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Sciarretta JD, Macedo FIB, Otero CA, Figueroa JN, Pizano LR, Namias N. Management of traumatic popliteal vascular injuries in a level I trauma center: A 6-year experience. Int J Surg 2015; 18:136-41. [DOI: 10.1016/j.ijsu.2015.04.056] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 02/21/2015] [Accepted: 04/21/2015] [Indexed: 12/12/2022]
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Characteristics and clinical outcome in patients after popliteal artery injury. J Vasc Surg 2015; 61:1495-500. [DOI: 10.1016/j.jvs.2015.01.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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103
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Dua A, Desai SS, Ali F, Yang K, Lee C. Popliteal vein repair may not impact amputation rates in combined popliteal artery and vein injury. Vascular 2015; 24:166-70. [DOI: 10.1177/1708538115589251] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction This study aimed to determine the incidence, management, and outcomes of popliteal artery injury, popliteal vein injury, and concomitant popliteal artery injury and vein injury. Methods A retrospective analysis was completed using the 2000–2010 Nationwide Inpatient Sample utilizing International Classification of Diseases-9 codes to select patients with isolated popliteal artery injury (904.41), isolated popliteal vein injury (904.42), and isolated concomitant popliteal artery and vein injury (958.92). Variables included demographics, procedure type, and outcome during hospital course. Statistical analysis was with chi-square, Fisher exact test, and multivariate analysis. Results A total of 2216 patients presented with injury to the popliteal system; 71% (1568) presented with isolated popliteal artery injury, 14% (306) with isolated popliteal vein injury, and 15% (342) with concomitant popliteal artery and vein injury. Amputation was significantly increased in popliteal artery injury and concomitant popliteal artery and vein injury ( P < 0.001) as compared to popliteal vein injury. Ligation of the vein was more common in concomitant popliteal artery and vein injury when compared to popliteal vein injury ( P < 0.05). The rate of amputation was 9.8% for popliteal artery injury, significantly greater than for popliteal vein injury (0.7%, P < 0.001) but not different than for concomitant popliteal artery and vein injury (8.2%, P = NS). Conclusion Evidence-based management of popliteal vasculature may increase rates of limb salvage. Within the limitations of the data set used, conclusions appear to be that patients with popliteal vein injury or concomitant popliteal artery and vein injury may be managed with vein ligation without increased amputation rates as compared to popliteal artery injury.
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Affiliation(s)
- Anahita Dua
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sapan S Desai
- Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA
| | - Fadwa Ali
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kai Yang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cheong Lee
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Watson JDB, Houston R, Morrison JJ, Gifford SM, Rasmussen TE. A Retrospective Cohort Comparison of Expanded Polytetrafluorethylene to Autologous Vein for Vascular Reconstruction in Modern Combat Casualty Care. Ann Vasc Surg 2015; 29:822-9. [DOI: 10.1016/j.avsg.2014.12.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/11/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
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A Lower Extremity Musculoskeletal and Vascular Trauma Protocol in a Children's Hospital May Improve Treatment Response Times and Appropriate Microvascular Coverage. J Orthop Trauma 2015; 29:239-44. [PMID: 25272203 DOI: 10.1097/bot.0000000000000246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Pediatric lower extremity (LE) vascular injuries present many issues: microvascular surgeons are usually unavailable to stand-alone pediatric institutions, and the rate of morbidity including limb loss can be high if revascularization is delayed beyond the critical period of 8 hours. We assessed if time to revascularization was impacted by institution of a lower extremity vascular trauma protocol (LEVP). DESIGN Level II retrospective prognostic. SETTING Level I pediatric trauma center. PATIENTS/PARTICIPANTS Pediatric patients presenting with ischemic lower extremities requiring urgent management (2000-2013). INTERVENTION LEVP-a team of specialized microvascular surgeons, who have developed and manage a call schedule for our pediatric trauma center to offer care 24 h-1·d-1, 7 d-1·wk-1, and 365 d-1·y-1 to our children's hospital. MAIN OUTCOME MEASUREMENTS Treatment team expertise, time to revascularization, and use of time-delaying preoperative radiographic vascular studies performed before and after initiation of LEVP. RESULTS We identified 22 patients with ischemic LEs (16 patients treated before/6 patients treated after LEVP initiation). Mean time from admission to definitive vascular care was 6.4 hours preprotocol (20% > 8 hours)/4.6 hours postprotocol (0% > 8 hours). Before protocol initiation, 38% of LE vascular injuries were treated by LE microvascular repair-capable surgeons, and 37.5% had a preoperative radiographic vascular study compared with 100% and 0%, respectively, postprotocol initiation. Before protocol initiation, 37.5% had a preoperative radiographic vascular study compared with 0% after protocol initiation. CONCLUSIONS Since LEVP initiation, we have required no preoperative radiographic vascular studies, there has not been a revascularization delay of >8 hours, and with appropriate staff surgeon coverage, the flow of care has improved with the new ability to address and care for these challenging injuries. To potentially improve the timeliness of vascular care and better match the skills of the practitioner to the injury, pediatric centers should consider implementation of an LEVP within their institutions. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Secondary abdominal compartment syndrome after complicated traumatic lower extremity vascular injuries. Eur J Trauma Emerg Surg 2015; 42:207-11. [PMID: 26038042 DOI: 10.1007/s00068-015-0524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 03/22/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. METHODS From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. CONCLUSIONS The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.
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Yan H, Zhao B, Kolkin J, Li Z, Chen X, Chu T, Gao W. The management of lower extremity multilevel arterial injuries: a 10-year experience. PLoS One 2015; 10:e0121769. [PMID: 25793506 PMCID: PMC4368051 DOI: 10.1371/journal.pone.0121769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 02/05/2015] [Indexed: 11/18/2022] Open
Abstract
Background Limb amputation due to lower extremity arterial injury is not uncommon and multilevel arterial injury is even more limb-threatening and easily missed with potentially devastating consequences. There is limited information on multilevel arterial injuries. Purpose We undertook a review of our experience to gain insight on multilevel arterial injury patterns associated with lower extremity trauma and to analyze the results of management of such injuries with a special focus on the influence of initial diagnosis on limb salvage. Patients and Methods Between August 2002 and September 2012, 38 patients with lower extremity multilevel arterial injuries were reviewed, retrospectively. The injury patterns and amputation rates associated with initial diagnosis or misdiagnosis were analyzed. Results According to their injury levels, three multilevel arterial injury patterns were seen in this series: arterial injuries with the involvement of femoral artery and popliteal artery (pattern A), femoral artery and anterior or (and) posterior artery (pattern B), and popliteal artery and anterior or (and) posterior artery (pattern C). The general missed diagnosis rate was 31.6%. Pattern B had a much higher missed diagnosis rate than the other two patterns. The missed diagnosis rate was significantly correlated with the amputation rates (Odds Ratio =10.7, 95% CI: 2.04-56.61). The definite diagnosis rate was only 14.8% using duplex ultrasonography examination. Conclusions Diagnosis of pattern B injury is more prone to be missed. DUS has low specificity in the detection of multilevel arterial injuries. Aggressive intraoperative exploration is considered to be valuable in the definitive diagnosis of highly suspected cases when other diagnostic tools are unavailable.
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Affiliation(s)
- Hede Yan
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bin Zhao
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - John Kolkin
- Department of Plastic and Hand Surgery, Duke Raleigh Hospital, Raleigh, North Carolina, United States of America
| | - Zhijie Li
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinglong Chen
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tinggang Chu
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Weiyang Gao
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- * E-mail:
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Vielgut I, Gregori M, Holzer LA, Glehr M, Hashemi S, Platzer P. Limb salvage and functional outcomes among patients with traumatic popliteal artery injury: a review of 64 cases. Wien Klin Wochenschr 2015; 127:561-6. [DOI: 10.1007/s00508-015-0715-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/19/2015] [Indexed: 11/28/2022]
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Perkins ZB, Yet B, Glasgow S, Cole E, Marsh W, Brohi K, Rasmussen TE, Tai NRM. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015; 102:436-50. [DOI: 10.1002/bjs.9689] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/16/2014] [Accepted: 09/29/2014] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision-making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT.
Methods
A systematic review was conducted to identify potential prognostic factors. Bayesian meta-analysis was used to calculate an absolute (pooled proportion) and relative (pooled odds ratio, OR) measure of the amputation risk for each factor.
Results
Forty-five studies, totalling 3187 discrete LEVT repairs, were included. The overall amputation rate was 10·0 (95 per cent credible interval 7·4 to 13·1) per cent. Significant prognostic factors for secondary amputation included: associated major soft tissue injury (26 versus 8 per cent for no soft tissue injury; OR 5·80), compartment syndrome (28 versus 6 per cent; OR 5·11), multiple arterial injuries (18 versus 9 per cent; OR 4·85), duration of ischaemia exceeding 6 h (24 versus 5 per cent; OR 4·40), associated fracture (14 versus 2 per cent; OR 4·30), mechanism of injury (blast 19 per cent, blunt 16 per cent, penetrating 5 per cent), anatomical site of injury (iliac 18 per cent, popliteal 14 per cent, tibial 10 per cent, femoral 4 per cent), age over 55 years (16 versus 9 per cent; OR 3·03) and sex (men 7 per cent versus women 8 per cent; OR 0·64). Shock and nerve or venous injuries were not significant prognostic factors for secondary amputation.
Conclusion
A significant proportion of patients who undergo lower extremity vascular trauma repair will require secondary amputation. This meta-analysis describes significant prognostic factors needed to inform surgical judgement, risk assessment and patient counselling.
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Affiliation(s)
- Z B Perkins
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - B Yet
- Department of Computer Science, Queen Mary, University of London, London, UK
| | - S Glasgow
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - E Cole
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - W Marsh
- Department of Computer Science, Queen Mary, University of London, London, UK
| | - K Brohi
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - T E Rasmussen
- US Army Medical Research and Materiel Command, Fort Detrick, Maryland, USA
| | - N R M Tai
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Macedo FIB, Sciarretta JD, Salsamendi J, Karmacharya J, Romano A, Namias N. Repair of an Acute Blunt Popliteal Artery Trauma via Endovascular Approach. Ann Vasc Surg 2015; 29:366.e5-366.e10. [DOI: 10.1016/j.avsg.2014.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 09/26/2014] [Accepted: 10/04/2014] [Indexed: 12/14/2022]
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Dua A, Desai SS, Shah JO, Lasky RE, Charlton-Ouw KM, Azizzadeh A, Estrera AL, Safi HJ, Coogan SM. Outcome predictors of limb salvage in traumatic popliteal artery injury. Ann Vasc Surg 2014; 28:108-14. [PMID: 24332260 DOI: 10.1016/j.avsg.2013.06.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/08/2013] [Accepted: 06/16/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Significantly reduced amputation rates for traumatic popliteal artery injuries have been achieved with improved revascularization and resuscitative techniques. Predictive scores have failed to accurately predict outcomes in patients who sustain popliteal artery damage. This study aimed to identify predictors of limb salvage in a civilian cohort after popliteal artery trauma. METHODS A single-institution, retrospective review was performed of all patients with popliteal artery trauma presenting between January 2002 and June 2009. Data were compiled using the institutional trauma registry, with demographics, mechanism of injury, associated injury, fasciotomy, Mangled Extremity Severity Score (MESS), and Injury Severity Score (ISS) all documented. Statistical analysis included descriptive statistics, univariate analysis, and multiple exact logistic regression. RESULTS Seventy traumatic popliteal artery injuries were identified in 68 patients with a mean age of 33 years (range: 5-88 years). The majority of patients were male (n = 57; 81%), and 73% sustained blunt injury. Associated venous injury was present in 16 (23%) cases. Associated orthopedic injuries included 19 (27%) dislocations and 49 (70%) fractures. The median MESS was 5 (range: 2-9) and the median ISS was 9 (range: 4-41). Revascularization was performed in 62 cases (89%). Twenty-three percent of patients had compartment syndrome and 56% underwent fasciotomy. Fifteen (21%) patients required amputation, 11% of which were primary and 10% secondary. Variables associated with amputation included ISS >10 compared to ISS <9 (odds ratio [OR]: 7.4; P < 0.045), blunt injury (OR: 10.7; P = 0.009), MESS >7 (OR: 2.4; P < 0.0001), and fractures (OR: 0.13; P < 0.045). In a multiple exact logistic regression analysis, a MESS >7 (P < 0.05) was the only significant predictor of amputation. CONCLUSION Patients with traumatic popliteal artery injury are at high risk for amputation. Blunt injury, fractures, ISS >9, and MESS >7 were associated with an increased odds of amputation. Although in our data, MESS was the strongest predictor of amputation, we recognize that MESS was previously invalidated as a scoring system. New methods to determine limb viability in the mangled extremity are needed.
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Affiliation(s)
- Anahita Dua
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Sapan S Desai
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Jaecel O Shah
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Robert E Lasky
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Ali Azizzadeh
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
| | - Sheila M Coogan
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX.
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113
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Dua A, Patel B, Desai SS, Holcomb JB, Wade CE, Coogan S, Fox CJ. Comparison of military and civilian popliteal artery trauma outcomes. J Vasc Surg 2014; 59:1628-32. [DOI: 10.1016/j.jvs.2013.12.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 11/30/2022]
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Ratnayake A, Samarasinghe B, Bala M. Outcomes of popliteal vascular injuries at Sri Lankan war-front military hospital: case series of 44 cases. Injury 2014; 45:879-84. [PMID: 24462283 DOI: 10.1016/j.injury.2014.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 12/24/2013] [Accepted: 01/04/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Traumatic injury to the popliteal vascular zone remains a challenging problem on the modern battlefield and is frequently associated with more complications than other vascular injuries. Limb salvage and morbidity (graft infection, thrombosis and delayed haemorrhage) were studied. MATERIALS AND METHODS All popliteal vascular injuries over an 8 month period admitted to the Military Base Hospital were analyzed. Local limb evaluation included confirmation of the presence of ischaemia, extent of soft tissue damage, muscle viability after calf fasciotomy, and neurological injury. Ischaemic time was recorded from the time of injury to definitive revascularization. If there was a prior attempt at reconstruction, the amputation was considered delayed. RESULTS For a series of 44 patients with popliteal vascular injury average time to presentation was 390min, 46% were completely ischaemic. Of those 39 (89%) had popliteal artery injuries. There were 24 (62%) complete popliteal artery transections and associated venous (69%) and osseous (46%) injuries. The preferred technique of repair was inter-position venous graft (IPVG) (54%). Eleven immediate amputations were performed (28%). There were 13 wound infections (33%), 5 early graft thromboses (5 of 21 IPVG, 238%), 2 anastomotic disruptions (2 of 21 IPVG, 9%), which resulted in 4 delayed amputations. Mortality was 5% (2 patients). CONCLUSIONS In this case series of popliteal artery injury early identification of limbs at risk, early four compartment fasciotomy, temporary intra-luminal shunting, definitive repair of concomitant venous injuries and aggressive treatment of haemodynamic instability were shown to be beneficial in achieving reasonable outcome in an austere environment with limited recourses.
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Affiliation(s)
| | | | - Miklosh Bala
- Department of General Surgery and Trauma Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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115
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Reid JJ, Kremen TJ, Oppenheim WL. Death after closed adolescent knee injury and popliteal artery occlusion: a case report and clinical review. Sports Health 2014; 5:558-61. [PMID: 24427433 PMCID: PMC3806179 DOI: 10.1177/1941738113498068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A healthy adolescent male soccer player sustained a radiograph-negative, effusion-negative physeal injury of the proximal tibia from a ground-level fall with traumatic occlusion of the popliteal artery. Orthopaedic evaluation and arteriography were delayed for 72 hours after the injury. He arrived at a tertiary referral center in multisystem organ failure secondary to lower extremity ischemic necrosis, septic pulmonary thromboembolism, and systemic shock. Emergent medical evaluation, a high index of suspicion, and a careful neurovascular examination are imperative after every closed knee injury in the young athlete.
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Affiliation(s)
- Jeremy J Reid
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Thomas J Kremen
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - William L Oppenheim
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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116
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Vascular complications and special problems in vascular trauma. Eur J Trauma Emerg Surg 2013; 39:569-89. [DOI: 10.1007/s00068-013-0336-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/30/2013] [Indexed: 12/17/2022]
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118
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McKenna SM, Hamilton SW, Barker SL. Salter Harris Fractures of the Distal Femur. J Investig Med High Impact Case Rep 2013; 1:2324709613500238. [PMID: 26425580 PMCID: PMC4586811 DOI: 10.1177/2324709613500238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Salter Harris–type injuries of the distal femur should be treated as a dislocation of the knee and therefore as a medical emergency. Senior medical staff should be involved early, ankle–brachial index ratio should be measured in all patients and the clinician should have a high index of suspicion for a vascular injury. Ideally reduction, stabilization, and vascular repair, if necessary, should be carried out within 6 hours of the initial event. There should be a low threshold for fasciotomies. These 2 cases demonstrate the importance of having a high index of suspicion for vascular injury and the need for continued reassessment.
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119
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Lesión completa de vasos distales tras traumatismo por cuerpo extraño. ANGIOLOGIA 2013. [DOI: 10.1016/s0003-3170(13)70088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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120
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Worni M, Scarborough JE, Gandhi M, Pietrobon R, Shortell CK. Use of Endovascular Therapy for Peripheral Arterial Lesions: An Analysis of the National Trauma Data Bank From 2007 to 2009. Ann Vasc Surg 2013; 27:299-305. [DOI: 10.1016/j.avsg.2012.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 04/30/2012] [Accepted: 04/30/2012] [Indexed: 10/27/2022]
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Markov NP, DuBose JJ, Scott D, Propper BW, Clouse WD, Thompson B, Blackbourne LH, Rasmussen TE. Anatomic distribution and mortality of arterial injury in the wars in Afghanistan and Iraq with comparison to a civilian benchmark. J Vasc Surg 2012; 56:728-36. [DOI: 10.1016/j.jvs.2012.02.048] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 02/17/2012] [Accepted: 02/19/2012] [Indexed: 12/01/2022]
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Sciarretta JD, Perez-Alonso AJ, Ebler DJ, Mazzini FN, Petrone P, Asensio-Gonzalez JA. Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. Eur J Trauma Emerg Surg 2012; 38:373-91. [PMID: 26816119 DOI: 10.1007/s00068-012-0217-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 11/30/2022]
Abstract
The incidence of popliteal vessel injuries is low, even in busy urban trauma centers. As a result of this fact, few trauma centers and trauma surgeons have developed extensive experience in the management of these injuries. Popliteal vessel injuries in both civilian and military arenas incur significant morbidity. These injuries present a difficult challenge, and, although the overall incidence of these injuries remains low, the sequelae can be devastating. Successful outcomes for limb salvage and survival result from early recognition and rapid surgical intervention by a multidisciplinary approach with a great participation of different surgical specialties. From the historical perspective, anatomy, incidence and associated injuries, to the clinical presentation, diagnosis, management, and morbidity and mortality, the aim of this article is to review the various aspects of these complex injuries.
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Affiliation(s)
- J D Sciarretta
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A J Perez-Alonso
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - D J Ebler
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - P Petrone
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - Juan A Asensio-Gonzalez
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA. .,Westchester University Medical Center, New York Medical College, Trauma Department of Surgery, 100 Woods Road Taylor Pavilion, Suite E137, Valhalla, NY, 10595, USA.
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123
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De Santis F, Martini G, Haglmüller T, Mani G, Conati C, Bonatti G. Anticoagulation Therapy for Postoperative Deep Vein Thrombosis Coupled with Pulmonary Embolism: A Potential Trigger for Delayed Popliteal Artery Injury Presentation after Total Knee Arthroplasty. Phlebology 2012; 28:275-7. [PMID: 22865417 DOI: 10.1258/phleb.2012.012027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives: A case of delayed popliteal artery injury (PA-INJ) onset after total knee arthroplasty (TKA) in a patient under postoperative anticoagulation therapy is reported. The role of anticoagulation both in late PA-INJ presentation and in PA-INJ management is discussed. Report: An obese 76-year-old woman was presented with a common femoral vein thrombosis coupled with pulmonary embolism five days after TKA. She was immediately placed under anticoagulation therapy. Four days later, during physiotherapy-supervised mobilization, she developed a calf haematoma and large retro-articular pseudoaneurysm. Angiography revealed a minor PA-INJ successively treated with a covered stent-graft. Conclusions: In cases of initially undetected and staunched TKA-related PA-INJs, postoperative anticoagulation therapy may act as a potential trigger for final arterial rupture during mobilization exercises, followed by acute bleeding; in these cases, endovascular management represents an excellent treatment option. Close clinical and instrumental monitoring is strongly recommended after TKA, in patients who imperatively require full-dose anticoagulation therapy.
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Affiliation(s)
- F De Santis
- Department of Vascular Surgery, Bressanone Hospital, Bressanone
| | - G Martini
- Department of Vascular Surgery, Bressanone Hospital, Bressanone
| | - T Haglmüller
- Department of Radiology, Bolzano Hospital, Bolzano, Italy
| | - G Mani
- Department of Vascular Surgery, Bressanone Hospital, Bressanone
| | - C Conati
- Department of Vascular Surgery, Bressanone Hospital, Bressanone
| | - G Bonatti
- Department of Radiology, Bolzano Hospital, Bolzano, Italy
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124
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Bakia JM, Tordoir JHM, van Heurn LWE. Traumatic dissection and thrombosis of the popliteal artery in a child. J Pediatr Surg 2012; 47:1299-301. [PMID: 22703810 DOI: 10.1016/j.jpedsurg.2012.03.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/27/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
Injuries of the popliteal artery have the highest rate of limb loss compared with other peripheral vascular injuries. Particularly, blunt popliteal artery trauma is known to be associated with a high rate of amputation. Traumatic vascular injuries are usually associated with dislocations and fractures. We describe the radiographic findings as well as the delayed presentation and management of a crush injury of the left leg in an 8-year-old girl resulting in dissection of the popliteal artery without a dislocation or fracture.
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Affiliation(s)
- J-M Bakia
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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125
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Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg 2012; 214:756-68. [PMID: 22321521 PMCID: PMC3334459 DOI: 10.1016/j.jamcollsurg.2011.12.013] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/08/2011] [Accepted: 12/08/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. STUDY DESIGN A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. RESULTS Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. CONCLUSIONS There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.
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Affiliation(s)
- Adil H Haider
- Center for Surgery Trials and Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21212, USA.
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126
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Simmons JD, Duchesne JC, Ahmed N, Schmieg RE, Rushton FW, Porter JM, Mitchell ME. The weight of obesity in patients with lower extremity vascular injuries. Injury 2012; 43:582-4. [PMID: 20494351 DOI: 10.1016/j.injury.2010.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 03/29/2010] [Accepted: 04/26/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Clinical obesity is an epidemic problem in the United States. The impact of this disease upon traumatic lower extremity vascular injuries (LEVI) is as yet undefined. We hypothesized that clinical obesity adversely affects outcome in patients with traumatic LEVI. METHODS All adult patients admitted over a 5-year period with a traumatic LEVI were identified. Clinical obesity was defined as body mass index (BMI)>30. Obese and non-obese patient groups were compared for surgical management and outcome. RESULTS A total of 145 patients were identified. BMI data were available for 115 (79.3%) of these patients (obese n=47; non-obese n=68). Obese and non-obese groups were similar. Obese patients underwent more vascular repairs but the amputation rate and mortality were not significantly different. CONCLUSIONS While obese body habitus can increase the complexity of evaluation and management of patients with LEVI, we have demonstrated that equivalent outcomes to the non-obese population can be achieved for the clinically obese patient with a BMI>30. However, patients with a BMI>40 did reveal a significantly higher chance of amputation and death after LEVI. Due to the small number of patients in this subset, one should use caution when interpreting this data.
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Affiliation(s)
- Jon D Simmons
- Section of Trauma and Surgical Critical Care Surgery, The University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216, United States.
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127
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Stovall RT, Pieracci FM, Johnson JL. Perioperative Management of Peripheral Vascular Trauma. Semin Cardiothorac Vasc Anesth 2012; 16:133-41. [DOI: 10.1177/1089253212445929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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128
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Jupiter DC, Shibuya N, Clawson LD, Davis ML. Incidence and risk factors for amputation in foot and ankle trauma. J Foot Ankle Surg 2012; 51:317-22. [PMID: 22285499 DOI: 10.1053/j.jfas.2012.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Indexed: 02/03/2023]
Abstract
Mobility, especially in elderly patients, is often a proxy for overall health. It is thus of interest to understand the rates of lower extremity amputation and the risk factors for these procedures in the trauma population. We compared the rates of lower extremity amputation in low- versus high-level trauma by analyzing the National Trauma Data Bank. We also attempted to identify the risk factors in the low-level trauma population with foot and ankle trauma that predispose to lower extremity amputation. The factors associated with lower extremity amputation in foot and ankle trauma differed slightly from those in other multi-trauma patients. The factors associated with lower extremity amputation in the low-level foot and ankle trauma population that were statistically and clinically significant in this study included male gender, confounding injury, other trauma type versus blunt trauma, penetrating versus blunt trauma, occurrence of fracture, and occurrence of crush injury or wound. Understanding these risk factors will assist in educating patients and their family about their prognosis. Also, understanding these risk factors will assist surgeons with patient selection when considering salvage procedures.
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Affiliation(s)
- Daniel C Jupiter
- Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX, USA.
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129
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Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM. Imaging vascular trauma. Br J Surg 2011; 99:494-505. [DOI: 10.1002/bjs.7763] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2011] [Indexed: 01/06/2023]
Abstract
Abstract
Background
Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.
Methods
A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.
Results
Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.
Conclusion
Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.
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Affiliation(s)
- B O Patterson
- St George's Vascular Institute, St George's University of London, London, UK
| | - P J Holt
- St George's Vascular Institute, St George's University of London, London, UK
| | - M Cleanthis
- Imperial College Regional Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - N Tai
- Trauma Clinical Academic Unit, Barts and the London NHS Trust, London, UK
| | - T Carrell
- National Institute for Health Research Comprehensive Biomedical Research Centre of Guy's and St Thomas' NHS Foundation Trust and Department of Vascular Surgery, King's College London, London, UK
| | - T M Loosemore
- St George's Vascular Institute, St George's University of London, London, UK
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130
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Abstract
BACKGROUND The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes. METHODS Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0. RESULTS During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001). CONCLUSION Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.
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131
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Simmons JD, Gunter JW, Schmieg RE, Manley JD, Rushton FW, Porter JM, Mitchell ME. Popliteal Artery Injuries in an Urban Trauma Center with a Rural Catchment Area: Do Delays in Definitive Treatment Affect Amputation? Am Surg 2011. [DOI: 10.1177/000313481107701144] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 ( P < 0.01), and length of stay, 43 versus 15 days ( P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent ( P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.
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Affiliation(s)
- Jon D. Simmons
- Divisions of Trauma and Surgical Critical Care, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Joseph W. Gunter
- Department of Surgery, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert E. Schmieg
- Divisions of Trauma and Surgical Critical Care, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Justin D. Manley
- Department of Surgery, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Fred W. Rushton
- Divisions of Vascular Surgery, The University of Mississippi Medical Center, Jackson, Mississippi
| | - John M. Porter
- Divisions of Trauma and Surgical Critical Care, The University of Mississippi Medical Center, Jackson, Mississippi
| | - Marc E. Mitchell
- Divisions of Vascular Surgery, The University of Mississippi Medical Center, Jackson, Mississippi
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132
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García AF, Sánchez ÁI, Millán M, Carbonell JP, Ferrada R, Gutíerrez MI, Peitzman AB, Puyana JC. Limb amputation among patients with surgically treated popliteal arterial injury: analysis of 15 years of experience in an urban trauma center in Cali, Colombia. Eur J Trauma Emerg Surg 2011; 38:281-93. [DOI: 10.1007/s00068-011-0158-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 09/21/2011] [Indexed: 10/16/2022]
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133
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Tan TW, Joglar FL, Hamburg NM, Eberhardt RT, Shaw PM, Rybin D, Doros G, Farber A. Limb Outcome and Mortality in Lower and Upper Extremity Arterial Injury. Vasc Endovascular Surg 2011; 45:592-7. [DOI: 10.1177/1538574411415125] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To examine the outcomes of lower extremity (LE) and upper extremity (UE) arterial trauma. Methods: Retrospective review of 2008 version of National Trauma Databank. Adult patient with LE and UE arterial trauma was identified and outcomes were compared. Results: There were 8311 cases of extremity arterial trauma and 37% involved the LE. The LE cohort had higher blunt injury (56.2% vs 37.4%; P < .0001). The LE cohort was more likely to require fasciotomy (23.6% vs 6.7%; P < .0001) and amputation (7.8% vs 1.3%; P < .0001). Complication (18.8% vs 5.1%; P < .0001) and mortality rate (7.7% vs 2.2%, P < .0001) were higher in the LE cohort. Regardless of extremity, blunt trauma was associated with higher mortality (4.8% vs 3.8%; P = .03) and amputation (6.7% vs 1.3%; P < .0001). In multivariable analysis, LE arterial trauma was associated with increased mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9; P < .0001) and amputation (OR 4.3, 95% CI 3.2-5.8; P < .0001). Conclusions: Lower and upper extremity arterial injuries have different modes of presentation and outcomes. Lower extremity arterial trauma is more commonly caused by blunt injury and associated with worse outcomes despite more intensive intervention.
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Affiliation(s)
- Tze-Woei Tan
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Fernando L. Joglar
- Section of Vascular Surgery, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Naomi M. Hamburg
- Section of Cardiovascular Medicine, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Robert T. Eberhardt
- Section of Cardiovascular Medicine, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Palma M. Shaw
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Denis Rybin
- Department of Biostatistics, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
| | - Alik Farber
- Section of Vascular and Endovascular Surgery, Boston University Medical Center and Boston University School of Public Health, Boston, MA, USA
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134
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Abstract
Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence of obvious signs of vascular compromise, limb-threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.
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135
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Endovascular repair of iatrogenic popliteal artery trauma. Eur J Trauma Emerg Surg 2011; 38:617-22. [DOI: 10.1007/s00068-011-0124-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 05/21/2011] [Indexed: 11/25/2022]
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136
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Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg 2011; 53:1604-10. [DOI: 10.1016/j.jvs.2011.01.052] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/20/2011] [Accepted: 01/21/2011] [Indexed: 10/18/2022]
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137
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Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011; 53:1598-603. [DOI: 10.1016/j.jvs.2011.01.056] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 01/14/2011] [Accepted: 01/22/2011] [Indexed: 11/26/2022]
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138
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Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management. Vasc Health Risk Manag 2010; 6:1103-10. [PMID: 21191430 PMCID: PMC3004513 DOI: 10.2147/vhrm.s15316] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Limb loss following lower extremity arterial injury is not uncommon and has serious implications on the patient's life and functionality. This retrospective study was performed to analyze the results of lower extremity arterial injuries and to identify the risk factors associated with amputation. METHODS Between 2002 and 2009, retrospectively collected data on 140 patients with 173 lower extremity arterial injuries were analyzed. RESULTS There were 133 males (95%) and 7 females (5%). The mechanism of injuries was gunshot wounds in 56.4% of cases, stab wounds in 30%, and blunt trauma in 13.4%. Associated injuries included vein injury in 45% of cases, nerve injury in 16.4%, and bone fracture in 31.4%. The most frequently injured artery was superficial femoral artery (31.2%). More than 1 artery was injured in 18.6% of patients. Surgery was carried out, with a limb salvage rate of 90.4% and a survival of 97.1%. Amputation was performed in 75% of patients in whom only 1 artery was repaired, although all crural arteries were injured. Multivariate logistic regression analysis showed that significant risk factors of outcome were below-knee multiple arterial injuries (odds ratio [OR] 6.62, P < 0.001), associated 2-bone fractures (OR 2.71, P = 0.003), development of compartment syndrome (OR 1.94, P = 0.042), and great soft tissue disruption (OR 1.74, P = 0.010). CONCLUSIONS Limb loss may be decreased by performing prophylactic fasciotomy more often and by repairing at least 2 crural arteries.
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Affiliation(s)
- Aşkin Ender Topal
- Cardiovascular Surgery Department, Dicle University Medicine Faculty, Diyarbakir, Turkey.
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139
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Iatrogenic and Non-Iatrogenic Vascular Trauma in a District General Hospital: A 21-year Review. World J Surg 2010; 34:2363-7. [DOI: 10.1007/s00268-010-0647-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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140
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Ge PS, Ishaque BM, Bonilla J, de Virgilio C. Popliteal artery pseudoaneurysm after isolated hyperextension of the knee. Ann Vasc Surg 2010; 24:950.e7-950.e11. [PMID: 20471789 DOI: 10.1016/j.avsg.2010.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Accepted: 01/04/2010] [Indexed: 11/30/2022]
Abstract
We report an unusual case of a traumatic pseudoaneurysm of the popliteal artery after an isolated blunt hyperextension injury to the knee. A 56-year-old man presented with a 1-month history of left knee pain that occurred after a fall onto his buttocks with hyperextension of the knee while transferring a relative out of a wheelchair. A large pulsatile mass in the posterior aspect of the left knee was palpated on physical examination, although he had warm distal extremities and 2+ distal pulses bilaterally. Magnetic resonance angiography revealed a 7.6 × 6.2 × 4.9 cm left popliteral artery pseudoaneurysm, which was subsequently treated with aneurysm exclusion with end to end reverse saphenous vein graft bypass. The development of a popliteal artery pseudoaneurysm after blunt knee injury without dislocation, fracture, or ligament injury is extremely unusual, but requires prompt treatment to avoid the potential complications of permanent functional impairment and limb loss.
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Affiliation(s)
- Phillip S Ge
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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141
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Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K, Propper BW, Rasmussen TE. Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg 2010; 52:91-6. [PMID: 20471774 DOI: 10.1016/j.jvs.2010.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/25/2010] [Accepted: 02/07/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury. METHODS The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation. RESULTS Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P < .01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score >5 (hazard ratio [HR], 2.7; P = .01) and amputation. CONCLUSIONS This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.
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Affiliation(s)
- Gabriel E Burkhardt
- Department of Surgery, San Antonio Military Medical Consortium, Lackland Air Force Base, San Antonio, Texas 78236, USA
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Motorcycle-related injuries: effect of age on type and severity of injuries and mortality. ACTA ACUST UNITED AC 2010; 68:441-6. [PMID: 20154556 DOI: 10.1097/ta.0b013e3181cbf303] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the relationship of age to the injury types, distribution, and severity in motorcycle crash (MCC) victims admitted to Los Angeles County emergency hospitals in California. METHODS This Los Angeles countywide trauma registry study included all MCC victims admitted to the 13 trauma centers of the Los Angeles County between January 1995 and December 2007. Besides demographical data collected, the Injury Severity Score, body area (head, chest, abdomen, and extremities), Abbreviated Injury Scale score >or=3, specific organ injuries, and mortality were calculated according to age groups (<or=18 years, 19-55 years, and >55 years). A stepwise logistic regression model was used to identify independent risk factors for death. RESULTS Among 6,530 admissions due to MCCs, there were 493 patients (7.5%) aged 18 years or younger, 5,627 patients (86%) aged 19 years to 55 years, and 398 patients (6.5%) older than 55 years. The incidences of severe injury (Injury Severity Score >15) in the three ascending age groups were 23.5%, 30.3%, and 36.2%, respectively (p < 0.05), and critical injuries (Injury Severity Score >25) occurred in 6.5%, 12.3%, and 13.8%, respectively (p < 0.05). Severe head injuries were significantly more likely in the population older than 55 year (odds ratio [OR] {95% confidence interval [CI] } = 1.45 {1.03-2.03}, p = 0.04). The risk of sustaining a severe chest injury (Abbreviated Injury Scale Chest Score >or=3) increased in a stepwise fashion with increasing age, with an OR (95% CI) = 1.86 (1.44-2.39) in the age group 19 years to 55 years and 2.81 (2.03-3.88) in the older than 55 years group, p < 0.001. Mortality was twofold higher in the 19-year- to 55-year-old group [OR (95% CI) = 2.30 (1.08-4.93), p = 0.03] and threefold higher in the older than 55 years group [OR (95% CI) = 3.28 (1.36-7.93), p = 0.05] compared with the <or=18-year-old group. CONCLUSIONS Injuries related to MCCs show age-related injury distribution, severity, and mortality rates. Older patients are significantly more likely to suffer severe trauma, severe head and chest injuries, and spinal fractures. Adaptation of trauma team activation criteria and more aggressive triage of older victims of motorcycle trauma should be considered.
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143
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Traumatic limb amputations at a level I trauma center. Eur J Trauma Emerg Surg 2010; 37:67-72. [PMID: 26814753 DOI: 10.1007/s00068-010-0011-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Accepted: 01/02/2010] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of this study was to analyze the epidemiology and outcomes after traumatic amputation of the upper (UEA) and lower (LEA) extremities. METHODS The Los Angeles County + University of Southern California Medical Center trauma registry was utilized to identify all patients sustaining traumatic amputation during the years 1996-2007. The demographics, mechanism of injury, clinical characteristics, associated injuries, surgical procedures, complications, and outcomes were obtained for these patients. RESULTS During the 12-year study period, 130 patients suffered limb amputation, accounting for 0.25% of all trauma admissions. Thirteen patients (10%) were excluded because they were transferred from another facility after amputation or died in the emergency department. Of the remaining 117 patients, mean age was 38.1 ± 16.4 years and 77.8% were male. The predominant mechanism of injury was automobile versus pedestrian (27.4%), followed by work-related accidents (23.9%). Patients struck by vehicles were more likely to suffer LEA (93.8% versus 6.2%, p < 0.001), while patients with work-related accidents were more likely to sustain UEA (81.5% versus 18.5%, p < 0.001). Only nine patients underwent reattachment, all of which were for UEA and unsuccessful. Overall, 24.8% developed a complication during their hospital course, 55.2% of which were extremity related. Overall mortality was 3.4%, primarily attributed to associated severe traumatic brain injuries and thoracic injuries. Patients with LEA had longer hospital and intensive care unit (ICU) length of stay; however, after adjusting for confounders, this difference did not reach statistical significance (adjusted mean difference: 2.1 and 1.2 days, p = 0.69 and 0.79, respectively). A higher percentage of patients with LEA required discharge to a skilled nursing facility or rehabilitation center when compared with patients with UEA (29.6% versus 4.8%, p = 0.001). CONCLUSIONS Traumatic limb amputation is a rare consequence of civilian trauma. Amputation is rarely the primary cause of death; however, these devastating injuries are associated with significant intensive care unit and hospital lengths of stay. Although no mortality difference was detected, when compared with patients with upper extremity amputations, patients with lower extremity amputations were more severely injured, required revision extremity surgery more often, had a higher complication rate, and more frequently required discharge to a long-term facility.
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Aidinian G, Fox CJ, Rasmussen TE, Gillespie DL. Varied presentations of missile emboli in military combat. J Vasc Surg 2009; 51:214-7. [PMID: 19703749 DOI: 10.1016/j.jvs.2009.06.054] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 06/22/2009] [Accepted: 06/22/2009] [Indexed: 10/20/2022]
Abstract
Fragment embolization is a rare phenomenon in trauma patients. Although surgical and endovascular management of vascular injuries have evolved significantly, the detection and management of fragment emboli remain a formidable challenge. We reviewed our experience with this entity from December 2001 to March 2008. During this time period, four (1.1%) of 346 US soldiers evacuated to Walter Reed with arterial or venous injuries were discovered to have suffered missile emboli. Venous emboli were treated with anticoagulation and arterial emboli were treated with standard embolectomy techniques with good result. The presentation, diagnosis, and surgical management of these cases are described.
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Affiliation(s)
- Gilbert Aidinian
- Department of Surgery, Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington, DC, USA.
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Impact of Intraoperative Arteriography on Limb Salvage for Traumatic Popliteal Artery Injury. ACTA ACUST UNITED AC 2009; 67:252-7; discussion 257-8. [DOI: 10.1097/ta.0b013e31819ea796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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146
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Glass G, Pearse M, Nanchahal J. Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm. J Plast Reconstr Aesthet Surg 2009; 62:571-9. [DOI: 10.1016/j.bjps.2008.11.117] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Revised: 11/23/2008] [Accepted: 11/27/2008] [Indexed: 01/29/2023]
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Talving P, DuBose J, Barmparas G, Inaba K, Demetriades D. Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents. Eur J Trauma Emerg Surg 2009; 35:225-39. [PMID: 26814899 DOI: 10.1007/s00068-008-8153-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 12/08/2008] [Indexed: 12/19/2022]
Abstract
Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.
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Affiliation(s)
- Peep Talving
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, 1200 North State Street, Room 9900, Los Angeles, CA, 90033, USA.
| | | | | | | | - Demetrios Demetriades
- Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, Los Angeles, USA
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Franz RW, Jump MA. Endovascular repair of post-traumatic, concomitant popliteal artery pseudoaneurysm and arteriovenous fistula. Int J Angiol 2009; 18:41-4. [PMID: 22477476 PMCID: PMC2726564 DOI: 10.1055/s-0031-1278322] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Popliteal artery trauma is a potentially devastating injury to the lower extremity with substantial associated morbidity. Pseudoaneurysm and arteriovenous fistula formation are complications of arterial injury that often present in a delayed fashion. Although these have traditionally been repaired using an open procedure, the growth of minimally invasive techniques has provided new therapeutic options for the treatment of such lesions. The present report discusses the successful treatment of concomitant popliteal pseudoaneurysm and arteriovenous fistula after delayed presentation by placing covered stents endovascularly.
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Affiliation(s)
- Randall W Franz
- Vascular and Vein Center, Grant Medical Center, Columbus, Ohio, USA
| | - Mark A Jump
- Vascular and Vein Center, Grant Medical Center, Columbus, Ohio, USA
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A decade's experience with temporary intravascular shunts at a civilian level I trauma center. ACTA ACUST UNITED AC 2008; 65:316-24; discussion 324-6. [PMID: 18695465 DOI: 10.1097/ta.0b013e31817e5132] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A 10-year review of temporary intravascular shunts (TIVS) at a regional trauma center. METHODS Retrospective chart review of all patients treated with temporary intravascular shunts from January 1, 1997 to January 1, 2007. RESULTS Seven hundred eighty-six patients were treated for vascular injuries. Sixty-seven (9%) had a total of 101 (72 arterial, 29 venous) TIVS placed to facilitate damage control or to allow for reconstruction of Gustilo IIIc fractures or limb replantation. Seven patients who, on trauma day 0, died or had an extremity which was deemed unsalvageable were excluded. Of 60 patients who met inclusion criteria, seven died from TBI (3%), MOF (3%), sepsis (2%), deceleration of care (2%), and loss of airway (2%), which was deemed preventable. CONCLUSIONS TIVS have a shunt thrombosis rate of 5%, amputation rate of 18%, overall survival of 88%, and combination limb/patient survival rate of 73%. TIVS have an established role primarily in patients requiring either "damage control" for exsanguination or temporary vascular conduits during stabilization of Gustilo IIIc fractures. Truncal injuries are associated with the highest mortality likely due to accompanying multisystem trauma.
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