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Lower extremity arterial injury

Key sources
The following summarized guidelines for the evaluation and management of lower extremity arterial injury are prepared by our editorial team based on guidelines from the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023), the World Society of Emergency Surgery (WSES/AAST 2020), the Society of Interventional Radiology (SIR 2020), the American College of Radiology (ACR 2019), the American College of Surgeons (ACS 2014), and the Eastern Association for the Surgery of Trauma (EAST 2012).
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Guidelines

1.Screening and diagnosis

Indications for testing, hard signs of arterial injury: perform surgical exploration to rule out vascular injury in patients with hard signs of arterial injury on physical examination (pulse deficit, pulsatile bleeding, thrill, expanding hematoma).
B
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  • Indications for testing (no hard signs of arterial injury)

2.Diagnostic investigations

Computed tomography angiography: as per ACR 2019 guidelines, obtain CTA with IV contrast for the initial imaging of lower extremity vascular trauma.
B

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  • Catheter angiography

  • Doppler monitoring and duplex ultrasound

3.Medical management

Nonoperative management: as per EAST 2012 guidelines, consider nonoperative observation of asymptomatic, nonocclusive arterial injuries.
C

4.Nonpharmacologic interventions

Tourniquet placement: as per ABC-T 2023 guidelines, place adjunct tourniquet to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting.
B

5.Therapeutic procedures

Temporary intravascular shunts
As per EAST 2012 guidelines:
Consider using temporary intravascular shunts to restore arterial flow in patients with combined vascular/orthopedic injuries, in order to facilitate limb perfusion during orthopedic stabilization.
C
Consider using temporary intravascular shunts in "damage control" situations, to facilitate limb perfusion when the physiologic status of the patient or operative capabilities prevent definitive repair.
C

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  • Angioembolization

6.Perioperative care

Postoperative imaging: obtain a completion arteriogram in patients who have undergone arterial repair procedures.
B

7.Surgical interventions

Surgical exploration: perform surgical intervention within 6 hours in patients with impaired limb perfusion due to an arterial injury, in order to maximize limb salvage.
B

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  • Ligation

  • Fasciotomy

  • Repair