Vascular Trauma Of Extremities Research Articles

An Experience of Surgical Management of Peripheral Vascular Injuries at Pakistan Institute of Medical Sciences, Islamabad

Background: Peripheral vascular trauma is fairly common and its repercussions lead to need for urgent management and multidisciplinary approach. We hereby evaluate the presentation, management and outcomes of peripheral vascular injuries presenting in a tertiary care hospital in Islamabad, Pakistan.
 Material and Methods: This was a prospective clinical study conducted in the Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS) Hospital, Islamabad Pakistan from January 2016 to June 2018. A total of 60 patients with vascular extremity trauma were included in the study. Initial assessment and resuscitation were done and patients with vascular injury were directly shifted to operating room for primary vascular repair (if defect size < 2 cm) or vein graft (great saphenous). Fractures and nerve injuries were also treated. Fasciotomies were performed where indicated. Post-operative monitoring of limb was done for palpable pulses, temperature and color changes. Collected data included age, gender, duration of injury, nature of injury, operative findings, other associated injuries, type of definitive repair, involvement of artery, complications including amputations, infections, re-exploration, ligation or death. Statistical Package for Social Sciences (SPSS) version 23 was used to analyze data.
 Results: Out of total 60 patients, 53 (88.3%) were males and 7 (11.7%) were females, with a mean age of 27.8±14.1 years. Most of the patients presented after 6 hours of trauma (n=36; 60%). Blunt trauma accounted for 37 (61.7%) while penetrating trauma was seen in 23 (38.3%) patients. Per operatively, 33 (55%) patients had intimal injury, 7 (11.7%) had partial tear and 20 (33.3%) had complete transection of artery. Primary repair was performed in 9 (15%) patients and reverse vein graft in 51 (85%) patients. Most commonly injured arteries were femoral (n=21; 35%), brachial (n=18; 30%) and popliteal (n=12; 20%) arteries, respectively. Amputations were significantly related to presentation of patients later than 6 hours (P=0.035).
 Conclusion: Patients who present with vascular trauma need an early diagnosis, referral and timely management in order to save both limb and life of patients with special concern for good quality of life and cost-effective management.

Operative Treatment and Clinical Outcomes in Peripheral Vascular Trauma: The Combined Experience of Two Centers in the Endovascular Era

Arterial traumas of the extremities are quite rare in civilian records; nevertheless, patients with trauma of limbs are admitted daily in emergency departments worldwide. The up-to-date information about epidemiology and treatment (open vs. endovascular surgery) comes from war records and it is not always easy getting data on mortality and morbidity in these patients. The aim of this study is to analyze the approach (open or endovascular) and the outcome of patients with vascular trauma of upper limbs (from the subclavian artery) and/or lower limbs (distal to the inguinal ligament), in the greater Milan area. A retrospective analysis was conducted on data recorded by the emergency departments of two hospitals of the greater Milan between 2009 and 2017. We collected all patients with arterial injuries of the limbs in terms of demography, injury patterns, clinical status at admission, therapy (open or endovascular approach), and outcomes in terms of limb salvage and survival. We studied 52 patients with vascular trauma of extremities. The main mechanism of trauma was road accident (48.1%), followed by criminal acts (32.7%), self-endangering behavior (13.5%), work (3.8%), and sport accidents (1.9%). Associated lesions (orthopedic, neurological, and/or venous lesions of the limbs) were present in 39 patients (75%). All patients underwent emergency surgery, forty-six patients (88.5%) by open repair (polytetrafluoroethylene or greater saphenous vein bypass grafts, arterial suture or ligation), whereas endovascular approach was used only in 6 patients (11.5%), all treated with embolization. The overall postoperative mortality rate was 5.7% (3 patients). Among survivors, we report 5 major amputations of the lower limbs, 3 of them after bypass graft infection, and 2 after graft failure. The rate of limb salvage was 90.4%. Isolated arterial trauma of the extremities are rare, usually they occur in the setting of multiple trauma patients. Despite progresses in surgical techniques, there are still controversies in diagnosis and treatment of these patients. We treated most cases with open surgery (n=46), choosing endovascular approach (embolization performed mainly by interventional radiologists) in difficult anatomic districts. We believe that, during decision-making of the surgical strategy, it is important to consider the anatomical site of lesions and the general condition of the patients. Moreover, in case of multiple trauma, we suggest a multidisciplinary approach to provide the best medical care to the victims.

To shunt or not to shunt in combined orthopedic and vascular extremity trauma.

There exists a long established but not validated practice of placing temporary intravascular shunts (TIVS) in cases of combined vascular and orthopedic extremity trauma. Though logical to prioritize blood flow, large-scale data to support this practice is lacking. We hypothesize that the order of repair yields no difference in outcomes in combined vascular and orthopedic extremity trauma and offer a larger-scale analysis than is previously available. A retrospective chart review was conducted at six Level I trauma centers from 2004 to 2015 comparing patients who received a TIVS during their initial surgery versus those who did not. Nonshunted patients were further divided into initial definitive vascular repair versus initial orthopedic fixation groups. Metrics were used to control for sampling bias while revision rate, amputation, hospital length of stay (HLOS), and development of thrombosis and compartment syndrome were used to assess outcomes. Of 291 total patients, 72 had TIVS placement, 97 had initial definitive vascular repair, and 122 had initial orthopedic fixation. The shunted group had a higher Abbreviated Injury Scale (3.0 vs. 2.8 p = 0.04) and Mangled Extremity Severity Score (6.1 vs. 5.7 p = 0.006) and a significantly lower rate of compartment syndrome (15% vs. 34% p = 0.002). Among patients who developed compartment syndrome, those who were shunted were younger (23 vs. 35 yrs, p = 0.03) and were more likely sustain a penetrating injury (p = 0.007). Those receiving initial orthopedic fixation had a longer HLOS (HLOS >15 days in 61% vs. 38%, p = 0.049) and a higher amputation rate (20% vs. 7%, p = 0.006) when compared with those undergoing initial definitive vascular repair. Lack of TIVS was associated with a significant increase in the development of compartment syndrome. Though it seems to have become common practice to proceed directly to vascular repair during the initial surgery, morbidity is improved with the placement of a TIVS. Therapeutic cohort, level III.