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Vascular trauma

  • 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

Interpositional vein graft for repair of the superficial femoral artery

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

Colour flow doppler of a false aneurysm

Picture provided by Samuel Zhou, Burnley General Hospital, Burnley, United Kingdom

femoral false aneurysm

Picture provided by Bill Humphreys, Bangor General Hospital, United kingdom

Brachial false aneurysm

Picture provided by Joe Das, Government Medical College, Thiruvananthapuram, Kerala, India

Radial false aneurysm

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.

South L M.  Arterial injury.  Hosp Med 2002;  63:  553-555.
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