Trauma: Peripheral Vascular Trauma

AAST Peripheral Vascular Injury Scale

• *See AAST
• Injury Scale is Under Copyright

Vascular Injury Signs

• Major/Hard Signs
  • Active Arterial Hemorrhage
  • Expanding or Pulsatile Hematoma
  • Absent Pulse
  • Palpable Thrill or Audible Bruit
• Minor/Soft Signs
  • History of Significant Arterial Hemorrhage at the Scene
  • Nonexpanding Hematoma
  • Diminished Pulse
  • Proximity to Major Vessels
  • Neurologic Deficit

Initial Management

• First Step: Stop the Bleed (Manual Pressure or Tourniquet)
• Major/Hard Signs: Surgical Exploration
• Minor/Soft Signs: Imaging (ABI #1; Then CTA If ABI < 0.9)

Operative Sequence

• Temporary Bleeding Control
  • Options:
    • Manual Pressure
    • Balloon Catheter Inserted into the Wound if Deep & Narrow
    • Tourniquet
• Extensive Exposure
• Definitive Control
• Decision (Repair vs Damage Control)
  • Bony Stabilization Before Vascular Reconstruction
  • If Extremity is Grossly Ischemic or Actively Hemorrhaging – Control with a Temporary Shunt & Fasciotomy Prior to Bony Stabilization & Then Vascular Reconstruction

Arterial Exposure

• *See Trauma: Vascular Exposure

Arterial Injury Management

• Partial Injury:
  • < 50% Circumference: Arteriorrhaphy
    • Small Transverse Wound are Often Amenable to Primary Repair
    • Longitudinal or More Complex Injury Often Requires Patch Angioplasty
      • Primary Repair Risks Stricture/Occlusion
      • Can Use Autologous Vein or Synthetic Patch
  • ≥ 50% Circumference: Resect & Treat as a Complete Transection
    • *Consider Lateral GSV Patch Angioplasty for Longitudinal Elliptical Defects 50-75%
    • Avoid Reducing Diameter > 50% – Risk Hemodynamically Significant Occlusion
• Complete Transection:
  • Short-Segment (< 2 cm): Debridement & End-to-End Anastomosis
  • Long-Segment (> 2 cm): Bypass/Interposition Graft
    • Preferred Graft: Contralateral Saphenous Vein
    • Other Options: Ipsilateral Saphenous Vein or PTFE
  • Consider Addition of Proximal & Distal Thrombectomy
• Damage Control: Temporary Shunt vs Ligation

Temporary Vascular Shunts

• Types:
  • Commercially Available
  • Improvised Shunts:
    • Chest Tubes
    • IV Tubing
    • Feeding Tubes
• Diameter:
  • Diameter Should Be Chosen to Match Corresponding Vessel
  • Largest Possible Without Forcing
• Length:
  • Commercially Available Shunts Should Generally Not Be Trimmed – Smooth Edges Avoid Intimal Damage
  • Improvised Shunts Should Allow 2 cm Overlap on Each Side
• Removal:
  • Maximum Length of Time Able to Leave in Situ is Unknown
  • Perform Definitive Repair as Soon as Feasibly Safe
  • Most Remain Patent for 24-48 Hours

Traumatic Arteriovenous (AV) Fistula

• Sx: Palpable Thrill & High-Output Cardiac Failure
• Branham Sign: HR Drop 10 bpm When Occluded