LETTER TO EDITOR Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 335-336

Rule of 3 for peripheral vascular injuries

Harshit Agarwal1, Joses Dany James2, Vignesh Kumar3, Anand Katiyar4
1 Department of Trauma and Minimal Access Surgery, Apollomedics Hospital, Lucknow, Uttar Pradesh, India
2 Department of Trauma Surgery and Critical Care, Trauma Surgery and Critical Care, AIIMS, New Delhi, India
3 Department of Trauma Surgery, CMC, Vellore, Tamil Nadu, India
4 Department of General Surgery, Command Hospital, Udhampur, Jammu and Kashmir, India

Date of Submission15-Aug-2022Date of Acceptance25-Aug-2022Date of Web Publication8-Nov-2022

Correspondence Address:
Harshit Agarwal
Department of Trauma and Minimal Access Surgery, Apollomedics Hospital, Lucknow, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijves.ijves_53_22

How to cite this article:
Agarwal H, James JD, Kumar V, Katiyar A. Rule of 3 for peripheral vascular injuries. Indian J Vasc Endovasc Surg 2022;9:335-6

Sir,

Peripheral vascular injuries (PVIs) range from 45% to 80% of all vascular traumas.[1] They are limb-threatening injuries which could eventually lead the patient disabled for lifetime. Hence, it is important that these injuries are identified early and managed accordingly. We would like to suggest a “Rule of 3” to ease up their management.

  3 Clinical Parameters to be Evaluated During Assessment 

Hemodynamic status

This remains one of the most important clinical evaluation sign. Any patient who is hemodynamically unstable due to PVI should directly go to the operation room. Only hemodynamically stable patients proceed ahead for imaging.

Soft signs and hard signs

These signs are time tested and are an important part during the initial evaluation of PVIs. However, they are more sensitive in penetrating injuries. While in blunt injuries, there sensitivity is less [Table 1].

Ankle brachial index or arterial pressure index

Peripheral arterial injury in penetrating injuries can be excluded if ankle brachial index (ABI)/arterial pressure index of >0.9. However, in blunt injuries, additional imaging may be required, even though physical examination and ABI may be normal. For example, in cases of knee dislocations, popliteal injury may be missed.[2]

The above-mentioned clinical parameters can exclude arterial injury when used in combination. However, a normal ABI or negative Color Doppler cannot independently exclude arterial injury.[3]

  3 Imaging Modalities 

Color Doppler

It is often the 1st investigation/screening investigation for PVIs in cases with soft signs. It has high specificity. However, it is time taking and operator dependent. To reduce the time taken by imaging, FAST-D protocol was given by Montorfano et al. where dorsalis pedis artery and posterior tibial artery were scanned.[4] If any abnormality was detected, further investigation in the form of angiography was done. However, it had a major drawback in being unable to differentiate between acute and chronic conditions.

Computed tomography angiography

It is now considered as the gold standard investigation for PVIs.[5] The advantages being noninvasive and provide a road map for surgical intervention. The direct signs of PVIs on computed tomography angiography (CTA) include occlusion, thrombosis, intimal flap, spasm, external compression, pseudoaneurysm, active contrast extravasation, and arterio-venous fistula.[6] Indirect signs include perivascular hematoma, a projectile tract near a neurovascular bundle, and shrapnel in a distance of <5 mm from the vessel. However, one of the major disadvantages of CTA is that it is nontherapeutic and not useful in cases with multiple foreign bodies in situ.

Conventional angiography

This was once considered a the gold standard for PVIs. However, its role is now limited in cases of pellet injury where CTA shows multiple artifacts. Furthermore, it is advantageous in cases where therapeutic endovascular intervention is required. Recently, its role has shown a resurgence with the introduction of “hybrid-operation room” where it is utilised for both diagnostic and therapeutic uses.

  3 Management Modalities 

Nonoperative management

This approach is used in case of PVIs to smaller vessels like branch vessels, in single forearm vessel injury (radial artery or ulnar artery), and in single tibial vessel injury. This strategy is primarily used in blunt injuries and rarely in penetrating injuries.

Endovascular management

Endovascular management is an upcoming modality.[7] It is mainly used for the treatment of pseudoaneurysms (thrombin instillation or embolization) and/or arterio-venous fistulas (stenting can be done). Its use is still limited in PVIs as they are easy to access surgically.

Operative management

The primary approaches include simple ligation, primary repair, and interposition graft placement. Simple ligation is not recommended for arterial injuries while it can be done for venous injuries in cases where repair is not possible. In hemodynamically unstable patients with arterial injuries, intravascular shunt may be placed as a time buying option.

Thus, the rule of 3 should be followed while managing PVI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Feliciano DV, Moore FA, Moore EE, West MA, Davis JW, Cocanour CS, et al. Evaluation and management of peripheral vascular injury. Part 1. Western trauma association/critical decisions in trauma. J Trauma 2011;70:1551-6.  
    2.Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr., Robinson JT, Volgas DA. Vascular injuries in knee dislocations: The role of physical examination in determining the need for arteriography. J Bone Joint Surg Am 2004;86:910-5.  
    3.deSouza IS, Benabbas R, McKee S, Zangbar B, Jain A, Paladino L, et al. Accuracy of physical examination, ankle-brachial index, and ultrasonography in the diagnosis of arterial injury in patients with penetrating extremity trauma: A systematic review and meta-analysis. Acad Emerg Med 2017;24:994-1017.  
    4.Montorfano MA, Montorfano LM, Perez Quirante F, Rodríguez F, Vera L, Neri L. The FAST D protocol: A simple method to rule out traumatic vascular injuries of the lower extremities. Crit Ultrasound J 2017;9:8.  
    5.Wallin D, Yaghoubian A, Rosing D, Walot I, Chauvapun J, de Virgilio C. Computed tomographic angiography as the primary diagnostic modality in penetrating lower extremity vascular injuries: A level I trauma experience. Ann Vasc Surg 2011;25:620-3.  
    6.Kumar A, Agarwal H, Gupta A, Sagar S, Banerjee N, Kumar S. Imaging modalities in trauma and emergency – A review. Indian J Surg 2021;83:42-52.  
    7.Ganapathy A, Khouqeer AF, Todd SR, Mills JL, Gilani R. Endovascular management for peripheral arterial trauma: The new norm? Injury 2017;48:1025-30.  
    

 
 

  [Table 1]