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Kim S, Schneider A, Raulli S, Ruiz C, Marston W, McGinigle KL, Wood J, Parodi FE, Farber MA, Pascarella L. Current outcomes following upper and lower extremity arterial trauma from the National Trauma Data Bank. J Vasc Surg 2024; 80:365-372.e1. [PMID: 38570174 DOI: 10.1016/j.jvs.2024.03.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The modern treatments of trauma have changed in recent years. We aim to evaluate the factors associated with limb salvage and mortality after extremity arterial trauma, especially with respect to the type of conduit used in revascularization. METHODS The National Trauma Data Bank was queried to identify patients with upper and lower extremity (UE and LE) arterial injuries between 2016 and 2020. The patients were stratified by the types of arterial repair. The primary outcome was in-hospital mortality. RESULTS 8780 patients were found with 5054 (58%) UE and 3726 (42%) LE injuries. Eighty-three percent were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UEs and LEs (73% and 67%, respectively) with a mean injury severity score of 14 ± 8. For UEs, the majority underwent primary repair (67%, P < .001), whereas the remainder received either a bypass (20%) or interposition graft (12%). However, LEs were more likely to receive a bypass (52%, P < .00001) than primary repair or interposition graft (34% and 14%, respectively). Compared with the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, P < .001) and death (6%, P < .001). Notably, compared with primary repair, the use of a prosthetic conduit was associated with a 6.7-fold increase in the risk of amputation in UE and a 2.4-fold increase in LE (P < .0001 for both). Synthetic bypasses were associated with a nearly 3-fold increase in return to the operating room (OR) in UE bypasses (P < .05) and a 2.4-fold increase in return to the OR in LE bypasses (P < .0001). CONCLUSIONS In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, LE injuries more often led to amputation and mortality than UE injuries. The most frequently used bypass conduit was vein, which was associated with less risk of unplanned return to the OR and limb loss, corroborating current practice guidelines for extremity arterial trauma.
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Affiliation(s)
- Sooyeon Kim
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Andrew Schneider
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Stephen Raulli
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Colby Ruiz
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - William Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Katharine L McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jacob Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - F Ezequiel Parodi
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
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Falcon AK, Caballero LM, Filiberto DM, Lenart EK, Easterday TS, Bhatt MN, Mitchell EL, Byerly S. Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis. Am Surg 2024; 90:1879-1885. [PMID: 38527489 DOI: 10.1177/00031348241241645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
BACKGROUND Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.
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Affiliation(s)
- Allison K Falcon
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Ladd M Caballero
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Dina M Filiberto
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Emily K Lenart
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Thomas S Easterday
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Maunil N Bhatt
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Erica L Mitchell
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Saskya Byerly
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
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Lagazzi E, Teodorescu DL, Argandykov D, Samotowka MA, King DR. Moving toward point-of-care surgery in Ukraine: testing an ultra-portable operating room in an active war zone. Eur J Trauma Emerg Surg 2024; 50:857-866. [PMID: 38175279 DOI: 10.1007/s00068-023-02410-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/19/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE In conflict zones, providers may have to decide between delaying time-sensitive surgeries or performing operative interventions in the field, potentially subjecting patients to significant infection risks. We conducted a single-arm crossover study to assess the feasibility of using an ultraportable operating room (U-OR) for surgical procedures on a porcine cadaver abdominal traumatic injury model in an active war zone. METHODS We enrolled participants from an ASSET-type course designed to train Ukrainian surgeons before deployment to active conflict zones. They performed three standardized consecutive abdominal surgical procedures (liver, kidney, and small bowel injury repair) with and without the U-OR. Primary outcomes included surgical procedure completion rate, procedure time, and airborne particle count at the start of surgery. Secondary survey-based outcomes assessed surgery task load index (SURG-TLX) and perceived operative factors. RESULTS Fourteen surgeons performed 76 surgical procedures (38 with the U-OR, 38 without the U-OR). The completion rate for each surgical procedure was 100% in both groups. While the procedure time for the liver injury repair did not differ significantly between the two groups, the use of the U-OR was associated with a longer time for kidney (155 vs. 56 s, p = 0.002), and small bowel (220 vs. 103 s, p = 0.004) injury repair. The average airborne particle count within the U-OR was substantially lower compared to outside the U-OR (6,753,852 vs. 232,282 n/m3, p < 0.001). There was no statistically significant difference in SURG-TLX for procedures performed with and without the U-OR. CONCLUSION The use of the U-OR did not affect the procedure completion rate or SURG-TLX. However, there was a marked difference in airborne particle counts between inside and outside the U-OR during surgery. These preliminary findings indicate the potential feasibility of using a U-OR to perform abdominal damage-control surgical procedures in austere settings.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
- Department of Surgery, Humanitas Research Hospital, Rozzano, MI, Italy
| | - Debbie Lin Teodorescu
- SurgiBox Inc., Cambridge, MA, USA
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | | | - David Richard King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
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Kontopodis N, Tosounidis T, Kehagias E, Kouraki A, Tzirakis K, Ioannou CV. Concomitant vascular and orthopedic trauma: 10 points to consider. J Clin Orthop Trauma 2024; 51:102407. [PMID: 38681997 PMCID: PMC11053217 DOI: 10.1016/j.jcot.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
Although vascular injuries complicate only 1-2% of patients with orthopedic trauma, they may be encountered in a much higher rate of around 10 % in injuries around the knee and elbow joints following both fractures and dislocations. In case of vascular involvement, specific diagnostic and therapeutic challenges arise and there is a higher risk for significant morbidity (i.e. limb loss) or mortality. In the absence of randomized data, diagnostic and therapeutic algorithms are not always straightforward and clinical practice may be based on experience and local protocols rather than firm evidence. With this article we intend to review available literature regarding concomitant skeletal and vascular trauma in order to provide concise information and clear guidelines of when to operate with least investigations and when to go for a full spectrum of investigations in the absence of hard clinical signs. Additionally, other aspects concerning the manipulation of these patients are discussed, such as the indications of primary amputation, the potential role of endovascular techniques and the value of the Resuscitative Endovascular Balloon Occlusion of the Aorta. In summary, this scoping review summarizes current practices in the diagnostic and therapeutic management of patients with concomitant orthopedic and vascular injuries, discusses different treatment strategies and gives a practical perspective for implementation on every day practice.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Theodoros Tosounidis
- Orthopedic Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, University of Crete-Medical School, Heraklion, Crete, Greece
| | | | - Konstantinos Tzirakis
- Department of Mechanical Engineering, Hellenic Mediterranean University, Heraklion, Crete, Greece
| | - Christos V. Ioannou
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
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Izawa Y, Futamura K, Murakami H, Sato K, Tsuchida Y. Efficacy of Orthoplastic Management in the Treatment of Traumatic Popliteal Artery Injury. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5696. [PMID: 38528846 PMCID: PMC10962880 DOI: 10.1097/gox.0000000000005696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/06/2024] [Indexed: 03/27/2024]
Abstract
Background Popliteal artery injury (PAI) is a challenging condition. Even with appropriate initial treatment and reconstruction of the associated injuries, extensive soft-tissue necrosis may occur, requiring lower leg amputation. There are no reports on the effectiveness of orthoplastic surgery in treating traumatic PAI. However, orthoplastic surgery is also considered very effective in PAI treatment, which requires delicate handling of soft-tissue and blood vessels. This study aimed to examine the treatment outcomes of traumatic PAI at a trauma center with the capacity for orthoplastic management. Methods Patients with PAI who were treated at our institution between August 2013 and December 2021 were included in this study. The surgeons included multiple orthoplastic surgeons with capabilities in vascular repair, bone and ligament reconstruction, and soft-tissue reconstruction. Patient demographics, injury characteristics, degree of ischemia, and treatment were investigated. We also investigated whether soft-tissue reconstruction and lower limb amputation were necessary as outcomes of treatment. Results Fifteen limbs of 14 patients with PAI met the inclusion criteria. Extensive soft-tissue necrosis was observed in three limbs. Two of these limbs were covered with a free latissimus dorsi flap and could be salvaged. In the remaining limb, lower limb amputation was unavoidable because of unexplained cardiac arrest during the initial surgery, but a fillet flap was used to successfully preserve the knee joint. Conclusion Orthoplastic management has the potential to improve limb salvage rates and provide good outcomes for the treatment of traumatic PAI.
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Affiliation(s)
- Yuta Izawa
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Hiroko Murakami
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Kazuo Sato
- From the Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
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Izawa Y, Futamura K, Murakami H, Shirakawa T, Nishida M, Suzuki T, Tsuchida Y. Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury. Ann Vasc Surg 2024; 99:305-311. [PMID: 37858669 DOI: 10.1016/j.avsg.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the case series of traumatic PAI treated using CLS and verify the usefulness of CLS. METHODS All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on the Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. RESULTS We used CLS as treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and 4 with grade 3. Amputation of the lower extremities was avoided except for 1 extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CONCLUSIONS CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.
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Affiliation(s)
- Yuta Izawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan.
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Hiroko Murakami
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Tetsuya Shirakawa
- Department of Orthopaedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Masahiro Nishida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Takafumi Suzuki
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
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Croman M, Lamberton T, Covington A, Keeley JA. Outcomes Following Below Knee Arterial Trauma. Am Surg 2023; 89:4045-4049. [PMID: 37177882 DOI: 10.1177/00031348231175502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Lower extremity vascular injuries have significant implications for trauma patients with regards to morbidity from limb loss. There is limited evidence on outcomes for patients with injuries to tibial arteries. Our study focuses on defining outcomes of traumatic vascular injury to vessels below the knee. METHODS A retrospective review using ICD-9 and 10 codes of all patients with below knee vascular injuries was performed at a Level 1 trauma center from November 2014 to June 2022. Interventions, outcomes, and complications were assessed. RESULTS Seventy-six patients were identified fitting inclusion criteria. The mean age was 35.3 +/- 15.2 years and 67 (88%) patients were male. Thirty-nine suffered penetrating trauma, 37 suffered blunt trauma. The most injured artery was posterior tibial artery (40%) followed by anterior tibial artery (36%). Injuries included 51 transections, 22 occlusions and 4 pseudoaneurysms. Forty-five (59%) patients underwent operative intervention. Thirty (67%) operations were performed by trauma surgery. Arterial ligation was performed in 30 cases (67%), arterial bypass in 12 (27%), and 2 (4%) primary amputations. Vascular surgery performed all bypasses. Overall amputation rate was 8% (n = 6) with 3 for mangled extremity and 3 due to failed bypass graft. All amputations were associated with open fracture and amputations for failed bypass had multiple arterial injuries. CONCLUSION The management of below knee vascular trauma requires a multidisciplinary approach. Patients requiring reconstruction are more likely to have multiple vessel injuries and may have significant risk of graft failure. These patients as well as those with extensive soft tissue injury and/or multi-vessel injuries are at increased risk for amputation.
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Affiliation(s)
- Millicent Croman
- Harbor-UCLA Medical Center, Department of Surgery, Torrance, CA, USA
| | - Tessa Lamberton
- Harbor-UCLA Medical Center, Department of Surgery, Torrance, CA, USA
| | - Audrey Covington
- Harbor-UCLA Medical Center, Department of Surgery, Torrance, CA, USA
| | - Jessica A Keeley
- Harbor-UCLA Medical Center, Department of Surgery, Torrance, CA, USA
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Harutyunyan M, Hnath JC, Jacobson X, Le J, Shah MD, Kleene J, Darling RC. Trauma bypass performed by vascular surgeons demonstrate excellent long-term outcomes and limb preservation. J Vasc Surg 2023; 78:779-787. [PMID: 37330703 DOI: 10.1016/j.jvs.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Long-term outcomes in civilian trauma patients requiring upper or lower extremity revascularization is poorly studied secondary to limitations of certain large databases and the nature of the patients in this specific vascular subset. This study reports on the experience and outcomes of a Level 1 trauma center that serves both an urban and a large rural population over a 20-year period to identify bypass outcomes and surveillance protocols. METHODS Database of a single vascular group at an academic center was queried for trauma patients requiring upper or lower extremity revascularization between January 1, 2002, and June 30, 2022. Patient demographics, indications, operative details, operative mortality, 30-day nonoperative morbidity, revisions, subsequent major amputations, and follow-up data were analyzed. RESULTS A total of 223 revascularizations were performed, 161 (72%) lower and 62 (28%) upper extremities. One hundred sixty-seven patients (74.9%) were male, with a mean age of 39 years (range, 3-89 years). Comorbidities included hypertension (n = 34; 15.3%), diabetes (n = 6; 2.7%), and tobacco use (n = 40; 17.9%). Mean follow-up time was 23 months (range, 1-234 months), with 90 patients (40.4%) lost to follow-up. Mechanisms included blunt trauma (n = 106; 47.5%), penetrating trauma (n = 83; 37.2%), and operative trauma (n = 34; 15.3%). Bypass conduit was reversed vein (n= 171; 76.7%), prosthetic (n = 34; 15.2%), and orthograde vein (n = 11; 4.9%). Bypass inflow artery was superficial femoral (n = 66; 41.0%), above-knee popliteal (n = 28; 17.4%), and common femoral (n = 20; 12.4%) in the lower extremity, and brachial (n = 41; 66.1%), axillary (n = 10; 16.1%), and radial (n = 6; 9.7%) in the upper extremity. Lower extremity outflow artery was posterior tibial (n = 47; 29.2%), below-knee popliteal (n = 41; 25.5%), superficial femoral (n = 16; 9.9%), dorsalis pedis (n = 10; 6.2%), common femoral (n = 9; 5.6%), and above-knee popliteal (n = 10; 6.2%). Upper extremity outflow artery was brachial (n = 34; 54.8%), radial (n = 13; 21.0%), and ulnar (n = 13; 21.0%). Total operative mortality was nine patients (4.0%), all involving lower extremity revascularization. Thirty-day non-fatal complications included immediate bypass occlusion (n = 11; 4.9%), wound infection (n = 8; 3.6%), graft infection (n = 4; 1.8%), and lymphocele/seroma (n = 7; 3.1%). All major amputations (n = 13; 5.8%) were early and in the lower extremity bypass group. Late revisions in the lower and upper extremity groups were 14 (8.7%) and four (6.4%), respectively. CONCLUSIONS Revascularization for extremity trauma can be performed with excellent limb salvage rates and has demonstrated long-term durability with low limb loss and bypass revision rates. The poor compliance with long-term surveillance is concerning and may require adjustment in patient retention protocols; however, emergent returns for bypass failure are extremely low in our experience.
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Affiliation(s)
- Misak Harutyunyan
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Jeffrey C Hnath
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Xander Jacobson
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Jeremy Le
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Melissa D Shah
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - Julia Kleene
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY
| | - R Clement Darling
- Division of Vascular Surgery, Department of Surgery, Albany Medical Center Hospital, Albany, NY.
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Qiu C, Cheng L, Wang L, Li Z, Liu X. Therapeutic management and amputation options in a long time delayed blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1811-1819. [PMID: 36847787 DOI: 10.1007/s00068-023-02236-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors. METHODS From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared. RESULTS A total of 55 patients with a median age of 41.4 years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6 h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56 months (range 12-132), no death, another limb loss, or claudication was found in all patients. CONCLUSIONS Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.
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Affiliation(s)
- Cheng Qiu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Lin Cheng
- Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Lianlei Wang
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China
| | - Zhenfeng Li
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China.
| | - Xinyu Liu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China.
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Stafforini NA, Singh N. Management of Vascular Injuries in Penetrating Trauma. Surg Clin North Am 2023; 103:801-825. [PMID: 37455038 DOI: 10.1016/j.suc.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).
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Affiliation(s)
- Nicolas A Stafforini
- Division of Vascular Surgery, Department of Surgery, University of Washington, 325 9th Avenue, Box 359908, Seattle, WA 98104, USA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, 325 9th Avenue, Box 359908, Seattle, WA 98104, USA.
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11
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Jha RK, Jayaram PV, Shankaran R, Pillai HJ. Salvage of a severely mangled limb following traumatic injury. BMJ Case Rep 2023; 16:e254629. [PMID: 37321642 PMCID: PMC10277066 DOI: 10.1136/bcr-2023-254629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Management of a severely damaged extremity poses a dilemma-whether to perform a primary amputation or attempt limb salvage. A multitude of factors-such as the extent of neurovascular injury, limb ischaemia time, severity of bone and soft tissue loss, physiological reserve of the patient and availability of surgical expertise and resources-influence this decision. The Mangled Extremity Severity Score (MESS) was developed as a predictor of the need for limb amputation, and a MESS of 7 or more is considered a predictor of primary amputation. Here we describe a case where a man in his 20s sustained traumatic avulsion of his right ankle with severe neurovascular damage and multiple tendon injuries onboard a ship at high sea. Despite a MESS of 10, limb ischaemia time of more than 10 hours and injuries to all three extremity vessels (anterior tibial, posterior tibial and peroneal arteries), limb salvage was successfully carried out at a level-II trauma centre.
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Affiliation(s)
- Rakesh Kumar Jha
- Department of Surgery, Indian Naval Hospital Ship Asvini, Mumbai, Maharashtra, India
| | - Prasad Vijay Jayaram
- Department of Surgery, Indian Naval Hospital Ship Asvini, Mumbai, Maharashtra, India
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12
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Derbel B, Mazzaccaro D, Krarti N, Miri R, Khadhar Y, Ben Mrad M, Righini P, Nano G, Denguir R. Penetrating Vascular Injuries of the Lower Limbs after Stab Wounds: Predictive Factors of Limb Loss and Mortality. J Clin Med 2023; 12:jcm12103476. [PMID: 37240581 DOI: 10.3390/jcm12103476] [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: 03/20/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Penetrating vascular injuries (PVIs) of the lower limbs due to stab wounds are associated with high mortality and limb loss rates. We analyzed the outcomes of a series of patients who underwent surgical treatment of these lesions, assessing the presence of any factor associated with limb loss and mortality; (2) Methods: Data of patients admitted from 01/2008 to 12/2018 were retrospectively analyzed. Primary outcomes were the limb loss and the mortality rate at 30 days postoperatively. Univariate and multivariate analyses were performed as appropriate. p values < 0.05 were considered significant; (3) Results: Data of 67 male patients were analyzed. Two died (3%) and three (4.5%) had a lower limb amputation after failed revascularization. In the univariate analysis, the clinical presentation significantly affected the risk of postoperative mortality and limb loss. The location of the lesion at the superficial femoral artery (OR 4.32, p = 0.001) or at the popliteal artery (OR 4.89, p = 0.0015) also increased the risk. In the multivariate analysis, the need for a vein graft bypass was the only significant predictor of limb loss and mortality (OR 4.58, p < 0.0001); (4) Conclusions: PVIs of lower limbs due to stab wounds were lethal in 3% of cases and lead to a secondary major amputation in 4.5% more cases. The need for a vein bypass grafting was the strongest predictor of postoperative limb loss and mortality.
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Affiliation(s)
- Bilel Derbel
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Nidhal Krarti
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Rim Miri
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Yassine Khadhar
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Melek Ben Mrad
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
| | - Paolo Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giovanni Nano
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
- Department of Biomedical Sciences for Health, University of Milan, 20161 Milan, Italy
| | - Raouf Denguir
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis 1002, Tunisia
- Cardiovascular Surgery Department, La Rabta Hospital, Tunis 1007, Tunisia
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García AM, Gutiérrez J, Villamil E, Sánchez W, Villarreal L, Lozada-Martinez ID, Picón-Jaimes YA, Pérez M, Cabrera-Vargas LF. Predictors for limb amputation in war vascular trauma: A 20-years retrospective analysis from the Colombian armed conflict. Am J Surg 2023; 225:787-792. [PMID: 36220700 DOI: 10.1016/j.amjsurg.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Latin American military vascular trauma is virtually unknown. The aim of this study was to describe severe war vascular trauma during the last 20 years of the Colombian armed conflict, and to identify predictors of limb amputation. METHODS Retrospective analysis of a follow-up cohort from 1999 to 2019 of patients with associated severe vascular injuries (ISS >15) in the Colombian armed conflict treated at the Hospital Militar Central. RESULTS Out of 5948 patients, 243 had military vascular trauma with 430 vascular injuries. The most frequent trauma mechanisms were gunshot wounds (n = 153; 63%). The most common injured vessels were femoral. 24 (10%) patients required amputations. Mortality was 4.1%. Amputation was associated with arteriovenous lesions (RR 4.82, p = 0.025), compartment syndrome (RR 4.2, p = 0.007), arteriovenous femoropopliteal injuries (RR 3.5, p = 0.0026), multiple arterial injuries (RR 3.35, p = 0.0218), associated fractures (RR 3.1, p = 0.0032). CONCLUSIONS Concomitant arteriovenous injuries in popliteal and femoropopliteal lesions, multiple arterial lesions, bone fractures, and compartment syndrome are associated with amputation in severe vascular injury.
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Affiliation(s)
- Ana Maria García
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Jorge Gutiérrez
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia; Department of Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Edwin Villamil
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - William Sánchez
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Laura Villarreal
- Department of Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ivan David Lozada-Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia; International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua.
| | | | - Mauricio Pérez
- Department of Surgery, Universidad El Bosque, Bogotá, Colombia
| | - Luis Felipe Cabrera-Vargas
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia; Department of Surgery, Universidad El Bosque, Bogotá, Colombia
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Shaikh SP, Haqqani MH, Alfson DB, Forsyth A, Brea F, Richman A, Siracuse JJ, Rybin D, Eberhardt RT, Farber A, Brahmbhatt TS. Outcomes following ipsilateral great saphenous vein bypass for lower extremity arterial injuries. Injury 2023:S0020-1383(23)00286-3. [PMID: 36973136 DOI: 10.1016/j.injury.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Use of autologous great saphenous vein (GSV) grafts for repair of extremity arterial injuries is well established. Contralateral great saphenous vein (cGSV) is traditionally used in the setting of lower extremity vascular injury given the risk of occult ipsilateral superficial and deep venous injury. We evaluated outcomes of ipsilateral GSV (iGSV) bypass in patients with lower extremity vascular trauma. METHODS Patient records at an ACS verified Level I urban trauma center between 2001 and 2019 were retrospectively reviewed. Patients who sustained lower extremity arterial injuries managed with autologous GSV bypass were included. Propensity-matched analysis compared the iGSV and cGSV groups. Primary graft patency was assessed via Kaplan-Meier analysis at 1-year and 3-years following the index operation. RESULTS A total of 76 patients underwent autologous GSV bypass for lower extremity vascular injuries. 61 cases (80%) were secondary to penetrating trauma, and 15 patients (20%) underwent repair with iGSV bypass. Arteries injured in the iGSV group included popliteal (33.3%), common femoral (6.7%), superficial femoral (33.3%), and tibial (26.7%), while those in the cGSV group included common femoral (3.3%), superficial femoral (54.1%), and popliteal (42.6%). Reasons for using iGSV included trauma to the contralateral leg (26.7%), relative accessibility (33.3%), and other/unknown (40%). On unadjusted analysis, iGSV patients had a higher rate of 1-year amputation than cGSV patients (20% vs. 4.9%), but this was not statistically significant (P = 0.09). Propensity matched analysis also found no significant difference in 1-year major amputation (8.3% vs. 4.8%, P = 0.99). Regarding ambulatory status, iGSV patients had similar rates of independent ambulation (33.3% vs. 38.1%), need for assistive devices (58.3% vs. 57.1%), and use of a wheelchair (8.3% vs. 4.8%) compared cGSV patients at subsequent follow-up (P = 0.90). Kaplan-Meier analysis of bypass grafts revealed comparable primary patency rates for iGSV versus cGSV bypasses at 1-year (84% vs. 91%) and 3-years post-intervention (83% vs. 90%, P = 0.364). CONCLUSION Ipsilateral GSV may be used as a durable conduit for bypass in cases of lower extremity arterial trauma where use of contralateral GSV is not feasible, with comparable long-term primary graft patency rates and ambulatory status.
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Affiliation(s)
- Shamsh P Shaikh
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Maha H Haqqani
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Daniel B Alfson
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Alexandra Forsyth
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Fernando Brea
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Aaron Richman
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 840 Harrison Ave, Dowling 2 South, Suite 2509, Boston, MA, 02118, United States
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Denis Rybin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Robert T Eberhardt
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Tejal S Brahmbhatt
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 840 Harrison Ave, Dowling 2 South, Suite 2509, Boston, MA, 02118, United States.
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15
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Ben Romdhane M, Boufi M, Dona B, Hartung O, Alimi Y. Predictive factors of amputation in infra-inguinal vascular trauma: a monocentric experience. Ann Vasc Surg 2023:S0890-5096(23)00150-4. [PMID: 36906127 DOI: 10.1016/j.avsg.2023.02.035] [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: 12/14/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES Infra-inguinal vascular injuries (IIVI) are emergencies involving both functional and vital prognosis. The choice between saving the limb or doing a first-line amputation is difficult even for an experienced surgeon. The aims of this work are to analyze early outcomes in our center and to identify predictive factors for amputation. M METHODS Between 2010 and 2017, we reviewed retrospectively patients with IIVI. The main criteria for judgement were: primary, secondary and overall amputation. Two groups of potential risk factors of amputation were analyzed: Those related to the patient: age, shock, ISS score; those related to the lesion: mechanism, above or below the knee, bone lesions, venous lesions and skin decay. A univariate and multivariate analysis were performed to determine the risk factor(s) independently associated with the occurrence of amputation. RESULTS 57 IIVI were found in 54 patients. The mean ISS was 32,3 ± 21. A primary amputation was performed in 19%, and secondary in 14% of cases. Overall amputation rate was 35% (n=19). Multivariate analysis reveals that the ISS is the only predictor of primary (p=0.009; OR:1.07; CI:1.01-1.12) and global (p=0.04; OR:1.07; IC:1.02-1.13) amputation. A threshold value of 41 was selected as a primary amputation risk factor with a negative predictive value of 97%. CONCLUSIONS The ISS is a good predictor of the risk of amputation in IIVI. A threshold of 41 is an objective criterion helping to decide for a first-line amputation. Advanced age and hemodynamic instability should not be important in the decision tree.
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Affiliation(s)
| | | | - Bianca Dona
- Vascular Surgery Department, Marseille, France
| | | | - Yves Alimi
- Vascular Surgery Department, Marseille, France
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16
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Ponomarenko OV, Serhieieva LN, Parkhomenko KY. Surgical treatment results in patients with defects of the integumentary tissues of the trunk and limbs of mechanical origin. J Med Life 2022; 15:1358-1364. [PMID: 36567839 PMCID: PMC9762375 DOI: 10.25122/jml-2022-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 09/13/2022] [Indexed: 01/03/2023] Open
Abstract
This study aimed to develop and implement a universal method for the quantitative assessment of treatment effectiveness in patients with skin and underlying soft tissue defects of the trunk and extremities. The study involved 242 patients, including 46 patients with upper extremity injuries, 179 with lesions of lower extremity tissues, and 17 patients with defects of the integumentary tissues of the trunk. The greatest treatment effectiveness was observed in patients with upper limb injury: excellent result - 60.0%, good - 33.3%, unsatisfactory - 6.7% of patients. In the group of patients with lower extremity injuries, an excellent result was recorded in 19.6% of cases, good (58.1%), satisfactory (15.1%), and unsatisfactory in 7.2% of patients. In patients with trunk injuries, an excellent treatment result was obtained in 23.5%, good - 35.5%, satisfactory - 23.5%, and unsatisfactory - 17.6%. The universal quantitative method for evaluating treatment effectiveness in patients with various types of damage to the trunk and extremities tissues was proposed. This method makes it possible to objectively determine the level of medical service provided to each patient, which is of great importance in the context of medical service reorganization in the state.
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Affiliation(s)
- Olena Vasylivna Ponomarenko
- Department of Medicine of Catastrophes, Military Medicine and Neurosurgery, Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine,Corresponding Author: Olena Vasylivna Ponomarenko, Department of Medicine of Catastrophes, Military Medicine and Neurosurgery, Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine E-mail:
| | - Ludmila Nylsivna Serhieieva
- Department of Medical Physics, Biophysics and Higher Mathematics, Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine
| | - Kyrylo Yuriiovych Parkhomenko
- Department of General Practice Family Medicine and Internal Medicine, Kharkiv National Medical University, Kharkiv, Ukraine
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17
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Comparison of patient-reported outcomes at one year after injury between limb salvage and amputation: A prospective cohort study. PLoS One 2022; 17:e0274786. [PMID: 36121827 PMCID: PMC9484632 DOI: 10.1371/journal.pone.0274786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/05/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose This single-center, prospective cohort study aimed to compare the patient-reported outcomes one year after injury between limb salvage and amputation and to elucidate whether amputation contributes to early recovery of functionality and quality of life. Methods We included 47 limbs of 45 patients with severe open fractures of the lower limb and categorized them into limb salvage and amputation groups. Data on patient-reported outcomes one year after injury were obtained from the Database of Orthopaedic Trauma by the Japanese Society for Fracture Repair at our center. Patients’ limbs were evaluated using the lower extremity functional scale and Short-Form 8. Early recovery was assessed using functionality and quality-of-life questionnaires. Results Of the 47 limbs, 34 limbs of 34 patients were salvaged, and 13 limbs of 11 patients were amputated. Significant differences were noted between the limb salvage and amputation groups in terms of the lower extremity functional scale scores (mean: 49.5 vs. 33.1, P = 0.025) and scores for the mental health component (mean: 48.7 vs. 38.7, P = 0.003), role–physical component (mean: 42.2 vs. 33.3, P = 0.026), and mental component summary (mean: 48.2 vs. 41.3, P = 0.042) of the Short-Form 8. The limb salvage group had better scores than the amputation group. Conclusions As reconstruction technology has advanced and limb salvaging has become possible, the focus of studies should now be based on the perspective of “how the patient feels;” hence, we believe that the results of this study, which is based on patient-reported outcomes, are meaningful.
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Perkins ZB, Kersey AJ, White JM, Lauria AL, Propper BW, Tai NRM, Rasmussen TE. Impact of Ischemia Duration on Lower Limb Salvage in Combat Casualties. Ann Surg 2022; 276:532-538. [PMID: 35972512 DOI: 10.1097/sla.0000000000005560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The 6-hour threshold to revascularization of an ischemic limb is ubiquitous in the trauma literature, however, contemporary evidence suggests that this threshold should be less. This study aims to characterize the relationship between the duration of limb ischemia and successful limb salvage following lower extremity arterial trauma. METHODS This is a cohort study of the United States and UK military service members injured while serving in Iraq or Afghanistan between 2003 and 2013. Consecutive patients who sustained iliac, femoral, or popliteal artery injuries, and underwent surgery to attempt revascularization, were included. The association between limb outcome and the duration of limb ischemia was assessed using the Kaplan-Meier method. RESULTS One hundred twenty-two patients (129 limbs) who sustained iliac (2.3%), femoral (56.6%), and popliteal (41.1%) arterial injuries were included. Overall, 87 limbs (67.4%) were successfully salvaged. The probability of limb salvage was 86.0% when ischemia was ≤1 hour; 68.3% when between 1 and 3 hours; 56.3% when between 3 and 6 hours; and 6.7% when >6 hours ( P <0.0001). Shock more than doubled the risk of failed limb salvage [hazard ratio=2.42 (95% confidence interval: 1.27-4.62)]. CONCLUSIONS Limb salvage is critically dependent on the duration of ischemia with a 10% reduction in the probability of successful limb salvage for every hour delay to revascularization. The presence of shock significantly worsens this relationship. Military trauma systems should prioritize rapid hemorrhage control and early limb revascularization within 1 hour of injury.
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Affiliation(s)
- Zane B Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Alexander J Kersey
- Battlefield Shock and Organ Support Laboratory, Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD
- Walter Reed National Military Medical Center, Bethesda, MD
| | - Joseph M White
- Battlefield Shock and Organ Support Laboratory, Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD
- Walter Reed National Military Medical Center, Bethesda, MD
| | - Alexis L Lauria
- Battlefield Shock and Organ Support Laboratory, Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD
- Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Nigel 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
| | - Todd E Rasmussen
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
- Mayo Clinic, Rochester, MN
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PAPAGEORGOPOULOU CP, NIKOLAKOPOULOS KM, PAPADOULAS SI. Popliteal artery injury repair in a mangled extremity. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05323-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Lin CH, Consuegra MDL, Lin TS. Revisiting Management Strategies for Popliteal Artery Injuries. Ann Plast Surg 2022; 88:S44-S49. [PMID: 35102016 DOI: 10.1097/sap.0000000000003067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Popliteal artery injuries (PAIs) were reported to own the highest rates of limb loss in vascular injuries of extremities. The complex nature of PAIs makes the treatment more difficult. We aimed to present our cases using our proposed algorithm and revisit the strategies for management. PATIENTS AND METHODS A retrospective study of 45 cases with PAIs managed at the Kaohsiung Chang Gung Memorial Hospital over a 10-year period was conducted. The proposed algorithm for decision making was applied, which contains variables including the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, the acquisition of preoperative angiography, and the existence of collateral circulation. Whether the injured limbs were salvaged successfully avoiding amputation was recorded. RESULTS Of all the included 45 patients, the rate of a successful salvage of the injured limb from amputation was 71.1%. Six patients did not receive revascularization because of their poor conditions of the injured limbs. In terms of limb salvage in PAIs, the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, or the acquisition of preoperative angiography did not make a significant difference (P > 0.05). Instead, an existence of collateral circulation at the distal injured limb was correlated to a significant higher rate of salvage, regardless of having revascularization or not (P = 0.001 and < 0.001, respectively). Seven patients had the injured vessels repaired directly and all were prevented from amputation. In other patients who underwent vascular repair using a graft, vein graft (n = 20) showed a higher successful rate in salvage significantly than Gore-Tex graft (n = 9, P < 0.001). CONCLUSIONS Collateral circulation determines much of the fate of limb salvage in PAIs. As a result, a delayed revascularization could be accepted as long as there is existence of collateral circulation at the distal injured limb. An autologous vein graft is favored when a direct repair is not able to be performed for revascularization. Although fasciotomy was not found to be associated with a successful salvage in this study, its importance could not be neglected and it should be performed when there is an observed or impending compartment syndrome.
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Affiliation(s)
| | - Ma Dulce Lafuente Consuegra
- Section of Surgical Oncology, Department of General Surgery, Vicente Sotto Memorial Medical Center, Cebu City, Philippines
| | - Tsan-Shiun Lin
- From the Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City
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21
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Kluckner M, Gratl A, Gruber L, Frech A, Gummerer M, Wipper S, Enzmann FK, Klocker J. Risk factors for major amputation after arterial vascular trauma of the lower extremity. Scand J Surg 2022; 111:14574969211070668. [DOI: 10.1177/14574969211070668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background & objective: Arterial vascular trauma bears a great risk of poor functional outcome or limb loss. The aim of this study was to analyze amputation rates of patients after vascular trauma and to perform a predictor analysis for the risk of major amputation. Methods: In a single-center retrospective analysis of 119 extremities treated for arterial vascular injury between 1990 and 2018 amputation rates and factors associated with limb loss were assessed. All patients were treated for traumatic vascular injuries; iatrogenic injuries were not included in the study. Results: During the study period, a total of 119 legs in 118 patients were treated after arterial vascular trauma. The in-hospital major amputation rate was 16.8% and the mortality rate was 2.5%. In the predictors analysis, vascular re-operation (amputation rate 53.8% vs 12%, odds ratio = 8.56), a Rutherford category ⩾IIb (25.4% vs 4.2%, odds ratio = 6.43), work-related or traffic accidents (28.2% vs 0%, odds ratio = 4.86), concomitant soft tissue or bone injuries (26.7% vs 7.3%, odds ratio = 4.64), polytrauma (33.3% vs 12%, odds ratio = 3.68), and blunt trauma (18.9% vs 0% for penetrating trauma, odds ratio = 1.64) were found to be associated with amputation. Conclusions: Lower extremity arterial vascular trauma was associated with a significant major amputation rate. Several predictors for limb loss were identified, which could aid in identifying patients at risk and adapting their treatment.
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Affiliation(s)
- Michaela Kluckner
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Alexandra Gratl
- Department of Vascular Surgery Medical University Innsbruck Anichstraße 35 A-6020 Innsbruck Austria
| | - Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Frech
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Maria Gummerer
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Sabine Wipper
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Florian K. Enzmann
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Josef Klocker
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
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22
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Kleinsorge GHD, Teixeira PGR, Pfannes CCB, Lago RDVD, Abib SDCV. Prognostic factors in treatment of traumatic femoropopliteal arterial injuries at a Brazilian trauma center. J Vasc Bras 2022; 21:e20220020. [PMID: 36187215 PMCID: PMC9499723 DOI: 10.1590/1677-5449.202200202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Abstract
Background Despite significant improvements in outcomes, traumatic arterial limb injuries remain a significant cause of limb loss and mortality. Objectives This study sought to identify predictors of mortality and major amputation in patients undergoing revascularization after femoropopliteal arterial trauma. Methods This was a retrospective review of a trauma registry from an urban trauma center in Brazil. All patients admitted to our hospital with a femoropopliteal arterial injury from November 2012 to December 2017 who underwent vascular reconstruction were included. Univariate analyses and logistic regression analyses were conducted to identify factors independently associated with the primary outcome of amputation and the secondary outcome of mortality. Results Ninety-six patients were included. Eleven patients (11.5%) had an amputation and 14 (14.6%) died. In the logistic regression model for amputation, patients with ischemia duration greater than 6 hours were approximately 10 times more likely to undergo an amputation compared to those with ischemia duration less than or equal to 6 hours (adjusted odds ratio (AOR) [95% confidence interval (CI)]: 9.6 [1.2-79.9]). The logistic regression model for mortality revealed that patients with ischemia duration greater than 6 hours were approximately 6 times more likely to die compared to those with ischemia duration less than or equal to 6 hours (AOR [95% CI]: 5.6 [1.3 to 24.7). Conclusions Ischemia duration remains the most important factor independently associated with limb loss and mortality for patients undergoing femoropopliteal arterial revascularization after traumatic injuries. Physiological status on admission and trauma scores are also important.
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Giordano V, Souza FS, Belangero WD, Pires RE. Limb Salvage after Lower-Leg Fracture and Popliteal Artery Transection-The Role of Vessel-First Strategy and Bone Fixation Using the Ilizarov External Fixator Device: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1220. [PMID: 34833438 PMCID: PMC8624929 DOI: 10.3390/medicina57111220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 11/16/2022]
Abstract
Open traumatic lesion of the popliteal artery is relatively rare. Ischemia time longer than 6 h and severity of limb ischemia have been shown to be associated with an increased risk of limb loss. Severe local infection is critical in the presence of major soft tissue trauma or open fractures. We report the case of a young female who suffered a traumatic transection of the popliteal artery associated with an open fracture of the distal tibia and fibula managed by direct vessel reconstruction with an end-to-end repair and skeletal stabilization initially with half-pin external fixation, then replaced by an Ilizarov circular frame. The patient had a very satisfactory outcome, but the fracture healed malunited, later corrected by open reduction and internal fixation with lag-screwing and a neutralization plate.
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro 22430-060, Brazil;
| | - Felipe Serrão Souza
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro 22430-060, Brazil;
| | - William Dias Belangero
- Departamento de Ortopedia, Universidade Estadual de Campinas, Campinas 13083-887, Brazil;
| | - Robinson Esteves Pires
- Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil;
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Hines EM, Dowling S, Hegerty F, Pelecanos A, Tetsworth K. Bacterial infection of fasciotomy wounds following decompression for acute compartment syndrome. Injury 2021; 52:2914-2919. [PMID: 34233855 DOI: 10.1016/j.injury.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Acute Compartment Syndrome (ACS) is a serious complication generally requiring treatment with an emergency decompressive fasciotomy. The aim of this study was to identify the most prevalent organisms involved in fasciotomy wound infections, and to determine the best strategies to mitigate this risk. DESIGN Retrospective review. SETTING Single tertiary referral centre. PATIENTS/PARTICIPANTS Patients (n = 370) who underwent fasciotomy for emergency ACS were included in this study. Positive wound swabs and tissue samples within 30 days post fasciotomy were identified, and extended antibiotic sensitivities were recorded. Patient medical charts were reviewed to assess infection rate, causative organism(s), and clinical outcomes. INTERVENTION Fasciotomy Main Outcome Measurements: Most prevalent organism in fasciotomy wound infections, and the rate of any associated morbidity and mortality. RESULTS The overall infection rate was 16.7%. Infection rates were significantly higher in burns (27%) and trauma (22%) patients than vascular patients (13%) (p = 0.002). The most prevalent organism was Pseudomonas aeruginosa, isolated from 23% of all wound specimens and comprising over a third (35%) of infections overall. Ten patients required amputation for infection control. Six of these were secondary to Pseudomonas infection, whereby one patient mortality occurred. CONCLUSION In this series, one in six fasciotomies for ACS developed an infection within 30 days of their index procedure. Burns and trauma comprised the highest risk groups. Facultative anaerobes were the predominant organisms involved in fasciotomy wound infections. A combination of aminoglycosides and beta-lactams with quinolones should be considered when commencing empiric therapy for fasciotomy wound infections. Antibiotic coverage for routine peri‑operative prophylaxis following emergency decompression for acute compartment syndrome should be strongly considered, particularly in burns or trauma cases. LEVEL OF EVIDENCE Aetiologic Level III.
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Affiliation(s)
- Elizabeth Magdelin Hines
- Department of Internal Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Mater, Brisbane, QLD, Australia.
| | - Samantha Dowling
- Department of Internal Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Fergus Hegerty
- Department of Internal Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | | | - Kevin Tetsworth
- Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Orthopaedic Research Centre of Australia, Brisbane, QLD, Australia; Limb Reconstruction Centre, Macquarie University Hospital, Sydney, NSW, Australia
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Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis. J Orthop Trauma 2021; 35:512-516. [PMID: 33512862 DOI: 10.1097/bot.0000000000002067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN Retrospective. SETTING Nine trauma centers. PATIENTS This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Predictors for the need for fasciotomy after arterial vascular trauma of the lower extremity. Injury 2021; 52:2160-2165. [PMID: 34130853 DOI: 10.1016/j.injury.2021.05.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Compartment syndrome of the lower extremity following arterial vascular trauma can cause irreversible damage to muscle as well as nerve tissue leading to long-term functional impairment of the extremity or worse limb loss. Prompt diagnosis and treatment of compartment syndrome is mandatory to preserve muscle tissue and prevent limb loss. The aim of the study was to analyze the fasciotomy rate of our patient cohort and to perform a predictors analysis for the need of fasciotomy. MATERIAL AND METHODS In a retrospective study all patients treated for arterial vascular trauma since 1990 were identified. Demographics, clinical data and outcome were analysed. After separation in a fasciotomy and non-fasciotomy group, a Bayes Network was used to arrive at a predictor ranking for the need of fasciotomy via a gain ratio feature evaluation. RESULTS In the period of 28 years, 88 (73.9%) of a total of 119 patients, predominantly male (80.7%) and aged under 40 years (37.5 ± 17.5), required fasciotomy after arterial vascular trauma. Patients of the fasciotomy group presented at higher Rutherford categories (grade III 34.1% vs. 9.7%, p = 0.005), varied in terms of the type of arterial vascular injury (dissection 25% vs. 61.3%, p <0.001, occlusion 15.9% vs. 0%, p = 0.011) and showed prolonged hospitalization (35.17 ± 29.3 vs. 21.48±25.4, p = 0.002). Ischaemia duration exceeding 2.5 h followed by the Rutherford grade IIa and greater, the site (popliteal artery segment 3), type (transection and occlusion), and mechanism of vascular trauma (work related accident over traffic and sports accidents), as well as the male gender presented as strong predictors for fasciotomy. CONCLUSIONS Arterial vascular trauma requiring fasciotomy for compartment syndrome accounted for 73.9% of all cases. Immediate diagnosis and treatment is mandatory to prevent long-term functional impairment or limb loss. The above mentioned predictors should help identifying patients at risk for developing a compartment syndrome to provide best possible treatment.
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Ali G, Berlas MF, Din NU, Rehman KU, Muhammad Saleh W, Naqvi SAA. Outcomes of Revascularization and Factors Associated With Major Amputation in Patients With Lower Limb Arterial Injury: A Single-Center Retrospective Analysis. Cureus 2021; 13:e17290. [PMID: 34567854 PMCID: PMC8452226 DOI: 10.7759/cureus.17290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/05/2022] Open
Abstract
Objective To identify the amputation rates and causative factors for failed revascularization leading to amputation in patients undergoing primary limb salvage procedures for lower-extremity vascular injuries. Methods This retrospective study was conducted at the vascular surgery department, Shaheed Mohtarma Benazir Bhutto (SMBB) Institute of Trauma, Karachi, Pakistan. The data were collected from hospital record using the non-probability sampling technique. Patients aged 17-70 years, undergoing primary revascularization during April 2016 to March 2021, were included in the study. Patients with crush injuries/non-salvageable limbs underwent primary amputation, isolated deep femoral artery or crural arteries (non-limb threatening) injuries, and non-traumatic injuries like intravenous drug-induced or iatrogenic injuries were excluded. The data analysis is done using SPSS Version 20.0 (IBM Corp., Armonk, NY, USA). A P-value of <0.05 was considered as significant. Results This study includes 56 patients of mean age 30.82 ± 9.29 years with male gender four times more affected than their counterpart. About 32% of patients were smokers, while 58% of patients had no co-morbidities. All patients presented with a mean time of 7.66 ± 1.69 hours of injury with an average of 1.14 arterial segments involved. The most frequent artery involved was popliteal artery (both above and below the knee), followed by superficial femoral artery injury constituting 50% and 26%, respectively, with arterial laceration and transection being common findings on exploration. Out of 56 patients, 27 (48.2%) had open fractures, 21 (37.5% ) closed fractures, and eight patients (14.3 % ) presented with dislocation as associated injuries. Following the procedure, secondary amputation was recorded in 18 (32.1%) patients. Thrombosis and infection were the leading causes of revascularization failure. Type of injury, segment of arterial injury, and associated bony injuries were associated with limb amputation. Conclusion Type and site of injury along with concomitant bony injuries are associated with major amputations after revascularization in lower-extremity arterial injuries.
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Affiliation(s)
- Ghulam Ali
- Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, PAK
| | | | - Najam U Din
- Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, PAK
| | - Khalil Ur Rehman
- Vascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, PAK
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McCulloch I, Valerio I. Lower extremity reconstruction for limb salvage and functional restoration - The Combat experience. Clin Plast Surg 2021; 48:349-361. [PMID: 33674056 DOI: 10.1016/j.cps.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned applied and translated among military and civilian settings. In recent periods of war, improvements in protective equipment, in-theater damage control resuscitation/surgery, delivery of antibiotics locally/systemically, and rapid evacuation to higher levels of medical care capabilities have greatly improved combat casualty survivability rates. Additionally, widespread application of lower extremity tourniquets also has prevented casualties from exsanguination, thus reducing hemorrhagic-related deaths. Secondary to these, a high number of combat casualties suffering lower extremity traumatic injuries have presented for functional limb reconstruction and restoration as well as residual limb care.
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Affiliation(s)
- Ian McCulloch
- The Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 435, Boston, MA 02114, USA
| | - Ian Valerio
- The Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; Medical Corps, U.S. Navy Active Reserve Component, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 435, Boston, MA 02114, USA.
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Laverty RB, Brock SG, Walters TJ, Kauvar DS. Outcomes of Arterial Grafts for the Reconstruction of Military Lower Extremity Arterial Injuries. Ann Vasc Surg 2021; 76:59-65. [PMID: 33831531 DOI: 10.1016/j.avsg.2021.03.006] [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: 01/07/2021] [Revised: 03/02/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Lower extremity (LE) arterial injuries are common in military casualties and limb salvage is a primary goal. Bypass grafts are the most common reconstructions; however, their specific outcomes are largely unreported. We sought to describe the outcomes of LE arterial grafts among combat casualties and their association with limb loss. METHODS Retrospective cohort study of 2004-2012 Iraq/Afghanistan casualties with LE arterial injury undergoing bypass graft from a database containing follow-up until amputation, death, or military discharge. Primary outcome was composite graft complications (GC-thrombosis, stenosis, pseudoaneurysm, blowout, and/or arteriovenous fistula). RESULTS Two hundred and twenty-two grafts were included (99 femoral, 73 popliteal, 48 tibial). 56 (26%) had at least one GC; thrombosis was most common in femoral, stenosis most common in popliteal and tibial. GC was not associated with graft level but was associated with synthetic conduit (P = 0.01) and trended towards an association with multiple-level arterial injuries (P = 0.07). Four of eight (50%) synthetic grafts had amputations, all within 72h. Two of the eight synthetic grafts thrombosed, and both limbs were amputated. There were 52 total amputations. Amputation was performed in 13 (23%) of limbs with a GC and 24% of those without (P = 0.93) Overall, 24 (11%) of grafts thrombosed, 16 within 48h and 13 (25%) in limbs undergoing amputation (P = 0.001 for association of thrombosis with amputation). CONCLUSION GC are common among LE bypass grafts in combat casualties but are not associated with limb loss. Thrombosis is predominantly early and is associated with amputation. Closer attention to ensuring early patency may improve limb salvage.
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Affiliation(s)
- Robert B Laverty
- Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | | | - Thomas J Walters
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; Department of Surgery, Uniformed Services University, Bethesda, Maryland.
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Hundersmarck D, Hietbrink F, Leenen LPH, De Borst GJ, Heng M. Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy. Eur J Trauma Emerg Surg 2021; 48:1045-1053. [PMID: 33743028 PMCID: PMC9001538 DOI: 10.1007/s00068-021-01632-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 02/26/2021] [Indexed: 12/01/2022]
Abstract
Purpose Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF). Methods Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined. Results Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication. Conclusion Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01632-0.
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Affiliation(s)
- Dennis Hundersmarck
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, 55 Fruit Street, Boston, USA. .,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J De Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, 55 Fruit Street, Boston, USA
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American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg 2021; 89:1183-1196. [PMID: 33230048 DOI: 10.1097/ta.0000000000002967] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.
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Jiang C, Chen Z, Zhao Y, Zhang WW, Zeng Q, Li F. Four-year outcomes following endovascular repair in patients with traumatic isolated popliteal artery injuries. J Vasc Surg 2021; 73:2064-2070. [PMID: 33340706 DOI: 10.1016/j.jvs.2020.12.050] [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: 07/02/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The effectiveness of endovascular treatment for popliteal arterial injury has not been well-documented. This study was aimed to investigate the midterm outcomes of endovascular repair of traumatic isolated popliteal arterial injury. METHODS Medical records of the patients who underwent endovascular repair for traumatic popliteal arterial injuries from January 2012 to February 2020 were reviewed retrospectively. Clinical data including patient demographics, Injury Severity Score, type of injury, classification of acute limb ischemia, concomitant extremity fracture, runoff vessel status, complications, time of endovascular procedure, time interval from injury to blood flow restoration, length of hospital stay, reintervention, and follow-up were collected and analyzed. RESULTS Endovascular repair was performed in 46 patients with traumatic popliteal arterial injuries. The mean Injury Severity Score was 15.8 ± 6.2. The overall limb salvage rate was 89.1%. There were 10 penetrating and 36 blunt injuries (78.3%). The initial angiographic findings revealed occlusion in 34 patients (73.9%), pseudoaneurysm in 2 (4.4%), active extravasation in 9 (19.5%), and arteriovenous fistulas in 1 (2.2%). Technical success was achieved in all 46 patients, via antegrade access in 24 patients (52.2%) and concurrent retrograde access in 22 (47.8%). The mean time interval from popliteal artery injury to blood flow restoration was 10.6 ± 4.9 hours and mean operative time was of 54.9 ± 10.0 minutes. The mean follow-up was 36.1 ± 14.5 months. The primary patency rate was 75.3% at 12 months, 61.9% at 24 months, and 55.7% at 48 months. The secondary patency rate was 92.2% at 12 and 24 months and 85.2% at 48 months. A Cox multivariate analysis revealed that single vessel runoff was an independent risk factor for primary patency loss. CONCLUSIONS Endovascular repair of an isolated popliteal artery injury may be a safe and effective alternative treatment in select patients, with acceptable midterm outcomes. Single vessel runoff was an independent risk factor for primary patency loss.
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Affiliation(s)
- Chuli Jiang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington and Puget Sound VA Health Care System, Seattle, Wash
| | - Qiu Zeng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fenghe Li
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Watras JB, Collins DT, Newcomb A, Liu C, Griffen MM. Effect of Obesity on Early, In-Hospital Amputation Risk Following Popliteal Artery Injury Using an Analysis of the National Trauma Data Bank. Am Surg 2021; 88:1111-1117. [PMID: 33522836 DOI: 10.1177/0003134820988819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Popliteal artery injury is associated with a high risk of limb loss; identifying factors associated with increased morbidity and mortality is hampered by its rare occurrence and confounding factors. Anecdotal observations suggest delay in diagnosis of obese patients may be associated with amputation. We aimed to determine whether there is an increased risk of early amputation and if diagnosis is delayed in obese patients with popliteal artery injuries. METHODS We conducted a retrospective cohort study using National Trauma Data Bank (NTDB) data from 2013 to 2017. We extracted those sustaining popliteal artery injury, assigning obesity class based on body mass index. We included select demographic and clinical variables, using time to imaging as a surrogate for time to diagnosis. Statistical models were used to calculate the impact of obesity on amputation rates and time to diagnosis. RESULTS We identified 4803 popliteal artery injuries in the data set; 3289 met inclusion criteria. We calculated an 8.5% overall amputation rate, which was not significantly different between obese (N = 1305; 39.7%) and nonobese (N = 1984; 60.3%) patients. Statistical analysis identified peripheral vascular disease, diabetes, and smoking as risk factors for amputation. Time to imaging was similar for obese and nonobese patients. CONCLUSIONS AND RELEVANCE Analysis of NTDB data suggests that obesity is associated with neither increased early amputation rate nor longer time to imaging in patients with popliteal artery injury. However, our study suggests that underlying comorbidities of peripheral vascular disease and diabetes are associated with an increased risk for amputation in these patients.
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Affiliation(s)
- Jill B Watras
- Trauma Services, Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA.,Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Devon T Collins
- Department of Global and Community Health, College of Health and Human Services, 3298George Mason University, Fairfax, VA, USA.,Inova Heart and Vascular Institute, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Anna Newcomb
- Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Chang Liu
- Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Margaret M Griffen
- Trauma Services, Department of Surgery, 3313Inova Fairfax Medical Campus, Falls Church, VA, USA
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Kochuba M, Rozycki GF, Feliciano D. Outcome after ligation of major veins for trauma. J Trauma Acute Care Surg 2021; 90:e40-e49. [PMID: 33502152 DOI: 10.1097/ta.0000000000003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Kochuba
- From the Division of Acute Care Surgery, Department of Surgery, UF Health Jacksonville Medical Center (M.K.), University of Florida-Jacksonville, Jacksonville, Florida; Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University School of Medicine (G.F.R.), Johns Hopkins University; and Division of Surgical Critical Care, Department of Shock Trauma Center, Shock Trauma Center (D.F.), University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
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Yu L, Deng L, Zhu S, Deng K, Yu G, Zhu C, Qi B, Pan Z. Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites. Med Sci Monit 2021; 27:e927652. [PMID: 33431786 PMCID: PMC7812700 DOI: 10.12659/msm.927652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity. Materal/Methods From January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed. Results External iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery. Conclusions Although limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon’s best efforts.
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Affiliation(s)
- Li Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Linglong Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Shaobo Zhu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Kai Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Guorong Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Chunquan Zhu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Baiwen Qi
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
| | - Zhenyu Pan
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (mainland)
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Cho H, Huh U, Lee CW, Song S, Kim SH, Chung SW. Traumatic Peripheral Arterial Injury with Open Repair: A 10-Year Single-Institutional Analysis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:291-296. [PMID: 33020347 PMCID: PMC7553829 DOI: 10.5090/kjtcs.19.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/18/2020] [Accepted: 04/12/2020] [Indexed: 11/16/2022]
Abstract
Background We report our 10-year experience with traumatic peripheral arterial injury repair at an urban level I trauma center. Methods Between January 2007 and December 2016, 28 adult trauma patients presented with traumatic peripheral arterial injuries. Data were retrospectively collected on demographic characteristics, the mechanism of injury, the type of vascular injury, and physiological status on initial assessment. The analysis also included the Mangled Extremity Severity Score (MESS), Injury Severity Score, surgical procedures, and outcome variables including limb salvage, hospital stay, intensive care unit stay, and postoperative vascular complications. Results Four (14.3%) patients required amputation due to failed revascularization. MESS significantly differed between patients with blunt and penetrating trauma (8.2±2.2 vs. 5.8±1.3, respectively; p=0.005). The amputation rate was not significantly different between patients with blunt and penetrating trauma (20% vs. 0%, respectively; p=0.295). The overall mortality rate was 3.6% (1 patient). Conclusion Blunt trauma was associated with higher MESS than penetrating trauma, and amputation was more frequent. In particular, patients with blunt trauma had significantly higher MESS than patients with penetrating trauma (8.2±2.2 vs. 5.8±1.3, respectively; p=0.005), and amputation was performed when revascularization failed in cases of blunt trauma of the lower extremity. Therefore, particular care is needed in making treatment decisions for patients with peripheral arterial injuries caused by blunt trauma.
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Affiliation(s)
- Hoseong Cho
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Up Huh
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Chung Won Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Seon Hee Kim
- Department of Trauma Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea
| | - Sung Woon Chung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea
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Predicting the Outcome of Limb Revascularization in Patients With Lower-extremity Arterial Trauma. Ann Surg 2020; 272:564-572. [DOI: 10.1097/sla.0000000000004132] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review. Disaster Med Public Health Prep 2020; 15:389-397. [PMID: 32456743 DOI: 10.1017/dmp.2020.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs). METHODS A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis. RESULTS Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3. CONCLUSION This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.
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Ratnayake AS, Jayatilleke AU, Worlton TJ. Examination of Mechanism of Injury Is Sine Qua Non in Combat Vascular Trauma. Ann Vasc Surg 2020; 65:e303-e304. [DOI: 10.1016/j.avsg.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
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Kauvar DS, Propper BW, Arthurs ZM, Causey MW, Walters TJ. Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury. Ann Vasc Surg 2020; 62:119-127. [DOI: 10.1016/j.avsg.2019.08.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/17/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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Guice JL, Gifford SM, Hata K, Shi X, Propper BW, Kauvar DS. Analysis of Limb Outcomes by Management of Concomitant Vein Injury in Military Popliteal Artery Trauma. Ann Vasc Surg 2020; 62:51-56. [DOI: 10.1016/j.avsg.2019.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/15/2019] [Accepted: 05/25/2019] [Indexed: 11/15/2022]
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Hohenberger GM, Konstantiniuk P, Cambiaso-Daniel J, Matzi V, Schwarz AM, Lumenta DB, Cohnert TU. The Mangled Extremity Severity Score Fails to be a Good Predictor for Secondary Limb Amputation After Trauma with Vascular Injury in Central Europe. World J Surg 2019; 44:773-779. [DOI: 10.1007/s00268-019-05263-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Azoury SC, Stranix JT, Kovach SJ, Levin LS. Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important? J Reconstr Microsurg 2019; 37:42-50. [PMID: 31454835 DOI: 10.1055/s-0039-1695753] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation. METHODS A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol. RESULTS Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes. CONCLUSION The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible.
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Affiliation(s)
- Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania
| | - John T Stranix
- Department of Plastic Surgery, University of Virginia, Charlottesville, Virginia
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania.,Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, Pennsylvania
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Pennsylvania.,Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, Pennsylvania
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Sharrock AE, Tai N, Perkins Z, White JM, Remick KN, Rickard RF, Rasmussen TE. Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort. J Vasc Surg 2019; 70:224-232. [DOI: 10.1016/j.jvs.2018.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/21/2018] [Indexed: 11/29/2022]
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Impact of time to repair on outcomes in patients with lower extremity arterial injuries. J Vasc Surg 2019; 69:1519-1523. [DOI: 10.1016/j.jvs.2018.07.075] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/27/2018] [Indexed: 11/22/2022]
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Kim J, Jeon YS, Cho SG, Hong KC, Park KM. Risk Factors of Amputation in Lower Extremity Trauma with Combined Femoropopliteal Arterial Injury. Vasc Specialist Int 2019; 35:16-21. [PMID: 30993103 PMCID: PMC6453600 DOI: 10.5758/vsi.2019.35.1.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Purpose The clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI. Materials and Methods We retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates. Results Twenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation. Conclusion In cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.
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Affiliation(s)
- JeaHwan Kim
- Department of Surgery, Inha University Hospital, Incheon, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University Hospital, Incheon, Korea
| | - Soon Gu Cho
- Department of Radiology, Inha University Hospital, Incheon, Korea
| | - Kee Chun Hong
- Department of Surgery, Inha University Hospital, Incheon, Korea
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Matsumoto S, Jung K, Smith A, Coimbra R. Outcomes Comparison Between Ligation and Repair after Major Lower Extremity Venous Injury. Ann Vasc Surg 2019; 54:152-160. [DOI: 10.1016/j.avsg.2018.05.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/07/2018] [Accepted: 05/18/2018] [Indexed: 10/28/2022]
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Góes Junior AMDO, Simões Neto JFA, Abib SDCV, de-Andrade MC, Ferraz TC. Trauma vascular na Amazônia: atualizando o desafio. Rev Col Bras Cir 2018; 45:e1844. [DOI: 10.1590/0100-6991e-20181844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/03/2018] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: avaliar dados epidemiológicos dos pacientes operados por trauma vascular em hospital de referência para traumatismos vasculares do Estado do Pará, determinar as variáveis que aumentam o risco de óbito e fazer uma análise comparativa com os resultados previamente publicados pela mesma instituição. Métodos: estudo retrospectivo analítico realizado através da coleta de dados de pacientes operados por lesões vasculares, entre março de 2013 e março de 2017. Foram analisados dados demográficos e epidemiológicos, como o mecanismo e topografia da lesão, distância entre o local do trauma e o hospital, tipo de tratamento e complicações. Foi feito ainda o estudo de uma matriz de correlação com regressão logística entre as variáveis e a ocorrência de óbito. Resultados: foram estudados 288 pacientes, com 430 lesões; 92,7% era do sexo masculino, 49,7% entre 25 e 49 anos de idade; 47,2% das lesões foi ocasionada por projéteis de arma de fogo; 47,2% das lesões situava-se nos membros superiores, 42,7% nos membros inferiores, 8% em região cervical, 3,1% torácicas e 0,7% abdominais; 52,8% dos pacientes teve hospitalização por sete dias ou menos. Amputação foi necessária em 6,9% e a mortalidade foi 7,93%. Conclusão: distâncias superiores a 200km foram associadas à internação prolongada e maior probabilidade de amputação de membros. Foi encontrada correlação significativa entre a ocorrência de óbito e o fato de haver lesão arterial, lesão vascular na topografia cervical e lesão vascular na topografia torácica.
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Fairhurst PG, Wyss TR, Weiss S, Becker D, Schmidli J, Makaloski V. Popliteal vessel trauma: Surgical approaches and the vessel-first strategy. Knee 2018; 25:849-855. [PMID: 30207279 DOI: 10.1016/j.knee.2018.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 05/11/2018] [Accepted: 06/12/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND In this study, we analyzed long-term outcomes following treatment of traumatic popliteal vascular injuries in an urban level I trauma center, using a vessel-first approach in the case of combined vascular and bony/ligamentous injuries and discussing the relative merits of the medial and posterior approach to popliteal vessels. METHODS Data including patient demographics, mechanism and type of injury, severity of limb ischemia, Injury Severity Score (ISS), limb ischemia time, time to revascularization from admission, treatment strategy, type of vascular reconstruction, limb salvage and mortality were retrospectively collected in patients treated for traumatic popliteal vessel lesions. All patients in this study were operatively treated using medial and posterior approaches. A vessel-first approach was used where possible. RESULTS Twenty-four patients (13 male) with a median age of 45 years (range 21-88) and popliteal vessel injury after traumatic knee dislocation (n = 10, 42%), proximal tibia fracture (n = 5, 21%), distal femur fracture (n = 4, 17%), blunt popliteal injury (n = 3, 12%) and penetrating trauma (n = 2, 8%) were identified. Twelve (50%) patients were treated via a medial approach and 12 (50%) via a posterior approach. All had injury of the popliteal artery (15 complete transection, eight local intimal disruption and one pseudoaneurysm) with seven having additional popliteal vein and five with nerve injury. Nineteen patients (88%) presented with limb ischemia Rutherford category ≥II. Vessel reconstruction (four direct sutures, four patch plasties, 16 venous interposition/bypasses) was performed prior to bone/joint stabilization in 22 patients (92%). Thirty-day mortality was zero. Two above-knee amputations were performed within 30 days due to severe infection. During a median follow-up of 59 (range 12-143) months, there were no deaths and no amputations. At the end of follow-up, all patients denied claudication. CONCLUSIONS The vessel-first strategy promises an excellent outcome, independent of the surgical approach needed to repair traumatic popliteal vessel injuries.
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Affiliation(s)
- Paul G Fairhurst
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
| | - Thomas R Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
| | - Salome Weiss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
| | - Daniel Becker
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
| | - Juerg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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Usman R, Jamil M, Anwer MF. Evaluation, Surgical Management and Outcome of Traumatic Extremity Vascular Injuries: A 5-year Level-1 Trauma Centres Experience. Ann Vasc Dis 2018; 11:312-317. [PMID: 30402181 PMCID: PMC6200616 DOI: 10.3400/avd.oa.18-00068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: We aim to share our experience regarding the surgical management and outcome of extremity vascular trauma in level-1 trauma centres in Pakistan. Patients and methods: All consecutive patients with traumatic extremity vascular injury (TEVI) fulfilling the inclusion criteria; between June 2012 and June 2017 were included. The demographics, clinical presentation, management, and outcome measures were recorded. Results: The study included 81 patients. The mean age±standard deviation was 28.6±14.5 years and 81.5% (n=66) of the patients were males. Blunt TEVI was found in 65.4% (n=53) of the cases. Partial laceration was the most common type of arterial injury (64.2%, n=52) and autologous interposition venous grafting was the most common repair performed (60.5%, n=49). Fasciotomy was performed in 67.9% (n=55) of the patients. The limb salvage rate was 82.7%. The amputation rate was higher in the blunt trauma group when compared with that of the penetrating trauma group. The length of the intensive care unit stay and the use of polytetrafluoroethylene as interposition graft were two independent predictors of limb loss. The mortality rate in this series was 8.6%. Conclusion: Blunt TEVI is associated with higher morbidity and limb loss. The use of synthetic graft should be discouraged. The liberal use of autologous interposition venous graft and the judicious use of fasciotomies are helpful to achieve favorable outcomes.
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Affiliation(s)
- Rashid Usman
- Department of Vascular Surgery, Combined Military Hospital, Lahore Cantt, Pakistan
| | - Muhammad Jamil
- Department of Vascular Surgery, Combined Military Hospital, Peshawar Cantt, Pakistan
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