Lower Extremity Vascular Trauma Research Articles

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

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

Assessment of the “Weekend Effect” in Lower Extremity Vascular Trauma

Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this "weekend effect." The objective of this study was to determine if a weekend effect exists for LEVT. The National and Nationwide Inpatient Sample Database (2005-2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models. There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45years (68% weekend vs. 55% weekday, P<0.001), male (81% weekend vs. 75% weekday, P<0.001), and uninsured (22% weekend vs. 17% weekday, P<0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P=0.209), amputation (7.2% weekend vs. 6.6% weekday, P=0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P=0.271). There was no clinically significant difference in LOS (median 7days weekend vs. 7days weekday), P=0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups. This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.

Brachial Artery Injuries in a Rural Catchment Trauma Center: Are the Upper and Lower Extremity the Same?

The predictors of amputation for patients with lower extremity vascular trauma are well described in the literature, but the predictors of amputation in the upper extremity are not so well defined. We hypothesize that the predictors of amputation in the lower extremity are much different when compared with the upper extremity. Retrospective chart review of all brachial artery traumatic injuries presenting to a rural-state university trauma center. In a 6-year period, 41 patients presented with brachial artery injuries. Operative management was performed in 38 (93%) patients which included 23 reversed saphenous vein grafts, 13 primary repairs, and 2 synthetic grafts. There were four deaths (9.8%) and four (9.8%) amputations. Comparing the amputation and limb salvage groups, the Injury Severity Score (ISS) was 32 versus 12, whereas the Mangled Extremity Severity Score (MESS) was 7 versus 4.3. Five patients had a MESS score greater than 7; four of whom had an amputation or died. Amputation was performed in only 4 of 23 patients with neurologic deficits. Limb salvage was successful in 24 of 28 patients without a palpable pulse on arrival. Predictors of amputation in brachial artery injuries differ from lower extremity vascular injuries. Delayed presentation greater than 6 hours, MESS, open fracture, nerve deficits, and diminished capillary refill were not predictive of amputation for patients with brachial artery injuries. These data suggest that the vast majority of upper extremity injuries should have attempted salvage regardless of the severity scoring systems.