Evaluation and Management of Peripheral
Annotation for Point C
For all locations of peripheral vascular injuries, preparation of the skin and draping should encompass all potential areas of proximal and distal vascular control, the area where a distal fasciotomy would be performed and one lower extremity from the thigh to the toenails for possible retrieval of the greater or lesser saphenous vein.11 Therefore, preparation and draping for a vascular injury in the proximal upper extremity would be from chin to umbilicus from opposite nipple to ipsilateral fingernails and include one lower extremity to toenails. In a lower extremity, preparation and draping would be from nipples to bilateral toenails. Upon presentation in the EC or operating room, some patients have overt physical evidence of a compartment syndrome in the distal extremity (leg or forearm) beyond a proximal arterial occlusion or in the musculofascial compartment around the area of the peripheral vascular injury. For example, a patient with an anterior compartment syndrome in the leg would have hypesthesia in the dorsal first web space, weakness of toe extension and foot dorsiflexion, and pain on passive toe flexion and foot plantar flexion.12,13 A patient with a volar compartment syndrome in the forearm would present with hypesthesia of the volar aspect of the fingers, weakness of finger and wrist flexion, and pain on finger and wrist extension.12,13 Other patients cannot be examined so comprehensively secondary to intoxication, hypovolemic shock, or traumatic brain injury but have significant swelling of the injured extremity or area of injury. Measurement of a compartment pressure can confirm or eliminate the diagnosis of a compartment syndrome. When the diagnosis of a compartment syndrome is made (pressure >30 mm Hg), a preliminary or concurrent (with the arterial repair) fasciotomy is performed. Operative techniques to perform fasciotomies in the leg, forearm, thigh, and arm are well described.12,13 A longitudinal incision is made over the area of the peripheral vascular injury. When the area of injury is in proximity to a joint, a gently curved incision to prevent a postoperative scar contracture is appropriate. Examples would be the axillobrachial ‘‘S’’ over an injury to the distal axillary/proximal brachial vessels or the medial-to-lateral ‘‘S’’ over the antecubital area of the upper extremity. Proximal and distal control around a peripheral vascular injury is appropriate when arterial occlusion is present or when compression or a proximal tourniquet prevents further bleeding from the area of injury. When hemorrhage cannot be controlled or a large hematoma is present, it is appropriate to enter the area of injury and apply vascular clamps directly around the perforation in the peripheral artery and/or vein. Adequate suction devices and appropriate retractors are mandatory to limit blood loss during this approach. After proximal and distal vascular control has been attained with the use of small DeBakey vascular clamps, bulldog clamps, or vessel loops, the magnitude of the vascular injury (see D, E, F later) is assessed. A laceration encompassing greater than 25% of the circumference of the artery increases the risk of distal embolization of local clot. With this injury or when there has been a delay in treatment, Fogarty balloon catheters are passed proximally and distally through the area of injury. Appropriate sizes of the Fogarty catheters would include the following: #6 for the common and external iliac arteries, #4 to #5 for the common femoral artery, #4 for the superficial femoral artery, #3 to #4 for the popliteal artery, and #3 for the arteries in the leg. Overdistension of the Fogarty balloon should be avoided because this may injure normal intima. The goal is to confirm proximal arterial inflow and have no thrombus on return of two consecutive distal passes of the balloon catheter. It is helpful to remember that passage of a Fogarty balloon catheter into the leg will result in entrance into the peroneal artery approximately 90% of the time.14 One option to overcome this anatomic issue is to first inflate a Fogarty balloon in the proximal peroneal artery. Then, Fogarty balloon catheters are likely to be passed into the anterior and posterior tibial arteries. In contrast, balloon catheters are never passed into venous injuries because they will disrupt valves. If heparin was not given before this time, it should be administered intravenously at an appropriate dosage. In addition, 20 mL to 25 mL of heparinized saline (50 U/mL) can be injected into the proximal and distal artery (40-50 mL or another 2,000-2,500 U) after passage of a Fogarty catheter. After a passage of Fogarty balloon catheters and administration of heparin, a laceration of an artery from a knife or piece of glass is debrided minimally back to healthy intima. Many arterial injuries from gunshot wounds or blunt trauma, however, have extensive intimal or wall injuries, and segmental resection may be necessary (see F later).