The management of vascular injuries of the extremity associated with civilian firearms.

A penetrating extremity trauma registry was created to prospectively study the physical findings, use of arteriography, nonoperative management with embolization or observation and operation in the management of vascular injuries. During a recent ten month period, 228 patients with 320 injuries of the extremity secondary to firearms were admitted to the Trauma Service. Twenty-four percent of the patients had more than one injury, and there were six perioperative deaths related to associated injuries. Fifty-one patients had 50 arterial and 17 venous injuries. Limb salvage was 100 percent. Twenty-two patients with obvious arterial injuries were taken directly to the operating room without arteriography. Arteriography was performed immediately after admission in 41 patients and the findings were positive in 46.4 percent of the patients; nine required operation. Arteriography was performed for injuries in proximity to a major vessel as the indication in 153 injuries and revealed seven arterial injuries (4.6 percent). Three patients underwent operation. Five patients with arterial injuries had successful embolization during the initial arteriography and five patients with intimal injuries were observed, four healed and one patient was lost to follow-up evaluation. Operative repair of arterial injuries included the use of saphenous vein (21 patients), prosthetic grafts (seven patients) and ligations (four patients). Seventeen venous injuries were either repaired (eight patients) or ligated (nine patients). In the patients undergoing operative repairs, 68.7 percent had fasciotomies performed. The excellent results in the current study (no amputations with 51 survivors of arterial injuries) were obtained by a multidisciplinary approach, involving selective arteriography to avoid unnecessary operation and operative repair in those with extensive vascular injuries. The use of arteriography for proximity characterized a few vascular injuries requiring operation or observation. It should serve as the standard for evaluating noninvasive diagnostic studies and for studying the natural history of asymptomatic injuries.