Peripheral Vascular Injuries
Peripheral vascular injuries may result from penetrating or blunt trauma to the extremities. If not recognized and treated rapidly, injuries to major arteries, veins, and nerves may have disastrous consequences resulting in the loss of life and limb.
In the upper extremity, the areas of greatest concern include the axilla and the area from the deltopectoral groove distally across the elbow to the proximal forearm. The axilla, medial and anterior upper arm, and antecubital fossa particularly are considered high-risk areas because of the superficial location of the axillary and brachial arteries in these regions. [1, 2]
Wounds distal to the bifurcation of the brachial artery are less likely to result in serious limb ischemia, as long as either the ulnar or radial artery remains intact. Injuries to a single distal artery can often be managed by ligation alone if the palmar arches are complete and no prior injury is present. This is the case in 95% of these patients.
In the lower extremity, the area of greatest concern extends from the top of the leg marked by the inguinal ligament anteriorly and by the inferior gluteal fold posteriorly, across the knee inferiorly to the level of the mid calf. The inguinal region, medial thigh, and popliteal fossa particularly are considered high-risk locations. [3, 4]
Below the knee, the popliteal artery trifurcates to form the anterior and posterior tibial arteries and the peroneal artery. Arterial wounds affecting a single vessel distal to the trifurcation are unlikely to produce serious limb ischemia. If distal collateralization is adequate, injuries to a single branch may therefore be managed by ligation.
The highest risk of serious vascular injury is associated with high-energy gunshot wounds such as those produced by military rifles and shotguns. Explosives are a frequent cause of vascular injury in military combat. The rate of vascular injury in modern combat (ie, the wars in Iraq and Afghanistan) is 5 times greater than in the past.  Blunt and penetrating trauma resulting in extremity fractures also have a high incidence of concomitant vascular injuries, even in the absence of clinical signs. The likelihood of serious vascular injury is lower in patients who sustain low-energy wounds such as those produced by handguns and knives.
Peripheral injuries account for 80% of all cases of vascular trauma. The lower extremities are involved in two thirds of all patients with vascular injuries.
Penetrating trauma accounts for 70-90% of vascular injuries. In the past, iatrogenic injuries related to endovascular procedures accounted for less than 10% of all cases. This percentage is increasing due to the growing use of endovascular procedures for diagnostic and therapeutic purposes.
Death due solely to peripheral vascular injuries is uncommon, but does occur due to exsanguination or development of a necrotizing myofascial infection. Major venous injuries accompany 13-51% of significant arterial injuries.
Compartment syndrome may result from ischemia of a muscle compartment. Limb survival is threatened by delays in diagnosis and treatment, particularly when limb perfusion is compromised for more than 6 hours at body temperature (“warm” ischemia).
Extensive concurrent musculoskeletal, nerve, and skin injuries indicate a poor prognosis. Concomitant peripheral nerve injuries may be missed and can lead to long-term disability and deformity. 
Crush injuries associated with open tibial fractures are particularly likely to result in loss of the lower leg and amputation.
Ninety percent of patients with peripheral vascular injuries are male.
Vascular injuries most often occur in patients aged 20-40 years.
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Niels K Rathlev, MD, FACEP Professor and Chair, Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center
Niels K Rathlev, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine, Association of Academic Chairs of Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine
Disclosure: Nothing to disclose.
David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School
David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association
Disclosure: Partner received salary from Pfizer for employment.
Peripheral Vascular Injuries
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