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Lee CS, Scheidt J, Causey MW, Kauvar DS. Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries. Ann Vasc Surg 2024; 102:223-228. [PMID: 37926142 DOI: 10.1016/j.avsg.2023.09.099] [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: 08/10/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. METHODS A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). RESULTS Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar. CONCLUSIONS In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.
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Affiliation(s)
- Christina S Lee
- Department of Surgery, Brooke Army Medical Center, Ft. Sam, Houston, TX
| | - Justin Scheidt
- Department of Surgery, Brooke Army Medical Center, Ft. Sam, Houston, TX
| | - Marlin W Causey
- Vascular Surgery Service, Brooke Army Medical Center, Ft. Sam, Houston, TX; Department of Surgery, Uniformed Services University, Bethesda, MD
| | - David S Kauvar
- Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Mihas AK, Prather JC, Alexander BK, Boateng IB, Moran TE, Turnbull LM, Allen A, Vise H, Kammire MS, Moreno AF, McGwin G, Chen AT, Talerico MT, Obremskey WT, Weiss DB, Bergin PF, Spitler CA. Use of Computed Tomography Angiography to Predict Complications in Tibia Fractures: A Multicenter Retrospective Analysis. J Orthop Trauma 2023; 37:456-461. [PMID: 37074790 DOI: 10.1097/bot.0000000000002618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention. DESIGN Multicenter retrospective review. SETTING Six Level I trauma centers. PATIENTS AND INTERVENTION Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured. MAIN OUTCOME MEASUREMENTS Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation. RESULTS There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation. CONCLUSIONS Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander K Mihas
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - John C Prather
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Bradley K Alexander
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Isaac B Boateng
- Department of Orthopaedic Surgery, Vanderbilt Medical Center, Nashville, TN
| | - Thomas E Moran
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Lacie M Turnbull
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida-Gainesville, Gainesville, FL; and
| | - Andrew Allen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Healy Vise
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Maria S Kammire
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Andres F Moreno
- Department of Orthopaedic Surgery, Vanderbilt Medical Center, Nashville, TN
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew T Chen
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michael T Talerico
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida-Gainesville, Gainesville, FL; and
| | | | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Patrick F Bergin
- Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL
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ETLİ M, GÜRSU Ö. Derin venöz yaralanmalarda yüzeysel damarlar drenaj yolu olarak kullanılabilir mi? ACTA MEDICA ALANYA 2021. [DOI: 10.30565/medalanya.882073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Chrencik MT, Caraballo B, Yokemick J, Pappas PJ, Lal BK, Nagarsheth K. Infrapopliteal Arterial Pseudoaneurysm Development Secondary to Blunt Trauma: Case Series and Literature Review. Vasc Endovascular Surg 2020; 54:367-374. [PMID: 32079503 DOI: 10.1177/1538574420907184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Infrapopliteal arterial pseudoaneurysms (IAP) following blunt trauma with associated orthopedic injuries are uncommon, often present in a delayed fashion, and encompass a diagnostic and therapeutic dilemma. Herein, we present a series of IAPs that were diagnosed following blunt trauma and their management. METHODS Case series consisting of 3 patients and a review of the international literature. RESULTS Our case series included 3 patients presenting with IAPs following blunt trauma with associated orthopedic injuries. They were all identified in a delayed manner (>3 weeks) after the orthopedic injuries were treated. All patients presented with pain and a pulsatile mass while one concurrently had neurologic deficits. The pseudoaneurysms were diagnosed by duplex ultrasound and confirmed by angiography to be originating from the tibioperoneal trunk, anterior tibial, and posterior tibial arteries respectively. Two patients were treated with surgical excision. Of these, one required an arterial bypass procedure while the other underwent direct ligation only. The third patient was treated by endovascular coiling. A literature review from 1950 to the present found 51 reported cases of IAP resulting from blunt trauma. Ninety percent of trauma-related infrapopliteal injuries occurred in men with a mean delay in diagnosis of 5.6 months (median 1.8 months) after injury. Since 1950, management has shifted from primarily ligation to incorporating minimally invasive endovascular techniques when appropriate. CONCLUSIONS Infrapopliteal artery pseudoaneurysms are rare following blunt skeletal trauma. A delay in diagnosis often occurs and can result in major morbidity and extensive surgical intervention. We recommend a high index of suspicion and a thorough vascular examination in patients with lower extremity skeletal trauma to help identify and treat these injuries early and effectively.
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Affiliation(s)
- Matthew T Chrencik
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Brian Caraballo
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John Yokemick
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | | | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Khanjan Nagarsheth
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
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Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience. J Trauma Acute Care Surg 2019; 88:197-206. [DOI: 10.1097/ta.0000000000002548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tse C, Grigorian A, Nahmias J, Kabutey NK, Schubl S, Beckord B, Bowens N, de Virgilio C. Racial Disparities in Limb Amputations After Traumatic Vascular Injury. J Clin Orthop Trauma 2019; 10:S100-S105. [PMID: 31700207 PMCID: PMC6823806 DOI: 10.1016/j.jcot.2019.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/13/2019] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The influence of race or ethnicity on limb loss after traumatic vascular injury is unclear. We sought to determine whether there were racial differences in rates of amputation between American Indians, blacks, Asians, and Hispanics compared to white patients following arterial axillosubclavian vessel injury (ASVI), femoral artery injury (FAI), or popliteal artery injury (PAI). As black race has been identified as an independent prognostic factor for postsurgical complication in trauma-associated lower extremity amputation, we further hypothesized that black race would be associated with a higher risk for limb loss after arterial ASVI, FAI, and PAI injury in a large national database. METHODS The National Trauma Data Bank was queried for patients ≥16-years-old with arterial ASVI, FAI, or PAI to determine the risk of arm, above knee amputation (AKA), and below knee amputation (BKA), respectively. Covariates were included in separate multivariable logistic regression models for analysis. The reference group included white trauma patients. RESULTS From 5,683,057 patients, 21,843 were identified with arterial ASVI, FAI, or PAI (<0.4%). For arterial ASVI, American Indian race was associated with higher risk for upper-extremity amputation as compared to white race (OR = 5.10, CI = 1.62-16.06, p < 0.05). For FAI, black race was associated with (OR = 0.66, CI = 0.49-0.89, p < 0.05) a lower risk of AKA, compared to white race. For PAI, race was not associated with risk for BKA. CONCLUSION Black race is associated with a lower risk of AKA after FAI, compared to whites. Race was not associated with a risk for limb loss after PAI. Future prospective studies examining socioeconomic factors and access to healthcare within this patient population is warranted to identify barriers and areas of improvement.
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Affiliation(s)
- Christina Tse
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
- Corresponding author. Division of Trauma, Burns and Surgical Critical Care Department of Surgery University of California, Irvine Medical Center 333 The City Blvd West, Suite 1600; Orange, CA, USA.
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Nii-Kabu Kabutey
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Sebastian Schubl
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Brian Beckord
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nina Bowens
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
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Taman E, Ragab A, Khereba W, Attia K, Alshafey EO, Shoab SS. Single-Stage Vascular Repair and Tissue Cover in Complex Ankle Injuries. Ann Vasc Surg 2019; 61:467.e11-467.e16. [PMID: 31377391 DOI: 10.1016/j.avsg.2019.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/16/2019] [Accepted: 04/26/2019] [Indexed: 11/25/2022]
Abstract
Infragenicular arterial trauma with associated soft-tissue defects presents a challenging scenario. Vascular reconstruction along with concurrent tissue cover may be necessary. We present our experience with six vascular injuries with associated tissue loss. There were 3 male and 3 female patients (age range: 4-60 years). Minimum follow-up was for 12 months. All patients survived with satisfactory coverage of the defect. There was one partial necrosis treated conservatively. Satisfactory limb function was observed in all patients. Thus, these injuries may be treated by simultaneous vascular repair and local flap cover. This may help prevent postoperative infection and save the limb.
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Affiliation(s)
- Essam Taman
- Plastic Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt; Vascular Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt
| | - Almetwaly Ragab
- Plastic Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt; Vascular Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt
| | - Walied Khereba
- Plastic Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt; Vascular Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt
| | - Khaled Attia
- Plastic Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt; Vascular Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt
| | - Elghareeb Osman Alshafey
- Plastic Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt; Vascular Surgery Department, Faculty of Medicine for Boys, Al-Azhar University, New Damietta, Egypt
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8
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Lee CJ, Loo R, Wohlauer MV, Patel PJ. Diagnostic workup and endovascular treatment of popliteal artery trauma. VASA 2018; 48:65-71. [PMID: 30326793 DOI: 10.1024/0301-1526/a000756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial trauma.
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Affiliation(s)
- Cheong J Lee
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Rory Loo
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Max V Wohlauer
- 1 Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Parag J Patel
- 2 Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, USA
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Mansor S, Bendardaf R, Issa Y, Moftah M. The impact of urgent computed tomography angiography for gunshot wounds in extremities with concomitant vascular injuries on diagnosis and postoperative outcomes. Vascular 2018; 26:600-607. [PMID: 30041567 DOI: 10.1177/1708538118777445] [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: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Computed tomography angiography represents one of the most important investigation modalities in the diagnosis and follow-up of vascular diseases. We prospectively compare between patients who have had preoperative computed tomography (CT) angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in gunshot cases. METHODS A Cohort study to compare between patients who underwent preoperative CT angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in patients who suffer from urgent vascular reconstruction due to gunshot wounds in extremities with concomitant vascular injuries, in the time period from 17 February 2011 to 31 December 2011 in Al-Jalaa Hospital, Benghazi, Libya. RESULTS During the study period, 89 patients were included, of whom 88 (99%) were males and 1 (1%) was female; the mean age was 29.5 years. Patients were arranged into two groups. The first group of 38 patients (43%) were operated urgently without preoperative CT angiographic evaluation. The second group of 51 patients (57%) have had a preoperative CT angiographic evaluation. CONCLUSION In the light of our study, we favor the immediate operative exploration of gunshot wounds in extremities with concomitant hard signs of vascular injuries without waiting for preoperative CT angiography, thereby minimizing the shock state and ischemic interval. CT angiography may be required for a more stable patient to avoid unnecessary surgical exploration.
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Affiliation(s)
- Salah Mansor
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya.,2 Department of General Surgery, Libyan International Medical University, Benghazi, Libya
| | - Rashid Bendardaf
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya
| | - Youssef Issa
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya
| | - Muad Moftah
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya
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Vascular Damage Control. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0131-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Vascular Reconstruction Is Not Warranted in Most Civilian Traumatic Shank Vascular Injuries. Ann Vasc Surg 2016; 35:38-45. [DOI: 10.1016/j.avsg.2016.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 02/09/2016] [Accepted: 02/12/2016] [Indexed: 11/22/2022]
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Sun YF, Fang QX, Zhan HY, Wang F, Cao W, Zhao G. Outcome Assessments of Patients with Posttraumatic "Ultra-Time Vascular Injuries" of the Extremities. Sci Rep 2015; 5:17913. [PMID: 26639214 PMCID: PMC4671146 DOI: 10.1038/srep17913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 11/09/2015] [Indexed: 11/15/2022] Open
Abstract
The management of posttraumatic vascular injury that presents after 8 h, or “ultra-time vascular injury”, is daunting, and inciting recognition of this injury is vital. We retrospectively analyzed 29 patients with ultra-time vascular injuries to determine the patients’ demographic characteristics and identify the determinants for amputation and disability. The age distribution of the high-risk population was from 18 years to 40 years, which indicated that these patients had plenty of productive life remaining. Injuries to the lower limbs (79.31%) were over four times more common than injuries to the upper limbs (17.24%), and open and blunt injuries occurred most commonly. The overall rate of limb salvage was 82.76% (24/29) and limb function is excellent in 45.83% (11/24) of the patients. The remaining patients experienced different degrees of disability in their limbs, which was determined by the anatomic location of the injury, and the presence of a combined arterial and venous injury, nerve injury, and complex soft tissue injury, as well as the occurrence of compartment syndrome. Hence, we recommend limb-salvage treatment for patients with traumatic ultra-time vascular injuries, particularly for those aged between 18 years and 40 years. Furthermore, we encourage the development of limb-salvage techniques for ultra-time vascular injuries.
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Affiliation(s)
- Yi-Feng Sun
- Traumatology Department of Shandong Provincial Qianfoshan Hospital, Shandong University, Jingshi Road 16766, Jinan, Shandong 250014, PR China
| | - Qiong-Xuan Fang
- Liver Disease Department of the Second Hospital of Shandong University (SHSU), Beiyuan Road 247, Jinan, Shandong 250033, PR China
| | - Hong-Yan Zhan
- The Fourth Hospital of Jinan city, Jinan, Shandong, 250031, PR China
| | - Fan Wang
- Traumatology Department of Shandong Provincial Qianfoshan Hospital, Shandong University, Jingshi Road 16766, Jinan, Shandong 250014, PR China
| | - Wei Cao
- Traumatology Department of Shandong Provincial Qianfoshan Hospital, Shandong University, Jingshi Road 16766, Jinan, Shandong 250014, PR China
| | - Gang Zhao
- Traumatology Department of Shandong Provincial Qianfoshan Hospital, Shandong University, Jingshi Road 16766, Jinan, Shandong 250014, PR China
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Rattan R, Jones KM, Namias N. Management of Lower Extremity Vascular Injuries: State of the Art. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0118-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Late revascularization of brachial artery injury: two cases. Indian J Thorac Cardiovasc Surg 2014. [DOI: 10.1007/s12055-014-0343-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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15
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Tsuji Y, Kitano I, Tsuji Y, Sawada K. Traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. Ann Vasc Dis 2014; 7:325-7. [PMID: 25298838 DOI: 10.3400/avd.cr.14-00046] [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: 04/06/2014] [Accepted: 05/29/2014] [Indexed: 11/13/2022] Open
Abstract
We describe a rare case of traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. The vein graft was disrupted at the level of ankle joint by blunt trauma and symptoms of acute foot ischemia were recognized. The injured vein graft was reconstructed with cephalic vein graft interposition. He has been free from any events of foot ischemia at 10 months follow-up with patent vein graft to the dorsalis pedis artery.
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Affiliation(s)
- Yoshihiko Tsuji
- Department of Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Ikuro Kitano
- Department of Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Yoriko Tsuji
- Department of Plastic Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Katsuhiro Sawada
- Department of Surgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
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Management of major limb injuries. ScientificWorldJournal 2014; 2014:640430. [PMID: 24511296 PMCID: PMC3913364 DOI: 10.1155/2014/640430] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/02/2013] [Indexed: 12/16/2022] Open
Abstract
Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.
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Stuebing E, Lieberman H, Vu T, Mazzini FN, De Gregorio L, Gigena A, Iglesias E, Gonzalo R, Perez-Alonso AJ, Asensio JA. Shank vessel injuries: the forgotten vascular injuries. Eur J Trauma Emerg Surg 2012; 38:393-401. [PMID: 26816120 DOI: 10.1007/s00068-012-0196-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 05/04/2012] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Vascular injuries in branch vessels of the popliteal artery, such as the tibioperoneal trunk, and shank vessels, such as anterior, posterior tibial, and peroneal vessels, occur in both blunt and penetrating trauma. Their management has evolved significantly in the past few decades. While their incidence is variable, limb loss and morbidity remain significant. MATERIAL AND METHODS Physical examination, along with measuring an Ankle-Brachial Index (ABI), is still sometimes all that is required for diagnosis and can expeditiously triage those that require urgent operation. Despite our technological advancements and newer algorithms for lower extremity vascular trauma, operative intervention and exposure still remain difficult and pose a great challenge for surgeons that normally do not operate on this area. CONCLUSIONS Shank vessel injuries still comprise a significant proportion of combat and civilian vascular injuries, and modern advances have led to a dramatic decrease in amputation rates.
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Affiliation(s)
- E Stuebing
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - H Lieberman
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - T Vu
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - L De Gregorio
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A Gigena
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - E Iglesias
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - R Gonzalo
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A J Perez-Alonso
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J A Asensio
- Division of Trauma Surgery and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA.
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18
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Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg 2011; 53:1604-10. [DOI: 10.1016/j.jvs.2011.01.052] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/20/2011] [Accepted: 01/21/2011] [Indexed: 10/18/2022]
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Abstract
Poor vascularity can be a potential contributor in the development of fracture nonunion. There is little evidence in orthopaedic literature suggesting that poor vascularity alone may lead to the development of nonunion. Experimental models addressing the effects of ischemia on fracture healing have yielded conflicting views. The case presented here describes a patient who sustained a Type IIIC tibial shaft fracture requiring vascular repair and soft tissue coverage. The patient developed an aseptic, atrophic nonunion. In preparation for operative management of her nonunion, the patient underwent angioplasty in the lower extremity for stenotic vessels. Shortly thereafter, the patient's nonunion went on to unite with no additional intervention, suggesting that revascularization alone resulted in this dramatic progress to union. Further prospective clinical studies may reveal a role for the use of vascular evaluation and intervention in the diagnosis and treatment of nonunion.
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20
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Causey MW, Oguntoye MO, Miller S, Andersen C, Singh N. Limb salvage after delayed diagnosis for blunt traumatic infrapopliteal occlusion. J Vasc Surg 2010; 52:734-7. [DOI: 10.1016/j.jvs.2010.03.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 03/24/2010] [Accepted: 03/25/2010] [Indexed: 11/24/2022]
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21
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Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K, Propper BW, Rasmussen TE. Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg 2010; 52:91-6. [PMID: 20471774 DOI: 10.1016/j.jvs.2010.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/25/2010] [Accepted: 02/07/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury. METHODS The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation. RESULTS Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P < .01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score >5 (hazard ratio [HR], 2.7; P = .01) and amputation. CONCLUSIONS This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.
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Affiliation(s)
- Gabriel E Burkhardt
- Department of Surgery, San Antonio Military Medical Consortium, Lackland Air Force Base, San Antonio, Texas 78236, USA
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23
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Crural artery traumatic injuries: treatment with embolization. Cardiovasc Intervent Radiol 2008; 31:550-7. [PMID: 18299924 DOI: 10.1007/s00270-008-9309-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 01/15/2008] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
Abstract
The purpose of this paper is to report our experience with the endovascular treatment of crural arterial injuries using transcatheter and direct embolization techniques. A total of eight consecutive patients have been treated during a 7-year period. Six males and two females, mean age 32 years (range, 15-56 years), presented with penetrating trauma to the lower extremities. Mechanisms of injuries were stab wounds in six patients, gun shot wound in one patient, and iatrogenic injury in one patient. Five patients presented with acute trauma, while three patients presented with delayed injuries. Crural arterial injuries encountered included pseudoaneurysms with arteriovenous fistulas (n = 6), pseudoaneurysms with vessel transections (n = 2), and pseudoaneurysm (n = 1). Proximal and distal embolization with coils was used in three cases, proximal embolization with coils in three cases, percutaneous thrombin injection in one case, and liquid n-butyl cyanoacrylate in one case. Complete exclusion of the lesions was accomplished by sacrifice of one crural vessel in seven cases and of two crural vessels in one case. Two cases of delayed injuries required combined coil and liquid embolization techniques for lesion exclusion. A minor complication (groin hematoma) occurred in one patient, no distal ischemia was seen, and no amputations were required. Mean follow-up was 61 days (range, 1-180 days). One pseudoaneurysm treated with thrombin injection recurred and required surgical excision. We conclude that transcatheter embolization alone or in combination with different endovascular techniques is useful in the treatment of traumatic crural vessel injuries.
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Abstract
The management of lower extremity vascular injuries has undergone dramatic changes over the last century. With the optimal management of femoral and popliteal injuries established, controversy still exists with respect to management of vascular injuries below the popliteal fossa, in the shank arterial vessels. These injuries are uncommon, often limb threatening, and usually require complex management decisions. Incidence of shank vessel injuries, imaging studies required for accurate and expedient diagnosis, determinants influencing the decision for repair or amputation, and details of techniques in surgical intervention are discussed.
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Affiliation(s)
- Vincent L Rowe
- Division of Vascular Surgery, Keck School of Medicine, Los Angeles, California 90033, USA.
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25
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Abstract
BACKGROUND Guidelines for the management of popliteal artery trauma emanate mainly from military experience. This study was undertaken to describe the management of popliteal injuries in a civilian vascular surgical unit with a large trauma workload. METHODS A retrospective review of records of patients treated between 1983 and 1997 was undertaken. RESULTS Some 117 popliteal artery gunshot injuries were treated (83 low velocity, 16 high velocity, 18 shotgun). Associated fractures occurred in 44 patients and 40 had popliteal vein injuries. Treatment of the arterial injury included vein graft interposition in 71, primary reanastomosis in 19, prosthetic graft interposition in four, lateral suture in one, vein patch in one and ligation in one patient; 84 fasciotomies were performed. No perioperative deaths occurred. There were 20 primary and 14 secondary amputations. Factors associated with amputation were high-velocity injuries, delay in revascularization in excess of 7 h, arterial transection, associated fracture, and compartment syndrome or muscle infarction. CONCLUSION Civilian popliteal gunshot injuries are attended by a high amputation rate. Prompt resuscitation and revascularization appear to be the only correctable factors that may improve limb salvage rates.
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Affiliation(s)
- R Nair
- Metropolitan Vascular Service, Department of Surgery, University of Natal, Durban, South Africa
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26
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Grossman MD, Reilly P, Mcmahan D, Kauder D, Schwab C. Gunshot Wounds below the Popliteal Fossa: A Contemporary Review. Am Surg 1999. [DOI: 10.1177/000313489906500416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.
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Affiliation(s)
- Michael D. Grossman
- Division of Trauma and Surgical Critical Care, St. Luke's Hospital, Bethlehem, Pennsylvania
| | - Patrick Reilly
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Damian Mcmahan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donald Kauder
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - C.W. Schwab
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Abstract
This article focuses on some general principles of care and then discusses devastating pelvic injury secondary to both blunt and penetrating trauma. The authors describe the current approach to the mangled extremity and discuss indications for primary amputation.
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Affiliation(s)
- S M Henry
- Department of Emergency Medicine, SUNY, Health Science Center at Brooklyn, USA
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Radonic V, Baric D, Petricevic A, Kovacevic H, Sapunar D, Glavina-Durdov M. War injuries of the crural arteries. Br J Surg 1995; 82:777-83. [PMID: 7627509 DOI: 10.1002/bjs.1800820620] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Twenty-eight patients with military crural vascular injuries are presented. In the group undergoing immediate repair (21 patients), the time interval between trauma and surgery was 20 min to 30 h (mean 8 h 30 min). In those receiving delayed repair (seven patients), the interval between trauma and surgery was 3-47 (mean 14) days. Hyperbaric oxygenation therapy was used in conjunction with surgery and antibiotic therapy in 13 of the 28 patients. Explosive injuries were found in 14 patients and high-velocity missile injuries in nine; associated fractures were present in 20. Twenty of the 28 patients with crural vascular injuries had combined arterial and venous injuries, while eight had isolated arterial injuries. Twenty-five patients with distal ischaemia required arterial repair; five late amputations resulted. Military crural vascular injuries should be treated with soft tissue debridement, removal of foreign material, and microvascular arterial and concomitant vein reconstruction. This should be followed by external skeletal stabilization for bony and/or soft tissue instability, with fasciotomy for any associated compartment syndrome. The wound should be left open, with delayed closure or split skin grafting. It was felt that hyperbaric oxygen therapy reduced the amputation rate following combat-related crural vessel injuries.
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Affiliation(s)
- V Radonic
- Surgical Clinic, Split Clinical Hospital Centre, Croatia
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29
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Lazarides MK, Arvanitis DP, Kopadis GC, Tsoupanos SS, Dayantas JN. Popliteal artery and trifurcation injuries: is it possible to predict the outcome? EUROPEAN JOURNAL OF VASCULAR SURGERY 1994; 8:226-30. [PMID: 8181620 DOI: 10.1016/s0950-821x(05)80465-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The records of 18 consecutive patients with popliteal and/or trifurcation civilian arterial injuries, who underwent revascularisation procedures during a 5-year period, were retrospectively assessed. All patients were classified using four, previously described, severity scoring systems in an effort to investigate the accuracy of predicting the outcome of this type of injury. Classification of the severity of popliteal artery trauma would be useful (a) for setting objective criteria (if any) for primary amputation and (b) for retrospective assessment of the results in vascular audit. The amputation rate in this group was 28%. Limbs which could not be salvaged were all in the "trifurcation" group and in this subset of patients the amputation rate was 71% (5/7). The scoring index having the higher overall accuracy (94%) was the mangled extremity syndrome index (MESI) with a predictive value for amputation of 83%. The use of these indices as criteria for primary amputation needs further evaluation as no scoring system was specific enough to permit primary amputation on that basis alone. The predictive value for limb salvage was 100%, for all four scoring systems enabling their use in vascular trauma audit.
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Affiliation(s)
- M K Lazarides
- Department of Vascular Surgery, Athens General Hospital, Greece
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