CHAPTER 45 - Peripheral Vascular Injury

Abstract

Injury to the major peripheral arteries or veins is often lifethreatening but invariably poses a threat to the viability of the affected limb. Historically, because of rapid blood loss, injury to major vessels was often quickly fatal in the field. Most patients who survived to reach a hospital had relatively minor vascular injuries. However, with the advent of modern emergency medical services systems with advanced extrication methods and rapid transport, more patients with major vascular injury reach the hospital alive. In addition, the incidence of penetrating civilian injuries from interpersonal violence and blunt injuries from motor vehicle– related trauma in the United States has increased dramatically during the past 50 years. Consequently, emergency physicians are frequently confronted with critically ill patients harboring overt or occult vascular injuries. Management of vascular injuries has evolved with advances in diagnostic methods and surgical techniques. Treatment of vascular injuries before and during World War II was simple ligation of the peripheral artery or vein involved. This approach resulted in limb amputation rates ranging from 40% for axillary artery injuries to 72% for popliteal artery injuries. During the Korean War, routine attempts to repair injured arteries decreased the amputation rate for popliteal injuries to 32%. During the Vietnam War, repair of penetrating axillary and popliteal artery injuries with routine angiography and improved surgical techniques resulted in decreases in the amputation rate to as low as 5 and 15%, respectively, which approach the current rates of amputation for civilian injuries. Owing to the nature of the munitions and the extensive use of body armor in the Iraq and Afghanistan wars, the proportion of severe wounds of the extremities has increased. The amputation rates thus far are 5% for upper extremity and 21% for lower extremity vascular injuries. However, extrapolation of high-velocity military wound data to low-velocity civilian gunshot wounds may not be valid, and even lower rates might be expected with civilian wounds. Tremendous progress has been achieved in diagnostic and therapeutic techniques for dealing with peripheral vascular injuries, and several noninvasive diagnostic modalities have emerged as accurate alternatives to surgical exploration or angiography. These techniques are easily used in the emergency department, and the goal of timely detection and repair of serious vascular injuries is achievable in the vast majority of cases.