Popliteal Artery Injury Research Articles

Popliteal Artery Injury During Total Knee Replacement: A Single-Center Experience

Popliteal Artery Injury During Total Knee Replacement: A Single-Center Experience

Evaluation of early results of diagnosis and treatment of popliteal artery injury in knee trauma at Binh Dan Hospital

Objectives:To describe the clinical and subclinical signs for early diagnosis and evaluate the short-term outcomes of surgical treatment of popliteal artery injury in knee trauma. Materials and methods: A retrospective descriptive study was conducted on 30 patients with knee trauma and popliteal artery injury who underwent surgery at Binh Dan Hospital from August 2016 to June 2021. Results: The mean age of admitted patients was 35.5±12.8 years, predominantly male (73.3%). The majority of cases were due to traffic accidents (83.4%). Peripheral pulse was absent or decreased in 76.7% of patients. Most patients (95.3%) showed loss of flow signal on ultrasound. The most common surgical intervention was venous graft repair (63.3%). After surgery, 93.3% of patients had good flow restoration. The postoperative arterial occlusion rate was 6.7%. There were two cases that required a second surgery for popliteal artery recanalisation: one case where limb salvage was achieved, and one case that resulted in amputation. Conclusion: The application of appropriate diagnostic measures, emergency management, and surgical intervention has resulted in positive treatment outcomes, helping to reduce the rate of limb amputation and other severe complications

Popliteal artery injury in and about knee injury: An experience in Manmohan Cardiothoracic vascular and transplant center

Popliteal artery injury in and about knee injury: An experience in Manmohan Cardiothoracic vascular and transplant center

Identifying Risk Factors for Poor Outcomes Following Popliteal Vascular Injuries

IntroductionPopliteal artery injuries may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following popliteal artery injuries in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries. MethodsA retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with popliteal artery injuries were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation. Results188 patients with popliteal artery injuries were identified, 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (p= 0.0132) and neurologic deficits on arrival (p=0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N=93), there was no significant difference in amputation rates between those who had vein repair (p=0.21) and those who underwent ligation (p=0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (p=0.20) or skin graft area (p=0.48) based on linear regression analysis. ConclusionOur study suggests that major amputations following popliteal artery injuries are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries.

What is the Optimal Treatment Protocol for Traumatic Popliteal Artery Injury? A Comparative Study between Two Institutions

What is the Optimal Treatment Protocol for Traumatic Popliteal Artery Injury? A Comparative Study between Two Institutions

Efficacy of Orthoplastic Management in the Treatment of Traumatic Popliteal Artery Injury.

Popliteal artery injury (PAI) is a challenging condition. Even with appropriate initial treatment and reconstruction of the associated injuries, extensive soft-tissue necrosis may occur, requiring lower leg amputation. There are no reports on the effectiveness of orthoplastic surgery in treating traumatic PAI. However, orthoplastic surgery is also considered very effective in PAI treatment, which requires delicate handling of soft-tissue and blood vessels. This study aimed to examine the treatment outcomes of traumatic PAI at a trauma center with the capacity for orthoplastic management. Patients with PAI who were treated at our institution between August 2013 and December 2021 were included in this study. The surgeons included multiple orthoplastic surgeons with capabilities in vascular repair, bone and ligament reconstruction, and soft-tissue reconstruction. Patient demographics, injury characteristics, degree of ischemia, and treatment were investigated. We also investigated whether soft-tissue reconstruction and lower limb amputation were necessary as outcomes of treatment. Fifteen limbs of 14 patients with PAI met the inclusion criteria. Extensive soft-tissue necrosis was observed in three limbs. Two of these limbs were covered with a free latissimus dorsi flap and could be salvaged. In the remaining limb, lower limb amputation was unavoidable because of unexplained cardiac arrest during the initial surgery, but a fillet flap was used to successfully preserve the knee joint. Orthoplastic management has the potential to improve limb salvage rates and provide good outcomes for the treatment of traumatic PAI.

Our Surgical Results in Popliteal and Infrapopliteal Artery Injuries: 21 Cases without Amputation.

Popliteal and infrapopliteal artery injuries have significant morbidity and mortality rates, especially in terms of amputation. In our study, we aimed to evaluate patients who operated due to popliteal and infrapopliteal vascular injuries in our clinic. Patients and Methods. Between 2016 and 2023; 21 patients who were operated in our clinic due to popliteal and infrapopliteal artery injuries were retrospectively evaluated. 2 of the patients were female (9.5%) and 19 were male (90.5%). Age ranges were 21-78. The causes of injury were gunshot wounds in 9 patients (42.86%), blunt trauma in 7 patients (33.33%), and sharp object injuries in 5 patients (23.80%). Reversed saphenous vein interposition in 7 patients (33.33%), primary repair in 6 patients (28.57%), 6 mm polytetrafluoroethylene graft (PTFE) interposition in 3 patients (14.28%), end-to-end anastomosis in 2 patients (9.52%), saphenous-PTFE composite graft interposition in 2 patients (9.52%), and embolectomy in 1 patient (4.76%) were performed. Arterial ligation was not performed. Simultaneous orthopedic intervention was performed in 8 patients. Fasciotomy was performed in 3 patients. Venous repair was performed in 5 patients with venous injuries. Vein ligation was not performed. Mortality was observed postoperatively in 1 patient. No patient developed amputation. Foot drop developed with nerve damage in 2 patients. Mortality and morbidity rates may increase in popliteal and infrapopliteal artery injuries in cases of hemodynamic disorder, simultaneous bone fracture, multivessel injury, and nerve transection. These rates can be reduced by appropriate surgical repair and ensuring hemodynamic stability.

Endovascular Repair of a Popliteal Artery Injury after an Arthroscopic Intervention

Endovascular Repair of a Popliteal Artery Injury after an Arthroscopic Intervention

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center.

To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery And Orthopedic Injuries

The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P=0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P=0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25years is 100%. In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.

Delayed Presentation of Popliteal Artery Injury after Salter-Harris III Proximal Tibia Fracture

Introduction. Proximal tibia physeal fractures in children are not very common but can be dangerous because they can harm popliteal fossa structures, especially the popliteal artery. Popliteal artery injuries (PAI) are most commonly the result of trauma to the lower extremity, including blunt force, hyperextension injuries, complex fractures, and knee dislocations that can compromise popliteal neurovascular structures. Case Presentation. A 14-year-old boy presents to the emergency department after being transferred from an outside hospital 24 hours after a left lower extremity hyperextension injury. Radiographs demonstrated a Salter-Harris III proximal tibia fracture with posterior displacement. ABIs were deferred due to palpable distal pulses and no evidence of compartment syndrome. Closed reduction and percutaneous pinning were planned to correct the fracture. Intraoperatively, it was discovered that knee extension decreased lower extremity perfusion while knee flexion returned perfusion. An angiography revealed a popliteal artery occlusion with no distal flow. Based on this, an above-knee to below-knee popliteal bypass using the contralateral great saphenous vein was performed followed by closed reduction and percutaneous pinning of the proximal tibia. Conclusion. Proximal tibia physeal injuries, especially the Salter-Harris III and IV injuries, warrant a high index of suspicion of popliteal artery injuries. Palpable pulses and delayed presentation in the distal lower extremity do not rule out a PAI because collateral flow to the anterior and posterior tibial arteries may mask signs of an avascular limb, highlighting the need for a thorough history and physical exam. The authors present this case to reaffirm the importance of an ankle-brachial index when evaluating hyperextension injuries with proximal tibial epiphyseal fractures.

Validity of Mangled Extremity Score System to Predict Limb Salvage on Cases of Traumatic Popliteal Artery Injuries: A Case Series and Review of the Literature

Background: Popliteal artery injuries carry a risk of amputation rate ranging from 9.7% to 28%. The mangled extremity score system (MESS) was originally authenticated in only 26 patients and it was concluded that an MESS ≥ 7 equated to a 100% rate of amputation. In this study we add the effects of combined arterial venous injuries and combined arterial venous and nerve injuries to the risk of amputation and correlate them with the MESS.Methods: This is a retrospective single arm cohort study conducted using 25 patients included between 1 January 2020 and 1 January 2023 at two hospitals, Ain Shams University Hospital and Shebin Elkoom Teaching Hospital. The study defined two groups: the amputation and non-amputation groups. It assessed the validity of the MESS to predict limb salvage in cases of traumatic popliteal artery injuries.Results: The overall rate of amputation was 64%. Patients presenting with MESS ≥ 8 had an amputation rate of 25%, while patients with MESS ≥ 9 had an amputation rate of 75%. Patients presenting with combined popliteal artery and vein or combined artery, vein and nerve injury had a 100% rate of amputation (MESS ≥ 8). There was no 30-day mortality.Conclusions: MESS ≥ 9 carries a high risk of amputation (75%). Combined arterial and venous injuries or arterial, venous and nerve injuries, which already have a high MESS, also carry a high risk of amputation. All of them could be predictors of limb salvage in popliteal artery injury.

Tibiofemoral Dislocation Management in a Rural High School Football Scenario: Development of a Popliteal Artery Injury Suspicion Index.

This study evaluated the knowledge and preparedness of athletic trainers (ATs) for diagnosing and managing an anterior tibiofemoral knee dislocation in a rural or limited-resource high school football setting scenario. The study hypothesis was that more experienced ATs would display greater preparedness than less experienced ATs. A secondary objective was to develop evidence-based guidelines to help the AT provide better emergency triage care. This prospective cross-sectional study distributed a rural high school football game scenario survey electronically to a random sample of 2000 certified ATs to determine their perceptions of readiness to diagnose and manage an anterior tibiofemoral knee dislocation with signs or symptoms of possible popliteal artery injury. A total of 249 surveys (12.5%) were completed. Years of athletic training experience were ≤5 years (n = 82, group 1) and ≥6 years (n = 167, group 2). Both groups perceived that they could not "rule out" an arterial injury and had similar "red flag" sign and symptom rankings. Group 2 perceived a more serious situation than group 1 (77.5 ± 15 vs 70.8 ± 14, P < 0.0001) and were more likely to activate the emergency action plan (74.5 ± 25 vs 64.4 ± 26, P = 0.005). Both groups were "neutral" about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that evidence-based guidance was needed. More experienced ATs perceived a more serious situation than less experienced ATs and were more likely to activate the emergency action plan. Both groups were neutral about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that they would benefit from evidence-based guidance. Proposed guidelines provide the AT with a more measured, evidence-based index of suspicion for potential popliteal artery injury in anterior tibiofemoral dislocation cases. This will complement existing hospital emergency department-based management algorithms, decreasing the likelihood of this condition progressing to limb loss or death.

Transected popliteal artery via gunshot wound: A case report

Introduction: Popliteal artery transection is an uncommon injury but can be seen in traumas like gunshots, stabs, and complex fractures of the distal femur or proximal tibia. Although uncommon, these injuries carry the greatest risk of limb loss of any peripheral vascular injury. Timely hemostasis and repair is crucial to limb-salvage and overall survival, as lower extremity amputation is known to have very high mortality rates. We present a multiple gunshot wound patient who was found to have a completely transected popliteal artery injury and who underwent open surgical repair with interposition vein graft using the greater saphenous vein, ultimately resulting in two-vessel runoff and limb salvage. Case Report: A 30-year-old man with no known past medical history presented to the hospital via private vehicle after being shot multiple times just prior to arrival. Obvious injuries noted were two gunshot wounds to the left hand with hemorrhage, two gunshot wounds to the right thumb without hemorrhage, one gunshot wound to the left upper quadrant, one gunshot wound to the left flank, and one to the right lower extremity in the posterior distal thigh with massive hemorrhage. He was emergently taken to the operating room where exploration of the right popliteal artery and vein was performed which revealed a completely transected popliteal artery. The bullet was found to be lodged in the distal femur. The left great saphenous vein was then harvested in order to use it to repair the right popliteal artery with an interposition vein bypass. Intraoperative angiogram confirmed 2-vessel runoff. A four-compartment fasciotomy was performed prophylactically to avoid compartment syndrome. Postoperatively, the patient was extubated on post-op day 1. On post-op day 7, he was transferred out of the ICU and underwent split thickness skin grafting to the right lower extremity fasciotomy wounds. On post-op day 18, he was discharged home with a walker and the ability to move all extremities. He has now recovered full ambulatory function. Conclusion: Transection of popliteal artery should be considered in trauma patients with profuse lower extremity bleeding. In severe injuries and hemodynamically unstable patients, prompt hemostasis should be achieved and open surgical repair with an interposition vein graft should be considered for limb salvage.

Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury

Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting (IVS) and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the cases series of traumatic PAI treated using CLS and verify the usefulness of CLS. All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. We used CLS for treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and four with grade 3. Amputation of the lower extremities was avoided except for one extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.

Emergency vascular repairs in trauma: Predictors of poor prognosis and a novel scoring system.

Vascular injuries comprise 1% to 4% of all trauma patients, and there are no widely used risk-stratification tools. We sought to establish predictors of revascularization failures and compare outcomes of trauma and vascular surgeons. We performed a single-institution, case-control study of consecutive patients with traumatic arterial injuries who underwent open repair between 2016 and 2021. Multivariable logistic regression was used to investigate covariates impacting the primary composite outcome of repair failure/revision, amputation, or in-hospital mortality. Among 165 patients, the median age was 34 years, 149 (90%) were male, and 99 (60%) suffered penetrating injury. Popliteal (46%) and superficial femoral (44%) arterial injuries were most common. Interposition graft/bypass was the most frequent repair (n = 107 [65%]). Revascularization failure was observed in 24 patients (15%). Compared with trauma surgeons, vascular surgeons more frequently repaired blunt injuries (66% vs. 20%, p < 0.001), anterior tibial (18% vs. 5%, p = 0.012), or tibioperoneal injuries (28% vs. 4%, p < 0.001), with a below-knee bypass (38% vs. 20%, p = 0.019). Revascularization failure occurred in 10% (9 of 93) of repairs by trauma surgeons and 21% (13 of 61) of repairs by vascular surgeons. Mangled Extremity Severity Score >8 (odds ratio, 15.6; 95% confidence interval, 4.4-55.9; p < 0.001) and concomitant laparotomy or orthopedic procedure (odds ratio, 6.7; 95% confidence interval, 1.6-28.6; p = 0.010) were independently associated with revascularization failure. A novel composite scoring system (UT Houston Score) was developed by combining Mangled Extremity Severity Score, concomitant procedure, mechanism of injury, and injury location. This score demonstrated a sensitivity of 100% with a score of 0 and a specificity of 95% with a score of >3. After traumatic arterial injury, trauma surgeons repaired less-complex injuries but with fewer revascularization failures than vascular surgeons. The UT Houston Score may be used to risk stratify patients to determine who may benefit from vascular surgery consultation. Therapeutic/Care Management; Level III.

LARAI portal provides a safe method for lateral meniscus repair: three-dimensional computed tomography and cadaveric assessment

BackgroundLateral, All-Round and All-Inside (LARAI) portal is a viewing or working portal for observing and repairing the lesions of the lateral meniscus. However, there are safety concerns about popliteal artery (PA) injuries during the procedure. This study aimed to assess the safe distance between the trajectory of the LARAI portal and PA.Materials and methodsBoth three-dimensional computed tomography (3D-CT) and cadavers were used to simulate the LARAI portal trajectory. In the 3D-CT study, between January 2020 and September 2020, 45 participants who underwent computed tomography angiography were included in the study. The shortest distance from the PA to the simulated trajectory needle (PS) was measured using 3D-CT. Mean −3SD −2 was calculated to assess the safety of the LARAI portal trajectory. If this value was more than zero, the trajectory was considered “safe.” In the cadaveric study, lower limbs from seven fresh-frozen cadavers were used to establish the “safe” trajectories of the LARAI portal, and the PS was measured.ResultsIn the 3D-CT study, the longest PS (P < 0.001) was found 20 mm lateral to the edge of the patellar tendon trajectory at 0 mm from the posterior cruciate ligament (PCL). Safe trajectories were also found 10 mm, 15 mm, and 20 mm lateral to the edge of the patellar tendon at 0 mm from the PCL, as well as the 20 mm lateral to the edge of the patellar tendon at 3 mm from the PCL. The cadaveric study showed that the average PS of all safe trajectories closely adjoined to PCL was greater than 14 mm.ConclusionsThe LARAI portal trajectory in the “figure of four” is safe, and the optimal insertion point is 10–20 mm lateral to the edge of the patellar tendon and closely adjoined to the posterolateral margin of the PCL at knee joint line level.Level of evidenceLevel IV.

Delayed Diagnosis of Ischemia after Popliteal Artery Injury during total Knee Arthroplasty

Over 600,000 TKA are performed annually in the USA. Injuries to the popliteal artery are unusual, estimated to occur in less than 0.2% of cases [1-3]. Three mechanisms of injury have been reported, the use of a pneumatic tourniquet in patients with advanced atherosclerosis [4], sharp, direct trauma to the vessels and stretching or kinking of the artery when the knee is manipulated [5,6]. It is generally believed that popliteal artery occlusion rapidly causes acute ischemia after popliteal artery occlusion because of the paucity of collaterals. Cases of acute ischemia after TKA that slowly evolve and that have been diagnosed and treated on a delayed basis have been rarely reported [3]. This may be because delays in diagnosis frequently result in major morbidity and litigation.

1001 A Case Report on Popliteal Artery Occlusion After a Low-Energy Trauma Years After Total Knee Arthroplasty

Abstract Aim To highlight the significance of dislocated total knee arthroplasty, which is more likely to happen after a low-energy trauma and can result in limb-threatening neurovascular complications and compartment syndrome, we present a case of mild trauma that resulted in the co-occurrence of the occlusion of the left popliteal artery and vein 10 years after the implantation. Method Three weeks after a low-energy fall on her knee at home, a 69-year-old woman presented to our orthopedics clinic with swelling, paresthesia, and paralysis in her left leg. She had edema and significant ecchymosis, and the tibial pulses in her left knee had vanished. She had uneventful bilateral knee arthroplasty surgery on her right and left knees six and ten years ago, respectively. Her medical history is significant for type 2 diabetes mellitus and hypertension. Doppler ultrasound and CT angiography showed occluded popliteal artery and vein. Following thromboembolectomy by cardiovascular surgeons, orthopedic surgeons underwent lower leg preventative fasciotomy under general anesthesia by creating two longitudinal incisions on either side of the tibia. Results Doppler ultrasonography on the fifth follow-up day revealed biphasic flow in the posterior tibial artery and monophasic flow in the dorsal tibial artery, however, the paralysis and paresthesia were still present. Ultimately, unilateral above-knee amputation was performed. Conclusions Due to the high level of concern for vascular injury and compartment syndrome, we advise physicians to consider popliteal artery injury while treating patients who underwent total knee arthroplasty years ago and present with minimal trauma.

Association between time to revascularization and limb loss in military femoropopliteal arterial injuries

ObjectiveExpeditious revascularization is key to limb salvage after arterial injuries, but the relationship between time to revascularization and amputation risk is not well-defined. We aimed to explore amputation risk based on time to revascularization in a cohort of military femoropopliteal arterial injuries. MethodsA database of vascular injuries from Iraq and Afghanistan casualties (2004-2012) was queried for femoral (common, superficial, or deep) and/or popliteal arterial injuries that underwent revascularization. Time from injury to initial revascularization (via shunt or reconstruction) was divided into groups of <3 hours, 3 to 6 hours, 6 to 9 hours, and >9 hours, and bivariate comparisons were performed. ResultsRevascularization times were available for 120 cases. Injury and treatment characteristics by time group were generally similar between time groups. Shunting and vein injuries were more common in limbs revascularized earlier, whereas blast mechanism and fasciotomy were more common with later revascularization. Ten cases (8%) underwent revascularization in less than 3 hours, 63 (53%) were revascularized in 3 to 6 hours, 33 (28%) in 6 to 9 hours, and 14 (12%) after 9 hours. Amputation rates within the cohorts were 10%, 21%, 24%, and 50%, respectively (P = .085, χ2 of amputation rates across time groups). The mean ± standard deviation revascularization time for amputated limbs was 442 ± 348 minutes vs 347 ± 183 minutes for salvaged limbs (P = .057). Amputation was performed in 19% of limbs revascularized in <6 hours and in 32% revascularized >6 hours from injury (P = .112). The >9-hour group, however, had a 50% amputation rate vs 21% for those with revascularization in <9 hours (P = .016). Fractures were more common in >9-hour limbs than <9-hour limbs (79% vs 44%; P = .016), but other limb injury characteristics were similar, with no difference in limb injury severity scores. Among 91 salvaged limbs, neither vascular nor other complications were predicted by time to revascularization. All seven >9-hour limbs had a limb complication, most commonly infection (71%), and three (42%) required a skin graft to close their fasciotomies. ConclusionsIncreasing time from injury to initial revascularization was associated with increasing rates of limb loss. Revascularization within 3 hours of injury resulted in a low amputation rate, whereas one-half of limbs treated after 9 hours were amputated. Arterial shunting was associated with earlier revascularization and should be considered a mainstay of combat casualty vascular care. Forward-deployed surgical assets play a pivotal role in providing early revascularization and reducing rates of limb loss in modern combat casualty care.