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15Lower Extremity Vascular TraumaNEIL G. KUMAR, BRIAN S. KNIPP,
AND DAVID L. GILLESPIE
IntroductionVascular injury to the lower extremity is a common
pattern of vascular trauma. Injuries to junctional zone vessels are
espe-cially challenging and potentially lethal. Foremost, injury to
the distal iliac and proximal femoral arteries and veins poses a
challenge with hemorrhage control. The term junctional vascular
injury was a product of the militarys recognition during the wars
in Afghanistan and Iraq that, although tour-niquets were effective
in controlling lower extremity hemor-rhage, they did not work if
the penetrating wounds were too proximal on the lower extremity
(i.e., the junctional zone between the torso and the lower
extremity). Furthermore, injury to the distal iliac and proximal
femoral arteries result-ing in hemorrhage is often very difficult
for a medic or bystander to control with manual pressure because
the vessels are either large or deep under the inguinal ligament
and the distal pelvic outlet. Because of this injury patterns
propensity for exsanguinating hemorrhage, the military has coined
the term junctional lower extremity vascular injury to facilitate
study and to improve management strategies. More distal injuries
such as those to the femoral, popliteal, and tibial seg-ments may
also lead to lethal hemorrhage; but from a practical standpoint
these injuries are amenable to tourniquet control. Lower extremity
vascular trauma at any anatomic level poses challenges not only
related to control of bleeding but also with regard to decisions
related to restoration of perfusion and reconstruction of the
vascular injury.
History and BackgroundWhen considering those who died of combat
wounds from 2001 to 2009, nearly 41% had potentially survivable
injuries if hemorrhage had been controlled in a more prompt and
effective manner.1 In this context, potentially survivable death
means mortality that occurred in the absence of a lethal head or
cardiac wound or body disruption from explosive injury. The body
regions accounting for death with otherwise surviv-able injuries
include trauma to the torso (48%), to the extrem-ities (31%), and
to the junctional region (21%). Table 15-1 shows the incidence of
lower extremity vascular injury in mili-tary conflicts, past and
present. The rate of exsanguination from torso trauma has decreased
over the years possibly due to the use of body armor. Similarly,
the rate of extremity hemorrhage has decreased likely due to the
broad distribution, training, and use of tourniquets.2-4 With
improvements in body armor, which protects from central torso
trauma, injury to the extremity vessels has contributed a larger
percentage of
overall vascular injuries. Lower extremity vascular injuries
will likely continue to be common due to practical limitations
associated with extremity and junctional zone armor.5
Lower extremity vascular injury is also common in the civilian
setting where injuries to the iliac artery and vein have a higher
incidence than in the military setting. Mattox et al documented 232
iliac artery injuries and 289 vein injuries, representing 4% and
5%, respectively, of all vascular injuries in a single-center
civilian registry.13 Femoral and popliteal vessel injuries are more
common than iliac vessel injuries in civilian trauma centers, which
likely reflects their longer extent and exposed position. In a
report by Branco et al femoral vessel injury comprised
approximately 25% of all extremity vascular injuries.14
Comparatively, Asensio et al reported femoral vessel injuries to be
even more common, accounting for nearly 70% of peripheral vascular
injuries.15 However, in isolated lower extremity trauma, the most
commonly injured artery is the popliteal, with the majority of
injuries resulting from blunt mechanism.16 Blunt injuries are more
likely to be associated with orthopedic fractures or dislocations
and likely to result in longer hospital stays and higher rates of
amputa-tion than other lower forms of extremity arterial
injury.17
Similarly, the number of tibial artery injuries and the
pro-portion of all vascular injuries they represent have increased
in the past number of years. A recent single institution study of
lower extremity vascular trauma reported that the tibial arteries
were the most commonly injured vessels and accounted for 36% of
cases. The most common mechanism of tibial artery injury is gunshot
wound (37%) with motor-vehicle accidents (26%) contributing a
significant portion as well.13,18
Presentation and DiagnosisAssessment of a patient with a
potential lower extremity injury or a junctional zone vascular
injury follows a standard approach outlined in the Advanced Trauma
Life Support (ATLS) program developed by the American College of
Sur-geons (ACS) and its Committee on Trauma (COT).19 Fore-most,
control of bleeding with a tourniquet or manual pressure is
necessary to prevent exsanguination. Depending on the location, if
a standard Combat Application Tourniquet (C-A-T North American
Rescue, LLC, Greer, SC) is not available, a manual blood pressure
cuff may be inflated proximal to the injury to act as a tourniquet
to control bleeding. As described, the vexing problem lies with
junctional vascular injuries which are not amenable to tourniquet
application and are difficult to control with manual pressure. In
these instances, manual pressure with or without a topical
hemostatic agent such as
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15 / LowER ExtREMIty VAScULAR tRAUMA 168.e1
ABSTRACTVascular trauma of the lower extremities is associated
with high rates of morbidity and mortality and is especially
chal-lenging when it involves the junctional zone between the torso
and the lower extremities. Lower extremity junctional injuries are
those that occur to the distal iliac and proximal femoral vessels.
In the absence of hard signs of injury, lower extremity junctional
vascular trauma may be challenging to diagnose; and, in the
presence of hard signs, they may be hard to control, expose, and
repair. the successful man-agement of lower extremity vascular
injury is dependent on early diagnosis and control of hemorrhage,
resuscitation of the patient, and prompt intervention to minimize
associ-ated ischemia. the most important factors in life- and
limb-saving interventions relate to prompt control of hemorrhage
and time to reperfusion in the setting of ischemia. the anatomic
level of lower extremity vascular injury (iliac-femoral,
femoral-popliteal, tibial), the severity of the mangled extremity,
and the presence of associated injuries are also important factors
influencing patient outcomes.
KeyWords: lower extremity trauma, mangled extremity, tourniquet,
vascular shunt, venous injury, arterial injury, amputation
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15 / LowER ExtREMIty VAScULAR tRAUMA 169
setting of trauma and because the comparison may be between the
occlusion pressure in an injured upper extremity to that in the
noninjured upper extremity, this ratio is also referred to as the
IEI. In the absence of vascular injury, the ratio of the occlusion
pressures between the injured and noninjured extremities should be
0.9 or greater. An IEI of less than 0.9, especially in a patient
with a normal contralateral IEI, indi-cates a flow-limiting
abnormality and has been shown to cor-relate with identifiable
arterial injury.
Importantly, the IEI should be repeated in patients who are
hypothermic and/or hypotensive as these factors may result in
initial false negative ratios. The IEI should also be repeated in
patients who have an extremity fracture or dislocation after the
orthopedic injury has been reduced or aligned with trac-tion. In
patients with these types of extremity injuries, the Doppler signal
and therefore the IEI may improve with resus-citation, warming, and
fracture reduction. However, an IEI that is persistently less than
0.9 should be considered to indi-cate arterial injury, and one
should pursue further imaging or operative exploration. In most
cases in which there are soft signs of vascular injury and a
persistently diminished IEI further diagnostic imaging such as
duplex ultrasound, CTA, or conventional arteriography is
performed.20-23 In complex cases, arteriography should be performed
in the operating room (OR) using a mobile or fixed fluoroscopic
imaging system to provide access to all options including
definitive operative exploration if necessary. In cases of
extremity frac-ture or dislocation, performance of arteriography in
the OR may be combined with procedures such as fracture reduction
or fixation.
JunctionalDistalIliacandProximalFemoralInjuries
Injury to the external iliac vessels should be suspected in all
penetrating injuries to the junctional zone including wounds to the
lower quadrants of the abdomen, hips, buttocks, and groins (Fig.
15-1). Symptoms of iliac vessel injury are the same as those to the
more commonly recognized lower extremity vessels but may also
include abdominal distension, evidence of bowel injury (e.g.,
rectal blood), or a suggestion of genito-urinary injury (e.g.,
hematuria, blood in the vagina or at the
Combat Gauze (Z-Medica Corporation, Wallingford, CT) and rapid
operative control may be necessary.
In the absence of significant hemorrhage, one has time to
examine the lower extremity including assessing the femoral,
popliteal, and pedal pulses. Palpation in the resuscitation room or
intensive care unit is subjective and prone to false positive or
negative recordings, and this portion of the exami-nation should be
augmented with continuous-wave Doppler. The utility of Doppler
ultrasound in the diagnosis of extrem-ity vascular injury is
detailed in Chapter 5 of this textbook. At the time of palpation of
pulses, the injured lower extremity should be assessed for hard or
soft vascular injury. Hard signs are grouped as clear or obvious
indicators of blood vessel disruption or occlusion and include
pulsatile bleeding, expanding hematoma, palpable thrill, audible
bruit or pro-found ischemia distal to the point of injury. Soft
signs are suggestive of vascular injury but less obvious. These
include reports of bleeding at the scene of injury, the presence of
a peripheral nerve deficit, an injury pattern (including long-bone
fracture or dislocation, indicative of vascular compro-mise), and
injury in close proximity to a main or axial extremity vessel.
In nearly all cases, the presence of hard signs of extremity
vascular injury indicates the need for prompt operative
inter-vention. In the presence of confounding factors such as
pen-etrating wounds to multiple levels of the lower extremity,
arteriography or other imaging such as duplex or computed
tomographic angiography (CTA) may be appropriate even in the
setting of hard signs. In the presence of soft signs of vas-cular
injury, using the continuous-wave Doppler to calculate the injured
extremity index (IEI) is necessary. Initially, the quality of the
audible arterial signal in the distal aspect of the injured
extremity (wrist, ankle and foot) gives the examiner information
regarding the nature of perfusion to the limb. For example, a
strong, clearly audible, bi- or triphasic arterial signal is
typically normal and noticeably different than a weak monophasic
signal, which may be an indicator of vascular injury. However, the
quality of the audible signal is also some-what subjective and may
be influenced by a patient who is cold and hypotensive. A more
objective modality using the continuous-wave Doppler and a manual
blood pressure cuff is the IEI.
The IEI is a measure of the arterial occlusion pressure of the
audible Doppler signal in the distal aspect of the injured limb
compared to the occlusion pressure in one of the other noninjured
extremities. This measurement or ratio is the same as the
ankle-brachial index (ABI) that is used in the diagnosis of
arterial occlusive disease in the lower extremity. In the
FIGURE 15-1 Junctional zone penetrating injury with concomitant
bowel injury.
Table 15-1 Incidence of Lower Extremity Vascular Injury
WarIliacVessels
FemoralVessels
PoplitealVessels
TibialVessels
world war I 1% 35% 12% 11%world war II 2% 21% 20% 20%Korean war
2% 31% 26% 18%Vietnam war 3% 35% 22% 0%Iraq and Afghanistan
2% 28% 9% 10%
Data compiled from the following references 5-12.
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170 SEctIoN 3 / DEFINItIVE MANAGEMENt
it may not be possible to determine the location of operation
without contrast imaging. Physical examination alone has been shown
to be associated with a false positive rate as high as 87%.26 The
amputation rate for patients with blunt extrem-ity trauma has been
reported to be extremely high due to missed injuries. Surgeons must
maintain a high index of sus-picion for popliteal artery injuries
in any patient with anterior or posterior knee dislocations, distal
femur fractures or tibial plateau fractures. In some situations,
the diagnostic adjunct of intraoperative arteriography may reduce
the rate of nega-tive surgical exploration.25 Recent studies
support a practice of selective arteriography and operative
exploration based on IEI, duplex ultrasound, and CTA. The uses of
this strategy contrast arteriography and operative exploration are
reserved for instances in which one or more of these noninvasive
modalities are abnormal. This selective approach to arteriog-raphy
and operation for posterior knee dislocation has been shown to be
safe and effective and has reduced the rate of negative or
nontherapeutic exploration (Figs. 15-2 and Fig. 15-3).27
TibialLevelInjuries
The redundant nature of perfusion to the ankle and foot through
three tibial arteries (anterior, posterior, and peroneal) means
that vascular trauma at this level is better tolerated than that to
more proximal levels of the lower extremity. In order for
limb-threatening ischemia to result from trauma at this level, all
three tibial vessels must be disrupted which is uncom-mon. In the
civilian setting, patients with penetrating injuries to the leg
(i.e., below the knee) have been shown to be less likely to present
with signs of ischemia than those with blunt
penile meatus). In the setting of penetrating lower abdominal or
pelvic injury, the absence of femoral pulse(s) or a discrep-ancy
between the femoral pulses should alert the provider to the
likelihood of an iliac artery injury.
The soft sign of a junctional vascular injury may initially be
proximity of a lower abdominal or pelvic wound to the external
iliac vessels. In these cases, the provider must have a high index
of suspicion to pursue additional imaging or oper-ative
exploration.24 Further imaging is not generally indicated in
patients who are hemodynamically unstable with penetrat-ing lower
abdominal or pelvic injury. Instead, these patients should be
managed with operative exploration in conjunction with balanced,
blood component-based resuscitation. In cases of penetrating lower
abdominal trauma, exploration will require exploratory laparotomy
to achieve vascular control and hemostasis. If patients with lower
abdominal or pelvic injuries are hemodynamically normal, further
imaging is useful and can include plain radiographs of the abdomen
and pelvis followed by CTA. In addition to providing detail
regard-ing intraabdominal and retroperitoneal structures and pelvic
fracture, CTA may demonstrate contrast extravasation from or
occlusion of an iliac or proximal femoral vessel. In these
instances, CTA provides a quick and detailed assessment of injury
allowing for better operative planning including the sequence of
steps and the selective use of endovascular techniques.
In contrast to penetrating trauma, iliac injury from blunt
mechanisms often presents with more gradual, insidious blood loss.
If the patient has an unstable pelvic fracture, early application
of a pelvic sheet or binder is indicated and should precede
additional diagnostic workup. Early application of a binder around
the pelvis is especially useful in controlling venous bleeding
associated with complex pelvic fractures and works by stabilizing
the fracture and inducing tamponade. In some instances of pelvic
fracture with hemodynamic instabil-ity, arteriography with the
option of embolization of bleeding is helpful. This is especially
true if contrast extravasation is observed from a branch or
branches of the internal iliac arter-ies on the initial CTA.
Increasingly, embolization of bleeding vessels can be pursued in an
endovascular OR that is able to accommodate catheter-based
procedures as well as traditional open operations.
FemoralandPoplitealInjuries
Patients with femoral or popliteal vascular trauma may present
with hard or soft signs of injury. However, experience shows that
most injuries in this location are accompanied by hemor-rhage
and/or ischemia at some point following the event.15 In some cases,
limb-threatening complications may result from overlooking or
missing the hard signs of vascular injury because the active
bleeding will have stopped or the degree of ischemia will be
incomplete.25 Although most cases of femoral or popliteal trauma
with hard signs require prompt operative intervention, contrast
arteriography or CTA may be useful in more complex scenarios. In
cases of mangled lower extremity with vascular and orthopedic
components, the location of fracture(s) and vascular injury may be
best determined with arteriography or CTA. Management of the
extremity with multiple penetrating wounds at different levels of
the limb may also be aided with arteriography and/or CTA before
oper-ation. In these cases although hard signs of bleeding and/or
ischemia may be present, the level of the injury and therefore
FIGURE 15-2 computed tomography yielding diagnostic informa-tion
regarding vascular status in light of significant potential
artifacts.
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15 / LowER ExtREMIty VAScULAR tRAUMA 171
metallic fragments may cause artifacts, which make
interpre-tation of the adjacent vessels difficult. However, even in
the presence of metallic artifact, MDCTA often provides impor-tant
diagnostic information (Fig. 15-4). Inaba et al provided an
important study of MDCTA and showed its value in man-aging severe
lower extremity injury. In their study, only 1 of 63 scans was
indeterminate due to retained metallic artifact; and the rest
provided elements of important diagnostic infor-mation helping
guide management. Furthermore, in their clinical series, three
injuries distal to the knee were evaluated by conventional
arteriography after MDCTA, and in all cases the arteriogram
confirmed MDCTA providing no additional information. Moreover, in
White et als analysis of MDCTA in the evaluation of vascular
trauma, additional benefits were delineated. In this study,
multiple extremities (i.e., simultane-ous) were evaluated in 15 of
20 CT studies. Most commonly, this meant both lower extremities
were evaluated with one study, but an upper and a lower extremity
could be evaluated simultaneously as well. This study also
demonstrated that MDCTA was diagnostic in the presence of retained
metallic fragments. Finally, the study by White and colleagues
showed that MDCTA also provided useful diagnostic information in 8
of 10 patients with external fixator devices or intramedullary
nails in place. Together, these experiences confirmed that MDCTA is
a useful diagnostic option to detect vascular injury when one has a
high index of suspicion, even in the absence of hard signs or a
normal IEI examination.21,28
JunctionalDistalIliacandProximalFemoralInjuries
As stated previously, control of hemorrhage from junctional
injuries can be difficult and must first be managed with direct
compression. Operative exposure and/or control of junctional
vascular injuries typically requires either an inguinal or a
transplant incision (Fig. 15-5) to gain access to the external
iliac artery and vein. Once exposed, the common or external iliac
or common femoral arteries can be controlled using vas-cular
clamps. Additional techniques and devices to rapidly apply pressure
to junctional vascular injuries in the pre- and out-of-hospital
settings have been developed including the Combat Ready Clamp
(CRoC; Combat Medical Systems,
trauma (33% vs. 68%, respectively). This observation may be
partly due to the redundant nature of perfusion and the fact that
penetrating wounds are less likely to affect all of the tibial
arteries. In contrast, blunt trauma to the leg often results in
complex tibia and fibula fractures (i.e., Gustillo fractures) which
are more prone to injure all of the tibial arteries and result in
ischemia.27 Studies have shown that when tibial vessels are injured
by blunt mechanisms, they injuries are almost always associated
with a fracture (97%). Blunt mecha-nisms leading to tibial vascular
trauma may also result in open fractures with soft-tissue injuries
(59% of cases) and periph-eral nerve injuries (53% of cases). Less
commonly, penetrating trauma leading to tibial vascular injury is
associated with frac-ture (31% of cases), soft-tissue injury (6% of
cases), and nerve dysfunction (20% of cases).27 Like the diagnosis
of popliteal artery injury, imaging of the tibial vessels should be
performed selectively. In most cases, contrast arteriography and/or
explo-ration of the tibial arteries is reserved for patients with
persis-tent signs of ischemia such as a diminished IEI (
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172 SEctIoN 3 / DEFINItIVE MANAGEMENt
second tourniquet should be applied to increase the effective
tourniquet width. Kragh and others from the United States Army
Institute of Surgical Research reported that the applica-tion and
use of tourniquets to control extremity bleeding before the onset
of shock resulted in lower mortality than application of
tourniquets after the onset of hemodynamic instability.2-4 The
importance of the proper application of the tourniquet cannot be
overemphasized as incorrect placement is associated with mortality
from hemorrhage. In addition to their effectiveness, properly
applied tourniquets are safe. In a clinical series of 428
tourniquets applied on 309 severely injury limbs, the incidence of
nerve palsy was 1.7%. There was no association with vascular
thrombosis, myonecrosis, rigor, pain, fasciotomy, or renal
failure.3 It is important to under-stand the success of tourniquets
in the wars in Afghanistan and Iraq in the context of short medical
evacuation and there-fore relatively short tourniquet times.
Reports from those wars and clinical experience of the editors
suggest that the vast majority of tourniquets applied during the
wars in Afghani-stan and Iraq were in place for 2 hours or less.
Clearly tour-niquet application and the potential adverse effects
of complete limb ischemia for longer periods of time in future
military or civilian scenarios will need to be reappraised.
TibialLevelInjuries
Tibial vascular injury may be the result of penetrating or blunt
trauma and is most commonly associated with fracture of the tibia
or fibula.27 The order or priority of injury management in these
cases is dictated by the presence or absence of hemor-rhage and/or
complete ischemia. In cases in which control of bleeding is
difficult, exploration of the vascular injury with ligation of the
vessel or placement of a temporary vascular shunt may be necessary
before fracture reduction and stabili-zation. The same is true in
some cases in which there is com-plete ischemia (i.e., no audible
Doppler signal) of the leg below the injury. However, in most
instances, fracture reduc-tion or traction and stabilization can be
performed promptly and results in restoration of perfusion to the
leg and foot. If evidence of arterial ischemia persists (i.e., IEI
less than 0.9) after maneuvers to reduce and stabilize the
fracture, further diagnostic evaluation such as CTA or
arteriography may be required. Alternativelyand especially in the
setting of open,
Fayetteville, NC) and the Junctional Emergency Treatment Tool
(JETT; North American Rescue, Greer, SC). These devices are
designed to be placed on the patient by initial responders in the
tactical environment (e.g., Tactical Combat Casualty Care) and
include mechanical properties that allow compres-sion of the distal
external iliac and proximal femoral vessels. The utility of the
CRoC, JETT, and other emerging adjuncts to control junctional
vascular injury has not been fully evalu-ated. However, promising
reports on their efficacy have been registered from the terminal
stages of the war in Afghanistan and anecdotal cases of civilian
trauma. Despite successes asso-ciated with the development of a
small number of junctional hemorrhage control devices, further
research is needed to develop approaches or tools to control
noncompressible torso and junctional hemorrhage at the point of
injury and in the acute, out-of-hospital phase of care.
FemoralandPoplitealInjuries
In the case of extremity trauma, hemorrhage control strategies
including tourniquets and topical hemostatic agents have been
successfully codified in the Committee on Tactical Combat Casualty
Cares (TCCCs) PreHospital Trauma Life Support (PHTLS) manual.29,30
Considerable detail on the con-tributions of the TCCC and the PHTLS
manual is provided in the Chapter 15 of this textbook. The TCCC
guidelines emphasize three objectives: Treat the patient, prevent
addi-tional casualties, and complete the mission. Advances in the
prehospital care of those with femoral and popliteal vascular
trauma put forth by the TCCC include prompt hemorrhage control,
establishment of intravenous or intraosseus access, and use of
fluid resuscitation in only those patients who are in shock.
Training and adherence to these and other PHTLS guidelines has been
shown by Kotwal and colleagues to reduce preventable death in
wounded service personnel.2
If extremity hemorrhage cannot be controlled with direct
pressure, prompt application of a tourniquet should be per-formed.
Tightening of the tourniquet should continue until arterial
bleeding from the limb has stopped or until distal pulses are no
longer palpable (Fig. 15-6). If a single tourniquet is not
successful in controlling extremity hemorrhage, a
FIGURE 15-5 Bilateral tourniquets applied allowing transport for
definitive surgical repair. the application of tourniquets prevents
death from hemorrhage.
FIGURE 15-6 Posterior knee dislocation.
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15 / LowER ExtREMIty VAScULAR tRAUMA 173
Operative Strategy and TechniquePreparation begins with
expeditious transport of the patient to the OR, because longer
ischemic time is associated with higher amputation rates and poorer
neuromuscular recovery. The surgical scrub and draping of the
patient should be from the umbilicus to the toes of both lower
extremities. Preparing the operative field to include the umbilicus
and lower abdomen allows for retroperitoneal exposure and control
of the iliac vessels if needed. Preparation of the contralateral
lower extremity allows one to use saphenous vein from the
nonin-jured extremity as conduit for vascular reconstruction if
needed. Also, access to the contralateral femoral artery may be
useful to perform percutaneous, transluminal arteriography of the
injured lower extremity either as a pre- or completion step using
an up and over approach. In rare cases, having access to the
contralateral femoral artery can be useful as a source of inflow
(i.e., cross femoral bypass) for complex femoral or distal iliac
artery injuries.
Regardless of anatomic level, lower extremity vascular
reconstruction begins with exposure of the injured segment.
Depending on the experience of the surgeon and the anatomic
location of the injury, this may be preceded by obtaining remote
proximal arterial control. Frequently junctional or proximal
femoral vascular injuries require control at an unin-jured segment
such as the iliac artery through a retroperito-neal exposure.
Injuries in the popliteal fossa and those at the tibial
trifurcation may also benefit from inflow control at a proximal,
uninjured segment. In contrast, superficial femoral injuries in the
thigh and those below the tibial trifurcation can often be
controlled by extending any penetrating wounds and exploring the
injured area directly.
Once the injured segment of vessel(s) has been exposed and
controlled, assessment should be made as to the extent of injury
and adequacy of distal perfusion. The later aspect of this
assessment is greatly aided by use of the continuous-wave Doppler
machine in the OR. The spectrum of vascular trauma ranges from
vessel contusion with degrees of thrombosis to transection with a
missing segment. In considering manage-ment strategies, one must
remember that ligation is a viable option in many scenarios. In
other words management of lower extremity vascular trauma does not
always require vas-cular reconstruction and restoration of flow
through the injured segment. For example, injury of a tibial artery
or a branch of the superficial femoral or profunda femorus arteries
can often be ligated without compromising viability of the
extremity. In these instances, redundant or collateral circula-tion
often exists, which will keep the limb viable, even with a degree
of ischemia, without repair of the injured vessel. Viabil-ity in
these scenarios is most reliably predicted by assessment of
capillary refill and with the presence of an arterial Doppler
signal distal to the injury. Vessel ligation, with or without
primary amputation, may also be a prudent damage control option in
patients with a severely mangled extremity or those with a
constellation of other life-threatening injuries or physi-ology. In
these damage control scenarios, viability of the limb may not be of
as much concern because amputation is accepted as a necessity to
save the individuals life.
If reconstruction of lower extremity vascular injury is planned,
standard operative techniques should be used regard-less of
anatomic level. The nature of vascular trauma means that the use of
systemic heparin as an anticoagulant must
penetrating woundsthe tibial vessel(s) can be explored and
evaluated, directly obviating the need for additional imaging (Fig.
15-7).
Helpful Considerations to Avoid Pitfalls
Evaluation and diagnosis of the injured lower extremity should
be preceded by hemorrhage control, initiation of resuscitation, and
evaluation of life-threatening injuries.
Junctional vascular injury carries a high mortality and must be
considered in the setting of lower abdominal, pelvic, peroneal, and
buttock wounds.
Control of hemorrhage from proximal and junctional lower
extremity trauma may be difficult to obtain using direct manual
pressure and tourniquets.
Physical examination of the injured and noninjured lower
extremity should be performed using continuous-wave Doppler to
improve sensitivity.
CT angiography is a useful diagnostic adjunct, especially in
patients with soft signs of lower extremity vascular trauma and who
require CT imaging of the torso or head.
The anterior compartment of the leg is the most com-monly
neglected compartment in the performance of lower extremity
fasciotomy. Care must be taken to ensure that this compartment is
identified separately from the lateral compartment through the
lateral leg incision. Opening of the anterior compartment exposes
the muscles and anterior neuromuscular bundle, as well as the
intermuscular septum, which separates the anterior and the lateral
compartments. Both sides of this septum should be visualized
assuring that both the anterior and the lateral compartments have
been opened widely.
FIGURE 15-7 transplant incision allowing rapid exposure of the
iliac artery and vein. the artery is being mobilized using a vessel
loop to explore the iliac vein for bleeding. (Courtesy Dr.
Christopher T. Barry.)
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174 SEctIoN 3 / DEFINItIVE MANAGEMENt
not be narrowed with this approach. In most instances of
extremity trauma, this type of lateral wall repair is not possible
because the vessels are small by nature. If 50% or more of the
vessel wall is uninjured, patch angioplasty using autologous vein
or other synthetic material may be an option to allow repair and to
prevent narrowing of the lumen. End-to-end anastomosis is another
form of primary repair that can be used if the vessel is transected
sharply. In order for primary, end-to-end repair to be possible,
the vessel must approximate without tension (i.e., tension-free)
after dbridement of the edges has taken place. Because extremity
vessels are elastic and frequently spasm and retract in the setting
of trauma, it is the exception that the edges will come together in
a satisfactory manner. In these cases and in those where a segment
of vessel has been transected with a missing segment, performance
of an interposition graft is required. It is the authors and
editors experience that most cases of significant extremity
vascular injury and especially injury from penetrating gunshot or
explosive mechanisms requires vessel resection and use of an
interposition graft.
Reversed saphenous vein is generally preferred as the conduit in
instances where an interposition graft is required. Autologous vein
is especially recommended in contaminated cases such as those with
an open or penetrating mechanism. Synthetic conduit such as
expanded polytetrafluoroethylene (ePTFE) or polyester (Dacron) may
also be used for larger vessel (i.e., proximal) extremity vascular
injury and may be preferred because of size match with the injured
vessel. Expe-rience from the wars in Afghanistan and Iraq has
demon-strated the effectiveness of saphenous vein as the conduit of
choice for lower extremity vascular trauma. However, this same
experience has highlighted challenges associated with the
dismounted complex blast injury pattern that often results in one
or more severely mangled lower extremities. In these cases, most if
not all of the saphenous vein is injured or absent and therefore is
not able to be used as conduit. In these sce-narios, creative use
of temporary vascular shunts or synthetic conduits has been shown
to be effective in the short term and midterm. In review of combat
related registries, ePTFE grafts were used in 14 of 95 patients
with complex lower extremity blast injury undergoing extremity
vascular repair. Seventy-nine percent of these remained patent long
enough to allow the patient to be stabilized and to be evacuated to
a level 5 facility in the United States. In many instances, the
patient then underwent a more deliberate evaluation, reoperation,
and resection of the synthetic conduit in favor of remaining
autologous vein. Importantly, in this experience there were no
short- or midterm prosthetic graft disruptions, amputations, or
deaths due to graft failure confirming the utility of this damage
control approach (i.e., prosthetic first followed by resection and
use of vein later) in select injury patterns.31 Extraanatomic
bypass using synthetic conduit routed remotely from the zone of
injury should also be considered in some injury patterns in which
in-situ vein interposition graft place-ment is not possible.32
Considerations for Extremity Venous InjuryThe management of
extremity vein injury proceeds along similar lines as those for
arterial injury with the options being repair and restoration of
venous outflow versus ligation.
occur on a selective and sometimes partial basis. In instances
of isolated lower extremity vascular trauma with limited
soft-tissue damage, use of full-dose heparin before and during the
vascular reconstruction is often possible. In contrast, patients
with lower extremity vascular trauma who also have torso or head
injuries or larger, complex soft-tissue wounds are not able to
receive systemic heparin. As such, while preferable in all cases,
the use of anticoagulation is a judgment call made by the operative
surgeon in close communication with the anesthesia, neurosurgical,
and other specialty providers. When considering the use of heparin,
one should recognize and make use of the benefit of limited amounts
of local and regional heparin that can be used on and infused
proximal and distal to the segment undergoing repair.
One must also open and inspect the vessel and dbride the injured
segment until normal vessel wall is present (Fig. 15-8).
Intraluminal platelet aggregate and thrombus must be removed
directly using forceps or with a Fogarty thromboem-bolectomy
catheter and diluted amounts of heparin flush (i.e., heparinized
saline). As mentioned, this same dilute heparin should be gently
instilled proximal and distal to the controlled vascular segment to
reduce the incidence of thrombus forma-tion during assessment and
repair. Lower extremity vascular reconstruction generally consists
of primary repair, patch angioplasty, or placement of an in-situ
interposition graft. Bypass with ligation of the intervening
injured segment is another option that may be used with popliteal
and tibial level arterial injuries. Regardless of the method, fine
monofilament suture and surgical loupe magnification are central to
most attempts at vascular reconstruction.
Lateral arteriorrhaphy (or venorrhaphy) is a method of primary
repair that can be pursued if the vessel diameter will
FIGURE 15-8 Angiogram of popliteal artery after posterior knee
dis-location (prior figure).
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15 / LowER ExtREMIty VAScULAR tRAUMA 175
oping transient edema and with none progressing to perma-nent
sequelae.36 Kurtoglu et al recommended that patients with extensive
extremity vein laceration should undergo liga-tion coupled with
judicious use of leg fasciotomy, with eleva-tion of the limb, with
compression, and with monitoring for progression of deep venous
thrombosis. This same group reported that despite concomitant
arterial injury requiring revascularization, extremity vein
ligation resulted in mild venous morbidity (CEAP Classification
C2-C3) in 60% of their series.37
In contrast, a number of studies have touted the advantages of
extremity vein repair, suggesting that this approach may play a
role in recovery from a major trauma. Parry et al exam-ined the
short-term patency of several methods of extremity vein repair in a
civilian trauma setting and found a patency rate of nearly 75%
regardless of the type of reconstruction (primary repair, vein
patch angioplasty, interposition graft).34 This group also reported
that a large number of venous repairs that had thrombosed in the
early time period went on to recanalize over time. In a longer
follow-up study, Kuralay et al reported that patency was predicted
by the anatomic position of the venous injury rather than by the
type of repair.38 This group took advantage of excellent follow-up
of military per-sonnel in the Turkish Health System to compare
short- and long-term results of venous repair in the lower
extremity. At an average of 6 years following injury and vein
repair, this group reported patency rates of the common femoral,
the femoral, and the popliteal veins to be 100%, 78%, and 60%,
respectively. Notably all infrapopliteal veins in this series were
found to be thrombosed shortly after the time of repair. This group
suggested that higher venous flow in the larger, more proximal
veins was largely responsible for the improved patency. It is also
worth noting that there may have been a technical advantage to
repair of the larger veins compared to the smaller more distal
veins, which often present significant challenges because of their
diminutive sizes. As mentioned previously, in the largest review of
military venous repair since the 1970s, Quan et al from Walter Reed
reported a short-term patency of 85% with no increased rate of
venous thrombosis or thromboembolism in those having had
repair.39
JunctionalDistalIliacandProximalFemoralInjuries
Exposure of the iliac vessels can be accomplished via an
ante-rior, inframesocolic, transperitoneal approach by dissection
of the peritoneum of the paracolic gutter and by medial rotation of
the ascending (right iliac) or descending (left iliac) colon (Fig.
15-9). The external iliac arteries are relatively protected by the
walls of the pelvis as they rise to join the common femoral
arteries underneath the inguinal ligaments. The main side branch of
the external iliac artery is the inferior epigastric, although the
distal external iliac artery is also crossed by the lateral
circumflex iliac vein at the inguinal ligament. As with other
vascular injuries, direct pressure should be utilized to control
any obvious sources of bleeding. Proximal control is gained by
applying clamps to the common iliac artery. It is worth noting that
hurried, blind application of vascular clamps to vessels that are
not dissected or exposed is often fraught with problems, including
injury to adjacent vascular structures. This scenario is
particularly problematic in the iliac position because of the
direct apposition of the iliac veins underneath and alongside the
iliac arteries. As such, one must
Ligation of extremity venous injury is better tolerated and
performed much more commonly than arterial ligation, although
repair of larger, proximal venous injuries should be considered in
some scenarios. Specifically, repair of popliteal, superficial, and
common femoral vein injuries should be con-sidered to reduce acute
venous hypertension and longer-term morbidity if the injuries are
isolated and amenable to repair and if the patient is in good
physiologic condition. Experience from the wars in Afghanistan and
Iraq has shown the utility and effectiveness of this selective
repair strategy (i.e., repairs some but not all) for more proximal
vein injuries. The group from Walter Reed demonstrated a near-85%,
2-year patency of venous repair and a trend toward reduced symptoms
of chronic phlegmasia in those having been afforded venous repair.
Importantly, that experienced showed no increased incidence of
venous thrombosis or pulmonary thrombembo-lism in the cohort of
patients undergoing extremity vein repair.33
Extremity vein injury in the multiply injured patient who is in
poor physiologic condition should be ligated. Similarly, complex
extremity vein injuries that require long segment interposition
grafting or use of synthetic conduits should be managed with
ligation in most instances. A temporary vascu-lar shunt may provide
an interval option for some larger, more proximal vein injuries. In
this setting, shunts allow for contin-ued venous outflow (i.e.,
decompression) while the patient is resuscitated, and the surgeon
has the opportunity to consider the definitive management strategy,
be it reconstruction or ligation. In order for venous shunts to be
effective for more than a few hours, experience suggests that the
patient will need to be dosed with systemic heparin to avoid shunt
thrombosis. Maintaining venous patency and outflow with or without
the temporary use of a vascular shunt is especially important in
certain watershed or gatekeeper veins such as the popliteal vein;
in the confluence of the deep, superficial, and common femoral
veins; and in the iliac vein. Parry et al used temporary vascular
shunts in the management of 18 extremity vein inju-ries 16 of which
went on to venous repair after shunt removal. As part of their
advantage, placement of temporary vascular shunts is generally
quick and allows for manipulation and stabilization of concomitant
orthopedic fractures before the shunt is removed and consideration
given of vascular repair.34 Lateral venorrhaphy is the simplest
method to repair venous lacerations while end-to-end anastomosis
and patch veno-plasty are useful for repair of veins without
segmental loss. For injuries that destroy large portions of the
vein, an interposi-tion graft using autologous vein or prosthetic
conduit is the preferred approach. As noted previously, modern
experience from Walter Reed confirms observations first made in the
Vietnam War that repair of extremity venous injuries does not
increase the incidence of thrombophlebitis or pulmonary
thromboembolism.35
Those who advocate for routine ligation of extremity vein injury
take the point of view that the immediate side effects are few and
manageable and that the long-term complications are mitigated by
the development of venous collaterals. Pro-ponents of ligation also
show that symptoms of acute venous hypertension can be alleviated
by extremity elevation and by use of compression stockings.
Timerblake and Kerstein reported that 64% of patients with isolated
femoral venous injury and 59% of those with concomitant arterial
injury underwent ligation with only one third of the patients
devel-
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176 SEctIoN 3 / DEFINItIVE MANAGEMENt
FIGURE 15-9 Surgical anatomy of junctional zone. IMA, Inferior
mes-enteric artery; SMA, superior mesenteric artery.
Phrenic arteryCeliac artery
SMA
Leftrenal vein
Testicular(ovarian) vein
Testicular(ovarian) vein
Testicular(ovarian) arteryIMA
Ureter
IVC
FIGURE 15-10 Surgical retroperitoneal exposure of iliac
vessels.
Common iliac artery
External iliac artery
Aorta
Reflectedperitoneal cavity
be careful to place the proximal iliac clamp only on the artery
and not to inadvertently injure the adjacent vein because of chaos
surrounding the patients presentation. If necessary, proximal
control may be gained by initial cross-clamping of the distal
aorta. Division of the inguinal ligament may also be necessary for
distal control of junctional zone vascular
injuries. Careful dissection is necessary to isolate and control
the internal iliac artery to stem retrograde or cross-pelvic
bleeding. During dissection, one must also take care to iden-tify
and avoid injury to the ipsilateral ureter which crosses over the
anterior surface of the iliac artery at the pelvic rim. Careful
dissection starting at the most proximal and distal points of
exposure and moving toward the center of the field can help one
isolate the location of vascular disruption and also the internal
iliac artery.
In the case of iliac and/or junctional femoral vascular injury
from penetrating trauma, exposure and control can also be achieved
via a retroperitoneal incision (Fig. 15-10). The curvilinear
incision in this scenario starts above the pubic bone, extends
laterally and cranially, and passes along the edge of the rectus
abdominus muscle. The incision is deepened using the lateral edge
of the rectus as a guide proceeding in the lateral extraperitoneal
plane, reflecting the peritoneum and abdominal contents medial.
This incision can be done fairly quickly to gain access to the
iliac vessels and to apply proximal control. However, this exposure
is extraperitoneal and will not allow exploration of the abdominal
cavity. The authors use this exposure frequently because it can be
per-formed rapidly and can allow good visualization of lower
extremity junctional zone injuries.
Ligation of one internal iliac artery is generally well
toler-ated and does not result in the severity of ischemic
conse-quences as seen when ligating the common or external iliac
artery. Ligation of the common or external iliac artery should be
considered in only the most extreme situations as a life-saving
maneuver. Ligation at this proximal inflow point to the extremity
is poorly tolerated and results in a high likelihood of proximal
limb loss. Interval arterial repair is also poorly tolerated,
possibly due to the severity of reperfusion injury. The use of a
temporary vascular shunt may be beneficial and should be considered
to restore or to maintain perfusion through the iliac or
iliofemoral segment in complex scenarios in which the patient has
other life-threatening injuries or
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15 / LowER ExtREMIty VAScULAR tRAUMA 177
done in combination with a two-incision, four-compartment
fasciotomy of the leg to monitor viability of the extremity
musculature and to reduce the risk of compartment syn-drome. If or
when a patients condition stabilizes, consider-ation should be
given to an operation that would provide inflow to the extremity
such a cross-femoral (femoralto- femoral) bypass with 8-mm ringed
ePTFE. If the patient will not tolerate further operative
procedures, resuscitation should proceed in the surgical intensive
care unit; and consideration should be given to a return to the OR
for extraanatomic bypass or amputation at the earliest possible
time.
FemoralandPoplitealInjuries
The common femoral artery and vein are exposed via a
lon-gitudinal incision beginning at the inguinal ligament. The
proximal position of the incision to expose the common femoral
artery can be estimated by locating and visualizing the midpoint of
the inguinal ligament. The incision is extended caudal 8 to 10 cm
but may be extended as necessary for proxi-mal or distal exposure,
control, and repair of injuries (Fig. 15-13). Areas of hematoma or
wounds should be avoided initially until after proximal and distal
control is achieved. In the setting of vascular injury with
occlusion or disruption of the superficial femoral artery, the
perfusion from the profunda femoral artery often is not sufficient
to prevent ischemia of the lower leg. As noted previously, the
continuous-wave
adverse physiology. If possible, maintaining flow through a
vascular shunt would be preferable to damage control ligation in
such a scenario. A large shunt such as a 14 Fr Argyle or even a 14
or 16 Fr pediatric chest tube may be inserted into the ends of the
injured iliac vessel after they have been flushed in an antegrade
and retrograde manner to restore extremity perfu-sion. The shunt
may be secured to the artery using heavy silk sutures (Fig. 15-11),
and a third suture can be tied in the midportion of the shunt to
aid in positioning and removal. The midline suture may also provide
a vantage point to discern whether or not the shunt has migrated
distally (Fig. 15-12). This same sequence of steps may be used to
insert a smaller shunt in a more distal extremity vascular injury
(e.g., superfi-cial femoral or popliteal) to limit extremity
ischemic time until formal vascular repair can be considered and
performed. Because they limit the burden of extremity ischemia,
tempo-rary vascular shunts have been shown to be associated with
lower mortality and with lower amputation rates compared to
arterial ligation.40
When no other options are available and it is necessary to save
the patients life, the common or external iliac artery may be
divided and oversewn with a double row of sutures above the level
of injury. This damage control maneuver should be
FIGURE 15-11 temporary intravascular shunt as applied in the
superficial femoral artery.
FIGURE 15-12 temporary intravascular shunt with midline suture
tied at the time of application. on reexploration, migration is
obvi-ously seen.
FIGURE 15-13 Surgical anatomy of femoral vessels.
Ext. iliac a.Deep iliacSuperf. iliaccircumflex a.
Superf.epigastric a.Ascend. branch lat.circumflex a.Transverse
branch lat.circumflex femoral a.Lat. circumflexfemoral a.Descend.
branch lat.circumflex femoral a.
Perforating branchesdeep femoral a.
Rightcommon iliac a.
Int. iliac a.Superiorgluteal a.
Inf. gluteal a.Commonfemoral a.
Obturator a.Medial circumflexfemoral a.
Superf.femoral a.
Deep femoral a.
Descend.genicular a.
Lat. sup. genicular a.
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178 SEctIoN 3 / DEFINItIVE MANAGEMENt
Doppler should be used in these scenarios to assess for the
presence of an arterial signal in the foot before or at the time of
operative exploration. Control of the profunda femoris artery is
gained in the same incision and exposure. The origin of the
profunda is most commonly on the posterior lateral aspect of the
common femoral artery. Approximately one third of patients have a
dual profunda origin with the second orifice arising from the
posterior common femoral artery. Of note, the lateral circumflex
femoral vein crosses the proximal portion of profunda artery and
should be identified, ligated, and divided to facilitate proper
exposure of the profunda and avoid inadvertent venous injury.
Injuries to the profunda femoral artery should be repaired if this
can be accomplished relatively expeditiously in an otherwise-stable
patient. Options include direct repair, placement of an
interposition graft or proximal ligation and distal reimplantation
to the superficial femoral artery. If this is not possible,
ligation should be per-formed. In the young patient, acute ligation
of the profunda femoral artery is generally well-tolerated if the
superficial femoral artery is uninjured. In a report by Woodward et
al on methods of repair of femoropopliteal injury during Operation
Iraqi Freedom (OIF), no patients undergoing profunda femoral artery
ligation progressed to require amputation.6
The mechanism of injury will often dictate the type of vascular
reconstruction. Stab wounds or laceration injuries are often able
to be repaired by using lateral suture or endto-end primary
methods. Gunshot wounds or pene-trating injuries from explosive
mechanisms often require arte-rial dbridement to uninjured aspects
of the vessel and placement of an interposition graft. As noted
previously, the favored conduit in these scenarios is autologous
saphe-nous vein. However, use of a synthetic vascular graft is
acceptable in certain scenarios in which there is no saphenous vein
or in which the available saphenous vein is being saved for a
later, more-definitive reconstruction (i.e., interval
reconstruction).31,41
In order to expose the popliteal space, the knee is flexed or
bent slightly (i.e., frog leg position); and a soft roll or bump is
placed behind the leg, below the knee to elevate or suspend the
thigh. This maneuver makes it such that the medial mus-culature of
the thigh pulls freely away from the femur and allows gravity to
open up the above-knee popliteal space. Con-versely, to expose the
below-knee popliteal space, the soft roll or bump is placed above
the knee such that the muscles of the gastrocnemius and soleus
muscles pull freely away from the tibia. While these maneuvers may
seem rudimentary, they are absolutely essential to be successful in
this challenging ana-tomic exposure. Failure to flex the knee and
move the elevat-ing bump or roll of towels in this manner will
result in the surgeon attempting to expose an inaccessible
popliteal space that is compressed closed on the OR table.
Once the lower extremity has been positioned in such a manner to
expose the above-knee popliteal space, an incision is placed on the
anterior border of the sartorius muscle (Fig. 15-14). The muscle is
retracted posterior or down to expose the popliteal space, which
contains the neurovascular bundle. The popliteal vein is generally
medial to and covering the artery and therefore encountered first
in the exposure. Ten-donous attachments of the adductor magnus
muscle can be divided if necessary for improved proximal extent of
exposure (Fig. 15-15). A medial incision 2 to 3 fingerbreadths
posterior to the medial edge of the tibia will initiate exposure of
the
FIGURE 15-14 Surgical anatomy of popliteal vessels including
bony landmarks.
Femoral a.
Descend.genicular a.
Post. tibial a.
Inf. medialgenicular a.
Superior medialgenicular a.
Articular branchesdescend. genicular a.
Descend. branchlat. circumflex
femoral a.
Popliteal a.
Superior lat.genicular a.
Inf. lat. genicular a.
Ant. tibialrecurrent a.
Ant. tibial a.
FIGURE 15-15 Surgical exposure of popliteal vessel via medial
incision.
Medial approach
Vastus medialis m.
Vastus medialis m.
Popliteal a.
Popliteal a.Popliteal v.
Popliteal v.Sartorius m.
Medial headgastrocnemiusm.
Cut ends ofmedial headgastrocnemiusm.
Tibial n.
Popliteal vv.
A
B
below-knee popliteal space. Care should be taken not to divide
the saphenous vein in this location as it generally lies just under
the skin in this medial incision. Division of the proximal-most
portion of the medial head of the gastrocnemius and its attachments
to the tibia will facilitate opening of the below-knee popliteal
space. After these initial maneuvers above and below the knee have
been accomplished, one should spend time positioning and
repositioning deep, narrow, handheld retractors and performing
further dissection of the popliteal vessels. The uses of Weitlaner
and/or Henly popliteal retractor instruments will also be necessary
to spread open the popliteal space as widely as possible. The Henly
retractor has a set of blades with adjustable depths that often
facilitate opening of the above- and below-knee popliteal
spaces.
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15 / LowER ExtREMIty VAScULAR tRAUMA 179
trauma. In contrast, injury to the distal-most popliteal artery
or to the tibial peroneal trunk may result in more complete leg
ischemia. When managing tibial vascular injuries, one must control
bleeding, reduce any fractures, warm and resus-citate the patient,
and examine the foot with continuous-wave Doppler. In most cases
after these maneuvers an arterial signal will be present in the
foot indicating viability and obviating the need for additional
maneuvers. If there is no Doppler signal after these steps, one
must consider that there may be injury to more than one tibial
vessel or to the tibial peroneal trunk. The options in this
scenario are (1) to attempt to restore flow with a small caliber,
temporary vascular shunt, (2) to perform vascular reconstruction
with a below-knee poplitealto-tibial bypass or interposition graft
using saphenous vein, or (3) to accept ligation and to continue
expectant management.
An analysis of combat-related tibial injuries by Burkhardt et al
demonstrated the effectiveness of a selective revascular-ization
approach to tibial arterial injuries (i.e., repair some but not
all). Burkhardt and colleagues confirmed that a portion of patients
with tibial vessel injury can be managed with ligation and
expectant observation without increased rates of amputation. In
this experience, the amputation rate in the patients managed with
no reconstruction (22%) was no different than that in patients who
underwent tibial level arterial reconstruction (19%). Presenting
factors that were associated with the need for subsequent tibial
level vascular reconstruction were occlusion of more than one
tibial artery, lack of Doppler signal in the foot, and a
less-severe Injury Severity Score (ISS) of 16) were less likely to
undergo tibial level reconstruction confirmed effective use of the
damage control approach of ligation and expectant man-agement.7,43
In this context, one should be mindful that in some cases primary
amputation should be performed when ischemic damage has been
present for more than 6 hours or when the severity of the mangled
extremity is such that there is severe orthopedic injury to the
foot and/or ankle with asso-ciated injuries, which would preclude a
safe attempt at limb salvage.27
Postoperative CarePostoperative care of the junctional zone and
lower extremity vascular trauma patient requires excellent
communication between the various surgical teams, the intensive
care team, and the nursing staff. Standard intensive care
monitoring of critically ill trauma patients is initiated for the
first 24 hours postoperatively. Pulse and Doppler signal exams are
per-formed hourly in conjunction with vital signs. The location and
quality of the pulse (weakly palpable or strongly palpable) or the
Doppler signal (monophasic, biphasic, triphasic) is documented in
the postoperative note by the attending surgery team. Change in the
vascular examination or signs of bleeding warrant either open
surgical exploration or angiography depending on the hemodynamic
stability of the patient.
Mechanical thromboprophylaxis in the form of pneumatic
compression devices is initiated along with subcutaneous
If after intentional efforts have been made to dissect and
retract the popliteal space and vessels cannot be seen, the tendons
of the semimembranosus, semitendinosus, and graci-lis muscles may
be divided to improve exposure. While it is acceptable to divide
these structures, doing so carries some morbidity; and it may not
be necessary in some cases. There-fore the authors generally start
this exposure without dividing these tendonous attachments and make
an intentional effort to control and expose the popliteal space
with more moderate steps. If the nature of the injury or body
habitus of the patient are such that more extensive dissection is
required, the tendons of these muscles are divided.
TibialLevelInjuries
The tibial vessels originate at the end of popliteal artery
below the tibial plateau of the knee. The majority of limbs (91%)
have a redundant branching pattern that has the anterior tibial
artery as the first branch and the tibial-peroneal trunk giving
rise to the posterior tibial and peroneal arteries. Other
branch-ing patterns are also seen. For example, approximately 3% of
limbs do not have a true tibial-peroneal trunk and instead have a
true trifurcation of the anterior tibial, posterior tibial, and
peroneal arteries. Perhaps of more importance in vascular trauma is
the anatomic variant with altered perfusion to the foot. Hypoplasia
of the posterior tibial artery or anterior tibial artery has been
reported in about 1% of limbs. These cases may be identified only
by use of continuous-wave Doppler ultrasound and in such rare cases
it is paramount to recognize that the peroneal artery may be the
only perfusion to the foot.42
The posterior tibial and peroneal vessels, which lie in the deep
posterior compartment of the leg, are best approached through the
medial incision previously described. This inci-sion is made 1 to 2
fingerbreadths below the medial edge of the tibia, again with care
taken not to injure the saphenous vein. The incision may be a
continuation of the original below-knee exposure or made separately
depending on the location of injury. The skin, subcutaneous tissue,
and super-ficial fascia are all incised to open the posterior
superficial compartment of the leg. The attachments of the soleus
muscle to the medial edge of the tibia must be incised
longitudinally along the length of the tibia to enter the posterior
deep com-partment of the leg which contains the posterior tibial
and peroneal arteries. The posterior tibial artery is medial to the
peroneal and is therefore the first to be encounter through the
medial approach and dissection.
The anterior tibial artery and vein are in the anterior
com-partment of the leg and are exposed and controlled via a
longitudinal, lateral leg incision. The incision and division of
fascia open the anterior and lateral compartments, which are
separated by an intermuscular septum. The anterior tibial artery
lies deep in the anterior compartment underneath the anterior
tibialis and extensor muscles and on the surface of the
interosseous membrane with the deep peroneal nerve. Typically, to
locate this neuromuscular bundle, one bluntly develops a plane
between the anterior tibialis and the extensor muscles. Because of
the close proximity and the narrow space between the tibia and
fibula, exposure of the anterior tibial vessels is very difficult
as one moves more distal on the leg.
As stated, the redundant nature of circulation to the foot makes
it likely that control with ligation and Doppler assess-ment will
be the maneuver of choice for isolated tibial vessel
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180 SEctIoN 3 / DEFINItIVE MANAGEMENt
thrill, or audible bruit long after the initial injury. In some
instances, it is feasible to use duplex ultrasonography to
diag-nose associated venous injuries. Ultrasound is an excellent
modality because of its ease of use, noninvasive nature, and
immediate results. However, for situations with extensive
soft-tissue or orthopedic injuries, ultrasound may not be feasible.
In these cases, computed venography is a viable alternative.
JunctionalDistalIliacandProximalFemoralInjuries
Prompt management and repair of common femoral artery trauma has
encouraging results. Nationwide, mortality from common femoral
artery injury in patients with isolated lower extremity trauma is
low (7.5%). Those that died were hypo-tensive on arrival and had
Glasgow Coma Scale (GSC) scores of 3, even in the absence of
associated head injuries.9 Postop-erative complications are common
(23%) and include wound infections (15%), venous thrombosis (3%),
postoperative hemorrhage (2.5%), acute respiratory distress
syndrome (ARDS) (2%), and arterial thrombosis (0.5%). Factors
associ-ated with an increased risk for postoperative complications
included ISS greater than 25, deranged physiology in the OR
(acidosis, hypothermia, hypotension, coagulopathy) and the presence
of other injuries.8
Leg fasciotomy following femoral vessel injury is consis-tently
reported to be around 25%.44,45 The need for calf fasci-otomy is
increased in concomitant venous and arterial injury as compared to
arterial injury alone (33% and 13%, respec-tively).8 Other factors
associated with fasciotomy include increased resuscitation with
packed red blood cells (PRBCs) (8.2 units versus 1.8), plasma (3.7
versus 0.8), platelets (0.5 versus 0.1), dislocation, and open
fracture.7
Overall, amputation rate is substantial (from 15% to 35%) with
femoral artery injury.46 Primary amputation is reserved for the
situation where limb salvage is impossible, such as in the mangled
extremity, in extensive gangrene, and in muscle necrosis.
Blunt-injury and high-velocity firearm injuries are associated with
higher delayed amputation rates compared to other mechanisms of
injury. Likely, this is due to the increased force in these types
of injuries, which causes associated nerve and soft-tissue damage.
In terms of vascular revascularization procedure performed, the
only association with increased amputation rates was reexploration
and failed revascularization.46
FemoralandPoplitealInjuries
Popliteal artery injury is associated with lower mortality than
injuries to the common femoral artery and superficial femoral
artery, but is also associated with a higher incidence of
ampu-tation.9 As seen from the military experience, ligation is
poorly tolerated and has a high rate of limb-loss.8,9 However,
using modern vascular surgical technique and minimizing warm
ischemic time, increased limb salvage can be achieved with
repair.
TibialLevelInjuries
In penetrating trauma, prompt revascularization for ischemic
limbs in tibial artery injury affords excellent results.
Revascu-larization to a single target is sufficient to provide flow
to the lower leg. Ligation and/or observation in single-vessel
injuries is well tolerated as long as collateral circulation is
confirmed before the ligation, preferably by arteriography. Some
double
prophylactic dosing of low molecular weight heparin if the risk
of bleeding is sufficiently low. If there has been an extrem-ity
venous injury treated with ligation, the leg should be ele-vated
and wrapped from the toes to the groin with a compression wrap
cutting openings to monitor the arterial pulse or the Doppler
signal. The entire extremity must be monitored for viability and
compartment syndrome in the first 24 to 72 hours, even if a leg
fasciotomy has been per-formed, as a small risk of compartment
syndrome in the thigh still exists.
ComplicationsThrombosis or occlusion is the most notable
complication following repair of an extremity vascular injury.
Primary repair of small vessel injuries is less likely to result in
this complication than the use of longer prosthetic grafts although
many other factors play into this possibility. Frequent
postop-erative pulse examination with early recognition and
manage-ment of this complication is necessary to reduce morbidity.
When prosthetic vascular grafts are used, special attention for
signs of graft infection is needed. While graft infection in the
immediate postoperative period and in the short term are not highly
reported, ominous signs include fever, leukocytosis, and continued
bleeding. When graft infection is suspected, the process of removal
and revascularization through clean surgi-cal fields is the
operation of choice (Fig. 15-16).
For later manifestation of venous injury, imaging modali-ties
are the keys to discovery. Traumatic arteriovenous fistulae may
manifest with tenderness, edema, varicosities, palpable
FIGURE 15-16 computed tomography showing extraanatomic bypass
through clean surgical fields after excision of infected bypass
graft.
-
15 / LowER ExtREMIty VAScULAR tRAUMA 181
ConclusionExtremity vascular trauma is common in both the
civilian and the military settings. Recent experience in the wars
in Afghani-stan and Iraq has confirmed the imperative of initial
hemor-rhage control including the use of tourniquets and direct or
manual pressure with or without hemostatic agents if possible. Once
hemorrhage control has been achieved, management options include
(1) continued tourniquet application or liga-tion of the vascular
injury, (2) restoration of perfusion (arte-rial and/or venous) with
a temporary vascular shunt, and (3) vascular reconstruction either
initially or following use of a vascular shunt. The choice of
management depends on the anatomic location of the extremity
vascular injury; whether it is arterial, venous, or both; the
extent of the mangled extrem-ity; and the physiologic status of the
patient (i.e., associated injuries or adverse physiology). While
simple vascular recon-struction may be possible for uncomplicated,
isolated vascular injuries cared for by experienced surgeons, more
complex injury patterns occurring in the setting of the mangled
extrem-ity benefit greatly from damage control adjuncts and from a
multidisciplinary approach.
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FIGURE 15-17 Surgical exposure for 2-incision, 4-compartment
lower extremity fasciotomy.
TibiaGreat saphenous v.
Medial incision
Lateral incision
Saphenous nerve
Smallsaphenous v.
Anterior tibial a.and v.
Posterior tibial a.and v.
Fibular a.and v.
Tibial n.
Peroneal n.
Fibula
-
182 SEctIoN 3 / DEFINItIVE MANAGEMENt
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15 Lower Extremity Vascular TraumaAbstractKey
Words:IntroductionHistory and BackgroundPresentation and
DiagnosisJunctional Distal Iliac and Proximal Femoral
InjuriesFemoral and Popliteal InjuriesTibial Level Injuries
Preoperative PreparationJunctional Distal Iliac and Proximal
Femoral InjuriesFemoral and Popliteal InjuriesTibial Level
Injuries
Helpful Considerations to Avoid PitfallsOperative Strategy and
TechniqueConsiderations for Extremity Venous InjuryJunctional
Distal Iliac and Proximal Femoral InjuriesFemoral and Popliteal
InjuriesTibial Level Injuries
Postoperative CareComplicationsJunctional Distal Iliac and
Proximal Femoral InjuriesFemoral and Popliteal InjuriesTibial Level
Injuries
ConclusionReferences