Extremity Arterial Injuries Research Articles

Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting

To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25±4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.

Tourniquet use is not associated with limb loss following military lower extremity arterial trauma.

The effect of battlefield extremity tourniquet (TK) use on limb salvage and long-term complications following vascular repair is unknown. This study explores the influence of TK use on limb outcomes in military lower extremity arterial injury. The study database includes cases of lower extremity vascular injury from 2004 to 2012 with data recorded until discharge from military service. We analyzed all limbs with at least one named arterial injury from the femoral to the tibial level. Tourniquet (TK) and no TK (NTK) groups were identified. Univariate analyses were performed with significance set at p ≤ 0.05. A total of 455 cases were included, with 254 (56%) having a TK for a median of 60 minutes (8-270 minutes). Explosive injuries (53%) and gunshot wounds (26%) predominated. No difference between TK and NTK was present in presence of fracture, level of arterial injury, type of arterial repair, or concomitant venous injury. More nerve injuries were present in the TK group, and Abbreviated Injury Scale extremity and Mangled Extremity Severity Score tended toward greater injury severity. Amputation and mortality rates did not differ between groups, but the incidence of severe edema, wound infection, and foot drop was higher in the TK group. Vascular above-knee amputation, arterial repair complication, and severe edema were higher in the TK group also (p = 0.10). Tourniquet duration of 60 minutes or longer was not associated with increased amputations, but more rhabdomyolysis was present. Field TK use is associated with wound infection and neurologic compromise but not limb loss. This may be due to a more severe injury profile among TK limbs. Increased TK times may predispose to systemic, but not limb, complications. Therapeutic/care management, level IV.

Management and Outcome of 597 Wartime Lower Extremity Arterial Injuries: Results From an International Military Cohort

Management and Outcome of 597 Wartime Lower Extremity Arterial Injuries: Results From an International Military Cohort

Evaluation of a Novel Fibrin Sealant Patch in Hemorrhage Control After Vascular or Hepatic Injury

Acute hemorrhage remains the leading cause of death in potentially survivable injuries. The use of topical hemostatic agents has increased over the last two decades with the evolution of damage control surgery. By 2008, the military widely adopted Combat Gauze as the hemostatic dressing of choice for compressible hemorrhage. The goal of this study was to compare the performance of a novel fibrin sealant patch to Combat Gauze in two clinically relevant models of hemorrhage. Yorkshire swine underwent unilateral femoral artery puncture or a grade V liver laceration with timed free bleeding then received either the fibrin patch or Combat Gauze packing with 3 minutes of standardized pressure. Animals were then resuscitated to maintain a mean arterial pressure of 60 mmHg for 4 hours. Hemostasis, blood loss, resuscitation volume, survival, vessel patency, and hematologic parameters were evaluated. Hemostasis was equivalent in both groups after hepatic and vascular injury. Survival was 80% in the fibrin patch vascular injury group and 100% in all other groups. Hematologic parameters were not significantly different between treatment groups. Femoral artery patency was 80% in both groups after vascular injury. With simulated ambulation after vessel injury, 60% of the Combat Gauze group and 80% of the fibrin patch group remained hemostatic (p > 0.05). In simulated re-exploration with packing removal, all animals rebled after hemostatic product removal. There was no significant difference in hemostasis between a novel fibrin patch and Combat Gauze after extremity arterial or hepatic injury. This novel fibrin patch may have a clinical advantage over the Combat Gauze, as it can be left in the body, thereby limiting the potential need for reoperation.

Evaluation of Experience with Lower Extremity Arterial Injuries at an Urban Trauma Center.

Lower extremity arterial injuries (LEAIs) can be complicated injuries resulting in limb loss and death. Patients with LEAI often have multiple injuries increasing the risk for morbidity and mortality. We sought to evaluate the incidence and management of LEAI and to define associations between injuries and outcomes. We performed a retrospective review of LEAI at an urban level-1 trauma center from April 2005 to April 2015. Chi-square tests were used to compare independent groups with respect to mortality and amputation. Means were compared between independent groups using two-sample t -tests. From April 2005 to April 2015, 208 arterial injuries occurred in 163 patients. The majority (80.4%) suffered concomitant lower extremity injuries with 35.6% suffering systemic injuries. Surgical intervention was required for 72.1% of injuries. Amputation rate was 14.7%. Mortality rate was 8.0%. Data from 2010 to 2015 were more specifically analyzed. Injury severity score (ISS) was higher with fatalities (37 ± 13.16 vs. 11.8 ± 8.51, p < 0.0001) and in patients requiring an amputation (25.4 ± 15.32 compared with 11.6 ± 9.05, p = 0.0015). Popliteal artery injury was most likely to require an amputation (odds ratio [OR] = 2.9, p = 0.04). Mortality was more likely when systemic injuries were present (OR = 18.1, p = 0.0005). The majority of patients with arterial injuries require surgical management, most often with open surgical techniques. Arterial injuries associated with systemic injuries, blunt injury mechanisms, and higher ISS are at a significantly increased risk of mortality.

Effect of temporary vascular shunting as a previous intervention on lower extremity arterial injury: Single center experiences in the Syrian Civil War.

The goal of this retrospective study was to clarify the effect of using temporary vascular shunt (TVS) as a previous intervention. A total of 96 cases with war-related lower extremity arterial injury and surgically treated between October 2013 and March 2016 were included in the study. The patients were divided into two groups: those in which TVS was performed as a previous intervention on admission (TVS group, n=24) and those in which compression, tourniquet, and ligation/clampage were performed as a previous intervention on admission (non-TVS group, n=72). In comparing injury pattern, there was no difference between the two groups. In addition, mean hematocrit level, mean systolic blood pressure, the incidence of concomitant vein injury, nerve injury, soft tissue damage, and bone injury were similar in both groups. The overall amputation rate was 19%. There were a total of 18 amputations, with 1 (4%) in the TVS group and 17 (24%) in the non-TVS group. The difference on amputation rate was statistically significant. The mean values of the mangled extremity severity score (MESS) were 6.45 in the TVS group and 7.44 in the non-TVS group. The overall mean MESS was 7.1. The duration of ischemia (DoI) was 4.84+-1.84 h in the TVS group and 5.95+-1.92 h in the non-TVS group. These differences in MESS and DoI were statistically significant. We think that it may be beneficial for patients to consider a TVS to reduce DoI and gain time for surgical revascularization. As a result, the present study demonstrates that the use of TVS may successfully serve as a bridge between initial injury and definitive repair with a reduction in amputation rates.

A Comparative Analysis of Open versus Endovascular Techniques for Management of Non-Aortic Cervicothoracic Arterial Injuries

The objective of this study is to describe the contemporary management of proximal upper extremity and neck arterial injuries by comparing open and endovascular repair at a single institution. This is a retrospective study of 22 patients that sustained subclavian, axillary, and carotid artery injuries from 2011 to 2016 that were managed with open or endovascular repair. There were nine subclavian, eight axillary, and five carotid artery injuries of which 10 (45.5%) underwent endovascular repair and 12 (54.5%) underwent open repair. There was no statistically significant difference between the groups including injury severity score or preoperative hypotension. There were no deaths in the endovascular group, and three (25.0%) deaths in the open group. All patients in the endovascular group were discharged home. In the open group, seven (58.3%) patients had at least one inpatient complication with a mean of 1.1 (standard deviation 1.4) complications per patient. In the endovascular group, there were three (30.0%) patients with inpatient complications and a mean of 0.4 (standard deviation 0.7) complications per patient (P = 0.18). Endovascular management of nonaortic cervicothoracic arterial injuries was successfully performed in hypotensive patients and patients with other life threatening traumatic injuries. Further studies are warranted to look at long-term patency of these repairs and to help develop a protocol to guide decision-making in the management of cervicothoracic injuries.

Penetrating extremity arterial injury

Penetrating extremity arterial injury

Systemic anticoagulation in the setting of vascular extremity trauma

IntroductionThere is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities. MethodsWe analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data. ResultsBetween February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4–91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p=0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p=0.002). Patients treated with ISA also stayed longer in the ICU (median 3days vs. 1day, p=0.001) and hospital (median 9.5days vs. 6days, p=0.01). DiscussionIn this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries.

The mangled extremity score and amputation: Time for a revision.

The Mangled Extremity Severity Score (MESS) was developed 25 years ago in an attempt to use the extent of skeletal and soft tissue injury, limb ischemia, shock, and age to predict the need for amputation after extremity injury. Subsequently, there have been mixed reviews as to the use of this score. We hypothesized that the MESS, when applied to a data set collected prospectively in modern times, would not correlate with the need for amputation. We applied the MESS to patient data collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment registry. This registry contains prospectively collected demographic, diagnostic, treatment, and outcome data. Between 2013 and 2015, 230 patients with lower extremity arterial injuries were entered into the PROspective Vascular Injury Treatment registry. Most were male with a mean age of 34 years (range, 4-92 years) and a blunt mechanism of injury at a rate of 47.4%. A MESS of 8 or greater was associated with a longer stay in the hospital (median, 22.5 (15, 29) vs 12 (6, 21); p = 0.006) and intensive care unit (median, 6 (2, 13) vs 3 (1, 6); p = 0.03). Of the patients' limbs, 81.3% were ultimately salvaged (median MESS, 4 (3, 5)), and 18.7% required primary or secondary amputation (median MESS, 6 (4, 8); p < 0.001). However, after controlling for confounding variables including mechanism of injury, degree of arterial injury, injury severity score, arterial location, and concomitant injuries, the MESS between salvaged and amputated limbs was no longer significantly different. Importantly, a MESS of 8 predicted in-hospital amputation in only 43.2% of patients. Therapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury. Prospective, prognostic study, level III.

Contemporary outcomes of civilian lower extremity arterial trauma

Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation. The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis. We identified 149 patients (86% male; mean age, 33± 14years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more (P< .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1± 1.8 vs 4.3± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation. Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.

Development of an ovine model of occlusive arterial injury for the evaluation of endovascular interventions.

Endovascular intervention for occlusive arterial trauma is becoming more common in clinical practice. The aim of this study is to present an ovine model of extremity arterial injury for use in future endovascular translational research. Animals under general anesthesia had their left superficial femoral artery exposed, which was bluntly injured over a 2-cm section using a hemostat and injection of air. Occlusion was confirmed on angiography and the flow characteristics measured by ultrasonography. Of five animals enrolled, four occluding lesions were created successfully. Post injury, there was a significant reduction in the median (interquartile range) systolic velocity (cm/sec) on the left (injury) compared to the right (control) side (3.5 (0-16.5) vs. 29 (23.8-43.3); p < 0.001). The ovine superficial femoral artery can be used to consistently produce an occlusive lesion that is suitable for use in the future evaluation of endovascular trauma interventions.

Diagnosis and Surgical Treatment of Extremity Vascular Injuries: Error Analysis

Актуальность Вопросы ранней диагностики и тактики лечения острой травмы магистральных артерий конечностей в мирное время – нерешённая проблема сосудистой хирургии. Это проявляется продолжающимся увеличением хирургических ошибок, высокой общей летальностью, большой частотой первичных ампутаций и обусловлено отсутствием нужных знаний и практических навыков у медицинских работников, плохо знакомых с принципами организации медицинской помощи данной категории пациентов на этапах эвакуации.Цель исследования Поиск эффективных способов профилактики хирургических ошибок и осложнений при лечении больных с ангиотравмой конечностей.Материалы и методы Проведён ретроспективный анализ 606 историй болезни и ангиограмм пациентов с повреждением артерий конечностей, лечившихся в хирургических отделениях г. Твери и Тверской области в 1966–2013 гг. Мужчин было 593, женщин – 13. Возраст больных колебался от 5 до 76 лет. Изолированная травма составила 19,3% от всех случаев, сочетанная – 80,7%, повреждения острым предметом и огнестрельные ранения – 41,6%, тупая травма – 54,8%, ятрогенная травма – 2%, аррозия сосудов – 1,6%. Результаты и их обсуждение Восстановительные операции выполнены у 47,5% пациентов, лигатурные – у 32,2%, первичные ампутации конечностей – у 20,3%. Выздоровело 96,9% пострадавших, умерло – 3,1%. У 222 (36,6%) больных на госпитальном этапе выявлено 41,4% диагностических, 33,8% тактических и 24,8% технических ошибок. Наиболее часто ошибки допускались при сочетании повреждений магистральных артерий с нарушением целости нервных стволов, костей и мышечных массивов.Выводы Большое количество ошибок в диагностике и лечении повреждений магистральных сосудов конечностей во многом обусловлено недочетами оказания больным неотложной, квалифицированной и специализированной медицинской помощи. Клиническая картина ранений и травм магистральных артерий в сочетании с современными методами ангиографического исследования позволяет достоверно, точно и информативно оценить состояние магистрального кровотока и функцию коллекторов коллатерального кровообращения. Риск неудовлетворительных исходов лечения больных с повреж-дениями магистральных сосудов конечностей можно уменьшить за счет снижения числа диагностических, тактических, технических и организационных ошибок. Восстановительные операции на магистральных артериях конечностей должны производиться только сосудистыми хирургами или травматологами, имеющими специальную подготовку по ангиологии и практический опыт работы в сосудистой хирургии.

Diagnostic value of 64-slice CT post-processing techniques in lower extremity arterial injury

Diagnostic value of 64-slice CT post-processing techniques in lower extremity arterial injury

The Impact of Geniculate Artery Collateral Circulation on Lower Limb Salvage Rates in Injured Patients

This study aimed to determine the association between geniculate artery flow on admission computed tomography (CT) angiography and limb salvage outcomes in patients with lower extremity arterial injury. All injured patients at a level I trauma center with CT angiogram (CTA) confirmed limited or no flow to the tibial vessels were included. Demographics, injury severity score (ISS), mechanism of injury, physiological parameters, the presence of geniculate artery collateral circulation (superior medial, superior lateral, medial, inferior medial, inferior lateral), and 30-day limb salvage outcome were recorded. Statistical analysis was completed using descriptive statistics and the chi-squared tests. From 2009 to 2012, a total of 84 patients with lower extremity arterial injury underwent diagnostic evaluation with CTA on admission that confirmed limited or no flow to the tibial vessels. A total of 10 patients (12%) underwent amputation. Primary amputation was performed in 3 (4%) patients, and secondary amputation was performed in 7 (8%) patients. There was no difference in age, gender, ISS, extremity abbreviated injury score, mechanism of injury, admission systolic blood pressure, heart rate, respiratory rate, transfusion volume, or type of vascular interventions between patients who had successful limb salvage and those who received an amputation. The number of patent geniculate arterial vessels was inversely associated with amputation with 3.3 patent geniculate arteries in the limb salvage group compared to 2.1 in the amputation group (P < 0.05). The 2 geniculate artery vessels that were significantly associated with limb salvage were the superior lateral geniculate and the inferior medial geniculate arteries (P < 0.05). Geniculate collateral circulation may have an important role in limb salvage after lower extremity vascular injury. The geniculate arteries that are associated with the highest rates of limb salvage appear to be the superior lateral geniculate and the inferior medical geniculate artery.

Repair of Lower Extremity Arterial Injuries: “A Race Against Time”

Repair of Lower Extremity Arterial Injuries: “A Race Against Time”

Endovascular management of traumatic peripheral arterial injuries

BackgroundTraumatic injuries to peripheral arterial vessels are increasingly managed with endovascular techniques. Early small series have suggested that endovascular therapy is feasible and decreases operative blood loss, but these data are limited. The purpose of this study was to evaluate the feasibility and outcomes of endovascular management of nonaortic arterial trauma. Materials and methodsWe reviewed records of traumatic nonaortic arterial injuries presenting at an urban level 1 trauma center from December 2009–July 2013. Patients undergoing treatment in interventional radiology and patients whose injuries occurred >72 h before presentation were excluded. Demographics, indicators of injury severity, operative blood loss, transfusion requirements, and clinical outcome were compared between patients undergoing endovascular and open management using appropriate inferential statistics. ResultsDuring the study period, 17 patients underwent endovascular interventions and 20 had open surgery. There were 19 upper extremity and/or thoracic outlet arterial injuries, 15 lower extremity injuries and 11 pelvic injuries. Endovascular cases were completed using a vascular imaging C-arm in a standard operating room. Estimated blood loss during the primary procedure was significantly lower with endovascular management (150 versus 825 cc, P < 0.001). No differences were observed between cohorts in age, injury severity score, intensive care unit length of stay, arterial pH, transfusion requirements, inpatient complication rate, or mortality. ConclusionsOur experience with endovascular management demonstrates its feasibility with commonly available tools. Operative blood loss may be significantly decreased using endovascular techniques. Further study is needed to refine patient selection criteria and to define long-term outcomes.

Ateşli Silah Yaralanmalarında Üst Ekstremite Arteriyel Yaralanmalarının Değerlendirilmesi

Ateşli Silah Yaralanmalarında Üst Ekstremite Arteriyel Yaralanmalarının Değerlendirilmesi

Multidetector CT and three-dimensional CT angiography of upper extremity arterial injury.

Successful management of upper extremity arterial injury requires fast and accurate diagnosis. The rate of limb preservation depends on the location, severity, and time of ischemia. Indications for diagnostic imaging depend on the mechanism and type of injury, clinical signs, cardiovascular stability, and clinical suspicion. Because of ease of access, speed, and high accuracy for this diagnosis, multidetector computed tomographic (MDCT) angiography is often used as the first line imaging modality. MDCT systems with 64 slice configuration and more afford high temporal and spatial high-resolution, isotropic data acquisition and integration with whole-body trauma MDCT protocols. The use of individual injection timing protocols ensures high diagnostic image quality. Several strategies are available to reduce radiation exposure. Direct MDCT angiography findings of arterial injuries include active extravasation, luminal narrowing, lack of luminal contrast opacification, filling defect, arteriovenous fistula, and pseudoaneurysm. Important descriptors are location and length of defect, degree of luminal narrowing, and presence of distal arterial supply reconstitution. Proximal arterial injuries include the subclavian, axillary, and brachial arteries. Distal arterial injuries include the ulnar and radial arteries, as well as the palmar arterial arches. Concomitant venous injury, musculoskeletal injury, and nerve damage are common. In this exhibit, we outline the role of MDCT angiography in the diagnosis and management of upper extremity arterial injury, discuss strategies for MDCT angiography acquisition and concepts of data visualization, and illustrate various types of injuries.

Limb salvage after complex repairs of extremity arterial injuries is independent of surgical specialty training

Major peripheral vascular trauma is managed by several surgical specialties. The impact of surgical specialty training and certification on outcome has not been evaluated. We hypothesized that general surgeons without specialty training in vascular surgery would have outcomes equivalent to surgeons with vascular training in the management of extremity arterial injuries requiring interposition grafting. We performed a multicenter, retrospective study of patients undergoing interposition grafting for peripheral vascular injury between 1995 and 2010. Specialty was defined by training and certification. Outcomes were recorded at the time of discharge from the index hospitalization. Factors affecting limb salvage were determined using logistic regression. From the 11 participating centers, 615 patients were identified. General surgeons performed 69.9%, cardiac/vascular surgeons performed 27.3%, and surgeons of other specialties performed 2.8% of the grafts. There were 32 amputations (5.2%). Outcomes did not differ by institution. Factors associated with amputation were blunt mechanism, older age, female sex, hospital length of stay, and Injury Severity Score (ISS). There was no significant difference in limb salvage among specialty groups (general surgeons, 94%; cardiac/vascular, 95%; other, 100%). Limb salvage following major peripheral vascular injury is independent of surgeon specialty training. The majority of complex repairs are performed by general surgeons. Therapeutic/care management, level III.