PERIPHERAL VASCULAR INJURIES 54

ORIGINAL PROF1217

PERIPHERAL VASCULAR INJURIES;

EPIDEMIOLOGY AND MANAGEMENT

DR. SHABBIR HUSSAIN RANA DR. YOUSUF JAMAL, FCPS (Surgery)

FCPS (General Surgery) Surgical Specialist Department of Surgery
Surgical Specialist BV Hospital Bahawalpur
CMH Kohat
Dr. Muhammad Afzal,
DR. TARIQ MUKHTAR FARANI FCPS (General Surgery)
FCPS (General Surgery) Surgical Specialist Department of Surgery
Surgical Specialist Department of Surgery CMH Kohat
CMH Kohat

SUMMARY... [email protected]. , [email protected]. Introduction: Peripheral vascular injuries constitute

4-6% major trauma. Although uncommon the complication of hemorrhage and Ischemia can be limb threatening and
life threatening. Rapid diagnosis and appropriate treatment is therefore essential. Delay allows irreversible Ischemic
injury to take place and encourages propagation of intravascular thrombosis, which results in eventual loss of function
or even limb itself. Objective: (I) To collect data about different aspect of epidemiology and management of Peripheral
vascular injuries. (II) To study the relationship between latent period for revascularization and outcome of surgery.
Design: Non interventional observational study. Setting: C M H Kohat. Period: From 01 Jan 2004 to 31 Dec 2006.
Material & Methods: Total of 46 cases of all age and sex groups was included in the study. Only those patients were
included who had vascular injury to extremities whether direct (penetrating, blunt) or indirect (associated with fracture
and dislocations) injuries. Relevant history was obtained from the patients themselves and from their relatives or
witnesses. Relevant physical examination was performed. Necessary investigations were done. Patients were treated
according to standard protocol. Results: The peripheral vascular injuries were more common in 21-40 years of age
group (69%) and among male(82%).Vascular trauma caused by the firearm injuries (60.86%) was the most common
cause, other being road traffic accidents (26.08%) and blunt trauma (13.04%). The most common clinical presentation
was shock and paresthesia (50%). Most off the patient reached hospital within 6-12 hours (47%), and belongs to rural
areas (69%). Frequency of involvement of vessels was femoral artery (41%) and brachial artery (23%). Types of
vascular injuries were , laceration to the vessel wall (56%) and loss of vessel wall segment (17%). End-to-end
anastomosis was most common (78%) .others being interposition reverse vein graft (13%) and direct suturing of vessel
wall (8.7%)Amputation rate was highest in cases where revascularization occurred after more than 12 hour (71%).
Common complications after repair were residual edema (17%) and infection (6%). Overall mortality rate was 4 % and
morbidity rate was 28%. Conclusion: All cases of peripheral vascular injuries should be surgically explored.
Revascularization should be achieved within 12 hours. Patients presenting late or with crush injuries may need

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 PERIPHERAL VASCULAR INJURIES 55

amputation.

Key words: Epidemiology, Vascular trauma, Shock, Firearm injuries.

INTRODUCTION angiography can be followed5. There are difficulties in

Peripheral vascular injuries constitute 4-6% of major obtaining emergency arteriograms in vascular trauma
trauma. Although uncommon the complications of even in the best centers in the world and routine
hemorrhage and ischemia can be limb threatening and artergraphic evaluation of patients with trauma to the
life threatening. Rapid diagnosis and appropriate extremities has been declining in popularity6. A
treatment is therefore essential. Delay allows irreversible diminished or absent distal pulse, a history of persistent
ischemic injury to take place and encourages arterial bleeding, a large or expanding hematoma, major
propagation of intravascular thrombosis, which results in hemorrhage with hypoptention, an injury to anatomically
eventual loss of function or even limb itself1. The related nerves or a bruit, alone or in combination are
mechanism of injury can be direct or indirect. Direct useful in the diagnostic evaluation7. Urgent amputation
variety includes blunt trauma and penetrating injuries like of the limb is indicated when perfusion of limb can not be
gunshot and stab wounds. In indirect group fractures and resorted for sepsis and for a limb which is so severely
dislocations due to road traffic accidents are the common injured that can be no prospect for return of any
causes of vascular injuries. Penetrating and blunt injuries function8. Venous trauma has been neglected for long
to arteries are major cause of morbidity and mortality in the reason being absence of significant short and long
the trauma patients. The results are more promising in term problems and inaccurate analysis of the venous
case of penetrating injuries when compared with blunt trauma9. Some authors have achieved best results with
trauma2. When repair is possible operative procedures simple ligation, other consider the issue controversial.
include lateral repair, end-to-end anastomosis, and The type, severity and location of the injury all are
interposition of autogenous vein graft or prosthetic graft. important. The role of interposition vein graft or synthetic
Repair depends upon type of injury. There are three graft in venous injury is not well established. The rate of
types of injuries lateral wall injury, complete transaction post operative oedema following ligation of vein is
and segment loss of vessel. In an ideal setting the variable. Hardin did not observe long term sequalae in
patient must reach the hospital within six hours to obtain these cases10, while Sullivan had many patients with long
the promising results. The shortened transportation time, term venous insufficiency11. The role of heparin or
repair of associated venous injuries and availability of dextran in increasing the patency of venous repair is still
experienced surgeon all contribute towards a successful not well defined12.
outcome3. Associated extensive soft tissue injury, bony
injury or avulsed nerve may make the limb useless even MATERIAL AND METHODS
in setting of a successful repair. The liberal use of Patient with trauma to the extremity whether direct or
fasciotomy in the injured extremity is imperative in indirect admitted in CMH Kohat, were studied for
reducing post operative oedema and compartment vascular injuries. All the patients of vascular injuries of
syndrome. Knowing the key signs of ischaemia, every age and sex group were included in the present
parasthesia, pallor, pain, paralysis, and pulselessness study. A total of 46 patients were studied. Relevant
will help in preventing limb loss. Successful management history was obtained from the patient themselves and
of traumatic vascular injuries depend upon a high index also from their relatives or witnesses. In case of
of suspicion, aggressive resuscitation and prompt penetrating trauma victims were enquired about the size
surgery4. In emergency practice no special investigations of stabbing weapon or caliber of the gun and distance
are necessary and a selective policy for use of from which the firearm was discharged. In case of road

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 PERIPHERAL VASCULAR INJURIES 56

traffic accident and blunt trauma, history was taken of 46 cases of peripheral vascular injuries were included
regarding the time, mode of injury, position of the patient in the present study. Although no age was found to be
and speed of the vehicle. Presenting complaints of the safe yet the peak occurrence was noted between 21-40
patients especially of severe hemorrhage, pain years of age (69.55%).,mean age in male was noted to
paresthesia, and paralysis were recorded. Physical be 29 years while in females it was 26 years (table I).Out
examination was done by recording of vital sign like of 46 patient of peripheral vascular injuries, 38(82.6%)
Pulse, Blood pressure, Temperature and respiratory rate were male and 8(17.3%) were female with sex ratio of
was strictly maintained. Careful examination of the 4.5:1 (table-II).
injured extremity was done and special attention was
given to establish the diagnosis. Diminished or absent Table-I. Age Distribution
pulse. Major hemorrhage with hypo-tension. Large or
Age (year) No. of Pts %age
expanding haematoma. Bruit at or distal to injury.
Anatomically related neurological defect. Proximity of 0-10 02 4.34%
injury to major vessel. We diagnosed vascular injuries on
11-20 05 10.86%
clinical ground and to some extent with Doppler
ultrasonography in doubtful cases. Associated fractures 21-30 20 43.47%
were diagnosed clinically and confirmed radiologically. 30-40 12 26.08%
Hb % estimation was done in every case. In all patients
with suspected vascular injury, exploration was done. 40-50 04 8.69%
Method adopted for repair were according the type of 51 onward 03 6.52%
vascular injury and includes end-to-end anastomosis,
direct suturing of vessel wall and interposition reverse Total 46 100%
vein graft where segment loss was more than 6-8 cm.
Graft was taken from the great saphenous vein of contra Aetiological factors were firearm injuries in 28(60.86%),
lateral side. Fasciotomies were performed in those cases road traffic accident seen in 12(26.08%), blunt trauma
which were operated after 12 hours or had gross seen in 4(8.69%) and injury due to sharp instruments
oedema of limb. The main nerves were repaired primarily seen in 2(4.34%), (table-III). We have also calculated the
in clean cases and repair was deferred for 6-8 weeks in time interval between injury and hospital arrival. 39
contaminated cases. patients (84.78%) reached hospital within 12 hours and
7 patients reached after 12 hours.
INCLUSION CRITERIA
All patients of every age and sex group Those patients Table-II. Sex distribution
who had vascular injury of the extremity Sex No. of pts %age

EXCLUSION CRITERIA Males 38 82.60%

All patients who had severely crushed limbs in whom Females 08 17.40%
there was no prospect of return of function. Heavily
contaminated wounds Total 46 100%

RESULTS In our study 32 patients (69.57%) were evacuated from

Patient with trauma to the extremity whether blunt, stab rural area and 14(30.43%) were from urban area.
or gunshot admitted in CMH Kohat, were evaluated for Frequency of vessels involved in the upper limb was
the peripheral vascular injuries. The results of various brachial artery in 11(23%) and axillary artery in 6(13%)
observation were recorded in the form of tables. A total patients. In the lower limb femoral artery was involved in

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PERIPHERAL VASCULAR INJURIES 57

19(41%) and popliteal artery in 10(21%) patients (table 2(4.34%) patients. All of these injuries were repaired
IV). Most common pattern of vascular injury which we after 8 weeks. Associated venous trauma included
encountered was laceration of the vessel wall with or popliteal vein injury in 3(6.50%) patients and femoral vein
without thrombus formation in 26 patients (56.52%). Loss injury in 1(2.17%) patient. These veins were ligated.
of vessel wall segment was found in 8 patients (17.39%), Among post operative complications residual oedema
complete transaction of vessel wall in 6(13%) patients was present in 8(17.39%) patients and infection in
and compression of vessel in situ in 4(8.7%) patients. 3(6.25%) patients.

Table-III. Aetiology Table-V. Pattern of vascular injury

Mechanism of injury No of pts %age Pattern of injury No of pts %age

Firearm injuries 28 60.86% Laceration of vessel wall with or 26 56.52%

without thrombus formation
Road Traffic accident 12 26.8%
Loss of vessel wall segment 08 17.39%
Blunt trauma 04 8.86%
Complete transaction of vessel wall 06 13.04%
Injury due to sharp instruments 02 4.34%
Compression of vessel in situ 04 8.70%
Total 46 100%
Partial cut of vessel wall 02 4.34%

Partial cut of the vessel wall was found in 2(4.3%) Total 46 100%
patients (table V).Method used for vascular repair were
end-to-end anastomosis in 36(78.20%) patients, Table-VI. Method of vascular repair
interposition reverse vein graft in 6(13.04%) patients and
direct suturing of vessel wall in 4(8.7%) patients (table Method of repair No of pts %age
VI). End to anastomosis 36 78.26%

Interposition reverse vein graft 06 13.04%

Table-IV. Frequency of involvement of vessels
Direct suturing of vessel wall 04 8.70%
Vessel involved No of pts %age
Total 46 100%
UPPER LIMB

Axillary artery 6 13.04% Residual oedema was treated successfully by

Brachial artery 11 23.91% conservative measures and infection with antibiotics.
Haemorrhage occurred in 2(4.34%) patients, while acute
LOWER LIMB renal failure developed in 2(4.34%) patients, both these
Femoral artery 19 41.30% complications were managed accordingly. One patient
(2.17%) had thrombosis which ultimately resulted in
Popliteal artery 10 21.73%
amputation (table VII).
Total 46 100%
Time interval between injury and revascularization was
Rib fractures were found in 5(10.86%) patients and injury directly proportional to the rate of amputation. In most of
to long bones in 4(8.69%) patients, these fractures were the patients 39(87.75) revascularization was restored
fixed prior to vascular repair. Radial nerve injury was within 6-12 hours and out of them 8(20.51%) patients
found in 2(4.34%) patients and median nerve injury in required amputation. Seven (15.45%) patients arrived

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 PERIPHERAL VASCULAR INJURIES 58

after 12 hours and 5(79.49) of them required amputation. peripheral vascular trauma similar results were observed.
18(34%) patients were operated within 8 hours of injury
Table-VII. Post operative complication and in 34(65%) patients revascularization occurred after
8 hours16. Brachial artery was most commonly affected
Complications No of pts %age
in upper limb (23%) and femoral artery in lower extremity
Residual oedema 08 17.39% (41%). These observations are similar to the study of
Nassoura et al, who described a study of 101 patients in
Wound infection 03 6.52%
whom femoral artery injury 40% was most common17.
Hemorrhage 02 4.34%

Acute renal failure 02 4.34%

Common pattern of vascular injury that were found in our
study were laceration of vessel wall with or without
Thrombosis 01 2.17% thrombosis formation in 26(56.52%) patients, loss of
Total 16 34.76% vessel wall segment in 8(17.39 ) patients, Savage and
Walker observed in their study of vascular trauma, a rise
DISCUSSION of 40(60%) patients had laceration of vessel wall and
Vascular injuries are major cause of morbidity and 10(15%) patients were having loss of vessel wall
mortality in trauma patients and have the highest segment18. Method of vascular repair adopted were end-
resuscitation priority after the airway and breathing have to-end anastomosis in 36(78.26%) patients, interposition
been protected. The most important and critical reverse vein graft in 6(13.04%) cases and direct suturing
prognostic factor is time of presentation since injury. Our of vessel in 4(8.70%) cases. Hughes reported in his
main aim of this study was to see epidemiology and study on the primary repair of wound of major arteries
management of peripheral vascular injuries, secondly to that end-to-end anastomosis was most common
study the relationship between latent period for method19. Vanway described that interposition reverse
revascularization and outcome of surgery. The age vein graft is usually needed in cases where vascular
group most prone to get peripheral vascular injury injury is associated with blunt trauma20. In our study most
observed in our study was between 21-40 (69.55%). common associated injury was fracture of ribs and long
Similar finding have been reported by Hood and bones in 9(19.59%) cases. Rich in Vietnam reported
associates in their study age group was 25-40 years thousand cases out of 310(31%) had associated fracture
(65%)13. Knudson and associates found in 42 cases that of long bones or ribs21. Other associated injury was
most commonly affected group was between 20-40 years popliteal vein injury in 3(6.5%) cases. Drost et al
age (60%)14. Large number of cases in this age group concluded in his study that popliteal vein injury was
can be explained by the fact that persons in this age common in lower extremity vascular trauma22. Residual
group are at their peak of their activity and are subjected oedema was most commonly encountered post operative
to the hazards of accidents and injuries. In our study we complication (17.39%) which was treated conservatively
observed that males are more vulnerable to sustain by elevation and compression bandage. It was due to
peripheral vascular injury. Out of 46 cases 38 (82.60%). combined effect of trauma and surgery, moreover in
The firearm injury is the most frequent aetiology of most of our cases we ligated veins. Wound infection and
peripheral vascular injury . Frykberg ER. et al studied 65 haemorrhage were the next common complications
victums of vascular injury caused by firearm in a one occurring in 3(6.5%) and 2(4.34%) patients respectively.
year period representing 58% of vascular trauma15. Thrombosis was found in only in 1(2.17%) patient. Smith
and associates reported that thrombosis is more
In our study most of patients reached hospital between common after vascular repair ,23 but in our study only 1
6-12 hours 39(84.78%) patients. In recent study carried patient developed thrombosis. Rate of amputation was
out at Nishter Hospital Multan in which 52 patients of 71.42% when revascularization established after 12

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 PERIPHERAL VASCULAR INJURIES 59

hours but it dropped to 28.58%, when arterial repair was 9. Gasper MR, Treman LR. The management of injuries to
accomplished in 6-12 hours period. Fryberg and major veins. Ann Surg 1960 Jul; 100:171-75.

associates noted that gangrene was rare if repair done 10. Hardin WD, Adinolfi MF, Connel O, Kerstein RC.
within 6 hours but occurred in 50% cases if repair was Management of traumatic peripheral vein injuries. Ann
delayed for 12 hours24. Where as in study of Nishter Surg 1982 Oct; 144:235-38.
Hospital in 52 patients were studied showed that
11. Sullivan WG, Thornton FH, Baker LH, Chohen A.
61.56%cases reached the hospital after 8 hour and in
Influence of early popliteal vein repair in the treatment
these amputation rate was 38.46%. The rate of of popliteal vessel injuries. Ann Surg 1982 Feb; 140: 25-
amputation was 5% when repair was accomplished 38.
within 8 hours.16
12. Rich N. Management of venous trauma. Arch Surg 1988
Oct; 68:809-21.
CONCLUSION
All cases of peripheral vascular injuries should be 13. Hood DB, Weaver FA, Yellin AE. Changing perspectives
surgically explored. Every effort should be made to in the diagnosis of peripheral vascular trauma. J vasc
achieve revascularization within 12 hours. Patients Surg 1998 Dec; 11(4): 255-60.
presenting late or with crush injuries should under go
14. Knudson MM, Lewis FR, Atkinson K. The role of duplex
amputation.
ultrasound arterial im aging in patients with
penetrating extremity trauma. Arch Surg 1993 Sep;
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