HORIZONS IN TRAUMA SURGERY 0039-6109/95 $0.00 + .

20

ADVANCES IN THE DIAGNOSIS

AND TREATMENT OF
EXTREMITY VASCULAR TRAUMA
Eric R. Frykberg, MD, FACS

The field of vascular trauma is one of the youngest surgical disci-

plines. Although physicians have long been confronted by the challenges
of hemorrhage and ischemia from injured blood vessels, most of our
current knowledge of the principles and techniques of management of
this unique form of trauma has developed just over the past 50 years.
In fact, this field is continuing to rapidly evolve, especially in the area
of the most common site of vascular injury, the extremities. Several
issues relating to the diagnosis and treatment of extremity vascular
trauma are still being debated. These issues are reviewed in order to
understand the appropriate management of these patients, as well as
the directions that future investigations must take.

HISTORICAL PERSPECTIVE

The repair of vascular injuries was only first proven feasible in the
early twentieth century, and it wasn't until the 1950s that repair was
proven safer and more effective than ligation when routinely performed
on a large scale.86 The first suggestion of this was demonstrated in
American casualties in World War II, in whom extremity arterial repair
resulted in a 35.8% amputation rate, whereas 49% of ligations were
ultimately amputatedY These results were clearly confirmed on a large
scale during the Korean and Vietnam conflicts, when repair supplanted

From the Department of Surgery, University of Florida Health Science Center; and the
Division of General Surgery, University Medical Center, Jacksonville, Florida

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 75· NUMBER 2· APRIL 1995 207

208 FRYKBERG

ligation as the primary management and resulted in a remarkably im-

proved 13% overall amputation rate. 40, 83
In view of these findings, repair of vascular injuries also became
established in the civilian sector during the 1950s, with equally impres-
sive results (Fig. 1).22 Virtually all progress in this field since the 1970s
has occurred in the civilian sector, with substantial improvements being
achieved in diagnosis, surgical techniques, management prioritization of
multiply injured patients, and an aggressive use of adjunctive modal-
ities. 19, 56, 91 Limb salvage rates of over 95% are now routinely achieved
following injury to most extremity arteries. Even popliteal artery injuries,
which are the most prone to limb 10ss,11, 40, 83 are now associated with
limb salvage rates of over 90%.20,51,102,109
With these advances, the limb-threatening consequences of delaying
the diagnosis and treatment of extremity vascular injuries became in-
creasingly evident. The three major clinical manifestations of diagnostic
delay (false aneurysm, arteriovenous fistula, and gangrene) were all
found to increase the difficulty of surgical repair of injured blood vessels,
and therefore to increase the risk of limb morbidity and limb loss
compared with the results of repair of acute vascular injuries?' 15, 23, 84, 110
Rapid diagnosis and treatment, ideally within 6 to 12 hours of injury,
were thus established as the most important tenets of management of
extremity vascular trauma. 65 The significant improvements in limb sal-
vage since the Korean War can be attributed to our understanding of
this and other prognostic factors that have been found to influence
outcome following vascular injuries (Table 1).

100

90

80

70

60

50

40
30

20

10

o
1950 1951 1952 1953 1954 1955 1956 1957 1958 1959
Figure 1. Ten-year trend in the treatment of civilian vascular injuries by repair rather than
ligation. Solid bar = percentage of cases treated by repair; hatched bar = percentage of
repairs successful (restoration of distal pulses). (From Ferguson lA, Byrd WM, McAfee
DK: Experiences in the management of arterial injuries. Ann Surg 153:980, 1961; with
permission.)
 ADVANCES IN DIAGNOSIS AND TREATMENT OF EXTREMITY VASCULAR TRAUMA 209

Table 1. POOR PROGNOSTIC FACTORS IN EXTREMITY VASCULAR TRAUMA

Treatment delay >6 to 12 hours
Blunt mechanism of injury
Location in lower extremity (especially popliteal artery)
Presence of associated injuries
Presence of chronic occlusive vascular disease
Clinical presentation with obvious hemorrhage or ischemia

ADVANCES IN DIAGNOSIS

All injured extremities must be evaluated for the presence of vascu-

lar trauma. Rapid and accurate diagnosis requires a thorough under-
standing of those clinical manifestations that reliably indicate the pres-
ence of vascular injury. Most significant extremity vascular trauma
manifests "hard signs," or clear, unequivocal physical findings (Table 2).
These hard signs generally mandate immediate surgery in the setting of
limb trauma, without further time-consuming evaluation. 16, 20, 29, 32, 69, 80, 91
"Soft signs" represent another category of more equivocal physical
findings in injured extremities, which have been considered to correlate
to some degree with the presence of major vascular trauma (Table 2).
Many have advocated either surgery or further diagnostic evaluation in
the setting of soft signs.16, 78, 80, 90, 91, 97 Recent studies, however, have
shown no clinically relevant correlation with significant vascular injury,
suggesting that soft signs should not influence therapeutic decisions. 12,
28,29 Further study is required to determine their true clinical significance
and diagnostic implications.
The appropriate evaluation of extremity trauma for vascular injury
must balance the need for prompt treatment against the extra time, cost,
and resource utilization that many diagnostic tests require. A review of
the modalities that have been most widely applied to the diagnosis of
extremity vascular trauma should serve to clarify current issues.

Table 2. CLINICAL MANIFESTATIONS OF EXTREMITY VASCULAR TRAUMA

Hard signs
Absent or diminished distal pulses
Active hemorrhage
Large, expanding, or pulsatile hematoma
Bruit or thrill
Distal ischemia (pain, pallor, paralysis, paresthesias, coolness)
Soft signs
Small, stable hematoma
Injury to anatomically related nerve
Unexplained hypotension
History of hemorrhage no longer present
Proximity of injury to major vessel
210 FRYKBERG

Contrast Arteriography

Radiographic visualization of blood vessels by direct injection of

radiopaque contrast was first applied to vascular trauma in the late
1950s.52,97 Another 20 years passed, however, before contrast arteriogra-
phy developed a widely accepted role in the evaluation of extremity
vascular trauma (Table 3). Its two major indications are the exclusion of
vascular injury in those low-risk circumstances when hard signs are
absent, and the delineation of the location, nature, and extent of vascular
injury when these are not clearly evident by physical examination.25, 45, 54
It should be performed only in hemodynamically stable patients because
life-threatening conditions must be treated before those that threaten
limbs. Arteriography is very safe when performed by radiologists in the
radiology suite, with major complication rates of less than 1%.28,90,95

General Indications
Published series of extremity vascular trauma report the majority of
cases to be caused by penetrating mechanisms, most commonly gunshot
wounds. 9, 12, 14, 20, 28, 29, 45 In this setting, it is the consensus of most authori-
ties that the presence of one or more hard signs on physical examination
so reliably predicts the presence of major vascular injury, and the
wounds so clearly indicate the location of that injury, that immediate
surgical exploration is mandated.* Further evaluation with arteriography
would be not only superfluous but also dangerous, in terms of the delay
of at least 1 to 3 hours that this modality entails even in the most active
trauma centers.28, 43, 107
Exceptional circumstances exist in which penetrating extremity
trauma that manifests hard signs may warrant arteriography, when
either the existence or location of a vascular injury is still not clear (Table
3). These include injuries in which there are multiple possible sites of
vascular disruption,42,88 patients with chronic vascular disease who may

*References 14, 16,20,29,34,45,54, 77, 103, 107

Table 3. INDICATIONS FOR ARTERIOGRAPHY IN EXTREMITY TRAUMA

Hemodynamic stability
Blunt trauma with signs of vascular injury
Intraoperative or postoperative evaluation
Delayed diagnosis
Follow-up of nonoperatively managed arterial injuries
Proximity (??)
Penetrating trauma with hard signs plus:
Multiple potential sites of injury (i.e., shotguns)
Missile parallels vessel over long distance
Chronic vascular disease
Extensive bone or soft tissue injury
Thoracic outlet wounds
 ADVANCES IN DIAGNOSIS AND TREATMENT OF EXTREMITY VASCULAR TRAUMA 211

already have pulse deficits,45, 54, 97,100 injuries with extensive bone or soft
tissue destruction that may give rise to hard signs without vascular
injury,2, 8, 72 and thoracic outlet injuries in which the surgical approach
may vary with the exact site of vascular involvemenU,66, 107
Arteriography should be more liberally applied to blunt extremity
trauma because of the high incidence of associated injuries to bone,
nerve, and soft tissue that may account for hard signs and obscure the
clinical picture. * It is also indicated for the intraoperative or postopera-
tive confirmation of patency of a repaired vascular injury.16, 55, 91 Still
another indication for arteriography is any extremity vascular injury that
presents with an established complication of delay (i.e., false aneurysm,
arteriovenous fistula, gangrene) because there is no longer any urgency
in treatment, and operative planning requires a knowledge of injury
morphology and 10cation.45,86

Role in Proximity Injuries

Penetrating extremity wounds or trajectories that may have poten-
tially injured major vessels and yet manifest no hard signs of vascular
injury have posed one of the most persistent and controversial diagnostic
dilemmas since the 1960s. As arteriography was more frequently used
to evaluate injured extremities, it became evident that occult vascular
injuries may occur in as many as 23% of limbs afflicted by these penetrat-
ing "proximity" wounds. t This unique category of trauma called atten-
tion to the apparent unreliability of physical examination in detecting a
substantial number of vascular injuries. It was also found that proximity
wounds comprise the great majority of all penetrating extremity injuries
in this country,29, 32, 41, 57, 59, 73, 101 making the issue of their appropriate
management quite relevant.
From the 1950s through the 1970s, surgical exploration of extremity
vessels at risk from penetrating proximity wounds was routinely prac-
ticed. This was considered the only modality that could most reliably
and completely exclude occult vascular injury and thereby avoid the
limb-threatening consequences of missing these injuries. 22, 45, 66, 80 The
relatively meager experience with arteriography, as well as several ex-
perimental and clinical studies that demonstrated its poor performance
in excluding vascular injury, prevented any widespread reliance on this
modality during these years. 9, 49, 69 The low incidence of arteriovenous
fistulas, false aneurysms, and limb loss in several large series of this
time confirmed the effectiveness of this approach.14' 33, 36, 78 However, the
60% to 80% rate of negative explorations in this setting added a signifi-
cant burden to the already strained resources of major trauma centers.
By the early 1980s, "exclusion" arteriography had been proven, in
fact, to be just as accurate, and certainly safer and less costly, than
routine surgical exploration of asymptomatic penetrating proximity

*References 6, 39, 55, 69, 80, 81, 99, 105

tReferences 12, 16, 24, 32, 35, 38, 47, 57-59, 63, 73, 82, 101, 108
212 FRYKBERG

injuries. 32, 63, 90, 98, 101 Both arteriography and surgical exploration were
shown to have acceptably low, though real, false-negative (i.e., missed
injury) rates, ranging between 0.5% and 6%.14,18,87,89,95,101 These data
rapidly led to arteriography becoming the diagnostic procedure of choice
in this setting.
Since the mid-1980s, even arteriography has been challenged in its
routine application to asymptomatic penetrating proximity wounds of
the extremities, for the same reasons that surgical exploration had been.
Although less invasive and less costly, up to 95% of these arteriograms
are negative,12, 24, 59, 82, 90 representing a substantial expenditure of re-
sources by those centers with a high volume of these injuries. These
considerations· have prompted the investigation of other methods of
evaluating extremity trauma for the presence of vascular injury.

Emergency Center Arteriography

One-shot percutaneous hand-injected arteriograms that can be per-
formed by clinicians in the emergency center or operating room have
been advocated as a safe, rapid, and cost-effective means of imaging
potentially injured extremity vessels. 73 One recent study41 documents
this method to have an accuracy that is entirely comparable to that of
multiplanar arteriography performed by radiologists. This modality is
most beneficial in rapidly and reliably excluding vascular trauma in
patients with low-risk extremity wounds who already require surgery
for other associated injuriesY

PhYSical Examination

Before arteriography was widely used, physical findings were the

sole basis of the diagnosis and of the decision to operate on extremity
vascular traumaY, 22, 40, 68, 83 Most still agree that in penetrating extremity
trauma, a positive physical examination (i.e., one or more hard signs
present) is a highly reliable indicator of vascular injury.16, 20, 29 It is also
widely accepted that a negative physical examination (i.e., the absence
of any hard signs) reliably excludes vascular injury when a penetrating
wound is clearly at a distance from any major extremity vessep,29
A negative physical examination, however, generally has not been
trusted to exclude vascular injury in penetrating proximity wounds or
most blunt trauma in the extremities. It has been assumed that all of the
5% to 23% of asymptomatic vascular injuries in these settings must be
found and repaired in order to prevent the well-documented complica-
tions of false aneurysm, arteriovenous fistula, and gangrene. 16, 63, so, 91, 101
Several recent series have challenged this view by demonstrating
that most clinically occult vascular injuries, in fact, are benign and self-
limited in their natural history and never require surgery.* Eight studies

*References 12, 24, 28, 35, 44, 82, 104, 108

 ADVANCES IN DIAGNOSIS AND TREATMENT OF EXTREMITY VASCULAR TRAUMA 213

that generally observed occult vascular injuries following arteriography

of almost 2600 cases of penetrating extremity trauma documented that,
on average, only 1.7% ever required surgical repair (Table 4). Without
arteriography, this would be the missed injury rate of physical examina-
tion alone, and this is the same such rate associated with arteriography.18,
87,90,95 One study showed that with a policy of routine arteriography of
asymptomatic extremity wounds, over $66,000 in charges are required
to detect one vascular injury that needs surgical intervention and thus
needs detection. 28 The conclusion derived from these data was that a
negative physical examination may be just as accurate as arteriography,
but far less costly, in excluding surgically significant vascular trauma.
This conclusion was confirmed by the only prospective study of the
accuracy of physical examination of penetrating extremity trauma for
vascular injury.29 It documented a missed injury rate of only 0.8% in 366
wounds, a 99.5% diagnostic accuracy, and a savings of over $255,000 in
1 year. No limb loss or limb morbidity resulted from this management,
and the small minority of missed injuries were repaired when they
became evident without complication. This study excluded thoracic out-
let injuries and shotgun injuries in view of the uncertain reliability of
physical examination in these cases, in which arteriography is liberally
used. A follow-up of 27% of these asymptomatic extremity wounds over
a mean interval of 2 years has confirmed these results. 62
Most prior studies that documented the limb-threatening conse-
quences of delayed treatment of vascular trauma failed to report the
initial clinical presentation. It is probable that these complications result
from overlooking injuries that manifest hard signs, which should never
be ignored. 14, 15, 23, 34, 100, 110 The recent studies described above indicate
that our aggressive approach toward clinically obvious vascular trauma
should not necessarily be extrapolated to penetrating extremity trauma
with a negative physical examination, which current evidence suggests
can safely exclude significant vascular injury as reliably as a negative

Table 4. PROFILE OF ASYMPTOMATIC PENETRATING TRAUMA IN PROXIMITY TO

EXTREMITY ARTERIES
Number of Occult
Number of Number of Occult Vascular Injuries
Proximity Vascular Injuries Requiring
Author(s) Wounds (%) Surgery (%)"
Dennis et al'2 318 32 (10] 6 (1.8)
Francis et al 24 160 17 (11) 7 (4.4)
Gomez et al 3s 72 17 (24) 1 (1.4)
Hartling et al 38 36 5 (14) o
Itani et al 41 1712 216 (14) 28 (1.6)
McCorkell at al S ? 57 7 (12) o
McDonald et al s9 85 5 (6) o
Weaver et al'°B 157 17 (11) 1 (0.6)
TOTAL 2597 316 (12) 43 (1.7)

'Percentage of all proximity wounds

214 FRYKBERG

arteriogram. Other studies have recently shown that this principle ap-
pears to apply equally well to blunt extremity trauma,4 including poste-
rior knee dislocationP, 46, 106
Essential to the success of physical examination in this setting is
careful counseling and follow-up of patients, so as to promptly detect
and treat the small number of occult vascular injuries that ultimately
require surgery.

Noninvasive Modalities

Noninvasive tests of extremity vascular injury include Doppler arte-

rial pressure measurements and duplex or B-mode ultrasonography,
which both have an established benefit in the evaluation of chronic
vascular disease. These have been advocated as more rapid, less costly,
less invasive, and equally accurate alternatives to arteriography for the
detection of asymptomatic vascular trauma.*
Doppler devices screen for arterial injury by measuring an arterial
pressure index, which is the ratio of blood pressure distal to an extremity
injury and that in an uninjured extremity. Diagnostic accuracy has been
reported as high as 95%,43,53 although sensitivity and specificity vary
according to whether an abnormal test is defined as less than either 1.0
or 0.9.94,108 Asymptomatic nonocclusive arterial injuries, such as intimal
flaps and false aneurysms, are not reliably detected with this method,
but the reduced use of arteriography led to a savings of over $65,000.43
Ultrasonography has the advantage of imaging extremity vessels
with nearly as much resolution as contrast arteriography, but more
rapidly, more safely, and at less expense. It can detect those minimal
arterial injuries that are generally missed by Doppler and physical
examination. This modality is highly operator dependenV' 5, 48, 94 but
with experienced interpretation has a diagnostic accuracy of 96% to 98%
and false-negative rates between 1% and 3%.5,10,61 It can also readily
diagnose venous injuries. 26 Sensitivity has been reported as low as 50%.5
As promising as these early reports are, the reliability of noninva-
sive screening of injured extremities is not yet sufficiently established to
either understand its proper role or allow management decisions based
solely on its results. All studies of these tests require abnormal results
to be confirmed by arteriography or operation. The reported true-nega-
tive rates in most studies are not confirmed by operation, arteriography,
or any documentation of the length of follow-up/' 10, 26, 43, 48 thereby
invalidating any clear expression of accuracy. Accuracy is unknown in
the setting of blunt trauma or in severely injured extremities with open
wounds, bone fractures, large hematomas, bulky dressings, or traction
devices. 3, 5, 91 Duplex ultrasonography and the expert interpretation it
requires are not available in most trauma centers when these patients
typically present. 91 These modalities have yet to be directly compared

*References 3, 5, 10, 26, 43, 48, 50, 53, 61, 75, 108
 ADVANCES IN DIAGNOSIS AND TREATMENT OF EXTREMITY VASCULAR TRAUMA 215

with or to demonstrate any advantage whatsoever over physical exami-

nation alone, which is obviously the least expensive and most widely
applicable screening method available. The basic premise of ultrasonog-
raphy is identical to that of surgical exploration and arteriography-that
the vessels at risk must be imaged and that all arterial abnormalities
must be found. Advocates of physical examination alone assert that this
is not necessary for the reasons discussed above, and its completely
comparable accuracy, which was achieved without any noninvasive
tests, supports this contention.29
The compelling evidence that is available on these issues indicates
that all diagnostic modalities currently being applied to extremity
trauma will probably play useful roles in specific settings (Fig. 2). Dopp-
ler pressures can serve as an extension of the physical examination in
such areas, for example, as objectively confirming a subjective impres-
sion of a diminished pulse. Duplex scans can probably supplant arteriog-
raphy in most of those equivocal circumstances that require vascular
imaging to confirm or exclude extremity vascular injury (see Table 3).
Arteriography will probably continue to be used to confirm equivocal
results from noninvasive tests and to evaluate truncal or thoracic outlet
vessels that are not evaluable by noninvasive tests or physical examina-
tion. Finally, surgical exploration will remain the ultimate diagnostic and
treatment modality when vascular injury cannot otherwise be excluded.
Because all of these screening methods have comparable accuracy in the

INJURED EXTREMITY

1 Resuscitation

PHYSICAL EXAMINATION

Hard Signs - - - - - - - - - - Absent or Soft Signs

----------- ------------ ~
l
Penetrating "Mechanism Blunt Mechanism - _(71 - --Duplex Scan'-
and/or
Doppler Pressures
/' \
/'/' \
Delayed Presentation /' \
Severe Bone Fracture /' \
Chronic Vascular Disease A~nOrmal Norl"(lal
Soft·TIssue Injury /' \
Shotgun Wound /' /' \
Thoracic Outlet Location /
j
Missile parajllel Vessels ARTERIOGRAPHY \
~ Yes ~ (Consider Percutaneous 8"L \
Hand·lnjected Study in ~U& \
ER or OR) "9"e" \
ro.

/~
"ve/, \
N10 ,~ Iy"r(f s.. \
\
~I). \

Surgical_ Positive (Occlusion Negative or "Minimal" ~NONOPERATIVE

Exploration or Extravasation) Nonocclusive Arterial Injury OBSERVATION

Figure 2. Algorithm of the suggested evaluation of injured extremities for vascular trauma.
Dotted lines indicate possible alternative modalities.
216 FRYKBERG

evaluation of extremity trauma, future investigations should focus more

on which modality offers the most efficient evaluation for the presence
of vascular injury in a specific circumstance. 29,30

ADVANCES IN TREATMENT

General Considerations

Many favorable advances have developed over the past two decades
in the treatment of extremity vascular trauma, which have collectively
contributed to the excellent results in limb salvage currently being
achieved. 16,86 Our improved understanding of resuscitation of hemor-
rhagic shock and of the management of critically injured patients has
improved the survival of these victims. Interventional radiographic tech-
niques have allowed definitive nonoperative treatment of a spectrum of
vascular injuries. 6o,95 Although repair of extremity venous injuries has
been shown to safely improve limb salvage and function,85 the accepta-
bly low morbidity of venous ligation has led to the current consensus
that venous repair should be performed only in stable patients with
simple injuries that can be managed rapidly?O, 111 Detection of asymptom-
atic venous injuries with venography generally is considered unneces-
sary, in view of the absence of any demonstrated benefit from their
treatment. 64 The substantial amputation rates that have been associated
with complex extremity injuries, which have extensive bone, nerve, and
soft tissue destruction in addition to vascular injury, have been greatly
improved by strict attention to rapid diagnosis, prompt revasculariza-
tion, thorough debridement, the use of temporary shunts, and liberal
application of fasciotomy.2, 6, 8, 72, 74 An increased awareness of compart-
ment syndrome in high-risk extremity vascular trauma has led to a trend
of aggressive and early fasciotomy that has been directly associated with
improved limb salvage. 19 Prosthetic grafts have been shown to be safe
and effective for the expeditious repair of complex vascular injuries
when autogenous vein cannot be used or when hemodynamic instability,
the severity of the extremity injury, or multiple associated injuries man-
date rapid reconstruction. 21 In the setting of extremity vascular injury
with extensive tissue loss, the use of myocutaneous flap coverage and
that of extra-anatomic bypass have substantially improved limb sal-
vageP

Nonoperative Observation

One of the most striking new directions that has been taken in
recent years in the treatment of vascular trauma has been the nonsurgical
management of select injuries. As arteriography was widely used since
the 1960s to evaluate injured extremities, its high sensitivity led to
the detection of a variety of subtle, asymptomatic arterial lesions of
 ADVANCES IN DIAGNOSIS AND TREATMENT OF EXTREMITY VASCULAR TRAUMA 217

questionable significance. These clinically occult arterial injuries are al-

most exclusively those detected in the setting of proximity extremity
wounds. They are as unique in their morphology as in their absence
of physical findings, consisting predominantly of intimal flaps, focal
narrowing, small false aneurysms, and arteriovenous fistulas. 12, 24, 28, 108
The nonocclusive nature of these injuries explains the absence of any
signs or symptoms of vascular compromise, and they make up only
about 8% of all arteriographically detected vascular injuries. 76
It has long been a standard practice to surgically explore and
"repair" all such minimal arteriographic abnormalities that follow
trauma. This was due to a widely held, but largely unfounded, percep-
tion that these lesions pose the same high risk of thrombosis and other
limb-threatening complications that the more common clinically obvious
vascular injuries do when untreated.* However, several studies have
shown that up to 89% of these distinct arterial injuries have not required
surgical intervention during follow-up periods that range up to 27
months. t Most of these lesions have been documented to completely
resolve on follow-up arteriography (Figs. 3 and 4). Intimal flaps and
focal narrowing are the most common minimal nonocclusive arterial
injuries, and they are the safest to observe. 12, 27, 28, 104 Although the dangers
of large, symptomatic false aneurysms are well known/ a substantial
number of small «1 cm), asymptomatic false aneurysms still resolve,
improve, or remain stable if provided the opportunity under a strict

*References 16, 32, 37, 45, 79, 80, 98, 101

+References 12, 27, 28, 31, 44, 57, 59, 67, 96, 104

Figure 3. A. Asymptomatic intimal flap of superficial femoral artery following gunshot wound
of thigh. B, Complete spontaneous resolution 1 week later. (From Dennis JW, Frykberg
ER, Crump JM, et al: New perspectives on the management of penetrating trauma in
proximity to major limb arteries. J Vasc Surg 11 :84, 1990; with permission.)
218 FRYKBERG

Figure 4. A, Asymptomatic focal narrowing of brachial artery following gunshot wound of

arm. B, Complete resolution after 10 days of nonoperative observation. (From Frykberg
ER, Vines FS, Alexander RH: The natural history of clinically occult arterial injuries: A
prospective evaluation. J Trauma 29:577-583, 1989; with permission.)

follow-up regimen.27, 89,90,96 The small minority of clinically occult arterial

injuries that deteriorate (all developing into false aneurysms, with no
reports ever clearly documenting thrombosis) do not develop any ad-
verse sequelae from the treatment delay if they are promptly repaired
when the deterioration is detected.
Experimental studies of surgically created intimal flaps in canine
arteries71,93 have reported as much as a 40% rate of subsequent thrombo-
sis within 3 weeks. These and other studies47,104 have suggested that
most intimal flaps, especially those that are large or are directed
"upstream," should be liberally operated upon and "repaired" owing
to a high risk of dissection and thrombosis. In fact, this conjecture is not
at all supported by available evidence (Fig. 5). The clinical relevance of
these experimental studies must be questioned, in view of the very
different results that are documented from nonoperative observation of
these lesions when they occur in humans suffering real trauma. There
appears to be no correlation between the natural history of minimal
arterial injuries and their radiographic appearance, anatomic location, or
mechanism of injury.27
There does appear to be a role for nonoperative observation of a
select minority of vascular injuries. In order to maximize the safety of
this approach, it should be applied only to those vascular injuries that
do not manifest hard signs and that occur in intact vessels without
extravasation or occlusion of contrast on arteriography. Any subsequent
development of hard signs mandates arteriography and surgical repair.
No other selection or management criteria have been proven to add to
the efficacy of this approach. Anticoagulation or antiplatelet medications
 ADVANCES IN DIAGNOSIS AND TREATMENT OF EXTREMITY VASCULAR TRAUMA 219

Figure 5. A, Large, upstream·directed intimal injury of superficial femoral artery following

gunshot wound of thigh with sciatic nerve injury, but no hard signs present. B, Marked
improvement in injury at 7-month follow-up. Clinical follow-up at 1 year showed no evidence
of vascular compromise. (From Frykberg ER, Vines FS, Alexander RH: The natural history
of clinically occult arterial injuries: A prospective evaluation. J Trauma 29:577-583, 1989;
with permission.)

do not appear to be necessary, as the successful results reported in most

clinical studies were achieved without these agents. Not a single instance
of limb loss or limb morbidity has clearly resulted from nonoperative
observation of clinically occult arterial injuries when carried out ac-
cording to the above criteria. If further follow-up and experience confirm
the safety of this management, the avoidance of potentially unnecessary
surgery will substantially benefit these patients, especially the critically
and multiply injured patients in whom these minimal arterial lesions
may occur.

SUMMARY

Extremity vascular trauma poses several difficult dilemmas in diag-

nosis and treatment. The still evolving trend in management of these
injuries is toward more rapid, less costly, and less invasive diagnostic
modalities, an improved understanding of the therapeutic implications
of the clinical presentation, prompt repair of significant vascular injuries,
and a liberal use of adjunctive techniques such as fasciotomy. Many
issues remain to be resolved by further experience and investigation, in
order to achieve optimal limb salvage in this setting.

ACKNOWLEDGMENTS
Grateful appreciation is extended to Sharon Omeechevarria for manuscript prepara-
tion and to Alicia Azouz for figure artwork.
220 FRYKBERG

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6. Bishara RA, Pasch AR, Lim LT, et al: Improved results in the treatment of civilian
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9. Burnett HF, Parnell CL, Williams GD, et al: Peripheral arterial injuries: A reassess-
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Department of Surgery
University of Florida Health Science Center
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