Fasciotomy in peripheral vascular surgery. Report of 164 patients

Outcomes After Selective Fasciotomy for Revascularization of Nontraumatic Acute Lower Limb Ischemia

Objectives: Limited data support the use of fasciotomies in acute limb ischemia (ALI) in patients with isolated arterial occlusion. This study describes an experience in which fasciotomies are not regularly performed post-revascularization. Methods: Using International Classification of Diseases, Ninth and Tenth Edition codes, patients presenting to the University of California Davis Medical Center between January 2003 and July 2018 with ALI, excluding those with traumatic injuries were identified. The primary outcome was major amputation, and the secondary outcome was foot drop. Additionally, the characteristics of those patients in each category of ischemic severity excluding those with grade 3 ischemia were summarized. Results: Of the 253 patients identified, revascularization was successful in 230 patients with 11 total fasciotomies performed. One hundred thirty-five patients were Rutherford Class 1/2A and 95 were 2B. In those with 1/2A ischemia, 134 (102 had >6 hours of symptoms) did not undergo fasciotomy with only one amputation occurring in this group. In those with 2B ischemia, 65 had >6 hours of symptoms; 58 did not undergo fasciotomy with 4 major amputations. In the 30 patients with ≤6 hours of ischemic symptoms, 27 did not undergo fasciotomy with 1 major amputation occurring in this group. There were no amputations in those patients who underwent fasciotomies. Additionally, there were 14 patients with a foot drop, of which 11 were in patients with 2B ischemia without fasciotomy. Conclusions: The data suggest that regardless of ischemic duration, 1/2A patients may not need fasciotomies, while those patients with 2B ischemia may benefit.

Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique

BACKGROUND

Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion.

METHODS

Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications.

RESULTS

Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting.

CONCLUSIONS

The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

Comparison of vacuum-assisted closure device and conservative treatment for fasciotomy wound healing in ischaemia-reperfusion syndrome: preliminary results

Ischaemia-reperfusion syndrome (IRS) is a condition that may require early fasciotomy. In the past, fasciotomies ultimately required prolonged hospitalisation. Vacuum-assisted closure (VAC) therapy system is an innovative method which promotes wound healing by reducing wound oedema, increasing microcirculation, and stimulation of granulation tissue. The aim of this retrospective study was to compare the VAC treatment with the conservative treatment of the fasciotomy wound until definitive surgical closure. The researchers retrospectively identified 15 patients, 3 females and 12 males, with a mean age of 69 years, who underwent a fasciotomy between January 2003 and December 2009 at the University Hospital of Geneva. All of the fasciotomies performed on the patients were on account of IRS. Seven patients were subjected to wound treatment using the VAC-system device and eight patients underwent treatment through the usual conservative method. The data were analysed by comparing the operative wound size, length of time for wound closure and duration of hospital stay in both groups. The number of days after fasciotomy until surgical wound closure in the VAC-system group (n = 7) ranged from 8 to 13 days with a mean of 11 days. The wound size at the day of closure was decreased in length by a mean of 58% (range 29-67%) and in diameter by a mean of 56% (range 33-75%). The duration of hospital stay for this group ranged from 12 to 18 days with a mean of 14 days. No signs of infections were observed and no re-operation was required after first closure. In the conservative group (n = 8), the time to wound closure ranged between 12 and 20 days with a mean of 15 days. The wound size was decreased in length by a mean of 40% (range 32-53%) and in diameter by a mean 46% (range 30-70%). The mean duration of hospital stay was 18·5 days. Three of the patients in the conservative treatment group manifested wound infection during the course of the treatment. VAC device could be a new standard for treatment of fasciotomy wound. VAC therapy is a recent innovation and becoming more and more a necessary complementary therapy to hasten wound healing. In our preliminary study, the VAC-system device showed significantly reduction of the wound size, decreased tissue oedema, duration of hospital days and improvement of granulation tissue.

Compartment syndrome in patients with massive venous thrombosis after inferior vena cava filter placement

Massive venous thrombosis, which can occur acutely after inferior vena cava filter placement, has 2 forms: phlegmasia cerulea dolens and phlegmasia alba dolens. In phlegmasia cerulea dolens, complete occlusion of venous outflow occurs. In the milder phlegmasia alba dolens version, collateral venous flow out of the limb remains despite the venous thrombosis. This article presents, to our knowledge, the first 2 cases of massive venous thrombosis (1 phlegmasia cerulea dolens, 1 phlegmasia alba dolens) below inferior vena cava filters occurring after the acute period. Phlegmasia cerulea dolens and phlegmasia alba dolens can present as compartment syndrome. Prompt fasciotomies were performed, but the underlying massive venous thrombosis was not addressed surgically. Phlegmasia cerulea dolens and phlegmasia alba dolens have high morbidity and mortality. The patient with phlegmasia alba dolens required leg and thigh fasciotomies and eventually required an above-knee amputation. The patient with phlegmasia cerulea dolens developed compartment syndrome in the left leg, right leg, and right thigh. Although he underwent decompression of all of these compartments, he died from multiple organ failure. A multidisciplinary approach with the vascular service and the intensivists is required in the treatment of patients with massive venous thrombosis. Treatment goals include preventing additional propagation of the thrombus via anticoagulation, with strong consideration for catheter-directed thrombolysis or thrombectomy and fasciotomies for compartment syndrome. The orthopedic surgeon should keep phlegmasia cerulea dolens and phlegmasia alba dolens in the differential for compartment syndrome, especially in patients who have had a history of acute or chronic inferior vena cava filter placement.

The use of an innovative device for wound closure after upper extremity fasciotomy

INTRODUCTION

The purpose of this paper is to evaluate the Silver Bullet Wound Closure Device (SBWCD, Boehringer Laboratories, Norristown, PA), a new device for delayed primary closure of fasciotomy wounds.

MATERIALS AND METHODS

A retrospective review was performed over a period of 36 months of all patients with an upper extremity fasciotomy that could not be closed primarily. Cases that underwent fasciotomy closure with the SBWCD were separated from the patients that had a split thickness skin graft (STSG).

RESULTS

Seven patients had their wound closed with the SBWCD within 10 days (mean of 7.4 days). The seven patients that underwent STSG had their wound closed in an average of 8.4 days. The average number of days between the day of the fasciotomy incision and the date of the placement of the SBWCD was 1.9 days. STSGs were placed on the fasciotomy wounds on an average of 10.3 days after the date of the fasciotomy incision. We found that the SBWCD allowed for starting to approximate the edges of the fasciotomy wound at an earlier time when compare to STSG (2.1 vs 10.3 days).

CONCLUSIONS

We feel that the SBWCD as a one-stage procedure provides a consistent and efficacious way to manage upper extremity fasciotomy wounds while minimizing the morbidity associated with STSG. Elimination of a second-stage procedure reduces hospital costs. Our findings may help to inform surgeons about an available alternative when an upper extremity fasciotomy wound is not amenable to primary closure.

Tibial compartment syndrome and the cavovarus foot

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

The Pathophysiology of Skeletal Muscle Ischemia and the Reperfusion Syndrome: A Review

There are two components to the reperfusion syndrome, which follows extremity ischemia. The local response, which follows reperfusion. consists of limb swelling with its potential for aggravating tissue injury and the systemic response, which results in multiple organ failure and death. It is apparent that skeletal muscle is the predominant tissue in the limb but also the tissue that is most vulnerable to ischemia. Physiological and anatomical studies show that irreversible muscle cell damage starts after 3 h of ischemia and is nearly complete at 6 h.

These muscle changes are paralleled by progressive microvascular damage. Microvascular changes appear to follow rather than precede skeletal muscle damage as the tolerance of capillaries to ischemia vary with the tissue being reperfused. The more severe the cellular damage the greater the microvascular changes and with death of tissue microvascular flow ceases within a few hours—the no reflow phenomenon. At this point tissue swelling ceases.

The inflammatory responses following reperfusion varies greatly. When muscle tissue death is uniform, as would follow tourniquet ischemia or limb replantation, little inflammatory response results. In most instances of reperfusion, which follows thrombotic or embolic occlusion, there will be a variable degree of ischemic damage in the zone where collateral blood flow is possible. The extent of this region will determine the magnitude of the inflammatory response, whether local or systemic. Only in this region will therapy be of any benefit, whether fasciotomy to prevent pressure occlusion of the microcirculation, or anticoagulation to prevent further microvascular thrombosis. Since many of the inflammatory mediators are generated by the act of clotting, anticoagulation will have additional benefit by decreasing the inflammatory response. In instances in which the process involves the bulk of the lower extremity, amputation rather than attempts at revascularization may be the most prudent course to prevent the toxic product in the ischemic limb from entering the systemic circulation.

Limb loss following lower extremity arterial trauma: what can be done proactively?

We performed a retrospective review of patients admitted to two Level I trauma centres over a 15-year period with arterial injuries (excluding primary amputations). Preoperative factors analysed included mechanism of injury, site and type of arterial and venous injury and repair, time to operating room, initial blood pressure, evidence of ipsilateral limb fracture and/or extensive tissue damage, status of preoperative pulses and angiographic data. One hundred and fifty-one arterial injuries were treated (80 penetrating). Overall mortality was 10 (6.6%) and limb loss 16 (10.6%). Only two factors that might possibly be modified by specific interventions were noted. The incidence of limb loss was higher in patients who developed compartment syndrome (41% versus 7% without, P=0.003) and in those who did not receive intra- or immediately postoperative anticoagulation (15% without versus 3% with, P=0.02). Unfortunately, no factor was found that reliably predicted the risk of compartment syndrome. In addition, patients who did not receive peri-operative anticoagulation were more severely injured than those that did were. Despite this, there were no bleeding complications associated with anticoagulation. These findings suggest that the primary interventions that may improve limb salvage include liberal use of fasciotomy (recognising that any patient may require this) as well as early use of anticoagulation.

The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?

OBJECTIVE

To assess whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings.

DATA SOURCES

A MEDLINE search of the English literature from 1966 to 2001 was performed using "compartment syndromes" as the subject. A manual search of the bibliographies of retrieved articles and of major orthopaedic texts was also performed.

STUDY SELECTION AND EXTRACTION

Of 1,932 titles identified, 433 abstracts of potential relevance were reviewed, and 104 articles from relevant abstracts were examined in their entirety. Four studies met all eligibility criteria. Criteria for inclusion included the following: (a) target population, traumatic or iatrogenic tibia injuries; (b) diagnostic test, presence of data needed to calculate both the sensitivity and specificity of clinical findings; (c) outcome, the presence or absence of compartment syndrome; and (d) methodologic criteria, prospective study design.

DATA SYNTHESIS

The likelihood ratio form of Bayes' theorem was used to assess the discriminatory ability of the clinical findings as tests for the compartment syndrome.

CONCLUSIONS

There are limited data from which to define the usefulness of clinical findings for the diagnosis of compartment syndrome. Data from eligible studies suggest that the sensitivity of clinical findings for diagnosing compartment syndrome is low (13% to 19%). The positive predictive value of the clinical findings was 11% to 15%, and the specificity and negative predictive value were each 97% to 98%. These findings suggest that the clinical features of compartment syndrome of the lower leg are more useful by their absence in excluding the diagnosis than they are when present in confirming the diagnosis. Likelihood ratio calculations found that the probability of compartment syndrome with one clinical finding was approximately 25%, and the probability was 93% with 3 clinical findings present. However, these findings are based on limited information; because of the paucity of data available, the predictive value of the clinical findings for the diagnosis of compartment syndrome has yet to be defined.

A simpler, less expensive technique for delayed primary closure of fasciotomies

A variety of techniques have recently been advanced for delayed primary closure of wounds following emergent fasciotomy for compartment syndrome. We introduce a very simple, effective method for gradual reapproximation of margins using daily reapplication of Steri-strips (3M Surgical Products, St. Paul, Minnesota). This method allows final closure of fasciotomy wounds with simple suture in 5-8 days without scar contractures, marginal necrosis, infection, or significant pain. Moreover, because it requires no specialized equipment and can be applied in skilled nursing centers or at home by trained nurses, this technique could reduce the cost of caring for fasciotomy patients.

Forearm compartment pressures: an in vitro analysis of open and endoscopic assisted fasciotomy

Pressure reduction for standard open fasciotomy and a novel endoscopic fascial release were compared in experimental conditions of elevated forearm compartment pressures by continuously monitoring intracompartmental pressures in 22 cadaver forearms. Both methods were effective in diminishing tissue pressures. Intracompartmental pressures were reduced to significantly lower levels following open versus endoscopic assisted fasciotomy (2.9 mm Hg vs. 13.2 mm Hg). In the endoscopic group a statistically significant second decrease in pressure was observed after dermatomy, reducing intracompartmental tissue pressures from 13.2 mm Hg to 3.1 mm Hg. The results of this study suggest that endoscopic assisted fasciotomy can reduce elevated tissue pressures, confirming previous findings that fascial release is of primary importance in decreasing intracompartmental tissue pressures. Open fasciotomy, however, gave significantly greater decompression than the endoscopic technique, a difference that may be even more substantial in the clinical setting due to several limiting factors of this in vitro model. Our results also suggest that immediate skin closure following fasciotomy increased tissue pressure and therefore should be avoided.

Incipient compartment syndrome of the thigh following total knee arthroplasty

Compartment syndrome of the thigh is in itself a rarity because of the large size of the compartment and the relatively high compliance of the thigh which allows accommodation to volume changes due to hematoma or tissue edema. Most cases have been reported in association with impact trauma to the lower extremity or in association with crush syndrome. A previously unrecognized complication of total knee arthroplasty where an incipient compartment syndrome developed in the thigh extensor compartment is reported.

Compartment syndrome and fasciotomy in vascular surgery. A review of 57 cases

OBJECTIVE

To investigate the occurrence of compartment syndrome and the results of fasciotomy in vascular surgical patients.

DESIGN

Retrospective study of case records from 1980-1994.

MATERIALS

Fifty-seven limbs in 53 patients had fasciotomies following surgical revascularisation. Fifty-three (93%) limbs were acutely ischaemic, while four (7%) had undergone elective vascular surgery. Forty-four (77%) limbs had signs of compartment syndrome, while 13 (23%) fasciotomies were prophylactic.

METHODS

The fasciotomies were done as subcutaneous procedures (n = 40), as double-incision fasciotomies (n = 11), or by an unknown method (n = 6). The skin incisions were closed primarily in 26 (46%) cases, delayed primarily in 11 (19%) cases, and by skin grafting in eight cases (14%).

RESULTS

Five (13%) subcutaneous fasciotomies required revision. Surgical debridement was required in four (7%) limbs. At discharge, 36 (68%) patients had kept their limbs, 11 (21%) patients were amputated, and six (11%) had died. No complications relating to the fasciotomies were observed.

CONCLUSIONS

Compartment syndrome is usually related to acute ischaemia and rarely following elective vascular surgery. Subcutaneous fasciotomy does not always ensure sufficient decompression of all four lower leg compartments. Complications related to fasciotomy are rare.

A simple device for closure of fasciotomy wounds

Early decompressive fasciotomy is essential in the prevention of the sequelae of compartment syndrome. Many techniques have been described for the closure of the fasciotomy wound, and controversy exists as to which method is the best. Primary closure is often impossible secondary to tissue retraction and edema. Split-thickness skin grafting leaves a thin, insensate, and often aesthetically unpleasing result. Gradual mechanical dermal apposition has been used with increasing frequency, and has been shown to be effective in the closure of fasciotomies, but often takes 7-10 days for closure. We present our experience with the STAR, a mechanical method of fasciotomy wound closure that is effective in 2-4 days, and is extremely simple to use.

Thigh ischemia complicating femoral vessel cannulation for cardiopulmonary bypass

Compartment syndrome of the lower leg is an occasional complication of prolonged ischemia and reperfusion. Compartment syndrome of the thigh is a less well-recognized complication. We present 2 patients with compartment syndrome of the ipsilateral thigh after femoral arterial and venous cannulation for cardiopulmonary bypass. Early diagnosis and urgent decompressive fasciotomy may limit the extent of local tissue damage and subsequent myonephropathic syndrome.

Compartment syndrome: a complication of acute extremity trauma

Compartment syndrome is a serious potential complication of trauma to the extremities. Fractures, crush injuries, burns, and arterial injuries, among others, can result in increased tissue pressure within closed osseofascial or compartmental spaces. Prolonged exposure to elevated pressure can result in nerve and muscle necrosis. Extreme pain unrelieved with analgesia, subjective complaint of pressure, pain with passive muscle stretching, paresis, paresthesia, and intact pulses, in the presence of a physically tight compartment, should alert the physician to the presence of a compartment syndrome. The diagnosis is a clinical one, but it may be aided by measurements of intracompartmental tissue pressures. Compartment syndrome is a surgical emergency requiring prompt treatment by fasciotomy. Time is a critical factor; the longer the duration of elevated tissue pressure, the greater the potential for disastrous sequelae. Emergency medicine providers must be cognizant of this clinical syndrome so that early emergent surgical consultation can be obtained to avoid complications.

Clinical results of decompressive dermotomy-fasciotomy

Seventy-three dermotomy-fasciotomies (DFs) were performed in 68 patients from 1986 to 1991. A database record was compiled on each patient. Variables included age, mode of injury, method of initial wound closure, and associated injuries. A multivariate stepwise logistic regression analysis was performed to determine which variables were associated with wound complications. Thirty-eight percent of patients who underwent DF developed wound complications. One hundred percent of those patients with postoperative arterial or graft thrombosis developed wound complications (p less than 0.01) as did 78% of those with thromboembolic disease (p less than 0.05). Conversely, only 5% of those who underwent closure of their DF wounds utilizing skin grafts developed wound complications (p less than 0.01) as compared with 51% of those who underwent secondary or primary closure only. Subsequent analysis of the remaining patients, excluding those with severe soft tissue injury, showed an association between location of DF (upper versus lower extremity) and the development of wound complications that approached statistical significance (p less than 0.06). DF is frequently necessary in the treatment of patients with compartment syndrome but is associated with significant morbidity. This study suggests that closure of DF wounds utilizing skin graft allows for continued osteofascial decompression while concomitantly minimizing invasive sepsis.

Fasciotomy after trauma to the extremities

Over a 9-year period, fasciotomy for presumed compartmental syndromes after trauma was performed in 25 upper extremities and 100 lower extremities in 122 patients. This procedure was most commonly indicated after vascular injuries in the lower extremities. Twenty percent of patients underwent fasciotomy before vascular repair. Nineteen percent of patients with vascular injuries in the lower extremities had fasciotomies performed at reoperation. Seventy-five percent of amputations in the lower extremities were related to a delay in performing fasciotomy or an incomplete fasciotomy. Upper-extremity fasciotomies most commonly did not decompress the deep component of the volar compartment, whereas lower extremity fasciotomies without fibulectomy most commonly decompressed all four below-knee compartments. Fasciotomy sites were closed by direct suture in more than half of the patients.

A new quantitative spectrophotometric assay of ischemia-reperfusion injury in skeletal muscle

Characterization of ischemia-reperfusion injury of skeletal muscle remains poorly defined. A new quantitative assay to measure ischemic skeletal muscle injury is described and validated in a rat hindlimb model. This biochemical spectrophotometric technique measures triphenyltetrazolium chloride reduction in ischemic muscle. The reduction assay demonstrated significant injury after 3 hours of ischemia (25.4 +/- 9.7 percent of control activity; p less than 0.05). More severe injury occurred after 4 or more hours (less than 3 percent of control activity; p less than 0.05). This assay is an objective and quantitative method for characterizing ischemia-reperfusion injury.

Acute volar compartment syndrome of the forearm secondary to fractures of the distal radius

We present five cases of acute volar compartment syndrome developing as a complication of fractures of the distal radius. The patients were all males under the age of 50 years who sustained comminuted or displaced fractures of the distal radius. We suggest that this indicates an 'at risk' group. The interval between injury and the onset of symptoms of volar compartment syndrome varied between 12 and 48 hours. The diagnosis of each case was made clinically and confirmed at operation. With early extensive decompression full neurovascular recovery can be expected.

Osteofascial compartment syndrome in the dog

Experimentally induced osteofascial compartment syndrome (OFCS) has been reported in the craniolateral compartment of the canine crus. In this study, anatomic dissections and contrast radiographs were used to describe three additional osteofascial compartments in canine limbs. Experimental OFCS was produced in four different compartments, and caused muscle and nerve pathology in each. When compartment pressures were evaluated in traumatized animals, moderate elevations in compartment pressures were found. A compartment syndrome that developed in one dog was surgically decompressed, returning elevated pressures to a safe level.

Hypertonicity of intestinal smooth muscle as a factor of intestinal ischemia in necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is thought to be secondary to mucosal ischemia. Because blood flow to the submucosal plexus is derived from vessels traversing three separate layers of visceral smooth muscle (longitudinal, circular, and muscularis mucosa), we investigated whether an increase in their tone might elicit mucosal ischemia. The intestinal intraluminal pressure (IIP) and the superior mesenteric artery (SMA) blood flow were evaluated in 23 dogs before and after either ligation of the SMA or neostigmine infusion into the SMA. Changes in vascularity were assessed by silicone rubber casting, India ink, or arteriography. Ten minutes after ligation of the SMA, there was a considerable increase in peristalsis, IIP, and inability to fill the intestinal microcirculation by the three methods described. Mucosal necrosis was present three hours later. In the neostigmine infusion group after a transient increase in mesenteric flow, the IIP rose 750%, while the mesenteric flow fell by 40%, mucosal necrosis occurred in one hour. When myotomy was performed on the antimesenteric border, mucosal necrosis was prevented. In a third group, neostigmine infused (femoral artery) in the hind limb demonstrated vasodilating effects. The data indicate that an increase in the myogenic tone and frequency of contraction of intestinal smooth muscle can produce mucosal ischemia, thus, intestinal hypertonicity may be an important factor in the pathogenesis of intestinal ischemia and possibly NEC. The effects of neostigmine in these experiments raise questions regarding its use during anesthesia in neonates with intestinal low flow states.

Management of arterial emboli. Gleanings from 20 years of experience

Arterial embolism is usually caused by cardiac disease, and atherosclerotic coronary vascular disease is the primary precursor. Other cardiac states, as well as several uncommon causes, are part of the etiologic spectrum. The earliest signs are pain, paresthesias, pallor, and pulselessness. Severe ischemia is indicated by paralysis, a late feature. Arterial embolism and acute thrombosis can be difficult to distinguish, and deep venous thrombosis may also be suspected in the differential diagnosis. To restore arterial flow, anticoagulation treatment with heparin (Lipo-Hepin, Liquaemin) is given and surgical embolectomy is performed. Heparin infusion is continued until the patient is ambulatory, and then warfarin sodium (Coumadin, Panwarfin) is given over the long term. Fibrinolysis has also been used to treat acute arterial occlusion. Complications of embolism must be carefully guarded against, and additional procedures are sometimes necessary.

A technique for the long term measurement of intra-compartmental pressure in the lower leg

The early diagnosis of an acute compartmental pressure syndrome is often difficult, but can be facilitated by long term, up to several days, measurement of intra-compartmental pressures. A measuring system has been developed, together with its associated surgical and operational procedures, which may be applied in a variety of situations, including an immobile patient or a patient mobilized following surgery. If the technique is adopted as soon as the patient enters hospital, or immediately postoperatively, an acute compartmental syndrome may be recognized early and measures taken to alleviate its consequences.

Management of compartmental syndrome. Diagnostic and surgical considerations

Compartmental syndrome is a condition in which swelling within a closed anatomic space increases the intracompartmental pressure to compromise the circulation and function of tissue within that space. Unless this condition is recognized early and treated by prompt surgical decompression, permanent neuromuscular deficits may result. In those instances in which early clinical evidence of this syndrome is difficult to assess, monitoring of intramuscular pressures may be valuable adjunct in the clinical evaluation of patients at risk for this syndrome. The association of compartmental syndrome with a wide variety of circumstances and the importance of an early diagnosis make it essential that all physicians be familiar with this condition. As physician awareness and recognition of this condition increase, the complications associated with it can be greatly reduced.

An exercise-induced compartment syndrome of the dorsal forearm--a case report

A 46-year-old male patient experienced extreme pain in the dorsal forearm after strenuous work. He had the classical physical findings of compartment syndrome and elevation of compartment pressure of 45 mm by direct measurement. A decompressive fasciotomy of the dorsal musculature provided total relief of pain, and subsequently full recovery of all function occurred.

The continuing challenge of popliteal vascular injuries

During a 6 year period, 35 patients with 56 popliteal vascular injuries were treated. Thirty-three arteries and 23 popliteal veins were affected. Fifty-four percent of the patients had both an arterial and a venous injury. Twenty injuries were due to penetrating trauma and 15 injuries to blunt force. An overall amputation rate of 16 percent followed attempts at vascular repair. Blunt injuries were associated with a 30 percent amputation rate, whereas penetrating injuries were associated with only a 5 percent amputation rate. When our results were reviewed and compared with those of others, several factors important for determining the rate of limb salvage in popliteal vascular injuries were noted: (1) early recognition and prompt treatment, (2) absence of blunt injury with attendant soft tissue damage; (3) resection of damaged arterial tissue with end-to-end anastomosis or saphenous vein grafting in conjunction with the liberal employment of local heparin and a Fogarty catheter thrombectomy, (4) repair of concomitant popliteal venous injuries; (5) use of completion arteriography to reveal technical errors amenable to correction at time of operation; and (6) fasciotomy, used liberally but selectively.

Intramuscular pressure after revascularization of the popliteal artery in severe ischaemia

Swelling is known to occur after peripheral revascularization. In this study of 14 patients undergoing revascularization of the popliteal artery for severe ischaemia, leg swelling and intramuscular pressure were recorded before and after operation. Calf circumference increased with a maximum swelling of 3.9 +/- 1.1 cm on postoperative day 6. There was a gradual increase in intramuscular pressure from 9 +/- 2 mmHg on the day before operation in the anterior tibial compartment to a maximum pressure on postoperative days 6-7 of 26 +/- 4 mmHg. Similar intramuscular pressure changes were seen in the superficial posterior compartment. These high intramuscular pressures may lead to a compartment syndrome and perhaps graft failure, which was actually observed in one case. Deep-vein thrombosis in the postoperative course may contribute to the high intramuscular pressures. Phlebography revealed a deep-vein thrombosis in 2 patients. In conclusion popliteal revascularization causes leg swelling and increased intramuscular pressure which may lead to a compartment syndrome and graft failure. Therefore follow-up of intramuscular pressure in patients with marked swelling after distal revascularization procedures and early fasciotomy may be considered on wide indications.

Arterial injuries in two Bristol hospitals from 1974 to 1980

Fifty-eight patients with 63 peripheral arterial injuries coming to the Bristol Royal Infirmary and Frenchay Hospital, Bristol over a six-year period from 1974-1980 were studied. The majority followed road traffic accidents, and over 70 per cent occurred in teenagers and young adults. Arterial reconstructions were undertaken in 51 cases (81 per cent) with concomitant fasciotomy in 3. Pulse volume recordings and on table arteriograms were used to detect and correct 2 reconstructions which were initially less than ideal. Forty-eight of 51 reconstructions were patent at follow up.

Devastating distal arterial trauma and continuous intraarterial infusion of tolazoline

Trauma due to motor vehicles accident and urban violence have made distal arterial reconstruction an increasingly important part of the surgeon's work. During the 20 month period from October 1980 to May 1982, 13 patients with below the knee and 2 patients with forearm trauma had nonviable extremities despite fastidious vascular and orthopedic reconstruction. A continuous intraarterial infusion of tolazoline into the femoral or brachial arteries restored vascular perfusion and viability in 13 of 15 patients (87 percent), with eventual limb salvage in 67 percent. Seven of 15 patients (47 percent) had transient systemic hypertension. There was no mortality. There exists in patients with these catastrophic injuries a local low-flow state due to a combination of distal arterial spasm and venous outflow obstruction. Tolazoline, a peripheral alpha-adrenergic blocking agent, increases blood flow, albeit nonnutritionally, and thus theoretically prevents thrombosis due to stasis in the repaired distal vessel. When limb loss seems inevitable, a trial of intraarterial tolazoline is justified.

Percutaneous transluminal angioplasty (PTA) as an adjunct in vascular trauma: case report

An iliac stenosis causing a pressure gradient of 70 mm Hg proximal to repair of a traumatically divided superficial femoral artery was relieved by percutaneous transluminal balloon angioplasty (PTA). Though the magnitude of the accompanying crush injury led to massive muscle necrosis and ultimately necessitated mid-thigh amputation, the arterial repair remained patent.

Tibial artery injuries

Twenty-eight consecutive patients with tibial or peroneal artery injury are reported. Of these, eight underwent direct arterial repair, eight received vein graft reconstruction, and the involved artery was ligated in the remainder, with amputation required for various reasons in four. Tibial or peroneal artery injury is a relatively common problem. Successful management requires an aggressive approach to early diagnosis, which in turn requires a high index of suspicion and arteriography. Early appropriate management will prevent the serious complications of ischemia, false aneurysm, arteriovenous fistula, and fascial compartment compression. The reconstruction of injured arteries of the lower leg is usually possible and should be accorded more attention than it has received in the past.

Management of vascular injuries to the leg

Our experience with 69 vascular injuries in 56 patients led us to modify the management of vascular injuries to the leg. We believe that prompt and complete angiography whenever the general condition of the patient allows it, early fasciotomy when indicated before vascular repair, thrombectomy of the injured artery and vein and local instillation of heparinized saline solution, vascular repair before orthopedic stabilization of fractures in selected cases, external fixation of the fracture when there is significant soft tissue injury, and early skin grafting resulted in an improved level of care with a low morbidity and no mortality in our series.

Management of vascular injuries of civil strife

Over a 12-year period of civil hostilities in Northern Ireland, the Vascular Unit of the Royal Victoria Hospital, Belfast, has dealt with a wide variety of vascular injuries inflicted by low- and high-velocity missiles and bomb explosions. 'Knee-cappings' or punishment shootings, accounted for a large proportion of popliteal vessel injuries. In addition to specific vascular injuries a majority of patients suffered damage to other regions of the body. Experience gained in the management of vascular injuries is outlined and surgical methods developed here are also discussed. The surgical approach to injuries of vessels in the neck, abdomen and lower limb receive particular emphasis.

Vascular trauma

Experience with vascular trauma over a nine month period is presented. Not all cases of arterial injury are obvious on initial presentation. Preoperative arteriography may be helpful but should not delay arterial reconstruction. Fractures should be established prior to arterial repair. Intra-operative arteriography may be useful, and fasciotomy should be used liberally in all cases of established ischaemia. Serious associated injuries are common and may determine the ultimate outcome.