MANAGEMENT OF

VASCULAR TRAUMA
 Vascular Emergency Cases
• Vascular Trauma
• Ruptured aneurysm
• Acute Limb Ischemia
• DVT 
o Compartement Syndrome
o Phlegmasia Cerulea Dolens

• Ascending Infection (Diabetic

Foot)
 Vascular Trauma

• 90% of all peripheral arterial

injuries occur in extremity

• Extensive associated
musculoskeletal injury is
common
 Mechanism of Injury
• Penetrating trauma
o Gunshot wounds
o Cut wounds

• Blunt Trauma
o Motor vehicle
accidents
o Fall
Types of Vascular Injury
Primary survey :
• ABCD
• STOP BLEEDING
o Local compression
o Tourniquet
o Foley catheter
o Clamping &
ligation
 Damage control
Where by a rapid “bailout” operation
 Control hemorrhage & spillage
 Delayed reconstruction after the
patient’s physiology has been
stabilized

 Aim : to save the patient’s life

Secondary Survey :
Clinical Findings
Diagnostic evaluation
 Diagnostic evaluation
• Color Flow Duplex Ultrasound
o Non invasive, save, painless, easy to use,
relatively inexpensive
o Highly operator dependent
• CT Angiography
o 3D, high-resolution images
o specificity & sensitivity > 90%
 Angiography

Popliteal artery injury

Filling defect in popliteal artery
 Arterial Injuries Treatment
1. Non-operative management

 low-velocity Injury
 minimal (<5 mm) disruption for
intimal defects and
pseudoaneurysm
 adherent or downstream
protrusion of intimal flaps
 intact distal circulation
 no active hemorrhage
 Arterial Injuries Treatment
2. Operative Management

General principles
 Perioperative  antibiotics
 Initial goal  obtaining proximal control
 Incisions are placed longitudinally
 Debridement injured tissue
 Remove intraluminal thrombus  Forgarty
 Saline & heparin
 Operative Management
Repair of injured vessels:
• lateral suture patch angioplasty
• end‐to‐end anastomosis
• interposition graft
• bypass graft

• Monofilament 5.0 or 6.0 sutures are 
suitable for most peripheral vascular 
repairs
• All repairs should be tension free &
covered by viable soft tissue
 Vein Graft

Graft:
• Greater saphenous vein from uninjured extremity  most durable arterial 
graft
• expanded polytetrafluoroethylene (ePTFE)  prosthetic autogenous grafts
 Arterial Injuries Treatment
3. Endovascular management

 Trans Catheter embolization (coil /

balloon)
◦ low-flow arteriovenous fistulae
◦ false aneurysm
◦ active bleeding from noncritical arteries

 Endograft
◦  endoluminal repair of false aneurysms or large arteriovenous
fistulae
Trans
Catheter
Embolization

Large peroneal
artery false 
aneurysm (left) that 
was successfully 
treated by coil 
embolization (right)
Trauma
KIDNEY
 Specific
artErial injuries
 1. Axilary Artery
 Injury of axillary artery is more common than injury to
the subclavian artery
 Causes:
penetrating trauma, anterior shoulder dislocation,
fracture of the humeral neck
 Upper extremity critical ischemia : uncommon
 Endovascular therapy : high success rate
 Surgically approached : infraclavicular incision
 2. Brachial, Radial, & Ulnar
Arteries
• Brachial artery injuries  usually due to 
penetrating trauma & frequently iatrogenic
• Blunt injuries  supracondylar fractures of the 
humerus

• Single‐vessel injury in the forearm  need not be 

repaired but may be ligated or embolized
• Must be repaired if either the radial or ulnar 
artery, was previously traumatized or ligated
 3. Femoral Artery
• Blunt/penetrating injuries
to the superficial femoral
artery  very common

• Injuries to the proximal

deep femoral artery
should always be
repaired in
hemodynamically stable
patients
 4. Popliteal Artery
• The most challenging of all extremity vascular injuries
• The amputation rate for gunshot wounds 20%; stab
wounds near 0%
• The popliteal vein, infrapopliteal arteries, & tibial
nerve are frequently involved in penetrating injuries
 4. Popliteal
Artery
• Above the knee joint
 medial thigh incision
• Below-knee injury  leg
incision
• Injury directly behind
the knee 
approached from
behind
 5. Tibial Artery
• Isolated infrapopliteal injury rarely results in limb
ischemia  does not require therapeutic
intervention
• A single actively bleeding traumatized vessel 
simple ligation or angiographic embolization
• Tibioperoneal trunk or two infrapopliteal arteries are
injured  repair is required
 5. 
Tibial
Artery
 Extremity Venous Injuries
• Most commonly injured:
o Superficial femoral vein (42%)
o Popliteal vein (23%)
o Common femoral vein (14%)
• When localized  end-to-end or lateral
venorrhaphy should be performed if possible
unless the patient is unstable ligation
• When more extensive venous injuries exist, an
interposition, panel, or spiral graft can be
configured for repair
• When venous injury occurs with an ischemic
arterial injury  vein should be repaired before the
arterial repair is initiated
 Orthopedic Injuries
• The incidence of combined injury  0.3% to 6.4%
• The arterial repair should be performed first before
orthopedic stabilization addressed

• Massive musculoskeletal trauma  external

fixation must be accomplished before vascular
procedure  intraluminal shunts
• Inspect the vascular reconstruction before final
wound closure
 Soft Tissue Injury
• Major soft tissue injuries, debridement is
mandatory
• Unexplained fever & leukocytosis assumed to
be due deep tissue infection until proved
otherwise
• Delayed primary closure, rotational flaps, or free
tissue transfer  minimizes the risk of invasive
sepsis
 Primary Amputation vs.
Reconstruction
• Durham and colleagues  Mangled Extremity
Syndrome Index, MESS, Predictive Salvage Index,
and Limb Salvage Index  None of the indices
could predict functional outcome

• Extremity salvage:
o 90%  < 6 hours of ischemia
o 50% 12 to 18 hours of ischemia
o 20%  > 24 hours for ischemia
Primary Amputation vs. Reconstruction
Primary amputation done on patients with :
 Massive orthopedic, soft tissue, & nerve injuries
 Hemodynamically unstable patients in whom
a complex vascular repair might lessen
survival rate
THANK  
YOU…