Peripheral Vascular Trauma Research Articles

Invited Commentary

The article by Ikonomidis and colleagues [1Ikonomidis J.S. Ad N. Aldea G.S. et al.Vascular operations performed by cardiothoracic surgeons: The Society of Thoracic Surgeons survey.Ann Thorac Surg. 2016; 102: 589-592Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar] is a contemporary snapshot of thoracic surgeons performing peripheral vascular surgery and their perceived need for vascular surgery to be part of the formal cardiothoracic surgery training. This is an important and timely survey as our specialty continues to adapt and evolve to the growing number of minimally invasive approaches, catheter-based therapies, and endovascular procedures for cardiovascular diseases. In addition, the roots of cardiothoracic and vascular surgery have largely been intertwined. Historically, because of pioneering cardiovascular surgeons such as Drs DeBakey, Cooley, Crawford, and Spencer, who were major contributors to peripheral vascular surgery, vascular operations were commonly taught in thoracic training programs well into the late 1980s. Importantly, the American Board of Thoracic Surgery decided in the late 1970s not to examine candidates in vascular surgery primarily because of the growth of coronary bypass procedures. In 1982, a Certificate for Special Competence in Vascular Surgery was administered by the American Board of Surgery (ABS) to thoracic surgeons performing vascular surgery. In 1986, the vascular certificate was replaced with an ABS written and oral exam. Thoracic surgeons with at least150 peripheral cases per year were able to sit for the exam. By 1998, board certification was limited to residents formally finishing vascular surgery training programs. Thereafter, thoracic surgeons performing vascular surgery declined. Although this survey is limited by the number of respondents, 395 of 5,271 members responding (7.5%), and may have a bias toward those who practice vascular surgery, it does provide the best assessment of our member’s current involvement in vascular surgery. The survey found that 44% of thoracic surgeons are taking routine vascular call and performing a wide breadth of vascular procedures, both open and endovascular, including thoracoabdominal aneurysms, abdominal aneurysms, aortoiliac disease, peripheral vascular disease, dialysis access, and vascular trauma. Interestingly, only 11% of respondents are board certified in vascular surgery, but 43% would like to have vascular surgery boards. In addition, 81% of respondents would like to see vascular surgery as a part of the formal cardiothoracic curriculum and 90% believe that a cardiovascular track should be offered as a part of the cardiothoracic surgery education. To answer this growing need for vascular training within our specialty, the Allegheny General program has an integrated curriculum with our 0-5 vascular residency and with our thoracic surgery residency program, providing 6 months of cardiac surgery in the fourth year. Residents are also encouraged to finish the 2-year thoracic surgery residency 0-5-2. With dual certification in both vascular surgery and cardiothoracic surgery, residents have both a strong open and endovascular skill set. Thought leaders in both fields should study the Allegheny model. [2Magovern G. Simpson K. Curriculum innovation: the key to recruiting the best and brightest.J Thorac Cardiovasc Surg. 2011; 141: 1114-1115Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar] Because the 2 fields are highly differentiated, it is unrealistic to consider a fully integrated 7-year curriculum. Efforts to integrate both fields make sense to primary care physicians, the general public, and to hospital-based cardiovascular institutes, all of whom are looking for multidisciplinary teams to augment quality, safety, and value. Vascular Operations Performed by Cardiothoracic Surgeons: The Society of Thoracic Surgeons SurveyThe Annals of Thoracic SurgeryVol. 102Issue 2PreviewMany cardiothoracic surgeons supplement their case volume through the performance of vascular surgical procedures. Information regarding this practice is not well defined. Full-Text PDF

Difficulties in the Management of Civilian Peripheral Vascular Trauma and their Complications at the University Teaching Hospital of Yaoundé, Cameroon

Background: The incidence of peripheral vascular lesions remains undetermined in Cameroon. The objective of this study was to report our experience with the management of peripheral vascular trauma in civil life at the University Teaching Hospital of Yaounde. Patients and methods: We have reviewed retrospectively all the cases of peripheral vascular trauma treated at the Yaounde’s University Teaching Hospital between 2008 and 2010. We excluded all patients with crushing members or traumatic amputations. Case notes were reviewed for demographic factors, nature of trauma, vascular injury observed and treatment applied. Results: We found 12 patients on 2,436 traumas giving a prevalence of 0.5%. There were 11 men and one woman, mean age was 28.5 (18-55) years. All patients were victims of a penetrating wound. Nine patients were received at the stage of complications from 6 weeks to 2 years after the trauma: 5 of them had arteriovenous fistulas and the other four presented with pseudo aneurysms, they were all operated successfully. Three patients came in emergency at the time of the injury and they presented lesions to the popliteal vessels, brachial and radial arteries. They were amputated after a failed attempt revascularization performed beyond 6 hours after trauma. Conclusion: Vascular injuries are usually overlooked in our environment, and we would recommend a vascular exam in patients with penetrating injuries to the limb to avoid missing them.

Intraoperative indocyanine green angiography for the objective measurement of blood flow.

PurposeIntraoperative assessment of tissue perfusion is important to predict wound healing or improvement of symptoms in patients with peripheral arterial disease (PAD) or vascular trauma. There is no widely accepted standard for intraoperative measurement of tissue perfusion. Here, we report the use of indocyanine green (ICG)-based angiography to determine the blood flow in patients with PAD and vascular trauma.MethodsThe SPY fluorescent imaging system was utilized. A dose of 3–5 mL of ICG (2.5 mg/mL) was injected intravenously followed by a 10 mL normal saline flush. The SPY imaging system was used to quantitatively assess perfusion. During the study period, the SPY imaging system was applied in 4 patients with PAD and one patient with vascular trauma.ResultsIn 3 patients with PAD associated with an ischemic wound, complete wound healing was achieved with the indication of viable tissue by the SPY system. In one patient with severe claudication in both lower extremities, the ICG angiography was used to determine the increased blood flow after revascularization. In the case of vascular trauma, this imaging system enabled the delineation of viability of the injured tissue.ConclusionICG angiography can determine the surface tissue viability in PAD patients. In cases of severe vascular trauma,the SPY system can be used to determine tissue perfusion. Further study is warranted to define the definite utility of this technology to assess perfusion, response to revascularization, and potentially, to predict the likelihood of wound healing.

Preventing and treating foot complications associated with diabetes mellitus

Diabetes mellitus is associated with a series of macrovascular and microvascular changes that can manifest as a wide range of complications. Foot ulcerations affect ∼2-4% of patients with diabetes mellitus. Risk factors for foot lesions include peripheral and autonomic neuropathy, vascular disease and previous foot ulceration, as well as other microvascular complications, such as retinopathy and end-stage renal disease. Ulceration is the result of a combination of components that together lead to tissue breakdown. The most frequently occurring causal pathways to the development of foot ulcers include peripheral neuropathy and vascular disease, foot deformity or trauma. Peripheral vascular disease is often not diagnosed in patients with diabetes mellitus until tissue loss is evident, usually in the form of a nonhealing ulcer. Identification of patients with diabetes mellitus who are at high risk of ulceration is important and can be achieved via annual foot screening with subsequent multidisciplinary foot-care interventions. Understanding the factors that place patients with diabetes mellitus at high risk of ulceration, together with an appreciation of the links between different aspects of the disease process, is essential to the prevention and management of diabetic foot complications.

Hybrid Operating Theater Could Increase Role of Endovascular Adjuncts in Peripheral and Thoracic Outlet Vascular Trauma

Trauma is one of the leading causes of mortality and morbidity especially in the young or middle age group. The lethal triad of trauma (hypothermia, coagulopathy, and acidosis) is almost always triggered by initial uncontrolled or concealed hemorrhage. Time is of utmost importance in terminating the vicious cycle. Endovascular interventions along with open surgical management in a hybrid suite not only decrease surgical time, avoid exposure to anesthesia, hasten recovery, but most importantly breakdown the catastrophic sequelae of ongoing bleed by rapid hemorrhage control. They allow vascular control at difficult surgical terrains such as subclavian or iliac vessels with much compared ease and rapidity. We present four interesting cases of peripheral and thoracic outlet vascular trauma and its sequelae managed with endovascular adjuncts at different points in the resuscitative and rehabilitation stations. In our first case of a stab injury over the right femoral artery with acute hemorrhage, a covered stent across the transected artery was curative as well as hastened recovery. In the second case in the hybrid suite, a long segment of balloon occlusion of the iliac artery allowed rapid physiology control and easier surgical repair of the transected common femoral vessels. The third case required a covered stent across the leak from a previously repaired subclavian vessel to prevent life-threatening hemothorax. In another interesting case of a badly mutilated posttraumatic shoulder with an axillary pseudo-aneurysm, a covered stent across the axillary vessel facilitated further reconstructive shoulder surgery.

Concomitant Repair of Superficial Femoral Artery and Vein in a Case of Peripheral Vascular Trauma

Concomitant Repair of Superficial Femoral Artery and Vein in a Case of Peripheral Vascular Trauma

Trauma vascular periférico em crianças: fatores relacionados pelo método de regressão logística

The objective of the present study was to identify the factors related to “peripheral vascular trauma” in children aged six months to 12 years. This prospective cohort study included children with peripheral vein punctured for the first time per side and excluded those with high/complete healing of trauma signs after removing the catheter. Daily clinical evaluations were performed in intervals shorter than 24 hours. Data were treated according to Pearson’s test and the logistic regression method. Among the 14 variables considered intervenient, four were statistically associated to the occurrence of trauma: dirtiness and humidity in the catheter insertion site, catheter caliber, and age. A causal relationship was found between the intervenient variables and the outcome, “peripheral vascular trauma”, thus, contributing to forming the knowledge of the peripheral venous puncture in children aged six months to 12 years. Descriptors: Child; Nursing Diagnosis; Veins; Injuries.

Prioridades de pesquisa em enfermagem neonatal e pediátrica

Thaila Correa Castral, Mariana Firmino Dare, Carmen Gracinda Silvan Scochi 1 Enfermeira, Doutora em Ciencias. Professora Adjunto I da Faculdade de Enfermagem da Universidade Federal de Goias. Goiânia, Goias, Brasil. E-mail: thaccastral@gmail.com. 2 Enfermeira. Doutoranda do Programa de Pos-Graduacao Enfermagem em Saude Publica Escola de Enfermagem de Ribeirao Preto da Universidade de Sao Paulo (EERP/USP). Bolsista Regular de Doutorado Direto FAPESP. Ribeirao Preto, Sao Paulo, Brasil. E-mail: mari_dare@hotmail.com. 3 Enfermeira, Livre-Docente. Professora Titular do Departamento de Enfermagem Materno-Infantil e Saude Publica da EERP/USP. Bolsista Produtividade em Pesquisa 1B do CNPq. Coordenadora da Area de Enfermagem na CAPES. Ribeirao Preto, Sao Paulo, Brasil. E-mail: cscochi@eerp.usp.br.

Western Trauma Association Critical Decisions in Trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on the evaluation and management of peripheral vascular trauma, the algorithm is based on the expert opinion of the WTA members and published observational studies. It may not be applicable at all hospitals caring for injured patients. The algorithm contains letters that correspond to lettered text that is intentionally concise. This Part II algorithm focuses on operative techniques, while the Part I algorithm (J Trauma 2011;70: 1551-1556) emphasized evaluation, diagnosis, and need for operation versus a therapeutic procedure performed in an interventional suite.

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.

Survey of clinical manifestations of peripheral vascular trauma in children admitted to pediatric wards

Aim: To analyze the clinical evidence for a diagnosis of “peripheral vascular trauma” based on occurrence and type, in children between six months and twelve years old. Method: Survey of peripheral venous punctures performed in children having a first puncture on that site. Daily clinical evaluations were performed on the puncture site and adjacent areas at intervals, commencing within 24 hours following the puncture and continuing until the resolution of the trauma, or the patient’s discharge, excluding any subsequent punctures. Results: From the 338 punctures observed, 53.3% presented with at least one clinical manifestation of trauma, characterized by: pain (30.1%), change in the skin color (18.6%), skin integrity (47.7%), functional capacity (6.2%) or local temperature (14.2%). Discussion: The defining characteristics of peripheral vascular trauma generated a scientific theoretical structure for the nurses in their clinical practice, alerting them to the occurrence of this event in children. Conclusion: The characterization of vascular trauma in children permits a re-evaluation of this procedure.

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.

Periferik Vasküler Yaralanmalarda Deneyimlerimiz

Purpose: The aim of this study was to determine etiology and management in patients with peripheral vascular trauma. Method: From May 2010 to May 2012, 48 cases who was admitted Adana Sample Education and Research Hospital Department of cardiovascular surgery with a diagnosis peripheral artery injury have been included in this study. All files of the patients have been reviewed retrospectively. Results: Upper extremity vascular trauma have been seen in 30 patients lower extremitiy vascular trauma in 18 patients too. The causes of injuries were penetrating injuries in 26 patients , gon shot injuries in 3 patients , blunt tarauma in 1 patients. . The causes of lower extremity injuries were; penetrating injuries in 5 patients , blunt trauma in 3 patients. As a surgical procedure simple repair , end to end anastomosis , venous graft or PTFE graft interposition was performed. Conclusions: Early intervention and treatment decreased the morbidity and mortality in patients with peripheral vascular injuries.

Perioperative Management of Peripheral Vascular Trauma

Peripheral vascular trauma is not uncommon in the civilian setting, and it can be uniquely challenging because of the limited time during which intervention can salvage an ischemic extremity. Injuries can be from a blunt or penetrating mechanism, and these injuries can be isolated or can be in the setting of a complex multisystem trauma. The intent of this review is to discuss the perioperative management of peripheral vascular trauma with an emphasis of predicting, preventing, and managing common postoperative complications.

Evaluation and Management of Peripheral Vascular Injury. Part 1. Western Trauma Association/Critical Decisions in Trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on the evaluation and management of peripheral vascular trauma, the algorithm (Fig. 1) is based on the expert opinion of WTA members and published observational studies. It may not be applicable at all hospitals caring for injured patients. The algorithm contains letters that correspond to lettered text that is intentionally concise. This Part I algorithm emphasizes evaluation, diagnosis, and need for operation versus a therapeutic procedure performed in interventional radiology, while a Part II algorithm (2011) will focus on operative techniques. Peripheral vascular injures defined as axillobrachial and branches in the upper extremity and femoropopliteal and branches in the lower extremity account for 40% to 75% of all vascular injuries treated in civilian trauma centers.1–4 With the exception of the axillary artery, the long tracks of named arteries and veins in the extremities make them particularly susceptible to either penetrating or blunt trauma. This fact coupled with the smaller diameter of many of these vessels (as compared with those in the thorax or abdomen) and the ability of the patient and others to control external hemorrhage with compression contribute to a low incidence of death in the field.

Acute ischemia of the lower limb after injury by gunshot: case report and review of literature.

Civilian and military vascular trauma has evolved dramatically. It is estimated that 80% of all cases of vascular injuries are due to peripheral vascular trauma, most involving the lower extremities. Arterial below-knee injuries by gunshot still remain a challenge, with an associated rate of amputation of 20-54%. This case reports a 48year-old male patient who sustained a gunshot below his left knee. At hospital admission, loss of substance and hemorrhage at the medial and lateral faces of the upper third of his left leg were present with signs of distal ischemia. Arteriography revealed infra-popliteal arterial lesions of the three arterial axes. Two reversed great saphenous vein interposition grafts were performed into the anterior and posterior tibial arteries with immediate revascularization of the left leg and foot. Later, soft tissue reconstruction was accomplished by a split-thickness skin graft. At the fifth month of follow-up, the left leg and foot were viable with good healing, without limitations and with controlled pain. Posterior tibial and dorsalis pedis pulses were palpable. This case report shows the importance of an adequate team approach for treatment of a gunshot extremity injury with vascular lesion. The authors want to highlight the scientific background evidence and the value of comparing worldwide civilian trauma center outcomes, mostly reported previously from the military field.

Differences in Gait Characteristics Between Persons With Bilateral Transtibial Amputations, Due to Peripheral Vascular Disease and Trauma, and Able-Bodied Ambulators

Su P-F, Gard SA, Lipschutz RD, Kuiken TA. Differences in gait characteristics between persons with bilateral transtibial amputations, due to peripheral vascular disease and trauma, and able-bodied ambulators. Objectives To examine differences in gait characteristics between persons with bilateral transtibial amputations because of trauma and peripheral vascular disease (PVD); and to compare that with data from able-bodied controls that were previously collected and maintained in a laboratory database. Design Observational study of persons with bilateral transtibial amputations. Setting A motion analysis laboratory. Participants Nineteen bilateral transtibial amputees. Intervention No experimental intervention was performed. To standardize the effect of prosthetic foot type, subjects were fitted with Seattle Lightfoot II feet 2 weeks before quantitative gait analyses. Main Outcome Measures Temporospatial, kinematic, and kinetic gait data were recorded and analyzed. Results Results showed that the freely selected walking speeds of subjects with PVD and trauma were 0.69m/s and 1.11m/s, respectively, while that of able-bodied control subjects was 1.20m/s. When data were compared on the basis of freely selected walking speed, numerous differences were found in temporospatial, kinematic, and kinetic parameters between the PVD and trauma groups. However, when data from similar speeds were compared, the temporospatial, kinematic, and kinetic gait data demonstrated no statistically significant differences between the 2 amputee groups. Although not statistically significant, the PVD group displayed increased knee ( P=.09) and hip ( P=.06) flexion during the swing phase, whereas the trauma group displayed increased pelvic obliquity ( P=.06). These actions were believed to represent different strategies to increase swing phase foot clearance. Also, the PVD group exhibited slightly greater hip power ( P=.05) before toe-off. Conclusions Many of the differences observed in the quantitative gait data between the trauma and PVD groups appeared to be directly associated with their freely selected walking speed; the trauma group walked at significantly faster freely selected speeds than the PVD group. When their walking speeds were matched, both amputee groups displayed similar gait characteristics, with the exception that they might use slightly different strategies to increase foot clearance.

Vascular injuries of the upper extremity

OBJECTIVE: This study analyzes the causes of injuries, presentations, surgical approaches, outcome and complications of vascular trauma of the upper limbs, in spite of limited hospital resources. METHODS: A 5-year retrospective analysis. From 01/01/2001 to 31/12/2005, 165 patients were operated for vascular injuries at King Fahd Hospital, Medina, Saudi Arabia. Of all peripheral vascular trauma patients (115), upper limb trauma was present in 58. Diagnosis was made by physical examination and hand-held Doppler alone or in combination with Doppler scan/angiography. Primary vascular repair was performed whenever possible; otherwise, the interposition vein graft was used. Fasciotomy was considered when required. Patients with unsalvageable lower extremity injury requiring primary amputation were excluded from the study. RESULTS: Fifty patients were male (86%) and eight were female (14%), aged between 2.5-55 years (mean 23 years). Mean duration of presentation was 8 h after the injury. The most common etiological factor was road traffic accidents, accounting for 50.5% in the blunt trauma group and 33% among all penetrating and stab wound injuries. Incidence of concomitant orthopedic injuries was very high in our study (51%). The brachial artery was the most affected (51%). Interposition vein grafts were used in 53% of the cases. Limb salvage rate was 100%. CONCLUSION: Patients who suffer vascular injuries of the upper extremities should be transferred to vascular surgery centers as soon as possible. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present.

Tactical Surgical Intervention With Temporary Shunting of Peripheral Vascular Trauma Sustained During Operation Iraqi Freedom: One Unit??s Experience

Rapidly restoring perfusion to injured extremities is one of the primary missions of forward military surgical teams. The austere setting, limited resources, and grossly contaminated nature of wounds encountered complicates early definitive repair of complex combat vascular injuries. Temporary vascular shunting of these injuries in the forward area facilitates rapid restoration of perfusion while allowing for deferment of definitive repair until after transport to units with greater resources and expertise. Standard Javid or Sundt shunts were placed to temporarily bypass complex peripheral vascular injuries encountered by a forward US Navy surgical unit during a six month interval of Operation Iraqi Freedom. Data from the time of injury through transfer out of Iraq were prospectively recorded. Each patient's subsequent course at Continental US medical centers was retrospectively reviewed once the operating surgeons had returned from deployment. Twenty-seven vascular shunts were used to bypass complex vascular injuries in twenty combat casualties with a mean injury severity score of 18 (range 9-34) and mean mangled extremity severity score of 9 (range 6-11). All patients survived although three (15%) ultimately required amputation for nonvascular complications. Six (22%) shunts clotted during transport but an effective perfusion window was provided even in these cases. Temporary vascular shunting appears to provide simple and effective means of restoring limb perfusion to combat casualties at the forward level.

Return to Driving After Lower-Extremity Amputation

Boulias C, Meikle B, Pauley T, Devlin M. Return to driving after lower-extremity amputation. Objectives To study driving behaviors after major lower-extremity amputations and to determine which factors influence return to driving after amputation. Design A cross-sectional study. Setting Data were collected from patients attending an outpatient amputee and prosthetics clinic between February 2001 and September 2001. Participants A convenience sample (N=123). Inclusion criteria were: age greater than 18 years, unilateral or bilateral major lower-extremity amputation, minimum 1 year since prosthetic fitting, and active automobile driver within 6 months prior to amputation. Subjects had an average age of 63.4±12.1 years and were on average 6.8±8.3 years since amputation. Common causes for amputation were peripheral vascular disease (73.2%), trauma (13.8%), and tumor (12.2%). Interventions Not applicable. Main Outcome Measure Driving habits after lower-extremity amputation. Results Overall, 80.5% of participants were able to return to driving an average of 3.8 months after amputation, although the majority reported a decreased driving frequency. Female sex (odds ratio [OR]=.08; 95% confidence interval [CI], .02–.34), age of 60 years or greater (OR=.16; 95% CI, .03–.74), right-sided amputation (OR=.13; 95% CI, .03–.52), and preamputation driving frequency of less than every day (OR=.18; 95% CI, .05–.69) were all significantly related to a reduced likelihood of return to driving postamputation. Items that did not have a statistically significant association with return to driving included level of amputation, reason for amputation, preamputation automobile transmission, and accessibility to public transit. Subjects with left-sided amputation had significantly fewer concerns about driving, while those with a right amputation frequently required vehicle modifications (40.6%) or switch to a left-foot driving style for braking (81.3%) and accelerating (65.6%). Common barriers to return to driving included preference not to drive, fear and/or lack of confidence, and related medical conditions. Conclusions The majority of subjects with major lower-extremity amputation were able to return to driving after major lower-extremity amputation. Major automobile modifications are commonly performed by right-sided amputees. Several predictors of return to driving and barriers preventing return to driving were identified.