Upper extremity arterial injuries: experience at the Royal Adelaide Hospital, 1969 to 1991

Management of Traumatic Radial and Ulnar Artery Injuries and Risk Factors for Amputation

INTRODUCTION

Traumatic injuries to the radial and/or ulnar arteries represent a subset of arterial injuries. In the absence of injury to both forearm arteries, treatment was historically ligation if perfusion was maintained to the hand via the uninjured vessels or adequate collateral vessels. We sought to determine management of traumatic forearm arterial injuries in 2019 and to identify risk factors for major upper extremity amputation.

METHODS

The American College of Surgeons Trauma Quality Improvement Program database was queried by International Classification of Diseases 10 code for patients with traumatic radial and/or ulnar artery injuries within the year 2019. Patient demographics, Injury Severity Score, time to operating room, type of repair, outcomes, and mortality were collected. Multivariable logistic regression was used to identify risk factors for major upper extremity amputation.

RESULTS

A total of 4048 patients with traumatic radial and/or ulnar artery injuries were identified. A total of 1907 radial artery operations were performed including repair (59%), ligation (29%), and interposition bypass (12%). A total of 1637 ulnar artery operations were completed including repair (67%), ligation (21%), and interposition bypass (12%). Major upper extremity amputation occurred in 0.6%. Older age (adjusted odds ratio [AOR]: 1.014, 95% confidence interval [CI]: 1.004-1.024, P = 0.0048), blunt mechanism (AOR: 2.457, 95% CI: 1.730-3.497, P < 0.0.0001), and ipsilateral radial and ulnar artery injury (AOR: 2.148, 95% CI: 1.298-3.553, P = 0.0029) were associated with major amputation. Surgical revascularization, time to operating room, fasciotomy, and compartment syndrome were not associated with major amputation, but this may be secondary to Type II error.

CONCLUSIONS

In the operating room, radial and ulnar artery injuries were managed more often with restoration of flow versus ligation. Older age, blunt mechanism, and ipsilateral radial and ulnar artery injury were associated with major amputation. Amputation rate was low at 3% overall and 0.6% for amputation of the hand or a more proximal level. Upper extremity fracture, upper extremity nerve injury, and ipsilateral radial and ulnar artery injury were associated with need for revision operation.

Patency of arterial repairs from wartime extremity vascular injuries

BACKGROUND

Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability.

METHODS

Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency.

RESULTS

The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency.

CONCLUSIONS

Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries

Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress.

Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies.

Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.

Brachial Artery Transection After a Closed Traumatic Isolated Medial Epicondyle Fracture in a Pediatric Patient: A Case Report

BACKGROUND

Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage.

METHODS

A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported.

RESULTS

A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand.

CONCLUSIONS

Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome.

A Novel Combined Hybrid Approach to Enable Revascularisation of a Trauma-Induced Subclavian Artery Injury

Introduction

This case highlights the complexity of upper limb revascularization after a subclavian artery traumatic injury and strengthens the role of a hybrid/multi-disciplinary approach to such injuries.

Report

A 45-year-old male patient presented with an acute right upper limb following a traumatic injury to the right subclavian artery due to a motor vehicle accident (MVA). Associated injuries included an unstable cervical spine injury, a large open right clavicular injury, and a brain injury, which limited the potential revascularisation options available. The arm was revascularised using a hybrid endovascular/open surgical approach, namely embolization of the proximal subclavian artery (just distal to vertebral artery) and a right common femoral artery to distal axillary artery bypass using prosthetic material.

Discussion

Blunt injuries to the subclavian artery are often high impact, complex and associated with multiple injuries to surrounding structures, which limit the role of standard procedures used in the elective setting. This case highlights the role of multidisciplinary team involvement, using a hybrid approach and a novel distal inflow site to restore upper limb perfusion.

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Major vascular trauma often requires a multidisciplinary team approach.

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Prompt decision is required even if it involves unusual methods of treatment.

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A combined hybrid endovascular/open surgical treatment should be considered.

Surgical management of axillosubclavian vascular injuries

Objective:

Complex surgical exposures to upper extremity injuries required for conventional surgery correlate with a high morbidity and mortality. We present our results with conventional surgery following injuries of the subclavian and axillary vessels.

Methods:

Between November 2007 and March 2012, 29 cases with subclavian-axillary vascular injury were operated. Diagnostic and treatment methods, associated organ injury, morbidity and mortality rates in these cases were respectively reviewed.

Results:

The causes of injuries were stab wounds in 11 cases (37.9%), gunshot wounds in 9 cases (31%), iatrogenic injuries in 5 cases (17.2%) and blunt trauma 4 cases (13.7%). Eight patients (27.5%) had isolated arterial injury while 21 patients (72.4%) had coexisting organ injury (vein, bone, soft tissue, nerve). Primary repair and usage of saphenous vein were the most common surgical methods. One patient died due to myocardial infarction. (Mortality 3.4%)

Conclusions:

Vascular injuries of axillosubclavian are frequently associated with neurogenic, osseous and soft tissue injuries and should have early intervention. Conventional surgery remains the choice of treatment in patients with poor status and urgency.

Timing of forearm arterial repair in the well-perfused limb

The purpose of this study was to evaluate the difference in the outcomes of patients with a well-perfused hand who were taken to the operating room (OR) within 6 hours of forearm arterial injury vs patients who were treated in a semiurgent fashion. A review of 201 consecutive patients who were taken to the OR with forearm-level radial or ulnar arterial injury identified 26 patients who had a well-perfused hand at presentation in whom hemostasis was achieved within 15 minutes with manual pressure and no signs of hemodynamic instability. Outcomes of interest included short-version Disabilities of the Arm, Shoulder and Hand (quickDASH) scores and patient-reported cold intolerance. Of the 26 patients, group 1 included 17 patients who were taken to the OR within 6 hours and group 2 included 9 patients who were taken to the OR in a delayed fashion. Minimum follow-up in both groups was 13 months. Average quickDASH score was 24.5 and 14.1 for groups 1 and 2, respectively. Average time spent in the OR was significantly less in group 2 compared with group 1 (1.7 vs 2.8 hours). In the setting of forearm arterial injury with a well-perfused distal limb, there was no difference in functional outcome in patients taken to the OR emergently compared with those who underwent surgery in a delayed manner. With careful evaluation and monitoring, semiurgent operative repair is feasible and may improve certain aspects of patient care and hospital resource use. Outcome measures in this study support semiurgent treatment of these injuries.

Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients

BACKGROUND

The brachial artery is the most common vascular injury encountered in upper extremity trauma. If not treated promptly, it can result in compartment syndrome (CS) and long-term disability. Here, we report an institutional experience of traumatic brachial artery injuries and establish risk factors for the development of upper extremity CS in this setting.

METHODS

A retrospective review of 139 patients with traumatic brachial artery injury from 1985 to 2001 at a single institution. Patients were divided into two cohorts, those with evidence of CS and those without CS (NCS), for comparison.

RESULTS

One hundred thirty-nine patients presented with traumatic brachial artery injuries (mean age, 28.4 years). Twenty-nine patients (20.9%) were diagnosed with upper extremity CS, and 28 of these patients underwent fasciotomy on recognition of their CS. Seven patients (6.4%) in the NCS cohort underwent fasciotomy as a result of absent distal pulses on initial examination. Mean follow-up was 51.6 days. Two patients required revision of their arterial repair, and one patient underwent amputation. The risk of CS was increased in the presence of combined arterial injuries (p = 0.03), combined nerve injuries (p = 0.04), motor deficits (p < 0.0001), fractures, and increased intraoperative blood loss (p = 0.001). Multivariate logistic regression performed on these variables revealed that elevated intraoperative blood loss, combined arterial injury, and open fracture were independent risk factors for the development of CS (OR 1.12, 5.79, and 2.68, respectively).

CONCLUSION

Prompt evaluation and management of traumatic brachial artery injuries is important to prevent CS, which can lead to functional deficits. In the setting of combined arterial injury, open fracture, and significant intraoperative blood loss, prophylactic fasciotomy should be considered.

Endovascular intervention in thoracic arterial trauma

The management of thoracic vascular injury has improved dramatically over the past two decades. The availability of multi-row detector CT has facilitated early diagnosis and incorporation of minimally invasive endograft repair for traumatic aortic injury has improved mortality and paraplegia rates. This review evaluates the available data on stent-graft repair of acute blunt traumatic aortic injury and traumatic great vessel injury with regard to safety and efficacy in comparison with conventional open surgical repair.

Unusual presentation of ulnar artery aneurysm and dissection with associated anomalous radial artery: appearances on multi-detector row CT angiography

We present a case of ulnar artery aneurysm and dissection associated with a congenitally hypoplastic ipsilateral radial artery. We postulate that the aetiology is due to increased blood flow through the ulnar artery as a consequence of the radial artery anomaly, therefore making the ulnar artery more vulnerable to aneurysm formation and traumatic damage. This might represent a variant of the hypothenar hammer syndrome with associated ulnar artery dissection and recurrent distal embolisation manifesting as Raynaud's phenomenon. Forearm arterial injuries, treatment and the importance of upper limb arterial anatomical variations are also discussed. To our knowledge, this is the first reported case of its type diagnosed by multi-detector row computed tomography angiography.

Traumatic injuries to the subclavian and axillary arteries: a 13-year review

PURPOSE

By reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma.

METHODS

We retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002.

RESULTS

Arterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months.

CONCLUSION

Successful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.

Scapulothoracic dissociation: evaluation and management

Scapulothoracic dissociation is an infrequent injury with potentially devastating outcomes. Knowledge of this injury is based on small patient series and case reports. The aim of this article is to review the evaluation, management and functional outcomes following scapulothoracic dissociation. Often caused by high traction forces applied to the shoulder girdle, there is a complete loss of the scapulothoracic articulation with lateral scapular displacement and intact skin. This is frequently associated with muscular, ligamentous and osseous injuries to the shoulder girdle, vascular injuries to the subclavian, or axillary, vessels and brachial plexus lesions. In the acute setting, the timely diagnosis of the associated neurovascular injuries is crucial. Severe neurovascular and soft tissue compromise often requires an early above-elbow amputation. Further, complete brachial plexus avulsions are associated with a limited potential for functional recovery.

[Vascular injuries in extremities]

Vascular injuries of the extremities account for most instances of vascular trauma (ca. 70%), and they entail a risk of amputation about 10-20%. According to the kind of force that has acted, arterial trauma is classified as direct or indirect. The scale of hemorrhage and peripheral ischemia depend on the nature and severity of the arterial lesion. In patients with multiple injuries, routine use of Doppler sonography and duplex sonography can facilitate early diagnosis and treatment of vascular injuries. With great certainty, clinical examination and an AB or WB index of >1.0 can rule out the presence of vascular injury that requires treatment. After excluding further life-threatening injuries, surgery should be performed immediately when there is critical ischemia, squirting hemorrhage, or a rapidly expanding hematoma. Angiography or duplex sonography findings determine the further procedure in vascular injuries that do not require immediate treatment. Occlusion of a reconstructed artery, manifestation of a compartment syndrome, and insufficient anticoagulation are the main factors affecting the risk of amputation.

Acute ligation of the radial and ulnar arteries: A case report and review of literature

Isolated injury to the radial or ulnar artery results in no significant complications in patients who undergo repair or ligation of the injured artery. However, ligation of both infrabrachial vessels of the upper extremity is associated with limb loss from ischemia due to lack of collateral circulation. A rare case of acute ligation of both the radial and ulnar arteries in a drug abuser where collateral vessels preserved the circulation to the hand is reported.

An analysis of 124 surgically managed brachial artery injuries

BACKGROUND

A 3-year review of surgically managed brachial artery injuries is presented.

METHODS

The medical records were analyzed for demographic data, mechanism of injury, associated injuries, treatment, and outcome.

RESULTS

There were 113 males and 11 females with a mean age of 28.7 years. The majority of the injuries were caused by stab and gunshot wounds in 57.3% and 29%, respectively. Primary anastomosis was possible in 47 patients, whereas 73 patients required vein interposition grafting. Lower arm fasciotomy was performed in 15 patients (12.1%). Associated injuries included peripheral nerve lesions in 77 (62.1%), nonpaired brachial vein injuries in 17 (13.7%), and concomitant humerus fracture in 12 (9.7%) patients. Thirty-nine patients (31.5%) had remote injuries.

CONCLUSIONS

The primary repair of penetrating brachial artery injuries was possible in approximately one third of the patients. Approximately two thirds of the patients had associated nerve lesions. Critical limb ischemia rarely occurred.

Medicolegal evaluation of vascular injuries of limbs in Turkey

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group (n = 372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18 +/- 6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery (n = 73), and the deep femoral vein (n = 41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was 'organ dysfunction' in 37 (9.9%) and 'organ loss' in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents.

Functional outcome following scapulothoracic dissociation

BACKGROUND

Scapulothoracic dissociation is an infrequent injury that is often accompanied by neurovascular injuries with a potentially devastating outcome. The aim of this study was to evaluate the functional outcome following scapulothoracic dissociation.

METHODS

During a twenty-four-year period, we treated twenty-five patients with a scapulothoracic dissociation. The average age was 32.5 years. The average Injury Severity Score was 22 points. Nine patients had a complete brachial plexus avulsion, and ten had an incomplete brachial plexus avulsion. Three patients died from their associated injuries, and six patients required an above-the-elbow amputation. The outcome was assessed with use of the Short-Form 36-Item Health Survey, and the shoulder function of the patients who had not had an amputation was evaluated with use of the Subjective Shoulder Rating System. The degree of initial scapular lateralization was quantified with the scapula index.

RESULTS

The average duration of follow-up was 12.6 years. The physical and mental component summary scores and the scores on the role-physical, general health, vitality, and mental health subscales of the Short-Form 36-Item Health Survey were significantly lower for patients with a complete brachial plexus avulsion (p < 0.05). The Subjective Shoulder Rating System score was also significantly lower in patients with a complete brachial plexus avulsion (33.8 points compared with 72.5 points for the patients with no or an incomplete avulsion, p = 0.046). The average scapula index was 1.29 +/- 0.19. The scores on the Short-Form 36-Item Health Survey scales and the Subjective Shoulder Rating System score did not correlate with the initial scapula index (p > 0.05).

CONCLUSIONS

The presence of a complete brachial plexus avulsion is predictive of a poor functional outcome in a patient with a scapulothoracic dissociation. Therefore, we suggest a modification of the classification of the severity of this injury, with complete brachial plexus avulsion considered to be the most severe injury type.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Brachial and forearm vessel injuries

Upper extremity vascular injuries are common in trauma. The mortality rate from these injuries is quite low; however, the morbidity rate is quite significant. Prompt diagnosis and treatment can reduce the amputation rate for these injuries to minimal. Furthermore, morbidity from late complications of chronic ischemia, restenosis, and cold intolerance can be decreased as well. Fasciotomy, although less frequently required than in lower extremity injuries, should be used in all cases of suspected compartment syndrome.

Aggressive management of vascular injuries of the thoracic outlet

PURPOSE

We present a review of 35 patients who underwent an operation for subclavian (n = 18) or axillary (n = 17) vessel injury. In some patients, both an artery and a vein were damaged, resulting in a total of 30 arterial and 16 venous injuries.

METHODS

The wounding source included a gunshot (n = 19), a stab wound (n = 9,) and blunt trauma (n = 7). Seven patients had hypotension and were taken immediately to the operating room. Seventeen patients had diminished or absent pulses, whereas 13 patients had normal pulses despite an arterial injury. Associated injuries included nerve injury (n = 15), pneumohemothorax (n = 5), and fractures (n = 7). Angiography in 21 patients demonstrated an intimal flap (n = 8), extravasation (n = 5), a pseudoaneurysm (n = 3), an arteriovenous fistula (n = 2), and occlusion (n = 1). Two angiograms were normal. Arterial repair was accomplished by interposition graft (n = 17), primary repair (n = 9), patch angioplasty (n = 3,) and ligation (n = 1).

RESULTS

No functional deficits occurred in patients with an isolated vascular injury. Seven patients with associated brachial plexus injuries experienced severe disability. One arm of a patient was amputated. Two patients died.

CONCLUSIONS

The use of angiography helps to confirm and localize injuries. Prompt correction of the vascular injury avoids disability resulting from ischemia. Although the amputation rate is low with vascular repair, the functional disability resulting from associated nerve injuries can be devastating.

Difficult peripheral vascular injuries

Successful management of the difficult peripheral vascular injury requires a multidisciplinary approach. Prompt recognition of the vascular injury and adherence to the recognized principles of vascular repair provide a successful short-term surgical result. The long-term consequences of an injury are determined by the associated orthopedic, soft tissue, and nerve injuries.