Penetrating Extremity Trauma Endovascular versus Open Repair?

Abstract

Penetrating extremity trauma (PET) accounts for an estimated 5–15% of trauma with vascular injury and these injuries are accountable for a significant percentage of trauma-related deaths. Historically, vascular injuries were best treated by open repair. While a defined selection criteria and a comprehensive algorithm have not been validated, the advancement of endovascular techniques, embolotherapy, and stent grafting have become viable options for the treatment of penetrating arterial extremity trauma in select patients. Advantages endovascular repair offers include decreasing mortality and morbidity associated with open repair, decreasing blood loss, decreasing iatrogenic injury such as nerve injury, and lower rate of wound infection. Patients stability, type of vascular injury, and lesion location are main factors help deciding between endovascular and open repair. Patient selection between endovascular and open repair should be determined by on a case-by-case situation, individual hospital guidelines, a multidisciplinary approach, and technical expertise.

Keywords

penetrating extremity trauma - arterial trauma - vascular injury - endovascular repair

Financial interest

None declared.

• References

• 1 Huber GH, Manna B. Vascular Extremity Trauma. StatPearls; 2019
• 2 Sharrock AE, Tai N, Perkins Z. , et al. Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort. J Vasc Surg 2019; 70 (01) 224-232
• 3 White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011; 253 (06) 1184-1189
• 4 Greer LT, Patel B, Via KC, Bowman JN, Weber MA, Fox CJ. Management of secondary hemorrhage from early graft failure in military extremity wounds. J Trauma Acute Care Surg 2012; 73 (04) 818-824
• 5 Sise MJ, Shackford SR. Peripheral vascular injury. In: Mattox KL, Moore EE, Feliciano DV. , eds. Trauma. 7th ed. 2014: 816-849
• 6 Feliciano DV, Moore FA, Moore EE. , et al. Evaluation and management of peripheral vascular injury. Part 1. Western Trauma Association/critical decisions in trauma. J Trauma 2011; 70 (06) 1551-1556
• 7 Lebowitz C, Matzon JL. Arterial injury in the upper extremity: evaluation, strategies, and anticoagulation management. Hand Clin 2018; 34 (01) 85-95
• 8 Manthey DE, Nicks BA. Penetrating trauma to the extremity. J Emerg Med 2008; 34 (02) 187-193
• 9 Doody O, Given MF, Lyon SM. Extremities--indications and techniques for treatment of extremity vascular injuries. Injury 2008; 39 (11) 1295-1303
• 10 Williams TK, Clouse WD. Current concepts in repair of extremity venous injury. J Vasc Surg Venous Lymphat Disord 2016; 4 (02) 238-247
• 11 Feliciano DV. Management of peripheral arterial injury. Curr Opin Crit Care 2010; 16: 602-608
• 12 Gonzalez RP, Falimirski ME. The utility of physical examination in proximity penetrating extremity trauma. Am Surg 1999; 65: 784-789
• 13 Dennis JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma 1998; 44: 243-52 ; discussion 242–243
• 14 Mavrogenis AF, Panagopoulos GN, Kokkalis ZT. , et al. Vascular Injury in Orthopedic Trauma. Orthopedics 2016; 39: 249-259
• 15 Levy BA, Zlowodzki MP, Graves M, Cole PA. Screening for extermity arterial injury with the arterial pressure index. Am J Emerg Med 2005; 23: 689-695
• 16 Lynch K, Johansen K. Can Doppler pressure measurement replace “exclusion” arteriography in the diagnosis of occult extremity arterial trauma?. Ann Surg 1991; 214: 737-741
• 17 Kurtoglu M, Dolay K, Karamustafaoglu B, Yanar H, Kuzkaya M. The role of the ankle brachial pressure index in the diagnosis of peripheral arterial injury. Ulus Travma Acil Cerrahi Derg 2009; 15: 448-452
• 18 deSouza IS, Benabbas R, McKee S. , et al. Accuracy of Physical Examination, Ankle-Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24: 994-1017
• 19 Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma 1991; 31: 515-9 ; discussion 519–522
• 20 Bynoe RP, Miles WS, Bell RM. , et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg 1991; 14: 346-352
• 21 Rieger M, Mallouhi A, Tauscher T, Lutz M, Jaschke WR. Traumatic arterial injuries of the extremities: initial evaluation with MDCT angiography. Am J Roentgenol 2006; 186: 656-664
• 22 Montorfano MA, Montorfano LM, Perez Quirante F, Rodriguez F, Vera L, Neri L. The FAST D protocol: a simple method to rule out traumatic vascular injuries of the lower extremities. Crit Ultrasound J 2017; 9: 8
• 23 Colip CG, Gorantla V, LeBedis CA, Soto JA, Anderson SW. Extremity CTA for penetrating trauma: 10-year experience using a 64-detector row CT scanner. Emerg Radiol 2017; 24: 223-232
• 24 Kelly SP, Rambau G, Tennent DJ, Osborn PM. The role of CT angiography in evaluating lower extremity trauma: 157 patient case series at a military treatment facility. Mil Med 2019; 184 (9–10): e490-e493
• 25 Wallin D, Yaghoubian A, Rosing D, Walot I, Chauvapun J, de Virgilio C. Computed tomographic angiography as the primary diagnostic modality in penetrating lower extremity vascular injuries: a level I trauma experience. Ann Vasc Surg 2011; 25: 620-623
• 26 Inaba K, Potzman J, Munera F. , et al. Multi-slice CT angiography for arterial evaluation in the injured lower extremity. J Trauma 2006; 60: 502-6 ; discussion 506–507
• 27 Protack C, Wengerter B, Jean RA. , et al. Overutilization of Cross-Sectional Imaging in the Lower Extremity Trauma Setting. Int J Angiol 2018; 27: 23-28
• 28 Seamon MJ, Smoger D, Torres DM. , et al. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma 2009; 67: 238-243 ; discussion 243–244
• 29 Keen JD, Dunne PM, Keen RR, Langer BG. Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma. J Vasc Interv Radiol 2001; 12: 813-821
• 30 Frykberg ER. Advances in the diagnosis and treatment of extremity vascular trauma. Surg Clin North Am 1995; 75: 207-223
• 31 Weaver FA, Yellin AE, Bauer M. , et al. Is arterial proximity a valid indication for arteriography in penetrating extremity trauma? A prospective analysis. Arch Surg 1990; 125: 1256-1260
• 32 Peck MA, Rasmussen TE. Management of blunt peripheral arterial injury. Perspect Vasc Surg Endovasc Ther 2006; 18: 159-173
• 33 Abada HT, Golzarian J. Gelatine sponge particles: handling characteristics for endovascular use. Tech Vasc Interv Radiol 2007; 10: 257-260
• 34 Bauer JR, Ray CE. Transcatheter arterial embolization in the trauma patient: a review. Semin Intervent Radiol 2004; 21: 11-22
• 35 White R, Krajcer Z, Johnson M, Williams D, Bacharach M, O’Malley E. Results of a multicenter trial for the treatment of traumatic vascular injury with a covered stent. J Trauma 2006; 60: 1189-1195 ; discussion 1195–1196
• 36 DuBose JJ, Rajani R, Gilani R. , et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury 2012; 43: 1785-1792
• 37 MC OD, Shah J, Martin JG, Kies D. Emergent Endovascular Treatment of Penetrating Trauma: Solid Organ and Extremity. Tech Vasc Interv Radiol 2017; 20: 243-247
• 38 Chong VE, Lee WS, Miraflor E, Victorino GP. Applying peripheral vascular injury guidelines to penetrating trauma. J Surg Res 2014; 190: 300-304
• 39 Maynar M, Baro M, Qian Z. , et al. Endovascular repair of brachial artery transection associated with trauma. J Trauma 2004; 56: 1341 ; discussion 1341
• 40 Gilani R, Tsai PI, Wall Jr MJ, Mattox KL. Overcoming challenges of endovascular treatment of complex subclavian and axillary artery injuries in hypotensive patients. J Trauma Acute Care Surg 2012; 73: 771-773
• 41 Stewart DK, Brown PM, Tinsley Jr EA, Hope WW, Clancy TV. Use of stent grafts in lower extremity trauma. Ann Vasc Surg 2011; 25: 264 e9–13
• 42 Desai SS, DuBose JJ, Parham CS. , et al. Outcomes after endovascular repair of arterial trauma. J Vasc Surg 2014; 60: 1309-1314
• 43 Scott AR, Gilani R, Tapia NM, Mattox KL, Wall MJ, Suliburk JW. Endovascular management of traumatic peripheral arterial injuries. J Surg Res 2015; 199: 557-563