Extremity Arterial Injuries Research Articles

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

ObjectiveThe 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. MethodsThe 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. Results8780 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). ConclusionsIn 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.

Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma

ObjectiveAutologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma. MethodsA retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment. ResultsThere were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment. ConclusionsAutologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.

Effect of Combination of Temporary Vascular Shunt and Prophylactic Fasciotomy on Limb Salvage after Lower Extremity Arterial Injuries among Yemeni Patients with War-Related Polytrauma

Context and Aim: In cases of severe lower extremity arterial injuries (LEAI), such as those resulting from combatrelated injuries, the preservation of the affected limb is a significant challenge. The combination of a temporary vascular shunt (TVS) and prophylactic fasciotomy (PF) has emerged as a potential approach to improving limb salvage outcomes in these cases. In the context of the war in Yemen, we aimed to assess the effect of combination TVS and PF on limb salvage after LEAI in patients with war-related polytrauma (WRPT). Patients and Methods: A retrospective study was conducted among patients with WRPT at Al Hazm Hospital in Al Jawf Governorate in northeastern Yemen. Cases identified as polytrauma with LEAI in which PF was used comprise the study. These cases were matched to patients, or a control group, injured during the same period having polytrauma with LEAI requiring major vascular intervention but managed without fasciotomy. The primary outcome was surgical amputation. Results: Inclusion criteria were met in 39 cases, 18 (46.2%) had undergone fasciotomy, while the other 21 (53.8%) did not. Both study groups were entirely young (mean age 26.32 ± 5.01 years) males (100%). The overall amputation rate was 17.9% (7 of 39 cases), with 6 (28.57%) cases in the non-fasciotomy group and 1 (5.55%) case in the fasciotomy group. The difference in amputation rate was not statistically significant (p-value, 0.071). Likewise, the mechanism of injury, clinical findings on admission, arterial injuries, and types of surgical procedures were similar in both groups. By contrast, the fasciotomy group had a lower rate of limb infection than their non-fasciotomy counterpart (38.1% vs. 5.6%, respectively). The mortality rate in the hospital was 5.1% (2 of 39 cases), and all of them did not undergo fasciotomies. Conclusion: The combination of TVS and PF was associated with significantly improved limb infection. While statistically unproven, this combination may also enhance limb salvage. Therefore, it should be performed in cases of WRPT.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk

BackgroundPrehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. Materials and MethodsWe performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. Results251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 – 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. ConclusionsArterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries

ObjectiveUse of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. MethodsPatient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. ResultsA total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). ConclusionIpsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.

Usefulness of Intravenous Regional Anesthesia for Upper Extremity Arterial Injury Emergencies in Patients with COVID-19: A Case Series and Literature Review

The medical field has undergone many changes since the start of the coronavirus disease 19 (COVID-19) pandemic. In small- and medium-sized hospitals that lack negative pressure facilities for operating rooms, it is impossible to operate on patients infected with COVID-19. As a result, many patients requiring emergency surgery experience serious complications or die. The authors performed intravenous regional anesthesia (IVRA) and emergency surgery in an isolation room on three patients who needed prompt surgical management for upper extremity arterial injuries but could not enter the operating room due to COVID-19 infection. Anesthesia was successful in all cases. A minor anesthetic complication occurred in one patient, who recovered spontaneously. IVRA is a relatively safe and easy method for anesthesia. Moreover, since the tourniquet is inflated before anesthesia, it is well-suited for patients with arterial injury. The method is simple and therefore easy to perform in an isolation room where space and manpower are limited. IVRA can be a good option in emergency surgery for upper extremity artery injury.

Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center

Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma. A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes. A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5±15.5years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n=42, 38%), popliteal artery (n=35, 31.5%), and tibial vessels (n=19, 17.1%). The most common intervention required in patients was an autologous bypass (n=85, 76.5%), followed by ligation (n=9, 8.1%) and primary repair (n=6, 5.4%). Most interventions overall required VS involvement (n=95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n=79, 92.9% vs. n=6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n=79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P=0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P=0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P<0.001) or primary repair (13% vs. 3%, P=0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P<0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P=0.04). Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

The Relevance of Mangled Extremity Severity Score to Predict Amputation: A Systematic Review

BACKGROUND: Amputation is one of the most common surgical procedures in the world. One of the criteria for assessing amputation is the mangled extremity severity score (MESS). The MESS criterion has been used for many years, but the accuracy remains unknown. The aim of this study is to know the accuracy of MESS. METHOD: Keywords of “relevance,” “mangled extremity score,” and “amputation,” and its combination were entered into the PubMed database. Four evaluators reviewed articles from the past 5-year publication date with the English language to select relevant articles. RESULTS: The outcomes of this systematic review are the sensitivity and specificity of several scoring tools to predict amputation and recommendations for MESS use. The author identified 26 relevant articles with MESS to predict amputation, and most of them recommend using MESS. The sensitivity and specificity of MESS were variable from 63–73% to 70–76%. CONCLUSION: The MESS performs better in the amputation prediction of the lower extremity arterial injury. Other scoring recommendations are LogisticReg + Nearmiss, ISS, BN, and GHOIS.

Timing and choice of systemic anticoagulation in the setting of extremity arterial injury repair.

The role of perioperative anticoagulation in the setting of peripheral arterial injury remains unclear. We hypothesized that early initiation of anticoagulation is associated with a reduced amputation rate without increasing bleeding complications. Using the 2016-2019 ACS-TQIP database, adult patients with upper and lower extremity vascular injuries who underwent open arterial repair and received anticoagulation were included. Patients were divided into two groups: (1) early venous thromboembolism prophylaxis (≤ 24h) and (2) late prophylaxis (> 24h) following arterial repair. The primary outcomes were the rates of limb amputation and bleeding complications. Multivariable logistic regression was used to estimate the impact of timing and type of anticoagulation on the rates of limb amputation and bleeding complications. 4379 patients were included, and 83.9% were males. 68.1% of patients received early anticoagulation, whereas 31.9% received late thromboprophylaxis. Low-molecular-weight heparin (LMWH) was used in 62.0% of patients, and unfractionated heparin (UFH) was administered in 34.3% of patients. Multivariable analysis showed that late initiation of thromboprophylaxis (OR = 1.69 [1.16-2.45], p = 0.006) and use of UFH (OR = 2.61 [1.80-3.79], p < 0.001) were associated with increased rate of amputation. Early initiation of anticoagulation (OR = 2.16 [1.63-2.85], p < 0.001) was associated with increased risk of bleeding complications requiring blood transfusions. Similarly, the use of UFH was associated with a higher rate of bleeding events compared to LWMH (OR = 2.61, [1.80-3.79], p < 0.001). Patients with the operative repair of arterial injuries receiving early perioperative anticoagulation demonstrated an improved limb salvage outcome than those who received late thromboprophylaxis. Our data also suggest that early initiation of prophylaxis may be associated with increased bleeding risk, which may be attenuated using LMWH compared to UFH.

The VA vascular injury study: A glimpse at quality of care in Veterans with traumatic vascular injury repair

ObjectiveThe high number of limb injuries among Post-9/11 Veterans and their long-term care pose significant challenges to clinicians. Current follow-up for extremity arterial vascular injury (EVI) is based on guideline-concordant care for treatment of peripheral vascular disease (GCC-PVD), including anticoagulant/antiplatelet or statin therapy and duplex ultrasound. No best practices exist for arterial EVI. Our goal was to determine correlates of GCC-PVD and other care among Post-9/11 Veterans with combat-related arterial EVI. Materials and methodsWe identified Post-9/11 Veterans with arterial EVI who underwent initial limb salvage repair or ligation (e.g., for single-vessel injury) attempt per DoD Trauma Registry validated by chart abstraction. Veterans Health Administration (VHA) data characterized the cohort in the first five years of VHA care. Models predicted (a) GCC-PVD, (b) pain clinic use, (c) mental/behavioral health care, (d) long-term opioid use, and (e) time to complication, controlling for injury severity and type, mental health parameters, and demographics. ResultsThe 490-Veteran cohort with validated arterial injury was 77% White averaging 25.2 years at injury (range: 18–56). Mechanism of injury was primarily explosive (63%). Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%). Approximately 25% received at least one component of VHA GCC-PVD including 8% arterial ultrasounds, 5% statins, and 11% anticoagulants/antiplatelets; 77% had mental/behavioral healthcare. GCC-PVD, as well as PTSD and substance use disorders, were associated with receipt of mental/behavioral health care. Complications affected 46% of the cohort and were more common among those prescribed 90+ days of opioids or receiving GCC-PVD. ConclusionDespite injury severity (40% moderate/severe), only 25% of cohort patients received VHA GCC-PVD, and nearly half had complications from their arterial injury. Receiving GCC-PVD appeared to potentiate receiving care for mental and behavioral disorders. ImpactThe treatment gap in Veterans with arterial EVI may be due to lack of appropriate guidelines, lack of vascular specialists in VHA or accessing care outside the VHA. Focused study of care options and their outcomes will help define optimal care processes for combat Veterans with arterial EVI.

Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?

Background This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods. Methods A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed. Results In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001). Conclusion The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.

Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity.

Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications. Online supplemental material is available for this article. ©RSNA, 2022.

A single-center retrospective analysis of 77 traumatic arterial injuries of lower extremities

Objective: To analyze the treatment and clinical prognosis of lower extremity arterial injury caused by trauma. Methods: The clinical data of 77 patients with traumatic lower extremity arterial injury admitted to Department of Vascular Surgery,Yichang Central People's Hospital from January 2013 to June 2021 were collected retrospectively. There were 65 males and 12 females, with an average age of 47.4 years (range: 7 to 75 years). Among the 77 patients, 56 cases (72.7%) had open injury and 21 cases (27.3%) had closed injury. Iliac artery was injured in 9 cases (11.7%), common femoral artery in 7 cases (9.1%), superficial femoral artery in 1 case (1.3%), popliteal artery in 11 cases (14.3%) and inferior knee artery in 49 cases (63.6%). The treatment methods and clinical effects were analyzed. Results: One case with pelvic fracture combined the internal iliac artery injury and 1 case with multiple injuries involving the common femoral artery died of circulatory failure before surgery. Seventy-five cases received vascular-related operations, including arterial ligation in 24 cases, arterial reconstruction in 40 cases, stent graft implantation in 1 case, primary amputation in 2 cases, and arterial embolization in 8 cases. The overall mortality rate was 6.5% (5/77), all of which were closed injuries. Except for 2 cases who died before surgery, 3 cases with pelvic fracture combined the internal iliac artery injury died of multiple organ failure after internal iliac artery embolization. There were 8 cases received amputation (10.4%, 8/77), 5 cases with closed injury and 3 cases with open injury. In addition to 2 cases with primary amputation, 6 cases underwent secondary amputation due to ischemia-reperfusion injury after revascularization (4 cases with popliteal artery injury and 2 cases with subpatellar artery injury). The average followed-up time was 17 months (range: 2 months to 8 years). One patient with femoral artery injury underwent autologous great saphenous vein bypass, and lower limb artery CT angiography was re-examined 6 months after the operation, and 30% distal anastomotic stenosis was found. Ankle brachial index<0.8 was found in two patients 1 year after popliteal artery repair, but none of the patients had intermittent claudication symptoms, and no further intervention was performed. Five patients suffered delayed healing due to severe lower limb injury, fracture and skin injury. Among them, 2 cases had poor wound healing at the stump of amputation, which gradually healed 3 to 5 months after several debridements. The other 3 vascular injury combined with tibial fracture patients had delayed tibial healing after surgery, but no symptoms of vascular ischemia occurred. All the other patients recovered well and no other serious complications occurred. Conclusions: The proportion of death and disability in patients with lower limb artery injury caused by trauma is high. Active and orderly surgical repair according to the site and type of injury can reduce the mortality, save the function of the affected limb, and promote the healing of injury.

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center

Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P=0.001), high body mass index (P=0.001), blunt injury (P=0.001), associated fractures (P=0.005), significant soft tissue injury (P=0.007), delayed repair after shunt placement (P=0.003), bypass revascularization (P=0.001), initial revascularization failure (P=0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n=7), revascularization failure (n=9), bleeding (n=3), and vascular surgical wound complications (n=5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.

A fabric reinforced small diameter tubular graft for rabbits’ carotid artery defect

Tissue engineering small diameter artificial blood vessel is an indispensable graft for repairing extremity arterial injury. Previous researches demonstrated that suitable porosity and matching mechanical properties are two keys for tubular tissue reconstruction. In this study, we fabricated a fabric reinforced small diameter tubular graft (PPTG) from PLGA fabric and three-dimensional porous PEEUU with a structure of the bionic extracellular matrix for transplanting in situ combined braiding and thermally induced phase separation (TIPS). The prepared PPTG presented smooth and dense inner surface, fluffy and porous grafts wall, and tubular PLGA fabric evenly dispersed PEEUU matrix, which provide mechanical support for PPTG. The mechanical tests and hemolysis results showed that PPTG possess matched mechanical properties with autologous blood vessels and stable blood compatibility. Six weeks after rabbits’ carotid artery defect replacement indicated that there were no blockage occurred for PPTG group. Histological staining exhibited positive expression of endothelial cells on the inner surface of PPTG and distinct smooth muscle in the wall of PPTG, which migrated from peripheral tissues and flowing blood. Therefore, this fabric reinforced small diameter tubular graft provides a solution for endothelialization and tissue regeneration and have a potential application in vascular trauma. A fabric reinforced small diameter tubular graft from PLGA fabric and three-dimensional porous PEEUU with a structure of the bionic extracellular matrix exhibited matched mechanical properties, especially they demonstrate excellent performance to induce the migration of host cells to the wall of tubular graft and effective anti-thrombosis properties in rabbit carotid artery defect.

Impact of Antiplatelet Therapy on Early Outcomes After Operative Repair of Traumatic Extremity Arterial Injuries

Antiplatelet therapy after operative repair of traumatic arterial injuries of the extremities remains a frequently used adjunct to facilitate patency. This is despite a paucity of supporting data. We here seek to evaluate the efficacy of antiplatelet therapy in preventing early graft and limb-related complications after operative repair of traumatic arterial injuries of the extremities.

Brachial Artery Revascularization for Trauma: 18-year Single-center Experience

Vascular injuries are present in an estimated 1% to 2% of trauma patients, with the majority of injuries occurring to the extremities. We determined predictors of poor outcomes in upper extremity bypasses performed for traumatic upper extremity arterial injury.

On the Shoulders of Giants: A Tribute to Professor Norman Rich's Work on Graft Thrombosis

Recent papers such as “Outcomes of arterial graft for the reconstruction of military lower extremity arterial injuries” by Dr. Laverty et al. have reminded us of the strong military vascular surgery foundation established by Retired U.S. Army Colonel Norman M. Rich, MD, FACS, DMCC, MC.1 Col Rich's medical career began at Stanford University. He graduated from surgical residency at Letterman General Hospital. Directly following his graduation, he was assigned to the second Mobile Army Surgical Hospital as chief of surgery during a tour of duty in An Khe, Vietnam from 1965 to 1966.

Management of traumatic extremity arterial injuries in a tertiary care center: A report with 197 cases

Management of traumatic extremity arterial injuries in a tertiary care center: A report with 197 cases

Management and Outcomes after Upper Versus Lower Extremity Vascular Trauma

BackgroundWhile significant literature exists regarding peripheral vascular injury management, the vast majority focuses on lower extremity arterial injury. As a result, clinical management of arterial injury in the upper extremities is often guided by literature specific to lower extremity vessel injury. The purpose of this study is to use the largest series of patients reported in the literature to compare management and outcomes of upper and lower extremity traumatic vascular injuries. MethodsPatients who underwent operative repair of traumatic vascular injuries of the extremities were identified from the trauma registry of a level I trauma center. A retrospective chart review (2011–2019) was conducted. Demographics, mechanism of injuries, operative techniques, and outcomes were compared between patients with upper versus lower extremity vascular injuries. ResultsFive hundred thirty-five patients were included with 234 (43.8%) patients undergoing repair of upper extremity vascular injuries. Patients with upper extremity vascular injuries were more likely to be female (16.7% vs. 9%, P = 0.007), have a pre-hospital tourniquet (21.8% vs. 12%,P = 0.002), have associated nerve injuries (40.2% vs. 4.7%, P < 0.0001) or present with bleeding (76.1% vs. 64.1%, P = 0.002) but were less commonly associated with concomitant fractures (25.6% vs. 39.9%, P = 0.0006). There was no difference in age, race, or mechanism of injury. In regards to operative management, upper extremity injuries were more likely to be managed with vessel ligation (38% vs. 17.6%, P < 0.0001) or primary reanastomosis (12.4% vs. 5.6%, P = 0.009) and were less frequently associated with concomitant fasciotomies (13.3% vs. 56.5%, P < 0.0001). Postoperatively, upper extremity injuries were associated with persistent nerve deficits (21.7% vs. 10%, P = 0.0002) while lower extremity injuries had a higher incidence of 30-day limb loss (5.7% vs. 1.3%, P = 0.008). There were no differences in mortality or graft-patency rates between groups. ConclusionsUpper extremity injuries are associated with a lower limb-loss rate but increased prevalence of neurological deficits after vascular trauma compared to lower extremities. A high level of suspicion is paramount to intraoperative identify associated nerve injuries to improve postoperative functional outcomes.