AAST-WSES GUIDELINES
American Association for the Surgery of Trauma–World Society of
Emergency Surgery guidelines on diagnosis and management of
peripheral vascular injuries
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Leslie Kobayashi, MD, Raul Coimbra, MD, PhD, FACS, Adenauer M. O. Goes, Jr., MD, PhD, Viktor Reva, MD,
Jarrett Santorelli, MD, Ernest E. Moore, MD, Joseph Galante, MD, Fikri Abu-Zidan, MD,
Andrew B. Peitzman, MD, Carlos Ordonez, MD, Ronald V. Maier, MD, Salomone Di Saverio, MD,
Rao Ivatury, MD, Nicola De Angelis, MD, Thomas Scalea, MD, Fausto Catena, MD, Andrew Kirkpatrick, MD,
Vladimir Khokha, MD, Neil Parry, MD, Ian Civil, BSc, MBChB, Ari Leppaniemi, MD, Mircea Chirica, MD,
Emmanouil Pikoulis, MD, Gustavo P. Fraga, MD, Massimo Chiarugi, MD, Dimitrios Damaskos, MD,
Enrico Cicuttin, MD, Marco Ceresoli, MD, Belinda De Simone, MD, Felipe Vega-Rivera, MD,
Massimo Sartelli, MD, Walt Biffl, MD, Luca Ansaloni, MD,
Dieter G. Weber, MBBS, and Federico Coccolini, MD, Moreno Valley, California
The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas.
Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable
patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of
utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment
of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to
perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for
the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and
provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. (J Trauma Acute Care Surg.
2020;89: 1183–1196. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Review study, level IV.
KEY WORDS:
Extremity vascular injury; femoral artery injury; popliteal artery injury; tibial artery injury; peroneal artery injury.
ABSTRACT:
Submitted: September 18, 2020, Revised: September 22, 2020, Accepted: September
24, 2020, Published online: October 1, 2020.
From the Division of Trauma (L.K., J.S.), Surgical Critical Care, Burns, and Acute
Care Surgery, University of California San Diego, San Diego, California; Comparative Effectiveness and Clinical Outcomes Research Center (R.C.), Riverside University Health System Medical Center, Loma Linda University School of
Medicine, Riverside, California; Vascular and Trauma Surgery (A.M.O.G. Jr.),
Universidade Federal do Pará/Centro Universitário do Estado do Pará, Belém,
PA, Brazil; Department of War Surgery (V.R.), Kirov Military Medical Academy,
Saint Petersburg, Russia; Department of Surgery (E.E.M.), Ernest E. Moore Shock
Trauma Center at Denver Health, University of Colorado, Denver, Colorado; Division Chief Trauma and Acute Care Surgery (J.G.), Department of Surgery. University of California Davis, Sacramento, California; Department of Surgery
(F.A.-Z.), College of Medicine and Health Sciences, UAE University, Al-Ain,
United Arab Emirates; Division of Trauma and Acute Care Surgery, Department
of Surgery (A.B.P.), University of Pittsburgh School of Medicine, Pittsburg,
Pennsylvania; Division of Trauma and Acute Care Surgery, Department of Surgery (C.O.), Fundación Valle del Lili, Universidad del Valle, Cali, Colombia; Department of Surgery (R.V.M.), University of Washington, Seattle, Washington;
Department of Surgery (S.D.S.), University Hospital of Varese, University of
Insubria, Varese, Italy; Division of Acute Care Surgery, Department of Surgery
(R.I.), Virginia Commonwealth University Richmond, Virginia; Unit of Digestive
and HPB Surgery (N.D.A.), CARE Department, Henri Mondor University Hospital
(AP-HP) and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France;
R. Adams Cowley Shock Trauma Center (T.S.), University of Maryland, Baltimore,
Maryland; Emergency Surgery Department (F.C.), Parma University Hospital,
Parma, Italy; Department of Surgery and Critical Care Medicine (A.K.), University
of Calgary, Calgary, Alberta, Canada; Department of Emergency Surgery (V.K.),
City Hospital, Mozyr, Belarus; Departments of Surgery and Medicine (N.P.),
Schulich School of Medicine and Dentistry, Western University London Health Sciences Centre, London, Ontario, Canada; Trauma Services (I.C.), Auckland City
Hospital, Faculty of Medical and Health Sciences, University of Auckland, Auckland,
New Zealand; Abdominal Center, Department of Surgery (A.L.), University Hospital Meilahti, Helsinki, Finland; Department of Digestive Surgery (M. Chirica),
Grenoble University Hospital, Grenoble, France; 3rd Department of Surgery (E.P.),
Attikon General Hospital, National and Kapodistrian University of Athens, Athens,
Greece; Division of Trauma/Acute Care Surgery and Surgical Critical Care (G.P.F.),
University of Campinas, Campinas, Brazil; General, Emergency Surgery, and Trauma
Center (M. Chiarugi, F.C.), University of Pisa, Pisa, Italy; Department of General
and Upper GI Surgery (D.D.), Royal Infirmary of Edinburgh, Edinburgh, United
Kingdom; Dipartimento di Scienze Clinico Chirurgiche (E.C.), Diagnostiche e
Pediatriche, University of Pavia, Pavia; General and Emergency Surgery Department
(M. Ceresoli), School of Medicine and Surgery, Milano-Bicocca University, Monza,
Italy; Service de Chirurgie Generale, Digestive, Metabolique Centre Hospitalier de
Poissy (B.D.S.), St Germain en Laye, France; Universidad Nacional Autónoma de
México, Curso Universitario Posgrado de Cirugía, Departamento de Cirugía
(F.V.-R.), Hospital Angeles Lomas, Mexico, Mexico; Department of Surgery
(M.S.), Macerata Hospital (ASUR Marche), Macerata, Italy; Trauma Surgery Department (W.B.), Scripps Memorial Hospital, La Jolla, California; General Surgery Department (L.A.), Bufalini Hospital, Cesena, Italy; and Trauma Service,
Department of General Surgery (D.G.W.), Royal Perth Hospital, The University
of Western Australia, Perth, Australia.
Address for reprints: Raul Coimbra, MD, PhD, FACS, Comparative Effectiveness and
Clinical Outcomes Research Center, Riverside University Health System Medical
Center, Loma Linda University School of Medicine, 26520 Cactus Ave, Moreno
Valley, CA 92555; email: raulcoimbra62@yahoo.com.
DOI: 10.1097/TA.0000000000002967
J Trauma Acute Care Surg
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J Trauma Acute Care Surg
Volume 89, Number 6
Kobayashi et al.
V
ascular trauma (VT) is relatively uncommon in the civilian
setting but is increasingly common in combat casualties.1–9
Vascular trauma of the extremities in particular has increased as
a source of morbidity and mortality in combat likely due to the
increased utilization and efficacy of body armor.8–11 Patients
of all ages and sexes are at risk for VT. However, it is less common among the elderly, children, and women.1,2,4,5,12–14 Blunt
trauma is the most common cause of VT among children and
in most civilian trauma series with the exception of certain geographic areas.1,3,4,12,13,15,16
Vascular injuries are unevenly distributed between body
regions, and many patients have injured more than one vessel.
Injuries occur in the thorax (25%) and abdomen/pelvis (25%),
upper (25%) and lower extremities (20%), and, less frequently,
in the neck (10%).4 Among military casualties, extremity injuries account for 70% or more of VTs with the lower extremity
as the most prevalent anatomic location (45%–65%).6,9,10,17–19
Soft tissue destruction and fractures are common in patients with
extremity VT. Arterial injuries (AIs) are diagnosed more often
than venous injuries; however, combined arteriovenous injuries
can occur and are three times more frequent in military (55%)
than civilian practice (18%).2,13 Among AIs, complete or partial
transections account for half of the cases, while complete occlusion, pseudoaneurysm (PSA), and other types of injuries occur
less frequently.12 When they do occur, arteriovenous combined
injures are associated with higher morbidity, particularly compartment syndrome and mortality.20–28
Prompt prehospital hemorrhage control, reduced prehospital
transport times, and timely diagnosis and treatment along with
adequate resuscitation remain crucial for better outcomes. A
paradigm shift in prehospital hemorrhage control has occurred
during the last decade because of extensive lifesaving tourniquet applications and use of local hemostatic agents. Even in
civilian practice, every fifth patient with suspected VT received
prehospital tourniquet application.12 Aggressive hemorrhage
control has led to significant improvements in mortality confirmed by many civilian and military studies. These achievements
were summarized by the corresponding societies National Association of Emergency Medical Technicians and Committee on Tactical Combat Casualty Care and established in Prehospital
Trauma Life Support and Tactical Combat Casualty Care Protocols and Guidelines.29–31
The Advanced Trauma Life Support (ATLS) protocols should
be followed in the initial management of VT. Damage-control
resuscitation and surgical approaches should be used early for
patients presenting with hemorrhagic shock. Diagnostic and
treatment strategies vary depending on anatomic region of VT,
associated injuries, and physiological status of the patient. Initial
diagnosis and treatment of VT have been the subject of debate
over time and have been addressed in several evidence-based
guidelines. In 2011 and 2013, the Western Trauma Association
published two parts (Part I, Evaluation; Part II, Management) of
a position article detailing treatment of peripheral vascular injuries (PVIs).32,33 In 2012, the Eastern Association for the Surgery
of Trauma published the practice management guidelines for
penetrating lower extremity arterial trauma.34 In 2015, the World
Society of Emergency Surgery (WSES) published a position paper on vascular emergency surgery.35 The purpose of this document was to provide the American Association for the Surgery
1184
of Trauma (AAST)–WSES recommendations for diagnosis and
management of PVIs.
Notes on the Use of the Guidelines
The guidelines are evidence based, with the grade of recommendation (GoR) based on the evidence. The practice guidelines promulgated in this work do not represent a standard of
practice. They are suggested plans of care, based on best available evidence and the consensus of experts, but do not exclude
other approaches as being within the standard of practice. For
example, they should not be used to compel adherence to a given
method of medical management, which method should be finally determined after taking account of the conditions at the relevant medical institution (staff levels, experience, equipment,
etc.) and the characteristics of the individual patient. However,
responsibility for the results of treatment rests with those who
are directly engaged therein and not with the consensus group.
PATIENTS AND METHODS
A computerized search was done by a bibliographer in different databanks (MEDLINE, Scopus, EMBASE). Citations
were included for the period between January 2007 and
January 2020 using the primary search strategy: trauma, blunt,
penetrating, blood vessel, vascular injury, extremity, femoral artery, popliteal artery, tibial artery, peroneal artery, brachial artery,
radial artery, ulnar artery, amputation, fasciotomy, mangled extremity, classification, guidelines, injury, surgery, diagnosis, operative, nonoperative, shunting, shunt, endovascular management,
anticoagulant, and antiplatelet, combined with and/or. No search
restrictions were imposed. The dates were selected to allow comprehensive published abstracts of clinical trials, consensus conference, comparative studies, congresses, guidelines, government
publication, multicenter studies, systematic reviews, meta-analysis,
large case series, original articles, and randomized controlled trials.
Selected older articles felt to be landmark papers in the field
were also included. The level of evidence was evaluated using
a modified form of the Grading of Recommendations Assessment, Development and Evaluation system (Table 1).36 A group
of experts in the field coordinated by a central coordinator was
contacted to express their evidence-based opinion on several issues about VT. The central coordinator assembled the different
answers derived from a round of discussion and created, based
on the evidence available, a set of recommendations. The recommendations were then submitted for comments multiple times
using an online modified Delphi process, until complete consensus was achieved. The definitive version reported herein represents the position of the expert group from both the AAST and
the WSES.
Epidemiology of PVIs
Extremity PVIs account for 45% to 80% of all VTs representing the majority of emergency vascular cases in civilian
trauma centers, community hospitals, and medical treatment facilities in war zones.2–4,9,11–13,37 In general, lower extremities are injured more often than upper extremities in adults; this discrepancy
is most dramatic among military cohorts.2,4,6,9,12–14,18,38,39 Conversely, a larger proportion of upper extremity vascular injuries
have been reported among pediatric populations.1,15,40,41
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J Trauma Acute Care Surg
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Kobayashi et al.
TABLE 1. Modified System for GoR36
GoR
Clarity of Risk/Benefit
Quality of Supporting Evidence
Implications
1A
Strong recommendation,
high-quality evidence
Benefits clearly outweigh risk and
burdens, or vice versa
RCTs without important limitations
or overwhelming evidence from
observational studies
Strong recommendation, applies to
most patients in most circumstances
without reservation
1B
Strong recommendation,
moderate-quality evidence
Benefits clearly outweigh risk and
burdens, or vice versa
RCTs with important limitations
(inconsistent results, methodological
flaws, indirect analyses or imprecise
conclusions) or exceptionally strong
evidence from observational studies
Strong recommendation, applies to
most patients in most circumstances
without reservation
1C
Strong recommendation,
low-quality or very
low-quality evidence
2A
Weak recommendation,
high-quality evidence
Benefits clearly outweigh risk and
burdens, or vice versa
Observational studies or case series
Strong recommendation but subject to
change when higher quality evidence
becomes available
Benefits closely balanced with
risks and burden
RCTs without important limitations or
overwhelming evidence from
observational studies
Weak recommendation, best action
may differ depending on the
patient, treatment circumstances, or
social values
2B
Weak recommendation,
moderate-quality evidence
Benefits closely balanced with
risks and burden
RCTs with important limitations
(inconsistent results, methodological flaws,
indirect or imprecise) or exceptionally
strong evidence from observational studies
Weak recommendation, best action
may differ depending on the
patient, treatment circumstances,
or social values
2C
Weak recommendation,
Low-quality or very
low-quality evidence
Uncertainty in the estimates of benefits,
risks, and burden; benefits, risk, and
burden may be closely balanced
Observational studies or case series
Very weak recommendation; alternative
treatments may be equally reasonable
and merit consideration
Mechanism of injury varies by country or region. In many
countries, especially in Europe and Asia, blunt mechanisms predominate in both adults and children.14,15,42–45 Among adult penetrating injuries, gunshot wound (GSW) and stab wound account
for the majority of VT cases in civilian practice.23,37,40,46–49 In
children younger than 6 years, falls and road traffic accidents
are the most common causes of blunt trauma, while glass cuts
are the most common cause of penetrating injuries.48,50
Peripheral vascular injuries are graded by vessel in accordance with the AAST Organ Injury Scale grading of PVI (Table 2)
and can be occlusive or nonocclusive depending on vascular
patency. Nonocclusive injuries are presented as an intimal
irregularity/tear (Grade I, <25% narrowing), dissection/intramural
hematoma (Grade II, ≥25% narrowing), or partial transection with
PSA formation (Grade III). Occlusive injuries include thrombotic
occlusion (Grade IV, vessel wall is preserved) or complete transection (Grade V).
Two thirds of upper extremity arterial injuries (UEAIs) are
distal (radial and ulnar arteries), and one third are proximal (primarily brachial artery).52 A National Trauma Data Bank (NTDB)
analysis demonstrated the most common lower extremity arterial
injury (LEAI) to be the popliteal (35.5%) and superficial femoral
arteries (SFAs) (27.8%), followed by the common femoral artery
(18.4%), the posterior tibial artery (12.6%), and the anterior tibial
artery (8.6%).28 The femoral artery is also the most frequently injured vessel in combat.11,53–55 Delayed diagnosis and inappropriate treatment of injuries in the femoropopliteal arterial segment
can lead to devastating results. Postmortem analysis has revealed
that femoral artery and vein injuries account for the majority of
patients deaths due to PVIs.56 The extent of blood loss and rates
of hemodynamic instability upon admission are higher in more
proximal AIs, which also have a larger proportion of severe associated injuries.49
Approximately 12% of patients with LEAIs and 14% of
patients with UEAIs have multiple AIs.52,57,58 Concomitant vein
and nerve injury are present in every fourth and tenth LEAI patient, respectively.28,59,60 In children, UEAIs are frequently associated with nerve injuries.1,40,50 Every fourth or fifth patent with
UEAI or LEAI has an associated orthopedic injury.28,52,57 In pediatric patients, isolated VT is more common, and thus, children
have less severe injuries compared with adults.1
Lower and upper extremity VT present differently because
of morphological differences, for example, larger vessels, larger
muscles, fewer collaterals, and tighter compartments in the legs.
Hemorrhage from LEAI is more difficult to control, and patients
TABLE 2. AAST Organ Injury Scale Grading PVI51
Grade
I
II
III
IV
V
Injury
Digital artery/vein, palmar artery/vein, deep palmar artery/vein, dorsalis
pedis artery, plantar artery/vein, nonnamed arterial/venous branches
Basilic/cephalic vein, saphenous vein, radial artery, ulnar artery
Axillary vein, superficial/deep femoral vein, popliteal vein, brachial
artery, anterior tibial artery, posterior tibial artery, peroneal artery,
tibioperoneal trunk
Superficial/deep femoral artery, popliteal artery
Axillary artery, common femoral artery
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are more critically ill upon hospital admission, have higher Injury Severity Score and lower Glasgow Coma Scale scores,
and have significantly higher perioperative complication rates,
including the need for major limb amputation compared with
patients with UEAIs (7.8% vs. 1.3%).20
Clinical Presentation and Diagnosis of PVI
• A structured physical examination (PEX) is mandatory in the
diagnostic work-up of an injured extremity. Patients with
“hard” and “soft” signs of PVI should be evaluated without
delay. (GoR 1B)
• Patients with hard signs of PVI should be transported directly
to the operating room for surgical exploration. Where available, patients with multilevel penetrating injuries and those
with blunt PVI may benefit from use of a hybrid operating
room with the ability to perform on table angiography for
both diagnostic and therapeutic purposes. When not available, C-arm can be used for on-table angiography to augment
surgical exploration and repair. (GoR 1B)
• Hemodynamically unstable patients with soft signs of PVI
should be transported to the operating room, with or without
endovascular capability, for resuscitation and appropriate
evaluation/intervention. (GoR 2B)
• Presence of peripheral pulses alone cannot reliably exclude
AI. For hemodynamically stable patients with concerning
mechanism, proximity injury, or soft signs of PVI, additional
evaluation with ankle brachial index (ABI) or arterial pressure index (API) measurements is required. (GoR 1B)
• Ankle brachial index and API are effective screening methods
for detecting major AI; an ABI/API of >0.9 generally excludes
the need for additional imaging. (GoR 1B)
• Patients with knee dislocations are at higher risk of occult
popliteal artery injury. Normal distal pulse upon PEX does
not exclude popliteal artery injury. Additional imaging including formal or computed tomography angiography (CTA) may
be beneficial. (GoR 2B)
• Computed tomography angiography is recommended as the
first-line modality for investigating blunt and penetrating
PVIs in adults and children who are hemodynamically stable
without active bleeding. (GoR 1B)
• Invasive catheter angiography should be reserved for patients
in need of interventional procedures, if vasospasm is clinically suspected or when CTA is unavailable, equivocal, or
nondiagnostic due to artifact from retained metallic objects.
(GoR 1B)
• Patients with penetrating extremity trauma (having no other
injuries) who present with normal PEX and normal ABI/
API may be safely discharged (GoR 1B). These patients,
however, should be followed up in an outpatient setting because of the risk of delayed PSA.
Peripheral vascular injuries represent two main threats: exsanguination and limb ischemia. Early recognition followed by
adequate and prompt treatment are critical for good outcomes.
According to the Prehospital Trauma Life Support/Committee
on Tactical Combat Casualty Care/ATLS protocols, hemorrhage
should be temporarily addressed by direct pressure followed by
dressing, elastic bandage, local hemostatic agent, or tourniquet
1186
application. In-hospital initial evaluation begins with primary
survey using ATLS protocol followed by secondary survey
and necessary radiographic evaluation of the injured limb, if indicated. On admission, trauma patients may present with either
spontaneously or medically controlled hemorrhage. In such a
scenario, history of prehospital blood loss or hypotension and
the presence of a tourniquet are especially important for further
diagnosis and treatment strategy.
The patient’s hemodynamic status on arrival is important
not only for complex assessment of limb salvageability but also
for defining treatment strategy and predicting outcomes. Hemodynamically unstable patients (pediatric systolic blood pressure
[BP], < [70 + 2 age] mm Hg; adults’ systolic BP, <90 mm
Hg; geriatric patients’ systolic BP, <100 mm Hg) suspected of
PVI should be taken immediately to the operating room for
emergency exploration.61–63 In stable patients, structured PEX
is critical for the primary evaluation of extremity trauma in civilian and military practice. Although important, pulse evaluation
is physician dependent and cannot be the only investigation to
diagnose PVI. Assessment of limb perfusion is more important
than pulse examination for outcome prediction. Limb perfusion
is evaluated by assessment of such markers of ischemia as pain,
skin temperature and color, sensory and motor dysfunction, and
capillary refill evaluation in comparison with an uninjured limb.
Abnormalities of these markers, typically diagnosed as “six P’s”:
pain, pallor, poikilothermia, pulselessness, paresthesia, and paralysis, indicate a certain degree of ischemia. Physical examination
findings can be classified into no signs, “soft” signs, or “hard”
signs. Although slight variations exist among guidelines and publications, there is a certain agreement on definitions of the hard
and soft signs, which are summarized in Table 3.32,34,64 Hard,
soft, and no signs of PVI were encountered in 5.5%, 11.5%,
and 83% of 635 patients with extremity injury respectively.65
Some studies confirm that PEX alone is reliable enough
for exclusion of VT with overall sensitivity and specificity for
surgically significant injury of 92% and 95%, respectively.66–69
A systematic review and meta-analysis evaluating the accuracy
of PEX in the diagnosis of penetrating AI found that, when used
in combination with normal ABI, a normal PEX (no hard or soft
signs) resulted in zero probability of AI.69 This was confirmed
by another large retrospective cohort study of penetrating PVIs
showing that PEX and ABI reliably excluded AIs and no angiography was required.70 Thus, patients with completely normal
PEX without any signs of VT and normal ABI, particularly after
penetrating injuries, can safely be discharged in the absence of
associated injuries. Unfortunately, sensitivity and specificity of
PEX are lower in blunt compared with penetrating PVI.68,71 In
TABLE 3. Clinical Signs of PVI
Hard Signs
Soft Signs
Pulsatile bleeding
Expanding/pulsating hematoma
Loss of distal pulses
Bruit/thrill
Nonpulsatile bleeding
Nonexpanding/nonpulsatile hematoma
Diminished pulse
History of arterial (massive)
bleeding/hypotension
Previously applied tourniquet
Neurologic deficit
Wound in proximity to named vessel
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J Trauma Acute Care Surg
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Kobayashi et al.
a meta-analysis of 284 AIs caused by knee dislocations, it was
demonstrated that abnormal pulse examination had a sensitivity
and a specificity of 79% and 91%, respectively, in detection of
AI and positive predictive value and negative predictive value
of 75% and 93%.72 Because of the lack of sensitivity, particularly for detection of popliteal artery injury following knee dislocation, postreduction imaging is recommended to reliably
exclude popliteal artery injury.26,57,59,65,72–75
Hard signs of PVI are overt and reliably define major AI,
while soft signs merely raise the index of suspicion for possible
PVI. Loss of pulses and active bleeding are the most frequent hard
signs of AI found during PEX followed by expanding hematoma.38,61,67,76 Nearly 100% of patients (with rare exceptions),
who present with hard signs on admission, have a confirmed major PVI.52,63,65,67,70,76 Patients who present with hard signs on initial examination should immediately undergo surgical exploration
without being submitted to radiological investigation; an exception to this rule is when the patient presents with multilevel trauma
to an extremity (e.g., a shotgun injury or an extremity with multiple fractures, or multiple GSWs or stab wounds). In those cases,
the level of AI may be uncertain, and contrast imaging may be
needed to define surgical planning. These cases may particularly
benefit from the utilization of a hybrid operating room with angiographic capabilities where both diagnostic angiography and
open and endovascular intervention can be performed.77–81
Compared with hard signs, soft signs are more subjective,
and not all soft signs represent an equal risk of injury. Proximity,
defined as any penetrating wound in which the path of the penetrating agent could potentially cross the normal anatomic position of a vascular bundle, is the most controversial soft sign
having poor value in the diagnosis of VT.64,82 Inaba et al.65
found no patients with PVI who had a negative PEX on admission and proximity wounds to arteries who underwent CTA. In a
cohort study of patients with 220 penetrating lower extremity injuries (92% GSWs) presenting with normal PEX, 169 patients
had proximity injuries, and 8 of them (5%) had a confirmed
acute venous injury in the form of deep venous thrombosis
and only 2 had arteriovenous fistulas (AVFs).82 Other soft signs
have an important role in raising a high index of suspicion for VT,
and their presence warrants additional imaging to reliably exclude
or confirm an injury.17,49,52,57,58,63–65,69,82,83 Nonexpanding and
nonpulsatile hematoma is the most often encountered soft sign
in PVI (35%), followed by diminished pulse and external bleeding (20% each).65 Some reports have estimated the risk of an AI
to be as low as 3% if a single soft sign is detected, but it can
reach as high as 25% if multiple soft signs are present.78
For patients with soft signs of VT and without indication
for immediate surgery, assessment of ABI or API in addition
to formal PEX was of high value to exclude AI.69,71,84 The
ABI is the ratio of the BP at the ankle (defined by a Doppler device) to the BP in the arm. Similarly, the API is calculated as the
BP in injured limb divided by the BP in the corresponding uninjured limb. The API cutoff value has been traditionally established as <0.9.71,77,78,85 In case of associated orthopedic
injuries, traction to the extremity and limb realignment is recommended before measuring the API to avoid false-negative results.77 Both the ABI and the API have limitations. These
indices are focused on major arteries, but injuries to the profunda
brachii, profunda femoris, or peroneal arteries are not detected
because no direct flow from these arteries is measured distally;
minor luminal injuries (that do not affect flow) such as small intimal flaps may not be detected. The indices do not detect venous
injuries and are also less sensitive in hypotensive and/or hypothermic patients, hence should be used with caution in those patients.77
Given the reliability of PEX, ABI, and API in determining risk of
PVI, these quick clinical tests should be undertaken as soon as
possible to identify signs of PVI and, thus, to determine whether
further imaging and treatment is required (Fig. 1).
When concerning soft signs of injury are present or abnormal
ABI and/or API measurements are encountered, several imaging
modalities are available to diagnose PVI: conventional angiography,
Doppler ultrasonography, CTA, magnetic resonance imaging
Figure 1. Peripheral vascular injury diagnostic and management algorithm.
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(MRI)/magnetic resonance (MR) angiography.34,77,78,82,83,86–96
Continuous monitoring of bilateral limbs with near-infrared
spectroscopy has recently been proposed for detecting changes
in limb perfusion, but its role in primary evaluation and diagnosis of VT is not yet well defined.97
Doppler ultrasound continues to have a role in screening for
occult vascular injuries, but the experience and time needed to assess for PVI can be a limitation in the acute trauma setting.93,94
For extremity trauma, the FAST Doppler protocol (focused
goal-directed Doppler procedure) has been proposed as a triage tool
for both prehospital and in-hospital settings.91 However, this protocol cannot differentiate whether the pathologic flow is caused by an
acute or a chronic lesion. Thus, in positive cases (presenting absent,
monophasic, or biphasic waveforms at dorsalis pedis/fibular arteries), further immediate imaging evaluation is required.91
Computed tomography angiography has emerged as an
important and reliable tool in the diagnosis of PVI. Its sensitivity
and specificity in identifying PVI exceed 90% in many
studies,12,65,88,89,95,98–104 and it has been shown to effectively
detect injuries to small vessels in adults and children.98,103,105
Another advantage of CTA is the display of vascular injuries in
the context of the surrounding tissues, especially the relationship
to bones. The CTA generates, in comparison with subtraction angiography, multipurpose images that require postprocessing to reduce the provided information to the targeted structure, that is,
vessels. Axial and multiplanar reformatted images are usually
accompanied by maximum intensity projections and a form of
3-dimensional volume rendering. The goal of these additional
methods is to provide overviews of the vasculature that are partially comparable to angiography.94 Institutional protocols for
performing CTA should be observed with 64-slice multidetector
scanner preferably used (minimum, 16 slices).78
For upper extremity CTA, a venous access should preferably
be placed in the noninjured arm, and ideally, the injured extremity
should be raised above the head, decreasing beam-hardening artifact from the torso. For a lower extremity CTA, legs should be
secured to the table, and both limbs are to be included in the
field of view, since the inclusion of the contralateral extremity
may be useful as a reference during interpretation of findings
in the injured side.78,106 Computed tomography angiography
signs of injury can be classified into direct or indirect. Direct
signs relate to the vessel wall and often indicate significant VT
that may require either surgical or endovascular repair, and include occlusion, thrombosis, intimal dissection, spasm, external
compression, PSA, active arterial hemorrhage, and AVF. Indirect signs represent findings within the perivascular soft tissues
such as perivascular hematoma, a projectile tract near a
neurovascular bundle, and shrapnel in a distance of <5 mm from
a vessel. The presence of indirect signs secondary to VT should
raise suspicion for an occult injury.92,101,104,106 Sensitivity and
specificity are consistently high in most modern series, thus defining CTA as the primary imaging tool for the assessment of
PVI in the daily trauma center routine.34,94
Before the wide adoption of CTA for diagnosis of VT, conventional angiography represented the criterion standard for diagnosis. Despite the many advantages of CTA, it continues to have
its limitations. Computed tomography angiography may become
nondiagnostic with poor timing of contrast material injection,
which may be seen in multiple injury patients with circulatory
1188
compromise or multilevel VT. In addition, the presence of artifacts
caused by metal fragments related to ballistic injury causes streaks
that make the vessel in question difficult to evaluate. In such patients, the use of traditional or on-table angiography with digital
subtraction angiography may prove helpful in making a definitive
diagnosis. In addition, in patients with multiple injuries, time to
diagnosis may be reduced with early operative intervention in a
hybrid suite allowing for simultaneous operative and diagnostic
evaluation on multiple regions of injury.79–81,107,108
The role of MRI and MR angiography in the setting of
acute trauma is limited because of the practicalities of trauma patients in a MR scanner. In addition, a patient suffering from penetrating trauma may have retained metal fragments, which are
noncompatible with MRI and may result in artifacts.92–94
Treatment of PVI
NOM of PVI
• Nonoperative management (NOM) can be considered in selected stable patients with AAST Grades I and II injuries without active hemorrhage or signs of distal ischemia. (GoR 2C)
• NOM can also be considered for isolated AAST Grade III
tibial and peroneal injuries where either the anterior or posterior tibial artery remains intact and there is no active hemorrhage or distal ischemia. (GoR 2C)
Surgical dogma has long dictated that all VTs require operative intervention. Recently, a prospective registry was formed
capturing trauma related VTs. Within the report, it was seen that
injuries were initially treated with a variety of modalities, including NOM in 50.9% of cases.12 A review of the literature lacks
significant data on what injuries may safely undergo NOM. A
report by Dennis et al.66 first questioned this paradigm after observing patients with penetrating VT identified on angiography
without clinically significant findings. The patients underwent
an average of 9 years of follow-up with only 9% developing clinical deterioration requiring surgical intervention.66 In 2009,
Franz et al.58 proposed that nonocclusive AIs may undergo an
initial period of observation. In 2011, Franz et al.57 proposed that
nonocclusive injuries may be definitively managed nonoperatively
based on four criteria: <5 mm intimal disruption, adherent intimal
flaps, intact distal circulation, and no active hemorrhage. A third
report by Franz et al.52 in 2012 reported successful management
of five AIs using the previously proposed criteria. In addition,
Burkhardt et al.25 demonstrated that a majority of patients
(83%) with single vessel tibial-level AIs in whom limb salvage
was pursued could be managed without arterial reconstruction.
While there are not enough data to recommend NOM of proximal arterial PVI, it appears that branch vessels, single forearm
vessels, and single tibial-level vessels may be candidates for a
trial of NOM. These patients should be monitored closely, and
any change in clinical examination should be followed by immediate repeat imaging, endovascular, or operative intervention
(Fig. 1). For the purposes of these guidelines, we consider any
endovascular intervention to be a part of operative management.
The decision to group both open and endovascular therapies into
“operative” management was made for several reasons. First,
many trauma and vascular surgeons perform diagnostic and
therapeutic angiography in interventional suites, in hybrid
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J Trauma Acute Care Surg
Volume 89, Number 6
Kobayashi et al.
operating rooms, and in traditional operating rooms with the use
of portable C-arms. Second, even when performed by interventional radiologists, endovascular intervention should be guided
by the surgeon primarily responsible for the trauma patient.
Lastly, many sequelae and complications of endovascular therapy as well as the failure of endovascular management of ischemic or bleeding injuries must be treated with surgical repair and
are best identified and addressed by surgeons.
Operative Management of PVI
• In the presence of external hemorrhage, the use of direct pressure and tourniquets is recommended in the prehospital setting. (GoR 1C)
• Isolated radial or ulnar AIs without evidence of distal ischemia can be managed with simple ligation. (GoR 2C)
• Isolated infrageniculate AI where either the anterior or posterior tibial artery is intact and there is no distal ischemia can be
managed with simple ligation, unless there is extensive soft
tissue injury. (GoR 2C)
• Proximal and distal thrombectomy should be done with a
Fogarty catheter for major AIs, and the proximal and distal
segments should be flushed with heparinized saline. (GoR 1B)
• For AAST Grades IV and V injuries, tension-free end-to-end
primary repair is the procedure of choice. (GoR 1C)
• Where primary repair is not technically possible, resection
and interposition graft should be performed. When performing arterial reconstruction, autologous saphenous vein is the
conduit of choice. (GoR 1C)
• For complex injuries and injuries with significant ischemic
time, and in damage-control situations, intravascular shunts
should be used to rapidly restore perfusion and bridge to definitive repair. (GoR 2C)
• Peripheral venous injuries should be repaired, if possible, to reduce the risk of amputation and venous insufficiency. (GoR 2C)
• In unstable patients and in those with destructive venous injuries not amenable to repair, ligation of peripheral veins is acceptable, but prophylactic fasciotomy or serial monitoring of
compartment pressures should be considered particularly in
combined arteriovenous injuries because of the high risk for
compartment syndrome. (GoR 2C)
• Primary amputation may be considered in the unstable patient with a mangled extremity (Mangled Extremity Severity
Score [MESS], >7) if presentation is significantly delayed
(i.e., prolonged ischemic time with no sensation or motor activity) and in injuries with irreparable soft tissue damage leading
to a functionally nonviable extremity. Optimally, this decision
should be made by a multidisciplinary team. (GoR 2C)
• Endovascular repair may be considered in the management
of peripheral PSAs, AVF, and other small vessel injuries diagnosed on CTA without hard signs of vascular injury. (GoR 2C)
• There is no evidence to support the use of systemic intraoperative heparinization or postoperative antiplatelet agents or
anticoagulation after most vascular repairs. The exception is prolonged ischemic time with small vessel occlusions. (GoR 2C)
Prehospital Treatment of PVI
The management of PVI begins before arrival to the trauma
center. Multiple studies have demonstrated that tourniquets are a
rapid, safe, effective, and lifesaving method for hemorrhage
control.109–111 Tourniquet use in civilian trauma scenarios has
been increasing since 2008. Previous recommendations on use
vary; however, recent studies have emphasized that waiting until
trauma center arrival to apply a tourniquet is associated with
lower BP, increased need for plasma transfusions, a higher rate
of transfusion within the first hour, and greater than 4.5-fold increase in mortality. Both the American College of Surgeons
Committee on Trauma and the American College of Emergency
Physicians now recommend that tourniquets be used when extremity hemorrhage presents a threat to life.112 In these cases,
tourniquets should be applied as soon as significant bleeding
is noted or suspected, and application should not be delayed
waiting for shock or arrival at a medical center.109
Particularly challenging are cases of junctional extremity
bleeding in the groin or axilla, which are not amenable to tourniquet placement. Multiple devices have been developed to deal
with these challenging injuries including wound clamps, junctional tourniquets, pelvic stabilizers, and self-expanding injectable hemostatic agents. Unfortunately, the evidence to support
their use remains low in volume and poor in quality.113 Simple
direct pressure applied to the site of injury with or with addition
of hemostatic agents remains the best and easiest way to reduce
bleeding from junctional injuries in the prehospital setting.
While multiple retrospective studies have shown efficacy of hemostatic agents over simple gauze in both military and civilian
settings, no hemostatic agent has emerged as superior.114–116
In addition, a recent analysis using swine models by Littlejohn
et al.117 demonstrated that standard gauze dressing was just as
efficacious as Celox-A, Chitoflex, and combat gauze in treating
uncontrolled hemorrhage from small penetrating wounds not
amenable to tourniquet placement.
Operative Management of PVI
Lower Extremity
Patients with lower extremity injury often present with
significant multiple injuries necessitating immediate operative
intervention. In general, simple nondestructive injuries are
repaired, and complex injuries are either ligated or shunted.
Prepping and draping should include the foot, bilateral groins,
and the lower abdomen with consideration of prepping the entire
abdomen and chest if the trajectory is unclear. The contralateral
extremity should be prepped and draped to facilitate saphenous
vein harvest should more complex reconstruction of the injured
extremity be required. Access to the femoral vessel can be obtained by a vertical groin incision generous enough to expose
the bifurcation of the SFA and profunda femoris. In the case of
a high common femoral artery injury, the inguinal ligament
may require division, and consideration to obtaining proximal
control through a hockey stick incision with retroperitoneal dissection and isolation of the external iliac artery should be
given.35 In a more distal injury, exposure of the proximal SFA
is again obtained through a longitudinal incision on the medial
thigh, as the midportion of the vessel is located posterior to the
Sartorius muscle, which can be retracted posteriorly to improve
exposure. When approaching the popliteal vessels, the preferred
approach is external rotation of the injured leg with elevation
and flexing of the knee. The artery is in a fixed position at the
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adductor tendon proximally and the gastrocnemius distally. The
incision is made medially using the posterior edge of the femur
as an anatomical landmark. It is important to avoid injury to the
greater saphenous vein. Division of the medial head of the gastrocnemius muscle and the semimembranosus and semitendinous
tendons is often required to provide a complete view of the artery
and vein. To expose the below knee popliteal artery, the incision
is extended below the knee along the posterior margin of the
tibia. Division of the soleus may be required to isolate the
tibioperoneal trunk.118
Primary repair is the procedure of choice for isolated AIs
with low-velocity penetrating wounds as long as a tension-free
repair can be performed. However, this is often not possible with
high-velocity injuries and injuries due to blunt trauma. When
primary repair is not an option, a decision needs to be made at
the time of the initial surgery to proceed with immediate reconstruction or switch to a vascular damage-control approach. Patient physiology, blood transfusion requirements, associated
injuries, and time to reperfusion should all be considered when
determining if damage-control techniques are necessary. If a
damage-control approach is necessary, temporary intravascular
shunt (TIVS) can be used to achieve temporary limb perfusion
and allow delayed reconstruction. Commercially available vascular shunts come in a variety of types; if none are available,
shunts can also be constructed using a piece of plastic tubing
from a high-flow intravenous line, nasogastric tube, or chest
tube, all of which are inexpensive and immediately available.
Multiple studies have shown that initial surgery with TIVS does
not worsen outcomes compared with definitive repair at the initial
operation and is associated with similar rates of amputation-free
survival.53,119 Even when damage control is not deemed necessary, TIVS can be useful if associated bony fractures and unstable
joints are present to reduce the risk of disruption of vascular repairs during orthopedic manipulation and repair. Once vascular
control has been obtained and TIVS used to restore distal perfusion, the orthopedic team can be called to stabilize associated
fractures before shunt removal and definitive vascular reconstruction.44 A meta-analysis by Fowler et al.120 described no significant influence on the overall amputation rate by whether the
bone or vascular repair was done first in a large multicenter retrospective review of 213 patients with TIVS placement. Furthermore, dwell times were compared over four-patient groups
including <6 hours, 6 hours to 24 hours, 24 hours to 48 hours,
and >48 hours. In these groups, there was no association between dwell time and shunt thrombosis.121
Choice of arterial bypass graft material has remained a
topic of debate. While autologous saphenous vein graft remains
the best choice, this is not always an option. Stone et al.122 found
that polytetrafluoroethylene (PTFE) maintained structural integrity even in the face of staphylococcal infection with a low incidence of anastomotic disruption. Several studies have shown
that PTFE grafts resist infection more than other prosthetic conduits such as Dacron.123 A study published by Watson et al.124
demonstrated that overall PTFE and autologous vein had statistically equal graft complication rates at 62-month follow-up.
However, when performing subgroup analysis in the periphery,
autologous vein demonstrated greater 8-year freedom from
graft-related complication (77%) compared with PTFE
(31%).122,124,125 Regardless of type of repair performed, care
1190
should be taken to thoroughly clean the site of injury, remove
all devitalized tissue, and, if possible, ensure that the repair or
graft is covered with layers of healthy viable tissue before surgical completion.
There is much debate in the literature as to whether ligation
or reconstruction should be the method of choice for complex
lower extremity venous injuries. Proponents of routine ligation
claim that venous stasis is mitigated by collaterals, and multiple
studies have demonstrated no permanent sequelae of venous ligation including no difference in amputation rates.22,126,127 Conversely, those in favor of repair report acceptable patency rates
and theoretical reduction in venous hypertension after
repair.128–131 Quan et al.129 reviewed combat venous injuries
and confirmed that the majority of patients (63%) were treated
with ligation without significant differences in postoperative
thromboembolic complications compared with the repaired vein
group. Limited published civilian experience has shown that
more distal repaired veins tend to thrombose early without effect
on morbidity.128,131 A recent NTDB study of lower extremity
venous injuries found that ligation was significantly associated
with increased rates of fasciotomy (44.6% vs. 33.5%) and secondary amputation (6.1% vs. 3.4%) when compared with repair.
This study also found that patients undergoing ligation also had
a longer hospital length of stay, although mortality was unchanged. This association appeared to be most strong with popliteal vein injuries, suggesting that particular care should be
given to attempting popliteal vein repair when at all possible.132
On a review of the literature, there appears to be a 30% to
71% fasciotomy rate in the case of combined arterial and venous
popliteal injuries.133 Compartment syndrome frequently complicates severe lower extremity injury and is associated with prolonged ischemia time (>4–6 hours) in patients with AI.
Multiple reports have suggested the importance of prophylactic
fasciotomy as opposed to waiting for symptoms to perform therapeutic fasciotomy.35,44,134,135 In a recent review of the NTDB,
early fasciotomy was associated with shorter length of stay,
lower rates of infectious complication, and lower amputation
rates.136 This result was replicated in the combat setting with
soldiers undergoing early fasciotomy having a 50% decrease in
amputation rate.137
The MESS, popularized by Johansen et al.,138 is an objective criterion that was first used for amputation prediction after
lower extremity injury; it was later applied for amputation prediction in upper extremity injuries as well.27,139 A score of ≤6
reliably predicts limb salvage for both upper and lower extremity
PVI.43,138 A MESS of >7 has been used as a cutoff point for
predicting the need for early amputation but has not proven reliable in predicting limb salvage in adults.22–24,140,141 The MESS
appears even less reliable in children, in which all extremities
with the score of ≤6 and every third limb with MESS of ≥7 were
salvaged.142 In major popliteal injuries, primary amputation
should be considered when there is more than 6 hours of ischemic
time, disruption of the posterior tibial nerve, severe lower leg and
foot wounds, open comminuted fractures with segmental bone
loss, multiple injuries in an unstable patient, and injuries requiring
overwhelming extensive soft tissue coverage.24,35,119,143 Patients
with combat related blast injury demonstrate significant risk
for late amputation following discharge after the original injury.
In these patients, open fractures, multiple fractures, and large
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soft tissue defects are common, and primary amputation as opposed to limb salvage should be strongly considered.144
Upper Extremity
The criterion standard for VT to the upper extremity remains open surgical repair. Rapid access can be gained to the
brachial vessels by making an incision along the medial groove
of the biceps and triceps muscle. Extension of this incision
obliquely across the antecubital fossa and onto the volar forearm
can be used to access the proximal radial and ulnar arteries. After
obtaining proximal and distal control, repair is dependent on the
severity and location of injury. Techniques include lateral suture,
patch angioplasty, tension-free end-to-end anastomosis, and interposition graft. The majority of UEAIs can be repaired primarily with lateral arteriorrhaphy or resection with end-to-end
anastomosis. Isolated radial and ulnar injuries with an intact palmar arch confirmed by Doppler examination after occlusion of
the injured vessel can be ligated with low rates of distal ischemia
and amputation.52,58,141,145,146 Bypass grafts are required in approximately 20% to 30% of cases. When required, autologous
vein graft from an uninjured extremity is the preferred
conduit.52,58,67,141,147–149 The combined presence of vascular
and orthopedic injuries creates a challenge for management
and functional outcome of upper extremity vascular injury.52 Ischemic time is of critical importance for outcomes, and thus, it is
generally recommended that vascular repair precedes orthopedic
intervention.58,118,150–152 However, in the event of major musculoskeletal damage requiring external fixation, while generally
not used in the upper extremity, TIVS represents an important
tool to restore perfusion prior to definitive repair.52,121,141,153
Venous injuries in the upper extremity can generally be ligated because of the extensive collateral venous system.128,129,131
In a review performed by Quan et al.129 of 103 venous injuries,
there was no significant difference in postoperative thromboembolic complications in the ligation group compared with the venous repair group. Although the need for fasciotomy is
markedly reduced in the upper extremity compared with the lower
extremity PVI, if ischemic time is long (>6 hours), forearm
fasciotomy should be performed.20
Perioperative Anticoagulation
The use of perioperative systemic anticoagulation for traumatic vascular injury has been a topic of significant debate. Multiple studies have shown that anticoagulation given to patients
with traumatic AI without absolute contraindication has not
been reported to increase the rate of bleeding complications.154,155 Wagner et al.156 found no hemorrhagic complications in patients receiving intraoperative anticoagulation. In
addition, Humphries et al.154 found that use of intraoperative anticoagulation did not significantly change intraoperative blood
loss or overall bleeding complications.157 However, this study
also failed to demonstrate any improvement in rates of reoperation or limb salvage with systemic anticoagulation and found a
trend toward worse outcomes. A retrospective analysis performed by Wang et al.158 matching patients given heparin, aspirin, and the use of no agents found no statistically significant
difference in the rates of bleeding, compartment syndrome, or
mortality. However, again, it also failed to demonstrate any improvement in rates of thrombosis or amputation.158 Lastly, a
recent study performed by Loja et al.157 demonstrated that systemic anticoagulation given during an operation was not associated with improved graft patency or limb salvage but was
associated with prolonged hospital stay and increased blood
product use. Overall, while systemic anticoagulation for VT
does not definitively increase bleeding risk, it also does not seem
to improve outcomes and its routine use is not recommended.
Endovascular Management
Recently, there has been increasing interest in the use of
endovascular techniques for PVI. The placement of endovascular
stents and stent grafts has been demonstrated to be safe and is
considered an accepted alternative to open surgery for the management of peripheral artery aneurysms and AVFs.159 Stents
and stent grafts alone and in combination with embolization, although rare in PVI, have been described.93,160 Reviews of case reports and small case series have demonstrated the safety of
endovascular repairs and generally favorable outcomes. However,
early and late stent thrombosis has been reported, and long-term
surveillance studies are lacking.39,93,161–165 In addition, concern
remains regarding the feasibility of obtaining follow-up and surveillance in the trauma population.163 Associated complications
of the endovascular approach include stent occlusion, deformation and kinking, loss of vessel branches after stent placement,
and intimal hyperplasia.93,159,166
Outcomes and Complication of PVI
Avariety of factors affect limb outcomes after PVI, including mechanism of injury, associated orthopedic injury, number
of vessels injured, and location and type of vessel injured. Patency rates of upper extremity PVI repairs are generally good,
ranging from 93% to 97%.45,167 Functional deficits are common
in upper extremity PVI. While ischemic time does impact functional outcome, deficits appear to be more strongly associated
with concomitant bony and nerve injury, and need for fasciotomy
rather than type and timing of arterial repair.146,167,168 Significant
nerve and bone injury, and combined arterial and venous injury
are associated with increased need for fasciotomy, morbidity,
and need for amputation.20–28 Blunt trauma has also been reported to have a persistent long-term effect on functional disability outcome in both upper and lower extremity PVI.26,44,168,169
The restoration and preservation of vascular flow remains
one of the most important factors for subsequent success.43 Acceptable duration of total (tourniquet) and warm (no flow in a
major artery) ischemia is considered to be limited by 2 and 6
hours, respectively. It has been demonstrated by modern studies
that there is a negative association between duration of ischemia
and rate of complications and/or limb salvage. Kauvar et al.,28
analyzing 455 patients with combat LEAIs with or without applied tourniquet, found that tourniquet dwell time of 60 minutes
or longer was associated with more rhabdomyolysis, wound infection, and neurologic compromise. Timing of revascularization has long been considered to contribute to amputation
rates. A greater than 6-hour interval between injury and revascularization has often been quoted as increasing risk for amputation; however, others have found a lack of correlation between
timing and vascular outcome.24,26,133,156 Thus, while expedited
reperfusion is optimal, time of ischemia itself should not define
treatment strategy.50,74,170
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Kobayashi et al.
Overall, patients sustaining PVI have an amputation rate
of 1% and 11% for the upper and lower extremity,
respectively.1,20,22,23,27,45,61,147,170–173 Amputation for upper extremity PVI is much less common compared with lower extremity injuries and is associated with severity and location of PVI
and associated injuries.20,45,141 Ligation of the common brachial
artery carries the highest risk for amputation at 18% to 55%.35
The MESS scale has also been applied to upper extremity
PVI. Studies suggest that patients with a MESS of <7 are unlikely to require amputation.141 In the lower extremity, popliteal
and femoral artery injuries carry the highest risk of amputation
reaching 28% to 37%, and as high as 70% for late presentations.1,27,42,44,74,133,173 Studies have suggested that tibioperoneal
trunk injury results in even higher amputation rates than
below-knee popliteal injuries. Anterior tibial artery injuries,
in particular, were considerably more likely to require amputation
compared with posterior tibial or peroneal artery injuries.21,43 In
addition, there was a significantly higher rate of amputation
among patients undergoing bypass with tibioperoneal trunk targets, with these patients requiring amputation at rates of approximately three times that of below knee popliteal targets.43 In
general, the more vessels to the foot that remain patent, the higher
chance for limb salvage.105,174 In a subsequent multicenter study
conducted by Branco et al.,105 it was noted that no amputations
occurred in patients with two or more patent vessels to the foot,
whereas there was a 68.2% amputation rate documented for patients with no patent vessels and 16.0% for those with 1 patent
vessel. Blunt VT is associated with significantly higher amputation rate (6.7% vs. 1.3%) and mortality (4.8% vs. 3.8%) compared with penetrating trauma.20,23 Risk of amputation for PVI
is similar in military (excluding blast injuries) and pediatric populations.1,9,11,41,53,55,142,175 Recent NTDB analysis demonstrated
that children with PVIs had significantly lower amputation rate
if treated in American College of Surgeons-verified adult or pediatric trauma centers.41 The geriatric population has a higher risk
of lower limb amputation compared with adults.4
A comparison of UEAI and LEAI using the NTDB has reported mortality of 2.2% for UEAI and 7.7% for LEAI.20 Lower
extremity arterial injury was independently associated with a
twofold increase in mortality for both blunt and penetrating injuries. Other authors reported mortality for LEAI of 1.5% to 5% in
civilian and military PVI.22,23,43,55,133
CONCLUSIONS
Peripheral vascular injury represents a significant percentage of injuries in civilian and military trauma and remains a significant source of morbidity and mortality. For patients not
requiring urgent operative intervention, PEX supplemented with
ABI/API adequately screens the majority of patients. In those
with equivocal findings, thin-slice CTA is the diagnostic test
of choice. Historically, the management of these injuries has
been an open operative intervention. While most injuries continue to be managed this way, over recent years, use of
endovascular techniques have increased. Risk of death, compartment syndrome, and amputation depend on the type of vessel injured, number of vessel injuries, and associated nonvascular
injuries. Prehospital tourniquet use, damage-control resuscitation, and damage-control surgical techniques including TIVS
1192
have improved outcomes following PVI. As the landscape continues to change with emerging technology, it is clear that rapid
diagnosis and management with a multidisciplinary approach
are essential to optimize outcomes for these complex injuries.
AUTHORSHIP
L.K., R.C., and J.S. contributed in the study design, literature search, and
grading of evidence.
L.K., R.C., J.S., A.M.O.G. Jr., and V.R. contributed in the literature review
and writing of article. All authors contributed in the guideline consensus
and critical review of article.
DISCLOSURE
The authors declare no conflicts of interest.
L.K. and R.C. contributed equally for the article.
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