Guideline 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). 1 2 3 4 5 6 Calculator Pathway Calculator Bastion classification of lower li Lower extremity arterial injury Mangled E Evaluation and management Guidelines https://web.pathway.md/diseases/recdn9O2uram157vY 1/5 6/29/23, 5:54 AM Lower extremity arterial injury Pathway 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 Indications for testing (no hard signs of arterial injury): Obtain further evaluation to rule out vascular injury in patients with abnormal physical examination findings without hard signs of arterial injury (nonexpanding hematoma, history of arterial bleeding, proximity of the wound to an artery, neurologic deficit) and/or an ABI < 0.9. B Consider discharging patients with normal physical examination findings and an ABI > 0.9, in the absence of other injuries requiring admission. C 2. Diagnostic investigations Computed tomography angiography: As per ACR 2019 guidelines, obtain CT angiography with IV contrast for the initial imaging of lower extremity vascular trauma. B As per EAST 2012 guidelines, obtain CT angiography as the first-line imaging modality to assess for penetrating lower extremity vascular injury. A Catheter angiography: As per EAST 2012 guidelines: Obtain arteriography for injuries with proximity to major vascular structures in patients with shotgun injuries. B Avoid routinely obtaining arteriography for injuries with proximity to major vascular structures in patients with injuries other than shotgun injuries. D Doppler monitoring and duplex ultrasound: consider obtaining noninvasive Doppler pressure monitoring or duplex ultrasound to confirm or exclude arterial injury in patients with soft signs of vascular injury or with proximity injuries. C 3. Medical management Non-operative 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 https://web.pathway.md/diseases/recdn9O2uram157vY 2/5 6/29/23, 5:54 AM Lower extremity arterial injury Pathway As per EAST 2012 guidelines, consider using tourniquets as a temporary adjunct to control hemorrhage from penetrating lower extremity trauma in patients in whom manual compression is unsuccessful. C 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 Angioembolization: As per SIR 2020 guidelines, consider performing embolization for active hemorrhage in the extremities in the appropriate context of expendability of the embolized artery. C As per EAST 2012 guidelines: Insufficient evidence to support the routine use of endovascular therapies following infrainguinal trauma. I Consider performing angioembolization of profunda branches or tibial vessels, if indicated to control bleeding. C 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 Ligation: as per EAST 2012 guidelines, consider ligating tibial vessels if there is documented flow distally. C Fasciotomy: Perform early four-compartment lower leg fasciotomy in patients with associated injuries that increase the risk of compartment syndrome, or if there has been prolonged ischemia. B Monitor compartment pressures closely in patients in whom fasciotomy is not performed. B https://web.pathway.md/diseases/recdn9O2uram157vY 3/5 6/29/23, 5:54 AM Lower extremity arterial injury Pathway Repair: as per EAST 2012 guidelines, simple arterial repairs fare better than grafts. If complex repair is required, vein grafts seem to be the best choice. PTFE, however, is also an acceptable conduit. B Clinical findings Symptoms Past medical history Bleeding Acute limb compartment syndrome Leg pain Blunt trauma Leg paresthesia Traumatic injury Leg swelling Vascular exam Vital signs Arterial bleeding Hypotension Cold limb Integument exam Expanding hematoma Palpable thrill Bruises Pulsatile bleeding Leg pallor Pulse deficit ABI Lab findings urine myoglobin References 1. Leslie Kobayashi, Raul Coimbra, Adenauer M O Goes Jr et al. American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg. 2020 Dec;89 6 1183 1196. Open 2. 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 Nov;73 5 Suppl 4 S315 20. Open 3. Rolf Rossaint, Arash Afshari, Bertil Bouillon et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27 1 80. Open 4. Bulger EM, Snyder D, Schoelles K et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr- Jun;18 2 163 73. Open 5. Expert Panels on Vascular Imaging:, Christopher J Francois, Erik P Skulborstad et al. ACR Appropriateness Criteria Nonatherosclerotic Peripheral Arterial Disease. J Am Coll Radiol. 2019 May;16 5S S174 S183. Open https://web.pathway.md/diseases/recdn9O2uram157vY 4/5 6/29/23, 5:54 AM Lower extremity arterial injury Pathway 6. Siddharth A Padia, Christopher R Ingraham, John M Moriarty et al. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31 3 363 369.e2. Open 7. Christopher Tanga, Randall Franz, Joshua Hill et al. Evaluation of Experience with Lower Extremity Arterial Injuries at an Urban Trauma Center. Int J Angiol. 2018 Mar;27 1 29 34. Open https://web.pathway.md/diseases/recdn9O2uram157vY 5/5