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Diagnosis and management of penetrating arterial and venous injuries in the extremities
Diagnosis and Management of Penetrating Arterial and Venous Injuries in the Extremities
Frederick A. Reichle, MD, Philadelphia, Pennsylvania Muhammad Golsorkhi, MD, Philadelphia, Pennsylvania
Prompt operative management of known or suspected vascular injuries of the extremities continues to be an important principle in preventing distal tissue loss and associated morbidity and mortality. Whereas the diagnosis of a major vascular injury is frequently obvious, significant arterial or venous injuries may not be initially apparent. Experience in the diagnosis and management of 44 patients with penetrating extremity wounds and associated major vessel injuries is reported herein. Material
and Methods
Forty-four patients, 37 men and 7 women with an average age of 27 years, had penetrating injuries to the arms or legs. Twenty-one of 44 injuries were produced by a sharpedged instrument. There were 21 gunshot wounds; 18 were single isolated bullet injuries and 3 were, produced by multiple pellet penetrations from a shotgun. In addition, two patients had penetrating wounds of the extremity with significant vascular injury produced by blunt, lacerating trauma. Patients entered the hospital 30 minutes to 6 hours after injury; the average time between injury and arrival at the hospital was 45 minutes. The average interval between injury and repair with restoration of function of the blood vessel was 2 hours and 50 minutes. Severe distal extremity ischemia including coldness, hypesthesia and pallor was present preoperatively in only six patients in whom more than 1 hour elapsed between the time of the injury and entrance into the hospital. Our indications for operative exploration of a suspected major arterial or venous injury of an extremity at this hospital have for a number of years included (1) diminished or absent distal pulse, (2) history of excessive blood loss or persistent hemorrhage, (3) large or expanding hematoma, (4) alteration in vital signs due to hypovolemia (hypotenFrom ths Department of Surgery Presbyterian-University of Pennsylvanla Medical Center, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Frederick A. Relchle. MD, Department of Surgery, Presbyterian-University of Pennsylvania Medical Center, 51 North 39th Street, Philadelphia. Pennsylvania 19140.
Volume 140, Seplember 1960
sion, tachycardia), (5) local physical findings (a bruit or thrill), (6) penetrating injury in anatomic proximity to major vessel, (7) signs of ischemia of the distal extremity (coldness, pallor, altered nerve function), and (8) injury of anatomically related nerves. Arteriography is not used routinely for preoperative diagnosis. Preoperatively, almost all patients with significant arterial or venous injuries of the extremity caused by penetrating trauma had one or more positive physical findings associated with vascular injury, particularly alteration of distal pulse, history of persistent, significant hemorrhage, or a large or expanding hematoma. Twenty-three of 44 patients had a diminished or absent distal pulse. Seventeen of 44 patients had a history of persistent or significant hemorrhage (as manifested by an obvious blood loss on the patient’s clothing or on the stretcher). Significant or expanding hematoma was present in 12 of 44 patients. Eight patients had hypotension and other signs of shock. In five patients preoperative alteration in peripheral nerve function indicated injury to a nerve anatomically related to the blood vessel in question. In all patients a missiletract appeared to extend to the region of major blood vessels. It is stressed that almost half of the patients (21 of 44) with significant vascular injuries of the extremities did not have diminished or absent peripheral pulsations preoperatively. An altered distal pulse or severe ischemia is highly significant, however, the absence of these findings does not preclude significant major vessel injury. Arteriography was performed in eight patients. In three of them multiple areas of penetration by shotgun pellets produced multiple injuries of the extremity, and associated physical findings suggested vascular injury. Arteriography was performed to help localiie the site and extent of arterial injury. In these three patients arteriography was thought to have been helpful. In five other patients arteriography ias performed for various reasons; in three of them a normal distal pulse was present and arteriography was performed in an attempt to avoid operation. However, vascular injury was seen on arteriography and therefore operation was performed. One of these five patients had a diminished distal pulse, and in one patient a bruit was heard at the site of the penetrating wound. Although an
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Reichle et al
arteriovenous fistula was demonstrated arteriographically in the latter patient, the preoperative arteriogram was not considered helpful. Nor did the arteriogram alter the management in another patient who had a single penetrating wound and in whom physical findings demonstrated arterial injury. In these patients arteriography only delayed the treatment and served no purpose. Direct suture repair was performed in 24 injuries, most of which were produced by sharp-edged instruments. Resection of blood vessel with end-to-end anastomosis was performed in 10 patients and a patch graft with resection of a portion of the artery was performed in four. In six patients an interposition reversed vein graft (cephalic or saphenous) was performed when resection of larger segments of arteries became necessary, for example, after a gunshot wound of the artery. . Twelve injuries occurred in the arm: 6 in the brachial artery, 4 in the radial artery and 2 in the ulnar artery. Thirty-two patients had arterial injuries of the leg: common iliac, 7; common femoral, 3; superficial femoral, 12; profunda femoris, 3; popliteal, 3; anterior tibia& 2; and posterior tibial, 2. Eighteen major arterial injuries had associated injury in the adjacent vein. Four patients had acute abdominal findings necessitating coincidental laparotomy. One patient had penetration of the abdominal aorta and two patients had penetration of the vena cava along with the extremity vascular injury.
Results Extremity salvage with restoration of distal arterial perfusion and function of the extremity was achieved in 43 of 44 patients. In one patient significant blunt injury in the region of the popliteal artery did not result in restoration of arterial function despite recognition of postoperative ischemia and reoperation. Fasciotomy was performed in the anterior and posterior compartments of the leg in three patients. Two of these three were performed at the time of arterial repair because more than 4 hours elapsed from injury to restoration of blood flow and signs of severe tissue ischemia were present. One patient had delayed fasciotomy when the anterior compartment became tense within the first 6 postoperative hours. We do not hesitate to perform fasciotomy primarily in any patient who has signs of distal ischemia (including pallor, decreased temperature and hypesthesia) before revascularization. All fasciotomies were both anterior and posterior and included skin and deep fascia of the entire length of the lower leg. Skin graft without any attempt at primary approximation was subsequently performed in each. Blood transfusions were required in 33 of 44 patients. In the patients requiring blood transfusions, the average amount of blood administered was 5.4 units. Eight patients had preoperative hypotension and shock. Shock occurred in 11 patients either pre386
or intraoperatively. One of the 44 patients died, from
irreversible shock and cardiac complications directly related to extensive preoperative blood loss. Comments The standard indications for exploration of suspected arteriovenous injuries of the extremities correctly substantiate the diagnosis of major vascular injury in most patients. Prompt diagnosis and operation will produce a high rate of limb salvage and a low mortality. Many civilian injuries are caused by sharp instruments, and local repair or resection is usually sufficient operative management for these injuries. Military injuries are associated with higher morbidity and greater blood loss due to the high velocity of missiles. Arteriography is only occasionally indicated in the immediate management of penetrating extremity wounds. Arteriography is indicated when only relative indications for operation exist. A normal arteriogram will help substantially in planning nonoperative care of selected patients. Arteriography can be particularly helpful in the delayed treatment of neglected arterial injury. In patients with acute arterial injury, the time that elapses while arteriography is performed leads to further delay and may increase morbidity and prolong distal tissue ischemia. Arteriograpby is helpful, however, in patients with blunt extremity injuries, in whom localization and identification of a significant arterial injury can be very important. Peacetime surgery should provide the most favorable circumstances for primary repair of vascular injuries. This is reflected in the high percentage of primarily repaired vessels in our experience. Massive tissue injury is usually not present. A minimum of time should elapse between the injury and the restoration of vascular function. The applicability of primary suture in civilian experience is reflected in the relatively high percentage of vessels treated by primary suture in the civilian experience of others [1-d] which differs from military experience [5]. In civilian practice, the vascular injury is generally produced by a sharp object such as a knife or glass. However, if any question of tissue injury exists, excision of the injured tissue should be performed. Particular attention should be directed at avoiding tension of the vessel after end-to-end anastomosis by adequate proximal and distal anastomosis. In cases where adequate mobilization of the vessel sufficient to allow repair without tension cannot be achieved, an adequate autogenous vein graft should be used. Fasciotomy should be performed in the arm or leg if signs or symptoms of distal tissue ischemia exist. The Ante&an
Journal ol Surgery
Arterial and Venous Injuries in Extremities
When operation has been delayed, fasciotomy should be strongly considered. In a large civilian experience, Drapanas et al [1] found fasciotomy to be indicated in 913 percent of the patients; in others, such as those with popliteal injuries, the indications for fasciotomy occur more often. Delayed complications of untreated vascular injuries are false aneurysms and arteriovenous fistulas. These complications are becoming less common because of increased exploration and correction of acute arterial injuries. Mortality in civilians with extremity injuries is usually related to concomitant injuries. Drapanas et al [I] reported mortality in 24 of 226 patients, 12 of whom had thoracic aortic injuries and other major abdominal vascular injuries. Among 181 patients with injuries to the arteries of the extremity, the mortalitv rate was 5.5 percent and the overall amputation” rate 7.1 percent. Perry et al [2] reported a 10.4 percent mortality in patients with significant arterial injuries.
volume 140, September 1990
Summary Physical examination of a patient in whom a significant vascular injury of the extremity is suspected will almost always provide a prompt and accurate diagnosis of arterial injury. Prompt operation based on the clinical assessment, without specialized diagnostic studies, results in limb salvage and minimal morbidity. References 1. Drapanas T, Hewitt RL, Weichert RF III, Smith AD. Civilian vascular injuries: a critical appraisal of three decades of management. Ann Surg 1970; 172:351. 2. Perry MO, Thal ER, Shires GT. Management of arterial injuries. Ann Surg 197 1; 173:403-8. 3. Morris GC Jr, Beall AC Jr, Roff WR, DeBakey ME. Surgical experience with 220 acute arterial injuries in civilian practice. Am J Surg 1960;99:775-81. 4. Bozer AY, Bdte E, Saylam A. Vascular injuries: an analysis of 115 cases. J Cardiovasc Surg 1973; 14502-7. 5. Rich NM. Vascular Trauma. Surg Clin North Am 1973;53: 1367-92.
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Frederick A. Reichle, MD, Philadelphia, Pennsylvania Muhammad Golsorkhi, MD, Philadelphia, Pennsylvania
Prompt operative management of known or suspected vascular injuries of the extremities continues to be an important principle in preventing distal tissue loss and associated morbidity and mortality. Whereas the diagnosis of a major vascular injury is frequently obvious, significant arterial or venous injuries may not be initially apparent. Experience in the diagnosis and management of 44 patients with penetrating extremity wounds and associated major vessel injuries is reported herein. Material
and Methods
Forty-four patients, 37 men and 7 women with an average age of 27 years, had penetrating injuries to the arms or legs. Twenty-one of 44 injuries were produced by a sharpedged instrument. There were 21 gunshot wounds; 18 were single isolated bullet injuries and 3 were, produced by multiple pellet penetrations from a shotgun. In addition, two patients had penetrating wounds of the extremity with significant vascular injury produced by blunt, lacerating trauma. Patients entered the hospital 30 minutes to 6 hours after injury; the average time between injury and arrival at the hospital was 45 minutes. The average interval between injury and repair with restoration of function of the blood vessel was 2 hours and 50 minutes. Severe distal extremity ischemia including coldness, hypesthesia and pallor was present preoperatively in only six patients in whom more than 1 hour elapsed between the time of the injury and entrance into the hospital. Our indications for operative exploration of a suspected major arterial or venous injury of an extremity at this hospital have for a number of years included (1) diminished or absent distal pulse, (2) history of excessive blood loss or persistent hemorrhage, (3) large or expanding hematoma, (4) alteration in vital signs due to hypovolemia (hypotenFrom ths Department of Surgery Presbyterian-University of Pennsylvanla Medical Center, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Frederick A. Relchle. MD, Department of Surgery, Presbyterian-University of Pennsylvania Medical Center, 51 North 39th Street, Philadelphia. Pennsylvania 19140.
Volume 140, Seplember 1960
sion, tachycardia), (5) local physical findings (a bruit or thrill), (6) penetrating injury in anatomic proximity to major vessel, (7) signs of ischemia of the distal extremity (coldness, pallor, altered nerve function), and (8) injury of anatomically related nerves. Arteriography is not used routinely for preoperative diagnosis. Preoperatively, almost all patients with significant arterial or venous injuries of the extremity caused by penetrating trauma had one or more positive physical findings associated with vascular injury, particularly alteration of distal pulse, history of persistent, significant hemorrhage, or a large or expanding hematoma. Twenty-three of 44 patients had a diminished or absent distal pulse. Seventeen of 44 patients had a history of persistent or significant hemorrhage (as manifested by an obvious blood loss on the patient’s clothing or on the stretcher). Significant or expanding hematoma was present in 12 of 44 patients. Eight patients had hypotension and other signs of shock. In five patients preoperative alteration in peripheral nerve function indicated injury to a nerve anatomically related to the blood vessel in question. In all patients a missiletract appeared to extend to the region of major blood vessels. It is stressed that almost half of the patients (21 of 44) with significant vascular injuries of the extremities did not have diminished or absent peripheral pulsations preoperatively. An altered distal pulse or severe ischemia is highly significant, however, the absence of these findings does not preclude significant major vessel injury. Arteriography was performed in eight patients. In three of them multiple areas of penetration by shotgun pellets produced multiple injuries of the extremity, and associated physical findings suggested vascular injury. Arteriography was performed to help localiie the site and extent of arterial injury. In these three patients arteriography was thought to have been helpful. In five other patients arteriography ias performed for various reasons; in three of them a normal distal pulse was present and arteriography was performed in an attempt to avoid operation. However, vascular injury was seen on arteriography and therefore operation was performed. One of these five patients had a diminished distal pulse, and in one patient a bruit was heard at the site of the penetrating wound. Although an
385
Reichle et al
arteriovenous fistula was demonstrated arteriographically in the latter patient, the preoperative arteriogram was not considered helpful. Nor did the arteriogram alter the management in another patient who had a single penetrating wound and in whom physical findings demonstrated arterial injury. In these patients arteriography only delayed the treatment and served no purpose. Direct suture repair was performed in 24 injuries, most of which were produced by sharp-edged instruments. Resection of blood vessel with end-to-end anastomosis was performed in 10 patients and a patch graft with resection of a portion of the artery was performed in four. In six patients an interposition reversed vein graft (cephalic or saphenous) was performed when resection of larger segments of arteries became necessary, for example, after a gunshot wound of the artery. . Twelve injuries occurred in the arm: 6 in the brachial artery, 4 in the radial artery and 2 in the ulnar artery. Thirty-two patients had arterial injuries of the leg: common iliac, 7; common femoral, 3; superficial femoral, 12; profunda femoris, 3; popliteal, 3; anterior tibia& 2; and posterior tibial, 2. Eighteen major arterial injuries had associated injury in the adjacent vein. Four patients had acute abdominal findings necessitating coincidental laparotomy. One patient had penetration of the abdominal aorta and two patients had penetration of the vena cava along with the extremity vascular injury.
Results Extremity salvage with restoration of distal arterial perfusion and function of the extremity was achieved in 43 of 44 patients. In one patient significant blunt injury in the region of the popliteal artery did not result in restoration of arterial function despite recognition of postoperative ischemia and reoperation. Fasciotomy was performed in the anterior and posterior compartments of the leg in three patients. Two of these three were performed at the time of arterial repair because more than 4 hours elapsed from injury to restoration of blood flow and signs of severe tissue ischemia were present. One patient had delayed fasciotomy when the anterior compartment became tense within the first 6 postoperative hours. We do not hesitate to perform fasciotomy primarily in any patient who has signs of distal ischemia (including pallor, decreased temperature and hypesthesia) before revascularization. All fasciotomies were both anterior and posterior and included skin and deep fascia of the entire length of the lower leg. Skin graft without any attempt at primary approximation was subsequently performed in each. Blood transfusions were required in 33 of 44 patients. In the patients requiring blood transfusions, the average amount of blood administered was 5.4 units. Eight patients had preoperative hypotension and shock. Shock occurred in 11 patients either pre386
or intraoperatively. One of the 44 patients died, from
irreversible shock and cardiac complications directly related to extensive preoperative blood loss. Comments The standard indications for exploration of suspected arteriovenous injuries of the extremities correctly substantiate the diagnosis of major vascular injury in most patients. Prompt diagnosis and operation will produce a high rate of limb salvage and a low mortality. Many civilian injuries are caused by sharp instruments, and local repair or resection is usually sufficient operative management for these injuries. Military injuries are associated with higher morbidity and greater blood loss due to the high velocity of missiles. Arteriography is only occasionally indicated in the immediate management of penetrating extremity wounds. Arteriography is indicated when only relative indications for operation exist. A normal arteriogram will help substantially in planning nonoperative care of selected patients. Arteriography can be particularly helpful in the delayed treatment of neglected arterial injury. In patients with acute arterial injury, the time that elapses while arteriography is performed leads to further delay and may increase morbidity and prolong distal tissue ischemia. Arteriograpby is helpful, however, in patients with blunt extremity injuries, in whom localization and identification of a significant arterial injury can be very important. Peacetime surgery should provide the most favorable circumstances for primary repair of vascular injuries. This is reflected in the high percentage of primarily repaired vessels in our experience. Massive tissue injury is usually not present. A minimum of time should elapse between the injury and the restoration of vascular function. The applicability of primary suture in civilian experience is reflected in the relatively high percentage of vessels treated by primary suture in the civilian experience of others [1-d] which differs from military experience [5]. In civilian practice, the vascular injury is generally produced by a sharp object such as a knife or glass. However, if any question of tissue injury exists, excision of the injured tissue should be performed. Particular attention should be directed at avoiding tension of the vessel after end-to-end anastomosis by adequate proximal and distal anastomosis. In cases where adequate mobilization of the vessel sufficient to allow repair without tension cannot be achieved, an adequate autogenous vein graft should be used. Fasciotomy should be performed in the arm or leg if signs or symptoms of distal tissue ischemia exist. The Ante&an
Journal ol Surgery
Arterial and Venous Injuries in Extremities
When operation has been delayed, fasciotomy should be strongly considered. In a large civilian experience, Drapanas et al [1] found fasciotomy to be indicated in 913 percent of the patients; in others, such as those with popliteal injuries, the indications for fasciotomy occur more often. Delayed complications of untreated vascular injuries are false aneurysms and arteriovenous fistulas. These complications are becoming less common because of increased exploration and correction of acute arterial injuries. Mortality in civilians with extremity injuries is usually related to concomitant injuries. Drapanas et al [I] reported mortality in 24 of 226 patients, 12 of whom had thoracic aortic injuries and other major abdominal vascular injuries. Among 181 patients with injuries to the arteries of the extremity, the mortalitv rate was 5.5 percent and the overall amputation” rate 7.1 percent. Perry et al [2] reported a 10.4 percent mortality in patients with significant arterial injuries.
volume 140, September 1990
Summary Physical examination of a patient in whom a significant vascular injury of the extremity is suspected will almost always provide a prompt and accurate diagnosis of arterial injury. Prompt operation based on the clinical assessment, without specialized diagnostic studies, results in limb salvage and minimal morbidity. References 1. Drapanas T, Hewitt RL, Weichert RF III, Smith AD. Civilian vascular injuries: a critical appraisal of three decades of management. Ann Surg 1970; 172:351. 2. Perry MO, Thal ER, Shires GT. Management of arterial injuries. Ann Surg 197 1; 173:403-8. 3. Morris GC Jr, Beall AC Jr, Roff WR, DeBakey ME. Surgical experience with 220 acute arterial injuries in civilian practice. Am J Surg 1960;99:775-81. 4. Bozer AY, Bdte E, Saylam A. Vascular injuries: an analysis of 115 cases. J Cardiovasc Surg 1973; 14502-7. 5. Rich NM. Vascular Trauma. Surg Clin North Am 1973;53: 1367-92.
367