A series of case studies demonstrating the utility of endovascular techniques and tools to treat traumatically injured vessels in the extremities

U pper and lower extremity traumas are infrequently seen in the civilian health care system. Their frequency is significantly higher in military facilities during periods of armed conflict. The National Trauma Databank reported that 66% of traumas involve upper and lower extremities, and 18% of these (15% lower and 3.31% upper extremities) are Abbreviated Injury Scale > 3. Vascular injuries involving the extremities are rare, and in fact, only 26% of extremity traumas have vascular lesions. Extremity arterial injuries are a result of penetrating (stab or gunshot wounds) or blunt (traffic accidents, compressions) traumas and iatrogenic injuries. The main mechanisms of vascular lesions include laceration or rupture of the vessel, hematoma development, dissection, pseudoaneurysm or arteriovenous fistula formation, and distal acute ischemia. In the past 2 decades, diagnostic angiography was used to identify arterial damage, but due to technological advancements, mutidetector computed tomography angiography (CTA) has essentially replaced traditional diagnostic angiography. Selective angiography is now reserved for the patients with suspected (previously detected through CTA) vascular injuries and are indicated for endovascular treatment. A traumatic lesion of the main artery in extremities can be treated with bare-metal stent or stent graft placement, whereas distal branch bleeding can be embolized. Embolization can be performed with coils, vascular plugs, gelfoam pledgets, particles, liquid embolic (N-butyl cyanoacrylate and ethylene vinyl alcohol copolymer), or a combination of these. Endovascular treatment is a minimally invasive option and an alternative to open surgery, which avoids adjacent tissue damage and has potentially lower morbidity and mortality rates than conventional management. The following cases demonstrate the importance of endovascular treatment for traumatic vascular injuries in the upper and lower extremities.