Comparison of Outcome in Upper and Lower Limb Blunt Arterial Trauma: A Single-Center Experience

Abstract

Introduction - In literature, data reporting on outcome after repair of arterial limb trauma frequently include and combine upper (UE) and lower (LE) extremity lesions as well as blunt and penetrating mechanisms. However, outcome analyses in such combined cohorts depend on the case mix and may not be comparable in upper and lower limb lesions. We hereby report on our experience and the differences in upper and lower limb blunt trauma in our large European Level I Trauma Centre. Methods - All patients that underwent repair of main arteries in the upper (axillary artery or distal) or lower (common femoral artery or distal) limb for blunt traumatic injuries since 1990 were included and retrospectively analysed. Exclusion criteria were: iatrogenic and penetrating injuries; more proximally located lesions (e.g. to subclavian artery or iliac arteries); posttraumatic aneurysms; ligation or occlusion (e.g. endovascular coil embolization) and / or conservatively managed injuries. Endpoints of outcome analysis were: in-hospital mortality; limb loss; early vascular re-intervention (within initial hospital stay); length of hospital stay. Descriptive statistics was performed. For comparison of categorical variables, Fisher´s Exact test was used; for continuous variables Mann-Whitney U test was performed; both were considered significant if P<0.05. Results - A total of 204 patients underwent repair of blunt arterial injuries to the UE (n=88) or LE (n=116). Distribution of age (UE: median: 35.7 yrs [range: 2.5-80.5]; LE: 33.4 [5.3-84.4]) and gender (UE: 80.7% male; LE: 80.2%) was similar. Injuries were most frequently located in the brachial (58% of all UE lesions) or the popliteal (51% of all LE lesions) artery. Associated lesions were frequently seen, and included skeletal (UE: 77.3% vs. LE: 85.3%; P=.15) and / or nerve injuries (UE: 38.6% vs. LE: 25.9%; P=.07). Arterial repair was achieved using various types of surgery (direct suture, patchplasty, end-to-end anastomosis or interposition grafts), most frequently autologous vein graft interposition (UE: 73.9%; LE: 75.9%). None of the patients underwent endovascular treatment. In-hospital mortality was 3.4% in UE vs. 7.8% in LE trauma (P=.24). Limb loss rate was significantly higher in the lower limb (UE: 4.5%; LE: 15.5%; P<.05). Early vascular re-intervention rate due to early graft occlusions was 8% (UE) vs. 9.5% (LE) (P=.81). Length of hospital stay was significantly longer in lower limb arterial injuries (UE: median: 10 days [range: 2-17]; LE: 25 [7-132]) (P<.001). Conclusion - Our cohort analysis indicates that outcome after arterial repair in blunt extremity trauma differs between upper and lower extremity: Limb loss rate is significantly higher in lower limbs, and so is length of hospital stay. Noteworthy, early graft occlusions occurred in up to 10% with similar rates in upper and lower limb. In general, outcome data after arterial repair in limb trauma largely depend on associated injuries and the case-mix. Analyses of outcome data (e.g. on limb salvage rates) in combined upper and lower limb cohorts, as frequently shown in literature, are inappropriate.