Peripheral Vascular Trauma

EAST Guidelines 2012

Level 1

1. Computed tomographic angiography (CTA) may be used as the primary diagnostic study for evaluation of penetrating lower extremity vascular injury when imaging is required.

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Level 2

1. Patients with hard signs of arterial injury (pulse deficit, pulsatile bleeding, bruit, thrill, expanding hematoma) should be surgically explored. There is no need for arteriogram in this setting unless the patient has an asociated skeletal or shotgun injury. Restoration of perfusion to an extremity with an arterial injury should be performed in less than 6 hours to maximize limb salvage (2002).

2. Patients (without hard signs of vascular injury) who have abnormal physical examination findings and/or an Ankle-Brachial Index (ABI) < 0.9 should have further evaluation to rule out vascular injury.

3. Patients with normal physical examination findings and an ABI > 0.9 may be discharged (in the absence of other injuries requiring admission).

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Level 3

1. In cases of hemorrhage from penetrating lower extremity trauma in which manual compression is unsuccessful, tourniquets may be used as a temporary adjunct for hemorrhage control until definitive repair.

2. The use of temporary intravascular shunts (TIVSs) may be indicated to restore arterial flow in combined vascular/orthopedic injuries (Gustillo IIIC fractures) to facilitate limb perfusion during orthopedic stabilization.

3. TIVSs may be indicated in “damage control” situations to facilitate limb perfusion when the physiologic status of the patient or operative capabilities prevent definitive repair.

4. There are no data to support the routine use of endovascular therapies following infrainguinal trauma.

5. Embolization of profunda branches or tibial vessels is acceptable, and there are no data to support preferential use of coils or n-butyl-2-cyanoacrylate (NCBA) glue.

6. The role of noninvasive Doppler pressure monitoring or duplex ultrasonography to confirm or exclude arterial injury is not well defined. There may be a role for these studies in patients with soft signs of vascular injury or with proximity injuries (2002).

7. Nonoperative observation of asymptomatic nonocclusive arterial injuries is acceptable (2002).

8. Repair of occult and asymptomatic nonocclusive arterial injuries managed nonoperatively that subsequently require repair can be done without significant increase in morbidity (2002).

9. Simple arterial repairs fare better than grafts. If complex repair is required, vein grafts seem to be the best choice. PTFE, however, is also an acceptable conduit (2002).

10. PTFE may be used in a contaminated field. Effort should be made to obtain soft tissue coverage (2002).

11. Tibial vessels may be ligated if there is documented flow distally (2002).

12. Early four-compartment lower leg fasciotomy should be applied liberally when there is an associated injury or there has been prolonged ischemia. If not performed, compartment pressures should be closely monitored (2002).

13. Arteriography for proximity is indicated only in patients with shotgun injuries (2002).

14. Completion arteriogram should be performed after arterial repair (2002).

Ankle/Brachial (lower extremity) or Wrist/Brachial (upper extremity)  indices using Doppler (DPI) of 1.0 or greater with normal PE excludes peripheral vascular injury in one large, retrospective study Doppler pressure indices (DPI) were determined by placing a blood pressure cuff on the ankle or wrist of the injured extremity and obtaining Doppler pressure measurements in both distal arteries. This pressure was then compared with the Doppler pressure of the brachial artery in an uninvolved arm. The ratio of these two numbers (ankle or wrist over brachial pressure) constitutes the index. The DPI was considered normal if it was 1.0 or greater whereas a DPI of less than 1.0 was considered abnormal.

(Am Surg 68:269 2002)

in another study, >.90 excluded vascular injury (ABI 0.90 was 100 sensitive and specific in prospective trial of 38 patients (J Trauma 2004;56:1261-5)

Hard Signs of Arterial Injury Absent distal pulses or distal ischemia Bruit or thrill at injury site Active pulsatile hemorrhage Large, pulsatile, or expanding hematoma

(soft signs)—small or stable hematoma, injury adjacent to nerve, history of unexplained hypotension, history of brisk hemorrhage, or proximity of injury to major vessels

aneurysm

pseudoaneurysm

av fistula

intimal flap

transection

Fasciotomies

Consider putting the stitches (vertical mattress) in the OR initially and tape them to the leg

Best review article on arterial side (Am J EM 2005;23:689)

Warm ischemia interval is 6 hours

arterial pressure index=ABI ankle brachial index

place on supine patient, use doppler on the brachial and then DP or PT

API of >0.9=very low risk for injury in blunt and penetrating

API may not detect injuries to profunda femoris, profunda brachii, or peroneal arteries.

Lesions that do not decrease blood flow (minor intimal flaps) may not be detected.

apply traction and correct gross deformities prior to APIs

World J Surg. 1999 Mar;23(3):252-5. Related Articles, Links Distal pulse palpation: is it reliable? Lundin M, Wiksten JP, Perakyla T, Lindfors O, Savolainen H, Skytta J, Lepantalo M. Department of Surgery, Division of Vascular Surgery, Helsinki University Central Hospital, P.O. Box 262, 00029 HUCH, Helsinki, Finland. The aim of this study was to evaluate the reliability of distal pulse palpation. The dorsalis pedis and the tibialis posterior arteries of 25 patients with suspected lower limb arterial disease were independently palpated by three vascular surgeons and three medical students in the outpatient clinic and by two vascular nurses and one physician in the vascular laboratory. The palpation findings were compared to the ankle/brachial index (ABI). The degree of misdiagnosis was unacceptably high, with an underdiagnosis of more than 30%. The poor agreement and the high proportion of misdiagnosis obtained in the outpatient clinic argue against the use of pulse palpation as a single diagnostic method. Palpable pulses with low ABIs clearly state the need for more objective measurements whenever ischemia is suspected. Ann R Coll Surg Engl. 1992 May;74(3):169-71. Related Articles, Links Peripheral pulse palpation: an unreliable physical sign. Brearley S, Shearman CP, Simms MH. Department of Surgery, Selly Oak Hospital, Birmingham. Fifty observers, including two fully trained vascular surgeons, were asked to determine the presence or absence of the femoral and distal pulses of four patients with peripheral vascular disease and one asymptomatic subject (50 pulses assessed). Pulses felt by both vascular surgeons were deemed to be palpable. Among the other observers, the sensitivity of palpation was 95% or over for the femoral pulse, but 33% to 60% for observers of varying experience feeling for the posterior tibial pulse. Up to 20% false-positive observations were reported. Accuracy was greater among more experienced observers, suggesting that careful teaching of this skill is likely to be beneficial. Even so, pulse palpation alone is an unreliable physical sign and should only be used in combination with objective measurements as a guide to clinical management Am Surg. 1996 Apr;62(4):315-9. Related Articles, Links Assessment of noninvasive lower extremity arterial testing versus pulse exam. Kazmers A, Koski ME, Groehn H, Oust G, Meeker C, Bickford-Laub T, Abson K, Bass N. Vascular Surgery Laboratory, Harper Hospital, Detroit, Michigan, 48201, USA. Palpation of pedal pulses was compared to noninvasive testing in 100 patients referred to a vascular laboratory. Given the frequent disparity of pulse exam and ankle pressures, noninvasive Doppler testing may be necessary for many patients to accurately assess the vascular status of the leg. n R Coll Surg Engl. 1992 May;74(3):166-8. Related Articles, Links Should we palpate foot pulses? Magee TR, Stanley PR, al Mufti R, Simpson L, Campbell WB. Royal Devon and Exeter Hospital Wonford. Palpation of foot pulses is traditionally used to evaluate patients with arterial disease. This study investigated observer variation in assessment of pedal vessels by pulse palpation and Doppler auscultation. Pedal pulse palpation in patients with arterial disease is subject to substantial observer error. Doppler pressure measurement is preferable unless pulses are bounding.

Arm

CT Scan

Multi-slice CT for eval of lower extremity arterial injuries (J Trauma 2006;60:502) It was sensitive and specific

Kenji performed best prospective trial to date (J Trauma 2011;70:808)

when excluding patients with obvious artifact (missle scatter, etc.)

they had 100% sens and spec

soft signs got MDCTA

they still observed soft signs for 24 hours even with this study?

Western Trauma Clinical Guideline

A. Bleeding from an injured extremity affects “Circulation” during the Primary Survey of Advanced Trauma Life Support and should be managed with direct pressure or a compressive dressing and ongoing resuscitation. In the absence of bleeding, the injured extremity is assessed during the Secondary Survey of Advanced Trauma Life Support. The assessment for a possible arterial injury is dependent on the presence of normal versus diminished or absent pulses on physical examination or use of the Doppler device. Therefore, a fracture or dislocation of a joint in the injured extremity should be realigned or relocated, respectively, should first palpation of distal pulses during the Secondary Survey document a difference between the injured and a contralateral uninjured extremity in the hemodynamically stable patient.16,17   B. “Hard” or overt signs of an arterial injury in an extremity are as follows: (1) external bleeding; (2) a rapidly expanding hematoma; (3) any of the classical signs of arterial occlusion (pulselessness, pallor, paresthesias, pain, paralysis = 5 “P”s); and (4) a palpable thrill/audible bruit.17,23 Immediate operation on the injured extremity is appropriate in the patient without other life-threatening injuries (see “C’ and “D” below). In the patient with an intracranial hematoma with midline shift of the brain, hemorrhage in the chest, abdomen or pelvis, gastrointestinal contamination in the abdomen, or injuries to vessels in two extremities, two operative teams, are appropriate. One team should manage the life-threatening injury elsewhere, while the second team should control peripheral arterial (or venous) hemorrhage or correct arterial occlusion and insert a temporary intraluminal shunt in the injured artery or vein.24   C. Patients with external bleeding or a rapidly expanding hematoma anywhere in an injured extremity undergo immediate operation. Other patients with presumed occlusion of a major named artery (limb is threatened) or clinical signs of an arteriovenous fistula (thrill/bruit) in the upper extremity, thigh (excluding the profunda femoris artery), or proximal to the anterior tibial artery and tibioperoneal bifurcation in the leg should undergo immediate operation, as well.13,17 The remaining hemodynamically stable patients with a presumed wall defect or occlusion of a named artery(i.e., doralis pedis pulse is absent, but foot is clearly well perfused) or clinical signs of an arteriovenous fistula in the distal two third of the leg should undergo diagnostic imaging (see “I,” “J,” and “K”) and possible therapeutic embolization versus nonoperative management (see “M”).25   D. If a hard sign of arterial injury is present, but localization of the defect is necessary (i.e., shotgun wound or multiple fractures), two rapid options are available. Either a preliminary surgeon-performed arteriogram is performed in the emergency center or operating room or a duplex ultrasonography study is performed by an experienced vascular surgeon or registered vascular technologist if it can be done in a timely fashion.26–28   E. “Soft” signs of an arterial injury in an extremity are as follows: (1) a history of arterial bleeding at the scene or in transit; (2) proximity of a penetrating wound or blunt injury to an artery; (3) a small nonpulsatile hematoma over an artery; and (4) a neurologic deficit originating in a nerve adjacent to a named artery.17,23 The incidence of arterial injuries in such patients ranges from 3% to 25%, depending on which soft sign or combination of soft signs is present.29–32 A physical examination that documents pulses at the wrist or ankle equal to those in the contralateral uninjured extremity is excellent evidence that no arterial injury or a limited arterial injury (i.e., intimal injury) is present.32–34 In addition to a comprehensive physical examination, one of the following should be performed: (1) Ankle or Brachial/Brachial Index (ABI or BBI = systolic blood pressure in extremity distal to area of injury/systolic blood pressure in brachial artery of uninjured upper extremity); (2) Arterial Pressure Index (API= Doppler arterial pressure distal to injury/Doppler arterial pressure in uninvolved upper extremity).35–38 Using a cutoff of >=0.9 to rule out the need for diagnostic imaging studies, the sensitivity and specificity as compared with clinical outcome have been reported to be >95%.36,38 In older patients with a greater incidence of preexisting peripheral arterial occlusive disease, the ABI and/or API may not be as accurate as in younger injured patients. For this reason, some trauma centers will use a difference in ABI or API of >=0.1 when comparing an injured extremity with an uninjured extremity as an indication for a diagnostic imaging study.   F. A patient with pulses at the wrist or ankle equal to those in the contralateral uninjured extremity or with an API >=0.9 in the injured extremity is discharged from the emergency room. This would include patients who have had reduction of posterior dislocation of the knee.34 Follow-up in these patients is described in “G.”   G. As 1% to 4% of these patients, primarily those with penetrating wounds, eventually come to operation as the original undetected injury (i.e., small pseudoaneurysm) progresses rather than heals, compulsive follow-up in the outpatient clinic is mandatory.29,32,33,39,40 This would include a comprehensive physical examination in addition to a noninvasive Doppler examination. Any abnormality in these evaluations would mandate the performance of a duplex ultrasound and/or standard or computed tomographic (CT) arteriogram.   H. A patient with diminished pulses at the wrist or ankle as compared with those in the contralateral uninjured extremity or with an API <0.9 in an injured extremity should undergo an imaging study to document the presence and location of a likely arterial injury.36–38,41 The choice of an imaging study varies depending on local expertise, but most data are available on arteriography, CT arteriography, or a duplex ultrasonography study.   I. Standard arteriography options include conventional film, digital subtraction after intra-arterial or intravenous injection of a contrast agent, or surgeon-performed “one-or two-shot” studies.26,42–44 Digital subtraction arteriography has replaced conventional film arteriography in most centers, because it decreases the time of examination, amount of contrast material, discomfort of the patient, and costs of films.42,43 A mobile digital subtraction arteriography unit can even be used in the trauma resuscitation room when surgeon-angiographers are available.45 If computed tomographic angiography (CTA) (see below) is not available, surgeon-performed arteriography can be performed in the emergency center using conventional films and one or two intra-arterial injections of 25 mL to 50 mL of meglumine diatrizoate dye. In the operating room, surgeon-performed arteriography can be performed under fluoroscopy or with the use of conventional films. Surgeon-performed percutaneous intra-arterial injection studies in injured patients have a complication rate of 1% to 4% and sensitivity/specificity greater than 95%.44,46 As certain contrast agents cause renal toxicity, adequate fluid resuscitation is mandatory before all the studies described.   J. Multidetector row helical CTA has the advantages of using only intravenous contrast, being readily available in almost all American hospitals evaluating injured patients, and having an accuracy comparable with that of conventional arteriography.47–50 As it can be readily performed at the same time as other CT evaluations, it is cost effective as well.50 Since conventional arteriography of the extremities has increased risks in children, CTA would be of particular benefit in this group. Limitations in diagnostic quality may occur when metallic fragments or bullets cause CT artifacts, but this was not a significant problem in a recent series from a military hospital.51 Also, no therapeutic interventions can be performed during the study. Finally, the increased contrast load needed may be detrimental in a patient with preexisting renal insufficiency or a concurrent renal injury.   K. Duplex ultrasonography is a combination of real-time B (brightness)-mode imaging and pulsed Doppler velocimetry that demonstrates anatomic relationships and flow.52 Flow to and from the point of the Doppler examination can be represented on a color scale as well. Numerous clinical studies have documented the excellent accuracy of duplex ultrasonography in assessing arterial injuries. While sensitivity has ranged from 50% to 100%, specificity and accuracy have consistently exceeded 95%.28,53–55 Disadvantages of this diagnostic approach include the initial cost of the equipment, need for 24-hour availability of a registered vascular technologist or experienced vascular surgeon trained in duplex, and concerns about studies in the axilla and bifurcated arteries in older studies.56   L. An imaging study that documents the presence of extravasation, an acute pulsatile hematoma or early pseudoaneurysm, occlusion, or an arteriovenous fistula of a major named artery mandates an emergent operation, depending on location. As in “C,” this would be appropriate in major named arterial injuries in the upper extremity, thigh excluding the profunda femoris artery, or proximal to the anterior tibial artery and tibioperoneal bifurcation in the leg.   M. In the hemodynamically stable patient, an imaging study that documents a wall defect with extravasation, occlusion, or the presence of an arteriovenous fistula in the profunda femoris, anterior tibial, posterior tibial, or peroneal arteries is followed by observation (occlusion) or therapeutic embolization (extravasation, arteriovenous fistula). A repeat arteriogram or duplex ultrasonography is performed 3 days to 5 days later in patients with occlusion to rule out the presence of an acute pulsatile hematoma or pseudoaneurysm developing from distal backflow.   N. An intimal defect documented on an imaging study is expected to heal 87% to 95% of the time without operation.33,57 In the absence of injuries to the brain, solid viscera of the abdomen, or extensive soft tissue wounds, some centers will initiate prophylaxis against thrombosis with heparin or aspirin during the period of observation. A patient who maintains flow to the hand or foot and has no clinical findings suggestive of a developing pseudoaneurysm or arteriovenous fistula is discharged home at the discretion of the attending surgeon. The patient is then reexamined in the outpatient clinic (see G). Patients who develop abrupt changes in perfusion to the hand or foot or signs of a new pseudoaneurysm or arteriovenous fistula undergo urgent diagnostic imaging.   O. Spasm of a peripheral artery in an injured extremity in a young patient is a common finding on imaging, whether or not the artery has been injured. If distal flow to the hand or foot is intact, observation with warming of the affected part of the extremity is appropriate. Before arterial spasm is thought to be the cause of an ischemic hand or foot, distal in situ thrombosis, distal embolism, or the presence of an advanced compartment syndrome must be ruled out.58 This mandates a repeat arteriographic study or emergent measurement of compartment pressures in both the proximal and distal limb. Severe limb-threatening arterial spasm has been treated with a proximal intra-arterial bolus injection of papaverine 60 mg followed by an infusion of 30 mg/h to 60 mg/h in the past.59 Another option used on rare occasions has been a proximal intra-arterial infusion of a solution of 1,000 mL normal saline; 1,000 units heparin; and 500 mg tolazoline at a rate of 30 mL/h to 60 mL/h.60,61 Currently used vasodilators in angiography suites include intra-arterial nitroglycerin (50–100 mg) or nifedipine (10 mg per os or sublingual).   P. It is difficult to assess pulses at the wrist or ankle or measure an ABI, a BBI, or an API in a patient who is obese or when the patient is in shock or is hypothermic.   Q. An oversized blood pressure cuff appropriate to the patient’s size should be used to assess an arterial pressure index in the obese patient.   R. A patient in shock or one who is hypothermic should be resuscitated in the usual fashion and treated with all the standard warming maneuvers. Palpation of distal pulses and/or another attempt at measuring an arterial pressure index should then be performed.  S. If a comparison (between the injured and the contralateral uninjured extremity) of pulses at the wrists or ankles or an ABI, a BBI, or an API cannot be completed in the now hemodynamically stable patient, a diagnostic imaging study should be performed on the injured extremity. This would be necessary, as well, if the hand or foot of the injured extremity seems to be cooler or have slower capillary refill at the fingernails/toenails as compared with the contralateral uninjured extremity.

(J Trauma 2011;70(6):1551)

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