Principles for Evaluation and

Treatment of Patients with

Vascular Injury
Timothy McHenry, MD

Overview
Epidemiology
Types of Injury
Evaluation
Treatment

Mechanisms of Vascular Injury
in the Extremities
Gunshot wound 54%
Stab wound 15%
Shotgun wound 12%
Blunt trauma 15%
Iatrogenic 3%
Types of Injuries
Active Hemorrhage
Laceration

Partial
transection

Complete
Transection
Types of Injury
Potentially non-occlusive
Contusion with:

Segmental Spasm


Thrombosis


True Aneurysm

Types of Injury
Potentially non-occlusive
Pseudoaneurysm


Arteriovenous Fistula


Intimal Flap
Presentation of Vascular Injury
First priority is
hemorrhage
control followed
by appropriate
diagnostic work-
up
Presentation of Vascular Injury
Dislocations and
displaced or
angulated
fractures:
realigned
immediately if
vascularity is
compromised
Evaluation for Vascular Injury
Physical Examination
Doppler Flowmeter
Duplex Ultrasonography
Arteriogram
Local wound exploration should
not be done in an uncontrolled
setting
Close coordination with a general
or vascular surgeon recommended

Physical Examination
Hard Signs

Absent or diminished distal pulses
Active hemorrhage
Large, expanding or pulsatile hematoma
Bruit or thrill
Distal ischemia (pain, pallor, paralysis,
paresthesias, coolness)

Physical Examination
Soft Signs

Small, stable hematoma
Injury to anatomically related nerve
Unexplained hypotension
History of hemorrhage no longer present
Proximity of injury to major vessel
Doppler Examination
Non-invasive adjunct to physical examination
Small, hand-held (non-directional) Doppler flowmeter
provides for subjective interpretation of audible signal
Useful as modality for determining the Ankle-Brachial
Index (ABI)

Doppler
Normal arterial signals are triphasic or
biphasic
Doppler
Flow distal to a transection may be absent
or monophasic and low-pitched due to
collateral circulation
Determination of Ankle-Brachial
Index
Appropriate sized blood pressure cuff is
placed above the ankle or wrist
Doppler derived opening pressure of distal
artery
Calculate by dividing ankle pressure by
brachial pressure
Measure injured/ uninjured sides
Normal ABI is 1.00 or greater
ABI Criteria
ABI > 0.9
Advantages
Strong negative predictor for major vascular injury
Objective noninvasive evidence of vascular
competence
Disadvantages
Does not exclude all injuries
Not useful in presence of vascular disease


Duplex (B-mode) Ultrasonography
Direction-sensing Duplex (B-mode)
ultrasound allows for visual waveform
analysis
Highly operator dependent
96-98% accurate in experienced hands
Generally not available during peak trauma
times

Arteriography
Gold standard for evaluation of peripheral
vascular injuries
Formal arteriograms done in radiology may cause
critical delays in diagnosis or intervention
Single-shot arteriograms done in the emergency
room or operating room should be considered in
cases where arteriography is indicated.
Indications for Arteriography
Multiple potential sites of injury (shotgun wounds)
Missile track parallels vessel over long distance
Blunt trauma with signs of vascular trauma
Chronic vascular disease
Extensive bone or soft tissue injury
Thoracic outlet wounds
Evaluation of equivocal results from non-invasive
tests
Proximity (gsw, knife wound) (controversial)
ABI < .9
Single-shot Arteriogram
21 or 20 gauge angiocatheter ( at least 2
long) or single lumen central line or a-
line kit
3 way stop-cock
30 cc syringes (x2)
Iodinated contrast (full strength)
Heparinized saline (1,000 IU/liter)
IV extension tubing
Consider inflow and/or outflow occlusion

Single-shot Arteriogram in the
Emergency or Operating Room
Summary of Evaluation
Initial priority is to control hemorrhage
Direct Pressure
Pressure Points
Tourniquet
If penetrating injury with one or more hard signs
of vascular injury then immediate surgical
exploration is usually warranted
If hard signs present with blunt mechanism or
multi-site penetrating mechanism then an
arteriogram may be warranted
If soft signs present, consider further diagnostic
modalities (usually initially non-invasive)
Treatment
Operative Repair
Indications:
injuries with hard signs of vascular injury

OR

arteriogram showing occlusion or extravasation
Treatment
Non-operative Observation
Certain non-occlusive injuries without hard signs
(often occult injuries) can be managed
conservatively
Criteria:
Low-velocity injury
Minimal arterial wall disruption
Intact distal circulation
No active hemorrhage
Serial arteriography or duplex scanning
recommended
Close coordination with a vascular or general
surgeon is recommended


Non-operative Management
Intimal injuries and segmental narrowing are most
amenable to conservative care and may resolve
over time
Small pseudoaneurysms sometimes enlarge,
become symptomatic and require operative repair
Asymptomatic acute AV fistulas may be less
certain to resolve and should be followed closely


Sequelae of Missed Arterial
Injuries
Deterioration of arterial injury can lead to:
Intimal dissection with resulting occlusion
Arteriovenous fistula
Thromboemboli
Stenosis
These can cause distal ischemia with
significant morbidity:
Pain
Gangrene
Amputation
Penetrating Arterial Injury
Limb Salvage Rates
World War II (Debakey and Simeone, 1946)
2,471 cases
51% salvage for ligation
64.2% salvage for repair
Viet Nam War (Rich et al, 1970)
1000 cases
28.5% with concomitant fractures
87% overall salvage
Recent civilian (Trooskin et al, 1993)
50 arterial and 17 venous injuries in 51 patients
22% with concomitant fractures
100% salvage
Other recent civilian studies approach a 100% salvage rate as
well


Blunt Arterial Injury Salvage
Rates
Have a high amputation rate due
to associated soft-tissue and
nerve injuries (the mangled
extremity)
These injuries may result in a
non-functional limb in spite of a
successful revascularization
Mangled Extremity
Indications for Primary Amputation
Anatomically complete disruption of sciatic or
posterior tibial nerves in adult even if vascular
injury is repairable
Prolonged warm ischemia time
Life threatening sequelae
rhabdomyolysis

Mangled Extremity
Relative Indications for Primary
Amputation
Serious associated polytrauma
Severe ipsilateral foot trauma
loss of plantar skin/weight bearing surface
Anticipated protracted course to obtain soft-
tissue coverage and skeletal reconstruction
Variables in Consideration of
Limb Viability
Skin/Muscle Injury
Bone Injury
Ischemia (time, degree)
Type of Vascular Injury
Shock
Age
Infection
Associated injuries (pulmonary, abdominal, head, etc.)
Comorbid Disease (peripheral vascular disease, diabetes
mellitus, etc.)

Classification Systems
Mangled Extremity Syndrome Index (MESI)
10 variables
Predictive Salvage Index (PSI)
4 variables
Mangled Extremity Severity Score (MESS)
4 variables
Limb Salvage Index (LSI)
7 variables
NISSSA scoring system
5 variables

Mangled Extremity Scoring System
Factor Score
Skeletal/soft-tissue injury
Low energy (stab, fracture, civilian gunshot wound) 1
Medium energy (open or multiple fracture) 2
High energy (shotgun or military gunshot wound, crush) 3
Very high energy (above plus gross contamination) 4
Limb Ischemia (double score for ischemia > 6 hours)
Pulse reduced or absent but perfusion normal 1
Pulseless, diminished capillary refill 2
Patient is cool, paralyzed, insensate, numb 3
Shock
Systolic blood pressure always >90 mm Hg 0
Systolic blood pressure transiently <90 mm Hg 1
Systolic blood pressure persistently <90 mm Hg 2
Age, yr
<30 0
30-50 1
>50 2
Mangled Extremity Severity
Score
All information for classification available
at time of ER presentation
Simplest to apply of all scoring systems
Most thoroughly studied
A score of less than 7 is supposed to predict
limb salvageability

LEAP Data
556 lower extremity injuries
prospectively scoredMESS, PSI, LSI, NISSSA,
HFS-97
High specificity (84-98%)
LOW SENSITIVITY (33-51%)
Not a substitute for clinical judgment and
experience for salvage vs amputation decision
making

Bosse et al, JBJS, 83-A, 2001
Mangled Extremity Management
Involves a determination of both the
feasibility (restoring viability) and
advisability (restoring function) of
salvaging the limb
Should be a coordinated effort of the
orthopaedic, vascular and plastic surgeons
starting at the initial evaluation of the
patient
Fasciotomies
Prophylactic fasciotomies after vascular repair
have been credited as being a major reason for
increased limb salvage rates in recent years
Fasciotomies after prolonged ischemia prevent
compartment syndrome that may result from
reperfusion injury
The reperfusion injury is delayed and may manifest
after the patient leaves the operating room



Indications for Fasciotomies
No absolute clinical indications for fasciotomy
exist
Subjective criteria
Extensive soft-tissue or bony injury
Progression of swelling
Compartment tightness
Objective criteria
Ischemia time greater than 6 hours
Compartment pressure within 20 mm Hg of diastolic blood
pressure



Morbidity of Fasciotomies
Increased risk of infection
Exposure of injured or ischemic muscle
Decreased fracture healing
Potentially converting a closed to an open fracture
Iatrogenic injury
Neuroma
Chronic venous insufficiency

Pharmacologic Treatment of
Reperfusion Injury
Following reperfusion, byproducts of anaerobic
metabolism may be released causing local and
systemic effects
Administration before reperfusion
Mannitol
Free radical scavenging
Heparin
Anti-coagulant
Anti-inflammatory
May be contraindicated in acute trauma
Issues Concerning Surgical Order
The order of surgical repair in penetrating
injuries requiring both vascular repair and
orthopaedic fixation is controversial:
Delayed revascularization until after
orthopaedic stabilization may adversely effect
limb salvage
Fractures instability or subsequent orthopaedic
stabilization may disrupt a vascular repair

Surgical Order
In general, revascularization takes precedence
over definitive orthopaedic fixation
In cases with gross fracture instability
a temporary vascular shunt can be placed and vascular
repair deferred until after orthopaedic fixation
If the ischemia time is short, consideration can be given to
application of a provisional unilateral external fixator
prior to revascularization
Temporary Vascular Shunt
Definitive Vascular Repair
Definitive Fixation
Definitive orthopaedic fixation should be
internal in most cases
Consider external fixation for:
Pediatric fractures
Extensive soft-tissue injuries
Contaminated wounds
Hemodynamically unstable patients

Penetrating Superficial Femoral
Artery Injury with Femur Fracture
Summary
The treatment of fractures or dislocations
with vascular injury requires close
coordination between the orthopaedic
surgeon and the vascular or general surgeon
to facilitate optimal limb outcome.
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