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Blunt Popliteal Artery Injuries

Blunt injury to the popliteal artery is commonly associated with trauma to the knee of sufficient force to result in either a knee dislocation or fracture. A review of 100 blunt popliteal artery injuries at our institution found that automobile collisions with pedestrians were the most common mechanism of blunt injury. A review of 100 blunt popliteal artery injuries at our institution found that the most…

Open and Endovascular Treatment of Penetrating Extremity Arterial Injuries

Lessons learned during United States military operations continue to advance the practice of vascular trauma surgery. Evolving resuscitative strategies, surgical management of fractures and soft tissue wounds, and the expanding application of endovascular therapies represent the latest developments in the current management of penetrating extremity arterial injury. Resuscitation and Surgical Assessment Optimal management of penetrating extremity injury requires early recognition and treatment of hemorrhagic shock. The…

Complications of Upper and Lower Extremity Percutaneous Arterial Puncture and Catheterization

Although there is appeal in the less invasive nature of percutaneous procedures, access-related complications can be a source of significant morbidity and even mortality. Bleeding, arterial injury, ischemia, and nerve injury are common problems encountered in an environment where high volumes of percutaneous procedures are performed. Complications of Lower Extremity Arterial Punctures Risk factors for complications associated with lower extremity arterial punctures include increasing sheath size,…

Aortic Injury

Aortic trauma is typically fatal, with 80% of mortality occurring at the scene of injury. Recent improvements in prehospital care, decreases in transport times, and improvement in diagnosis have increased the opportunity for patients to undergo operative intervention. The management of patients with aortic trauma has undergone a paradigm shift. Historically, recommendations were that all aortic trauma should be repaired immediately upon diagnosis, but this doctrine…

Open and Endovascular Management of Blunt and Penetrating Nonaortic Abdominal Vascular Injury

Abdominal vascular trauma is quite infrequent within the broader context of all traumatic injuries. However, these injuries can have high morbidity and mortality. Their significant heterogeneity in acuity of presentation, associated morbidity, and recommended management styles make an algorithmic approach to their treatment more challenging. Several arbitrary distinctions facilitate the review of abdominal vascular trauma, such as whether it is primarily arterial or venous, if it…

Penetrating Injuries to the Aortic Arch and Intrathoracic Great Vessels

This chapter provides an overview of penetrating injures to the aortic arch and intrathoracic great vessels. Because these short-segment vascular structures are clustered in the confined space of the mediastium, the first portion of this chapter reviews the overall epidemiology, presentation, diagnosis, and management of all arterial injuries in this location. The second part of this chapter addresses penetrating injury to each of the innominate, subclavian,…

Blunt Arterial Injuries of the Shoulder: Open and Endovascular Therapy

The major vessels injured with shoulder girdle trauma are the axillary and subclavian arteries. The muscles and bones of the shoulder girdle, which surround these vessels, provide considerable protection against injury. Thus, blunt injuries to the axillary and subclavian arteries are relatively unusual, and most series of upper extremity arterial injuries report that a majority are caused by penetrating injury and involve the brachial artery and…

Penetrating and Blunt Injuries of the Carotid Artery

Injuries to the carotid arteries are relatively uncommon, but not rare. Despite some variability in reported data from center to center, certain principles have evolved. Injuries to the carotid artery are traditionally considered blunt or penetrating ( Box 1 ). BOX 1 Selected Perspectives on Carotid Artery Trauma Penetrating neck injuries have a 20% incidence of major vascular injury. Routine exploration of penetrating neck wounds produces…

Nonarteriographic Diagnosis of Penetrating Vascular Trauma

Massive bleeding, acute limb ischemia, or a pulsatile hematoma can make the diagnosis of penetrating vascular trauma straightforward, and the first diagnostic procedure is often an appropriate operative exploration. However, the vast majority of vascular injuries arising from penetrating trauma are not so clinically obvious, manifesting signs that are subtle, evanescent, and minimal. Even more vexing are clinical scenarios in which there is no evidence for…

Conventional and Computed Tomographic Arteriography in Penetrating Vascular Injuries

The mid-20th century saw the emergence of contrast angiography to clarify and define the extent of vascular wounds. Percutaneous catheter-based angiography began to replace surgical cutdown and needle injection of contrast in the 1950s and 1960s, and became the gold standard for the diagnostic evaluation of penetrating vascular injury over subsequent decades. However, as the quality of computed tomography (CT) imaging using spiral multidetector techniques has…

Rehabilitation of the Amputee

Approximately 100,000 to 150,000 persons experience some level of major lower limb amputation in the United States each year. The majority of these patients have diabetes and/or peripheral vascular disease (approximately 90%). A rehabilitation medicine physician (physiatrist) has much to offer the patient who is going to require an amputation. The physiatrist can provide counsel to the patient and family about rehabilitation and the possibility of…

Upper Extremity Amputations

Upper extremity amputations are less common than lower extremity amputations in both wartime and civilian settings. During wartime, the incidence of upper extremity amputees is between 13% and 25% of all extremity amputations. A survey of the U.S. National Trauma Databank found 8910 amputations reported from 2000 to 2004, of which 41.1% of those with single-limb amputation were of the upper extremity. Indications for surgery for…

Above-Knee Amputation and Hip Disarticulation

The incidence of major above-knee amputation (AKA) and below-knee amputation (BKA) has been relatively stable over the past few decades, with approximately 60,000 procedures per year performed in the United States. It is not clear that the widespread implementation of the endovascular therapies has favorably affected these rates, and this apparent paradox has been attributed to the aging population, the increasing incidence of diabetes and peripheral…

Below-Knee Amputation

Amputation is one of the oldest surgical procedures known to humans. The earliest forms of below-knee amputation (BKA) occurred on or near battlefields, where wounded warriors had few alternatives other than to face the surgeon’s knife. Amputations for lower extremity trauma are still performed when the leg is so mangled that salvage is precluded. However, the most common indications for limb amputation today is not trauma,…

Minor Amputations

The first use of limb amputation was as an implement of punishment or torture. Hippocrates is credited with performing the first amputation for therapeutic purposes. Well into the 20th century, toe or forefoot gangrene was associated with limb loss. Leland McKittrick’s publication of his technique for transmetatarsal amputation (TMA) in 1949 led to thousands of spared limbs. For decades, however, a TMA was much more likely…

Noninvasive Methods of Diagnosing Cardiac and Noncardiac Sources of Macroemboli

Peripheral arterial macroembolism is an important cause of acute limb ischemia. Identification of the underlying source is imperative in managing the threatened extremity and preventing recurrence. Many noninvasive studies are readily available that can aid in identifying the cardiac and noncardiac sources of arterial macroemboli. Echocardiography Echocardiography has emerged as the primary diagnostic tool for detecting cardiogenic and proximal aortic sources of peripheral arterial emboli. Two…

Balloon Catheter Embolectomy for Macroembolization in the Extremities

Acute lower extremity ischemia remains a common vascular disease with considerable associated morbidity, limb loss, and mortality. Both arterial embolism and thrombosis are recognized causes of acute limb ischemia. It is imperative that a distinction between the two be made preoperatively because this guides the appropriate approach to therapy. Surgical embolectomy remains the treatment of choice in managing most cases of acute embolic limb ischemia because…

Anticoagulant and Lytic Therapy for Arterial Thromboembolism in Extremities

Acute limb ischemia and thromboembolic events continue to remain a challenge to vascular surgeons. Pharmacologic thrombolysis and, more recently, percutaneous mechanical thrombectomy have proved to hold great potential in this regard. Both techniques can effectively clear peripheral arteries from occluding thrombus in a minimally invasive fashion, restore blood flow to the affected extremity, and facilitate identification of any underlying lesion potentially responsible for the occlusive event.…

Operative Revascularization for Trash Foot

Distal embolization of atherosclerotic debris to the foot is a serious and challenging dilemma. Most commonly it occurs during open and endovascular aortoiliac aneurysm repair, but it is also known to occur during lower extremity endovascular interventions as well as from material within femoral and popliteal artery aneurysms. If allowed to progress, prolonged ischemia to the foot can result in soft tissue gangrene, requiring major amputation.…