Lower Extremity Arterial Injuries Research Articles

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.

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.

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.

Outcomes Of Arterial Grafts For The Reconstruction Of Military Lower Extremity Arterial Injuries

Outcomes Of Arterial Grafts For The Reconstruction Of Military Lower Extremity Arterial Injuries

Utility of the Mangled Extremity Severity Score in Predicting Amputation in Military Lower Extremity Arterial Injury

Effective amputation prediction may help inform appropriate early limb salvage efforts in military lower extremity (LE) arterial injury. The Mangled Extremity Severity Score (MESS) is the most commonly applied system for early amputation prediction but its utility in military trauma is unknown. Retrospective cohort study of Iraq and Afghanistan casualties with LE arterial injury who underwent a vascular limb salvage attempt. Retrospectively assessed MESS was statistically explored as an amputation predictor and MESS component surrogates (mechanism, vascular injury characteristics, tourniquet use, and transfusion volume) were used to characterize limb injuries by presenting characteristics and evaluated for amputation prediction. A total of 439 limbs were included with 99 (23%) amputations, 29 (7%) within 48 hr of injury. Median MESS was 5 (interquartile range 4-6) among salvaged limbs and 7 (5-9) among amputations (P<0.0001). An MESS cutoff of ≥7 had a better receiver operating characteristic sensitivity/specificity profile (area under the curve 0.696 overall, 0.765 amputation within 48 hr) than MESS ≥8 (0.593, 0.621), but amputation rates were only 43% for MESS ≥7 and 50% for ≥8. MESS ≥7 was significantly associated with age, polytrauma, blast or crush mechanism, fracture, tourniquet use, distal (popliteal/tibial) and multiple arterial injuries, and massive transfusion. Amputation was significantly associated with polytrauma, blast or crush mechanism, fracture, and massive transfusion; however, 83 casualties had all 4 characteristics with an amputation rate of only 46%. In combat casualties with arterial injury, LE amputation after attempted vascular limb salvage is inadequately predicted by existing scoring systems or the presenting characteristics available in this registry. Limb loss is predominantly late and likely because of factors not projectable at initial presentation.

Current results of arterial injuries seen at femoral and popliteal arteries in civil society

Background: Lower extremity arterial injuries caused by penetrating or fired-gun trauma may result in limb or loss of life. Early intervention has critical importance. The aim of this study was to investigate the importance of early intervention and outcomes.Methods: We retrospectively reviewed the data on 144 patients (18 females, 126 males) who were treated in Istanbul Medipol University Hospital between January 2016 to 2018. All patients had an arterial injury at level of femoral and popliteal arteries. Standard statistical methods were used for data analysis.Results: Revascularization was performed to all 144 (18 females, 126 males) patients. Autologous saphenous vein graft interposition was performed in 96 patients. End-to-end repair was performed in 39 patients. 9 patients underwent a polytetrafluoroethylene graft (8 mm ringed) interposition.Conclusions: All viable limbs should be revascularized rapidly. The primary goal is to provide bleeding control rapidly and to prevent the prolongation of ischemic time. It should be kept in mind that in addition to surgical technique, fasciotomy may be required in arterial injuries with ischemic time of more than 6-8 hours.

Utility of The Mangled Extremity Severity Score In Predicting Amputation In Military Lower Extremity Arterial Injury

Utility of The Mangled Extremity Severity Score In Predicting Amputation In Military Lower Extremity Arterial Injury

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

Impact of time to repair on outcomes in patients with lower extremity arterial injuries

BackgroundSix hours has long been considered the threshold of ischemia after peripheral artery injury. However, there is a paucity of evidence regarding the impact of operative delays on morbidity and mortality in patients with lower extremity arterial injuries. MethodsWe analyzed the records of 3,441,259 injured patients entered into the National Trauma Data Bank Research Dataset from 2012 to 2015. Patients (≥16 years) with lower extremity arterial injuries were identified by International Classification of Diseases, Ninth Revision injury and procedure codes. Patients with crush injuries, patients with prehospital or emergency department cardiac arrest, those not transferred directly from point of injury, and patients in whom a nonoperative management strategy was attempted were excluded from analysis. ResultsWe examined the data from 4406 patients with lower extremity arterial injuries; 85% of the patients were male, with a mean age of 35 years. The overall mortality in this cohort was 3.2% (143/4406); the amputation rate was 11.3% (499/4406). Using a multivariate logistic regression model, blunt mechanisms of injury, increased time from injury to operating room arrival, nerve injury, associated lower extremity fractures, increased age, and Injury Severity Score were associated with increased amputation risk. The amputation rate in those undergoing repair within 60 minutes was 6% compared with 11.7% and 13.4% in those undergoing repair after 1 to 3 hours and 3 to 6 hours, respectively. ConclusionsOptimal limb salvage is achieved when revascularization of lower extremity arterial injury occurs within 1 hour of injury. To improve survival and recovery after extremity arterial injury, efforts should be focused on strategies to expedite reperfusion of the injured limb.

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.

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.

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

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

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

What is the Potential for False Positive Results in Ankle Brachial Index Measurements Performed by Emergency Providers?

Introduction: The Ankle-Brachial Index measurement (ABI) is an easily performed bedside test used to screen for lower extremity arterial injury. It is possible that the ABI is not always correctly performed in the acute setting, depending on available equipment and provider familiarity with validated measurement techniques. We sought to determine the potential for false positive ABI results in healthy subjects if the ABI is performed incorrectly. We also sought to identify the method most likely to minimize false positive results. Materials and methods: Healthy volunteers and low acuity emergency department patients were enrolled. Exclusion criteria included a known history of documented peripheral arterial disease or extremity trauma. Subjects were examined by two investigators. “Most Accurate” (MA) ABI measurements used the higher of the two ankle readings and the higher of the two brachial readings to calculate the result. “Least Accurate” (LA) measurements used the lower of the two ankle readings and the higher of the two brachial readings. Results: 118 study subjects were enrolled: mean age 32.8 years (range 19 to 49), 50% female, none with known peripheral vascular disease or extremity trauma, and none with documented femoral artery bruit at the time of the study. When a single provider performed LA ABI’s, the false positive rate was 29%, while single provider MA ABI’s lowered the false positive rate to 2%. For two provider ABI’s, these rates were 4% and 0%, respectively. Conclusions: We identified an unacceptably high rate of false positive ABI results if the test is performed incorrectly. We recommend strict adherence to standardized ABI measurement protocols to minimize this error. Ideally, an ABI measurement of less than 0.9 in a patient with lower extremity trauma should be confirmed by a second provider in order to minimize the risk of inappropriately implementing invasive diagnostic procedures.

A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center

A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center

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.

Lower extremity arterial injury: Results of 550 cases and review of risk factors associated with limb loss

Purpose: We sought to analyze the results of lower limb arterial injury (LLAI) management in a busy metropolitan vascular unit and to identify risk factors associated with limb loss. Patients and Methods: Between 1987 and 1997, prospectively collected data on 550 patients with 641 lower limb arterial injuries were analyzed. Results: The mechanism of LLAI was gunshot wounds in 46.1%, blunt in 19%, stabbing in 11.8%, and shotgun in 9.1%. The most frequently injured vessel was the superficial femoral artery (37.2%), followed by the popliteal (30.7%), crural (11%), common femoral (8.7%), and deep femoral (5.3%) arteries. In 3.4% of cases, there was a combined injury on either side of the knee (ipsilaterally). Associated injuries included bony injury in 35.1% of cases, nerve injury in 7.6%, and remote affecting the head, chest, or abdomen in 3.6%. Surgery was carried out on 96.2% of cases with a limb salvage rate of 83.8% and a survival of 98.5%. In spite of a rising trend in LLAI, our total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant ( P < .01) independent risk factors for amputation were occluded graft (odds ratio [OR] 16.7), combined above- and below-knee injury (OR 4.4), tense compartment (OR 4.2), arterial transsection (OR 2.8), and associated compound fracture (OR 2.7). Conclusion: LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputations, whereas high-velocity firearm injuries are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization. (J Vasc Surg 2001;33:1212-9.)

Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss

Abstract Background The authors' experience of lower limb arterial injury (LLAI) management was analysed and risk factors associated with limb loss were identified. Methods Between 1987 and 1997, data on 550 patients with 646 LLAIs were analysed retrospectively. Results The mechanism of LLAI was gunshot wounds in 46 per cent, blunt trauma in 19 per cent, stabbing in 12 per cent and shotgun in 9 per cent. The most frequently injured vessel was the superficial femoral artery (37 per cent) followed by the popliteal (31 per cent), crural (11 per cent), common femoral (9 per cent) and profunda (59 per cent) arteries. In 3 per cent of patients there was a combined injury on either side of the knee. Associated injuries included bony injury in 35 per cent, nerve injury in 8 per cent and remote injuries affecting the head, chest or abdomen in 4 per cent. Surgery was carried out in 96 per cent of patients with a limb salvage rate of 84 per cent and a survival rate of 98 per cent. Despite a rising trend in LLAI, total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant (P &amp;lt; 0·01) independent risk factors for amputation were blocked graft (odds ratio (OR) 16·7), combined above- and below-knee injury (OR 4·4), tense compartment at presentation (OR 4·2), arterial transection (OR 2·8) and associated compound fractures (OR 2·7). Factors such as simple fractures, venous injury/ligation and the use of synthetic grafts were not associated with increased risk of limb loss. Conclusion LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputation whereas injuries associated with severe soft tissue damage, such as high-velocity firearm injuries and blunt trauma with compound fractures, are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization.