New perspectives on the management of penetrating trauma in proximity to major limb arteries

Abstract

Current management of penetrating injuries in the proximity of major extremity arteries with no evidence of vascular trauma remains controversial. A total of 318 such injuries in 254 patients were evaluated prospectively to clarify the appropriate timing and role of arteriography, as well as the natural history of these injuries. The arteries at risk were: axillary, 47; brachial, 57; superficial femoral, 176; and popliteal, 38. No deaths occurred, and no morbidity resulted from arteriographic delay of 6 to 24 hours after injury. Of the 48 arteriographic abnormalities detected, 16 involved noncritical branch vessels. There were 32 injuries to major arteries (10.0%), including localized narrowing (n = 13), intimal flap (n = 12), false aneurysm (n = 6), and arteriovenous fistula (n = 1). Shotgun wounds led to a greater arterial injury rate (3/17; 17.6%) than did gunshot wounds (24/247; 9.7%) or stab wounds (5/54; 9.3%). At the surgeon's discretion, three injuries underwent immediate exploration (one negative), whereas the remaining 29 vessel injuries were followed up nonoperatively by repeat arteriography (n = 22) or clinical examination (n = 7), for a mean interval of 2.8 months. Fifteen abnormalities resolved, 10 improved or remained unchanged, and 4 worsened. The four lesions (13.7%) that worsened (two shotgun and two axillary artery injuries) were identified within 3 months of injury and repaired surgically with no morbidity. In conclusion, only 6 operations were required out of 3218 potential injuries (1.8%), suggesting that routine arteriography is not a cost-effective means of evaluating these injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of Physical Examination, Ankle‐Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta‐analysis

“…demonstrating the equivalent diagnostic performance of CT Angiography (CTA) to catheter angiography remains the only level 1 data available. Several studies contribute to the formulation of the guidelines, some of which describe the importance of physical examination and ABI and utility of imaging including US, CTA, and catheter angiography, either individually or comparatively . The guidelines are based upon qualitative review of observational studies with expert consensus, and the void for a systematic and quantitative analysis of the available data is apparent.…”

Very bad clinical aspect towards diagnosis of deep femoral artery injury: Hypovolemic shock

“…In the early period, it is difficult to diagnose profunda femoral artery injuries. [12] In our case, the patient had no significant bleeding when he was in the emergency department and before admission to hospital, wound area was bandaged. Hemodynamic parameters were stable but within minutes progressive hypotension and confusion were occurred and then the patient was immediately operated.…”

“…[1] The etiologies of vascular injuries especially in young males, in our country, 50-70% are gunshot injury and stab wounds. [23] Early diagnosis and appropriate treatment can reduce mortality and morbidity in vascular injuries. In the early period, it is difficult to diagnose profunda femoral artery injuries.…”

“…Significant contribution to the development of collateral vessels and the lower extremity arterial circulation, the profunda femoral artery ligation is not recommended. [123] In peripheral vascular diseases with diabetic and non-diabetic, profunda femoral artery is the most considerable vessel, limb preservation of the infrapopliteal region through the nutrition with providing of collateral circulation. [45]…”

Penetrating nontorso trauma: the extremities

“…8 It should be noted that despite the very high sensitivity inherent within ABIs, clinically less significant nonocclusive vascular injuries remain possible with an ABI > 0.9 (i.e., intimal flap, spasm, subintimal or intramural hematoma, tiny pseudoaneurysm). 9 These are rarely treated with intervention.…”