Vascular injuries, especially arterial injuries may have disastrous consequences resulting in the loss of life and limb.
A vessel can get injured any where in its course but certain areas are more prone than others due to location of the vessel.
The axilla, medial and anterior upper arm, and antecubital fossa particularly are high-risk areas because of the superficial location arteries in these regions. In lower limb, the inguinal region, medial thigh, and popliteal fossa particularly are considered high-risk locations.
both in upper and lower limbs, there is one single vessel at the beginning of limb which divides into branches after it has traversed some distance. In upper limb this division is beyond elbow and in lower limb just below knee.
Thus before the furcation or division of the vessel, there is a single vessel supply and after furcation it becomes two in upper limb and three in lower limb. This is important because when injury is to a vessel above elbow or knee, it means loss of entire supply to the limb and thus risk of loss of limb.
Therefore, an injury in region of axilla to the proximal forearm is more dangerous. similarly, lower limb is at higher risk if the injury is in an area between inguinal ligament and proximal part of calf.
Wounds distal to the bifurcation of the brachial artery are less likely to result in serious limb ischemia, as long as the ulnar and radial arteries remain intact. Injuries to a single distal artery can often be managed by ligation alone if the palmar arches are complete and no prior injury is present. This is the case in 95% of these patients.
the injury can occur with both blunt or penetrating trauma though later is more common etiology.
Signs suggestive of vascular injury
- Active or pulsatile hemorrhage
- Pulsatile or expanding hematoma
- Dusky limb
- Cold limb
- Signs of limb ischemi, 5Ps
- Pallor
- Paresthesias
- Pulse deficit
- Paralysis,
- Pain on passive extension of the compartment. Pain on passive extension is the earliest and most sensitive physical finding.
- Diminished or absent pulses
Investigations
Doppler ultrasound can help to find whether the vessel distal to injury is patent or not. Arteriography is a seminvasive technique that can tell the presence of arterial injury reliably.
Treatment
Arterial Injury is an emergency. Not only it carries a potential risk of limb and life but also it needs to be treted emergently. Th eclock starts ticking after the injury has occured. The goal should be ro avoid every kind of delay so that adisgnosis can be made early and be treated if needed.
The results of vascular surgery are best before 6 hours after the injury has occured.
At site of emergency, the affected limb should be immobilized. It is important not to elevate the affected limb. Ice may be helpful if it is available. Bleeding from open wounds must be controlled by direct pressure. Tourniquet should not be applied to control bleeding.
After the diagnosis has been made and patient planned for treatment, there are two things to take care of. One vessels needs repair and fracture needs to be fixed.
It is important to individualize the treatment. If much time has not elapsed after injury, fracture should be fixed first as it would provide limb stability andavoids further injury. However, if sufficient time has passed one can operate the vessel first and then fix the fracture.
Vessel repair is a specialized procedure and vascular surgeon is required for this.
After both the surgeries have been done, fasciotomy of the limb is advised to avoid compartment syndrome. In case compartment syndrome was already present, first thing to do is fasciotomy.
Compartment syndrome is an acute problem following injury or surgery in which increased pressure within a confined space in the limb impairs blood supply of the lmb resulting in ischaemia.
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