Coagulopathy after trauma remains significantly associated with complications and death. If coexisting traumatic brain injury is present, there is a dramatic increase of all-cause mortality compared to non-brain-injured patients. As an extension of this concept, the use of anticoagulants following severe injury may be associated with worsened outcomes. Anticoagulation following penetrating trauma may be considered under some select circumstances; however, careful evaluation of these patients should be undertaken to exclude contraindications. Injury burden will dictate the decision to consider the use of anticoagulants, if they are indicated for a particular injury.

Vascular reconstruction following penetrating injury is commonly accomplished by either primary repair, interposition, bypass, or patch with autologous vein or interposition, bypass, or patch with prosthetic. The type of reconstruction and the patient’s existing medical comorbidities may influence the decision to use anticoagulants and antiplatelet agents.

In the absence of severe existing ischemic vascular disease, arterial and venous injuries repaired with autologous vein do not require postoperative systemic anticoagulation or antiplatelet therapy. Additionally, if the popliteal vein is ligated at time of surgery, postoperative anticoagulation does not influence rate of thrombosis or recanalization. If no contraindications exist (such as traumatic brain injury or existing trauma-related coagulopathy), intraoperative anticoagulation during reconstruction (regardless of conduit) may improve rate of limb salvage. Shunting with anticoagulation may also improve limb salvage if definitive reconstruction needs to be delayed. The use of intraoperative angiography (as opposed to preoperative CT angiogram or formal angiography) may also improve chances of saving a limb.

Reconstruction with polytetrafluoroethylene (PTFE) has been shown to be effective when autologous vein is not available, especially the heparin-bonded variety. Limb salvage rates are comparable to autologous vein reconstruction, although there may be increased infection risk in contaminated wounds. Similar to autologous vein reconstruction, PTFE reconstruction after trauma does not require long-term postoperative anticoagulation or antiplatelet agents unless there is existing severe ischemic vaso-occlusive disease.

All penetrating trauma patients, without contraindication, should be placed on early pharmacologic deep venous thrombosis prophylaxis. This should not be conflated with therapeutic anticoagulation discussed above.

Early, or prophylactic, fasciotomy should be carefully considered for traumatic vascular reconstructions, particularly of the lower extremity. The military experience suggests higher limb salvage rates with aggressive prophylactic fasciotomy although the civilian literature suggests a selective approach be utilized. Factors contributing to likely benefit from early or prophylactic fasciotomies include long interval from presentation to repair, prolonged operative time, complex reconstruction, and existing peripheral vascular disease. If the surgeon feels a limb is at particularly high risk for compartment syndrome, then intraoperative anticoagulation may offer benefit. There is some evidence that the use of intraoperative heparin may prevent compartment syndrome and obviate the need for fasciotomy. Consequently, this should be considered when contraindications do not exist.

In conclusion, early aggressive revascularization should be undertaken for penetrating vascular injuries. The use of intraoperative angiography is associated with improved limb salvage, as is the use of intraoperative anticoagulation. Primary lateral repair or autologous vein graft remains the preferred option for reconstruction; however, PTFE should be used liberally if autologous vein is not available, even in a potentially contaminated field. The use of prophylactic fasciotomies is controversial; however, the surgeon should carefully weigh the risk and benefits for each patient. Heparin anticoagulation during surgery may help avoid compartment syndrome. Finally, unless there is coexisting ischemic vascular disease, no postoperative or long-term anticoagulation or antiplatelet therapy is required for vascular repairs following penetrating trauma.