Early Recognition and Effective
Intervention in Peripheral Vascular Trauma
Samantha Redden Chirinos1, Miguel Eduardo Rodriguez1, Gioacchino De Sario Velasquez1, Jesus Alejandro Cordova Guilarte1, Coralvia Yaroslangna Villanueva Perez2, Yeisson Rivero-Moreno1, Carolina Michelle Mejia Alaniz3, Andreina Rojas Marron1, Uche Brigid Smith4, Sruthi Siddada5, Victor Bolivar1, Maria Isabel Gomez-Coral6*
1Universidad de Oriente, Venezuela
2Universidad Nacional Experimental Francisco de Miranda, Venezuela
3Universidad Americana, Nicaragua
4Richmond Gabriel University, Saint Vincent, and the Grenadines
5Ramaiah Medical College, India
6Universidad del Valle de México, México, USA
Submission: September 13, 2023;; Published: September 25, 2023
*Corresponding author: Shreya Jayaram, Kasturba Medical College, Manipal, India, Email ID: [email protected]
How to cite this article: Samantha Redden Chirinos1, Miguel Eduardo Rodriguez1, Gioacchino De Sario Velasquez1, Jesus Alejandro Cordova Guilarte1, Coralvia Yaroslangna Villanueva Perez, et al. Early Recognition and Effective
Intervention in Peripheral Vascular Trauma. Open Access J Surg. 2023; 14(5): 555898. DOI: 10.19080/OAJS.2023.14.555898.
The history of vascular trauma repair dates back to the 1700s when Dr. Hallowell introduced a significant paradigm shift. Dr. Hallowell advocated for repairing arterial injuries while maintaining the integrity of the blood vessel lumen. This change in approach emerged from the recognition of the high rates of morbidity and mortality associated with arterial ligation. It sparked optimism for improved patient outcomes through more straightforward repair techniques. Penetrating extremity traumas account for 5-15% of all traumatic injuries, with vascular injuries making up 1% of these cases. These injuries can result from various mechanisms, including blunt trauma, penetrating wounds, or both. Often, soft signs, such as a history of bleeding, are the primary symptoms observed. It’s worth noting that hard signs typically signal the need for surgical intervention. However, it’s essential to acknowledge that the incidence of arterial injuries in patients presenting with soft signs can vary widely, ranging from 3% to 25%. Therefore, while soft and hard signs remain valuable for guiding injury management, diagnostic tools like duplex ultrasound have become increasingly indispensable for confirming diagnoses. A comprehensive assessment, facilitated by a multidisciplinary approach, plays a pivotal role in making informed treatment decisions and ultimately improving patient outcomes. As we integrate modern diagnostic capabilities and maintain a high level of clinical suspicion, managing vascular extremity trauma continues to evolve, offering promising prospects for enhanced patient care.
Peripheral vascular trauma refers to injuries sustained by blood vessels, encompassing both arteries and veins, with a diameter exceeding 4 mm . Statistics indicate that approximately 1.5% of civilian trauma patients in the United States experience vascular injuries. Yet, the gravity of these injuries is evidenced by their contribution to over 20% of all trauma-related fatalities [2,3]. This classification is further categorized based on the mechanism of injury—blunt, penetrating, or a combination
thereof—as well as the anatomical location, specifically the upper or lower extremity. Penetrating trauma can result from projectiles like bullets, blast fragments, or sharp objects like knives, coat hangers, and keys. In contrast, blunt trauma arises secondary to fractures or dislocations . The predominant clinical manifestations of vascular trauma include hemorrhage and tissue and organ ischemia. Clinical presentations are intricately tied to the mechanism of injury. Significant damage to major vessels, including the brachiocephalic trunk artery, can trigger substantial
bleeding, resulting in hypotension and shock [3,4].
Physical examination plays a pivotal role in confirming
vascular injuries and subsequently guiding the decision for
surgical intervention. Signs and symptoms of limb vascular
injuries can be categorized as “hard” or “soft,” delineating the
urgency of intervention. For diagnosis, methods such as the
ankle-brachial index assessment, Doppler ultrasound, and
angiography prove invaluable [3,4]. Swift and accurate diagnosis
is pivotal in averting complications and expediting necessary
interventions. Central to effective management is the rapid
control of bleeding and the restoration of blood flow. In cases
where timely revascularization cannot be achieved, amputation
may become a necessary recourse. Consequently, immediate
surgical intervention facilitates functional recuperation and limb
preservation [3,4]. Considering these critical considerations,
the principal objective of this article is to offer a comprehensive
overview of early recognition and intervention in cases of
peripheral vascular trauma. By shedding light on the multifaceted
aspects of this topic, we aim to enhance medical understanding
and promote effective clinical management.
In urban trauma centers in the United States, the majority
(75-80%) of peripheral vascular injuries stem from penetrating
trauma, as reported by studies [5,6]. Roughly half of these
penetrating injuries result from low-velocity handgun projectiles
with minimal kinetic energy, typically around 1,000 ft lbs. In
contrast, stab wounds contribute to 30% of such injuries in the U.S.,
but they become a more prevalent cause in regions with stricter
firearm access . Shotgun injuries, on the other hand, account
for only 5% of peripheral vascular injuries [5,6]. Furthermore,
peripheral vascular injuries resulting from blunt trauma to the
extremities, including fractures, dislocations, crush injuries, and
traction-related incidents, constitute a smaller portion, ranging
from 5% to 25% of cases being treated .
Understanding the physiopathology of peripheral vascular
trauma is essential for effective diagnosis and management.
It involves a complex interplay of vascular injury, hemostasis,
inflammation, and tissue repair. A comprehensive understanding
of these processes is essential to provide optimal care and
minimize the potential long-term consequences. Peripheral
vascular trauma can result from various mechanisms, including
blunt or penetrating trauma, crush injuries, and fractures, and
it often leads to life-threatening consequences if not promptly
In peripheral vascular trauma, the initial pathophysiological
response involves injury to the vessel wall. Both arteries and
veins can be affected, with arteries being more susceptible due
to their higher pressure. Damage to the endothelial lining can
lead to the exposure of subendothelial collagen, initiating platelet
aggregation and the formation of a primary hemostatic plug
[8-10]. This temporary plug helps minimize bleeding initially.
Simultaneously, vasoconstriction occurs in response to releasing
vasoactive substances, such as endothelin, from the damaged
endothelium. This vasoconstriction helps reduce blood loss by
narrowing the vessel lumen. However, these initial mechanisms
may not be sufficient to control significant bleeding, especially in
cases of severe vascular injury.
The next phase of physiopathology involves the activation of
the coagulation cascade. Tissue factor and exposed collagen trigger
the intrinsic and extrinsic pathways, forming fibrin strands and a
stable blood clot. While this clot formation is necessary for wound
healing, it can also cause complications such as thrombosis if it
occludes the vessel entirely [8,11]. Inflammation plays a crucial
role in the subsequent stages of peripheral vascular trauma. The
damaged tissue releases proinflammatory cytokines, attracting
neutrophils and macrophages to the injury site. This inflammatory
response can exacerbate tissue damage and contribute to
compartment syndrome, which occurs when increased pressure
within a closed fascial compartment impairs blood flow and can
lead to tissue necrosis [10,12].
The final phase of peripheral vascular trauma physiopathology
involves tissue repair and remodeling. Fibroblasts produce
collagen and other extracellular matrix components, leading to
scar formation and the restoration of tissue integrity. However,
complications such as aneurysm formation, stenosis, or chronic
limb ischemia may occur if the repair process is disrupted or
inadequate [9,13]. Timely diagnosis and intervention are crucial
to prevent complications such as hemorrhage, ischemia, and limb
loss. Early surgical repair or endovascular procedures may be
necessary to restore vascular continuity and maintain adequate
blood flow to the affected extremity.
The clinical presentation of peripheral vascular trauma
depends on different factors such as trauma mechanism, severity,
time, and location. It can be represented by several signs and
symptoms, usually classified as soft and hard signs, and this
classification facilitates accurate and prompt diagnosis. Although
some presentations are apparent, others are entirely masked, so
this entity requires high suspicion and timely action . The most
frequently present symptoms are the soft signs, represented by a
history of hemorrhage, among the most commonly encountered
in peripheral vascular trauma setting at the time of injury. This
may manifest as the history of oozing or spurting of blood from
the wound site. While external bleeding alone may not confirm
a vascular injury, it should raise suspicion, especially following
penetrating trauma1. Also, developing a stable hematoma near
the trauma site suggests vascular injury. This type of hematoma
exhibits a non-pulsatile and non-expansive nature with non-lifethreatening
Pulse abnormalities, such as asymmetry and diminished
peripheral pulse in the affected extremity compared to the
contralateral limb. This could be suggestive of compromised blood
flow. However, the association with other soft signs increases
vascular trauma’s likelihood. These could be unexplained
hypotension, a decreased mean arterial blood pressure without
significant explanation, or a neurologic deficit like paresthesia,
numbness, or tingling, which should heighten suspicion and
require further tests and investigation. However, the total pulse
absence suggests a hard sign and must advance to immediate
action . The hard signs involve more obvious, accurate,
specific, and guided characteristics that expedite diagnosis and
typically demand immediate action to prevent further morbidities
and complications. These signs are more severe and acute in the
trauma or injury setting, such as active hemorrhage, which is
typically rapid, pulsatile, and life-threatening within minutes.
Immediate intervention is imperative to control bleeding and
restore perfusion .
Also is the presence of a rapidly expanding pulsatile
hematoma. The palpable pulsation arises from blood escaping the
artery with each heartbeat . This situation can be associated
with a bruit/thrill over the site of injury, and both signs represent
classic signs of vascular trauma with continuous hemorrhage. In
the case of the absence of pulse, especially when compared to the
unaffected limb, this indicates a significant reduction or cessation
of blood flow and distal limb ischemia, with evidence of paralysis,
poikilothermic, severe pain, and hypothermia. The existence of
one or more of these signs demands immediate surgical evaluation
and intervention [14,16].
Peripheral vascular injuries can be categorized into three
distinct groups. Category 1, often referred to as “Hard Signs,”
encompasses indicators like pain, pallor, pulselessness,
parasthesias, paralysis, pulsatile bleeding, and the presence of
large or expanding hematomas. Patients displaying these signs
have a greater than 90% likelihood of vascular injury. In Category
2, known as “Soft Signs,” patients exhibit relatively diminished
yet palpable pulses, non expanding hematomas, and peripheral
nerve injuries, with 30-35% of these cases resulting in vascular
injury. Lastly, Category 3, or “Asymptomatic high risk,” includes
individuals with penetrating wounds located within 1 cm of major
neurovascular bundle areas (e.g., axillary, femoral, and carotid
regions), as well as knee dislocations and severely displaced long
bone fractures. In this group, up to 15-20% of patients may harbor
vascular injuries [14-16].
Diagnosing peripheral vascular trauma involves a
comprehensive evaluation of the patient’s clinical presentation
and often relies on a combination of clinical assessment and
various imaging studies. These assessments aim to identify the
location and severity of vascular injuries, guiding appropriate
treatment decisions. Clinical evaluation is fundamental in
diagnosing peripheral vascular trauma [17,18]. This involves
a thorough physical examination, focusing on assessing vital
signs, perfusion status, and visible injuries, such as wounds or
ecchymosis. A detailed medical history, including the mechanism
of injury, is also crucial in understanding the context of the trauma
Imaging studies are essential for confirming the diagnosis and
characterizing the extent of vascular injuries. Common imaging
modalities include computed tomography angiography (CTA),
duplex ultrasonography, magnetic resonance angiography (MRA),
and conventional angiography [19,20]. CTA and MRA provide
detailed visualization of the vascular anatomy and can identify
the presence of arterial or venous injuries, pseudoaneurysms, or
vascular occlusions. Duplex ultrasonography helps assess blood
flow and detect hematomas or vessel dissections. Additionally,
conventional angiography, although less commonly used in recent
years, remains a valuable diagnostic tool for precisely identifying
the location and severity of vascular injuries and often guides
endovascular or surgical interventions [20,21].
Laboratory tests, such as complete blood counts and
coagulation profiles, are also routinely performed to assess the
patient’s overall health status, identify potential coagulopathies,
and monitor for ongoing bleeding. Clinical correlation of the
findings from these assessments and input from vascular
surgeons, interventional radiologists, and other specialists is
essential for making a definitive diagnosis and determining the
appropriate treatment approach [18,22]. Accordingly, diagnosing
peripheral vascular trauma involves a multidisciplinary approach,
combining clinical evaluation with various imaging studies
to accurately identify and characterize vascular injuries. This
comprehensive assessment helps guide treatment decisions and
improve patient outcomes.
Diagnosing peripheral vascular trauma requires a thorough
evaluation using various imaging studies to identify and
characterize vascular injuries accurately. These imaging modalities
are critical in guiding treatment decisions and improving patient
outcomes. Computed Tomography Angiography (CTA) is one
of the primary imaging modalities used to diagnose peripheral
vascular trauma. CTA provides detailed cross-sectional images
of blood vessels, allowing visualization of the vascular anatomy,
identification of arterial or venous injuries, and assessment of
pseudoaneurysms or vascular occlusions. It is a non-invasive and
widely available technique, making it a valuable tool in trauma
settings . Duplex Ultrasonography is another essential
imaging study. This real-time, non-invasive technique combines
conventional ultrasound with Doppler technology to assess
blood flow within the vessels. Duplex ultrasonography can detect
hematomas, vessel dissections, and vascular injuries, particularly in cases of blunt trauma or suspected deep vein thrombosis .
Magnetic Resonance Angiography (MRA) is a non-invasive
imaging modality that uses magnetic resonance imaging (MRI)
techniques to create detailed images of blood vessels. MRA is
particularly useful for evaluating peripheral vascular injuries
in patients with contraindications to iodinated contrast agents
or when detailed soft tissue characterization is required .
Although less commonly used today, conventional angiography
remains a valuable diagnostic tool in peripheral vascular trauma.
It involves the injection of contrast directly into the blood vessels
and real-time X-ray imaging to visualize the vascular system.
Conventional angiography provides high spatial resolution and
can precisely identify the location and severity of vascular injuries,
often guiding endovascular or surgical interventions .
Digital Subtraction Angiography (DSA) is a variation of
conventional angiography that enhances the visualization of
blood vessels by subtracting the surrounding structures, resulting
in a clearer image of the vasculature. DSA is particularly useful
in identifying vascular abnormalities and guiding therapeutic
interventions . Lastly, Magnetic Resonance Imaging (MRI) can
provide additional information in cases of suspected vascular
trauma, particularly when MRA is contraindicated or unavailable.
While not primarily used for vascular assessment, MRI can help
evaluate soft tissue injuries and potential complications related to
vascular trauma [26-28].
Treatment options for peripheral vascular trauma are tailored
to the specific nature and severity of the injury. Management
involves a systematic approach that encompasses initial
stabilization, surgical intervention tailored to the anatomical
location of the injury, achieving vascular control, and selecting
repair techniques based on hemodynamic status. Complex cases
may require vascular shunts, and an endovascular approach is
suitable for stable patients. Timely and appropriate management
is crucial to preserve limb function and prevent complications
[29-31]. A stepwise management approach is shown in Table 1.
In hemodynamically unstable patients, immediate attention
is given to addressing life-threatening injuries using the ABCDE
approach of Advanced Trauma Life Support (ATLS) (American
College of Surgeons, 2018) . This includes securing airways,
breathing, and circulation while initiating damage control
resuscitation through the institution’s massive transfusion
protocol to restore blood volume and prevent hypovolemic shock.
Once the patient is stabilized, the focus shifts to identifying and
managing the vascular injury. Surgical intervention becomes
essential, and the choice of approach depends on the anatomical
region affected. This may involve accessing the injured vessel
through various incision techniques, including “S”-shaped
incisions for axillary and popliteal arteries, vertical incisions for
radial and ulnar arteries, and a vertical incision over the sartorius
muscle for the femoral artery [32,33].
The next step is to achieve proximal and distal control of the
injured vessel to prevent further hemorrhage. Thrombectomy
or embolectomy of the injured vessel is performed routinely
before proceeding with definitive repair. The choice of repair
technique depends on the patient’s hemodynamic stability.
Hemodynamically stable patients may undergo primary vascular
repair, while partial resection may be considered if necessary,
provided the anastomosis is not under excessive tension.
Excessive tension may necessitate an interposition graft with an
autologous vein or synthetic graft. Ligating the injured vessel may
be appropriate in specific cases, such as isolated radial or cubital
arterial injuries with a patent palmar arch [31,33].
Complex vascular injuries, especially those resulting in
prolonged ischemia or persistent hemodynamic instability, may
require the placement of a vascular shunt after achieving proximal
and distal control. The purpose of the shunt is to reperfuse the
limb and minimize ischemic damage . In cases where venous
injuries cannot be primarily repaired, vessel ligation may be
necessary. Prophylactic fasciotomies are indicated in patients
with compartment hypertension or impending compartment
syndrome to prevent complications. An endovascular approach
may be considered for hemodynamically stable patients, involving
options such as stent placement and thrombo-embolectomy of the
injured vessel. Long-term patency rates are comparable to open
repair for proximal arterial injuries of the extremities [32,34].
Despite advancements in diagnostic technologies, diagnosing
compartment syndrome, especially in high-risk injuries, remains
a challenge without a clear consensus . While measuring
intracompartmental pressure is considered the gold standard
when clinical signs are evident, there is a growing trend towards
continuous pressure monitoring rather than relying solely on
isolated pressure readings. This shift aims to provide a more
comprehensive understanding of the evolving pressure dynamics
within the affected compartment, which can be especially valuable
in high-risk cases where early detection is critical.
Ongoing research efforts are directed toward refining
diagnostic techniques and treatment strategies for compartment
syndrome. Non-surgical or minimally invasive interventions, such
as intermittent pressure pumps, tissue ultrafiltration, hyperbaric
oxygen therapy, and targeted pharmacological approaches, are
being explored to mitigate tissue damage and reduce the risk of
irreversible consequences . These innovative approaches
promise to improve patient outcomes and preserve limb function,
particularly in cases where rapid surgical intervention may be
challenging or less effective.
In conclusion, despite the challenges in diagnosing
compartment syndrome, the medical community actively seeks
ways to enhance diagnostic accuracy and treatment efficacy.
Continuous pressure monitoring and exploring non-surgical
interventions represent promising avenues for addressing this
complex condition [37,38].
This article provides a comprehensive overview of peripheral
vascular trauma, encompassing its epidemiology, physiopathology,
clinical presentation, diagnosis, treatment strategies, and
potential complications. Peripheral vascular injuries, although
relatively rare, contribute significantly to trauma-related fatalities.
Most cases arise from penetrating trauma, with gunshot wounds
and stabbings being prominent causes. Blunt trauma, while less
common, also presents its own challenges. Understanding the
physiopathology of vascular trauma is essential to grasp the
complexities of diagnosis and management. Vascular injuries
trigger events, including vessel wall damage, platelet aggregation,
clot formation, inflammation, and tissue repair. These processes
underscore the importance of timely intervention and effective
treatment strategies. Clinical presentation plays a pivotal role
in diagnosing peripheral vascular trauma, with soft and hard
signs guiding the urgency of intervention. Early recognition and
swift action are crucial, as delayed treatment can lead to severe
complications, including limb loss. Diagnosis relies on clinical
evaluation and various imaging studies, such as CTA, duplex
ultrasonography, and MRA, to accurately identify and characterize vascular injuries. A multidisciplinary approach involving vascular
surgeons and interventional radiologists is often necessary
to determine the appropriate treatment approach. Treatment
strategies vary depending on the nature and severity of the injury,
with a focus on achieving vascular control and restoring blood
flow. Complex cases may require vascular shunts or endovascular
approaches. Prophylactic fasciotomies may also be necessary to
prevent compartment syndrome.
Despite advancements in diagnostic technologies, the
diagnosis of compartment syndrome remains a challenge,
emphasizing the need for continuous pressure monitoring and
exploration of non-surgical interventions to improve patient
outcomes. In conclusion, this article aims to enhance medical
understanding and promote effective clinical management of
peripheral vascular trauma, emphasizing the critical importance
of early recognition and intervention to preserve limb function
and prevent life-threatening complications.
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