For the patient—Evolution in the management of vascular trauma
There has been an evolution in the diagnosis and management of vascular trauma over the past 100 years. The primary stimulus to these changes has been the increased volume of patients with cervical, truncal, and peripheral vascular injuries during military conflicts and in civilian life. Patients with “hard” signs of a vascular injury are taken to surgery emergently with a few exceptions to be described. In contrast, patients with “soft” signs of a vascular injury undergo a careful physical examination including measurement of vascular index to determine if radiologic imaging is necessary. Computed tomography arteriography has become the most commonly used method of imaging, whereas duplex ultrasonography is used in some centers. Nonoperative management is now common for nonocclusive injuries diagnosed on computed tomography arteriography. Proximal tourniquets are commonly used to control exsanguinating hemorrhage from injuries to extremities, whereas balloons can be used to control hemorrhage from difficult to expose areas at operation. Temporary intraluminal shunts are now used in 3% to 9% of arterial injuries. Operative techniques of repair have been refined and contribute to the excellent results noted in modern trauma centers.