Vascular injury

Background

Types

• Complete Occlusive
  • Transection
  • Thrombosis
  • Embolism
  • Reversible spasm
• Non-occlusive
  • Lacerations
  • Intimal flaps
  • Pseudoaneurysm
  • A/V fistula
  • Compartment syndrome

Occult Upper Extremity Vascular Injury

• Clavicle fracture/1st rib => subclavian artery
• Anterior shoulder dislocation => axillary artery
• Proximal humerus fracture => axillary artery
• Humeral shaft fracture => brachial artery
• Elbow dislocation => brachial artery

Clinical Features

Hard signs

• Absent distal pulses
• Signs of distal ischemia
  • Pain, pallor, paresthesia, paralysis, poikilothermia
• Audible bruit or palpable thrill at injury site
• Active pulsatile hem
• Large expanding hematoma
• Pulsatile hematoma

Soft Signs

• Small nonexpanding hematoma
• Peripheral nerve deficit
• History of pulsatile or significant hemorrhage at time of injury
• Unexplained hypotension
• Bony injury (fracture, dislocation, penetration) or proximity penetrating wound

Differential Diagnosis

Extremity trauma

• Peripheral nerve injury
• Vascular injury
• Tendon injury
• Laceration
• Fracture
  • Open fracture
• Open joint injury
• Crush syndrome
• Compartment syndrome
• Rhabdomyolysis
• Contusion
• Myositis ossificans

Evaluation

Arterial Pressure Index (API)

• Doppler-determined arterial sys BP in injured limb divided by pressure in uninjured limb
  • <0.90 abnormal
  • Allows for serial, objective monitoring
  • Only detects obstructive lesions
  • unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock
  • false negative with deep femoral artery injury

Duplex Doppler

• S 95-100%; Sp 97-100%; Acc 98-100%
• Sens for vessel injury, thrombosis, pseudoaneurysm, intimal flap and A-V fistula

Evaluation Algorithm

Hard (>90% risk of arterial injury; 50% require intervention)

• Immediate arterial exploration without further investigation

Soft (30% risk of arterial injury)

• API → if < 0.9 obs/admit for 24h, serial API, consider:
  • Doppler U/S
  • CTA
  • Eval of compartment syndrome

Management

• Emergency vascular surgery consult (General surgery if vascular not available)

Prognosis

Warm Ischemia Time

• 6 hours (10% irreversible damage)
• 12 hours (90% irreversible damage)

See Also

• Angiogram Complication
• Acute arterial ischemia

References

Authors

Ross Donaldson, Allen Bookatz, Jordan Swartz, Neil Young, Daniel Ostermayer, Michael Holtz