Assessment and Interventions for Vascular Injuries Associated With Fractures

Clay A. Spitler, MD; David A. Patch, MD; Graeme E. McFarland, MD; Walt R. Smith, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(9):387-394. 

In This Article

Interventions

When localization of the injured vessel is apparent and the limb is ischemic, proceeding to the OR for direct exploration and repair is indicated as opposed to additional diagnostic evaluation.[29] The preferred sequence of repair in orthopaedic vascular injuries is multifactorial and remains controversial.[7,8] Although restoration of blood flow remains top priority, logistical factors such as ease of achieving fracture stability may dictate which intervention occurs first. Numerous authors endorse the need for early arterial repair to minimize distal ischemia and reduce the risk of in situ thrombosis.[30] Others have emphasized that early orthopaedic repair stabilizes the extremity while improving exposure to the vascular injury. Some surgeons contend that this approach may reduce the risk of thrombosis or injury to the arterial anastomosis during fracture reduction. In some highly comminuted injuries, poor exposure to the vascular injury may result, and difficulty in determining the appropriate length of the vascular bypass can also be challenging. In these cases, early orthopaedic intervention with provisional fixation may be warranted. In patients presenting with a cold or pulseless extremity, restoration of arterial inflow has the highest priority and should be repaired with early vascular intervention by a temporary intraluminal vascular shunt if the orthopaedic injuries are such where doing a bypass would be difficult or likely result in inaccurate length of bypass. All these factors must be balanced with the ultimate goal of reducing total warm ischemia time and maximizing the rate of limb salvage.[7] Communication between both orthopaedic and vascular surgeons is, therefore, imperative in optimizing outcomes in these serious injuries.

Temporary intravascular shunts may be used for damage control by providing a means of quick perfusion restoration to allow for orthopaedic stabilization or in the scenario where the patient's physiologic status does not allow for a prolonged surgical time.[7,31] The short-term patency of temporary shunts allowing for orthopaedic stabilization (1 to 3 hours) and long-term patency when used for damage control efforts (12 to 24 hours) are nearly equivalent[32,33] when used in more proximal vessels. The use of shunts in more distal/tibial vessels is fraught with poorer patency duration.[34] Nonsurgical management of vascular injuries can be considered in the setting of a nonischemic injury, no arterial extravasation, or with a defect (ie, pseudoaneurysm and intimal flap) <2 cm, particularly in blunt trauma.[35] Serial imaging with CT angiography or duplex ultrasonography is essential to assess for progression. When intervention is warranted for the development of limb ischemia or enlargement/rupture of a pseudoaneurysm, endovascular and open techniques can be used. Endovascular techniques are primarily used for more axial injuries or when exposure and repair from an open approach would incur undue morbidity (ie, subclavian and iliac artery injuries).[36] In general, extremity vascular trauma is best treated with open surgical management. The basic tenets of open vascular surgery hold true for extremity trauma: proximal control, distal control, and restoration of in-line flow. Wide débridement of nonviable soft tissue is necessary, and protection of the bypass graft with flap coverage is oftentimes indicated.[37] Vascular repair options include primary anastomosis, patch angioplasty, and interposition grafting. The preferential conduit is the autologous vein because the risk for infection is high in prosthetic conduits, and the patency of vein is superior to that of prosthetic conduit.[18] Noncritical vessels may be treated with ligation of bleeding.

Management of venous injuries is more controversial. The concern with venous ligation includes severe edema and development of deep vein thrombosis while the concern over venous repair is that the majority are likely to thrombose in the acute setting. Although venous ligation is associated with higher rates of transient edema, this typically resolves in the long term.[38] Similarly, the rates of deep vein thrombosis are markedly higher with venous ligation; however, the rates of pulmonary embolism are similar between repair and ligation.[39] Thrombosis of venous repair is as high as 45% to 100% in different series in the acute setting; however, this may be a transient finding because most of these repairs are found to be patent at a long-term follow-up.[38] Given the divergent nature of these outcomes, venous repair is usually sought when the repair is straightforward and the added surgical intervention is well tolerated by the patient. In most cases, after vascular repair prophylactic fasciotomies are indicated to prevent compartment syndrome that can develop with reperfusion. Prophylactic fasciotomy after vascular extremity trauma has been shown to improve patient outcomes.[40] However, the timing of fasciotomy remains controversial, and randomized control trials are lacking.[41]

For notable vascular injuries associated with fractures of the pelvis, many studies have shown angioembolization to have favorable outcomes if used in the appropriate scenario. Possible benefits include decreased mortality from exsanguination and decreased need for blood transfusions.[42,43] Retroperitoneal pelvic packing is an additional treatment option that has also shown promising results. It may be equally as effective as pelvic angiography in some instances and is especially useful in centers where interventional radiology staff may not be readily available.[44]

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