Lower extremity arterial injury Evaluation and management Indications for testing Hard signs of arterial injury Q Does the patient have hard signs of arterial injury on physical examination (pulse deficit, pulsatile bleeding, thrill, expanding hematoma)? Yes 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 No Indications for testing No hard signs of arterial injury Q Does the patient have soft signs of arterial injury on physical examination (nonexpanding hematoma, history of arterial bleeding, proximity of the wound to an artery, neurologic deficit)? Q Does the patient have an ABI < 0.9? No to all Consider discharging patients with normal physical 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 Yes to any 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 Computed tomography angiography Obtain CT angiography as the first-line imaging modality to assess for penetrating lower extremity vascular injury. A Catheter angiography Obtain arteriography for injuries with proximity to major vascular structures in patients with shotgun injuries. B Non-operative management EAST Q Does imaging show an occlusive arterial injury? Q Does the patient have symptoms or signs of impaired perfusion? Yes to any Perform surgical intervention within 6 hours in patients with impaired limb perfusion due to an arterial injury, in order to maximize limb salvage. B No to all Consider nonoperative observation of asymptomatic, nonocclusive arterial injuries. C Indications for testing No hard signs of arterial injury Q Does the patient have soft signs of arterial injury on physical examination (nonexpanding hematoma, history of arterial bleeding, proximity of the wound to an artery, neurologic deficit)? Q Does the patient have an ABI < 0.9? No to all Consider discharging patients with normal physical examination findings and an ABI > 0.9, in the absence of other injuries requiring admission. C Yes to any 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 Computed tomography angiography Obtain CT angiography as the first-line imaging modality to assess for penetrating lower extremity vascular injury. A Catheter angiography Obtain arteriography for injuries with proximity to major vascular structures in patients with shotgun injuries. B Non-operative management EAST Q Does imaging show an occlusive arterial injury? Q Does the patient have symptoms or signs of impaired perfusion? No to all Consider nonoperative observation of asymptomatic, nonocclusive arterial injuries. C Yes to any Perform surgical intervention within 6 hours in patients with impaired limb perfusion due to an arterial injury, in order to maximize limb salvage. B Fasciotomy Q Does the patient have associated injuries that increase the risk of compartment syndrome? Q Has the patient experienced prolonged ischemia prior to vascular repair? No to all Monitor compartment pressures closely in patients in whom fasciotomy is not performed. B Yes to any 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 Postoperative imaging Obtain a completion arteriogram in patients who have undergone arterial repair procedures. B