Peripheral vascular trauma

Peripheral Vascular Trauma* Report

of Ninety

Cases

G. DOYNE WILLIAMS, M.D., Little Rock, Arkarms

Front the Deportment of Surgery, Center, Little Rock, Arkansas.

Cniversity

sometimes becomes impossibly complex. However, since all repairs involved relatively young patients free of arteriosclerosis, a repair that persists for three months should be safe. Table I summarizes the variety and number of arteries repaired, the type of repair, and a brief summary of the failures.

Medical

of RECONSTRUCTION major peripheral

traumatically severed arteries assumes primary importance when survival of the injured limb is in balance. The absolute necessity for repair of these injured arteries is underlined by the military surgical experiences of World Wars I and II in which simple ligation of these vessels resulted in amputation of 45 per cent of limbs so treated [I 1. .%ttempts at reconstruction of similar injured vessels reduced amputations to 11 per cent in the latter portion of the Korean conflict [2,3]. Even better results are currently being obtained in Vietnam \P]. Recent advances in all phases of vascular surgery have encouraged attempts at repair of arteries in almost all such cases, with justifyingly good results. Adherence to specific reparative technics unique to these injuries has been found essential.

RESULTS Seventy-seven patients (85 per cent) recovered withotrt incident and maintained good distal pulses. Ten patients (11 per cent) required reoperation for graft or anastomosis failures with good secondary result. Three cases (4 per cent) required eventual amputation for causes not related to vascular repair. Six of thirty-six primary end to end anastomoses failed and excessive suture line tension was found at reoperation in all. Five were detected by cessation of distal pulses within the first twenty-four hours postoperatively. The sixth was heralded by gross wound hemorrhage on the seventh postoperative day. Partial suture line disruption was found at exploration. All of these patients were successfully salvaged by further arterial resection and vein graft repair. The possibility that inadequate resection of the contused arterial ends may have also contributed to thrombosis of these excessively taut anastomoses cannot be excluded. Only four failures occurred in the fifty-four primary vein graft repairs. Two were due to “kinking” of an excessively long vein graft and were relieved by shortening the graft. The third graft was found in spasm and completely thrombosed. It had been inadequately dilated with saline prior to its insertion and the initially weak distal pulses disappeared in the seventh hour postoperatively. Reoperation and replace-

MATERIAL This communication describes the author’s experience with ninety civilian and military major arterial injuries in extremities of American, Korean, and Vietnamese patients. All patients were male, ranging in age from nineteen to forty-three years with a mean of twenty-six years. Elapsed time from injury to operation varied from forty-five minutes to nine and a half hours. The mean elapsed time was four and a half hours and helicopter evacuation aided greatly. All injuries were due to missiles, either bullets or fragments of explosive projectiles. Follow-up periods ranged from three months to four and a half years. The three month follow-up period in some cases is less than desirable but such cases were evacuated via circuitous military routes. Tracing such patients

* Presented at the Twentieth Annual Meeting of the Southwestern Surgical Congress, Denver, Colorado, April 22-25, 1968. Vol. 116. November lY6R

725

Williams TABLE CASE

I

MATERIAL

Artery

Number of Cases

Femoral

33

9

“4

4

Popliteal

19

7

12

3

Brachial

28

I7

11

2

Axillary

10

3

7

1

Total

90

36

54

10

End to End Anastomosis

Vein Grait Repair

Technical Failures

Cause of Failure -_

with a properly dilated graft were successful. The fourth graft failure was due to sepsis at the graft site. An initial attempt at redebridement with a new vein graft also resulted in sepsis. Ultimately the infected graft was removed, the distal and proximal arterial ends ligated, and a fresh graft used to establish continuity from the distal to proximal artery completely outside the original limits of the wound. This technic was described by Carter, Cohen, and Whelan [5] in 1963. Three patients (4 per cent) ultimately required amputations, one above and two below the knee. The supracondylar amputation was performed nine days after graft repair of a left superficial femoral artery involving a comminuted mid-femoral fracture and sciatic nerve division. There were also multiple other small fragment wounds of the distal extremity. Distal pulses were maintained post repair but extensive distal necrosis required eventual amputation despite of two additional debridements. Initial distal debridement apparently should have been more extensive. The two amputations below the knee were performed in almost identical injuries involving cornminuted proximal tibia1 fractures and disruption of the popliteal artery bifurcation. Vein graft anastomosis of the popliteal to anterior tibia1 artery was accomplished but other multiple contused areas in both distal anterior tibia1 arteries produced repeated distal arterial thrombosis. Attempts at Fogarty catheter thrombectomy and heparinization were unsuccessful and ischemic necrosis in both limbs forced amputation. ment

(3) Excessive tension on primary anastomosis (1) Infected vein graft (2) Excessive tension on primary anastomosis (1) “Kinked” graft (1) Excessive tension (1) “Purse-stringed” anastomosis on proximal graft (1) Excessive tension with graft spasm

The 11 per cent over-all technical failure rate was tempered somewhat by successful reoperation in all these cases. The 4 per cent amputation rate is most acceptable for this type of arterial surgery. No technical failures occurred in the last fifty-five cases, confirming the fact that careful utilization of specific vascular trauma technics can markedly improve results. TECHNICS AND MANAGEMENT

A thorough understanding of the effects of high velocity missiles on tissue is mandatory in repair of associated arterial injuries. Such effects, known as blast injury or tissue contusion, are produced as the shock wave initiated by the high velocity missile travels through the soft tissue medium in expanding concentric rings about the tract of the wound. This shock wave can produce irreparable damage at cellular and gross levels in the tissue. The magnitude of this damage is proportional to the velocity of the missile and occurs to significant degree in most wounds involving velocities of 1,000 feet per second or greater. Since the ubiquitous 0.22 caliber long rifle projectile develops 1,145 feet per second, the importance of this concept, even in purely civilian surgical practice, is emphasized. The contused tissue must be entirely removed at initial debridement. Failure to do so will result in necrosis and wound suppuration. Contused muscle is recognized at operation by its ischemic salmon-pink color, failure to bleed when cut, and failure to “jump” or retract when grasped with tissue forceps. All such muscle is removed in a radicular direction from the wound tract. The wounds of entrance and The American Journal of Surgery

Peripheral

Vascular

exit of the skin need only be minimally debrided as the skin as well as fascia and nerves shows considerable resistance to contusion. L\rteries lying in or near the missile tract may be contused, severed, or, more likely, may display both types of injury. Unfortunately, the contusion injury of arteries is not as easy to delineate as that of muscle. A typical artery severed by a high velocity missile (Fig. 1) displays a tattered end with a band of contusion (subadventitial bluish discoloration) extending from the severed point for a variable number of millimeters. This is seen on microscopic sections as a zone of hemorrhage into, and cellular disruption of. all arterial layers. This can be very deceptive as the vessel in this area appears grossly structurally intact. It will indeed hold sutures well initially, only to disrupt on the seventh to tenth postoperative day. Furthermore, it will not suffice to limit resection to this visible band of bluish discoloration as a short band of invisible contusion lies adjacent to it. (Fig. 1.j This area can be identified on microscopic sections as an irregular area of hemorrhage and cellular disruption. For practical purposes, resection of the artery for 1 cm. back from the visible bluish ring of contusion will suflice [2]. However. if excessive amounts of contused tissue surround the artery, one should assume that the missile was of unusually high velocity and resect an additional 0.5 cm of each

FIG. L’. Contusion-thrombosis

7“; i

Trauma BAND OF

I-I V2cms

.

RESECTION

FIG. 1. Schematic damage.

drawing

VISIBLE CONTUSION

INVISIBLE CONTUSION of high

velocity

arterial

arterial end. Such a wound may occur from a very near burst of an artillery or mortar round with initial fragment velocities in excess of S,OOOfeet per second. Three representative examples of arterial contusion injury are shown in Figures 2, 3, and 4. Figure 2 illustrates an arterial injury by a missile of approximately 2,750 feet per second (0.30 caliber rifle). The bullet passed 2 cm. medial to the left superficial femoral artery, 10 cm. distal to the profundus origin. The distal limb was cold and there was no popliteal or pedal pulse. The wound of entrance (Fig. 2A) was not bleeding. Exploration revealed extensive muscle contusion and the dark band of arterial contusion is indicated by the forceps in Figure 2B. There lvas no pulse distal to this point, and the artery felt firm and thrombosed in this area. The blue segment \vas excised with

of right superficial

femoral artery.

(See test for details.

1

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728

text.) 1.5 cm. margins and replaced with a saphenous vein graft. (Fig. 2C.) Visualization of the interior of the resected arterial segment revealed complete transection of the intima and portions of the media by the blast effect, without visible structural injury to the exterior of the artery. (Fig. 2D.) The injured intima and media had folded upon themselves and produced occlusion and thrombosis of the vessel. The second case, shown in Figure 3, illustrates a partial diameter injury to a right superficial femoral artery by a missile in excess of 4,000 feet per second (mortar round fragment). This projectile passed through the right thigh approximately 3 cm. lateral to the midportion of the superficial femoral artery. The distal extremity was warm and both popliteal and pedal pulses were present. No arterial injury was suspected and the small bluish arterial “blister” shown in Figure 3A was found on routine debridement. Although a good pulse was present distal to the contusion, it was resected with 1.5 cm. margins and replaced with a saphenous vein graft. Internal arterial injury was suspected and the open specimen (Fig. 3B) revealed intimal disruption with hematoma dissecting into the media and subadventitial planes. If this injury had been overlooked, the artery would most certainly have ruptured during the postoperative period, possibly with fatal outcome if it occurred while transporting the patient. The last case (Fig. 4) probably represents the end result of an arterial injury similar to that in case 3 which was overlooked at the initial debridement. This patient had a high velocity

wound of the right thigh which was debrided with subsequent delayed primary closure without demonstrated arterial injury. Three weeks later a bruit was noted under the distal skin incision. The Brabham-Nicoladoni sign was present and hemorrhage through the wound occurred shortly afterward. Exploration revealed a false aneurysm of the distal supeticial femoral artery with an arteriovenous fistula to the femoral vein. The aneurysm is shown in the clamps in Figure 4A and the excised specimen in Figure 4B. After resection of the aneurysm continuity was restored with a vein graft, and the vein was ligated. Fortunately this case was still under medical surveillance when hemorrhage occurred and points out emphatically the importance of carefully visualizing all nearby arteries when exploring patients with high velocity wounds. TECHNIC

OF REPAIR

Repair can be performed with primary end to end anastomosis or a graft of saphenous vein [6 1. One must absolutely avoid tension in these compromised arteries and, in our experience, it was difficult to repair in end to end fashion without unacceptable tension after adequate arterial debridement. An interesting exception was the brachial artery which seemed to stretch easily to bridge rather long defects. The saphenous vein grafts were hydrostatically dilated with saline almost to the bursting point. This helped prevent vasospasm in the graft after anastomosis which may cause thrombosis. After debridement and Qrimming, the arterial ends may spasm to a size which makes The American

Jcurnal

of Suwery

Peripheral

velocity

contusion

Vascular

ISee test.)

accurate anastomosis to the vein graft impossible. Dilatation can be easily accomplished by grasping the arterial ends with a sponge and gently, stretching the orifice with the smooth of a vascular needle holder. This ma“nose neuver will facilitate suture of the anastomosis as well as aid in preventing postoperative spasm at the suture line. We have not found the use of heparin necessary or desirable as the large areas of debrided muscle would create worrisome ooze or hemorrhage. The distal artery must be patent prior to repair and brisk back bleeding is a good indicator. Absence of good back flow was attacked with vigorous massage of the distal limb in a centripetal direction, exploration with a FOgarty catheter [7], and irrigation of the distal vessel with small catheters. X11 anastomoses were carried out with No. 5-0 or (i--O Mersilene@ in continuous fashion starting from initial stay sutures which trifurcated or bifurcated the anastomosis. It is important to avoid silk or cotton in these contaminated wounds and, or course, Dacron’ or Teflon*’ grafts are not permitted. After repair, the graft or anastomosis is completely buried in a tunnel of nearby healthy muscle. The skin and subcutaneous tissues are left open to be approximated by delayed primary closure five to seven days later. Posterior plaster splint immobilization of the limb is maintained for ten to fourteen days after delayed primary closure even in the absence of fracture. The presence of a fracture does not significantly affect results of arterial anastomosis if care with immobilization is L’ol. 110, November

196X

Traunla

taken. One must not use any type 0i traction that would increase tenGot1 on the nnastomosis, and contaminated wounds preclude internal metal fixation. These factors thus limit immobilization to various casts, posterior splints, or spica cast variants. Experience has proved these technics initially adequate, and internal fixation can be used later when the soft tissue wounds have healed and danger of sepsis is past. The continued integrity of the arterial repair is assessed postoperatively by distal pulses and improved color and warmth of the litnb. High velocity wounds may produce severe spasm of the otherwise uninjured distal arterial tree, and radial or pedal pulses may not appear for several hours after a completely adequate repair. This is worrisome and map lead to unnecessary exploration. We found that spasm commonly persisted for six to eight hours. Absent pulses after this length of time detnand exploration. An arteriogram will resolve the problem if available or one can try sympathetic blocks which we found helpful despite reports to the contrary [R-IO]. Stellate ganglion blocks or spinal anesthetics frequently produced distal bounding pulses in spasm problems fifteen to twenty minutes after injection. In addition to proving anastomotic patency, the increased flow across the graft aids in maintaining patency in the critical early postoperative period. Previous reports [9,10] have indicated that application of local anesthetics to vessels in spasm is ineffectual. However, formal proximal sympathetic blocks in many of our patients produced immediate return of distal pulses and

Williams

730

color in the extremity with a rapidity and degree that could not be coincidental. Antibiotics were not found necessary in wounds that had been adequately debrided. Others have encouraged their use routinely [8] but we restricted them to a small number in which superficial wound infections developed. Sensitivity-specific antibiotics were used and the infections checked prior to deeper invasion involving the grafts or anastomoses. The combination of chloramphenicol and penicillin was most useful for the Southeast Asian flora.

REFERENCES

DEBAKEY,M. E. and SIMEONE,F. A. Battle injuries of the arteries in World War II. Ann. Surg., 123 : 534, 1946. 2. JAHNCKE,E. J. and SEELEY,S. F. Acute vascular injuries of the Korean War: an analysis of 77 consecutive cases. Ann. Surg., 138: 158, 1953. 3. HUGHES,C. W. Arterial repair during the Korean War. Ann. Surg., 147: 555, 1958. 4. WILLIAMS,G. D., JR. Vascular repairs. U. S. A. 1.

Vietnam M. Bull., 40: 40, 1967. 5. CARTER,S. C., COHEN,A., and WHELAN, T. J.

SUMMARY

Ninety cases of arterial trauma requiring resective repair are presented. Ten cases (11 per cent) required reoperation for anastomotic complications. These were successfully repaired secondarily. Three patients (4 per cent) eventually required amputation of the extremity. These results compare most favorably with earlier series of similar injuries. Careful utilization of observed technical factors unique to these injuries is credited with the improved results. It is hoped that these observations may prove helpful to others in the management of arterial trauma.

6. 7.

8.

9.

Clinical experience with management of the infected Dacron graft. Ann. Surg., 158: 249, 1963. DETAKATS,G. Vascular Surgery, pp, 14, 549, Philadelphia, 1959. W. B. Saunders Co. FOGARTY,T. J. A method for extraction of arterial emboli and thrombi. Surg. Gynec. b Obst., 116: 241, 1963. WHELAN,T. J., and BAUGH,J. H. Non-atherosclerotic arterial lesions and their management, Current Probl. Surg., p. 25, February, 1967. KINMONTH.J. B. The physiology and relief of traumatic arterial spasm. Brit. M. J., 1: 59, 1952.

10. KINMONTH, J. B., SIMEONE, F. A., and PERLOW,V.

Factors affecting the diameter of large arteries with particular reference to traumatic spasm. Surgery, 26: 452, 1949.

The American Journal of Surecry