Most injuries of the axillary artery arise from penetrating trauma. Associated brachial plexus injuries are present in 33% of patients. Beginning at the clavicle and ending at the lower axillary border, the axillary artery is divided into three parts by the pectoralis minor. Exposure of the vessel can be obtained by splitting the pectoralis major and dividing the minor at its insertion on the coracoid process. If additional exposure is required, the major can be divided medial to its humeral insertion and retracted medially. The extensive collaterals about the shoulder can produce a radial pulse even in the presence of an occlusive injury of the axillary artery. It is for this reason that patients with penetrating injuries of the axilla that manifest findings of brachial plexus injury should undergo angiography even in the presence of distal pulses.

Arterial injuries may be repaired primarily or with graft interposition with either polytetrafluoroethylene (PTFE) or vein. No difference exists in patency rates. It is thought to be better to interpose a graft rather than extensively ligate collaterals to effect a primary end-to-end repair. Patency rates are high. Limb loss is rare, but functional deficits are common. The functional deficits are generally not related to the vascular injury. Twenty-five percent of these deficits are secondary to musculoskeletal injury, and 64% are due to nerve injury. The axillary vein should be repaired if a simple repair is possible. If not, ligation can be done without complication. Ligation of the axillary artery, on the other hand, results in a 10% to 40% amputation rate.

Injuries of the brachial artery can be penetrating, blunt, and iatrogenic. The diagnosis is usually obvious in the case of penetrating injuries secondary to blood loss, which may be life threatening. These injuries lend themselves to external pressure control, which has usually been effected in the field by prehospital providers. Removal of these devices is best done in the operating room after volume replacement has been effected and blood has been drawn for type and crossmatch. Blunt injuries usually involve fractures and dislocation above the elbow. The supracondylar fracture of the humerus, which gives rise to Volkmann ischemic contracture, is the best known of these. The diagnosis is suspected due to the absence of radial and ulnar pulses, as well as ischemic changes in the hand. When these occur in children, repair is challenging because of the small size of the brachial artery in young children. Magnification is necessary. Vasospasm can be a confounding issue and is occasionally found at exploration to be the sole cause of the ischemia. In these cases, papaverine often produces gratifying results. Elbow dislocations, 80% of which are posterior, are associated with brachial artery injury in 10% of patients. The diagnosis is increased in open dislocations. The diagnosis is clinically obvious, and associated median nerve injury is common. Ligation results in an amputation rate of 40% secondary to disruption of periarticular collaterals by the injury itself. Reconstruction usually requires vein interposition secondary to the length of arterial injury. Venous reconstruction should be considered if possible. A low index for simultaneous forearm fasciotomy should be maintained with or without venous repair.

As with axillary artery injuries, functional impairment or amputation is rarely due to the brachial artery injury. Median nerve injuries are common due to its intimate association with the brachial artery throughout its course. Blunt nerve injuries encountered during the course of vessel exploration need not be addressed if the nerve sheath has not been disrupted. Functional recovery usually occurs without specific therapy. If the nerve has been transected, as in penetrating injury, reconstruction will be necessary. This can be done primarily at the time of vascular repair if the cut is clean. Alternatively, this repair can be delayed without compromising ultimate functional results. The nerve repair is accomplished by properly lining up the cut ends using surface blood vessels. Anastomosis is accomplished with magnification and 7-0 or 8-0 monofilament simple sutures in the epineurium. If secondary repair is elected, it should not be delayed beyond a month.

Controversy exists regarding the necessity for reconstruction in simple vessel injuries
of the forearm. Clinical evidence of ischemia obviously mandates repair versus ligation. However, distal ischemia accompanies single vessel injury in less than 5% of injuries.

Patency rates of ulnar and radial artery repairs range from 50% to 70%, and ischemic sequelae do not accompany postoperative single vessel occlusion. Thus a compelling argument for single vessel repair cannot be made.

With injury to both radial and ulnar arteries, amputation rates approach 40% without successful repair of one vessel. Thus, repair of at least one vessel is necessary.

End-to-end repair or venous interposition grafts produce the same patency rates. The method of repair is thus guided by the length of vessel injury. Concomitant venous repair is unnecessary, and ligation of forearm venous injuries is appropriate.

Injuries of the common femoral arteries can be blunt or penetrating, but unlike most other lower-extremity vascular injuries, they are not generally associated with underlying fractures or dislocations. The diagnosis is usually clinically obvious from hemorrhage, hematoma, or distal ischemia. Angiography is rarely indicated and is often precluded by hemodynamic instability. Injuries that occur near the inguinal ligament may be difficult to control through a standard groin incision. The situation is greatly simplified if proximal control is achieved at the level of the external iliac artery through a separate suprainguinal retroperitoneal approach prior to opening the groin. Once hemorrhage is controlled, reconstruction is accomplished with end-to-end repair or interposition grafting with polytetrafluoroethylene (PTFE).

PTFE is the preferred conduit in both blunt and penetrating injuries, despite the potentially contaminated states of all penetrating wounds. In grossly contaminated wounds, vessel ligation should be accompanied by extra-anatomic reconstruction via the obturator foramen.

Venous injuries frequently accompany the arterial injuries and should be repaired if this can be relatively simply accomplished. Commonly, the venous injury is technically impossible to repair. Common femoral venous ligation is a risk factor for amputation. However, injuries requiring venous ligation are generally more severe, and the risk the venous ligation itself poses is not entirely clear. Certainly, fasciotomy should be given very serious consideration if venous ligation is necessary, as early swelling invariably occurs. This generally improves in time as venous collaterals develop.

Clinically apparent injuries of the profunda femoris artery are unusual in blunt trauma with or without femur fracture. Undoubtedly, some of the thigh hematomas ascribed to femur fractures and soft tissue injury are related to profunda branch injuries that spontaneously cease bleeding. When hemorrhage persists, the presentation is unexplained hypotension, and it is frequently assumed to be due to associated pelvic fractures. As hemorrhage continues, a compartment syndrome develops in the thigh. The suspected diagnosis is confirmed by angiography. Angiographic embolization is effective treatment. Frequently, thigh fasciotomy is necessary to decompress the affected compartment.

Superficial femoral artery injuries are usually obvious because of distal ischemic findings. The location of the injury is predicted by the course of a penetrating injury or the site of fracture in blunt trauma. Angiography only serves to delay reconstruction and should not be done, unless the diagnosis is in doubt. Conversely, angiography should not be done for penetrating wounds that are near major vessels when there are no physical findings that suggest injury.

Reconstruction with vein, PTFE, or end-to-end anastomosis is acceptable and associated with good results.

Injury to the popliteal vessels is the vascular injury most frequently associated with amputation. Though perigenicular vascular injury accounts for only 10% of total vascular injuries, it accounts for 65% of the amputations. Limb amputations accompany ligation of the popliteal artery in 73% of cases. With current limb salvage techniques, amputation rates of 0% to 15% are reported.

Though the majority of reported popliteal artery injuries are due to penetrating trauma, the majority of amputations occur as a result of blunt injury. The diagnosis of popliteal artery injury in penetrating trauma can be made on the basis of clinical findings and angiography is unnecessary. Conversely, lack of physical findings excludes significant injuries and angiography is also unnecessary. In complex blunt injury, physical findings that mimic vascular injuries can be caused by bone, soft tissue, and nerve injuries. In these instances, angiography may prevent vessel exploration, which is unnecessary in as many as 87% of cases. The role of angiography in unstable blunt injuries of the knee is controversial. The incidence of popliteal artery injuries in supracondylar femur fractures, posterior knee dislocations, and tibial plateau fractures is 0.5%, 40%, and 2%, respectively. The extremely high frequency of vessel injury has led some to recommend angiography for all posterior knee dislocations unless critical ischemia is present. Proponents cite a missed injury rate of at least 5% in the presence of normal palpable distal pulses. Other studies state that the physical exam alone predicts the need for surgical intervention in 100% of cases either acutely or on follow up. Some of the disparity regarding the need for angiography relates to various opinions regarding the need for surgical correction of “minimal vascular injuries.” These mainly consist of small nonocclusive intimal flaps, or small pseudoaneurysms, which tend to spontaneously resolve without surgical treatment. The argument is that if surgical treatment of the minimal lesions is unnecessary, angiography to detect them is similarly unnecessary. They do emphasize the need for follow up to assure that no progression of these minimal lesions occurs. Current trends seem to be leaning away from routine angiography for knee dislocations in the absence of clinical evidence of vessel injury.

Arterial injuries are often accompanied by popliteal venous injury. Repair of these should be done if lateral suture or end-to-end anastomosis is all that is required. Injuries, which require more complex repairs should undergo ligation. Again, fasciotomy should be strongly considered if venous ligation accompanies arterial repair.

Repair of arterial injuries may be end-to-end anastomosis if it can be accomplished without tension. The approach is the standard medial approach both above and below the knee, as is the case for elective reconstructive procedures. As in elective vascular reconstruction, vein interposition is preferable to PTFE if the knee joint is traversed. Though it is sometimes tempting to sacrifice major collaterals in an effort to mobilize sufficient artery to facilitate end-to-end anastomosis, reconstruction by
interposition vein graft is preferable under these circumstances.

The incidence of arterial injuries below the knee is hard to assess. Given the large numbers of violent lower-extremity orthopedic injuries that are seen in trauma centers and relatively few patients that require reconstruction of the anterior or posterior tibial vessels, these vessels are either relatively resistant to injury or collateral circulation is sufficient to obviate physical findings suggestive of arterial injury. Thus arteriography is never done and the presence of injury is never confirmed.

The necessity for repair of tibial vessels is controversial. Some have said that vessel ligation is safe if at least one tibial vessel is patent. Others say that only peroneal vessels may be safely ligated. Amputation rates of 14% for single vessel injuries and 65% for injuries of both tibial arteries are cited as evidence for the necessity of complete reconstruction. However, nerve and soft tissue injuries, as well as nonunion of fractures, not ischemia, is commonly the reason for amputation. Proponents of multiple reconstructions would argue that these soft tissue and orthopedic problems are in fact the result of inadequate blood supply.