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Góes AMDO, de Albuquerque FBA, Feijó MO, de Albuquerque FBA, Corrêa LRDV, de Andrade MC. Prognostic factors for femoropopliteal vascular injuries: surgical decisions matter. J Vasc Bras 2023; 22:e20230050. [PMID: 38021276 PMCID: PMC10647908 DOI: 10.1590/1677-5449.202300502] [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: 05/09/2023] [Accepted: 08/04/2023] [Indexed: 12/01/2023] Open
Abstract
Background Lower limbs are frequently involved in vascular trauma, but it is still not clear which factors lead to unfavorable clinical outcomes. Objectives To determine the clinical profile of patients with femoropopliteal injuries, the trauma mechanisms, and treatment and identify which factors led to unfavorable outcomes. Methods A retrospective study based on the medical records of patients treated from 2017 to 2021. The following data were assessed: sex, age, distance to reach the hospital, trauma mechanism, hypovolemic shock, additional injuries, treatment of vascular injuries, whether fasciotomy was needed, inappropriate intraoperative decisions, and injury severity score. Need for surgical reintervention, amputation, and death were defined as unfavorable outcomes. Univariate, bivariate, and logistic regression analyses were conducted. Results The sample comprised 94 patients; 83% were men; mean age was 30.8 years; combined arterial and venous injuries prevailed (57.5%); and superficial femoral vessels were the most affected (61.7%). Penetrating mechanisms prevailed (80.9%). Arterial injuries were most frequently treated with venous graft (59.6%) and venous injuries underwent ligation (81.4%). In 15% of cases, inappropriate surgical decisions were detected; most often use of the ipsilateral great saphenous vein for arterial reconstruction. Unfavorable outcomes occurred in 44.7%: surgical reintervention was necessary in 21.3% and limb amputation in 25.5%, while 9.5% of the patients died. Conclusions These injuries mainly involved young men, victims of gunshot wounds. Superficial femoral vessels were the most injured; concomitant non-vascular trauma was frequent, mainly fractures. Inappropriate surgical decisions increased the need for reinterventions by 34 times. Need for fasciotomy, presence of fracture/dislocation, blunt trauma mechanism, and popliteal artery injury increased the risk of amputation.
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Venous Shunting and Limb Outcomes in Military Lower Extremity Combined Arterial and Venous Injuries. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abdou H, Edwards J, Stonko D, Elansary N, Ottochian M, DuBose JJ, Scalea TM, Morrison JJ, Kundi R. The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting. Ann Vasc Surg 2022; 87:522-528. [PMID: 35760265 DOI: 10.1016/j.avsg.2022.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. METHODS The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the pre-defined noninferiority margin. RESULTS 3698 patients met inclusion criteria, with blunt injury accounting for 2117 (57%) and penetrating injury accounting for 1581 (43%). Within the blunt group, 1976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6). CONCLUSION These data suggest that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation . Further examination of endovascular repair in popliteal artery injury is warranted.
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Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - David Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Marcus Ottochian
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
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O'Shea AE, Lee C, Kauvar DS. Analysis of Concomitant and Isolated Venous Injury in Military Lower Extremity Trauma. Ann Vasc Surg 2022; 87:147-154. [PMID: 35460859 DOI: 10.1016/j.avsg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. METHODS The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). RESULTS 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries (IVI)) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). CONCLUSION Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.
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Affiliation(s)
- Anne E O'Shea
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Christina Lee
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Ft. Sam Houston, TX, USA; Department of Surgery, Uniformed Services University, Bethesda, MD, USA.
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Abstract
ABSTRACT This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed. LEVEL OF EVIDENCE Review article, levels IV and V.
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Affiliation(s)
- David V Feliciano
- From the Department of Surgery (D.V.F.), Shock Trauma Center, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (M.P.K.), University of Florida Health Jacksonville Medical Center, Jacksonville, Florida; and Division of Acute Care Surgery, Department of Surgery (G.F.R.), John Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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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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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Magee GA. Reply. J Vasc Surg Venous Lymphat Disord 2020; 8:903-904. [PMID: 32800260 DOI: 10.1016/j.jvsv.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Gregory A Magee
- Department of Surgery, University of Southern California, Los Angeles, Calif
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