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20 • Neck and Thoracic Outlet 245
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If necessary, an autogenous repair with a vein graft is
recommended, particularly in the presence of aerodigestive
tract injuries. However, in the absence of a contaminated
eld prosthetic grafts are a better size match for the common
carotid and have excellent patency (Fig. 20.5). For proximal internal carotid injuries, transposition of the external
carotid to internal carotid provides another option when
autogenous conduit is not available (Fig. 20.6). Zone III
internal carotid artery injuries may extend to the skull base,
thereby precluding direct operative repair. In this situation,
depending on the type of injury, nonoperative management
or an endovascular approach may be the better option. In
selected circumstances, ligation may be necessary, but this
is associated with a high incidence of stroke.52 Completed
vascular repairs should be tension free and covered by viable soft tissue. Intraoperative completion arteriography or
duplex scanning is helpful to document technical perfection of the repair and patency of distal arterial segments.53
Fig. 20.7 depicts a successful endovascular treatment of an
internal carotid artery pseudoaneurysm caused by a gun-
AA
shot wound to zones II and III of the neck.
Endovascular management permits repair of injuries
that are difcult or impossible to surgically expose (e.g., distal zone III injuries). Endovascular treatment is particularly
useful for treatment of ow-limiting dissections and size-
B
B
able pseudoaneurysms. Vascular access can be achieved
with a femoral approach followed by placement of a 70- to
80-cm sheath into the proximal common carotid artery.
Covered stents may be useful to quickly cover a pseudoaneurysm, but they are more likely to cause thrombosis than
uncovered stents so they should be used cautiously and
treated postoperatively with dual antiplatelet therapy for 3
months. Endovascular management is certain to expand as
hybrid operating rooms become more widely available and
surgeons become more adept at endovascular treatment
Fig. 20.3 Operative photograph of a left zone I common carotid artery
repair performed with a reversed greater saphenous vein interposition
graft (A). Note the position of the left common carotid origin posterior
to the innominate artery (B) on the aortic arch. In this approach, which
was through a median sternotomy extended proximally in continuity
with a left longitudinal cervical incision, the left subclavian artery origin
is not visible. (Operative photo courtesy Todd E. Rasmussen, the Uniformed Services University.)
modalities. The outcome of internal carotid artery ligation
or embolization for high zone III injuries is acceptable in
patients who remain neurologically intact with preligation
provocative temporary balloon occlusion testing.
VERTEBRAL
The vertebral artery arises as the rst branch of the subclavian, usually at the C6–C7 level. In up to 6% of individuals, the left vertebral artery arises directly from the aortic
should be administered to decrease the risk of thrombosis and
clot propagation. Intraluminal temporary vascular shunts
(such as the Sundt or Argyl) establish antegrade arterial ow
to the internal carotid artery and may be benecial in select
circumstances where other life-threatening injuries require
immediate attention and the operative surgeon has experience
with their use. Proximal common carotid injuries, however,
can be repaired without the use of a shunt in most instances.
The type of repair is dictated by the extent of injury. Primary repair or patch angioplasty is possible if the injury is
a simple, small laceration as might occur with a stab wound
(Fig. 20.4). For more extensive injuries, it is important to
identify and débride the injured arterial segment back to
normal artery. Repair of more extensive injuries will require
an end-to-end anastomosis, an interposition graft or, when
adjacent soft injury is extensive, a bypass graft (i.e., routed
away from the extensive soft tissue injury).
arch between the origins of the left common carotid and
left subclavian arteries.54 The vertebral artery is divided
into four anatomic segments (Fig. 20.8). V1 spans from the
origin until entry into the C6 transverse foramen. The V2
segment extends from entry into the C6 transverse foramen until exit from the transverse process of C2. V3 is the
extracranial segment between the transverse process of C2
and the base of the skull. V4 describes the intracranial segment, beginning at the entrance to the foramen magnum
and terminating at its junction with the contralateral vertebral artery forming the basilar artery. The redundant
nature of the posterior circulation reduces the likelihood of
adverse neurologic consequences should the smaller, nondominant vertebral artery need to be ligated.
55,56
Unilateral
hypoplasia of the vertebral artery occurs in approximately
10% of individuals and can be identied on preoperative CT
or catheter-based angiography.
40
246 SECTION 4 • The Management of Vascular Trauma
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Fig. 20.4 (A and B) Through and through injury to the common carotid artery from an ice pick managed by primary repair. (Operative photos courtesy
Damon Clark, University of Southern California.)
Management of a vertebral artery injury depends upon
which anatomic segment is injured, and on the condition
of the contralateral vertebral artery. Vertebral arteries are
more difcult to surgically access than the carotid, making
surgical repair challenging. Consequently, for most penetrating or blunt injuries, regardless of the segment injured,
ligation, embolization, or nonoperative management is
appropriate. It is important to determine, if possible, which
of the vertebral arteries is the larger or dominant vessel.
If it is determined that the injured artery is the dominant
or only vertebral artery, an effort should be made to maintain antegrade ow. When there is signicant hemorrhage
from a vertebral artery it should be surgically explored and
ligated or embolized, accepting the risk of a possible posterior circulation stroke.
For the rare injury requiring open repair, exposure of
the V1 segment of the vertebral artery is via a medial
transverse supraclavicular incision over the two heads
of the sternocleidomastoid. Dividing the heads or splitting the two heads longitudinally exposes the carotid
sheath. Opening the sheath, retracting the carotid medially, retracting the vagus nerve and internal jugular vein
laterally, and dividing the vertebral vein allows direct
access to the vertebral artery and proximal subclavian
artery.
Exposure of the V2–V4 segment is rarely necessary
and challenging as the V2 segment courses through the
Fig. 20.5 Interposition expanded polytetrafluoroethylene (ePTFE)
repair of right common carotid injury. (Operative photo courtesy Todd E.
Rasmussen, the Uniformed Services University.)
bony transverse foramina. Through the same exposure
discussed for the V1 segment, the longus coli muscle is
encountered in the deep posterior aspect of the neck. Once
20 • Neck and Thoracic Outlet 247
A
AB
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Fig. 20.6 Illustration of external
carotid–internal carotid tra nspos ition .
(A) Proximal ICA injury is depicted.
(B) Transposition is accomplished
by proximal mobilization of ECA
with transposition and end-to-end
anastomosis of the proximal ECA
and ICA distal to the injury. ECA,
B
External carotid artery; ICA, internal
carotid artery.
10.32*mm
10.32*mm
51.69*mm
51.69*mm
this muscle is swept off of the underlying bony structure,
the anterior tubercle of the transverse process and the
vertebral bodies are visualized. A bone rongeur may be
used to remove the anterior rim of the vertebral foramen
to expose the vertebral artery. Moderate to severe bleeding may occur during this part of the dissection due to
the venous plexus of the bony canal. Care should be taken
not to injure the cervical nerve roots, which lie directly
posterior to the artery. A posterior auricular approach is
required to expose the V3 segment of the artery, and the
V4 segment can only be exposed with a craniotomy. Exposure of V3 and V4 segments is best done with the assistance of a neurosurgeon.
SUBCLAVIAN
The left subclavian artery arises as the third and nal great
vessel from the aortic arch. The right subclavian artery
arises from the innominate artery. The subclavian artery
extends from its origin to the lateral border of the rst rib
and is divided into three segments based on the relationship
of the anterior scalene muscle (Fig. 20.9). The rst portion,
Fig. 20.7 (A) Angiogram of right internal carotid artery pseudoaneurysm
due to a shotgun blast to zones II and
III. The arrow points to the pseudoaneurysm. (B) Completion angiogram following endovascular treatment with a
bare-metal stent and coiling (arrow) of
the pseudoaneurysm.
medial to the anterior scalene muscle, contains the most
important branches, including the vertebral artery, the
internal mammary artery, and the thyrocervical trunk. The
second segment of the subclavian artery is posterior to the
anterior scalene, and the short third segment extends from
the lateral border of the anterior scalene muscle to the lateral edge of the rst rib, where it becomes the axillary artery.
The phrenic nerve lies either directly on or medial to the
anterior scalene muscle and can be injured during exposure
of the rst and second segments of the artery. The artery
anatomically is posterior to the subclavian vein, the vertebral vein, the anterior scalene muscle, and the thoracic duct
on the left.
55
Penetrating subclavian injuries are commonly associated
with hemodynamic instability, which requires immediate
surgical exploration. For injuries that are bleeding, temporizing measures including resuscitative thoracotomy in the
ED may be necessary. Rapid control has also been achieved
by inserting a Foley catheter in the wound tract and inating the balloon.9 Patients who are hemodynamically normal require CTA for delineation of the penetrating wound
and of the extent of vessel injury.
248 SECTION 4 • The Management of Vascular Trauma
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III II
I
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V4
V3
V2
V1
Fig. 20.8 Anatomic segments of the vertebral artery. V1 is from the subclavian origin to the entry into the C6 transverse foramen. V2 is from the
C6 transverse foramen to the exit from the bony canal at the transverse
process of C2. V3 is the extracranial segment between the transverse
process of C2 and the base of the skull. V4 is the intracranial segment,
terminating at its junction with the contralateral vertebral artery.
Anterior scalene
muscle
Ver tebral arter
Fig. 20.9 Anatomic segments of the subclavian artery. Segment I
extends from the subclavian origin to medial border of the anterior scalene muscle. Segment II is posterior to the anterior scalene muscle. Segment III extends from the lateral edge of the anterior scalene muscle to
the lateral edge of the first rib.
the right subclavian artery, a median sternotomy is necessary to achieve proximal control. The sternotomy incision may be combined with a supraclavicular extension
to allow full exposure of the right subclavian artery. On
the left, proximal control requires a third or fourth space
anterolateral thoracotomy due to the left subclavian's origin from the more posterior distal arch. Following proximal control, a supraclavicular incision can be made for
exposure. If the capability is present, proximal control of
either subclavian artery can also be achieved by endovascular balloon occlusion at the time of diagnostic angiography or operation.
If the vessel injury is localized to the second or third
segments of the subclavian artery on the left or right,
a supraclavicular incision may be all that is needed to
access and repair the injury. Injuries associated with cervical or supraclavicular swelling, mediastinal widening,
or intrathoracic bleeding may still require intrathoracic
proximal control. Distal control may be obtained bilaterally by exposure of the axillary artery through an infraclavicular incision.
9
For simple stab wounds, primary repair may be possible, but in most cases an interposition graft is necessary
for reconstruction. Prosthetic graft with 8-mm diameter
is recommended. Saphenous vein should be reserved for
cases of severe contamination due to the poor size match
between saphenous vein and the subclavian artery. When
extensive repair is required or if the patient is physiologically compromised, ligation can be performed as a damage
control maneuver. In cases in which the subclavian artery
must be ligated, the robust collateral network of the shoulder and supraclavicular fossa often provides enough perfusion to maintain a viable, if not relatively ischemic, arm and
hand. Concomitant venous injuries are common and lateral
repair is preferable to ligation, when possible. More complex
repairs are not necessary because subclavian vein ligation
is usually well tolerated, although it can be associated with
arm swelling. More proximal venous injuries involving the
brachiocephalic veins or the superior vena cava should be
repaired when possible.
Endovascular repair of subclavian artery injuries has been
performed in stable patients with success rates over 93%.
57–60
Endovascular therapy can be utilized as denitive treatment
or as a means to stabilize the patient and to provide a bridge
to denitive therapy. It is estimated that approximately 50%
of penetrating subclavian artery injuries are amenable to
endovascular treatment.
58,61,62
The procedure is performed in
conjunction with a diagnostic arteriogram via femoral access
and long sheaths or via an ipsilateral retrograde brachial
artery approach. Once the guidewire traverses the injured
segment, a covered stent can be delivered and deployed. If
coverage of the vertebral artery is necessary, a patent normal or dominant contralateral vertebral artery should be
documented by catheter-based angiography or CTA.
63
The anatomic location of the injury on the subclavian
artery dictates which operative exposure will best facilitate
vascular control and repair. For all operative repairs of
subclavian injuries, the neck and chest should be included
in the operative eld. For injuries of the rst segment of
Postoperative Care, Complications,
and Outcomes
Patients who undergo operative or endovascular repair
should be monitored postoperatively in the intensive care
20 • Neck and Thoracic Outlet 249
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unit (ICU) for vascular or neurologic changes. Cerebral
edema, and on rare occasions hemorrhagic conversion of
an infarct, may be preceded by headache and a deterioration
in neurologic status.64 Intracranial hypertension resulting
from cerebral injury is associated with hemodynamic instability, particularly bradycardia and hypertension. Continuous infusion of intravenous calcium channel blockers may
be used to lower blood pressure in patients who are hypertensive. With injury to extracranial cerebral vessels with or
without clinical neurologic change, the injured brain may
be sensitive to hypotension and prone to secondary brain
injury. As such, strict maintenance of a normal mean arterial pressure (70–90 mm Hg) and avoidance of hypoxemia
are crucial to limiting extension of any neurologic damage
in the ischemic penumbra.
65
For vascular injuries in the cervical region, postoperative
coagulopathy and soft tissue swelling may lead to airway
compromise. To protect the airway, endotracheal intubation should be maintained until the neck hematoma and
Fig. 20.10 Completed closure of right common carotid artery repair
over a closed suction drain. (Operative photo courtesy Todd E. Rasmus-
sen, the Uniformed Services University.)
edema have subsided. For zone I carotid and proximal subclavian injuries, monitoring of chest tube and wound drain
output as well as daily chest x-rays are required to promptly
detect unexpected bleeding. Chest CT may also be helpful in
identifying occult postoperative bleeding. Refractory hypotension and falling hemoglobin should prompt a return to
the operating room for wound exploration and hemorrhage
control.
Patients who have undergone axillary or subclavian
artery repairs run the risk of upper extremity reperfusion
injury and subsequent compartment syndrome. Although
this phenomenon is less common in the upper than in the
lower extremity, patients should be monitored closely in the
postoperative period for increased forearm or hand pain and
for the development of neurologic decits in the forearm or
hand. In patients who develop such symptoms, evaluation
of compartment pressures and/or performance of a forearm fasciotomy is indicated.
Nearly all cases of open operative repair of vascular
trauma in the thoracic outlet or cervical region should be
closed over a closed suction drain (e.g., at Jackson-Pratt
or similar closed suction drain) (Fig. 20.10). This practice
allows control and management of missed or inadvertent
injuries to the esophagus, or the thoracic duct should the
operative exposure have been of the left thoracic outlet.
Generally, there should be minimal if any output from these
drains. However, should there be persistent drainage, the
uid can be checked for elevated triglycerides and the presence of chylomicrons either of which would conrm an
injury to the thoracic duct.
66
In the absence of contraindications, postoperative antiplatelet therapy should be administered in the form of
aspirin if vein or prosthetic graft was used for arterial
reconstruction. Typically, antiplatelet therapy is continued for a minimum of 30 days. Patients undergoing stent
placement should be placed on dual antiplatelet therapy for
a minimum of 30 days and up to 6 months after the intervention. This has been recommended in patients undergoing stenting for atherosclerotic carotid disease67 and has
been conrmed to be of benet in the trauma literature as
68–70
well.
of the stent is recommended during follow-up to evaluate
for restenosis.
Repeat imaging using CTA or duplex ultrasound
67
The development of a postoperative lateralizing neurologic decit after carotid reconstruction is an ominous development. In most patients, this is due to either progressive
cerebral edema or occlusion of the arterial repair. Cerebral
edema should be managed by monitoring of intracranial
pressure, measures to limit brain swelling, and craniectomy
if refractory. If an occluded arterial repair is documented,
the decision for carotid exploration and repair depends
upon the degree of neurologic decit, the head CT scan ndings, and the hemodynamic stability of the patient. For stable patients with minimal to no evidence of cerebral injury
on brain CT, a rapid return to the OR for thrombectomy
and repair is indicated. As was the case with the primary
repair, gentle passage of a thrombectomy catheter distally
with the reestablishment of back-bleeding is required before
proceeding with formal repair and reperfusion. Intraoperative angiography is helpful to document complete evacuation thrombus and evaluate for stenoses or other causes of
early graft failure. For patients with a large cerebral injury
shown on head CT, nonoperative management is probably
the best course of action, as the prognosis is poor regardless
of whether or not ow can be established in through the
injured carotid artery segment.
Penetrating carotid artery trauma is associated with
an all-cause mortality of 60%, with a mortality due specically to the carotid injury of 20% to 42%.
71,72
Worse
outcomes are associated with hypotension or coma on
arrival at the ED. Internal carotid artery injuries have a
higher stroke rate than common carotid injuries because
antegrade internal carotid artery ow can be maintained
via retrograde ow from the external carotid.73 Operative
management of patients with a neurologic decit leads to
stabilization or improvement in the neurologic decit in up
to 92% of patients.28 Worse operative outcomes are associated with a gunshot wound versus a stab wound and with
more complex operative repairs. Endovascular therapy has
been focused on the management of carotid and vertebral
pseudoaneurysms that are surgically inaccessible. Multiple
studies evaluating the use of stents to treat cerebrovascular
injuries have shown high technical success with low stroke
and mortality rates.
53,68,69,74
250 SECTION 4 • The Management of Vascular Trauma
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The value of intensive screening and treatment for clinically occult blunt carotid and vertebral artery injuries cannot be overemphasized. If one can detect and then treat
BCVI with antiplatelet and or anticoagulation therapy, the
incidence of adverse neurologic events can be reduced. In a
retrospective review of 147 patients with BCVI, the stroke
rate was 25.8% for untreated patients versus 3.9% for those
receiving any mode of antiplatelet or anticoagulation therapy.75 Blunt carotid trauma tends to have a higher stroke
rate correlated with an increasing grade or severity of
injury. However, blunt vertebral artery injuries have a more
consistent stroke rate of approximately 20% for all grades
of injury.
6
A 2005 review of the National Trauma Data Bank documented that blunt carotid artery trauma leads to more
severe functional disability at discharge than penetrating
carotid trauma.76 At discharge, 78% of penetrating carotid
artery injury patients were fully independent versus 37%
of blunt carotid artery injury patients. The main cause of
disability was concomitant stroke and other associated nonvascular injuries such as traumatic brain injury.
The mortality rate for subclavian artery injury is approximately 34% for those who survive to the hospital, and
15% for those who survive to reach the OR.14 Open repair
is associated with early failure rates of approximately 5%.58
Endovascular management of a subclavian arterial injury
avoids the morbidity of extensive open exposures, but longterm durability remains to be seen. The overall incidence
of reported complications following endovascular subclavian artery repair is 12%, including arm effort fatigue,
stent thrombosis, and stent fracture.77 However, these complications can frequently be effectively managed with an
additional endovascular procedure. A study of 27 patients
who had subclavian and axillary artery injuries and who
were selectively treated with open or endovascular techniques demonstrated endovascular repair to be associated
with signicantly shorter operative time and blood loss,
with similar 1-year patency.61 These results suggest that
an endovascular approach can be advantageous in stable
patients, particularly those with subclavian pseudoaneurysms assuming the stent graft would not cover a dominant
vertebral artery.
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21
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Upper Extremity and Junctional
Zone Injuries
MATTHEW VUONCINO, JOSEPH M. WHITE, and W. DARRIN CLOUSE
Epidemiology of Upper Extremity
Vascular Injury
available studies, and several general comments pertaining
to the characterization of upper extremity vascular injury
and subsequent outcomes can be made.
Upper extremity vascular trauma is less common than
Reports from civilian and military settings have shown the
distribution and outcomes of major vascular injuries going
as far back as the Civil War (Table 21.1).
1–24
Although some
publications comment on and provide details related to vascular injury in the upper extremity, it is often difcult to discern specic epidemiology and outcomes of upper extremity
vascular injuries. An exception to this would be the contemporary epidemiologic characterization of the wars in Iraq
and Afghanistan.
1,23,24
Following implementation of a modern trauma system registry, detailed analysis of vascular
injury is now feasible. As a consequence, patterns concerning upper extremity vascular injury can be observed across
Table 21.1 Select Civilian and Military Series Reporting Upper Extremity Arterial Injuries.
Series Setting Year
Graham et al. Civilian 1955–78 93%:8% 93 93 NR NR NR
Mattox et al. Civilian 1958–88 NR 859 : 4901
Hardin et al. Civilian 1967–79 84%:16% 100 NR 21 43 36
Fitridge et al. Civilian 1969–91 55%:45% 114 16 12 62 24
Graham et al. Civilian 1970–80 95%:5% 85
Humphrey et al. Civilian 1970–90 59%:41%
Pasch et al. Civilian 1979–84 100%:0%
Costa et al. Civilian 1981–87 0%:100% 15 15 NR NR NR
Shaw et al. Civilian 1983–92 78%:12% 43 15 28 NR
Lin et al. Civilian 1991–2001 100%:0% 54 54 NR NR NR
Demetriades et al. Civilian 1993–97 100%:0% 79
Brown et al. Civilian 1992–98 70%:30% 64 6 13 26 5 6
Menakruru at al. Civilian 1996–2002 16%:84%
Zellweger et al. Civilian 1999–2002 97%:3% 124 NR NR 124 NR
Shanmugam et al. Civilian 2000–02 55%:44% 27 0 2 13 7 5
Dragas et al. Civilian/Military 1992–2006 77%:23% 189 3 41 104 40
Peck et al. Civilian 2004–06 88%:3%
DeBakey et al. Military WWII NR 864 : 1607 21 74 601 99 69
Hughes Military KW NR 112 : 192 3 20 89 NR
Rich et al. Military 1965–68 95%:1.1%
Clouse et al. Military 2004–05 85%:15% 43 10 25 23
Clouse et al. Military 2004–06 94%:6%
a
Data combines upper and lower extremity artery injury data.
b
Data combines upper extremity artery and venous injury data.
c
Data combines all cardiovascular injuries.
d
Data is for upper extremity artery injury only.
AVAG/P, Autologous vein or artery graft or patch angioplasty; KW, Korean war; LE, lower extremity; NR, not reported; UE, upper extremity.
Penetrating:
Blunt
c
a
a
a
a
a
that in the lower extremity, in both military and civilian environments. Historically, upper extremity vascular
injury accounts for approximately 30% of all vascular inju-
4,9,16
ries.
In several of the most recent civilian series, as well
as in the Balad Vascular Registry (BVR) and Department
of Defense Trauma Registry (DoDTR), upper extremity
arterial injury constitutes 30% to 40% of extremity arterial trauma. Penetrating mechanisms of injury are more
common than blunt mechanisms, especially in the military
setting. However, in civilian series, blunt mechanisms are
associated with a higher morbidity and mortality compared
to penetrating injury. This is mostly attributable to the
Injured Artery Distribution
Number of Injured
Arteries (UE:LE)
c
b
115 : 56 3 9 30 36 37
48 : 91 NR 15 33 NR
b
67 : 63 6 4 38 11 8
40 : 150 NR 4 25 11
350 : 650 8 59 283 NR
76 : 225 11 42 23
Subclavian Axillary Brachial Radial Ulnar
168 143 446 261
9 51 13 NR
59 NR NR
252
21 • Upper Extremity and Junctional Zone Injuries 253
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effects of concomitant injuries. Interestingly, recent epidemiologic data has demonstrated a transition with respect
to the most commonly injured vessels in the upper extremity. Previously, the brachial artery was reported as the vessel with the most signicant incidence of trauma; however,
distal or forearm vessels are now the most common injury
identied. The next most commonly injured are the brachial
vessels, whereas the axillary and subclavian arteries in the
junctional zone are the least frequently injured vessels of
the upper extremity. With respect to types of repair, primary, patch angioplasty, and autologous vein interposition
grafting are the most common techniques used to manage
vascular injuries in the arm.
The incidence of amputation associated with upper
extremity arterial injury ranges from 1% to 28% with
more recent reports demonstrating a rate of approximately 10%. It has been suggested that in modern military
settings, the rate of early limb loss with upper extremity
vascular injury may be more pronounced than in the
lower extremity.
1,2
Multimechanistic etiology with blast,
penetration, and burn are common. This, along with the
smaller surface area and soft tissue structure of the arm,
may lead to difculties with revascularization and soft tissue coverage. Mortality associated with upper extremity
vascular trauma is rare but not negligible, ranging from
0% to 34% and mostly attributable to concomitant head
and torso injuries.
Addressing Complex Upper
Extremity Vascular Injury
GENERAL CONSIDERATIONS
Unpredictable arterial injury patterns require that surgeons
be able to apply a diverse armamentarium of techniques.
Efcient application requires foresight of potential intraoperative and postoperative issues during the diagnostic and
assessments stage. Failure to correctly prepare can prolong
operative time and result in suboptimal outcomes. Intravenous access should be obtained in another uninjured
extremity, and central venous access may be helpful. As
detailed in previous chapters of this text, attention to resuscitation must be diligent.
Orthopedic and soft-tissue injuries often occur in tandem with upper extremity vascular injuries. This is especially germane in combat scenarios given the frequency of
high-energy weaponry and improvised explosive devices.
When faced with arterial injury in conjunction with bone
and/or nerve injuries, several concepts should be reviewed.
Orthopedic long bong injuries should be brought to length
with temporary xation before denitive vascular repair.
In most instances, when vascular and orthopedic injuries
occur together, wound concerns require external xation of
the fracture with permanent internal xation kept as an
option, if needed, once other aspects of injury are optimized.
Series Limb
Loss
c
a
a
a
a
40
32
40
462
47
c
a
a
a
a
15
4
14
4
1
c
a
a
a
a
c
47
63 (29%)
d
NR 16 (10%)
a
1639
a
15
a
13
NR NR NR 214 (24%)
424 (42%)
NR NR NR 7 (8.5%)
c
70 (32%)
NR 62 (45%)
a
90 (60%)
a
285 (29%)
c
NR 26 (11.4%)
a
a
a
13 (9%)
377 (38%)
a
1 (0.7%)
9 (6%) 12 (8%)
a
a
a
13%
19 (2%)
a
a
d
a
Series
Mortality
b
c
10 (4.8%)
0
2 (1.5%)
d
NR
c
a
b
a
NR
17 (1.7%)
14 (4.3%)
a
a
254 SECTION 4 • The Management of Vascular Trauma
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Temporary vascular shunts should be considered as a way
to quickly restore perfusion to the extremity before placement of external xation devices. This strategy or sequence
allows for expedited perfusion to the extremity, a more
thoughtful and well-done xation, and an easier platform
for denitive arterial and/or venous reconstruction.
Débridement of devitalized tissue should be performed
and, in some scenarios, primary amputation should be considered. In our experience, routing of vascular bypass grafts
through deep anatomic planes is possible in the majority of
cases. In instances where cavitary soft-tissue defects exist,
extraanatomic routes may be needed and deep intermuscular or subcutaneous planes can be used depending on
which path provides the best route for protecting the graft.
Consideration must be given to primary repair of concomitant nerve injuries versus tagging the nerve ends for
delayed neurorrhaphy once the wound has been stabilized.
As described in the following sections of this chapter, repair
of venous injury may improve limb outcomes and should be
entertained particularly with axillosubclavian injuries and
in the absence of other life-threatening injuries. We give
serious consideration to reconstruction of at least one vein
in the upper arm when brachial, cephalic, and basilic veins
have been disrupted (Fig. 21.1). The brachial or basilic veins
are favored for reconstruction because they lie within the
exposure eld required to manage the arterial injury and
are more easily covered with tissue.
TOURNIQUETS IN UPPER EXTREMITY VASCULAR
INJURY
The use of tourniquets in the modern civilian trauma setting has not been systematically endorsed, but the effectiveness of tourniquets has been demonstrated in the combat
environment. Early application of tourniquets in Operation
Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) has
proven effective and life-saving in patients with extremity
injuries. In 2009, Kragh et al. reported that application of a
tourniquet in the absence of shock in a prehospital setting
B
D
Fig. 21.1 View from the patient's head. A high-energy gunshot injury
to the left inner arm resulted in a “blowout” injury at the bullet exit site.
A greater saphenous vein (GSV) brachial artery to radial artery bypass
was performed to address the brachial artery injury, and a GSV interposition graft was used to repair the basilic vein injury. Fasciotomy was
performed. Arrows indicate cavitation injury, brachioradial GSV bypass,
basilic vein interposition, and median nerve. (A) Cavitation injury. (B)
Brachioradial GSV bypass. (C) Basilic vein. (D) Median nerve.
A
C
had a survival advantage as compared with application of
the tourniquet in the emergency department (ED) after the
patient had developed shock (90% vs. 10%; P < .001).
25,26
A
small percentage (1.7%) of patients experienced nerve palsy
at the application level, but no amputations resulted from
tourniquet use.
In another study by the Israeli Defense Forces, the use of
combat tourniquets was evaluated over 4 years. In all, 110
tourniquets were applied for extremity injury, of which 34
were used to treat upper limb trauma. In that study, 94% of
upper limb injuries were controlled by tourniquet, as compared to only 74% of lower extremity injuries.27 Neurologic
complications developed in seven limbs and four of these
involved nerve palsies of the upper extremity. Injuries distal
to the axillary artery are most amenable to control by tourniquet. Designs include windlass tourniquets, such as the
Combat Application Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet (SOFTT), both of which
are commonly issued to combat troops. The Emergency and
Military Tourniquet (EMT) has a pneumatic compression
design. One study of volunteers who self-applied the CAT,
SOFTT, or EMT found each design to consistently interrupt
distal perfusion as assessed by Doppler.
28
Historically, there had been apprehension about the use
of tourniquets in the prehospital setting. However, more
recent studies, largely propelled from modern combat experience in Iraq and Afghanistan, have shown tourniquets
to be an important means of preventing extremity hemorrhage death.
29,30
It is difcult to generalize this data to settings outside of military systems which, through extensive
training efforts and rapid medical transport, have created
circumstances that lend themselves to successful tourniquet use.31 Thus, although it may be premature for widespread use of tourniquets in the civilian setting, some upper
extremity vascular injuries would surely benet from their
use as long as they are removed as soon as possible.
Considerations for Management of Upper
Extremity Vascular Trauma
1. Tourniquets for hemorrhage control, temporary shunts
for early restoration of perfusion, and low threshold
for fasciotomy when facing delayed repair or complex
upper extremity injuries.
2. Prepare and drape the patient to allow for appropriate
proximal and distal control of the injury, as well as harvesting of autologous conduit such as saphenous vein.
3. Exposure in the upper extremity junctional zone is dif-
cult. Be prepared for sternotomy and thoracotomy.
4. Long bong fractures should be brought to length before
vascular repair. (Consider immediate vascular shunt
placement followed by placement of xation devices.)
5. Liberal use of interposition grafting and patching
avoids arterial narrowing that often results from primary repair.
6. Prosthetic conduit is an acceptable option in upper
extremity junctional zone injuries where size match is
important and where infectious complications are less
common than in the groin.
7. Repair of venous injury may improve limb outcomes
and should be entertained, particularly in the proximal
upper extremity or junctional zone.
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