Peripheral vascular trauma from close-range shotgun injuries

Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.

Literature review of peripheral vascular trauma: Is the era of intervention coming?

Traumatic peripheral vascular injury is a significant cause of disability and death either in civilian environments or on the battlefield. Penetrating trauma and blunt trauma are the most common forms of vascular injuries. Besides, iatrogenic arterial injury (IAI) is another pattern of vascular trauma. The management of peripheral vascular injuries has been improved in different environments and wars. There are different types of vascular injuries, such as vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection and focal wall defects, etc. The main clinical manifestations of vascular injuries are shock following massive hemorrhage and limb necrosis due to tissue and organ ischemia. Ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are most valuable for assessment of peripheral vascular injuries. Angiography remains the gold standard for diagnosing vascular trauma. Immediate hemorrhage control and rapid restoration of blood flow are the primary goals of vascular trauma treatment. There are many operative treatment methods for vascular injuries, such as vascular suture or ligation, vascular wall repair and vascular reconstruction with blood vessel prostheses or vascular grafts. Embolization, balloon dilation and covered stent implantation are the main endovascular techniques. Surgical operation is still the primary treatment for vascular injuries. Endovascular treatment is a promising alternative, proved to be safe and effective, and preferred selection for patients. In summary, rapid diagnosis and timely surgical intervention remain the mainstays of the treatment. However, many issues need to be resolved by further studies.

Pattern, presentation and management of vascular injuries due to pellets and rubber bullets in a conflict zone

Background:

Rubber bullets and pellet guns are considered non-lethal low-velocity weapons. They are used to disperse a mob during street protests. The present study was undertaken to analyze the pattern, presentation and management of vascular injuries caused by these weapons.

Patients and Methods:

This was a prospective study of patients with features of vascular injuries due to pellets and rubber bullets from June 2010 to November 2010. All patients with features of vascular injuries due to these non-lethal weapons were included in the study. Vascular injuries caused by other causes were excluded from the study.

Results:

A total of 35 patients who presented with features of vascular injury during this period were studied. All of them were males. The mean age was 22 years. Fifteen patients were revascularized primarily, 19 patients needed reverse saphenous vein graft and, in one, patient lateral repair was done. There were two mortalities in our series. Wound infection was the most common complication. The amputation rate was around 6%.

Conclusion:

Pellet and rubber bullets can cause serious life-threatening injuries. Vascular injury caused by these weapons need no different approach than other vascular injuries. Early revascularization and prompt resuscitation prevents the loss of limb or life.

Despite the increasing use of nonoperative management of firearm trauma, shotgun injuries still require aggressive operative management

BACKGROUND

The energy dissipation between gunshot and shotgun blasts is very different. Injuries from shotgun blasts vary depending on the distance of the victim from the shooter, the choke of the shotgun, the pellet load, and the wad of the ammunition. We postulated that gunshot and shotgun blasts create different injury patterns that dictate different treatment plans.

METHODS

Medical records of patients with gunshot and shotgun trauma were reviewed from 1998 through 2007 at our university-based trauma center. Statistical comparisons were made via Fisher's test or t-test calculations.

RESULTS

We evaluated 2833 patients injured by firearms; of these 61 had shotgun wounds (2.2%). The remainder sustained gunshot wounds. Mortality between shotgun and gunshot trauma patients was similar (7% versus 9%, respectively, P=0.8). There was no difference in the mean Injury Severity Score (ISS) (13.7+/-1.6 versus 12.9+/-0.2; P=0.6). Overall, 61% of patients underwent operative intervention after shotgun injuries versus 36% of patients with gunshot wounds (P<0.0001). Patients surviving shotgun injuries had a longer length of stay (10.1+/-2.0 d versus 5.9+/-0.21, P<0.05).

CONCLUSIONS

Although the injury severity was similar, injuries from shotguns required more operations and resource utilization. Shotgun blasts can create impressive superficial injuries as well as significant deep organ damage. An aggressive operative approach to managing shotgun trauma is advantageous.

Medicolegal evaluation of vascular injuries of limbs in Turkey

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group (n = 372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18 +/- 6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery (n = 73), and the deep femoral vein (n = 41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was 'organ dysfunction' in 37 (9.9%) and 'organ loss' in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents.

Clinical update: gunshot wound ballistics

Although firearm related injury and mortality actually may be declining, gunshot trauma remains a significant cause of morbidity and socioeconomic cost with 115,000 missile injuries annually and as many as 40,000 deaths. Wounds typically are classified as low-velocity (< 2000 feet/second) or high-velocity (> 2000 feet/second). However, these terms can be misleading. More important is the efficiency of energy transfer, which is dependent on the projectile's physical characteristics including deformation and fragmentation, kinetic energy, stability, entrance profile, path traveled through the body, and the biologic characteristics of the tissues. Therefore, the decision whether to explore the wound should not be based solely on the involvement of a high-velocity or low-velocity weapon. The majority of low-velocity gunshot wounds can be treated safely nonoperatively with local wound care and outpatient treatment. Treatment of associated fractures generally is dictated by the bony injuries, which have similar personalities to closed fractures. Because contamination is not always apparent, routine antibiotic prophylaxis still is recommended. The soft tissues assume a more crucial role in high-velocity and shotgun fractures, whereas high-energy injuries and grossly contaminated wounds mandate irrigation, appropriate debridement, and the use of open fracture protocols. However, a patient with a high-velocity wound with limited soft tissue disruption, no significant functional deficits, no evidence of bullet fragmentation, and minimal bony involvement can be a candidate for simple wound care. When exploration is indicated, decompression and excision of necrotic tissue is the rule with color, consistency, contractility, and capacity to bleed providing valuable information regarding muscle viability.

Difficult peripheral vascular injuries

Successful management of the difficult peripheral vascular injury requires a multidisciplinary approach. Prompt recognition of the vascular injury and adherence to the recognized principles of vascular repair provide a successful short-term surgical result. The long-term consequences of an injury are determined by the associated orthopedic, soft tissue, and nerve injuries.

Carotid artery pseudoaneurysm and pellet embolism to the middle cerebral artery following a shotgun wound of the neck

Arterial missile embolism is a rare complication of penetrating vascular trauma. We report a case of middle cerebral artery pellet embolism and delayed appearance of a carotid artery pseudoaneurysm following a shotgun wound of the neck. The pseudoaneurysm was repaired. Because the patient had no associated neurologic deficits, the pellet embolus was left within the patient middle cerebral artery. He remains well 4 years after injury. A selective approach to the management of a pellet embolus to the middle cerebral artery based on clinical signs or symptoms and status of arterial patency is recommended. In addition, several principles are suggested to improve the reliability of arteriography for shotgun wounds of the neck.

Acute treatment of penetrating popliteal artery trauma: the importance of soft tissue injury

During a 20-year period from 1973 to 1992, 109 patients underwent early operation for acute popliteal artery trauma. Clinical variables were analyzed for their association with amputation. Gunshot wounds accounted for the majority of injuries (73%), followed by shotgun wounds (18%), stab wounds (6%), iatrogenic injuries (2%), and lacerations (1%). Fasciotomies were performed selectively in 41% of patients. Seven patients (6%) lost the injured extremity despite arterial repair. The mean time from injury to arterial repair was not significantly different for patients with or without subsequent amputation (8.6 +/- 3.6 and 9.7 +/- 7.4 hours, respectively; p = 0.69). Delay in diagnosis longer than 6 or 12 hours after the injury did not increase the risk of amputation. Other factors not associated with limb loss were preoperative ischemic neurologic deficit or compartmental hypertension, concomitant fracture, and popliteal vein injury. Severe soft tissue injury (p < 0.0001) or postoperative wound sepsis (p < 0.0001) substantially increased the risk of amputation. Delayed fasciotomies were uncommon (4%) but were associated with a significantly increased risk of amputation (p < 0.0001). Vein grafting for arterial repair (p = 0.0017) and shotgun injuries (p < 0.0001) were associated with amputation to the extent that they were related to severe soft tissue injury. The degree of soft tissue trauma and subsequent infection of devitalized tissue limits the success of popliteal arterial repair. Changes in the mechanism of trauma, liberal use of four-compartment fasciotomies, and aggressive management of soft tissue injury resulted in a significant decline in the amputation rate from 21% (4/19) in the first 5 years to 0% (0/39) in the last 5 years of the study.

Shotgun wounds of the limbs

Shotgun blasts may cause devastating injuries in civilian trauma practice. We have reviewed 23 consecutive patients with 28 deliberate shotgun wounds to limbs treated over a 4-year period. Wounds were categorized using the Red Cross wound classification. Twenty wounds were high-energy transfer grade 2 and 3 injuries: eight involved only the soft tissues (five category 2ST, three category 3ST), 10 wounds involved fractures (two category 2F, seven category 3F, one category 3VF), and three wounds involved major vessel injury (two category 3V, one category 3VF). Category 2ST and 3ST wounds were managed successfully with thorough wound excision of devitalized tissue, fasciotomy, and early wound closure. The more complex category 3F, 3V and 3VF wounds required a multidisciplinary approach to their management. Three lower limbs (category 3F, 3V, and 3VF wounds) with associated major nerve injury were amputated at the first operation; there were no cases of secondary amputation. Of the salvaged limbs, those with category 3F injury at or below the level of the elbow or knee had poor functional results.

Advances in treatment of vascular injuries from blunt and penetrating limb trauma

Military and civilian experience has contributed to the current state of the art in management of extremity vascular injuries. Thorough physical examination and judicious use of emergency center arteriography and formal arteriography provide means for prompt diagnosis and treatment which is critical is limb loss and disability are to be avoided. Prosthetic graft material has provided an alternative to vein grafting in many circumstances for arterial and venous injuries. Compartment syndrome should be anticipated when an ischemic extremity is revascularized and fasciotomy should be used liberally. Vascular repairs are the first priority in extremity wounds, but associated injuries to bones, joints, soft tissues, and nerves are often critical determinants of rehabilitation once blood supply has been re-established. The best results are obtained when a multidisciplinary approach is used combining expertise in orthopedic surgery, neurosurgery, and plastic surgery.

Pelvic abscess or pseudoaneurysm: diagnostic and therapeutic dilemma following iliac arterial trauma

Intra-abdominal abscesses often complicate operations for abdominal trauma and are particularly dangerous in patients whose injuries involve major vessels. We report our experience with 10 patients who developed pelvic abscesses among 75 survivors of iliac arterial injuries. Pseudoaneurysms of primarily repaired iliac arteries occurred in 8 of these 10 patients. Emergency operations were required for acute arterial thrombosis or hemorrhage in four patients; massive hemorrhage that complicated the drainage of pelvic abscesses led to the recognition of the pseudoaneurysms in the other four patients. Three of the eight patients with pseudoaneurysm died of postoperative complications; ischemic extremity sequelae occurred in all five survivors. The association of pelvic abscesses with the complications iliac arterial repairs has not been previously emphasized. The integrity of an arterial repair should be arteriographically confirmed before proceeding with drainage of a pelvic abscess that developed after iliac arterial trauma.

Extraanatomic bypass for peripheral arterial injuries

Over an 8-year period, extraanatomic bypass grafting was performed for peripheral arterial injuries or infections in 12 patients. The indications for use of the technique were as follows: (1) extensive loss of soft tissue over arterial injury or avulsion; (2) wound infection with rupture of a previous arterial repair; or (3) combined infections in soft tissue and the underlying artery due to illicit drug injection. The technique involved excision of the injured or infected artery beyond the margins of the debrided wound and insertion of an autogenous saphenous vein as an extraanatomic bypass graft in a medial or lateral position around the wound. Shotgun wounds were the mechanism of injury in six patients, whereas an extensive injury or infection in the brachial artery was present in eight patients. Successful wound coverage or closure was accomplished and distal arterial flow preserved in 11 patients, 5 of whom had residual neuromuscular or bony defects related to the magnitude of the original injury.

The problem of vascular shotgun injuries: diagnostic and management strategy

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.

Vascular trauma at a university teaching hospital

Fifty-two patients with vascular trauma have been managed by the St Vincent's Hospital Vascular Surgical Unit during the 5 year period 1982-86. The mean age of the patients was 39.7 years; 81% were male. Penetrating, blunt and iatrogenic trauma were equally represented. Forty-nine of the patients underwent 63 operations performed by members of the unit. Twenty-five of the patients had significant non-vascular injuries, requiring 29 other operations. Pre-operative angiography was used rarely in urgent cases. All vascular reconstructions were noted to be patent during the follow-up period, with a mean of 20 months, except in one instance, where an amputation resulted from failed surgery. One patient died from a complication of the vascular surgery.

Trauma angiography of the extremity: the impact of injury mechanism on triage decisions

A review of angiographic studies of 227 consecutive injured patients suspected of having sustained extremity arterial trauma was done to determine whether knowledge of the mechanisms of injury was of use in the establishment of priority in multiply injured patients. Stab wounds and other lacerations occurred in 32 patients. Major arterial injury occurred in only 3 (12%) cases; in no case was arterial occlusion present or limb viability threatened. These injuries may be angiographically evaluated on a nonurgent basis. Alternatively, patients with gunshot wounds (130 patients) and blunt injuries (63 patients) had a high incidence of major arterial injury (18 and 38%, respectively), especially arterial occlusion (15 and 24%, respectively) as well as a significant incidence of threatened limb viability (5 and 21%, respectively). Disproportionately increased risk of arterial injury occurred in patients with high-energy gunshot wounds (75%), motorcycle accidents (62%), and crush injuries (63%). Patients who sustain gunshot wounds or blunt injuries and have an abnormal vascular physical examination should be evaluated angiographically on an urgent basis.

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.