-POSTGRAD. MED. J. (I963), 39, 724 Postgrad Med J: first published as 10.1136/pgmj.39.458.724 on 1 December 1963. Downloaded from

BLOOD VESSEL : FEATURES OF THE PATHOLOGY EDWARD A. EDWARDS, M.D. RICHARD V. FIDDIAN, M.Chir.* Department of , Harvard Medical School, Boston I5, Massachusetts, U.S.A.

THE pathology of trauma to vessels may be after gynxecological procedures. Extensive dis- discussed under the heading of with section for malignancy and previous irradiation breach of the vessel wall and the less common were additional factors in these patients. occlusions of apparently intact vessels. Con- Hammostasis after a vessel is opened depends comitant injury, such as that of the , will upon three mechanisms (Quick, 1942). Con- not be considered. traction of the vessel is most significant in the In every series of vascular injuries, various case of , especially after complete tran- degrees of division of vessels are commoner than section. An incomplete laceration may continue occlusions (Morris, Creech and DeBakey, 1957; to bleed because contraction of the arterial muscle Neely, Hardy and Artz, I96I). Th2 former give tends to open the of the wound. The other the following frequency of lesions in their series: two mechanisms are those of cellular aggregation, Laceration-36, 3 with subintimal dissection especially platelets, and of fibrinous clot formation. Transection-7I. All three processes become more effective afterProtected by copyright. Contusion-6, 4 with hmmorrhage has caused some hypotension. Spasm-3. Hamorrhage thus usually ceases spontaneously in wounds of even the largest , until operative Lacerations and Transections manipulation releases the pressure of the peri- The most common cause of penetrating vessel vascular ha-matoma (Starzl, Kaupp, Beheler and injury in America is wounding by knife or gun- Freeark, I962). It should be noted that air shot, less commonly by a fracture fragment, or into the jugular or subclavian veins is by the surgeon's rongeur or curette (as when favoured if the patient is placed in the sitting operating on a herniated intervertebral disc.) position and the local venous pressure is thus may also rupture arteries or veins, lowered. especially in the or chest (McBurney and Shuck and Aside from immediate haemorrhage, a significant Gegan, I962; Trump, I96I). Special result of arterial laceration is the formation of an interest focuses on the rupture of the thoracic or . Trauma rarely produces a true in car accidents. The rupture occurs at the aneurysm, but it may cause rupture or thrombosis of anhttp://pmj.bmj.com/ junction of the arch and the descending part. It existing one. This sequence is well known in popliteal has been attributed to contusion of the arteriosclerotic , following sharp knee flexion, aorta, as in squatting. False aneurysms or pulsating hmema- downward acceleration of the and arch, or tomas are very common after incomplete arterial to forward acceleration of the division. A systolic murmur is characteristic. Severe (Zehnder, 1956). With large tears, death is hemorrhage is a constant threat and the lesion, when immediate; smaller tears lead to aneurysm forma- recognized, should be dealt with at once. tion. Surprisingly, these aneurysms may remain A side-by-side injury of an and produces

an arteriovenous fistula. Usually the decompression on September 27, 2021 by guest. unruptured for years, as in five cases recently offered by the low pressure of the vein obviates the reported by Steinberg (I957). Primary operative danger of h2emorrhage, although rarely an intervening to vessels needs no comment, but dissecting hematoma may exist. Small arteriovenous injury secondary fistule have closed spontaneously, generally by throm- erosion of a major artery by is reported bosis, in months or years (Takaro and Scott, i960), by Brunschwig and Brockunier (I960) as the but as Schumacher (in Elkin and DeBakey, 1955) cause of iliac artery rupture in a group of patients observes, this happens so infrequently as to make this a factor of little significance in planning treatment. The tendency for arteriovenous fistule to induce Based upon a postgraduate lecture given at the cardiac enlargement and failure depends upon the size Annual Congress of the American College of Surgeons of the communication and the proximity of the lesion to at Atlantic City, October I6, I962. These studies were the heart. Thus large fistulae between the abdominal aided by grants from the American Medical Research aorta and inferior vena cava produce early Foundation and the Massachusetts Heart Association. (Hufnagel and Conrad, 1962). Janes and Jennings (i96i) * In receipt of a Peel Travelling Fellowship. have reported on a group of young patients in each of December I963 EDWARDS and FIDDIAN: Vessel Injury: Features of the Pathology 725 Postgrad Med J: first published as 10.1136/pgmj.39.458.724 on 1 December 1963. Downloaded from whom a fistula, one half-inch in length, was produced in the and vein, in order to stimulate growth of a short limb. These fistulm did produce some cardiac enlargement, but no instances of heart failure were observed over the several years between the making and the surgical closure of the fistulhe. Occasionally, infection may be established on the interior of the fistula with the production of a subacute bacterial endocarditis. As with the similar process in cases of patent ductus arteriosus, cure is usually effected after excision of the fistula, unless the heart valves are also involved (Parmley, Orbison, Hughes and Mattingley, '954). The degree of resulting from blood vessel injury depends on many factors and will be discussed later. Non-Penetrating Occlusions Blunt injury, such as fracture and dislocation at the elbow or knee, is the commonest cause of traumatic occlusion of apparently intact vessels (Hoover, 196I; Makins, I919). Vascular spasm, internal parietal dissection and thrombosis are three of the important mechanisms of this occlusion (Gryska, I962). More insidious injury, as by infection, irradiation (Wolbach, I909), or chemical irritation, causes both and Protected by copyright. intimal proliferation. The latter is also a stage in healing after mechanical trauma (Valls-Serra, 195I) as well, so that partial or total occlusion may develop slowly in a vessel not occluded early after injury. There is little opportunity for recanalization of a -post-traumatic thrombosis, since injury also leads to fibrosis and contraction of the vessel. That local spasm of an injured vessel is myogenic in origin and thus unrelieved by block, but relieved by the local application of papaverine, is well documented by Kinmonth, Hadfield, Connolly, Lee and Amaroso (I956). There may be added to this a FIG. i.-Post-amputation arteriogram after high tension spasm of the distal arterial tree, often highly significant electrical burn of the forearm in a boy of 14. The soft tissues of the forearm were extensively in the upper extremity, which is under nervous control http://pmj.bmj.com/ and amenable to nerve block. However, spasm alone destroyed, with thrombosis of both the radial and is rare in an artery, and experience dictates that a vessel ulnar arteries. Thrombosis did not extend beyond in apparent spasm which cannot be adequately relieved the wrist. The limit of this process is indicated for should be explored, since thrombosis is usually present the and its branches ('Thromb'). (Gryska, I962; Hoover, I96I; Morris and others, 1957). Some of the arteriographic medium is extravasated More rarely, an intimal rupture, with subintimal ('Extrav'). hiematoma, may cause obstruction in the contused vessel, as it may in vessels which have also been lacerated externally. The intravascular injection of chemical irritants may produce thrombosis. This occurs frequently on September 27, 2021 by guest. Certain special situations deserve mention. after intravenous therapy and is usually harmless. Ballistic wounds produce blast effects over wide Intra-arterial injection is more serious. Gangrene areas, and arteries thus contused may show long of a limb has occurred after intra-arterial trans- thrombi (Makins, I919). Fibrosis may later fusion and is frequent after inadvertent injection develop far beyond an apparently localized of pentothal (Stone and Donnelly, 1961). wound. Jahnke (1958), in a long-term sttidy of Burns of thermal or electrical origin cause repaired war injuries of arteries, found a high extensive local thrombi. In the case of high incidence of late fibrosis and thrombosis, and tension contact, the current is said to pass for was of the opinion that the initial seemingly great distances along the main vessels, with adequate debridement should have been more resultant extensive thrombosis and gangrene extensive. (Muir, 1958). Fig. i, however, shows that the 726 POSTGRADUATE MEDICAL JOURNAL December i963Postgrad Med J: first published as 10.1136/pgmj.39.458.724 on 1 December 1963. Downloaded from

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duringaffthxprmet+ --hr,2Mil FIG.2.-ffetgfenea artriao feoralvenuspressure.1/ cclsio onfoVntecopno rey nadgVne ne-mbuani tei.Teatnain(atn) fvnu rsuercrigwsmdfe

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general arterial pressure. thrombosis need not extend to the very end of the The rectus femoris, for example, may become vascular tree. readily produces major entirely necrotic on interruption of its single

venous or arterial thrombosis, especially in the supply from the lateral femoral circumflex artery.http://pmj.bmj.com/ presence of pre-existing arterial disease. The gastrocnemius is vulnerable because of the single artery to each of its two heads. The biceps Variations in Ischaemic Effect humeri likewise may have but one artery supplying The degree of ischwmia produced by occlusion it, although in most subjects it possesses up to or division of an artery depends first of all upon eight arteries. Occlusion of the anterior tibial the degree to which the artery is normally endowed- artery may cause of the entire contents with collaterals. Thus, injuries to the popliteal of the anterior tibial compartment. artery show a greater incidence of gangrene than Theoretically, collaterals may exist in sufficient on September 27, 2021 by guest. do injuries to the femoral artery (Edwards, 1958). number so as to re-establish the original flow, but Concomitant injury to collaterals obviously adds as the accompanying Table i (taken from a work to the ischbmia. on plumbing engineering) illustrates, these small It is well appreciated that effective collaterals vessels must be exceptionally numerous indeed to are lacking for the supply of most viscera. The attain such a happy result. same is true for some portions of , the nerves Flow is, of course, also directly related to gnd the muscles of the limbs (Edwards, 1954). pressure, and inversely related to viscosity. Some individual muscles are notoriously limited Adequate restoration of blood volume and pressure in their supply and may become ischmmic or is thus of great importance in restoring blood flow, necrotic, quite out of proportion to the state of while the judicious use of saline or low-molecular the remainder of the limb (Edwards, 1953). weight dextran may assist flow considerably. December I963 EDWARDS and FIDDIAN: Blood Vessel Injury: Features of the Pathology 727 Postgrad Med J: first published as 10.1136/pgmj.39.458.724 on 1 December 1963. Downloaded from TABLE i.-The number of i-inch pipes that will discharge as much as a single pipe of other sizes for the same pressure loss. (From Babbitt, H. E., Plumbing. McGraw-Hill Book Company, New -York, I960).

Size of pipe, in. j I 2 4 8 io Number of j-in. pipes with same capacity I 6.2 37.8 I89 _I,200 2,090 Subfascial aedema, alone or associated with hmmorrhage, can produce ischamic changes in a limb. This is not infrequently the dominant mechanism of ischmmia following injury such as supracondylar fracture of the humerus. The occlusion is relieved in these cases by division of the deep . Muscle is very sensitive to ischaimia and at least partial necrosis follows arterial occlusion lasting four hours or more (Edwards, I953). FEMORAL ARTERY FLOW Indeed, contracture of muscle may be noted FIG. 3.-Effect of femoral venous occlusion on arterial within an hour of ischlemia. This early con- flow in another dog. While the flow vacillated tracture wears off completely if blood flow is somewhat, there was a tendency to a considerable quickly restored. If high grade ischaemia con- increase during the venous occlusion.

tinues, autolysis then produces a flail limb within Protected by copyright. 24 hours. Lesser degrees of unrelieved ischaemia go on to the fibrotic contracture of Volkmann ARTERIAL PRESSURE Neosynephrine 20mg. 220 (Griffiths, I940). 120 mm.Hg. 116 116 Since World War I, there has been a good deal of conflicting testimony regarding the effect of venous ligation for concomitant arterial occlusion. Since flow is directly related to differential pressure, any increase in resistance to the outflow of an in vitro system lowers flow, but even the more recent physiologic experiments, with the VENOUS PRESSURE better instrumentation now available, do not always show this result in the living animal. The 13 mm. Hg. 16 13 10 factor operating to help maintain the flow is the increased transmural pressure which produces passive vasodilatation of the vascular tree and a 5- min. http://pmj.bmj.com/ consequent reduction in resistance to flow (McDonald, I960; Read, Kuida and Johnson, > FEMORAL ARTERY FLOW Thrombosis of I958). IV with .67mm. lumen narrowed arterial 6E inserted in Fem. art. lumen . The results in the dog, as observed in our Vein released laboratory, have varied somewhat. An immediate diminution in arterial flow was constant, but this 7ml./min.| 4 1 could be quite transient and succeeded by a on September 27, 2021 by guest. FIG. 4.-Effect of femoral venous occlusion on arterial substantial rise, while the venous pressure, flow when is present in the artery. Flow although diminishing, was still far above its initial falls with the venous occlusion, and thrombosis of level (Figs. 2 and 3). When the inflow arterial the stenotic lumen finally occurs. pressure was very low, no such secondary rise in arterial flow was observed throughout the hour To return to arterial injury, it would seem from or two of duration of our experiments, and in one our own observations and the work of others that case thrombosis of a narrowed arterial lumen there is no adequate justification for adding venous resulted (Fig. 4). One clinical counterpart of these insult to arterial injury, especially as reconstructive experiments is arteriosclerosis, where venous is so well established that the new point ligation or thrombosis may diminish flow suffi- of discussion is whether to reconstruct the vein ciently to precipitate gangrene. as well as the artery, when both are injured. 728 POSTGRADUATE MEDICAL JOURNAL December I963Postgrad Med J: first published as 10.1136/pgmj.39.458.724 on 1 December 1963. Downloaded from Summary and Conclusions Variation in ischimic effect depends at the The most common cause of penetrating vessel outset upon the excellence of collateral endow- injury is wounding by knife or gun-shot, although ment. Not only the viscera, but also other tissues, blunt trauma may also rupture major vessels. notably the muscles, may anatomically lack Spontaneous haemostasis more readily follows adequate collaterals, and may thus be subject to complete, than incomplete, transection. Incom- total necrosis after relatively localized vascular plete laceration may be followed by dissecting interruption. hlmatoma, aneurysm or arteriovenous fistula. Experiment also demonstrates that local venous Blunt injury, as in fractures, is the commonest obstruction produces a fall in arterial flow which cause of traumatic vascular occlusion, which may is transient unless a general or local arterial also follow repeated lesser trauma, irritation of a hypotension exists. In other instances the fall may vessel by infection, irradiation, or the accidental be followed by a moderate increase. This has injection of chemical irritants. Electrical burns been ascribed to passive vasodilatation of the cause thrombosis which does not necessarily vascular tree and a consequent reduction of extend to the acral arterial tree. peripheral resistance.

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McDONALD, D. A. (I960): 'Blood Flow in Arteries'. Baltimore: Williams and Wilkins. http://pmj.bmj.com/ MoRRis, G. C., CREECH, O., and DEBAKEY, M. E. (1957): Acute Arterial Injuries in Civilian Practice, Amer. 3. Surg., 93, 565. MUIR, I. F. K. (1958): The Treatment of Electrical Burns, Brit. 7. plast. Surg., 10, 292. NEELY, W. A., HARDY, J. D., and ARTZ, C. P. (I96I): Arterial Injuries in Civilian Practice: A Current Reappraisal with Analysis of 43 Cases, 3. Trauma, I, 424. PARMLEY, L. F., ORBISON, J. A., HUGHES, C. W., and MATTINGLY, T. W. (1954): Acquired Arteriovenous Fistulas Complicated by Endarteritis, and Endocarditis Lenta due to Streptococcus fecalis, New Engl. J7. Med., 250, 305. QUICK, A. J. (1942): 'The Hemorrhagic Diseases and the Physiology of '. Springfield, Illinois: Charles C Thomas. READ, R. C., KUIDA, H., and JOHNSON, J. A. (1958): Venous Pressure and Total Peripheral Resistance in the Dog, on September 27, 2021 by guest. Amer. 3. Physiol., I92, 609. SHUCK, J. M., and TRUMP, D. S. (I96I): Nonpenetrating Abdominal Trauma with Injury to Blood Vessels, Amer. Surg., 27, 693. STARZL, T. E., KAUPP, H. A., BEHELER, E. M., and FREEARK, R. J. (I962): The Treatment of Penetrating Wounds of the Inferior Vena Cava, Surgery, 5I, 204. STEINBERG, I. (1957): Chronic Traumatic Aneurysm of the Thoracic Aorta, New Engl. Y. Med., 257, 9I3. STONE, H. H., and DONNELLY, C. C. (I961): The Accidental Intra-arterial Injection of Thiopentol, Anesth., 22, 995. TAKARO, T., and SCOTT, S. M. (I960): Spontaneous Closure of a Traumatic Arteriovenous Fistula of Seven Years' Duration, Arch. Surg., 8i, 965. VALLS-SERRA, J. (I951): Arteritis por Muletas: Trombosis Aguda Tratada por Arteriectoma Axilar, Angiologia, 3, 59. WOLBACH, S. B. (I909): The Pathological of Chronic X-ray Dermatitis and Early X-ray , med. Res., x6, 415. Y. ZEHNDER, M. A. (1956): Delayed Post-traumatic Rupture of the Aorta in Young Healthy Individual after Closed Injury: Mechanical-etiological Considerations, , 7, 252.