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The Diagnosis and Treatment of Arterial Injuries of the Upper Extremity
The Diagnosis and Treatment of Arterial Injuries of the Upper Extremity LLOYD D. MAcLEAN, M.D., PH.D., F.A.C.S.
The practice of restoring nonnal blood flow following arterial lllJury, established during the Korean War, represents an outstanding advance in the surgery of trauma. When ligation was practiced,a· 4 the amputation rate was 50 per cent. With arterial repair or replacement, this rate has been lowered to 15 per cent, and the salvaged limb is much more likely to be functional. Injuries of the brachial artery above the profunda, in World War II, led to amputation in 56 per cent of 97 patients treated by ligation. In 209 patients in whom the injury was below the profunda, ligation was followed by amputation in 26 per cent. In marked contrast, 80 patients with injuries of the brachial artery, both above and below the profunda, treated by repair during the Korean War, resulted in the saving of all limbs without amputation. Similar findings are noted for the axillary artery. In World War II, a 43 per cent amputation rate existed in 74 patients treated by ligation for injuries of the axillary artery. This was lowered to 7 per cent during the Korean War when repair with restoration of blood flow was practiced. 1 • 3 It is the purpose of this report to classify the types of arterial injuries involving the upper extremity seen in civilian practice, to summarize the diagnostic features of each, to emphasize the importance of arteriography in the diagnosis of such injuries, and to illustrate with case reports several basic types of injury.
CLASSIFICATION OF ARTERIAL INJURY AND REPAIR
The types of injury encountered and the ideal repair for each are illustrated in Figure 1. In large vessels such as the innominate, lateral repair is frequently possible. Adequate debridement and repair can be accomplished without narrowing lumen size to the point where decreased Supported by grants from United States Public Health Service and Medical Research Council of Canada
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1?O...-t.'l.o-n.,
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A
B
.... :
A-V fut;u.'1.a.
Figure 1. Arterial injuries and suggested treatments. A, Lateral repair is ideal for large arteries like the innominate. B, Debridement with resection and end-to-end anastomosis is selected treatment for smaller arteries such as the axillary or brachial. C, Dacron or vein graft should be used when loss or damage to artery does not permit end-to-end anastomosis following debridement. D, "Spasm" is more often subintimal hemorrhage or intimal laceration which requires resection and anastomosis. E, True and false aneurysms and arteriovenous fistulae are best treated by resection and restoration of blood How as illustrated.
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blood flow and subsequent thrombosis would result (A). In B, a laceration of a smaller vessel such as the axillary is illustrated. Treatment of a laceration in an artery of this size or smaller is best performed by resection of the involved artery and end-to-end anastomosis. In C there is an absolute loss of a portion of a vessel. End-to-end anastomosis is not possible after adequate debridement, hence a graft must be inserted. The graft material of choice for the upper extremity is probably saphenous vein. If a synthetic graft must be used, this should be knitted and not woven-either Teflon or Dacron. In D there is pictured a narrowed segment of artery of the type which has frequently been called "spasm." At operation for debridement of a wound or for fixation of a fracture, the pulse distal to an area of "spasm" in an artery is absent. A more probable diagnosis in this situation is either arterial contusion with subintimal hemorrhage or intimal disruption (Fig. 2, A and B). Frequently thrombosis follows an episode of "spasm" which leads to complete occlusion of the vessel and peripheral ischemia. If, at the time of operation, measures taken to relieve arterial spasm do not restore a normal pulse distal to the area in question, resection and anastomosis should be performed. Measures which can be tried prior to resection include local administration of papaverine 0.25 per cent, arterial neurectomy and intraluminal injection of saline under pressure with the area of
Figure 2. A, External appearance of subclavian artery in a patient without a palpable radial pulse on the injured side. There is no suggestion of the serious nature of the arterial injury from external appearance. B, Intimal rupture was the cause of obstruction first believed to be due to spasm in the artery.
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spasm between vascular clamps as described by Mustard and Bull. 7 Arterial spasm is a treacherous lesion and should be treated vigorously. In Figure 1, E, traumatic aneurysms are illustrated. This lesion may be a rupture through all of the layers of the arterial wall with formation of a pulsating hematoma (false aneurysm), or there may be rupture into an adjacent vein with formation of an arteriovenous fistula. The treatment, whether the lesion is a true aneurysm, false aneurysm or arteriovenous fistula, is resection with restoration of normal flow either by direct anastomosis or insertion of a graft. Lateral repair may be useful in vessels the size of the innominate.
DIAGNOSIS
The diagnosis of arterial injuries is usually not difficult. Serious arterial injuries may be and have been overlooked, however, for relatively long periods of time. Since early operation is important for successful treatment, diagnosis should be prompt. In addition to the examination of the site of injury, careful inspection and palpation of the distal extremity frequently lead to proper diagnosis. The findings of (1) color and temperature differences between the injured and normal limbs, (2) absent peripheral pulses on the affected side, (3) sensory changes, numbness, hypalgesia, analgesia and pain, and (4) on oscillometry, an absence or reduction of pulsation on the injured side, suggest major arterial injury. All these classical findings may be absent in the presence of severe arterial injury, such as traumatic aneurysm. The absence of pulses in the normal extremity, owing to arterial sclerosis, may confuse the diagnosis. Differences in color and temperature of limbs which have been exposed to cold following an auto accident may be of no value in making a diagnosis of arterial injury. Subjective findings of numbness and pain are likewise of little value in establishing diagnosis of arterial injury in a patient with a fractured bone in the limb under surveillance. Arteriography in patients with suspected arterial injury is useful for the following reasons: (1) Diagnosis can be established with certainty without a dangerously long period of observation. In certain types of arterial injuries such as traumatic aneurysm or arteriovenous fistula, the final diagnosis is frequently dependent upon arteriography. (2) The precise location of arterial disruption can be determined. This may be located at a surprising distance from the fracture site when a fracture is the cause of the lesion. (3) The degree of collateral flow about an injured artery can be estimated. (4) It can be determined if a peripheral pulse in an injured extremity is due to collateral flow or to an uninjured main vessel. (5) Arteriography is one of the best methods to evaluate reparative surgery, and the only way to be certain of what one has accomplished by therapy. Arteriography on the operating table after restorative surgery can
DIAGNOSIS AND TREATMENT OF ARTERIAL INJURIES OF UPPER EXTREMITY 1041
Figure 3. Visualization of brachiocephalic vessels. Note that this patient has only 2 major branches from the aortic arch instead of 3. The angiogram was otherwise normal.
clarify doubtful results, or may demonstrate a second unsuspected lesion at a more distal site in the vessel. Arteriographic studies of the extremities in the adult can be accomplished by using standard roentgen equipment and with the hand injection of 10 to 20 mr. of 60 per cent Renografin or 50 per cent Hypaque. Visualization of the intrathoracic portion of the arterial tree to the upper extremity is conveniently performed by passing a catheter from the femoral artery to the desired position. In this instance, 25 to 50 ml. of 75 per cent Hypaque can be injected under high pressure through the catheter, to deliver the dose in 1.5 to 2.0 seconds. A series of films are taken in two planes using the Schonandet biplane rapid film changer, or utilizing cine film. Figure 3 is an example of this type of study with visualization of the aortic arch and the brachiocephalic vessels.
CASE REPORTS
The following case reports illustrate several types of arterial injury affecting the hand. CASE 1. F.T., a 26 year old man, was admitted to hospital on April 17, 1959, 30 minutes after sustaining a 32 caliber bullet wound in the left neck. Roentgen examination indicated that the passage of the bullet was across the superior mediastinum from the left neck into the right axilla posteriorly. A right pneumothorax with a fracture of the right third rib posteriorly was present on admission. A tube thoracostomy was performed, following which the lung re-expanded. On the ninth post-injury day, a thrill and continuous murmur were detected with maximum intensity over the right claviculosternal junction. This was accompanied by an increase in pulse rate to 120, dyspnea and exercise intolerance. A clinical diagnosis of arteriovenous fistula was made and was confirmed by cardiac catheteriza-
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Figure 4 (Case I). Arteriovenous fistula between the innominate artery and right innominate vein with a false aneurysm. The right innominate vein and false aneurysm could not be separated. Both were resected. The completed repair, which was accomplished in 9 minutes of innominate artery occlusion, appears at right.
tion and by an increase in venous pressure in the right arm and increased circulation time (arm to tongue) when performed from the right arm. The maximal elevation of oxygen saturation and elevation of pressure occurred in the right innominate vein, suggesting a communication between the innominate artery and the right innominate vein. This waS found at operation, together with a false aneurysm. The false aneurysm and the right innominate vein were resected, and the innominate artery was repaired, as illustrated in Figure 4. This patient made an uneventful recovery.
Comment. This arterial injury, in all likelihood, progressed from a false aneurysm to an arteriovenous fistula. Cardiac failure is a common sequel of such injuries, and was present in five of seven previously reported cases. 5 Venous catheterization, with serial measurements of pressure and oxygen saturation of the blood proximal and distal to the point of suspected fistula, is a convenient method widely available for precisely localizing a fistula. The patient was given prophylactic penicillin during the interval between the onset of the fistula and the operative repair to avoid subacute bacterial endocarditis which has been noted as a complication of arteriovenous fistula. Sacrifice of the right innominate vein in this patient caused no apparent difficulty. The venous pressure was identical and normal in both arms within 24 hours of the operation. CASE II. R.P., a 4 year old boy, waS admitted to hospital On January 19, 1960, with a supracondylar fracture of the left humerus. A radial pulse WaS not palpable, and did not return after the arm waS placed in traction. An angiogram waS per-
DIAGNOSIS AND TREATMENT OF ARTERIAL INJURIES OF UPPER EXTREMITY 1043 formed which revealed a block in the brachial artery immediately proximal to its bifurcation into the brachial and ulnar arteries (Fig. 5). The angiogram revealed an extensive collateral circulation with excellent blood flow below the site of occlusion, with visualization of the radial and ulnar arteries at the wrist. The patient had no vascular insufficiency of the limb and no operation was performed.
Comment. Volkmann's ischemic contracture is a well-known complication of this type of fracture. The decision on whether or not to perform fasciotomy is frequently difficult to make, and is often delayed, so that permanent damage and subsequent wasting of the arm results. It is suggested that an angiogram be performed when the pulses are absent beyond the site of injury. Fasciotomy should be performed when collateral vessels are not present, as their absence would indicate increased pressure in the subfascial plane, preventing collateral flow. When collateral flow is abundant, as in this patient, one does not need to perform fasciotomy, and can be confident of an adequate blood supply to the limb. At the present time, anastomosis of vessels of this size cannot be readily accomplished. This case illustrates the value of angiography in determining collateral flow. CASE III. M.M., a 21 year old man, was admitted to hospital on April 29, 1960, following an auto accident. Injuries included a compound fracture of the right humerus, with a cold, pulseless limb distal to the site of injury. At operation, the wound was debrided. There was a transection of the biceps and triceps muscles, spasm of the brachial artery, and no apparent nerve injury. The fracture was internally fixed with a Rush intramedullary nail. The area of "spasm" in the artery, beyond which no pulsation existed, was treated with periarterial injections of lidocaine (Xylocaine) 1 per cent, and intraluminal injections of papaverine. The pulse beyond the area of "spasm" was not restored, and no improvement in the color or temperature of the limb was noted. Right stellate ganglion block was also per-
Figure 5 (Case II). Angiogram reveals a block in the brachial artery, with the presence of excellent collateral blood supply to the hand. Fasciotomy was not required and no vascular insufficiency supervened.
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Figure 6 (Case IV). A, Chest roentgenogram showing widening of mediastinum immediately following automobile accident on January 1, 1960. B, Mass persists in right superior mediastinum on March 21, 1960. C, The true nature of the mediastinal mass is revealed by the arteriogram. There is a traumatic aneurysm of the right subclavian artery immediately beyond the innominate. Note filling of the carotid, vertebral and internal mammary arteries.
c formed, which was of questionable value. On the following day the stellate ganglion block was repeated. On May 2, 1960 (4 days after injury) , the right arm was amputated at the site of fracture because of ischemic necrosis of the extremity.
Comment. One cannot depend upon collateral blood flow to establish circulation in the injured upper extremity. This patient illust rates the futility of the use of medication and sympat hetic block in the t reatment of a serious arterial injury. The so-called arterial "spasm" occurring after injury is frequently subintimal hemorrhage with occlusion or laceration, and these demand resection and anastomosis. Pathological examination of the injured vessel in this patient showed hemorrhage within the vessel wall with occlusion from thrombosis which was probably secondary. CASE IV. B.C., a 30 year old man, was admitted to hospital on January 1, 1960, following an auto accident. He complained of anterior chest pain and widening of the superior mediastinum was noted on the posteroanterior chest roentgeno-
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gram (Fig. 6, A). On March 21,1960, the patient was readmitted to the hospital for investigation of a persistent mass which was seen in the superior mediastinum on the right side (Fig. 6, B). A retrograde aortogram, which was performed on March 21, 1960, demonstrated an aneurysm of the right subclavian artery which was located immediately distal to the bifurcation of the innominate artery (Fig. 6, C). This patient underwent resection of the aneurysm with graft replacement.
Comment. The value of angiography in the diagnosis of traumatic aneurysm is again illustrated by this patient. The history and chest films should arouse suspicion. However, the precise anatomical location, which is of considerable surgical importance, is best determined before surgery by arteriography. Aneurysms are best treated by resection and anastomosis.
DISCUSSION
Halpert and co-workers2 have suggested that the ideal prosthesis will be synthetic. Fibers of this prosthesis will be interspersed with absorbable hemostatic fibers ,,,oven or knitted tightly enough to prevent blood IOES at the time of insertion and yet provide sufficient porosity to allow heavier growth of fibroblasts and endothelial cells into the prosthesis at a later date. This would provide good hemostasis at the time of operation as well as a firm attachment of the prosthesis to the host tissues. The lining coagulum of fibrin, platelets, leukocytes and erythrocytes is not firmly attached to woven Teflon grafts, but it is more firmly attached to knitted Dacron prostheses because of the fibroblastic growth into this more porous material. In the upper extremity, autologous vein graft is probably superior to any synthetic material presently available. The lining coagulum of an impervious or closely woven graft may be detached by minimal trauma, and slip down as an inner lining of the graft, causing occlusion of the vessel. For this reason, also, a woven Teflon graft is not recommended, especially if the graft must pass over a joint where a greater opportunity for trauma exists. Utilizing venous autografts, a patch may be used to enlarge an anastomotic site for injuries of the upper extremity. Attention to details and fastidious technique are most necessary in salvaging severely traumatized limbs. The edges of the arterial wound should be debrided before suture repair. Fine, atraumatic, nonabsorbable suture material should be used in the repair with a continuous over-andover suture. Both ends of the artery should be flushed clear of all clots initially, as well as just prior to placing the last few sutures. Palpable distal pulses should be present after repair. Local anticoagulants are used. Systemic anticoagulation has not been necessary. If distal pulses do not return following the repair, angiography performed on the operating table provides very important information at the earliest possible time. Arterial hemorrhage can usually be controlled by simple pressure over
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the bleeding site and a tourniquet need not be used. The danger of myoglobinuria and oliguria after the release of a tourniquet has been emphasized by Montagnani and Simeone. 6 This variant of the crush syndrome is hazardous, and leads to death in a high percentage of patients within a week after injury. Thompson and Campbells were able to reduce significantly the degree of myoglobinemia by perfusing ischemic limbs in dogs with intra-arterial dextran given prior to restoration of normal circulation. This technique might be used in patients with arterial injuries in whom blood loss can be controlled only by tourniquet. Recent experimental work would indicate that packing limbs in ice to forestall the consequences of severe arterial injury is detrimental rather than beneficial. Devascularized limbs of animals are vulnerable to cold injury. On the basis of these experiments, heparinization of a devascularized extremity to prevent thrombosis in small vessels permitted maximum salvage. Injuries involving all vessels of the upper extremity down to and including the radial and ulnar arteries at the wrist should be repaired. Developments presently under way may permit successful suture of smaller vessels in the hand, or even the finger. The vascular suturing device of Vogelfanger 9 and microscopic techniques will probably be useful in this regard.
SUMMARY The current concept of treatment of acute arterial injuries designed to save both life and limb is to restore normal blood flow. The diagnosis of acute arterial injuries can usually be established by history and physical examination. Many serious arterial injuries are not apparent from examination and may require further study before corrective measures can be instituted. The use of angiography will help establish the diagnosis, save valuable time in initiating definitive treatment, and provide information on collateral circulation, anatomical site of injury, and the type of lesion present. The classification of arterial injuries, with clinical examples of several types, has been presented. Treatment includes debridement with lateral repair, resection and anastomosis, or graft.
REFERENCES 1. DeBakey, M. E. and Simeone, F. A.: Battle injuries of the arteries in World WarII: An analysis of 2,471 cases. Ann. Surg. 123: 534-579, 1946.
2. Halpert, B., DeBakey, M. E., Jordan, G. L. and Henley, W. S.: The fate of homografts and prostheses of the human aorta. Surg. Gynec. & Obst. 111: 659-674, 1960.
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3. Hughes, C. W.: Arterial repair during the Korean War. Ann. Surg. 14-7: 555-561, 1958. 4 Inui, F. K., Shannon, J. and Howard, J. H.: Arterial injuries in the Korean conflict. Experiences with 111 consecutive injuries. Surgery 37: 850-857, 1955. 5. MacLean, L. D. and Mazzitello, W. F.: Innominate arteriovenous fistula. J. Thoracic & Cardiovasc. Surg. 39: 770, 1960. 6. Montagnani, C. A. and Simeone, F. A.: Observations on the liberation and elimination of myohemoglobin after release of muscle ischemia. Surgery 34-: 169-185, 1953. 7. Mustard, W. T. and Bull, C.: A reliable method for relief of traumatic vascular spasm. Ann. Surg. 155: 339-344, 1962. 8. Thompson, W. W. and Campbell, G. A.: Studies on myoglobin and hemoglobin in experimental crush syndrome in dogs. Ann. Surg. 14-9: 235-242,1959. 9. Vogelfanger, I. J. and Beattie, W. G.: A concept of automation in vascular surgery. Canad.J.Surg. 1:262-265, 1958. Royal Victoria Hospital Montreal 2, Quebec
The practice of restoring nonnal blood flow following arterial lllJury, established during the Korean War, represents an outstanding advance in the surgery of trauma. When ligation was practiced,a· 4 the amputation rate was 50 per cent. With arterial repair or replacement, this rate has been lowered to 15 per cent, and the salvaged limb is much more likely to be functional. Injuries of the brachial artery above the profunda, in World War II, led to amputation in 56 per cent of 97 patients treated by ligation. In 209 patients in whom the injury was below the profunda, ligation was followed by amputation in 26 per cent. In marked contrast, 80 patients with injuries of the brachial artery, both above and below the profunda, treated by repair during the Korean War, resulted in the saving of all limbs without amputation. Similar findings are noted for the axillary artery. In World War II, a 43 per cent amputation rate existed in 74 patients treated by ligation for injuries of the axillary artery. This was lowered to 7 per cent during the Korean War when repair with restoration of blood flow was practiced. 1 • 3 It is the purpose of this report to classify the types of arterial injuries involving the upper extremity seen in civilian practice, to summarize the diagnostic features of each, to emphasize the importance of arteriography in the diagnosis of such injuries, and to illustrate with case reports several basic types of injury.
CLASSIFICATION OF ARTERIAL INJURY AND REPAIR
The types of injury encountered and the ideal repair for each are illustrated in Figure 1. In large vessels such as the innominate, lateral repair is frequently possible. Adequate debridement and repair can be accomplished without narrowing lumen size to the point where decreased Supported by grants from United States Public Health Service and Medical Research Council of Canada
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LLOYD
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1?O...-t.'l.o-n.,
-r-ecectAZd. ,,_
A
B
.... :
A-V fut;u.'1.a.
Figure 1. Arterial injuries and suggested treatments. A, Lateral repair is ideal for large arteries like the innominate. B, Debridement with resection and end-to-end anastomosis is selected treatment for smaller arteries such as the axillary or brachial. C, Dacron or vein graft should be used when loss or damage to artery does not permit end-to-end anastomosis following debridement. D, "Spasm" is more often subintimal hemorrhage or intimal laceration which requires resection and anastomosis. E, True and false aneurysms and arteriovenous fistulae are best treated by resection and restoration of blood How as illustrated.
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blood flow and subsequent thrombosis would result (A). In B, a laceration of a smaller vessel such as the axillary is illustrated. Treatment of a laceration in an artery of this size or smaller is best performed by resection of the involved artery and end-to-end anastomosis. In C there is an absolute loss of a portion of a vessel. End-to-end anastomosis is not possible after adequate debridement, hence a graft must be inserted. The graft material of choice for the upper extremity is probably saphenous vein. If a synthetic graft must be used, this should be knitted and not woven-either Teflon or Dacron. In D there is pictured a narrowed segment of artery of the type which has frequently been called "spasm." At operation for debridement of a wound or for fixation of a fracture, the pulse distal to an area of "spasm" in an artery is absent. A more probable diagnosis in this situation is either arterial contusion with subintimal hemorrhage or intimal disruption (Fig. 2, A and B). Frequently thrombosis follows an episode of "spasm" which leads to complete occlusion of the vessel and peripheral ischemia. If, at the time of operation, measures taken to relieve arterial spasm do not restore a normal pulse distal to the area in question, resection and anastomosis should be performed. Measures which can be tried prior to resection include local administration of papaverine 0.25 per cent, arterial neurectomy and intraluminal injection of saline under pressure with the area of
Figure 2. A, External appearance of subclavian artery in a patient without a palpable radial pulse on the injured side. There is no suggestion of the serious nature of the arterial injury from external appearance. B, Intimal rupture was the cause of obstruction first believed to be due to spasm in the artery.
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spasm between vascular clamps as described by Mustard and Bull. 7 Arterial spasm is a treacherous lesion and should be treated vigorously. In Figure 1, E, traumatic aneurysms are illustrated. This lesion may be a rupture through all of the layers of the arterial wall with formation of a pulsating hematoma (false aneurysm), or there may be rupture into an adjacent vein with formation of an arteriovenous fistula. The treatment, whether the lesion is a true aneurysm, false aneurysm or arteriovenous fistula, is resection with restoration of normal flow either by direct anastomosis or insertion of a graft. Lateral repair may be useful in vessels the size of the innominate.
DIAGNOSIS
The diagnosis of arterial injuries is usually not difficult. Serious arterial injuries may be and have been overlooked, however, for relatively long periods of time. Since early operation is important for successful treatment, diagnosis should be prompt. In addition to the examination of the site of injury, careful inspection and palpation of the distal extremity frequently lead to proper diagnosis. The findings of (1) color and temperature differences between the injured and normal limbs, (2) absent peripheral pulses on the affected side, (3) sensory changes, numbness, hypalgesia, analgesia and pain, and (4) on oscillometry, an absence or reduction of pulsation on the injured side, suggest major arterial injury. All these classical findings may be absent in the presence of severe arterial injury, such as traumatic aneurysm. The absence of pulses in the normal extremity, owing to arterial sclerosis, may confuse the diagnosis. Differences in color and temperature of limbs which have been exposed to cold following an auto accident may be of no value in making a diagnosis of arterial injury. Subjective findings of numbness and pain are likewise of little value in establishing diagnosis of arterial injury in a patient with a fractured bone in the limb under surveillance. Arteriography in patients with suspected arterial injury is useful for the following reasons: (1) Diagnosis can be established with certainty without a dangerously long period of observation. In certain types of arterial injuries such as traumatic aneurysm or arteriovenous fistula, the final diagnosis is frequently dependent upon arteriography. (2) The precise location of arterial disruption can be determined. This may be located at a surprising distance from the fracture site when a fracture is the cause of the lesion. (3) The degree of collateral flow about an injured artery can be estimated. (4) It can be determined if a peripheral pulse in an injured extremity is due to collateral flow or to an uninjured main vessel. (5) Arteriography is one of the best methods to evaluate reparative surgery, and the only way to be certain of what one has accomplished by therapy. Arteriography on the operating table after restorative surgery can
DIAGNOSIS AND TREATMENT OF ARTERIAL INJURIES OF UPPER EXTREMITY 1041
Figure 3. Visualization of brachiocephalic vessels. Note that this patient has only 2 major branches from the aortic arch instead of 3. The angiogram was otherwise normal.
clarify doubtful results, or may demonstrate a second unsuspected lesion at a more distal site in the vessel. Arteriographic studies of the extremities in the adult can be accomplished by using standard roentgen equipment and with the hand injection of 10 to 20 mr. of 60 per cent Renografin or 50 per cent Hypaque. Visualization of the intrathoracic portion of the arterial tree to the upper extremity is conveniently performed by passing a catheter from the femoral artery to the desired position. In this instance, 25 to 50 ml. of 75 per cent Hypaque can be injected under high pressure through the catheter, to deliver the dose in 1.5 to 2.0 seconds. A series of films are taken in two planes using the Schonandet biplane rapid film changer, or utilizing cine film. Figure 3 is an example of this type of study with visualization of the aortic arch and the brachiocephalic vessels.
CASE REPORTS
The following case reports illustrate several types of arterial injury affecting the hand. CASE 1. F.T., a 26 year old man, was admitted to hospital on April 17, 1959, 30 minutes after sustaining a 32 caliber bullet wound in the left neck. Roentgen examination indicated that the passage of the bullet was across the superior mediastinum from the left neck into the right axilla posteriorly. A right pneumothorax with a fracture of the right third rib posteriorly was present on admission. A tube thoracostomy was performed, following which the lung re-expanded. On the ninth post-injury day, a thrill and continuous murmur were detected with maximum intensity over the right claviculosternal junction. This was accompanied by an increase in pulse rate to 120, dyspnea and exercise intolerance. A clinical diagnosis of arteriovenous fistula was made and was confirmed by cardiac catheteriza-
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Figure 4 (Case I). Arteriovenous fistula between the innominate artery and right innominate vein with a false aneurysm. The right innominate vein and false aneurysm could not be separated. Both were resected. The completed repair, which was accomplished in 9 minutes of innominate artery occlusion, appears at right.
tion and by an increase in venous pressure in the right arm and increased circulation time (arm to tongue) when performed from the right arm. The maximal elevation of oxygen saturation and elevation of pressure occurred in the right innominate vein, suggesting a communication between the innominate artery and the right innominate vein. This waS found at operation, together with a false aneurysm. The false aneurysm and the right innominate vein were resected, and the innominate artery was repaired, as illustrated in Figure 4. This patient made an uneventful recovery.
Comment. This arterial injury, in all likelihood, progressed from a false aneurysm to an arteriovenous fistula. Cardiac failure is a common sequel of such injuries, and was present in five of seven previously reported cases. 5 Venous catheterization, with serial measurements of pressure and oxygen saturation of the blood proximal and distal to the point of suspected fistula, is a convenient method widely available for precisely localizing a fistula. The patient was given prophylactic penicillin during the interval between the onset of the fistula and the operative repair to avoid subacute bacterial endocarditis which has been noted as a complication of arteriovenous fistula. Sacrifice of the right innominate vein in this patient caused no apparent difficulty. The venous pressure was identical and normal in both arms within 24 hours of the operation. CASE II. R.P., a 4 year old boy, waS admitted to hospital On January 19, 1960, with a supracondylar fracture of the left humerus. A radial pulse WaS not palpable, and did not return after the arm waS placed in traction. An angiogram waS per-
DIAGNOSIS AND TREATMENT OF ARTERIAL INJURIES OF UPPER EXTREMITY 1043 formed which revealed a block in the brachial artery immediately proximal to its bifurcation into the brachial and ulnar arteries (Fig. 5). The angiogram revealed an extensive collateral circulation with excellent blood flow below the site of occlusion, with visualization of the radial and ulnar arteries at the wrist. The patient had no vascular insufficiency of the limb and no operation was performed.
Comment. Volkmann's ischemic contracture is a well-known complication of this type of fracture. The decision on whether or not to perform fasciotomy is frequently difficult to make, and is often delayed, so that permanent damage and subsequent wasting of the arm results. It is suggested that an angiogram be performed when the pulses are absent beyond the site of injury. Fasciotomy should be performed when collateral vessels are not present, as their absence would indicate increased pressure in the subfascial plane, preventing collateral flow. When collateral flow is abundant, as in this patient, one does not need to perform fasciotomy, and can be confident of an adequate blood supply to the limb. At the present time, anastomosis of vessels of this size cannot be readily accomplished. This case illustrates the value of angiography in determining collateral flow. CASE III. M.M., a 21 year old man, was admitted to hospital on April 29, 1960, following an auto accident. Injuries included a compound fracture of the right humerus, with a cold, pulseless limb distal to the site of injury. At operation, the wound was debrided. There was a transection of the biceps and triceps muscles, spasm of the brachial artery, and no apparent nerve injury. The fracture was internally fixed with a Rush intramedullary nail. The area of "spasm" in the artery, beyond which no pulsation existed, was treated with periarterial injections of lidocaine (Xylocaine) 1 per cent, and intraluminal injections of papaverine. The pulse beyond the area of "spasm" was not restored, and no improvement in the color or temperature of the limb was noted. Right stellate ganglion block was also per-
Figure 5 (Case II). Angiogram reveals a block in the brachial artery, with the presence of excellent collateral blood supply to the hand. Fasciotomy was not required and no vascular insufficiency supervened.
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Figure 6 (Case IV). A, Chest roentgenogram showing widening of mediastinum immediately following automobile accident on January 1, 1960. B, Mass persists in right superior mediastinum on March 21, 1960. C, The true nature of the mediastinal mass is revealed by the arteriogram. There is a traumatic aneurysm of the right subclavian artery immediately beyond the innominate. Note filling of the carotid, vertebral and internal mammary arteries.
c formed, which was of questionable value. On the following day the stellate ganglion block was repeated. On May 2, 1960 (4 days after injury) , the right arm was amputated at the site of fracture because of ischemic necrosis of the extremity.
Comment. One cannot depend upon collateral blood flow to establish circulation in the injured upper extremity. This patient illust rates the futility of the use of medication and sympat hetic block in the t reatment of a serious arterial injury. The so-called arterial "spasm" occurring after injury is frequently subintimal hemorrhage with occlusion or laceration, and these demand resection and anastomosis. Pathological examination of the injured vessel in this patient showed hemorrhage within the vessel wall with occlusion from thrombosis which was probably secondary. CASE IV. B.C., a 30 year old man, was admitted to hospital on January 1, 1960, following an auto accident. He complained of anterior chest pain and widening of the superior mediastinum was noted on the posteroanterior chest roentgeno-
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gram (Fig. 6, A). On March 21,1960, the patient was readmitted to the hospital for investigation of a persistent mass which was seen in the superior mediastinum on the right side (Fig. 6, B). A retrograde aortogram, which was performed on March 21, 1960, demonstrated an aneurysm of the right subclavian artery which was located immediately distal to the bifurcation of the innominate artery (Fig. 6, C). This patient underwent resection of the aneurysm with graft replacement.
Comment. The value of angiography in the diagnosis of traumatic aneurysm is again illustrated by this patient. The history and chest films should arouse suspicion. However, the precise anatomical location, which is of considerable surgical importance, is best determined before surgery by arteriography. Aneurysms are best treated by resection and anastomosis.
DISCUSSION
Halpert and co-workers2 have suggested that the ideal prosthesis will be synthetic. Fibers of this prosthesis will be interspersed with absorbable hemostatic fibers ,,,oven or knitted tightly enough to prevent blood IOES at the time of insertion and yet provide sufficient porosity to allow heavier growth of fibroblasts and endothelial cells into the prosthesis at a later date. This would provide good hemostasis at the time of operation as well as a firm attachment of the prosthesis to the host tissues. The lining coagulum of fibrin, platelets, leukocytes and erythrocytes is not firmly attached to woven Teflon grafts, but it is more firmly attached to knitted Dacron prostheses because of the fibroblastic growth into this more porous material. In the upper extremity, autologous vein graft is probably superior to any synthetic material presently available. The lining coagulum of an impervious or closely woven graft may be detached by minimal trauma, and slip down as an inner lining of the graft, causing occlusion of the vessel. For this reason, also, a woven Teflon graft is not recommended, especially if the graft must pass over a joint where a greater opportunity for trauma exists. Utilizing venous autografts, a patch may be used to enlarge an anastomotic site for injuries of the upper extremity. Attention to details and fastidious technique are most necessary in salvaging severely traumatized limbs. The edges of the arterial wound should be debrided before suture repair. Fine, atraumatic, nonabsorbable suture material should be used in the repair with a continuous over-andover suture. Both ends of the artery should be flushed clear of all clots initially, as well as just prior to placing the last few sutures. Palpable distal pulses should be present after repair. Local anticoagulants are used. Systemic anticoagulation has not been necessary. If distal pulses do not return following the repair, angiography performed on the operating table provides very important information at the earliest possible time. Arterial hemorrhage can usually be controlled by simple pressure over
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the bleeding site and a tourniquet need not be used. The danger of myoglobinuria and oliguria after the release of a tourniquet has been emphasized by Montagnani and Simeone. 6 This variant of the crush syndrome is hazardous, and leads to death in a high percentage of patients within a week after injury. Thompson and Campbells were able to reduce significantly the degree of myoglobinemia by perfusing ischemic limbs in dogs with intra-arterial dextran given prior to restoration of normal circulation. This technique might be used in patients with arterial injuries in whom blood loss can be controlled only by tourniquet. Recent experimental work would indicate that packing limbs in ice to forestall the consequences of severe arterial injury is detrimental rather than beneficial. Devascularized limbs of animals are vulnerable to cold injury. On the basis of these experiments, heparinization of a devascularized extremity to prevent thrombosis in small vessels permitted maximum salvage. Injuries involving all vessels of the upper extremity down to and including the radial and ulnar arteries at the wrist should be repaired. Developments presently under way may permit successful suture of smaller vessels in the hand, or even the finger. The vascular suturing device of Vogelfanger 9 and microscopic techniques will probably be useful in this regard.
SUMMARY The current concept of treatment of acute arterial injuries designed to save both life and limb is to restore normal blood flow. The diagnosis of acute arterial injuries can usually be established by history and physical examination. Many serious arterial injuries are not apparent from examination and may require further study before corrective measures can be instituted. The use of angiography will help establish the diagnosis, save valuable time in initiating definitive treatment, and provide information on collateral circulation, anatomical site of injury, and the type of lesion present. The classification of arterial injuries, with clinical examples of several types, has been presented. Treatment includes debridement with lateral repair, resection and anastomosis, or graft.
REFERENCES 1. DeBakey, M. E. and Simeone, F. A.: Battle injuries of the arteries in World WarII: An analysis of 2,471 cases. Ann. Surg. 123: 534-579, 1946.
2. Halpert, B., DeBakey, M. E., Jordan, G. L. and Henley, W. S.: The fate of homografts and prostheses of the human aorta. Surg. Gynec. & Obst. 111: 659-674, 1960.
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3. Hughes, C. W.: Arterial repair during the Korean War. Ann. Surg. 14-7: 555-561, 1958. 4 Inui, F. K., Shannon, J. and Howard, J. H.: Arterial injuries in the Korean conflict. Experiences with 111 consecutive injuries. Surgery 37: 850-857, 1955. 5. MacLean, L. D. and Mazzitello, W. F.: Innominate arteriovenous fistula. J. Thoracic & Cardiovasc. Surg. 39: 770, 1960. 6. Montagnani, C. A. and Simeone, F. A.: Observations on the liberation and elimination of myohemoglobin after release of muscle ischemia. Surgery 34-: 169-185, 1953. 7. Mustard, W. T. and Bull, C.: A reliable method for relief of traumatic vascular spasm. Ann. Surg. 155: 339-344, 1962. 8. Thompson, W. W. and Campbell, G. A.: Studies on myoglobin and hemoglobin in experimental crush syndrome in dogs. Ann. Surg. 14-9: 235-242,1959. 9. Vogelfanger, I. J. and Beattie, W. G.: A concept of automation in vascular surgery. Canad.J.Surg. 1:262-265, 1958. Royal Victoria Hospital Montreal 2, Quebec