- Vascular trauma can result from either blunt or penetrating injury
- Penetrating injury is more common in the USA than Europe
- Pattern of injury differs according to the mechanism of injury
- Blunt vascular trauma is associated with an increased amputation
rate
- Results from blunt injury being associated with significant
fractures and tissue loss
- The diagnosis of blunt vascular trauma is often delayed
Types of vascular injury
- Contusion
- Puncture
- Laceration
- Transection
Clinical features
- Depends on site, mechanism and extent of injury
- Signs classically divided into 'hard' and 'soft' sign
Hard signs of vascular injury
- Absent pulses
- Bruit or palpable thrill
- Active haemorrhage
- Expanding haematoma
- Distal ischaemia
Soft signs of vascular injury
- Haematoma
- History of haemorrhage at seen of accident
- Unexplained hypotension
- Peripheral nerve deficit
Investigation
- Hard signs often require urgent surgical exploration without prior
investigation
- Arteriography should be considered:
- To confirm extent of injury in stable patient with equivocal signs
- To exclude injury in patient without hard signs but strong
suspicion of vascular injury
- The role of doppler ultrasound in vascular trauma remains to be
defined
Management
- Often requires a multidisciplinary approach with orthopaedic and
plastic surgeons
- Aims of surgery are to:
- Control life-threatening haemorrhage
- Prevent limb ischaemia
- If surgery is delayed more than 6 hours revascularisation is
unlikely to be successful
- The use of arterial shunts is controversial
- May reduce ischaemic time and allow early fixation of fractures
Vascular repair
- Usually performed after gaining proximal control and wound
debridement
- Options include :
- Simple suture of puncture hole or laceration
- Vein patch angioplasty
- Resection and end-to-end anastomosis
- Interpositional graft
- Contralateral saphenous vein is the ideal interpositional graft
- Prosthetic graft material may be used if poor vein or bilateral limb
trauma
Primary amputation
- Usually considered in two situations
- Severe injury with significant risk of reperfusion injury
- The limb is likely to be painful and useless
Complications of vascular injury
False aneurysm
- Most commonly occurs following catheterisation of femoral artery
- Often presents with pain, bruising and a pulsatile swelling
- Diagnosis can be confirmed by doppler ultrasound
- May respond to ultrasound guided compression therapy
- Suturing of puncture site may be required
- Vein patching may be required
Picture provided by Samuel Zhou, Burnley General
Hospital, Burnley, United Kingdom
Picture provided by Bill Humphreys, Bangor General
Hospital, United kingdom
Picture provided by Joe Das, Government Medical
College, Thiruvananthapuram, Kerala, India
Picture provided by Chris Pring, St Jame's University
Hospital, Leeds, United Kingdom
Arteriovenous fistula
- Often presents several weeks after the injury
- Patient complains of a swollen limb with dilated superficial veins
- Machinery type bruit often present throughout cardiac cycle
- Diagnosis can be confirmed by angiography
- Fistula can be divided an both the vein and artery sutured
- Flap of fascia can be interposed between vessels to reduce risk of
recurrence
Bibliography
Baker W E, Wassermann J. Unsuspected
vascular trauma. Emerg Med Clin North Am 2004; 22:
1087-1098.
Frykberg E R.
Advances in the diagnosis and treatment of extremity vascular
trauma. Surg Clin North Am
1995; 75: 207-223.
Feld R,
Patton G M, Carabasi A
et al. Treatment of
iatrogenic femoral artery injuries with ultrasound guided compression.
J Vasc Surg 1992;
16: 832-240.
South L M. Arterial injury. Hosp
Med 2002; 63: 553-555. |