Authors

EAST Practice Management Guidelines Work Group

Abenamar Arrillaga, MD, Greenville Memorial Hospital, Greenville, SC 
Raymond Bynoe, MD, Richland Memorial Hospital, Columbia, SC 
Eric R. Frykberg, MD, University of Florida Health Science Center, Jacksonville, FL 
Kimberly Nagy, MD, Cook County Hospital, Chicago, IL

Address for correspondence and reprints

Abenamar Arrillaga, MD 
Greenville Memorial Hospital 
890 W. Faris Rd. MMOB, Suite 270, Box 17, Greenville, SC 29605 
Phone: (864) 455-7895 / Fax: (864) 455-4337 
E-mail: aarrillaga@ghs.org

I. Statement of the Problem

Evaluation and management of arterial injuries to the lower extremity due to penetrating trauma continues to challenge trauma surgeons. Questions remain concerning the method of evaluation and management of the arterial injury. The vast majority of the literature on this subject is retrospective in nature. There is sufficient data to support the recommendations made.

II. Process

A Medline computer search was conducted on all articles in the English Literature during the years 1980-1997 pertaining to arterial injuries of the lower extremity. The subject words used included "vascular injury," "artery injury," "extremity trauma," "penetrating trauma," "vascular trauma," and "artery trauma." The references of these articles were also used to locate articles not found in the Medline search. Personal files were also used. All letters to the editor, case reports, book chapters, review articles, series involving less than 20 cases, and series in which the percentage and outcome of the penetrating injuries were not clearly specified were excluded. This left 36 articles of relevance to this practice parameter. In addition there were 2 abstracts that were relevant to this practice parameter.

III. Recommendations

A. Level 1

There is no class I evidence to support a standard of care for this parameter.

B. Level 2

Patients with hard signs of arterial injury (pulse deficit, pulsatile bleeding, bruit, thrill, expanding hematoma) should be surgically explored. There is no need for arteriogram in this setting unless the patient has an associated skeletal injury or a shotgun injury. Restoration of perfusion to an extremity with an arterial injury should be performed in less than six hours in order to maximize limb salvage.

C. Level 3

1. There is no defined role for the use of noninvasive Doppler pressure monitoring or duplex ultrasonography to confirm or exclude arterial injury. There may be a role for these studies in patients with soft signs of vascular injury or with proximity injuries.
2. Absence of hard or soft signs of vascular injury reliably excludes surgically significant arterial injury and does not require arteriography.
3. Nonoperative observation of asymptomatic nonocclusive arterial injuries is acceptable.
4. Repair of occult and asymptomatic nonocclusive arterial injuries managed nonoperatively that subsequently require repair can be done without significant increase in morbidity.
5. Simple arterial repairs fare better than grafts. If complex repair is required, vein grafts appear to be the best choice. PTFE, however, is also an acceptable conduit.
6. PTFE may be used in a contaminated field. Effort should be made to obtain soft tissue coverage.
7. Tibial vessels may be ligated if there is documented flow distally.
8. Early four-compartment lower leg fasciotomy should be applied liberally when there is an associated injury or there has been prolonged ischemia. If not performed, compartment pressures should be closely monitored.
9. Arteriography for proximity is indicated only in patients with shotgun injuries.
10. Completion arteriogram should be performed after arterial repair.

IV. Scientific Foundation

The limb salvage rate following uncomplicated penetrating arterial injury is over 95%. Faster transport times, improved resuscitation, early operative intervention, and advances in critical care have all contributed to these impressive results. The approach to these injuries continues to evolve. Based on the physical exam, patients with hard signs of arterial injury (pulse deficit, arterial bleeding, bruit, thrill, expanding hematoma) without associated skeletal injury can proceed to operative exploration without an arteriogram^{[1] [8] [9] [15] [21] [24] [25] [27] [30] [35]}. There may be some exceptions to this statement. Patients with shotgun wounds or with preexisting peripheral vascular disease may still benefit from a preoperative arteriogram. Soft signs of arterial injury (nerve deficit, nonexpanding hematoma, associated fracture, significant soft tissue injury, history of bleeding or hypotension ), while being a widely recommended indication for arteriography, do not appear to be clinically useful predictors of arterial injuries with the exception of shotgun wounds ^{[8] [15] [20] [24] [35]}. In those patients without hard or soft signs of arterial injury there is no role for proximity angiogram ^{[9] [15] [20] [21] [23] [24] [35] [36]}. Patients with clinically occult arterial injuries may be treated nonoperatively in most instances ^{[8] [19] [26] [27] [28] [29]}. There still remains questions on selection criteria for nonoperative management of patients with pseudoaneurysms or arteriovenous fistulae. Patients with clinically occult arterial injuries which later manifest themselves as needing repair can be repaired without additional morbidity ^{[19] [21] [25] [26] [27]}. Patients with hard signs that are surgically explored are best managed with simple repair, either by end-to end anastomosis or arteriorrhaphy ^{[1] [7] [8] [9] [11] [12] [16]}. If complex repair is required, vein grafts appear to have the highest patency rates. PTFE however seems to be an acceptable alternative even in contaminated fields ^{[2] [3] [5] [9] [11] [12] [14] [15] [38]}. Ligation of tibial vessels is acceptable when there is evidence of good perfusion distally ^{[7] [8] [13] [14] [24]}.

The role of noninvasive evaluation of the lower extremity has not been elucidated. There is data to suggest that duplex studies are accurate in diagnosing arterial injuries ^{[17] [18] [23] [31] [32] [33] [34]}. However, it is unclear when to initiate these studies. Should they be performed for proximity or in the presence of soft signs of arterial injury? If there is no role for proximity arteriography, why then do noninvasive testing for proximity? Should they be used to follow up patients with normal vascular exams? These questions require further investigation.

V. Summary

Most patients with hard signs of arterial injury should be operated upon without a preoperative arteriogram. A preoperative arteriogram may be helpful in patients with shotgun wounds or preexisting peripheral vascular disease. There appears to be no role for proximity angiography in patients with soft signs of arterial injury, as most patients with occult injury may be treated nonoperatively.

Patients who have an arterial injury that requires exploration (ie. those with hard signs) are best repaired with simple repair or vein grafts. PTFE grafts are an acceptable alternative even in a contaminated field.

VI. Future Investigation

Several issues in diagnosis and management of arterial extremity injuries remain unresolved. Future studies should focus on prospective evaluation of the following:

Role of noninvasive tests to diagnose vascular injury in extremity penetrating trauma

1. Use of PTFE versus autogenous vein in the repair of arterial injuries
2. Role of intraoperative completion arteriogram
3. Nonoperative observation of asymptomatic nonocclusive arterial injuries
4. Proper follow up of patients treated nonoperatively for asymptomatic nonocclusive arterial injuries
5. Role of heparin/thrombolytics in the repair of arterial injuries
6. Evaluation of patients with Asoft@signs of vascular injury
7. Role of antioxidants in prevention of reperfusion injury and need for fasciotomy

VII. References

1. Reichle FA, Golsorkhi M. Diagnosis and Management of Penetrating Arterial and Venous Injuries in the Extremities. Am J Surg 140: 365-367, 1980.
2. Shah DM, Leather RP, Corson JD, et al. Polytetrafluoroethylene Grafts in the Rapid Reconstruction of Acute Contaminated Peripheral Vascular Injuries. Am J Surg 148: 229-233, 1984.
3. Feliciano DV, Mattox KL, Graham JM, et al. Five-year Experience with PTFE Grafts in Vascular wounds. J Trauma 25:71-82, 1985.
4. Meyer JP, Lim LT, Schuler JJ, et al. Peripheral Vascular Trauma From Close Range Shotgun injuries. Arch Surg 120: 1126-1131, 1985.
5. Menzoian JO, Doyle JE, Cantelmo NL, et al. A Comprehensive Approach to Extremity Vascular Trauma. Arch Surg 120: 801-805, 1985.
6. Whitman GR, McCroskey BL, Moore EE, et al. Traumatic Popliteal and Trifurcation Vascular Injuries: Determinants of Functional Limb Salvage. Am J Surg 154: 681-684, 1987.
7. Armstrong K, Sfeir R, Rice J, et al. Popliteal Vascular Injuries and War: Are Beirut and New Orleans similar? J Trauma 28: 836-839, 1988.
8. Ashworth EM, Dalsing MC, Glover JL, et al. Lower Extremity Vascular Trauma: A Comprehensive, Aggressive Approach. J Trauma 28: 329-336, 1988.
9. Feliciano DV, Herskowitz K, O=Gorman RB, et al. Management of Vascular Injuries in the Lower Extremities. J Trauma 28: 319-328, 1988.
10. Feliciano DV, et al. Extraanatomic Bypass for Peripheral Arterial Injuries. Am J Surg 158: 506-9, 1989.
11. Peck JJ, Eastman AB, Bergan JJ, et al. Popliteal Vascular Trauma: A Community Experience. Arch Surg 125: 1339-1344, 1990.
12. Cargile JS III, Hunt GF. Acute Trauma of the Femoral Artery and Vein. J Trauma 32: 364, 1992.
13. Padberg FT, Rubelowsky JJ, Hernandez-Maldonado JJ, et al. Infrapopliteal arterial injury: Prompt revascularization affords optimal limb salvage. J Vasc Surg 16: 877-885, 1992.
14. Trooskin SZ, Sclafani S, Winfield J, et al. The Management of Vascular Injuries of the Extremity Associated with Civilian Firearms. SG & O 176: 350-354, 1993.
15. Degiannis E, Levy RD, Sofianos C, et al. Arterial Gunshot Injuries of the Extremities: A South African Experience. J Trauma 39: 570-575, 1995.
16. Melton SM, Croce MA, Patton JH Jr, et al. Popliteal Artery Trauma: Systemic Anticoagulation and Intraoperative Thrombolysis Improves Limb Salvage. Ann Surg 225: 518-527, 1997.
17. Fry WR, Smith RS, Sayers DV, et al. The Success of Duplex Ultrasonographic Scanning in Diagnosis of Extremity Vascular Proximity Trauma. Arch Surg 128: 1368-1372, 1993.
18. Knudson MM, Lewis FR, Atkinson K, et al. The Role of Duplex Ultrasound Arterial Imaging in Patients with Penetrating Extremity Trauma. Arch Surg 128: 1033-1038, 1993.
19. Frykberg ER, Vines FS, Alexander RH. The Natural History of Clinically Occult Arterial Injuries: A Prospective Evaluation. J Trauma 29: 577-583, 1989.
20. Francis H, Thal ER, Weigelt JA, et al. Vascular Proximity: Is it a Valid Indication for Arteriography in Asymptomatic Patients? J Trauma 31: 512-514, 1991.
21. Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year. J Trauma 31: 502-511, 1991.
22. Johansen K, Lynch K, Paun M, et al. Non-invasive Vascular Tests Reliably Exclude Occult Arterial Trauma in Injured Extremities. J Trauma 31: 515-522, 1991.
23. Anderson RJ, Hobson RW, Lee BC, et al. Reduced Dependency on Arteriography for Penetrating Extremity Trauma: Influence of Wound Location and Noninvasive Vascular Studies. J Trauma 30: 1059-1065, 1990.
24. Martin LC, McKinney MG, Sosa JL, et al. Management of Lower Extremity Arterial Trauma. J Trauma 37: 591-599, 1994.
25. Richardson JD, Vitale GC, Flint LM. Penetrating Arterial Trauma: Analysis of Missed Vascular Injuries. Arch Surg 122: 678-683, 1987.
26. Stain SC, Yellin AE, Weaver FA, et al. Selective Management of NonOcclusive Arterial Injuries. Arch Surg 124: 1136-1141, 1989.
27. Feliciano DV, Cruse PA, Burch JM, et al. Delayed Diagnosis of Arterial Injuries. Am J Surg 154: 579-584,1987.
28. Frykberg ER, Crump JM, Vines FS, et al. A Reassessment of the Role of Arteriography in Penetrating Proximity Trauma: A Prospective Study. J Trauma 29: 1041-1052, 1989.
29. Rose SC and Moore EE. Angiography in patients with arterial trauma: correlation between angiographic abnormalities, operative findings, and clinical outcome. AJR Am J Roentgenol 149:613-619, 1987.
30. Sirinek KR, Gaskill HV, Dittman WI, et al. Exclusion Angiography for Patients with Possible Vascular Injuries of the Extremities a Better Use for Trauma Center Resources. Surgery 94: 598-603, 1983.
31. Meissner M, Paun M, Johansen K. Duplex Scanning for Arterial Trauma. Am J Surg 161: 552-555, 1991.
32. Schwartz M, Weaver F, Yellin A, et al. The Utility of Color Flow Doppler Examination in Penetrating Extremity Arterial Trauma. Am Surg 59: 375-378, 1993.
33. Bergstein JM, Blair JF, Edwards J, et al. Pitfalls in the Use of Color- Flow Duplex Ultrasound for Screening of Suspected Arterial Injuries in Penetrated Extremities. J Trauma 33: 395-402, 1992.
34. Bynoe RP, Miles WS, Bell RM, et al. Noninvasive Diagnosis of Vascular Trauma by Duplex Ultrasonography. J Vasc Surg 14: 346- 352, 1991.
35. Menzoian JO, Doyle JE, LoGerfo FW, et al. Evaluation and Management of Vascular Injuries of the Extremities. Arch Surg 118: 93-95, 1983.
36. Gomez GA, Kreis DJ, Ratner L, et al. Suspected vascular trauma of the extremities: the role of arteriography in proximity injuries. J Trauma 26: 1005-1008, 1986.
37. Dennis JW, Veldenz HC, Menawat MD, et al. Validation of Nonoperative Management of Occult Vascular Injuries and Accuracy of Physical Examination Alone in Penetrating Proximity Trauma: Five to Ten Year Follow-up. J Trauma 43: 196, 1997.
38. Carillo EH, Spain DA, Wilson MA, et al. Alternatives in the Management of Penetrating Injuries to the Iliac vessels. J Trauma43: 196, 1997.

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