Vascular Injury

First aid for a suspected vascular injury

1. Call 911 or your local emergency number.
2. Apply firm, direct pressure to the wound with a clean cloth or gauze, without lifting to check.
3. Pack deep wounds in the groin, armpit or neck with gauze and press hard.
4. Use a tourniquet for life-threatening bleeding from an arm or leg: place it 5 to 7 cm (2 to 3 inches) above the wound and tighten until bleeding stops. Note the time.
5. Keep the person warm and lying down.
6. Do not remove embedded objects.

See hemorrhage for more on controlling bleeding.

Types of vascular injury

• laceration or transection: a cut or complete division of the vessel, causing bleeding
• contusion or intimal injury: damage to the inner lining that can lead to clotting and blockage
• pseudoaneurysm: a contained leak forming a pulsating sac, often after catheter procedures
• arteriovenous fistula: an abnormal connection between an artery and vein after penetrating injury
• thrombosis: clotting from vessel damage
• spasm: temporary narrowing, a diagnosis of exclusion

Common sites and causes

Hard and soft signs

Trauma teams use these signs to decide on immediate surgery or further imaging:

Hard signs (usually need immediate surgery):

• pulsatile bleeding
• expanding or pulsatile hematoma
• absent distal pulses
• signs of ischemia: pain, pallor, coldness, numbness, paralysis
• a palpable thrill or audible bruit

Soft signs (need imaging):

• history of significant bleeding at the scene
• diminished pulses
• a stable, non-expanding hematoma
• nerve injury near a major vessel
• wound near a major vessel

Diagnosis

• ankle-brachial or arterial pressure index: comparing blood pressure in the injured limb to an uninjured arm; a ratio below 0.9 suggests arterial injury
• CT angiography: the main imaging test
• duplex ultrasound: especially for pseudoaneurysms and vein injuries
• catheter angiography: used for diagnosis and treatment together

Treatment

• open surgical repair: direct repair, patch, or bypass using a vein graft or synthetic graft
• endovascular treatment: covered stents to seal tears, or embolization coils to block bleeding branches
• temporary shunts in damage-control surgery for severely injured patients
• ligation (tying off) for some veins or minor arteries
• fasciotomy: surgically opening tight muscle compartments to prevent or treat compartment syndrome after restoring blood flow
• ultrasound-guided thrombin injection or compression for some pseudoaneurysms
• anticoagulation in selected injuries

Restoring blood flow within about 6 hours gives the best chance of saving a limb.

Complications

• life-threatening blood loss
• limb loss from prolonged ischemia
• compartment syndrome
• infection
• graft failure, arteriovenous fistula or pseudoaneurysm formation
• stroke from neck vessel injuries

Frequently asked questions

What is a vascular injury?

A vascular injury is damage to an artery or vein, most often from stab or gunshot wounds, blunt trauma, fractures, dislocations or medical procedures. It can cause severe bleeding or block blood flow to a limb or organ.

What are the signs of an arterial injury?

Hard signs include spurting or pulsing bleeding, a rapidly expanding swelling, absent pulses, and a cold, pale, numb limb. Softer signs include weaker pulses, a stable bruise near a major artery, or nerve injury near the wound.

How is a vascular injury treated?

Bleeding is first controlled with pressure or a tourniquet. Surgeons then repair the vessel, bypass it with a graft, or use stents or coils through a catheter. Restoring blood flow quickly is critical to save the limb.

Why is a knee dislocation so dangerous?

A knee dislocation can tear or stretch the popliteal artery behind the knee, even if the knee has popped back into place. Without prompt diagnosis and repair, the lower leg can lose its blood supply. All knee dislocations need assessment of blood flow.