Vascular Repair in Wartime Casualties.

In the third installment of the "Lest We Forget" series, the authors discuss a critical advance-vascular repair, pioneered by Dr. Carl Hughes-in the care of the war-wounded during the Korean War. This article reviews the management of large vessel injuries in wartime, the challenges and advances in military medicine during the Korean War, and the application of these lessons to current practices.

Endovascular treatment for 2 types of subclavian artery injury: A case report.

RATIONALE: Subclavian artery (SCA) injuries, though rare, carry significant morbidity and mortality risks due to significant blood loss causing hypovolemic shock. Early diagnosis and adequate treatment are crucial to minimize bleeding and associated morbidity. Recent advances in endovascular techniques offer faster and more accurate treatment options compared to traditional open surgical repair. This study demonstrates the efficacy of endovascular treatment in 2 cases of SCA injury and reviews its indications, limitations, and precautions. PATIENT CONCERNS: A 69-year-old man presented with a penetrating SCA injury from a steel bar, and a 38-year-old woman presented with a blunt SCA injury caused by a fall. Both patients were hemodynamically unstable upon presentation. DIAGNOSES: Both patients were diagnosed with SCA injuries. The man had a penetrating injury, while the woman had a blunt injury, both resulting in hemodynamic instability and significant risk of hypovolemic shock. INTERVENTIONS: Endovascular techniques, including the use of covered stent grafts, were employed to manage the injuries. These techniques allowed for rapid and efficient treatment, reducing the need for open surgical intervention. OUTCOMES: Both patients were successfully treated using endovascular methods and were discharged without any complications. The endovascular approach minimized blood loss, transfusion needs, and hospital stay. LESSONS: This study demonstrates the effectiveness of endovascular techniques in rapidly diagnosing, bridging, and definitively treating SCA injuries, suggesting their use as a first-line therapy.

[Surgical treatment of traumatic arteriovenous fistulas of extremities]. / Osobennosti khirurgicheskogo lecheniya travmaticheskikh arteriovenoznykh fistul konechnostei.

The number of victims with damage to the great vessels has increased in recent years due to escalation of armed conflicts. Vascular damages comprise 3% of traumatic injuries in peacetime, and their incidence increases to 15% during hostilities. False aneurysms and traumatic arteriovenous fistulas follow vascular injury in 48.9-68.7% of cases. We present open surgical treatment of traumatic arteriovenous fistulas. The issues of diagnosis, surgical tactics, algorithm of intervention and options for successful treatment are described.

In-Hospital Risk Factors for Reintervention and Amputation in Brachial Arterial Trauma.

INTRODUCTION: Brachial artery trauma is a rare but potentially devastating injury. There is little data regarding risk factors for reintervention and amputation prevention in this population, as well as anticoagulant (AC) and antiplatelet (AP) regimens and outcomes after discharge in trauma patients with vascular injuries requiring repair. This study aims to identify in-hospital risk factors for reintervention and amputation and stratify outcomes of follow-up by discharge AC or AP regimen. METHODS: The AAST Prospective Observational Vascular Injury Trial database was queried for all patients who underwent traumatic brachial arterial repair from 2013 to 2022. Patients were evaluated by need for reintervention, amputation, and outcomes at follow-up by AC or AP regimen. RESULTS: Three hundred and eleven patients required brachial repair, 28 (9%) required reoperation, and 8 (2.6%) required amputation. High injury severity score and an increased number of packed red blood cells and platelets showed a significant increase for reoperation and amputation. Damage control and shunt use were significant for the need to reoperate. Seventy-four percent (221/298) of patients were discharged with postoperative AC or AP regimens. There was no significant difference of short-term follow-up by type of AC or AP regimen. CONCLUSIONS: Damage control and temporary shunt may lead to additional operations but not an increase in amputations. However, anticoagulation intraoperatively and postoperatively does not appear to play a significant role in reducing reintervention. It also suggests that there is no increase in short-term follow-up complications with or without AC or AP therapy.

Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center.

Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

PURPOSE: This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. METHODS: A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. RESULTS: Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. CONCLUSION: These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Current outcomes following upper and lower extremity arterial trauma from the National Trauma Data Bank.

OBJECTIVE: The modern treatments of trauma have changed in recent years. We aim to evaluate the factors associated with limb salvage and mortality after extremity arterial trauma, especially with respect to the type of conduit used in revascularization. METHODS: The National Trauma Data Bank was queried to identify patients with upper and lower extremity (UE and LE) arterial injuries between 2016 and 2020. The patients were stratified by the types of arterial repair. The primary outcome was in-hospital mortality. RESULTS: 8780 patients were found with 5054 (58%) UE and 3726 (42%) LE injuries. Eighty-three percent were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UEs and LEs (73% and 67%, respectively) with a mean injury severity score of 14 ± 8. For UEs, the majority underwent primary repair (67%, P < .001), whereas the remainder received either a bypass (20%) or interposition graft (12%). However, LEs were more likely to receive a bypass (52%, P < .00001) than primary repair or interposition graft (34% and 14%, respectively). Compared with the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, P < .001) and death (6%, P < .001). Notably, compared with primary repair, the use of a prosthetic conduit was associated with a 6.7-fold increase in the risk of amputation in UE and a 2.4-fold increase in LE (P < .0001 for both). Synthetic bypasses were associated with a nearly 3-fold increase in return to the operating room (OR) in UE bypasses (P < .05) and a 2.4-fold increase in return to the OR in LE bypasses (P < .0001). CONCLUSIONS: In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, LE injuries more often led to amputation and mortality than UE injuries. The most frequently used bypass conduit was vein, which was associated with less risk of unplanned return to the OR and limb loss, corroborating current practice guidelines for extremity arterial trauma.

Occurrence, predictors, and management of late vascular complications following extracorporeal membrane oxygenation.

OBJECTIVE: Vascular complications (VCs) associated with extracorporeal membrane oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VCs following ECMO; this study aims to assess occurrence and management practices of late VCs following discharge. METHODS: A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1, 2019, and December 31, 2020. Primary outcomes were to categorize and determine the rate of late VCs. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations. RESULTS: A total of 229 patients were identified, of which 50.6% (n = 116) survived until discharge. Late VCs occurred in 7.8% of the surviving cohort (n = 9/116); with a median time until presentation of 150 days (interquartile range, 83-251 days). The most common late VC was infection (n = 5; 55.6%) followed by progression to limb-threatening ischemia (n = 4; 44.4%). Urgent procedures were required in 55.6% of patients (n = 5), whereas 44.4% (n = 4) were elective interventions. Interventions performed for management of late VCs included lower extremity arterial revascularization (n = 6; 66.7%), major (n = 1; 11.1%) or minor amputation (n = 1; 11.1%), and wound debridement (n = 1; 11.1%). The majority of patients presenting with late VCs had initially been cannulated for peripheral VA ECMO (n = 8; 88.9%), and one patient (11.1%) was cannulated for peripheral VV ECMO. VCs during index hospitalization were seen in 77.8% of patients (n = 7) returning with late VCs. Odds for late VCs were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal cardiopulmonary resuscitation (odds ratio, 8.4; P = .016) and in cases where patients had experienced an index VC during index hospitalization (odds ratio, 19.3; P = .001). CONCLUSIONS: Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.

Rural Vascular Trauma: Time to Care.

Previous rural vascular trauma research has focused on case series dating back two decades. The current research aims to measure clinical decline in comparison to time to care in rural vascular trauma. This single-center retrospective cohort study included adult trauma patients with vascular injury who were admitted to a level II trauma center. Multivariable logistic regression assessed the effect of clinical decline based on arrival within the golden hour. 149 patients were included. For every 1 unit increase in the shock index ratio, there was 99.9% reduction in odds that the patient would arrive to the trauma center within the golden hour. This study is the first of its kind within the last two decades to comprehensively review rural vascular trauma. Our research showed clinical decline in SIR associated with prolonged time to care and will allow us to optimize pre-hospital care and transport in regions with prolonged arrival times.

Editor's Choice - International Perspective on Extremity Vascular Trauma in Children: A Scoping Review.

OBJECTIVE: Extremity vascular trauma in children can result in significant morbidity and mortality. Most published studies have focused on supracondylar humeral fracture related injuries, with little focus on other injuries. This scoping review describes the current state of knowledge on paediatric vascular injuries in the upper and lower limbs, excluding injuries related to supracondylar humeral fractures. METHODS: MEDLINE, PubMed, Web of Science, and Cochrane databases were searched for relevant studies evaluating the epidemiology, diagnosis, management, and outcomes of upper and lower limb vascular trauma in those aged under 18 years. Studies related to supracondylar humeral fractures were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews was used. RESULTS: A total of 39 studies was included, all of which were retrospective, and 74% of which were based in North America or Europe. Extremity vascular trauma was reported to cause 0.6 - 4.4% of all paediatric trauma admissions, with penetrating mechanisms and upper limb injuries being the most common. Operative intervention was reported in 80 - 100% of children in the included studies. Primary repair was the most commonly reported operative intervention, followed by interposition graft and bypass graft. Synthetic graft use was less commonly reported (incidence range 0.5 - 33%). Lower limb fasciotomies and amputations were not commonly reported (incidence range 0 - 23% and 0 - 13%, respectively). The mortality rate appeared low, with 23 studies reporting no deaths (incidence range 0 - 4%). Complications were reported inconsistently, with no uniform outcome or follow up measures used. CONCLUSION: The incidence of extremity vascular trauma appears low in children, with penetrating mechanisms and upper extremity injuries appearing to dominate. Most studies are from high income countries, with probable selection bias towards those treated by operative intervention. Prospective studies are required focusing on patterns of injury, rates of operative and endovascular intervention, and long term outcomes.

Using machine learning to predict outcomes of patients with blunt traumatic aortic injuries.

BACKGROUND: The optimal management of blunt thoracic aortic injury (BTAI) remains controversial, with experienced centers offering therapy ranging from medical management to TEVAR. We investigated the utility of a machine learning (ML) algorithm to develop a prognostic model of risk factors on mortality in patients with BTAI. METHODS: The Aortic Trauma Foundation registry was utilized to examine demographics, injury characteristics, management and outcomes of patients with BTAI. A STREAMLINE (A Simple, Transparent, End-To-End Automated Machine Learning Pipeline Facilitating Data Analysis and Algorithm Comparison) model as well as logistic regression (LR) analysis with imputation using chained equations was developed and compared. RESULTS: From a total of 1018 patients in the registry, 702 patients were included in the final analysis. Of the 258 (37%) patients who were medically managed, 44 (17%) died during admission, 14 (5.4%) of which were aortic related deaths. Four hundred forty-four (63%) patients underwent TEVAR and 343 of which underwent TEVAR within 24 hours of admission. Among TEVAR patients, 39 (8.8%) patients died and 7 (1.6%) had aortic related deaths ( Table 1 ). Comparison of the STREAMLINE and LR model showed no significant difference in ROC curves and high AUCs of 0.869 (95% confidence interval, 0.813-0.925) and 0.840 (95% confidence interval, 0.779-0.900) respectively in predicting in-hospital mortality. Unexpectedly, however, the variables prioritized in each model differed between models. The top 3 variables identified from the LR model were similar to that from existing literature. The STREAMLINE model, however, prioritized location of the injury along the lesser curve, age and aortic injury grade. CONCLUSION: Machine learning provides insight on prioritization of variables not typically identified in standard multivariable logistic regression. Further investigation and validation in other aortic injury cohorts are needed to delineate the utility of ML models. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Knee dislocations with vascular injuries - a review article.

Knee dislocations are complex and devastating injuries that are potentially limb threatening. A high level of suspicion is required to diagnose and treat these injuries properly and timely because some of the knee dislocations spontaneously reduce, and the seriousness of the injury might not be appreciated early. Early diagnosis of concomitant vascular injuries is imperative to avoid limb loss because the risk of amputation is high when diagnosis and timely intervention are delayed. It is recommended that serial ankle-brachial index (ABI) be performed in all patients with suspected knee dislocation. This is particularly important in fracture dislocations, high-energy trauma, morbidly obese patients, lateral sided injuries, concomitant peroneal nerve injuries and fracture in the ipsilateral limb because these were demonstrated to be associated with a high risk of concomitant vascular injuries in knee dislocations. In cases where serial ABI cannot be performed, in high-risk patients and ABI less-than 0.9, a CT angiography should be performed.

Pediatric Peripheral Vascular Trauma: Incidence and Outcomes.

Peripheral vascular trauma (PVT) is rare in children, with an incidence estimated below 1%. We studied pediatric PVT and risk factors for major amputation by accessing the 2019 National Trauma Data Bank (NTDB). Demographics, injury type and location, trauma center capability, injury severity score (ISS), length of stay (LOS), and major amputation rates were evaluated. Statistical analysis included chi-square testing for categorical variables and t-tests for continuous variables. Of 130,554 pediatric trauma patients, 1196 (.9%) had 1460 upper extremity (UE) and lower extremity (LE) PVT. Patients were predominantly male (n = 933, 78%) with a mean age of 14 years. Most patients suffered penetrating injury (n = 744, 62.2%). The most common vessels injuries were radial (n = 198, 13.6%) and femoral (n = 196, 13.4%). Major amputation occurred in 2.6% of patients (n = 31). Patients who suffered blunt injury (OR, 3.3; 95% CI, 1.5-7.5; P = .004) and lower limb PVT (OR, 11.1; 95% CI, 3.3-37.9, P = .0001) had higher odds of amputation.

Nonoperative Management for Low-Grade Blunt Thoracic Aortic Injury.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the standard of care for the treatment of blunt thoracic aortic injury (BTAI) requiring intervention. Data suggest that low-grade BTAI (grade I [intimal tears] or grade II [intramural hematoma]) will resolve spontaneously if treated with nonoperative management (NOM) alone. There has been no comparison specifically between the use of NOM vs TEVAR for low-grade BTAI. We hypothesize that these low-grade injuries can be safely managed with NOM alone. STUDY DESIGN: Retrospective analysis of all patients with a low-grade BTAI in the Aortic Trauma Foundation Registry from 2016 to 2021 was performed. The study population was 1 primary outcome was mortality. Secondary outcomes included complications, ICU length of stay, and ventilator days. RESULTS: A total of 880 patients with BTAI were enrolled. Of the 269 patients with low-grade BTAI, 218 (81%) were treated with NOM alone (81% grade I, 19% grade II), whereas 51 (19%) underwent a TEVAR (20% grade I, 80% grade II). There was no difference in demographic or mechanism of injury in patients with low-grade BTAI who underwent NOM vs TEVAR. There was a difference in mortality between NOM alone and TEVAR (8% vs 18%, p = 0.009). Aortic-related mortality was 0.5% in the NOM group and 4% in the TEVAR group (p = 0.06). Hospital and ICU length of stay and ventilator days were not different between the 2 groups. CONCLUSIONS: NOM alone is safe and appropriate management for low-grade BTAI, with lower mortality and decreased rates of complication when compared with routine initial TEVAR.

Emergency vascular repairs in trauma: Predictors of poor prognosis and a novel scoring system.

BACKGROUND: Vascular injuries comprise 1% to 4% of all trauma patients, and there are no widely used risk-stratification tools. We sought to establish predictors of revascularization failures and compare outcomes of trauma and vascular surgeons. METHODS: We performed a single-institution, case-control study of consecutive patients with traumatic arterial injuries who underwent open repair between 2016 and 2021. Multivariable logistic regression was used to investigate covariates impacting the primary composite outcome of repair failure/revision, amputation, or in-hospital mortality. RESULTS: Among 165 patients, the median age was 34 years, 149 (90%) were male, and 99 (60%) suffered penetrating injury. Popliteal (46%) and superficial femoral (44%) arterial injuries were most common. Interposition graft/bypass was the most frequent repair (n = 107 [65%]). Revascularization failure was observed in 24 patients (15%). Compared with trauma surgeons, vascular surgeons more frequently repaired blunt injuries (66% vs. 20%, p < 0.001), anterior tibial (18% vs. 5%, p = 0.012), or tibioperoneal injuries (28% vs. 4%, p < 0.001), with a below-knee bypass (38% vs. 20%, p = 0.019). Revascularization failure occurred in 10% (9 of 93) of repairs by trauma surgeons and 21% (13 of 61) of repairs by vascular surgeons. Mangled Extremity Severity Score >8 (odds ratio, 15.6; 95% confidence interval, 4.4-55.9; p < 0.001) and concomitant laparotomy or orthopedic procedure (odds ratio, 6.7; 95% confidence interval, 1.6-28.6; p = 0.010) were independently associated with revascularization failure. A novel composite scoring system (UT Houston Score) was developed by combining Mangled Extremity Severity Score, concomitant procedure, mechanism of injury, and injury location. This score demonstrated a sensitivity of 100% with a score of 0 and a specificity of 95% with a score of >3. CONCLUSION: After traumatic arterial injury, trauma surgeons repaired less-complex injuries but with fewer revascularization failures than vascular surgeons. The UT Houston Score may be used to risk stratify patients to determine who may benefit from vascular surgery consultation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Management of Vascular Injuries in Penetrating Trauma.

Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).

Outcomes Following Below Knee Arterial Trauma.

INTRODUCTION: Lower extremity vascular injuries have significant implications for trauma patients with regards to morbidity from limb loss. There is limited evidence on outcomes for patients with injuries to tibial arteries. Our study focuses on defining outcomes of traumatic vascular injury to vessels below the knee. METHODS: A retrospective review using ICD-9 and 10 codes of all patients with below knee vascular injuries was performed at a Level 1 trauma center from November 2014 to June 2022. Interventions, outcomes, and complications were assessed. RESULTS: Seventy-six patients were identified fitting inclusion criteria. The mean age was 35.3 +/- 15.2 years and 67 (88%) patients were male. Thirty-nine suffered penetrating trauma, 37 suffered blunt trauma. The most injured artery was posterior tibial artery (40%) followed by anterior tibial artery (36%). Injuries included 51 transections, 22 occlusions and 4 pseudoaneurysms. Forty-five (59%) patients underwent operative intervention. Thirty (67%) operations were performed by trauma surgery. Arterial ligation was performed in 30 cases (67%), arterial bypass in 12 (27%), and 2 (4%) primary amputations. Vascular surgery performed all bypasses. Overall amputation rate was 8% (n = 6) with 3 for mangled extremity and 3 due to failed bypass graft. All amputations were associated with open fracture and amputations for failed bypass had multiple arterial injuries. CONCLUSION: The management of below knee vascular trauma requires a multidisciplinary approach. Patients requiring reconstruction are more likely to have multiple vessel injuries and may have significant risk of graft failure. These patients as well as those with extensive soft tissue injury and/or multi-vessel injuries are at increased risk for amputation.

Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation.

While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38 days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.