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Missed arterial injuries in military patients
Missed Arterial
Injuries
in Military
Ahmet T. Yilmaz, MD, Mehmet Arslan, MD, JJfuk Devirkiliq, Harun Tatar, Omer Y. Oztijrk,
BACKGROUND: Military vascular injuries frequently result from fragment wounds while civilian vascular injuries usually are caused by gunshot wounds. The natural history of untreated major injuries by small low velocity fragments is not well known. This study evaluated the nature of these wounds. METHODS: From 1990 to 1995,40 patients with a delayed diagnosis of an arterial injury in the extremity, abdomen, or neck were treated. The median delay between injury and diagnosis was 60 days. All patients had been seen at other military hospitals immediately after trauma. RESULTS: During initial hospitalization, immediate exploration had been performed in 23 patients and arteriogram in 3 patients. According to analysis of the records of patients, none of them had hard signs of vascular injury at the time of initial evaluation after trauma. Complications of missed arterial injuries included the following: false aneurysm, 21 (52.5%); arteriovenous fistula, 14 (35%); and occlusion, 5 (12.5%). The superficial femoral artery (n = 11) was the most commonly injured vessel. The remaining arteries included the following: carotid, 2; vertebral, 1; subclavian, 5; axillary, 2; brachial, 3; radial or ulnar, 2; internal iliac, 2; common femoral, 1; profunda femoris, 2; popliteal, 1; tibioperoneal, 8. Thirty-eight patients had penetrating wounds (21 fragments, 9 gunshot, 3 shotgun, 5 stab wounds), and only 2 patients had blunt trauma. All patients underwent surgery. There were no deaths and no loss of extremity, but 10 patients had fair results and only 4 patients required later reoperation. CONCLUSION: Traumatic arterial injuries that particularly are caused by low-velocity small fragment wounds can result in serious delayed complications months or even years after the injury. Patients with penetrating injuries must be closely monitored, and arteriography is recommended to evaluate the conditions of patients with potential vascular injury even when overt clinical signs or symptoms of vascular injury are absent. Am J Surg. 1997;173:1 IO-I 14. 0 1997 by Excerpta Medica, Inc.
From the Cardiovascular Requests MD, GATA key. Manuscript form March .____ 110
6 1997 by Excerpta All rights reserved.
June
27, 1995
and accepted
MD, Erkan Kuralay,
MD,
Turkey
P
rompt diagnosis and definitive treatment are essential in preventing the late seyuelae of untreated vascular injuries including arterial occlusion, pseudoaneurysm, and arteriovenous fistula.‘,’ There is little difficulty in detertnining that the patients have a serious injury, and when major arteries are involved usually there are clear signs that an operation is needed.‘,’ More problems in diagnosis are encountered when minor stab or gunshot wounds of the extremities are treated.’ At prczent, the three most common approaches to an asymptomatic patient present with trauma to an extremity or to the neck, especially a penetrating wound, are observation alone, mandatory operation, and arteriography.’ None of these, however, has been shown to be uniformly successful in preventing the problem of delayed diagnosis of an arterial injury when a large number of patients have been evaluated. To date, long-term followup data that verify the accuracy of these approaches in regard to missed injuries and long-term complications have been lacking.’ Our study presented a review of complications encountered as a result of missed or untreated arterial injuries.
MATERIALS
AND
METHODS
For this present study, records of 40 patients who had missed arterial injuries between 1990 and 1995 (with the majority of the cases accumulated occurred during the last2 years) were reviewed. Only military patients were included in this review. All patients were seen at another military hospital immediately following injury, and were then admitted to our cardiovascular unit in Giilhane Military Medical Academy, Ankara, Trlrkey, complaining of late manifestations of untreated arterial injury or referred directly to our clinic for definitive care. Patients had been provided copies of medical records to document the initial examination after the injury. These documents included the etiology of trauma, associated orthopedic and other injuries, vital findings of patients at initial examination, presence or absence of signs of vascular injury, methods of management of the trauma at initlal acceptance and during the initial hospitalization, result of management, period of delay between time of wounding and time of delayed diagnosis of vascular injury, and whether the imtnediate exploration or arteriography was performed during the initial hospitalization. In all patients admitted to our service with a delayed diagnosis of arterial injury, preoperative arteriography (digital subscription angiogtaphy) was performed depending on the injury location. All patients underwent operation. Treatments of the complication of arterial injury and perioperative morbidity were recorded. Followup data were available in all cases, and averaged 8 months (range 3 months to 5 years).
Giilhane Military Medical Academy, Department of Surgery, Ankara, Turkey. for reprints should be addressed to Ahmet T. Yilmaz, Lojmanlari Numan Apt. No. 5,06018 Etlik, Ankara, Tursubmitted 25, 1996.
MD, ErtuQrul &al, Ankara,
Patients
in revised I
Medica,
Inc.
0002-961 O/97/$1 PII SOOO2-9610(96)00423-O
7.00
[MISSED TABLE
I Mechanism
of lniunr
in Missed
Mechanism Stab
%
wound
(5)
Blunt injury (2) Shotgun wound
22.5 52.5
(1)
(2) (6)
(12)
40
II Localization
Injured
Injury
False aneurysm A-V fistula (4) Occlusion (2) False aneurysm A-V fistula (1) False aneurysm A-V fistula (3) Occlusion (3) False aneurysm A-V fistula (6)
5 7.5
(3)
Arteries
Upper extremity Subclavian Axillary Brachial Radial or ulnar Internal iliac Lower Extremity Common femoral Profunda femoris Superficial femoral Popliteal Tibioperoneal Neck External carotid Common carotid Vertebral artery Total
of Missed
Arterial
Injuries
Number
%
12 5 2 3 2 2 23 1 2 11 1 8 3
30
5 57.5
7.5
1 40
Figure 1. Fragment wound of the thigh caused this false aneurysm of deep femoral artery. Diagnosis was made 9 weeks later when a painful mass appeared. THE
INJURIES
IN MILITARY
PATIENTSNILMAZ
ET AL 1
RESULTS
Trauma Arterial
12.5
Gunshot wound (9) (rifles, pistols) Fragment (21) (from various exploding devices; hand grenades, mines, mortars, rocket) Total
TABLE
Arterial
ARTERIAL
AMERICAN
All patients underwent operative repair for late manifestations of missed arterial injuries. The age range was from 20 to 48 years and included 34 patients between 20 and 22, 4 patients between 23 and 40, and 2 patients older than 41 years. All patients were male. Thirty-eight patients had penetrating wounds and only two patients had blunt trauma. The majority of penetrating arterial injuries, 2 1 or 52.5%, were caused by fragments from various exploding devices such as hand grenades, mortars, rockets, ie 27 patients sustained multiple penetrating wound. Bullet or fragments were still present in nine patients (Table I). There were 2 injuries (5%) in the abdominal cavity; 87.5% of these lesions werr found in extremity vessels (Table II). Arteries In the lower extremities were involved in 23 of 40 patients (57.5%), whereas arteries in the upper extremities or neck were involved in 12 patients (30%) and 3 patients (7.5%), respectively. The superficial femoral artery was the most frequently involved: 11 or 27.5%. This was followed by 8 (20%) tibioperoneal arterial injuries and 5 (12.5%) subclavian arterial injuries. Head and neck vessels accounted for only 3 (7.5%) injured arteries. In these 3 patients, penetrating trauma had occurred by fragments of a hand grenade and none of them had exploration and arteriogram performed in their neck region. Twenty-three patients (57.5%) had undergone a surgical procedure for immediate exploration of wound or associated injuries in another military hospital after the injury. In 11 of these 23 patients, surgical explorations were performed for injuries close to major vascular structure. However, in all 23 patients, injured vascular structure had not been detected at first O~wrdtiOn after trauma (Figure 1). Arteriography had been performed in only three patients at initial hospitalization. Two patients had f&e-negative arteriographic findings. The first patient had ‘1 normal axillary arteriographic fmding after a gunshot wo~1r~1 to the shoulder girdle. After 2 months, a second artrriogram revealed arteriovenous fist& of the axillary artery and vein. The other patient with fragment trauma had normal ileofemoral arteriographic findings after a large laceration caused by a hand grenade to the abdomen and groin. After 37 days, a second arteriogram showed a large artcriovenous fistula of the internal iliac artery (Figure 2). In one patient in whom an error in reading was made, an injury to the superficial femoral artery by bullet was considered as an insignificant irregularity that was an intimal injury and subintimal hematoma. This patient was admitted tcl our clinic complaining of severe cl&cation after 1 month. Arteriography performed on admission to our service revealed occlusion of the superf;cial femoral artery. In the remaining 16 patients, arteriogram and exploration had not been performed during initial hospitalization. After a careful analysis of patient records, it was found that Failure to perform an arteriogram and absence of “hard” signs of vascular injury at initial examination despite injury occurred in 40 patients were the most common causes of a delayed diagnosis (Figure 3). The delay in diagnosis from the time of injury ranged from 3 days to 16 months, with a median delay of 60 days. The delay was from 3 days to 30 days in 9 patients, the majority of which included gunshot and stab wounds; frcm 30 days to 90 days in 23 patients with a majority of fragment wounds; from 90 days to 1 year in 6 patients (4 fragment wounds, 1 gunshot, JOURNAL
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1997
111
M IISSED
ARTERIAL
INJURIES
IN MILITARY
PATIENTWYILMAZ
ET AL TABLE
Ill Complications
Complications False Aneurysm
wound. cardiac Occlusion
Total
Figure 3. Large false aneurysm, 15 weeks after fragment trauma of the superficial femoral artery. In spite of serious compression of superficial femoral artery, all the distal pulses were palpable.
1 shotgun wound); and from 12 months to 16 months in 2 patients (1 fragment wound, 1 stab wound). The majority of patients with missed arterial injury were asymptomatic. In these patients, late sequelae of missed arterial injury were found during routine examination. Peripheral pulses were present in all except four patients. The presence of a palpable painful or painless mass was the principal symptom in 10 cases. Murmur was detected in all patients with arteriovenous fistula. Detectable thrill w;1s present in 7 of 14 patients with arteriovenous tistula. High output cardiac failure secondary to iliac arteriovenous fistula was present in one case (Fig. 2). Symptoms of venous insufficiency were present in five cases; all of these patients had arteriovenous tistula on their primary lesions. Two patients presented with acute arterial insufficiency caused hy 112
THE
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Arterial
Injuries
Number
%
21 (1)
52.5
Axillary Subclavian (3) Brachial (1) Common femoral (1) Profunda femoris (2) Superficial femoral (7) Tibioperoneal (2) Vertebral (1) External carotid (1) Common carotid (1) 14 Subclavian (2) Axillary (1) Radial (1) Ulnar (1) Internal iliac (2) Superficial femoral (3) Popliteal (1) Tibioperoneal (3) 5 Superficial femoral (1) Tibioperoneal (2) Brachial (2) 40
A-V Fistula
Figure 2. Internal iliac arteriovenous fistula after fragment Diagnosis was made 4 months later when a high output failure symptoms developed.
of Missed
35
12.5
emboli from a false aneurysm. Three patients presented with chronic arterial insufficiency distal to the site of injury. Three patients had a neurologic symptom that occurred owing to persisting compression to hrachial plexus in two and to femoral nervosa in one. Late complications of missed arterial injuries based on an@graphic and operative examinations were pseudoaneurysm in 21 patients (52.5%), arteriovenous fistula in 14 patients (35X), and occlusion in 5 patients (12.5%) (Table III). The treatment of the injured arteries was segmental resection in 26 patients (65%), followed by an end to end anastomosis (5 patients) or insertion of a graft (21 patients: saphenous vein graft in 14 patients, polytetrafluroethylene in 6 patients, dacron in 1 patient). The remaining patients had ligation (9 patients: 3 tihioperoneal, 1 vertebral, 1 external carotid, 2 profundo femoris, 1 ulnar, 1 hypogastric artery) or a primary repair (lateral suture or patch plasty) (5 patients with one of the following: common carotid, common femoral, superficial femoral, suhclavian, radial artery). The venous side of arteriovenous fistula was generally closed with a primary suture. In 5 patients with an arteriovenous fistula (1 internal iliac, 2 tihioperoneal, 1 ulnar, 1 radial) venous side were oper,& by ligation. There was no operative mortality and significant perioperative morbidity. Local complications occurred in six patients, and included five wound infections, one hrachial plexopathy from compression. The 4 late complications after corrective surgery were dacrcm graft thrombosis in 3 patients and anastomotic aneurysm in one patient, 2, 3, 6, and 14 months after surgery (Table IV). In these patients, reoperations was performed and safenous vein grafts were inserted at anatomic position in three, at extra-anatomic position in one patient with excellent results. FEBRUARY
1997
( MISSED TABLE IV Complications
of Treatment
Complications Neurologic* Wound infections Reoperations Graft thrombosis Infected anastomotic
of Missed
Arterial Number
aneurysm
1 5 4 3 1
Injuries % 2.5 12.5 10 7.5 2.5
* Brachiai p/exop&y.
DISCUSSION The presence of distal pulses with proximal arterial injury has been well described. The pressure wave can be transmitted beyond an intimal flap, through soft, fresh cloth, or through collateral and be palpable in the distal arteries.’ A brachial pulse may be present even after complete disruption of the axillary artery because of the rich collateralization around the shoulder.6’i Drapanas et al found that 27% of the patients admitted to the emergency room with a major arterial injury in the extremities had a normal distal pulse.H MacCormick and Burch found physical examination to be less reliable in detecting major arterial injuries; they reported that in 91 patients 42% of the examinations were falsely positive, and 20% were falsely negative.” In the extensive experience with civilian arterial injuries at Parkland Hospital in Dallas, 69 (25%) of 271 patients presenting with serious extremity vascular injuries were recorded as having palpable pulses on initial examination.‘” In the Hewitt and Collin series, peripheral pulse were present in all patients with acute arteriovenous fistulae, and the importance of auscultation of all penetrating wounds near major arteries was emphasized. ‘I In our study, all of patients with missed arterial injury in the extremities had no “hard” signs of vascular injury at the time of initial hospitalization after wounding. In our cases, a number of factors, such as multiple wounds, other more serious problems, and the majority of wounds having been caused by many small low velocity fragments, might lead to a delay in recognition of these lesions. More frequently the injury that occurred by small fragments is tangential, with good flow persisting despite a false aneurysm involving one wall. The lack of a specific physical finding caused by some arterial injuries and the morbidity from missed injuries have led some authorities to recommend exploration of all wounds in proximity to major vessels.sz” Certainly this approach prevents missing vascular injuries; but it also results in unnecessary operations, some morbidity, and occasionally even death. In the report of Sirinek and colleagues, routine exploration of 390 proximity wounds resulted in 64% unnecessary explorations, and these explorations were associated with significant morbidity in 5% and 1 death.” In another series, in which the only indication was proximity of the wound to a major vessel, only 8% of patients explored had a significant injury.” In our cases, 23 patients underwent operative exploration to detect continued bleeding areas (11 patients) or nonvascular surgical repair of associated other lesions when the wound was proximal to an artery (12 patients), but arterial injuries had been missed when these patients had been seen at other military hospitals. Military vascular injuries are usually multiple and THE AMERICAN
ARTERIAL
INJURIES
IN MILITARY
PATIENTWYILMAZ
ET AL 1
frequently cause an exsanquinating hemorrhage in the neck, thorax, and abdomen. Also, wounds in these anatomical regions prompt exploration more than do multiple small extremity wounds. With fragments accounting for 52.5% of the lesions in our series, it is obvious that lowvelocity small fragments cause wounds that require less extensive debridement and less definitive vascular repair than do high velocity missile wounds. In our cases, there are some factors that failed to find the injury initially at immediate exploration: (1) no “hard” signs of vascular injury; (2) taken to the operating room to treat more important injuries such as head, thorax, or abdominal injuries or even of other injuries in the same extremity; (3) absence of an exit wound with an unusual or reconstructable trajectory that occurred by fragments; (4) presence of multiple penetrating trauma such as fragment wounds and shotgun wounds; and (5) sometimes the internal evidence of injury occurred by fragment or blunt trauma is greater than that seen externally. Arteriography is a well-accepted alternative to surgical exploration in injuries to the extremities that do not exhibit obvious signs of vascular trauma.““,’ ’ Preoperative arteriography to document the presence and location of an arterial injury in an asymptomatic patlent or a patient with soft signs is the approach favored by many authors.‘4.15 Patients with a normal arteriographic finding have less than 1% to 2% incidence of missed injuries.’ Richardson et al noted that 8 late injuries were detected from a series of 440 arteriograms.5 Moreover, with large numhers of negative angiographies being reported, particularly if the only indication is the proximity to a major vessel, some authors have suggested a more selective use of aIl~iography.lh.I’ In our series, only 3 of 40 patients with missed arterial injury had undergone arteriographic study immediately after first admission to previous hospitals and these patients had a falsenegative arteriographic findings. The indications for arteriography when the existence of an arterial injury has already been recognized, include multiple penetrating trauma such as shotgun wounds or fragment wounds, absence of an exit wound with an unusual or reconstructable trajectory, and extensive blunt trauma. Particularly when the penetrating agent is a high-velocity missile, the surgeon has the additional task of estimating the extend of mural injury and, particularly, the intimal-endothelial damage and integrity of the external elastic lam& and adventitia; the former leading to delayed thrombosis and absence of the latter to delayed aneurysm formation. With blunt trauma, the internal evidence of injury is nearly always greater than that seen externally. An occluded vessel may offer little external evidence of the location of the offending lesion, usually an intimal tear or flap. A few petechial hemorrhages in the adventitia, with or without local spasm, may be the only sign of significant injury in a vessel that may be patent with a palpable distal pulse.‘” Late complications of missed arterial injury include arterial occlusion, A-V fistula, and pseudoaneurysm formation. The frequency of occurrence is suggested by Rich et al who reported 558 A-V fistulae and false aneurysms occurring in 507 patients, representing 7% of the injuries in the Vietnam Vascular Registry; 55% involved extremities, usually the leg, and there was a delay in diagnosis of more than 30 days in 47% of patients. ly Escobar et al reported false aneurysms (38.5%) and arterial insufficiency (24.5%) secondary to arJOURNAL
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MISSED
ARTERIAL
INJURIES
IN MILITARY
PATlENTSPllLMAZ
ET AL 1
teriovenous fistulae accounted for the majority of missed arterial injuriesz Perry reported 16 pseudoaneurysms and 4 A-V fistulae in 31 patients with missed arterial injury.’ In our study, there were 52.5% false aneurysms, 35% A-V fistulae, and 12.5% arterial occlusion. Failure to recognize and surgically correct subclavian or axillary arterial injury may result in delayed injury of the brachial plexus by compression of an expending false aneurysm. Even small false aneurysms can result in injury to the neuroplexus owing to the close anatomical relationship, and because a single fascial envelope surrounds the structures, the compression effect is heightened.‘” In 2 patients of our series, there were a delayed injury of the brachial plexus by compression of an expanding false aneurysm of subclavian and axillary artery 3 and 5 weeks after the injury. Two months after surgery, there was partial return of motor function but complete return of sensation. In conclusion, military vascular traumas frequently result from fragments and usually cause some complications of missed arterial injuries. Most of these patients have no “hard” signs of vascular injury. Therefore, patients with injuries proximal to major vessels must be closely monitored and arteriography is highly recommended to evaluate the conditions of patients with potential vascular injury.
REFERENCES 1. O’Gorman RB, Feliciano DV, Bitondo CG, et al. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries. Arch Surg. 1984;119:568-573. 2. Escobar GA, Escobar SC, Marquez L, et al. Vascular trauma: Late sequelae and treatment. J Cardiovasc Surg. 1980;21:135-140. 3. Perry OM. Complications of missed arterial injuries. J Vast Surg. 1993;17:399-407. 4. Feliciano DV, Cruse PA, Burch JM, Bitondo CG. Delayed diagnosis of arterial injuries. Am J Surg. 1987;154:579-584.
EDITORIAL
COMMENT
The Minimalist Approach to Vascular Injury The article by Yilmaz et al is a timely reminder of the importance of diligent detection of potential vascular injuries. The authors report a series of 40 patients with delayed diagnosis of an arterial injury in the extremity, neck, or abdomen. The median time of delay from injury to diagnosis was 60 days and the complications predominantly included false aneurysms and arteriovenous fistulae. There were two striking features in this report in my opinion. First, none of the patients was described as having hard signs of vascular injury. There are several reports in this country of the safety of observation alone in patients who do not present with hard signs of vascular injury. This report emphasizes the traditional view that some means to evaluate a potential arterial injury is important to prevent lifeor limb-threatening complications even in the absence of hard signs of injury.
114
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5. Richardson JD, Vitale GC, Flint LM. Penetrating arterial trauma: Analysis of missed vascular injuries. Arch Swg. 1987;122:678-683. 6. Raju S, Camer DV. Brachial plexus compression. Arch Stlrg. 1981;116:175-178. 7. Schaff HV. Brawley RK. Op err it’ ive. management of penetrating vascular injuries of the thoracic outlet. Surgery. 1977;82:182-191. 8. Drapanas T, Hewitt RL, Weichert RF, et al. Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg. 1970;172:351-360. 9. MacCormick TM, Burch BH. Routine angiographic evaluation of neck and extremity injuries. J Tmmna. 1979;19:384-390. 10. Shires GT. Patman RD. Vascular injuries. In Shires GT (ed): The Cnre of the Truwnu Patient. New York: McGraw-Hill; 1966, 223-239. 11. Hewitt RL, Collins DJ. Acute arteriovenous fistulas in war injuries. Ann Surg. 1969;169:447-449. 12. Sirinek KR, Levine BA, Gaskill HV III, Root HD. Reassessment of the role of routine operative exploration in the vascular trauma. J Trauma. 1981;21:339-344. 13. Snyder WH III, Thai ER, Bridges RA, et al. The validity of normal arteriography in penetrating trauma. Arch Surg. 1978;113:4244428. 14. Turcotte JK, Towne JR, Bernhard VM. Is arteriography necessary in the inanagement of vascular trauma of the extremities? Surgery. 1978;84:557-562. 15. Raju S. Shotgun arterial injuries of the arteries. Am .l Surg. 1979;138:421-425. 16. Reid JDS, Weigelt ]A, Thal ER, Francis H. Assessment of proximity of a wound to major vascular structures as an indication for arteriography. .4rch Surg. 1988;123:942-946. 17. MC Corkell SC, Harley JD, Morishima MS, et al. Indications for angiography in extremity trauma. AJR. 1985;145:1245-1247. 18. Rutherford RB. Diagnostic evaluation of extremity vascular injuries. Surg Clin North Am. 1988;68:683-691. 19. Rich NM, Hobson RW, Collms GJ. Traumatic arteriovenous fistulas and false aneurysms: A review of 558 lesions. Swrgery. 1975;78:817-828. 20. Braun RM, Newman J, Thacher B. Injury to the brachial plexus as a result of diagnostic arteriography. J Hnnd Surg. 1978;3:90-94.
The second point is that exploration of the artery often fails to define an injury even when it exists. Half of these patients had some limited exploration that failed to detect the injury. This occurred most commonly in the superficial femoral artery where thick musculature may prevent adequate exploration, The authors recommend arteriography as the best means to detect vascular injury and prevent missed injuries. While this is clearly speculative, it is consistent with our observations in a civilian population (Richardson, JD, Vitale GC, Flint LM. Penetrating arterial trauma: Analysis of missed vascular injuries. Arch Surg. 1987;122:678-683.)
University
FEBRUARY
1997
J. David Richardson, MD Professor and Vice Chair Department of Surgery of Louisville School of Medicine Louisville, Kentucky
Injuries
in Military
Ahmet T. Yilmaz, MD, Mehmet Arslan, MD, JJfuk Devirkiliq, Harun Tatar, Omer Y. Oztijrk,
BACKGROUND: Military vascular injuries frequently result from fragment wounds while civilian vascular injuries usually are caused by gunshot wounds. The natural history of untreated major injuries by small low velocity fragments is not well known. This study evaluated the nature of these wounds. METHODS: From 1990 to 1995,40 patients with a delayed diagnosis of an arterial injury in the extremity, abdomen, or neck were treated. The median delay between injury and diagnosis was 60 days. All patients had been seen at other military hospitals immediately after trauma. RESULTS: During initial hospitalization, immediate exploration had been performed in 23 patients and arteriogram in 3 patients. According to analysis of the records of patients, none of them had hard signs of vascular injury at the time of initial evaluation after trauma. Complications of missed arterial injuries included the following: false aneurysm, 21 (52.5%); arteriovenous fistula, 14 (35%); and occlusion, 5 (12.5%). The superficial femoral artery (n = 11) was the most commonly injured vessel. The remaining arteries included the following: carotid, 2; vertebral, 1; subclavian, 5; axillary, 2; brachial, 3; radial or ulnar, 2; internal iliac, 2; common femoral, 1; profunda femoris, 2; popliteal, 1; tibioperoneal, 8. Thirty-eight patients had penetrating wounds (21 fragments, 9 gunshot, 3 shotgun, 5 stab wounds), and only 2 patients had blunt trauma. All patients underwent surgery. There were no deaths and no loss of extremity, but 10 patients had fair results and only 4 patients required later reoperation. CONCLUSION: Traumatic arterial injuries that particularly are caused by low-velocity small fragment wounds can result in serious delayed complications months or even years after the injury. Patients with penetrating injuries must be closely monitored, and arteriography is recommended to evaluate the conditions of patients with potential vascular injury even when overt clinical signs or symptoms of vascular injury are absent. Am J Surg. 1997;173:1 IO-I 14. 0 1997 by Excerpta Medica, Inc.
From the Cardiovascular Requests MD, GATA key. Manuscript form March .____ 110
6 1997 by Excerpta All rights reserved.
June
27, 1995
and accepted
MD, Erkan Kuralay,
MD,
Turkey
P
rompt diagnosis and definitive treatment are essential in preventing the late seyuelae of untreated vascular injuries including arterial occlusion, pseudoaneurysm, and arteriovenous fistula.‘,’ There is little difficulty in detertnining that the patients have a serious injury, and when major arteries are involved usually there are clear signs that an operation is needed.‘,’ More problems in diagnosis are encountered when minor stab or gunshot wounds of the extremities are treated.’ At prczent, the three most common approaches to an asymptomatic patient present with trauma to an extremity or to the neck, especially a penetrating wound, are observation alone, mandatory operation, and arteriography.’ None of these, however, has been shown to be uniformly successful in preventing the problem of delayed diagnosis of an arterial injury when a large number of patients have been evaluated. To date, long-term followup data that verify the accuracy of these approaches in regard to missed injuries and long-term complications have been lacking.’ Our study presented a review of complications encountered as a result of missed or untreated arterial injuries.
MATERIALS
AND
METHODS
For this present study, records of 40 patients who had missed arterial injuries between 1990 and 1995 (with the majority of the cases accumulated occurred during the last2 years) were reviewed. Only military patients were included in this review. All patients were seen at another military hospital immediately following injury, and were then admitted to our cardiovascular unit in Giilhane Military Medical Academy, Ankara, Trlrkey, complaining of late manifestations of untreated arterial injury or referred directly to our clinic for definitive care. Patients had been provided copies of medical records to document the initial examination after the injury. These documents included the etiology of trauma, associated orthopedic and other injuries, vital findings of patients at initial examination, presence or absence of signs of vascular injury, methods of management of the trauma at initlal acceptance and during the initial hospitalization, result of management, period of delay between time of wounding and time of delayed diagnosis of vascular injury, and whether the imtnediate exploration or arteriography was performed during the initial hospitalization. In all patients admitted to our service with a delayed diagnosis of arterial injury, preoperative arteriography (digital subscription angiogtaphy) was performed depending on the injury location. All patients underwent operation. Treatments of the complication of arterial injury and perioperative morbidity were recorded. Followup data were available in all cases, and averaged 8 months (range 3 months to 5 years).
Giilhane Military Medical Academy, Department of Surgery, Ankara, Turkey. for reprints should be addressed to Ahmet T. Yilmaz, Lojmanlari Numan Apt. No. 5,06018 Etlik, Ankara, Tursubmitted 25, 1996.
MD, ErtuQrul &al, Ankara,
Patients
in revised I
Medica,
Inc.
0002-961 O/97/$1 PII SOOO2-9610(96)00423-O
7.00
[MISSED TABLE
I Mechanism
of lniunr
in Missed
Mechanism Stab
%
wound
(5)
Blunt injury (2) Shotgun wound
22.5 52.5
(1)
(2) (6)
(12)
40
II Localization
Injured
Injury
False aneurysm A-V fistula (4) Occlusion (2) False aneurysm A-V fistula (1) False aneurysm A-V fistula (3) Occlusion (3) False aneurysm A-V fistula (6)
5 7.5
(3)
Arteries
Upper extremity Subclavian Axillary Brachial Radial or ulnar Internal iliac Lower Extremity Common femoral Profunda femoris Superficial femoral Popliteal Tibioperoneal Neck External carotid Common carotid Vertebral artery Total
of Missed
Arterial
Injuries
Number
%
12 5 2 3 2 2 23 1 2 11 1 8 3
30
5 57.5
7.5
1 40
Figure 1. Fragment wound of the thigh caused this false aneurysm of deep femoral artery. Diagnosis was made 9 weeks later when a painful mass appeared. THE
INJURIES
IN MILITARY
PATIENTSNILMAZ
ET AL 1
RESULTS
Trauma Arterial
12.5
Gunshot wound (9) (rifles, pistols) Fragment (21) (from various exploding devices; hand grenades, mines, mortars, rocket) Total
TABLE
Arterial
ARTERIAL
AMERICAN
All patients underwent operative repair for late manifestations of missed arterial injuries. The age range was from 20 to 48 years and included 34 patients between 20 and 22, 4 patients between 23 and 40, and 2 patients older than 41 years. All patients were male. Thirty-eight patients had penetrating wounds and only two patients had blunt trauma. The majority of penetrating arterial injuries, 2 1 or 52.5%, were caused by fragments from various exploding devices such as hand grenades, mortars, rockets, ie 27 patients sustained multiple penetrating wound. Bullet or fragments were still present in nine patients (Table I). There were 2 injuries (5%) in the abdominal cavity; 87.5% of these lesions werr found in extremity vessels (Table II). Arteries In the lower extremities were involved in 23 of 40 patients (57.5%), whereas arteries in the upper extremities or neck were involved in 12 patients (30%) and 3 patients (7.5%), respectively. The superficial femoral artery was the most frequently involved: 11 or 27.5%. This was followed by 8 (20%) tibioperoneal arterial injuries and 5 (12.5%) subclavian arterial injuries. Head and neck vessels accounted for only 3 (7.5%) injured arteries. In these 3 patients, penetrating trauma had occurred by fragments of a hand grenade and none of them had exploration and arteriogram performed in their neck region. Twenty-three patients (57.5%) had undergone a surgical procedure for immediate exploration of wound or associated injuries in another military hospital after the injury. In 11 of these 23 patients, surgical explorations were performed for injuries close to major vascular structure. However, in all 23 patients, injured vascular structure had not been detected at first O~wrdtiOn after trauma (Figure 1). Arteriography had been performed in only three patients at initial hospitalization. Two patients had f&e-negative arteriographic findings. The first patient had ‘1 normal axillary arteriographic fmding after a gunshot wo~1r~1 to the shoulder girdle. After 2 months, a second artrriogram revealed arteriovenous fist& of the axillary artery and vein. The other patient with fragment trauma had normal ileofemoral arteriographic findings after a large laceration caused by a hand grenade to the abdomen and groin. After 37 days, a second arteriogram showed a large artcriovenous fistula of the internal iliac artery (Figure 2). In one patient in whom an error in reading was made, an injury to the superficial femoral artery by bullet was considered as an insignificant irregularity that was an intimal injury and subintimal hematoma. This patient was admitted tcl our clinic complaining of severe cl&cation after 1 month. Arteriography performed on admission to our service revealed occlusion of the superf;cial femoral artery. In the remaining 16 patients, arteriogram and exploration had not been performed during initial hospitalization. After a careful analysis of patient records, it was found that Failure to perform an arteriogram and absence of “hard” signs of vascular injury at initial examination despite injury occurred in 40 patients were the most common causes of a delayed diagnosis (Figure 3). The delay in diagnosis from the time of injury ranged from 3 days to 16 months, with a median delay of 60 days. The delay was from 3 days to 30 days in 9 patients, the majority of which included gunshot and stab wounds; frcm 30 days to 90 days in 23 patients with a majority of fragment wounds; from 90 days to 1 year in 6 patients (4 fragment wounds, 1 gunshot, JOURNAL
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Ill Complications
Complications False Aneurysm
wound. cardiac Occlusion
Total
Figure 3. Large false aneurysm, 15 weeks after fragment trauma of the superficial femoral artery. In spite of serious compression of superficial femoral artery, all the distal pulses were palpable.
1 shotgun wound); and from 12 months to 16 months in 2 patients (1 fragment wound, 1 stab wound). The majority of patients with missed arterial injury were asymptomatic. In these patients, late sequelae of missed arterial injury were found during routine examination. Peripheral pulses were present in all except four patients. The presence of a palpable painful or painless mass was the principal symptom in 10 cases. Murmur was detected in all patients with arteriovenous fistula. Detectable thrill w;1s present in 7 of 14 patients with arteriovenous tistula. High output cardiac failure secondary to iliac arteriovenous fistula was present in one case (Fig. 2). Symptoms of venous insufficiency were present in five cases; all of these patients had arteriovenous tistula on their primary lesions. Two patients presented with acute arterial insufficiency caused hy 112
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Arterial
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Number
%
21 (1)
52.5
Axillary Subclavian (3) Brachial (1) Common femoral (1) Profunda femoris (2) Superficial femoral (7) Tibioperoneal (2) Vertebral (1) External carotid (1) Common carotid (1) 14 Subclavian (2) Axillary (1) Radial (1) Ulnar (1) Internal iliac (2) Superficial femoral (3) Popliteal (1) Tibioperoneal (3) 5 Superficial femoral (1) Tibioperoneal (2) Brachial (2) 40
A-V Fistula
Figure 2. Internal iliac arteriovenous fistula after fragment Diagnosis was made 4 months later when a high output failure symptoms developed.
of Missed
35
12.5
emboli from a false aneurysm. Three patients presented with chronic arterial insufficiency distal to the site of injury. Three patients had a neurologic symptom that occurred owing to persisting compression to hrachial plexus in two and to femoral nervosa in one. Late complications of missed arterial injuries based on an@graphic and operative examinations were pseudoaneurysm in 21 patients (52.5%), arteriovenous fistula in 14 patients (35X), and occlusion in 5 patients (12.5%) (Table III). The treatment of the injured arteries was segmental resection in 26 patients (65%), followed by an end to end anastomosis (5 patients) or insertion of a graft (21 patients: saphenous vein graft in 14 patients, polytetrafluroethylene in 6 patients, dacron in 1 patient). The remaining patients had ligation (9 patients: 3 tihioperoneal, 1 vertebral, 1 external carotid, 2 profundo femoris, 1 ulnar, 1 hypogastric artery) or a primary repair (lateral suture or patch plasty) (5 patients with one of the following: common carotid, common femoral, superficial femoral, suhclavian, radial artery). The venous side of arteriovenous fistula was generally closed with a primary suture. In 5 patients with an arteriovenous fistula (1 internal iliac, 2 tihioperoneal, 1 ulnar, 1 radial) venous side were oper,& by ligation. There was no operative mortality and significant perioperative morbidity. Local complications occurred in six patients, and included five wound infections, one hrachial plexopathy from compression. The 4 late complications after corrective surgery were dacrcm graft thrombosis in 3 patients and anastomotic aneurysm in one patient, 2, 3, 6, and 14 months after surgery (Table IV). In these patients, reoperations was performed and safenous vein grafts were inserted at anatomic position in three, at extra-anatomic position in one patient with excellent results. FEBRUARY
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( MISSED TABLE IV Complications
of Treatment
Complications Neurologic* Wound infections Reoperations Graft thrombosis Infected anastomotic
of Missed
Arterial Number
aneurysm
1 5 4 3 1
Injuries % 2.5 12.5 10 7.5 2.5
* Brachiai p/exop&y.
DISCUSSION The presence of distal pulses with proximal arterial injury has been well described. The pressure wave can be transmitted beyond an intimal flap, through soft, fresh cloth, or through collateral and be palpable in the distal arteries.’ A brachial pulse may be present even after complete disruption of the axillary artery because of the rich collateralization around the shoulder.6’i Drapanas et al found that 27% of the patients admitted to the emergency room with a major arterial injury in the extremities had a normal distal pulse.H MacCormick and Burch found physical examination to be less reliable in detecting major arterial injuries; they reported that in 91 patients 42% of the examinations were falsely positive, and 20% were falsely negative.” In the extensive experience with civilian arterial injuries at Parkland Hospital in Dallas, 69 (25%) of 271 patients presenting with serious extremity vascular injuries were recorded as having palpable pulses on initial examination.‘” In the Hewitt and Collin series, peripheral pulse were present in all patients with acute arteriovenous fistulae, and the importance of auscultation of all penetrating wounds near major arteries was emphasized. ‘I In our study, all of patients with missed arterial injury in the extremities had no “hard” signs of vascular injury at the time of initial hospitalization after wounding. In our cases, a number of factors, such as multiple wounds, other more serious problems, and the majority of wounds having been caused by many small low velocity fragments, might lead to a delay in recognition of these lesions. More frequently the injury that occurred by small fragments is tangential, with good flow persisting despite a false aneurysm involving one wall. The lack of a specific physical finding caused by some arterial injuries and the morbidity from missed injuries have led some authorities to recommend exploration of all wounds in proximity to major vessels.sz” Certainly this approach prevents missing vascular injuries; but it also results in unnecessary operations, some morbidity, and occasionally even death. In the report of Sirinek and colleagues, routine exploration of 390 proximity wounds resulted in 64% unnecessary explorations, and these explorations were associated with significant morbidity in 5% and 1 death.” In another series, in which the only indication was proximity of the wound to a major vessel, only 8% of patients explored had a significant injury.” In our cases, 23 patients underwent operative exploration to detect continued bleeding areas (11 patients) or nonvascular surgical repair of associated other lesions when the wound was proximal to an artery (12 patients), but arterial injuries had been missed when these patients had been seen at other military hospitals. Military vascular injuries are usually multiple and THE AMERICAN
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frequently cause an exsanquinating hemorrhage in the neck, thorax, and abdomen. Also, wounds in these anatomical regions prompt exploration more than do multiple small extremity wounds. With fragments accounting for 52.5% of the lesions in our series, it is obvious that lowvelocity small fragments cause wounds that require less extensive debridement and less definitive vascular repair than do high velocity missile wounds. In our cases, there are some factors that failed to find the injury initially at immediate exploration: (1) no “hard” signs of vascular injury; (2) taken to the operating room to treat more important injuries such as head, thorax, or abdominal injuries or even of other injuries in the same extremity; (3) absence of an exit wound with an unusual or reconstructable trajectory that occurred by fragments; (4) presence of multiple penetrating trauma such as fragment wounds and shotgun wounds; and (5) sometimes the internal evidence of injury occurred by fragment or blunt trauma is greater than that seen externally. Arteriography is a well-accepted alternative to surgical exploration in injuries to the extremities that do not exhibit obvious signs of vascular trauma.““,’ ’ Preoperative arteriography to document the presence and location of an arterial injury in an asymptomatic patlent or a patient with soft signs is the approach favored by many authors.‘4.15 Patients with a normal arteriographic finding have less than 1% to 2% incidence of missed injuries.’ Richardson et al noted that 8 late injuries were detected from a series of 440 arteriograms.5 Moreover, with large numhers of negative angiographies being reported, particularly if the only indication is the proximity to a major vessel, some authors have suggested a more selective use of aIl~iography.lh.I’ In our series, only 3 of 40 patients with missed arterial injury had undergone arteriographic study immediately after first admission to previous hospitals and these patients had a falsenegative arteriographic findings. The indications for arteriography when the existence of an arterial injury has already been recognized, include multiple penetrating trauma such as shotgun wounds or fragment wounds, absence of an exit wound with an unusual or reconstructable trajectory, and extensive blunt trauma. Particularly when the penetrating agent is a high-velocity missile, the surgeon has the additional task of estimating the extend of mural injury and, particularly, the intimal-endothelial damage and integrity of the external elastic lam& and adventitia; the former leading to delayed thrombosis and absence of the latter to delayed aneurysm formation. With blunt trauma, the internal evidence of injury is nearly always greater than that seen externally. An occluded vessel may offer little external evidence of the location of the offending lesion, usually an intimal tear or flap. A few petechial hemorrhages in the adventitia, with or without local spasm, may be the only sign of significant injury in a vessel that may be patent with a palpable distal pulse.‘” Late complications of missed arterial injury include arterial occlusion, A-V fistula, and pseudoaneurysm formation. The frequency of occurrence is suggested by Rich et al who reported 558 A-V fistulae and false aneurysms occurring in 507 patients, representing 7% of the injuries in the Vietnam Vascular Registry; 55% involved extremities, usually the leg, and there was a delay in diagnosis of more than 30 days in 47% of patients. ly Escobar et al reported false aneurysms (38.5%) and arterial insufficiency (24.5%) secondary to arJOURNAL
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teriovenous fistulae accounted for the majority of missed arterial injuriesz Perry reported 16 pseudoaneurysms and 4 A-V fistulae in 31 patients with missed arterial injury.’ In our study, there were 52.5% false aneurysms, 35% A-V fistulae, and 12.5% arterial occlusion. Failure to recognize and surgically correct subclavian or axillary arterial injury may result in delayed injury of the brachial plexus by compression of an expending false aneurysm. Even small false aneurysms can result in injury to the neuroplexus owing to the close anatomical relationship, and because a single fascial envelope surrounds the structures, the compression effect is heightened.‘” In 2 patients of our series, there were a delayed injury of the brachial plexus by compression of an expanding false aneurysm of subclavian and axillary artery 3 and 5 weeks after the injury. Two months after surgery, there was partial return of motor function but complete return of sensation. In conclusion, military vascular traumas frequently result from fragments and usually cause some complications of missed arterial injuries. Most of these patients have no “hard” signs of vascular injury. Therefore, patients with injuries proximal to major vessels must be closely monitored and arteriography is highly recommended to evaluate the conditions of patients with potential vascular injury.
REFERENCES 1. O’Gorman RB, Feliciano DV, Bitondo CG, et al. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries. Arch Surg. 1984;119:568-573. 2. Escobar GA, Escobar SC, Marquez L, et al. Vascular trauma: Late sequelae and treatment. J Cardiovasc Surg. 1980;21:135-140. 3. Perry OM. Complications of missed arterial injuries. J Vast Surg. 1993;17:399-407. 4. Feliciano DV, Cruse PA, Burch JM, Bitondo CG. Delayed diagnosis of arterial injuries. Am J Surg. 1987;154:579-584.
EDITORIAL
COMMENT
The Minimalist Approach to Vascular Injury The article by Yilmaz et al is a timely reminder of the importance of diligent detection of potential vascular injuries. The authors report a series of 40 patients with delayed diagnosis of an arterial injury in the extremity, neck, or abdomen. The median time of delay from injury to diagnosis was 60 days and the complications predominantly included false aneurysms and arteriovenous fistulae. There were two striking features in this report in my opinion. First, none of the patients was described as having hard signs of vascular injury. There are several reports in this country of the safety of observation alone in patients who do not present with hard signs of vascular injury. This report emphasizes the traditional view that some means to evaluate a potential arterial injury is important to prevent lifeor limb-threatening complications even in the absence of hard signs of injury.
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5. Richardson JD, Vitale GC, Flint LM. Penetrating arterial trauma: Analysis of missed vascular injuries. Arch Swg. 1987;122:678-683. 6. Raju S, Camer DV. Brachial plexus compression. Arch Stlrg. 1981;116:175-178. 7. Schaff HV. Brawley RK. Op err it’ ive. management of penetrating vascular injuries of the thoracic outlet. Surgery. 1977;82:182-191. 8. Drapanas T, Hewitt RL, Weichert RF, et al. Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg. 1970;172:351-360. 9. MacCormick TM, Burch BH. Routine angiographic evaluation of neck and extremity injuries. J Tmmna. 1979;19:384-390. 10. Shires GT. Patman RD. Vascular injuries. In Shires GT (ed): The Cnre of the Truwnu Patient. New York: McGraw-Hill; 1966, 223-239. 11. Hewitt RL, Collins DJ. Acute arteriovenous fistulas in war injuries. Ann Surg. 1969;169:447-449. 12. Sirinek KR, Levine BA, Gaskill HV III, Root HD. Reassessment of the role of routine operative exploration in the vascular trauma. J Trauma. 1981;21:339-344. 13. Snyder WH III, Thai ER, Bridges RA, et al. The validity of normal arteriography in penetrating trauma. Arch Surg. 1978;113:4244428. 14. Turcotte JK, Towne JR, Bernhard VM. Is arteriography necessary in the inanagement of vascular trauma of the extremities? Surgery. 1978;84:557-562. 15. Raju S. Shotgun arterial injuries of the arteries. Am .l Surg. 1979;138:421-425. 16. Reid JDS, Weigelt ]A, Thal ER, Francis H. Assessment of proximity of a wound to major vascular structures as an indication for arteriography. .4rch Surg. 1988;123:942-946. 17. MC Corkell SC, Harley JD, Morishima MS, et al. Indications for angiography in extremity trauma. AJR. 1985;145:1245-1247. 18. Rutherford RB. Diagnostic evaluation of extremity vascular injuries. Surg Clin North Am. 1988;68:683-691. 19. Rich NM, Hobson RW, Collms GJ. Traumatic arteriovenous fistulas and false aneurysms: A review of 558 lesions. Swrgery. 1975;78:817-828. 20. Braun RM, Newman J, Thacher B. Injury to the brachial plexus as a result of diagnostic arteriography. J Hnnd Surg. 1978;3:90-94.
The second point is that exploration of the artery often fails to define an injury even when it exists. Half of these patients had some limited exploration that failed to detect the injury. This occurred most commonly in the superficial femoral artery where thick musculature may prevent adequate exploration, The authors recommend arteriography as the best means to detect vascular injury and prevent missed injuries. While this is clearly speculative, it is consistent with our observations in a civilian population (Richardson, JD, Vitale GC, Flint LM. Penetrating arterial trauma: Analysis of missed vascular injuries. Arch Surg. 1987;122:678-683.)
University
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1997
J. David Richardson, MD Professor and Vice Chair Department of Surgery of Louisville School of Medicine Louisville, Kentucky