Controlling hemorrhage is the first priority, with close hemodynamic monitoring and judicious replacement of fresh, warm blood products in equal ratios. The patient should have broad antibiotic coverage and be positioned supine on a fluoroscopic table with at least one uninjured limb prepped for a vein harvest.
Proximal control of hemorrhage is often accomplished by firm digital occlusion using an assistant’s gloved hand prepped directly into the bleeding wound bed with povidone–iodine spray. This is followed by a careful dissection proximal and distal to the site of injury. Balloon catheters can also tamponade hemorrhage when a tourniquet or manual pressure is not effective, but blind insertion of surgical instruments can be unproductive or harmful and is discouraged. Tourniquets are left in place until the anesthetist has sufficient time to resuscitate the patient.
Proximal thigh injuries are best managed by division of the inguinal ligament or by the retroperitoneal approach with clamp control of the external iliac artery. For proximal axilla–subclavian wounds, sternotomy or left anterior thoracotomy and clamping of the subclavian artery eliminate the error of uncontrolled dissection through an expanding hematoma of the chest. The distal axillary and proximal brachial arterial injuries should be approached with infraclavicular incisions and should extend across the deltopectoral region into the upper arm as needed. The medial approach is preferred over the posterior approach for femoropopliteal injuries.
The approach in relation to the knee joint is directed by the level of the wound, but total division of muscular attachments at the knee is sometimes required to control hemorrhage of transected arteries and veins. Although often thrombosed at the time, these vessels must be found and ligated because they will rebleed later after the patient is resuscitated.
Retrograde advancement of a Fogarty catheter inserted from an uninjured distal site can also be used to locate the transected artery in a horrific wound that is no longer bleeding. A single bleeding tibial vessel can be ligated; however, injury to the tibioperoneal trunk or multiple vessels should be repaired.
Associated nerve, bone, and soft tissue injury are the essential determinants of limb salvage. When making a decision to amputate or salvage an extremity, consider the patient’s condition and extent of injury, and the surgeon’s willingness to commit the patient to the necessary definitive orthopedic care and physical rehabilitation. No one situation or scoring system can replace the surgical judgment developed by an experience team.
A primary end-to-end repair is preferred when lateral sutures cannot repair the injured vessel. Advantages of this repair include a single anastomosis and use of autologous tissue. Dividing nearby branches might gain some length in noncalcified vessels, but this repair should be both expedient and tensionless. Complete débridement of any disrupted tissue is an essential step of the repair, and sacrifices made to avoid an interposition conduit should be keenly resisted. The complexity and additional operative time required for vein harvest and interposition grafting or bypass should be appreciated, and the final operative plan and estimated time should be communicated early to the entire operative team.
The saphenous vein taken from an uninjured limb is the preferred conduit for the reconstruction of extremity vascular injuries. In the author’s experience, expanded polytetrafluoroethylene (ePTFE) prosthetic grafts placed in larger vessels with good muscle coverage have been used successfully.
Systemic anticoagulation is generally avoided for trauma except for an isolated vascular injury in a patient who has no coagulopathy or extensive soft tissue damage. Ballistic injuries transmit kinetic energy and result in intimal damage well beyond the transected arterial segment. Therefore, one should carefully open vessels longitudinally and inspect the quality of the luminal surface and the arterial inflow relative to the mean arterial pressure. When necessary, a Fogarty embolectomy catheter should be carefully advanced because tourniquets and limited heparin dosing easily result in thrombus accumulation. Special precautions should include routine flushing of the graft and native artery with heparinized saline to dislodge fibrin strands and platelet debris. This is best done with a solution of papaverine and warm heparinized saline.
A well-spatulated four-quadrant, heel-to-toe anastomosis is the easiest to perform in difficult situations. Small Heifitz clips or bulldog clamps can also minimize potential clamp injury.
There is documented value in repair of concomitant venous injuries to avoid the potential for early limb loss from venous hypertension or long-term disability from chronic edema. With combined arterial and venous injuries, arterial repair should precede venous repair to minimize further ischemic burden, unless the vein repair requires very little effort.
Shotgun or fragment injury produces large cavitary wounds; disruption of the skin and loss of underlying muscle can disadvantage attempts to achieve suitable graft coverage. When confronted with this situation, a longer vein graft tunneled completely around the zone of injury should be chosen over a shorter, poorly covered vein interposition conduit. Appropriately applied external fixation takes this issue into consideration, and this is an important matter to discuss before fasciotomy incisions are made.
Devitalized tissue is excised and irrigated under low pressure, with careful evaluation of muscle tissue for viability. Injured nerve tissue should be tagged at both ends with monofilament suture. A lengthy and meticulous débridement at the outset is not usually necessary because these wounds look much better in a few days after subsequent washouts and vacuum dressings.
A low threshold for performing a four-compartment fasciotomy should be maintained. This is usually performed first, and the length of the incision may vary with the clinical scenario, but an incomplete fasciotomy can be catastrophic. The application of vessel loops to prevent skin retraction and the use of negative-pressure dressings has made primary closure more successful and eliminated the need for routine split-thickness skin grafts.
Upper extremity injuries often have significant transfusion requirements. The arm swelling and wound expansion that can result underscores the importance of making a wide tunnel when routing a saphenous vein graft (Figure 1). Injuries below the profunda brachii are often well tolerated because of a rich collateral network unique to the upper extremity. A single-vessel injury in the forearm may be ligated unless an incomplete superficial palmar arch is detected by continuous wave Doppler probe. When both the radial and ulnar arteries are injured, repair of the ulnar artery is preferable because it is the dominant vessel.
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