2 - Vascular Injury

Vascular “Arterial” trauma Dr.
Sameer
Mechanism of injury
Vascular injury can result either from:
• Blunt (RTA, FFH, and compression).
• Penetrating injury.
Blunt vascular trauma is associated with an increased amputation rate. Why???
• Delayed diagnosis due to misleading signs (mobile limb and there is pulse).
• Associated with significant amount of fractures and soft tissue loss.
Types of vascular injury

1. Contusion: more with blunt injury (damaged T.intima with risk of thrombosis).
2. Puncture: usually during cardiac catheterization through femoral a., or cannula
insertion.
3. Laceration: the most serious (no reflex vasoconstriction leading to continuous
bleeding).
4. Complete transection. Classification:
Management 1. Completely-severed artery.

2. Partially-severed artery.
Diagnosis 3. Non-severed artery.
Clinical:
• Depend on site (which artery), mechanism of injury and extent of injury (associated
injuries).
Signs classically divided into hard and soft signs:
Hard signs Soft signs
1. Active hemorrhage. 1. History of hemorrhage at site of the
artery.
2. Expanding hematoma. 2. Non-expanding Hematoma.
3. Signs of distal ischemia (pain, 3. Unexplained hypotension.
parasthesia, paralysis, pallor, OR the site of injury near the course
coldness “poikilothermia”, of an artery. (Dr. Alaa kassar).
pulselessness).
4. Bruit or palpable thrill. 4. Peripheral nerve deficit (due to
hypoxia).
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How to differentiate arterial from venous bleeding?
• Arterial bleeding is profuse, pulsatile, bright-red colored, and site of injury.

• Venous bleeding is less profuse, continuous and dark-red colored.
Nerves that are more vulnerable to hypoxia are sensory so the first features of ischemia
is pain. Then skin, muscle and then the bone are the subsequent tissues vulnerable for
ischemia.
Completely-severed artery
Complete transection of the artery…. As a protective mechanism, there will be
“constriction, retraction, and thrombus formation”…. Stopping the bleeding.
Diagnosis:
1. No bleeding.
2. Negative distal pulses.
3. Ischemia (its occurrence & timing depend on: size & number of the injuries, state of
the collaterals, and tissue demand).
Initially after the injury, there’s no ischemia (the limb is viable), but later on (after
hours), ischemia will occur, explain why???
Initially the distal limb is supplied by the collaterals, however later on, there will
enlargement of the thrombus which occludes the collaterals resulting in ischemia.
Partially-severed artery
Partial cut in the wall of the artery (puncture or laceration)… As a protective mechanism,
there will be “constriction, retraction, and thrombus formation”…. Increasing the
bleeding.
Diagnosis:
Early presentation:
1. Continuous profuse bleeding.

2. Recurrent bleeding (patient presented with shock, being resuscitated, then re-bleed
again).
3. The distal pulses may be positive (usually weak). (Thus, positive distal pulse doesn’t
exclude an arterial injury).
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Late presentation:
1. Pulsatile, expanding hematoma.

2. False aneurysm with/without AV fistula.
Non-severed artery
Mostly seen along with orthopedic traumas.
The worst type of arterial injury.
Diagnosis:
Late occurrence of limb ischemia.
Causes:
• Intimal tear (with false lumen formation).

• Intimal flap.
• Vessel wall hematoma.
Investigations:
Hard signs often required urgent surgical exploration without prior investigations.
Indications:
1. To exclude injury in patient without hard signs (equivocal signs) but with strong
suspicion of vascular injury.
2. To prevent unnecessary surgery.
3. To know the site & extent of injury.
• Arteriography (the most important).
• Doppler US.
Treatment of arterial injury

Often requires a multidisciplinary approach with orthopedic and plastic surgeons.
Aims of surgery are to:
1- Control life threatening conditions.
2- Control Hemorrhage.
3- Prevent limb ischemia.
If surgery is delayed more than 6 hours (in the upper limb) or 4 hours (in the lower
limb), revascularization is unlikely to be successful.
Sequelae...
• Hyper-acute metabolic acidosis.
• Crush syndrome (acute renal shutdown). |Page3
Stop the bleeding: (Dr. Alaa kassar)
1. By applying direct digital or hand pressure.
2. By compression dressing.
Never apply tourniquet???

✓ It will occlude the collaterals reducing the time required for ischemia to occur.
✓ It will occlude the venous return.
Never clamp an artery blindly???
✓ May convert the partial injury into a complete one.

✓ May injure another vessel (artery or vein).
Never expose the site of the injury (unless resuscitating the patient)???
✓ May result in severe bleeding and shock.
Primary amputation: “Life-saving” Usually considered in two situations:
1- Sever injury with significant risk of reperfusion injury (Deadly).

2- The limb is likely to be painful and useless (Dead loss).
Vascular repair (Revascularization) “Limb-saving”

Options include:
1. Simple suture of puncture or laceration “Suturing: in-out”.
2. Vein patch angioplasty (large laceration).
3. Resection and end to end anastomosis.
4. Interpositional graft:
• Contralateral saphenous vein (the ideal interpositional graft).
• Prosthetic graft (Dacron or gortex, poly-tetra chloro ethylene “PTCE”) may be used (if
poor vein or bilateral limb trauma).
Pre-requisites prior to resection and anastomosis or grafting:

• IV heparin 5000 IU.
• Irrigation catheter, 500 cc NS & 5000 IU heparin in pulsatile manner (distal
segment).
• Fogarty catheter, for embolectomy.
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• Why Contralateral saphenous vein???
The presence of associated injuries causes prolonged immobility, risk of DVT, with
resulting return of venous blood through the superficial veins….so if removed there will
be venous gangrene.
• The use of arterial shunts is controversial (during the period of orthopedic

repair) but the priority to the vascular repair. May reduce ischemic time and allow
early fixation of fracture.
Complications of vascular injury

1. False aneurysm:
Most commonly occurring following catheterization of femoral artery (after more than 72
hrs).
Diagnosis:
1. Pain due to stretch on nerve.
2. Bruising.
3. Pulsatile swelling.
Diagnosis can be confirmed by Doppler ultrasound or angiography.
Treatment: excision of the false aneurysm with suturing of puncture site or vein patching or
resection and end to end anastomosing or graft.
2. Arteriovenous fistula:
Often present several weeks following the injury.
Diagnosis:
1. Swollen limb with dilated superficial veins.
2. Machinery type bruit (present throughout cardiac cycle) (beneficial for localization).
Diagnosis can be confirmed by angiography.
Treatment:
• Fistula can be divided and both the vein and the artery sutured.
• Flap of fascia can be interposed between vessels to reduce risk of recurrence of fistula
at the site of suturing.
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3. Limb ischemia and amputation.
4. Death.
Fasciotomy:
By making a small skin incision and then dividing the fascia by inserting a scissor.
(Decreases the risk of infection and large scar formation).
Indications:
1. Suspected compartment syndrome (clinically, swelling, hard limb with absent distal
pulses).
2. Pressure more than 30-35 mmHg.
3. Prolong period of shock.
4. Prolong period of arterial occlusion and ischemia.
5. Combined arterial – venous injury.
6. Need Arterial or vein ligation.
7. Massive crush injury.
***Important questions (Dr. Alaa Kassar)

How to stop the bleeding?
How to diagnose arterial injury?
How to know the type of arterial injury?
Edited By: Ali Abdul-JaleeL Noori
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Vascular “Arterial” trauma Dr.

Types of vascular injury

Management 1. Completely-severed artery.

• Arterial bleeding is profuse, pulsatile, bright-red colored, and site of injury.

1. Continuous profuse bleeding.

1. Pulsatile, expanding hematoma.

The worst type of arterial injury.

Late occurrence of limb ischemia.

• Intimal tear (with false lumen formation).

Treatment of arterial injury

Never apply tourniquet???

✓ May convert the partial injury into a complete one.

✓ May result in severe bleeding and shock.

Primary amputation: “Life-saving” Usually considered in two situations:

1- Sever injury with significant risk of reperfusion injury (Deadly).

Vascular repair (Revascularization) “Limb-saving”

Pre-requisites prior to resection and anastomosis or grafting:

• The use of arterial shunts is controversial (during the period of orthopedic

Complications of vascular injury

***Important questions (Dr. Alaa Kassar)

Edited By: Ali Abdul-JaleeL Noori

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