Arterial Injury in the Upper Limb Resulting from Dog Bite

Accepted Manuscript Arterial injury in the upper limb resulting from dog bite Oliver Vincent Cawley, MBChB BSc Hons, Anna S. Walsh, MBChB MRCS, Imran Asghar, MD, Hans U. Desmarowitz, FRCS(Glas) MD (ECFMG), George A. Antoniou, MD PhD MSc FEBVS PII:

S0890-5096(18)30153-5

DOI:

10.1016/j.avsg.2017.11.053

Reference:

AVSG 3708

To appear in:

Annals of Vascular Surgery

Received Date: 25 June 2017 Revised Date:

9 November 2017

Accepted Date: 19 November 2017

Please cite this article as: Vincent Cawley O, Walsh AS, Asghar I, Desmarowitz HU, Antoniou GA, Arterial injury in the upper limb resulting from dog bite, Annals of Vascular Surgery (2018), doi: 10.1016/ j.avsg.2017.11.053. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Arterial injury in the upper limb resulting from dog bite

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Anna S. Walsh MBChB MRCS

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Imran Asghar MD

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Hans U. Desmarowitz FRCS(Glas) MD (ECFMG)

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George A. Antoniou MD PhD MSc FEBVS

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Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine

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Acute Hospitals NHS Trust, Manchester, UK

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Oliver Vincent Cawley MBChB BSc Hons

*corresponding author

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Surgical Offices, Phase 1, The Royal Oldham Hospital, Rochdale Road, OL1 2JH, Oldham,

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UK

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e-mail: [email protected]

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ACCEPTED MANUSCRIPT Abstract

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Dog bites in the upper limbs have particular significance, as despite the small size of the

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puncture wounds, penetration is deep, causing serious injuries to deeper structures. There

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is currently very little data relating to upper extremity dog bite arterial injury. We present

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the case of a 32-year-old man who sustained a dog bite injury to his right arm, leading to

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direct puncture and spasm of the brachial artery. He was successfully treated with a jump

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bypass graft to the right brachial artery, with the use of the reversed ipsilateral cephalic vein

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as a conduit. We identified 34 cases in the literature reporting upper limb arterial injury

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secondary to dog bite. Twenty-two cases in the literature detailed axillo-brachial artery

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damage (65%), 24% radial artery, 3% ulnar artery and 9% combined. Presentation was most

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commonly with diminished pulses found in at least 45% of the patients. Arterial thrombosis

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occurred in 29% of cases of single artery injury, transection in 15%, intimal tear in 9% of

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cases and undisclosed in 44%. Management most commonly included interposition graft

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(47%) and primary repair (20%), while 15% did not undergo surgical intervention, 9%

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underwent ligation and 3% were treated with thromboembolectomy. Follow up data for

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these patients is scarce, with some experiencing residual neurological deficit. This report

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highlights the importance of prompt recognition and treatment of vascular injury following

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dog bite in order to attain an optimal outcome and minimise complications.

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ACCEPTED MANUSCRIPT Introduction

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The need for surgical reconstruction in upper limb vascular trauma is a rare event,

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representing less than 5% of the vascular surgical workload [1]. Nevertheless, it carries a

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significant risk of immediate or long-term morbidity. Mechanisms of trauma are typically

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categorized as penetrating or blunt injury, encompassing long bone fracture/dislocations,

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gunshot wounds and stab wounds. Dog-bite injuries are unique in that they are the result of

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both penetrating and blunt trauma [2]. Such components vary depending on the size of the

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teeth and the power of the masticator muscles, with the majority of major vascular trauma

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within the literature caused by police dogs [2]. Despite the small size of the puncture

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wounds of these bites, they penetrate deeply, causing serious injuries to deeper structures.

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Arterial injury secondary to dog bite is rare with only few cases being reported in the

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literature. As a result, there is paucity of clinical data with regards to optimal management

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and outcomes [2].

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Brachial artery trauma can present a significant challenge to the clinician due to its

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equivocal clinical presentation [3]. Although some patients can suffer immediate

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symptomatic limb ischaemia, others can present asymptomatically due to the extensive

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collateral circulation around the elbow [4]. Hence, identifying so called ‘hard signs’

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ACCEPTED MANUSCRIPT indicative of vasculature trauma is essential to limit the period of ischaemia and so minimize

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the degree of ischaemia-reperfusion injury [3].

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Our objective by reporting the case (clinical presentation, management, outcome) is to alert

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the physician dealing with trauma cases to the possibility of severe arterial damage in dog-

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bite injury, and conduct a systematic review to identify all cases described in the literature

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and synopsize the available evidence.

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ACCEPTED MANUSCRIPT Case study

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We present a case of a 32-year-old male, who presented to our emergency department

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immediately after sustaining a dog-bite injury to the right arm. He was haemodynamically

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stable, and examination revealed four puncture wounds to the right arm: two on the

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anterolateral aspect, two on the posteromedial aspect (Figure 1). He was also noted to have

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significantly reduced radial and ulnar pulses in the right forearm with monophasic signal on

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Doppler assessment. An urgent computed tomographic (CT) angiogram was performed and

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revealed reduction in calibre in the proximal half of the brachial artery with an occluded

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segment of 13mm in the mid-arm. The brachial artery distal to this, along with the radial

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artery and ulnar artery were patent. There was no extravasation of contrast to suggest

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active ongoing haemorrhage. The right arm remained viable through some collateral flow,

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but sensation was impaired with ‘pins and needles’ in the right hand and there was some

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reduction in power. Regarding neurological assessment, no focal deficit could be elicited,

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with sensation and power present but globally reduced in the radial, ulnar, median and

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anterior interosseous nerve distribution.

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The patient was treated with broad spectrum intravenous antibiotics, specifically co-

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amoxiclav 1.2g three times daily. A broad-spectrum antibiotic was selected because of the

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polymicrobial flora present in a dog’s mouth. The patient was taken to theatre for

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emergency surgery with input from both the vascular and orthopaedic teams. A medial arm

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ACCEPTED MANUSCRIPT incision was used to expose the majority of the length of the brachial artery in order to

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achieve proximal and distal arterial control. Intraoperative Doppler was used for guidance.

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The segment of the artery in spasm was identified and two direct puncture marks to the

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artery were noted, one anterolateral and one posteromedial (Figure 2). There was no

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evidence of vein injury. A short segment of reversed cephalic vein was harvested on the

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ipsilateral limb to allow a jump graft to bypass the damaged brachial artery segment. This

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resulted in full restoration of good distal brachial and forearm pulses on completion. An

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incision was then made to join the two posterior puncture wounds for exploration,

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debridement and washout (Figure 3). There was no evidence of radial nerve damage. This

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wound was then closed.

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The anterior puncture wounds were washed out and a drain was inserted into each. There

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was also no evidence of damage to the median nerve, and the medial arm incision used to

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expose the injured brachial artery was closed. The patient subsequently returned to the

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ward for close monitoring of arm, forearm and hand circulation and neurological function.

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No post-operative neurological deficit was found. Doppler ultrasonography post-operatively

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revealed triphasic radial and ulnar pulses. Post-operative antibiotics were continued for a

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further three days and the patient was discharged two days later. The patient was

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subsequently followed up in clinic three weeks later and found to have full restoration of

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function, with no residual deficit.

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ACCEPTED MANUSCRIPT Discussion

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We present the case of a 32-year-old man who sustained two direct puncture wounds to the

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right brachial artery which then went into spasm, due to a dog bite injury. He was

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successfully treated with a jump bypass graft, with the use of the reversed ipsilateral

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cephalic vein as a conduit.

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Although the principles of surgical management of brachial artery injuries are well known,

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dog bites as a cause of these injuries are rare and unique. We conducted a literature review

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to identify studies by searching electronic databases and scanning references lists of

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relevant articles. Selection criteria included studies involving upper limb arterial injury as a

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result of dog-bite trauma. The search was applied to Medline, Embase and Science Direct.

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The following terms were used in conjunction with the Boolean operators AND or OR: “dog

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bite”, “arterial”, “artery”, “brachial artery” and “interposition graft”. Only English language

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articles were considered. The search yielded nine articles. Articles whose title and abstract

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had no relevance to the research topic were dismissed. Furthermore, articles addressing

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predominantly injury other than mechanism of dog bite where we were unable to yield data

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specifically relating to dog bites were excluded. The final list consisted of seven articles: five

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retrospective studies and two case reports (Table 1).

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ACCEPTED MANUSCRIPT All literature included within our review composed of populations involving upper limb

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arterial injury secondary to uniquely dog bites, with exception to the study of Degiannis et al

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that range of other mechanisms of injury within its study population [4]. Dog bites were

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responsible for four injuries (6%) within this study population, and thus only data specifically

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relating to such was included within our analysis. Synder et al also included two cases of

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lower limb trauma secondary to dog bite injury which we also excluded from our analysis

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[2].

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Our literature review identified 34 cases of upper limb arterial injury secondary to dog bite.

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Type of injury sustained is illustrated in Figure 4. Twenty-two cases in the literature detailed

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axillo-brachial artery damage (65%), eight radial artery (24%), one ulnar artery (3%) and

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three involved combined (10%). Arterial thrombosis occurred in 29% of cases of single

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artery injury, transection in 15%, intimal tear in 9% of cases and undisclosed in 44%. Almost

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two thirds were identified by CT angiography, the remaining by arteriogram (23%), doppler

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and MR angiography (3%) or operative exposure (11%).

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Only Atkingba et al described combined vascular injuries as a result of dog bite injury. Three

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(9%) of 34 patients were subject to combined vascular injuries in upper extremity, which

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included the radial plus ulnar arteries in two patient (6%) and brachial plus radial arteries in

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one patient (3%). No studies described combined arterial-vein injuries in upper limb.

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ACCEPTED MANUSCRIPT Whilst reviewed studies refer to accompanied nerve injuries, we found no studies that

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reported venous injuries in combination with arterial injuries. In fact, only Atkingba et al

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alluded to any venous injuries, a single finding of an isolated cephalic vein injury that was

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subsequently ligated. The only report of combined arterial and venous injuries was also

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reported by Atkingba et al, however this involved the popliteal artery and vein. Due to its

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anatomical location, we excluded this from our analysis.

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Considering the proximity of such structures, we suspect that there is an element of under-

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reporting from the literature. Equally, it could it be that there were vein injuries that did not

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require reconstructions because these veins were thrombosed at the time or simply that

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they were ligated intraoperatively, as reported by Atkingba et al in the lower limb.

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However, this is purely speculative as there is no evidence to confirm this.

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Only two studies recorded specifically the nerve affected in cases where there was

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associated nerve damage, reflecting the paucity in data within the current literature [7, 10].

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Both case reports identified in the literature identified long-term neurological deficit, which

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we did not encounter. As the mechanism of dog bite injury is typically crush or lacerating

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injuries, it is likely that neurological trauma was due to direct trauma of the nerve. However,

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considering compartment syndrome is one of the most common complications following

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upper limb vasculature trauma, this cannot be definitely excluded (12). No studies stated

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specific mechanism of nerve injury and hence we cannot safely conclude this. However, in

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ACCEPTED MANUSCRIPT our case, we suspect initial neurological deficit was due to ischaemia secondary to arterial

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spasm. Detection of such injuries is significant since abnormal neurological function is the

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most significant reported factor adversely affecting restoration of extremity function [7].

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Clinical presentation and mechanism of injury play a crucial role in directing trauma

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management and diagnosis. Significant clinical findings in extremity trauma that increase

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suspicion for arterial injury include ‘hard signs’ such as pulse deficit, active bleeding, thrill,

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and expanding haematoma. The most common physical finding in patients identified in the

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literature with confirmed arterial insult resulting from dog bite, as found in our case, is

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decreased or absent pulses, found in approximately 45% of the patients (Table 1). However,

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due to extensive collateral blood supply, this may not always be identified, complicating

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management [7]. Rothrock et al described a case of delayed presentation of occlusion of the

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brachial artery from a dog bite of the upper extremity in a five-year old male. In setting of

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seemingly minor trauma, lacerations were cleaned and closed to subsequently present one

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day later with a critically ischaemic limb. With exception to decreased arterial pulses and

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moderately reduced sensation, initial examination in our case did not clinically correspond

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to occlusion of the brachial artery identified on later imaging. Recognition of the equivocal

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presentation that can occur in such penetrating mechanisms therefore is crucial to prevent

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delayed diagnosis and jeopardizing limb viability [7, 8, 9]. Dog bites have particular

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significance, as despite the small size of the puncture wounds, penetration is deep, causing

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ACCEPTED MANUSCRIPT serious injuries to deeper structures as illustrated in the literature (Table 1). Consequently, a

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high index of suspicion is needed to enable expeditious management with surgical

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intervention.

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In terms of intervention, interposition graft (16/34, 47%), primary repair (7/34, 20%),

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ligation (3/34, 9%), thromboembolectomy (1/34, 3%) or no surgical treatment (5/34, 15%)

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were performed in the cases reported in the literature. Data upon the remaining patients

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was not provided in the literature. This data is illustrated in Figure 5. Despite reversed vein

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bypass grafting being commonly utilized method for reconstruction of upper limb major

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arterial injury, there remains no clear guidelines on the venous harvest site, highlighting a

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field that requires further development [6]. Due to the relatively small size of the brachial

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artery, the saphenous or the cephalic vein are typically used whenever an interposition graft

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is required [4]. More recently, studies have reported successful use of vein grafting from the

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ipsilateral traumatized limb, arguing that the vein graft-to-artery match naturally had a

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closer match to the calibre of the artery and as a result functioned better as an interposition

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graft [6]. This was reinforced by superior outcomes in limb salvage rates and wound

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morbidity. Our case study suggests potential of ipsilateral vein grafting, although long-term

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morbidity remains to be seen. We would also consider an upper limb vein of suitable calibre

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and quality that could be used as a bypass graft, such as the basilic vein.

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ACCEPTED MANUSCRIPT From the reviewed literature, it is clear the role of imaging is highly physician dependent.

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However, we agree that in the presence of hard signs or those already planned for the

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operating room, for instance for irrigation and debridement, early exploration is warranted

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and aggressive preoperative imaging causes an unnecessary delay in management and

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possibly outcome. However, preoperative angiography does have a crucial role in

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determining need for exploration in the presence of soft signs, when vascular trauma

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cannot be definitively confirmed. The importance of which is alluded to by Rothrick et al,

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whereby major vascular trauma, due to extensive collateral supply can appear seemingly

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innocuous at initial presentation, and without rigorous examination can lead to major

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complications. We opt that all patients presenting with soft signs should receive imaging

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and encourage low threshold for clinicians in this context.

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Data regarding outcome and follow up was extremely limited within the identified

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literature. Four studies analysed follow up. One study reported a limb salvage rate at 1 year

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of 100%, whilst two studies reported residual nerve weakness [7, 10, 12]. The remaining

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literature did not discuss follow up or outcomes could not be assigned specifically to upper

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limb trauma secondary to dog bite injury.

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The main weakness of our study is in the literature review: there is not sufficient literature

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data to allow a pooled analysis of management and reported outcomes, with paucity of

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detailed clinical reports and many patients being lost in follow up.

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ACCEPTED MANUSCRIPT Conclusion

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In conclusion, dog bites have particular significance, as despite the small size of the

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puncture wounds, penetration is deep, causing serious injuries to deeper structures. The

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evaluating physician must be aware that although such injuries are rare, they can result in

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significant arterial damage that may require significant reconstruction. Brachial artery

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trauma can present a significant challenge to the clinician due to its equivocal clinical

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presentation, yet evidence of underlying arterial injury will often be apparent after a careful

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and thorough physical examination. Emergency physicians must be vigilant and maintain a

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high index of suspicion to detect such injuries to ensure expeditious management. Resection

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of the traumatized segment of artery and repair using suitable reversed interposition vein

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grafting from the ipsilateral traumatized limb or close to the zone of injury is safe and

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efficacious.

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ACCEPTED MANUSCRIPT References

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1. Casey RG, Richards S, O’Donohoe M. Vascular surgery of the upper limb: the first year of a new vascular service. Ir Med J. 2002;95:104–105. 2. Snyder WH, Thal ER and Percy MO. Vascular injuries of the extremities. In: Rutherford RB ed. Vascular Surgery. Philadel- phia: WB Saunders, 1990, pp. 613-637. 3. Ergüneş K, Yazman S, Yetkin U, et al. Axillary artery transection after shoulder dislocation. Ann Vasc Surg. 2013;27:974.e7–974.e10. 4. Degiannis E, Levy RD, Sliwa K,et al. Penetrating injuries of the brachial artery. Injury. 1995;26(4):249-52. 5. Wolosker N, Gaudêncio A, Guimarães PC, et al. [Non-iatrogenic trauma of the brachial artery]. Acta Med Port. 1994;7:25–28 6. Ramdass MJ, Harnarayan P. Brachial Artery Reconstruction in trauma using reversed arm vein from the injured upper limb. PRS global open. 2016 5;4(10):e1034. 7. Rothrock, S G; Howard, R M. Delayed brachial artery occlusion owing to a dog bite of the upper extremity. Pediatr Emerg Care. 1990;6(4):293-5. 8. Shaker IJ, White JJ, Singer RD et al. special problems of vascular injuries in children. J Trauma 1976;16;863-867 9. Polesky RE, Harvey JP. Gangrene of the extremity following femoral venepuncture. Paediatrics 1968;42;676 10. Eser O, Kocaogullari C.U, Cosar M et al. Dog bite causing ischemia and neurological deficit at the upper extremity: a case report. Turk Neurosurg. 2008;18(2):219-21. 11. Calkins, CM, Bensard DD, Partrick DA et al. Life-threatening dog attacks: a devastating combination of penetrating and blunt injuries. J Pediatr Surg. 2001;36(8):1115-7. 12. Akingba AG, Robinson EA, Jester AL et al. Management of vascular trauma from dog bites. J Vasc Surg. 2013;58(5):1346-52. doi: 10.1016/j.jvs.2013.05.101. Epub 2013 13. Alluri RK, Pannell W, Heckmann N. Predictive Factors of Neurovascular and Tendon Injuries Following Dog Bites to the Upper Extremity. Hand (N Y). 2016;11(4):469-474. doi: 10.1177/1558944715620794. Epub 2016.

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ACCEPTED MANUSCRIPT

Eser O et al (10)

Case study

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Paraesthesia, absent pulses, weakness

Laceration

Rothrock S et al (7)

Case study

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Absent pulses, delayed CRT

Calkins CM (11)

Case series (n=1) Case series (n=8)

{5}

{27}

Snyder et al (2)

Clinical presentation

Wound type

Site and type of arterial damage

Management

Outcome

Thrombosed brachial artery

Thromboembolectomy

Residual radial & median nerve weakness

Laceration

Occlusion of brachial artery

Resection & interposition graft (GSV)

N/R

Laceration

Right axillary artery intimal tear

Primary repair

Residual anterior interosseous nerve weakness N/R

Absent/diminished pulses (62.5%), active bleeding (12.5%), haematoma (12.5%)

N/R

Right brachial artery: occlusion (25%), intimal tear (12.5%)

Interposition graft (12.5%); primary repair (12.5%); ligation (12.5%); no surgical repair (62.5%)

N/R

Interposition graft (50%); primary repair (50%)

No occlusion at 1 month

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Age {Mean}

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Study design

Right radial artery: intimal tear (12.5%), occlusion (12.5%), transection (12.5%)

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Cool extremity (75%) absent/decreased pulses (75%) haematoma (50%) paraesthesia (25%) Diminished pulse (35%), active bleeding (6%), neurological deficit (60%), sensory loss (12%), motor loss (12%), motor+ sensory (36%) Abnormal vascular exam (66%)

N/A

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Case series (n=4)

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Left radial artery: partial transection (12.5%)

Atkingba et al (12)

Case series (n=17)

{33}

Alluri et al (13)

Case series (n=3)

{37}

Left ulnar/interosseous artery: occlusion (12.5%) Brachial Artery (thrombosed 50%; transected 50%)

Nerve injury (25%)

Laceration (53%), crush (47%)

Axillo-brachial artery (53%) Radial artery (24%) Radial & ulnar artery (12%) Brachial & radial artery (6%)

Primary repair (18%), interposition graft (70%), ligation (12%)

Wound infection (20%), compartment syndrome (12%), limb salvage 1 year 100%.

N/R

Brachial artery: thrombosis (66%) transection (33%)

N/R

N/R

Table 1: Summary of literature review CRT: capillary refill time, GSV: great saphenous vein, N/R: not reported

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Figure 1. Photographic image demonstrating the two anterolateral puncture wounds to the right arm

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Figure 2: Intraoperative assessment of brachial artery following dissection. The segment of the artery in spasm was identified and two direct puncture marks to the artery are noted, one anterolateral and one posteromedial.

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Figure 3. Incision made to join the two posterior puncture wounds for exploration, debridement and washout

ACCEPTED MANUSCRIPT Figure 4. Analysis of data regarding site of arterial trauma identified in the literature

Transection

intimal Tear

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ULNAR ARTERY

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RADIAL ARTERY

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AXILLO-BRACHIAL ARTERY

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Thrombosis

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RADIAL ARTERY + ULNAR ARTERY

1 BRACHIAL + RADIAL ARTERY

ACCEPTED MANUSCRIPT Figure 5. Intervention performed for upper limb vascular trauma secondary to dog bite injury within the literature

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Intervention Performed 6% 3%

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20%

Primary repair

Ligation

no surgical treatment

thromboembolectomy

Undisclosed

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Interposition graft