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Blood Vessel Injury: Features of the Pathology Edward A -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 INJURY: FEATURES OF THE PATHOLOGY EDWARD A. EDWARDS, M.D. RICHARD V. FIDDIAN, M.Chir.* Department of Anatomy, 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 injuries 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 nerves, 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 arteries, 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 lips 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 thrombosis hmmorrhage has caused some hypotension. Spasm-3. Hamorrhage thus usually ceases spontaneously in wounds of even the largest veins, 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 embolism 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 Blunt trauma may also rupture arteries or veins, lowered. especially in the abdomen 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 aneurysm or fistula. Trauma rarely produces a true aorta 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 aneurysms, following sharp knee flexion, aorta, as in squatting. False aneurysms or pulsating hmema- downward acceleration of the heart and arch, or tomas are very common after incomplete arterial to forward acceleration of the descending aorta 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 artery and vein 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 infection 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 heart failure 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: Blood 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 femoral artery 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 ischemia 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 inflammation 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 nerve 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 ulnar artery 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 ..........A. VEOU ....E..URE. : ~~i11 0 i FEMORAL ART-ERY. FLO-W Protected by copyright. duringaffthxprmet+ --hr,2Mil FIG.2.-ffetgfenea artriao feoralvenuspressure.1/ cclsio onfoVntecopno rey nadgVne ne-mbuani tei.Teatnain(atn) fvnu rsuercrigwsmdfe mInu2Efetes Fow incorease aferou venousio release but this cmpaynhveben duter to andgincreasin general arterial pressure. thrombosis need not extend to the very end of the The rectus femoris, for example, may become vascular tree. Frostbite 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.
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