Peripheral Arterial Injury Research Articles

Management of peripheral arterial injury

Significant changes in the management of patients, with possible or documented injuries to peripheral arteries, have occurred over the last 20 years. Based on recent military experience, it is likely that the use of tourniquets by civilian emergency medical services systems will increase. Evaluation in the emergency center will continue to rely on a careful physical examination and measurement of an ankle-brachial index (ABI) or arterial pressure index (API). Patients without 'hard signs' of an arterial injury and an API or ABI less than 0.9 should undergo arteriography in the trauma room with a digital subtraction device, in radiology by computed tomography arteriography, which is rapidly replacing conventional arteriography, or surgeon-performed arteriography in the operating room. A temporary intraluminal arterial shunt is indicated in patients with unstable fractures in the extremity or in near-exsanguinated patients needing 'damage control'. A saphenous vein interposition graft is the conduit of choice when segmental resection of an injured artery is necessary. Measurement of postarterial repair compartment pressure is the most definitive way to determine the need for fasciotomy in an injured extremity. The care of patients with injured peripheral arteries has remained the same in some areas; however, lessons from the battlefield, new imaging technology, the safety of nonoperative management, use of temporary intraluminal shunts, and better recognition of postrepair compartment syndromes have had a significant impact on current management.

The angiographic manifestations and diagnostic value of digital subtraction angiography in peripheral arterial injury

目前各类意外创伤日渐增多,各种原因的创伤大多伴有血管损伤或主要是血管损伤,其中四肢血管损伤约占全身血管损伤的1/2以上[1],是导致患者死亡或致残的重要原因,如能早期发现、合理治疗对挽救患者生命,提高生活质量具有重要的意义。

Commentary on "Management of Blunt Peripheral Arterial Injury"

Commentary on "Management of Blunt Peripheral Arterial Injury"

Management of Blunt Peripheral Arterial Injury

The recognition of blunt vascular injury has increased in recent years due to an improved understanding of blunt mechanical forces, mechanisms of injury, and awareness that such injuries are often occult. This has been aided by improved quality and expanded availability of noninvasive studies. As a result, outcomes following blunt vascular injury have improved. Compared to penetrating vascular injury and other vascular disease processes, blunt vascular injury has unique features that make it useful to consider as a distinct clinical entity. Manifestations of blunt vascular injury may develop in a delayed fashion and present with more subtle findings, such as a pulse deficit or diminished ankle-brachial pressure index. The objective of this review is to present a brief historical perspective on blunt vascular injury as well as an appraisal of current diagnostic and treatment strategies. Blunt vascular injury will be discussed in distinct anatomic regions, including cervical and upper and lower extremity and evidence-based management strategies developed.

Civil and War Peripheral Arterial Trauma: Review of Risk Factors Associated with Limb Loss

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Surgery of traumatic peripheral arterial injury with delayed transfer during the Ethio-Eritrean War - 1997-2000

Background : The traditional approach to severe vascular injuries in Ethiopia has been ligation. This paper presents the results of an alternative approach in which Ethiopian surgeons with some basics of vascular reconstruction techniques used vein patch-repair, whenever possible, during the Ethio-Eritrean war between 1997-2000. Patients and methods: The population study consisted of 13 military and 7 civilian patients with vascular injuries. The superficial femoral and the brachial arteries were involved each in eight patients respectively. Four victims each sustained injury to the deep femoral, radial, ulnar and anterior tibial arteries respectively. Intra operative findings revealed arteriovenous fistulae and false aneurysms each in nine patients. Results : Vein Patch reconstruction was undertaken in 12 patients. In eighteen Patients, a perfect or near perfect functional result was achieved. Surgery failed in two cases. The two failures may have been due to extraordinarily concomitant injury or late presentation. Conclusion : Our result suggests that; repair rather than ligation represents the "gold-standard" and that it can be achieved in the absence of "high tech" vascular facilities. This is because viability of the limb has been maintained by the development of an A-V fistula, false aneurysm, or through an alternative arterial source on those whose limb survives during the several days required to transport them to an appropriate facility.

Use of pulse oximetry in peripheral arterial injury

Pulse oximetry was used in two cases of iatrogenic arterial injury where it provided the evidence of sufficiency of collateral circulation. Its use was helpful in taking a decision in deferring arterial reconstruction, though it was otherwise indicated. We suggest that in a situation, such as in the operation theatre, where Doppler or ultrasound may not be bandy, dpulse oximetry may be of immense help.

Injuries of the Peripheral Arteries and Their Surgical Treatment

196 cases of peripheral arterial injury presented to our clinic between 1976 and 1986 are summarised. Most of the cases were between 11 and 30 years of age and most of the injuries were by fire-arms and sharp weapons. The most common localisations were a. femoralis (29% cases), a. poplitea and branches (28%), a. brachialis injury (20%). The most common surgical measures were end-to-end anastomosis (43% cases) and venous orthograft replacement (17%). There were 5 mortalities. Factors affecting treatment success are discussed.

Intra-Arterial Digital Subtraction Angiography in the Evaluaton of Peripheral Vascular Trauma

The role of intra-arterial digital subtraction angiography (IADSA) in the evaluation of extremity trauma has not been clearly established. Several potential advantages would make IADSA a preferable study to conventional angiography (CA). This retrospective study analyzed 104 major peripheral arteries with suspected injury. Multiplane IADSA studies were compared with conventional angiography of the same vessel in 97 patients. The arteriograms were evaluated by a physician and a radiologist in a double-blinded fashion. IADSA correlated well with CA. Similar findings comparing both studies were noted in 101 of 104 angiograms (97%) (p less than 0.001) in review by the radiologist and in 100 of 104 (96%) (p less than 0.001) by the surgeon. Only one injury confirmed at surgery was not seen on IADSA; this study was read as equivocal by both examiners. These data confirm that IADSA is a reliable and reasonable study for the evaluation of patients with suspected peripheral arterial injury.

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.

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.