Penetrating Lower Extremity Arterial Trauma, Evaluation and Management of

Published 2012

Level 1

  1. Computed tomographic angiography (CTA) may be used as the primary diagnostic study for evaluation of penetrating lower extremity vascular injury when imaging is required.

Level 2

  1. 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 asociated skeletal or shotgun injury. Restoration of perfusion to an extremity with an arterial injury should be performed in less than 6 hours to maximize limb salvage (2002).
  2. Patients (without hard signs of vascular injury) who have abnormal physical examination findings and/or an Ankle-Brachial Index (ABI) < 0.9 should have further evaluation to rule out vascular injury.
  3. Patients with normal physical examination findings and an ABI > 0.9 may be discharged (in the absence of other injuries requiring admission).

Level 3

  1. In cases of hemorrhage from penetrating lower extremity trauma in which manual compression is unsuccessful, tourniquets may be used as a temporary adjunct for hemorrhage control until definitive repair.
  2. The use of temporary intravascular shunts (TIVSs) may be indicated to restore arterial flow in combined vascular/orthopedic injuries (Gustillo IIIC fractures) to facilitate limb perfusion during orthopedic stabilization.
  3. TIVSs may be indicated in “damage control” situations to facilitate limb perfusion when the physiologic status of the patient or operative capabilities prevent definitive repair.
  4. There are no data to support the routine use of endovascular therapies following infrainguinal trauma.
  5. Embolization of profunda branches or tibial vessels is acceptable, and there are no data to support preferential use of coils or n-butyl-2-cyanoacrylate (NCBA) glue.
  6. The role of noninvasive Doppler pressure monitoring or duplex ultrasonography to confirm or exclude arterial injury is not well defined. There may be a role for these studies in patients with soft signs of vascular injury or with proximity injuries (2002).
  7. Nonoperative observation of asymptomatic nonocclusive arterial injuries is acceptable (2002).
  8. Repair of occult and asymptomatic nonocclusive arterial injuries managed nonoperatively that subsequently require repair can be done without significant increase in morbidity (2002).
  9. Simple arterial repairs fare better than grafts. If complex repair is required, vein grafts seem to be the best choice. PTFE, however, is also an acceptable conduit (2002).
  10. PTFE may be used in a contaminated field. Effort should be made to obtain soft tissue coverage (2002).
  11. Tibial vessels may be ligated if there is documented flow distally (2002).
  12. 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 (2002).
  13. Arteriography for proximity is indicated only in patients with shotgun injuries (2002).
  14. Completion arteriogram should be performed after arterial repair (2002).