Peripheral injuries account for 80% of all cases of
The lower extremities are involved in two thirds of
all patients with vascular injuries.
90% of patients with vascular trauma are male
Complex extremity trauma involving both arterial
and skeletal injuries is rare, comprising only 0.2%
of all military and civilian trauma, and only 0.5%-
1.7% of all extremity fractures and dislocations
Combined arterial and skeletal extremity trauma
imparts a substantially higher risk of limb loss and
limb morbidity than do isolated skeletal and arterial
CHALLENGES OF VASCULAR INJURIES
most dramatic challenges facing trauma surgeons because
the repair is often urgent
Gaining control of and reconstructing a major arterial injury
can be technically demanding.
Limited exposure to vascular surgery in the general surgery
Major vascular trauma remains a crucial element of trauma
surgery, and every general surgeon must be prepared to deal
with them either definitively or using so-called bail-out
vascular damage control tactics.
The fundamental difference between elective vascular
surgery and vascular trauma is the physiology of the wounded
A lacerated major vessel is typically only one component of the
multi trauma complex that includes injuries to other organs and
systems. These patients are often critically ill and rapidly
approaching a point of physiologic irreversibility. In these
dramatic clinical circumstances, the key to a favorable outcome
is maintaining correct priorities.
The surgeon must keep in mind that although major hemorrhage
(typical of trunkal vascular injuries) is an immediate threat to the
patient's life, ischemia (commonly from peripheral arterial injury)
is a threat to limb viability, a much lower priority.
Furthermore, although control of hemorrhage is usually
mandatory and life-saving, the reconstruction of an injured vessel
may be neither. As the injured patient is approaching the
boundaries of his or her physiologic envelope, a simpler,
sometimes temporary technical solution is often a safer option
than a complex and time-consuming re construction. In the
severely traumatized patient, the best technically feasible
definitive solution is not always in the patient's best interest
Gunshot wounds, 70-80%
of all vascular injuries
Stab wounds (5-10% of
cases require intervention)
Blunt trauma (5-10% of
cases): Presence of fracture
or dislocation increases the
Iatrogenic injury (5% of
central line placement
• Control bleeding
• Replace volume loss
• Cover wounds
Active or pulsatile hemorrhage
Pulsatile or expanding hematoma
Signs of limb ischemia and elevated
compartment pressure including the 5
Diminished or absent pulses
Bruit or thrill is( present in 45% of
patients with an arteriovenous fistula)
Hypotension or shock
Neurologic deficit due to primary
nerve injury occurs immediately after
injury. In contrast, ischemic
neuropathy is delayed in onset
(minutes to hours).
Stable, non pulsatile or small
Proximity of the wound to major
vascular structures ( Beware of bone
fr. ! )
Delayed diagnosis and treatment may result in
Rupture with hemorrhage.
Risk factors for amputation include
Elevated compartment pressure
Associated open fractures
The combination of injuries above and below the knee.
CHRONIC PRESENTATION OF
typically take months to mature and often
require surgical repair.
may resolve completely or grow over time
presenting months to years later. They may
cause neuropathy due to compression or
embolization , or they may present as a
growing pulsatile mass.
Intimal tears and flaps
generally heal spontaneously.
can present with diminished flow but intact pulses. This
injury may resolve spontaneously with fluids and rest, or
it occasionally may require surgical intervention.
Approximately 10% of patients with non occlusive,
clinically occult injuries require repair within a month
of initial injury.
The remaining 90% of patients do not report symptoms
or see a physician for vascular problems during long-
A reduction in oximeter
readings from one limb,
as compared to
another is suggestive
of, but neither confirms
nor excludes a
Evalution of the affected extremity with hand held doppler
ultrasound should be performed routinely.
Absent doppler signals need further examination- either
with angiography or duplex scan.
Every doppler examination whether normal or abnormal
should be followed by Ankle Brachial Pressur Index(ABPI)
An ABPI > 1 is normal
Any measurement < 0.9 need
further evalution with
Duplex can detect intimal
tears, thrombosis, false
Although it is limited by
It has senitivity of 95% and
specificity of 99% with
overall accuracy of 98%
Angiography remains the gold-
standard investigation for the further
investigation and delineation of
vascular injury. In most traumatic
injury settings, angiography is best
performed in the operating room,
with the surgeon exposing the vessel
proximal to the injury for control and
Specificity above 96%
With the advent of improved CT scan, detection
of vascular injuries has greatly improved
In fact CTA is becoming a viable
alternative to angiography
Occasionally CTA be non-diagnostic due
to significant artifact from bullet
fragements or other foreign bodies
Specificity 98-100 %
MRA is used less frequently in acute settings
Metal implants such as cerebral aneurysm clips and
cardiac pacemakers preclude the use of MRI or it is
difficult to acertain whether the patient have such
devices in emergency situation
Additionally MRI takes longer and needs more co-
operation from patient than CT.
Control of haemorrhag:
Direct pressure over the
site of injury
One individual manually
compress the site of
Deep knife or gunshot
track → catheter
If angiography is
performed prior to
surgery, it may be
possible to obtain
proximal control by
passing an angioplasty
balloon catheter into the
proximal vessel and
inflating the balloon
Prior to haemorrhage control :
Minimal fluids should be administered
Raising the blood pressure will increase haemorrhage
from the vessel injury and dislodge any clot that has
Systolic blood pressure can be maintained at a level
that is appropriate for perfusion of the brain
aggressive volume resuscitation to restore circulating
Warm fluids -crystalloid, blood or clotting factors as
necessary -are administered to correct acidosis,
hypothermia and coagulopathy,
The patient is positioned on the operating table to allow on-table
angiography of the affected region and distal perfusion.
The entire affected limb is prepped and draped, as well as proximal
structures if control has to be gained more proximally. The hand or foot is
prepped so that intra-operative assessment of distal perfusion is
possible. An entire uninjured limb should also be prepped so that a vein
graft can be harvested as required. Often the person applying manual
compression at a bleeding site will have to be temporarily prepped into
the operative field until scrubbed personnel can take over.
Gain proximal and distal control of injured vessel before investigating the
site of injury. It is achieved by a separate incision away from site of injury.
Direct exploration of site of injury lead to failure of haemostasis and
damage to adjacent tissue.
Control is best achieved by passing slings twice around the vessels. If
clamps are used they should be applied with minimum force to obstruct
the flow of blood not racked closed to damage the vessel.
Once the injured vessel is identified, then debride devitalised tissue.
Asses the inflow and outflow at both end of vessel, if inadequate pass
forgatry at proximal and distal end to disloge any thrombus.
Instill heparinized saline at proximal and distal ends to locally
anticoagulate the vessel.
Use an arterial shunt if temporizing is required or delay is anticipated,
e.g. to stabilize fracture.
Obtain an on-table angiogram if suspecting further injury or chronic
If necessary select a more distal site for anastomosis of bypass graft.
Harvest vein for a conduit. Avoid synthetic material in a potentially
contaminated operative field.
Perform appropriate bypass using inlay, end-to-end, or end-to-side
Co-ordinate wound closure and dressings with orthopaedic/plastics
teams. Ensure at least soft tissue cover of vessels.
Standard limb observations with pulse check and
Doppler probe insonation if necessary. Record
ABPI at least once in postoperative period if
Check for compartment syndrome, even if
fasciotomies were performed (they are sometimes
Monitor urinary output.
Consider heparin anticoagulation (with great
caution) or aspirin.
Plan wound inspections with delayed closure (3-5
days) of fasciotomies/wounds with or without skin
Direct Suturing: Small, clean,
transverse wounds to vessels
that involve only part of the
circumference can be repaired
with a direct suture technique
Vein or synthetic graft:A vein
(or synthetic) patch may be
required where there is a larger
defect in the vessel wall where
direct sutuing may lead to
narrowing of the vessel lumen.
While vein grafts probably have
a longer patency, the graft
infection rates are the same for
both vein and synthetic grafts,
regardless of wound
Direct suturing(end to
ends of a transected
artery usually retract. If
the ends can be
tension, a direct end-to-
end anastomosis repair
can be employed.
Mobilisation of the two
ends may be necessary,
and aided by division of
minor arterial branches
approximation of the
vessels is not possible, a
reversed vein graft, or
synthetic graft is used to
repair the defect. If there
is a concomitant vein
injury, this should usually
be repaired first, if
possible to avoid low-flow
thrombosis of the arterial
Managed in a similar way to transection
In either way ,
Thrombectomy is Part of the Procedure
DAMAGE CONTROL SURGERY
The principles of damage control surgery can be
applied to vascular trauma. The basic damage
control techniques are :
There are very few vessels that cannot be ligated in extremis, at
varying risk to life and limb. The common and external carotid,
subclavian, axillary, internal iliac can be ligated with few
Ligation of the internal carotid artery carries a 10-20% risk of
Ligation of the exteral iliac artery, common femoral or superficial
femoral have a signficant risk of critical limb ischaemia following
ligation. Ischaemia is more likely if there is significant soft tissue
injury and distruction of supporting collateral circulation.
Arteries of the celiac axis can be ligated but ligation of the
superior or inferior mesenteric artery will almost inevitably lead to
gut necrosis in the young trauma patient.
Almost all veins, including the inferior vena cava, can be ligated
where necessary, with the consequence of lower limb oedema.
Ligation of the portal vein is possible but bowel oedema with
massive 'third-space' fluid losses will ensue..
Where there is a significant risk of limb
loss, or other serious consequence of
ligation, intraluminal shunts may be
employed to temporarily restore flow.
shunts can be rapidly constructed out of
sterile intravenous tubing or chest tubes
for larger calibre vessels.
Where there is a vascular injury
associated with a fracture, and there is a
risk of orthopaedic manoeuvers disrupting
an arterial repair, shunts may be
employed to temporarily restore flow to
an injured limb.
ASSESING THE PATIENT AND INJURY
The anatomic extent of injury is revealed only when the
traumatized vessel is carefully explored and opened, specially
in blunt trauma. The entire length of the injured segment must
be precisely delineated at operation because leaving proximal
or distal intimal damage will result in early failure of the
The selection of the repair technique is heavily influenced not
only by the anatomic situation but also by the patient's
physiologic condition, associated injuries, and overall clinical
trajectory. The massively bleeding patient incurs a rapidly
increasing burden of physiologic insults.
The marker of an irreversible (and lethal) physiology is a self-
propagating triad of
The hypothermia-coagulopathy-acidosis syndrome
effectively marks the boundaries of the patient's
physiologic envelope beyond which there is
The operative management of a vascular injury
must therefore focus not only on restoration of
anatomic integrity but also, more importantly, on the
patient's physiologic envelope.
The complexity and duration of the planned repair
must be inversely proportional to the physiologic
insult that the patient has already sustained.
The mangled extremity is defined as injury that involves at least three of
the four major tissue systems of a limb, consisting of bone, soft tissue,
vessels, and nerves.
The decision to immediately amputate a severely wounded extremity
(rather than attempt salvage) is difficult and emotionally charged,
especially because vascular reconstruction is usually technically feasible,
being one of the less problematic aspects of the injury.
Several scoring systems have been proposed to predict the ultimate
fate of the limb based on the severity of injury and the patient's
associated injuries and comorbid factors. e.g mangled extremity
syndromes index (MESI), predictive salvage index(PSI), mangled
extremity severity score(MESS), or limb salvage index(LSI).
However, in practice, the decision to proceed with amputation hinges on
surgical judgment and the patient's specific circumstances. It is a team
decision and is made only after careful examination and consideration.
The decision is usually made in the operating room, where the extremity
is examined under optimum conditions
As a general rule, a totally interrupted distal innervation, extensive soft
tissue destruction, and bone loss exceeding 6 cm in length all portend a
grave prognosis for the limb.
UPPER LIMB VASCULAR INJURIES
Vascular injuries to upper extremity are relatively
common representing 30 to 40% of vascular trauma
in urban civilian settings
Vessels of upper extremity are defined as those
coursing through axilla to wrist
Injuries to subclavian artery are commonly reported
with axillery artery and their management is similar.
The most commonly injured vessel in upper limb is
brachial artery with an incidence of 50%, followed by
radial and ulnar arter(25% each), least commonly
injuried artery being axillosubclavian vessels(3-5%).
The most common mechanism of injury is penetrating
AXILLO-SUBCLAVIAN ARTER INJURIES
Accounts for 3-5 % of upper limb vascular injuries
BRACHIAL ARTERY INJURIES
Accounts for 50% of upper limb vascular injuries
Operative exposure:The artery is exposed through
a medial arm incision in the groove between the
biceps and triceps muscles. The first structure
encountered in the neurovascular bundle is the
median nerve, which must be isolated and
preserved. If the brachial artery is exposed in the
proximal arm, the deep brachial artery is identified
and controlled at the lateral border of the teres
RADIAL OR ULNAR ARTERY INJURY
Most isolated ulnar or radial artery injuries can be ligated.
An ischemic hand (due to an incomplete palmar arch or injury
to both arteries) requires an arterial reconstruction.
In the presence of associated bone and soft tissue injury, it is
often safest to begin the exposure of a radial artery proximally
at the brachial bifurcation and then proceed distally to the
A lower medial arm incision is carried into the antecubital
fossa in an S-shaped configuration to avoid a longitudinal
incision across the antecubital skin crease. The bicipital
aponeurosis is divided to expose the brachial bifurcation, and
the radial artery is identified and isolated.
Exposure of the ulnar artery in the proximal forearm is more
difficult because of the deeper location of the artery at this
level. It is found deep to the antebrachial fascia, between the
flexor carpi ulnaris and flexor digitorum superficialis muscles.
LOWER LIMB VASCULAR INJURIES
Lower extremity injuries are defined as those occuring
below inguinal ligament.
The most commonly injured artery is femoral artery.
Injuries to common femoral artery, superficial femoral
artery, profunda femoris, and popliteal artery above and
below the knee represents the bulk of injuries requiring
revascularization procedures or surgical exploration.
Because of blood supply to calf and foot with anterior
tibial artery, posterior tibial artery and peroneal artery,
one or two of these artery can be disrupted without loss
of distal perfusion and limb ischemia.
Bleeding from these vessels can lead to elevated
compartment pressure causing compartment synd.,
POPLITEAL ARTERY INJURY
Popliteal artery injuries result in limb loss more
often than any other peripheral vascular injury.
Amputation rates as high as 20% especially from
The collateral arterial system around the knee is not
well developed and is very susceptible to
interruption by significant trauma, making delays in
diagnosis and treatment particularly unforgiving
Posterior dislocation of the knee- 3 out of 5 pts
Bumper to proximal tibia
The proximal popliteal artery is exposed through an
incision along the anterior border of the sartorius muscle
above the knee. The deep fascia is incised, and the
sartorius is retracted, providing access to the popliteal
space between the semimembranosus muscle and the
adductor magnus tendon.
The distal artery is approached through a medial
incision immediately behind the posterior border of the
tibia. The crural fascia is incised, and the popliteal space
is entered between the medial head of the
gastrocnemius and the soleus muscles. Wide exposure
of the entire length of the popliteal artery can be
achieved by joining the incisions and dividing the
tendons of the semitendinosus, semimembranosus,
gracilis, and sartorius and then dividing the medial head
of the gastrocnemius.
longitudinal incision is
made about 2
to the tibial crest,
below the tibial
extending to the ankle
It decompress anterior
The posterior compartments are decompressed
through a separate medial incision placed
immediately posterior to the posterior edge of the
tibia, carefully avoiding injury to the long saphenous
vein. The superficial posterior compartment is
decompressed by incising the deep fascia.