hamilton PA, Garber AB, Tien HC, Chughtai T, Rizoli SB, et al.
Extravasation of intravenous computed tomography scan contrast in blunt abdominal and
pelvic trauma. J Trauma. 2009;66(4):1102-7.

C
101. Kordzadeh A, Melchionda V, Rhodes KM, Fletcher EO, Panayiotopolous YP. Blunt
abdominal trauma and mesenteric avulsion: a systematic review. Eur J Trauma Emerg
C
Surg. 2016;42(3):311-5.
102. Mellnick VM, McDowell C, Lubner M, Bhalla S, Menias CO. CT features of blunt
A
abdominal aortic injury. Emerg Radiol. 2012;19(4):301-7.
103. Pinto A, Niola R, Tortora G, Ponticiello G, Russo G, Di Nuzzo L, et al. Role of
multidetector-row CT in assessing the source of arterial haemorrhage in patients with
pelvic vascular trauma. Comparison with angiography. Radiol Med. 2010;115(4):648-67.
51

104. Rowland SP, Dharmarajah B, Moore HM, Dharmarajah K, Davies AH. Venous injuries in
pediatric trauma: Systematic review of injuries and management. J Trauma Acute Care
Surg. 2014;77(2):356-63.
105. Tsai R, Raptis C, Schuerer DJ, Mellnick VM. CT Appearance of Traumatic Inferior Vena
Cava Injury. AJR Am J Roentgenol. 2016;207(4):705-11.
D
106. Branco BC, Linnebur M, Boutrous ML, Leake SS, Inaba K, Charlton-Ouw KM, et al. The
predictive value of multidetector CTA on outcomes in patients with below-the-knee
TE
vascular injury. Injury. 2015;46(8):1520-6.
107. Pieroni S, Foster BR, Anderson SW, Kertesz JL, Rhea JT, Soto JA. Use of 64-row
multidetector CT angiography in blunt and penetrating trauma of the upper and lower
EP
extremities. Radiographics. 2009;29(3):863-76.
108. Fleischmann D HR, Rubin G. CT Angiography of Peripheral Arterial Disease. J Vasc
Interv Radiol. 2006;17:3-26.

C
109. Walizewska M JA, Guzinski M, Sasjadek M. Application of the 64-slice computed
tomography as a diagnostic method in acute posttraumatic ischaemia of the upper limbs –

C
3 case reports. Pol J Radiol. 2010;75(2):94-7.
110. Dennis JW FE, Veldenz HC, Huffman S, Menawat SS. Validation of nonoperative
A
management of occult vascular injuries and accuracy of physical examination alone in
penetrating extremity trauma: 5- to 10-year follow-up. J Trauma. 1998;44:243-52.
52

111. Scerbo MH, Holcomb JB, Taub E, Gates K, Love JD, Wade CE, et al. The trauma center
is too late: Major limb trauma without a pre-hospital tourniquet has increased death from
hemorrhagic shock. J Trauma Acute Care Surg. 2017;83(6):1165-72.
112. Kragh JF WT, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. . Practical use of
emergency tourniquets to stop bleeding in major limb trauma. . J Trauma. 2008;64(2):S38-
D
S49.
113. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Urive P, Mallett O, Zubko T,
TE
Oetjen-Gerdes L, Rasmussen TE. Death on the Battelfield (2001-2011): implications for
the future of combat casualty care. J Trauma. 2012;73(6):s431-7.
114. Bulger EM SD, SChoelles K, Gotschall C, Dawson D, Lang E, Samddal ND, Butler FK,
EP
Fallat M, Taillac P. An evidence based prehospital guideline for external hemorrhae
control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care.
2014;18(2):163-73.
C
115. van Oostendorp SE, Tan EC, Geeraedts LM, Jr. Prehospital control of life-threatening
truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a
C
review of treatment options and their applicability in the civilian trauma setting. Scand J
Trauma Resusc Emerg Med. 2016;24(1):110.

A
116. Rhee P BC, Martin M. Quicklot use in trauma for hemorrhage control: case series of 103
documented uses. J Trauma. 2008;64:1093-9.
117. Wedmore I MJ, Pusateri AE, Holcomb J. A special report on the chitosan-based
hemostatic dressing: experience in current combat operations. J Trauma. 2006;60:655-8.
53

118. Brown MA MR, Worley JA. Experience with chitosan dressings in a civilian EMS
system. J Emerg Med. 2009;37:1-7.
119. Littlejohn LF, Devlin JJ, Kircher SS, Lueken R, Melia MR, Johnson AS. Comparison of
Celox-A, ChitoFlex, WoundStat, and combat gauze hemostatic agents versus standard
gauze dressing in control of hemorrhage in a swine model of penetrating trauma. Acad
D
Emerg Med. 2011;18(4):340-50.
120. Pereiara BM CO, Tamponi F, Wever D, Cimbanassi S, De Simone B, Musicki K,
TE
Meirelles GV, Catena F, Ansaloni L, Coccolini F, Sartelli M, Di Saverior S, Bendinelli C,
Fraga GP. WSES position paper on vascular emergency surgery World J Emerg Surg.
2015;10(49).
EP
121. Sise M SS. Extremity Vascular Trauma. In: Rich N, Mattox K. Vascular Trauma 2nd
edition. Vascular Trauma 2nd edition. Philadelphia PA2004. p. 353-89.
122. Oliver JC, Gill H, Nicol AJ, Edu S, Navsaria PH. Temporary vascular shunting in vascular
C
trauma: a 10-year review from a civilian trauma centre. S Afr J Surg. 2013;51(1):6-10.
123. Fowler J MN, Rehman S, Gaughan JP, Leslie S. . The importance of surgical sequence in
C
the treatment of lower extremity injuries with concomitant vascular injury: a meta-
analysis. Injury. 2009;40:72-6.

A
124. Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, et al. Multicenter
evaluation of temporary intravascular shunt use in vascular trauma. J Trauma Acute Care
Surg. 2016;80(3):359-64; discussion 64-5.
54

125. Stone KS WR, Sugiyama G, Dean R, Dunstan R. Polytetrafluoroethylene versus
autogenous vein grafts for vascular reconstruction in contaminated wounds. . Am J Surg.
1984;147:692-5.
126. Vertrees A, Fox CJ, Quan RW, Cox MW, Adams ED, Gillespie DL. The use of prosthetic
grafts in complex military vascular trauma: a limb salvage strategy for patients with
D
severely limited autologous conduit. J Trauma. 2009;66(4):980-3.
127. Watson J HR, Morrison J, Gifford S, Rasmussen T. A Retrospective Cohort Comparison
TE
of Expanded Polytetrafluorethylene to Autologous Vein for Vascular Reconstruction in
Modern Combat Casualty Care. Ann Vasc Surg. 2015;29(4):822-9.
128. D.V. Feliciano KLM. Five-year experience with PTFE grafts in vascular wounds. J
EP
Trauma. 1985;25:71-82.
129. Timberlake GA, Kerstein MD. Venous injury: to repair or ligate, the dilemma revisited.
Am Surg. 1995;61(2):139-45.
C
130. Kurtoglu M YH, Taviloglu K, Sivrikoz E, Plevin R, Aksoy M. Serious lower extremity
venous injury management with ligation: prospective overview of 63 patients. Am Surg.

C
2007;73(10):1039-43.
131. Giannakopoulos TG, Avgerinos ED. Management of Peripheral and Truncal Venous
A
Injuries. Front Surg. 2017;4:46.
132. Quan RW GD, Stuart RP, Chang AS, Whittaker DR, Fox CJ. . The effect of vein repair
on the risk of venous thromboembolic events: a review of more than 100 traumatic
military venous injuries. J Vasc Surg. 2008;47(3):1-7.
55

133. Parry NG FD, Burke RM, Cava RA, Nicholas JM, Dente CJ, et al. Management and short-
term patency of lower extremity venous injuries with various repairs. Am J Surg.
2003;186(6):631-5.
134. Quan RW AE, Cox MW, Eagleton MJ, Weber MA, Fox CJ, et al. . The management of
trauma venous injury: civilian and wartime experiences. Perspect Vasc Surg Endovasc
D
Ther. 2006;18(2):149-56.
135. Matsumoto S, Jung K, Smith A, Coimbra R. Outcomes Comparison Between Ligation and
TE
Repair after Major Lower Extremity Venous Injury. Ann Vasc Surg. 2019;54:152-60.
136. Ratnayake A, Samarasinghe B, Bala M. Outcomes of popliteal vascular injuries at Sri
Lankan war-front military hospital: case series of 44 cases. Injury. 2014;45(5):879-84.

EP
137. ER. F. Popliteal vascular injuries. Surg Clin North Am. 2002;82:67-89.
138. Fainzilber G R-SA, Wall MJ, Jr, Mattox KL. Predictors of amputation for popliteal artery
injuries. Am J Surg. 1995;170:568-70.

C
139. Farber A TT, Hamburg NM, Kalish JA, Joglar F, Onigman T,, al. e. Early fasciotomy in
patients with extremity vascular injury is associated with decreased risk of adverse limb
C
outcomes: a review of the National Trauma Data Bank. Injury. 2012;43:1486-91.

A
140. Ritenour AE DW, Fang R, Woods T, Jenkins DH, Flaherty SF, et al. . Complications
after fasciotomy revision and delayed compartment release in combat patients. J Trauma.
2008;64:S153–S61.
141. Harrell DJ SD, Bergamini TA, et al. . Blunt popliteal artery trauma: a challenging injury.
Am Surg. 1997;63(228-231).
56

142. Johansen K, Daines M, Howey T, Helfet D, Hansen ST, Jr. Objective criteria accurately
predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568-72;
discussion 72-3.
143. PretreR B, RossierJ,et al. . .Lower limb trauma with injury to the popliteal vessels. J
Trauma. 1996;40:595–601.
D
144. Prichayudh S, Verananvattna A, Sriussadaporn S, Kritayakirana K, Pak-art R, Capin A, et
al. Management of upper extremity vascular injury: outcome related to the Mangled
TE
Extremity Severity Score. World J Surg. 2009;33(4):857-63.
145. Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, et al. Traumatic
extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic

EP
value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010;5:25.
146. Sfeir Re KG, Haddad FF, Fakih RR, Khalifeh MJ. The Belfast approach to managing
complex lower limb vascular injuries. Eur J Vasc Endovasc Surg. 1992;32(3):246-56.
C
147. Gwinn DE, Tintle SM, Kumar AR, Andersen RC, Keeling JJ. Blast-induced lower
extremity fractures with arterial injury: prevalence and risk factors for amputation after
C
initial limb-preserving treatment. J Orthop Trauma. 2011;25(9):543-8.
148. Baghi I, Herfatkar MR, Shokrgozar L, Poor-Rasuli Z, Aghajani F. Assessment of Vascular

A
Injuries and Reconstruction. Trauma Mon. 2015;20(4):e30469.
149. Topel I, Pfister K, Moser A, Stehr A, Steinbauer M, Prantl L, et al. Clinical outcome and
quality of life after upper extremity arterial trauma. Ann Vasc Surg. 2009;23(3):317-23.
57

150. Klocker J, Falkensammer J, Pellegrini L, Biebl M, Tauscher T, Fraedrich G. Repair of
arterial injury after blunt trauma in the upper extremity - immediate and long-term
outcome. Eur J Vasc Endovasc Surg. 2010;39(2):160-4.
151. Brown KV, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC. Complications of
extremity vascular injuries in conflict. J Trauma. 2009;66(4 Suppl):S145-9.
D
152. Kohli A, Singh G. Management of extremity vascular trauma: Jammu experience. Asian
Cardiovasc Thorac Ann. 2008;16(3):212-4.
TE
153. Cakir O SM, Erdem K, Eren N. . Treatment of vascular injuries associated with limb
fractures. Ann R Coll Engl. 2005;87:348-52.
154. Rowe VL YA, Weaver FA. . Vascular Injuries of the Extremities. Vascular Surgery 6th
EP
ed. Philadelhia, PA: Elsevier Saunders; 2005. p. 1001.
155. Fields CE LR, Ivatury RR. . Brachial and forearm vessel injuries. Surg Clin North Am.
2002;82:105-14.
C
156. Weaver FA PG, Yellin AE. . Difficult peripheral vascular injuries. Surg Clin North Am.
1996;76:843-59.
C
157. Humphries M, Blume MK, Rodriguez MC, DuBose JJ, Galante JM. Outcomes After
A
Anticoagulation for Traumatic Arterial Injuries of the Extremity. JAMA Surg.
2016;151(10):986-7.
158. Guerrero A GK, Kralovich K, Pipinos I, Agnostopolous P, Carter Y. Limb loss following
lower extremity arterial trauma: what can be done proactivel? Injury. 2002;33(9):765-9.
58

159. Wagner W CE, Weaver F, Goodwin J, Myles R, Yellin A. Blunt popliteal artery trauma:
one hundred consectuvie injuries. J Vasc Surg. 1988;7(5):736-48.
160. Loja MN, Galante JM, Humphries M, Savage S, Fabian T, Scalea T, et al. Systemic
anticoagulation in the setting of vascular extremity trauma. Injury. 2017;48(9):1911-6.
161. Wang E, Inaba K, Cho J, Byerly S, Rowe V, Benjamin E, et al. Do Antiplatelet and
D
Anticoagulation Agents Matter after Repair of Traumatic Arterial Injuries? Am Surg.
2016;82(10):968-72.
TE
162. Onal B IE, et al. . Endovascular treatment of peripheral vascular lesions with stent-grafts.
Diagn Intervent Radiol. 2005;11:170-4.
163. Doody O GM, Lyon S. Extremities-Indications and techniques for treatment of extremity
EP
vascular injuries. Injury. 2008;39:1295-303.
164. Mavili E DH, Ozcan N, Akcali Y. Endovascular treatment of lower limb penetrating
arterial traumas. Cardiovasc Intervent Radiol 2007;30(6):1124-9.

C
165. Stewart DK, Brown PM, Tinsley EA, Jr., Hope WW, Clancy TV. Use of stent grafts in
lower extremity trauma. Ann Vasc Surg. 2011;25(2):264.e9-13.

C
166. Desai SS, DuBose JJ, Parham CS, Charlton-Ouw KM, Valdes J, Estrera AL, et al.
A
Outcomes after endovascular repair of arterial trauma. J Vasc Surg. 2014;60(5):1309-14.
167. Rocha L, Dalio MB, Joviliano EE, Piccinato CE. Endovascular approach for peripheral
arterial injuries. Ann Vasc Surg.. 2013;27(5):587-93.
59

168. Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Caronno R, Lagana D, et al. Endovascular
treatment for traumatic injuries of the peripheral arteries following blunt trauma. Injury.
2007;38(9):1091-7.
169. Biagioni RB, Burihan MC, Nasser F, Biagioni LC, Ingrund JC. Endovascular treatment of
penetrating arterial trauma with stent grafts. Vasa. 2018;47(2):125-30.
D
170. Beregi JP PA, et al. Covered stents in the treatment of peripheral arterial aneurysms:
procedural results and mid- term follow-up. Cardiovasc Intervent Radiol. 1999;22(1):9-
TE
13.
171. Frech A, Pellegrini L, Fraedrich G, Goebel G, Klocker J. Long-term Clinical Outcome and
Functional Status After Arterial Reconstruction in Upper Extremity Injury. Eur J Vasc
EP
Endovasc Surg. 2016;52(1):119-23.
172. Joshi V, Harding GE, Bottoni DA, Lovell MB, Forbes TL. Determination of functional
outcome following upper extremity arterial trauma. Vasc Endovasc Surg. 2007;41(2):111-
C
4.
173. Brown KR J-CJ, Seabrook GR, et al. Determinants of functional disability after complex
C
upper extremity trauma. Ann Vasc Surg. 2001;15:43-8.
174. Alarhayem AQ, Cohn SM, Cantu-Nunez O, Eastridge BJ, Rasmussen TE. Impact of time
A
to repair on outcomes in patients with lower extremity arterial injuries. J Vasc Surg.
2019;69(5):1519-23.
175. Kalish J, Nguyen T, Hamburg N, Eberhardt R, Rybin D, Doros G, et al. Associated
venous injury significantly complicates presentation, management, and outcomes of
60

axillosubclavian arterial trauma. The International journal of angiology : official
publication of the International College of Angiology, Inc. 2012;21(4):217-22.
176. Tan TW, Rybin D, Doros G, Kalish JA, Farber A, Eslami MH. Observation and surgery
are associated with low risk of amputation for blunt brachial artery injury in pediatric
patients. J Vasc Surg. 2014;60(2):443-7.
D
177. Dua A, Patel B, Desai SS, Holcomb JB, Wade CE, Coogan S, et al. Comparison of
military and civilian popliteal artery trauma outcomes. J Vasc Surg. 2014;59(6):1628-32.
TE
178. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. Limb salvage
and outcomes among patients with traumatic popliteal vascular injury: an analysis of the
National Trauma Data Bank. J Vasc Surg. 2006;44(1):94-100.

EP
179. Dua A DS, Johnston S, Chinapuvvula NR, DuBose J, Charlton-Ouw K, Azizzadeh A,
Burgess A, Wade CE, Fox CJ, et al. . . Observation may be an inadequate approach for
injured extremities with single tibial vessel run-off. Vascular. 2015;23(5):468-73.

C
180. Villamaria CY, Morrison JJ, Fitzpatrick CM, Cannon JW, Rasmussen TE. Wartime
vascular injuries in the pediatric population of Iraq and Afghanistan: 2002-2011. J Pediatr
C
Surg. 2014;49(3):428-32.
181. Moore EE, Malangoni MA, Cogbill TH, Peterson NE, Champion HR, Jurkovich GJ, et al.
A
Organ injury scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis, and
scrotum. J Trauma. 1996;41(3):523-4.
61

Legend for Figure
Figure 1: PVI Diagnostic and Management Algorithm
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TE
EP
C
C
A
62

Figure 1
D
TE
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C
C
A
63

Table 1. Modified System for Grade of Recommendation (36).
Grade of recommendation Clarity of risk/benefit Quality of supporting evidence Implications
1A
Strong recommendation, high- Benefits clearly outweigh RCTs without important limitations or Strong recommendation, applies to
quality evidence risk and burdens, or vice overwhelming evidence from most patients in most circumstances
versa observational studies without reservation
1B
Strong recommendation, Benefits clearly outweigh RCTs with important limitations Strong recommendation, applies to
D
moderate-quality evidence risk and burdens, or vice (inconsistent results, methodological most patients in most circumstances
versa flaws, indirect analyses or imprecise without reservation
conclusions) or exceptionally strong
evidence from observational studies
TE
1C
Strong recommendation, low- Benefits clearly outweigh Observational studies or case series Strong recommendation but subject to
quality or very low-quality risk and burdens, or vice change when higher quality evidence
evidence versa becomes available
2A
EP
Weak recommendation, high- Benefits closely balanced RCTs without important limitations or Weak recommendation, best action
quality evidence with risks and burden overwhelming evidence from may differ depending on the patient,
observational studies treatment circumstances, or social
values
2B
C
Weak recommendation, moderate- Benefits closely balanced RCTs with important limitations Weak recommendation, best action
quality evidence with risks and burden (inconsistent results, methodological may differ depending on the patient,
flaws, indirect or imprecise) or treatment circumstances, or social
exceptionally strong evidence from values
C
observational studies
2C
A
Weak recommendation, Low- Uncertainty in the estimates Observational studies or case series Very weak recommendation;
quality or very low-quality of benefits, risks, and alternative treatments may be equally
evidence burden; benefits, risk, and reasonable and merit consideration
burden may be closely
balanced
64

Table 2. AAST-OIS grading peripheral vascular injury (181).
Grade Injury
I Digital artery/vein, Palmar artery/vein, deep palmar artery/vein, dorsalis pedis artery, plantar
artery/vein, non-named arterial/venous branches.
II Basilic/cephalic vein, saphenous vein, radial artery, ulnar artery.
III Axillary vein, superficial/deep femoral vein, popliteal vein, brachial artery, anterior tibial
artery, posterior tibial artery, peroneal artery, tibioperoneal trunk.
IV Superficial/deep femoral artery, popliteal artery.
D
V Axillary artery, common femoral artery.
TE
EP
C
C
A
65

Table 3. Clinical signs of peripheral vascular injury.
Hard Signs Soft Signs
Pulsatile bleeding Non pulsatile bleeding
Expanding/pulsating hematoma Nonexpanding/non pulsatile hematoma
Loss of distal pulses Diminished pulse
Bruit/Thrill History of arterial (massive) bleeding/hypotension
D
Previously applied tourniquet
Neurologic deficit
TE
EP Wound in proximity to named vessel
C
C
A
66

AAST - WSES Guidelines On Diagnosis and Management of Peripheral Vascular Injuries

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AAST - WSES Guidelines on Diagnosis and Management of Peripheral

Ronald V. Maier, MD10, Salomone Di Saverio, MD11, Rao Ivatury, MD12,

Andrew Kirkpatrick, MD16, Vladimir Khokha, MD17, Neil Parry, MD18,

Emmanouil Pikoulis, MD22, Gustavo P. Fraga, MD23, Massimo Chiarugi, MD24,

Belinda De Simone, MD28, Felipe Vega-Rivera, MD29, Massimo Sartelli, MD20,

Raul Coimbra, MD, PhD, FACS

Riverside University Health System Medical Center

Comparative Effectiveness and Clinical Outcomes Research Center - CECORC

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Disclosures of Funding: None

Medicine. Comparative Effectiveness and Clinical Outcomes Research Center. Riverside,

3 Vascular and Trauma Surgery- Universidade Federal do Pará/Centro Universitário do Estado

do Pará; Belém-PA Brazil

4 Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian

Colorado, Denver, Colorado, USA

California Davis, Sacramento, California, USA

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

United Arab Emirates

School of Medicine, Pittsburg, Pennsylvania, USA

Cali - Universidad del Valle, Cali, Colombia

11 Department of Surgery, University Hospital of Varese, University of Insubria, Italy

Richmond, Virginia, USA

15 Emergency Surgery Department, Parma University Hospital, Parma, Italy

17 Department of Emergency Surgery, City Hospital, Mozyr, Belarus

University London Health Sciences Centre, London, Ontario, Canada

Health Sciences, University of Auckland, Auckland, New Zealand

20 Abdominal Center, Department of Surgery, University Hospital Meilahti, Helsinki, Finland

21 Department of Digestive Surgery, Grenoble University Hospital, Grenoble, France

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

25 Department of General and Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh,

26 Dipartimento di Scienze Clinico Chirurgiche, Diagnostiche e Pediatriche; University of Pavia,

27 General and Emergency Surgery Department. Milano-Bicocca University, School of

Medicine and Surgery, Monza, Italy

Germain en Laye, France

29 Universidad Nacional Autónoma de México, Curso Universitario Posgrado de Cirugía,

Departamento de Cirugía, Hospital Angeles Lomas, Mexico

30 Department of Surgery, Macerata Hospital (ASUR Marche), Macerata, Italy

31 Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA

32 General Surgery Department, Bufalini Hospital, Cesena, Italy

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Jarrett Santorelli MD - jsantorelli@health.ucsd.edu

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Salomone Di Saverio MD – salo75@inwind.it

Rao Ivatury MD – raoivatury@gmail.com

Nicola De Angelis MD – nic.deangelis@yahoo.it

Thomas Scalea MD – tscalea@som.umaryland.edu

Fausto Catena MD – faustocatena@gmail.com

Andrew Kirkpatrick MD – andrewkirkpatrck@albertahealthservices.ca

Vladimir Khokha MD – vladimirkhokha@gmail.com

Neil Parry MD – neil.parry@lhsc.on.ca

Ian Civil BSc, MBChB – icivil@xtra.co.nz

Ari Leppaniemi MD – Ari.Leppaniemi@hus.fi

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