kumar 2016

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168 15 Lower Extremity Vascular Trauma NEIL G. KUMAR, BRIAN S. KNIPP, AND DAVID L. GILLESPIE Introduction Vascular injury to the lower extremity is a common pattern of vascular trauma. Injuries to junctional zone vessels are espe- cially challenging and potentially lethal. Foremost, injury to the distal iliac and proximal femoral arteries and veins poses a challenge with hemorrhage control. The term junctional vascular injury was a product of the military’s recognition during the wars in Afghanistan and Iraq that, although tour- niquets were effective in controlling lower extremity hemor- rhage, they did not work if the penetrating wounds were too proximal on the lower extremity (i.e., the junctional zone between the torso and the lower extremity). Furthermore, injury to the distal iliac and proximal femoral arteries result- ing in hemorrhage is often very difficult for a medic or bystander to control with manual pressure because the vessels are either large or deep under the inguinal ligament and the distal pelvic outlet. Because of this injury pattern’s propensity for exsanguinating hemorrhage, the military has coined the term “junctional lower extremity vascular injury” to facilitate study and to improve management strategies. More distal injuries such as those to the femoral, popliteal, and tibial seg- ments may also lead to lethal hemorrhage; but from a practical standpoint these injuries are amenable to tourniquet control. Lower extremity vascular trauma at any anatomic level poses challenges not only related to control of bleeding but also with regard to decisions related to restoration of perfusion and reconstruction of the vascular injury. History and Background When considering those who died of combat wounds from 2001 to 2009, nearly 41% had potentially survivable injuries if hemorrhage had been controlled in a more prompt and effective manner. 1 In this context, potentially survivable death means mortality that occurred in the absence of a lethal head or cardiac wound or body disruption from explosive injury. The body regions accounting for death with otherwise surviv- able injuries include trauma to the torso (48%), to the extrem- ities (31%), and to the junctional region (21%). Table 15-1 shows the incidence of lower extremity vascular injury in mili- tary conflicts, past and present. The rate of exsanguination from torso trauma has decreased over the years possibly due to the use of body armor. Similarly, the rate of extremity hemorrhage has decreased likely due to the broad distribution, training, and use of tourniquets. 2-4 With improvements in body armor, which protects from central torso trauma, injury to the extremity vessels has contributed a larger percentage of overall vascular injuries. Lower extremity vascular injuries will likely continue to be common due to practical limitations associated with extremity and junctional zone armor. 5 Lower extremity vascular injury is also common in the civilian setting where injuries to the iliac artery and vein have a higher incidence than in the military setting. Mattox et al documented 232 iliac artery injuries and 289 vein injuries, representing 4% and 5%, respectively, of all vascular injuries in a single-center civilian registry. 13 Femoral and popliteal vessel injuries are more common than iliac vessel injuries in civilian trauma centers, which likely reflects their longer extent and exposed position. In a report by Branco et al femoral vessel injury comprised approximately 25% of all extremity vascular injuries. 14 Comparatively, Asensio et al reported femoral vessel injuries to be even more common, accounting for nearly 70% of peripheral vascular injuries. 15 However, in isolated lower extremity trauma, the most commonly injured artery is the popliteal, with the majority of injuries resulting from blunt mechanism. 16 Blunt injuries are more likely to be associated with orthopedic fractures or dislocations and likely to result in longer hospital stays and higher rates of amputa- tion than other lower forms of extremity arterial injury. 17 Similarly, the number of tibial artery injuries and the pro- portion of all vascular injuries they represent have increased in the past number of years. A recent single institution study of lower extremity vascular trauma reported that the tibial arteries were the most commonly injured vessels and accounted for 36% of cases. The most common mechanism of tibial artery injury is gunshot wound (37%) with motor-vehicle accidents (26%) contributing a significant portion as well. 13,18 Presentation and Diagnosis Assessment of a patient with a potential lower extremity injury or a junctional zone vascular injury follows a standard approach outlined in the Advanced Trauma Life Support (ATLS) program developed by the American College of Sur- geons (ACS) and its Committee on Trauma (COT). 19 Fore- most, control of bleeding with a tourniquet or manual pressure is necessary to prevent exsanguination. Depending on the location, if a standard Combat Application Tourniquet (C-A- T’ North American Rescue, LLC, Greer, SC) is not available, a manual blood pressure cuff may be inflated proximal to the injury to act as a tourniquet to control bleeding. As described, the vexing problem lies with junctional vascular injuries which are not amenable to tourniquet application and are difficult to control with manual pressure. In these instances, manual pressure with or without a topical hemostatic agent such as

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  • 168

    15Lower Extremity Vascular TraumaNEIL G. KUMAR, BRIAN S. KNIPP, AND DAVID L. GILLESPIE

    IntroductionVascular injury to the lower extremity is a common pattern of vascular trauma. Injuries to junctional zone vessels are espe-cially challenging and potentially lethal. Foremost, injury to the distal iliac and proximal femoral arteries and veins poses a challenge with hemorrhage control. The term junctional vascular injury was a product of the militarys recognition during the wars in Afghanistan and Iraq that, although tour-niquets were effective in controlling lower extremity hemor-rhage, they did not work if the penetrating wounds were too proximal on the lower extremity (i.e., the junctional zone between the torso and the lower extremity). Furthermore, injury to the distal iliac and proximal femoral arteries result-ing in hemorrhage is often very difficult for a medic or bystander to control with manual pressure because the vessels are either large or deep under the inguinal ligament and the distal pelvic outlet. Because of this injury patterns propensity for exsanguinating hemorrhage, the military has coined the term junctional lower extremity vascular injury to facilitate study and to improve management strategies. More distal injuries such as those to the femoral, popliteal, and tibial seg-ments may also lead to lethal hemorrhage; but from a practical standpoint these injuries are amenable to tourniquet control. Lower extremity vascular trauma at any anatomic level poses challenges not only related to control of bleeding but also with regard to decisions related to restoration of perfusion and reconstruction of the vascular injury.

    History and BackgroundWhen considering those who died of combat wounds from 2001 to 2009, nearly 41% had potentially survivable injuries if hemorrhage had been controlled in a more prompt and effective manner.1 In this context, potentially survivable death means mortality that occurred in the absence of a lethal head or cardiac wound or body disruption from explosive injury. The body regions accounting for death with otherwise surviv-able injuries include trauma to the torso (48%), to the extrem-ities (31%), and to the junctional region (21%). Table 15-1 shows the incidence of lower extremity vascular injury in mili-tary conflicts, past and present. The rate of exsanguination from torso trauma has decreased over the years possibly due to the use of body armor. Similarly, the rate of extremity hemorrhage has decreased likely due to the broad distribution, training, and use of tourniquets.2-4 With improvements in body armor, which protects from central torso trauma, injury to the extremity vessels has contributed a larger percentage of

    overall vascular injuries. Lower extremity vascular injuries will likely continue to be common due to practical limitations associated with extremity and junctional zone armor.5

    Lower extremity vascular injury is also common in the civilian setting where injuries to the iliac artery and vein have a higher incidence than in the military setting. Mattox et al documented 232 iliac artery injuries and 289 vein injuries, representing 4% and 5%, respectively, of all vascular injuries in a single-center civilian registry.13 Femoral and popliteal vessel injuries are more common than iliac vessel injuries in civilian trauma centers, which likely reflects their longer extent and exposed position. In a report by Branco et al femoral vessel injury comprised approximately 25% of all extremity vascular injuries.14 Comparatively, Asensio et al reported femoral vessel injuries to be even more common, accounting for nearly 70% of peripheral vascular injuries.15 However, in isolated lower extremity trauma, the most commonly injured artery is the popliteal, with the majority of injuries resulting from blunt mechanism.16 Blunt injuries are more likely to be associated with orthopedic fractures or dislocations and likely to result in longer hospital stays and higher rates of amputa-tion than other lower forms of extremity arterial injury.17

    Similarly, the number of tibial artery injuries and the pro-portion of all vascular injuries they represent have increased in the past number of years. A recent single institution study of lower extremity vascular trauma reported that the tibial arteries were the most commonly injured vessels and accounted for 36% of cases. The most common mechanism of tibial artery injury is gunshot wound (37%) with motor-vehicle accidents (26%) contributing a significant portion as well.13,18

    Presentation and DiagnosisAssessment of a patient with a potential lower extremity injury or a junctional zone vascular injury follows a standard approach outlined in the Advanced Trauma Life Support (ATLS) program developed by the American College of Sur-geons (ACS) and its Committee on Trauma (COT).19 Fore-most, control of bleeding with a tourniquet or manual pressure is necessary to prevent exsanguination. Depending on the location, if a standard Combat Application Tourniquet (C-A-T North American Rescue, LLC, Greer, SC) is not available, a manual blood pressure cuff may be inflated proximal to the injury to act as a tourniquet to control bleeding. As described, the vexing problem lies with junctional vascular injuries which are not amenable to tourniquet application and are difficult to control with manual pressure. In these instances, manual pressure with or without a topical hemostatic agent such as

  • 15 / LowER ExtREMIty VAScULAR tRAUMA 168.e1

    ABSTRACTVascular trauma of the lower extremities is associated with high rates of morbidity and mortality and is especially chal-lenging when it involves the junctional zone between the torso and the lower extremities. Lower extremity junctional injuries are those that occur to the distal iliac and proximal femoral vessels. In the absence of hard signs of injury, lower extremity junctional vascular trauma may be challenging to diagnose; and, in the presence of hard signs, they may be hard to control, expose, and repair. the successful man-agement of lower extremity vascular injury is dependent on early diagnosis and control of hemorrhage, resuscitation of the patient, and prompt intervention to minimize associ-ated ischemia. the most important factors in life- and limb-saving interventions relate to prompt control of hemorrhage and time to reperfusion in the setting of ischemia. the anatomic level of lower extremity vascular injury (iliac-femoral, femoral-popliteal, tibial), the severity of the mangled extremity, and the presence of associated injuries are also important factors influencing patient outcomes.

    KeyWords: lower extremity trauma, mangled extremity, tourniquet, vascular shunt, venous injury, arterial injury, amputation

  • 15 / LowER ExtREMIty VAScULAR tRAUMA 169

    setting of trauma and because the comparison may be between the occlusion pressure in an injured upper extremity to that in the noninjured upper extremity, this ratio is also referred to as the IEI. In the absence of vascular injury, the ratio of the occlusion pressures between the injured and noninjured extremities should be 0.9 or greater. An IEI of less than 0.9, especially in a patient with a normal contralateral IEI, indi-cates a flow-limiting abnormality and has been shown to cor-relate with identifiable arterial injury.

    Importantly, the IEI should be repeated in patients who are hypothermic and/or hypotensive as these factors may result in initial false negative ratios. The IEI should also be repeated in patients who have an extremity fracture or dislocation after the orthopedic injury has been reduced or aligned with trac-tion. In patients with these types of extremity injuries, the Doppler signal and therefore the IEI may improve with resus-citation, warming, and fracture reduction. However, an IEI that is persistently less than 0.9 should be considered to indi-cate arterial injury, and one should pursue further imaging or operative exploration. In most cases in which there are soft signs of vascular injury and a persistently diminished IEI further diagnostic imaging such as duplex ultrasound, CTA, or conventional arteriography is performed.20-23 In complex cases, arteriography should be performed in the operating room (OR) using a mobile or fixed fluoroscopic imaging system to provide access to all options including definitive operative exploration if necessary. In cases of extremity frac-ture or dislocation, performance of arteriography in the OR may be combined with procedures such as fracture reduction or fixation.

    JunctionalDistalIliacandProximalFemoralInjuries

    Injury to the external iliac vessels should be suspected in all penetrating injuries to the junctional zone including wounds to the lower quadrants of the abdomen, hips, buttocks, and groins (Fig. 15-1). Symptoms of iliac vessel injury are the same as those to the more commonly recognized lower extremity vessels but may also include abdominal distension, evidence of bowel injury (e.g., rectal blood), or a suggestion of genito-urinary injury (e.g., hematuria, blood in the vagina or at the

    Combat Gauze (Z-Medica Corporation, Wallingford, CT) and rapid operative control may be necessary.

    In the absence of significant hemorrhage, one has time to examine the lower extremity including assessing the femoral, popliteal, and pedal pulses. Palpation in the resuscitation room or intensive care unit is subjective and prone to false positive or negative recordings, and this portion of the exami-nation should be augmented with continuous-wave Doppler. The utility of Doppler ultrasound in the diagnosis of extrem-ity vascular injury is detailed in Chapter 5 of this textbook. At the time of palpation of pulses, the injured lower extremity should be assessed for hard or soft vascular injury. Hard signs are grouped as clear or obvious indicators of blood vessel disruption or occlusion and include pulsatile bleeding, expanding hematoma, palpable thrill, audible bruit or pro-found ischemia distal to the point of injury. Soft signs are suggestive of vascular injury but less obvious. These include reports of bleeding at the scene of injury, the presence of a peripheral nerve deficit, an injury pattern (including long-bone fracture or dislocation, indicative of vascular compro-mise), and injury in close proximity to a main or axial extremity vessel.

    In nearly all cases, the presence of hard signs of extremity vascular injury indicates the need for prompt operative inter-vention. In the presence of confounding factors such as pen-etrating wounds to multiple levels of the lower extremity, arteriography or other imaging such as duplex or computed tomographic angiography (CTA) may be appropriate even in the setting of hard signs. In the presence of soft signs of vas-cular injury, using the continuous-wave Doppler to calculate the injured extremity index (IEI) is necessary. Initially, the quality of the audible arterial signal in the distal aspect of the injured extremity (wrist, ankle and foot) gives the examiner information regarding the nature of perfusion to the limb. For example, a strong, clearly audible, bi- or triphasic arterial signal is typically normal and noticeably different than a weak monophasic signal, which may be an indicator of vascular injury. However, the quality of the audible signal is also some-what subjective and may be influenced by a patient who is cold and hypotensive. A more objective modality using the continuous-wave Doppler and a manual blood pressure cuff is the IEI.

    The IEI is a measure of the arterial occlusion pressure of the audible Doppler signal in the distal aspect of the injured limb compared to the occlusion pressure in one of the other noninjured extremities. This measurement or ratio is the same as the ankle-brachial index (ABI) that is used in the diagnosis of arterial occlusive disease in the lower extremity. In the

    FIGURE 15-1 Junctional zone penetrating injury with concomitant bowel injury.

    Table 15-1 Incidence of Lower Extremity Vascular Injury

    WarIliacVessels

    FemoralVessels

    PoplitealVessels

    TibialVessels

    world war I 1% 35% 12% 11%world war II 2% 21% 20% 20%Korean war 2% 31% 26% 18%Vietnam war 3% 35% 22% 0%Iraq and Afghanistan

    2% 28% 9% 10%

    Data compiled from the following references 5-12.

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    it may not be possible to determine the location of operation without contrast imaging. Physical examination alone has been shown to be associated with a false positive rate as high as 87%.26 The amputation rate for patients with blunt extrem-ity trauma has been reported to be extremely high due to missed injuries. Surgeons must maintain a high index of sus-picion for popliteal artery injuries in any patient with anterior or posterior knee dislocations, distal femur fractures or tibial plateau fractures. In some situations, the diagnostic adjunct of intraoperative arteriography may reduce the rate of nega-tive surgical exploration.25 Recent studies support a practice of selective arteriography and operative exploration based on IEI, duplex ultrasound, and CTA. The uses of this strategy contrast arteriography and operative exploration are reserved for instances in which one or more of these noninvasive modalities are abnormal. This selective approach to arteriog-raphy and operation for posterior knee dislocation has been shown to be safe and effective and has reduced the rate of negative or nontherapeutic exploration (Figs. 15-2 and Fig. 15-3).27

    TibialLevelInjuries

    The redundant nature of perfusion to the ankle and foot through three tibial arteries (anterior, posterior, and peroneal) means that vascular trauma at this level is better tolerated than that to more proximal levels of the lower extremity. In order for limb-threatening ischemia to result from trauma at this level, all three tibial vessels must be disrupted which is uncom-mon. In the civilian setting, patients with penetrating injuries to the leg (i.e., below the knee) have been shown to be less likely to present with signs of ischemia than those with blunt

    penile meatus). In the setting of penetrating lower abdominal or pelvic injury, the absence of femoral pulse(s) or a discrep-ancy between the femoral pulses should alert the provider to the likelihood of an iliac artery injury.

    The soft sign of a junctional vascular injury may initially be proximity of a lower abdominal or pelvic wound to the external iliac vessels. In these cases, the provider must have a high index of suspicion to pursue additional imaging or oper-ative exploration.24 Further imaging is not generally indicated in patients who are hemodynamically unstable with penetrat-ing lower abdominal or pelvic injury. Instead, these patients should be managed with operative exploration in conjunction with balanced, blood component-based resuscitation. In cases of penetrating lower abdominal trauma, exploration will require exploratory laparotomy to achieve vascular control and hemostasis. If patients with lower abdominal or pelvic injuries are hemodynamically normal, further imaging is useful and can include plain radiographs of the abdomen and pelvis followed by CTA. In addition to providing detail regard-ing intraabdominal and retroperitoneal structures and pelvic fracture, CTA may demonstrate contrast extravasation from or occlusion of an iliac or proximal femoral vessel. In these instances, CTA provides a quick and detailed assessment of injury allowing for better operative planning including the sequence of steps and the selective use of endovascular techniques.

    In contrast to penetrating trauma, iliac injury from blunt mechanisms often presents with more gradual, insidious blood loss. If the patient has an unstable pelvic fracture, early application of a pelvic sheet or binder is indicated and should precede additional diagnostic workup. Early application of a binder around the pelvis is especially useful in controlling venous bleeding associated with complex pelvic fractures and works by stabilizing the fracture and inducing tamponade. In some instances of pelvic fracture with hemodynamic instabil-ity, arteriography with the option of embolization of bleeding is helpful. This is especially true if contrast extravasation is observed from a branch or branches of the internal iliac arter-ies on the initial CTA. Increasingly, embolization of bleeding vessels can be pursued in an endovascular OR that is able to accommodate catheter-based procedures as well as traditional open operations.

    FemoralandPoplitealInjuries

    Patients with femoral or popliteal vascular trauma may present with hard or soft signs of injury. However, experience shows that most injuries in this location are accompanied by hemor-rhage and/or ischemia at some point following the event.15 In some cases, limb-threatening complications may result from overlooking or missing the hard signs of vascular injury because the active bleeding will have stopped or the degree of ischemia will be incomplete.25 Although most cases of femoral or popliteal trauma with hard signs require prompt operative intervention, contrast arteriography or CTA may be useful in more complex scenarios. In cases of mangled lower extremity with vascular and orthopedic components, the location of fracture(s) and vascular injury may be best determined with arteriography or CTA. Management of the extremity with multiple penetrating wounds at different levels of the limb may also be aided with arteriography and/or CTA before oper-ation. In these cases although hard signs of bleeding and/or ischemia may be present, the level of the injury and therefore

    FIGURE 15-2 computed tomography yielding diagnostic informa-tion regarding vascular status in light of significant potential artifacts.

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    metallic fragments may cause artifacts, which make interpre-tation of the adjacent vessels difficult. However, even in the presence of metallic artifact, MDCTA often provides impor-tant diagnostic information (Fig. 15-4). Inaba et al provided an important study of MDCTA and showed its value in man-aging severe lower extremity injury. In their study, only 1 of 63 scans was indeterminate due to retained metallic artifact; and the rest provided elements of important diagnostic infor-mation helping guide management. Furthermore, in their clinical series, three injuries distal to the knee were evaluated by conventional arteriography after MDCTA, and in all cases the arteriogram confirmed MDCTA providing no additional information. Moreover, in White et als analysis of MDCTA in the evaluation of vascular trauma, additional benefits were delineated. In this study, multiple extremities (i.e., simultane-ous) were evaluated in 15 of 20 CT studies. Most commonly, this meant both lower extremities were evaluated with one study, but an upper and a lower extremity could be evaluated simultaneously as well. This study also demonstrated that MDCTA was diagnostic in the presence of retained metallic fragments. Finally, the study by White and colleagues showed that MDCTA also provided useful diagnostic information in 8 of 10 patients with external fixator devices or intramedullary nails in place. Together, these experiences confirmed that MDCTA is a useful diagnostic option to detect vascular injury when one has a high index of suspicion, even in the absence of hard signs or a normal IEI examination.21,28

    JunctionalDistalIliacandProximalFemoralInjuries

    As stated previously, control of hemorrhage from junctional injuries can be difficult and must first be managed with direct compression. Operative exposure and/or control of junctional vascular injuries typically requires either an inguinal or a transplant incision (Fig. 15-5) to gain access to the external iliac artery and vein. Once exposed, the common or external iliac or common femoral arteries can be controlled using vas-cular clamps. Additional techniques and devices to rapidly apply pressure to junctional vascular injuries in the pre- and out-of-hospital settings have been developed including the Combat Ready Clamp (CRoC; Combat Medical Systems,

    trauma (33% vs. 68%, respectively). This observation may be partly due to the redundant nature of perfusion and the fact that penetrating wounds are less likely to affect all of the tibial arteries. In contrast, blunt trauma to the leg often results in complex tibia and fibula fractures (i.e., Gustillo fractures) which are more prone to injure all of the tibial arteries and result in ischemia.27 Studies have shown that when tibial vessels are injured by blunt mechanisms, they injuries are almost always associated with a fracture (97%). Blunt mecha-nisms leading to tibial vascular trauma may also result in open fractures with soft-tissue injuries (59% of cases) and periph-eral nerve injuries (53% of cases). Less commonly, penetrating trauma leading to tibial vascular injury is associated with frac-ture (31% of cases), soft-tissue injury (6% of cases), and nerve dysfunction (20% of cases).27 Like the diagnosis of popliteal artery injury, imaging of the tibial vessels should be performed selectively. In most cases, contrast arteriography and/or explo-ration of the tibial arteries is reserved for patients with persis-tent signs of ischemia such as a diminished IEI (

  • 172 SEctIoN 3 / DEFINItIVE MANAGEMENt

    second tourniquet should be applied to increase the effective tourniquet width. Kragh and others from the United States Army Institute of Surgical Research reported that the applica-tion and use of tourniquets to control extremity bleeding before the onset of shock resulted in lower mortality than application of tourniquets after the onset of hemodynamic instability.2-4 The importance of the proper application of the tourniquet cannot be overemphasized as incorrect placement is associated with mortality from hemorrhage. In addition to their effectiveness, properly applied tourniquets are safe. In a clinical series of 428 tourniquets applied on 309 severely injury limbs, the incidence of nerve palsy was 1.7%. There was no association with vascular thrombosis, myonecrosis, rigor, pain, fasciotomy, or renal failure.3 It is important to under-stand the success of tourniquets in the wars in Afghanistan and Iraq in the context of short medical evacuation and there-fore relatively short tourniquet times. Reports from those wars and clinical experience of the editors suggest that the vast majority of tourniquets applied during the wars in Afghani-stan and Iraq were in place for 2 hours or less. Clearly tour-niquet application and the potential adverse effects of complete limb ischemia for longer periods of time in future military or civilian scenarios will need to be reappraised.

    TibialLevelInjuries

    Tibial vascular injury may be the result of penetrating or blunt trauma and is most commonly associated with fracture of the tibia or fibula.27 The order or priority of injury management in these cases is dictated by the presence or absence of hemor-rhage and/or complete ischemia. In cases in which control of bleeding is difficult, exploration of the vascular injury with ligation of the vessel or placement of a temporary vascular shunt may be necessary before fracture reduction and stabili-zation. The same is true in some cases in which there is com-plete ischemia (i.e., no audible Doppler signal) of the leg below the injury. However, in most instances, fracture reduc-tion or traction and stabilization can be performed promptly and results in restoration of perfusion to the leg and foot. If evidence of arterial ischemia persists (i.e., IEI less than 0.9) after maneuvers to reduce and stabilize the fracture, further diagnostic evaluation such as CTA or arteriography may be required. Alternativelyand especially in the setting of open,

    Fayetteville, NC) and the Junctional Emergency Treatment Tool (JETT; North American Rescue, Greer, SC). These devices are designed to be placed on the patient by initial responders in the tactical environment (e.g., Tactical Combat Casualty Care) and include mechanical properties that allow compres-sion of the distal external iliac and proximal femoral vessels. The utility of the CRoC, JETT, and other emerging adjuncts to control junctional vascular injury has not been fully evalu-ated. However, promising reports on their efficacy have been registered from the terminal stages of the war in Afghanistan and anecdotal cases of civilian trauma. Despite successes asso-ciated with the development of a small number of junctional hemorrhage control devices, further research is needed to develop approaches or tools to control noncompressible torso and junctional hemorrhage at the point of injury and in the acute, out-of-hospital phase of care.

    FemoralandPoplitealInjuries

    In the case of extremity trauma, hemorrhage control strategies including tourniquets and topical hemostatic agents have been successfully codified in the Committee on Tactical Combat Casualty Cares (TCCCs) PreHospital Trauma Life Support (PHTLS) manual.29,30 Considerable detail on the con-tributions of the TCCC and the PHTLS manual is provided in the Chapter 15 of this textbook. The TCCC guidelines emphasize three objectives: Treat the patient, prevent addi-tional casualties, and complete the mission. Advances in the prehospital care of those with femoral and popliteal vascular trauma put forth by the TCCC include prompt hemorrhage control, establishment of intravenous or intraosseus access, and use of fluid resuscitation in only those patients who are in shock. Training and adherence to these and other PHTLS guidelines has been shown by Kotwal and colleagues to reduce preventable death in wounded service personnel.2

    If extremity hemorrhage cannot be controlled with direct pressure, prompt application of a tourniquet should be per-formed. Tightening of the tourniquet should continue until arterial bleeding from the limb has stopped or until distal pulses are no longer palpable (Fig. 15-6). If a single tourniquet is not successful in controlling extremity hemorrhage, a

    FIGURE 15-5 Bilateral tourniquets applied allowing transport for definitive surgical repair. the application of tourniquets prevents death from hemorrhage.

    FIGURE 15-6 Posterior knee dislocation.

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    Operative Strategy and TechniquePreparation begins with expeditious transport of the patient to the OR, because longer ischemic time is associated with higher amputation rates and poorer neuromuscular recovery. The surgical scrub and draping of the patient should be from the umbilicus to the toes of both lower extremities. Preparing the operative field to include the umbilicus and lower abdomen allows for retroperitoneal exposure and control of the iliac vessels if needed. Preparation of the contralateral lower extremity allows one to use saphenous vein from the nonin-jured extremity as conduit for vascular reconstruction if needed. Also, access to the contralateral femoral artery may be useful to perform percutaneous, transluminal arteriography of the injured lower extremity either as a pre- or completion step using an up and over approach. In rare cases, having access to the contralateral femoral artery can be useful as a source of inflow (i.e., cross femoral bypass) for complex femoral or distal iliac artery injuries.

    Regardless of anatomic level, lower extremity vascular reconstruction begins with exposure of the injured segment. Depending on the experience of the surgeon and the anatomic location of the injury, this may be preceded by obtaining remote proximal arterial control. Frequently junctional or proximal femoral vascular injuries require control at an unin-jured segment such as the iliac artery through a retroperito-neal exposure. Injuries in the popliteal fossa and those at the tibial trifurcation may also benefit from inflow control at a proximal, uninjured segment. In contrast, superficial femoral injuries in the thigh and those below the tibial trifurcation can often be controlled by extending any penetrating wounds and exploring the injured area directly.

    Once the injured segment of vessel(s) has been exposed and controlled, assessment should be made as to the extent of injury and adequacy of distal perfusion. The later aspect of this assessment is greatly aided by use of the continuous-wave Doppler machine in the OR. The spectrum of vascular trauma ranges from vessel contusion with degrees of thrombosis to transection with a missing segment. In considering manage-ment strategies, one must remember that ligation is a viable option in many scenarios. In other words management of lower extremity vascular trauma does not always require vas-cular reconstruction and restoration of flow through the injured segment. For example, injury of a tibial artery or a branch of the superficial femoral or profunda femorus arteries can often be ligated without compromising viability of the extremity. In these instances, redundant or collateral circula-tion often exists, which will keep the limb viable, even with a degree of ischemia, without repair of the injured vessel. Viabil-ity in these scenarios is most reliably predicted by assessment of capillary refill and with the presence of an arterial Doppler signal distal to the injury. Vessel ligation, with or without primary amputation, may also be a prudent damage control option in patients with a severely mangled extremity or those with a constellation of other life-threatening injuries or physi-ology. In these damage control scenarios, viability of the limb may not be of as much concern because amputation is accepted as a necessity to save the individuals life.

    If reconstruction of lower extremity vascular injury is planned, standard operative techniques should be used regard-less of anatomic level. The nature of vascular trauma means that the use of systemic heparin as an anticoagulant must

    penetrating woundsthe tibial vessel(s) can be explored and evaluated, directly obviating the need for additional imaging (Fig. 15-7).

    Helpful Considerations to Avoid Pitfalls

    Evaluation and diagnosis of the injured lower extremity should be preceded by hemorrhage control, initiation of resuscitation, and evaluation of life-threatening injuries.

    Junctional vascular injury carries a high mortality and must be considered in the setting of lower abdominal, pelvic, peroneal, and buttock wounds.

    Control of hemorrhage from proximal and junctional lower extremity trauma may be difficult to obtain using direct manual pressure and tourniquets.

    Physical examination of the injured and noninjured lower extremity should be performed using continuous-wave Doppler to improve sensitivity.

    CT angiography is a useful diagnostic adjunct, especially in patients with soft signs of lower extremity vascular trauma and who require CT imaging of the torso or head.

    The anterior compartment of the leg is the most com-monly neglected compartment in the performance of lower extremity fasciotomy. Care must be taken to ensure that this compartment is identified separately from the lateral compartment through the lateral leg incision. Opening of the anterior compartment exposes the muscles and anterior neuromuscular bundle, as well as the intermuscular septum, which separates the anterior and the lateral compartments. Both sides of this septum should be visualized assuring that both the anterior and the lateral compartments have been opened widely.

    FIGURE 15-7 transplant incision allowing rapid exposure of the iliac artery and vein. the artery is being mobilized using a vessel loop to explore the iliac vein for bleeding. (Courtesy Dr. Christopher T. Barry.)

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    not be narrowed with this approach. In most instances of extremity trauma, this type of lateral wall repair is not possible because the vessels are small by nature. If 50% or more of the vessel wall is uninjured, patch angioplasty using autologous vein or other synthetic material may be an option to allow repair and to prevent narrowing of the lumen. End-to-end anastomosis is another form of primary repair that can be used if the vessel is transected sharply. In order for primary, end-to-end repair to be possible, the vessel must approximate without tension (i.e., tension-free) after dbridement of the edges has taken place. Because extremity vessels are elastic and frequently spasm and retract in the setting of trauma, it is the exception that the edges will come together in a satisfactory manner. In these cases and in those where a segment of vessel has been transected with a missing segment, performance of an interposition graft is required. It is the authors and editors experience that most cases of significant extremity vascular injury and especially injury from penetrating gunshot or explosive mechanisms requires vessel resection and use of an interposition graft.

    Reversed saphenous vein is generally preferred as the conduit in instances where an interposition graft is required. Autologous vein is especially recommended in contaminated cases such as those with an open or penetrating mechanism. Synthetic conduit such as expanded polytetrafluoroethylene (ePTFE) or polyester (Dacron) may also be used for larger vessel (i.e., proximal) extremity vascular injury and may be preferred because of size match with the injured vessel. Expe-rience from the wars in Afghanistan and Iraq has demon-strated the effectiveness of saphenous vein as the conduit of choice for lower extremity vascular trauma. However, this same experience has highlighted challenges associated with the dismounted complex blast injury pattern that often results in one or more severely mangled lower extremities. In these cases, most if not all of the saphenous vein is injured or absent and therefore is not able to be used as conduit. In these sce-narios, creative use of temporary vascular shunts or synthetic conduits has been shown to be effective in the short term and midterm. In review of combat related registries, ePTFE grafts were used in 14 of 95 patients with complex lower extremity blast injury undergoing extremity vascular repair. Seventy-nine percent of these remained patent long enough to allow the patient to be stabilized and to be evacuated to a level 5 facility in the United States. In many instances, the patient then underwent a more deliberate evaluation, reoperation, and resection of the synthetic conduit in favor of remaining autologous vein. Importantly, in this experience there were no short- or midterm prosthetic graft disruptions, amputations, or deaths due to graft failure confirming the utility of this damage control approach (i.e., prosthetic first followed by resection and use of vein later) in select injury patterns.31 Extraanatomic bypass using synthetic conduit routed remotely from the zone of injury should also be considered in some injury patterns in which in-situ vein interposition graft place-ment is not possible.32

    Considerations for Extremity Venous InjuryThe management of extremity vein injury proceeds along similar lines as those for arterial injury with the options being repair and restoration of venous outflow versus ligation.

    occur on a selective and sometimes partial basis. In instances of isolated lower extremity vascular trauma with limited soft-tissue damage, use of full-dose heparin before and during the vascular reconstruction is often possible. In contrast, patients with lower extremity vascular trauma who also have torso or head injuries or larger, complex soft-tissue wounds are not able to receive systemic heparin. As such, while preferable in all cases, the use of anticoagulation is a judgment call made by the operative surgeon in close communication with the anesthesia, neurosurgical, and other specialty providers. When considering the use of heparin, one should recognize and make use of the benefit of limited amounts of local and regional heparin that can be used on and infused proximal and distal to the segment undergoing repair.

    One must also open and inspect the vessel and dbride the injured segment until normal vessel wall is present (Fig. 15-8). Intraluminal platelet aggregate and thrombus must be removed directly using forceps or with a Fogarty thromboem-bolectomy catheter and diluted amounts of heparin flush (i.e., heparinized saline). As mentioned, this same dilute heparin should be gently instilled proximal and distal to the controlled vascular segment to reduce the incidence of thrombus forma-tion during assessment and repair. Lower extremity vascular reconstruction generally consists of primary repair, patch angioplasty, or placement of an in-situ interposition graft. Bypass with ligation of the intervening injured segment is another option that may be used with popliteal and tibial level arterial injuries. Regardless of the method, fine monofilament suture and surgical loupe magnification are central to most attempts at vascular reconstruction.

    Lateral arteriorrhaphy (or venorrhaphy) is a method of primary repair that can be pursued if the vessel diameter will

    FIGURE 15-8 Angiogram of popliteal artery after posterior knee dis-location (prior figure).

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    oping transient edema and with none progressing to perma-nent sequelae.36 Kurtoglu et al recommended that patients with extensive extremity vein laceration should undergo liga-tion coupled with judicious use of leg fasciotomy, with eleva-tion of the limb, with compression, and with monitoring for progression of deep venous thrombosis. This same group reported that despite concomitant arterial injury requiring revascularization, extremity vein ligation resulted in mild venous morbidity (CEAP Classification C2-C3) in 60% of their series.37

    In contrast, a number of studies have touted the advantages of extremity vein repair, suggesting that this approach may play a role in recovery from a major trauma. Parry et al exam-ined the short-term patency of several methods of extremity vein repair in a civilian trauma setting and found a patency rate of nearly 75% regardless of the type of reconstruction (primary repair, vein patch angioplasty, interposition graft).34 This group also reported that a large number of venous repairs that had thrombosed in the early time period went on to recanalize over time. In a longer follow-up study, Kuralay et al reported that patency was predicted by the anatomic position of the venous injury rather than by the type of repair.38 This group took advantage of excellent follow-up of military per-sonnel in the Turkish Health System to compare short- and long-term results of venous repair in the lower extremity. At an average of 6 years following injury and vein repair, this group reported patency rates of the common femoral, the femoral, and the popliteal veins to be 100%, 78%, and 60%, respectively. Notably all infrapopliteal veins in this series were found to be thrombosed shortly after the time of repair. This group suggested that higher venous flow in the larger, more proximal veins was largely responsible for the improved patency. It is also worth noting that there may have been a technical advantage to repair of the larger veins compared to the smaller more distal veins, which often present significant challenges because of their diminutive sizes. As mentioned previously, in the largest review of military venous repair since the 1970s, Quan et al from Walter Reed reported a short-term patency of 85% with no increased rate of venous thrombosis or thromboembolism in those having had repair.39

    JunctionalDistalIliacandProximalFemoralInjuries

    Exposure of the iliac vessels can be accomplished via an ante-rior, inframesocolic, transperitoneal approach by dissection of the peritoneum of the paracolic gutter and by medial rotation of the ascending (right iliac) or descending (left iliac) colon (Fig. 15-9). The external iliac arteries are relatively protected by the walls of the pelvis as they rise to join the common femoral arteries underneath the inguinal ligaments. The main side branch of the external iliac artery is the inferior epigastric, although the distal external iliac artery is also crossed by the lateral circumflex iliac vein at the inguinal ligament. As with other vascular injuries, direct pressure should be utilized to control any obvious sources of bleeding. Proximal control is gained by applying clamps to the common iliac artery. It is worth noting that hurried, blind application of vascular clamps to vessels that are not dissected or exposed is often fraught with problems, including injury to adjacent vascular structures. This scenario is particularly problematic in the iliac position because of the direct apposition of the iliac veins underneath and alongside the iliac arteries. As such, one must

    Ligation of extremity venous injury is better tolerated and performed much more commonly than arterial ligation, although repair of larger, proximal venous injuries should be considered in some scenarios. Specifically, repair of popliteal, superficial, and common femoral vein injuries should be con-sidered to reduce acute venous hypertension and longer-term morbidity if the injuries are isolated and amenable to repair and if the patient is in good physiologic condition. Experience from the wars in Afghanistan and Iraq has shown the utility and effectiveness of this selective repair strategy (i.e., repairs some but not all) for more proximal vein injuries. The group from Walter Reed demonstrated a near-85%, 2-year patency of venous repair and a trend toward reduced symptoms of chronic phlegmasia in those having been afforded venous repair. Importantly, that experienced showed no increased incidence of venous thrombosis or pulmonary thrombembo-lism in the cohort of patients undergoing extremity vein repair.33

    Extremity vein injury in the multiply injured patient who is in poor physiologic condition should be ligated. Similarly, complex extremity vein injuries that require long segment interposition grafting or use of synthetic conduits should be managed with ligation in most instances. A temporary vascu-lar shunt may provide an interval option for some larger, more proximal vein injuries. In this setting, shunts allow for contin-ued venous outflow (i.e., decompression) while the patient is resuscitated, and the surgeon has the opportunity to consider the definitive management strategy, be it reconstruction or ligation. In order for venous shunts to be effective for more than a few hours, experience suggests that the patient will need to be dosed with systemic heparin to avoid shunt thrombosis. Maintaining venous patency and outflow with or without the temporary use of a vascular shunt is especially important in certain watershed or gatekeeper veins such as the popliteal vein; in the confluence of the deep, superficial, and common femoral veins; and in the iliac vein. Parry et al used temporary vascular shunts in the management of 18 extremity vein inju-ries 16 of which went on to venous repair after shunt removal. As part of their advantage, placement of temporary vascular shunts is generally quick and allows for manipulation and stabilization of concomitant orthopedic fractures before the shunt is removed and consideration given of vascular repair.34 Lateral venorrhaphy is the simplest method to repair venous lacerations while end-to-end anastomosis and patch veno-plasty are useful for repair of veins without segmental loss. For injuries that destroy large portions of the vein, an interposi-tion graft using autologous vein or prosthetic conduit is the preferred approach. As noted previously, modern experience from Walter Reed confirms observations first made in the Vietnam War that repair of extremity venous injuries does not increase the incidence of thrombophlebitis or pulmonary thromboembolism.35

    Those who advocate for routine ligation of extremity vein injury take the point of view that the immediate side effects are few and manageable and that the long-term complications are mitigated by the development of venous collaterals. Pro-ponents of ligation also show that symptoms of acute venous hypertension can be alleviated by extremity elevation and by use of compression stockings. Timerblake and Kerstein reported that 64% of patients with isolated femoral venous injury and 59% of those with concomitant arterial injury underwent ligation with only one third of the patients devel-

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    FIGURE 15-9 Surgical anatomy of junctional zone. IMA, Inferior mes-enteric artery; SMA, superior mesenteric artery.

    Phrenic arteryCeliac artery

    SMA

    Leftrenal vein

    Testicular(ovarian) vein

    Testicular(ovarian) vein

    Testicular(ovarian) arteryIMA

    Ureter

    IVC

    FIGURE 15-10 Surgical retroperitoneal exposure of iliac vessels.

    Common iliac artery

    External iliac artery

    Aorta

    Reflectedperitoneal cavity

    be careful to place the proximal iliac clamp only on the artery and not to inadvertently injure the adjacent vein because of chaos surrounding the patients presentation. If necessary, proximal control may be gained by initial cross-clamping of the distal aorta. Division of the inguinal ligament may also be necessary for distal control of junctional zone vascular

    injuries. Careful dissection is necessary to isolate and control the internal iliac artery to stem retrograde or cross-pelvic bleeding. During dissection, one must also take care to iden-tify and avoid injury to the ipsilateral ureter which crosses over the anterior surface of the iliac artery at the pelvic rim. Careful dissection starting at the most proximal and distal points of exposure and moving toward the center of the field can help one isolate the location of vascular disruption and also the internal iliac artery.

    In the case of iliac and/or junctional femoral vascular injury from penetrating trauma, exposure and control can also be achieved via a retroperitoneal incision (Fig. 15-10). The curvilinear incision in this scenario starts above the pubic bone, extends laterally and cranially, and passes along the edge of the rectus abdominus muscle. The incision is deepened using the lateral edge of the rectus as a guide proceeding in the lateral extraperitoneal plane, reflecting the peritoneum and abdominal contents medial. This incision can be done fairly quickly to gain access to the iliac vessels and to apply proximal control. However, this exposure is extraperitoneal and will not allow exploration of the abdominal cavity. The authors use this exposure frequently because it can be per-formed rapidly and can allow good visualization of lower extremity junctional zone injuries.

    Ligation of one internal iliac artery is generally well toler-ated and does not result in the severity of ischemic conse-quences as seen when ligating the common or external iliac artery. Ligation of the common or external iliac artery should be considered in only the most extreme situations as a life-saving maneuver. Ligation at this proximal inflow point to the extremity is poorly tolerated and results in a high likelihood of proximal limb loss. Interval arterial repair is also poorly tolerated, possibly due to the severity of reperfusion injury. The use of a temporary vascular shunt may be beneficial and should be considered to restore or to maintain perfusion through the iliac or iliofemoral segment in complex scenarios in which the patient has other life-threatening injuries or

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    done in combination with a two-incision, four-compartment fasciotomy of the leg to monitor viability of the extremity musculature and to reduce the risk of compartment syn-drome. If or when a patients condition stabilizes, consider-ation should be given to an operation that would provide inflow to the extremity such a cross-femoral (femoralto- femoral) bypass with 8-mm ringed ePTFE. If the patient will not tolerate further operative procedures, resuscitation should proceed in the surgical intensive care unit; and consideration should be given to a return to the OR for extraanatomic bypass or amputation at the earliest possible time.

    FemoralandPoplitealInjuries

    The common femoral artery and vein are exposed via a lon-gitudinal incision beginning at the inguinal ligament. The proximal position of the incision to expose the common femoral artery can be estimated by locating and visualizing the midpoint of the inguinal ligament. The incision is extended caudal 8 to 10 cm but may be extended as necessary for proxi-mal or distal exposure, control, and repair of injuries (Fig. 15-13). Areas of hematoma or wounds should be avoided initially until after proximal and distal control is achieved. In the setting of vascular injury with occlusion or disruption of the superficial femoral artery, the perfusion from the profunda femoral artery often is not sufficient to prevent ischemia of the lower leg. As noted previously, the continuous-wave

    adverse physiology. If possible, maintaining flow through a vascular shunt would be preferable to damage control ligation in such a scenario. A large shunt such as a 14 Fr Argyle or even a 14 or 16 Fr pediatric chest tube may be inserted into the ends of the injured iliac vessel after they have been flushed in an antegrade and retrograde manner to restore extremity perfu-sion. The shunt may be secured to the artery using heavy silk sutures (Fig. 15-11), and a third suture can be tied in the midportion of the shunt to aid in positioning and removal. The midline suture may also provide a vantage point to discern whether or not the shunt has migrated distally (Fig. 15-12). This same sequence of steps may be used to insert a smaller shunt in a more distal extremity vascular injury (e.g., superfi-cial femoral or popliteal) to limit extremity ischemic time until formal vascular repair can be considered and performed. Because they limit the burden of extremity ischemia, tempo-rary vascular shunts have been shown to be associated with lower mortality and with lower amputation rates compared to arterial ligation.40

    When no other options are available and it is necessary to save the patients life, the common or external iliac artery may be divided and oversewn with a double row of sutures above the level of injury. This damage control maneuver should be

    FIGURE 15-11 temporary intravascular shunt as applied in the superficial femoral artery.

    FIGURE 15-12 temporary intravascular shunt with midline suture tied at the time of application. on reexploration, migration is obvi-ously seen.

    FIGURE 15-13 Surgical anatomy of femoral vessels.

    Ext. iliac a.Deep iliacSuperf. iliaccircumflex a.

    Superf.epigastric a.Ascend. branch lat.circumflex a.Transverse branch lat.circumflex femoral a.Lat. circumflexfemoral a.Descend. branch lat.circumflex femoral a.

    Perforating branchesdeep femoral a.

    Rightcommon iliac a.

    Int. iliac a.Superiorgluteal a.

    Inf. gluteal a.Commonfemoral a.

    Obturator a.Medial circumflexfemoral a.

    Superf.femoral a.

    Deep femoral a.

    Descend.genicular a.

    Lat. sup. genicular a.

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    Doppler should be used in these scenarios to assess for the presence of an arterial signal in the foot before or at the time of operative exploration. Control of the profunda femoris artery is gained in the same incision and exposure. The origin of the profunda is most commonly on the posterior lateral aspect of the common femoral artery. Approximately one third of patients have a dual profunda origin with the second orifice arising from the posterior common femoral artery. Of note, the lateral circumflex femoral vein crosses the proximal portion of profunda artery and should be identified, ligated, and divided to facilitate proper exposure of the profunda and avoid inadvertent venous injury. Injuries to the profunda femoral artery should be repaired if this can be accomplished relatively expeditiously in an otherwise-stable patient. Options include direct repair, placement of an interposition graft or proximal ligation and distal reimplantation to the superficial femoral artery. If this is not possible, ligation should be per-formed. In the young patient, acute ligation of the profunda femoral artery is generally well-tolerated if the superficial femoral artery is uninjured. In a report by Woodward et al on methods of repair of femoropopliteal injury during Operation Iraqi Freedom (OIF), no patients undergoing profunda femoral artery ligation progressed to require amputation.6

    The mechanism of injury will often dictate the type of vascular reconstruction. Stab wounds or laceration injuries are often able to be repaired by using lateral suture or endto-end primary methods. Gunshot wounds or pene-trating injuries from explosive mechanisms often require arte-rial dbridement to uninjured aspects of the vessel and placement of an interposition graft. As noted previously, the favored conduit in these scenarios is autologous saphe-nous vein. However, use of a synthetic vascular graft is acceptable in certain scenarios in which there is no saphenous vein or in which the available saphenous vein is being saved for a later, more-definitive reconstruction (i.e., interval reconstruction).31,41

    In order to expose the popliteal space, the knee is flexed or bent slightly (i.e., frog leg position); and a soft roll or bump is placed behind the leg, below the knee to elevate or suspend the thigh. This maneuver makes it such that the medial mus-culature of the thigh pulls freely away from the femur and allows gravity to open up the above-knee popliteal space. Con-versely, to expose the below-knee popliteal space, the soft roll or bump is placed above the knee such that the muscles of the gastrocnemius and soleus muscles pull freely away from the tibia. While these maneuvers may seem rudimentary, they are absolutely essential to be successful in this challenging ana-tomic exposure. Failure to flex the knee and move the elevat-ing bump or roll of towels in this manner will result in the surgeon attempting to expose an inaccessible popliteal space that is compressed closed on the OR table.

    Once the lower extremity has been positioned in such a manner to expose the above-knee popliteal space, an incision is placed on the anterior border of the sartorius muscle (Fig. 15-14). The muscle is retracted posterior or down to expose the popliteal space, which contains the neurovascular bundle. The popliteal vein is generally medial to and covering the artery and therefore encountered first in the exposure. Ten-donous attachments of the adductor magnus muscle can be divided if necessary for improved proximal extent of exposure (Fig. 15-15). A medial incision 2 to 3 fingerbreadths posterior to the medial edge of the tibia will initiate exposure of the

    FIGURE 15-14 Surgical anatomy of popliteal vessels including bony landmarks.

    Femoral a.

    Descend.genicular a.

    Post. tibial a.

    Inf. medialgenicular a.

    Superior medialgenicular a.

    Articular branchesdescend. genicular a.

    Descend. branchlat. circumflex

    femoral a.

    Popliteal a.

    Superior lat.genicular a.

    Inf. lat. genicular a.

    Ant. tibialrecurrent a.

    Ant. tibial a.

    FIGURE 15-15 Surgical exposure of popliteal vessel via medial incision.

    Medial approach

    Vastus medialis m.

    Vastus medialis m.

    Popliteal a.

    Popliteal a.Popliteal v.

    Popliteal v.Sartorius m.

    Medial headgastrocnemiusm.

    Cut ends ofmedial headgastrocnemiusm.

    Tibial n.

    Popliteal vv.

    A

    B

    below-knee popliteal space. Care should be taken not to divide the saphenous vein in this location as it generally lies just under the skin in this medial incision. Division of the proximal-most portion of the medial head of the gastrocnemius and its attachments to the tibia will facilitate opening of the below-knee popliteal space. After these initial maneuvers above and below the knee have been accomplished, one should spend time positioning and repositioning deep, narrow, handheld retractors and performing further dissection of the popliteal vessels. The uses of Weitlaner and/or Henly popliteal retractor instruments will also be necessary to spread open the popliteal space as widely as possible. The Henly retractor has a set of blades with adjustable depths that often facilitate opening of the above- and below-knee popliteal spaces.

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    trauma. In contrast, injury to the distal-most popliteal artery or to the tibial peroneal trunk may result in more complete leg ischemia. When managing tibial vascular injuries, one must control bleeding, reduce any fractures, warm and resus-citate the patient, and examine the foot with continuous-wave Doppler. In most cases after these maneuvers an arterial signal will be present in the foot indicating viability and obviating the need for additional maneuvers. If there is no Doppler signal after these steps, one must consider that there may be injury to more than one tibial vessel or to the tibial peroneal trunk. The options in this scenario are (1) to attempt to restore flow with a small caliber, temporary vascular shunt, (2) to perform vascular reconstruction with a below-knee poplitealto-tibial bypass or interposition graft using saphenous vein, or (3) to accept ligation and to continue expectant management.

    An analysis of combat-related tibial injuries by Burkhardt et al demonstrated the effectiveness of a selective revascular-ization approach to tibial arterial injuries (i.e., repair some but not all). Burkhardt and colleagues confirmed that a portion of patients with tibial vessel injury can be managed with ligation and expectant observation without increased rates of amputation. In this experience, the amputation rate in the patients managed with no reconstruction (22%) was no different than that in patients who underwent tibial level arterial reconstruction (19%). Presenting factors that were associated with the need for subsequent tibial level vascular reconstruction were occlusion of more than one tibial artery, lack of Doppler signal in the foot, and a less-severe Injury Severity Score (ISS) of 16) were less likely to undergo tibial level reconstruction confirmed effective use of the damage control approach of ligation and expectant man-agement.7,43 In this context, one should be mindful that in some cases primary amputation should be performed when ischemic damage has been present for more than 6 hours or when the severity of the mangled extremity is such that there is severe orthopedic injury to the foot and/or ankle with asso-ciated injuries, which would preclude a safe attempt at limb salvage.27

    Postoperative CarePostoperative care of the junctional zone and lower extremity vascular trauma patient requires excellent communication between the various surgical teams, the intensive care team, and the nursing staff. Standard intensive care monitoring of critically ill trauma patients is initiated for the first 24 hours postoperatively. Pulse and Doppler signal exams are per-formed hourly in conjunction with vital signs. The location and quality of the pulse (weakly palpable or strongly palpable) or the Doppler signal (monophasic, biphasic, triphasic) is documented in the postoperative note by the attending surgery team. Change in the vascular examination or signs of bleeding warrant either open surgical exploration or angiography depending on the hemodynamic stability of the patient.

    Mechanical thromboprophylaxis in the form of pneumatic compression devices is initiated along with subcutaneous

    If after intentional efforts have been made to dissect and retract the popliteal space and vessels cannot be seen, the tendons of the semimembranosus, semitendinosus, and graci-lis muscles may be divided to improve exposure. While it is acceptable to divide these structures, doing so carries some morbidity; and it may not be necessary in some cases. There-fore the authors generally start this exposure without dividing these tendonous attachments and make an intentional effort to control and expose the popliteal space with more moderate steps. If the nature of the injury or body habitus of the patient are such that more extensive dissection is required, the tendons of these muscles are divided.

    TibialLevelInjuries

    The tibial vessels originate at the end of popliteal artery below the tibial plateau of the knee. The majority of limbs (91%) have a redundant branching pattern that has the anterior tibial artery as the first branch and the tibial-peroneal trunk giving rise to the posterior tibial and peroneal arteries. Other branch-ing patterns are also seen. For example, approximately 3% of limbs do not have a true tibial-peroneal trunk and instead have a true trifurcation of the anterior tibial, posterior tibial, and peroneal arteries. Perhaps of more importance in vascular trauma is the anatomic variant with altered perfusion to the foot. Hypoplasia of the posterior tibial artery or anterior tibial artery has been reported in about 1% of limbs. These cases may be identified only by use of continuous-wave Doppler ultrasound and in such rare cases it is paramount to recognize that the peroneal artery may be the only perfusion to the foot.42

    The posterior tibial and peroneal vessels, which lie in the deep posterior compartment of the leg, are best approached through the medial incision previously described. This inci-sion is made 1 to 2 fingerbreadths below the medial edge of the tibia, again with care taken not to injure the saphenous vein. The incision may be a continuation of the original below-knee exposure or made separately depending on the location of injury. The skin, subcutaneous tissue, and super-ficial fascia are all incised to open the posterior superficial compartment of the leg. The attachments of the soleus muscle to the medial edge of the tibia must be incised longitudinally along the length of the tibia to enter the posterior deep com-partment of the leg which contains the posterior tibial and peroneal arteries. The posterior tibial artery is medial to the peroneal and is therefore the first to be encounter through the medial approach and dissection.

    The anterior tibial artery and vein are in the anterior com-partment of the leg and are exposed and controlled via a longitudinal, lateral leg incision. The incision and division of fascia open the anterior and lateral compartments, which are separated by an intermuscular septum. The anterior tibial artery lies deep in the anterior compartment underneath the anterior tibialis and extensor muscles and on the surface of the interosseous membrane with the deep peroneal nerve. Typically, to locate this neuromuscular bundle, one bluntly develops a plane between the anterior tibialis and the extensor muscles. Because of the close proximity and the narrow space between the tibia and fibula, exposure of the anterior tibial vessels is very difficult as one moves more distal on the leg.

    As stated, the redundant nature of circulation to the foot makes it likely that control with ligation and Doppler assess-ment will be the maneuver of choice for isolated tibial vessel

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    thrill, or audible bruit long after the initial injury. In some instances, it is feasible to use duplex ultrasonography to diag-nose associated venous injuries. Ultrasound is an excellent modality because of its ease of use, noninvasive nature, and immediate results. However, for situations with extensive soft-tissue or orthopedic injuries, ultrasound may not be feasible. In these cases, computed venography is a viable alternative.

    JunctionalDistalIliacandProximalFemoralInjuries

    Prompt management and repair of common femoral artery trauma has encouraging results. Nationwide, mortality from common femoral artery injury in patients with isolated lower extremity trauma is low (7.5%). Those that died were hypo-tensive on arrival and had Glasgow Coma Scale (GSC) scores of 3, even in the absence of associated head injuries.9 Postop-erative complications are common (23%) and include wound infections (15%), venous thrombosis (3%), postoperative hemorrhage (2.5%), acute respiratory distress syndrome (ARDS) (2%), and arterial thrombosis (0.5%). Factors associ-ated with an increased risk for postoperative complications included ISS greater than 25, deranged physiology in the OR (acidosis, hypothermia, hypotension, coagulopathy) and the presence of other injuries.8

    Leg fasciotomy following femoral vessel injury is consis-tently reported to be around 25%.44,45 The need for calf fasci-otomy is increased in concomitant venous and arterial injury as compared to arterial injury alone (33% and 13%, respec-tively).8 Other factors associated with fasciotomy include increased resuscitation with packed red blood cells (PRBCs) (8.2 units versus 1.8), plasma (3.7 versus 0.8), platelets (0.5 versus 0.1), dislocation, and open fracture.7

    Overall, amputation rate is substantial (from 15% to 35%) with femoral artery injury.46 Primary amputation is reserved for the situation where limb salvage is impossible, such as in the mangled extremity, in extensive gangrene, and in muscle necrosis. Blunt-injury and high-velocity firearm injuries are associated with higher delayed amputation rates compared to other mechanisms of injury. Likely, this is due to the increased force in these types of injuries, which causes associated nerve and soft-tissue damage. In terms of vascular revascularization procedure performed, the only association with increased amputation rates was reexploration and failed revascularization.46

    FemoralandPoplitealInjuries

    Popliteal artery injury is associated with lower mortality than injuries to the common femoral artery and superficial femoral artery, but is also associated with a higher incidence of ampu-tation.9 As seen from the military experience, ligation is poorly tolerated and has a high rate of limb-loss.8,9 However, using modern vascular surgical technique and minimizing warm ischemic time, increased limb salvage can be achieved with repair.

    TibialLevelInjuries

    In penetrating trauma, prompt revascularization for ischemic limbs in tibial artery injury affords excellent results. Revascu-larization to a single target is sufficient to provide flow to the lower leg. Ligation and/or observation in single-vessel injuries is well tolerated as long as collateral circulation is confirmed before the ligation, preferably by arteriography. Some double

    prophylactic dosing of low molecular weight heparin if the risk of bleeding is sufficiently low. If there has been an extrem-ity venous injury treated with ligation, the leg should be ele-vated and wrapped from the toes to the groin with a compression wrap cutting openings to monitor the arterial pulse or the Doppler signal. The entire extremity must be monitored for viability and compartment syndrome in the first 24 to 72 hours, even if a leg fasciotomy has been per-formed, as a small risk of compartment syndrome in the thigh still exists.

    ComplicationsThrombosis or occlusion is the most notable complication following repair of an extremity vascular injury. Primary repair of small vessel injuries is less likely to result in this complication than the use of longer prosthetic grafts although many other factors play into this possibility. Frequent postop-erative pulse examination with early recognition and manage-ment of this complication is necessary to reduce morbidity. When prosthetic vascular grafts are used, special attention for signs of graft infection is needed. While graft infection in the immediate postoperative period and in the short term are not highly reported, ominous signs include fever, leukocytosis, and continued bleeding. When graft infection is suspected, the process of removal and revascularization through clean surgi-cal fields is the operation of choice (Fig. 15-16).

    For later manifestation of venous injury, imaging modali-ties are the keys to discovery. Traumatic arteriovenous fistulae may manifest with tenderness, edema, varicosities, palpable

    FIGURE 15-16 computed tomography showing extraanatomic bypass through clean surgical fields after excision of infected bypass graft.

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    ConclusionExtremity vascular trauma is common in both the civilian and the military settings. Recent experience in the wars in Afghani-stan and Iraq has confirmed the imperative of initial hemor-rhage control including the use of tourniquets and direct or manual pressure with or without hemostatic agents if possible. Once hemorrhage control has been achieved, management options include (1) continued tourniquet application or liga-tion of the vascular injury, (2) restoration of perfusion (arte-rial and/or venous) with a temporary vascular shunt, and (3) vascular reconstruction either initially or following use of a vascular shunt. The choice of management depends on the anatomic location of the extremity vascular injury; whether it is arterial, venous, or both; the extent of the mangled extrem-ity; and the physiologic status of the patient (i.e., associated injuries or adverse physiology). While simple vascular recon-struction may be possible for uncomplicated, isolated vascular injuries cared for by experienced surgeons, more complex injury patterns occurring in the setting of the mangled extrem-ity benefit greatly from damage control adjuncts and from a multidisciplinary approach.

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    Delayed fasciotomy and the need for fasciotomy revision (extension of the incision or opening of a missed compart-ment) are associated with increased morbidity and mortality. As such, the authors generally perform prophylactic four-compartment fasciotomy of the leg utilizing a two-incision approach for those at risk for compartment syndrome: namely, those patients with prolonged ischemia (>4 hours) before revascularization and severe infrageniculate leg injury (i.e., mangled extremity). The authors also have a low threshold to perform leg fasciotomy in patients who have had ligation of a large extremity venous injury, those who have had hemor-rhagic shock requiring significant resuscitation, and those with combined arterial and venous injuries.18 If uncertainty exists about whether or not fasciotomy is indicated at the time of the initial vascular repair, our preference is to proceed with fasciotomy due to the increased morbidity and mortality from delayed fasciotomy.47

    Using the two-incision approach, all four compartments can be quickly and safely decompressed. A longitudinal skin incision lateral to the tibia is used to visualize the anterior and lateral compartments. Parallel incisions in the fascia are used to decompress these compartments. The second skin incision is medial and immediately posterior to the tibia. This incision is used to access both posterior compartments (Fig. 15-17). Care must be taken to avoid the superficial peroneal nerve and the saphenous vein. Also, when decompressing the anterior and lateral compartments, the intermuscular septum should be identified to ensure that both compartments have indeed been opened and that one is not misguided by the appearance of the similar muscle groups.

    FIGURE 15-17 Surgical exposure for 2-incision, 4-compartment lower extremity fasciotomy.

    TibiaGreat saphenous v.

    Medial incision

    Lateral incision

    Saphenous nerve

    Smallsaphenous v.

    Anterior tibial a.and v.

    Posterior tibial a.and v.

    Fibular a.and v.

    Tibial n.

    Peroneal n.

    Fibula

  • 182 SEctIoN 3 / DEFINItIVE MANAGEMENt

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    15 Lower Extremity Vascular TraumaAbstractKey Words:IntroductionHistory and BackgroundPresentation and DiagnosisJunctional Distal Iliac and Proximal Femoral InjuriesFemoral and Popliteal InjuriesTibial Level Injuries

    Preoperative PreparationJunctional Distal Iliac and Proximal Femoral InjuriesFemoral and Popliteal InjuriesTibial Level Injuries

    Helpful Considerations to Avoid PitfallsOperative Strategy and TechniqueConsiderations for Extremity Venous InjuryJunctional Distal Iliac and Proximal Femoral InjuriesFemoral and Popliteal InjuriesTibial Level Injuries

    Postoperative CareComplicationsJunctional Distal Iliac and Proximal Femoral InjuriesFemoral and Popliteal InjuriesTibial Level Injuries

    ConclusionReferences