Abstract
Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress.Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies.Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.
Highlights
BackgroundExtremity vascular trauma is a major cause of morbidity and mortality leading to limb loss or life loss
More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon
Amputation rates vary according to the risk factors associated with an injury like associated soft tissue damage, bone damage and degree of shock measured by injury scoring systems, that is, mangled extremity severity score (MESS) and injury severity score (ISS), associated orthopedic fixation, and use of systemic anticoagulation [1,2]
Summary
Extremity vascular trauma is a major cause of morbidity and mortality leading to limb loss or life loss. Limb salvage rate following extremity vascular trauma is variable depending on the severity of tissue damage, mechanism of injury, time elapse in seeking emergency care, underlying hemodynamic status of the patient and associated concomitant injuries and use of anticoagulation in the perioperative period. While Guerrero et al have categorized the patients into subgroups as those received subcutaneous heparin, intravenous heparin, low molecular weight heparin and intravenous dextran but there was no relationship of a specific route of administration of heparin and type of anticoagulation with improved limb salvage rates [35] Both studies show higher limb loss associated with the popliteal artery injuries and the development of compartment syndrome. In a retrospective review article, studied 66 patients with lower limb vascular injury patients suggested the use of venous repair over ligation whenever possible to increase the drainage of the limb but long-term DVT thromboprophylaxis was given for three months after repair [14]. The sample size of review of Franz et al was 66 patients, while Allen et al reviewed data from 158 patients but this study included only patients with penetrating trauma that might have lesser effects on the development of PE [14,43]
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