Advertisement

Acute Arterial Ischemia

  • Danielle Sutzko
  • Jonathan L. EliasonEmail author
Chapter
  • 8 Downloads

Abstract

Acute limb ischemia (ALI) is defined as a sudden decrease in arterial perfusion to an extremity causing a potential threat to limb viability. There are many etiologies of ALI including trauma, embolism from the heart or other vascular beds, in-situ thrombosis, or iatrogenic causes. With ALI secondary to trauma, it is important to recognize the mechanism of injury (blunt, high or low velocity penetrating).

Rapid diagnosis is imperative to mitigate ischemic time and reperfusion injury. Physical exam is very sensitive for injuries to axial blood vessels. Immediate operative exploration for hard signs of vascular injury (pulsatile bleeding, expanding hematoma, absent distal pulses, palpable thrill, or audible bruit) should be considered in the context of other injuries. Decision making in subtle cases may be aided by computed tomography angiography (CTA) in the trauma context.

The concept of life over limb is standard of care, dictating potentially fatal concomitant injuries be addressed first. Non-life-threatening injuries involved in the mechanism of the ALI, such as orthopedic, should be handled simultaneously in a well-orchestrated fashion using a multidisciplinary approach. When repair is deemed necessary, degree of soft tissue injury and ischemic time should be considered in the selection of autologous versus prosthetic conduit.

The decision whether or not to perform fasciotomies is based on the time of ischemia, and should be considered if ischemia is 4 or more hours. Patients are best suited to intensive care unit (ICU) care post-operatively for close neurovascular monitoring.

Keywords

Acute limb ischemia Vascular injury Lower extremity trauma Shunt Fasciotomy Reperfusion CT angiography 

References

  1. 1.
    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;125:1256–60.CrossRefGoogle Scholar
  2. 2.
    Schwartz MR, Weaver FA, Bauer M, et al. Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis. J Vasc Surg. 1993;17:116–22.CrossRefGoogle Scholar
  3. 3.
    Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S315–20.CrossRefGoogle Scholar
  4. 4.
    Inaba K, Branco B, Reddy S, et al. Prospective evaluation of multidetector computed tomography for extremity vascular trauma. J Trauma. 2011;70:808–15.CrossRefGoogle Scholar
  5. 5.
    Seamon MJ, Smoger D, Torres D, et al. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma. 2009;67:238–44.CrossRefGoogle Scholar
  6. 6.
    DuBose JJ, Savage SA, Fabian TC, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78:215–23.CrossRefGoogle Scholar
  7. 7.
    Patterson BO, Hold PJ, Cleanthis M, et al. Imaging vascular trauma. Br J Surg. 2012;99:494–505.CrossRefGoogle Scholar
  8. 8.
    Stewart DK, Brown PM, Tinsley EA Jr, et al. Use of stent grafts in lower extremity trauma. Ann Vasc Surg. 2011;25:264.e9–e13.CrossRefGoogle Scholar
  9. 9.
    Arthurs ZM, Sohn VY, Starnes BW. Vascular trauma: endovascular management and techniques. Surg Clin North Am. 2007;87:1179–92.CrossRefGoogle Scholar
  10. 10.
    Hutto JD, Reed AB. Endovascular repair of an acute blunt popliteal artery injury. J Vasc Surg. 2007;45:188–90.CrossRefGoogle Scholar
  11. 11.
    Reuben BC, Whitten MG, Sarfati M, et al. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg. 2007;46:1222–6.CrossRefGoogle Scholar
  12. 12.
    Johnson CA. Endovascular management of peripheral vascular trauma. Semin Intervent Radiol. 2010;27:39–43.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Vascular Surgery and Endovascular TherapyUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Section of Vascular SurgeryUniversity of MichiganAnn ArborUSA

Personalised recommendations