New perspectives on the management of penetrating trauma in proximity to major limb arteries

Abstract

Current management of penetrating injuries in the proximity of major extremity arteries with no evidence of vascular trauma remains controversial. A total of 318 such injuries in 254 patients were evaluated prospectively to clarify the appropriate timing and role of arteriography, as well as the natural history of these injuries. The arteries at risk were: axillary, 47; brachial, 57; superficial femoral, 176; and popliteal, 38. No deaths occurred, and no morbidity resulted from arteriographic delay of 6 to 24 hours after injury. Of the 48 arteriographic abnormalities detected, 16 involved noncritical branch vessels. There were 32 injuries to major arteries (10.0%), including localized narrowing (n = 13), intimal flap (n = 12), false aneurysm (n = 6), and arteriovenous fistula (n = 1). Shotgun wounds led to a greater arterial injury rate (317; 17.6%) than did gunshot wounds (24247; 9.7%) or stab wounds (554; 9.3%). At the surgeon's discretion, three injuries underwent immediate exploration (one negative), whereas the remaining 29 vessel injuries were followed up nonoperatively by repeat arteriography (n = 22) or clinical examination (n = 7), for a mean interval of 2.8 months. Fifteen abnormalities resolved, 10 improved or remained unchanged, and 4 worsened. The four lesions (13.7%) that worsened (two shotgun and two axillary artery injuries) were identified within 3 months of injury and repaired surgically with no morbidity. In conclusion, only 6 operations were required out of 318 potential injuries (1.8%), suggesting that routine arteriography is not a cost-effective means of evaluating these injuries. Clinically occult arterial injuries do not necessarily mandate surgery and thus may not need to be found, because the vast majority (86.3%) have a self-limiting natural history. Shotgun and thoracic outlet injuries are at higher risk for vascular injuries requiring surgery and should undergo arteriography, which can be delayed safely. Avoiding arteriography in all other cases would have resulted in a missed operative arterial injury rate of only 0.8% (2254), which is within the range of missed injury rates reported for arteriography. Thorough clinical examination and close follow-up should suffice as the most appropriate management of penetrating proximity extremity trauma.