Vascular injury

Background

Types
  • Occlusive
    • Transection
    • Thrombosis
    • Embolism
    • Reversible spasm
  • Non-occlusive

Occult Upper Extremity Vascular Injury

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 hemorrhage
  • Large expanding hematoma

Soft Signs
  • Small nonexpanding hematoma
  • Peripheral nerve deficit
  • History of pulsatile or significant hemorrhage at time of injury
  • Unexplained hypotension
  • Bony injury (fracture, dislocation, penetration) or proximity to penetrating wound

Differential Diagnosis

Extremity trauma

Evaluation

Arterial Pressure Index (API)
  • Doppler-determined arterial systolic blood pressure in injured limb divided by systolic blood pressure in uninjured limb
    • <0.9 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

Evaluation Algorithm

Hard Signs (>90% risk of arterial injury; 50% require intervention)
  • Immediate arterial exploration without further investigation

Soft Signs (30% risk of arterial injury)
  • Perform API → if <0.9 obs/admit for 24h, serial API
  • Consider:
    • Doppler U/S
    • CT angiogram
    • Evaluation of compartment pressures

Management
  • Depends on injury type
  • Consider emergent vascular surgery consult

Disposition
  • Dependent on injury type

Prognosis
  • Warm Ischemia Time
    • 6 hours (10% irreversible damage)
    • 12 hours (90% irreversible damage)

See Also

References
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