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21 • Upper Extremity and Junctional Zone Injuries 265
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Operative Technique
Proximal control of the forearm vessels may require exposure of the distal brachial artery bifurcation. The patient is
positioned supine with the arm abducted 60 to 90 degrees
and supported on an arm-board. One should expose the
brachial bifurcation at the antecubital fossa through an
S-shaped incision across the antecubital crease while at the
same time identifying and protecting the basilic vein and
medial antebrachial cutaneous nerve. One can then divide
the bicipital aponeurosis to expose the brachial artery
which can be exposed distally to identify its bifurcation and
the proximal portions of the radial and ulnar arteries.
Generally, longitudinal incisions in the axis of the forearm are used to approach the mid and distal segments of
the radial and ulnar arteries. For the radial artery, the plane
of the incision extends from the midpoint of the antecubital
fossa to the styloid process of the radius, corresponding to
the groove on the medial edge of the brachioradialis muscle.
The extent of incision is based on the specic injury pattern
and the section of the artery requiring exposure. One can
divide the antebrachial fascia and in the proximal and midportions of the forearm, the radial artery will be deep to
the medial bers of the brachioradialis muscle and can be
exposed in the groove between this muscle and the pronator teres. In the distal forearm, the radial artery lies deep to
the fascia, between the tendons of the brachioradialis and
exor carpi radialis muscles. In the middle third of the forearm, one should identify and protect the supercial radial
nerve which lies closely adjacent to the radial artery. At
the wrist, a longitudinal incision is created directly over the
radial artery just proximal to the styloid process. The radial
artery lies directly underneath the antebrachial fascia.
The proximal ulnar artery is relatively deep and can be
challenging to expose. To accomplish this, a longitudinal
incision is created four ngerbreadths distal to the medial
epicondyle of the humerus extending on the plane from the
medial epicondyle to the pisiform. One should then divide
the antecubital fascai to expose the ulnar artery between
the exor carpi ulnaris and the exor digitorum supercialis muscles. In the middle of the forearm, the artery lies
deep to the exor carpi ulnaris muscle. Of note, the ulnar
nerve accompanies the artery near the border of the upper,
middle-third of the forearm and should be identied and
protected. In the wrist, the ulnar artery can be exposed
through a longitudinal incision on the radial side of the
exor carpi ulnaris in order to avoid the ulnar nerve, which
will be lateral to the artery at this level. At the wrist, a longitudinal incision is created over the ulnar artery just lateral to the exor carpi ulnaris muscle. The ulnar artery lies
directly underneath the antebrachial fascia.
Upper Extremity Venous Injury
Most upper extremity venous injuries can be ligated. Ligation is indicated for the smaller and more distal veins of the
forearm and most venous injuries between the elbow and
the axilla. Ligation is particularly indicated when the surgeon is in a resource-limited or austere condition and when
other life-threatening injuries takes priority. If the patient’s
condition permits, repair of larger more proximal veins of
the upper arm and axilla may reduce venous hypertension and its sequelae. Efforts to maintain venous outow of
the arm are most appropriate in the setting of a penetrating wound that has disrupted what is otherwise a generous venous collateral circulation.
repair gained popularity during the Vietnam War with Rich
reporting successful repair of 124 (33%) of 377 injuries.
Lateral suture was the most common form of reconstruction (n = 106) followed by end-to-end anastomosis (n = 10),
and vein interposition (n = 5) and patch (n = 3).54 Rich and
colleagues noted a low rate of thromboembolic complications, suggested that venous repair may play a role in limb
salvage, and posited that failed venous repair often recanalizes with a good result.
In a more-recent military series, Quan et al. reviewed
82 patients with 103 venous injuries sustained in the Iraq
War.55 The majority of patients (63%) in that series were
treated with ligation with no observed difference in postoperative thromboembolic complications between the ligated
and repaired groups. In 2009, Gifford and colleagues identied venous repair as protective against amputation (RR =
0.2; 95% CI [0.04–0.99], P = .05) in their evaluation of 135
injuries, 35 of which were to the upper extremity.49 These
studies and personal experiences have led these authors to
recommend selective ligation of extremity venous injury
(i.e., ligate some but not all).
Few civilian experiences have reported on upper extremity venous repair. Meyers et al. reported 34 patients with
venous injury (26 lower and 8 upper extremity) showing
an early patency rate of 61% for all repairs; 40% for interposition vein graft repairs. This report did not detail the differences between upper and lower extremity outcomes.56
Nypaver and colleagues reviewed longer-term follow-up
(mean 49 months; range 6–108 months) for 32 patients
who had venous reconstruction, and found long-term
patency to be 90% as determined by Duplex ultrasound.57
However, only six upper extremity vein reconstructions
(one axillary, ve brachial) were performed in this series and
60% of the brachial vein repairs eventually occluded.
54
52,53
Extremity venous
Endovascular Management of
Upper Extremity Vascular Injuries
As endovascular technologies have been developed for the
treatment of cardiovascular disease conditions, their use
in the diagnosis and management of trauma has become
more common.58 Several descriptions of endovascular
therapies in the Iraq and Afghanistan Wars can be found in
the literature, including Rasmussen and colleagues’ initial
report on the development and implementation of endovascular capability at a level III facility in Iraq.59 During this
period, 150 catheter-based procedures were performed, 12
of which included angiographic evaluation of the upper
extremity vasculature with two patients undergoing covered stent placement for axillosubclavian artery injury.
Catheter-based techniques may offer advantages for
proximal upper extremity and junctional zone injuries in
the acute setting, as well as for the less-urgent sequelae of
vascular trauma such as arteriovenous stula and pseudoaneurysm (Fig. 21.12). Endovascular approaches for the
266 SECTION 4 • The Management of Vascular Trauma
AB
AB
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A B
Fig. 21.12 (A) A 21-year-old (with
multiple injuries caused by an
improvised explosive device, including bilateral lower extremity long
bone fractures) underwent “clamshell” thoracotomy for bilateral hilar
injuries and subsequent laparotomy
with multiple enteric injuries. A large
6-cm pseudoaneurysm of the axillary brachial junction was identified
on CT angiogram postoperatively.
(B) A retrograde left brachial artery
endovascular approach allowed for
deployment of covered stents.
A B
axillary region may help avoid the morbidity associated with
emergent open operations in a hematoma near or around
the brachial plexus. The use of covered stents in the subclavian and axillary artery positions is evolving into a favored
alternative for the management of blunt and penetrating
injury to these vessels (Fig. 21.13).
60,61
Endovascular control and repair of junctional and upper extremity injuries
can even be considered in the presence of hard signs of
vascular injury. As hybrid operating rooms (i.e., open and
endovascular capabilities) become more commonplace,
starting with catheter-based techniques and converting to
an open operation as needed is favored by many surgeons
and trauma teams.
When the patient is stable and there are soft signs of vascular injury, CTA or Duplex allow for conrmation of an
injury and more organized planning for endovascular treatment. When there are hard signs of injury, the patient may
be taken directly for angiography and endovascular therapy
without preliminary imaging. Rapid control of the proximal brachial and axillosubclavian arteries can be achieved
with endovascular balloon occlusion, with follow-on
Fig. 21.13 (A) A 30-year-old woman
sustained a high-impact blunt injury
to her right shoulder with a clavicle
fracture. Active extravasation was
seen from the subclavian artery. (B)
Covered stent endovascular repair
was performed from a femoral
access approach.
management with a stent graft or open operative repair.
Endovascular control and repair of axillosubclavian injury
may require antegrade femoral access, retrograde brachial
access, or both. Passing the wire under uoroscopic guidance across the vessel disruption from either the antegrade
femoral or retrograde brachial approach may be challenging. The shorter distance from the access site to the injury
makes a retrograde brachial approach preferable in many
situations. Directional catheters and balloon centering and
guidance are other techniques to achieve wire access across
the injured vessel.
Self-expanding and balloon-expandable covered stents
are effective in managing select innominate and axillosubclavian injuries. In contrast, bare metal stents are
more commonly used for the treatment of intimal aps or
dissections. A multicenter trial evaluating the use of the
self-expanding Wallgraft Endoprothesis (Boston Scientic;
Natick, MA) for the treatment of 62 iliac, femoral or subclavian arterial injuries showed that self-expanding stents
achieved injury exclusion 94% of the time, including in
90% of subclavian artery injuries.62 Freedom from bypass
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was achieved in 100% of injured subclavian arteries. There
was no procedure-related mortality in that experience and
the most common complication involved eventual stenosis
or occlusion. Although data support endovascular management of extremity arterial injury, most of the procedures in
this series were for iatrogenic injury (78%) and extrapolation of these results should be done with caution.
Du Toit and colleagues reported 57 patients with penetrating subclavian artery injury who underwent stent-graft
treatment over a 10-year period.63 The most common injury
was pseudoaneurysm (74%) followed by arteriovenous stulas (21%) and occlusion (5%). None of the patients undergoing endovascular treatment required conversion to open
repair and the catheter-based approach was successful in all
cases as conrmed by angiography. One patient in this series
died due to other injuries, and three (5%) developed early,
non–limb-threatening stent-graft occlusion. Follow-up
data was available for 16 patients at a mean of 61 months
showing that ve had claudication and roughly half had
in-stent stenosis that was treated with balloon angioplasty.
Three asymptomatic patients in the follow-up cohort
had asymptomatic stent occlusion that did not require
intervention.
There are also case reports of the use of endografts in
the setting of upper extremity arterial trauma.
64–71
Hershberger et al. reviewed 195 studies published between
1995 and 2007 showing that endovascular treatment of
supradiaphragmatic arterial injury was successful in 96%
of cases.72 When all reports reviewing endovascular treatment of innominate (n = 7), subclavian (n = 91), and
axillary (n = 12) artery injuries were assessed, technical
success was achieved in 86%, 97%, and 100% of cases,
respectively. Procedural morbidity ranged between 0 and
12% depending on the anatomic location of the injury. Rare
complications associated with endovascular repair of upper
extremity vascular injury include access-site pseudoaneurysm, arm claudication, and stent fracture and thrombosis.
Although short-term durability of endovascular repair
has been suggested to be equivalent to operative repair, the
durability of either approach is not well-dened.
60,61,63,73–75
Despite concerns related to the durability of endovascular
repairs, results are encouraging with patency rates that
appear to be acceptable with few reports of open surgery
to revascularize after a failed upper extremity stent-graft
placement. The possibility of infection is a legitimate concern, but there is no suggestion that the use of covered
stents in trauma patients poses undue risk. The authors are
not aware of stent graft–related infectious complications
in the admittedly low number of grafts placed in Iraq and
Afghanistan. It is likely that case selection plays a role in limiting infectious complications associated with endovascular repair and that upper extremity/junctional injuries are
prone to fewer infections than injuries in other body regions.
The younger age of the trauma population makes attaining meaningful follow-up of these procedures difcult
and thus the data on patency and the effect of antiplatelet
therapy for these interventions is limited. However, the use
of endovascular stents as a rst option does not preclude
subsequent catheter-based procedures to assist patency
or future open repair if needed. As endovascular capabilities improve, their application in the management of more
distal upper extremity injuries seems likely. Reports of
endovascular intervention for brachial artery transection
have been published, although the long-term results of this
approach are unknown.
76
Nonoperative Management in
Upper Extremity Injury
Nonocclusive arterial injuries including pseudoaneurysm, intimal ap, and non–ow-limiting stenosis may be
managed nonoperatively.
77,78
Anticoagulants or antiplatelet therapy should be considered in the management of a
contained ap or with dissection-type injuries. These injuries must be monitored closely in the early phases of nonoperative care and treated with prompt endovascular or open
intervention if ischemic symptoms develop. Follow-up at
regular intervals is advisable for these injuries and should
include surveillance with noninvasive techniques such as
Duplex ultrasound.
Postoperative Care
MONITORING
Patients require close monitoring after treatment of the
injured limb and its circulation. The decision to admit the
patient to the intensive care unit or to an intermediate
care ward is institution-specific and depends on blood
loss and the need for resuscitation, rewarming, and correction of physiology. Continuous-wave Doppler helps
assess the adequacy of any vascular repair before return
of a palpable pulse, although the mere presence of an
arterial signal does not mean that the reconstruction is
patent. Other measures of perfusion include temperature, the presence or absence of sensorimotor function,
and capillary refill. Duplex can also be used to assess
patency of any vascular repair and in some cases identify
a technical defect that can require early reintervention.
For some injuries, the patient may also need monitoring for the development of extremity compartment syndrome.
WOUND CARE
Negative pressure dressings (e.g., vacuum-assisted closure
[VAC] dressing) can be benecial for controlling wounds in
which skin closure is not feasible. Negative pressure wound
therapy promotes wound granulation, but vascular repairs
should be covered with viable soft tissue or muscle to prevent
contact between the vacuum dressing sponge and the vessel
in order to prevent desiccation and disruption of the vessel
or anastomosis.
vascular repair can be delayed, soft-tissue coverage of the vessels must be completed as soon as possible, whether through
delayed primar y closure, skin graft, or muscle ap (Fig. 21.14).
REHABILITATION
Physical and occupational therapy should be started as
soon as possible after upper extremity injury to prevent
79,80
Similarly, whereas wound closure over a
268 SECTION 4 • The Management of Vascular Trauma
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AA
Fig. 21.14 (A) Wound vacuum-assisted closure (VAC) placement after a forearm fasciotomy was performed. (B) Maintenance of domain allowed for a
delayed primary closure to be performed. Full closure was achieved post injury day 6.
muscular contractures and atrophy. Checking for sensorimotor deficits is a requisite for therapy that is aimed
at regaining, or learning to compensate for, lost function. The timing of rehabilitation (e.g., range of motion,
weight-bearing) should be coordinated among the various specialists involved in the care of patients with
upper extremity vascular trauma. The intricate and
complex tasks of the hand and arm make rehabilitation of upper more challenging than that of the lower
extremity.
Complications After Upper
Extremity Vascular Injury
Complications after upper extremity arterial injury and
repair include reperfusion injury, thrombosis, anastomotic
hemorrhage, infection, and pseudoaneurysm. The risk of
complication varies according to the type and severity
of injury, but has not been well-dened in the literature.
In the authors' experience with 45 war-injured patients,
the rate of early complications after repair included infection (5%), thrombosis (9%), anastomotic hemorrhage
(2%), and early amputation (9%).2 A high index of suspicion with repeat clinical evaluations and use of Duplex
ultrasound and/or CTA is recommended to enable early
diagnosis of postoperative complications and mitigation
of their effects.
COMPARTMENT SYNDROME
Although less commonly observed in the upper extremity
compared with the lower extremity, compar tment syndrome
may affect the forearm or, less frequently, the upper arm
(triceps/deltoid). The diagnosis should always be considered
in any patient with blunt or penetrating extremity trauma,
B
particularly in patients who have endured prolonged ischemia or transport times and in those who require sizable
uid resuscitation. The earliest symptom of compartment
syndrome is increasing pain. As the syndrome progresses,
ndings on physical examination will be pronounced and
include tense compartments, pain on passive extension,
progressive loss of sensation, and weakness. Loss of a distal
pulse is a late nding.
Direct pressure measurement of the compartments can
help conrm the diagnosis, with normal compartment
pressures ranging from 0 to 9 mm Hg. Although debatable,
a compartment pressure over 30 mm Hg is considered elevated and warrants prompt fasciotomy. Some use the pressure difference between the diastolic blood pressure and
the compartment pressure as a marker for compartment
syndrome. When this difference in pressure is 30 mm Hg
or less, compartment syndrome is suggested. However, the
nding of normal pressure does not preclude the presence
of compartment syndrome or its development at a future
time point, and prophylactic fasciotomy should be considered. This is important if prolonged transport to denitive
care is anticipated. In austere environments such as military combat, where compartment pressure measurements
are not easily performed, the threshold to perform a prophylactic fasciotomy is much lower than in an urban civilian
setting. Indications for fasciotomy are shown in Box 21.1.
Furthermore, in one study from Iraq and Afghanistan of
air-evacuated patients with extremity injuries, the need
for fasciotomy revision predicted mortality and tissue loss,
whereas delayed fasciotomy predicted mortality, tissue loss,
and amputation.
Kim et al. reviewed 139 patients with brachial artery
injury and found that 29 patients (21%) were diagnosed
with upper extremity compartment syndrome. Multiple
arterial injuries, total intraoperative blood loss, and open
fractures were found to be signicant independent risk factors for the development of compartment syndrome in this
81
21 • Upper Extremity and Junctional Zone Injuries 269
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Box 21.1 Indications for Fasciotomy in the
Combat Setting
• >4- to 6-hour evacuation delay to revascularization
• Combined arterial and venous injuries
• Crush injuries
• High–kinetic energy mechanism
• Vascular repair
• Arterial or venous ligation
• Comatose, closed head injury, or epidural analgesia
• Tense compartments
• Prophylactic
Adapted from Starnes BW, et al. Extremity vascular injuries on the battle-
field: tips for surgeons deploying to war. J Trauma. 2006;60:432–442.
series (odds ratio 1.12, 5.79, and 2.68, respectively).82 In
a follow-up study, Kim et al. developed a prognostic score
for compartment syndrome after upper extremity vascular
injury based on the three aforementioned variables (1 point
for every 100 mL of intraoperative blood loss, 6 points for
the presence of multiple arterial injuries, 3 points for the
presence of open fracture).83 A score of less than 2.5 had
97% sensitivity and 37% specicity for development of
compartment syndrome, whereas a score of 20 had 97%
specicity and 38% sensitivity. Although this scoring system may offer an adjunct to the clinical decision making of
whether or not to perform a fasciotomy of the upper extremity after arterial injury, it is important to keep in mind this
score has not been prospectively validated.
The skin and fascial incisions for upper extremity fasciotomy extend from the lower medial aspect of the upper
arm, becoming sinusoidal from medial to lateral at the
antecubital fossa, incorporating the bicipital aponeurosis
(Fig. 21.15). The incision extends sufciently lateral to open
the forearm fascia over the extensor wad. The incision then
curves back to the volar aspect to release the fascia with or
without carpal tunnel release depending on the extent of
injury.
Outcomes after Treatment of
Upper Extremity Vascular Injury
Outcomes after treatment of upper extremity arterial injuries are presented in Table 21.1. In general, the more distal
the injury the lower the chance that it will be fatal or lead
to limb loss. Outcomes after upper extremity injury have
evolved beyond measurements of mortality alone, largely
because advancements in prehospital and early resuscitative care mean that injury to an upper extremity artery
rarely leads to death. Moreover, limb salvage in and of itself
is a poor indicator of successful treatment, as many limbs
may be painful or dysfunctional, even though they are
via ble after revascularization.
lead to delayed amputation, rehabilitation. Function-related
out come after upper extremity injury and vascular reconstruction may be a more relevant and modern measure of
success.
84,85
These limitations may
A
Fig. 21.15 (A) Fasciotomy of the upper extremity should begin medially in the arm and become sinusoidal from medial to lateral at the
antecubital fossa, incorporating the bicipital aponeurosis. Extension
must be sufficiently lateral to open the fascia over the extensor wad.
Gentle incision back to the volar fascia will help to also release this
aspect. (B) Extensor counterincision is rarely necessary.
In a retrospective study, Hardin et al. reviewed 99
upper extremity arterial injuries involving 21 axillary,
43 brachial, 12 radial, 13 ulnar, and 10 combined radial
and ulnar vessels.8 Ultimately, only ve patients required
amputation. Return of function occurred in half of these
patients, whereas half were left with permanent functional
impairment. Axillary artery injury was associated with
the highest rate of neurological impairment, attributed to
its proximity to the brachial plexus and a higher burden of
distal ischemia. Shotgun and gunshot injuries were more
often associated with long-term disability, whereas lacerations, stab wounds, and blunt injuries were associated with
better recovery.
Brown et al. performed a review of patients who underwent operative management of upper extremity arterial
injury.19 The limb-salvage rate was 94%, and follow-up after
injury was 6.3 months. Patients who sustained blunt injury
were more likely to have disability than patients with a penetrating injury. Those with concomitant orthopedic trauma
were as likely to have functional recovery as those without
such injury. The importance of associated nerve damage
was highlighted and patients who had a concomitant nerve
injury, whether combined with an orthopedic injury or not,
were less likely to regain function. Patients who had delayed
nerve repair were more likely to have severe disability or
delayed amputation. The authors found that patients with
injuries deemed severe enough to require fasciotomy did not
gain functional recovery and were left with the most severe
disability. It seems clear that whereas restoration of arterial
perfusion and stabilization of bony injuries is often feasible,
the ability to treat the functional sequelae of nerve and softtissue damage determines the outcome in many cases.
Dubose et al. performed a review of 32 reports describing the endovascular management of axillosubclavian
injuries.86 The most common mechanism of injury was
penetrating (56.3%), followed by iatrogenic catheter based
(22%), blunt (21%), and open surgical injury (1%). The
most common injury lesions treated in the review were
pseudoaneurysm (48%), arteriovenous (17%), perforation
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(14%), and occlusion (10%). Five of 160 (3%) injuries
treated with an endovascular approach had acute stent
failure, 4 requiring conversion to open repair; however, 97%
of patients in the analysis underwent successful stent-graft
repair. Procedure-related complications included access
site complications (2%), embolic events (1%), and mortality (1%). Repeat endovascular invention was required in
10 patients (6%) secondary to stent fracture, stenosis, or
occlusion. Seven patients in the review were found to have
asymptomatic stenosis, one patient required delayed open
bypass due to a symptomatic occlusion, and there were no
cases of mortality attributed to endovascular intervention.
Waller et al. published a multicenter review of patients
with subclavian or axillary artery injuries that included 223
patients.87 In 120 subclavian and 119 axillary artery injuries, open repair (83%) was more common than endovascular (17%) or hybrid (6%) repair. An endovascular approach
was more commonly used for the left versus right subclavian
artery when compared with both open and hybrid repairs.
The number of endovascular repairs remained stable during the 10-year course of the review. Amputations occurred
in seven patients with four being associated with large soft
tissue injury with neurologic damage. The remaining three
amputations were associated with graft or stent thrombosis. Early limb salvage was successful in 219 of 223 patients
(97%) and long-term limb salvage was 95%.
A retrospective study spanning 2003–13 at two academic centers by Branco et al. compared open and endovascular outcomes of axillosubclavian artery injuries.88 In 153
patients, open repair (88%) was more common than endovascular repair (12%). Whereas the incidence of injuries per
year was constant, the use of endovascular repair increased
from 5% in 2003 to 22% in 2013. Comparison of matched
groups revealed higher mortality in patients treated with
an open versus an endovascular repair (28% versus 6%,
respectively). On average, patients undergoing open intervention required more days of ventilator support, although
the trend did not reach statistical signicance in the study.
In Greece, Matsagkas performed a single-institution
review of blunt axillosubclavian artery injury treated with
endovascular techniques.89 Seven cases, all with concomitant injuries, underwent successful repair without procedure-related complications. Conversion to open repair was
not needed, nor were periprocedural blood transfusions.
One patient required an open exploration in the setting of
compressive symptoms secondary to a large hematoma.
Over 27-months of follow-up, one patient experienced an
asymptomatic stent-graft thrombosis identied with Duplex
ultrasound. There were no postprocedure interventions
required during the follow-up period in this patient cohort.
Conclusion
Upper extremity vascular trauma is a challenging injury
pattern. Fortunately, there now exists a range of open and
endovascular options to diagnose and treat this condition.
With attention to detail and a few key diagnostic tools, providers can accurately assess and diagnose this injury pattern.
Military experience has also shown that an emphasis on prehospital bleeding control and the use of damage control surgery techniques makes death from upper extremity trauma
rare. In the future, endovascular techniques are likely to play
a larger role in the management of this injury pattern and a
greater emphasis will be placed on improving functional limb
salvage as a benchmark of meaningful recovery.
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22
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Lower Extremity Vascular
Trauma
DAVID S. KAUVAR and BRANDON W. PROPPER
Introduction and Scope
In this chapter we present the workup and surgical management of vascular trauma to the lower extremities spanning from the common femoral vessels in the groin to the
tibial vasculature at the ankle. The term “vascular injury”
is used primarily to denote injury to a named artery of the
leg. Venous injuries will be considered separately from arterial injuries and both in the context of concomitant arterial
trauma and as isolated injuries. The topics of hemostasis,
vascular damage control, endovascular therapies, and the
implications of multiple tissue injuries (mangled extremity), though topically relevant to lower extremity vascular
trauma, are discussed in detail elsewhere in this textbook
and are not covered in signicant depth here. We intend for
this chapter to serve as a resource for the civilian or military practitioner of trauma surgery in the decision-making
process of planning for and executing open surgical lower
extremity revascularization procedures.
Injury Characteristics
LEVEL OF INJURY
The lower extremity is the most frequent site of arterial
injury in both civilian and military trauma.
arteries in general and the supercial femoral artery (SFA)
specically have the highest consistently reported rates of
injury, with the remainder divided between the popliteal
and tibial arteries. The distribution of tibial artery injuries
is not consistently reported in the literature and injuries to
the anterior tibial, posterior tibial, and peroneal arteries
are variably consolidated or reported individually, making
it difcult to compare injury location data across studies.
In general, however, the reported combined rate of overall
tibial artery injury is similar to that of combined femoral
injuries. Multiple arterial injuries in a single lower extremity are likely to have resulted from a devastating degree of
traumatic energy transfer—either trans-extremity penetrating trauma or near or complete traumatic amputations
from high impact blunt and shear forces. Such patterns of
vascular injury are reported most commonly at the tibial
level and are present in 6% to 20% of cases.
injury to multiple lower extremity artery levels is reported
in civilian trauma patients in 10% to 20% of cases.
nding is more common with more complex injury patterns, such as those produced by severe blunt trauma and
crush injuries. Multiple injuries at the same arterial level or
within the same artery (for example, multiple tibial artery
injuries or concomitant above- and below-knee popliteal
1–5
The femoral
6,7
Concomitant
6,8
This
injury) are not specically reported in the literature but
presumably occur more frequently than injury at multiple
levels.
MECHANISM OF INJURY
Most reports of lower extremity vascular injuries have about
equal proportions of blunt and penetrating injuries. In civilian trauma, blunt arterial injuries are more frequently seen
at or below the knee in the popliteal and tibial segments
than above the knee in the femoral segment. Common
supercial and deep femoral arterial injuries are more likely
to be caused by penetrating mechanisms.
nisms in civilian trauma produce higher rates of fracture
and signicant soft tissue and nerve injuries than penetrating ones.10 Correspondingly, these injuries tend to be associated with greater limb injury severity and have poorer limb
outcomes.
of lower extremity vascular injury consist of almost threequarters of injuries produced via explosions.
injuries are particularly devastating, resulting in extensive
tissue destruction and rates of limb salvage correspondingly
lower than those seen in civilian lower extremity vascular
trauma.
knee explosive trauma with fracture and arterial injury, the
delayed amputation rate following initial limb salvage has
been reported at almost 80%.
Table 22.1 presents selected civilian and military arterial
injury data since 2000.
6,8,11,12
In modern military trauma, recent reports
7,14–16
In limbs sustaining combat-related below-
17
6,9
Blunt mecha-
13–15
These
ARTERIAL PATHOLOGY
The nature of the injury to a lower extremity artery has
implications for the workup and treatment that will be discussed later in the chapter. Arterial occlusion is reported
in up to a third of cases, while transection is seen in 25%
to 45% of lower extremities. Other arterial injury types
explicitly reported in the civilian literature include: laceration (partial transection), intimal injury, and pseudoaneu-
1,8–10
rysm.
of the variety of traumatic injuries that can affect the arteries of the lower extremity. There are two basic categories of
these pathologies: occlusive and disruptive. These pathologic categories align with clinical presentations that will be
discussed later in this chapter.
Occlusive injuries can disrupt ow completely or partially and are the result of thrombosis, intimal dissection,
mural hematoma, or entrapment/kinking. Thrombosis
of an injured artery is caused by intimal damage that precipitates platelet activation and initiation of the clotting
mechanisms. Focal dissection and mural hematoma result
The reported pathologies represent the majority
273
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Table 22.1 Civilian and Military Arterial Injury Data
Author
Civilian Alarhayem
et al.
DuBose et al. 2013–14 PROOVIT 40% 26% 34% 47% NR 14 centers
Liang et al. 2004–14 Trauma Center
Franz et al. 2005–10 Trauma Center
Topal et al. 2002–09 Trauma Center
Military Sisli et al. 2011–13 Syrian Conflict
Perkins et al. 2003–12 JTTR-Iraq/
Stannard
et al.
Clouse et al. 2004–06 Field Hospital
CFA, Common femoral artery; JTTR, Joint Theater Trauma Registry; NTDB, National Trauma Data Bank; PFA, deep (profunda) femoral artery; PROOVIT,
Prospective Observational Vascular Injury Treatment registry; SFA, superficial femoral artery.
Time
Frame Source CFA SFA PFA Popliteal Tibial
2012–15 NTDB 11% 37% NR 30% 24% 46% 25%
(USA)
(USA)
(Turkey)
(Turkey)
Afghanistan
(USA)
2003–08 JTTR-Iraq/
Afghanistan
(UK)
Registry
13% 17% NR 33% 36% 46% 11%
5.30% 32% 5.30% 21% 36% 44% 31%
47% 19% 34% 12% 42%
41% 33% 27% 47% 41%
31% 5.40% 22% 42% 71% 43%
42% 16% 42% 76% NR Immediate
5.70% 34% 7.60% 25% 28% 55% NR
Blunt/
Blast
Concomitant
Vein Injury Notes
amputations
included
in direct luminal diameter compromise and can also serve as
a nidus for thrombosis. Lower extremity arterial entrapment
within, or kinking of a vessel around, a fracture can also
cause an occlusive injury. Depending on the degree of vessel wall trauma in the area of the bony injury, the occlusion
may resolve with surgical freeing of the entrapped artery or
fracture reduction without the necessity for vascular reconstruction. This highlights the importance of early reduction of displaced fractures and reassessment of the vascular
status of the limb prior to committing to an operative plan.
Regardless of the underlying pathology, complete or partial
occlusive lower extremity arterial injuries present with varying degrees of clinical ischemia distal to the arterial injury.
Complete and partial arterial transections, punctures,
and pseudoaneurysms comprise the pathologies producing
disruptive arterial injuries.10 These pathologies all involve
varying degrees of direct luminal disruption resulting in
the potential for blood to escape the vessel. Arterial wall
disruption usually results from direct trauma to the vessel
whether by a projectile, blade, or fragment of bone. Iatrogenic femoral artery injuries such as those resulting from
percutaneous access typically result in disruptive injuries that may be initially occult. These injuries manifest
as pseudoaneurysms or arteriovenous stulas and can be
a challenge to diagnose and treat. Bleeding from named
arterial disruptive injuries can be signicant, and even lifethreatening. These injuries present clinically with signs of
hemorrhage and usually demand prompt identication and
hemorrhage control. Traumatic arteriovenous stula may
also be present if a major artery and vein sustain disruptive
injuries in proximity to each other. Though not explicitly
reported, it stands to reason that occlusive arterial injuries
to the lower extremities are more likely to result from blunt
mechanisms, whereas transections (both partial and complete) are more likely to arise from penetrating trauma. The
degree of traumatic tissue disruption and the degree of limb
Fig. 22.1 Bilateral military lower extremity injuries resulting from an
improvised explosive device. Multiple arterial injuries are clearly present and the limbs may or may not be salvageable.
ischemia seem to predict limb loss regardless of mechanism.
Due to the complex nature of occlusive injuries and the
varying degree of thrombosis that can be involved, reconstruction of these injuries can be challenging.
Military lower extremity injuries usually result from
high-energy explosions and deserve special mention due to
their unique nature. Explosions produce extensive damage
to multiple limb tissues due to primary (blast overpressure),
secondary (fragment), and tertiary (blunt) blast trauma.
The high-energy and complex nature of the military explosion mechanism of injury can produce any of the arterial
pathologies listed previously alone or in combination. Complex segmental arterial destruction, sometimes at multiple
levels, is a common nding (Fig. 22.1).
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