trauma en extrem inferior

8/7/2019 trauma en extrem inferior

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Practice Management Guidelines for

Penetrating Trauma to the Lower Extremity

The EAST Practice Management Guidelines Work Group:

Abenamar Arrillaga, MD, Greenville Memorial Hospital, Greenville, SC

Raymond Bynoe, MD, Richland Memorial Hospital, Columbia, SC

Eric R. Frykberg, MD, University of Florida Health Science Center, Jacksonville

Kimberly Nagy, MD, Cook County Hospital, Chicago, IL

Address for Correspondence and Reprints:

Abenamar Arrillaga, MD

890 W. Faris Rd.

MMOB Suite 270, Box 17

G ill M i l H i l


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PRACTICE MANAGEMENT GUIDELINE FOR EVALUATION AND MANAG

LOWER EXTREMITY VENOUS INJURIES FROM PENETRATING TRA

I. Statement of the Problem

Venous injuries occur frequently with penetrating trauma to the lower extremity.

natural history nor the optimal treatment of isolated venous injuries is known. Most freq

venous injuries are diagnosed in association with a concomitant arterial injury or during e

for a presumed arterial injury. In this scenario, controversy still exists regarding the prop

management of these injuries.

II. Process

A Medline computer search was conducted on all articles in the English literature

years 1980-1997 pertaining to venous injuries of the lower extremity. The subject words

included Avascular injury, Avenous injury, Aextremity trauma, Apenetrating trauma,

trauma, and Avenous trauma. The references of these articles were also used to locate

found in the Medline search. Personal files were also used. All letters to the editor, casebook chapters, review articles, series involving less than 20 cases, series involving predom

trauma, and series in which the percentage and outcome of the penetrating injuries were n

specified were excluded. Also articles whose focus was the management of arterial injuri

included the results of their venous injuries were excluded. This left 14 articles of releva

practice parameter.

III. Recommendations

A. Level 1

There is no class I evidence to support a standard of care for this parameter.

B. Level 2

There is no class 2 evidence to support a standard of care for this parameter.

C. Level 31. There is insufficient data to recommend treatment for isolated venous injuries

venous injuries accompanied with active hemorrhage require exploration and

bleeding.

2. Venous injuries found during exploration for associated arterial injury should


3/34

5. Venous ligation in conjunction with leg elevation, compression stockings, andfasciotomies offers similar results to repair.

6. Fasciotomy should be considered when there is a combined arterial and venouIV. Scientific Foundation

Most available studies on venous injuries secondary to penetrating trauma to the l

extremity are retrospective in nature. There is virtually no data available on isolated veno

Except for Borman et al., virtually no one has attempted to diagnose venous injuries preo

Even in this paper, in which 30% of patients had a preoperative venogram, 90% of the pa

underwent exploration for the indication of suspected arterial injury. Since most patients

penetrating trauma to the lower extremity get evaluated for the possibility of arterial injur

probably an unknown population of patients with normal arterial evaluations and undiagn

venous injuries. There are no data to show adverse sequelae of missed isolated venous in

neither the natural history nor the optimum management of isolated venous injuries is kno

reasonable to assume that only the isolated injuries that present themselves because of act

need to be pursued. Otherwise, management recommendation cannot be given.

Most of the literature on venous trauma deals with venous injuries that are diagno

exploration for suspected arterial injuries. In this scenario, there has been an ongoing deb

the optimal management strategy. Again, except for one prospective study, most of the l

retrospective.6

Nonetheless, these studies provide enough evidence to support a number

recommended and suggested management options, as well as directions for future investi

The majority of papers on this subject deal with whether to ligate or repair. Venofound during exploration for associated arterial injury should be repaired if the patient is

hemodynamically stable and the repair itself will not significantly delay treatment of assoc

or destabilize the patient=s condition.7,9,12,14 With respect to the type of repair performed

patency rates are achieved with lateral venorrhaphies that do not significantly narrow the

repaired vein or vein patching.5,6,8,11,12 For complex repairs, end-to-end and paneled repa

probably the best options. Synthetic or interposition vein grafts have the worst reported

rates.

6,8,11

Nevertheless, irrespective of the type of repair chosen, the thrombosis rate andextremity edema rate are significant. Even the patent or recanalized repairs have significa

physiologic impairment when assessed with photoplethysmography.10

When ligation is p

clinically significant edema rate does not appear to be significantly different if leg elevatio

compression stockings, and liberal use of fasciotomies are utilized.7,8,9,11,12,14 Fasciotomy

affected by the type of management of the venous injury.1,7,9,12

Rather, it is the presence o


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V. Summary

Very little data exists on the diagnosis and management of isolated venous injurieliterature suggests that venous injuries encountered during exploration for an arterial injur

repaired if the patient is stable. Lateral venorrhaphies result in the best patency rates, syn

interposition vein grafts have much lower patencies. Complications of thrombosis and di

are common regardless of the type of repair chosen.

VI. Future Investigation

While all areas concerning the management of venous injuries require more rigoro

evaluation, there are some issues that have not been studied in great detail which lend the

prospective study:

The natural history of isolated venous injuries

The proper management of isolated venous injuries

Role for post operative venography or venous duplex

Role of anticoagulation after repair or ligation


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VII. References

1. Agarwal N, Shah PM, Clauss RH, et al. Experience with 115 Civilian Venous Injurie22:827-832, 1982.2. Phifer TJ, Gerlock AJ, Rich NM, et al. Long-term Patency of Venous Repairs Demo

Venography. J Trauma 25:342-346, 1985.

3. Richardson JB, Jurkovich GJ, Walker GT, et al. A Temporary Arteriovenous Shunt iManagement of Traumatic Venous Injuries of the Lower Extremity. J Trauma 26:50

4. Sharma PV, Shah PM, Vinzons AT, et al. Meticulously restored lumina of injured vepatent. Surgery 112:928-932, 1992.

5. Nypaver TJ, Schuler JJ, McDonnell P, et al. Long-term results of venous reconstructvascular trauma in civilian practice. J Vasc Surg 16:762-768, 1992.

6. Meyer J, Walsh J, Schuler J, et al. The Early Fate of Venous Repair after Civilian VaTrauma. Ann Surg 206(4):458-464, 1987.7. Timberlake GA, O=Connell RC, Kerstein MD. Venous injury: To repair or ligate, th

Vasc Surg 4:553-558, 1986.

8. Khaneja SC, Arrillaga A, Ernst A, et al. Outcome in the Management of Penetrating Injury. Vasc Surg 28:39-43, 1994.

9. Yelon JA, Scalea TM. Venous Injuries of the Lower Extremities and Pelvis: Repair VLigation. J Trauma 33:532-538, 1992.

10.Aitken RJ, Matley PJ, Immelman EJ. Lower limb vein trauma: a long-term clinical anassessment. Br J Surg 76:558-588, 1989.

11.Hardin WD, Adinolfi MF, O

=ConnellRC, et al. Management of Traumatic PeripheraInjuries. Am J Surg 144:235-238, 1982.

12.Borman KR, Jones GH, Snyder WH. A Decade of Lower Extremity Venous TraumaOutcome. Am J Surg 154:608-612, 1987.


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FirstAuthor

Reference

Class

Fin

dings

MeyerJ,etal

Theearlyfateofvenousrepair

aftercivilianvasculartrauma.

AnnSurg206(4

):458-464,1987

II

28L

Ev.v.injuries.Alldx=dinOR.94%assoc.a.a.injuries.Mostlypenetrating

trauma.Mostlycomplexrepairs-17%la

t.Venorrhaphy.AllptshadUS&impedance

plethysmographyonPOD7followedby

venography.39%thrombosisbyvenography.

Inte

rpositiongraftshadsignificantlyhigherthrombosis.Nodifferencebetw

eensights

ofrepair.4ptsw/edema(1patentrepai

r).Edemaresolvedintwo@3months.

Ven

ographywasmoreaccuratethanPE

whichwasmoreaccuratethannon-invasive

testsinassessingpatency.Limbsalvageequalinthepatentvs.thrombosed

groups.

MullinsRJ,etal

Thenaturalhistoryfollowing

venousligationforcivilian

injuries.

JTrauma20:737-743,1980

III

129

ptsw/majorv.v.injuriesidentified.6diedbeforeTX&wereexcluded

.68had

prim

aryrepairmostbylat.Venorrhaphy

.Theresultsofthesepatientswere

not

included.55pts.hadv.v.ligation.9of

theseexcludedforvariousreasons.

32ofthe

remainingwereoftheLE.11oftheseu

nderwentfasciotomies.Mainreasonsfor

ligationwerehemorrhagicshock,extens

iveinjurytov.,multipleassociated

injuries.

Mostinjurieswerefrompenetratingmechanism.Pt.Werekeptatbedrestw

/involved

legelevateduntiledemafree.Ambulationtrialsfollowedbybedrest&legelevation

cont=duntiledemawouldnotrecur-thisoccurredinmostptsbysecondtrial.Median

LOS

29d.40/46werefreeofedemaon

ambulation.Ofthe33ptsw/long-

termf/u,

30remainededemafreeonlong-termf/u.Nonehadsevereedemaorevidenceof

venousstasis.28/46w/assoc.a.a.injur

ieshadsuccessfula.a.repairs.

Agarw

alN,etal

Experiencewith

115Civilian

VenousInjuries

.JTrauma

22:827-832,1982

III

Retrospective.115pt.=sw/venousinju

ries.Intraabdominalv.v.included.9

2%

penetrating.28LEvenousinjuries.75%

assoc.a.a.injuries.8ligate;20repaired.

Incidenceofedemasignificantlygreater

inligationgroup.Compartmentsyn

drome

sign

ificantly>incombinedinjurygroup

.Noonewhohadfasciotomyattimeofinitial

repa

irdevelopedfootdrop.Patencyofv

enousrepairswasnotestablished

HardinWD,etal

Managementof

traumatic

peripheralveininjuries.

AmJSurg144:235-238,1982

III

86v

.v.injuries-69intheLE=s.97%pe

netrating.66%hadrepair-21%bylatsuture;

14%

hadinterpositiongrafts.2hadprim

aryamputation.Resultsclassifiedasgood(

nos

equelae),fair(shorttermsequelae),&poor(longtermsequelae).88%

hadlong-

term

fullrecovery.36%hadshort-term

sequelae(fair),10%hadlong-term

sequelae

(poo

r).1PEand1post-opamputationbothptshadhadrepairw/interpositionv.

grafts.Veininterpositionwasassociatedw/thehighestrateoflong-termmorbidity.

Prim

aryrepair&V.ligationhadlong-te

rmmorbidityof9.3&3.5%respec

tively.


7/34

HobsonRW,etal

Femoralvenous

trauma:

techniquesfors

urgical

managementandearlyresults.

AmJSurg146:220-224,1983

III

24femoralv.v.injuredover4yrpd.22

fromapenetratingmechanism.10

repairedby

lat.Venorrhaphy,5byvenouspatch,4byend-to-end,3byinterpositiongra

ft&2

ligated-1ofthemlaterunderwentinsitubypassw/saphenousv.3Aillustrativecase

repo

[email protected]/ligationh

adnocomplications.Oftherepairs74%

deemedpatentonf/uvenographyandornon-invasiveevaluation.Noclinicallyevident

PE=

s.3ptsw/narrowedrepairshadclinicallysignificantedema.5/6occlu

dedrepairs

had

significantedema.Claimtobefirsttoreportin-situsaphenousv.bypassandspiral

graftsforrepairoffemoralv.v.injuries.

PhiferTJ,etal

Long-termpatencyofVenous

RepairsDemonstratedby

Venography.

JTrauma25:34

2-346,1985

III

Retrospective.Attemptmadetolocate3

1patientsw/femoralv.injuryover

20yr.Pd.

24o

ftheserepaired.5patientsw/6reconstruction=slocated.5gsw,1shotgun.All

were5-20yr.post-injury.5/6werepatent.TheoccludedrepairhadusedTeflon

interpositiongraft.Thispatienthadedemaandincompetentdeepvalvularsystem.All

othe

rshadnlvalvularfxnandnoedema

.

Richa

rdsonJB,etal

ATemporaryA

VShuntinthe

Managementof

Traumatic

VenousInjuries

oftheLower

Extremity.

JTrauma26:50

3-509,1986

III

8pa

tientsovertwoyearperiodwithven

ousreconstructionwhohaddistalA

Vshunts

(Scribnertype)created.Allgsw=s.7ha

dcombineda.a&v.vinjuries.Allp

tsw/

shuntsthatworkedgreaterthan3daysh

adpatentvenousrepaironpost-opvenograms

@1

-2weeks.

TimberlakeGA,etal

Venousinjury:Torepairor

ligate,thedilem

ma.

JVascSurg4:5

53-558,1986

III

GpI31LEisolatedv.v.injuriesalldx=dduringoperationsforsuspecteda.a.injuries.

All

penetrating.GpII38pts.w/LEv.v.injuriesalsohadassoc.a.a.injuries.Venous

injurieswereeitherligatedorrepairedb

yend-to-endorlat.Venorrhaphy.N

o

perm

anentsequelaeofligationidentified.Nolimblossinthisseries.31/43

w/

isolatedinjurieswereligated.Transientpost-opedemawasnotsignificantlydifferent

betw

eenligation&repair.Fasciotomieswerehigherinpoplitealv.groupa

gainno

differencew/respecttoTx.Repairedpoplitealv.vthrombosed.Resultsinthe

com

binedinjurygp-similar.


8/34

Borm

anKR,etal

ADecadeofLo

werExtremity

VenousTrauma

:patencyand

outcome.

AmJSurg154:608-612,1987

III

Retrospectivelyidentifiedptsw/v.v.injurieswhohadbeenexplored.71v.v.injuries.

87%

penetrating.46%wereinshockonadmission.25(30%)hadpreoperative

venograms-22ofthesewereabnl.90%

ofpatientswereoperatedonforsu

spicionof

a.a.

injury.76%hadconcomitanta.a.in

juries.46%hadlat.venorrhaphies

therest

werecomplexrepairsofwhich44%we

reinterpositiongrafts.1v.wasrepairedw/

syntheticmaterial.8%ofv.wereligate

d.V.v.repairsusuallyprecededa.a.repairs.

40%

ofrepairsand43%ofligationshad

fasciotomies.11%ptsw/repairhadmajor

post-opmorbidity(sepsis),46%hadearlyLEcomplicationsmostlyedema

but24%

thes

ehadgangreneand8%hadPE=s.Thesecomplicationsweremoreofte

nfollowing

repa

ir49%vs.14%inligationgroup.67%repairedlimbswereintactw/osx=son

long

-termf/uand40%ofligations.9re

pairsandtwoligationshadedema.

Inthe

long

-termvenographygroup41(56%)-4initiallypatentoccluded,1initially

thro

mbosedwaspartiallyrecanalized.63%inrepairgrpremainedpatent.Simple

repa

irsweremorelikelypatentvs.Com

plexrepairs.19%ofpatentrepairs

had

DVT=satdistantsiteand33%ofoccludedrepairs.4%ofpatentrepairsan

d13%of

occludedrepairshadPE=s.74%ofpatentrepairshadintactlimbsvs.38%

of

occludedrepairs.Edemawashigherin

thefailedrepairs.

Aitke

nRJ,etal

Lowerlimbveintrauma:along-

termclinicalandphysiologic

assessment.

BrJSurg76:558-588,1989

III

f/ustudy.Ptsw/v.v.injurieswereidentified&askedtocomebackforasse

ssment.

Ven

ographyusedtoassesspatency&photoplethysmographyusedtoassess

fxn.26/48

ptscontacted.Medianelapsedtimefrominjurywas19.5months.Mostlyp

enetrating

trauma.6ligation.11repairswereeitherlat.orpatchvenorrhaphy,therem

aining

werecomplexrepairsofwhich5wereinterpositionv.v.grafts.11/12ptsw/

fasc

iotomieshadassoca.a.injuries.5/6

ptsw/ligationhadclinicaldepende

ntpedal

edema.9/20repairshadedema.12pt.

W/oedemahadabnlv.v.fxn.4/6ligations

wereassessedaspooroutcome;7/20of

repairswerepoor,6/20fair&7/20

weregood.

58%

oftherepairsthrombosed.Thepatentrepairedv.v.hadseriousphysio

logic

impairmentwhenassessedw/photoplethysmography.

NypaverTJ,etal

Long-termresultsofvenous

III

Follow-upstudy.Retrospectivelywere

abletolocate32pt.=sw/previousvenous


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reconstructionaftervascular

traumaincivilianpractice.

JVascSurg16:762-768,1992

reco

nstruction.94%penetrating.26LE

injuries.84%assoc.a.a.injuries.M

ostv.v.

inju

riesdiscoveredduringexplorationfora.a.repair-3seenonpreopa-gram

.56%lat.

venorrhaphy,13%patch,9%end-to-end,22%interpositiongrafts.41%had

fasc

iotomies.17/32pt.=shadearlyven

ography-53%thrombosed.4/32had

edema@

dc.1PE.2thrombosedrepairsrequiredrehospitalizationforIVanti-coagu

lation.7

had

venousstasis@longtermf/u.Long-termduplexstudiesrevealed90%

venous

repairspatent.94%oflatvenorrhaphie

sand86%ofcomplexrepairswere

patent-not

sign

ificant.Ofthe17ptswhohadhadv

enographyallpatentrepairsremainedpatent

and

8/9repairs,whichwereoccluded,w

erenowpatent.

Sharm

aPV,etal

Meticulouslyre

storedluminaof

injuredveinsremainpatent.

Surgery112:92

8-932,1992

III

38v

.v.injuriesmostlypenetrating;81%

assoc.a.a.injuries.Retrospectivelydivided

into

twogroups.Thosethatunderwent

intra-opvenogramandthosewhodidnot.2/17

ingroup1hadrepairrevisedsecondary

tovenogram.Group1hadsignifica

ntlybetter

pate

ncyratesandlowerpostrepairfasc

iotomyrates

YelonJA,etal

Venousinjuries

ofthelower

extremitiesand

pelvis:Repair

versusligation.

JTrauma33:53

2-538,1992

III

55L

Ev.v.injuries.Almostallpenetrating.24/55repaired.Mostoftherepairedv.v.

(74%)hadanassociateda.a.injury.48pts.60%oftotalgroup(pelvicandL

Ev.v.

inju

ries)hadassociateda.a.injuries.Poplitealv.v.weremorefrequentlyrep

airedthan

ligated.57%presentedinshock/71%ofthesehadvenousligationwhichrepresents

60%

ofthevenousligationgroup.39/45

w/gradeIII/IVv.v.injurieshadligation.15

had

lat.venorrhaphies&15hadcomplexrepairs.2hadinterpositiongrafts

.No

differenceinfasciotomyrates.Allpts.W/fasciotomieshadconcomitanta.a

.injuries.

Nodifferenceinclinicallysignificantpo

st-opedemarates.Nodifferencein

LOS.

KhanejaSC,etal

Outcomeinthe

managementof

penetratingvenousinjury.

VascSurg28:3

9-43,1994

III

19L

Ev.v.injuriesduetopenetratingtrauma.13/17femoralv.v.wererepairedforby

lat.venorrhaphytherestbycomplexrepair.Bothpoplitealv.vrepaired/thrombosed.

6/8interpositionv.graftsthrombosed.Theonlyisolatedv.injury(femoral)

wasTx=d

w/P

TFEanddistalAVfistula&waspatentonf/uafterligationoffistula.Noneofthe

pts.

w/ligationhadpost-opsequelae.4

/6thrombosedrepairshadpost-ops

equelae.


10/34

PRACTICE PARAMETER FOR DIAGNOSIS AND MANAGEMENT OF LO

EXTREMITY ISOLATED ARTERIAL INJURIES FROM PENETRATING T

I. Statement of the Problem

Evaluation and management of arterial injuries to the lower extremity due to pen

trauma continues to challenge trauma surgeons. Questions remain concerning the m

evaluation and management of the arterial injury. The vast majority of the literature

subject is retrospective in nature. There is sufficient data to support the recommend

II. Process

A Medline computer search was conducted on all articles in the English Literatur

years 1980-1997 pertaining to arterial injuries of the lower extremity. The subject w

included Avascular injury@, Aartery injury@, Aextremity trauma@, Apenetrating traum

Avascular trauma@, and Aartery trauma@, . The references of these articles were als

locate articles not found in the Medline search. Personal files were also used. All le

editor, case reports, book chapters, review articles, series involving less than 20 casein which the percentage and outcome of the penetrating injuries were not clearly spec

excluded. This left 36 articles of relevance to this practice parameter. In addition the

abstracts that were relevant to this practice parameter.

III. Recommendations

A. Level 1There is no class I evidence to support a standard of care for this parameter.

B. Level 2

Patients with hard signs of arterial injury (pulse deficit, pulsatile bleeding, bru

expanding hematoma) should be surgically explored. There is no need for ar

this setting unless the patient has an associated skeletal injury or a shotgun inj

Restoration of perfusion to an extremity with an arterial injury should be perf

than six hours in order to maximize limb salvage.

C. Level 3


11/34

3. Nonoperative observation of asymptomatic nonocclusive arterial injuries 4. Repair of occult and asymptomatic nonocclusive arterial injuries managednonoperatively that subsequently require repair can be done without signi

increase in morbidity.

5. Simple arterial repairs fare better than grafts. If complex repair is requireappear to be the best choice. PTFE, however, is also an acceptable cond

6. PTFE may be used in a contaminated field. Effort should be made to obtacoverage.

7. Tibial vessels may be ligated if there is documented flow distally.8. Early four-compartment lower leg fasciotomy should be applied liberally

an associated injury or there has been prolonged ischemia. If not perform

compartment pressures should be closely monitored.

9. Arteriography for proximity is indicated only in patients with shotgun inju10.Completion arteriogram should be performed after arterial repair.

IV. Scientific Foundation

The limb salvage rate following uncomplicated penetrating arterial injury is over

transport times, improved resuscitation, early operative intervention, and advances ihave all contributed to these impressive results. The approach to these injuries conti

evolve. Based on the physical exam, patients with hard signs of arterial injury (pulse

arterial bleeding, bruit, thrill, expanding hematoma) without associated skeletal injur

to operative exploration without an arteriogram(1,8,9,15,21,24,25,27,30,35). There m

exceptions to this statement. Patients with shotgun wounds or with preexisting periph

disease may still benefit from a preoperative arteriogram. Soft signs of arterial injury

deficit, nonexpanding hematoma, associated fracture, significant soft tissue injury, hi

bleeding or hypotension ), while being a widely recommended indication for arteriog

appear to be clinically useful predictors of arterial injuries with the exception of shot

(8,15,20,24,35). In those patients without hard or soft signs of arterial injury there i

proximity angiogram (9,15,20,21,23,24,35,36). Patients with clinically occult arterial

be treated nonoperatively in most instances (8,19,26,27,28,29). There still remains q


12/34

acceptable when there is evidence of good perfusion distally (7,8,13,14,24).

The role of noninvasive evaluation of the lower extremity has not been elucidateddata to suggest that duplex studies are accurate in diagnosing arterial injuries

(17,18,23,31,32,33,34). However, it is unclear when to initiate these studies. Shoul

performed for proximity or in the presence of soft signs of arterial injury? If there is

proximity arteriography, why then do noninvasive testing for proximity? Should the

follow up patients with normal vascular exams? These questions require further inve

V. SummaryMost patients with hard signs of arterial injury should be operated upon with

preoperative arteriogram. A preoperative arteriogram may be helpful in patients wit

wounds or preexisting peripheral vascular disease. There appears to be no role for p

angiography in patients with soft signs of arterial injury, as most patients with occult

be treated nonoperatively.

Patients who have an arterial injury that requires exploration (ie. those with hbest repaired with simple repair or vein grafts. PTFE grafts are an acceptable alterna

contaminated field.

VI. Future Investigation

Several issues in diagnosis and management of arterial extremity injuries remain u

Future studies should focus on prospective evaluation of the following:

Role of noninvasive tests to diagnose vascular injury in extremity penetrating trauma

1. Use of PTFE versus autogenous vein in the repair of arterial injuries2. Role of intraoperative completion arteriogram3. Nonoperative observation of asymptomatic nonocclusive arterial injuries4. Proper follow up of patients treated nonoperatively for asymptomatic non

arterial injuries

5. Role of heparin/thrombolytics in the repair of arterial injuries


13/34

VII. References

1. Reichle FA, Golsorkhi M. Diagnosis and Management of Penetrating Arterial anInjuries in the Extremities. Am J Surg 140: 365-367, 1980.2. Shah DM, Leather RP, Corson JD, et al. Polytetrafluoroethylene Grafts in the R

Reconstruction of Acute Contaminated Peripheral Vascular Injuries. Am J Surg

1984.

3. Feliciano DV, Mattox KL, Graham JM, et al. Five-year Experience with PTFE GVascular wounds. J Trauma 25:71-82, 1985.

4. Meyer JP, Lim LT, Schuler JJ, et al. Peripheral Vascular Trauma From Close Rinjuries. Arch Surg 120: 1126-1131, 1985.

5. Menzoian JO, Doyle JE, Cantelmo NL, et al. A Comprehensive Approach to ExVascular Trauma. Arch Surg 120: 801-805, 1985.

6. Whitman GR, McCroskey BL, Moore EE, et al. Traumatic Popliteal and TrifurcVascular Injuries: Determinants of Functional Limb Salvage. Am J Surg 154: 68

7. Armstrong K, Sfeir R, Rice J, et al. Popliteal Vascular Injuries and War: Are BeOrleans similar? J Trauma 28: 836-839, 1988.

8. Ashworth EM, Dalsing MC, Glover JL, et al. Lower Extremity Vascular TraumComprehensive, Aggressive Approach. J Trauma 28: 329-336, 1988.

9. Feliciano DV, Herskowitz K, O=Gorman RB, et al. Management of Vascular InLower Extremities. J Trauma 28: 319-328, 1988.

10.Feliciano DV, et al. Extraanatomic Bypass for Peripheral Arterial Injuries. Am 506-9, 1989.

11.Peck JJ, Eastman AB, Bergan JJ, et al. Popliteal Vascular Trauma: A CommunitExperience. Arch Surg 125: 1339-1344, 1990.

12.Cargile JS III, Hunt GF. Acute Trauma of the Femoral Artery and Vein. J Trau1992.


14/34

15.Degiannis E, Levy RD, Sofianos C, et al. Arterial Gunshot Injuries of the ExtremSouth African Experience. J Trauma 39: 570-575, 1995.

16.Melton SM, Croce MA, Patton JH Jr, et al. Popliteal Artery Trauma: SystemicAnticoagulation and Intraoperative Thrombolysis Improves Limb Salvage. Ann S

518-527, 1997.

17.Fry WR, Smith RS, Sayers DV, et al. The Success of Duplex Ultrasonographic Diagnosis of Extremity Vascular Proximity Trauma. Arch Surg 128: 1368-1372

18.Knudson MM, Lewis FR, Atkinson K, et al. The Role of Duplex Ultrasound Artin Patients with Penetrating Extremity Trauma. Arch Surg 128: 1033-1038, 199

19.Frykberg ER, Vines FS, Alexander RH. The Natural History of Clinically OcculInjuries: A Prospective Evaluation. J Trauma 29: 577-583, 1989.

20.Francis H, Thal ER, Weigelt JA, et al. Vascular Proximity: Is it a Valid IndicatioArteriography in Asymptomatic Patients? J Trauma 31: 512-514, 1991.

21.Frykberg ER, Dennis JW, Bishop K, et al. The Reliability of Physical ExaminatiEvaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One

Trauma 31: 502-511, 1991.

22.Johansen K, Lynch K, Paun M, et al. Non-invasive Vascular Tests Reliably ExclArterial Trauma in Injured Extremities. J Trauma 31: 515-522, 1991.

23.Anderson RJ, Hobson RW, Lee BC, et al. Reduced Dependency on ArteriograpPenetrating Extremity Trauma: Influence of Wound Location and Noninvasive V

Studies. J Trauma 30: 1059-1065, 1990.

24.Martin LC, McKinney MG, Sosa JL, et al. Management of Lower Extremity ArteJ Trauma 37: 591-599, 1994.

25.Richardson JD, Vitale GC, Flint LM. Penetrating Arterial Trauma: Analysis of MVascular Injuries. Arch Surg 122: 678-683, 1987.

26.Stain SC, Yellin AE, Weaver FA, et al. Selective Management of NonOcclusiveInjuries. Arch Surg 124: 1136-1141, 1989.


15/34

angiographic abnormalities, operative findings, and clinical outcome. AJR Am J R

149:613-619, 1987.

30.Sirinek KR, Gaskill HV, Dittman WI, et al. Exclusion Angiography for Patients Vascular Injuries of the Extremities a Better Use for Trauma Center Resources.

598-603, 1983.

31.Meissner M, Paun M, Johansen K. Duplex Scanning for Arterial Trauma. Am J552-555, 1991.

32.Schwartz M, Weaver F, Yellin A, et al. The Utility of Color Flow Doppler ExamPenetrating Extremity Arterial Trauma. Am Surg 59: 375-378, 1993.

33.Bergstein JM, Blair JF, Edwards J, et al. Pitfalls in the Use of Color- Flow DuplUltrasound for Screening of Suspected Arterial Injuries in Penetrated Extremities

33: 395-402, 1992.

34.Bynoe RP, Miles WS, Bell RM, et al. Noninvasive Diagnosis of Vascular TraumUltrasonography. J Vasc Surg 14: 346- 352, 1991.

35.Menzoian JO, Doyle JE, LoGerfo FW, et al. Evaluation and Management of VaInjuries of the Extremities. Arch Surg 118: 93-95, 1983.

36.Gomez GA, Kreis DJ, Ratner L, et al. Suspected vascular trauma of the extremitiof arteriography in proximity injuries. J Trauma 26: 1005-1008, 1986.

37.Dennis JW, Veldenz HC, Menawat MD, et al. Validation of Nonoperative ManagOccult Vascular Injuries and Accuracy of Physical Examination Alone in Penetra

Proximity Trauma: Five to Ten Year Follow-up. J Trauma 43: 196, 1997.

38.Carillo EH, Spain DA, Wilson MA, et al. Alternatives in the Management of PenInjuries to the Iliac vessels. J Trauma 43: 196, 1997.


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F

irstAuthor

Refere

nce

Class

Findings

FelicianoDV,etal.

Five-yearExperiencewithPTFE

Graftsin

Vascularwounds.

JTrauma25:71-82,1985

II

Prospectivestudy.206pt(85%

penetrating)allw/resex/PTFE.46%lower

extremity.CompletionarteriogramperformedroutinelyintheLE=s.

Fasciotomiesperformedonclinicalcriteriaalone.5%earlyocclusiondueto

technicalerror,delayinTx,or

lowflow-1/2successfullyrevised.Onlyexposed

graftsbecameinfected.Conclu

dedPTFEanacceptableconduitunlessnosoft

tissuecoverage.

FrykbergER,etal

TheNatu

ralHistoryofClinically

OccultA

rterialInjuries:A

ProspectiveEvaluation.

JTrauma29:577-583,1989

II

20arterialinjuriesmanagedno

noperatively(65%pen).9LEinjuries.Proximity

wastheindicationfora-gram.Intimalflapthemostcommon

finding(13),segmentalnarrowingin6cases,1pseudoaneurysm.Ofthosewho

hadfollow-upa-gram(15lesio

ns)10hadresolutionofthelesion,3showed

improvement.The4whorefusedf/uangioremainedasymptomatic

.Thefalse

aneurysmofbrachiala.require

dsurgeryduetoenlargement-w/om

orbidity.

FrykbergER,etal

AReasse

ssmentoftheRoleof

ArteriographyinPenetrating

ProximityTrauma:AProspective

Study.

JTrauma29:1041-1052,1989

II

Ptsw/ohardorsoftsignsofva

scularinj.werea-gramed.135ptsw/107LE

wounds.27abnormalitiesdetectedona-gram.11wereonnoncriticalvessels-all

didwellw/osurgery.16abnormalitiesinLEinmajora.a.included

7narrowing,

6intimalflaps,2sm.pseudoan

eurysms,1AVF.TheAVFwasrep

aired

immediately.Theother15wer

eobserved.1oftheseenlargedat10wks&even

thoughtheptremainedasymptomaticheunderwentrepairw/omorbidity.3pts

refusedf/ua-grambutremaine

dclinicallyasymptomatic.9showed

complete

resolution,2showedimprovem

ent.Bothptsthatrequiredsurgerywerefrom

SGW.50%ofptsw/softsigns

hadinjury.

B

ynoeRP,etal

NoninvasiveDiagnosisofVascular

TraumabyDuplex

Ultrasonography.

JVascSurg14:346-352,1991

II

ptsw/proximityinjurieswerestudied.Afterptswerestudiedfurth

erevaluation

&TXdependedonTraumasurgeonnotprotocol.319studiesperformed-23had

a.a.inj.dx=dbyduplex-13lacs,4intimalflaps,3pseudoaneurysm

s2AVF,1

shotguninj.Allconfirmedeitherbya-gramoroperation.13vasospasms&6ext.

compression=salsoidentifiedgiving42truepositivestudies.13operations

basedonDuplexalone.6veno

usinjuriesalsoidentified.2FNdup

lexstudies.

153TNstudiesbasedoncontinuednl.Vasc.Exam.Only20ofthe

sehada-

gramsaswell.1studycalledfalsepos.

F

rykbergER,etal

TheReliabilityofPhysical

II

ptsw/proximityinj.wereobse

rvedfor24hrs.AllSGWhada-gramsperformed.


17/34

ExaminationintheEvaluationof

PenetratingExtremityTraumafor

Vascular

Injury:ResultsatOne

Year.

JTrauma31:502-511,1991

260woundsoftheLE.2ptsw

/missedinj.1SGW&

1gsw.Both

ptwere

operatedonw/omorbidity.Therestofptw/vascularinjuryhadha

rdsigns.

Therefore92%ofinjuriesthat

requiredsurgeryweredetectableby

physical

exam.

JohansenK,etal

Non-invasiveVascularTests

Reliably

ExcludeOccultArterial

TraumainInjuredExtremities.

JTrauma31:515-522,1991

II

Allptsw/hardsignswereexplored.TherestunderwentDopplera

rterial

pressuremeasurement.Ptsw/API80%.Allstableptsh

adA-gram.Orthofixation&fasciotomy

performedbeforearterialrepair.Allfx=sofLEstabilizedw/ext.f

ixation.88%

resex/veingraft(16%extra-anat),10%repairorpatch,2%PTFE(extra-anat.).

Mosthadsystemicheparin.Co

nclusion:Ifstablepreopangiohelpful,most

requireveingraft,softtissuecoverageisimportant

G

omezGA,etal

Suspecte

dvasculartraumaofthe

extremities:theroleof

arteriographyinproximityinjuries.

JTrauma26:1005-1008,1986

III

72ptshada-gramforproximity.55/72(76%)werenl.17hadangio

abnormalitiesbutexplorationwasnotwarranted.1ptwasexplored&foundto

havespasmofa.&repairnotneeded.

FelicianoDV,etal

Delayed

DiagnosisofArterial

Injuries.

AmJSurg154:579-584,1987

III

Ptw/hardsignswereexplored

.Ptw/softsignsincludingdiminish

edpulseor

proximityinj.werea-gramed.Allclinicallydetectedinj.wererepa

ired.Ptsw/

delayeddxofa.a.injury(28)w

erestudied.27frompenmech.Dela

yrangedfrom

12hr.to26yr.64%delayeddxinvolvedLE-tibioperonealsbeing

themost

common.Theseinjurieswereeitherrepairedorembolized.Perioperative

morbiditywasconsideredsignificant.

R

ichardsonJD,etal

PenetratingArterialTrauma:

Analysis

ofMissedVascular

Injuries.

ArchSurg122:678-683,1987

III

137a.a.identifiedonsurgicalexploration.Someoftheseptweree

xploredfor

proximity,forhardsigns,somehada-gramsbeforeexploration.65

%ofthe

exploredLEhada.a.injuries.Themajorityofinj.Wererepairedw

/interposition

v.graftfollowedbyprimaryre

pair.8graftsthrombosed.Therewere17initially

unrecognizedinjuriesfoundon

f/u.8missedbya-gram,6byexplo

ration,3by


19/34

observation.Nolivesorlimbs

werelossasaresultofmissedinjur

ies.

R

oseSCandMooreEE

Angiographyinpatientswith

arterialtrauma:correlationbetween

angiogra

phicabnormalities,

operativefindings,andclinical

outcome.

AJRAm

JRoentgenol149:613-

619,198

7

III

smgpofptswhohadproximitya-grams&nlvasc.Examsw/angiographic

abnormalitieswhowereTX=d

nonoperatively.ConcludedthatnonoperativeTx

oftheselesionscanbesuccessfulaslongasthereisnoclinicalevidenceof

vascularinsufficiency.

W

hitmanGR,etal

TraumaticPoplitealand

TrifurcationVascularInjuries:

DeterminantsofFunctionalLimb

Salvage.

AmJSu

rg154:681-684,1987

III

Reviewof47pts(38%pen)w/pop/trifa.injury.Themajorityrepairedw/v.

graft.Allhadassoc.injuries.7

9%hadfasciotomy.Thegreaterthe

numberof

associatedinjuriestheworsetheoutcome.

A

rmstrongK,etal

PoplitealVascularInjuriesand

War:AreBeirutandNewOrleans

similar?

JTrauma28:836-839,1988

III

Reviewof76ptw/popliteala.injury.Veingrafthad36%amputationratevs.

11%forrepair&8%forend-to-endanastomosis.Veingraftgrouphadmore

assoc.injuries.

A

shworthEM,etal

LowerE

xtremityVascularTrauma:

AComprehensive,Aggressive

Approac

h.

JTrauma28:329-336,1988

III

Review25ptw/LEA/Vinjuries(84%pen).Anastorrepairin88%,12%

ligated-alltibialvessels.96%limbsalvage&88%patency.Rec:c

ompletion

angio,arterialrepairbeforeortho,liberalfasciotomy.

FelicianoDV,etal

ManagementofVascularInjuriesin

theLowerExtremities.

JTrauma28:319-328,1988

III

Reviewof220ptw/LEA/Vinj(82%pen).39%resex/graft,28%

anast.,17%

ligated,7%repaired.PTFEhadhigherocclusionratesbutwasmorecommonly

used.Noamputationsinthede

layedTxgroup.Rec.contralateralv

eingraftif

graftrequired.

FelicianoDV,etal

Extraana

tomicBypassfor

PeripheralArterialInjuries.

AmJSu

rg158:506-9;1989

III

Reviewed12ptw/aandsofttissueinjuries(67%pen).Extra-anat.RSVused.

92%w/pulsesatD/C,1ptw/

anastomoticblowout.Presentedas

anotheroption

forrepair.

S

tainSC,etal

SelectiveManagementof

NonOcclusiveArterialInjuries.

ArchSurg124:1136-1141,1989

III

Allptsa-gramedforproximity

&evenw/hardsigns.Allnonocclusivea.a.

injuriesdetectedwereTx=dnonoperativelyiftheywerenothemorrhagingorhad

evidenceofdistalischemia.Repeata-gramsobtained1-3wksafterinj.61

nonocclusivea.a.inj.weremanagedinthisfashion.44ofthesewe

reofmajor


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a.a.-20intheLE.17minor.5

pseudoaneurysms&5AVFwereembolizedonf/u

a-gram.21a.a.inj.wereobservedw/of/ua-gram-allw/nlvascularexams.30

inj=da.ahadseriala-grams-allptwereclinicallyasymptomatic.O

fthe6minor

a.a.inj.inthisgroup2resolve

d,1improved,1stabilized,2progressed.24major

a.a.wereseriallystudied.10intimaldefects-7ofwhichresolvedormarkedly

improvedonf/ustudy,1progressedbutpt.RefusedTx.,therewere4intimal

flaps-3resolved,1stabilized.7

pseudoaneurysms-4resolved,1stab

ilized.Only

oneptw/majora.injuryrequiredoperation.

A

ndersonRJ,etal

Reduced

Dependencyon

ArteriographyforPenetrating

ExtremityTrauma:Influenceof

WoundLocationandNoninvasive

VascularStudies.

JTrauma30:1059-1065,1990

III

Allptsw/hardsignsexplored.Performeda-gramson22ptsw/SWfor

proximityallwereneg.Performeda-gramon412gswforproxim

ity368

(89.3%)wereneg.Ofthe44p

os.results30wereexplored.Howeverofthe

surgicalgrouptherewere7intimalflaps,1pseudoaneurysm&4thrombosed

nonessentiala.a.thatcouldhavepotentiallybeenTxnonoperativelyw/

observationandembolization.

PeckJJ,etal

PoplitealVascularTrauma:A

CommunityExperience.

ArchSurg125:1339-1344,1990

III

Reviewed108ptw/popainj.

63%hadend-to-endanast.,37%ha

dvein

graft/patch.6%amputationrate(bothSGW).AllSW?GSWw

/goodresults.

Recommendoperativeexplora

tionw/hardsigns.Vascularrepairbeforeskeletal

repair.

FrancisH,etal

VascularProximity:IsitaValid

Indicatio

nforArteriographyin

AsymptomaticPatients?

JTrauma31:512-514,1991

III

160a-gramsperformedon14

6ptsw/proximityinjury(98%pen).89%true

neg.a-grams.10.6%(17pts)suggestiveofinj.6werefoundtobefalsepos.on

exploration,4ptsw/pos.studywerenotoperatedon.Ofthe7truepos.6were

intimalinjuries.3.8%a-gramcomplications(hematomas).SGWw

eremore

likelytohaveasymptomaticin

juries.

M

eissnerM,etal

DuplexScanningforArterial

Trauma.

AmJSu

rg161:552-555,1991

III

69LEstudiedoutof93totalstudygroup.65%doneforproximity.APIalso

measured.Duplexstudiesdoneforavarietyofreasons.Therewer

e25abnl

duplex.Intheproximitygroup

4/60scanswereabnl.-mostlytibialvessels.&a

lghematoma.Ptsw/signsofv

ascularinjury13/19werepos.-4

pseudoaneurysms,4occlusion

s,1laceration,1intimalflap,1AVF,1combined

AVF/pseudoaneurysm.Someptsreceivedpost-opscans.7/23pts

underwent

surgeryonbasisofduplexalone.4ptshadabnla-gram&nlduple

x.

B

ergsteinJM,etal

PitfallsintheUseofColor-Flow

III

Ptw/hardsignswereexplored

&notincludedinstudy.Ptsw/softsignsor


21/34

DuplexUltrasoundforScreeningof

SuspectedArterialInjuriesin

PenetratedExtremities.

JTrauma33:395-402,1992

proximitywerestudied.CFD=

sdonefirstifnotthoseperforming/interpreting

CFDwereblindedtoa-gramr

esults.72neg.&3pos.CFD.A-gramrevealed4

pos.results.CFD50%sensitivity,99%specificity.

CargileJSIII,etal

AcuteTraumaoftheFemoral

ArteryandVein.

JTrauma32:364,1992

III

Review233ptw/femoralA/V

inj(88%pen).18%repair,43%anast,37%vein

graft,1%PTFE,1%ligation.Rec:simplerepairs,veingraftwhen

graft

necessary.

PadbergFT,etal

Infrapop

litealarterialinjury:

Promptrevascularizationaffords

optimallimbsalvage.

JVascS

urg16:877-885,1992

III

Review68ptw/infrapopa.in

j.50%pen.21%ofsinglea.injurieswere

ischemic&requiredrepair.Otherstreatedw/ligationorobservation.Rec:preop

angio,mostsinglevesselinjdonotreq.repair.

FryWR,etal

TheSuccessofDuplex

Ultrason

ographicScanningin

DiagnosisofExtremityVascular

ProximityTrauma.

ArchSurg128:1368-1372,1993

II

175extremitieswereevaluatedforproximity.Duplexdetected18

injuries,17

confirmedbya-gram&1bysurgicalexploration.1falsepositive-

aCFAspasm

seenona-gram.7unsuspected

venousinjuriesdetected.ABIonly

demonstrated

4injuries.

KnudsonMM,etal

TheRoleofDuplexUltrasound

ArterialImaginginPatientswith

PenetratingExtremityTrauma.

ArchSurg128:1033-1038,1993

II

77patientsw/proximityinjurywerestudied.Allptshadnlvascularexams

includingABI.4ptsw/abnlcolorimagingunderwenta-gramwhichconfirmed

injury.3ofthesepatientsdidnotrequiresurgery.Theremaining7

3ptsw/nl

studiesnonedevelopedsignso

rsxofvascularinjuryonf/uexams.

SchwartzM,etal

TheUtilityofColorFlowDoppler

Examina

tioninPenetrating

ExtremityArterialTrauma.

AmSurg59:375-378,1993

III

12ptsw/angiographicallydocumentednonocclusivea.a.inj.from

penetrating

traumathatweremanagednon

operativelyhadcolorflowDoppler

examstoseeif

theinjuriescouldbedetected.

7/12injuriesdetected.

MartinLC,etal

ManagementofLowerExtremity

ArterialTrauma.

JTrauma37:591-599,1994

III

Ptsw/hardsignswereexplore

dw/oa-gram.Pts.W/softsignshada-gram.Pts

w/proximityinjurieswereobs

erved.Arterialflowforthemostpartwasrestored

priortoskeletalrepair.Localheparininfusionwasused.Systemic

heparinization

wasusedsparsely.Simplerepairs(lateralorend-to-end)wereattemptedas

muchaspossible.PTFEorveininterpositiongraftswereusedwhennecessary

dependingonthelocation,sizeofinjuredvesselandhemodynamicstatusofpt.


22/34

PTFEwasusedmorethanvein.Nosig.Diff.inpatencybetvein&

PTFEgrafts.

Veingraftswereusedmorefrequentlyforpoplitealrepairs.Noneoftheprimary

repairsofpopliteala.failedbu

t6/24ptsw/interpositiongraftsfailedatthissite

(2vein&4PTFE).Allofthesewerefromblunttrauma.31/45tib

iala.injuries

werenotrepaired.Intiliac,profunda,andsingletibiala.a.injuries

were

uniformlyligated.Completiona-gramperformedforpopliteal&

distala.a.but

notfora.a.proximaltopoplite

al.Fasciotomyperformedifclinicallyindicated,for

prolongedischemiatime&forcombinedA/Vinjuries.

DegiannisE,etal

ArterialGunshotInjuriesofthe

Extremities:ASouthAfrican

Experience.

JTraum

a39:570-575,1995

III

Reviewed173ptw/UE/LEpena.inj.76%req=dgraft(vein>PT

FE).PTFE

usedwhenveinnotavailable,veindiameter

trauma en extrem inferior

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