Peripheral Arterial Injuries

Educational Objectives

The goal of this program is to improve management of peripheral arterial injuries (PAIs). After hearing and assimilating this program, the clinician will be better able to:

1. Determine presence of a PAI through use of imaging modalities.
2. Apply surgical technique to repair PAIs.

Summary

Introduction: airway and breathing are usually intact; use a tourniquet, packing, application of pressure, or a Foley balloon (for tamponade-specific injuries) to control hemorrhage; administer a 1:1:1 ratio of red blood cells, fresh frozen plasma, and platelets for resuscitation; a low Glasgow Coma Scale score may indicate the need for resuscitation to correct cerebral underperfusion

Signs of vascular injury in the extremity: hard signs — include, eg, active arterial pulsatile bleeding, signs of ischemia (eg, pulselessness), expanding hematoma, thrill, bruit; soft signs — include, eg, injury close to a vessel, localized neurologic deficit, nonexpanding hematoma, venous bleeding, large blood loss

Diagnostic adjuncts in the absence of hard signs of vascular injury: arterial pressure index (API) — Johansen et al (1990) found that API <0.9 has high sensitivity and specificity, and the negative predictive value of API >0.9 is ≈99%; computed tomography angiography (CTA) — indications include an ankle-brachial index (ABI) value <0.9 in the presence of soft signs of vascular injury or with multiple injuries to the extremity; artifact from retained bullet fragments render CTA nondiagnostic in ≈7% of patients and necessitate use of adjunct imaging (eg, duplex ultrasonography [US], catheter-based angiography) for diagnosis; duplex US — highly sensitive and specific; must be performed by a trained ultrasonographer, who may not be available when needed (eg, weekends, nights); not cost-effective as a primary diagnostic tool; formal catheter angiography — useful only in cases of nondiagnostic CTA

Initial management: directly bring patients with hard signs of vascular injury to the operating room (OR); patients with multiple levels of injuries or soft signs (including ABI <0.9) require CTA; a positive CTA warrants operative evaluation and treatment; consider orthopedic stabilization (ie, serial examinations and anticoagulation), formal angiography, or operative exploration for a patient with minor injury on CTA (including, eg, a small dissection flap that does not limit flow); a nondiagnostic CTA warrants formal angiography; pulse and compartment checks are appropriate for a patient with ABI >0.9 who requires additional surgery, but intraoperative angiography is warranted for a patient with ABI <0.9 undergoing additional surgery

Exposure of peripheral vasculature: brachial artery — often confused with the median nerve by inexperienced operators; femoral artery — located within the femoral triangle and distally extends through the Hunter canal; popliteal artery — injury to the popliteal artery is the most threatening limb injury; exposure may be daunting for inexperienced surgeons, but the medial portion can be exposed with the leg propped up and through creation of an incision 1 cm posterior to the femur, with extension to the tibia; saphenous vein — accessible via supine patient positioning (ideal)

Management of PAIs: debride devitalized tissue and clean the ends of severed arteries; consider thrombectomy and shunt placement; if plain imaging is not obtained prior to surgery, obtain intraoperative imaging prior to definitive fixation of a concomitant orthopedic injury; perform shunt placement prior to full exposure and fixation of the fractured bone, and perform definitive vascular repair after orthopedic repair; the blood vessel may be repaired by primary repair or interposition grafting; although interposition grafting is preferred (secondary to increased risk for anastomotic stricture with primary repair), primary repair may be appropriate when the ends of the vessel can be mobilized without any tension or for injuries not requiring significant debridement (eg, stab wound)

Thrombectomy: establishes proximal and distal flow in patients with prolonged ischemia; use a 3 Fr Fogarty catheter in the arm and below the knee; use a 4 Fr Fogarty catheter above the knee

Damage-control surgery for PAI: a patient with the lethal triad (ie, hypothermia, acidosis, and coagulopathy) should undergo shunt placement in the OR and resuscitation in the intensive care unit; shunt placement is appropriate in cases of delayed definitive repair

Arterial shunting: Rasmussen et al (2006) published the experience of using temporary vascular shunts for damage control in wounded military members; accepted indications include, eg, reduction of reperfusion time, damage control, and concomitant bony injuries; Inaba et al (2016) showed that shunts can remain in place ≤48 hr (anticoagulation was not used in 75% of patients); Wlodarczyk et al (2018) found that despite higher Abbreviated Injury Scale scores and Mangled Extremity Severity scores in extremities with shunts vs extremities without shunts, the rate of development of compartment syndrome was lower with shunts in place (15% vs 34%)

Conduits for interposition grafting: Veith et al (1986) found no statistical difference in long-term patency following above-knee grafting with polytetrafluoroethylene (PTFE) vs autologous vein; although the 2-yr patency rates were similar below the knee, the long-term patency rate for autologous vein was 68% vs 47% for PTFE; poor long-term outcomes have been noted with use of PTFE in the upper extremity; Stonko et al (2022) found no difference in rates of in-hospital complications with PTFE vs autologous vein

Prophylactic fasciotomy: consider for ischemia ≥6 hr, associated venous injuries, and prolonged hypotension

Delayed injuries: pseudoaneurysms and arteriovenous fistulas are known complications of PAIs; data regarding frequency or diagnosis are inadequate

Complications: deep vein thrombosis — associated with venous injuries; amputations — rate is high (overall rate of 16% includes blunt trauma; follows 6-10% of penetrating injuries); risks increase with major soft tissue injury, compartment syndrome, multiple arterial injuries, prolonged ischemia, and patient age >55 yr old; missile emboli — usually impact the heart, though data are inadequate

Readings

Feliciano DV, Moore EE, West MA, et al. Western Trauma Association critical decisions in trauma: evaluation and management of peripheral vascular injury, part II. J Trauma Acute Care Surg. 2013;75(3):391-7. doi: 10.1097/TA.0b013e3182994b48; Johansen K, Lynch K, Paun M, et al. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma. 1991;31(4):515-9;discussion 519-22. doi:10.1097/00005373-199007000-00064; Stonko DP, Betzold RD, Abdou H, et al. In-hospital outcomes in autogenous vein versus synthetic graft interposition for traumatic arterial injury: a propensity-matched cohort from PROOVIT. J Trauma Acute Care Surg. 2022;92(2):407-412. doi:10.1097/TA.0000000000003465; Veith FJ, Gupta SK, Ascer E, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg. 1986;3(1):104-114. doi:10.1067/mva.1986.avs0030104; Wlodarczyk JR, Thomas AS, Schroll R, et al. To shunt or not to shunt in combined orthopedic and vascular extremity trauma. J Trauma Acute Care Surg. 2018;85(6):1038-1042. doi:10.1097/TA.0000000000002065.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Cone was recorded at How to Save a Life: IR and Surgical Management of the Trauma Patient, held October 9-11, 2022, in Lake Buena Vista, FL, and presented by the University of Chicago Pritzker School of Medicine. For more information about upcoming CME activities from this presenter, please visit https://cme.uchicago.edu/SaveALife2022#group-tabs-node-course-default5. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS700502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation