Vascular injury

Background

Types

• Complete Occlusive
  • Transection
  • Thrombosis
  • Embolism
  • Reversible spasm
• Non-occlusive
  • Lacerations
  • Intimal flaps
  • Pseudoaneurysm
  • A/V fistula
  • Compartment syndrome

Occult UE Vascular injury

• Clavicle fracture/1st rib => subclavian artery
• Anterior shoulder dislocation => axillary artery
• Proximal humerus fracture => axillary artery
• Humeral shaft fracture => brachial artery
• Elbow dislocation => brachial artery

Clinical Features

Hard signs

• Absent distal pulses
• Signs of distal ischemia
  • Pain, pallor, paresthesia, paralysis, poikilothermia
• Audible bruit or palpable thrill at injury site
• Active pulsatile hem
• Large expanding hematoma
• Pulsatile hematoma

Soft Signs

• Small nonexpanding hematoma
• Peripheral nerve deficit
• Hx of pulsatile or significant hemorrhage at time of injury
• Unexplained hypotension
• Bony injury (fx, dislocation, penetration) or proximity penetrating wound

Diagnosis

Arterial Pressure Index (API)

• Doppler-determined arterial sys BP in injured limb divided by pressure in uninjured limb
  • <0.90 abnormal
  • Allows for serial, objective monitoring
  • Only detects obstructive lesions
  • unreliable in proximal injuries, popliteal injuries, shotgun wounds, multiple wounds, shock
  • false negative with deep femoral artery injury

Duplex Doppler

• S 95-100%; Sp 97-100%; Acc 98-100%
• Sens for vessel injury, thrombosis, pseudoaneurysm, intimal flap and A-V fistula

Management

Hard (>90% risk of arterial injury; 50% require intervention)

• Immediate arterial exploration without further investigation

Soft (30% risk of arterial injury)

• API --> if < 0.9 obs/admit for 24h, serial API, consider:
  • Doppler U/S
  • CTA
  • Eval of compartment syndrome

Prognosis

Warm Ischemia Time

• 6 hours (10% irreversible damage)
• 12 hours (90% irreversible damage)

See Also

• Acute Arterial Occlusion
• Angiogram Complication