Vascular anatomy of the extremities

From Egyptian, Greek, and Roman battlefields centuries ago, extremity vascular injuries were identified and treated. Subsequently, knowledge regarding the management of vascular trauma has also been gained from more modern military conflicts. Napoleon’s surgeon Larrey was an expert with rapid amputations, having documented 200 amputations in 24 hours during the Battle of Borodino in 1812. During the American War Between the States, amputation was the known treatment for extremity injuries, including vascular injuries. Historians debate even today whether amputation was overused; however, it was, “life over limb.” Although there was knowledge both experimentally and clinically regarding repair of injured arteries and veins in the first half of the 20th century, amputation was still lifesaving. DeBakey and Simeone reported a 49% amputation rate in World War II following vascular trauma. During the Korean Conflict (1950–1953), Hughes, Spencer and others demonstrated that repair of both injured arteries and veins could be successful, even under less-than-ideal circumstances. In the last half of the 20th century, surgical advances lowered the amputation rate to approximately 13%, both during the Korean Conflict and in the Vietnam War. There have been further improvements in the early 21st century in managing American casualties in both Afghanistan and Iraq. Civilian management of vascular trauma in the last 50 years has led to even improved results over those from the battlefield. Battlefield wounding agents frequently cause much more extensive damage than low-velocity civilian wounds.

Pulsatile bright red bleeding, absence of distal pulses, a distal cool extremity, a pale distal extremity, neurologic deficits, and expanding or pulsatile hematomas all can be associated with arterial trauma. Presence of a thrill or a bruit at the injured site should alert one to the presence of an arteriovenous fistula. An injured vein can result in extensive hemorrhage, and the blood is dark, because it is less oxygenated. Proximity of a penetrating wound, previous hemorrhage that has stopped, osseous injury, hematoma, and neurologic deficit are all suspicious for vascular trauma. Further diagnostic studies can be helpful. Basic care for vascular trauma injuries should follow the precepts of the Advanced Trauma Life Support. A thorough knowledge of anatomy is very important; today gross anatomy is not taught to the extent that would be desirable in most medical schools. Distortion and destruction of tissue planes by hemorrhage occurs, challenging the vascular surgeon. Perineural hemorrhage in a nerve can look like a thrombosed artery in a massive wound, making it increasingly confusing and difficult to manage the patient.