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

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

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.

 

 
 

Last updated: 03 January 2010

Copyright © 1997- 2010 Surgical-tutor.org.uk