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Layman JR, Benarroch-Gampel J, Sciarretta JD, Rajani RR, Muralidharan VJ, García-Toca M, Ramos CR. Identifying Risk Factors for Poor Outcomes Following Popliteal Vascular Injuries. Ann Vasc Surg 2024; 109:309-315. [PMID: 39067847 DOI: 10.1016/j.avsg.2024.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/02/2024] [Accepted: 06/02/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Popliteal artery injuries (PAIs) may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following PAIs in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries. METHODS A retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with PAIs were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation. RESULTS One hundred eighty eight patients with PAIs were identified; 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (P = 0.0132) and neurologic deficits on arrival (P = 0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N = 93), there was no significant difference in amputation rates between those who had vein repair (P = 0.21) and those who underwent ligation (P = 0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (P = 0.20) or skin graft area (P = 0.48) based on linear regression analysis. CONCLUSIONS Our study suggests that major amputations following PAIs are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries.
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Affiliation(s)
- John R Layman
- Medical College of Georgia Augusta University/University of Georgia Medical Partnership, Athens, GA, USA
| | - Jaime Benarroch-Gampel
- Emory University School of Medicine, Atlanta, GA, USA; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jason D Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA; Acute Care and Trauma Surgery, Grady Memorial Hospital, Atlanta, GA, USA
| | - Ravi R Rajani
- Emory University School of Medicine, Atlanta, GA, USA; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Manuel García-Toca
- Emory University School of Medicine, Atlanta, GA, USA; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, Atlanta, GA, USA
| | - Christopher R Ramos
- Emory University School of Medicine, Atlanta, GA, USA; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, Atlanta, GA, USA.
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Juneja A, Garuthara M, Talathi S, Rao A, Landis G, Etkin Y. Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia. Vascular 2024; 32:632-639. [PMID: 36696536 DOI: 10.1177/17085381231154290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. METHODS A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. RESULTS The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality. CONCLUSIONS Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.
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Affiliation(s)
- Amandeep Juneja
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Melissa Garuthara
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sonia Talathi
- Division of Vascular and Endovascular Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Amit Rao
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Gregg Landis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Yana Etkin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Trinh SY, Boggs HK, Kiang SC, Tran Z, Abou-Zamzam AM, Tomihama RT. The Order of Operative Repair Does Not Influence Outcomes in Patients with Concomitant Popliteal Artery and Orthopedic Injuries. Ann Vasc Surg 2024; 101:23-28. [PMID: 38122977 DOI: 10.1016/j.avsg.2023.10.024] [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: 12/23/2021] [Revised: 09/23/2023] [Accepted: 10/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The most challenging lower extremity traumatic injuries involve concomitant vascular and orthopedic injuries with amputation rates approaching 50%. Controversy exists as to how to prioritize the vascular and orthopedic repairs. We reviewed patients with popliteal artery and lower extremity orthopedic injuries to analyze the sequence of the vascular and orthopedic repairs on outcomes. METHODS All adult patients with a diagnosis of concomitant popliteal artery and lower extremity fracture or dislocation were identified through a review of an institutional trauma registry performed at a level 1 trauma center from 2014 to 2019. Patient demographics, timing of presentation, injury severity score (ISS), surgical interventions, and limb outcome data were collected and examined. The sequence of operative repairs and factors influencing the operative order were analyzed. RESULTS Twenty-nine patients were treated for popliteal artery injuries. Twelve of these 29 patients had concomitant popliteal artery and orthopedic fractures requiring surgical repair. Injury mechanisms included both blunt (50%, 6/12) and penetrating trauma (50%, 6/12); the majority involved femur fractures (58%, 7/12). Vascular repair included arterial bypass (75%, 9/12) or interposition grafts (25%, 3/12). Orthopedic repair included external fixation (83%, 10/12) and open reduction internal fixation (17%, 2/12). Vascular repair was performed first in 7/12 limbs (58%). Patients having vascular repair first had a trend toward lower blood pressure on arrival (P = 0.068). There was no significant difference in emergency department to operating room (OR) time, OR time, ISS, mangled extremity severity score, estimated blood loss, or blood transfusion for the sequence of operative repair. Fasciotomy was nearly ubiquitous, present in 11/12 patients (92%). There were no graft complications related to orthopedic manipulation, and there were no reported limb-length to graft-length discrepancies. Early limb salvage trended lower in the cohort with revascularization first (71% vs. 100%, P = 0.19). Of the remaining limbs available for follow-up, limb salvage at 4.25 years is 100%. CONCLUSIONS In this small study of patients with concomitant lower extremity popliteal artery and orthopedic injuries, the order of operative repair does not appear to influence the success of revascularization.
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Affiliation(s)
- Shauna Y Trinh
- Department of Surgery, Riverside University Health System, Moreno Valley, CA
| | - Hans K Boggs
- Division of Vascular Surgery, Department of Surgery, Linda University School of Medicine, Loma Linda, CA
| | - Sharon C Kiang
- Division of Vascular Surgery, Department of Surgery, Linda University School of Medicine, Loma Linda, CA; Division of Vascular Surgery, Department of Surgery, VA Loma Linda Healthcare System, Loma Linda, CA.
| | - Zachary Tran
- Division of Trauma Surgery/Critical Care, Department of Surgery, Linda University School of Medicine, Loma Linda, CA
| | - Ahmed M Abou-Zamzam
- Division of Vascular Surgery, Department of Surgery, Linda University School of Medicine, Loma Linda, CA
| | - Roger T Tomihama
- Department of Radiology, Section of Vascular and Interventional Radiology, Linda University School of Medicine, Loma Linda, CA
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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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Liu G, Li L, Xu H, Kang B. Five-year outcomes after bypass graft versus Fogarty balloon catheter for the treatment of acute blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1989-1996. [PMID: 37039830 DOI: 10.1007/s00068-023-02268-y] [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: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To evaluate long-term clinical outcomes after revascularization by bypass graft versus Fogarty balloon catheter in acute blunt popliteal artery injury and identify risk factors contributing to amputation. METHODS A retrospective review was conducted in patients treated for acute blunt PAI between 2011 and 2019. Inclusion criteria were patients who underwent bypass graft and Fogarty balloon catheter. The cumulative limb salvage rate was calculated by the Kaplan-Meier test and compared with Breslow-Wilcoxon test. Cox proportional hazard model was performed to estimate the potential risk factors for amputation. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off value for the potential risk factors. RESULTS The overall limb salvage rate was 60.4% (29/48), including 24 patients (66.7%) in bypass graft, and 5 patients (41.7%) in Fogarty balloon catheter with mean follow-up of 5 years (range, 2-10 years). Among amputees, 15 patients (15/19, 78.9%) received primary amputation due to vascular failure or severe soft tissue damage, and 4 received secondary amputation because of chronic bone infection or neurologic deficit. Kaplan-Meier curves showed patients who received Fogarty balloon catheter had significantly higher amputation rate than those received bypass graft, with a hazard ratio of 3.801 (95% CI: 1.162-12.43, p = 0.009). In addition, Cox proportional hazard model revealed that MESS was the only independent risk factor for patients developing amputation, and the optimal cut-off value of MESS was 8. CONCLUSION Five-year outcome demonstrated that Fogarty balloon catheter is not a safe procedure and has significantly higher amputation rate in severe blunt PAI. MESS is the only risk factor for amputation.
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Affiliation(s)
- Gang Liu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Lin Li
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Han Xu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Bin Kang
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China.
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Edwards J, Treffalls RN, Abdou H, Stonko DP, Walker PF, Morrison JJ. Lower Extremity Staged Revascularization (LESR) as a new innovative concept for lower extremity salvage in acute popliteal artery injuries: a hypothesis. Patient Saf Surg 2022; 16:39. [PMID: 36522769 PMCID: PMC9756456 DOI: 10.1186/s13037-022-00349-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Popliteal artery injury following knee dislocation is associated with significant morbidity and high amputation rates. The complex and multi-disciplinary input required to manage this injury effectively can take time to arrange, prolonging the time to revascularization. Furthermore, open surgical bypass or interposition graft can be technically challenging in the acute setting, further prolonging ischemic time.Temporary intravascular shunts can be used to temporarily restore flow but require surgical exposure which takes time. Endovascular techniques can decrease the time to revascularization; however, endovascular popliteal stent-grafting is controversial because the biomechanical forces relating to flexion and extension of the knee may increase the risk of stent thrombosis. An ideal operation would result in rapid revascularization, eventually leading to a definitive and durable surgical solution.We hypothesize that a staged approach combing extracorporeal shunting, temporary endovascular covered stent placement, external fixation of bony injury, and definitive open repair provides for a superior approach to popliteal artery injury than current standard of care. We term this approach lower extremity staged revascularization (LESR) and the aim is to minimize the known factors contributing to poor outcomes after traumatic popliteal artery injury.
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Affiliation(s)
- Joseph Edwards
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Rebecca N. Treffalls
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Hossam Abdou
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - David P. Stonko
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA ,grid.411935.b0000 0001 2192 2723Department of Surgery, Johns Hopkins Hospital, Baltimore, MD USA
| | - Patrick F. Walker
- grid.411024.20000 0001 2175 4264R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Jonathan J. Morrison
- grid.66875.3a0000 0004 0459 167XDepartment of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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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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Lip HTC, Huei TJ, Peng LE, Huan KZ, Sen CJ, Muhamad I, Mohamad Y, Alwi RI. Outcomes of traumatic extremity vascular injuries from a Malaysian level 1 trauma center. Injury 2022; 53:3005-3010. [PMID: 35410740 DOI: 10.1016/j.injury.2022.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/03/2022] [Accepted: 03/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In Malaysia, management of traumatic vascular injuries is at the discretion of the treating surgeon (trauma or vascular surgery). This study was conducted to report on the epidemiology, mechanism of injury and outcomes of vascular injuries managed in a regional level 1 trauma center. METHODS This is a retrospective cohort study of all patients treated for traumatic extremity vascular injuries from January 2018 to December 2020. Demography, mechanism of injury, pre-operative physiologic vital signs, vessel injured, injury severity (NISS, RTS and TRISS score), type of revascularization surgery, fasciotomy, post-operative blood investigations, operative outcomes (amputation, length of stay and ICU admission) and long-term rehabilitation follow-up were recorded and analyzed. RESULTS Amongst the 35 recorded vascular injuries only 28 patients had adequate data that were included in the analysis. Majority of patients were males (23/28patients; 82%). Blunt injury to vessels was more likely in motorcycle crashes (16/28patients; 76%) than in automobile crashes (5/28patients; 24%). There were three lower limb amputees (3/3patients; 100%) that had early fasciotomy and were associated with three-fold higher post-operative median (interquartile range) CK levels of 16740 (8157 to 23116) u/l. Only two thirds (16/28 patients) had active rehabilitation follow-up and were back to work after a median duration of four months. CONCLUSION Male gender, blunt injury, road traffic crashes and motorcycles were the majority of vascular injuries. Lower limb vascular injuries had poorer outcome with three amputations performed after attempts at revascularization. Fasciotomy and high CK level may be related to higher risk of limb loss. Our study highlights the importance of rehabilitation and long-term follow-up in this cohort of patients.
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Affiliation(s)
- Henry Tan Chor Lip
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia.
| | - Tan Jih Huei
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
| | - Lee Ee Peng
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
| | - Khoo Zi Huan
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
| | - Chuah Jun Sen
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
| | - Izwan Muhamad
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
| | - Yuzaidi Mohamad
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
| | - Rizal Imran Alwi
- Trauma Surgery Unit, Department of General Surgery, Hospital Sultanah Aminah, Jalan Abu Bakar, masjid abu bakar, Johor Bahru 81100, Malaysia
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Hsieh YH, Lee MC, Hsu CC, Chen SH, Lin YT, Lin CH, Lin CH. Popliteal Artery Injury After Fracture and/or Dislocation of the Knee: Risk Stratification for Revascularization Outcome. Ann Plast Surg 2022; 88:S50-S55. [PMID: 35225847 DOI: 10.1097/sap.0000000000003076] [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
BACKGROUND Managing complex knee trauma involving both vascular and osseous injuries is challenging, yet the available guidelines for efficient popliteal artery injury management after high-velocity blunt knee trauma remain conflicting and inconsistent. In this study, the authors aim to identify the risk factors associated with delayed limb amputation and ischemic muscular sequela postrevascularization. Furthermore, we propose a treatment algorithm to improve the limb salvage rate. METHODS Patients who presented with traumatic popliteal artery injury resulting in vessel occlusion or rupture, followed by fracture and/or dislocation of the knee from January 2008 to December 2013, were included for retrospective review. RESULTS Overall delayed amputation rate was 24% (7/29) and 16% (4/25) after successful revascularization. Mangled Extremity Severity Score is higher in the delayed amputation group than the limb-salvaged group (P = 0.02). Higher-impact force (P = 0.03), ischemic limb on presentation (P = 0.03), prolonged ischemia time (P = 0.04), unstable hemodynamics (P = 0.01), longer operation time (P = 0.04), and prolonged intensive care unit stay (P = 0.03) are risk factors of delayed amputation. Longer ischemia time (P = 0.04) and length of popliteal artery injury (P = 0.02) are associated with ischemic muscular sequela. CONCLUSIONS Mangled Extremity Severity Score is a reliable predictor of limb salvage. An algorithmic approach may improve the outcome of popliteal artery injury after high-velocity blunt knee trauma.
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Affiliation(s)
- Yun-Huan Hsieh
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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11
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Fujioka M, Fukui K, Noguchi M. The Efficacy of Salvage Intervention with Emergency Transient External Arterial Bypass for Traumatic Artery Occlusion of Main Extremities. J Emerg Trauma Shock 2022; 15:56-59. [PMID: 35431483 PMCID: PMC9006713 DOI: 10.4103/jets.jets_88_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/04/2022] Open
Abstract
Even if the vascular repair is successful, the frequency of limb loss is still high when popliteal artery injury is associated with postischemic syndrome due to blunt trauma or a prolonged ischemic time. Because prolonged ischemia interferes with an injured foot rescue, shortening of the ischemic time is a major aim of surgeons. We present two types of transient external arterial bypass and two cases of ischemic extremities due to main arterial injury. Even though the injured extremities had no circulation for more than 6 h, a transient external arterial bypass supplied circulation immediately, and they were reconstructed successfully. Although transient external arterial bypass is a dated technique, it is a recommended option, especially in the management of acute traumatic ischemia of the extremities to shorten the ischemic time and provide immediate reperfusion, which will bring the opportunity to save the ischemic limbs.
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Affiliation(s)
- Masaki Fujioka
- Department of Plastic and Reconstructive Surgery, Nagasaki University, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan.,Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Kiyoko Fukui
- Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Miho Noguchi
- Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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12
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O'Banion LA, Dirks R, Saldana-Ruiz N, Farooqui E, Yoon WJ, Pozolo C, Fox CJ, Crally A, Siada S, Nehler MR, Brooke BS, Beckstrom JL, Kiang S, Boggs HK, Chandra V, Ho VT, Zhou W, Lee A, Bowens N, Cho Y, Woo K, Ulloa J, Magee GA. Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study. J Vasc Surg 2021; 74:1573-1580.e2. [PMID: 34023429 DOI: 10.1016/j.jvs.2021.04.064] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. METHODS A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis. RESULTS A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. CONCLUSIONS Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.
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Affiliation(s)
- Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif. leighann.o'
| | - Rachel Dirks
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif
| | - Nallely Saldana-Ruiz
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Emaad Farooqui
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - William J Yoon
- Division of Vascular Surgery, Department of Surgery, University of California, Davis, Davis, Calif
| | - Cara Pozolo
- Division of Vascular Surgery, Department of Surgery, University of California, Davis, Davis, Calif
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, Denver, Colo
| | - Alexis Crally
- Department of Surgery, Denver Health Medical Center, Denver, Colo
| | - Sammy Siada
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif; Division of Vascular Surgery, Department of Surgery, University of Colorado Denver, Denver, Colo
| | - Mark R Nehler
- Division of Vascular Surgery, Department of Surgery, University of Colorado Denver, Denver, Colo
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Julie L Beckstrom
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Sharon Kiang
- Division of Vascular and Endovascular Surgery, Department of General Surgery, Loma Linda University Medical Center, Loma Linda, Calif
| | - Hans K Boggs
- Division of Vascular and Endovascular Surgery, Department of General Surgery, Loma Linda University Medical Center, Loma Linda, Calif
| | - Venita Chandra
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Ashton Lee
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Nina Bowens
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif
| | - Yan Cho
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | - Jesus Ulloa
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
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13
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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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14
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Popliteal scoring assessment for vascular extremity injuries in trauma study. J Vasc Surg 2021; 74:804-813.e3. [PMID: 33639233 DOI: 10.1016/j.jvs.2021.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/06/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. A method to evaluate the predictors of amputation is needed because previous scores could not be validated. In the present study, we aimed to provide a simplified scoring system (POPSAVEIT [popliteal scoring assessment for vascular extremity injuries in trauma]) that could be used preoperatively to risk stratify patients with traumatic popliteal vascular injuries for amputation. METHODS A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared with those with limb salvage at the last follow-up. Of these patients, 80% were randomly assigned to a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (P < .1) on univariate analysis were included in a multivariable analysis. Those with P < .05 on multivariable analysis were assigned points according to the relative value of their odds ratios (ORs). Receiver operating characteristic curves were generated to determine low- vs high-risk scores. An area under the curve of >0.65 was considered adequate for validation. RESULTS A total of 355 patients were included, with an overall amputation rate of 16%. On multivariate regression analysis, the risk factors independently associated with amputation in the final model were as follows: systolic blood pressure <90 mm Hg (OR, 3.2; P = .027; 1 point), associated orthopedic injury (OR, 4.9; P = .014; 2 points), and a lack of preoperative pedal Doppler signals (OR, 5.5; P = .002; 2 points [or 1 point for a lack of palpable pedal pulses if Doppler signal data were unavailable]). A score of ≥3 was found to maximize the sensitivity (85%) and specificity (49%) for a high risk of amputation. The receiver operating characteristic curve for the validation group had an area under the curve of 0.750, meeting the threshold for score validation. CONCLUSIONS The POPSAVEIT score provides a simple and practical method to effectively stratify patients preoperatively into low- and high-risk major amputation categories.
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15
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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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16
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A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status. J Surg Res 2020; 257:363-369. [PMID: 32892132 DOI: 10.1016/j.jss.2020.08.015] [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] [Received: 04/30/2020] [Revised: 07/06/2020] [Accepted: 08/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Popliteal artery injuries are the second most common arterial injuries below the inguinal ligament. We aimed to compare outcomes in patients with popliteal injuries by hospital teaching status utilizing the National Trauma Data Bank Research Data Set (NTDB-RDS) 2013-2016. METHODS Four-year retrospective study using the NTDB-RDS, evaluating popliteal vascular injuries. Patients were divided by popliteal injury type and teaching status into; nonteaching hospital (NTH), community teaching (CTH), or University teaching (UTH). Demographics and outcome measures were compared between groups. Risk-adjusted mortality odds ratios (ORs) were calculated. Significance was defined as P < 0.05. RESULTS 3,577,168 patients were in the NTDB-RDS, with 1120 having a popliteal injury, (incidence = 0.03%). There was no significant difference in the amputation rate between patients treated in NTHs, CTHs, or UTHs (P > 0.05). There was no significant difference in the raw mortality rate between patients treated in NTHs, CTHs, or UTHs. After adjusting for confounders; compared to NTH, the odds ratio for mortality for popliteal artery injuries in the CTH group was significantly higher (OR: 15.95, 95% CI: 1.19-213.84), and for the UTH group the mortality was also significantly higher (OR: 5.74, 95% CI: 0.45-72.95). CONCLUSIONS The incidence of popliteal vascular injuries was 0.03% for 2013-2016. Patients with popliteal artery injuries treated at community teaching hospitals have a 16 times higher risk of mortality and at university teaching hospitals have a 5.7 times higher risk of mortality than patients treated at nonteaching hospitals.
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Brumberg RS, Kaelin LD, Derosier LC, Hutchinson H. Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts. Ann Vasc Surg 2020; 71:181-190. [PMID: 32800890 DOI: 10.1016/j.avsg.2020.07.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage. METHODS Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments. RESULTS All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10 days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3 months after their final surgery. At 24 months follow-up, 90% amputation free survival is still maintained. CONCLUSIONS Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.
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Parihar S, Benarroch-Gampel J, Teodorescu V, Ramos C, Minton K, Rajani RR. Vascular Surgeons Carry an Increasing Responsibility in the Management of Lower Extremity Vascular Trauma. Ann Vasc Surg 2020; 70:87-94. [PMID: 32422294 DOI: 10.1016/j.avsg.2020.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/21/2020] [Accepted: 05/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is preliminary evidence that vascular surgeons are increasingly relied on nationally to assist with the management of lower extremity vascular trauma. Current trauma center verification, however, does not require any level of vascular surgery coverage. We sought to assess practice patterns regarding vascular surgery consultation and temporal trends in the surgical management of these patients. METHODS A retrospective analysis was performed on all patients who underwent surgical repair for vascular trauma of the lower extremity at a single, academic, public hospital from 2011 to 2018. Demographic data and procedural data were collected. Patients were assigned to a vascular surgery (VS) or nonvascular surgery (NV) group. The primary outcome measure was the rate of VS consultation. Secondary outcome measures included 30-day mortality, length-of-stay, and limb salvage. RESULTS One hundred eighty patients were identified (77 VS group, 103 NV group). There was an increase in the proportion of repairs done by VS from 2011 to 2018 (P < 0.05). There were significant management differences between the 2 groups, with vascular surgeons more likely to perform primary end-to-end anastomosis for both arterial (21.33% vs. 6.90%) and venous (19.15% vs. 5.26%) injuries (both P < 0.05). Patients in the VS group were less likely to have balloon embolectomy, fasciotomy, or intravascular shunting than the NV group (all P < 0.05). There were no significant differences in mortality (5.35% vs. 4.85%), length-of-stay (15.05 vs. 18.38 days), or limb salvage (94.81% vs. 95.15%). CONCLUSIONS Lower extremity vascular trauma is increasingly managed by vascular surgeons. Furthermore, vascular surgeons are more selective in the use of potentially unnecessary adjunctive maneuvers. Current accreditation guidelines should be revisited to mandate vascular surgery coverage in trauma centers that frequently treat this patient population.
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Affiliation(s)
- Sid Parihar
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Jaime Benarroch-Gampel
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Victoria Teodorescu
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Christopher Ramos
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Keri Minton
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA
| | - Ravi R Rajani
- Division of Vascular and Endovascular Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA.
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Ikemura N, Kimura M, Matubara Y, Ito D, Yoshihara Y, Okumura H, Sawada T. Blunt Occlusive Traumatic Injury in the Popliteal Artery Revascularized by Stent Graft and Distal Puncture. JACC Cardiovasc Interv 2020; 13:1006-1008. [DOI: 10.1016/j.jcin.2019.12.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022]
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20
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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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21
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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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22
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Musonza T, Khouqeer A, Gilani R. Bilateral popliteal artery injury: Lessons learned. Trauma Case Rep 2019; 23:100230. [PMID: 31388540 PMCID: PMC6669397 DOI: 10.1016/j.tcr.2019.100230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2019] [Indexed: 11/19/2022] Open
Abstract
Popliteal artery trauma is reported to have the highest rates of limb loss in peripheral vascular injuries. It can be inferred that morbidity associated with bilateral popliteal artery trauma is worse. However, bilateral popliteal artery injuries are sparsely reported in literature and as such management options are not well defined. Despite the paucity of reported cases, a systematic and deliberate approach to these devastating injuries may result in reproducible limb salvage. We hereby use our case report as a provocateur to this conundrum. Consideration should be given to the utilization of surgical shunts or a two-surgical team and limb salvage attempted till proving the neurovascular bundle irreparable. Arterial grafts should be part of the surgeon's armamentarium. In massive hard to control hemorrhage, tourniquets or resuscitative endovascular occlusion devices (REBOA) may prove lifesaving. Larger studies are needed to define contemporary management and derive management guidelines.
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Affiliation(s)
- Tashinga Musonza
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
- Corresponding author at: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, BCM One Baylor Plaza, Suite 404D, Houston, TX 77030, United States of America.
| | - Ahmed Khouqeer
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
| | - Ramyar Gilani
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States of America
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Marcia L, Kim DY. Predictors of Peripheral Vascular Injury in Patients with Blunt Lower Extremity Fractures. Ann Vasc Surg 2019; 57:35-40. [DOI: 10.1016/j.avsg.2018.12.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/24/2018] [Accepted: 12/11/2018] [Indexed: 11/26/2022]
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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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Ramdass MJ, Muddeen A, Harnarayan P, Spence R, Milne D. Risk factors associated with amputation in civilian popliteal artery trauma. Injury 2018; 49:1188-1192. [PMID: 29704953 DOI: 10.1016/j.injury.2018.04.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/31/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023]
Abstract
Popliteal artery trauma is uncommon but is associated with a high risk of limb loss depending on the scenario involving blunt or penetrating trauma as well as the severity and extent of injury that has occurred. In our setting there is a significant amount of gang and civilian warfare resulting in Vascular Trauma. There were 32 patients over a decade who sustained traumatic injury to the popliteal artery consisting of 30 males (94%) and 2 females with an age range 16-59 years with a mean of 32. There were 20 cases of penetrating trauma (63%) and 12 cases of blunt trauma (37%). Of the penetrating trauma, 18 were due to gunshot wounds (GSWs) (90%) and 2 stabs. The majority (7/12; 58%) of blunt trauma was due to falls, and 42% (5/12) secondary to motor vehicular accidents (MVAs). In terms of extent of injury, 21 of 32 patients (65%) sustained an isolated popliteal artery injury, whilst 6 (19%) had injury to both the popliteal artery and vein and another 5 (16%) had combined popliteal artery, vein and nerve injuries. There were 14 cases with associated orthopaedic injuries: 7 posterior knee dislocations, 1 fracture/dislocation of the knee, 2 femoral fractures, 2 tibial plateau fractures and 2 tibia/fibula fracture. Methods of repair included 14 reversed vein grafts, 16 polytetrafluoroethylene (PTFE) grafts and 2 primary. The overall amputation rate was 28% (9 patients). Of the penetrating trauma patients 25% required amputations composed of 5 GSWs, 33% of the blunt trauma patients required amputations. It was noted that factors associated with (but not statistically significant) poor outcomes included combined artery/vein injury, artery/vein/nerve injury, concomitant fracture/dislocation and delayed transfer to a Vascular Surgery Unit. The type of graft or repair did not affect outcome. The incidence of popliteal artery trauma was calculated at 2.46 per 100,000 population per year.
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Affiliation(s)
- Michael J Ramdass
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies.
| | - Alyssa Muddeen
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies
| | - Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies
| | - Richard Spence
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies
| | - David Milne
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies
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Hafiz S, Zubowicz EA, Abouassaly C, Ricotta JJ, Sava JA. Extremity Vascular Injury Management: Good Outcomes Using Selective Referral to Vascular Surgeons. Am Surg 2018. [DOI: 10.1177/000313481808400136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Revascularization after extremity vascular injury has long been considered an important skill among trauma surgeons. Increasingly, some trauma surgeons defer vascular repair in response to training or practice patterns. This study was designed to document results of extremity revascularization surgery to evaluate trauma surgeon outcomes and judicious referral of more complex injuries to vascular surgeons (VAS). The trauma registry of an urban level I trauma center was used to identify all patients from 2003 to 2013 who underwent an early (<24 hours) procedure for urgent management of acute injury to extremity vessels. Patients were managed by trauma (TRA) versus VAS based on the practice pattern of the on-call trauma surgeon. Injury and outcome variables were recorded. Of 115 patients, 84 patients were revascularized by trauma and 31 vascular surgeries. There was no difference in complication rates or frequency of any type of complication associated with repairs performed by VAS or TRA. There were similar rates between the two groups for patients with multiple injuries, such as venous, bone or tendon, and nerve injury to the affected extremity. One VAS patient and two TRA patients developed compartment syndrome. In appropriately selected patients, trauma surgeons achieve good outcomes after revascularization of injured extremities.
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Affiliation(s)
- Shabnam Hafiz
- Department of Trauma and Burn Services, MedStar Washington Hospital Center, Washington, DC
| | - Elizabeth A. Zubowicz
- Department of Trauma and Burn Services, MedStar Washington Hospital Center, Washington, DC
| | - Chadi Abouassaly
- Department of Trauma and Burn Services, MedStar Washington Hospital Center, Washington, DC
| | - John J. Ricotta
- Department of Trauma and Burn Services, MedStar Washington Hospital Center, Washington, DC
| | - Jack A. Sava
- Department of Trauma and Burn Services, MedStar Washington Hospital Center, Washington, DC
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Song W, Zhou D, Dong J. Predictors of secondary amputation in patients with grade IIIC lower limb injuries: A retrospective analysis of 35 patients. Medicine (Baltimore) 2017; 96:e7068. [PMID: 28562573 PMCID: PMC5459738 DOI: 10.1097/md.0000000000007068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to identify risk factors for failure of limb salvage surgery in grade IIIC lower extremity injuries.A single-institution, retrospective review was performed of all patients with grade IIIC lower limb injuries presenting from January 2009 to April 2014. We gathered the data on each patient who underwent limb salvage and analyzed the final outcome for these patients (limb salvage vs secondary amputation).Grade IIIC lower limb injuries were identified in 41 patients. Primary amputation was performed in 6 patients (15%) as the initial procedure. Thirty-five patients (85%) underwent vascular reconstruction and other surgical procedures to salvage the limb. Limb salvage was successful in 23 patients (66%); 12 patients (34%) ultimately underwent secondary amputation. The median time from injury to secondary amputation was 22.5 days (range 4-380 days). The mean Mangled Extremity Severity Score (MESS) was 7.2 ± 1.5 (range 5-10). The MESS was significantly higher in the secondary amputation group compared with the limb salvage group. Additionally, statistical testing revealed that the limb ischemia time, complex fractures, rate of fasciotomy, and number of vascular reconstruction were significantly higher in the secondary amputation group. Muscle necrosis and extensive soft tissue defect were the main reasons for secondary amputation.The findings indicate that MESS of 7 or greater, complex fractures, limb ischemia time equal to or greater than 6 hours, and osteofascial compartment syndrome were associated with an increased risk of delayed amputation. The MESS is highly prognostic but not perfect; decision-making in patients with an MESS of 7 or greater should be re-evaluated for clinical use.
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Rivera JC, Wenke JC, Pugh MJ. Open Fracture Care During War: Opportunities for Research. JBJS Rev 2016; 4:01874474-201610000-00004. [PMID: 27792675 DOI: 10.2106/jbjs.rvw.15.00105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Reported infection rates following severe open fractures of the lower extremity sustained in combat have varied widely, from 23% to 85%. The infection rates have been either similar to or higher than those reported in the civilian trauma literature. Deployed surgeons have increased the frequency of fasciotomy procedures for limbs with or at risk for clinical compartment syndrome. The long-term sequelae of compartment syndrome and fasciotomies are not clearly defined. The definition of the term late amputation has varied in the literature, and studies have not consistently included information on the causes of the amputations. Preclinical and clinical translational studies on the reduction of the rates of infection and other limb morbidities are needed to address the acute care of combat extremity wounds.
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Affiliation(s)
- Jessica C Rivera
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas.,Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Joseph C Wenke
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas
| | - Mary Jo Pugh
- VERDICT Research Group, South Texas Veterans Healthcare System, San Antonio, Texas
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Comment on Factors Associated with Amputation after Popliteal Vascular Injuries. Ann Vasc Surg 2016; 36:325. [DOI: 10.1016/j.avsg.2016.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 06/09/2016] [Accepted: 06/09/2016] [Indexed: 11/20/2022]
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Bernhoff K, Björck M, Larsson J, Jangland E. Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury. Eur J Vasc Endovasc Surg 2016; 52:690-695. [PMID: 27637376 DOI: 10.1016/j.ejvs.2016.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management. METHOD The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method. RESULTS Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives." CONCLUSIONS Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.
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Affiliation(s)
- K Bernhoff
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - M Björck
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J Larsson
- Health Services Research, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - E Jangland
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Zhong S, Zhang X, Chen Z, Dong P, Sun Y, Zhu W, Pan X, Qi D. Endovascular Repair of Blunt Popliteal Arterial Injuries. Korean J Radiol 2016; 17:789-96. [PMID: 27587969 PMCID: PMC5007407 DOI: 10.3348/kjr.2016.17.5.789] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/05/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility and effectiveness of endovascular repair for blunt popliteal arterial injuries. MATERIALS AND METHODS A retrospective analysis of seven patients with clinical suspicion of popliteal arterial injuries that were confirmed by arteriography was performed from September 2009 to July 2014. Clinical data included demographics, mechanism of injury, type of injury, location of injury, concomitant injuries, time of endovascular procedures, time interval from trauma to blood flow restoration, instrument utilized, and follow-up. All patients were male (mean age of 35.9 ± 10.3 years). The type of lesion involved intimal injury (n = 1), partial transection (n = 2), complete transection (n = 2), arteriovenous fistula (n = 1), and pseudoaneurysm (n = 1). All patients underwent endovascular repair of blunt popliteal arterial injuries. RESULTS Technical success rate was 100%. Intimal injury was treated with a bare-metal stent. Pseudoaneurysm and popliteal artery transections were treated with bare-metal stents. Arteriovenous fistula was treated with bare-metal stent and coils. No perioperative death and procedure-related complication occurred. The average follow-up was 20.9 ± 2.3 months (range 18-24 months). One patient underwent intra-arterial thrombolysis due to stent thrombosis at 18 months after the procedure. All limbs were salvaged. Stent migration, deformation, or fracture was not found during the follow-up. CONCLUSION Endovascular repair seems to be a viable approach for patients with blunt popliteal arterial injuries, especially on an emergency basis. Endovascular repair may be effective in the short-term. Further studies are required to evaluate the long-term efficacy of endovascular repair.
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Affiliation(s)
- Shan Zhong
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
- Department of Medical Imaging, Weifang Medical University, Weifang 261053, P.R.China
| | - Xiquan Zhang
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Zhong Chen
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Peng Dong
- Department of Medical Imaging, Weifang Medical University, Weifang 261053, P.R.China
| | - Yequan Sun
- Department of Medical Imaging, Weifang Medical University, Weifang 261053, P.R.China
| | - Wei Zhu
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Xiaolin Pan
- Department of Interventional Vascular, The 148th Hospital of Chinese People's Liberation Army, Zibo 255300, P.R.China
| | - Deming Qi
- Department of Medical Imaging, Qilu Medical University, Zibo 255200, P.R.China
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Hicks CW, Canner JK, Zarkowsky DS, Arhuidese I, Obeid T, Malas MB. Racial disparities after vascular trauma are age-dependent. J Vasc Surg 2016; 64:418-424. [DOI: 10.1016/j.jvs.2016.01.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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Keeley J, Koopmann M, Yan H, DeVirgilio C, Putnam B, Y. Kim D, Plurad D. Factors Associated with Amputation after Popliteal Vascular Injuries. Ann Vasc Surg 2016; 33:83-7. [DOI: 10.1016/j.avsg.2016.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 10/22/2022]
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Jaña Neto FC, Canal MDP, Alves BAF, Ferreira PM, Ayres JC, Alves R. Análise das características dos pacientes com fratura exposta de tíbia grau III de Gustilo e Anderson. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Jaña Neto FC, de Paula Canal M, Alves BAF, Ferreira PM, Ayres JC, Alves R. Analysis of the characteristics of patients with open tibial fractures of Gustilo and Anderson type III. Rev Bras Ortop 2016; 51:143-9. [PMID: 27069881 PMCID: PMC4812037 DOI: 10.1016/j.rboe.2016.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/01/2015] [Indexed: 11/23/2022] Open
Abstract
Objective To analyze the characteristics of patients with Gustilo–Anderson Type III open tibial fractures treated at a tertiary care hospital in São Paulo between January 2013 and August 2014. Methods This was a cross-sectional retrospective study. The following data were gathered from the electronic medical records: age; gender; diagnosis; trauma mechanism; comorbidities; associated fractures; Gustilo and Anderson, Tscherne and AO classifications; treatment (initial and definitive); presence of compartment syndrome; primary and secondary amputations; MESS (Mangled Extremity Severity Score) index; mortality rate; and infection rate. Results 116 patients were included: 81% with fracture type IIIA, 12% IIIB and 7% IIIC; 85% males; mean age 32.3 years; and 57% victims of motorcycle accidents. Tibial shaft fractures were significantly more prevalent (67%). Eight patients were subjected to amputation: one primary case and seven secondary cases. Types IIIC (75%) and IIIB (25%) predominated among the patients subjected to secondary amputation. The MESS index was greater than 7 in 88% of the amputees and in 5% of the limb salvage group. Conclusion The profile of patients with open tibial fracture of Gustilo and Anderson Type III mainly involved young male individuals who were victims of motorcycle accidents. The tibial shaft was the segment most affected. Only 7% of the patients underwent amputation. Given the current controversy in the literature about amputation or salvage of severely injured lower limbs, it becomes necessary to carry out prospective studies to support clinical decisions.
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Affiliation(s)
- Frederico Carlos Jaña Neto
- Department of Orthopedics and Traumatology, Conjunto Hospitalar do Mandaqui, São Paulo, SP, Brazil; Universidade Nove de Julho, São Paulo, SP, Brazil
| | | | | | | | - Jefferson Castro Ayres
- Department of Orthopedics and Traumatology, Conjunto Hospitalar do Mandaqui, São Paulo, SP, Brazil
| | - Robson Alves
- Service of Traumatology and Orthopedics, Instituto Dr. José Frota, Fortaleza, CE, Brazil
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The Impact of Geniculate Artery Collateral Circulation on Lower Limb Salvage Rates in Injured Patients. Ann Vasc Surg 2015; 30:258-62. [PMID: 26541964 DOI: 10.1016/j.avsg.2015.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 07/03/2015] [Accepted: 07/19/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to determine the association between geniculate artery flow on admission computed tomography (CT) angiography and limb salvage outcomes in patients with lower extremity arterial injury. METHODS All injured patients at a level I trauma center with CT angiogram (CTA) confirmed limited or no flow to the tibial vessels were included. Demographics, injury severity score (ISS), mechanism of injury, physiological parameters, the presence of geniculate artery collateral circulation (superior medial, superior lateral, medial, inferior medial, inferior lateral), and 30-day limb salvage outcome were recorded. Statistical analysis was completed using descriptive statistics and the chi-squared tests. RESULTS From 2009 to 2012, a total of 84 patients with lower extremity arterial injury underwent diagnostic evaluation with CTA on admission that confirmed limited or no flow to the tibial vessels. A total of 10 patients (12%) underwent amputation. Primary amputation was performed in 3 (4%) patients, and secondary amputation was performed in 7 (8%) patients. There was no difference in age, gender, ISS, extremity abbreviated injury score, mechanism of injury, admission systolic blood pressure, heart rate, respiratory rate, transfusion volume, or type of vascular interventions between patients who had successful limb salvage and those who received an amputation. The number of patent geniculate arterial vessels was inversely associated with amputation with 3.3 patent geniculate arteries in the limb salvage group compared to 2.1 in the amputation group (P < 0.05). The 2 geniculate artery vessels that were significantly associated with limb salvage were the superior lateral geniculate and the inferior medial geniculate arteries (P < 0.05). CONCLUSIONS Geniculate collateral circulation may have an important role in limb salvage after lower extremity vascular injury. The geniculate arteries that are associated with the highest rates of limb salvage appear to be the superior lateral geniculate and the inferior medical geniculate artery.
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Characteristics and clinical outcome in patients after popliteal artery injury. J Vasc Surg 2015; 61:1495-500. [DOI: 10.1016/j.jvs.2015.01.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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Utsunomiya M, Takami Y, Kusunose K, Hayashi K, Osawa S, Chuman K, Matsuo R, Nakamura M. Endovascular therapy with intravascular ultrasound guidance for popliteal artery occlusion due to blunt trauma. EJVES Short Rep 2015. [DOI: 10.1016/j.ejvssr.2015.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Dua A, Desai SS, Johnston S, Chinapuvvula NR, DuBose J, Charlton-Ouw K, Azizzadeh A, Burgess A, Wade CE, Fox CJ, Holcomb JB. Observation may be an inadequate approach for injured extremities with single tibial vessel run-off. Vascular 2014; 23:468-73. [DOI: 10.1177/1708538114554925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Trauma patients with sudden loss of distal perfusion due to tibial injuries are frequently not offered vascular interventions if a single vessel retains patency. We hypothesized that sudden loss of either all or some tibial vasculature would result in increased non-operative failure and higher amputation rates. Methods In this retrospective observational study, all traumatically injured patients from 2009 to 2012 with CT-angiogram–confirmed anterior tibial, posterior tibial, or peroneal artery injuries were included. Results From 2009 to 2012, 437 patients were admitted with arterial extremity injury of which 234 (53%) were lower extremity. From this group, 84 (36%) patients were identified with CT-angiogram–confirmed limited or no flow in the tibial arteries. A total of 44% (4/9) with 0 or 1 tibial vessel failed observation while only 8% (2/27) failed if they had 2 or 3 patent vessels ( p < 0.05). Amputation rate was inversely related the number of open tibial vessels. There were 2.7 open tibial vessels in the limb salvage group compared to 1.1 in the amputation group ( p < 0.05). Conclusion Patients who failed an initial trial of observation were significantly more likely to have 0 or 1 tibial vessels patent. The number of open tibial vessels is significantly associated with limb salvage.
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Affiliation(s)
- Anahita Dua
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas–Houston, TX, USA
- Department of Surgery, Medical College of Wisconsin, WI, USA
| | - Sapan S Desai
- Department Vascular Surgery, Southern Illinois University, IL, USA
| | - Sean Johnston
- Department of Radiology, University of Texas–Houston, TX, USA
| | | | - Joseph DuBose
- Department of Cardiothoracic and Vascular Surgery, University of Texas–Houston, TX, USA
| | | | - Ali Azizzadeh
- Department of Cardiothoracic and Vascular Surgery, University of Texas–Houston, TX, USA
| | - Andrew Burgess
- Department of Orthopedic Surgery, University of Houston–Texas, TX, USA
| | - Charles E Wade
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas–Houston, TX, USA
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, CO, USA
| | - John B Holcomb
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas–Houston, TX, USA
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Dua A, Zepeda R, Hernanez FC, Igbadumhe AA, Desai SS. The national incidence of iatrogenic popliteal artery injury during total knee replacement. Vascular 2014; 23:455-8. [DOI: 10.1177/1708538114552464] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The aim of this study was to characterize national characteristics of patients who have a total knee replacement complicated by popliteal artery injury by incidence and patient demographics. Methods All patients with ICD-9 confirmed total knee replacement who had an iatrogenic popliteal artery injury were included from the national in-patient sample from 1998 to 2011. Age, gender and race, procedure type, time to popliteal artery injury, limb outcome, length of stay and hospital inpatient charges were reported. Results A total of 1,297,369 patients underwent a total knee replacement of which 43 were complicated by popliteal artery injury (0.003%); 93% had osteoarthritis as their primary diagnosis. The mean age was 61.7 ± 12.3 years. In all, 96% of patients had their popliteal injuries detected intra-operatively or on the day of total knee replacement surgery. The majority of these patients either received stent placement (44%) or peripheral bypass (30%) as their treatment modality for popliteal artery injury. There were no amputations or deaths in this cohort. The median hospital charges for this group were $27,570 (2014 USD). Conclusion The national incidence of iatrogenic popliteal artery injury in patients undergoing TKR is 0.003%. There were no amputations in our study population and 96% of patients had their injury detected intra-operative or immediately post-operatively.
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Affiliation(s)
- Anahita Dua
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas-Houston, Houston, TX, USA
| | - Reyna Zepeda
- National Autonomous University of Nicaragua, Managua, Nicaragua
| | | | | | - Sapan S Desai
- Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA
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Dua A, Patel B, Desai SS, Holcomb JB, Wade CE, Coogan S, Fox CJ. Comparison of military and civilian popliteal artery trauma outcomes. J Vasc Surg 2014; 59:1628-32. [DOI: 10.1016/j.jvs.2013.12.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 11/30/2022]
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