Major Arterial Injury Research Articles

Lower extremity vascular trauma: a comprehensive, aggressive approach.

During this study, 25 patients (26 limbs) incurred 37 vascular injuries to the lower extremity. The majority were young males injured by penetrating trauma (84%). There were 25 arterial and 12 venous injuries (two isolated). Sixteen patients had soft-tissue injuries, 12 had fractures, and six had peroneal nerve damage. Twenty-two arterial injuries were repaired, the majority (17) by saphenous vein bypass. Three tibial vessels were ligated. All major venous injuries were repaired. No synthetic material was used. Vascular repair took precedence in all but two cases. After repair, the vascular surgeon assisted with stabilization. Thirteen limbs required fasciotomy; nine required subsequent debridements and later plastic reconstruction. Limb salvage was 96%. More important, 21 patients can ambulate independently on the injured extremity (84%). These results support an aggressive approach to lower extremity vascular trauma with repair of all major arterial and venous injuries in conjunction with aggressive debridement and soft-tissue repair.

Trauma Angiography

Two-hundred eighty angiographic studies performed for suspected acute arterial trauma were reviewed to evaluate the relationship between the clinical findings and arterial injury. Extremity injury occurred in 237 cases. The proximity of a penetrating injury or a fracture to a major vascular structure was the sole indication for angiographic study in 136. No major arterial injury was discovered in either group. Exclusion of these patients would have improved the extremity angiographic yield from 25% to 58% while missing no patients with major arterial injury. We conclude, based on the negligible yield, that clinical observation of these patients is a safe alternative if adequate followup is assured; elective angiography may be performed if followup is questionable. Nineteen of 20 (95%) patients with an absent distal pulse and clinical signs of extremity ischemia had a major arterial injury. All extremity arterial injuries occurred within 5 cm of bullet fragments, bone fragments, entrance wound, or exit wound. Given the virtual assurance of finding major arterial injury, patients with unifocal injury and a threatened limb may proceed directly to the operating room to minimize ischemic time.

False-negative Angiograms in Missed Vascular Injuries

To the Editor.—Richardson et al1are to be commended on their article, which appeared in the June issue of theArchives, especially with regard to their long-term follow-up of this indigent population. Technical improvement hinges on evaluation of our errors and recognition of blind spots. For this reason, we wish to learn more about the angiographic false-negative examinations in their series. Eight patients described as angiographically were subsequently discovered to have sustained major arterial injury. What means were used to identify and prove vascular injury in these patients? Also, what was the time interval between the angiographic study and the subsequent discovery of arterial injury? Two patients were reported to have arterial thrombosis following a angiogram. Were the arteries intrinsically abnormal (eg, missed intimal flap), or could the occlusion have occurred on the basis of a delayed compartment syndrome? Interestingly, the one normal angiographic illustration

The early fate of venous repair after civilian vascular trauma. A clinical, hemodynamic, and venographic assessment.

Repair of major venous injuries of the extremities has been advocated to improve limb salvage rates and to prevent the early and late sequelae of venous interruption. The contribution of venous repair to the surgical outcome remains controversial, however, in part because the fate of venous reconstruction has previously not been well defined. The current study was done to determine the early patency rate of venous repair, to compare the accuracy of various methods used to assess venous patency, and to analyze the relationship between early venous patency and surgical outcome. During a recent 27-month period, 36 patients with major extremity venous injuries were treated by venous reconstruction; 34 patients (94%) had an associated major arterial injury that also required repair. Venous repair was performed in the upper extremity (22%) as well as the lower extremity (78%) using various reconstructive methods, including lateral repair (17%), end-to-end anastomosis (11%), autogenous vein patching (25%), interposition autogenous vein grafting (42%), and panelled autogenous vein grafting (6%). After operation, venous repair patency was evaluated by clinical examination, impedence plethysmography, and Doppler ultrasonography, and contrast venography. There were no perioperative deaths in these 36 patients. The limb salvage rate was 100% and all 34 major arterial repairs were patent at the time of hospital discharge. Venography performed on the seventh postoperative day demonstrated that 14 venous repairs had thrombosed (39%) and that 22 had remained patent (61%). Local venous repair had a significantly lower thrombosis rate (21%) than those requiring interposition vein grafting (59%) (p less than 0.03). Compared with venography, the clinical evaluation was 67% accurate in the assessment of venous repair patency, and the noninvasive examination was 53% accurate. In conclusion, a substantial percentage of venous repairs will thrombose in the postoperative period, especially if interposition vein grafting is used. However, in this series limb salvage was not adversely influenced by an unexpectedly high rate of venous repair thrombosis. In addition, clinical evaluation and noninvasive testing did not provide an accurate assessment of venous patency after venous repair.

Role of CT in excluding major arterial injury after blunt thoracic trauma.

The role of CT in the diagnosis of major vascular rupture following blunt decelerating chest trauma is controversial. Its value in excluding major arterial injury has not yet been determined. During a 12-month period we obtained dynamic enhanced thoracic CT studies in 20 patients with blunt decelerating thoracic trauma who had abnormal or equivocal mediastinal contours on chest radiographs. In all cases diagnosis was confirmed by either digital subtraction (18 patients) or conventional thoracic angiography (two patients). CT scans showed evidence of direct aortic injury in three patients and evidence of mediastinal hematoma in five others. Four of these eight patients had major arterial injury verified angiographically and at surgery. In two patients the CT scan was considered equivocal; both patients had normal thoracic angiograms. CT excluded direct vascular injury or mediastinal hematoma in 10 patients. All 10 had normal thoracic angiograms. This preliminary study suggests that, in patients sustaining blunt decelerating thoracic trauma, thoracic CT may be more valuable than chest radiography in excluding major vascular injury and, in some cases, may reduce the need for thoracic angiography.

Emergency trauma angiography: accuracy, safety, and pitfalls.

The accuracy, safety, pitfalls, and limitations of trauma angiography were determined by comparing the findings of 280 arteriograms performed for suspected arterial trauma with the patients' surgical findings and clinical courses. Trauma angiography was accurate, with a sensitivity for detecting major arterial injury of 98.3%, specificity of 98.5%, positive predictive value of 95.0%, and negative predictive value of 99.5%. Angiography was effective in eliminating the need for surgical arterial exploration in 203 cases (73%). These emergency procedures were associated with a 5% morbidity; all complications were minor. Sixteen percent of the studies were technically compromised. Common factors included poor vessel opacification with aortic contrast injection, over-penetrated films, mistimed lower extremity studies, and overlapped structures obscuring the vessels. In most cases, the field of study can be limited to a region 5 cm beyond the most distant fracture fragment, bullet fragment, and entrance or exit wound. Emergency trauma angiography is an ideal technique for evaluating injured patients with suspected arterial trauma. It is safe to perform and accurately separates patients who may be spared surgical exploration from those who require vascular intervention.

Use of temporary intraluminal shunts in selected peripheral arterial injuries.

Successful limb salvage following major peripheral arterial injury is now limited mainly by destruction of nerve, bone, and soft tissue. In some patients prolonged tissue ischemia may be a problem because of delays in treatment caused by associated injuries. In order to minimize tissue ischemia times, temporary arterial shunting was used in selected patients with injuries requiring fracture fixation or extensive debridement. Forty-two patients with major peripheral arterial injuries were seen in 27 months. Thirteen patients, including ten of the 12 with popliteal artery injuries, had placement of a temporary arterial shunt. All shunted patients had successful revascularization and no complications of the shunting occurred. In the total group of 42 there was one death and one below-knee amputation. In patients with extensive but salvageable injuries occurring with peripheral arterial injuries we feel that the use of a temporary arterial shunt is safe and may prevent prolonged severe ischemia.

The significance of first and second rib fractures.

There are differing opinions in the literature regarding the significance of first rib fractures. The plan at Westmead Centre is to standardize the initial assessment of patients with such fractures. A 3 year retrospective study of 170 trauma victims who sustained fractured ribs, was undertaken. Of the 15 patients with first rib fracture, all were involved in motor vehicle accidents. Over two-thirds of these patients sustained major chest injuries. Multisystem trauma involving cranial, abdominal or skeletal injury was common. One patient died as a result of head injury. Similar results were observed in 13 patients with second rib fractures. Brachial plexus injuries were noted in two patients with first rib fracture. Despite follow-up of high-risk patients at an interval which varied from 1 to 2 1/2 years after the original injury, major subclavian artery injury was not detected in patients with first rib fracture. From this experience and a literature review, we suggest that the general nature of trauma is similar in patients with first rib fracture to that in patients with second rib fracture. Patients with first rib fracture should be closely examined for neurovascular compromise. Guidelines for the use of angiography are discussed. If there is no evidence of neurovascular injury at presentation, and there is no other thoracic injury, recovery should be uneventful.

Diagnosis of major peripheral arterial trauma by transcutaneous oxygen monitoring

During a 6 month period, 36 consecutive suspected major peripheral arterial injuries in 33 patients were evaluated by clinical examination and Doppler signal. Thirty-three of these injuries were also evaluated using portable transcutaneous oxygen monitors. Of the 12 confirmed arterial injuries, 2 had normal Doppler-derived blood pressures and significantly decreased transcutaneous oxygen tensions. The transcutaneous oxygen values in traumatized limbs with arterial injury were significantly lower than in traumatized limbs without arterial injury (34 ± 6 versus 58 ± 3, p < 0.01). The ratio of the injured limb transcutaneous oxygen tension to the uninjured contralateral limb transcutaneous oxygen tension was also significantly lower in the group with arterial injury than in the group without arterial injury (0.72 ± 0.08 versus 1.12 ± 0.05, p < 0.01). The overall sensitivity and specificity of the diagnosis of major peripheral arterial injury by a bilateral transcutaneous oxygen ratio less than 0.90 was 80 percent and 91 percent, respectively. In addition, transcutaneous oxygen monitoring helped quantify tissue perfusion in limbs with decreased neurologic function and Doppler-derived blood pressure. The results suggest that transcutaneous oxygen monitoring is a valuable, noninvasive adjunctive method for the diagnosis of major peripheral arterial trauma.

Mediastinal hemorrhage: an evaluation of radiographic manifestations.

Eleven common radiographic signs of mediastinal hemorrhage were evaluated by two observers for the following three patient groups: normal subjects, patients with mediastinal hemorrhage and no arterial injury, and patients with major thoracic arterial injury. Supine chest radiographs were studied in all cases. Four major conclusions can be made based upon these findings. M/C ratio (mediastinal width to chest width), tracheal deviation, left hemothorax, paraspinal line widening, and aorto-pulmonary window opacification do not reliably separate these three groups of patients. The diagnosis of mediastinal hemorrhage may be made if the aortic contour is abnormal or if one of the following signs is positive: abnormal mediastinal width, apical cap, widening of the right paratracheal stripe, or deviation of the nasogastric tube. If either the right paratracheal stripe is widened or the nasogastric tube is deviated, the diagnosis of aortic rupture can be made with a 24% probability; if both signs are negative, there is a 98% probability that aortic rupture is absent. Due to interobserver variation, there is good agreement between observers for the following four signs only: transverse mediastinal width, tracheal deviation, nasogastric tube deviation, and right paratracheal stripe widening.

Electric current arterial injury: a laboratory model.

A laboratory model capable of creating reproducible, nonlethal, fourth-degree type electrical extremity burns in rats was developed. Fifty-seven rats were studied immediately after burn to 90 days after burn with microdissections, light microscopy, microangiography, and flow studies. Progressive necrosis was not observed. Minimal major vessel arterial injury was demonstrated. This significant finding supports the concept of early debridement and reconstruction to include possible free tissue transfer.

The right paratracheal stripe in blunt chest trauma.

Supine chest radiographs and thoracic arteriograms were obtained in 102 consecutive patients with blunt chest trauma. The initial chest radiographs were reviewed retrospectively without knowledge of the arteriographic findings, and measurements of the right paratracheal stripe were obtained. All patients with right paratracheal stripes less than 5 mm in width had normal arteriograms. In those patients in whom the right paratracheal stripe measured 5 mm or greater, arteriography revealed major arterial injury in 22.9% of cases. It is concluded that measurement of the right paratracheal stripe on supine 102-cm radiographs provides a reliable and quantitative indicator of mediastinal hemorrhage, allowing early arteriographic evaluation.

Profunda Femoris Arterial Laceration Secondary to Intertrochanteric Hip Fracture Fragments

A 54-year-old man incurred a major arterial injury from intertrochanteric fracture fragments. Brisk bleeding from such an injury may not be controllable through the incision used for internal fixation of the hip fracture. A separate standard vertical groin incision allows exploration, control of bleeding, and repair of either superficial or deep femoral arterial systems.

Arterial injuries in children.

Twenty-nine children sustained major arterial injuries secondary to gunshot wounds (nine), blunt injuries (11), penetrating injuries by sharp objects (five), and arteriographic injury (four). The femoral artery was most commonly injured, followed by the brachial, the carotid, subclavian, popliteal, aorta, innominate, and vertebral arteries. We repaired the majority of the arterial injuries by resecting the damaged vessel, with primary anastomosis or interposition grafting when necessary to avoid tension. Postoperative complications included clotted grafts in two patients, which were rendered patent by reoperation. Two children died postoperatively, although both had successful vascular repairs. All vascular repairs were patent at one year, and limb length disparity has occurred in one patient following a nerve injury. Our data indicate that early exploration and repair of all suspected vascular injuries can be accomplished with excellent results, even in young children.

Vascular trauma secondary to diagnostic and therapeutic procedures: Laparoscopy

Diagnostic and therapeutic laparoscopy are safe procedures that only rarely cause significant morbidity. However, major abdominal arterial and venous injury may occur, requiring prompt recognition and laparotomy. Direct compression will control major hemorrhage until resuscitation is complete. Vascular repair utilizing principles of proximal and distal control, good exposure, appropriate anticoagulation, and lateral suture technic should result in restoration of normal blood flow without significant sequelae.

Acute common femoral arterial trauma.

1) Acute common femoral arterial injuries remain relatively uncommon in both military and civilian practice. 2) The recent experience in Vietnam has provided the most complete statistics regarding this type of injury. Among 1,000 acute major arterial injuries, the incidence of common femoral arterial trauma was approximately 5%. This present study reports 109 acute common femoral arterial injuries. Nearly two thirds of the injuries were caused by fragments and slightly more than one half of the injuries were lacerations. It was possible to perform autogenous vein graft repairs in about 57%, end-to-end anastomoses in about 25%, and lateral suture repair in about 10% of the injuries. Prosthetic material was used in only three repairs. 3) The overall complication rate was 28.3%, the amputation rate was 13.2%, and the mortality rate was 2.8%. 4) In the treatment of iatrogenic injuries associated with diagnostic catheterizations of the common femoral artery at Walter Reed Army Medical Center, there were no complications and no mortalities.

Aortography in the investigation of traumatic mediastinal haematoma

Deceleration injuries occur more frequently each year, particularly as a result of road accidents. They are a major cause of closed visceral rupture. The most serious of these is aortic rupture, because it is nearly always fatal if untreated, and may be unsuspected clinically. Although many cases are rapidly fatal, about 20% survive the initial impact and, if the lesion is recognized, modern surgical techniques offer a curative operation. Early diagnosis depends on taking a routine chest radiograph in all cases of deceleration injury, even when the clinical evidence of chest injury is trivial or absent. The cardinal sign is mediastinal widening due to mediastinal haematoma. Once it is recognized, emergency aortography is indicated (a) to distinguish purely venous haematoma from major arterial injury and (b) to show the number and sites of any arterial lesions that are present. This information is important both in planning the correct surgical treatment, and in avoiding unnecessary thoracotomy in seriously injured patients. Percutaneous transfemoral aortography is nearly always the method of choice and its value depends on the urgency with which it is done. Six cases of mediastinal haematoma were investigated in this way. Arterial lesions were present in five and were multiple in three. The commonest site of injury was the aortic isthmus (four cases) but injuries to the right subclavian, innominate and left common carotid were also encountered. Deceleration injuries occur more frequently each year, particularly as a result of road accidents. They are a major cause of closed visceral rupture. The most serious of these is aortic rupture, because it is nearly always fatal if untreated, and may be unsuspected clinically. Although many cases are rapidly fatal, about 20% survive the initial impact and, if the lesion is recognized, modern surgical techniques offer a curative operation. Early diagnosis depends on taking a routine chest radiograph in all cases of deceleration injury, even when the clinical evidence of chest injury is trivial or absent. The cardinal sign is mediastinal widening due to mediastinal haematoma. Once it is recognized, emergency aortography is indicated (a) to distinguish purely venous haematoma from major arterial injury and (b) to show the number and sites of any arterial lesions that are present. This information is important both in planning the correct surgical treatment, and in avoiding unnecessary thoracotomy in seriously injured patients. Percutaneous transfemoral aortography is nearly always the method of choice and its value depends on the urgency with which it is done. Six cases of mediastinal haematoma were investigated in this way. Arterial lesions were present in five and were multiple in three. The commonest site of injury was the aortic isthmus (four cases) but injuries to the right subclavian, innominate and left common carotid were also encountered.

Combat Arterial Trauma Analysis of 106 Limb-Threatening Injuries

The experience afforded military surgeons in the management of arterial trauma has been largely responsible for the rapid evolution of restorative vascular surgery. This was particularly true during the Korean War when direct arterial surgery was first applied on a large scale.1-3With the subsequent development of synthetic materials for grafting and the utilization of autogenous veins, this military experience was duplicated in civilian practice.4,5Vessel reconstruction is now possible in the vast majority of arterial injuries, rendering unacceptable more conservative procedures. This study constitutes a review of major combat arterial injuries encountered in the Naval Hospital USS Repose (AH-16), the latter providing logistic support, Republic of South Vietnam. Clinical Material In the 18-month period from July 1966 to December 1967, 104 patients with 106 limb-threatening arterial wounds underwent definitive vascular surgery aboard the Naval Hospital ShipRepose. Excluded were vessel injuries of the head, neck, viscera, forearm,

Combined arterial, venous, and ureteral injury complicating lumbar disk surgery

The fourth case of ureteral injury complicating lumbar disk surgery is presented. It is the second reported case of combined vascular and ureteral injury and the first in which major arterial, major venous, and ureteral injuries have been successfully repaired. Factors contributing to their injury during such surgery are discussed and suggestions to avoid delayed diagnosis of ureteral injury are submitted.

ARTERIAL INJURIES OF THE BASE OF THE NECK.

Arterial injuries at the base of the neck are associated with a high mortality from uncontrolled hemorrhage and cerebral ischemia and, in survivors, frequently result in permanent crippling due to vascular insufficiency. This report is an analyses of 21 patients with proven major arterial injuries at the base of the neck treated at the City of Memphis Hospitals in the last 12 years. Etiology. —The incidence of arterial involvement from lacerations in this area cannot be proven due to the fact that many neck and shoulder lacerations are sutured and the patient sent home without hospital admission or long-term follow-up. In any case, a statement of the incidence of such wounds would have little clinical meaning. It appears that the majority of the gunshot wounds between the first intercostal space and the cricoid cartilage do involve major vessels. Likewise, only one of these 21 cases sustained a simple lacerating injury—this