Limb Arterial Injuries Research Articles

Structural and Functional Salvaging of Traumatic Brachial Artery Cut with Multiple Nerve Cut: Case Series

Upper limb arterial injury is relatively rare among trauma cases. Among them, the majority is contributed by brachial artery injury. Brachial artery injury is associated with nerve injuries given that its anatomical course, which brings a significant impact to the patient. We reported 2 cases of patients who sustained a deep laceration wound over the right upper limb. Both presented to the Emergency department with active bleeding over the wound, and clinically cold right hand, associated with absent radial and ulnar pulses with profound sensory and motor deficit. Wound exploration and brachial artery repair with reverse saphenous vein interposition graft, followed by structural and nerve repair. This case series highlighted the importance of prompt detection and intervention of brachial artery injury. Any further delay might result missing the golden hour of revascularization for the patients. It also showed the importance of consideration of limb salvage in a patient who was deemed Rutherford III, especially nerve cut was uncertain. In conclusion, prompt intervention of traumatic brachial artery injury and proper intraoperative assessment are mandatory to properly decide if a limb is salvageable or not.

Management of Ballistic Injuries Affecting the Limbs at the University Hospital of Tengandogo, Burkina Faso, West Africa

Abstract Introduction: Limb arterial injuries are serious clinical conditions that can lead to amputation or death. In Burkina Faso, there is a rise in gun shooting since 2016 because of armed conflict. In this study, the authors report the management of limb arterial injuries that occurred in ballistic traumas. Patients and Methods: From January 1, 2019, to December 31, 2022, 15 patients (14 males and 1 female) consecutively underwent operative management of limb arterial injuries at the University Hospital of Tengandogo. The mean age was 29.9 years old (17–55). Outcomes were defined according to intensive care unit stay time and postoperative morbidity and mortality. Results: Hospital admission after 6 h represented 93.7%. Unstable hemodynamic status was noted in 40%. Upper limbs arteries were more injured (60%) and these included false aneurysms (9) and complete arterial cut (6). Revascularization techniques consisted of direct suture in eight cases and prosthetic grafting in seven cases. Postoperatively, five patients presented complications: two superinfections, two skin necrosis, and one limb paresis. Amputation and mortality were nil. Conclusion: The management of ballistic arterial trauma to the limbs is late in our context. Circumstances are dominated by combat injuries and the militaries are more affected. However, a good indication for revascularization and rigorously executed technique can save the limbs.

WTP1.7 Long-term Outcomes After Repair of Paediatric Traumatic Lower Limb Arterial Injury: Systematic Review

Abstract Aims Paediatric vascular injuries account for 1% of paediatric major trauma cases with 30% of arterial injuries located in the lower limb. Current management of paediatric lower limb arterial injuries have been extrapolated from adult injuries. The aim was to review studies specific to paediatric population due to the anatomical and physiological differences, particularly limb length discrepancy (LLD) following injury. Methods A literature review was conducted. Study PICOS - Population: Patients <18 years old with traumatic lower limb arterial injury. Intervention: Surgical, endovascular or no intervention. Comparison: Primary repair or Conduit repair using autologous vein or synthetic material or endovascular repair. Outcomes: Rate of success of revascularisation, amputation, graft infection, long term limb function, LLD, mortality. Results 7 studies were included for data extraction, resulting in 15 male patients, aged 4-14. The popliteal artery was most commonly injured (60%), followed by the femoral (40%). The most common repair was with reversed Great Saphenous Vein graft (GSV)(13/15) for which good long-term outcomes were reported (85% success rate). One endovascular repair was identified which was successful and one with synthetic material which resulted in a minor complication. Conclusions There is a preference for the use of autologous vein grafts in paediatric lower limb arterial repair with good outcomes. Endovascular procedures are becoming more common whereas synthetic grafts are not favoured due to their inability to lengthen as vessels grow. Further research is required to evaluate the long-term outcomes as the current reported cases are scarce.

Assessing the variation in amount of pressure exerted by haemostatic pressure bandages: a volunteer study.

We assess the range of pressures exerted by haemostatic compression bandages on upper limb arterial injuries. Maintaining a pink hand can act as a safety marker to prevent excessive bandage pressure and avert compression injuries.

Protocolized approach saves the limb in peripheral arterial injury: A decade experience

PurposeOutcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The aim of this study was to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients. MethodsThis is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas). ResultsOut of 716 patients with PAI, the majority (92%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2–7 h). Brachial artery (28%) was the most common injured vessel followed by popliteal artery (18%) and femoral artery (17%). Limb salvage rate was 78%. Out of them, 158 (22%) patients needed amputation, and 53 (7%) had undergone primary amputation. The majority (86%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation. ConclusionOver all limb salvage rates was 78% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.

Outcomes of Revascularization and Factors Associated With Major Amputation in Patients With Lower Limb Arterial Injury: A Single-Center Retrospective Analysis.

ObjectiveTo identify the amputation rates and causative factors for failed revascularization leading to amputation in patients undergoing primary limb salvage procedures for lower-extremity vascular injuries.MethodsThis retrospective study was conducted at the vascular surgery department, Shaheed Mohtarma Benazir Bhutto (SMBB) Institute of Trauma, Karachi, Pakistan. The data were collected from hospital record using the non-probability sampling technique. Patients aged 17-70 years, undergoing primary revascularization during April 2016 to March 2021, were included in the study. Patients with crush injuries/non-salvageable limbs underwent primary amputation, isolated deep femoral artery or crural arteries (non-limb threatening) injuries, and non-traumatic injuries like intravenous drug-induced or iatrogenic injuries were excluded. The data analysis is done using SPSS Version 20.0 (IBM Corp., Armonk, NY, USA). A P-value of <0.05 was considered as significant.ResultsThis study includes 56 patients of mean age 30.82 ± 9.29 years with male gender four times more affected than their counterpart. About 32% of patients were smokers, while 58% of patients had no co-morbidities. All patients presented with a mean time of 7.66 ± 1.69 hours of injury with an average of 1.14 arterial segments involved. The most frequent artery involved was popliteal artery (both above and below the knee), followed by superficial femoral artery injury constituting 50% and 26%, respectively, with arterial laceration and transection being common findings on exploration. Out of 56 patients, 27 (48.2%) had open fractures, 21 (37.5% ) closed fractures, and eight patients (14.3 % ) presented with dislocation as associated injuries. Following the procedure, secondary amputation was recorded in 18 (32.1%) patients. Thrombosis and infection were the leading causes of revascularization failure. Type of injury, segment of arterial injury, and associated bony injuries were associated with limb amputation.ConclusionType and site of injury along with concomitant bony injuries are associated with major amputations after revascularization in lower-extremity arterial injuries.

Traumatismes artériels des membres supérieurs : particularités de la population en Tunisie et facteurs de risque d’amputation

Aim of the studyThe purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss. MethodsThis was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate. ResultsThe average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma. ConclusionPrompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

Lower Extremity Arterial Injuries: Impact of Time of Presentation, Type of Injury and Therapeutic Strategy With Limb Salvage at One Month

Introduction: Lower limb arterial injuries incidence has increased due to increase in road traffic accidents. Salvage of limb is a challenge due to delayed presentation which is the most common reason for limb loss, but time is not the only criteria, there are multiple other factors involved. Limb salvage can be achieved with good results even in patients who present in delayed fashion. The strategy to manage conservatively or to do expedite repair depends upon severity of injury to limb, patient factors and time of presentation. Methods: This is a prospective study of patients admitted at the trauma center of a tertiary care institute between January 2016 to February 2019. Patients with lower limb arterial injuries were followed from time of admission to 1 month following discharge. CT angiography was done in all patients where vascular intervention was planned. The management approaches were medical management, primary amputation, vascular repair and secondary amputations. Main outcomes analysed were time of presentation, mechanism of injury, type of injury, management procedures, and limb salvage rate. Results: During a 3-year period, a total of 104 patients with lower extremity arterial injuries were admitted. The study population was comprised of patients from 2 to 68 years of age (mean 32.5 years). Male patients were 7 times than female. 24% of patients presented within 8 hours and 21% patients presented after 24 hours. The majority of patients (76%) suffered concomitant musculoskeletal injuries. Arterial injuries were categorized into blunt (91%) and penetrating mechanisms (9%). The most common cause being road traffic accidents (92%). Involved arterial distribution was as follows: External iliac (4%), femoral (15%), popliteal (68%), anterior tibial (2%), posterior tibial (4%) and both anterior and posterior tibial (7%) arteries. The types of arterial injuries were as follows: contusion (48%), thrombosis (22%), transection/laceration (20%), compression/vasospasm (9%) and pseudoaneurysm (1%). Orthopedic surgeons performed amputations as primary procedures in 5% of patients. The majority (78%) of injuries receiving vascular management underwent surgical intervention, with procedure distribution as follows: bypass (saphenous vein 39% and prosthetic graft (1%); resection of contused segment and end to end anastomosis (16%); endovascular (1%); and isolated thrombectomy (14%) procedures. Conservative management was the primary strategy for 23% of patients of arterial injuries. Concomitant fasciotomy was performed in 38 % of cases. Subsequent major amputation was required for patients (9%) who initially received vascular management. Peri-operative mortality was 3%. Total Limb salvage rate was 84%. Limb salvage rate was 88% in patients presenting within 24 hours and 73% in patients presenting after 24 hours. In spite of delayed presentation, the limb salvage rate was not significantly different < 24 hours and >24 hours presentation group (p=0.103). Conclusion: The current multidisciplinary team management approach with prompt surgical management resulted in successful outcome in spite of significant patients presenting in delayed fashion. Comparable results can be achieved even in patients with delayed presentation, depending on limb status. Disclosure: Nothing to disclose

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

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.

The impact of arterial injury level on blood supply of distal limb in lower limb trauma

Objective To explore the impact of arterial injury on distal limb blood supply in lower limb trauma. Methods Retrospective analysis of 93 patients with different levels of lower limb arterial injury admitted to our hospital from June 2014 to August 2017. There were 84 males and 9 females aged 43.54±9.90 years (ranging 25-65 years). Revascularization was performed through open reduction. Patients were divided into three groups according to their arterial injury locations. Proximal vessels were along the superficial femoral artery, from its beginning to the point where it was divided into the descending genicular artery and direct periosteal branches. Intermediate vessels were from the dividing point on the superficial femoral artery to the popliteal artery before it was divided into the medial inferior genicular artery. Distal vessels were from the dividing point on the popliteal artery to the distal end of the peroneal artery. The duration from injury to revascularization in the three groups were 13.67±5.99 h, 11.15±4.43 h, and 11.92±5.48 h, respectively. There was no significant difference between groups (F=1.564, P=0.215). ISS in the three groups were 13.00±3.74, 12.77±3.81, and 11.50±3.99, respectively. There was no significant difference between groups (F=1.445, P=0.241). The following items were compared among the three groups, postoperative creatine kinase, arterial blood lactate and limb compartment cut. Results Creatine kinase of the intermediate vascular group was 8 743.15±6 968.48 u/L, proximal vascular group 1 467.67±1 810.27 u/L, distal vascular group 2 893.51±1 304.56 u/L. The data of intermediate vascular group were higher than those of proximal and distal vascular groups with significant difference among the groups (F=22.587, P=0.000). The lactate of the intermediate vascular group was 3.20±1.51 mmol/L, proximal vascular group 1.63±0.46 mmol/L, distal vascular group 1.85±0.69 mmol/L with significant difference among the groups (F=20.612, P=0.000). The compartment cut of the intermediate vascular group was incised in 24, but not in 15. The proximal vascular group was not incised in 18, while 15 was incised and 21 not incised in distal vascular group. The rates of compartment cut were 61.5%, 0 and 41.7%, respectively with significant differences (χ2=19.156, P=0.000). Conclusion In lower limb injuries, the intermediate vascular (from the superficial femoral artery after it is divided into the descending genicular artery and direct periosteal branches to the popliteal artery before it is divided into the medial inferior genicular artery) injury leads to the most severe distal limb ischemia. Key words: Vascular system injuries; Wounds and injuries; Vascular grafting

Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort

ObjectiveVascular injury is a leading cause of death and disability in military and civilian settings. Most wartime and an increasing amount of civilian vascular trauma arises from penetrating mechanisms of injury due to gunshot or explosion. The objective of this study was to provide a comprehensive examination of penetrating lower extremity arterial injury and to characterize long-term limb salvage and differences related to mechanisms of injury. MethodsThe military trauma registries of the United States and the United Kingdom were analyzed to identify service members who sustained penetrating lower limb arterial injury (2001-2014). Treatment and limb salvage data were studied and comparisons made of patients whose penetrating vascular trauma arose from explosion (group 1) vs gunshot (group 2). Standardized statistical testing was used, with Bonferroni corrections for multiple comparisons. ResultsThe cohort consisted of 568 combat casualties (mean age, 25.2 years) with 597 injuries (explosion, n = 416; gunshot, n = 181). Group 1 had higher Injury Severity Score (P < .05) and Mangled Extremity Severity Score (P < .0001), required more blood transfusion (P < .05), and had more tibial (P < .01) and popliteal (P < .05) arterial injuries; group 2 had more profunda femoris injuries (P < .05). Initial surgical management for the whole cohort included vein interposition graft (33%), ligation (31%), primary repair with or without patch angioplasty (16%), temporary vascular shunting (15%), and primary amputation (6%). No difference in patency of arterial reconstruction was found between group 1 and group 2, although group 1 had a higher incidence of primary (13% vs 2%; P < .05) and secondary (19% vs 9%; P < .05) amputation. Similarly, longer term freedom from amputation was lower for group 1 than for group 2 (68% vs 89% at 5.5 years; Cox hazard ratio, 0.30; P < .0001), as was physical functioning (36-Item Short Form Health Survey data; mean, 39.80 vs 43.20; P < .05). ConclusionsThe majority of wartime lower extremity arterial injuries result from an explosive mechanism that preferentially affects the tibial vasculature and results in poorer long-term limb salvage compared with those injured with firearms. The mortality associated with immediate limb salvage attempts is low, and delayed amputations occur weeks later, affording the patient involvement in the decision-making and rehabilitation planning. We recommend assertive attempts at vascular repair and limb salvage for service members injured by explosive and gunshot mechanisms.

Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries

Outcome after revascularisation of marginally viable limbs and dead limbs following lower limb arterial injuries

Practical application of bedside diagnostics in determining limb viability.

This study aimed to determine the practical application of vascular lab studies in determining limb salvage outcomes in injured patients with concerning clinical examinations. A retrospective review of the trauma registry at a level I center was conducted from January 2009 to June 2013. All patients >16 years of age who sustained a lower limb arterial injury had a concerning clinical exam (mottled skin, decreased skin warmth, diminished pulses) and had vascular lab studies to determine management were included. Data-points included demographics, type and location of injury, procedure type, vascular lab study results, and limb outcome. Over a five-year period, 11 trauma patients met inclusion criteria. Five of these patients had concerning clinical exams after revascularization, and six observed patients had a concerning clinical examination during the course of their hospitalization. All 11 patients had vascular lab studies that were within normal limits. As a result of normal vascular lab studies, none of these patients underwent further imaging or intervention. None of these patients underwent amputation. Vascular lab studies may be utilized to determine the need for intervention and/or lower limb bypass sufficiency in patients with questionable clinical examinations post injury.

Outcome after interposition of vein grafts for arterial repair of extremity injuries in civilians

The objective of this study was to report on immediate and long-term outcomes after vein graft interposition in patients with upper- and lower-limb arterial injuries. In the retrospective data analysis, all patients who underwent vein graft repair of limb arterial injuries in our civilian institution since 1990 were included, analyzed, and followed. Study end points were crude early and long-term patency, vascular reintervention, limb salvage, and perioperative death. A total 152 consecutive patients (127 men; median age, 31.7 years; range, 5.3-77.2) who presented with 158 lesions of limb arteries (lower limb: n = 90; upper limb: n = 68) underwent repair with the use of vein graft interposition. The vast majority of lesions were caused by blunt trauma (n = 144; 91%). In early results, the 30-day mortality rate was 3.3%. In-hospital limb loss rate was significantly lower in the upper limb (n = 2; 2.9%) than in the lower limb (n = 12; 13.3%; P < .05). Primary early patency was 93% (upper limb) and 89% (lower limb): early graft occlusions occurred both in the upper limb (n = 5; 7%) and the lower limb (n = 10; 11%; P = .59). Occlusions were followed by amputation in six cases (upper limb: one of five; lower limb: five of 10) despite successful revision of the occluded grafts. Long-term results after a median follow-up period of 6.0 years (range, 0.3-23.4) showed upper limb (62% of patients were followed): no late limb loss, no vascular reintervention; patency: 97.6%; lower limb (66% of patients were followed): one late limb loss, one redo bypass for vein graft dilation, patency: 98.3%. Emergency repair of civilian artery injuries with the use of vein grafts is associated with considerable risk of early occlusion and limb loss. When compared with the upper limb, limb loss rate is significantly higher in the lower extremity. Early graft occlusion is frequently followed by limb loss, especially in the lower limb. During long-term follow-up, occlusions of interposed vein grafts, vascular reinterventions, and late amputations are uncommon.

Efficacy of Multidetector Computed Angiotomography in the Diagnosis of Limb Arterial Injuries

ObjectiveTo determine the diagnostic usefulness of multidetector computed angiotomography in the diagnosis limb arterial injuries in patients with suspicion of arterial injury with no indication of immediate surgery. MethodsNon-invasive 64-channel multidetector computed tomography (MDCT) was performed on 99 limbs suspected of having a traumatic vascular injury over a 44-month period between August 2004 and April 2008. The results were interpreted by the duty radiologist and his findings were compared with those from surgery or clinical follow-up. Interobserver variability was evaluated by comparing the reading of the MDCT by the duty radiologists with the retrospective reading by radiology specialist in trauma. ResultsMDCT as a diagnostic method of vascular injury of the limbs, interpreted by a general radiologist showed a sensitivity of 98% (95% CI: 93–100), a specificity of 88% (5% CI: 77–99), a positive predictive value of 91% (95% CI: 82–99), a negative predictive value of 97% (95% CI: 90–100), a positive likelihood radio of 8.24 (3.6–18.7), and a negative likelihood radio of 0.02 (0–0.15). The inter-observer variability by comparing the interpretation of the MDCT by the duty radiologist with that of the radiology specialist in trauma had a kappa of 0.869. ConclusionMultidetector computed angiotomography is a high precision diagnostic imaging method in arterial injury of the limbs, offering a suitable and appropriate therapeutic approach, and could be considered as new gold standard for the diagnosis of arterial injuries of the limbs.

Eficacia de la angiotomografía con multidetectores en el diagnóstico del trauma arterial de extremidades

ObjectiveTo determine the diagnostic usefulness of multidetector computed angiotomography in the diagnosis limb arterial injuries in patients with suspicion of arterial injury with no indication of immediate surgery. MethodsNon-invasive 64-channel multidetector computed tomography (MDCT) was performed on 99 limbs suspected of having a traumatic vascular injury over a 44-month period between August 2004 and April 2008. The results were interpreted by the duty radiologist and his findings were compared with those from surgery or clinical follow-up. Inter-observer variability was evaluated by comparing the reading of the MDCT by the duty radiologists with the retrospective reading by radiology specialist in trauma. ResultsMDCT as a diagnostic method of vascular injury of the limbs, interpreted by a general radiologist showed a sensitivity of 98% (95% CI: 93-100), a specificity of 88% (5% CI: 77-99), a positive predictive value of 91% (95% CI: 82-99), a negative predictive value of 97% (95% CI: 90-100), a positive likelihood radio of 8.24 (3.6-18.7), and a negative likelihood radio of 0.02 (0-0.15). The inter-observer variability by comparing the interpretation of the MDCT by the duty radiologist with that of the radiology specialist in trauma had a kappa of 0.869. ConclusionMultidetector computed angiotomography is a high precision diagnostic imaging method in arterial injury of the limbs, offering a suitable and appropriate therapeutic approach, and could be considered as new gold standard for the diagnosis of arterial injuries of the limbs.

Incidence and predisposing factors of cold intolerance after arterial repair in upper extremity injuries

The purpose of this report was to present abnormal posttraumatic cold intolerance in patients that previously underwent repair of arterial injuries after civilian upper limb trauma in our institution. All patients who underwent repair of arterial lesions after upper limb trauma since 1990 were reviewed, and clinical follow-up studies were performed. Patients were asked to complete the cold intolerance symptom severity (CISS) questionnaire to evaluate presence and severity of self-reported cold sensitivity, and the disabilities of arm, shoulder, and hand (DASH) questionnaire to analyze functional disability. Abnormal cold intolerance was defined as a CISS score over 30. Further analysis included evaluation of epidemiologic, clinical, and perioperative data for factors predisposing to abnormal cold intolerance. A total of 87 patients with previous repair of upper limb arterial injuries were eligible to answer the CISS and DASH questionnaires, and 56 patients (64%; 43 men; median age: 31.9 years) completed both. In our cohort, blunt trauma was the predominant cause of injury (n = 50; 89%). Accompanying lesions of nerves (n = 22; 39%) and/or orthopedic injuries (n = 36; 64%) were present in 48 patients (86%). After a median follow-up period of 5.5 years (range, 0.5-19.7), 23 patients (41% of 56) reported on abnormal cold intolerance. Patients with cold intolerance had worse functional results (as measured by the DASH questionnaire; mean ± SD, 42.7 ± 29.7 vs 11.5 ± 23.9; P < .001) when compared with patients without. Cold intolerance was more frequently seen in patients with previous nerve lesion (P = .027) and in proximal injuries (subclavian or axillary vs brachial or forearm arteries: P = .006), but was not correlated to gender, age, involvement of the dominant or nondominant arm, and the presence of ischemia, bone injury, or an isolated vascular injury. Abnormal cold intolerance is frequently seen in patients with a history of arterial repair in upper limb trauma. It is associated with significant functional impairment. Concomitant nerve injury and involvement of the subclavian or axillary artery are the major predisposing factors for development of cold intolerance after upper limb trauma.

Transposition of an arterial segment from a traumatically amputated lower limb to treat an upper limb vascular lesion on a multi injured patient as an alternative technique for trauma patients

Trauma is a public health problem that throughout the world. Extremity vascular injuries need special consideration for they threaten limbs and lives [16,6]. Blunt trauma has worse prognosis and higher amputation rates, when compared to penetrating vascular injuries, for civilian and military wounds [16,3,1]. Repair can be achieved by lateral sutures, but more often the traumatized vessel requires excisions and end-to-end anastomosis. If a ‘‘tension free’’ anastomosis is not possible a graft interposition is indicated, using an autogenous vein if possible [16,17,9,14,10] or a prosthesis, that have a greater risk of infection and inferior patency rates when compared to autogenous ones, which is an important consideration in young injured patients with long life expectancies [14]. The quest for autogenous conduits in the multi injured patient can be challenging and an amputated limb can provide an important source of autologous conduits [10,11]. In Iraq, reversed saphenous grafts from contralateral amputated lower limbs were used to reconstruct injured arteries and veins of the remaining lower extremity [10,11]. To the best of our knowledge, however, the transposition of an arterial segment from a traumatically amputated lower limb to treat an upper limb arterial injury has not been previously reported. This option may be associated with important benefits when compared to the saphenous alternative for trauma patients.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs

To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67 +/- 0.91 days. PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Management of upper limb arterial injury without angiography—Chennai experience

We present our experience and observations in the management of upper limb arterial injury in a tertiary trauma care centre of a University Hospital in a developing country from January 2000 to January 2002. In this retrospective study, we had treated 27 patients (identified from trauma register) with upper extremity vascular injuries. Clinical examination and Doppler pressure studies were our prime modalities of investigation. Angiography was not employed. Our immediate limb salvage rate was 100%. Two patients developed complications during a mean follow up of 70 days with one requiring amputation. We thereby emphasise the fact that good results can be obtained by thorough clinical examination and Doppler evaluation and prompt surgery without the need for angiography in upper limb vascular trauma.