Penetrating Extremity Vascular Injury

Educational disclaimer. This article is intended for clinician education and historical record. It is not a substitute for individualized clinical judgment or institutional protocols. Always follow local trauma-system pathways, current society guidelines, and manufacturer instructions for devices.

Penetrating Extremity Vascular Injury

Introduction

Penetrating extremity vascular injuries are common at the University Hospital. A case of brachial-artery transection treated by reversed saphenous-vein interposition grafting is presented, and the modern operative approach to penetrating extremity vascular injury is discussed, with current indications for CT angiography (CTA) and fasciotomy noted (European Society for Vascular Surgery, 2025; Eastern Association for the Surgery of Trauma (EAST) Practice Management Guideline; AAOS 2025 Acute Compartment Syndrome CPG).

Historical case report

E.W., a 67-year-old male, presented to the Accident and Emergency Unit of the University Hospital with a gunshot wound to his right upper limb. He was shot with a handgun. Twenty years previously he had a laparotomy for a gunshot wound to his abdomen. He was hypertensive and maintained on antihypertensive medication.

On physical examination he had a pulse of 96/min and blood pressure of 130/90 mmHg. He had a 1-cm-diameter entry wound over the posteromedial aspect of the lower right arm and a 1-cm-diameter exit wound over the flexor surface of the right forearm. Both wounds were bleeding. The right radial and ulnar pulses were not palpable but there was no obvious distal neurological deficit. He also had a right paramedian abdominal surgical scar. His haemoglobin concentration was 13.1 g/dL, and radiographs of his right arm and forearm did not show any fractures.

He was assessed as having a right brachial arterial injury. Haemorrhage from the gunshot wounds was controlled by pressure dressings while the patient was transferred to the operating room. Prophylactic antibiotics (cloxacillin and gentamicin) were given. At wound exploration the right brachial artery in the cubital fossa was found transected. Five thousand units of intravenous heparin were given and the arterial injury repaired with an interposition saphenous-vein graft. After repair, pulsations were detected in the radial artery. Because time from injury exceeded six hours, forearm closed fasciotomies were performed. Postoperatively the right upper limb was kept elevated. There were no neurological deficits. He was discharged seven days after surgery and at two-week review had a good-volume right radial pulse with no apparent ischaemic muscular changes.

Modern equivalent

Today the same patient would typically receive:

  • Prehospital tourniquet if bleeding cannot be controlled by direct pressure or wound packing with a hemostatic dressing (TCCC/C-TECC, 2024; EAST PMG, Level 3).
  • ATLS 11th-edition resuscitation with early balanced (1:1:1) transfusion and early tranexamic acid (American College of Surgeons ATLS 11; ESVS 2025).
  • Hard signs (absent pulses, active bleeding) → immediate operative exploration, with CTA reserved for hemodynamically stable hard-sign patients in whom endovascular options are being considered (EAST PMG, Level 2).
  • Reversed saphenous-vein interposition graft remains the conduit of choice; PTFE is acceptable in contaminated fields when vein is unavailable (EAST PMG, Level 3).
  • Local intra-arterial heparinized saline rather than routine systemic heparin in penetrating trauma; systemic anticoagulation is selective (Martinelli et al., 2023).
  • Selective forearm fasciotomy (two-incision technique) — still appropriate after >6-hour ischemia, consistent with AAOS 2025 Acute Compartment Syndrome CPG and EAST PMG (Level 3).

Discussion

1. Initial management

Initial management begins with control of external haemorrhage. Current civilian and tactical guidelines prioritize direct pressure, wound packing with a hemostatic dressing, and prompt tourniquet application when manual measures fail (TCCC/C-TECC, 2024; EAST PMG, Level 3). Reported survival is approximately 90% when tourniquets are applied before the onset of shock versus 10% after, and prehospital placement carries lower mortality than emergency-department placement (EAST PMG).

Resuscitation follows the ATLS 11th-edition framework. Hemodynamically unstable patients with uncontrolled junctional or proximal extremity hemorrhage may, in selected centers, receive Zone-3 resuscitative endovascular balloon occlusion of the aorta (REBOA) as a hemorrhage-control adjunct (Joint Trauma System REBOA CPG v1.4). Early tranexamic acid is recommended for severe bleeding (ESVS 2025). Other life-threatening injuries take precedence; orthopaedic injuries require immobilization to prevent further neurovascular damage.

2. Hard and soft signs of vascular injury

“Hard signs” of arterial injury include pulselessness, rapidly expanding hematoma, massive bleeding, and a palpable or audible bruit or thrill; these have very high specificity (100%) but modest sensitivity (≈58%) for vascular injury requiring intervention (Simsek and Gur, 2024). Patients with hard signs should be taken directly to the operating room; CTA may be used in stable patients to plan endovascular alternatives (EAST PMG, Level 2).

“Soft signs” include diminished pulse, neurologic deficit in the territory of a named nerve, small non-pulsatile hematoma, and proximity of the wound to a major vessel. Soft signs and proximity injuries are now triaged by the Injured Extremity Index (or ABI): an ABI 0.9 has 100% negative predictive value for safe discharge (EAST PMG, Level 2; Simsek and Gur, 2024).

3. Imaging: CT angiography first

Multidetector CT angiography is the first-line imaging investigation in stable patients when imaging is required, with sensitivity and specificity approaching 100% for clinically significant extremity arterial injury (EAST PMG, Level 1; ESVS 2025; Simsek and Gur, 2024). CTA also reduces cost compared with conventional angiography (EAST PMG).

Duplex ultrasound has a defined adjunctive role for soft-sign and proximity injuries when CTA is unavailable or contraindicated. Catheter angiography is now used primarily for therapeutic intervention (endovascular repair, embolization) or for selected diagnostic dilemmas. Arteriography for “proximity alone” is no longer routine; it is reserved chiefly for shotgun injuries (EAST PMG, Level 3). A diagnosis of arterial “spasm” should never be made before formal vascular evaluation.

4. Further operative principles

Antitetanus prophylaxis is given when indicated and patients undergoing vascular reconstruction receive prophylactic antibiotics. Systemic heparinization is selective, not routine, and is contraindicated in patients with associated head, spinal, or solid-organ injury and ongoing hemorrhage. Most contemporary series rely on local intra-arterial heparinized saline during vascular reconstruction (Martinelli et al., 2023).

Operative-field principles remain unchanged. In proximal lower-limb trauma, the abdomen is included in the surgical field to allow iliac control if needed; in proximal upper-limb trauma, the chest is included. The hand or foot is included or wrapped in sterile clear plastic to allow palpation of distal pulses. The contralateral limb is prepared for potential vein harvest.

Proximal and distal vascular control is essential. Where collateral flow makes formal control impractical (axillary and upper-arm injuries), a direct approach may be more expedient; intraluminal balloon catheters can occlude proximal flow if exploration uncovers an injury before control is obtained. Fogarty thrombectomy is performed for extensive injury or delayed presentation.

5. Temporary intravascular shunts (TIVS)

TIVS are now standard practice for damage control and selected complex extremity injuries. The most commonly used civilian shunts are Pruitt-Inahara and Sundt devices; Argyle or improvised tubing remains useful in austere settings (Martinelli et al., 2023).

Indications include (Martinelli et al., 2023; EAST PMG, Level 3):

  • Systemic instability (systolic blood pressure 6 hours
  • Severe acute ischemia
  • Combined orthopaedic and vascular injury (Gustilo IIIC) requiring fixation before definitive vascular reconstruction
  • Concurrent life-threatening injuries
  • Patient evacuation to a higher level of care

Contemporary outcomes: in a 53-patient civilian series, TIVS use was associated with an acute amputation rate of 23.6% vs 62.5% without TIVS (p = 0.008); proximal-vessel shunt patency was 86% and distal patency 12% (Martinelli et al., 2023; EAST PMG). Routine systemic anticoagulation is not recommended during TIVS use; local heparinized saline is sufficient.

6. Arterial repair

If both the major artery and vein of a limb are injured, the vein is generally repaired first. Arterial repair should be done before orthopaedic stabilization unless the extremity is partially avulsed or there are unstable segmental fractures, in which case shunt-first sequencing allows orthopaedic stabilization before definitive vascular reconstruction (Martinelli et al., 2023).

Restoration of perfusion within six hours maximizes limb salvage (EAST PMG, Level 2). Options for arterial reconstruction include:

  • Lateral suture repair for small wall defects where lumen is preserved
  • Vein patch angioplasty (especially popliteal injuries)
  • End-to-end anastomosis when tension-free apposition is possible
  • Reversed autologous vein interposition graft — the preferred conduit; harvest from the contralateral leg when ipsilateral deep venous drainage is at risk
  • PTFE interposition when vein is unavailable; acceptable in contaminated fields with soft-tissue coverage (EAST PMG, Level 3)
  • Endovascular repair (covered stents, embolization for branch injuries) in stable patients with anatomically suitable lesions (Endovascular Management of Acute Extremity Trauma, 2025; EAST PMG, Level 3)

The principle that simple repairs fare better than grafts, and that vein outperforms prosthetic conduit, is reaffirmed in current guidelines (EAST PMG, Level 3). Short segmental loss may allow tension-free end-to-end anastomosis after mobilization; longer defects require interposition.

Distal-vessel ligation is acceptable when collateral flow is documented — for example, isolated radial or ulnar artery injury with a patent palmar arch, or isolated tibial-artery injury with documented distal flow (EAST PMG, Level 3). When both anterior and posterior tibial arteries are injured, vascular reconstruction is recommended.

7. Venous repair vs ligation

Modern evidence favors repair over ligation for isolated peripheral venous injuries when feasible. A 2026 systematic review and meta-analysis (9 cohort studies, 3,090 patients) found that compared with ligation, venous repair was associated with significantly lower 30-day mortality (OR 1.50; 95% CI 1.09–2.06; p = 0.01) and major amputation (OR 1.73; 95% CI 1.20–2.48; p = 0.003), with no significant difference in deep venous thrombosis or pulmonary embolism (Shahzad et al., 2026). Reported 30-day patency is approximately 87–88% for primary repair or vein patch and 50% for prosthetic grafts (Shahzad et al., 2026).

Lower limb

All major venous injuries at and proximal to the popliteal level should be repaired when patient stability allows. Venous repair is particularly important in popliteal injuries to reduce postoperative limb oedema, venous insufficiency, and amputation. Ligation remains acceptable in damage-control settings or when reconstruction would prolong an unstable patient’s anaesthetic.

Upper limb

Most upper-extremity venous injuries can be ligated when the patient is stable. Reconstruction is performed when venous hypertension is evident and the limb’s venous drainage is otherwise compromised; lateral repair or end-to-end anastomosis is preferred over interposition grafting.

8. Fasciotomy

Compartment syndrome arises when ischemia-driven cell injury and oedema raise pressure within a closed osseofascial compartment to a level that compromises perfusion, viability, and function (AAOS 2025 ACS CPG; EAST PMG, Level 3). Without fasciotomy, neuromuscular necrosis and permanent disability can develop within 6–12 hours, and myonecrosis can lead to myoglobinuria and renal failure.

Diagnosis is primarily clinical in the conscious patient — disproportionate pain on passive stretch, tense compartments, and sensory loss in the territory of a transcompartmental nerve (AAOS 2025 ACS CPG). In obtunded or anesthetized patients, continuous slit-catheter or hand-held manometry monitoring is recommended. The 2025 AAOS guideline notes that “perfusion pressure lacks diagnostic specificity for ACS,” so management decisions integrate clinical signs, pressure data, and clinical context rather than a single threshold (AAOS 2025 ACS CPG).

Indications for fasciotomy in extremity vascular injury include (EAST PMG, Level 3):

  • Ischemic time > 6 hours before revascularization (shorter in hypotensive patients)
  • Combined arterial and venous injuries
  • Sustained hypotension
  • Major venous ligation
  • Tight compartment on examination
  • Extensive soft-tissue injury or neuropathy

Postoperative indications include severe distal pain, decreased perfusion, increasing neurological signs, or limb swelling (EAST PMG). In severe ischemia or established compartment syndrome, fasciotomy is performed before vascular reconstruction.

Technique. The double-incision, four-compartment lower-leg fasciotomy popularized by Mubarak and Owens remains the standard for routine extremity vascular trauma. A single-incision technique is an evidence-supported alternative in selected tibial-plateau fracture cases and may reduce infection in those patients (AAOS 2025 ACS CPG). Forearm fasciotomy is most often performed after combined radial and ulnar arterial injury or after prolonged forearm ischemia. Secondary closure or skin grafting is usually required.

9. Completion imaging

Completion arteriography after arterial repair is recommended to verify reconstruction integrity (EAST PMG, Level 3). Intraoperative duplex ultrasound is an acceptable alternative in centers without intraoperative fluoroscopy.

10. Debridement, fractures, and surgical sequencing

General wound-care principles apply — debridement of devitalized and contaminated tissue, hemostasis, and copious irrigation. Frequent postoperative debridement may be required for severe soft-tissue contamination. External fixation is often preferred for fractures associated with major soft-tissue injury, as it minimizes operative time and infection risk and permits ongoing wound care (EAST PMG). When orthopaedic stabilization must precede vascular reconstruction, a TIVS maintains distal perfusion (Martinelli et al., 2023). After fracture reduction and fixation, the vascular repair and perfusion of the extremity should be reassessed.

11. Nerves and wound cover

Transected nerves in relatively clean wounds may be repaired primarily; in heavily contaminated wounds the nerve ends are tagged and primary repair is deferred. Primary skin closure can be achieved in clean wounds; negative-pressure wound therapy (NPWT) is widely used between debridements when soft-tissue cover is staged. Definitive coverage may require myocutaneous or microvascular free flaps, particularly for complex lower-extremity wounds; this should be planned in conjunction with plastic surgery at a level-1 center. Limbs are elevated to allow oedema to resolve.

12. Infection and other morbidity

Wound abscesses, deep wound infection, and osteomyelitis remain among the most common complications, and infection threatens vascular reconstructions and contributes to late amputation. Neurologic deficit, more than vascular reconstruction failure, is the dominant determinant of long-term function in extremity vascular injury — confirmed in contemporary popliteal-injury cohorts (Popliteal artery injuries in a level-1 trauma centre, 2025).

13. Limb salvage, secondary amputation, and mortality

Contemporary limb-salvage rates at level-1 trauma centers are substantially better than turn of the century figures. Upper-limb amputation following vascular injury is now less than 5%, lower-limb limb salvage is approximately 85–95%, and mortality in civilian extremity vascular injury is approximately 1–3% in modern series (Popliteal artery injuries 2025, PMC; Endovascular Management of Acute Extremity Trauma 2025). Late amputations generally result from delayed repair, the extent of the original injury, or postoperative infection. Secondary amputation is reserved for limb-threatening sepsis or a functionally useless limb due to irreversible ischemia or major neurologic deficit. Mangled-extremity severity scoring (MESS and related systems) remains a useful adjunct, but contemporary evidence does not support any single score as a stand-alone trigger for primary amputation (Re-evaluation of cutting criteria for limb amputation, PMC 2025).

14. Follow-up and rehabilitation

Duplex ultrasound surveillance is the modern follow-up modality after vascular reconstruction; CTA is reserved for suspected graft failure. Multidisciplinary rehabilitation — physiotherapy, occupational therapy, and where indicated psychological support — is essential, particularly for patients with neurologic deficits.

Conclusion

Management of penetrating extremity vascular injury rests on early hemorrhage control (direct pressure → wound packing → tourniquet) and ATLS-guided resuscitation with balanced transfusion and tranexamic acid; CTA as the first-line diagnostic study in stable patients with an ABI/IEI < 0.9 or soft signs; immediate operative exploration for hard signs; temporary intravascular shunts for damage control, prolonged ischemia, and combined ortho-vascular injury; autologous vein interposition as the conduit of choice with PTFE as a backup; venous repair preferred over ligation when feasible; and selective four-compartment fasciotomy guided by the AAOS 2025 ACS CPG framework. Contemporary level-1 trauma centers achieve limb-salvage rates of 85–95% and mortality of 1–3% with this approach.

References

American Academy of Orthopaedic Surgeons. "Management of Acute Compartment Syndrome — Clinical Practice Guideline." November 2025. Link: https://www.aaos.org/acscpg2025.

American College of Surgeons. "Advanced Trauma Life Support (ATLS), 11th Edition." 2024. Link: https://www.facs.org/quality-programs/trauma/education/advanced-trauma-life-support/atls-11/.

Committee for Tactical Emergency Casualty Care. "TECC ALS/BLS Guidelines." November 2024. Link: https://www.c-tecc.org/images/F_TECC_ALS_BLS_Guidelines_2024_FINAL.pdf.

Eastern Association for the Surgery of Trauma. "Penetrating Lower Extremity Arterial Trauma — Evaluation and Management of." Practice Management Guideline. Link: https://www.east.org/education-resources/practice-management-guidelines/details/penetrating-lower-extremity-arterial-trauma,-evaluation-and-management-of.

European Society for Vascular Surgery. "Clinical Practice Guidelines on the Management of Vascular Trauma." European Journal of Vascular and Endovascular Surgery (February 2025). Summary at Medscape Reference. Link: https://reference.medscape.com/viewarticle/clinical-practice-guidelines-management-vascular-trauma-esvs-2025a10004z8.

Joint Trauma System. "Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock — CPG ID 38, v1.4." December 2025. Link: https://jts.health.mil/assets/docs/cpgs/REBOA_for_Hemorrhagic_Shock_4.3.2026_ID38_v1.4.pdf.

Martinelli, Ombretta, Francesca Miceli, Simone Cuozzo, Francesco Giosuè Irace, Stefano Avenia, Immacolata Iannone, Ilaria Clementi, Paolo Sapienza, and Maria Irene Bellini. "Temporary Intravascular Shunts and Limb Salvage in Civilian Vascular Trauma." Frontiers in Surgery 10 (November 24, 2023): 1302976. doi:10.3389/fsurg.2023.1302976. Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC10704159/.

"Outcomes of Popliteal Artery Injuries in a Level 1 Trauma Centre." PMC, January 24, 2025. Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC11761999/.

"Re-Evaluation of Cutting Criteria for Limb Amputation Using the Mangled Extremity Severity Score." PMC, March 28, 2025. Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC11956282/.

Shahzad, Noman, Muhammad Asad Moosa, Nadeem Ahmed Siddiqui, and Fareed Ahmed Shaikh. "Ligation Versus Repair of Isolated Traumatic Peripheral Venous Injury: A Systematic Review and Meta-Analysis." Annals of Vascular Diseases 19, no. 1 (April 22, 2026): 25-00107. doi:10.3400/avd.ra.25-00107. PMCID: PMC13102516. Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC13102516/.

Simsek, Yeliz, and Aysenur Gur. "Vascular Injury of Penetrating Trauma of the Extremities." PMC, December 28, 2024. Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC11699988/.

"Endovascular Management of Acute Extremity Trauma." PubMed, September 26, 2025. Link: https://pubmed.ncbi.nlm.nih.gov/41234338/.