Blunt Vascular Trauma Research Articles

Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications.

Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications. A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital. Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications. Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.

Endovascular interventions in the management of acute extremity trauma: a narrative review.

Minimally invasive endovascular interventions including stenting and embolization have been widely adopted for the treatment of emergent and traumatic thoracoabdominal injuries. In recent years, these techniques have been utilized in the setting of extremity vascular trauma with promising outcomes. By allowing for the rapid diagnosis and subsequent treatment of penetrating or blunt vascular extremity trauma, these techniques can help to minimize blood loss, reduce operative complications, and potentially prevent limb amputation. Here, we present a narrative review of the ever-increasing role of minimally invasive interventions in the management of extremity trauma and compare its use and outcomes to open surgical repair. A special focus is placed on diagnostic imaging modalities in trauma and the role of interventional radiologists in the work-up and treatment of extremity trauma. We discuss diagnostic imaging modalities that aid in the triaging of extremity trauma, such as Doppler sonography, CT angiography, and catheter-based angiography. We present an overview on the literature related to endovascular interventions such as embolotherapy and stent grafting as well as the technical challenges associated with each technique. Finally, we present our own cases on the workup and endovascular treatment of extremity trauma, including CT angiography, particulate and coil embolization, and stent graft placement.

An isolated iliac vein injury due to blunt trauma by a bicycle handlebar without a pelvic fracture: A case report

Abdominal and pelvic blunt vascular trauma without skeletal injury is considered a rare condition. Iliac vein injuries are usually seen with penetrating trauma, whereas they result from blunt trauma very rarely. A 15-year-old boy was admitted who fell from a bicycle and got his left hypogastric region hit by the handlebar. He had an isolated left external iliac vein injury and massive bleeding related to this blunt trauma, which eventually resulted in hypovolemic shock and a huge regional hematoma. The hematoma compressed the left external iliac artery and triggered ischemia. In conclusion, prompt diagnosis and treatment are of utmost importance to save the extremities and lives of patients.

Challenging case of blunt vascular liver trauma: hematoma of the hepatic artery.

56-year-old male patient presented to emergency department after a car crash sustained a blunt thoracic and abdominal trauma. Patient according to the advanced trauma life support (A.T.L.S.®) protocol appeared stable. The patient complained of shortness of breathing and abdominal pain. Local examination revealed subcutaneous emphysema and hematoma of the right quadrant of the abdomen. CTA of the abdomen revealed free fluid in the Morrison space and multiple contusion of the IV and V hepatic segment. The patient stared a conservative managment but due to a continue drop of haemoglobin, after 24h the patient was shifted to the operating room. At laparotomy a haematoma of the hepatic artery was found with clotted blood all around. Due to the absence of any signs of bleeding, no further procedure were done. The patient was discharged 15 postop with no complication. Despite the fact that treatment of liver injuries has dramatically evolved, severe liver traumas in polytraumatic patients still have a significant morbidity and mortality. The decision for an emergency laparotomy is usually taken based upon the presence of the “lethal triad”, consisting of coagulopathy, acidosis and hypothermia. In this case a continuous bleeding with platelet deplation was the reason to look into the abdomen with the suspect of Hollow viscus or mesenteric injuries.

Blunt Handlebar Injury of the Common Femoral Artery in a Pediatric Patient: Case Report

Introduction - Vascular non-iatrogenic trauma in pediatric population is rare. Generally, they are associated to bone fractures, stab or cut wounds. Less common is the blunt trauma as a cause of a vascular lesion. There are implications in the treatment of this kind of lesion associated to the pediatric anatomy, physiology and the growth potential of the pediatric patient. Mainly by the small size of the vessels, thickness of the veins wall or the vascular spasm of the arteries. It’s still controversial which is the best treatment option in these cases, with a wide range of options from medical treatment, direct repair, autogenous saphenous vein graft, ligation and endovascular stenting. Methods - We describe a case of a 9-year-old boy with a very small groin hematoma and an acute left limb ischemia grade IIa after a handle bike trauma 24 hours ago. Ultrasound and CT scan showed a common femoral artery occlusion as well as an absence of femoral vein thrombosis. Results - A surgical treatment was chosen. A common femoral artery approach showed a focal contained artery transection with thrombosis. An autologous panel saphenous vein graft interposition was performed to avoid graft size mismatch. An uneventful postoperative course was developed, and he was discharged 72 hours later. Conclusion - Blunt vascular trauma is a rare condition in pediatric population and clinical suspicion is necessary to avoid a diagnosis delay. The handlebar pressure on the femoral artery against femur or pubis bone may be a traumatic weapon even in not severe bike trauma. Special considerations and technical difficulties should be considerate in the surgical and medical pediatric treatment. There are different options of treatment that depends on the type of injury and the clinical situation. References1Sarfati MR, Galt SW, Treiman GS, Kraiss LW. Common femoral artery injury secondary to bicycle handlebar trauma. J Vasc Surg. 2002 Mar;35(3):589-91.2Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, Krettek C, Probst C. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010 Apr 15;5:25. doi: 10.1186/1749-799X-5-25.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa

BackgroundThe optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death.MethodsProspective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications.ResultsOne-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35–60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications (p = 0.074).ConclusionSurgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

Intraabdominal Vascular Injuries in Blunt Trauma: Spectrum of Presentation, Severity and Management Options

Purpose of Review Blunt abdominal vascular injury is rare, hard to diagnose and there is little consensus as to what constitutes best management. This review was undertaken to assess how blunt abdominal vascular trauma management has changed over last few years and what new therapies have been reported.

Open Surgical Bypass for Superficial Femoral Artery Occlusion Caused by Blunt Trauma

Blunt vascular trauma of the lower extremities brings about a high amputation rate, because other organ injuries disturb revascularization. We experienced a case of a superficial femoral artery occlusion caused by blunt trauma. The patient also had a femoral bone fracture and a large skin defect with deep muscular injuries of the thigh. We performed a femoropopliteal (FP) bypass using a saphenous vein which was routed through the contaminated wound. Postoperative vacuum-assisted closure therapy was used to prevent graft infection. Surgical bypasses using saphenous veins are approved treatments for arterial occlusions from blunt trauma if the grafts go through contaminated wounds.

Vascular injuries following blunt polytrauma.

Motor vehicle collisions account for the majority of blunt vascular trauma. Much of the literature describes the management of these injuries in isolation, and there is little information concerning the incidence and outcome in patients suffering multiple trauma. This study was undertaken to describe the spectrum of blunt vascular injuries in polytrauma patients. All patients who had sustained blunt vascular trauma over a 6-year period (April 2007-March 2013) were identified from a prospectively gathered database at the Level I Trauma Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa. The retrieved data consisted of age, sex, mechanism of injury, referral source, Injury Severity Score (ISS), New Injury Severity Score (NISS), time from injury to admission, surgical intervention and outcome. The initial investigation of choice for patients sustaining multiple injuries was computed tomography (CT) angiography if they were physiologically stable, followed by directed angiography if there was doubt concerning any vascular lesion. If technically feasible, endovascular stenting was the preferred option for both aortic and peripheral vascular injuries. Of 1,033 patients who suffered blunt polytrauma, 61 (5.9%) sustained a total of 67 blunt vascular injuries. Motor vehicle collisions accounted for 92% of the injuries. The median ISS was 34 [interquartile range (IQR) 24-43]. The distribution of blunt vascular injuries was extremity (21), thorax (20), abdomen and pelvis (19), and head and neck (7). Endovascular repair was employed in 12 patients (ten blunt aortic injury, one carotid-cavernous sinus fistula, one external iliac artery). Of the extremity injuries, primary amputation was undertaken in 8 (38.1%) and secondary amputation in 2 (9.5%). The total amputation rate was 48%. There were 17 (28.3%) deaths, of which 11 (64.7%) were directly attributable to the vascular injury and 6 (35.3%) of these occurred on the operating table from exsanguination, the majority from injuries to the abdominal vena cava. Blunt vascular injury is uncommon in the patient with multiple trauma but confers substantial morbidity and mortality. In those cases with peripheral injuries, delays in referral to definitive care frequently exceed the ischaemic time, resulting in a high rate of amputations. Central injuries, especially those of the vena cava, account for the majority of directly attributable deaths.

Epidemiology and Outcome of Vascular Trauma at a British Major Trauma Centre

ObjectivesIn the United Kingdom, the epidemiology, management strategies and outcomes from vascular trauma are unknown. The aim of this study was to describe the vascular trauma experience of a British Trauma Centre. MethodsA retrospective observational study of all patients admitted to hospital with traumatic vascular injury between 2005 and 2010. ResultsVascular injuries were present in 256 patients (4.4%) of the 5823 total trauma admissions. Penetrating trauma caused 135 (53%) vascular injuries whilst the remainder resulted from blunt trauma. Compared to penetrating vascular trauma, patients with blunt trauma were more severely injured (median ISS 29 [18–38] vs. ISS 11 [9–17], p < 0.0001), had greater mortality (26% vs. 10%; OR 3.0, 95% CI 1.5–5.9; p < 0.01) and higher limb amputation rates (12% vs. 0%; p < 0.0001). Blunt vascular trauma patients were also twice as likely to require a massive blood transfusion (48% vs. 25%; p = 0.0002) and had a five-fold longer hospital length of stay (median 35 days (15–58) vs. 7 (4–13), p<0.0001) and critical care stay (median 5 days (0–11) vs. 0 (0–2), p < 0.0001) compared to patients with penetrating trauma. Multivariate regression analysis showed that age, ISS, shock and zone of injury were independent predictors of death following vascular trauma. ConclusionTraumatic vascular injury accounts for 4% of admissions to a British Trauma Centre. These patients are severely injured with high mortality and morbidity, and place a significant demand on hospital resources. Integration of vascular services with regional trauma systems will be an essential part of current efforts to improve trauma care in the UK.

Successful repair of complete popliteal artery rupture due to blunt trauma

Although blunt trauma of the extremities is a common diagnosis in emergency clinics, blunt vascular trauma may be difficult to diagnose in such patients. Time to repair is determinative for the success of vascular repair following vascular trauma. Late diagnosis or repair may result in neurological damage or even the loss of an extremity. This case report presents a 43-year-old male who sustained a blunt trauma to the right lower extremity resulting in the complete rupture of the popliteal artery. Although successful vascular repair with end-to-end anastomosis prevented the loss of the extremity, late diagnosis of the vascular injury caused postoperative mild neurological sequela in this case.

Computed tomographic angiography in pediatric blunt traumatic vascular injury

Pediatric vascular injuries are rare but can be difficult to diagnose and challenging to manage. We present our experience with computed tomographic angiography in 3 pediatric patients with vascular injuries secondary to blunt trauma. Computed tomographic angiography is noninvasive, fast, rapidly available in most centers, and can evaluate for other injuries. We present a review of the literature and recommend computed tomographic angiography as the diagnostic tool of choice in the evaluation of pediatric blunt vascular trauma.

Seat Belt Syndrome and Aortoiliac Lesion: Case Report and Review of the Literature.

Blunt vascular trauma represents 7-9% of the vascular lesions in civilians. There are few reports associating blunt trauma with aortoiliac lesion to the trauma associated with the use of seat belts. We report a case of aortic bifurcation disruption and bilateral iliac artery thrombosis directly related to seat belt use and not associated with pelvic fractures. Arterial revascularization was accomplished through an aortoiliac bypass with spiraled saphenous vein interposition graft and perfusion was restored to both limbs. However, the patient died 5 days after due to respiratory distress syndrome. A high index of suspicion and early diagnosis are essential for patient survival and limb salvage.

Occult Mediastinal Great Vessel Trauma: The Value of Aortography Performed During Angiographic Screening for Blunt Cervical Vascular Trauma

To determine the value of aortography in the assessment of occult aortic and great vessel injuries when routinely performed during screening angiography for blunt cerebrovascular injury (BCVI). One hundred and one consecutive patients who received both aortography and screening four-vessel angiography over 4 years were identified retrospectively. Angiograms for these patients were evaluated, and the incidence of occult mediastinal vascular injury was determined. Of the 101 patients, 6 (6%) had angiographically documented traumatic aortic injuries. Of these 6 patients, one injury (17%) was unsuspected prior to angiography. Four of the 6 (67%) also had BCVI. One additional patient also had an injury to a branch of the subclavian artery. Routine aortography during screening angiography for BCVI is not warranted due to the low incidence (1%) of occult mediastinal arterial injury. However, in the setting of a BCVI screening study and no CT scan of the chest, aortography may be advantageous.

Iatrogenic arterial injury is an increasingly important cause of arterial trauma

Background Iatrogenic arterial injuries (IAI) may result from any invasive diagnostic or therapeutic procedure. The relative occurrence and severity of IAI compared with those of penetrating and blunt vascular trauma is unknown. A review of arterial trauma at a university hospital level 1 trauma center, with a focus on iatrogenic injury, forms the basis of this report. Methods Patients treated for arterial trauma from January 1994 through October 2002 were identified from prospectively maintained registries. Record review included injury etiology, type of repair, 30-day all-cause mortality, and permanent morbidity. Permanent morbidity was defined as amputation or loss of extremity function. Results In all, 252 patients required treatment, 85 (33.7%) from IAI, 86 (34.1 %) from penetrating trauma, and 81 (32.1%) from blunt trauma. During the study period, the number of IAIs per year increased. Femoral artery injury from percutaneous intervention (50, 58.8%) was the most frequent IAI; intraoperative injury (including 14 tumor resections and 5 orthopedic procedures) was next most frequent (23, 27.1%). Three patients (3.5%) with IAI had permanent morbidity. The 30-day all-cause mortality was 7.1% (6) for patients with IAI. Conclusions Iatrogenic arterial injury is increasingly frequent and caused one third of the arterial trauma at our level 1 trauma center. These data suggest education and training regarding IAI deserves equal priority with the study of penetrating vascular trauma.

Blunt vascular trauma in the extremity: diagnosis, management, and outcome.

Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.

Blunt Injury to the External Iliac Artery: A Case Report

Blunt vascular trauma is rare as compared with penetrating vascular trauma. The incidence of iliac artery injury has been reported as low as 0.4 per cent of total arterial trauma. Iliac artery injury in blunt trauma is rare because of its anatomic location and protection by the pelvis. This article presents a case of external iliac artery injury secondary to blunt trauma. A deceleration-type mechanism is suggested that results in the production of an intimal flap and later vessel thrombosis. We discuss the clinical details of presentation and angiographic diagnosis as well as treatment options.

Blunt trauma of the common femoral artery

Blunt vascular trauma in children is relatively rare and usually occurs in combination with fractures. Direct blunt trauma of the common femoral artery can lead to complete obstruction of the artery. In children, this obstruction may cause difference in limb growth. The authors describe a case of traumatic intimal rupture of the common femoral artery in an 11-year-old child after a fall from a bicycle. There have been a few reports of blunt trauma to the common femoral artery in children. The patient described had immediate symptoms of ischemia. Prompt reconstruction of the common femoral artery resulted in full recovery. Principles of arterial reconstruction in children are generally the same as in adults. The use of artificial grafts is to be avoided. Follow-up term is unclear as well as the use of anticoagulation therapy.

Imaging traumatic and nontraumatic neck emergencies in the adult

Many traumatic and nontraumatic conditions affecting the adult neck may present emergently. A prompt and accurate imaging assessment is vital to patient management in many of these conditions. In this review we will discuss the imaging assessment of both penetrating and blunt vascular and laryngeal trauma, infectious neck emergencies such as supraglottitis and septic thrombophlebitis, and nontraumatic airway conditions that may present emergently such as subglottic stenosis and angioneurotic edema.

Traumatic peripheral vascular injuries

2-4% of vascular injuries need operative reconstruction. In polytraumatized patients the rate is even 10%. Arterial vascular repair should precede venous reconstruction and orthopaedic stabilization due to limb threatening ischemia. Penetration or blunt vascular trauma result either in acute blood loss, ischemia or compartmental compression. Reperfusion syndrome leads to vital threat of patient. Clinical assessment, measurement of limb pressures using a Doppler device and use of duplex ultrasonography are reliable adjuncts in the rapid evaluation. Arteriography is rarely indicated and should be spared for patients with abnormal physical examination. Minimizing ischemia (6-8 h) is an important factor in maximizing limb salvage. Vascular repair include direct anastomosis or lateral suture repair mostly combined with primary shortening of the extremity. In most cases autogenous vein graft is required. Rethrombosis, arteriovenous fistula and pseudoaneurysms are possible complications. Stabilisation of the fracture has priority over vascular reconstruction. The initial steps to success are surgical debridement, adequate bony stabilization mostly by external fixation, revascularisation of vascular injury, immediate fascial decompression and early soft-tissue reconstruction. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, vascular surgery and plastic surgery.